Every finding on record at Jeanne Jugan Residence

Based on interview and document review, it was determined that the facility failed to comply with the Delaware Food Code Certified Food Protection Manager Requirements. Findings include:Delaware Food Code:2-102.12 Certified Food Protection Manager(A) At least one employee, the PERSON IN CHARGE at the time of inspection, shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM.4/7/26 - During the survey of the facility at approximately 10:00 AM, an interview with E8 (Dining Services Manager), revealed that there was only one CFPM. E8 works on Tuesdays and Thursdays and for the other days, there is not a CFPM present. Today 4/7/26 E8 left at 1:00 PM.4/7/26 - During an interview with E8 at approximately 11:00 AM, the findings were confirmed.4/10/26 3:10 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (CEO) during the Exit Conference.

Based on observation and interview, it was determined that the facility failed to comply with Delaware Food Code storage and sanitation procedures.Delaware Food Code:3-305.11 Food Storage.(A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD:(1) In a clean, dry location;(2) Where it is not exposed to splash, dust, or other contamination; and(3) At least 15 cm (6 inches) above the floor.4/7/26 - During the survey of the facility at approximately 10:00 AM, an observation of the outdoor walk-in freezer revealed three turkeys were lying on the floor of the outdoor walk-in freezer.4/7/26 - During an interview with E8 and E6 (Cook) at approximately 11:00 AM, the findings were confirmed.7-204.11 Sanitizers, Criteria.Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACES shall:(A) Meet the requirements specified in 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions)4/7/26 - During the survey of the facility at approximately 10:00 AM, an observation of E8 testing the sanitation solution in the red bucket used to sanitize food prep surfaces, revealed the Quat Sanitation Level of 0PPM. E8 immediately prepped a new bucket, and retesting revealed the appropriate level of 300 PPM of Quat Sanitation solution.4/7/26 - During an interview with E8 at approximately 10:00 AM, the findings were confirmed.4/10/26 3:10 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (CEO) during the Exit Conference.

Based on interview and review of facility documentation, it was determined that the facility failed to ensure that a performance review was completed at least every twelve months for one (E19) out of five sampled employees. Findings include:4/10/26 10:00 AM - Review of the staff performance evaluations revealed that E19 (CNA) had a hire date of 3/29/22. A record review revealed lack of evidence of a performance evaluation for the past year and was confirmed by E4 (HR). 4/10/26 12:00 PM - Finding was discussed with E1 (NHA)4/10/26 3:10 PM - Finding was reviewed with E1 (NHA), E2 (DON) and E3 (CEO) during the Exit Conference.

Based on record review and interview it was determined that for one (R3) out of one resident reviewed for ROM the facility failed to ensure devices to prevent further decline in ROM were applied. Findings include: The facility policy on restorative nursing last updated December 2025 indicated, The interdisciplinary team is responsible for working with residents to assist them in adjusting to their disabilities, to use their prosthetic devices .Review of R3's clinical record revealed:8/22/24 - A physician's orders was written for R3 to receive a short splint to the left hand in the morning and off before supper. If splint is not tolerated, then apply stretch gauze wrap in a figure 8 pattern from the wrist and around the palm.3/25/25 - An initial evaluation and treatment for physical therapy documented that R3 had severe left-hand contracture.1/13/26- An annual MDS assessment documented that R3 had impairments to both upper extremities (hands) and moderate cognitive impairment. 1/28/26 - R3's care plan for Parkinson's Disease was reviewed by the facility's interdisciplinary team. Interventions for the care plan included application of a short splint to the left hand in the morning and off at bedtime as tolerated. If the splint is not tolerated, then apply stretch gauze wrap in a figure 8 pattern from the wrist and around the palm.1/1/26 - 4/9/26 - Review of R3's clinical record revealed only one documented refusal for application of wraps and splints on 3/13/26. 4/7/26 10:57 AM - R3 was observed in the common area of the facility without the ordered splint on her left hand. E13 (CNA) confirmed the observation. E13 was unaware that R3 wore a splint. 4/8/26 9:22 AM - During a medication pass observation completed by E12 (LPN), R3 was observed without the ordered splint on her left hand. 4/8/26 1:36 PM - R3 was observed without the ordered splint device on her left hand. E12 (LPN) confirmed that R3 had not worn the ordered splint and had not refused the application of the splint. E12 then applied R3's splint. 4/9/26 10:47 AM - R3's splint was observed on the bedside table while R3 attended religious services. 4/9/26 10:55 AM - During an interview, E14 (CNA) confirmed that R3's splint device had not been applied. 4/9/26 11:11 AM - During an interview, E2 (DON) confirmed that the facility lacked evidence of refusal of R3 to wear ordered splint devices and wraps. 4/10/26 3:10 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (CEO) during the Exit Conference.

Based on record review and interview it was determined that the facility failed to have measures in place to prevent the growth of Legionella and other opportunistic waterborne pathogens when they did not identify areas in the facility where Legionella could grow and spread and failed to establish measures for monitoring of water testing. Findings include: The facility policy for the Legionella Water Management Program, last updated July 2017, indicated As part of the infection prevention and control program, our facility has a water management program .The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaires disease. The water management program includes the following elements: A detailed description and diagram of the water system in the facility .identification of areas in the water system that could encourage growth and spread of Legionella and other water borne bacteria. The water management program will identify measures that are monitored. 8/19/21- The facility completed testing for Legionella in three areas of the facility. All areas were negative for the presence of Legionella. 3/21/24 12:57 PM - E5 (ICP) confirmed the facility had no current or past cases of Legionella. During an interview on 3/21/24 at 1:19 PM with E5 (ICP) and E12 (Maintenance Director) E12 reported that the facility did random testing however did not identify specific areas that could encourage the growth of Legionella. E12 also confirmed the facility did not have a diagram of the water system that identified possible areas for growth and that the current program did not have an established steps for frequency of water testing. Findings were reviewed with E1 (NHA) and E3 (DON) during the exit conference on 3/21/24 at 3:00 PM.

Based on interview and review of other facility documentation, it was determined that the facility failed to immediately report to the State Agency for one (R128) out of two residents reviewed for abuse. Findings include: Review of R128's clinical record revealed: 8/23/23 - Review of the facility investigation of an alleged physical abuse revealed the following: - On 8/23/23 2:15 PM, E2 (DON) informed E9 (SW) that R128 reported E15 (CNA) beat her up in her room. E20 (RN) performed a physical check of R128 ' s body from head to toe and reported not finding any bruises that would substantiate R128's allegation. - On 8/23/23 2:50 PM, E9 went to R128's room to discuss the incident with R128. E9 spoke briefly with R128 and inquired about R128's well-being and if R128 wanted to discuss anything. R128 said she was tired and did not feel like having a visit at this time. 8/25/23 11:25 AM - A report was submitted to the State Agency by E4 (ADON). 3/20/24 1:03 PM - During an interview E9 said, .(E3) reported the allegation of abuse to me. In, addition E9 said, .I believe the reporting time for abuse is within 24 hours. 3/20/24 2:15 PM - An interview with E3 confirmed, the facility was aware of the late reporting. In addition, E3 stated that the facility had documented on the five day follow up report submitted to the State Agency, .In the future, allegations of abuse will be reported immediately. The facility failed to ensure that an event reported by a resident of alleged abuse was reported State Agency. in the required two hours. Findings were reviewed with E1 (NHA) and E3 (DON) during the exit conference on 3/21/24 at 3:00 PM.

Based on record review and interview it was determined that the facility failed to ensure annual completion of abuse training for two (E18 and E19) out of eight staff reviewed. Findings include: The facility policy on abuse last updated 4/2023 indicated, Staff and volunteers will receive education about resident mistreatment, neglect, and abuse, including injuries of unknown source exploitation, and misappropriation of property upon first employment and annually after that . 3/20/24 10:01 AM - E5 (RN) Inservice Director was provided a worksheet requesting dates of staff training. 3/21/24 Review of the staff training worksheet provided revealed: - E18 last received training for abuse, neglect, and exploitation on 10/14/21. - E19 last received training for abuse neglect, and exploitation on 8/18/22. During an interview on 3/21/24 at 10:49 AM, E5 (RN) Inservice Director, confirmed the finding, and stated, We send out an email blast for them to complete the trainings but they don't return them. Findings were reviewed with E1 (NHA) and E3 (DON) during the exit conference on 3/21/24 at 3:00 PM.

Based on record reviews, interviews and review of the facility policy, it was determined that the facility failed to ensure that medications were administered in accordance with the resident care plan and per Physician orders for two (R1 and R30) out of 12 sampled residents. Findings include: Review of the facility policy entitled Medication, Administration, last reviewed August 2018, stated, .20. If medication is ordered but not present: a. Reasonable time for new medications is twenty-four (24) hours if ordered after 4 p.m. or arrival in the Pharmacy Tote during the third (3rd) shift . b. If any discrepancies, phone the pharmacy to inform of not receiving the medication. The nurse must notify their supervisor . Cross refer to F755 1. R30's clinical record revealed: R30 was admitted to the facility in 2018. 4/12/22 - Review of R30's care plan included a potential nutritional problem related to GERD ([CONDITION(S)] or acid reflux), including medication as ordered. 6/11/22 - A physician's order was written for [MEDICATION(S)] DR (delayed release) 40 mg by mouth every morning for GERD. Review of the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes from 8/15/22 through 8/23/22 revealed that awaiting (pharmacy) delivery followed by the initials of the assigned nurse was present daily for [MEDICATION(S)]. The progress notes lacked evidence that the pharmacy was called, the Nursing Supervisor was notified and/or that the Physician was advised so they had an opportunity to give a new order or state what they wanted to do until the medication was available. 8/25/22 - The above Physician's order was revised and stated stock. The 8/15/22 - 8/23/22 progress notes lacked evidence that [MEDICATION(S)] was obtained from stock medications (meds) and/or administered. 10/25/22 at approximately 3:00 PM- E2 (DON) was interviewed. Concerns about the lack of [MEDICATION(S)] administration were reviewed and confirmed. When asked what her expectation was, E2 stated the Nurses were to call the Physician to get the medication order changed or advise that they can't get the medication, an example was given for the medication being on back order. Before that, E2 stated that the Nurse should have already called the pharmacy to find out when the medication would be delivered so the Nurse had the information to give to the Physician. The Surveyor asked if there was a document to show if [MEDICATION(S)] was signed out for administration from facility stock meds. None was received by the survey exit on 10/27/22. 2. Review of R1's clinical record revealed: 10/22/14- R1 was admitted to the facility. 9/5/22- A physician's order was written for [MEDICATION(S)] Tablet 25 mg by mouth daily for [CONDITION(S)]. 10/17/22 through 10/19/22- Progress note: [MEDICATION(S)] Tablet 25 mg. Give 25 mg by mouth in the morning for [CONDITION(S)] for 90 days after meal awaiting delivery. The 10/1/22-10/27/22 electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 10/27/22- 2:45 PM- During an interview, E2 (DON) confirmed that [MEDICATION(S)] was not administered to R1 on 10/17/22, 10/18/22 and 10/19/22. Findings were reviewed with E1 (NHA) and E2 during the Exit Conference on 10/27/22, beginning at 3:15 PM.

Based on record review and interview, it was determined that the facility failed to provide routine pharmaceutical services for acquiring and receiving medication to meet one residents (R30) needs out 12 sampled. The facility failed to make any attempts to call or contact the pharmacy when R30 ran out of [MEDICATION(S)]. As a result, R30 did not receive her [MEDICATION(S)] for 9 days from 8/15/22 through 8/23/22. It was unclear whether [MEDICATION(S)] was a stock med in the facility at the time and whether it was available to be given in the interim. Findings include: R30's clinical record revealed: Review of the facility policy entitled Medication, Administration, last reviewed August 2018, stated, . 20. If medication is ordered but not present: a. Reasonable time for new medications is twenty-four (24) hours if ordered after 4 p.m. or arrival in the Pharmacy Tote during the third (3rd) shift . b. If any discrepancies, phone the pharmacy to inform of not receiving the medication . Cross refer to F684, example 1 1. R30's clinical record revealed: 6/11/22 - A physician's order was written for [MEDICATION(S)] DR (delayed release) 40 mg by mouth every morning for GERD ([CONDITION(S)] or acid reflux). Review of the electronic Medication Administration Record (eMAR) for August 2022 revealed that [MEDICATION(S)] was not administered from 8/15 through 8/23, nine days, despite a Physician's order for it to be given daily. Review of the progress notes from 8/15/22 through 8/23/22 revealed that awaiting (pharmacy) delivery followed by the initials of the assigned nurse was present daily for [MEDICATION(S)]. The progress notes lacked evidence that the pharmacy was called. 8/25/22 - The above Physician's order was revised and stated stock. The 8/15/22 to 8/23/22 progress notes lacked evidence that [MEDICATION(S)] was obtained from stock medications (meds) and/or that it was administered. 10/25/22 at approximately 3:00 PM - E2 (DON) was interviewed. Concerns about the lack of [MEDICATION(S)] administration were reviewed and when asked what her expectation was, E2 stated the Nurse should have called the pharmacy to find out when the medication would be delivered. The Surveyor asked if there was documentation to show if [MEDICATION(S)] was signed out for administration from the facility stock meds. None was received by the survey exit on 10/27/22, however, the Surveyor received a list of meds in facility stock entitled OTC (over the counter) Medications that included [MEDICATION(S)] 20 mg. It was unclear how many [MEDICATION(S)] capsules were in stock as daily administration would require two 20 mg capsules and if [MEDICATION(S)] was removed from stock for R30. E2 confirmed this and stated, We need to come up with a procedure. 10/27/22 at 3:30 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2.

Based on observations and interviews, it was determined that the facility did not store food and utensils in a sanitary manner. Findings include: The following were observed on 10/18/22 from 1:10 PM to 2:10 PM during the initial kitchen tour: 1. The ceiling tile in the fume hood area was loose. 2. The dry storage area had uncovered fluorescent light bulbs. Findings were reviewed and confirmed with E19 (Food Service Director) on 10/18/22 at approximately 2:00 PM. 10/27/22 at 3:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).

Based on record review, policy review, observations and interview, it was determined that for one (R29) out of 12 sampled residents, the facility failed to ensure that R29 received respiratory care consistent with her physician orders. Findings include: Review of the facility's policy: Oxygen Therapy, Nasal Cannula revised 8/2018, revealed the following: . Policy Purpose: To improve oxygenation and provide comfort to residents experiencing respiratory difficulties. Policy Procedure: . 6. Attach pre-filled humidifier bottle to flow meter if using concentrator . 7. Attach nasal cannula/face mask tubing to humidifier bottle, if using concentrator . Review of R29's clinical record revealed: 8/27/18- R29 was admitted to the facility with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 7/18/22- A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 7/19/22- A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 10/19/22- 11:15 AM- R29 was observed to be receiving Oxygen through a nasal cannula attached to an Oxygen concentrator; a humidifier bottle was not attached to the concentrator. 10/24/22- 10:00 AM- R29 was observed to be receiving Oxygen through a nasal cannula attached to an Oxygen concentrator; a humidifier bottle was not attached to the concentrator. 10/25/22- 9:45 AM- R29 was observed to be receiving Oxygen through a nasal cannula attached to an Oxygen concentrator; a humidifier bottle was not attached to the concentrator. 10/25/22- 9:50 AM- During an interview, E6 (LPN) confirmed that R29's Oxygen concentrator did not have a humidifier bottle attached. Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference on 10/27/22, beginning at 3:15 PM.

Based on observation, interview and review of the Manufacturers' recommendations as indicated, it was determined that the facility failed to ensure that a prescribed drug and biological currently in use must be labeled with the open/discard date to ensure that they are used and disposed of according to the Manufacturers' recommendations. Findings included: [MEDICATION(S)] is a diagnostic biological used to detect [CONDITION(S)] (a potentially serious infectious disease that mainly affects the lungs). According to the [MEDICATION(S)] Manufacturer's package insert (undated), a vial of [MEDICATION(S)] that was opened for 30 days should be discarded. [MEDICATION(S)] is a prescribed medication used to treat allergic rhinitis (stuffy nose/congestion). The [MEDICATION(S)]'s Manufacturer's package insert (revised 9/2018) stated, The correct amount of medication in each spray cannot be assured . after 200 sprays have been used, even though the bottle is not completely empty. The bottle should be discarded after 200 sprays have been used . 10/26/22 at 10:45 AM - Observation of Medication Storage with E11 (RN) revealed the following: - an opened multi-use vial of [MEDICATION(S)] with no open date listed; and - an opened prescribed nasal spray medication, [MEDICATION(S)], for R28 with no open/discard date listed. Findings were immediately confirmed with E11 during the observation and interview. 10/27/22 at 3:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).

Based on observation and interview, it was determined that the facility failed to post the required nurse staffing information requirement in a prominent place, readily accessible to residents and visitors for two out of two nursing units. Findings include: 1st Floor Observation 10/27/22 8:50 AM - An observation on the 1st floor Holy Family nursing station, revealed that nursing staffing data was posted on the magnetic white board. The posting lacked the licensed nurses and CNA (Certified Nurse Aide) hours and the resident census of the day. 2nd Floor Observation 10/27/22 8:55 AM - An observation on the 2nd floor St. (saint) Joseph nursing station revealed that nursing staffing data was posted on the magnetic white board. The posting lacked the licensed nurses and CNA hours and the resident census of the day. Lobby Hallway Observation 10/27/22 9:00 AM - An observation in the corner of the lobby hallway revealed that nursing staffing data was posted on a legal sized paper and the Surveyor could not easily read from a two foot distance. The posting lacked the facility name. In addition, the staffing information was posted in the lobby's corner hallway which was not a prominent place and it was not readily accessible to residents and visitors on the 1st and 2nd floors. 10/27/22 at 12:30 AM - Findings were discussed with E12 (Coordinator) and E13 (HR). Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference on 10/27/22, beginning at 3:15 PM.

Based on interviews and clinical record reviews, it was determined that for three out of four sampled residents (R1, R5 and R30) reviewed for hospitalization /discharge, the facility failed to provide notice of the hospital transfers to the Ombudsman. Findings included: 1. R5's clinical record revealed: 4/26/22 to 4/29/22 - R5 was hospitalized . 10/27/22 at 9:06 AM - During an interview, E5 (SW) confirmed that the Ombudsman's Office was not notified of R5's April 2022 hospitalization . 2. R30's clinical record revealed: R30 was admitted to the facility in 2018. 5/29/22 to 6/10/22 - R30 was hospitalized . 10/25/22 at approximately 3:00 PM - E2 (DON) was interviewed and asked if the Ombudsman was notified of R30's transfer to the hospital. E2 stated, I don't know. 10/25/22 at approximately 3:10 PM - E5 (Social Services) was interviewed and confirmed that she didn't know that the Ombudsman was supposed to be notified when residents were transferred to the hospital or discharged . 3. Review of R1's clinical record revealed: 8/22/14- R1 was admitted to the facility. 8/18/22 to 8/23/22 - R1 was hospitalized . 8/24/22 to 8/29/22 - R1 was hospitalized . Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference on 10/27/22, beginning at 3:15 PM.

Based on observations, interview, reviews of the facility's infection control policy and procedures and standards of practice for infection control, the facility failed to implement appropriate infection control practices as evidenced by the conservation method they used for personal protective equipment (PPE) by placing masks and disposable yellow gowns in individual clear plastic Ziploc bags for each staff member to reuse and stored them inside each of the 11 residents' rooms with suspected COVID-19 where staff had to enter the residents room to apply the PPE; and additional observations revealed that outside of each of the 11 resident's rooms lacked signage on the use of specific PPE for staff to follow. Findings include: The facility's policy, last revised October 2018, entitled Isolation - Categories of Transmission-Based Precautions stated, . 2. Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne . 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door . so that personnel . are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE . Contact Precautions . 4. Staff . will wear gloves . when entering the room . 5. Staff . will wear a disposable gown upon entering the room . The facility's policy, last revised August 2019, entitled Isolation - Initiating Transmission-Based Precautions stated, . 3. When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee): . e. Ensures that protective equipment (i.e. gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment . The Centers for Disease Control and Prevention (CDC) website for Coronavirus Disease 2019 (COVID-19) Strategies for Optimizing the Supply of Facemasks, page last revised March 17, 2020, stated, . Purpose: This document offers a series of strategies or options to optimize supplies of facemasks in healthcare settings when there is limited supply . Crisis Capacity Strategies . mask can be stored between uses in a clean sealable paper bag or breathable container . 3/25/2020 from 4:19 PM to approximately 5:15 PM - During a tour of the facility with E3 (Unit Staff Member), - observations on the A Hall revealed four (R8, R9, R10 and R11) out of 10 residents with suspected COVID-19 lacked evidence of PPE for staff to put on prior to entering each resident's room and signage on the specific use of PPE for staff to follow outside each resident's room; - observations on the B Hall revealed seven (R1, R2, R3, R4, R5, R6 and R7) out of 10 residents with suspected COVID-19 lacked evidence of PPE for staff to put on prior to entering each resident's room and signage on the specific use of PPE for staff to follow outside each resident's room; - an observation on the B Hall revealed a group of clear plastic Ziploc bags sitting inside R1's room, with each bag holding a mask and yellow disposable gown. When E3 was asked about this facility practice, E3 stated that each staff member had a bag with a mask and yellow gown in order to conserve PPE. E3 stated that the facility was attempting to obtain more PPE from their supplier and other outside sources. Finding was immediately confirmed and discussed with E3 about their conservation method of using plastic Ziploc bags for storage to reuse PPE (gowns and masks). 3/25/2020 at approximately 6:30 PM - Finding was reviewed with E1 (NHA) and E2 (DON).

Based on observation and interview it was determined that the facility failed to ensure the laundry room was maintained to prevent contamination of clean laundry. Findings include: 3/2/2020 10:27 AM - An observation of the soiled linen room revealed there was no evidence of negative pressure. E5 (Laundry Supervisor) confirmed there was no negative pressure and stated they were going to follow up with maintenance. 3/2/2020 2:33 PM - An observation of the soiled laundry room revealed there was no evidence of negative pressure. 3/3/2020 2:45 PM - An observation of the soiled linen room showed evidence of negative pressure. 3/6/2020 10:39 AM - An interview with E6 (Maintenance Director) revealed that the motor to ventilate the soiled linen room was not working and it was replaced on 3/3/2020. These findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 3/6/2020 at 3:20 PM.

Based on record review and interview it was determined that for one (R33) out of one sampled resident reviewed for pain management, the facility failed to identify the residents pain management goals. Findings include: Review of R33's clinical record revealed: 6/6/18 - A care plan related to pain did not include R33's pain goal. 1/20/2020 - A quarterly pain assessment indicated that R33 had pain. The assessment lacked R33's goal for an acceptable pain level. 1/21/2020 - A quarterly MDS assessment documented that R33 had frequent pain. February 2020 - The most recent orders on the Medication Administration Record [REDACTED]. Orders included: Document pain intensity on a scale of 0-10, 0= no pain and 10 = worst pain possible three times a day. Without assessing a resident for their desired pain goal it would be impossible to determine the effectiveness of the pain management interventions. 3/5/2020 2:15 PM - During an interview with R33 it was established that R33 has chronic pain. During an Interview on 3/5/2020 at 3:00 PM, E4 (RN) revealed that there was a document where the acceptable pain goal was recorded. E4 was unsure where it was currently located since the facility switched to a computerized medical record. During an interview on 3/6/2020 at 3:20 PM with E2 (DON), it was confirmed that R33 did not have a pain goal identified. E2 further revealed that an acceptable pain goal was added to R33's plan of care. These findings were reviewed with E1 (NHA) and E2 during the exit conference on 3/6/2020 at 3:20 PM.

Based on record review and interview it was determined that for one (R32) out of five residents reviewed for unnecessary medications, the facility failed to ensure that physician orders [REDACTED]. Findings include: 3/14/18 - A physicians order was initiated to have R32's stool tested for blood every three months. 6/24/19 and 12/17/19 - Progress notes documented that stools tested negative. 3/5/2020 at 2:00 PM - During an interview, E2 (DON) revealed that evidence could not be found that a stool test was completed in September 2019. Findings were reviewed with E1 (NHA), E2 and E3 (ADON) on March 6, 2020 during the exit conference beginning at approximately 3:20 PM.

Based on record review and interview it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least once every 12 months for two (E7 and E8) out of five employees sampled. Findings include: 3/6/2020- Review of employee performance reviews revealed the following: - E7 (CNA) had a hire date of 8/3/12. The most recent date of evaluation was 8/3/18. - E8 (CNA) had a hire date 7/9/13. The most recent date of evaluation was 7/19/18. During an interview on 3/6/2020 at 11:31 AM, E3 (ADON) confirmed that the facility was unable to provide evidence that performance reviews were completed at least once every twelve months for E7 (CNA) and E8 (CNA). These findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 3/6/2020 at 3:20 PM.

Based on record review, interview, and review of other facility documentation it was determined that for one (R30) out of one sampled resident for accident review the facility failed to ensure that R30 received adequate supervision to prevent accidents. On 11/22/18 at 2:30 AM R30 fell in the television room when left unsupervised resulting in an emergent transfer to the hospital. Later it was confirmed that R30 had suffered harm with an injury of a broken hip. Findings include: Review of R30's clinical record revealed the following: 6/16/18 at 6:40 AM - Incident Report - R30 had an unwitnessed fall in the room next to the bed. An intervention was added to use better body placement in bed. 8/8/18 at 4:25 PM - Incident Report - R30 attempted to get out of the chair and slid on to the floor. An intervention was to use a sofa for rest instead of the recliner. 9/10/18 at 4:43 AM - Incident Report - R30 had an unwitnessed fall next to the bed when trying to go to the bathroom. Interventions were added to keep active during the day, ambulating more with a walker, and try later at bedtime. 9/22/18 at 10:35 AM - Incident Report - R30 had an unwitnessed fall from the love seat when R30 leaned over and fell forward. Intervention was to use geri chair during the day when tired. 11/1/18 at 8:30 PM - Incident Report - R30 had an unwitnessed fall when R30 was trying to put on slippers. Interventions included R30 needs to wait for assistance and to stay awake on days so s/he will sleep at night. 11/6/18 - A quarterly MDS assessment documented R30 with a severe cognitive impairment, required extensive assistance for transfers and toileting with one-person physical assist. Also, R30 was not steady; only able to stabilize with human assistance. 11/7/18 - A care plan, with the most recent update prior to the fall that resulted in a broken hip, included the approaches to ensure appropriate footwear with non-skid soles when ambulating; hourly safety checks; provide a safe environment; physical therapy evaluate and treat as ordered. 11/22/18 at 2:20 AM - An incident form documented Resident was in the chair in the TV room. fell out of the chair on the left side on the floor, holding right hip/thigh. resident stated 'Oh it Hurts.' . Denied hitting head, denied anyone harming he/she. Review of witness statements obtained by the facility documented: 11/22/18 at 2:20 AM - E10 (CNA) in the rest room. 11/22/18 at 2:20 AM - E9 (RN) in nursing office. 11/22/18 at 2:20 AM - E8 (RN) in nursing office. No staff were present in the TV room and R30 experienced an unwitnessed fall. 11/22/18 at 2:30 AM - Progress Notes documented The resident was in the chair in the TV room and fell , was on the left side on the floor. 'Oh, my leg hurts here,' pointing to the right hip and thigh, resident was rubbing the area and was guarded not to bend the knee. Resident returned to room via lift. Stated, 'My arm hurts.' R30 was pointing to the right arm and right shoulder. Able to move right arm, full ROM to area. At 2:30 AM E11 (Nurse Practitioner) notified of fall. An order to send to emergency room for evaluation was obtained. Family notified that resident would be transferred to emergency room at 2:31 AM. Family is going to meet the resident at the hospital. 911 called for transport. Unit manager notified at 2:55 AM. Paramedics arrived at 2:58 AM and resident was taken to the emergency room . No bruising noted or other skin injuries. Resident would not extend right leg, wanted to keep it bent due to pain. Denied hitting head. 11/22/18 at 2:55 AM - Progress note - 911 was called R30 was transported to emergency room for treatment. Later it was confirmed R30 sustained a broken hip as a result of the fall. Review of the facility investigation revealed R30 was out of bed and in the TV room for supervision. The resident was left unattended/unsupervised and fell . 1/22/19 - MDS Annual Assessment Summary documented R30 has had multiple falls in the past year, when resident attempted to walk without assist and lost balance; or leaned over when in wheel chair or chair and lost balance. R30 sustained a right broken hip on 11/22/18 after a fall, and was hospitalized ,[DATE]-[DATE] for a surgical repair of the broken hip. Staff perform safety checks, and R30 utilizes a geri-chair or wheel chair for locomotion. MD H&P 1/13/19; Fall risk assessment 1/22/19; Fall notes 1/12/18, 1/16/18, 4/15/18, 6/6/18, 8/22/18, 9/10/18, 9/22/18, 11/1/18, 11/22/18, 1/12/19, 1/24/19. 3/8/19 at 10:46 AM - An interview with E5 (RN) revealed R30 is often moved to the TV room from the bedroom because of restlessness so we can watch R30 and complete our paper work at the same time. During a phone interview, on 3/8/19 at 12:14 PM with E4 (Physical Therapist), it was revealed that physical therapy has followed R30 for multiple falls prior to the broken hip. E4 further revealed that physical therapy worked with R30 for increased falls. R30 was evaluated for the 6/16/18 fall and recommendations from therapy were to increase the frequency of room checks and take R30 to a location like the television room to be more visible. These physical therapy recommendations were not added to the plan of care. During an interview with E2 (DON) on 3/8/19 at 12:58 PM it was confirmed the fall occurred when R30 was left alone unattended/unsupervised in the TV room at 2:30 AM after becoming restless in her room. Despite a history of unwitnessed falls and despite moving the resident to the TV room for observation and increased visibility due to restlessness, the resident experienced an unwitnessed fall resulting in injury when left alone and unsupervised in the TV room. These findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON) at exit conference on 3/8/19 at 2:40 PM.