Every finding on record at Immanuel Skilled Care Center

Based on observation, interview, and record review, the facility failed to ensure kitchen personnel had a process in place for documentation of weekly deep cleaning of the ovens; and failed to ensure areas surrounding the fryer and griddle were cleaned daily (end of shift). These deficient practices had the potential to increase the risk of foodborne illnesses for anyone receiving food, or having food prepared, from the facility kitchen. Findings include:1. Kitchen OvensDuring an observation and interview on 12/30/25 at 2:17 p.m., staff member C stated the ovens in the kitchen had been cleaned about a month ago. Staff member C opened the oven furthest away from the flat top griddle. The oven had dark brown, burnt food, and grease splatter covering both doors, burnt food chunks below the doors, and baked on grease splatter on all sides of the oven. Staff member C opened the oven closest to the flat top griddle, which also had the same baked on, burnt food, and grease splatter on both doors, all sides of the oven, and burnt food chunks below the doors. Staff member C stated she did not have any documentation of cleaning logs for the ovens. Staff member C stated the kitchen staff were always cleaning, and she trusted her employees to clean the equipment.During an interview on 12/30/25 at 2:25 p.m., staff member D stated he had not cleaned the ovens for over a month.Review of the facility's policy and procedure titled, Line Equipment Cleaning Policy & Procedure, undated, showed:- . Weekly Deep Cleaning- . Deep clean ovens . 2. Flat Top Griddle and FryerDuring on observation and interview on 12/30/25 at 2:25 p.m., the flat top griddle had a hole, at the front of the griddle, where excess grease and fried food particles were scraped from the top of the griddle throughout the day. Underneath the griddle and the hole, was a grease trap. Staff member D stated the grease trap was emptied daily. The hole in the flat top griddle was caked with layers of sticky, dried grease and food particles, which had accumulated over a period of time. Staff member D stated the hole in the griddle was not cleaned routinely when the grease trap was emptied. During an observation and interview on 12/30/25 at 2:39 p.m., on the walls surrounding the fryer was liquefied and dried accumulated grease. On the floor next to the fryer was black, dried grease around the wheels and on the floor tile. On the floor next to the fryer was liquefied grease on the tile and surrounding the wheels. Staff member C stated the area around the fryer was cleaned daily.During an observation and interview on 12/31/25 at 7:16 a.m., a food cart was placed on the left side of the fryer. When the food cart was moved, liquid, light brown grease was all down the left side of the fryer, on the floor, and around the wheels. Dark brown, congealed grease was caked on the wheels and the floor surrounding the wheels of the fryer. Staff member C stated she would get the area cleaned.Review of the facility's policy and procedure titled, Line Equipment Cleaning Policy & Procedure, undated, showed:- . Daily Cleaning (End of Shift)- Remove food debris and grease from all equipment,- . Wipe interior and exterior surfaces with approved cleaners,- . Sweep and mop floors under and around line equipment,- . Weekly Deep Cleaning- Degrease and polish flat top griddle and drain system, and- . Pull equipment when possible to clean floors and walls. [sic]

Based on observation, interview, and record review, staff member E failed to uphold infection control precautions for 1 (#29) resident, to include failing to use enhanced barrier precautions (EBP) while performing the treatment to an open skin tear for a resident with a known MDRO; placing wound care supplies onto an unclean surface during wound care; and failing to perform hand hygiene before entering a resident's room and donning clean gloves; failed to ensure staff member J followed EBP while administering medications in a gastrostomy tube for 1 (#66) out of 23 sampled residents. The facility also failed to ensure cleaning and a cleaning log was completed for a CoaguChek XS System for 1 (#10) of 1 resident utilizing the CoaguChek XS System. These deficient practices had the potential to increase the risk of communicable diseases within the facility. Findings include: 1. During an observation and interview on 12/30/25 at 9:39 a.m., resident #29 was holding a blood-soaked tissue on his left forearm. Resident #29 stated he had removed the sock fabric protector from his left forearm, and when he pulled the sock off, it removed the scab on his forearm, causing it to bleed. Staff member E entered resident #29's room and laid wound care supplies (unpackaged roll of gauze, scissors, and tape) down onto a pile of magazines, on top of a dresser. Staff member E donned clean gloves to begin care of resident #29's left forearm, to the open skin tear. Staff member E did not sanitize her hands before entering the room or before donning clean gloves; she did not don an isolation gown, and she did not put down a clean barrier when wound care supplies were placed onto the magazines. Staff member E needed additional supplies to cover resident #29's skin tear, so she doffed her gloves, retrieved her supplies, and left the room. Inside resident #29's room, next to the door, was a personal protective equipment (PPE) container with drawers holding isolation gowns. On top of the PPE container was a basket with various clothing items and a gait belt. Underneath the basket was an enhanced barrier precautions sign (which was visually blocked by the basket), which showed the appropriate PPE to be worn during high-contact resident care. During an observation on 12/30/25 at 9:44 a.m., staff member E entered resident #29's room and laid wound care supplies onto a pile of magazines, on top of a dresser. Staff member E did not put down a clean barrier on the unclean surface. Staff member E performed hand hygiene and donned clean gloves. Staff member E cleaned, applied antibiotic ointment, and dressed resident #29's skin tear. Staff member E did not wear an isolation gown during this high-contact resident care. Review of resident #29's electronic health record showed he was admitted to the facility on [DATE]. Resident #29's admitting diagnoses included, but was not limited to: - Infection following a procedure, other surgical site, subsequent encounter, - Infection and inflammatory reaction due to other internal orthopedic prosthetic devices, implants and grafts, subsequent encounter, - Methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, and - Other bacterial infections of unspecified site. During an interview on 12/30/25 at 9:53 a.m., staff member E stated resident #29 no longer had a PICC line (percutaneous indwelling central catheter) to deliver antibiotics, and she did not believe he was on any type of isolation precautions. Staff member E stated she should have placed a clean barrier under the bandages or wound care supplies; she just did not want to put the supplies on resident #29's bedside table. Staff member E stated she had completed hand hygiene training and should sanitize her hands before entering a room and before donning clean gloves. Staff member E stated she missed performing hand sanitization the first time she entered resident #29's room. Staff member E stated the CNA for resident #29 had told her he was bleeding profusely and she was trying to hurry. During an interview on 12/31/25 at 9:30 a.m., staff member B stated a resident with a diagnosis of a multi-drug resistant organism would be placed on enhanced barrier precautions (EBP), whether they had a wound or an indwelling device. Staff member B stated staff would know if a resident was on EBP because a PPE cart would be placed inside of the resident's room. Staff member B stated some families had requested the EBP sign not be placed on the outside of their family member's room, for privacy purposes. Staff member B stated annual employee infection control competencies had been performed in October of 2025, which included hand hygiene and donning/doffing of PPE. Staff member B stated any direct care staff should sanitize their hands before donning gloves. Staff member B stated a nurse would be routinely expected to put down a clean barrier before placing wound care supplies onto a surface. 2. During an observation on 12/30/25 at 8:24 a.m., resident #66 had a continuous tube feed running but did not have an EBP sign on the outside of his door for any isolation precautions. Review of resident #66's physician order showed: EBP – Enhanced Barrier Precautions d/t G-Tube, every shift for infection prevention. During an observation and interview on 12/31/25 at 8:44 a.m., staff member J administered the medications (amlodipine besylate, aspirin, clopidogrel bisulfate, lansoprazole, senna, and docusate sodium) for resident #66's G-tube with donned gloves but never used an isolation gown to ensure the employee was following the EBP guidelines. Resident #66's door had an EBP sign on the door as of 12/31/25 (not before that). Staff member J stated they felt EBP was unnecessary to wear, because nurses in the hospital were not required to wear EBP during any G-tube feedings or medication administration. Staff member J stated they were open to more education on why EBP was needed in a nursing home environment versus a hospital environment. Review of the facility's policy titled, Enhanced Barrier Precautions, last revised 12/24, showed: - Policy Statement - Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. - . 2. Enhanced barrier precautions apply when: - a. A resident is infected or colonized with a CDC-targeted MDRO, but does not have a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained, - . 4. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status, - . 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply, - a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room), - 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: - . j. wound care (any skin opening requiring a dressing). [sic] Review of the facility's document titled, Infection Prevention and Control Plan, undated, showed: - . Standard Precautions - . A. Hand Hygiene - 1. Staff must perform hand hygiene (even if gloves are used) - . a. before and after contact with the resident, and - . e. when entering and leaving a resident's room or apartment. 3. During an interview on 12/30/25 at 9:35 a.m., resident #10 stated the facility had been obtaining her INR levels, but the results were sometimes different from the hospital's INR lab result that was obtained on the same day. Resident #10 stated she felt the facility might need to recalibrate the CoaguChek XS System or she felt there might have been something wrong. During an interview and observation on 12/31/25 at 9:25 a.m., staff member K stated the facility did not have a cleaning log for the CoaguChek XS System and the facility had the machine for about a year now. Staff member K used her thumb to pop the plastic lid off the machine to expose the meter test strip guide, and there were two very small, uncleaned areas with a slightly greenish-blue substance. A request was made for the Coagucheck cleanings, but no supporting documentation was provided by the facility by the end of the survey. Review of a facility document titled, Coaguchek XS System Policies & Procedures Manual, no date, showed: - . Cleaning/disinfecting the meter test strip guide . Use only 70% isopropyl alcohol or 10% bleach solution . -Debris on the test strip guide can cause problems with results. Clean the meter as recommended in the CoaguChek XS System User Manual .

Based on interview and record review, facility nursing staff failed to document blood pressure readings before administering a blood pressure medication with provider orders to hold the medication, if the resident's blood pressure was under 110/60 mmHg, for 1 (#95) of 23 sampled residents. This deficient practice had the potential to cause the resident to become hypotensive. Findings include:A review of a provider order in resident #95's EHR, dated 9/5/25, and ordered by staff member F, showed: Medication: Labetalol HCL Oral Tablet 100 mg, **DAW** Give 50 mg by mouth in the morning for hypertension Hold for pressure below 110/60. [sic]A review of another provider order in resident #95's EHR, dated 9/5/25, and ordered by staff member F, showed: Medication: Labetalol HCL Oral Tablet, Give 25 mg by mouth at bedtime for HTN Hold for pressure below 110/60. [sic]A review of resident #95's blood pressure recordings in her EHR, showed 152 blood pressure readings were not recorded from 10/2/25 through 12/25/25. Resident #95 should have had two blood pressure readings recorded each day from 9/5/25. A review of resident #95's medication administration record, for the dates of 10/1/25 through 12/29/25, showed the morning and evening dose of Labetalol had been administered on all but seven encounters. During an interview on 12/31/25 at 9:29 a.m., staff member B stated if the medication order had parameters for administration, the vitals should have been taken on the resident and entered in the EMR, before the administration of the blood pressure medications.A review of a facility policy titled, Administering Medications, with a revised date of April 2019, showed: . 10. The following information is checked/verified for each resident prior to administering medications:a. Allergies to medications; andb. Vital signs, if necessary.

Based on interview and record review, the facility failed to identify and implement a care plan for concerns related to a resident's diagnosis of Post Traumatic Stress Disorder (PTSD), and or the triggers for the PTSD, for the provision of trauma-informed care, for 1 (#111) of 23 sampled residents. Findings include:A review of resident #111's diagnoses list in the EMR showed Post-traumatic stress disorder, unspecified, with a date of 7/14/2025.A review of a facility document titled, Trauma Informed Care Assessment-PTSD 5, with an effective date of 11/24/24, for resident #111, showed: PTSD SCREENREAD. Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, having a loved one die through homicide or suicide.1. Have you ever experienced this kind of event? . The yes box was checked.A review of resident #111's comprehensive care plan failed to show that he had PTSD or any interventions for PTSD.During an interview on 12/31/25 at 10:11 a.m., staff member G stated social services would revise a resident's care plan based on the MDS and the resident's diagnosis of PTSD.During an interview on 12/31/25 at 10:11 a.m., staff member I stated PTSD should have been care planned for resident #111. His PTSD triggers should have been identified, and care planned, even if they were not triggering him. A review of a facility policy titled, Trauma-Informed and Culturally Competent Care, with a revised date of August 2022, showed: PurposeTo guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice.To address the needs of trauma survivors by minimizing triggers and/or re-traumatization.Definition.'Trauma' results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being.'Trauma-informed care' is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization.'Trigger' is a psychological stimulus that prompts recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening.Resident Care Planning1. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate.2. Identify and decrease exposure to triggers that may re-traumatize the resident.3. Recognize the relationship between past trauma and current health concerns (e.g., substance abuse, eating disorders, anxiety and depression). [sic]

Based on observation, interview, and record review, the facility failed to ensure pain medications were offered or given prior to ambulation, and non-pharmacological pain interventions were present and used for 1 (#112) of 23 sampled residents, and the resident stated her pain would sometimes make her cry. Findings include:During an observation and interview on 12/29/25 at 4:07 p.m., resident #112 stated she was having terrible pain in her hands. She stated she had arthritis and staff members would make her do exercises even though she was having immense pain. She stated she had gotten up with staff twice today and both times she experienced pain. She also stated staff members would haul you out of bed at 5:00 a.m. sometimes, which she stated she did not prefer. She explained while staff members took her to the dining room, she had to grab a bar while standing and she winced while explaining the process with her hands. She stated the CNAs would sometimes tell the nurse that she needed an aspirin, but resident #112 stated the communication did not always happen. Resident #112 did not have any ice, heat, or any other forms of non-pharmacological pain interventions present at her bedside or on her hands. Observation of resident #112's hands showed large visible deformities and bony bumps on her knuckles. Resident #112 showed difficulty grabbing objects.During an interview on 12/30/25 at 8:03 a.m., resident #112 stated her hands felt miserable.During an interview on 12/30/25 at 8:30 a.m., resident #112 stated she would usually cry from the pain when ambulating but stated today she did not feel that bad concerning her level of pain.During an interview on 12/31/25 at 8:25 a.m., staff member L stated resident #112 would complain of her hands hurting quite often, but stated resident #112 was able to complete all of the necessary ADLs during the day.During an interview on 12/31/25 at 8:44 a.m., staff member J stated they were unsure how frequently resident #112 complained of pain. Staff member J stated resident #112 seemed to sleep at night with no concerns of pain but would show signs of pain when ambulating specifically. Staff member J stated staff members did not give resident #112 pain medication prior to ambulation and this was not in the care plan. Staff member J stated resident #112 did not have a lot of non-pharmacological interventions for the pain in her hands. Staff member J stated heat could be a helpful option for someone with arthritis, but the floor staff were unable to apply heat unless it was permitted by the DON. Staff member J also stated ice could be helpful for inflammation, anti-inflammatory medications, or movement could help resident #112's pain as well.Review of resident #112's physician order showed: AROM to lower extremities ankle, knee, hip active range of movement in bed and chair. Refer to handout provided in room with AROM exercises every day shift.Review of resident #112's Care Plan, with an initiation date of 11/20/25, showed: Anticipate (resident #112)'s need for pain relief and respond immediately to any complaint of pain. Resident #112's Care Plan showed pain interventions but failed to show pain medication offered prior to ambulation and non-pharmacological pain interventions such as range of motion, heat, ice, etc.

Based on interview and record review, the facility failed to report their investigative findings of a facility reported incident to the State Survey Agency in a timely manner for 7 (#s 1, 2, 3, 4, 5, 6 and 7) of 13 sampled residents. Findings include:1. Review of a facility-reported incident, dated 12/4/24, involved an allegation of an injury of unknown origin, where a 2.5 cm bruise was noted on resident #2's right deltoid. Review of the facility-reported incident findings, submitted on 12/13/24, showed resident #2 is on a blood thinner, is at high risk for bruising, and the bruise was noted on the deltoid where the blood pressure cuff would be placed. Resident #2 had blood pressure checks every morning by unit staff and 5 days a week with therapy.2. Review of a facility-reported incident, dated 12/11/24, involved an allegation of an injury of unknown origin, where a skin assessment revealed resident #4 had a 12 cm x 11cm bruise in various stages of healing on the resident's right lower rib cage extending to the right iliac crest. Resident #4 has a diagnosis of dementia, was unable to state how it occurred. Resident #4 had a documented fall on 12/1/24. Review of the facility-reported incident findings, submitted on 12/22/24, showed resident #4 has a history of falls due to self-transfers. Resident #4 also stood and walked without assistance. Resident #4 completed therapy services and participated in restorative walking with a gait belt, which would align with the area a gait belt would be placed.3. Review of a facility-reported incident, dated 12/11/24, involved an allegation of an injury of unknown origin where resident #3 was noted to have a purple-colored bruise below the eye where her glasses laid on her face. Review of the facility reported incident findings, submitted on 12/22/24, showed resident #3 was observed leaning on her right elbow with her head over her cup on her bedside table. The investigation concluded the bruise originated from resident #3's glasses while sleeping with head down on bedside table. 4. Review of a facility-reported incident, dated 3/21/25, showed resident #1 was found next to her bed and had blood on her face. Resident #1 was actively bleeding from both nares, had an open area to her lower gum, and a small cut on her right cheek. Facility staff obtained vital signs and a neurological examination. Resident #1's family and the provider were notified. A physician's order was received to send resident #1 to the emergency room for evaluation and treatment. Review of the facility reported incident findings, submitted on 3/31/25, showed resident #1 has a history of traumatic brain injury, cerebrovascular accident with right hemiparesis and aphasia, seizure disorder and migraine headaches. Resident #1 has a history of self-transfer attempts. CNA reported she was in resident #1's room ten minutes prior to fall and the CNA assisted the resident to bed. Approximately 10 minutes later CNAs came back to find resident on her right side on the floor next to bed with swelling and bleeding to her nose. At that time, resident #1 stated she hit her face on assist bar. The facility reported incident documentation showed resident #1 may have attempted to sit herself up on the side of bed, lost balance, hit her face on the assist bar and slid off the bed. Resident #1 was seen in the emergency room and evaluated. Resident #1 was positive for a urinary tract infection.5. Review of a facility reported-incident, dated 6/2/25, showed resident #5 and resident #6 were involved in a physical exchange in the hallway. No noted injuries, and staff immediately intervened. Skin checks were completed and alert charting was put into place for both residents. Review of the facility-reported incident findings, submitted on 7/11/25, showed both residents have a diagnosis of dementia and were unable to state what occurred during the incident. Resident #6 was to be within line of sight when both residents are in the same area. Referral made to another facility for resident #6. Care plans were updated.6. Review of a facility reported-incident, dated 6/9/25, showed resident #7 sustained a fall on 6/1/25, where she fell when a CNA let go of the resident momentarily to grab a personal item. Neurological exam was initiated at the time of event. Review of the facility reported findings, submitted on 6/18/25, showed the CNA had responded to resident #7's adamant request for a personal item. The CNA reported a gait belt was not used, and a review of the transfer status was conducted. The transfer card in resident #7's room did not specify a gait belt, and the status was updated to show gait belt for transfers. X-ray showed no findings.7. Review of a facility reported-incident, dated 7/9/25, showed an incident of an injury of unknown origin, where during a weekly skin assessment resident #5 was found bruising and swelling to right foot. The provider was notified and x-ray requested. A podus boot was applied for comfort. Review of the facility reported findings, submitted on 7/21/25, showed resident #5 self-propelled in wheelchair, wore nonskid socks or soft slippers and rocked back and forth when in wheelchair. Staff interviewed the resident and found no findings of change in routine or increased pain. Resident #5 had the potential to run her toes over with her wheelchair secondary to the advanced dementia and soft footwear.During an interview on 8/19/25 at 1:30 p.m., staff member C stated incidents that are reported to the state agency need to be investigated and closed in five days. Staff member C stated there was a change a few months back where the investigation is to be completed in five working days, excluding holidays. Staff member C was shown the seven reportable incidents that were identified as being late when the findings were submitted. Staff member C the facility had struggled in the past with what was showing in in bounds, [the state report portal]. Staff member C stated there was difficulty with the findings being reported timely because there was more than one person involved with the reportable.During an interview on 8/19/25 at 1:35, staff member B stated reportables are reviewed in the morning meetings and sometimes the reportables do not get handed to IDT members in those meetings, and they get missed. Staff member B stated the facility had difficulty with timely reporting of findings of the investigations when the timing was changed a while back.During an interview on 8/19/25 at 4:37 p.m., staff member A stated it was hard to say why some reportables dating back to December of 2024 had findings of the investigation reported late. Staff member A reported he did identify a trend of late submission of findings on 7/11/24 when he did a deep dive and audited all reportables to the state agency. Staff member A stated the identified findings were put on the QAPI board and a PIP was initiated.Review of facility QAPI minutes dated 7/17/25 showed, Our Facility reported incident have been late the last couple of months, we noted with the last QSO that the reporting period was changed to 5 business days. When reviewing the date in bounds we noted that the date was a day off being 6 business days, we will track the due date one day before Bounds in standup to beon time. 7/11/25 in audit of Reportables noted that there were two that had not been submitted on from 6/12/25, Social Services noted that they had wrote this and submitted, wondering if they had forgot to hit submit and got pulled away from computer, they will submit 7/11/2025. A PIP will be completed to monitor Reportables and tracked in QAPI for at least three months for sustainability. The benchmark will be 0 late Reportables. [sic]Review of the facility's, PIP for Facility Reported Incidents showed, FRI-Bounds will be looked at Daily during the work weekend then reported in Stand up for date due-FRI will be closed at the latest one day before the due date-Social Work and DON will work on completing FRI one day before their due date-Administrator and Social worker will go over FRI for the week every Friday [sic] Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, showed, .9. Investigate and report any allegations within timeframes required by federal requirements.The corrective measures were implemented by the facility at the time of the identification of the late reporting. No further late reports were noted after the corrective actions were implemented.

Based on observations, interviews and record review, the facility failed to ensure a resident is free from physical restraints, failed to identify a seatbelt as a restraint, failed to assess for safety for the use of a physical restraint prior to the placement of the restraint, and failed to ensure the use of a physical restraint was used to treat a resident's medical symptoms for 1 (#5) of 13 sampled residents. This deficient practice caused the resident to be restrained to her wheelchair by a seatbelt without a clinical rationale. Findings include:During an observation on 8/18/25 at 3:42 p.m., resident #5 was seated in her wheelchair in a small room near the dining area on the memory care unit. Resident #5 was observed to have a seatbelt in use in her wheelchair. During an interview on 8/18/25 at 3:44 p.m., staff member D stated resident #5 had a seatbelt on. Staff member D stated, she believed resident #5 could remove the seatbelt independently. During an interview on 8/18/25 at 3:55 p.m., staff member E stated she noticed resident #5 was wearing a seatbelt. Staff member E stated she was unaware why resident #5 was wearing a seatbelt. During an interview on 8/18/25 at 4:00 p.m., staff member F stated resident #5 was wearing a seatbelt because she had a tendency to fall out of her chair. Staff member F said resident #5 could not remove the seatbelt independently.During an interview on 8/19/25 at 2:53 p.m., NF2 stated she noticed the seatbelt about two months ago when she came to visit resident #5. NF2 said she had not been notified of the seatbelt placement or given consent for the use of the seatbelt. NF2 stated she believed the seatbelt was used to help her sit there and not fall, and stated resident #5 would not be able to remove the seatbelt independently.Review of resident #5's physician's orders showed no order for the use of a seatbelt.Review of resident #5's significant change MDS with an assessment reference date of 6/13/25, showed under section C, cognitive patterns, the resident was staff assessed for cognition due to the resident being rarely/never understood. Section P, physical restraints, showed no restraints used for resident #5.Review of resident #5's EHR showed a progress note dated 8/19/25 at 4:13 p.m., writer placed call to daughter discussed current wheelchair as chair belongs to resident. Discussed if seat belt on chair came with the chair daughter does not remember if it originally came on the chair. She was aware that the seatbelt has been used as it has been in place during her visits. Discussed therapy evaluated today for positioning and safety and would like to move forward with possibly changing out wheelchair. Also discussed removing the seat belt from the chair at this time. Daughter is in agreement. Will notify therapy to reach out to her as she shared her eye sight and cognition do not communicate with each other, explaining that when her chair gets caught up on a turn and she can't get away she will just get up and that is when she will fall. Work order also placed to removed the seatbelt from the wheelchair. [sic]Review of resident #5's Occupational Therapy note, titled Outpatient Clinic OT Eval and Plan of Treatment, dated 8/19/25, showed, .Seating/Mobility System Recommendations and Medical Necessity, Limitations, Current Impairments: Patient exhibits considerable balance impairments, is high risk for falls and recurring injury, is not a functional ambulator, Patient is non-ambulatory; cannot perform any form of self-ambulation nor assisted ambulation and Patient presents w/ mobility limitation restricting ability to participate in 1 or more ADLs.Examination/Functional Description: Resident was previously screened in May following report of forward falls from her wheelchair. At that time, her wheelchair cushion was found to be positioned backwards and was corrected. No further issues had been reported until a recent state visit, during which it was noted that staff had been using a seat belt with the resident. Resident does not demonstrate a clinical need for a seat belt at this time. [sic]A request was made for consent for seatbelt use for resident #5 on 8/19/25 at 4:43 p.m. No documentation was provided prior to the end of survey.

Based on observation, interview, and record review, the facility: - failed to ensure an enhanced barrier precautions door sign was posted to notify all staff of the infection control precautions, and have gowns readily available for use during a tube feeding, for 1 (#361); - failed to ensure staff member R adhered to standard precautions during medication administration via a tube feeding, by placing medications to be administered on an unclean surface without a protective barrier in place, for 1 (#361); - failed to ensure staff member S and Q adhered to proper infection prevention practices related to hand hygiene during donning and doffing of gloves, for 2 (#s 42 and 370); - failed to ensure staff members G and K adhered to proper hand hygiene prior to entering and exiting resident rooms, for 6 (#s 29, 68, 70, 73, 77, and 88) of 37 sampled residents; and, - failed to ensure staff member C was performing infection tracking, surveillance, and ensuring staff member H maintained infection control practices while transporting laundry. Findings include: 1. During an observation on 10/22/24 at 10:45 a.m., inside the door of resident #361's room, was an enhanced barrier precautions cart, with the precautions sign on the top of the cart. During the administration of medications and tube feeding, staff member R wore gloves, but was not wearing a gown, a mask, or any type of eye/face protection shield. Resident #361 had coughed several times during the medication administration via the feeding tube. Upon exit of resident #361's room, no enhanced barrier precautions sign was on the door. During an interview on 10/22/24 at 4:30 p.m., staff member R stated she believed resident #361 should be on enhanced barrier precautions due to her coughing during the tube feeding. She stated there were not any masks/shields or gowns in the precautions cart inside resident #361's room or precautions sign on the door. Review of resident #361's electronic health record document, titled, Order Summary, on 10/22/24 at 4:42 p.m., showed: - . EBP - Enhanced Barrier Precautions d/t peg tube. - . Active 10/17/2024. Review of the facility policy titled, Infection Control Plan, Enhanced Barrier Precautions, undated, showed: - .EBP are indicated for residents with any of the following: - . Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. 2. During an observation on 10/22/24 at 10:45 a.m., staff member R prepared to administer medications to resident #361 via a feeding tube. Staff member R placed the medication cups down on resident #361's bedside table, without wiping/cleaning the table, and the table was visibly dirty with spilled, dried residue. Staff member R moved some of resident #361's personal items off the bedside table, placed a protective barrier on the table, then moved the medication cups from the unclean surface, onto the barrier. During an interview on 10/22/24 at 4:25 p.m., staff member R stated she was unable to find a table specifically for the tube feedings of resident #361. Staff member R stated for resident #361's tube feeding/medication administration, she moved items off the resident's bedside table, laid down the barrier, but had already placed the medications down onto the uncleaned tabletop. She stated she should have prepared the table, cleaned it, set down the barrier, then retrieved the medications, after the barrier was already on the table. 3. During an observation on 10/23/24 at 8:43 a.m., staff member Q administered resident #370's oral medications to him in his room. Resident #370 also had an injection of enoxaparin 30 mg scheduled at this time. Staff member Q donned clean gloves, gave resident #370 his injection, then removed and disposed of the gloves. Staff member Q exited resident #370's room, walked to the dining room, poured juice into a cup with polyethylene glycol 17 grams, and stirred to dissolve the powder. Staff member Q returned to resident #370 and administered the polyethylene glycol/juice mixture. Staff member Q did not sanitize or wash her hands prior to donning clean gloves for the enoxaparin injection. Staff member Q did not sanitize or wash her hands after doffing the gloves or when she exited resident #370's room. During an interview on 10/23/24 at 8:51 a.m., staff member Q stated staff should sanitize their hands before putting gloves on and after taking gloves off. She stated staff should sanitize their hands before entering a resident's room and when leaving the same room. Staff member Q stated she did not sanitize her hands when she took her gloves off in resident #370's room or when she exited his room. 4. During an observation on 10/23/24 at 9:10 a.m., staff member S prepared to give resident #42 her eye drops in her room. Staff member S donned clean gloves, administered resident #42's eye drops, doffed her gloves, then sanitized her hands. Staff member S did not sanitize or wash her hands prior to donning clean gloves. During an interview on 10/23/24 at 9:13 a.m., staff member S stated she should have sanitized her hands prior to donning the clean gloves in resident #42's room. She stated hands should be sanitized before putting gloves on and after removing gloves. Review of the facility policy titled, Infection Control Plan, Standard Precautions, undated, showed: - . A. Hand Hygeine [sic] - . e. when entering and leaving a resident's room or apartment, and - f. after removing personal protective equipment (e.g., gloves, gown, facemask). 47752 5. During an observation and interview, on 10/22/24 at 8:55 a.m., staff member G was passing drinks to some residents. Staff member G knocked on resident #73's room and went in. Staff member G exited resident #73's room, grabbed the drink cart, picked up a coffee cup and poured coffee. Staff member G entered resident #73's room, placed the coffee cup on the bedside table and exited the room. No hand hygiene was performed prior to entering or exiting resident #73's room. Staff member G pushed the drink cart in front of resident #70's room, knocked on the door and entered the room. Staff member G came out of resident #70's room, touched the drink cart, picked up a cup, took the lid off the milk and poured it into the cup. Staff member G then went back into resident #70's room, placed the cup of milk on the bedside table and exited the room. No hand hygiene was performed prior to entering or exiting resident #70's room. Staff member G pushed the drink cart to resident #88's room, knocked on the door and entered the room. Staff member G exited resident #88's room and poured a glass of orange juice. Staff member G took the glass of orange juice into resident #88's room and gave the resident the glass. No hand hygiene was performed prior to entering or exiting resident #88's room. Staff member G stated, I should have either washed my hands or used sanitizer, I just didn't. I know that I am supposed to do it before and after I leave a resident's room. I have been educated on hand hygiene. During an observation and interview on 10/23/24 at 10:17 a.m., staff member K entered resident #77's room and took the lunch and dinner order. Staff member K exited the room. No hand hygiene was completed prior to entering or exiting the room. Staff member K walked down the hall pushing a cart and stopped at resident #29's room. Staff member K entered resident #29's room, took her lunch and dinner order and exited the room. No hand hygiene was completed prior to entering or exiting resident #29's room. Staff member K pushed a cart down the hall and stopped at resident #68's room. Staff member K entered resident #68's room, took his lunch and dinner order, and exited the room. No hand hygiene was completed prior to entering or exiting resident #68's room. Staff member K stated she knew the facility policy on hand hygiene and should have completed hand hygiene prior to entering and exiting resident rooms. Staff member K stated she had been educated on proper hand hygiene. 6. During an observation and interview on 10/22/24 at 10:33 a.m., staff member H had a cart in the hallway with clean clothes. The cart did not have a cover over the clothing. Staff member H stated clean clothes were supposed to be covered while being transported. Review of the document titled, Infection Prevention and Control Program, undated, showed no information related to clean linen procedures or distribution of clean linen. Review of a facility document titled, Main Laundry Procedure, undated, showed no information related to the clean linen procedures or distribution of clean linen. 7. During an interview on 10/24/24 at 8:25 a.m., staff member C stated she had done multiple hand hygiene trainings and audits with the staff. Staff member C stated she was responsible for the infection control program. Staff member C stated she had no documentation, or tracking and trending for infection surveillance at this time. Staff member C stated she needed to start documenting better. Review of a facility document titled, Infection Prevention and Control Program, undated, showed: Purpose: Provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. The infection prevention and control program will include elements for preventing, identifying, reporting, and controlling infections and communicable diseases. . B. Infection Control Nurse is responsible for 1. On-going monitoring of infections ., . g. tracking resident infections .

Based on observations, interviews, and record reviews, the facility failed to develop a person-centered, comprehensive care plan for 6 (#s 9, 10, 32, 52, 53, and 100) of 37 sampled residents. Findings include: 1. During an interview on 10/22/24 at 9:22 a.m., resident #9 stated she had constant pain, and some days were better than others. Review of resident #9's electronic medical record showed she had diagnoses of Fibromyalgia, Rheumatoid Arthritis, and Chronic Pain Syndrome. Review of resident #9's medication administration record, dated 8/1/24 - 10/24/24, showed resident #9 received oxycodone, 10 milligrams, every four hours, as needed for pain, and methadone, 10 milligrams, twice daily, for pain. Review of resident #9's comprehensive care plan showed no focus, goals, or interventions for pain, opioid pain medication, or non-pharmacological approaches. 2. During an observation and interview, on 10/22/24 at 3:20 p.m., resident #10 was in her room sitting in a recliner. Resident #10 had on two liters of oxygen via nasal canula. Resident #10 stated she wore oxygen all the time. Review of resident #10's physician orders, dated 8/30/24-10/24/24, showed no physician's order for oxygen or details for the use of it. Review of resident #10's comprehensive care plan showed no focus, goals, or interventions for oxygen use. 3. Review of resident #32's electronic medical record showed diagnoses of atrial fibrillation and heart failure. Review of resident #32's medication administration record showed the anticoagulant, Pradaxa, 150 milligrams, twice daily. Review of resident #32's comprehensive care plan showed no focus, goals, or interventions for the use of Pradaxa, an anticoagulant, or medication side effects. 4. During an observation and interview on 10/22/24 at 9:12 a.m., resident #53 was sitting in his room in a recliner, looking at the wall. Resident #53 stated he was in the [NAME] Corps and was a helicopter pilot during the Vietnam War. Resident #53 stated there were times when being around a lot of people would upset him and caused him to have flash backs. Review of resident #53's comprehensive care plan showed no focus, goals, or interventions for PTSD or trauma. During an interview on 10/23/24 at 3:22 p.m., staff member B stated she was aware care plans were not comprehensive, or person centered. Staff member B stated she had recently done a training with the staff and IDT on care planning. Staff member B stated, It is a work in progress and is going to take some time. I have a newer IDT right now. 47785 5. Review of resident #52's physician orders showed, Oxygen at 2L per NC. Resident #52's care plan was not specific to the flow of oxygen. The care plan showed, OXYGEN SETTINGS via NC per provider orders. During an interview on 10/24/24 at 9:30 a.m., staff member A stated the night shift nurses would be responsible for updating the care plans, and staff member B would be responsible for reviewing them to ensure they were correct. 6. Review of resident #100's electronic medical record showed an admitted [DATE]. All focus and interventions on the comprehensive care plan were labeled as CANCELLED. On the current care plan there were no focus or interventions. The care plan showed, No data found. During an interview on 10/23/24 at 3:33 p.m., staff member B stated, Someone is inadvertently closing the care plan when a resident is gone overnight instead of suspending it and putting it into review. That is why everything is cancelled. They have to start all over to recreate the comprehensive care plan. Staff member B was not aware this was occurring until the State Survey Agency requested these care plans. Review of a facility policy titled, Care Plans, Comprehensive Person-Centered, undated, showed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the needs of the resident's physical, psychosocial, and functional needs is developed and implemented for each resident . . 7. The comprehensive, person-centered care plan: a. Includes measurable time frames, b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation, interview, and record review, the facility failed to ensure provider orders were in place for the fluids to be administered during an enteral tube feeding and medication administration, for 1 (#361); and staff member R failed to ensure medications and enteral nutrition were administered in a timely manner, for 1 (#361) of 37 sampled residents. Findings include: During an observation on 10/22/24 at 10:53 a.m., staff member R verified the placement of resident #361's feeding tube. Staff member R opened the port, flushed the feeding tube with 60 ml of water, then closed the port. Staff member R added 30 ml of water to each cup of crushed medications, then stirred them to dissolve the medication. Staff member R administered the first of two medication cups with dissolved medications, then added 15 ml water to administer the rest of the dissolved medication residual in the cup. Staff member R then administered liquid potassium chloride 20 MEQ/15 ml, followed by 15 ml of water. Staff member R then administered crushed magnesium chloride 64 mg (dissolved partially in 30 ml of water). She added 15 ml of water to the undissolved portion of the magnesium and poured it into the feeding tube, followed by 30 ml (15 ml times two to administer the entire dose of magnesium), then a flush of 30 ml of water. Staff member R administered guaifenesin liquid 600 mg, followed by 15 ml of water. Staff member R then prepared the nutritional supplemental formula to be administered via the feeding tube. Review of resident #361's MAR for the scheduled AM 07 medications, on 10/24/24 at 9:05 a.m., showed: - Fluconazole Oral Tablet 100 MG . Give 100 mg via PEG-Tube one time a day ., Start Date 10/18/2024 0700, - hydroCHLOROthiazide Oral Tablet 25 MG . Give 25 mg by mouth in the morning ., Start Date 10/18/2024 0700, - Lisinopril Oral Tablet 40 MG . Give 40 mg via PEG-Tube one time a day ., Start Date 10/18/2024 0700, - Magnesium Chloride Oral Tablet 64 MG . Give 64 mg via PEG-Tube one time a day ., Start Date 10/18/2024 0700, - Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 MG . Give 100 mg by mouth in the morning ., Start Date 10/18/2024 0700, - Eliquis Oral Tablet 2.5 MG . Give 2.5 mg via PEG-Tube two times a day ., Start Date 10/17/2024 1900, - Potassium Chloride Oral Solution 20 MEQ/15ML . Give 20 mEq via PEG-Tube two times a day ., Start Date 10/17/2024 1900, - guaiFENesin Oral Liquid 100 MG/5ML . Give 600 mg via PEG-Tube four times a day ., Start Date 10/17/2024 1600, and - Enteral Feed Order four times a day Enteral: Enteral Nutrition via Pump (name of formula) at (375 cc) ml per hour for 4x per day via pump per (type) tube. If tube feeding is cycling/intermittent, Indicate start and stop times: Start infusion at scheduled time and continue for 1 hour, Start Date 10/18/2024 1900 . [sic] During an interview on 10/22/24 at 3:22 p.m., staff member R stated she would usually clarify provider orders regarding fluids during a tube feeding/medication administration, but there were no orders in place for resident #361. She stated she had just returned to work after days off. Staff member R stated she knew she was late administering her 7:00 a.m. medications and nutritional feeding to resident #361. She stated she usually would not call and notify the provider of late medication administration. Staff member R stated everything happened all at once in the morning and it put her behind on her schedule. During an interview on 10/22/24 at 3:25 p.m., staff member R stated during the tube feeding/medication administration for resident #361, she based the fluid administered on her knowledge. She stated she was taught to give between 15-20 ml of fluids between each cup of medication, then before and after the tube feeding. Staff member R stated she should have contacted the provider or dietician for a clarification order since there was not an order in place for the fluids during the tube feeding. During an interview on 10/22/24 at 4:30 p.m., staff member R stated she did give a 60 ml flush before resident #361's tube feeding this morning, without orders. During an interview on 10/24/24 at 10:17 a.m., staff member B stated physician orders should be in place for fluid administration during a tube feeding/medication administration. She stated if orders were not in place for fluid administration, a clarification with the provider would be requested. During an interview on 10/24/24 at 10:21 a.m., staff member B stated if the MAR had specific times listed for administration of the medications, then medications were to be administered one hour before or one hour after, per the facility's policy. Review of resident #361's medication administration record, on 10/24/24 at 9:05 a.m., showed: - Enteral Feed Order four times a day for Tube feed Enteral: - Flush feeding tube with 30 cc of water before and after medication and bolus administration. - Start Date 10/22/2024 1900 (7:00 p.m.). Resident #361 was admitted to the facility on [DATE]. No orders for the flush with water of the tube feeding, four times a day, were in place until 10/22/24 at 7:00 p.m., five days after her admission. Staff member R had administered medications and an enteral nutritional feeding four hours after the scheduled medication and enteral tube feeding administration times. The next scheduled enteral tube feeding, and medication administration time was less than 2 hours, when it was originally scheduled for 6 hours in between administration times. No provider notification was completed for clarification or adjustment of the next times of administration for the enteral feeding or medication.

Based on observation, interview, and record review, the facility failed to sufficiently assess residents for safe smoking, ensure residents were monitored while smoking, and allowed residents to keep smoking paraphernalia in their rooms, for 2 (#s 53 and 77) of 37 sampled residents. Findings include: 1. During an observation and interview on 10/22/24 at 8:33 a.m., resident #53 was walking through the dining room and had his coat on. Resident #53 stated he was going outside to smoke and would be back shortly. During an observation and interview on 10/22/24 at 9:12 a.m., resident #53 was in his room sitting in a recliner. Resident #53 stated he had just gone outside to smoke his last cigarette because he was getting ready to have a procedure done soon. Resident #53 stated when he went outside to smoke, he had to leave the property. Resident #53 stated, It is quite the walk to get off the property. By the time I get there I am exhausted. Resident #53 stated he would go outside with resident #77 sometimes. Resident #53 stated staff did not monitor him or anyone else while smoking. Resident #53 stated he kept his lighter and cigarettes in the room with him, and usually put them in the top drawer of his bedside table, or in his coat pocket. Resident #53 stated he had never let anyone know when he was going outside to smoke, he just went outside whenever he wanted to. During an interview on 10/23/24 at 10:34 a.m., staff member I stated she did not think that resident #53 signed out to go outside and smoke. Staff member I could not locate any sign out sheets for resident #53. Review of resident #53's care plan, dated 1/20/24, showed: Focus: [Resident #53] is a smoker. Goals: [Resident #53] will not suffer injury from unsafe smoking practices. Interventions: Instruct [Resident #53] about smoking risks and hazards . - Instruct [Resident #53] on the facility smoking policy, locations and safety concerns - [Resident #53] can smoke unsupervised. Review of resident #53's physician's orders, from 1/1/24 - 10/24/24, showed no physician's order for the resident to smoke. Review of resident #53's electronic medical record, from 1/1/24-10/24/24, showed no smoking assessment had been completed. 2. During an observation on 10/21/24 at 1:47 p.m., resident #77 was in an electric wheelchair. The resident had on a coat, hat, light knit gloves, and a vest with high visibility markings. Resident #77 pushed the automatic door button and went outside. Once resident #77 was outside and on the sidewalk, she lit a cigarette as she wheeled herself down the sidewalk. During an observation and interview on 10/22/24 at 8:38 a.m., resident #77 was in her room sitting in a recliner. Resident #77 stated she was a smoker and would have to leave the property to smoke, and it was down the street quite a bit. Resident #77 stated her and resident #53 often went outside and smoked together. Resident #77 stated she had never had to sign out or let anyone know she was leaving the building. Resident #77 stated, If I want to go smoke, I just go. Resident #77 stated she kept her lighter and cigarettes in the room with her, but also kept an old bottle to put butts in. During an interview on 10/23/24 at 7:51 a.m., staff member A stated, This facility is a non-smoking facility. There is no policy, smoking assessments, or physician's orders for residents to smoke. Staff member A stated the residents were supposed to be signing out when they left the building. During an observation and interview on 10/23/24 at 2:30 p.m., resident #77 showed this surveyor where she went to smoke. The surveyor noted the area resident #77 went to was past the end of the block, and about 10 feet between the facility, and the hospital. Resident #77 stated that it is quite far from the building and was happy she had an electric wheelchair. Resident #77 pulled a small plastic bottle out of her coat pocket. The bottle was most of the way full of cigarette butts. Resident #77 stated she used the bottle, so she did not throw the butts on the ground. Resident #77 put the bottle back in her coat pocket and headed back to the facility. During an interview on 10/23/24 at 3:17 p.m., resident #77 stated staff member A just came and told her she had to sign out when she left the building and had offered her options to quit smoking. Review of resident #77's care plan, with a revision date of 7/2/24, showed: Focus: [Resident #77] is a smoker. Goals: [Resident #77] will not suffer injury from unsafe smoking practices. Interventions: Instruct [Resident #77] about smoking risks and hazards . - Instruct [Resident #77] on the facility smoking policy, locations and safety concerns - [Resident #77] can smoke unsupervised. A review of resident #77's physician orders, from 1/1/24 - 10/24/24, showed no physician order for resident #77 to smoke. A review of resident #77's electronic medical record, from 1/1/24 - 10/24/24, showed no smoking assessment had been completed. During an interview on 10/24/24 at 7:51 a.m., staff member A stated he was not sure what the facility would do if something happened to resident #s 53 and 77 if they were outside smoking. Staff member A stated, I just need to follow and enforce the no smoking rule for the facility. Review of a facility document titled, Signing Residents out, with a revision date of August 2006, showed: 1. Each resident leaving the premises (excluding transfers/discharges) must be signed out. 2. A sign-out register is located at each nurses' station. Registers must indicate the resident's expected time of return. . 9. Residents must be signed in upon return to the facility. A request was made for the smoking policy, list of residents who smoke, smoking assessments, and physician's orders for smoking. The requested information was not received prior to the end of the survey.

Based on observation, interview, and record review, the facility failed to ensure residents were safe to self-administer medications before leaving the medications at the bedside, causing an increased potential for medications not being taken as the physician ordered, for 3 (#s 9, 23, and 48) of 37 sampled residents. Findings include: 1. During an observation and interview, on 10/22/24 at 8:44 a.m., resident #48 was seated in a chair, next to her bedside table, waiting for her breakfast to be delivered. A medication cup with several pills was on the bedside table. Resident #48 stated the nurses sometimes left the medications for her to take on her own, if she had not received her food/meal when nursing staff were in her room to pass medications. During an interview on 10/23/24 at 8:33 a.m., staff member Q stated medications were not left at a residents' bedside for self-administering medication unless it was determined by an assessment, and they were safe to self-administer them. She stated if medications were seen at the bedside of a resident, then there was a self-administration order in place. Review of resident #48's document titled, Self-Administration of Medication, dated 2/8/23, showed: - . 23. Resident is approved for self-administration of medications b. No, and - 24. Resident may keep meds at bedside b. No. - Resident #48 was not approved for self-administration of any medications. 41952 2. During an observation and interview, on 10/22/24 at 8:48 a.m., resident #23 was observed in her wheelchair, with a breakfast tray on her bedside table, in front of her. On the tray was a full medicine cup of various medications. Resident #23 stated the medications were just left on her tray. During an interview on 10/24/24 at 9:04 a.m., staff member O stated resident #23 preferred her medications when her breakfast tray was delivered. Staff member O stated it would depend on the day whether she would leave the medications for resident #23 to take herself. Staff member O gave the example of this morning. She left four medications for resident #23 to take herself. Staff member O was going to go back and check if resident #23 took the medications. Staff member O stated she would give the rest to resident #23 to take if her breakfast tray was delivered. Staff member O stated she did not know the protocol for residents to be deemed safe to self-administer their own medications. Staff member O stated she went by her nursing judgement. During an interview on 10/24/24 at 10:34 a.m., staff member B stated the nurses were to complete the self-administration of medications assessment for residents and then alert the IDT team to review and make a determination. Staff member B stated there were not a lot of residents that self-administered their own medications at the facility compared to what had been observed. Review of resident #23's Self Administration of Medication assessment, dated 10/11/24, showed resident #23 did not pass the assessment, and the IDT did not review the results of the assessment. 47752 3. During an observation and interview on 10/22/24 at 9:18 a.m., resident #9 was sitting in a recliner in her room. Resident #9 had a bottle of artificial tears (eye drops) on her bedside table. Resident #9 stated she had dry eyes and used the eye drops when she needed. Resident #9 could not state how many times a day she used the artificial tears drops. Resident #9 stated she could not always open the bottle and would ask a staff member for help. During an observation on 10/22/24 at 9:25 a.m., resident #9 could not open the bottle of artificial tears eye drops. During an interview on 10/23/24 at 10:03 a.m., staff member I stated resident #9 could have medications at the bedside. Staff member I stated she would give resident #9 her ordered eye drops and was not aware of any eye drops in resident #9's room. During an interview on 10/24/24 at 7:50 a.m., staff member B stated we do not need a physician's order for self-administration of medications. A self-administration assessment was completed, and the IDT would recommend if the resident can self-administer medications or not. Staff member B stated, Our policy aligns with the regulations. Review of a facility assessment titled, Self-Administration of Medication, dated 10/20/24, showed: . 2. Capable of opening/closing medication containers - yes. Review of a facility document titled, Self-Administration of Medications, undated, showed: . 2. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: . e. The resident has the physical capacity to open medication bottles .

Based on observation, interview, and record review, the facility failed to ensure that oxygen use was accurately coded on a resident's MDS for 1(#10) of 37 sampled residents. Findings include: During an observation and interview with resident #10, on 10/22/24 at 8:59 a.m., the resident was sitting in her recliner. Resident #10 had an oxygen concentrator positioned next to the recliner, and the concentrator was set at 2 liters per minute. Resident #10 was wearing a nasal canula. Resident #10 stated she had been on oxygen for quite some time now, and she had to wear it (oxygen canula) all the time. During an observation on 10/23/24 at 11:45 a.m., resident #10 was sitting in her recliner and had on oxygen via nasal canula. Review of resident #10's Significant Change MDS, with an ARD of 8/30/24, showed Section O was blank under oxygen use. During an interview on 10/23/24 at 3:22 p.m., staff member B stated she was responsible for making sure the MDSs were accurate. Staff member B stated, I have started to identify issues with the MDS. I have noticed this is about the time when our MDS staff member was out. I have hired another MDS person to help. This should help with accuracy and timing. Ultimately it is my responsibility to make sure everything is accurate. Review of a facility document titled, Resident Assessments, undated, showed: . 12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews.

Based on interview and record review, the facility failed to ensure the baseline care plan was completed with the staff member signature, title, date of completion, and a copy was given to the resident or resident representative, for 2 (#s 9 and 10) of 37 sampled residents. Findings include: 1. During an interview on 10/22/24 at 9:18 a.m., resident #9 stated she had been at the facility since January 2024. Resident #9 had a BIMS score of 15. The BIMS score showed resident #9 was cognitively intact. Resident #9 stated she never received a copy of her care plan after admission. Review of resident #9's baseline care plan showed the document was completed with some information, but under Section 5, BCP Summary and Signatures, was not completed with the staff signature, title, date of completion, or resident/resident representative signature or date. 2. During an interview on 10/22/24 at 8:59 a.m., resident #10 stated she had gone to the hospital but had returned to the facility in August 2024. Resident #10 had a BIMS score of 15. The BIMS score showed the resident was cognitively intact. Resident #10 stated she had never received a copy of any care plans (to include baseline). Review of resident #10's baseline care plan showed the document was completed with some information, but under Section 5, BCP Summary and Signatures, was not completed with the staff signature, title, date of completion, or resident/resident representative signature or date. During an interview on 10/23/24 at 11:37 a.m., staff member B stated care planning was currently an issue. Staff member B stated baseline care plans were to be done by the floor nurse upon admission. Staff member B stated, I just did a training with all the nurses and IDT on care planning last week, it is going to take some time (to improve). Review of a facility document titled, Care Plans-Baseline, undated, showed: . 4. The resident and/or representative are provided a written summary of the baseline care plan .

Based on observation, interview, and record review, the facility failed to meet professional standards of practice by administering oxygen without a physician's order for 1(#10) of 37 sampled residents. Findings include: During an observation and interview on 10/22/24 at 8:59 a.m., resident #10 was in her room sitting in a recliner. Resident #10 had oxygen on at two liters via nasal canula. Resident #10 stated she had to wear oxygen at all times because of respiratory failure. During an interview on 10/23/24 at 3:22 p.m., staff member B stated physician's orders were needed for oxygen use, and the nursing staff were aware they needed physician's orders for oxygen use. During an interview on 10/24/24 at 9:02 a.m., staff member L stated physician's orders were needed for any treatment or medication, including oxygen. Review of resident #10's physician's orders, dated 8/30/24-10/24/24, showed no physician's order was placed for oxygen use. Review of a facility policy titled, Oxygen Administration, undated, showed: . Procedure: 1. Verify physicians order. [sic]

Based on observation, interview, and record review, the facility failed to coordinate a resident's care with hospice for 1 (#24) of 37 sampled residents. Findings include: During an observation and interview on 10/23/24 at 11:36 a.m., resident #24 stated she was so itchy, as she was actively scratching the right side of her body and her upper back. Resident #24 asked if hospice was there because they were the only ones who put the lotion on areas she could not reach. Resident #24 pulled up her gown and showed her gastric tube and explained the tube kept leaking and having issues, so she was placed on hospice. During an interview on 10/23/24 at 12:07 p.m., NF1 stated she was the hospice nurse visiting this week for resident #24. NF1 stated resident #24 was declining cognitively. NF1 stated resident #24 tended to scratch and needed a lot of lotion applied during her hospice visits or would accidentally pull her gastric tube because of her poor vision. NF1 stated hospice staff did not send their documentation or look at the facility documentation for the hospice residents. NF1 stated she would check in with a facility staff member when she came to the facility for any updates or changes for resident #24. During an interview on 10/24/24 at 9:12 a.m., staff member P stated the facility was just faxed a hospice plan of care for resident #24 the day before and assumed they were sent information from hospice monthly because they did not have any other information before then. Staff member P stated the hospice bath aide would come and the hospice nurses would visit weekly. The hospice nurses would check in with staff on the unit for resident #24 but did not leave any information unless it was an order change. During an interview on 10/24/24 at 10:20 a.m., staff member B stated her expectation for hospice was to send their notes after their visits. Staff member B stated they had gotten resident #24's hospice notes and plan of care the day before. Staff member B stated resident #24's hospice had been invited but did not come to the facility for her care plan meetings. For any needs, the facility called the main number for hospice or spoke with the hospice nurse when they were conducting their visit. Review of resident #24's care plan, last updated 8/15/24, showed resident #24 was on comfort measures. The care plan did not show she was on hospice or how care and services were provided between the facility and hospice. Review of resident #24's hospice admission packet showed she was admitted on to hospice on 9/17/24. The hospice admission packet showed the facility and hospice agency were to share care plans, care plan updates, and care conferences. Review of resident #24's electronic health record, on 10/22/24 and 10/23/24, only showed the hospice admission packet for 9/17/24. The hospice plan of care and visit notes were provided to the facility by hospice after the State Survey Agency requested the hospice information on 10/23/24.

Based on observation, interview, and record review, the facility failed to weigh and document the weight in the resident's record, on intervals designed per the facility policy, after a readmission, for 1 (#10) of 37 sampled residents. Findings include: During an observation and interview on 10/22/24 at 8:59 a.m., resident #10 was in her room sitting in a recliner. Resident #10 stated she had been readmitted in August 2024 following a stay at the hospital. Resident #10 stated she did not have her weight checked very often and did not know how much she weighed. Resident #10 stated she would like to be weighed more frequently but had not asked staff to weigh her recently. During an interview on 10/23/24 at 10:34 a.m., staff member J stated weights were completed with showers at least monthly. Staff member J could not state when resident #10 was last weighed. Review of resident #10's recorded weights in the electronic medical record showed the only documented weight was on 9/1/24 at 2:50 p.m. Review of resident #10's care plan, with a revision date of 9/10/24, showed interventions under weight loss as, weigh at the same time of day and record: weekly. Review of a facility policy titled, Weight Assessment and Intervention, undated, showed: . 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team. a. LTC weight to be obtained at time of admission than [sic] the following two days to establish a baseline weight. Then weekly x4 weeks then monthly . 2. Weights are to be completed on the same day/time each week for consistency and documented in the individual's medical record.

Based on observation, interview, and record review, the facility failed to identify and address PTSD, provide trauma-informed care, and meet professional standards that accounted for the resident's experiences and preferences to manage and prevent or minimize PTSD triggers, for 1 (#53) of 37 sampled residents. Findings include: During an observation and interview on 10/22/24 at 9:12 a.m., resident #53 was sitting in his room in a recliner, looking at the wall. Resident #53 stated he was in the [NAME] Corps and was a helicopter pilot during the Vietnam War. Resident #53 stated there were times when being around a lot of people upset him and caused him to have flash backs. During an observation and interview on 10/23/24 at 8:22 a.m., resident #53 was sitting in his room. Resident #53 stated he had just finished his breakfast in the dining room. Resident #53 stated, I ate in the dining room today, I felt it would not be too overwhelming. There are times when I eat in my room because there are just too many people in the dining room. Resident #53 stated, I have a history of PTSD and know what triggers me and how to deal with it. If I feel like there is going to be an issue, I just stay in my room and away from everyone. Resident #53 stated he had never been asked about his PTSD or experiences by facility staff. Resident #53 became tearful during the interview. During an interview on 10/24/24 at 8:12 a.m., staff member F stated a trauma assessment was completed with residents upon admission and reviewed on an annual basis. Staff member F stated she could not find the trauma assessment for resident #53 and was not aware the resident had PTSD. During an interview on 10/23/24 at 10:34 a.m., staff members I and L stated they worked with resident #53. Staff members I and L stated they were not aware of any residents having PTSD. Staff members I and L stated they were trained annually on PTSD and trauma care online. During an interview on 10/24/24 at 9:16 a.m., staff member E stated in October 2023 the facility had implemented a PTSD screening on admission and it was reviewed yearly. Staff member E stated there was not a trauma assessment done on resident #53. Staff member E stated, We missed him, I am not sure why. Review of a facility policy titled, Trauma-Informed and Culturally Competent Care, undated, showed: . To address the needs of trauma survivors by minimizing and/or re-traumatization. . Resident Screening 1. Perform universal screening of residents . Utilize screening tools and methods that are facility approved, competently delivered, culturally relevant and sensitive. . Resident Assessment 1. Assessment involves in-depth process of evaluating the presence of symptoms,their relationship to trauma, as well as identification of triggers . [sic]

Based on interview and record review, the facility failed to adhere to the advanced directive for 1 (#1) of 8 sampled residents. This deficient practice cause the resident to be transferred to the ER and to receive services the resident did not want. Findings include: During an interview on 3/5/24 at 11:09 a.m., NF2 stated resident #1 was sent to the ER against his wishes. NF2 stated when she reached out to the ER, the staff did not know resident #1 was on hospice. NF2 stated resident #1 was very clear on his wishes to not be sent to the ER or hospital, and it was reflected on the resident's POLST. NF2 stated she was distraught because she knew he did not want to go, and did not want the labs and X-Rays that he received in the ER. During an interview on 3/5/24 at 12:11 p.m., staff member J stated if a resident was on hospice care, nursing staff were to look at the resident's POLST, and get in touch with hospice to see what they said, prior to sending the resident to the ER. During an interview on 3/5/24 at 1:03 p.m, staff member A stated when considering transferring a resident to the ER, the facility tried to honor the POLST, and expected staff to look at the form first. Review of resident #1's Emergency Department Note, dated 1/18/24, showed, Patient sent from [Facility Name] home for evaluation of fever, shortness of breath, and altered mental status. Soon after the patient arrived I received a call from his hospice nurse, who states that he is on hospice and does not wish to have workup or treatment in the emergency department . At this point the patient seemed more alert and was able to communicate on his dry erase board. I ordered morphine, Ativan, nebulizer treatments, and a chest x-ray, but he declined all of these things. He said he would like to return to [Facility Name] home and this seems appropriate. His labs from today are unremarkable . Review of resident #1's POLST, dated 6/7/23, showed the resident wanted, Comfort-focused treatment . Do not transfer to hospital for life-sustaining treatment . Review of the facility's policy, Advance Directives, revised September 2022, showed, . Advanced directives are honored in accordance with state law and facility policy . Resident's who refuse treatment will not be transferred to another facility unless all other criteria for transfer are met .

Based on interview and record review, the facility failed to investigate an allegation of staff to resident abuse for 1 (#8) of 8 sampled residents. Findings include: Review of a facility reported incident, dated 2/2/24, showed resident #8 alleged a black CNA staff member was rough with him during a transfer attempt in the morning shift on 1/30/24. Review of resident #8's statement regarding the facility reported incident, not dated, showed, CNA, not kind. I was not responding to her method of getting into (the) harness. She made it happen a little rough. Then left the room for hours, she was through with me. Normally, (I) wouldn't report something but this was rough. There was no one but her in the room using the lift. Do not want her to help me anymore. Review of a statement from NF1, dated 2/2/24, showed, . [Resident #8] felt that a black CNA with lots of jewelry was rough with the transfer in the lift with the sling on, being swung, on 1/30/24 Tuesday, that is wasn't Wed(nesday) because [staff member N] was on and she doesn't work on Wed(nesday). Review of resident #8's EMR showed the resident had a BIMS score of 14, cognitively intact. During an interview on 3/5/24 at 9:51 a.m., staff member B stated staff member P was responsible for investigating abuse, and the staff member was not available that week to be interviewed. Staff member B stated the facility decided the abuse allegation towards resident #8 was unsubstantiated because the facility felt the allegation was racially motivated towards the staff member. Staff member B stated the resident had made comments about African American CNAs working with him before. Review of resident #8's EMR failed to show documentation of comments regarding racial comments towards CNAs. During an interview on 3/5/24 at 10:26 a.m., staff member H stated during an investigation of abuse, the facility was to conduct interviews of staff who worked with the resident, and other residents who worked with the accused staff member, to see if other residents were affected. During an interview on 3/5/24 at 1:06 p.m., staff member A stated the facility did not have any notes or interviews of other residents or staff, or identification of the accused staff member, regarding the abuse allegation towards resident #8. During an interview on 3/5/24 at 3:25 p.m. resident #8 stated staff member P never followed up with the resident to check in to give the resident updates on the investigation or outcome, or to ask whether or not there were further issues with the staff member accused. Review of an e-mail sent from staff member O to staff member B, dated 3/6/24, showed, In the case of [Resident #8] no further employee interviews were done as the spouse stated [Staff member N] was there. When I met with [Staff member N] no one matching the description worked with him, and she relayed all lifts were done with two persons on her unit . Review of the facility's policy, Abuse Investigation and Reporting, revised July 2017, showed: Role of the Administrator: . 6. The Administrator or his or her designee will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Role of the Investigator: . g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; . i. Interview other residents to whom the accused employee provides care or services; .

Based on interview and record review, facility staff failed to follow a transfer order while transferring a resident, for 1 (#65) of 1 sampled resident. This deficient practice resulted in the resident's displacement of orthopedic hardware. Findings include: During an interview on 1/19/23 at 8:18 a.m., resident #65 stated on 12/21/22, staff member M was in her room doing therapy and assisted her to the restroom. Staff member M helped her transfer to the toilet from her wheelchair using a gait belt. After helping her get on the toilet, staff member M stated he had to go to a meeting, and he would ask the CNAs to get her off the toilet when she was finished. Two CNAs came to transfer her off the toilet to her wheelchair. The CNA's helped resident #65 to a standing position, using a gait belt, and then asked her to pivot transfer to the wheelchair. Resident #65 stated, I don't pivot very well due to hardware in both my knees. As the two CNA's had resident #65 standing, resident #65 stated that she was losing her balance, and she then, fell and twisted her right knee. The nurse came, and they used a sling to get the resident into the wheelchair. Resident #65 stated she had pain in her right knee immediately and had to go to the ED. During an interview on 1/19/23 at 8:43 a.m., staff member M stated he helped resident #65 onto the toilet with a gait belt, and then left the room, because he had to go to a meeting. Staff member M stated he notified nursing that resident #65 would need assistance getting off the toilet when she was finished. Staff member M further stated the nursing staff knew they were supposed to use a Vanderlift (mechanical lift) for transferring resident #65. During an interview on 1/19/23 at 8:57 a.m., staff member N stated staff member M, informed her and staff member O that resident #65 would need assistance transferring from the toilet to her wheelchair, and she would use the call light when she was ready. Staff member O answered resident #65's call light and called for staff member N to assist her with transferring resident #65. Staff member N stated they both knew they were supposed to use the Vanderlift to transfer resident #65, but it was difficult to get the lift sling under the resident when the resident was sitting on a toilet. Staff member N further stated resident #65 said she could transfer with a gait belt, and a wheelchair, because she had just transferred that way to the toilet with staff member M. During an interview on 1/19/23 at 9:38 a.m., staff member B stated according to the transfer order, resident #65 was to be transferred with a Vanderlift, not a gait belt. Nursing staff were supposed to use the protocols and orders for transferring a resident. In that instance they listened to the resident instead of following transferring protocols. A review of an orthopedic H&P, dated 12/21/22, from [Hospital], for resident #65, showed: Assessment and plan (1) Knee pain: . Pain in right knee Status: Acute . .who presents through the ER with with [sic] right knee pain. Xray evaluate [sic] shows displacement of poly. Patient was brought to the ER where xrays show displacement of the tibial component. Patient complains of sharp pain located inside the knee. A review of a facility reported incident and findings, submitted to the State Survey Agency on 12/30/22, showed: Investigation follow up: Resident was admitted to the hospital and manipulation of hardware was completed during stay. Interview with staff showed, therapy had placed resident on the toilet during a session, and let the nurse know that she needed to be transferred off when ready and to use a vander lift when the aides answered her llght they did ask the resident how she transferred on and If she was comfortable transferring that way as she was doing It with therapy and they were not able to get the sling under her on the toilet. The resident did respond yes she could, she did have some trouble with turning. staff attempted to transfer her using a two person transfer with a gait belt. Per the aide she was standing and they were holding the gait belt dragged her foot and her leg gave out. The aide did attempt to break the fall but her knee hyper extended when she fell , .Discussed staff attempted to transfer resident as they had known therapy to complete the transfer when talking with resident in the bathroom, residents leg was not able to hold resident and gave out to causing the fall, staff did attempt to break the fall but during the event her knee hyperextended. On review transfer status notes on 12/2/2022; resident is a Vender lift for all transfer, this was also posted in the guest room on the cork board for visual cues . [sic] A review of a facility email, dated 12/23/22 at 5:03 p.m., from staff member N to staff member B, showed: [Resident #65's] bathroom light was going off and [Staff member O] asked me to come help her get [Resident #65] off the toilet after [Staff member M] helped her on there and explained to me that there was no sling under her, and she was on the toilet, and I didn't know how else to get her off the toilet. [Staff member M] wasn't available and in a meeting to get her back off the toilet. I asked [Resident #65] if she would be comfortable doing a stand pivot since it wouldn't be possible to get the sling on her and she said she was doing it with therapy [Staff member M] and said she only had a hard time turning. So, we assisted [Resident #65] with standing up and she was doing great with that then her right leg buckled up and she fell to the right and [Staff member O] made sure she didn't hit her head. And I noticed she landed on her leg bent and straightened it out for her and got the nurse [name] we got the sling under her on the bathroom floor and got her in her chair and gave her an ice pack.[sic] A review of resident #65's care plan, with a start date of 12/1/22, showed, . ADL Functional/Rehab Potential . Transfer status: 2 Person Vanderlift for all transfers. A review of a facility policy titled, Safe Lifting and Movement of Residents, with a revised date of July 2017, showed: Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation l. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include the following: a. Resident's preferences for assistance; b. Resident's mobility (degree of dependency); c. Resident's size; d. Weight-bearing ability; e. Cognitive status; f. Whether the resident is usually cooperative with staff; and The resident's goals for rehabilitation, including restoring or maintaining functional abilities. 4. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary .[sic]

Based on observation, interview, and record review, the facility failed to prevent a severe 16 percent weight loss in 6 months (severe is greater than 10 percent in 6 months) related to not providing a current assessment for the appropriate texture, and not providing adequate supervision and assistance with eating, for 1 (#51), and failed to identify and put interventions in place for a severe weight loss of 10% in one month (severe is greater than 5 percent in one month) for 1 (#63) of 27 sampled residents. Findings include: During an observation on 2/2/19 at 12:35 p.m., staff member Q stood on the fall mat, next to resident #51's bed, and attempted to feed the resident. The resident ate less than 10%. Staff member K stated the resident was in a rapid decline and usually refused to eat. She said the family and resident declined hospice interventions. During an observation on 2/3/19 at 10:56 a.m., resident #51 was sitting at the dining room table, and did not attempt to feed herself. Staff did not sit with her and provide assistance. Staff member B intermittently stood above her and provided straws for her liquids. Her food was pureed. She ate less than 10 percent. Review of resident #51's current Physician ordered diet showed she was on a mechanical soft, ground meat diet prescription. The diet provided did not adhere to the physician ordered diet prescription. During an interview and observation on 2/3/19 at 12:30 p.m., staff member L stated the family had requested pureed food, so the cook just decided to give the resident her pureed food. Staff member I removed the resident from the table without asking if resident #51 was finished eating or wanted something else. During an interview on 2/3/19 at 3:09 p.m., NF1 stated resident #51 did not get fed at the facility, and she was losing a lot of weight. She stated there was not enough staff. She said resident #51's teeth were getting pulled in March, 2019 and she would get new dentures, because the resident's mouth was sore from ill-fitting dentures. During an observation and interview on 2/4/19 at 1:45 p.m., resident #51's lunch tray was on the room cart, untouched. Staff member I stated the resident did not get her lunch tray because she had a bath. She picked up the lid, and the meal was a ground turkey sandwich and French Fries. She said resident #51 would not have been able to eat that, because she could not chew the food. The tray was removed to the kitchen without being offered to the resident. During an interview on 2/4/19 at 3:50 p.m., staff member O stated the resident could feed herself, but would not. Review of resident #51's Nutrition Note, dated 12/22/18, showed Continue with General NDD2 diet with ground meat, consistent with the current physician diet order. Review of resident #51's Nutrition Note, dated 12/26/18, showed staff member DD talked with NF1, who was concerned about the resident's lack of food intake. She said resident #51 was having problems grabbing the silverware. Nursing states she eats better when someone is feeding her. Recommend (resident #52) be put at a table where she can receive total assistance. Review of resident #51's Quarterly MDS, with the ARD of 12/12/18, showed the resident received set-up help for eating, and the activity occurred only once or twice during the 7-day look-back period. Review of resident #51's Physician order, dated 1/2/19, showed NDD2 ground textures with extra moisture/thin liquids without straws, recommended by the speech therapist. Review of resident #51's diet card showed the extra moisture and no straws was not included on the card. During an interview on 2/4/19 at 1:20 p.m., staff member L stated she was learning a new diet card system and did not know how to add the extra moisture and no straws to the diet card. Review of resident #51's Quarterly MDS, with the ARD of 12/12/18, showed a 16 percent severe weight loss of 118 pounds to 99 pounds in six months. Her current weight was 96.5 pounds. 2. During an interview on 2/3/19 at 11:57 a.m., resident #63 stated she had lost weight since being admitted to the facility, however, she was not sure how much. Review of resident #63's weights showed the resident weighed 171.6 lbs on 11/25/18 and weighed 154.4 lbs on 12/23/18 a difference of 17.2 lbs and a 10% weight loss in one month. Review of resident #63's Nutritional Assessment, dated 12/4/18, showed the resident weighed 171.6 lbs and had the following interventions in place: -Continue with general diet, -Provide 8 ounce of 2% milk TID with meals, -Give yogurt at noon meal. Review of resident #63's medical record did not show additional nutritional assessments were completed. Review of resident #63's Interdisciplinary Note, dated 12/4/18, showed the resident's admit weight was 172 lbs, and showed the following; -Resident is eating both in her room, and in the dining room, -Resident is self-feeding, and does not require any adaptive equipment for meals, -Resident is taking 50-75% of general diet with regular texture, -Resident has her own teeth and does not have any chewing or swallowing concerns, -Resident is at mild risk for skin breakdown, -Will continue to monitor meal/fluid intakes, labs, wts, and MD orders for appropriate nutritional interventions. Review of resident #63's Care Plan showed the following: -Resident is at risk for altered nutritional status related to hypertension, chronic pain and [MEDICAL CONDITION], -Resident's nutritional status will remain/return to optimal status over the next 90 days, -Honor food preferences/intolerances as they become known, Resident can make her food likes/dislikes known, start date of 12/18/18, -RD/CDM to monitor meal/fluid intakes, labs, wts, and MD orders for appropriate nutritional interventions, start date of 12/18/18, -Provide ample time to eat. Encourage resident to eat 75-100% of meals. Record meal intake, start date of 12/18/18, -Encourage fluids with/between meals, start date of 12/18/18, -Provide general diet with regular texture in 3 meals daily, start date of 12/26/18. The care plan did not show the resident's weight loss or interventions to prevent weight loss. Review of resident #63's medical record did not show the dietitian, or the provider, were aware of the resident's weight loss. During an interview on 2/5/19 at 10:30 a.m., staff member L stated she was not aware of resident #63's weight loss until recently. Staff member L stated when a resident had a weight loss, she figured out the percentage, then notified the provider and requested interventions that could be implemented to prevent further weight loss. Staff member L stated she usually found out about a resident's weight loss from nursing staff or by review of the resident's record.

Based on observation, interview, and record review, the facility failed to ensure the provision of staff assistance during and with the resident meals, on the East Wing for 1 (#51), and the resident had a severe weight loss; the facility failed to provide supervised walks for a resident for 1 (#84), which resulted in increased pain, depression, and loss of dignity; and the facility failed to provide needed dining assistance for 3 (#s 44, 47, and 69); failed to assist with evening toileting care for 1 (#51); and failed to ensure a sufficient number of staff were on the night shift for the East Wing to respond to a resident's call light to prevent urinary incontinence for 1 (#1) of 32 sampled and supplemental residents. Four of the six residents (#s 1, 20, 84, and 91) of the Group Meeting stated the facility did not have enough staff to provide care for the residents. Findings include: 1. Review of resident #51's EHR showed a severe weight loss of 16 percent in six months. (weight loss greater than 10 percent in 6 months.) (Refer to F692). Observations on 2/2/19, 2/3/19, and 2/4/19, during meals, showed resident #51 did not receive full assistance with her meals, which had been determined as necessary on 12/26/18, by the registered dietitian. During an interview on 2/3/19 at 3:09 p.m., NF1 stated resident #51 did not get fed at the facility, and the resident was losing a lot of weight. She said the facility did not have enough staff to provide the eating assistance resident #51 required. For detailed information related to the resident's weight concerns, refer to F692. 2. During an interview on 2/2/19 at 4:13 p.m., resident #84 stated she could walk alone in her room but needed someone with her in the hall. She stated the facility was so short of staff the CNAs did not even have five minutes to walk with her. She said she got scolded by staff for walking by herself, and it made her cry. The resident stated, I have to walk, or my pain and depression gets worse. Review of an IDT note dated 1/26/19, showed Around 1630 the resident came walking out of her room with her FWW unassisted. Staff reminded the resident that she was supposed to be stand by assist when ambulating outside of her room for her safety. The resident then began to cry and went back to her room showing how the lack of walking and leaving the room was upsetting to the resident. During an observation on 2/3/19 at 3:35 p.m., resident #84 was walking in the hallway with her FWW and no CNA. She stated, I have to walk. During an interview on 2/5/19 at 7:57 a.m., staff member S stated she did exercises, mostly on the stationary bicycle, with resident #84. This occurred about two times per week. She said resident #84 often complained the CNAs do not have time to walk with her. Review of resident #84's IDT note, dated 1/22/19 showed Before exiting (resident #84) asked SWK (sic) to see if she can walk with someone daily. CNAs report that they offer walks to (resident #84) but she will say she does not feel like it at that time. Documentation of resident#84's refusals for when she was offered to walk, and she declined, was not provided. 3. During an interview on 2/2/19 at 2:44 p.m., resident #1 stated he was concerned there were not enough staff to assist with the needs of the residents. He stated they seem especially short staffed at night. The resident stated that when he was up and in his wheelchair, he was able to get to his urinal and was rarely incontinent of his bladder. He stated when he was in bed, he had limited mobility, and needed the staff to help him, if he could not reach his urinal. He stated he was often incontinent of his bladder at night, because the staff did not respond in time to his call light to get him his urinal. Resident #1 stated the staff had him start wearing a condom cath at night in case he could not get to the urinal. He stated he did not like wearing the condom cath, but felt it was necessary if the staff could not help him in time. He stated his call light may be on for over an hour before someone answered the light. He stated by that time, it was too late, and he was incontinent of his bladder and has wet his bed. He stated he did not like wetting the bed, and it made him feel uncomfortable. He stated he was worried that he will be made to get used to being incontinent in his bed if the facility cannot find adequate staff. He stated that was not something anyone should get used to doing. During an observation and interview on 2/3/19 at 6:09 a.m., resident #1 waited for 20 minutes for staff to respond to his call light. He stated he had needed to have a bowel movement and needed assistance getting onto the commode. He said he really needed have a bowel movement, and it caused him discomfort, as he waited for someone to assist him. During an interview on 2/3/19 at 6:20 a.m., staff member X stated it was the expectation that staff answer a resident's call light within five minutes. She stated it could be difficult if there was not enough help to answer the lights. She stated most residents needed a two-person assist, and when there were only two aides working the floor, answering call lights timely could be difficult to accomplish. During an interview on 2/4/19 at 7:53 a.m., resident #1 stated he laid in his urine all night last night. He stated he had to go to the bathroom and put on his call light. He said they did not answer the light for over 30 minutes, and he ended up urinating in the bed. He stated they did not put a condom catheter on him last night, so his urine soaked through the incontinent pad, on the bed, into the sheets. He stated the staff only changed the incontinent pad and did not change his sheets. He said he laid in cold, wet urine-soaked sheets for the rest of the night. He stated the urine burned his backside because he had open sores from his wheelchair. He said the open sores were healing, but it did not help to lay in a wet bed. He was capable of being continent of his urine, while he was in his bed, but was not able to hold his urine long enough for someone to help him. He stated he did not want to smell like one of those old men you read about that smell like urine, I thought it was only something you read about in books. He said since he has been in the facility, he has had over 20 accidents in bed, since (MONTH) (YEAR), because the staff did not answer his call light at night. During an interview on 2/4/19 at 8:06 a.m., staff member H stated it was the expectation of staff to answer the call light within five minutes. She stated she felt this was possible when there were enough aides on the hall, but if someone called off or they could not staff the shift, it was difficult to answer the call lights in a timely manner. During an interview on 2/4/19 at 8:15 a.m., staff member I stated it was the expectation for staff to respond to the resident's call light within five minutes. Staff member I did not wish to answer the question regarding sufficient staffing. During an interview on 2/5/19 at 8:37 a.m., staff member A stated it was the expectation for staff to respond to a call light in a timely manner. 4. During an observation on 2/3/19 at 7:45 a.m., resident #s 44, 47, and 69 were not in the East wing dining room partaking of the continental breakfast. During an observation on 2/3/19 at 8:01 a.m., resident #s 44, 47, and 69 were not in the East wing dining room partaking of the continental breakfast. During an interview on 2/3/19 at 8:02 a.m., staff member I said resident #s 44, 47, and 69 did not partake of the continental breakfast because they needed extensive to full assistance with eating. During an interview on 2/3/19 at 8:10 a.m., staff member I said the East wing did not have enough staff to feed residents #44, #47, and #69 at the continental breakfast. Staff member I said these residents would have to wait until the main breakfast was served at 10:30 a.m., which is when more staff would be available. Review of resident #44's Annual MDS, with an ARD of 12/3/18, Section G, showed the resident needed total assistance of one staff for eating. Review of resident #47's Quarterly MDS, with an ARD of 12/5/18, Section G, showed the resident needed the extensive assistance of one staff for eating. Review of resident #69's Quarterly MDS, with an ARD of 12/27/18, Section G, showed the resident needed total assistance of one staff for eating. 5. During the group meeting on 2/4/19 at 3:15 p.m., residents said: - Resident #1 said there were three ladies, in wheelchairs, that sat around the nurses' station on the East wing. The resident said these ladies would often say they needed to go to the bathroom. Resident #1 said they would call out for the bathroom for one to three hours at a time. Resident #1 said he would go past them, and they would smell strongly of urine. Resident #1 said the East wing was a heavy care unit, and a lot of the residents required mechanical lifts for toileting. Resident #1 said there were usually three to four CNAs on the day shift. - Residents #20, #84, and #91 said the Center wing did not have enough night staff. All three residents said there were two CNAs, one for each wing, at night. They said they had waited 45 minutes to an hour for their call lights to be answered. Resident #20 said there were times she had been incontinent due to delays in staff answering her call light at night. Resident #20 said these delays always happened on the night shift, but she could not remember the most recent dates. Review of the facility's resident roster showed 42 residents for the East unit, and 28 residents for the Center Unit. 6. During an observation on 2/3/19 at 7:25 a.m., resident #51 was lying in bed with her shirt and jacket on. She stated the staff did not put on her pajamas the night before. During an observation and interview on 2/4/19 at 4:27 p.m., resident #51 was lying in bed, and asked if her pants were on. She was in her pajama top, but had no bottoms on, just a brief. She requested her pajama bottoms be put on. During an interview on 2/4/19 at 8:20 a.m., staff member I stated the staff were trying to figure out why the resident was not dressed appropriately that morning. A review of the facility's policy and procedure titled, Staffing, showed, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. A review of the facility's policy and procedure titled, Activities of Daily Living, showed, Residents will provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. a. The existence of a clinical [DIAGNOSES REDACTED]. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with . c. Elimination (toileting) .

Based on observation, interview, and record review, the facility failed to ensure staff were trained sufficiently related to the use of aseptic technique, and proper procedural technique, during the provision of care for routine maintenance of a resident's de-accessed Portacath¹; failed to ensure there were physician orders for management of a Portacath; failed to provide regular routine care for the management of a Portacath; and failed to ensure routine skin assessment of the port site were performed for 1 (#39) of 27 sampled residents. This deficient practice resulted in the occlusion of the resident's Portacath, delaying surgical intervention, and delayed the access for labs to be drawn to determine critical lab values. Findings include: During an interview on 1/30/19 at 10:28 a.m., a confidential interviewee stated the facility was not providing routine maintenance for resident #39's Portacath, which has resulted in the delay of treatment for [REDACTED]. It was because of this history the resident's Urologist decided the resident needed a Portacath placed to ensure venous access in emergent situations. She stated the first incident was in (MONTH) of (YEAR), when resident #39 was scheduled at Same Day surgery for [REDACTED]. She stated when the staff attempted to access the resident's Portacath it was occluded. The Surgicenter administered medication to dissolve the clot which was causing the occlusion, but the resident's surgery had to be rescheduled for a later date. The second incident was around Christmas of (YEAR), when the resident was very sick, and the GI clinic needed to access the port to draw a liver panel to rule out liver failure. The clinic was not able to access the port, and treatment was again delayed until the clot could be dissolved, and labs could be drawn. The interviewee stated the third incident occurred in (MONTH) 2019, when the resident was brought to the ER due to a change in cognition, and a severe UTI. The confidential interviewee stated she was concerned the resident was septic again, so she rushed her to the ER. She stated the nurses at the ER could not access the resident's port, and treatment was delayed until the clot could be dissolved by the hospital's PICC team. The confidential interviewee stated she had asked the facility staff on several different occasions how the resident's Portacath was being managed, and she was told that the nurses did not know how to flush and lock a Portacath, and the facility also did not have necessary supplies to manage and flush the port. She stated the nurses had requested training on safe management of the resident's port from staff members A and B but felt their requests were ignored. She stated after the first incident in (MONTH) (YEAR), she approached the nursing staff to follow up on the ordered care of the resident's port. When the nurse checked resident #39's TAR, there were no orders for maintaining the port. The interviewee stated she had the nurse open the discontinued orders, and it appeared the port care was discontinued in (MONTH) of (YEAR). The confidential interviewee stated she had addressed this with staff member B, but felt her concerns were ignored. She stated the resident has had the Portacath since (MONTH) of (YEAR). The confidential interviewee stated she was concerned that the resident has not had regular care or maintenance of her port, which has resulted in the port being blocked, and delaying critical care for the resident. She stated she was worried the resident may develop another septic infection if the staff did not provide proper aseptic care and treatment of [REDACTED]. During an observation on 2/3/19 at 10:30 a.m., resident #39 had a Portacath site located on her right chest, below her clavicle. 1. No Orders for Port Care A review of resident #39's Hospital Progress Note, dated 1/5/18, showed, the resident was seen for a Port consult related to exhausted vascular access. The resident was determined to benefit from surgical placement of a port, and surgical placement was scheduled. A review of resident #39's Discharge Summary, dated 1/11/18, showed the resident was discharged back to the facility with a Portacath. There were no additional orders for maintaining the patency of the port. Review of resident #39's medical record, from 1/11/18 to 2/23/18, failed to show the facility obtained physician orders for the maintenance of the resident's port. A review of resident #39's TAR, with a start date of 2/23/18, showed, Port Care to flush portacath Q month with NS with 3-5 ml IV. This order was discontinued on 4/29/18. There were no further orders for the resident's port care until 10/5/18. Review of resident #39's medical record showed an order for [REDACTED]. During an interview on 2/5/19 at 8:30 a.m., staff member A stated the resident returned to the facility with a Portacath on 1/11/18, but there were no treatment orders obtained for maintenance of the port. She stated the facility did not obtain treatment orders for the Portacath until 10/5/2018. The resident had a short period of time in (MONTH) of (YEAR), which the port was accessed for [MEDICATION NAME] fluids, but there was no further documentation of care or management of the port before or after the use in March. Staff member A stated resident #39 did not have treatment orders for her Portacath when she came back to the facility after having it placed in (MONTH) of (YEAR). Staff member A stated the facility did not have orders to maintain the port from (MONTH) (YEAR), to (MONTH) of (YEAR), and (MONTH) (YEAR) to (MONTH) of (YEAR). She stated the Urologist wanted the Medical Director to write the orders for the port. She stated the orders which were not obtained until (MONTH) (YEAR), were the orders which the facility has been following for maintenance of the resident's port. 2. Missed Port Care A review of resident #39's EMR, showed the resident had the port placed on 1/11/18. An order was placed in the resident's TAR on 2/23/18 to flush the resident's port monthly. From 1/11/18 to 2/23/18, the facility failed to perform port care for the resident's Portacath to maintain the patency of the port. A review of resident #39's TAR, from (MONTH) (YEAR), to (MONTH) (YEAR), failed to show the facility provided routine port care to the resident's port to maintain the port's patency. The resident's port was found to be occluded in (MONTH) (YEAR), which delayed the resident's surgical procedure. Review of resident #39's TARs from (MONTH) (YEAR), through (MONTH) 2019, showed the following order: Flush Port-a-cath with 10 cc of normal saline then 5 cc [MEDICATION NAME] (100 units/cc) (follow instructions below). Must be done by RN - Draw up one syringe of 10 cc normal saline. Draw up syringe of 5 cc [MEDICATION NAME]. Wipe site with alcohol, then puncture cath with Huber needle and check for blood return. Flush 10 cc of NS then 5 cc [MEDICATION NAME] while using intermediate positive pressure. While infusing last 1 cc of [MEDICATION NAME], close the clamp on tubing to prevent blood reflux into the cath. Apply dressing when done 10-5 XX (sic) QM. A review of resident #39's TAR, from (MONTH) (YEAR), through (MONTH) 2019, showed the resident did not receive a scheduled port flush on 12/5/18, as ordered. The resident's port was occluded when the resident was seen in the ER at the end of (MONTH) (YEAR). During an interview on 2/5/19 at 8:30 a.m., staff member A stated it was the expectation that the resident's port was to be flush and locked and should be performed monthly to prevent occlusion of the port. Staff member A reviewed the resident's EMR and was not able to find any supporting documentation which supported additional port care between 1/11/18 to 2/23/18, and between 4/29/18 to 10/5/18. She stated there was no supporting documentation which showed the resident's port was also flushed and locked in (MONTH) (YEAR). 3. Lack of Training and Use of Improper Procedure and Aseptic Technique During an interview on 2/3/19 at 5:26 a.m., staff member J stated she did not provide care for resident #39's Portacath. She stated she has never been trained and was not comfortable performing any care or treatment to the port. During an interview on 2/4/19 at 10:30 a.m., staff member C stated she had just recently received training on how to flush and lock resident #39's port. She stated she was still not comfortable with the process and would ask staff member B for assistance on the next scheduled port flush and lock. During an interview on 2/5/19 at 8:00 a.m., staff member C stated the facility did not have any [MEDICATION NAME] available for the resident's port procedure that day. She stated she had ordered the [MEDICATION NAME] from the pharmacy last night and expected the [MEDICATION NAME] to arrive shortly. She stated then staff member B and herself would perform the port flush. During an interview on 2/5/19 at 8:30 a.m., staff member B stated he was performing the port flushes and [MEDICATION NAME] locks for resident #39. He stated he had also trained staff member C on the process, and planned to have her demonstrate her skill at the next scheduled routine maintenance. During an interview and observation on 2/5/19 at 11:20 a.m., staff member B and C stated they had received the [MEDICATION NAME] from the pharmacy, but the pharmacy only had 5 ml syringes of [MEDICATION NAME] ¹. They stated they planned to proceed with the procedure. Staff did not identify that they should not use a syringe smaller than 10 ml while flushing a Portacath. During an observation and interview, on 2/5/19 at 11:26 a.m., staff member B and C prepared the needed supplies for resident #39's Portacath flush and [MEDICATION NAME] lock. The supplies included sterile gloves, masks, three 10 ml syringe of NS, and three 5 ml syringes with [MEDICATION NAME], Huber needles, sterile dressings, and alcohol wipes. Staff member B and C stated the facility did not have Port-a-Cath Kits available, so they had to improvise on the needed supplies. Upon entering the resident's room, staff member B did not wash his hands. He donned a mask, offered staff member C a mask, and gave the resident a mask. Staff member B then cleared a space on the resident's over-the-bed table. He then wiped down the cleared space with bleach wipes, and used the supplies to fan the cleansed area dry. The staff member did not place a barrier down between the gathered supplies and the table. He then placed all the supplies on the table. The staff member donned a pair of gloves without washing his hands. Staff member B then began opening the sterile supplies and placed the opened packages directly on the table. The staff member failed to establish a sterile field in which to place the sterile supplies for the procedure. He opened packets, using the packets as the sterile field, overlapping packets, contaminating the sterile field. He then started to open the sterile syringes of NS and [MEDICATION NAME], which he placed the syringes with his non-sterile gloved hands onto the opened sterile packaging of the Huber needle, contaminating the sterile needle and syringes. The staff member continued to open the sterile dressings and the alcohol wipes using a non-sterile technique, continuing to contaminate the sterile field. Once the staff member opened all the supplies, he removed an alcohol swab from the sterile field with his non-sterile gloves and began to clean the resident's skin around the port site. The staff member cleansed the resident's port site less than five seconds with the alcohol swab. There were no [MEDICATION NAME] wipes available to cleanse the site. The staff member then removed his dirty gloves and opened a sterile glove without washing his hands between doffing the dirty gloves and donning the sterile glove. The staff member stated there was only one glove in each pack, and he would have to open a second package. Staff member B then contaminated his sterile glove when he picked up and opened the second packet containing the second sterile glove. The staff member then reached over his sterile field and withdrew the Huber needle and was going to access the resident's port. The procedure was stopped by the surveyor before the port was accessed, due to the inappropriate aseptic technique and the wrong sized [MEDICATION NAME] syringe. The surveyor addressed these concerns with staff member A and B outside of the resident's room. During an interview on 2/5/19 at 11:48 a.m., staff member B stated they were following the physician orders when using alcohol and not [MEDICATION NAME], and could not explain why the pre-filled syringe should contain no less than 10 mls. The staff member stated he was not aware of how long he should cleanse the resident's port site prior to completing the procedure. Staff member B stated he realized he had contaminated his sterile gloves when he had to open the second sterile glove pack. He stated he did not realize he should not fan the air around a disinfected site, that the site should dry normally based on the disinfection rate of the wipes used. He stated he also failed to establish a sterile site for the supplies. The staff member stated he has had no additional training by the facility on how to manage a port site, and was using his professional knowledge. He stated he had been the individual to train staff member C. Staff member B stated he would benefit from additional training himself. During an interview on 2/5/19 at 12:15 p.m., staff member B provided a copy of the physician's order he had followed for resident #39. He stated he would not be proceeding with any further maintenance of resident # 39's port until he received training from a certified PICC nurse. He stated he had contacted a PICC nurse from the hospital who was willing to come to the facility and provide additional training on port care. 4. No Skin Assessments During an interview on 2/3/19 at 5:26 a.m., staff member J stated there were no orders on resident #39's TAR to assess the resident port site for any signs of infection or possible complications. She stated she had never assessed the patient's Portacath site for signs of infection or other potential complications associated with maintaining a long-term Portacath. She stated she was never trained to complete such assessments. During an interview on 2/4/19 at 10:30 a.m., staff member C stated the resident did not have orders to assess the port site. She stated she has never assessed the resident's port site for signs of infection or other potential complications. She stated she was not trained to complete such assessments. A review of resident #39's TARs from (MONTH) (YEAR), to (MONTH) 2019, failed to show regular Portacath site assessments were ordered or performed by nursing staff. During an interview on 2/5/19 at 8:30 a.m., staff members A and B stated resident #39 did not have treatment orders on the resident's TAR for the nurses to assess the port site for signs of infection or potential problems. She stated the CNAs do regular skin checks and would report any abnormal findings to the nurse. She stated CNAs were not trained on what to assess at the port site for any abnormal findings. References: ¹ BARD. (2012). Power Port Implantable Port. Instructions for Use. Retrieved from https://www.bardaccess.com/assets/literature/ 85_PowerPort_IFU_web.pdf .2. During port access: Do not use a syringe smaller than 10 ml. Flushing occluded catheter with small syringe can create excessive pressures within the port system.

Based on interview and record review, the facility failed to prevent resident abuse occurrences with during staff interactions, which included: a resident reporting a staff member punched her and pulled her hair causing physical harm, and the staff member caused the resident ongoing fear and the resident requested the staff member not provide care for her, for 1 (#54); a resident who was upset and wanting to leave the facility, and a staff member disregarded the resident's needs and treated the resident in an abusive manner and then subjected the resident to isolation, for 1 (#82); and a resident's needs were disregarded when the resident requested assistance, and the neglect of care caused the resident to be incontinent, and this negatively affected the resident's psychosocial well being due to the neglect of care, for 1 (#44) of 41 sampled and supplemental residents. Findings include: 1. A review of resident #82's MDS, with an annual ARD of 9/4/17, showed the resident had a BIMS of 4, severe cognitive impairment. Review of a complaint received by the DPHHS Quality Assurance Division on 4/10/2018, showed resident #82 had left through the front doors (of the facility) witnessed by staff and that a staff member 'was called to bring her back (to the facility)' . 'which he did' and She was screaming rape and carrying on. She was put back in her room to calm down. The facility staff told (NF4) that they could either report it or he could resign. He resigned his position. Review of an elopement incident report provided by the facility on 5/15/18, showed resident #82 had been observed by a staff member to go through the front doors on 4/3/18 at 7:00 p.m. It showed A CNA got the resident and brought her back to her room. Review of a letter sent to staff member A from staff member MM on 5/5/18, described what staff member MM had witnessed on 4/3/18 of resident #82's elopement. It showed: (Resident #82) was in front of (name) window trying to head to the front door. She wanted to leave. I heard her say no one had the right to give her an injection and to call the police. She said this several times in the course of this event. A moment later (NF4 name) came over, grabbed the handles of her chair, jerked the chair and spun her around, and tipped her chair up so her feet couldn't touch the floor. She started screaming and continued to scream the whole way he pushed her to her room. She kept telling him to stop. He left her there and closed her door. He looked fed up with her. During an interview on 5/14/18 at 3:00 p.m., resident #82 verbally acknowledged that she had interactions with NF4 but did not describe them. During an interview on 5/14/18 at 4:10 p.m., staff member R said resident #82 has had gradually increasing behaviors and most of what she says is not true. She said she has severe sundowning episodes and becomes very paranoid and verbally abusive towards others; both staff and other residents. During an interview on 5/15/18 at 3:45 p.m., staff member N spoke about the findings of the investigation the facility conducted of resident #82's elopement on 4/3/18. He said resident #82 was attempting to go out the front entry facility doors in her wheelchair, and NF4 went out to bring her back in. Rather than talking to the resident or providing diversion, NF4 had shifted the resident's weight in her w/c to the back wheels, swung the chair around, and took the resident screaming and yelling, back into the facility, through the dining room to her room. After she was in her room, he shut her room door. Staff member N said staff member A determined that abuse had occurred on two accounts. First, NF4 had not made any effort to converse with resident #82, and reason with her to have her return to the facility; and second, that he had placed the resident in isolation that could have been considered a form of punishment when he had shut the door and left the resident in her room. Staff member N said the facility informed NF4 of the investigation findings and NF4 had chosen to resign. 2. During an interview on 5/14/18 at 4:10 p.m., staff member R said resident #54 had paranoid tendencies. Review of a complaint, sent to the State Survey Agency on 4/10/18, described a resident (not named) had wandered into a facility construction site. The complainant alleged involvement of facility staff member NF4 and said the staff member went out to get her and she claimed he pulled her hair and punched her. A review of a facility incident report, dated 1/19/18, showed resident #54 reported to staff member A an unnamed staff member had abused her more than a month ago. The incident showed resident #54 had stated she was in the construction area on center (a location within the facility) due to the door being left open, and having access, she went in to pick up nails and screws off the floor. She stated that (NF4) found her and told her she could not be in that area Resident stated that he then 'grabbed me by my hair and threw me out of my wheelchair. I was able to get back in my chair on my own.' The report also showed, Staff member's story is that resident was in the construction area on center, where she knew she was not suppose to be because it was supposed to be closed for safety, but at this time someone had left the door open Staff member stated 'You're not supposed to be in here' .(and) 'Come on, (resident #54), you know you are not suppose to be here.' The resident continued to pick up (nails and screws) and ignored the staff member . Staff member turned her wheelchair around and assisted her into the dining room. The incident report concluded: Due to the evidence stated above we find this allegation of abuse unsubstantiated at this time. Staff member will still not provide care for this resident, for comfort of resident at this time. During an interview on 5/15/18 at 3:45 p.m., staff member N said resident #54 was in the facility in a construction area in her wheelchair. NF4 found her there, and the resident later stated that he lifted her out of her chair. Verbal abuse was exchanged. The resident was removed back to the floor from the construction zone. The resident reported the incident to an Ombudsman at a much later date. Staff member N said the resident was concerned and did not want to have staff member NF4 working with her anymore. A review of resident #54's Interdisciplinary notes dated 3/1/18 showed the facility Ombudsman spoke with staff member A saying he had visited resident #54 the day before and she had reported an allegation of abuse from a staff member. It also showed that an investigation had been done, and a report had been sent to the State Survey Agency, showing the abuse allegation was not substantiated at that time. During an interview on 5/14/18 at 3:00 p.m., resident #54 verbally acknowledged that she had interactions with staff member NF4. She said she did not want to talk about it, that it had happened a long time ago, and she did not want it to be brought up again. She said she had not told anyone in the facility about the event for a long time after it happened. The facility Ombudsman had visited and she had told him about the incident. She said she had been somewhere where she knew she shouldn't have been and that if she had not been there the incident would not have happened. She did not describe the event in any way, but said the event had scared her. However, now staff member NF4 was gone, she felt safe again. When asked whether or not she felt the facility had taken measures to protect her, she said she felt the staff had done the right thing. She was glad the staff member was no longer working the facility. She said she had physical harm from the event, but would not describe it. She emphasized that she liked being in the facility and did want the event to be given any further attention. 3. During an observation on 5/16/18 at 10:36 a.m., staff member U was audibly making a groaning sound as she hurried from task to task on East wing. At 10:37 a.m., staff member U was observed sighing loudly as she pushed a resident, who was seated in his wheelchair, past the nursing station towards the dining room. During an observation on 5/16/18 at 10:39 a.m., resident #44 had her call light activated. Staff member U entered resident #44's room and in a harsh manner and tone stated, Continually pressing your call light will not make us get here faster; we will get to you when we can. Staff member U then left resident #44's room, and did not assist the resident for why the call light was on. During an observation and interview on 5/16/18 at 11:00 a.m., resident #44 started calling out help! This was heard from the East wing nurse's station. At 11:05 a.m., staff member R entered resident #44's room. Resident #44 stated she had turned on her call light earlier for assistance with toileting, and she became incontinent because of the delay. Resident #44 expressed frustration with time delays in call light response. Resident #44 was upset that staff member U had tuned (her) up, stating, She's so crazy (referring to staff member U)! Resident #44 appeared upset while speaking of the exchange with staff member U. Resident #44 stated that being incontinent affects her dignity. During an interview on 5/16/18 at 11:15 a.m., staff member R stated that resident #44's incontinence greatly affects resident #44 and It's such a loss of dignity for her. The suspected abuse was reported to staff member A on 5/16/18 at 3:05 p.m. During an interview on 5/16/18, at 3:30 p.m., staff member II stated that staff member U had not received any abuse training from the facility. Review of the facility's policy, Abuse Investigation and Reporting, showed The Administrator or his or her designee will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. During an interview on 5/17/18 at 9:03 a.m., staff member K stated that staff member U was working that day as a care provider on the East wing. During an interview on 5/17/18 at 9:30 a.m., staff member A stated that staff member U was not assigned to provide care to resident #44 that day. The staff member was providing other residents care during her shift.

Based on interview and record review, the facility failed to address and identify a resident's pain needs timely after a fall which caused several fractures, for 1 (#142) of 41 sampled and supplemental residents. Findings include: Review of resident #142's SBAR Communication Form, dated 3/19/18 at 3:15 p.m., showed Resident became weak while being stood (sic) from toilet and was 'purposefully' lowered to the floor in front of (sic) toilet so a sling could be placed under her for transfers. She had BLE weakness and could not stand even c (sic) gait belt, CNA assist & walker in her hands. Review of resident #142's Falls Management-Post Fall Assessment Tool showed for 7. Were you in pain? and resident #142's response was, Yes. Review of resident #142's nursing progress notes showed the following: -3/20/18 at 12:28 p.m., showed, Pain: c/o pain in legs today, given PRN Tylenol. -3/20/18 at 3:09 p.m., showed, Yesterday 3/19 around 15:15 (3:15 p.m.) at change of shift from day to evening, the CNA was toileting resident and was standing up the resident in front of toilet, using gait belt and walker and resident became weak in BLEs and was unable to stand even with the assist of CNA. Resident was puposely (sic) lowered to the floor in order to reposition her so a sling could be placed under her and a lift used to transfer the resident with 2 staff. Resident has a purposeful 'change of plain (sic) /change of position.' No injury noted. -3/21/18 no documentation on nursing progress notes to show pain was addressed after the fall. The MAR for (MONTH) (YEAR) showed the resident received Tylenol 500 mg on 3/21/18. -3/22/18 at 8:36 p.m., showed, During pericare it was noted that her right lower shin has a deep pink/maroon coloring and lumps along bone. Pedal pulses are palpable on both feet but right foot is cool to touch. Pain was not addressed for the identified injury. -3/23/18 at 10:07 a.m., showed, Resident has deformity/discoloration to right lower leg, denied any discomfort. (Name) notified, assessed resident. VS taken, BP 156/75, P 99, R 36, T 99.3, O2 90% on 2 lpm via nc. Resident transported to (hospital) via non-emergent ambulance. Son (name) was called and informed. -3/23/18 at 1:57 p.m., showed a late entry for 3/22/18, Resident grimacing, moaning during transfer from bed to w/c via 2 person vander lift. Resident reported generalized pain, PRN tylenol 500 mg given at 10:00 a.m. Review of resident #142's physician progress notes [REDACTED]. And Her blood pressure and heart rate are notably (sic) elevated today but are typically well controlled and normal. I am not sure if this may be pain related. The Assessment section showed Leg pain and the Plan section showed Leg pain. The notes did not address the pain further. Review of resident #142's MAR for (MONTH) (YEAR) showed the resident received Tylenol 500 mg on: -3/1/18 times one with no reason documented for use, -3/6/18 times one with no reason documented for use, -3/19/18 times three with no reason documented for use, third dose was give at 4:11 p.m. after the resident's fall. On 3/19/18 the resident had an increase in her pain level, with medication provided, which the facility did not identify at the time as a concern. -3/20/18 times two, one with no reason for use, one for complaints of leg pain, -3/21/18 times three, two with no reason for use, one for complaints of leg pain, -3/22/18 times three, two with no reason for use, one for complaints of back pain. -3/23/18 No evidence resident received PRN Tylenol or any other pain medication prior to leaving the facility, to ensure the resident was comfortable during the transfer, although the nurse documented she was grimacing and moaning. Review of resident #142's TAR for (MONTH) (YEAR) showed facility staff was to assess the resident's pain level, on a scale of 1-10, every shift. From (MONTH) 1, (YEAR) to (MONTH) 22, (YEAR) every shift was documented with a zero as the resident's pain level. Review of resident #142's SBAR Communication Form, dated 3/22/18, showed: -1. Noticed this shift a change if (R) lower extremity. Please assess her (R) shin, misshapen and discoloration. (+) dorsal flexion and side to side roll (+) pedal pulse, no c/o pain in the area. -2. She needs something stronger/longer [MEDICATION NAME] for her back pain. 500 mg Tylenol bid is not keeping up with pain control. She is constantly crying for pain control for her back pain. Review of resident #142's faxed physician order, dated 3/22/18, showed [MEDICATION NAME] 5 mg/325 mg 1 tab every four hours for prn pain. Dispense 30. Further down on the faxed page, dated 3/23/18, the pharmacy said the resident had allergies and they would not fill the medication. Review of resident #142's nursing progress notes, dated 3/1/18 to 3/23/18, failed to show the facility had contacted the physician regarding the pharmacy's refusal to provide [MEDICATION NAME] 5 mg/325 mg due to the resident's allergy to [MEDICATION NAME]. Review of resident #142's medical record, from 3/19/18 to 3/23/18, failed to show the facility had made the physician aware of the resident's continued leg pain until the SBAR Communication Form was faxed to the physician on 3/22/18. No documentation was found showing a nursing assessment was completed after the fall on 3/19/18. Review of resident #142's nurse practitioner progress note, dated 3/23/18, showed, She had a fall approximately one week ago where she was lowered to the ground by staff and was not able to stand. She was complaining of pain that day,. Staff noticed last night that there was a deformity to her right lower extremity. There is some swelling that extends down to the top part of her foot. The note further showed, ., the patient is very tender to the anterior part of her shin where the deformity is. I am concerned about a fracture. Review of resident #142's physician's telephone order, dated 3/23/18, showed Send to (hospital) ER. Review of resident #142's x-ray reports, dated 3/23/18, showed: -Indications: Lower leg pain after a fall. Altered mental status, -Left distal femoral metaphyseal fracture, -Left distal femoral metadiaphyseal fracture, which appears impacted and comminuted, -Right distal tibial and fibular diaphyseal fractures, which appear comminuted and are dorsally displaced. Review of resident #142's orthopedic history of present illness, dated 3/24/18, showed: -Fall when arising from the restroom [ROOM NUMBER]/19/18, -She had immediate pain in bilateral lower extremities, -emergency room evaluation on 3/23/18 showed right distal tibia and fibula fractures as well as a left intercondylar femur fracture. Review of resident #142's orthopedic operative note, dated 3/24/18, showed: -Left distal femoral replacement hinge knee arthoplasty, -Open reduction internal fixation right distal tibia and fibula. During an interview on 5/15/18 at 8:10 a.m., NF6 said he visited resident #142 every day. NF6 said he was not told of the incident resident #142 had on the evening of 3/19/18. NF6 said resident #142 told him about her fall on 3/20/18 when he came to visit her. NF6 said resident #142 was complaining of back and leg pain to him. NF6 said he did tell staff, and the resident received Tylenol. NF6 said the resident had never been a big complainer about her pain. NF6 said the facility should have sent the resident to the hospital sooner than they did for x-rays. NF6 said the facility did not communicate with resident #142's physician soon enough about her pain. During an interview on 5/16/18 at 10:10 a.m., staff member R said residents with chronic pain are monitored every shift, and that information was documented on the MAR. She said for residents that do not have chronic pain, their monitoring would found on the TAR. Staff member R said every resident was supposed to be monitored for pain daily on every shift. During an interview on 5/17/18 at 10:00 a.m., staff member A said she thought the facility had acted appropriately for the situation.

Based on observation, interview, and record review, the facility failed to provide sufficient staffing on East wing in regards to answering call lights timely which affected 8 (#s 2, 4, 8, 28, 37, 44, 45, and 49) of 41 sampled and supplemental residents, and this resulted in incontinence and loss of dignity for 2 (#s 44 and 45), caused 1 (#28) to worry that she might not receive help in an emergency, and caused 1 (#8) unhappiness due to the lack of assistance. Findings include: 1. a. During an observation on 5/16/18 at 10:39 a.m., resident #44 had her call light activated. Staff member U entered resident #44's room and stated in a harsh tone Continually pressing your call light will not make us get here faster; we will get to you when we can. Staff member U shut the call light off and left the room without addressing the resident's needs. During an observation and interview on 5/16/18 at 11:00 a.m., resident #44 started calling out help! At 11:05 a.m., staff member R entered resident #44's room. Resident #44 stated that she had activated her call light earlier for assistance with toileting and became incontinent because of the delay and not being helped prior. Resident #44 expressed frustration with time delays in call light response. Resident #44 was upset that staff member U had tuned (her) up, stating, She's so crazy! Resident #44 appeared pained while speaking of the exchange with staff member U. Resident #44 stated that being incontinent affected her dignity and she could avoid the embarrassment of incontinence if call lights were answered faster. Resident #44 stated that she was incontinent fairly often due to the delayed response of staff. During an interview on 5/16/18 at 11:15 a.m., staff member R stated, in regards to resident #44's incontinence, that it greatly affected resident #44, and It's such a loss of dignity for her. b. During an interview on 5/15/18 at 11:44 a.m., resident #45 stated that it usually took about one and a half hours for his call light to be answered. Resident #45 stated he was often incontinent due to delayed call light responses. Resident #45 stated that the incontinence affected his dignity and caused him to be frustrated with the loss of dignity. During an observation on 10:56 a.m., the call light for room seven was activated. It was answered at 11:13 a.m. During an observation on 5/16/18 at 10:59 a.m., the call light for room [ROOM NUMBER] was activated. It was answered at 11:16 a.m. During an observation on 5/16/18 at 1:32 p.m., the call light for room [ROOM NUMBER] was activated. It was answered at 1:49 p.m. During an observation on 5/16/18 at 1:33 p.m., the call light for room [ROOM NUMBER] was activated. It was answered at 1:52 p.m. c. During an interview on 5/14/18 at 2:39 p.m., resident #4 stated that he once had to wait one and a half hours for his call light to be answered when he was listed as requiring a two person transfer. He said that a second CNA was not available due to low staffing. d. During an interview on 5/14/18 at 3:23 p.m., resident #28 stated that she had activated her call light earlier that morning at 7:00 a.m., and no staff member came to her room for over an hour. Resident #28 stated she has been subject to call light response times of an hour or more a few times during her stay at the facility. Resident #28 stated that the facility was understaffed and needed more CNAs. Resident #28 stated that she was worried that she might not get help in time if she had a true emergency. e. During an interview on 5/14/18 at 3:23 p.m., resident #8 stated her call light typically takes no less than ten minutes to be answered. She stated she was unhappy about the length of time it took to receive assistance. f. During an interview on 5/15/18 at 11:16 a.m., resident #49 said that if he could change one thing about the facility it would be for call lights to get answered faster. g. During an interview on 5/15/18 at 2:30 p.m., resident #37 stated she had to wait one and a half hours for a response. h. During an interview on 5/15/18 at 2:32 p.m., resident #2 stated that she had to wait a couple of hours at a time for call lights to be answered. i. During an interview on 5/17/18 at 9:00 a.m., staff member A stated that they were currently staffing East wing with four CNAs. Staff member A said that she wanted to have five CNAs on East wing (along with the dedicated shower aide). She stated a fifth CNA would be appropriate for the workload but she could not get a fifth CNA hired. Review of facility's staff assignments posted at the East wing nursing station showed four CNAs on duty for the wing on 5/14/18. 2. a. During a telephone interview on 5/16/18, at 1:50 p.m., NF2 said that the facility was short staffed. In the months prior to her leaving employment at the facility, she had been subjected to too many shifts where she was expected to accept large numbers of additional resident responsibilities because other staff members had called in and no arrangements were made by the facility to get replacement staff. She said she would have 45 residents to care for and would be expected to take on an additional ten more that would be in another part of the facility. She said she had refused to accept the responsibility a few times but that it had become awkward for her to continue to do so. She said that part of the problem included that human resources hired individuals who were not physically capable to do their jobs. She said that when employees were unable to perform full duty, other employees were given additional duties to make up for them. The employees doing additional work were overwhelmed, and when they realized they could not perform their duties and provide safe care they left employment at the facility to save their work reputations. b. During an interview on 5/16/18 at 7:15 a.m., NF5 said she did have a concern about staffing. She said the CNA staff on the East unit were always running to help residents, but they just could not seem to get things done fast enough. NF5 said the East unit had a lot of residents that needed extra help. She said there just wasn't enough staff to get everything done in a timely manner. NF5 said her family member had waited up to an hour for her call light to be answered. She said she had been in the family member's room when this had happened. NF5 said the situation was not a one time thing. She said it did not happen daily but often enough to be a concern that her family member was not being taken care of properly. NF5 said she had heard residents had called the front desk on their cell phones because no one would answer their call lights. During an interview on 5/16/18 at 10:52 a.m., staff member KK said residents had called the front desk asking for her to call the nursing station to have staff answer call lights. During an interview on 5/16/18 at 2:01 p.m., staff member LL said she had been pulled to the floor when East unit was short staffed. During an interview on 5/17/18 at 8:47 a.m., staff member A said the facility always had staffing problems during the summer. Staff member A said human resources had graphed the rise and falls of the CNAs, and it did correlate to summer. Staff member A said the facility had identified this as a problem. Staff member A said the facility was considering hiring agency staff.

Based on observation, interview, and record review, the facility failed to prevent falls with hip fractures, repetitive falls, and follow through with investigating the root cause and analysis of falls for 4 (#s 1, 9, 14, 15 ) of 20 sampled residents. Findings include: 1. Review of resident #9's Interdisciplinary Notes, dated 12/10/16, showed she had a fall out of her lift recliner. She called out and was found on the floor in front of her lift recliner. The resident stated the floor was slippery. Review of resident #9's Care Plan for falls, dated 11/7/16, showed six interventions for fall prevention: 1. Insure that adaptive devices - walker/cane are within reach and in good repair. 2. Assist resident in wearing non-skid footwear. 3. Remind resident to lock wheelchair brakes and to ring for assistance when transferring. 4. Monitor resident for signs of fatigue during ambulation. 5. Use walker for ambulation. 6. Call light within reach. Review of the facility Incident Tracking Report showed resident #9 fell out of her lift recliner on 1/20/17, and was found lying on her left side. The recliner was in the high position. An X-ray was completed at 6:10 a.m. in the facility, and the resident was sent out with a left femur fracture. Review of #9's Care Plan dated 11/7/16, showed no interventions were put into place regarding the safety of the recliner, after the first fall on 12/10/16. It did not include the use of the recliner for sleeping. No root cause was identified for the fall and no preventative interventions were implemented. During an interview on 6/29/17 at 10:00 a.m., NF1 stated resident #9 fell during the night because she raised her recliner too high. The resident sustained [REDACTED]. NF1 stated the resident no longer had control of the chair remote because of falls. NF1 stated prior to the resident's fall, she would use the call light. NF1 stated the resident had needed assistance with standing since the fall and could not rise out of the chair on her own. 2. Review of the facility Incident Tracking Report showed resident #14 fell ten times from 11/23/16 through 6/27/17. The falls on 11/23/16 and 12/3/16 were out of bed. Review of resident #14's IDT review note, dated 12/9/16, showed the facility would implement side rails for positioning and assistance to sit up, and remove the wheelchair from room when the resident was not in it. During an observation on 6/28/17, resident #14's bed did not have side rails. The resident was sitting in his recliner, and the wheelchair was in the room. Review of resident #14's Interdisciplinary Note, dated 1/6/17, showed resident #14 had slid out of his recliner. The resident stated the recliner was slippery. Review of resident #14's Fall Note, dated 1/12/17, showed he slid out of the recliner twice; once on his own and once while his wife was trying to change his shirt and PT will be evaluating recliner. Review of resident #14's Care Plan showed an intervention, dated 1/16/17, to have a PT evaluation of the recliner. The facility did not provide documentation of the evaluation, or interventions related to the recliner. Review of the Incident Tracking Report showed resident #14 fell on [DATE], out of his recliner. No root cause for the fall was identified and no new interventions were documented. Review of the Incident Tracking Report showed resident #14 fell on [DATE], and was found in front of his bathroom, with his wife standing behind him. The resident stated he hit his head on the wall. He was barefoot and incontinent. Review of resident #14's Care Plan, dated 1/6/17, showed Assist resident in wearing non-skid foot wear. Review of the Incident Tracking Report showed resident #14 fell on [DATE]. He stated he slid out of the bed. Review of resident #14's Fall IDT note, dated 3/24/17, showed Review of recent fall, resident slid out of wheelchair. Wife reported fall. Family is aware of continued issue of wife attempting to assist resident and recurring falls. They have refused to separate residents to other room or units. IDT continue to discuss options with family. Review of resident #14's Fall IDT note, dated 4/4/17, showed resident #14 was impulsive, and often asked his wife for assist. Staff have removed extra over-bed table in room, toileting plan has been initiated. Review of resident #14's Care Plan did not include a toileting plan. Review of the Incident Tracking Report, dated 5/5/17, showed resident #14 was found sitting on the floor at his bed side, on his blanket and fall mat. The resident stated he slid off the bed on his blanket. Review of resident #14's undated Fall Note showed he was on therapy services, and the facility would implement slip strips on the floor to help reduce falls. During an observation on 6/28/17 resident #14's floor did not have slip strips. Review of resident #14's Fall IDT note, dated 5/9/17, showed Resident was found on floor on bedspread, wife observed carrying urinal to bathroom. Resident denied pain. He has been observed leaning forward in his wheelchair sleeping. Concern is he will fall out. Care conference to be held on Monday with his family to discuss these concerns and ongoing issue with wife attempting to assist resdent instead of getting help from staff. Review of the Care Plan showed no new interventions to prevent further falls. 3. Review of resident #15's Interdisciplinary Note, dated 12/15/16, showed the resident was found lying in the middle of her room. Resident lying supine, nothing was on her feet. No injuries noted, ROM WNL. Resident smiling and talking - word salad. Resident's bed was made, nice and neat. Resident was put to bed 2 hours before. Review of resident #15's Interdisciplinary Note, dated 12/16/16, at 6:46 a.m., showed resident on neuros and vitals from fall. Unable to verbally state in pain, however grimacing and touching left leg. CNA reported resident resisting being turned or touched on left leg. Nurse gave PRN norco. Had temp of 100 earlier on night shift. Temperature 99.4 at 5:45 a.m. No signs or symptoms of injury. No bruising noted. Review of resident #15's Interdisciplinary Note, dated 12/16/16, at 1:31 p.m., showed Received in report that resident fell last night around 22:00 (10:00 p.m.), neuros, vitals and assessment being obtained. Also resident received norco for pain in left hip, elevated temperature started around 3:00 a.m. Told day CNA that I would check (the resident) when she was going to get her up. CNA went to (LPN) who assessed the resident, came out of room and stated that the resident had no apparent injury and the resident was now in her wheelchair. When the resident was pushed out to the TV room, I went and obtained my own assessment and found her foot facing outward and that she was leaning to her right, taking the pressure off her left hip. She was also holding her left hip and grimacing. Norco given with am meds. Received order for portable x-ray of left hip, which showed fracture at the femoral head. Review of resident #15's Care Plan, dated 8/21/15, showed no new interventions for fall prevention had been implemented since 8/21/15. The first intervention on the Care Plan showed Non-slip footwear when up ambulating. Review of resident #15's IDT fall note, dated 12/31/16, showed resident sustained [REDACTED]. Resident returned from (hospital) with PT orders, floor mat in place. The review did not include an identified root cause for the fall with major injury. During an interview on 6/28/17 at 10:30 a.m., staff member B stated the facility was still working on getting in compliance with the fall regulations. She stated falls were discussed in the Quality Assurance meeting, but did not address root cause or resident-specific interventions. The facility had a Falling Star Program, and staff member B was unable to provide the protocol for this fall prevention program. During an interview on 6/26/17 12:35 p.m., staff member BB stated she thought the Falling Star Program meant the resident's bed should be in the low position, and a fall mat in place. 4. Review of resident #1's incident report, with a date of 12/6/16, with a time of 9:45 a.m., written by staff AA, showed the resident was being transferred in the vander lift from the bed to a wheel chair. The resident slipped out of the sling while the lift was up, hitting her head on lift frame. The resident was transferred to the emergency room . Review of resident #1's provider progress note, dated 12/7/16, showed the resident had fallen, from the hoyer list, four feet from the floor. A CT scan revealed a cerebral contusion. The resident had a laceration to her head and the treatment for [REDACTED]. During an interview on 6/29/17 at 7:09 a.m., staff member Y stated she was the only person assisting resident #1 in the lift on 12/6/16. The staff member stated the resident was a one to two person lift. The staff member did not know why resident #1 fell out of the lift. The staff member stated she had been trained on using the lift. Review of the licensed nurse position description, with a revision date of 3/18/14, showed a licensed nurse was to know how to operate lifts. Review of the facility educational training on lifts, dated 6/8/17 and 6/13/17, showed staff member Y was at the training on 6/8/17. There was no documentation of training prior to that date. Review of the facility policy on Transfer, Turn and Position, dated 1/21/15 as the revision date, showed all nursing services departmental employees would receive initial training upon hire, and also during an evaluation oft he employee's skills. All nursing staff would receive a refresher course whenever needed. All employees completing the training would sign off for understanding the contents of the training provided. There was no documentation showing staff member Y had completed the initial training. During an interview on 6/27/16 at 2:27, staff member AA stated resident #1 was a two person lift. The resident was a one-to-two person lift before she fell out of the lift. Review of a Transfer Memo, dated 4/24/17, showed resident #1 was to be transferred by two nursing staff members, using the Vander Lift. During an interview on 6/28/17 at 10:56 a.m., staff member B stated resident #1 had a fall out of a lift on 12/6/16. The staff member stated not having any information on the fall investigation. No documentation was found showing the facility had investigated resident #1's fall from the lift. There was no documentation showing the facility had identified the cause for the fall. There was no update to resident #1's fall care plan, from 4/6/16, when the fall mat was implemented.

Based on record review and interview, the facility failed to have an affective Quality Assurance Committee (QAPI). The facility quality assurance committee failed to adequately identify, implement plans to improve the deficient practices, and monitor for the plan and changes for adequate improvements, relating to Accidents and Hazards, Quality Assurance, Pressure Ulcers, and therapeutic diets, which occurred concurrently over the last four years. Findings include: A review of the facility CMS-2567 reports, maintained with the Stage Agency, showed the facility failed to maintain compliance for the following areas: - Prevention of Accidents and Hazards: 2016 (IJ) and 2017 - Quality Assurance: 2014, 2016, and 2017 - Pressure ulcers: 2014, 2016, 2017 - Therapeutic diets: 2016, 2017 - Refer to F314, F323, F367, and F520, for concerns identified during the current survey. During an interview on 6/29/17 at 9:45 a.m., staff members A and B stated the Quality Assurance Committee had identified concerns with falls, pressure ulcers and therapeutic diets, but didn't follow through with developing a plan of action for the concerns, monitoring, or updating current systems to adequately prevent future failures. Staff member A stated the follow up piece on concerns was not good.

Based on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers by failing to perform skin checks and failing to follow physician orders [REDACTED].#11); and failed to prevent the development and continued reopening of a pressure ulcer for 1 (#13)resident, of 19 sampled residents. Findings include: 1. Resident #11 was readmitted with [DIAGNOSES REDACTED]. During an observation on 10/18/16 at 8:04 a.m., staff member I was turning resident #11 to the right side; sores on the bottom of the left resident's foot were observed. During an observation on 10/18/16 at 10:40 a.m., resident #11 was observed in the assisted dining room to have dark colored socks on her feet. During an observation on 10/18/16 at 12:14 a.m., resident #11 was observed in the main dining room for an exercise activity, wearing dark colored socks on her feet. During an observation 10/18/16 at 1:24 p.m., resident #11 was observed in the main dining room, wearing only dark colored socks on her feet. During an interview on 10/18/16 at 2:02 p.m., staff members H and W stated resident #11 did not have pressure ulcers on her heels, and they stated they were not aware of any. During an observation on 10/18/16 at 2:45 p.m., resident #11 was being taken to her room from the main dining room. As she was being wheeled to her room, she stated she wanted her bunny boots on. During an observation on 10/18/16 at 2:49 p.m., resident #11's right heel had 2 black sores and the left heel had 1 red area. Staff member H measured the sores on both heels. Review of resident's nursing notes documented on 10/18/16 at 3:34 p.m. and 3:46 p.m., respectively, stated bunny boots wore during the day and rooke boots worn at night. During an interview on 10/18/16 at 4:15 p.m., staff member H stated the wounds on resident #11's heels were unstageable with eschar. She stated pressure ulcers can start on the inside. During an interview on 10/19/16 at 7:40 a.m., resident #11 stated the staff did not put her bunny boots on her in the morning when they got her up. She stated she had to tell them to. She also stated she did not refuse to wear them because the doctor ordered them, and said they were important to wear. Review of resident #11's MDS, with an ARD of 9/12/16, showed the resident had a cognition level of 13 out of 15. In an interview on 10/19/16 at 1:29 p.m., staff members A and B stated resident #11 was reliable in answering questions. Review of resident #11's physician orders [REDACTED]. an order for [REDACTED]. Review of resident #11's weekly skin evaluation record reflected several missed skin evaluations. There was only one weekly evaluation in July of 2016, and only two in September of 2016. There was no weekly skin evaluation between 9/19/16 and 10/18/16, the day the pressure ulcers were noticed on initial tour. A review of the resident's daily long term care nursing notes between 9/19/16 and 10/18/16 showed only three entries were documented on her skin. All of them showed the resident's skin was warm, dry, and intact. On 10/18/16 at 10:39 p.m., following discovery of the pressure ulcers on the resident's heels, the daily nursing note showed the resident's skin was still warm, dry, and intact. 2. Review of the resident's Interdisciplinary Notes, dated 7/28/16, showed the development of a 1 x 1 cm lesion next to anus, with granulated edges on 7/13/16; and a 1.2 x .6 cm open area full thickness does appear to be healing. Review of the resident's IDT notes, dated 7/29/16, showed the implementation of an alternating air mattress. Review of the resident's Quarterly MDS, with the ARD of 8/8/16, showed the presence of a stage II pressure wound, that developed on 7/13/16. Review of the resident's Interdisciplinary Notes, dated 8/11/16, showed the FNP and wound nurse observed wound, now healed. Review of the resident's Interdisciplinary Notes, dated 8/11/16 at 2:49 a.m., showed a small open pressure wound on right gluteal fold. Review of the resident's IDT notes, dated 9/15/16, showed a Re-opened pressure wound on right gluteal crease observed by FNP and wound nurse. Alternating pressure mattress on bed. Review of the resident's IDT notes, dated 9/23/16, showed a wound on right lower buttock, observed by FNP and now healed. Review of the resident's Skin evaluation Form, dated 10/12/16, showed 0.6 x 0.3 cm open area in center of old site. Review of the resident's Skin Evaluation Form, dated 10/18/16, showed healed pressure area reopened. During an interview on 10/19/16 at 4:10 p.m., staff members C and K stated resident #13's skin had recently healed. They stated they did not renew any treatment orders in September 2016 because the FNP said to keep the same treatment. Review of the resident's Physician orders [REDACTED]. During an interview on 10/18/16 at 9:15 a.m., NF1 stated she usually gave verbal orders for wound treatments. Review of the resident's current Care Plan showed no evidence of wounds or treatments. Review of the resident's Weight Records showed a severe weight loss for resident #13, which may have contributed to the skin concern. During an observation on 10/20/16 at 9:10 a.m., during care, resident #13 had an open area on the right gluteal fold with yellow slough. Staff member V stated the procedure was to notify the nurse verbally if any skin issues were noted. Staff member V also stated the open area looks better than last time. During an interview on 10/20/16 at 10:20 a.m., staff member C stated she and the FNP and had completed wound rounds that day but did not look at resident #13, because they were not aware the area was open. During an interview on 10/20/16 at 11:15 a.m., staff member H stated the area had probably reopened because the resident kept sliding out of his chair, and the air mattress had to be removed to use for some else, sometime in September. She had been notified of the open area by the staff member, but had not assessed the area yet. Review of the resident's IDT note, dated 10/20/16 at 2:52 a.m., showed Has open areas on bottom. See skin assessment. Staff member C looked for the assessment, and stated no assessment had been completed.

Based on observation, interview and record review, the facility failed to prevent severe weight loss, and monitor the effectiveness of interventions to prevent further weight loss for 3 (#'s 8, 13, and 14) of 19 sampled residents. Findings include: 1. Resident #13 was admitted to the facility on [DATE]. Review of the resident's Admission MDS, with the ARD of 5/20/16, showed an entry weight for the resident of 168 pounds. Review of the Quarterly MDS, with the ARD of 8/20/16, showed a weight of 155 pounds. Review of the facility Weight Tracking Systems Reports showed the resident's weight of 155 pounds on 8/2/16, and a weight of 145.5 pounds on 9/20/16. This was a 13 percent weight loss in 5 months, and considered severe. Review of the resident's Dietary Note, dated 8/3/16, showed staff member D called the resident's daughter regarding the daughter's concern for resident #13's weight loss. Staff member D stated the resident had lost greater than 5 percent in less than a month, but we do not start to be concerned unless po intake is less than 50 percent on a consistent basis. She also stated the resident would get Benaprotein to all his hot foods to increase protein intake for pressure ulcer prevention. During an observation of the dinner meal on 10/19/16 at 4:35 p.m., resident #13 had chicken, rice and squash on his plate. His diet card showed add benaPro to hot foods 2X per day. During an interview on 10/19/16 at 4;45 p.m., staff member R stated the benaPro was in the mashed potatoes. Resident #13 did not receive mashed potatoes. During an interview on 10/20/16 at 9:15 a.m., staff member D stated she verbally discussed the use of BenePro with the cooks, to ensure the residents received it in their food. Review of the resident's Dietary Note, dated 8/10/16, showed staff member D called the daughter again, and stated resident #13 continued to lose weight. She also stated the resident would get more help in the Inner dining room, but the daughter felt the Outer dining room was a better environment. Staff member D stated she would start a supplement to be given at night when the evening snacks were passed. Review of the resident's Dietary Note, dated 9/26/16, showed continued weight loss for resident #13. The note reflected He needs more help than is available in the Outer Dining room such as cueing to begin eating and sometimes needs assistance in feeding. On 9/27/16, resident #13 was moved to the inner dining room for assistance with his meals, two months after his initial significant weight loss. During an interview on 10/20/16 at 12:20 p.m., staff member D stated the resident lost weight because he did not get the help he needed in the outer dining room. During an observation on 10/20/16 at 10:40 a.m., resident #13 was being assisted with his breakfast. Staff member Z stated the resident chewed very slowly and pocketed food on one side of his mouth. During an interview on 10/20/16 at 12:20 p.m., staff member D stated she was not aware of any chewing difficulties or pocketing issues for resident #13. She also stated she did not conduct meal rounds. 2. Resident #14 was admitted to the facility on [DATE]. A review of the resident's Quarterly MDS, dated [DATE], showed resident #14 required extensive assist with eating. During an observation on 10/20/16 at 10:20 a.m., staff member BB was assisting resident #13 with breakfast. The resident drank 1/2 of her milk, ate 3 bites of her meal, and was taken to her room. A review of the resident's Quarterly and Significant Change MDS, dated [DATE] and 8/8/16, showed non physician prescribed severe weight loss. Review of resident #14's Resident Weight Tracking System Report showed the following: -2/23/2016;WT 133.50 -5/03/2016;WT 117.00;12% Weight Loss -8/02/2016;WT 107.00;8.5% Weight Loss Review of resident #14's Physician Orders, showed Ensure Plus was ordered TID along with Boost Breeze PRN. Benaprotein was ordered with hot meals. Review of resident #14's Care Plan, last updated 10/11/16, showed the resident was to be provided Benaprotein in hot foods, Ensure Plus at brunch, and dinner meals. Boost Breeze was not added to the care plan. Review of resident #14's Nutritional Assessment, dated 10/10/16, showed the resident should receive Ensure Plus at breakfast and dinner, Boost Breeze with medications, and Benaprotein in hot foods. Review of the Interdisciplinary Notes for resident #14, dated 10/17/16, showed the resident received Boost Breeze with medication pass. Review of the facilities Dietary Communication Book for resident #14 did not show any communication that stated the resident was to receive Benaprotein, Ensure Plus, or Boost Breeze for the month of September and October 2016. During an interview on 10/20/16 at 10:55 a.m., staff member H stated resident #14 did not get Boost Breeze at medication pass. Staff member H stated Boost Breeze was not on the MAR. Staff member H stated resident #14 was provided Ensure Plus at breakfast, and between 1:30 and 2:00 p.m. Staff member H stated she witnessed a resident who took an Ensure drink from resident #14 and consumed it. Staff member H stated this always happened to resident #14. Staff member H stated she did not get resident #14 a replacement Ensure Plus after she witnessed the other resident who took it from resident #14. During an interview on 10/20/16 at 11:10 a.m., staff member G stated resident #14 received a vanilla milk shake at dinner time. Staff member G stated resident #14 did not receive Ensure Plus or Boost Breeze. During an interview on 10/20/16 at 11:20 a.m., staff member S stated resident #14 received a milk shake in the a.m. and an Ensure with ice cream at Siesta. Staff member S stated resident #14 did not get Boost Breeze. During an interview on 10/20/16 at 1:00 p.m., staff member D stated new dietary changes for residents were communicated to nursing staff verbally, and the nursing staff was responsible for new dietary changes that would be entered onto the MAR. Staff member D stated new dietary changes were communicated to the dietary staff with pink slips of paper that would indicate the new dietary changes. Staff member D stated she did not do meal rounds on residents to ensure the recommended or ordered nutritional supplements had been provided to the residents. 3. Review of resident #8's MDS, with an ARD of 9/9/16, showed the resident's weight was recorded as 144 pounds. The resident's weight on the 30 day MDS assessment dated [DATE] was recorded as 135 pounds. This showed a nine pound weight loss of 6.25 % in one month. Review of resident #8's Care Plan, dated 9/14/16, under the Nutritional Status, showed resident #8 was to be provided Benaprotein in hot foods. Review of the facility's Weight Assessment and Intervention Policy showed negative weight trends should be evaluated by the multidisciplinary treatment team. The policy also showed if the weight loss was desirable it should be documented in the resident's medical record and no change to the care plan would be necessary. The policy showed individualized care plans should address the identified cause of weight loss for a resident. A review of the resident's care plan showed the identified weight loss was not documented on the care plan. Review of the Interdisciplinary Notes for resident #8, dated 10/3/16, showed staff member D documented resident #8 had a 5.92% weight loss. Staff member D stated if the resident continued to lose weight, the resident's calories would be increased and her diet would include a nutritional supplement. During an interview on 10/18/16 at 3:00 p.m., staff member N stated The CNAs weigh residents monthly, the dietitian monitors resident weights, and runs a report. Staff member N stated the dietitian would talk to the nursing staff and managers about resident weight loss. Staff member N stated the dietitian would communicate the resident weight loss to the doctor. During an interview on 10/18/16 at 3:05 p.m., resident #8 stated she was not aware of her weight loss and she did not try to lose weight. Resident #8 stated she did not want to lose weight. Resident #8 stated she was not surprised at her weight loss due to the physical therapy she had been doing. Resident #8 stated she was not aware of any nutritional supplements that had been served to her. During an interview on 10/18/16 at 4:15 p.m., staff member D stated resident #8 had a weight loss due to her new admission, and the resident was in a stressful situation. Staff member D stated there should be a dietary note in regards to this weight loss. Staff member D stated that the resident's doctor was not notified because it was not a trending weight loss. Staff member D stated if the resident's care plan was affected from a weight loss she should have updated the care plan. During an interview on 10/19/16 at 8:10 a.m., staff member T stated he was not notified of resident #8's weight loss. Staff member T stated he just saw the resident's weight loss in her chart. Staff member T stated dietary is responsible for resident supplements. During an interview on 10/19/16 at 9:00 a.m., staff member U stated CNA's should notify the nurses of a residents weight loss verbally. Staff member U stated she was unsure if resident #8 had any nutritional supplements served to her. During an interview on 10/20/16 at 9:15 a.m., staff member D stated that she should have noted the weight loss of resident #8 on the resident's care plan. Staff member D stated that she was not sure of the reason for the resident's weight fluctuation. Staff member D stated she did recognize that there was a pattern of weight loss for resident #8.

Based on clinical record and facility policy and procedure review, the facility failed to properly assess 1 (#22) of 25 residents on anticoagulant therapy after a fall resulting in a head injury. 1. Resident #22 was re-admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. During a review of the MDS, with an ARD of 4/28/14, section C, reflected resident #22 scored an 8 (moderately impaired) on her BIMs. A review of the resident's nursing notes for 6/23/14 at 5:40 a.m. reflected the resident had an unobserved fall. "Heard bed alarm - as aide entered room heard resident fall found resident sitting on fall mat facing bed with head resting against O2 concentrator (sic) - resident states she hit her head - indicating (R) side - no bumps noted - no lacerations" Nursing documented in the "Nursing Notes," on 6/23/14 at (time undecipherable), "Up in w/c, quiet and sleepy, 97.3, 110 - 36, 134/91, appetite poor, bruises note (sic) rt wrist, rt arm and rt knee. 1145 Awake 116 - 34, 129/60, (son's name) notified of fall and increased pulse. (Doctor's name) faxed in early am and in afternoon due to concerns in increased resp (sic) and decreased B/P, up in w/c, no verbal responsive, did say her head hurt - routine [MEDICATION NAME] 0.5mg given with [MEDICATION NAME]." The nurse noted on 6/24/14 at 7:00 a.m., "Up in early am for bath, quiet, would not verbalize, able to transfer into w/c. Out to DR (sic) - pale, eyes open with no eye contact, audible lt. (sic) wheezing noted. Ref (sic) food, drink and meds, ref (sic) breathing Tx. This nurse asked how she was feeling and she stated "terrible", no other verbal response 97.3 - 116-40 115/87, O2 sat 93% with O2 at 2 liters, family notified of changes." Medication administration records for June 2014 showed resident #22 received her scheduled doses of: 9 -[MEDICATION NAME] 60 mg, 4 doses were administered on the 23rd and refused by the resident on the 24th in the a.m. -[MEDICATION NAME] 0.2 mg was placed on the 23rd and the 24th -[MEDICATION NAME] 5mg was administered at HS on the 23rd -[MEDICATION NAME] 1 mg was administered at HS on the 23rd -[MEDICATION NAME] 10 mg was give in the a.m. on the 23rd and the 24th -[MEDICATION NAME] 0.5 mg, 3 doses were administered on the 23rd and 1 dose on the 24th -[MEDICATION NAME] 5/325 mg, 1/2 tab was administered twice on the 23rd and twice on the 24th -ECASA (enetric coated aspirin) 325mg, was administered on the 23rd and refused by the resident on the 24th in the a.m. Nursing note on 6/24/14 at 8:45 a.m., "(Son's name) and (daughter-in-law's name) here, choices shared with family and family requested to go to ER (emergency room ). 0915 To ER per bus accompanied by (son's name) and (daughter-in-law's name). Informed ER of transfer and message left for (Doctor's name) of transfer to ER. 1230 call made to (hospital's name) - admitted to (hospital's name) for subdural hematoma." Review of the ER report dated 6/24/14 reflected the following: CT Head: ....demonstrates a large acute subdural hemorrhage measuring 2.2 cm with 6 mm midline shift. Impression/Plan: Patient is a [AGE] year old female presenting with a large subdural hematoma and midline shift, potentially related to an unwitnessed fall the previous day. This is associated with mental status changes and, per review with neurosurgery, is not felt to be a survivable event with death imminent within the next day or two. The family has been apprised and all are in favor of comfort care measures.... Review of the Discharge summary dated 6/26/14 reflected: .....at the (name of hospital) where she received supportive cares.....She ultimately succumbed to her injury at approximately 4:40 a.m. on 6/26/14 with family at her bedside. Staff member A, DON, was interviewed on 8/12/14 at 3:30 p.m. When questioned about the facility's policy regarding resident falls, she provided a copy of the facility's Fall and Risk policy. She was also asked about policies and procedures for nursing staff and what was used. She replied, "We use the Lippincott's Nursing Procedures book for all of our nursing policies and procedures." She provided a copy of the facility's Lippincott's Nursing Procedures manual, 6th Edition, currently in use. On page 298 of the Lippincott's Nursing Procedures, under nursing alert, it states: "Patients taking anticoagulants or on aspirin therapy who experience head trauma are at increased risk for subdural hematoma." The facility's Fall and Risk policy and procedure, under Monitoring & Follow-Up, revealed: "a. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall." -"[MEDICATION NAME]-[MEDICATION NAME], ([MEDICATION NAME] or [MEDICATION NAME]) is to be used cautiously in patients with a history of respiratory depression, drug abuse, head injury or increased intracranial pressure." 1, 9 -[MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME] or [MEDICATION NAME]) include the following precautions; "before using this medication, tell your doctor or pharmacist your medical history, especially of: brain disorders (such as head injury, tumor, [MEDICAL CONDITION])." 2,9 -Aspirin: "Has an important inhibitory effect on platelets in the blood. This antiplatelet effect is used to prevent blood clot formation inside the arteries. In individuals older than 80, the treatment with aspirin was associated with more bleeding episodes which out weigh the protective benefits. Who should not be taking aspirin? Patients at risk for developing [MEDICAL CONDITION]. Another serious but rare side effect of aspirin is intracranial hemmorrhage (bleeding into the tissues of the brain), similar to a hemorrhagic stroke." 3,9 -[MEDICATION NAME] ([MEDICATION NAME]) is a benzodiazepine. Some of its' side effects include; "drowsiness, dizziness, loss of coordination, headache, nausea, and blurred vision. Precautions include; older adults may be more sensitive to the side effects of this drug , especially loss of coordination and drowsiness." 4,9 -[MEDICATION NAME] ([MEDICATION NAME]) is used for: "relaxing blood vessels in the body and heart and lowers the heart rate. Blood can flow more easily and your heart works less hard to pump blood. The side effects include; dizziness, lightheadedness, weakness, nausea, flushing, constipation, and headache." 5,9 -[MEDICATION NAME] Patch (Nitro-Dur or [MEDICATION NAME]-Nitro) is used to: "prevent chest pain ([MEDICAL CONDITION]) in people with a certain heart condition ([MEDICAL CONDITION]). Precautions include: Before using this medicine, consult your doctor or pharmacist if you have had a recent head injury." 6,9 -[MEDICATION NAME] ([MEDICATION NAME]) is an antipsychotic medication. Drug interactions include the following: "[MEDICATION NAME] causes sedation, and sedation may be greater if [MEDICATION NAME] is taken with alcohol and other drugs than (sic) can cause sedation such as the benzodiazepine class of anti-anxiety drugs for example: [MEDICATION NAME] ([MEDICATION NAME]). Narcotic class of pain medication and its derivatives for example: [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]). Some [MEDICATION NAME] for example: [MEDICATION NAME] ([MEDICATION NAME]). Some of the most common side effects include: tiredness, nausea and sedation." 7, 9 -[MEDICATION NAME] ([MEDICATION NAME]) is an antidepressant. It is recommended that the following medications be avoided: "nonsteroidal anti-[MEDICAL CONDITION] drugs (NSAID). This included aspirin, celecoxib, [MEDICATION NAME] and others. Using an NSAID with [MEDICATION NAME] may cause you to bruise or bleed easily." [MEDICATION NAME] side effects include: "headache, slurred speech, severe weakness, muscle cramps, feeling unsteady, [MEDICAL CONDITION] (convulsions), and shallow breathing (breathing may stop), drowsiness, and feeling tired." 8,9 ? "[MEDICATION NAME]/[MEDICATION NAME] - ORAL ([MEDICATION NAME]) Side Effects, Medical Uses, and Drug Interactions." MedicineNet. First Databank, Feb. 2014. Web. 18 Aug. 2014. <http://www.medicinenet.com/script/main/art.asp?articlekey= >. ? Rader, Janet, RN, BSN, and Dorothy Terry, RN. "[MEDICATION NAME]-[MEDICATION NAME]." Nursing 2014 Drug Handbook. By Lisa M. Bonsall. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014. 694-96. Print ? Nabili, Siamak T., MD, MPH, Daniel L. Kulick, MD, FACC, FSCAI, and William C. Shiel, MD, FACP, FACR. "Aspirin and Antiplatelet medications: [REDACTED]. FDA Prescribing Information, 3 Mar. 2009. Web. 18 Aug. 2014. <http://www.medicinenet.com/script/main/art.asp?articlekey= >. 4 "[MEDICATION NAME] ([MEDICATION NAME]) Dosages, Uses and Side Effects." MedicineNet. First Databank, Nov. 2013. Web. 18 Aug. 2014. <www.medicinenet.com%2Fscript%2Fmain%2Fart.asp%3Farticle%3D >. 5 "[MEDICATION NAME] TABLET - ORAL ([MEDICATION NAME]) Side Effects, Medical Uses, and Drug Interactions." MedicineNet. First Databank, Dec. 2013. Web. 18 Aug. 2014. <http://www.medicinenet.com/script/main/art.asp?articlekey= >. 6 "[MEDICATION NAME] Patch." Www.medicinenet.com/script/main/art.asp?articlekey= . N.p., 01 Mar. 2014. Web. 18 Aug. 2014. 7 Ogbru, Omudhome, PharmD, and Jay W. Marks, MD. "[MEDICATION NAME]: Drug Facts, Side Effects and Dosing." MedicineNet. FDA Prescribing Information, 23 Feb. 2012. Web. 18 Aug. 2014. <http://www.medicinenet.com/script/main/art.asp?articlekey= >. 8 "[MEDICATION NAME] ([MEDICATION NAME]) Uses, Dosage, Side Effects - Drugs.com." [MEDICATION NAME] ([MEDICATION NAME]) Uses, Dosage, Side Effects - Drugs.com. Cerner Multum, Inc., 21 Jan. 2014. Web. 18 Aug. 2014. <http://www.drugs.com/[MEDICATION NAME]>. 9 Nurses are obligated to follow the orders of a licensed physician or other designated health care provider unless the orders would result in client harm. DeLaune, S. & Ladner, P. (1998). Fundamentals of Nursing, Standards and Practice (p.237). Albany, N.Y.

Based on observation, resident and staff interview, and record review, the facility failed to ensure 1 (#11) of 24 sampled residents was provided the necessary care and services to maintain his highest level of well-being. Specifically: -Nursing staff failed to completely assess the resident after a fall and before allowing CNAs to use a lift to transfer him from the floor into a wheelchair; -Nursing staff failed to assess the resident for injuries in a timely manner after the fall. On 8/28/13 at 10:30 a.m., the facility administration was notified by the surveyors that an immediate jeopardy situation existed for resident #11. The resident had a history of [REDACTED]. When the resident fell on [DATE], the facility failed to ensure he was thoroughly assessed for injuries before moving him. There was a delay from the time the resident fell until he was assessed for injuries and sent to the ER. He was diagnosed with [REDACTED]. The facility was requested to provide a plan for how they would abate the immediate jeopardy situation for resident #11 to ensure nurses would respond appropriately to emergency situations and keep him from further harm. A summary of the facility's abatement plan to remove the immediate jeopardy is as follows: -All nurses would be trained on facility fall assessment policy and post falls notification policy. -The LPN, who became unstable during the emergency situation on 8/27/13, met with the DON prior to accepting assignment on the Bratsberg Unit. She provided a written statement of her perception of incident management and the nurse was relieved from duty until she could be reeducated on emergency responses, responses to falls, updating of the care plan, and notification of physician standards. -The second LPN, who was on shift during incident of 8/27/13, was educated on providing assistance to team members when the team member is noted to be unable to perform their duties. The LPN was educated that all residents are every staff member's responsibility and that when responding to a fall, she is not to leave the scene until the resident has been properly evaluated. -Beginning 8/28/13 (as licensed staff begin their shifts) until all licensed staff have been trained, all licensed nursing staff will be re-educated on emergency response to incident and accidents, post falls assessments and timely notification to physician when incidents such as falls occur. All licensed nurses will be provided this training and sign that they have received this training as they come onto their shift. -Written procedures and standards will be placed in the "falls management book" by the end of 8/29/13 for staff to refer to if they have questions about specific procedures. -A QA (quality assurance) monitor will be put into place to ensure correction and statistics will be reviewed at the quarterly QA meeting. The exit conference was held with administration on 8/28/13 at 1 p.m. The extended survey was conducted by several surveyors who remained in the facility, after the majority of the team left. The abatement plan for the immediate jeopardy plan was submitted by the facility to the surveyors at 3:12 p.m.; the immediate jeopardy was abated on 8/28/13 at 4:00 p.m. at which time the remaining survey team members exited the facility. After the immediate jeopardy was abated for resident #11, the deficient practice remained at a scope and severity level of a D (potential harm that was isolated). Findings include: Resident #11 was first admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident resided in the locked Bratsberg Memorial Wing for residents with dementia/[MEDICAL CONDITION]. According to the 7/3/13 Significant Change MDS assessment, the resident was severely impaired in cognition (Brief Interview of Mental Status score of 3). The resident required limited assistance of two or more staff for transfers and toileting. He required extensive assistance of 2 or more persons for bed mobility. The resident walked in his room with limited assistance of one staff member and used a walker or wheelchair. The resident was not steady for balancing; he was only able to stabilize with human assistance (sit to stand, walking, turning around while walking, surface to surface transfers, toileting). The resident was 56 inches tall (4'8") and weighed 82 pounds. The nurses notes ranging from 12/12/12 to 8/27/13 were reviewed on 8/27/13 at 11:20 a.m.. The nurses' notes indicated the resident fell 12 times during the 8 1/2 months prior to the survey. Many of the falls (at least 10) were unwitnessed and the resident hit his head or face in 9 of the falls. The resident sustained [REDACTED]. Cross refer to F323 for detailed information regarding his history of falls with injuries. The resident had an injury above his right eye first observed on the morning of 8/27/13 that was not there the previous day when he was last observed by the surveyor at 5:50 p.m. There was no record of the resident having sustained a fall or documentation of the injury in his medical record. During an observation on 8/27/13 at 7:45 a.m., resident #11 was lying in a recliner with the foot of the recliner raised. Staff member JJ, an LPN, walked by this surveyor and remarked that the resident might try to climb out of the chair. At 7:50 a.m., the resident made a noise and the surveyor observed resident #11 with both feet and legs up to his knees over the left arm of the recliner. The recliner was placed near the wooden fire place mantle which had a sharp corner protruding right where the resident was heading. Staff member JJ was near the nurse's desk but could not see the resident due to the large column attached to the half wall that impeded the view. This surveyor informed staff member JJ the resident was climbing out of his chair. Staff member JJ came to the resident and began to assist the resident back into the chair by pulling on his legs to get them back over the side of the chair. Staff member JJ hollered for assistance and staff came to assist her. The back of the chair was raised and the staff assisted the resident to stand. The resident complained his side was hurting as he was moved and held onto his right side and continued to complain of his discomfort as he was moved into his wheelchair. The surveyor noticed the resident had a large open, area that was bleeding a small amount over his right eyebrow and down around his right eye that was not there the previous day. This surveyor heard staff member JJ say, "He may need an x-ray of that side." This surveyor asked staff member JJ if resident #11 had fallen recently. Staff member JJ stated the resident's injuries were from the previous Friday. However, on 8/26/13 at 8:15 a.m., this surveyor observed the resident being bathed and there were no marks on his forehead and again at 5:50 p.m. he was without any injuries to his forehead. The resident was taken to his room. As the observation continued on 8/27/13, staff member KK, a CNA, took resident #11 into the bath room. An observation was made of resident #11 at 8:00 a.m. which revealed resident #11 neither had bruises on his right side nor did he have bruises on the right hip at that time. When asked if he hurt, the resident showed the surveyor his right hip bone and stated it hurt "a lot." During the observation, staff member KK stated the resident had a long scratch on his right upper thigh and that he probably needed an x-ray of his hip and his side. At 8:20 a.m. on 8/27/13, resident #11 was observed to be seated at the dining room table in his wheelchair with a buttered muffin and coffee on the table before him. The resident's head was down and his eyes were closed. At 8:30 a.m., resident #11 was still at the table, awake now and picking at his muffin. From 8:45-9:00 a.m. resident #11 was sitting quietly at the dining room table. He took an occasional bite of his muffin, swallowed some coffee and remained seated. At 9:25 a.m., resident #11 stated he still hurt. Later on 8/27/13, the resident was found lying on the floor, having sustained an unwitnessed fall. On 8/27/13 at 1:30 p.m., resident #11 was observed by the surveyor to be lying on his back on the floor with the the top of his head facing the nursing station. His walker was overturned, approximately, two feet away from the resident's right side on the floor. A "Wet Floor" sign was at his feet. The resident stated he had fallen over the sign. Staff member V, a LPN, kneeled directly above his head. Staff member V asked the resident if he hurt. The resident replied "yes, my head." Staff member E, a LPN, stood above the resident and straightened out his legs while saying "(resident name) you fell again." Then staff member E left the area. Staff member V, an LPN, asked the resident if his neck hurt and the resident said "yes it hurts." Staff member V did not check the resident's neck or spine for potential injuries. Staff member V told the resident to hold on because the lift was coming. Staff member KK, a CNA, told the nurse that resident #11's hip was hurting earlier that day. The nurse stated he had not had any x-rays today. CNAs had gathered the lift and a pillow to get resident #11 off the floor. Staff member KK turned the resident to his right side and placed a pillow under his left side and then turned the resident to his left side and placed a sling to the lift under his back. During this movement the surveyor observed the resident grimace and say "ouch, my legs" when he was turned. The nurse did not stop the CNAs from moving the resident after he complained of pain and without having a thorough assessment for injuries. The CNA then turned the resident back to his right side and pulled the sling out from under him on the left side. During this time, the nurse, staff member v, asked the resident, "Where do you hurt?" The resident grabbed both his legs at his hips showing her where he hurt. As the resident was placed in the sling and lifted, the resident was saying, "Ouch, ouch, ouch." Again staff member V and staff member E did not stop the transfer with the hoyer lift. The resident's statements of ouch were not acknowledged. The CNAs were directing the care of the resident by telling each other what to do next. The CNAs placed the resident in his wheelchair using the lift and took him down the hall. Staff member V, who was quiet during this procedure, followed the CNAs. Staff member E stated during the lift procedure, "The resident has a right to fall." When the surveyor asked staff member E what the procedure was for moving a resident that states they are in pain, she replied "He is not my resident." Then staff member E stated resident #11 wandered and could get himself up from a fall. She stated he had a previous neck injury with a hairline fracture. Staff member E also stated that the resident had fallen and hit both his front and back three times in a row over the last three months. Staff member E stated resident #11 had fallen August 25th and hurt his back. Staff member E stated he had a small hematoma that was "absorbing" and that the resident had chronic back pain and further stated, "He is always falling." When asked, staff member E stated the nurse should direct the care of the resident; that they always picked residents up with a lift. She stated if you couldn't move the resident's head you would get a board or an ambulance. You would get a fall matt and lift him bodily with 4-6 staff members, however, she stated she had never seen this done. When asked about the open area on his forehead and around his eye, staff member E stated if he fallen earlier it had to be between 5 and 7 am and that there had been no report of a fall. Review of the "Fall Protocol (Guidelines only)" revealed nurses were to take the following actions: -Take vital signs; -Note any injury; -Check ROM and if able to bear weight; -Note any complaint of pain; -Check for bruising, swelling or changes in skin x 24 hours; -Green tag chart x's 24 hours or as needed; -Complete incident report; -Notify MD and family; and -Chart in nurse's notes. An observation on 8/27/13 at 1:45 p.m. revealed resident #11 to be sitting at the nurse's station in his wheelchair with staff member V. He had an ice bag on the back of his head and it had a band around his head to hold the ice bag in place. Observation was made of staff member V sitting at the nurse's station taking the resident's vital signs. At 2:30 p.m., the unit manager stated that all falls were reviewed the next day unless it is on a weekend in the stand up meeting. The unit manager stated managers reviewed the falls and came up with interventions if possible. All the documentation for the interventions could be found in the nurses' notes. At 2:30 p.m., staff member V was asked what the protocol was for a fall and she stated "assess, do vitals, do not move the resident if they can not move, but I moved (resident's name) because he could move and he falls all the time." I gave him some pain medication and a glass of milk. At 2:45 p.m., staff member E ask the surveyor if this situation would be considered emergent and then placed a call to the physician. The call to the physician was placed one hour and 15 minutes after the fall. Review of nurse's notes (signed by staff member V) dated 8/27/13 at 1330 reflected: "Resident #11 was found flat on his back down (n) hall, wet floor sign laying at foot of resident, sm (sic) abrasion back of head, ROM to all extremities without pain or difficulty, lifted to w/c by Vander lift, ice to back of head, neuros started, c/o back, head and rt hip pain - prn [MEDICATION NAME] (pain medication) 600 milligrams given, Dr. ---- office nurse called - to obseve (sic) resident 98.6-70-20 110/65, POA ------ notified of fall." At 6:00 p.m., resident #11 was observed to be sitting in his wheelchair in the living area. He stood up and his chair alarm was activated. Staff member C was at the nurses's station sitting down with this surveyor. There were no other staff visible and no staff responded to the sound of the alarm. Staff member C said, "What is that?" Staff member C stood up and saw Resident #11 in the living area and saw that he was standing. Staff member C ran and assisted him to sit down. At 6:10 p.m., after meeting with the survey team leaders concerning the care of Resident #11, the DON arrived at the unit and told staff member C, an RN, to do a full head to toe assessment for resident #11. Staff member C went into resident #11's room. Resident #11's blood pressure was 120/64, his temperature was 98.8, his oxygen saturation was 96% and his pulse was 76. Staff member C asked resident #11, "You don't hurt anywhere?" The resident stated "no." Staff member C asked the resident his name and he did not respond. She asked again and he responded correctly. Staff member C stated resident #11 had a bump on the back of his head. Staff member C checked the resident's pupils for their reaction to light. She stated his pupils were equal (in size) but the reaction was a little sluggish. Staff member C checked the resident's tongue, said it was okay, then noted a bruise by his right eye and on his chin. Staff member C asked, "You're not having any pain anywhere?" Resident #11 stated, "No." Resident #11 was turning his head slightly back and forth. Staff member C asked, "Does it hurt when you do that?" The resident responded, "no." The resident looked up at the ceiling and the nurse asked, "Does that hurt?" The resident responded, "Nope." Staff member C asked, "Do I look normal or fuzzy?" The resident stated, "Normal." Staff member C asked, "Do you have a headache?" The resident stated, "Nope." Staff member C pulled the resident's left leg out straight without a problem, then pulled his leg sideways and the resident complained of pain. The staff did the same thing with his right leg without problems. Staff member C took his feet one at a time and moved them up and down and back and forth without problems. The resident leaned over in his wheelchair to get a blanket off his recliner and stated it didn't hurt when he did that when asked by staff member C. The resident refused to open his mouth when asked by staff member C. Staff member C asked, "What happened to your eye?" The resident stated, "I don't remember." Staff member C asked, "Do you have pain on standing?" The resident replied, "Nope." Staff member C asked, "Do you feel dizzy or nauseated?" The resident replied, "Nope." Staff member C said, "(called his name), do you hurt any where? The resident replied, "No, not now. It's all over with." Staff member C checked his nose and his ears. Staff member C checked the bump on the back of his head and stated it did not feel like a "goose egg" but stated it felt like bone at the back of his skull and that it was round and goes down "south." The resident did not complain when the area was touched. Staff member NN, a CNA, put a gait belt around the resident's body. The resident complained of "an ache" on his right arm and shoulder. When asked to stand, the resident placed his right hand on the arm of his wheelchair and pushed to get up, but stopped and sat back down. Staff member C encouraged him several times to stand up and he refused to stand or walk. Review of Nurse's Notes dated 8/27/13 (no time documented) reflected, "resident up on unit - ate and drank well at meal time. Resident was assessed and at 19:45 left per ambulance to (name of hospital) ER for evaluation. Resident checked and a RN from (Hospital) called. Resident has a T-3 compression fracture." The resident returned to the facility at 11:20 p.m. and a note that the night shift nurse would follow up. Review of the hospital discharge notes dated 8/27/13 for Resident #11 reflected: Home Care: Your fracture will most likely heal in 6-12 weeks. Follow these guideline to promote healing: -Rest in bed 2-3 days, unless your doctor says otherwise -Ask family members to help with daily activities until you are ready. -Create a safe home environment to avoid trips and falls. -When you are ready, go about your normal activity.

Based on observation, record review, staff interview and resident interview, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible; and 3 (#s 1, 18, 26) of 50 sampled and supplemental residents received adequate supervision and assistance devices to prevent accidents. Specifically: -Resident #11 was not protected from repeated falls. He hit his head numerous times and sustained injuries, thereby creating an immediate jeopardy situation. -Resident #18's care planned interventions to prevent falls were not implemented. -Resident #26 was not transferred in a safe manner by staff. -Water was not at a safe temperature in 3 resident's rooms. On 8/28/13 at 10:30 a.m., the facility administration was notified by the surveyors that an immediate jeopardy situation existed for resident #11. The resident continued to have falls with injuries including head trauma, lacerations to the arms and legs, and fractures of his neck and spine without sufficient and timely safeguards being put into place to his ensure safety. The facility was requested to provide a plan for how they would abate the immediate jeopardy situation for resident #11 to keep him from further harm. A summary of the facility's abatement plan to remove the immediate jeopardy is as follows: -Staff would perform 15 minute visual checks for resident #11 when he was lying down in his room; staff were required to be within line of sight by staff when he was up and in the common areas. -The pharmacist would evaluate resident #11's medication regime within 24-48 hours. -Daily skin checks for resident #11 would be performed to identify any unobserved injuries. -The physical therapist would evaluate resident #11 for transferring ability and status. The exit conference was held with administration on 8/28/13 at 1 p.m. The extended survey was completed by several surveyors, who remained in the facility, after the majority of the team left the facility. The abatement plan for the immediate jeopardy plan was submitted by the facility to the surveyors at 3:12 p.m.; the immediate jeopardy was abated on 8/28/13 at 4:00 p.m., at which time the remaining survey team members exited the facility. After the immediate jeopardy was abated for resident #11, the deficient practice remained at a scope and severity level of a G (actual harm that was isolated). Findings include: 1. Resident #11 was first admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident resided in the locked Bratsberg Memorial Wing for residents with dementia/Alzheimer's disease. According to the 7/3/13 Significant Change MDS assessment, the resident was severely impaired in cognition (Brief Interview of Mental Status score of 3). The resident required limited assistance of two or more staff for transfers and toileting. He required extensive assistance of 2 or more persons for bed mobility. The resident walked in his room with limited assistance of one staff member and used a walker or wheelchair. The resident was not steady for balancing; he was only able to stabilize with human assistance (sit to stand, walking, turning around while walking, surface to surface transfers, toileting). Care Plan for Wandering: Review on 8/26/13 at 5:30 p.m., of the resident's Care Plan included the problem of "Wandering related to dementia." The goal for wandering indicated "Resident will be able to wander safely in environment." The approaches for obtaining this goal included: -"Provide supervision, approach calmly, offer assistance and attempt to redirect." -"Accompany resident to go where desired." -"Room close to nurses station." -"Mark room with name, familiar object or picture" -"Sign on resident bathroom door with picture of toilet." -"Sign on resident's door "(resident #11's name) room." Care Plan for Falls: Review on 8/26/13 at 5:30 p.m., of the resident's Care Plan included the problem of falls. The goal for falls indicated "Would like to remain free from injury for he next 90 days." The approaches for staff to utilize in assisting the resident to obtain this goal included: -"Please insure that adaptive devices - walker is within reach and in good repair and remind resident to use FWW, -Please see resident communication report for current transfers, mobility and T/P status, -Remind resident to wear soft helmet, -Keep room clutter free and well lit, -Assist resident to wear glasses, when awake, -Bed in locked position, -Offer toileting frequently throughout the day, -Resident will try to pick up items on the floor that are not there, -Labs per MD (medical doctor) order, -Room closest to nurses station, -Fall mat, -hip protectors, -bed in lowest position, -Alarm on bed, chair, door, -and scoop mattress." Not all interventions that were care planned, were implemented. During all surveyor observations on 8/25, 8/26, 8/27 and 8/28/13, the approaches to mark the resident's room with name, familiar object or picture and sign on resident's bathroom door with picture of a toilet were not in place. The resident was not observed wearing eyeglasses during the survey; the resident did not consistently wear his helmet (see findings below). Staff member C, an RN MDS coordinator requested that the therapist do a transfer memo for resident #11 on 8/28/13 at 7:30 a.m. On 8/28/13 at 9:10 a.m., staff member WW, the therapy supervisor was interviewed and asked about the "transfer memo." Staff member WW stated the therapist did the transfer memo when it was requested by the nurse, and when it was completed, it went into the medical record under the rehabilitation section. Staff WW further stated it served as the back up to the card that was placed on the walker or wheelchair. During an interview on 8/28/13 at 12:30 p.m., staff member VV, a physical therapist stated, "I had filled out a Transfer Memo 6 to 7 weeks ago and listed him as independent with walker. I did a short course of therapy and balance seemed reliable. Left message with nurses to have him use walker. I completed another one this morning and he is independent with walker but needs supervision." During an observation on 8/26/13 at 12:45 p.m. resident #11 was in room 106 (resident #42's room and not his own room). No staff members were with the resident. At 1:19 p.m., staff walked with resident #11 to the dining room. The resident did not have his helmet on and staff did not encourage the resident to wear it. At 1:40 p.m., the resident was up walking without his helmet and without his walker in the dining room. At 2:15 p.m., the resident continued to walk around without his helmet. Staff commented on his walking towards the exit. Staff did not prompt/encourage the resident to use a helmet. During these observations the helmet was not attached to the walker. Fall History The nurses notes ranging from 12/12/12 to 8/27/13 were reviewed on 8/27/13 at 11:20 a.m. The following nurses' notes indicated the resident fell 12 times in the 8 1/2 months prior to the survey. Many of the falls (at least 10) were unwitnessed and the resident hit his head or face in 9 of the falls. The resident sustained [REDACTED]. The progression of the resident's falls and facility fall review results were as follows: Fall #1 on 1/12/13 On "1/12/13 0430 (4:30 a.m.) Res. (resident) on butt on fall mat next to bed... (0 with line through it) injuries noted. States R butt (ishium) tender nothing to see. Roommate # witnessed. Stated @ the time did not hit head. 0700 (7:00 a.m.), up to BR (bathroom) noted 1 1/2 in x 1 1/2 in blue raised area / in below crown of head. Mentation unchanged. Neuros (neurological checks) began. (1330 or 1:30 p.m.) Hit back of head - has 2 1/2 cm round red, raised bump on back of head, surrounded by bruising. " On "1-29-13 Fall review. Has bed, chair & door alarms Hip protectors. CT (computed tomography scan) of head was negative" Fall #2 on 3/6/13 On "3/6/13 0215 (2:15 a.m.) Heard door alarm to room sound - immediate staff response then heard loud bang. Into room resident sitting on floor near door - noted quarter size drops of blood on floor. Blood on head Resident alert - able to answer questions - LOC baseline Ice & cold wash clothes applied wash clothes applied Asked if neck hurt - stated "no", active bleeding stopped - noted Left elbow - golf ball size - swelling - 2 staff slipped lift sling under buttocks area - supporting spine & neck - Lifted into bed...on call for Dr. (name of doctor) notified. Resident received orders to send to ER for eval (evaluation)..." Based on review of the 3/6/13 fax sent to the doctor, "(resident #11) went to theER on [DATE]. He had a fall resulting in 3 staples to laceration back of his head...Also had T 1 (vertebrae) compression fracture..." Based on review of the "3/6/13 at 05:12 Radiology Report Indications: Patient has injuries from falling tonight. Findings: There is a recent or acute appearing fracture of the inferior endplate of the T 1 vertebrae with approximately 25% maximum loss of height. Inferior endplate is concave and fracture lucency is identified anteriorly. Fracture also extends to the posterior wall in its inferior aspect without displacement of posterior wall fragments..." Fall #3 on 3/19/13 On "3-19-13 (0030) (12:30 a.m.) found resident lying on floor in front of his chair in his room. Resident was lying on L (left) side has .25 cm laceration to bridge of nose - has 1.5 cm laceration to L eyebrow outer aspect - Back to bed per lift - laceration cleansed - steri- strips applied to (sic) lacerations to eyebrow - edges approximated well - VS (vital signs) 96 - 70 - 16 129/43 O2 (oxygen) 96% - neuro checks done - ROM gd (good) to extremities - ice applied to laceration" On "3-19-13 Fall review. Put non-slip strps (strips) on floor. Getting order for PT and OT. Try soft helmet." Fall #4 on 4/2/13 On "4/2/13 1515 (3:15 p.m.) fell Abraised L upper f/head-pale blue 1/2 in mark. Mentation @ baseline-pupils equal-grips equal- non skid socks on carpeting by bird cage. Well lit. got self up - Rolling onto knees et using chair to get up..." On "4/3/13 0915 (9:15 a.m.) Fall review. Cont (continue) same precautions." The care plan meeting documentation of 4/9/13 included, "4/9/13 Care Meeting-...Resident high fall risk. Refuses to wear collar and helmet. Has Ativan (antianxiety medication) PRN. has hx of seizures." Fall #5 on 4/17/13 On "4/17/13 0715 (7:15 a.m.) Found Resident in room 122 Standing /c (with) walker. Stated 'I fell & hit my head - Blood noted on back of head wheeled to nurses station-cleaned area - Ice pk (pack) applied neuro (check mark) initiated. Denies pain at this time. VSS soft helmet & ice pk placed on head" On "4/18/13 Review for fall - Resident has been wearing soft helment (sic). continue POC (plan of care)." Fall #6 on 6/12/13 On "6/12/13 1915 (7:15 p.m.) Res (resident) was seen standing @ the window in the west hallway. Nurse heard a loud crash & saw Res laying on floor. unable to say what happened Res states 'I'm just very tired.' Res was able to get self up off of floor /c help of walker -held in place by staff. Sm (small) laceration was noted to back of head 1 cm x .5 cm. Fax was sent to Dr. (name of doctor) office...VS 113/66 - 77 - 24 - 98..." On "6-14-13 Fall review - staff to keep reminding resident to use walker and encourage resident to wear soft helmet." Fall #7 on 6/19/13 On "6/19/13...At 1940 (7:40 p.m.) resident found by a second resident (resident #35) in room 120. Resident notified the staff. (resident #11) was found up using his walker. 2 cm Skin tear at his right hand near little digit. Also 2nd skin tear at the elbow 3 cm. And old head wound reopened /c Bump at the the base of his skull. Wound & skin tears cleansed and tx done steri stripes (sic) & drsg (dressing) on sites." On "6/20/13 fall review- MD decreased Flomax from 0.8 mg to 0.4 mg. MD thinks possibly too much Flomax (medication to improve urination) could be causing resident to fall." Fall #8 on 7/14/13 On "7/4/13 0600 (6:00 a.m.) (check mark)'d in Res in RM (room), Res was sitting /c his right side facing me in his chair, notice he had some things on floor & asked CNA to do RM (check mark). CNA called out my name for me to come in and see him because he was bleeding-Went in & he had an abrasion on the corner of his L eyebrow 1.5 cm long x .5 cm wide and a 1.5 cm round Abrasion above his left tempral (sic) area. Started Neuro assement (sic) sheet. V.S T (temperature) 98 P (pulse)71 R18 B/P 134/100 O2 Sat 98%. Neuros within normal limits ROM on extremities done for assessing injuries ROM on all extremities within normal limits. did skin assement (sic). No other visible injuries, Cleansed with soap & water, and cleansing wipes and applied steri strip to Eybrow (sic) area, Bed alarm did not go off - floor bare & Dry-feet was bare..." Review of a fax dated 7/4/13 indicated "(resident #11) was sitting in his chair in his room and when a CNA entered the room she noticed (resident #11) had a laceration to the L temple measuring 1.5 cm x 1 cm. Staff thinks (resident #11) self transferred from the bed to the chair and hit his head on the bed frame." Fall #9 on 7/29/13 On "7/29/13 (0010) (12:10 a.m.) heard crash - found resident sitting on floor in hall BR leaning against wall walker in front of him ROM gd (good) to extremities grasp gd - refused neuro eye check - Back to bed per Lift VS 97-68-14 118/62-92% O2 0 new abrasions." On "7/30/13-0910 (9:10 a.m.) fall review- Have MD check lab and check for MD assessment" On "7/29/13-0930 (9:30 a.m.) fall review for 7/28/13 & 7/29/13. Check UA (urinalysis) and dilantin levels" Fall #10 on 7/29/13 On "7/29/13 2000 (8:00 p.m.) Staff heard noise in TV area on BMW. Found Res laying on his back on floor /c walker beside him. Assessment done. Reopened R elbow wound. - Area was cleaned & drsg (dressing) applied. Res stated 'I did not hit my head.' No new injury noted to back of head. Vander lift was used to lift res off of floor into Recliner in TV area. Refused to have VS taken. Fax prepared & sent to (names of doctors) office.. Fall #11 and 12 on 8/24/13 On "8/24/13 1430 (2:30 p.m.) Res. wanders into other rooms; found him in Rm 127 between bed and window standing. (sic) Walker found on floor ; (sic) noted his occipital area to be bleeding ; (sic) ambulated /c help to NSG (nursing) station ; (sic) cleaned area ; (sic) has 2.0 cm x 0.2 cm laceration. T . 98.2 P. 76 R.16 126/62 ; Neuro checks stable @ this time." A fax received from the facility on 9/3/13 in regards to the above nurses note indicated "(14:20) Resident (up arrow down arrow) ambulates /c walker into other rooms. 1st Fall in Rm 127 found beside bed next to window, standing up. Abrasion on back of head - some bleeding. Cleansed scalp... (18:28)"(6:28 p.m.) 2nd Fall found on Floor With back up against chair in the room, sitting position with legs straight out front of self. Skin Tear Lt. (left) Elbow" On "8/27/13- fall review - falls 8/24 & 8/25/13. When resident is awake at noc, dress resident and allow to get up" Review of the above "falls reviews" did not indicate evidence of the facility specifically addressing unwitnessed falls. Review of the facility's policy titled: "Post Accident Investigation and Care Plan" with an origination date of 3/31/08 and review date of 7/19/13 indicated its "Purpose: To assess resident falls/incidents in efforts to prevent reoccurrence, injury, or the progression of an injury, following a reported incident by a multi-discipline assessment of the incident and development of interventions and/or recommendations." Review of this policy included section "III Post Incident Assessment: ...The nurse assesses the resident for injury and describes the incident in as much detail as possible. The nurse takes steps to prevent future occurrence and notifies the appropriate parties including the physician and documents in the clinical record. Daily following the stand-up meeting each new incident is reviewed by the interdisciplinary team....The team evaluates the individual incident and based on professional judgement and collaboration, determines an intervention to be taken in efforts to prevent further incidents from occurring." During an interview on 8/27/13 at 8:20 a.m., staff member C, RN MDS coordinator, stated, "Fall reviews, we do when there is a fall, do the meeting the next day. Those that meet are the PT, DON, social worker, dietician and unit manager. We talk about prevention. Only documentation would be what is in the nurses' notes. Sometimes he (resident #11) refuses to wear his eyeglasses. I don't know if they are for distance or close up. He puts them in his pocket. We encourage him to wear his eyeglasses. When he gets up in the morning we should be asking him encouraging him to wear. The Resident Safety Communication is communication from the PT on how to transfer. Card should indicate how to transfer. It should be on bed, walker or wheel chair." During an interview and observation on 8/28/13 at 8:55 a.m., staff member UU, CNA, stated, "I don't see the card (directing staff how to transfer the resident) on the bed, wheel chair or walker." During an interview on 8/26/13 at 1:30 p.m., staff member Z, a CNA, stated "They should offer him the helmet or attach it to his walker." During an interview on 8/26/13 at 1:55 p.m., resident #11, when asked if the helmet hurt him, stated, "No." When asked if he wanted to wear the helmet, stated, "No." During an interview on 8/26/13 at 2:00 p.m., staff member TT, an RN, stated, "Not sure if a different helmet has been tried. The doctor looked at Dilantin (seizure medication) levels thinking it was contributing to his falls." During an interview on 8/26/13 at 2:02 p.m., staff member SS, the nurse practitioner, when questioned as to whether resident #11 should be wearing his helmet indicated he should be. The resident had an injury above his right eye first observed on the morning of 8/27/13 that was not there the previous day when he was last observed at 5:50 p.m.. There was no record of the resident having sustained a fall or documentation of the injury in his medical record. During an observation on 8/27/13 at 7:45 a.m., resident #11 was lying in a recliner with the foot of the recliner raised. Staff member JJ, an LPN, walked by this surveyor and remarked that the resident might try to climb out of the chair. At 7:50 a.m., the resident made a noise and the surveyor observed resident #11 with both feet and legs up to his knees over the left arm of the recliner. The recliner was placed near the wooden fire place mantle which had a sharp corner protruding right where the resident was heading. The resident was 56 inches tall and weighed 82 pounds. Staff member JJ was near the nurse's desk but could not see the resident due to the large column attached to the half wall that impeded the view. This surveyor informed staff member JJ the resident was climbing out of his chair. Staff member JJ came to the resident and began to assist the resident back into the chair by pulling on his legs to get them back over the side of the chair. Staff member JJ hollered for assistance and staff came to assist her. The back of the chair was raised and the staff assisted the resident to stand. The resident complained his side was hurting as he was moved and held onto his right side and continued to complain of his discomfort as he was moved into his wheelchair. The surveyor noticed the resident had a large open, area that was bleeding a small amount over his right eyebrow and down around his right eye that was not there the previous day. This surveyor heard staff member JJ say, "He may need an x-ray of that side." This surveyor asked staff member JJ if resident #11 had fallen recently. Staff member JJ stated the resident's injuries were from the previous Friday. However, on 8/26/13 at 8:15 a.m., this surveyor observed the resident being bathed and there were no marks on his forehead and again at 5:50 p.m. he was without any injuries to his forehead. The resident was taken to his room. On 8/27/13 at 10:10 a.m., staff member B, the DON was interviewed in regards to the laceration over the corner of the resident's right eye. The DON stated she first observed the injury at 5:30 a.m. on 8/27/13 and had asked the nurse if resident #11 had fallen. The DON verified resident #11 had unwitnessed falls and agreed the laceration to the corner of the resident's right eye may have been from an unwitnessed fall. As the observation continued on 8/27/13, staff member KK, a CNA, took resident #11 into the bath room. An observation was made of resident #11 at 8:00 a.m. which revealed resident #11 did not have any bruises on his right side nor right hip at that time. When asked if he hurt, the resident showed the surveyor his right hip bone and stated it hurt "a lot." During the observation, staff member KK stated the resident had a long scratch on his right upper thigh and that he probably needed an x-ray of his hip and his side. Observation of resident #11 at 8:20 a.m. on 8/27/13, showed him to be placed at the dining room table in his wheelchair with a buttered muffin and coffee on the table before him. The resident's head was down and his eyes were closed. At 8:30 a.m., resident #11 was still at the table, awake now and picking at his muffin. From 8:45-9:00 a.m. resident #11 was sitting quietly at the dining room table. He took an occasional bite of his muffin, swallowed some coffee and remained seated. At 9:25 a.m., resident #11 stated he still hurt. During observations of 8/27/13 at 10:30 a.m., resident #11 continued to have the open laceration next to the top right corner of his right eye. Small spots of dried blood could be seen under the eye. During an interview on 8/27/13 at 10:40 a.m., staff member E, an LPN, stated, if staff handed the helmet to the resident, he would put it on and wear it for hours. However, if staff put it on for him, he would take it off immediately. According to the nurse, the last prn medication was given to the resident at 1:46 a.m. on the morning of 8/27/13. The resident was last checked at 0400 (4:00 a.m.) and nothing was documented about the laceration near his right eye. The nurse stated, "The laceration to the right eye has to have happened after 0500 (5:00 a.m.)." Review of the nurse's notes on 8/27/13 showed an entries at 4:00 a.m. and at 6:00 a.m. According to the 4:00 a.m. nurse's note, the resident was up twice during the night and had complained of pain to his right hip. He was administered pain medication for his hip pain and was sleeping at this time. A nurse's note at 6:00 a.m. indicated he was up and dressed, with "Neuros & VS Stable 145/55 + 98 P75 )." His oxygen saturations were 93% on room air and he was up in the wheelchair in the TV room. Later on 8/27/13, the resident was found lying on the floor, having sustained an unwitnessed fall. On 8/27/13 at 1:30 p.m., resident #11 was observed by the surveyor lying on the floor on his back with the the top of his head facing the nursing station. His walker was overturned approximately two feet away from the resident's right side on the floor. A "Wet Floor" sign was at his feet. The resident stated he had fallen over the sign. Staff member V, a LPN, kneeled directly above his head. Staff member V asked the resident if he hurt. The resident replied "yes, my head." Staff member E, a LPN, stood above the resident and straightened out his legs while saying "(resident name) you fell again." Review of nurse's notes (signed by staff member V) dated 8/27/13 at 1330 (1:30 p.m.) revealed resident #11 was found lying flat on his back down the hall with, "wet floor sign laying at foot of resident, sm (sic) abrasion back of head, ROM to all extremities without pain or difficulty, lifted to w/c by Vanderlift lift, ice to back of head, neuros started, c/o back, head and rt (right) hip pain - prn motrin (pain medication) 600 milligrams given, Dr. ---- office nurse called - to obseve (sic) resident 98.6-70-20 110/65, POA ------ notified of fall." At 6:10 p.m., staff member C was observed to assess the resident for injuries that he may have sustained from the fall at 1:30 p.m. Following the assessment, staff member NN, a CNA, put a gait belt around the resident's body. The resident complained of "an ache" to his right arm and shoulder. When asked to stand, the resident placed his right hand on the arm of his wheelchair and pushed to get up, but stopped and sat back down. Staff member C encouraged him several times to stand up, but he refused to stand or walk. The resident was sent to the ER approximately an hour and a half later. Review of Nurse's Notes dated 8/27/13 (no time documented) reflected, "resident up on unit - ate and drank well at meal time. Resident was assessed and at 19:45 (7:45 p.m.) left per ambulance to (name of hospital) ER for evaluation. Resident checked and a RN from (Hospital) called. Resident has a T-3 compression fracture (of the vertebrae). Resident returned with RN (RC) to (facility initials) and on Brattsberg (sic) at 23:20 (11:20 p.m.) Paperwork sent. NOC nurse will follow up." Review of the hospital discharge notes dated 8/27/13 for Resident #11 reflected: Home Care: Your fracture will most likely heal in 6-12 weeks. Follow these guideline to promote healing: -Rest in bed 2-3 days, unless your doctor says otherwise -Ask family members to help with daily activities until you are ready. -Create a safe home environment to avoid trips and falls. -When you are ready, go about your normal activity. On 8/27/13 at 10:10 a.m., staff member B, the DON was interviewed about what measures had been put into place to ensure the resident's safety with the possible unwitnessed fall with injury near the right eye and fall on 8/24/13. The DON indicated they had not revised the resident's care plan at this point. During further interview on 8/28/13 at 10:10 a.m., in regards to the resident being found on 8/27/13 by a visitor lying on the floor near the nurses station, the DON was asked if the care plan was revised at that point. The DON indicated she was having staff member C, RN/MDS coordinator, make a change in resident #11's care plan to include doing daily skin checks and keeping the resident in sight when out of his room. During interviews on 8/28/13 at 8:55 a.m., with staff members XX and UU, CNAs who had been answering resident #11's bed alarm the morning of 8/28/13, indicated they had not been given any new instructions regarding resident #11. During an interview on 8/28/13 at 12:27 p.m., staff member C, a RN/unit manager, stated "I haven't yet added the information about daily skin checks and visualization of the resident to his care plan." 2. Resident #18 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident resided in the Bratsberg locked unit. According to the 6/23/13 quarterly MDS, the resident had impaired vision, short and long term memory problems, and was severely impaired in decision making. The resident wandered and required extensive assistance from one staff member with bed mobility, transfers, toilet use, dressing and locomotion. Review of resident #18's MDS dated [DATE] in Section J 1700 Fall History on Admission/Entry or Reentry reflected, "J1900 Number of falls since Admission/ Entry or Reentry or Prior Assessment: (2) falls without injury; (2) falls with injury. The coding revealed the resident had two or more falls. On 8/28/13 at 8:40 a.m., a loud melody was heard coming from the hallway entrance to the Bratsberg Unit. About 15-20 seconds later, staff member PP, a CNA, said, "that is (resident #18)" and proceeded to the resident's room. An observation was made of Resident #18 standing in his room at the end of his fall mat with his walker and dressed in his brief and a t-shirt. Resident #18 refused the assistance of staff member PP and then backed up over his fall mat and sat down heavily on his bed. Staff member PP left the room to get more gloves. At 9:00 a.m. staff member PP returned and told the resident to go to the bathroom sink so she could change his brief. After incontinent care was completed, staff member PP applied a new brief and dressed the resident in knee socks, a foot brace, shoes, shirt and pants. When asked about the knee socks, staff member PP stated she put knee socks on him to protect him against his leg brace. Review of Resident #18's Fall Risk assessment dated [DATE] reflected his scale was "100" (36 and over was a Significant Risk of Falls). His assessment included, "Alzheimer's or other Dementia, Incontinence, Previous falls, Unsteady gait, Cannot transfer safely, Psychotropic drugs, Cathartics, and Hypertensive medications." Review of Resident #18's care plan with a goal date of 09/26/13 reflected, "Falls - at risk for falls due to deconditioning related to depression, dementia, and poor nutritional intake. The goal of the care plan was that the resident would not require an acute care stay due to a fall over the next 90 days. Approaches to the care plan for falls included: -Complete a fall risk assessment quarterly; -Reminder (sic) me to use walker when up and about; -Review meds that may contribute to falls and discontinue or decrease dosage of nonessential meds; -Gripper socks on if shoes not worn; -Front legs of FWW are 1 "click" higher than back legs to prevent FWW from tipping forward; -Fall Mat; -Hip Protectors; -Anti-roll backs on w/c; -Slip grip on floor; -Keep room clutter free and well lit; -My call light within reach; and -My bed in low locked position. During an interview on 8/28/13 at 9:55 a.m., staff member E, an LPN, stated that hip protectors and slipper socks were to be worn 24/7. Staff member E stated resident #18 should wear the hip protectors and slipper socks while in bed. Staff member E stated the resident had a bed alarm because he was independent in toileting. Resident #18's care plan interventions were not fully implemented. Observation of resident #18 during the care observation noted above did not reveal him to be wearing hip protectors or gripper socks when staff member PP first found him standing in his room (after rising from bed as the bed alarm was sounding). Staff member PP did not put hip protectors on the resident after providing care and dressing him. Observation of resident #11's bathroom floor during toileting revealed his floor did not have slip grips applied as directed on the care plan. 3. According to the MDS tracking record, resident #26 was admitted to the facility on [DATE]. An initial MDS and care plan had not been completed at the time of the survey due to his recent admission. On 8/28/13 at 10:24 a.m., the surveyor observed staff members E, an RN, and AA, a CNA, as they assisted resident #26 to the Bratsberg dining room. Both staff members E, RN and AA, CNA, were holding onto resident #26's forearms and escorting him to the dining room from the television lounge area. Neither staff member applied a gait belt to resident #26 prior to assisting him to ambulate. After resident #26 was sat down at his table, the surveyor interviewed staff member AA, who verified she should have used a gait belt to walk the resident. Reference: "Residents should never place their hands on the staff member's body during a transfer, never place the staff member's hands under a resident's arms, and use a transfer belt for standing transfers unless it is contraindicated." Hegner, B.R. and Needham, J.F. (2002) . Assisting in long term care (4th ed.). Clifton Park, NY: Delmar. 4. The temperature of hot water in the hand basins of residents' rooms and in a therapy room, exceeded 120 degrees Fahrenheit. This was identified by surveyors in both the main building and at the Retreat between 3:45 p.m. and 4:15 p.m. on 8/25/13. The water temperature in 4 rooms accessible to residents exceeded 120 degrees Fahrenheit; either a digital or laser thermometer were used for measuri