Every finding on record at Jesse Helms Nursing Center

Based on record review, physician, and staff interviews, the facility failed to ensure a Resident's abnormal vital signs were reported to the on-coming shift. This was for 1 of 3 residents reviewed for quality of care (Resident #67).The findings included: Resident #67 was admitted to the facility 5/14/25 with diagnoses including congestive heart failure and diabetes. The admission Minimum Data Set assessment dated [DATE] assessed Resident #67 to be cognitively intact. The medical record was reviewed and vital signs for Resident #67 were as followed: 6/22/25 at 7:07 PM temperature 103.1 Fahrenheit (F) (normal 98.6), pulse 137 (normal 60-100), blood pressure 147/135 (normal 120/70). 6/22/25 at 7:40 PM temperature 102.8 F, pulse 124, blood pressure 101/41. 6/22/25 at 8:59 PM temperature 99.1 F, pulse 112, blood pressure 89/39. Review of the nursing schedule for 6/22/25 revealed Nurse #3 was assigned to Resident #67 on 6/22/25 for the 7:00 AM to 7:00 PM shift. A phone interview was conducted with NA #1 on 8/13/25 at 4:20 PM. NA #1 reported she arrived early for her 7:00 PM to 7:00 AM shift on 6/22/25 and she started taking vital signs on her assigned residents. NA #1 reported that when she got the abnormal vital signs on Resident #67, she reported to Nurse #3, and Nurse #3 told her to recheck the vital signs. NA #1 explained that because she told Nurse #3 about the abnormal vital signs, when she rechecked Resident #67's vital signs at 7:40 PM and the vital signs were still abnormal, she did not report to Nurse #2 because she thought Nurse #3 would have reported to Nurse #2 at change of shift. A phone interview was conducted with Nurse #3 on 8/13/25 at 2:47 PM. Nurse #3 reported she worked on 6/22/25, but she did not recall if she was assigned to Resident #67 or anything about Resident #67, nor did she recall NA #1 reporting abnormal vital signs to her. A nursing note dated 6/22/25 at 11:56 PM written by Nurse #2 documented that the nurse was notified by the Nursing Assistant (NA) #1 that Resident #67 had a temperature of 102.8 F, and her blood pressure was low at 7:45 PM. Nurse #2 documented she administered acetaminophen (an analgesic pain medication used to reduce fevers) (time not specified, nor dosage) and she checked Resident #67's blood pressure getting a result of 92/44 and a pulse of 103. The nurse documented Resident #67 was sweating profusely but denied pain or discomfort. Resident #67's blood sugar was 201 (normal 70-120). Vital signs were checked after 1 hour and the on-call physician was notified. The on-call physician ordered STAT (immediate) labs to be drawn and intravenous fluids to be given. Labs were returned with elevated white blood cells (34.8; normal 4.5-11). The on-call physician was notified, and he ordered Resident #67 to be sent to the hospital for evaluation. Nurse #2 was interviewed by phone on 8/13/25 at 12:29 PM. Nurse #2 reported she was assigned to Resident #67 from 7:00 PM on 6/22/25 to 7:00 AM on 6/23/25. Nurse #2 reported when she received report from Nurse #3, nothing was said about Resident #67's abnormal vital signs. Nurse #2 reported she started her medication pass and in the middle of it, Nurse #4 came to her to report the family member of Resident #67 had called expressing concern about Resident #67 not acting like herself. Nurse #2 reported when she was given this information, she looked up vital signs for Resident #67 and discovered that Resident #67 had an abnormal temperature, pulse, and blood pressure. Nurse #2 reported she checked the vital signs for Resident #67 again at 8:59 PM and called the on-call provider with report. An interview was conducted by phone with Nurse #4 on 8/13/25 at 4:05 PM. Nurse #4 reported she had answered a phone call from Resident #67's family member and the family member had expressed concern that Resident #67 was not acting like herself. Nurse #4 explained she went to Nurse #2 and told her about the phone call and that's when Nurse #2 reviewed the charting for Resident #67 and discovered the abnormal vital signs. Nurse #4 reported Nurse #3 should have reported to Nurse #2 the abnormal vital signs at the change of shift. Nurse #4 reported the on-call provider was called about 9:00 PM with report and orders were received. The Physician was interviewed on 8/14/25 at 11:57 AM. The Physician conveyed the off going shift should have reported to the oncoming shift the abnormal vital signs, but the delay in care of about 2 hours had not adversely affected Resident #67. Review of the hospital records for Resident #67 revealed she was admitted with a urinary tract infection and sepsis on 6/22/25. Lab work for Resident #67 included a complete blood count, with white blood cells of 32.24 (normal 3.6-11.7), red blood cells 2.87 (normal 3.72-5.24), and a blood culture result positive for pseudomonas aeruginosa (a bacteria that causes infection). A urinalysis collected on 6/23/25 resulted that Resident #67 had 100 proteins in her urine (normal is none), 0.5 blood in her urine (normal is none), and many white blood cell clumps, as well as bacteria. The hospital note documented that the source of infection was Resident #67's urine. Two different antibiotics were started, as well as intravenous fluids. Resident #67 was admitted to the hospital 6/22/25 and discharged on 7/1/25 to another facility. During an interview with the Director of Nursing (DON) on 8/13/25 at 4:35 PM, she reported she was notified on 6/23/25 the oncoming night shift had not received a report of the change in condition on Resident #67 from the off-going shift. The DON reported she provided education to the nursing staff about reporting resident changes in condition but had not implemented a corrective action plan. The Administrator was interviewed on 8/14/25 at 11:22 AM and he reported that he expected any change in condition to be communicated between the nursing shifts.

Based on record review, and physician and staff interviews, the facility failed to notify the physician immediately of a change in condition for 1 of 3 residents reviewed for change of status (Resident #67). The findings included: Resident #67 was admitted to the facility 5/14/25 with diagnoses including congestive heart failure and diabetes. The admission Minimum Data Set assessment dated [DATE] assessed Resident #67 to be cognitively intact. The medical record was reviewed and vital signs for Resident #67 revealed the following: 6/22/25 at 7:07 PM temperature 103.1 Fahrenheit (F) (normal 98.6), pulse 137 (normal 60-100), blood pressure 147/135 (normal 120/70). Review of the nursing schedule for 6/22/25 revealed Nurse #3 was assigned to Resident #67 on 6/22/25 for the 7:00 AM to 7:00 PM shift. Review of the electronic documentation system revealed no nursing note written by Nurse #3 regarding the elevated temperature, pulse, or blood pressure had been communicated to the physician. The medical record documented a recheck of the vital signs on 6/22/25 at 7:40 PM: temperature 102.8 F, pulse 124, blood pressure 101/41. A phone interview was conducted with nursing assistant (NA) #1 on 8/13/25 at 4:20 PM. NA #1 reported she arrived early for her 7:00 PM to 7:00 AM shift on 6/22/25 and she started taking vital signs on her assigned residents. NA #1 reported that when she got the abnormal vital signs on Resident #67, she reported to Nurse #3, and Nurse #3 told her to recheck the vitals signs. NA #1 explained that because she told Nurse #3 about the abnormal vital signs, when she rechecked Resident #67's vital signs at 7:40 PM and the vital signs were still abnormal, she did not report to Nurse #2 because she thought Nurse #3 would have reported to Nurse #2 at change of shift. NA #1 reported that Resident #67 said she was ok, but Resident #67 was very sweaty and looked bad. A phone interview was conducted with Nurse #3 on 8/13/25 at 2:47 PM. Nurse #3 reported she worked on 6/22/25, but she did not recall if she was assigned to Resident #67 or anything about Resident #67, nor did she recall NA #1 reporting abnormal vital signs to her. Nurse #2 was interviewed by phone on 8/13/25 at 12:29 PM. Nurse #2 reported she was assigned to Resident #67 from 7:00 PM on 6/22/25 to 7:00 AM on 6/23/25. Nurse #2 reported when she received report from Nurse #3, nothing was said about Resident #67's abnormal vital signs. Nurse #2 reported she started her medication pass and in the middle of it, Nurse #4 came to her to report the family member of Resident #67 had called expressing concern about Resident #67 not acting like herself. Nurse #2 reported when she was given this information, she looked up vital signs for Resident #67 and discovered that Resident #67 had an abnormal temperature, pulse, and blood pressure. Nurse #2 reported she checked the vital signs for Resident #67 again at 8:59 PM and called the on-call provider with report. An interview was conducted by phone with Nurse #4 on 8/13/25 at 4:05 PM. Nurse #4 reported she had answered a phone call from Resident #67's family member and the family member had expressed concern that Resident #67 was not acting like herself. Nurse #4 explained she went to Nurse #2 and told her about the phone call and that's when Nurse #2 reviewed the charting for Resident #67 and discovered the abnormal vital signs. Nurse #4 described Resident #67 as sweating, and her blood pressure was very low. Nurse #4 reported Nurse #3 should have reported the abnormal vital signs to the on-call physician. Nurse #4 reported the on-call provider was called about 9:00 PM with report and orders were received. The Physician was interviewed on 8/14/25 at 11:57 AM. The Physician reported the on-call physician had not received notification of the change in Resident #67's status until about 9:00 PM on 6/22/25. The Physician conveyed the off going shift should have reported the abnormal vital signs to the on-call physician when the vital signs were obtained, but the delay in care of about 2 hours had not adversely affected Resident #67. During an interview with the Director of Nursing (DON) on 8/13/25 at 4:35 PM, she reported she was notified on 6/23/25 that Nurse #3 had not notified the on-call physician of the change in Resident #67's status. The DON reported she provided education to the nursing staff about reporting resident changes in condition but had not implemented a corrective action plan. The Administrator was interviewed on 8/14/25 at 11:22 AM and he reported that he expected any change in condition to be communicated to the physician.

Based on observations, record review and staff interview the facility failed to remove dry goods stored past the use by date and ensure all dry goods stored ready for use had use by dates, failed to remove scoops with the handles resting in ingredients from four of four dry storage bins, failed to clean silverware intended for the lunch meal for one of one silverware tray, failed to label a container of ice cream in the reach in freezer and failed to label and dispose of one of one expired food products in a resident community refrigerator. The findings included: 1. An initial observation of the off-site kitchen conducted on [DATE] from 9:50 AM to 10:44 AM with the Dietary Manager (DM) revealed the following opened dry storage items without a date to indicate how long the items was good for: - a 22.6 oz. opened package of chicken gravy mix best by October (unable to see the year) ,d+[DATE] bag left. - a 26.5 oz bag opened package ,d+[DATE] full of instant potato pearls best by [DATE]. - a 1 pound box of corn starch, ,d+[DATE] of the box left. The manufactures label was ripped off the cardboard making it unreadable. 2. An observation during the initial kitchen tour on [DATE] from 9:50 AM to 10:44 AM with the DM revealed the scoops were left inside the flour, rice and sugar bins. The scoop and handle were lying in the flour, sugar and brown and white rice. During the initial tour the DM stated that the scoops should be kept on the dry rack and cleaned after each use. 3. An observation of the service kitchen (a small kitchen which is used to serve, not prepare food) at the facility on [DATE] from 11:22 AM - 11: 45 AM was conducted. A clean tray of silverware intended for the lunch meal service revealed white paper on 2 forks, one spoon had a dried yellow dot, one spoon appeared dirty with streaks on it and one fork had a dried brown dot on it. An interview on [DATE] at 11:35 AM with the Dietary Assistant (DA) confirmed the silverware in the tray was clean and removed the dirty silverware. An observation of the reach in freezer in the service kitchen at the facility revealed a 3-gallon container of ice cream was not labeled with an open date. The container was ,d+[DATE] full. An interview on [DATE] at 2:45 PM with the Dietary Supervisor (DS) stated that she had sent the tray back to the main kitchen and has had to send silverware back approximately once every 2 weeks. The DS stated that they roll the silverware in a napkin to go on the resident tray and it is inspected, and no residents had received dirty silverware. The DS stated the container of ice cream that was in the reach in freezer is from the activities department and the Activity Director (AD) should be labeling their ice cream container when it was opened. 4. A observation of community refrigerator in the television room on [DATE] at 3:23 PM was conducted. The refrigerator had a sign on the front that read 'For resident and family use only'. Inside the refrigerator was a double bagged package that contained a package of bratwurst with a best by date of [DATE]. The outside of the package had the residents name and room number but no date. An interview with Nurse #1 on [DATE] at 3:24 PM who was shown the bratwurst and stated the residents name and date should have been on the package. An interview with the Director of Nursing (DON) on [DATE] at 3:27 PM who confirmed there was no date, and the bratwurst were expired. The DON stated that several people rotate cleaning out the refrigerator such as the night shift nurse and the Activities Coordinator. An interview on [DATE] at3:47 PM was completed with the Administrator who stated that the Activities is the person responsible for cleaning out the resident refrigerator. The Administrator stated he cannot understand why their would-be raw meat in the refrigerator as there is nowhere for meat to be cooked at the facility. An interview was completed with the DM on [DATE] at 9:03 AM who stated that once a product is opened it should have a label that states the opened date and the use by or expiration date. The DM stated that silverware gets cleaned at the off-site kitchen and then transported back 6 times a day to the facilities service kitchen and explain that we are not watching as close as possible and miss seeing some of the dirty silverware. The DM stated that in her opinion a spoon could be lying on top of another spoon and not get cleaned as well as it should. The DM stated that it is her expectation that we would be doing all the necessary things such as ensure the silverware is clean, items are labeled and dated properly, and scoops are stored properly. An interview was completed with the Administrator on [DATE] at 4:44 PM who stated that he would expect that there are no items in the refrigerator or freezer that have been opened with no labels or dates.

Based on record review and staff interviews, the facility failed to rescreen a resident with diagnoses including mental illness for Level II Preadmission Screening and Record Review (PASRR, a resident identified as having a serious mental illness or intellectual debility and/or developmental disability as defined by state and federal guidelines) for 1 of 3 residents reviewed for Preadmission Screening and Record Review (PASRR) (Resident # 41). Findings included: Resident #41 had been admitted on [DATE] with diagnoses that included epilepsy and schizophrenia. Resident # 41's admission Minimum Data Set (MDS) assessment dated [DATE] did not indicate that Resident # 41 was considered by the state Level ll PASRR process to have a serious mental illness or intellectual disability and /or developmental disability. Review of facility documentation revealed a Level II PASRR evaluation was completed for Resident # 41 on 06/09/2022 and indicated placement had been approved for 90 days with an expiration date of 09/07/2022 and further approval and screening was required within 5 days of the PASRR expiration date by the facility. On 12/13/2022 at 5:45 PM an interview with the Social Worker (SW) was conducted. The SW stated that she did not know Resident # 41 had a PASRR Level ll assigned to him on admission to the facility and she was not aware there was a 90-day expiration date, and that further approval and rescreening was required prior to the expiration date of 09/07/2022. The Administrator was interviewed on 12/15/2022 at 2:46 PM. He stated the SW was responsible for obtaining Level ll PASRR status and updating PASRR status as required and communicating PASRR status to members of the interdisciplinary care team.

Based on record review and staff interview, the facility failed to post accurate staffing information for licensed and unlicensed nursing staff for 3 of 5 posted daily staffing forms reviewed. Findings included: Daily staffing forms for 9/15/2022, 9/16/2022, 10/9/2022, 10/29/2022, and 12/8/2022 were reviewed and revealed the following were not accurate on 3 of 5 dates: a. The nursing schedule for 9/15/2022 had 2 Registered Nurses (RNs) scheduled for 2nd shift (3:00 PM to 11:00 PM). The posted daily staffing form indicated 1.5 RNs provided 12 hours of care on that date for 2nd shift. The nursing schedule for 9/15/2022 had 3 nursing assistants (NAs) scheduled to work the 3rd shift (11:00 PM to 7:00 AM). The posted daily staffing form reported 2 NAs provided 16 hours of care on that date for 3rd shift. b. The nursing schedule for 10/9/2022 had 1.5 Licensed Practical Nurses (LPNs) scheduled to work 2nd shift. The posted daily staffing form indicated 1 LPN provided 8 hours on that date for 2nd shift. c. The nursing schedule for 12/8/2022 had no RN scheduled to work 1st shift (7:00 AM to 3:00 PM), 3 LPN scheduled to work, and 4 NAs scheduled to work. The posted daily staffing form reported 1 RN provided 8 hours of care, 2 LPNs provided 16 hours of care, and 6 NAs provided 48 hours of care. The nursing schedule for 2nd shift on 12/8/2022 had 1.5 RNs, 2.5 LPNs, and 3 NAs scheduled to work. The posted daily staffing form indicated 2 RNs provided 16 hours of care, 1.5 LPNs provided 12 hours of care, and 4 NAs provided 32 hours of care. The schedule for 3rd shift on 12/8/2022 had 1 RN scheduled to work, 2 LPNs, and 1 NA was leaving early at 5:30 AM. The posted daily staffing form indicated 2 RNs provided 16 hours of care, 1 LPN provided 8 hours of care, and 4 NAs provided 32 hours of care for that shift. The Director of Nursing (DON) was interviewed on 12/15/2022 at 2:49 PM. The DON reported she was responsible for scheduling the nurses and NAs, and she was also responsible for the posted daily staffing form. The DON explained that the charge nurses would update the posted daily staffing sheet during 2nd and 3rd shift for any changes in staffing. The DON reported that a lot of call outs or schedule changes made it difficult to keep an accurate posted daily staffing sheet. The Administrator was interviewed on 12/15/2022 at 3:12 PM. The Administrator reported it was his expectation that the daily posted staffing sheet was updated with any staffing changes to accurately reflect the current staffing in the facility.

Based on record reviews, observations, and staff interviews, the facility failed to discard expired nutritional supplement drinks in 1 of 2 coolers observed and failed to dry before stacking meal trays for use for 1 of 3 kitchen observations. Findings included: 1. The kitchen was observed on [DATE] at 9:15 AM. A cooler designated as the resident drink cooler was observed to have 6 cartons of a clear nutritional supplement with an expiration date of [DATE]. The dietary supervisor (DS) was interviewed at the time of the observation and reported the coolers were checked daily by the dietary aide (DA) for expired items and the expired supplements should have been discarded. The DA was interviewed on [DATE] at 9:46 AM. The DA reported she had worked [DATE] and had checked the resident drink cooler, but she must have missed the nutritional supplement. The patient service manager (PSM) was interviewed on [DATE] at 10:50 AM. The PSM reported the coolers should be checked daily by a DA and all expired food and drinks should be discarded if expired. The PSM reported no residents were currently taking the clear nutritional supplement and thought the clear nutritional supplement was overlooked by the DA during the daily checks. The Administrator was interviewed on [DATE] at 12:35 PM. The Administrator reported the kitchen staff were expected to monitor and rotate the food and drinks in the coolers, discard food and drinks close to their expiration, and he did not know why the clear nutritional supplements were missed. The Administrator reported he expected all expired items were removed from the kitchen before their expiration date. 2. The Certified Dietary Manager (CDM) was observed preparing resident trays to serve lunch on [DATE] at 12:14 PM. The food trays were noted to be stacked and the surfaces of the trays were wet. The CDM was using a cloth dishtowel to dry the surface of the trays prior to setting up the tray for the meal. The CDM was interviewed at the time of the observation and she reported the trays were wet because the main kitchen was running behind. The CDM stated it was appropriate to dry the trays with a dishcloth. A follow-up interview was conducted with the CDM on [DATE] at 10:50 AM. The CDM explained the main kitchen had gotten behind and the food trays had been washed but did not have enough time to air dry before lunch. The CDM reported the trays should have been air dried and a dish towel should not have been used because it could allow for the spread of bacteria. The Administrator was interviewed on [DATE] at 12:35 PM. The Administrator reported he expected all food service items to be dry before stacking.

Based on record review, observation and staff interviews the facility failed to transfer a resident using a mechanical lift and adequate supervision to prevent two falls with injury for 1 of 2 residents, Resident #17, reviewed for supervision to prevent accidents. Findings included: Resident #17 admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] and anxiety. A care plan for fall risk that was initiated on 11/22/2019 and updated on 2/17/2021 indicated Resident #17 required a sit to stand lift mechanical lift for transfers and required assistance of two staff members. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact and required extensive assistance of two staff members for transfers and had falls since the last assessment. During an interview with Resident #17 on 6/9/2021 at 10:23 am she stated she fell recently and hit her face on the floor. Resident #17 stated she fell because the Nurse Aide instructed her to reach across to another chair and pull herself up. Resident #17 stated she did not remember exactly when the fall occurred, but it was within the past three months. Review of the Nursing Fall Assessments for Resident #17 revealed she had 3 falls since 4/1/2021: Review of a Nursing Fall assessment dated [DATE] written by Nurse # 1 stated Resident #17 fell on [DATE] while being transferred from the bed to the wheelchair by Nurse Aide #1. The report stated Resident #17 fell to the floor during the transfer and landed face down and sustained a knot above her right eye. The assessment stated the Physician was on site and was aware of the fall. Nurse #1 assessed the resident and documented Resident #17 denied a headache, and a neurological check was normal. During an interview with Nurse Aide #1 on 5/9/2021 at 11:52 am she stated on 4/7/2021 she was transferring Resident #17 from the bed to the wheelchair without the sit to stand mechanical lift when she got weak and fell to the floor on her face. Nurse Aide #1 stated she did not have another staff member helping her and Resident #17 should have two staff members to assist with her transfers and she should be transferred using a sit to stand mechanical lift. Nurse Aide #1 stated she was not able to find anyone to help her and did the transfer herself without the sit to stand mechanical lift, but she should have waited on someone to assist her. Nurse Aide #1 stated Resident #17 had a bruise under her eye due to the fall but did not complain of pain. An interview was conducted on 6/9/2021 at 10:05 am with Nurse #1 and she stated Resident #17 was her patient when the fall occurred on 4/7/2021. Nurse #1, which is also a Unit Manager, stated Resident #17 required a sit to stand mechanical lift to transfer and staff should have another staff member in the room when they transfer her with the sit to stand mechanical lift. Nurse #1 stated Nurse Aide # 1 should have asked someone to assist her before transferring Resident #17 and should have used the sit to stand mechanical lift. Resident #17's Care Plan was reviewed, and an intervention was found for neurological checks and a physician's referral for a fall on 4/7/2021. A Nursing Fall assessment dated [DATE] written by Nurse #1 stated Resident #17 fell during a transfer using a sit to stand lift. The assessment further stated Resident #17 sustained a bruise to her anterior left arm and left lower anterior leg. Nurse #1 documented she assessed Resident #17 and her neurological assessment was normal. Resident #17's Care Plan was reviewed, and an intervention dated 4/11/21 was found for neurological checks and cold compresses to a bruise to her left arm. During an interview with Nurse #3 on 6/10/2021 at 7:51 am she stated Nurse Aide #3 was with Resident #17 when she fell on [DATE]. She stated Nurse Aide #3 told her she tried to get Resident #17 up with the sit to stand mechanical lift, but her legs buckled, and she went down to the floor. Nurse #3 stated when she entered the room the belt that goes around the resident's waist on the sit to stand mechanical lift was not hooked to the lift as it should have been. Nurse #3 stated Nurse Aide #3 was the only staff member in the room when Resident #17 fell on [DATE]. Nurse #1 also stated Nurse Aide #3 should have had another staff member in the room when she transferred Resident #17. Nurse #3 stated Resident #17 had a bruise to her left anterior lower leg. She also stated Resident #17 did not complain of pain. Nurse #3 indicated Nurse #1, the Unit Manager, did an education with Nurse Aide #3 because she should have another staff member with her when using the sit to stand mechanical lift. An interview was conducted with Nurse Aide #3 on 6/10/2021 at 8:52 am and she stated she had cared for Resident #17 when she fell on [DATE]. Nurse Aide #3 stated Resident #17 was sitting on the edge of the bed and she put the belt to the sit to stand mechanical lift around her waist and pulled it snug. She stated she was lifting her up when Resident #17 got weak and she started sliding down and the lift belt slid up under her arms. Nurse Aide #3 stated she lowered Resident #17 to the floor and removed the lift belt, and she was not injured, and she did not complain of pain. Nurse Aide #3 stated Resident #17 was a two person assist and she should have two staff members with her when she transferred her. Nurse Aide #3 stated she looked for someone to help her, but everyone was busy. A Nursing to Therapy Referral dated 4/11/2021 stated Resident #17 was currently using a sit to stand lift and had two falls during the last week and requested therapy evaluate Resident #17 for balance and mobility. The Nursing to Therapy Referral also stated Resident #17 may need a total mechanical lift. A Physical Therapy Evaluation and Plan of Care dated 4/28/2021 stated the reason for the referral was Resident #17 had two recent falls. The Physical Therapy Evaluation and Plan of care further stated nursing felt Resident #17 was weak in both lower extremities and had difficulty performing sit to stand mechanical lift transfers. The Administrator was interviewed on 6/10/2021 at 2:40 pm and he stated the staff involved with Resident #17's falls had been educated on how to use the sit to stand mechanical lift and had Annual Competency Assessments on 5/18/2021 but the facility had not started a plan of correction for the falls. During an interview with the Director of Nursing on 6/10/2021 at 3:38 pm she stated the fall that occurred on 4/7/2021 should not have happened and it was not proper technique since Resident #17 should be transferred using a sit to stand mechanical lift. The Director of Nursing further stated Resident #17 did not need two people when the staff are using the sit to stand mechanical lift and she was safe to use a hand bar to pull up from a chair. The Director of Nursing stated the sit to stand mechanical lift is safe to use with one staff member per the manufacturer's directions

Based on record reviews, observations and staff interviews, the facility failed to place soiled linen and a soiled incontinence brief into a trash bag at the point of collection and transported the unbagged linen and brief out into the hallway for 1 of 1 staff observed (NA #4). Findings included: The facility policy Linen Services dated 9/90 and revised 7/18 was reviewed. The policy stated, in part: Soiled linen will be handled and transported in a manner to prevent contamination and transmission of pathogenic organisms. Nursing assistant (NA) #4 was observed entering room [ROOM NUMBER] at 10:08 AM on 6/9/2021. NA #4 was observed exiting the room at 10:12 AM with a yellow stained bed sheet and a soiled incontinent brief. The bed sheet and the incontinence brief were not in a trash bag. Fecal matter was noted to be on the brief. NA #4 disposed of the soiled brief in the trash bin that was in the hallway. NA #4 was interviewed on 6/9/2021 at 10:12 AM. NA #4 reported there were no trash bags in room [ROOM NUMBER] and she had forgotten to take trash bags into the room. NA #4 reported the soiled linen and soiled brief should have been placed into trash bags in the room to be taken out into the hall. The Director of Nursing (DON) was interviewed on 6/9/2021 at 3:38 PM. The DON reported that soiled linen and trash with biohazard fluids or solids were to be bagged in a trash bag in the resident ' s room for transport out into the hallway to the trash and linen bins. The DON reported she did not know why NA #4 did not bag the linen or brief at the point of collection. The Administrator was interviewed on 6/10/2021 at 12:37 PM. The Administrator reported NA #4 should not have taken the soiled linen or brief out into the hallway without bagging in the resident ' s room. The Administrator reported it was his expectation staff properly bagged linen and soiled briefs before leaving a resident ' s room, and if they did not have a trash bag available, to ask another staff member to retrieve trash bags.

Based on observations, record review, resident interview, hospice representative interview, and staff interviews, the facility failed to ensure quality of care for the care plan development for one of one resident reviewed for hospice (Resident #12). The findings included: Review of the contract between the facility and hospice with an effective date 8/26/13 revealed the following: Section 1.6 hospice Plan of Care. A written care plan jointly established, maintained, reviewed and modified as necessary, at regular intervals, by the hospice Medical Director, Attending Physician and hospice Interdisciplinary Group, and with the participation of Skilled Nursing Facility (SNF), to the extent practical, which includes: (a) an assessment of each hospice Patient's needs; (b) an identification of the hospice Services, including management of discomfort and symptom relief, needed to manage and palliate the hospice Patient's terminal illness and to meet the related needs of the hospice Patient's family; and (c) details concerning the scope and frequency of hospice Services. Section 3.6 hospice recognizes that SNF is required under State and Federal regulations to have individualized care plans with physician concurrence on each resident soon after admission, and to revise said care plans as needed based upon the condition of the Resident. As SNF has care plan meetings at least quarterly, SNF agrees to notify hospice in writing or verbally the dates and regularly scheduled times of the meetings. hospice will participate in the interdisciplinary care plan process to include quality review and cooperate with SNF so as to ensure that care plans for hospice Patients are consistent with, and allowed by laws and regulations, the same as SNF's; that the care plans meet the highest professional standards and state licensure requirements for Long Term Care Facilities as well as Medicare Conditions of Participation for Long Term Care Facilities and hospices. Section 3.7 SNF recognizes that hospice is required under State and Federal regulations to have individualized care plans with physician concurrence on each patient soon after admission, and to revise said care plans as needed based upon the condition of the patient. Hospice will discuss each patient every fifteen (15) days and notify SNF of any updated care plans. SNF will participated in the interdisciplinary care plan process to include quality review and cooperate with hospice so as to ensure that care plans for hospice Patients are consistent with, and to the extent allowed by laws and regulations, the same as SNF's; that the care plans meet the highest professional standards and state licensure requirements for hospices as well as Medicare Conditions of Participation for hospices and Long Term Care Facilities and Joint Commission on Accreditation of Healthcare organization requirement for hospices; and that the care plan reflects participation of hospice, SNF, and the patient/family to the extent possible. Resident #12 was admitted to the facility 1/29/16 with [DIAGNOSES REDACTED]. A review of Resident #50's Minimum Data Set (MDS) revealed the most recent completed assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 3/7/18. The MDS assessment indicated Resident #50 was unable to complete the Brief Interview for Mental Status due to having been rarely or never understood which indicated severe cognitive impairment. The resident was coded as having had a condition or chronic disease that may have resulted in a life expectancy of less than 6 months. The resident was coded as having had received hospice care while she was a resident at the facility. Review of Resident #12's Electronic Medical Record revealed the resident had an Informed Consent/Election of Benefits with hospice dated 11/30/17. Review of Resident #12's Record of Admission sheet revealed the primary payor for the resident was hospice. A review completed of Resident #12's care plan which had been documented as having been last reviewed on 3/27/18 was completed on 5/8/18 at 3:47 PM. The review revealed no hospice care plan. The only discovered mention of hospice care in the care plan except for the care plan addressing Activities of Daily Living function rehabilitation care plan. The information listed related to hospice services were hospice services were discontinued on 9/21/17 and were reinitiated on 11/30/17. An interview was conducted with the Social Worker (SW) on 5/10/18 at 9:25 AM. The SW stated Resident #12 was on hospice when she first was admitted to the facility. The resident's condition then stabilized and the resident no longer met hospice criteria and was discharged from hospice services. The resident was then determined to qualify for hospice services and was readmitted to hospice. The SW stated the resident was nonresponsive due to cognitive loss. The SW stated hospice services had not participated in the care plan meetings. The SW stated she did not think she had invited hospice for the last care plan meeting. The SW stated she usually just sends invitations to care plan meetings to family members. The resident's last care plan meeting was 3/27/18 and the attendees included the MDS nurse, the dietitian, the day shift floor nurse, and herself. The SW stated the resident's family was invited but did not attend. The SW stated she did not have a hospice care plan for the resident. The SW further stated the facility only did care plans on certain parts or for certain problems, for example, if the resident had a combative behavior, she would do a care plan for the resident being combative. The SW stated there would not be a care plan for hospice. A second interview was conducted with the SW on 5/10/18 at 10:06 AM. The SW stated she had received input from hospice from the care plan staff. The SW stated she did not enter anything in the care plan about hospice. The SW stated there was not a care plan, or intervention for hospice in the care plan. The SW stated if she received input from hospice or a concern, they address it. The SW stated hospice did not supply a care plan for the resident. The SW stated she thought hospice left a note when they visit the resident, and she was unable to identify if a note entered into the system or a handwritten note. The SW stated there was not a care plan where the hospice care plan and the facility care plans were integrated. An interview was conducted with the MDS nurse on 5/10/18 at 10:19 AM. The MDS nurse stated she did not know if Resident #12 had a hospice care plan and she would have to ask the Medical Records Manager. The MDS nurse stated she did not know if hospice participated in the care plan meetings at the facility and she would have to ask the SW. An interview was conducted with the Medical Records Manager (MAM) on 5/10/18 at 10:22 AM. The MAM stated there was a hospice assessment plan of care in addition to handwritten hospice notes which she scans and enters into the facility's EMR system. The MAM stated there were several recertification notes under the provider section of Resident #12's hospice tab. A phone interview was conducted with the Case Worker from the hospice agency on 5/10/18 at 10:30 AM. The Case Worker stated she had not collaborated with the facility for Resident #12's care plan. The Case Worker stated she had not been invited to attend care plans for the resident at the facility. The Case Worker stated the care plan for hospice was reviewed twice per week and she reviewed the hospice care plan weekly. The Case Worker stated the facility staff would have access to the hospice care plan but she did not know if the facility staff had reviewed the hospice care plan. The Case Worker stated there was not a process from hospice to integrate the hospice care plan and the facility care plan for the resident. The Case Worker stated she was not familiar with the contract between the hospice agency and the facility. The Case Worker stated there was not a care plan which was written jointly by hospice and the facility. The Case Worker stated there was not a separate care plan kept at the hospice office. The Case Worker stated information in regards to the resident would be communicated to front line facility staff such as Nursing Assistants (NAs) through a verbal report. The Case Worker stated the care plan after each visit was handwritten. The Case Worker stated there was an Interdisciplinary Group which consisted of members of only the hospice staff and they would discuss their hospice Care Plan. An interview conducted with the DON was conducted on 5/10/18 at 10:51 AM. The DON stated the facility prepares their care plans with the resident's family. The DON stated the SW reviewed the hospice care plan with the nursing staff. The DON stated hospice was on a different computer system than the facility. The DON stated there was not a hospice care plan in the software system the facility used. The DON stated there was not a set care plan meeting with hospice. The DON stated hospice residents were discussed between the hospice staff and the facility staff when the hospice staff were in the facility several times per week. The DON stated he would have to refer me to the hospice staff to discuss interventions or goals related to areas in the hospice care plan. The DON stated frontline staff received information about hospice residents through verbal reports. The DON stated there were notes which were in the system under hospice which had been scanned into their computer system. A copy of the hospice Plan of Care (P[NAME]) for Resident #12, dated 12/1/17, was received on 5/10/18 at approximately 11:20 AM. The P[NAME] included information such as the resident's name, address, diagnoses, and advance directives (code status). Other information included were listed such as goals, a nursing plan of care will be established that meets the patient's needs. The resident's medications were listed. The orders section of the P[NAME] documented the hospice Nurse was to coordinate the plan of care with the facility staff. The P[NAME] was signed by the hospice physician on 12/1/17. Further review of the P[NAME] revealed no associated measurable goals or interventions related to identified diagnoses, problems, or focus areas.

Based on observations, record review, resident interview, hospice representative interview and staff interviews, the facility failed to collaborate with hospice to develop and implement an interdisciplinary care plan for one of one resident reviewed for hospice (Resident #12). The findings included: Review of the contract between the facility and hospice with an effective date 8/26/13 revealed the following: Section 1.6 hospice Plan of Care. A written care plan jointly established, maintained, reviewed and modified as necessary, at regular intervals, by the hospice Medical Director, Attending Physician and hospice Interdisciplinary Group, and with the participation of Skilled Nursing Facility (SNF), to the extent practical, which includes: (a) an assessment of each hospice Patient's needs; (b) an identification of the hospice Services, including management of discomfort and symptom relief, needed to manage and palliate the hospice Patient's terminal illness and to meet the related needs of the hospice Patient's family; and (c) details concerning the scope and frequency of hospice Services. Resident #12 was admitted to the facility 1/29/16 with [DIAGNOSES REDACTED]. A review of Resident #50's Minimum Data Set (MDS) revealed the most recent completed assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 3/7/18. The MDS assessment indicated Resident #50 was unable to complete the Brief Interview for Mental Status due to having been rarely or never understood which indicated severe cognitive impairment. The resident was coded as having had a condition or chronic disease that may have resulted in a life expectancy of less than 6 months. The resident was coded as having had received hospice care while she was a resident at the facility. Review of Resident #12's Electronic Medical Record revealed the resident had an Informed Consent/Election of Benefits with hospice dated 11/30/17. A review completed of Resident #12's care plan which had been documented as having been last reviewed on 3/27/18 revealed no hospice care plan. The only discovered mention of hospice care in the care plan except for the care plan addressing activities of daily living. The information listed related to hospice services were hospice services were discontinued on 9/21/17 and were reinitiated on 11/30/17. An interview was conducted with the Social Worker (SW) on 5/10/18 at 9:25 AM. The SW stated Resident #12 was determined to qualify for hospice services and was readmitted to hospice on 11/30/17 due to the [DIAGNOSES REDACTED]. The SW stated she did not think she had invited hospice for the last care plan meeting and she usually just sent invitations to care plan meetings to family members. The resident's last care plan meeting was 3/27/18 and the attendees included the MDS nurse, the dietitian, the day shift floor nurse, and herself. The SW explained the resident's family was invited but did not attend. The SW stated hospice services had not participated in the care plan meetings since the resident had been readmitted to hospice. The SW stated she did not have a hospice care plan for the resident. A second interview was conducted with the SW on 5/10/18 at 10:06 AM. The SW stated if she received input from hospice or a concern, they addressed it. The SW stated hospice did not supply a care plan for the resident. The SW stated there was not a care plan where the hospice care plan and the facility care plans were integrated. An interview was conducted with the MDS nurse on 5/10/18 at 10:19 AM. The MDS nurse stated she did not know if hospice participated in the care plan meetings at the facility and she would have to ask the SW. A phone interview was conducted with the Case Worker from the hospice agency on 5/10/18 at 10:30 AM. The Case Worker stated she had not collaborated with the facility for Resident #12's care plan and she had not been invited to attend care plans for the resident at the facility. The Case Worker stated she reviewed the hospice care plan weekly. The Case Worker stated there was not a process from hospice to integrate the hospice care plan and the facility care plan for the resident. The Case Worker stated she was not familiar with the contract between the hospice agency and the facility and there was not a care plan which was written jointly by hospice and the facility. The Case Worker stated information in regards to the resident would be communicated to front line facility staff such as nursing assistants (NAs) through a verbal report. An interview conducted with the DON was conducted on 5/10/18 at 10:51 AM. The DON stated the facility prepares their care plans with the resident's family. The DON stated hospice was on a different computer system than the facility and there was not a hospice care plan in the software system the facility used. The DON stated there was not a set care plan meeting with hospice. The DON further stated hospice residents were discussed between the hospice staff and the facility staff when the hospice staff were in the facility several times per week. The DON stated frontline staff received information about hospice residents through verbal reports.

Based on observation, staff interviews, record review and service representative interview the facility failed to maintain sanitary conditions in the kitchen by failing to ensure the kitchen ' s dish machine maintained proper temperatures to effectively sanitize dishware and equipment, failed to air-dry dishes completely before storing for use and failed to cover fish thawing in the kitchen ' s walk in cooler. The findings included: 1. On 4/20/2016 at 10:40 am the dishwashing area at the Carolinas Medical Center-Union was observed. This kitchen was identified as the food provider for Jesse Helms Nursing Center. The Interim Dietary General Manager, was present for the observation. The dish machine ' s rinse temperature was observed operating at 172 degrees Fahrenheit. Interview with the Interim Dietary General Manager on 4/20/2016 10:45 am revealed the dish machine ' s rinse cycle should operate at a temperature of 180 degrees to sanitize equipment being washed in the machine. The General Manager also explained that the dish machine ' s manufacturer was scheduled to come to the facility to work on the machine ' s thermometer. He referenced a work order with maintenance to check the dishwasher, but explained the machine is new and under warranty. A review of the dish machine ' s temperature log showed that the recommended temperature for the machine ' s final rinse was 180 degrees Fahrenheit. Review of the dish machine ' s temperature log revealed since 4/13/2016 staff had documented the machine ' s final rinse cycle was operating at temperatures lower than 180 degrees Fahrenheit. On 4/13/2016 at 8:00 am the final rinse temperature was documented on the temperature log as 185 degrees Fahrenheit and on 4/13/2016 at 12:45 pm the machine ' s final rinse temperature was documented as only 118 degrees Fahrenheit. Further review of the dish machine ' s log revealed from 4/13/2016 at 12:45 pm through 4/21/2016 the machine ' s final rinse cycle temperature was never recorded by staff to be operating at 180 degrees or higher. On 4/21/2016 at 8:43 am maintenance staff #1 was interviewed. He provided a work order dated 4/13/2016. The work order noted that maintenance staff #1 had responded to the maintenance request to check the kitchen ' s dish machine on 4/14/2016 at 12:00am. Comments on the work order included; I notified dietary staff #1 to call the dish machine manufacturer for warranty on dish machine. Maintenance staff #1 verified that he had expected dietary staff to call to have the dish machine serviced on 4/14/2016 because the machine ' s final rinse temperature was not reaching 180 degrees Fahrenheit. The Interim Dietary General Manager joined the meeting and explained that he thought the facility ' s maintenance staff had called to have the dish machine serviced. Both maintenance staff #1 and the Interim Dietary General Manager confirmed that neither the maintenance department nor the dietary department had called to have the kitchen ' s dish machine serviced. On 4/21/2016 at 9:39 am the administrator was interviewed. He explained that he expected the dietary management to notify him of a problem with the dishwasher temperatures. He explained that to his knowledge there had been no incidences of residents experiencing food-borne illness at the facility. He stated, I will correct this today. One 4/21/2016 at 10:10 am, the dish machine ' s Service Representative was interviewed. He stated, I flushed the steam line and adjusted the final rinse temp. When asked if he had worked on the thermometer he said no, I believe it was more in the steam line. Observation of the dish machine on 4/21/2016 at 10:15 am revealed the machine ' s final rinse temperature was consistently operating at temperatures above 180 degrees Fahrenheit. 2. Observations on 4/20/2016 revealed 4 out of 10 steam table pans were stored wet and there was water pooled in the rims of the pans. The Interim Dietary General Manager, was present for the observation. He removed the pans from service. An interview with the Interim Dietary General Manager revealed that he expected staff to air dry pans before storing them. He also corrected the staff responsible for washing dishes, directing them to make sure the dishes were dry before storing them. He pointed out one small rack beside the dishwashing area and two additional rolling racks with several shelves to be used when drying dishes. He explained that if the racks are full and more storage is needed, management should be notified. 3. On 4/18/2016 at 11:35 am the kitchen ' s second cooler, identified as the vegetable cooler was observed. A pan of fish was observed thawing uncovered on a stacked, rolling rack. Other pans above and below with thawing foods were covered. Unidentified, dark debris was observed on the fish. The Retail Operations Manager was present for observation. The Interim Dietary Manager was notified. An interview with the Interim Dietary General Manager revealed that he expected staff to cover all foods thawing in the coolers. He instructed staff to remove the fish from the cooler.

Based on observations, record review and staff interviews the facility failed to provide protective sleeves to prevent skin injury for one of one resident (Resident #25) with skin tears. The findings included: Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set, a quarterly, dated 2/26/16 indicated Resident #25 had long and short term memory impairment and severe impairment with decision making abilities. This MDS indicated she required extensive assistance of one staff for dressing. There were no skin tears present at the time of this assessment. The care plan dated 2/29/16 included a problem in Activities of Daily Living (ADLs) due to history of a stroke, [MEDICAL CONDITION] and left upper extremity contracture. Resident #25 required extensive assistance to total dependence with ADLs. Interventions included total lift for transfers, extensive assistance for bed mobility, dressing toileting and bathing. Apply protective sleeves to arms, and a pillow to the left side for positioning when leaning. The signed April monthly physician orders [REDACTED]. Review of a nurse ' s note dated 4/12/16 at 3:30 PM revealed a skin tear was noted on Resident #25 ' s left arm above the elbow. The resident was pulled up in her chair by 2 staff when skin tear was noted. A 0.5 centimeter (cm) upside down v shape skin tear. Her arm may have been under the edge of the arm at the time she was repositioned in the chair. Resident #25 ' s skin very fragile. Review of a skin assessment dated [DATE] revealed a dressing was on the left elbow, with bruising and discoloration noted on bilateral upper extremities. Review of the Medication Administration Record (MAR) for April 2016 revealed initials of nurses for each shift was present indicating the sleeve protectors had been applied. Observations on 4/19/2016 at 10:08 AM revealed Resident #25 had bruising on both arms. A dressing was observed on the left arm, and bruising was greater on the left arm. Sleeve protectors were not on either arm. Observations on 04/20/2016 at 11:58 AM with Nurse Aide (NA) #1 revealed she had just checked Resident #25 and checked her positioning in the chair. Resident #25 did not have the sleeve protectors on her arms, and a pillow was not in place to her left arm. Observations on 04/20/2016 at 1:35 PM revealed Resident #25 was in bed and the sleeve protectors were not on her arms. Interview on 04/20/2016 at 2:55 PM with NA #1 revealed positioning devices used for resident #25 included a pillow when she was in bed. NA #1 explained she was not aware sleeve protectors were to be applied. NA #1 explained the resident did have skin tears and fragile skin. Review of the care tracker (computer care instructions) for Resident #25 with NA#1 revealed the use of sleeve protectors was not included in the care guide. On 04/21/2016 at 9:46 AM an interview was conducted with the charge nurse (Nurse #1) for Resident #25. Nurse #1 explained Resident #25 was supposed to have the sleeves on each day. Nurse #1 was not aware the resident did not have the sleeves on her arms. Further explanation was provided the documentation of the nurses ' initials on the MAR indicated the nurses ensured the sleeves were on the resident. This nurse looked in the resident's room for the sleeves, and none were found. She stated she would have to get her some. Interview with MDS nurse on 04/21/2016 at 9:47 AM revealed the information was on the MAR to apply the sleeve protectors and it would be the nurse's responsibility to make sure the sleeves were on the resident. The MDS nurse explained it would not have to be on the care tracker for the aides, if it was on the MAR. The nurse would be expected to inform the aides, and to make sure it was applied. Interview with the Director of Nursing (DON) on 04/21/2016 at 10:02 AM revealed he would expect the nursing staff to apply the sleeve protectors, and initial the MAR it was done. Interview with administrator on 04/21/2016 at 12:00 PM revealed the resident had the sleeves last week per the unit nurse. He explained if the sleeves became soiled, and were sent to the laundry, they may not have returned.

Based on observations, record review and staff interviews the facility failed to provide interventions on a care plan for protective sleeves to prevent skin injury for one of one resident (Resident #25) with skin tears. The findings included: Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), a quarterly, dated 2/26/16 indicated Resident #25 had long and short term memory impairment and severe impairment with decision making abilities. This MDS indicated she required extensive assistance of one staff for dressing. There were no skin tears present at the time of this assessment. The care plan dated 2/29/16 included a problem in Activities of Daily Living (ADLs) due to history of a stroke, [MEDICAL CONDITION] and left upper extremity contracture. Resident #25 required extensive assistance to total dependence with ADLs. Interventions included total lift for transfers, extensive assistance for bed mobility, dressing toileting and bathing. Apply protective sleeves to arms, and a pillow to the left side for positioning when leaning. Review of a nurse ' s note dated 4/12/16 at 3:30 PM revealed a skin tear was noted on Resident #25 ' s left arm above the elbow. The resident was pulled up in her chair by 2 staff when skin tear was noted. A 0.5 centimeter (cm) upside down v shape skin tear. Her arm may have been under the edge of the arm at the time she was repositioned in the chair. Resident #25 ' s skin was very fragile. Observations on 4/19/2016 at 10:08 AM revealed Resident #25 had bruising on both arms. A dressing was observed on the left arm, and bruising was greater on the left arm. Sleeve protectors were not on either arm. Observations on 04/20/2016 at 11:58 AM with Nurse Aide (NA) #1 revealed she had just checked Resident #25 and checked her positioning in the chair. Resident #25 did not have the sleeve protectors on her arms, and a pillow was not in place to her left arm. Observations on 04/20/2016 at 1:35 PM revealed Resident #25 was in bed and the sleeve protectors were not on her arms. Interview on 04/20/2016 at 2:55 PM with NA #1 revealed she was not aware sleeve protectors were to be applied. NA #1 explained the resident did have skin tears and fragile skin. On 04/21/2016 at 9:46 AM an interview was conducted with the charge nurse (Nurse #1) for Resident #25. Nurse #1 explained Resident #25 was supposed to have the sleeves on each day. Nurse #1 was not aware the resident did not have the sleeves on her arms. Interview with the Director of Nursing (DON) on 04/21/2016 at 10:02 AM revealed he would expect the nursing staff to apply the sleeve protectors. Interview with Administrator on 04/21/2016 at 12:00 PM revealed the resident had the sleeves last week per the unit nurse. He explained if the sleeves became soiled, and were sent to the laundry, they may not have returned.

Based on record review, observation, staff and resident interview, the facility failed to supervise, prompt and assist 1 of 1 residents reviewed for assistance with meals (Resident #71). The findings included: Resident #71 was admitted on [DATE] with a [DIAGNOSES REDACTED]. A review of her minimum data set (MDS) assessment dated [DATE] indicated that she required supervision and cueing with her activities of daily living including her meals. The assessment also revealed that she was cognitively impaired. The care plan updated on 4/8/2016, stated, Resident is independent with eating with set-up help. Encourage, assist as needed to promote optimal intake. The resident ' s weight was noted to be 96.4 on 4/5/2016. Her weight on 10/15/2016 was 104.2 pounds. On 4/18/2016 at 12:20 pm Resident #71 was observed during lunch. She was served her food with staff placing the plate of food and other items from her lunch tray on the table. The resident attempted to open a pack of salad dressing. She was unable to do so. She placed it back on the table. She left the dining room without eating any salad. She ate less than 50% of her lunch tray. On 4/20/2016 at 8:30 am the resident was observed being served by dietary staff #1. The food was taken off the tray and placed in front of her. No other assistance was offered. She was served orange juice, grits, English muffin with butter, scrambled eggs, sausage, coffee and water. She ate approximately half of the eggs and sausage, and drank part of the orange juice. She did not eat her English muffin and did not drink her coffee. She had no milk on her tray for her coffee. The butter container was unopened. No staff was observed offering her any assistance or encouraging the resident to eat. On 4/20/2016 at 8:55 am dietary staff #1 was interviewed. She said that Resident #71 feeds herself. She explained that we just serve her the tray and she can do the rest by herself. Resident #71 was interviewed on 4/20/2016 at 3:05 pm. Resident explained that she is able to feed herself. She indicated that she liked the food, but gets full really fast. She indicated that she likes salad with ranch dressing and likes milk in her coffee. On 4/21/2016 at 1:31 pm Nurse #3 was interviewed. She explained that there was a time not long ago when the resident was sick and she needed more assistance. She indicated that she expected staff to assist her more with her meals than just to set it up. She explained that her intake had not been that good. She had offered her snacks, but she doesn ' t eat them that often. She also indicated that she had given her ensure at times and encouraged her to drink it while she watched. She explained that the resident at 25% for lunch and that she would expect the staff to encourage her to eat more. The MDS Nurse was interviewed on 4/21/2016 at 1:45 pm. She explained that the resident has had times that she has not felt good that she needed more assistance. She indicated that the resident should be supervised and encouraged to eat. She explained that the resident ' s weight has been monitored by the Nutrition Alert Team. She explained that she expected the staff to assist with opening packages and assisting residents as needed with harder to open items such as the dressing. She indicated that would be considered part of the set-up of the meal. The DON was interviewed on 4/21/2016 at 1:57 pm. He explained that he was on the Nutrition Alert Team and that the resident had lost some weight in the past, but it has been stable in the last month. He explained that he expected staff to assist with meals as needed including opening dressing and butter. He indicated that when a resident doesn ' t eat that staff should encourage them and if intake is low they should tell the nurse.

Based on record review, observation and staff interviews the facility failed to provide catheter care using clean technique for 1 of 1 residents with indwelling urinary catheters (Resident # 105). The findings included: Resident #105 was admitted [DATE] following a fall at home. She had a history of [REDACTED]. An indwelling urinary catheter was placed on 3/26/2016 due to [MEDICAL CONDITION] as noted in nursing notes and physician orders. On 4/21/2016 at 10:17 am Nurse Aide #2 was interviewed She explained that she offered the resident catheter care each shift or more as needed if soiled. She explained that she would wash her hands and put on gloves, cleanse with soapy water and a washcloth for one pass, then fold the washcloth to expose a new area and make another pass. When the area was clean she indicated she would clean down the catheter tubing. She also expressed that she would change cloths as needed and rinse with a new cloth and dry the resident. On 4/21/2016 at 10:26 am catheter care was observed for Resident #105. Nurse Aide #2 went to gather linens while Nurse Aide #3 prepared pan of water. Nurse Aide #3 performed hand hygiene and donned gloves. She went into the bathroom, removed a pan from the cabinet, turned on the water, filled the pan with water and placed the pan on the bedside table. Nurse Aide #2 had returned to room and placed a towel over the bedside table and placed other towels and washcloths on the towel covering the table. She performed hand hygiene and donned gloves. She entered the bathroom and retrieved a second pan, filled it with water, touching the pan, cabinet doors and handles for the water. She left the bathroom and placed the second pan on the bedside table. She turned down the bed, locked resident ' s wheelchair and opened the closet door to get a gait belt which she used to transfer the resident. She removed the resident ' s pants and opened the resident ' s brief and positioned her for catheter care. Without changing gloves or performing hand hygiene, Nurse Aide #2 proceeded to provide catheter care. She cleansed, rinsed and dried the resident ' s front including the catheter area and catheter and cleansed her buttocks. She removed the used brief, and placed a second brief under the resident, turned her to position the brief properly and fastened it. She dressed the resident, covered her, placed the bed in low position, and placed the resident ' s call bell on the bed. She then cleaned up the bedside table, bagging used linen, emptied the pans of water in the bathroom, rinsed them and returned them to the bathroom cabinet prior to removing soiled gloves or performing hand hygiene. On 4/21/2016 at 2:00 pm the Director of Nursing was interviewed. He explained he expected the Nurse Aides to wash their hands and change gloves prior to touching the resident and immediately after performing care. He referenced and provided a Lippincott Procedures-Indwelling urinary catheter (Foley) care and management , dated October 2, 2015. He explained that they use Lippincott Procedures to guide their care. This guide referenced performing hand hygiene and donning new gloves just prior to patient contact at the catheter site and removing gloves and performing hand hygiene immediately following care. He explained that he expected them to perform care in this way.

Based on record review and pharmacist interview the facility failed to ensure monthly Medication Regimen Review (MRR) were conducted each month for 1 of 5 residents (Resident #108) reviewed for unnecessary medications. Resident #108 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].#108 was being treated with an antipsychotic 7 days a week. A record review of Resident #108 MMR revealed pharmacy documentation on 1/21/2015 and pharmacy documentation on 3/9/2015. A review dated 11/18/14 revealed on 10/20/2014 Seroquel (antipsychotic) 25 mg at hour of sleep was restarted due to a failed gradual dose reduction. On 05/19/2015 at 12:30 PM the Pharmacist acknowledged monthly pharmacy reviews were expected and she was responsible for all the residents in the building. She did not complete a review in February 2015. She reported that residents in the facility change rooms often and the February MMR was missed. Her personal notes revealed the February MMR was missed and the review was done on a resident with like name (Resident #73). On 05/20/2015 at 10:10 AM the Administrator stated the Pharmacist are to do monthly reviews. She reported there were name alert stickers on the resident charts with like names and name alerts were also identified on the medication administration record. The Administrator's expectation was for staff to use the common identifiers e.g. name, picture, room number to accurately identify residents.

Based on observation, interviews with a resident and staff and review of the medical record, the facility failed to provide timely extensive staff assistance with eating for 1 of 3 sampled residents dependent on staff for activities of daily living. (Resident #49) The findings included: Resident #49 was admitted to the facility 12/31/12. [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Additionally, a physician's orders [REDACTED].#49 to receive one to one staff assistance with meals due to pocketing solid food. Review of an annual minimum (MDS) data set [DATE] revealed Resident #49 was assessed with [REDACTED]. Review of a care plan, revised 01/22/14, revealed Resident #49 required extensive staff assistance with activities of daily living (ADL) to include assistance with eating. Interventions included respond promptly to requests for assistance, provide necessary assistance at meal time, and encourage as needed to promote optimal meal intake. Resident #49 was observed on 02/19/14 at 9:01 AM in her room after receipt of her breakfast meal from nurse aide (NA) #3. NA #3 placed the meal on the Resident's over bed table, uncovered the breakfast meal, the Resident expressed her preferences regarding condiments and NA #3 set up her meal. NA #4 entered the room to assist with positioning the Resident. NA #4 was observed to inform NA #3 that Resident #49 required one to one assistance with her meal; NA #4 left the room. NA #3 sat down to assist Resident #49 with breakfast. Prior to providing assistance, at 9:07 AM, NA #3 was called out of Resident #49's room to help distribute breakfast trays on another hall. Resident #49 was left with her breakfast meal in front of her and uncovered. Resident #49 sat with her hands in her lap and starred at her food until she dozed off to sleep at 9:19 AM. Resident #49 awoke at 9:21 AM, removed the straw from her juice, placed the straw in her mouth and with the straw in her mouth, made several unsuccessful attempts to insert the straw back in the apple juice. At 9:31 AM, NA #4 returned to the Resident's room and offered Resident #49 some juice. Resident #49 drank approximately 3 ounces of juice continuously at which time NA #4 said "You were thirsty weren't you?" Resident #49 shook her head up and down. NA #4 gave Resident #49 two bites of pureed eggs, which were observed as stiff and without any signs of steam, to which the Resident responded "I'm not too crazy about it." Resident #49 was asked by the surveyor if the food was warm enough to which the Resident replied "Huh, uh, I'm not eating it." NA #4 continued to feed Resident #49 pureed eggs without offering to reheat the food, Resident #49 held the pureed eggs in her mouth and responded "It doesn't taste good." Resident #49 removed the pureed eggs from her mouth with a napkin. As NA #4 fed Resident #49 pureed sausage, also stiff and without signs of steam, Resident #49 grimmaced and shook her head back and forth, NA #4 stated to the resident "You don't like it?", to which Resident #49 responded "Uh, uh" while moving her head side to side. At 9:40 AM, NA #4 exited Resident #49's room to answer the call light for another resident; Resident #49's food was left uncovered. At 9:42 AM NA #4 returned to Resident #49's room and asked the Resident if she wanted anymore of her breakfast, the Resident moved her head side to side and responded "Uh, uh " Resident #49's breakfast tray was removed and placed on a cart. An interview was conducted on 02/19/14 at 09:43 AM with NA #4 who revealed she worked with Resident #49 once to twice weekly. NA #4 stated Resident #49 did not eat much, but drank fluids well and usually ate 25% of her meals. NA #4 stated that if she had to step away while feeding a resident when she returned she usually asked the resident if they want their food reheated, but she did not ask Resident #49, nor did she assess the temperature of the Resident's food because the Resident typically ate her meals very slowly and for this reason NA #4 stated that she thought Resident #49 did not like hot food. On 02/19/14 at 1:22 PM, Resident #49 was observed in her room assisted by NA #5 with her lunch meal. Resident #49 received prompt assistance with her lunch meal and ate 25% of her meal and drank 340 ml of her fluids. NA #5 stated that Resident #49 usually ate about 25% of her meals and could express meal preferences, including whether or not her food was hot. An interview with nurse #2 (charge nurse) occurred on 02/20/14 at 11:31 AM. The interview revealed that staff was trained to assist residents with meals who ate in their rooms by distributing meal trays first to residents who fed themselves, followed by those residents who required cueing and then lastly by those required to be fed. Nurse #2 stated meal trays should be left covered and on the cart to prevent staff from starting to feed someone and then getting up to go pass out a meal tray. Nurse #2 stated that if a staff member had to walk away from feeding a resident, the meal tray should be covered with the lid and then when the staff member returned, they should check to see if the food needed to be warmed and reheat it. Nurse #2 stated not offering to reheat a resident's food was not an acceptable practice. An interview on 02/20/14 at 3:15 PM with the director of nursing revealed she would expect that if a resident was fed by staff in their room, staff would not be pulled away from assisting with the meal, but if so, the meal should be covered and when staff returned, the staff should offer to reheat the meal for the resident.

Based on observations, staff interviews and record review, the facility failed to disinfect a glucose meter (used for blood sugar monitoring) after a finger stick blood sugar for 2 of 3 sampled residents observed for finger stick blood sugar checks (Residents #2 and #29). The findings included: 1. Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of monthly physician's orders [REDACTED]. Review of an orange topped disinfectant wipes container's label revealed the manufacturer's direction for disinfection required the surface to be thoroughly wet. The direction specified: "Treated surface must remain visibly wet for a full 4 minutes. Use additional wipes if needed to assure continuous visible wetness for 4 minutes wet contact time." The container was located in a cupboard on the nursing unit. Observation of Nurse Aide (NA) #1 on 02/18/14 at 4:15 PM revealed she obtained Resident #2's fsbs by placing a strip with Resident #2's blood in the glucose meter. After removing the strip, NA #1 used a wipe from a container with an orange top. NA #2 wiped the glucose meter once and placed it in a charger. Interview with NA #1 on 02/18/14 at 4:20 PM revealed her usual practice was to wipe the surface and immediately place the glucose meter into the charger. NA #1 explained she wiped the shared glucose meter with the wipe each time she obtained a fsbs and there was no "set time" for saturation. NA #1 reported she did not realize the surface required visible wetness for 4 minutes. A second interview with NA #1 on 02/18/14 at 4:55 PM revealed she received training in disinfecting but forgot the time required for wetness. Interview with Nurse #2 on 02/19/14 at 4:09 PM revealed staff should wipe the glucose meter and wait 4 minutes until charge placement. Nurse #2 was not aware of the requirement for visible saturation for 4 minutes. Nurse #2 reported the directions given the staff did not include 4 minutes of visible saturation. Nurse #2 reported residents' blood sugars were checked by shared glucose meters. Interview with Nurse #3 on 02/19/14 at 4:14 PM revealed she oversaw the facility's infection control program. Nurse #3 explained the facility changed the type of wipes used for disinfection last week due to an outbreak of a gastrointestinal virus. Nurse #3 reported she directed staff to wipe the surface and keep the surface visibly wet for 4 minutes. 2. Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of monthly physician's orders [REDACTED]. Review of an orange topped disinfectant wipes container's label revealed the manufacturer's direction for disinfection required the surface to be thoroughly wet. The direction specified: "Treated surface must remain visibly wet for a full 4 minutes. Use additional wipes if needed to assure continuous visible wetness for 4 minutes wet contact time." The container was located in a cupboard on the nursing unit. Observation on 02/19/14 at 3:50 PM revealed Nurse Aide (NA) #2 revealed she obtained Resident #29's fsbs by placing a strip with Resident #29's blood in the glucose meter. After removing the strip, NA #2 used a wipe from a container with an orange top. NA #2 wiped the glucose meter and placed it on the counter. The surface was visibly wet from 3:55 PM to 3:57 PM. Interview with NA #2 on 02/19/14 at 3:59 PM revealed she received direction to wet the surface with a wipe and wait 4 minutes until it could be placed in the charger. NA #2 explained she did not realize the surface was to remain visible wet so did not check the surface. NA #2 reported she received direction to wipe down the glucose meter and wait 4 minutes until charge placement. Interview with Nurse #2 on 02/19/14 at 4:09 PM revealed staff should wipe the glucose meter and wait 4 minutes until charge placement. Nurse #2 was not aware of the requirement for visible saturation for 4 minutes. Nurse #2 reported the directions given the staff did not include 4 minutes of visible saturation. Nurse #2 reported residents' blood sugars were checked by shared glucose meters. Interview with Nurse #3 on 02/19/14 at 4:14 PM revealed she oversaw the facility's infection control program. Nurse #3 explained the facility changed the type of wipes used for disinfection last week due to an outbreak of a gastrointestinal virus. Nurse #3 reported she directed staff to wipe the surface and keep the surface visibly wet for 4 minutes.

Based on observed medication passes, staff interviews and record review, the facility failed to administer a correct dose of medication (Resident #2) and omitted a medication (Resident #15) which did not ensure a medication error rate of less than 5%. There were 2 errors of 30 opportunities for error which resulted in a medication error rate of 6.6%. Findings included: 1. Resident #2 was admitted to the facility on [DATE]. Review of a monthly physician order [REDACTED]. On 02/19/14 at 8:40 AM, Nurse #4 was observed at the Resident's bedside with a plastic dosing card used for [MEDICATION NAME] sodium gel 1%. The plastic dosing card was marked in the middle as 2g and at the end as 4g. Nurse #4 applied the gel from one end of the plastic dosing card the other end marked 4g, removed the medication from the card with gloved hands and rubbed it into Resident #2's left shoulder. Nurse #4 applied more medication on the plastic dosing card from one end of the plastic dosing card to the other end marked 4g, removed the medication from the card with gloved hands and rubbed it into Resident #2's right shoulder. While she was rubbing the medication into Resident #2's right shoulder, she stated she squeezed a ribbon of medication from one end of the measuring tool to the other end. Nurse #4 removed her gloves, washed her hands, discarded the plastic dosing card and left the Resident's room with the tube of medication. On 02/09/14 at 8:45 AM, Nurse #4 reviewed Resident #2's Medication Administration Record [REDACTED]. Nurse #4 obtained a plastic dosing card from the drawer in the medication cart where the medication was stored and stated she squeezed the medication from end to end which was a 4g dose. Nurse #4 stated she should have dispensed a 2g dose of medication for each shoulder. 02/19/14 at 4:42 PM the Director of Nursing (DON was interviewed. She stated she expected nurses to cross check dispensed medication dosages with the MAR, making sure medications were administered by the right route and for the right patient, and then to recheck this again after the medication was administered. She stated for ointment medications that nurses were to use the measuring device provided with the medication by the manufacturer. 2. Resident #15 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of Resident #15's February 2014 Medication Administration Record [REDACTED]. Observation on 02/19/14 at 8:42 AM revealed Nurse #1 checked Resident #15's blood pressure and apical pulse. Nurse #1 announced a blood pressure measurement of 160/80 mmHg and the apical pulse of 72. Further observation on 02/19/14 at 8:44 AM revealed Nurse #1 prepared five medications to administer to Resident #15. The medications did not include Carvedilol. Nurse #1 administered the medications via Resident #15's feeding tube at 8:45 AM and flushed the tube with 240 milliliters of water. Nurse #1 exited the room. Interview with Nurse #1 on 02/19/14 at 9:51 AM revealed Resident #15 received all of the medications scheduled for administration at 9:00 AM. Nurse #1 explained she thought she administered the Carvedilol since she obtained Resident #15's blood pressure and apical pulse measurements. After review of Resident #15's MAR indicated [REDACTED]. Nurse #1 reported the MAR binder became undone earlier in the shift. Nurse #1 reported the MAR indicated [REDACTED]. Interview with the Director of Nursing on 02/19/14 at 1:40 PM revealed she expected staff to administer medications as ordered by the physician.

Based on observations, record review, and staff, resident, and family interviews the facility failed to provide nail care to 1 of 3 residents reviewed for nail care. (Resident #4) The findings included: Review of an addendum to the facility Nursing Care Guide updated 05/23/13 revealed care of fingernails should be provided to residents on shower day and as needed. Resident #4 was readmitted to the facility 05/27/13 with [DIAGNOSES REDACTED]. An Admission Minimum Data Set ((MDS) dated [DATE] coded the resident with moderately impaired cognition, able to make needs known, and understands others. The MDS indicated extensive staff assistance was required for activities of daily living (ADL) such as transfers, person hygiene, and bathing. A Care Area Assessment (CAA) documented Resident #4 experienced short and long term memory loss and had poor safety awareness. The CAA also specified nursing staff was to provide assistance as needed to complete ADL. A care plan dated 06/07/13 identified Resident #4 as needing assistance with ADL related to weakness from recent hospital stay and [MEDICAL CONDITION]. The care plan goal specified the resident would be able to reach and maintain the need for limited assistance to supervision with completion of ADL. Interventions included assist with personal hygiene, dressing, and bathing. A review of the facility shower log revealed Resident #4 was scheduled to have a shower on the evening shift on Saturdays. A review of nurse aide documentation revealed bed baths were provided on 06/30/13 and 07/06/13 by Nurse Aide (NA) #1. No other documentation of baths or showers was provided on these Saturdays. An observation on 07/09/13 at 11:29 AM revealed Resident #4 was sitting in her wheel chair in the hallway. The resident was observed nicely dressed with hair recently shampooed and set. The resident held out her hands and looked at her fingers. All 10 fingernails were observed extending approximately ? inch above each fingertip. Resident #4 stated her fingernails needed to be cut. She added she had never worn her nails so long. Resident #4 explained she was unable to cut her nails due to weakness in her right arm and hand. An interview with Resident #4's family member was conducted on 07/09/13 at 2:48 PM. The family member confirmed the resident's fingernails were too long and needed to be cut. The family member stated 2 weeks ago he had tried to set up an appointment with a lady that visits the facility and does nail manicures but had been unable to locate her. An interview with the Director of Nursing (DON) was conducted on 07/09/13 at 2:52 PM. The DON stated the facility had a volunteer that does nail care which consisted of filing and polishing. The DON explained facility nurse aides were expected to do nail care with resident showers. She stated facility nail care included cutting the nails. The DON added the nails were soft and easier to cut following a shower or bath. An interview with NA #1 was conducted via phone on 07/10/13 at 8:38 AM. The NA stated she worked the 11:00 PM to 7:00 AM night shift. She had provided bed baths to Resident #4 on 06/30/13 and 07/06/13 as part of her daily care of getting dressed for the day. NA #1 explained nail care should be provided with weekly showers which were not done on the night shift. She added if she had realized Resident #4's nails had needed cutting, she would have provided the service.

Based on observations, staff interviews, and record review the facility failed to transfer a resident with a mechanical lift (Resident #21), and failed to implement the fall prevention measures of a low bed and floor mats (Resident #7) for two (2) of five (5) sampled residents. The findings are: 1. Resident #21 was most recently readmitted [DATE]. [DIAGNOSES REDACTED].#21 with moderately impaired cognition, requiring extensive assistance with bed mobility, transfers, and does not ambulate. On 12/20/12 at 2:25 PM direct care staff were observed transferring Resident #21 from her bed to a recliner chair with a total mechanical lift. Appropriate lift technique was used for safe transfer. Review of care plan entitled activities of daily living dated 11/26/12 noted the resident's non ambulatory status. Care plan approaches included to ensure a safe environment, and to use a lift for transfers. Review of PT (Physical Therapy) Rehab Screening dated 12/19/11 indicated Resident #21 required a mechanical lift for transfer due to inability to support weight on the lower extremities. Review of PT Rehab Screening dated 12/13/12 identified no change in the resident's baseline mobility status, and indicated that Resident #21 continued to require mechanical lift for transfers. Review of Post Fall Incident report dated 11/15/12 indicated Resident #21 was transferred from the wheelchair to the toilet with two person assistance. Resident #21 twisted her right ankle and was assisted to the floor by staff. The resident was sent out to the emergency department for evaluation. Review of hospital history and physical (H&P) dated 11/16/12 indicated [DIAGNOSES REDACTED]. The H&P summary indicated conservative management with no surgical repair was appropriate due to Resident #21's history of immobility and no report of pain. The resident returned to the facility 11/16/12 with a splint device to the right lower extremity. On 12/19/12 at 5:50 PM an interview was conducted with Nurse Aide (NA) #3. NA #3 stated she assisted Resident #21 to the bathroom on 11/15/12. NA #3 stated Resident #21 was seated in her wheelchair and asked to go to the bathroom. NA #3 stated she referred to the nursing care guide for direction on how to transfer the resident. NA #3 stated the care guide indicated to transfer Resident #21 with a stand up lift. NA #3 stated she obtained the stand up lift however it would not fit into the bathroom. NA #3 stated she wheeled Resident #21 into the bathroom in her wheelchair and stood her up to assist her onto the toilet. NA #3 stated the resident's legs became weak and her ankle twisted. NA #3 stated she assisted the resident to the floor and notified the nursing staff. On 12/19/12 at 6:23 PM an interview was conducted with NA #4. NA #4 stated she assisted NA #3 to transfer Resident #21 to the bathroom on 11/15/12. NA #4 stated she referred to the nursing care guide and was aware the resident should be transferred with a stand up lift. NA #4 confirmed that she and NA #3 transferred the resident from the wheelchair to the toilet without the use of the mechanical lift. On 12/20/12 at 3:04 PM an interview was conducted with the Physical Therapist who completed the PT Rehab Screening dated 12/13/12. The Physical Therapist stated her assessment indicated Resident #21 was dependent for all functional mobility and required mechanical lift for all transfers. On 12/20/12 at 3:22 PM an interview was conducted with the Director of Nursing (DON). The DON stated she expected staff to transfer Resident #21 as directed on the plan of care and nursing care guide to ensure residents were transferred safely. 2. Resident #7 was admitted on [DATE] to the facility with [DIAGNOSES REDACTED]. Review of Resident #7's quarterly Minimum Data Set ((MDS) dated [DATE] revealed she understood and could understand others with intact cognition. Resident # 7 required limited assistance of one person for transfers and walking. Review of Resident #7's care plan dated 10/15/12 revealed Resident #7 required interventions to prevent falls. Interventions included a sensor pad on the bed, a low bed, floor mats, assistance with ambulation and offer assistance to the bathroom during rounds. Review of nursing notes dated 11/6/12 revealed Resident #7 fell without injury at 9:40 PM during an attempt to independently use the bathroom. The intervention of increasing rounds during the night was added to the care plan. Resident #7's bed alarm sounded before the fall. Review of nursing notes dated 12/12/12 revealed Resident #7 fell without injury at 4:50 PM in the room during an attempt to move an object from a chair. Review of Resident #7's nursing care guide updated 12/17/12 revealed Resident #7 required a low bed, floor mats, bed sensor alarm and required limited assistance to the toilet before and after meals. Observation on 12/17/12 at 4:15 PM revealed Resident #7 in bed with a sensor alarm. The bed was not in the lowest position and the top of the mattress was approximately 2 feet from the floor. There were no floor mats. Observation on 12/18/12 at 3:26 PM revealed Resident #7 in bed with a sensor alarm. The bed was not in the lowest position and the top of the mattress was approximately 2 feet from the floor. There were no floor mats. Observation on 12/19/12 at 8:41 AM revealed Resident #7 in bed with a sensor alarm. The bed was not in the lowest position and the top of the mattress was approximately 2 feet from the floor. There were no floor mats. Interview on 12/19/12 at 8:45 AM with Resident #7 revealed she required assistance to bathroom and fell in the past. Resident #7 explained she had to call for help but did not always wait for staff ' s assistance. Observation on 12/19/12 at 10:35 AM revealed Resident #7 sleeping in bed. The bed was not in the lowest position and the top of the mattress was approximately 2 feet from the floor. There were no floor mats. Interview with Nurse Aide (NA) #1 on 12/19/12 at 11:10 AM revealed Resident #7 did not require the bed in the lowest position or floor mats. Nurse Aide #1 explained Resident #7 received assistance with transfers and ambulation with a walker. NA #1 reported the bed could be lowered more but Resident #7 did not require this. NA #1 explained he used the care guide for direction in resident care and provided the copy of the care guide for examination. NA #1 did not see the direction for floor mats and a low bed. Observation on 12/19/12 at 11:40 AM revealed Resident #7 seated on the edge of the bed with both feet dangling. Resident #7 activated the call light. At 11:43 AM, the Director of Nursing (DON) responded and at 11:42 AM, Nurse #1 entered the room assisted Resident #7 with a sweater and transfer into a wheelchair. The bed remained at the same height and there were no floor mats. Observation on 12/19/12 at 2:09 PM revealed Resident #7 sleeping in bed. The bed was not in the lowest position and the top of the mattress was approximately 2 feet from the floor. There were no floor mats. Observation on 12/19/12 at 3:40 PM revealed NA #2 entered the room and assisted Resident #7 to the bathroom and back to bed. NA #2 did not lower the bed to the lowest position. NA #2 exited Resident #7's room. Interview with NA #2 on 12/19/12 at 3:55 PM revealed Resident #7's bed should be in the lowest position to the floor. During this interview, NA #2 returned to Resident #7's room and lowered the bed to the lowest position. NA #2 reported Resident #7 did not require floor mats but the bed should have been in the lowest position. Interview with Nurse #1, the 7:00 AM to 7:00 PM charge nurse, on 12/19/12 at 4:00 PM revealed she was not aware of a need for floor mats for Resident #7. Nurse #1 reported Resident #7's bed should always be in the lowest position and did not notice the bed position. Interview with Nurse #2, nursing supervisor, on 12/19/12 at 4:15 PM revealed Resident #7 should have floor mats and the bed in the lowest position. A search for floor mats in Resident #7's room was conducted during this interview. There were no floor mats available in Resident's #7's room Interview with the Director of Nursing (DON) on 12/19/12 at 4:35 PM revealed she expected staff to use the care guide for direction in care. The DON explained if the care guide directed a low bed and floor mats, then Resident #7 required a low bed and floor mats.