Every finding on record at Joe-Anne Burgin Health and Rehabilitation

Based on staff interviews, record review, and review of the facility's policies titled, Elopement and Wandering Patients, the facility failed to ensure adequate supervision to prevent elopement for one of 28 sampled residents (R) (R13) resulting in the resident exiting the facility unsupervised. This deficient practice had the potential for injury and inability to safely navigate outside the facility.Findings include:Review of the facility's policy titled, Elopement dated 12/27/2024 revealed an Intent to promote person-centered care for patients at risk for elopement. Section titled Definition defined elopement as when a patient leaves the premises or a safe area without authorization and/or necessary supervision. Section titled Guideline revealed the center implements mechanisms and procedures for monitoring and managing patients at risk for elopement to minimize the risk of a patient leaving a safe area without authorization and/or appropriate supervision. Under section titled Procedure, subsection Assessment revealed the center will take a proactive approach for new patients and assess new admissions for elopement risk. Further review revealed elopement risk factors related to the patient and appropriate interventions will be identified and implemented into the patient's plan of care.Review of the facility's policy titled, Wandering Patients dated 12/27/2024 revealed an Intent to identify wandering behavior of a patient and to address this behavior appropriately. Section titled Guideline revealed the issue of wandering should be addressed on the interdisciplinary care plan with an appropriate goal and interventions defined.Review of R13's electronic medical record (EMR) revealed R13 was admitted to the facility on [DATE] and pertinent diagnoses included but were not limited to Alzheimer's and dementia.Review of R13's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 6, indicating severe cognitive impairment. Section E, Behaviors, revealed rejection of care occurring daily and wandering occurring daily. Section GG, Functional Status, revealed R13 required setup or clean-up assistance with eating, oral hygiene, toileting, shower/bath, and putting on/taking off footwear. Further review revealed R13 required supervision or touching assistance with upper and lower body dressing. Section J, Health Conditions, revealed R13 had a fall prior to admission within the last two to six months.Review of R13's care plan revealed a focus of elopement/risk of elopement evidenced by aimless wandering and/or exit seeking behavior with an onset dated 1/16/2026. The goal of this focus revealed that the patient will have no injuries during any attempts to leave the grounds during the review period. Further review revealed an intervention dated 1/16/2026 for 1:1 supervision while outside and an intervention dated 1/21/2026 to maintain close observation of patient's location.Further review of R13's care plan revealed a focus of attempt to elope evidenced by short-term memory problem with an onset date of 1/16/2026. Goals included patient safety will be maintained through the review period. Further review revealed an intervention dated 1/16/2026 to include analyze key times, places, circumstances, triggers, and what de-escalates behavior, to observe patient's behavior, and to observe the patient's location.Further review on R13's care plan revealed a focus of behaviors evidenced by pacing with an onset date of 1/30/2026, wandering with an onset date of 1/30/2026, and wanders at risk for elopement (exit seeking behavior) with an onset date of 1/16/2026. Goals included patient's needs will be met and safety maintained during review period. Further review revealed an intervention dated 1/21/2026 to observe for location frequently and redirect when noted with exit seeking behaviors.Review of the final report for the Facility Incident Report #202600853 dated 1/28/2026 revealed a conclusion that documented, The facility can confirm that the resident exited the building unsupervised. The root cause was the exit door being remotely opened for another resident, and the door was not in line of sight of the staff.An interview on 03/19/2025 at 2:25 PM with the Administrator revealed that regarding the R13's elopement that occurred on 1/21/2026 he was notified by Licensed Practical Nurse (LPN) AA that R13 had exited the building through the side door located near room [ROOM NUMBER]. The administrator stated that R13 was subsequently located across the street near a nearby college.An interview on 03/19/2026 at 3:35 PM with LPN AA, who is the assigned nurse providing care for R13, revealed that R13 exhibited exit-seeking behaviors since her admission to the facility, including going to the door with personal belongings. Interventions implemented to address this behavior included frequent monitoring ensuring R13 remained in the building and to check on R13 every 15 to 30 minutes. LPN AA stated that on the day of the elopement incident, R13 likely exited the building when the doors were unlocked due to a generator outage, reportedly following another resident, and she was located within five minutes by staff across the street near a nearby college.

Based on record review, interview and review of the facility's policy titled, Advance Directives, the facility failed to ensure two of 30 residents (R) (R54 and R31) code status was accurately reflected in the electronic medical record (EMR). As a result, the residents' code status had the potential to not be honored in the event they would have coded. Findings include: Review of the facility's policy titled, Advance Directives with a review date of [DATE], stated, Each patient with decision making capacity has the right to make their own decisions related to their medical care .including the right to refuse or alter treatment plans, to accept or refuse medical or surgical treatment .and formulate advance directives. 1.Review of R54's EMR revealed she was coded as a Do Not Resuscitate (DNR) on the EMR's dashboard. R54 had a physician's order in the EMR under the Orders tab dated [DATE] for Allow Natural Death (AND) - Do Not Attempt Resuscitation (DNR). Review of a document titled Physician Orders for Life-Sustaining Treatment (POLST) signed by the responsible party and dated [DATE] and signed by the physician on [DATE] indicated Attempt Resuscitation (CPR) marked in section A of the form indicating the resident's wishes were to be resuscitated in the event they were nonresponsive. Interview on [DATE] at 3:41 pm, Licensed Practical Nurse (LPN)1 and Certified Medication Aide (CMA) 1 stated that if R54 was found nonresponsive or coded, they would check the EMR dashboard on the computer screen where it stated DNR, and they would not attempt CPR. Interview on [DATE] at 3:45 pm, Registered Nurse (RN) 1 stated that if R54 was found nonresponsive or were to code she would check the EMR dashboard on the computer screen where it stated DNR, and she would not attempt CPR. On [DATE] at 3:48 pm the information was reviewed with the Division Nurse Consultant (DNC), the Administrator, and the Director of Nursing (DON). The DON and DNC both checked the EMR and verified the above findings. The Social Worker (SW) was present during the interview, and she stated she spoke to the daughter and the daughter stated she wanted the facility staff to do CPR if her mother coded even though she was on hospice. Interview on [DATE] at 4:47 pm the DNC and Administrator stated they called the daughter, and she wanted her mother to be a DNR with her being on hospice. They stated the daughter was coming into the facility to sign the DNR paperwork. Interview on [DATE] at 5:32 pm, R54's daughter/ responsible party stated her mother wanted to be full code until today ([DATE]) when she arrived at the facility and signed the paperwork changing her mother from a full code to a DNR code status. She stated she decided to change the code status because her mom is now cognitively unable to make decisions, and declining in health. She does not want her mother to suffer if CPR were to be attempted. 2. Review of R31's EMR revealed admitted on [DATE] with diagnosis of acute and chronic respiratory failure with hypoxia. Review of the EMR revealed a document titled POLST located in the Advanced Directive tab of the EMR signed by the resident and the physician and dated [DATE]. Under section A Code Status of the document the resident marked Allow Natural Death (AND)-Do not Attempt Resuscitation. Review of the Dashboard of the EMR and the physician's orders with a start date of [DATE] indicated the resident was Full Code. The resident's care plan for Advanced Directive located in the care plan tab of the EMR stated Full Code Status with an onset date of [DATE]. Interview on [DATE] at 3:41 pm, LPN1 and CMA1 stated they would check the EMR, dashboard on the computer screen where it stated, Full Code and they would do CPR. Interview on [DATE] at 3:45 pm, RN1 stated for R31 if she coded, she would check the EMR, dashboard on the computer screen indicates Full Code she would start CPR. On [DATE] at 3:48 pm the information was reviewed with the DNC, the Administrator, and the DON. The DON and DNC both checked the EMR and verified the dashboard and physician's order should have been marked Allow Natural Death (AND)-Do not Attempt Resuscitation. After the information was shared the code status in the dashboard and the physician's orders were changed to reflect the resident's wishes to be a DNR.

Based on observation, interview, facility policy review titled, Pharmacy Services Insulin Administration, and review of manufacturer's instructions, the facility did not ensure that one of one Licensed Practical Nurse (LPN)2 had primed an insulin pen prior to dialing the ordered dose for one of one (Resident (R)227). In addition, LPN2 did not keep the needles in R227's arm for 10 seconds. Not priming an insulin pen prior to dialing the ordered dose and the failure to keep the needle in the arm for 10 seconds has the potential to reduce the insulin dose which could have affected R227's blood glucose. Findings include: Review of the facility's policy Pharmacy Services Insulin Administration dated 2025 revealed, Prime the pen and clear air from the needle. Turn the dose knob at end of pen to 1 or 2 units. Hold the pen with needle upward. Press dose knob while watching for insulin drop or stream to appear. Repeat, if needed, until insulin is seen at tip. The dial should be back at zero after priming complete .Needle should remain in subcutaneous tissue for 10 seconds to allow all of the medication to be administered properly. Review of the manufacturer's Instructions for use Humalog ([NAME]-ma-log) KwikPen(R) (insulin lispro) revealed, Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Observation on 2/13/2025 at 11:48 am revealed Licensed Practical Nurse (LPN) 2 retrieved R227's Humalog insulin pen from the medication cart. She dialed the pen to four units of insulin and then placed a new needle. She went ahead and injected the insulin in R227's left arm. She only left the needle in for approximately six seconds.] Interview on 2/13/2025 at 12:15 pm, LPN 2 stated that she was not aware that an insulin pen needle system should have been primed with two units prior to dialing the four units. LPN2 also acknowledge that she had not left the needle in the arm for the 10 seconds. Interview on 2/13/2025 at 1:00 pm with the Director of Nursing (DON) and the Divisonal Nurse Consultant, both stated that the nurses have all been educated on using the insulin pens and about priming the insulin pen first. Interview on 2/14/2025 at 9:00 am, Registered Nurse (RN) 1 revealed when giving insulin with an insulin pen it was required to prime the pen, after the needle unit had been placed, with two units of insulin. Priming the pen ensured the resident received the correct dose of insulin ordered.

Based on observation, interview, review of the facility's policy titled, Disinfecting Point of Care Devices and manufacturer's instructions, the facility did not ensure one of two nurses (Licensed Practical Nurse (LPN)4 sanitize the glucometer between (Residents (R)72, R227, and R228) use. The failure to ensure the glucometer had been disinfected between residents increased the risk of residents' contracting a blood borne disease. Findings include: Review of the facility's policy for Disinfecting Point of Care Devices dated 12/27/2024 revealed the center would ensure that reusable Point of Care devices, including glucose meters, were to have been cleaned and disinfected per manufacture's guidelines after each use. Review of the (Company Name) ProView Meter manufacturer's Caring for the Meter instructions indicated, Glucose meters used in a clinical setting for testing multiple persons must be cleaned and disinfected between patients the meter must be disinfected between patient uses by wiping it with a CaviWipe towelette or EPA-registered disinfecting wipe in between tests and be cleaned prior to disinfecting. The disinfection process reduces the risk of transmitting infectious diseases if it is performed properly. Observation on 2/13/2024 at 11:18 am. LPN4 removed the glucometer from the top drawer of the medication cart and placed the glucometer without sanitizing it on a clean tissue she had laid on top of the medication cart. Before she went into Resident (R)72's room she wiped the glucometer with an alcohol wipe and placed the glucometer back on the same tissue. LPN4 carried the glucometer into R72's room with the tissue wrapped around it and set it on R72's overbed table. She then used the glucometer to complete R72's accu chek. LPN4 brought the glucometer out of R72's room wrapped in the tissue, set the glucometer on the medication cart, took a clean tissue, and set the glucometer on that tissue without sanitizing the glucometer. LPN4 cleaned the glucometer with an alcohol wipe. LPN4 used the same glucometer for R227 and R228 and only wiped the glucometer with an alcohol wipe between residents' use of the glucometer. Review of R72's diagnoses under the Summary tab in her electronic medical record (EMR) revealed she did not have a communicable disease. Review of R72's February 2025 Medication Administration Record (MAR) revealed the order date for accu chek was 1/13/2025. Review of R227's diagnoses under the Summary tab in her EMR revealed she did not have a communicable disease. Review of R227's February 2025 MAR revealed the order date for accu chek was 2/06/2025. Review of R228's diagnoses under the Summary tab in her EMR revealed she did not have a communicable disease. Review of R228's February 2025 MAR revealed the order date for accu chek was 2/06/2025. Interview on 2/13/2025 at 11:55 am, LPN4 stated that she had not maintained the proper infection control procedures when she had used the glucometer between residents' use. She said she was told to use alcohol wipes to clean the glucometer between residents' use instead of the purple-top Santi-cloth wipes. Interview on 2/13/2025 at 1:00 pm with the Director of Nursing (DON) and the Divisional Nurse Consultant both stated that the glucometers were to be disinfected between residents with a purple-top Sani-cloth wipes. They agreed if the glucometer had been set on the medication cart and then on the clean barrier it would have contaminated the barrier. During a phone interview with the facility Medical Director (MD) on 2/14/2025 at 3:56 pm, the MD stated that he felt the alcohol swab and the antimicrobial cleaner could be interchangeable with the same sanitizing result. He stated, . as long as it was cleaned between residents and there are no communicable diseases in the building, I expect the outcomes would be the same with either cleaner.

Based on observation, staff interview, record review, and review of policy titled Elopement the facility failed to ensure the doors leading into the attached vacant hospital were secured to prevent an elopement by one resident (R1) from a sample of six residents. Findings include: Review of the facility policy titled Elopement with a review date of 12/29/2023 revealed the following: The center implements mechanisms and procedures for monitoring and managing patients at risk for elopement to minimize the risk of a patient leaving a safe area without authorization and/or appropriate supervision. R1 was admitted to the facility on [DATE] with the following but not limited diagnoses: schizophrenia, other abnormalities of gait and mobility, muscle weakness, difficulty walking, anxiety disorder and unspecified dementia with other behavioral disturbance. The resident had a Quarterly Minimum Data Set (MDS) assessment completed on 10/15/2024 noted a Brief Interview for Mental Status (BIMS) of 0 indicating the resident had severely impaired cognition, had hallucinations, delusions, verbal behavioral symptoms directed towards others and rejection of care daily. The resident had a care plan since 7/18/2024 for elopement/risk for elopement as evidenced by the resident exited the facility on 10/27/2024, aimless wandering and/or exit seeking behavior since 7/21/2024 and the resident stated they would leave the center on 10/14/2024 with the following interventions: 1:1 supervision while outside, maintain close observation of patient's location, provide activities of interest, redirect as needed and talk to patient in a calm reassuring voice. The resident had an Elopement Risk Assessment completed on 6/27/2024 with a score of 21 indicating the resident above high risk for elopement. The Elopement Risk Assessment completed on 10/27/2024 with a score of 16 indicated the resident was moderate risk for elopement. Review of the 10/27/2024 Nurses Note revealed the resident was observed walking through by the Nursing Station around 6:50 pm going down the back hallway on Tulip Lane Hallway. The resident went all the way down toward the kitchen way through the double doors and the right side of the door was open. The resident went through the double doors through the kitchen area, then walked through the hospital area and the resident through the front doors of the hospital area. Registered Nurse (RN) AA noticed the resident did not come back down the hallway that went through the hospital area out through the front doors because all the other doors had to have a code put in. All the staff started searching through the kitchen area, hospital area, and through the nursing home area. Some of the staff started looking outside and spotted the resident over in the hospital parking lot walking in front of the hospital. The Certified Nursing Assistant (CNA) brought the resident back in safely. The resident was given a head-to-toe assessment, and the resident did not have any new areas noted on her body. The resident was alert and verbally responsive. No distress noted. No complaints of pain noted. The resident is now walking around doing her usual things. The resident's daughter was called around 8:10 pm and notified about the incident. The doctor was also called around 8:15 pm with no new orders. During an interview with RN AA on 10/30/2024 at 12:30 pm, she stated around 7:15 pm on 10/27/2024 she saw the resident walking up the hall going to the kitchen. She told the resident to come back. At the same time a visitor was at the front door, so she had to go let that person in. When she got back she noticed the resident had not come back so she walked up that way and met the Maintenance Supervisor and asked him to go with her to look for the resident and told the other staff to look for her as well. She stated the door to the hospital/kitchen was open. She stated the resident wasn't missing longer than 10 minutes when she was found in the parking lot across from the hospital entrance. When they walked through the hospital only one of the halls had light. She stated they could see but they had to use the lights on their cell phones. She stated the resident was walking all day long. She stated she has never known the resident to try and get out of the building. She usually just stays in the visitor's bathroom that is in the front of the building, or she is in the front lobby just looking out the window but has never tried to get out. She stated the resident also paces up and down the hallways and a few times has gone in other resident's rooms. She immediately called the Administrator and the DON. During an observation of the double doors leading to the kitchen area and the vacant hospital on 10/29/2024 at 2:20 pm with the Business Office Manager (BOM), the doors were observed to be closed and locked and could only be opened after entering a code. The magnets which hold the double doors open had been removed causing the doors to close. The surveyor and the BOM then walked throughout the vacant hospital which consisted of old patients rooms, a nursing station, surgical rooms and surgical suite, a radiology area, offices and other empty rooms. Although equipment except for some patient beds and furniture had been removed, the majority of the vacant hospital was dark with only certain areas having lights on. The exit doors leaving the hospital were all locked except the main front entrance doors that were unlocked from the inside. During an interview with the BOM at that time, she stated apparently on 10/27/2024 staff did not close the doors once the meal carts were pushed through the double doors and the resident walked through the doors and entered the hospital. She stated they think the resident continued to walk straight through the hospital finding her way to the front main entrance of the hospital and went out the unlocked doors out to the hospital parking lot where she was found by staff. She stated the next morning, maintenance removed the magnets from the double doors so the doors could not be held open anymore. Review of the conclusion of the facility's investigation indicated the facility identified the root cause as a door that was held ajar to allow staff passage but was not re-secured. Interventions were put in place to prevent staff from propping secure doors open. Education had been provided to all associates regarding elopement risks and ensuring all exterior doors are securely shut when they enter/exit through them. An ADHOC QAPI meeting was held with the Medical Director regarding investigation findings and interventions and was in agreement with the facility's interventions. The facility will continue to assess residents routinely for elopement risk and implement interventions as appropriate to ensure safety. Routine plant inspections will continue and any safety risk will be addressed immediately upon identification. Review of the Allegation of Compliance that the facility developed following the elopement revealed the following actions were implemented: Beginning 10/27/2024 at 7:30 pm, an accounting for all residents was conducted by the Nurse Managers and charge nurses to ensure all residents were accounted for. 1. Education was provided to nursing staff on duty 10/27/2024 regarding resident's noted wandering and risk for elopement by the Charge Nurse. 2. Education was provided to all other staff by the Administrator for residents' risk for elopement related to wandering and ensuring all exterior doors close completely when entering and exiting the facility, including closure of doors on the hospital side to prevent access without code. 3. All exterior doors were tested to ensure they were closing properly without complication on 10/27/2024 by the maintenance director at 8:00 pm. 4. An Root Cause Analysis (RCA) of how the resident was able to exit the facility, obtained through interviews with staff who may have witnessed the incident, identified an unsecured right door left open to the closed hospital side. 5. Magnets were removed from the doors that lead to the kitchen area so doors would automatically close upon entry/exit and disabled from being braced open with the magnets by the Maintenance Director by 9:00 am on 10/28/2024. Systemic Changes 1. Education provided to staff to not leave doors open and to increase monitoring of patients with elopement risks. I. Review of elopement drills will be provided to associates actively working by the Administrator on 10/28/2024. Associates on leave will be provided education upon return to work duty. Newly hired associates will be provided upon hire. The facility does not utilize agency at this time. II. The DON will provide nursing staff with education on identifying behaviors that increase residents risk for elopement and completing behavior assessments and elopement risk assessments by 11/1/2024. III. By 11/1/2024, the facility will complete an elopement risk assessment on all residents to determine whether any changes in baseline have occurred that may warrant additional intervention. Review of the documentation revealed all residents had elopement assessments completed on 10/28/2024. IV. The facility Maintenance Director or designee will start conducting rounds on 10/28/2024 to ensure all exterior doors are secure with concerns every 2 hours x24 hours , every 4 hours x24 hours and then every 6 hours x 24 hours and report findings to the Administrator for QAPI tracking. V. Monitoring was implemented for resident for nursing staff to be aware of her location that included q 30 minute checks x7 hours initially, then tapered to hourly checks during the night from x4 hours. Monitoring was re-evaluated at 7:00 am on 10/28/24 and increased to q 15 minutes checks x8 hours, then q 30 minutes checks x12 hours, then hourly checks x12 hours. 2. The resident was assessed for any possible injury from noted wandering with no injury identified on 10/27/2024 by the Charge Nurse. 3. On 10/27/2024 around 8:00 pm the Charge Nurse notified the resident's daughter of resident wandering and high risk for elopement. Education on risk for injuries related elopement and review of care needs was discussed. 4. A new elopement assessment was conducted on the resident by the DON on 10/27/2024 to aid in identifying any additional behaviors that increase risk for elopement. 5. The elopement notebook at the nurses station was updated to reflect current high elopement risk residents. 6. On 10/27/2024 the charge nurse notified the resident's primary care provider of the wandering behaviors and risk for elopement. 7. The deficient practice door being unsecured leading to the kitchen was due to an associate not detaching the magnet from the right door to close it which allowed the resident to reach an unsecured area of the adjacent building. Magnets were detached from the doors leading to the kitchen area to prevent propping and increasing monitoring of residents with wandering behaviors were the interventions communicated with the Medical Director as part of Ad Hoc QAPI on 10/28/2024 and incorporated the facility's QAPI plan for continued monitoring of compliance and review with the Medical Director at least quarterly for maintenance of compliance standards. 8. The Administrator and Maintenance Director conducted rounds and identified secondary doors beyond the kitchen leading to the hospital side of the building that is not utilized by the facility. These doors have key coded magnet locking mechanisms and were activated and secondary doors secure to limit access to the hospital side of building. These doors are past the point of the doors that provide access to the kitchen side of the building. Utilization/activation of these doors was implemented by the Maintenance Director on 10/29/2024. A review of In-service sign in sheets, Elopement Risk Assessments/Clinical Assessment List, Patient Frequent Rounds for Increased Surveillance Related to Wandering Behaviors logs and Door Checks Logs and observations of the exit doors and double doors leading to the hospital revealed the facility's allegation of compliance was implemented with no additional deficient practice identified. The facility indicated that all tasks would be performed by 11/1/2024 but after review all tasks were confirmed to have been performed prior to surveyor entry to the facility on [DATE].

Based on observation, record review, resident and staff interviews, and review of facility policy/procedure titled Clinical Resource Tool; Topical Treatment of Wounds, the facility failed to ensure 1 (Resident #17) of 3 residents with pressure ulcers received treatment and services to promote healing. Actual harm was identified when a deep tissue injury (DTI, which is a purple or maroon localized area of discolored skin due to damage of the underlying soft tissue from pressure and/or shear) was identified on 3/10/2023 to the right ischium (buttock) of Resident #17 and the facility failed to assess/monitor the wound and provide necessary treatment to prevent the wound from worsening. This failure resulted in the DTI to Resident #17's right ischium worsening to an open area that was 2.5 centimeters (cm) deep, with 3 cm of undermining (erosion of tissue creating a pocket underneath the intact skin), a moderate amount of pink-yellow drainage, and a mild odor. Findings included: Review of the facility's undated policy/procedure titled, Clinical Resource Tool: Topical Treatment of Wounds, revealed, In keeping with the patient's medical condition and goal for wound care, prevent and manage infection, cleanse the wound, remove nonviable tissue (debridement), manage exudate, eliminate dead space, control odor, eliminate pain, protect wound and periwound skin, prevent deterioration, and encourage moist-wound healing. According to the tool, a shallow wound with none/light drainage, could be treated with medical-grade honey gel applied daily. For shallow wounds with moderate/heavy drainage, medical-grade honey alginate or calcium alginate with composite should be used. Further review of the resource tool revealed for deep wounds with none/light drainage hydrogel or medical grade honey gel daily and cover with dry dressing change (daily) should be used. For moderate/heavy drainage of deep wounds, calcium alginate should be used. A review of Resident #17's Face Sheet revealed the facility admitted the resident on 11/02/2022 with diagnoses of chronic obstructive pulmonary disease, acute and chronic respiratory failure, and pain in the left leg. The significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/16/2023, revealed the resident had a readmission on 03/10/2023 from an acute care hospital. The MDS revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident was moderately cognitively impaired. Per the MDS, Resident #17 exhibited disorganized thinking behaviors that fluctuated. The resident required extensive assistance of two or more staff persons with bed mobility; was totally dependent on one staff person for dressing, toilet use, and personal hygiene; and transfers and walking did not occur. Furthermore, the MDS indicated the resident had sustained a physician prescribed weight loss of five percent or more. The MDS revealed Resident #17 was always incontinent of bowel and bladder. According to the MDS, Resident #17 had one unstageable pressure ulcer (the wound bed is covered with slough and/or eschar, which is dead tissue) that was present upon reentry/readmission and the resident had a surgical wound. A review of the Care Plan for Resident #17, dated 03/10/2023, revealed the resident had a recent right above the knee amputation. The Care Plan dated 02/02/2023, revealed Resident #17 was at risk for skin breakdown related to incontinence. Interventions directed staff to apply protective or barrier lotion after incontinence, assist to turn/reposition frequently, inspect the skin during care/bathing and report any changes to the nurse supervisor, provide a pressure redistribution device to the bed, and a pressure redistribution device to the chair. A review of a Nurses Note, dated 03/10/2023, revealed Resident #17 was readmitted to the facility at 2:16 PM with a dressing to the right above the knee amputation. According to the note, all other skin areas were intact, and the skin was warm and dry. A review of a Nurses Note, dated 03/16/2023, revealed a late entry for 03/13/2023 that indicated a certified nursing assistant (CNA) called the nurse to Resident #17's room concerning an open wound to the right buttock. The note indicated on 03/10/2023, the resident had no open areas. The nurse covered the wound with an adhesive dressing and notified the treatment nurse. Review of the Weekly Wound record, dated 03/01/2023 through 04/26/2023, revealed on 03/14/2023, the Wound Treatment Nurse documented Resident #17 had a DTI to the right ischium (buttock) that measured 4 cm long by (x) 3 cm wide x 0.1 cm deep. The surrounding skin was intact and there was no drainage. According to the wound record, the area was being treated with honey gel. However, a review of Resident #17's physician orders and the eTAR [electronic treatment administration record] revealed a treatment was not ordered to the DTI until 03/23/2023, when the resident's physician gave a verbal order to the Wound Treatment Nurse to clean the right ischium with normal saline, pat the area dry, apply honey gel, and cover with a foam dressing every two days. Continued review of the Weekly Wound record revealed on 03/23/2023, Resident #17's right ischium DTI measured 5 cm x 5.5 cm x 0.1 cm. The wound base continued to be maroon/purple with a moderate amount of tanned color drainage and a mild odor. The treatment for honey gel every two days continued. A review of physician's orders revealed on 03/29/2023, the frequency of the treatment for honey gel to Resident #17's right ischium was changed from every two days to every Monday, Wednesday, and Friday. The Weekly Wound record revealed on 03/30/2023, Resident #17's right ischium wound measured 3.5 cm x 3.5 cm x 0.1 cm. The wound base had changed to slough (dead cells that usually indicates an inflammatory process and delays wound healing) and continued to have a moderate amount of tanned color drainage. The wound had no odor, and the surrounding skin was intact. According to the report, a treatment with honey-gel continued. Further review of the Weekly Wound record revealed on 04/05/2023, Resident #17's right ischium wound measured 4 cm x 5 cm x 2.5 cm. The wound base contained epithelial (new skin tissue) growth with a light amount of pink drainage and no odor. The surrounding skin was intact. The wound record indicated a honey gel treatment continued (three times per week). Resident #17 was interviewed on 04/24/2023 at 10:04 AM and the resident indicated they had a wound on their bottom that was not improving. A review of the Weekly Wound record revealed there was no further assessment of Resident #17's right ischium wound until 04/26/2023 (21 days since the last documented assessment of the wound). The wound measured 3 cm long x 2.5 cm deep, with 3 cm of undermining (erosion of tissue creating a pocket underneath the intact skin) located in the wound at the 12 to 1 o'clock position. The wound base was covered with slough with surrounding skin intact. The wound had a moderate amount of pink-yellow drainage and a mild odor. According to the wound record, even though undermining had developed, the wound was covered with slough, and had an odor, the wound was responding to treatment and a treatment with honey gel three times per week continued. During an interview with the Nurse Supervisor on 04/27/2023 at 9:17 AM, she stated the Wound Treatment Nurse decided on treatments/staging for Resident #17, while nursing staff cleaned and dressed the wounds. She indicated she provided the treatment for Resident #17's wound on 04/26/2023, and there was a little yellow drainage/slough that needed to be debrided, but the tissue was pink. The Nurse Supervisor indicated that 04/26/2023 was the first time she provided a treatment for Resident #17's right ischium wound. An observation of Resident #17's right ischium pressure ulcer treatment on 04/26/2023 at 11:35 AM revealed the wound had a moderate amount of thick, yellow slough. The borders surrounding the area were observed with pink tissue. The area measured 4.5 cm and the depth of the wound measured 2.5 cm. On 04/26/2023 at 2:50 PM, the Wound Treatment Nurse was interviewed. She stated she had only worked as the treatment nurse four days in the last two weeks due to covering overnight shifts for the facility. She stated she was the only staff person assigned to assess wounds weekly and due to working the floor she did not have time to make sure all wounds were measured. A follow-up interview with the Wound Treatment Nurse was conducted on 04/27/2023 at 8:16 AM. She stated when she provided a dressing change to Resident #17's right above the knee amputation on 03/14/2023, she noticed a purple-colored area on the resident's right ischium and measured it as a precaution. Since the area was not draining/had no exudate, she was going to monitor the area and the order for honey gel was entered as pending. She stated the intent was not to do the treatment order for 03/14/2023. The Wound Treatment Nurse indicated that when she saw the DTI again on the 03/23/2023, the wound was bigger and had a mild amount of tan colored drainage. Subsequently, she ordered the honey gel treatment. According to the Wound Treatment Nurse, she assessed Resident #17's wound for the weeks of 04/13/2023 and 04/18/2023 during her shifts as a floor nurse and handwrote the measurements on a notepad. She indicated she did not have enough time to input the information into the Weekly Wound report. On 04/26/2023, she stated she had measured Resident #17's wound during the overnight shift when she was working as a floor nurse. Further, she stated Resident #17's wound changed from a DTI to stageable pressure ulcer when slough was present in the wound bed. However, the Wound Treatment Nurse indicated she did not change the description of the DTI to a stageable pressure ulcer (upstage). She stated if the wound's measurements were worse, the treatment should be changed, and she notified the nurse practitioner. Further interview with the Wound Treatment Nurse revealed she was not sure if the Nurse Practitioner (NP) saw Resident #17's right ischium wound, but stated she did verbally notify her of the area. An observation of Resident #17's right ischium wound and an interview with the Director of Nursing (DON) on 04/27/2023 at 10:55 AM revealed the DON stated the wound was at least a stage 3 pressure ulcer (full thickness tissue loss and subcutaneous fat may be visible), and there was slough. The DON indicated that according to the Topical Treatment of Wounds protocol, the wound would fall under deep wounds with moderate/heavy drainage that required calcium alginate treatment. During a follow-up interview with the DON on 04/27/2023 at 11:38 AM, she revealed the Wound Treatment Nurse should have documented the upstage (stage 3) of Resident #17's right ischium wound. During this interview, the DON stated the current treatment of honey gel was sufficient for the stage 3 wound. Further interview with the DON revealed if a treatment was documented on the weekly wound report, the treatment should have been ordered and provided. According to the DON, the staff member assigned to provide the resident's treatment should have measured all wounds weekly and documented findings in the Weekly Wound report. The DON indicated that no staff reviewed the Weekly Wound report after the Wound Treatment Nurse entered her assessments. She stated if the Wound Treatment Nurse did not follow the Topical Treatment of Wounds protocol, she should have brought it to the attention of the clinical team or wound consultant, and then notified the physician of the change of wound treatment. The NP was contacted on 04/26/2023 at 3:28 PM during the investigation, but she was unavailable for an interview. The Medical Director was contacted on 04/27/2023 at 9:37 AM, but he was unavailable for an interview. The Administrator was interviewed on 04/27/2023 at 12:06 PM, and he stated he did not have the appropriate training to answer clinical questions.training to answer clinical questions.

Based on observation and staff interviews, the facility failed to serve food, monitor food and drink expiration dates, and maintain cooking equipment in a manner to prevent potential food safety issues. Specifically, the facility failed to: 1. allow 77 plate covers to air dry prior to assemblage and stacking in preparation for use during 1 of 2 meal observations; and 2. discard expired perishable foods and milk from 1 of 1 walk-in refrigerators; and 3. clean the convection oven weekly. These practices had the potential to affect 72 of 76 residents who received meals from the kitchen. Findings included: Reference: As viewed on [DATE], FDA Food Code | FDA indicated, in part, under ,d+[DATE] Storing, (B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying. Under ,d+[DATE].12 Cooking and Baking Equipment, the food code indicated, in part, Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. Under ,d+[DATE].13 Nonfood-Contact Surfaces, the food code indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Under ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking and ,d+[DATE].18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition, the food code indicated, Refrigeration prevents food from becoming a hazard by significantly slowing the growth of most microbes and Food which is prepared and held, or prepared, frozen, and thawed must be controlled by date marking to ensure its safety based on the total amount of time it was held at refrigeration temperature, and the opportunity for Listeria monocytogenes to multiply, before freezing and after thawing. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date. 1. During an observation of the kitchen on [DATE] at 9:07 AM, 77 plate covers were stacked wet and ready for use on the tray line. At that time, the Dietary Manager (DM) stated the plate covers should not be wet nested (the stacking of wet items such as pans, preventing them from drying and allowing an environment where microorganisms could begin to grow) but, instead, should be left to air dry before usage. She indicated Dietary Aide (DA) #1 was responsible to ensure all dishes were allowed to air dry. During an interview on [DATE] at 9:12 AM, DA #1 revealed she loaded and unloaded the dish machine that morning but did not allow the plate covers to air dry due to being in a rush to finish everything. She stated she had previously received training regarding wet nesting. During an interview on [DATE] at 12:00 PM, the Administrator revealed the plate covers in question should not have been wet before usage but, instead, should have been air dried. 2. During an observation of the kitchen on [DATE] at 9:16 AM, the following expired food items were identified in the walk-in refrigerator: one sealable plastic bag of sliced turkey (expiration date of [DATE]), one sealable plastic bag of sliced ham (expiration date of [DATE]), one sealable plastic bag of parmesan cheese (expiration date of [DATE]), and 21 whole milk cartons (expiration date of [DATE]). Additionally, a sealable plastic bag of sliced cheese was found unlabeled and undated. At that time, the Dietary Manager (DM) stated that all outdated food and milk items should be discarded before the expiration date. During an interview on [DATE] at 12:00 PM, the Administrator noted food in the refrigerator should be labeled, dated, and discarded by the expiration date. 3. During an observation of the kitchen on [DATE] at 9:39 AM, the bottom of the convection oven had a thick, black substance and the glass doors were covered with a thick layer of brown grease that obstructed visualization of the interior of the oven. During an interview on [DATE] at 9:40 AM, Cook #1 revealed the oven had not been cleaned in two months. She stated the convection oven should be cleaned weekly, but she did not have the time to do so due to the absence of an Assistant Manager. During an interview on [DATE] at 9:10 AM, the Dietary Manager (DM) stated the Assistant Manager had been out for the prior two months. On [DATE] at 9:42 AM, the DM revealed the oven was not cleaned because staff did not have enough time due to a full census in the facility. During an interview on [DATE] at 12:00 PM, the Administrator revealed all kitchen equipment should be cleaned prior to usage if soiled.

Based on record review and interviews, the facility failed to assess a wound, obtain treatment orders on admission, and provide treatment as ordered for 1 (Resident #74) of 3 residents reviewed for skin issues. Specifically, Resident #74 was admitted on [DATE] with a wound to the left great toe. The facility failed to obtain treatment orders for the wound until 03/24/2023, two days after admission, and failed to provide the treatment during two days in March of 2023. Findings included: A review of Resident #74's Face Sheet revealed the facility admitted the resident on 03/22/2023 with diagnoses that included peripheral vascular disease (PVD), end stage renal disease (ESRD) dependent on hemodialysis (HD), and diabetes. A review of Resident #74's Nurses Note, dated 03/22/2023 at 4:20 PM, revealed the resident was newly admitted to the facility. The note indicated the resident had a wound to the left big toe with an intact dressing and a left groin wound due to a stent placement. A review of Resident #74's Comprehensive Nursing Assessment V4.0, dated 03/23/2023, revealed the resident had a left great toe wound and pain to the left foot. There was no documented description of the wound. A review of Resident #74's History and Physical revealed a nurse practitioner completed a telehealth visit on 03/24/2023. The note indicated the resident had been hospitalized after a fall at home and recently underwent a left leg angiogram endarterectomy (removal of plaque buildup in an artery) and stent placement on 03/15/2023. The note indicated the resident complained of left foot pain during the visit and per nursing, the resident had a wound present. The note indicated the resident had bilateral foot pain and the left great and second toe had a darkened area. The nurse practitioner's note indicated see skin assessment documentation; however, there was no evidence an assessment of the resident's left toe had been completed. A review of Resident #74's physician order Summary Report revealed a treatment was not ordered for the resident's left great toe until 03/24/2023, two days after admission to the facility. The order directed staff to clean the toe with normal saline, pat the area dry, apply a petroleum gauze, cover with a four-by-four dressing, and wrap with Kling (a [NAME] conforming bandage). Review of Resident #74's eTAR [electronic treatment administration record] for the month of March 2023 revealed left great toe treatments for Resident #74 were held on 03/28/2023 and 03/30/2023 without an explanation documented. During an interview with Licensed Practical Nurse (LPN) #2 on 04/25/2023 at 3:12 PM, she stated she was the admitting nurse for Resident #74 on 03/22/2023 and recalled the resident had a bandage on the left great toe. She stated she did not remove the bandage but verbally notified the Wound Treatment Nurse of the issue with the toe on 03/23/2023, the day after admission. LPN #2 stated if a newly admitted resident had a dressing intact, she did not usually remove the dressing. She stated she documented the location of the dressing and allowed the Wound Treatment Nurse to perform the initial assessment. She stated if the Wound Treatment Nurse was not in the building, then one of the Nurse Supervisors would complete the wound assessment. During an interview with the Wound Treatment Nurse on 04/27/2023 at 8:31 AM, she stated when Resident #74 was admitted , treatment orders for the left great toe were not provided. She stated she saw the resident on 03/24/2023, removed the dressing to assess the left great toe, and ordered a Vaseline gauze treatment. According to the Wound Treatment Nurse there should have been documentation of her initial assessment on 03/24/2023. Further interview with the Wound Treatment Nurse revealed the treatments were held on 03/28/2023 and 03/30/2023 because the resident was away for dialysis. She stated if a resident was out of the facility on the day of their scheduled treatment, the treatment would not be completed until the next scheduled day. The Wound Treatment Nurse stated the Nurse Supervisors were assigned to provide wound treatments when she was off or not in the building. Nurse Supervisor #1 was interviewed on 04/26/2023 at 10:46 AM. She stated if a resident was admitted with a skin issue, the nurse on duty should complete an assessment, and the Wound Treatment Nurse should conduct an in-depth wound assessment the next time she was available. Nurse Supervisor #1 indicated if the Wound Treatment Nurse could not look at the wound within two days, then she or the other Nurse Supervisor would do an in-depth assessment. Nurse Supervisor #1 stated the Wound Treatment Nurse measured wounds and ordered the treatments. She stated when the Wound Treatment Nurse was not available, the Nurse Supervisors provided wound treatments. Nurse Supervisor #1 stated bandages were removed upon admission only if the hospital ordered them to be removed. If there were not any orders/instructions for the wound on admission, the bandage would need to be taken off and assessed upon arrival at the facility. Further interview with Nurse Supervisor #1 revealed if a treatment was coded as Held, then there should have been a note with an explanation. The Director of Nursing (DON) was interviewed on 04/25/2023 at 2:51 PM. She stated Resident #74's left great toe did not look good when the resident was admitted , and it looked black the day after the resident arrived at the facility. The DON stated nursing staff should have documented a description of the left great toe upon admission, and the Wound Treatment Nurse should have also documented an assessment of the wound. The DON stated documentation of the wound should have included the location; a description, including color/drainage; and the type of wound (arterial/ulcer). During a follow-up interview with the DON on 04/27/2023 at 10:16 AM, she stated nursing staff should not have taken off Resident #74's dressing unless they were told to remove it during a report from the hospital, or orders from the hospital to remove the dressing were provided. She indicated LPN #2 should have documented dressing to left great toe, clean and dry. The Wound Treatment Nurse would have then taken off the bandage and assessed the wound to determine the plan of treatment. The DON indicated she expected the Wound Treatment Nurse to have assessed Resident #74's left great toe wound within 24 hours of admission and the assessment should have been documented in the weekly wound report. The DON stated documentation should have included size, color, and drainage. She further stated that nursing staff were expected to follow the physician orders for dressing changes. If Resident #74 was out of the building, then staff should have documented the treatment was deferred and postponed to the next scheduled dressing change. However, the DON also stated she expected the nurse on duty to have assessed Resident #74's wound on 03/28/2023 and 03/30/2023 to determine if the resident needed a dressing change on those dates. The DON stated if the nurse on duty could not complete the dressing change on the date assigned, they should have notified the Wound Treatment Nurse or the DON. The Administrator was interviewed on 04/27/2023 at 12:06 PM. He stated he did not have the appropriate training to answer clinical questions.

Based on observations, interviews, record review, and review of facility policy titled Dental Services/Oral Assessment, it was determined that the facility failed to assist residents in obtaining necessary dental care for 1 (Resident #43) of 1 resident reviewed for dental services. The facility census was 76 residents. Findings included: A review of the facility policy titled, Dental Services/Oral Assessments, with a review date of 12/30/2022, revealed the facility will promptly refer patients who have lost or damaged dentures within three (3) business days for dental services. The policy indicated, In the case of damage or loss to a patient's dentures, the center will investigate the circumstances of what happened to the dentures. In the event it is determined that the center/center associate was responsible for the loss or damage, the center will assume the financial responsibility for repairing or replacing the dentures. A review of Resident #43's Face Sheet revealed Resident #43 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes and need for assistance with personal care. A review of Resident #43's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2023, revealed Resident #43 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The MDS indicated Resident #43 was totally dependent on staff for transfers, locomotion on and off unit, dressing, and toilet use. Resident #43 required extensive assistance from staff for bed mobility, eating, and personal hygiene. The MDS indicated Resident #43 did not have broken or loosely fitting full or partial dentures. A review of Resident #43's Care Plan, with a most recent review date of 02/09/2023, revealed Resident #43 required assistance to clean teeth or dentures and included an intervention that instructed staff to assist with activities of daily living (ADLs) as needed. The Care Plan indicated the resident elected to receive a regular diet with chopped meats. The Care Plan did not mention or address missing or broken dentures. A review of a Comprehensive Nursing Assessment, dated 02/03/2023, revealed Resident #43 had no visible problems to the mouth. The assessment indicated Resident #43 needed assistance to clean teeth or dentures but did not mention broken or missing dentures. A review of a Comprehensive Nursing Assessment, dated 04/14/2023, revealed Resident #43 had broken, loose, or missing teeth. The assessment indicated Resident #43 needed assistance to clean teeth or dentures but did not mention broken or missing dentures. In an interview on 04/26/2023 at 9:07 AM, Resident #43 said they had dentures when they admitted to the facility but did not currently have their dentures. Resident #43 said they had told the Social Service Director (SSD) about the missing dentures. In an interview on 04/26/2023 at 8:50 AM, Licensed Practical Nurse (LPN) #1 said she knew Resident #43 had upper dentures but was not sure about bottom dentures. She said she was unaware of any problems with Resident #43's dentures. LPN #1 said if a resident had dental issues, including missing or broken dentures, the physician would be notified, and social services would help as needed. LPN #1 said if an item was missing, staff would look for it and talk with the family as needed. In an interview on 04/26/2023 at 9:17 AM, Certified Nursing Assistant (CNA) #3 said Resident #43 had broken their dentures about a month previously. CNA #3 said Resident #43 told CNA #3 the resident had dropped the dentures. CNA #3 said she told the SSD about the broken dentures and that CNA #3 had put them in a cup in the resident's bathroom if the family wanted to do anything with them. CNA #3 showed the surveyor the broken dentures in a cup in Resident #43's bathroom. In an interview on 04/26/2023 at 9:42 AM, the SSD said Resident #43 did not have dentures when they were admitted to the facility, and Resident #43 could not say where the dentures were. The SSD said she did not remember anyone telling her about Resident #43 breaking their dentures. The SSD said if a resident loses or breaks their dentures, she would notify the Administrator. She said that if it was the facility's fault, the facility would make any necessary appointments and replace them or let the family know they were missing. In an interview on 04/26/2023 at 9:53 AM, the Director of Nursing (DON) said her expectation was that if a resident reported anything missing, the charge nurse should be notified, as well as the SSD, and the facility would investigate. She said she had not heard about Resident #43's denture issues. In an interview on 04/26/2023 at 11:58 AM, the Administrator said that if a resident loses something, the family would be notified. He said that if a CNA was told, the CNA would look for the item, and if not found, the SSD would be notified and begin an investigation. He said the facility would search, notify the family, and replace the item if not found. The Administrator said he had not heard about Resident #43's missing dentures. He said Resident #43 did not have dentures on admission.

Based on record review and staff interview, the facility failed to provide the skilled Notice of Medicare Non-Coverage Form CMS (Center for Medicare and Medicaid Services) -(NOMNC) and/or the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two of three residents (R) R#18 and R#38) reviewed that were discharged from Medicare Part A coverage. Findings Include: Review of facility policy titled Financial Liability Notices (updated January 2020) revealed It is the intent of this nursing center to issue all required Financial Liability Notices in compliance of CMS (Centers for Medicaid and Medicare Services) or other payer regulations. 1. R#18 was discharged from Medicare Part A services on 5/29/21 and remained in the facility. However, the only notice provided to the resident was the Notice of Medicare Non - Coverage (NOMNC) (Form CMS- ). There was no evidence that the facility had Issued the SNF ABN to R#18 or his responsible party, providing the opportunity to continue with skilled services, at his cost if Medicare did not reimburse. 2. R#38 was discharged from Medicare part A services on 7/9/21 and remained in the facility. However, the only notice provided to the resident was the Notice of Medicare Non - Coverage (NOMNC) (Form CMS- ). There was no evidence that the facility had issued an SNF ABN (Form CMS - ) to R#38 or his responsible party, providing the opportunity to continue with skilled services, at his cost if Medicare did not reimburse. During interview on 10/20/2021 at 1:30 p.m. with the Administrator she confirmed that R#38, and R#18 had not been issued the SNF ABN (Form CMS- ). Interview on 10/21/2021 at 2:30 p.m. with the Admissions Coordinator who revealed that she was responsible for providing the Beneficiary Protection Notifications to residents prior to discharge from skilled services. She acknowledged that the facility provided her with training in April 2021 on what notices to provide but she still has failed to provide the correct notices.

Based on record reviews, interviews, and review of facility policy titled Patient's Plan of Care, the facility failed to develop a comprehensive person-centered care plan for three residents (R) R#35 related to anticoagulant use, R#8 for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of facility policy titled Patient's Plan of Care (dated 2020) revealed Intent: Each patient will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the patient's medical, physical, mental, and psychosocial needs. 1. Record review revealed R#35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#35 Admission Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 15 out of 15 indicating intact cognition. Section N (medications) of the MDS revealed resident received three days of anticoagulant therapy. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed no person-centered care plan to address residents need for anticoagulant therapy. During interview on 10/21/21 at 10:12 a.m. with the Director of Nursing DON), she confirmed there was no care plan to address R#35's need for anticoagulant therapy. DON stated that she expected residents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plan was created for anticoagulant use after surveyor brought to attention of DON there was not one. 2. Record review revealed R#8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Admission MDS dated [DATE] for R#8 revealed a BIMS score of 0, indicating severe cognitive decline. Section J (health conditions) of the MDS revealed resident received as needed medication for pain, vocalized pain, and protective body movements/posture. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed no person-centered care plan to address resident's pain. During interview on 10/21/21 at 10:15 a.m. with the DON she confirmed there was not a care plan to address resident's pain. Stated that she expected residents to have care plans to address pain. 3. Record review revealed Resident # 11 was an [AGE] year-old female, admitted on [DATE], no BIMS score, and Full code status. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Lab (Laboratory) dated 2/22/21: Hemoglobin A1C every 13 weeks (4 times per year) monitoring of blood glucose levels and symptoms of hyper/[CONDITION(S)]. Glucometers and insulin dated 2/2/21: [MEDICATION(S)] U-100 insulin 100 units/milliliter (units/ml) subcutaneous (sq) solution (Insulin Detemir) 20 units sq 2 times a day (bid), Do not mix with other insulins, expires 42 days after 1st use. [MEDICATION(S)] R Regular U-100 insulin 100 units/ml injection solution (insulin Regular, Human) Units per sliding scale sq before meals and at bedtime (ACHS), expires 28 days from 1st use. Supplement dated 9/24/21: Boost Glucose control oral liquid, 1 carton by mouth 1 time per day (qd). Further review of the Consolidated Orders revealed on page 3/3, the second diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS Quarterly assessment dated [DATE] revealed Section I (active diagnoses) included Diabetes Mellitus; Section N- medications reported insulin injections on seven out of seven (7/7) days in the look back period. Further review of the MDS schedule revealed a comprehensive Entry tracking/5-day assessment dated [DATE], a significant change assessment dated [DATE] and 6/17/21, with Diabetes Mellitus listed under Section I, as an active diagnosis, for all of these assessments. Record review revealed no person-centered comprehensive care plan was developed, with interventions implemented to meet the resident's medical needs related to the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, and review of the care plan, on 10/21/21 at 1:05 p.m. with the DON, she confirmed there was no care plan for Diabetes Mellitus. DON then stated there should be a care plan for diabetes but felt the reason why there was not, was because the nurses failed to develop one or report to the MDS staff. The DON revealed that nurses can implement and update care plans for new diagnoses, new orders, new problem areas, new interventions, change in condition, etc., or they must report to MDS, the Assistant Director of Nursing (ADON) or the DON, so they can develop and implement an individualized care plan. DON expressed that her expectation was that the care plan should include Diabetes Mellitus, with goals, and interventions that included performing finger stick blood sugar (FSBS) checks, administration of insulin and monitoring for hypo and [CONDITION(S)].

Based on interview, observation, and review of the facility policy titled Sanitary Food Storage the facility failed to discard expired items, failed to label and date items upon delivery, failed to maintain temperatures of food during community dining service. This included storage and refrigeration areas in the kitchen and emergency food supply. The facility census was 73 residents. Findings include: During the initial tour on [DATE] at 10:08 a.m. there were 21 loaves of bread on bread rack that did not have a thaw date or a use by date identified. During an observation of Cooler #13 on [DATE] at 10:20 a.m. there was a plastic container that contained multiple containers of individual cranberry juice cartons and there was no use by date. During community dining on [DATE] at 11:40 a.m. in the main dining room there were 14 residents being served lunch. The Certified Dietary Manager (CDM) provided the following food temperatures: Broccoli and Cheese Casserole 127 degrees Fahrenheit (F), Creamed corn 134.9 degrees F, Fried pork chops 118.9 degrees F, and the banana pudding was 52 degrees F. Emergency food storage tour on [DATE] at 12:45 a.m. revealed that there was no way to identify expiration dates for tuna in the pouch. There were some cans of emergency food items that were dated for (YEAR) as an in date but there was no way to indicate an expiration date. During observation of the emergency water storage area on [DATE] at 12:50 a.m. there were 23 cases with 6 gallons of water in each case with an expiration date of [DATE]. There were also two 35 count packages of water with a use by date of [DATE]. During an interview on [DATE] at 10:29 a.m. with Dietary Team Leader revealed that the cranberry juice was delivered on Friday and further reported that the juice is typically gone in three days. During an interview on [DATE] at 10:34 a.m. with CDM revealed that they have about a week to use the bread but acknowledged that there is no expiration date on the bread. The CDM revealed that she is unsure of when the cranberry juice expires. During an interview on [DATE] at 11:40 a.m. with the CDM revealed that the banana pudding was 41 degrees F when taken out of the refrigerator and they have two hours to use it. The CDM further reported that the containers that the food is in should be insulating the food to help maintain the temperatures, but the items had been uncovered for 20 minutes and the temperature drops once uncovered. The CDM reported that the containers should be maintaining food temperatures as they come from the kitchen at the correct temperature. During an interview with the CDM on [DATE] at 12:55 p.m. she reported that she had checked the emergency water supply earlier this week but had not opened the boxes to check for expiration dates. During an interview on [DATE] at 12:29 p.m. with the CDM it was reported that during community dining there is a two hour time frame for using the food. It is reported that food is to be checked every two hours when on the steamtable, but their food does not stay on the steam table that long. The CDM reported that when food for community dining is sent to the dining room from the kitchen it is 135 degrees F or greater. She reported that they have been using the insulated container to keep foods hot. However, she acknowledges that the food did not maintain temperature once opened on Tuesday. The CDM further reported that she will have to come up with another plan for assuring that temperatures remain at 135 degrees F or higher when holding. The CDM acknowledged that cranberry juice and bread were not labeled in such a way as to determine the expiration date for consumption. The CDM also reported that after checking she confirmed that the tuna and other identified canned items in emergency food was expired. The CDM reported that ultimately, she is responsible for assuring that emergency foods, water, and other items are used prior to expiration. Frozen food that has been thawed shall be used within the date range and never refrozen. 2. Foods that are frozen and used as needed should be taken out as needed, labeled with a use by date: a. Bread (already cooked) - use within 5 days of thawing b. Pasteurized juices - used with 7 days of thawing (sic)

Based on observation and staff interview, the facility failed to ensure that it was maintained in a safe, clean comfortable environment related to stained ceiling tiles for two of six halls, a hole in the wall in restorative dining, and one fall mat that was stained and in disrepair. Findings include Observation on 9/24/18 at 11 a.m. revealed that there were brown circles in ceiling tiles near rooms 121 -123. Observation made on 9/24/18 at 11:20 a.m. revealed that there were brown and black circular stains on ceiling tile in the hallway between rooms [ROOM NUMBERS]. Observation of restorative dining room on 9/24/18 at 11:43 a.m. revealed that there was a hole in the wall near the floor under the hand sanitizer. Observation on 9/25/18 at 8:44 a.m. in room [ROOM NUMBER] there is a brown substance observed on blue fall mat by the bed. There is also build up on the tube feeding monitor and brown rusted areas on the base of tube feeding pole. Environmental tour began on 9/27/18 at 9:48 a.m. with the Maintenance Supervisor and Housekeeping Supervisor. It was reported by the Maintenance Supervisor that the stained ceiling tiles in the hallways are due to condensation. He further reported that the ceiling tiles on the front hallway have been changed out twice this week and that there is a plan in place to replace the covering on the water pipes. During an interview and observation on 9/27/18 at 9:54 a.m. in the restorative dining room with the Maintenance Supervisor reported that the hole in the wall in restorative dining was noticed this week but has been patched in the past. It was further reported that the food cart is the cause of the hole and to repair this area will require the replacement of the entire piece of sheetrock, but it must be done at night due to dust. He further reported that the person who would complete this task returned to work on today. During an interview and observation with Maintenance Supervisor on 9/27/18 from 9:57 a.m. to 9:59 a.m. he confirmed the four stained ceiling tiles across from room [ROOM NUMBER]. The Maintenance Supervisor confirmed the stained ceiling tiles between room [ROOM NUMBER] and 130 but reported that he had not been made aware of the stained ceiling tiles in this area. During an interview and observation on 9/27/18 at 10:22 a.m. in room [ROOM NUMBER] the Housekeeping Supervisor confirmed that the fall mat bedside Bed B was stained and ripped. The Housekeeping Supervisor also reported that it is her expectation that her staff will remove stains from floor as they are identified. She further reported that the fall mat should be taken out and replaced. Interview on 9/27/18 at 10:35 a.m. with the Assistant Director of Nursing (ADON) who reported that she expects staff to report and let someone know if items are dirty or in disrepair related to fall mats or other equipment. Interview on 9/27/18 at 10:40 a.m. with the Director of Nursing (DON) related to the stained and torn fall mat. It was reported that the expectation is that any staff, that saw that fall mat, to notify someone so that it could be removed. The DON further reported that spills they should be cleaned up as they happen. During interview on 9/27/18 at 11:03 a.m. with the Maintenance Supervisor he provided documentation of a quality measures meeting from (MONTH) in which stained ceiling tiles were addressed as old business from July. At this time, he reported that they are waiting on reports from two contractors so that they will best know how to proceed with fixing this issue. Maintenance Supervisor was to provide more information related to contractors and when notified to provide services, but this documentation was not received when surveyors exited on 9/27/18.

Based on observation, interview and policy review the facility failed to ensure that the Consultant Pharmacist Communications were signed and addressed in a timely manner and that the policy included time frames for different steps in the process. Findings include: R#38 has [DIAGNOSES REDACTED]. Medications include but not limited to [MEDICATION NAME] 40mg daily started 1/31/18, [MEDICATION NAME] 45mg QHS started on 1/31/18, [MEDICATION NAME] 100mg QHS started on 2/23/18, [MEDICATION NAME] 30 units BID started on 5/2/18 and [MEDICATION NAME] R SS 4 times daily with glucose checks before meals and at QHS started 2/20/18. Quarterly MDS section N dated 7/25/18 revealed R#38 received an antipsychotic, antidepressant and diuretic for 7 days of the look back period. Section I revealed that R#38 has dementia. Care plan dated 7/19/18 revealed behavior problems r/t dementia with goals and approaches including but not limited to anticipate and meet needs, praise all progress and keep routines familiar and consistent. Dated 7/20/18 potential for hyper/[DIAGNOSES REDACTED] r/t diabetes with goals and interventions including but not limited to administer medications as ordered by MD and monitor for s/s of hyper/[DIAGNOSES REDACTED]. Dated 7/20/18 potential for drug related complications associated with use of [MEDICAL CONDITION] medications with goals and interventions including but not limited to monitor for target behaviors and report hallucinations and delusions. GDR's reviewed with issues noted, GDR's are not signed and recommendations are not addressed for the month of (MONTH) and no recommendation noted for the month of August. Consultant Pharmacist communication to Physician dated 7/26/18 revealed RE: CMS-F329duplicate antidepressant drugs Use of two antidepressants simultaneously may increase the risk of side effects and require additional documentation concerning the rationale under CMS F-329. With 4 check box answers, with the physician checking: Duplicate agents are being used d/t differing mechanisms of action that result in augmentation in managing symptoms of depression. Usage is based on clinical experience or medical literature and the risk vs benefit has been considered. Signed 9/25/18 after surveyor inquired about signatures and addressing issues. In an interview with the Assistant Director of Nursing (ADON) RN on 9/25/18 at 3:21 p.m. she said that she is the nurse that usually does rounds with the doctors to ensure that the recommendations get signed and addressed, however the rounds were completed on the weekend in the months of (MONTH) (YEAR) and (MONTH) (YEAR) and that the recommendations did not get addressed or signed. The ADON revealed that the nurses' that are responsible for their residents with recommendations are responsible to get the recommendation signed and follow up with new orders if any are given. The ADON revealed that she is the one that is responsible for ensuring that the nurses do their jobs. The ADON revealed that she is ultimately responsible for making sure the doctors sign and address the recommendations. In an interview with Licensed Practical Nurse (LPN) AA on 9/25/18 at 3:26 p.m. revealed that the nurses' have roles, LPN AA does not see the pharmacy recommendations, they are responsible for pulling the orders off the charts and transcribing them to the Medication Administration Record [REDACTED]. In an interview with LPN BB on 9/25/18 at 3:29 p.m. revealed that if she sees the Pharmacy recommendations on the fax machine at the nurses' station that she will either call the doctor or go see the doctor and inform him of anything that needs to be addressed. Further interview with LPN BB revealed that she is not sure if it is the LPN's responsibility, LPN BB revealed that she just addresses the Pharmacy recommendations when they are left on the fax machine. LPN BB Continued by stating that she did not see any pharmacy recommendations for the months of (MONTH) (YEAR) and (MONTH) (YEAR) and does not know why they were not addressed or signed. In an interview with the Administrator on 9/25/18 at 3:38 p.m. revealed that the recommendations are usually addressed and signed every month during rounds. When asked what happened in (MONTH) (YEAR) and (MONTH) (YEAR) she said they must have been overlooked. She stated that her expectation is for the recommendations to be addressed and signed as soon as possible but definitely before the next review date. Policy titled Pharmacy Services revised 11/28/17 under heading Drug Regimen Review revealed: The pharmacist must report any irregularities to the attending physician and the Director of Nursing (DON) and these reports must be acted upon. The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps the process and steps the pharmacist must take when he/she identifies an irregularity that requires urgent action. Policy titled Pharmacy Policy and Procedure for(NAME)Anne Burgin Nursing Home revised 9/12/17 revealed Consultant pharmacist will conduct Medication Management Reviews of each resident of the LTC facility monthly and as needed per CMS regulations. The consultant pharmacist must report any irregularities to the attending physician and/or director of nursing (DON). The pharmacy consultant reports to the Physician must be submitted to the physician by the facility staff and acted upon. Consult reports to nursing staff or DON need to also be read and acted upon.

Based on staff interview and record review, the facility failed to notify the physician timely of an unavailable medication for one resident (A) from a total sample of four residents. Findings include: Resident (R) A had a physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. During an interview on 11/14/17 at 1:15 p.m., RA stated that she had run out of her inhaler and went without it for a few days. During an interview on 11/14/17 at 1:55 p.m., the Director of Nursing (DON) confirmed, after speaking with Licensed Practical Nurses (LPN) BB and CC, that the resident did not recieve the [MEDICATION NAME] inhaler as scheduled, because it was unavailable, for the evening dose on 10/27/17 and for both ordered doses on 10/28 and 10/29/17. The nurses administered the [MEDICATION NAME] medication via nebulization instead, on 10/28/17 and 10/29/17. However, there was no evidence that the physician was notified of the unavailability of the [MEDICATION NAME] inhaler. During an interview on 11/15/17 at 10:50 a.m., the physician stated that not receiving the [MEDICATION NAME] medication would not have caused a severe consequence. However, the nurses should have contacted the physician on call of the medication unavailibility to receive an order for [REDACTED].

Based on staff interview and record review, the facility failed to ensure that licensed nursing staff documented medication administration accurately for one resident (A) from a total sample of four residents. Findings include: Resident (R) A had a physician's orders [REDACTED]. During an interview on 11/14/17 at 1:15 p.m., RA stated that she had run out of her inhaler and went without it for a few days. During an interview on 11/14/17 at 1:55 p.m., the Director of Nursing (DON) confirmed, after speaking with Licensed Practical Nurses (LPN) BB and CC and DD, that the resident did not recieve the [MEDICATION NAME] inhaler as scheduled, because it was unavailable, for the evening dose on 10/27/17 and for both ordered doses on 10/28 and 10/29/17. However, a review of the October 2017 Medication Administration Record [REDACTED].

Based on record review and staff interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) assessment to address a decline in Activities of Daily Living (ADL's) for one resident (#57) from a total sample of 26 residents. Findings include: Resident (R) #57 had Quarterly MDS assessments, with Assessment Reference Dates (ARD) of 1/19/17 and 4/19/17, completed by facility staff. A review of the MDS assessments revealed that the resident's self performance declined from the 1/19/17 to the 4/19/17 MDS, in the area of ADL's. The resident was documented as being provided with more assistance from staff for bed mobility, transfers, ambulation, dressing, toileting, and performing personal hygiene. Although interventions were implemented to address the decline, there was no evidence that a Significant Change MDS was completed. During an interview on 10/19/17 at 12:35 p.m. the Director of Nursing (DON) confirmed that a Significant Change MDS assessment was not completed but should have been for R #57.

Based on observation, record review and staff interview the facilty failed to develop a plan of care for the use of [MEDICAL CONDITION] medications for two residents (R), (#76, and #57) from a sample of 26 residents. Findings include: 1. Record review of resident R#76 Admission assessment on 8/7/17 coded under section V-Care triggered for [MEDICAL CONDITION] Drug use. R#76 physician orders [REDACTED]. On 10/19/17 at 1:48 p.m. in a interview with Registered Nurse AA she reviewed resident R#76's care plan and reported that she usually does a care plan on all resident's that receive antipsychotic's and that she could not find where she had done a care plan to reflect that resident R#76 was receiving antipsychotic. RN AA also reported that we do not have a system in place to catch all the changes on residents. We have morning meetings and management meetings but we do not get everything. Sometimes we get information from the nurses as well. I will usually update or revise the residents care plan when we have that specific resident's care plan meeting and we do those quarterly. 2. R #57 had been receiving [MEDICATION NAME], and antipsychotic medication, since 3/17/16 for [DIAGNOSES REDACTED]. The medication was increased from the initially ordered dose of 1 milligram (mg) daily at bedtime to 1 mg twice daily on 4/14/16. On 9/16/16 the [MEDICATION NAME] was increased again to the current dose of 1.5 mg twice daily. Licensed nursing staff completed an Annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/23/16. The use of antipsychotic medication was documented on the MDS assessment, and staff also documented that the use of [MEDICAL CONDITION] medication would be included in the care plan. However, there was no evidence that a care plan was developed to address the use of the [MEDICATION NAME] until 10/19/17, after surveyor inquiry. During an interview on 10/19/17 at 4:17 p.m. Registered Nurse AA confirmed that the care plan had not been developed.

Based on observation, record review, and staff interview the facility failed to update/revise the plan of care for one resident R#35, from a sample of 26. Findings include: Review of resident R#35's the care plan for R#35 with a start date: 3/07/17 Resident R#35 has alteration in skin related to Pressure ulcer of buttocks. Review of R#35's the medical record for R#35 revealed that on 8/14/17 resident was assessed and documented on the Skin Condition/Wound Progression form: New (1st recording) Present on the Left Heel is a Abrasion. On 8/31/17 documentation on the Skin Condition/Wound Progression Form: The following findings were documented, Weekly skin assessement. Abrasion noted to left heel. Area cleansed every 3 days and prn (as needed). Dressing intact. Area healing. On 9/28/17 documentation on the Skin Condition/Wound Form: Skin and Wound update. Condition changed (from: Abrasion To: Pressure ulcer) Reason: Pressure ulcer present on the left heel is a pressure Ulcer. The following findings were documented, unable to accurately stage-suspected deep tissue injury in evolution. Length in centimeters (cm)=2.8, Width in cm=1.8, depth in cm=0, skin is not blanchable, no odor is apparent, no drainage is apparent. On 10/19/17 1:48 p.m. Interview with Minimum Data Assessment (MDS RN) Registered Nurse AA and review of resident #35's plan of care AA reported that the plan of care had not been updated to reflect the pressure area to the residents left heel. At this time AA also reported that they do not have a process in place to receive information that has changed on residents. That sometimes she may get information in the morning or from management meetings but usually its when everyone meets to discuss the residents plan of care and that is quarterly.

Based on observation, interview and record review, the facility failed to obtain vision services to address the light sensitivity of one resident (#57) from a total sample of 26 residents. Findings include: Resident (R) #57 was observed wearing sunglasses, while inside the facility, on 10/17/17 at 3:45 p.m., 10/18/17 at 1:15 p.m. and on 10/19/17 at 11:16 a.m. A review of the clinical record revealed multiple care plan meeting notes that documented the resident's aversion to light. A 2/18/16 note documented the resident liked to stay in his room with no lights on. A 5/12/16 note documented that the resident needed shades for brightness. A 10/20/16 note documented that the resident was sensitive to light. A 1/17/17 note documented that the resident wears sunglasses due to light aversion. A 4/11/17 note documented that the resident stated that the light hurt his eyes. However, there was no evidence that facility staff had attempted to obtain vision services to address and evaluate the possible cause for the resident's aversion and sensitivity to light. During interviews on 10/18/17 at 3:34 p.m. and on 10/19/17 at 11:30 a.m., the Director of Nursing (DON) stated that she could not find where facility staff had offered vision services to the resident. She stated that the resident had been wearing sunglasses since admission and was on his third pair, that she brought for him. After surveyor inquiry, an appointment was obtained for an eye exam for R #57.

Based on electronic clinical record review, staff interviews, review of the facility's policy titled, Fall Management and review of the facility forms titled, Incident Details report the facility failed to evaluate and revise the care plan interventions and/or determine the need to identify additional approaches for fall prevention for one (1) resident (R) (#1) who had been assessed to be at risk for falls and who sustained additional falls. This resulted in actual harm for R #1 when the resident experienced a subsequent fall and sustained a laceration to the head. The sample size was 3 residents with history of falls. Findings include: Review of the facility's Policy titled, Fall Management revealed, in pertinent part, the policy was to establish criteria for the identification of residents who are at a higher risks for falls/injury, to be utilized by Nursing Staff to help prevent falls and subsequent injury related to falls. Further review revealed that, all potential safety problems should be identified and included in the resident's plan of care. If resident has other falls, has repeated falls or falls with injury, Fall Prevention protocol will be implemented. Record review for R#1 revealed that the [DIAGNOSES REDACTED]. The facility had completed a Quarterly Minimum Data Set (MDS) assessment on 12/15/16. Section C- Cognitive Patterns documented the resident as having severe cognitive impairment. Section G- Functional Status of this MDS documented that the resident was independent with walking/locomotion in the room and required supervision while walking in the corridor. The resident had a care plan start date of 2/2/17 for being at risk for falls related to impaired cognition and short/long term memory problems. It noted that the resident was found on floor on 2/2/17. The care plan approaches included: be sure call light is within reach and encourage to use for assistance as needed, respond promptly to all requests for assistance, bed in lowest locked position at all times, coordinate with appropriate staff to ensure a safe environment, ensure resident is wearing appropriate footwear when ambulating or up in wheelchair, keep floors even and free from spills or clutter, notify MD and family members of fall, provide activities that minimize the potential for falls while providing diversion and distraction, Physical Therapy (PT)/Occupational Therapy (OT) evaluation and treat as ordered and use adequate, glare-free light. The facility Incident Details report documented that on 2/2/17 at 8:30 a.m. the resident was found on the floor in her room. The facility Incident Details report documented that on 2/7/17 at 11:30 a.m., the resident was found on the floor in the dining room with no apparent injuries. The facility Incident Details report and the Progress Notes documented that on 2/14/17 at 8:20 p.m., revealed that the resident was ambulating through the dining room with an unsteady gait. The resident fell against the corner of the wall and hit head. The resident had a small opening to back of head to the right side. The physician was notified and the resident was sent to the emergency room and received four staples to the area. Further review revealed that the resident was admitted to the hospital for closer observation and returned to the facility on [DATE]. Review of the resident's care plan revealed an entry of 2/14/17 which documented the resident's fall of that date, as noted on the 2/14/17 Incident Details report referenced above. However, further review of this care plan revealed that there was not any evidence to indicate that the facility reviewed the care plan to evaluate the care plan approaches listed above, which existed prior to the resident's fall on 2/7/17, were effective and there was not any evidence that the facility attempted to determine if additional interventions were needed to address the residents fall potential to prevent future falls. The only care plan documentation for 2/14/17 was to gather information on past falls and attempt to determine cause of falls and anticipate and intervene to prevent future recurrence. Further review revealed that the facility Incident Details report documented that on 3/30/17 at 4:30 p.m., the resident fell while ambulating and sustained a skin tear to the right hand. Review of the resident's care plan revealed an entry of 3/30 /17 which documented that the resident's fall on that date, as noted on the 3/30/17 Incident Details report referenced above. However, further review of this care plan revealed that there was not any evidence to indicate that the facility reviewed the care plan to evaluate the care plan approaches listed above, which existed prior to the resident's fall on 3/30/17, were effective and there was not any evidence that the facility attempted to determine if additional interventions were needed to address the residents fall potential to prevent future falls. Further review of the facility Incident Details reports revealed that on 4/14/17 at 3:20 p.m. a visitor reported seeing R#1 on the floor in the lobby. The resident was disoriented and sitting up on floor with only socks on, took shoes off. On 4/16/17 at 8:45 a.m., R#1 was found on the floor next to bed with legs crossed. Noted with no socks or shoes on. No apparent injuries. On 4/17/17 at 10:05 a.m., R#1 was noted by the certified nursing assistant (CNA) in the solarium staggering and fell to floor on bottom. Resident noted with skid free socks on. No apparent injuries. During an interview with MDS nurse Registered Nurse CC, and the Assistant Director of Nursing (ADON) on 4/17/17 at 10:45 a.m., revealed that there were not any new interventions to the falls care plan after the 2/2/17 and 2/7/17 falls. She further revealed that the only new intervention put in place after the 2/14/17 fall was: gather information on past falls and attempt to determine cause of falls and to anticipate and intervene to prevent future recurrence. The MDS Registered Nurse CC also confirmed that the care plan was not revised to include the Fall Prevention Protocol II to include half-hour hourly checks and/or placement of resident at the nursing station. Despite the resident experiencing multiple falls, there was no indication that the facility had re-evaluated the appropriateness of the care plan interventions pertaining to falls. Cross refer to F323

Based on electronic clinical record review, staff interviews, review of the facility policy titled, Fall Management, review of the facility forms titled, Incident Details reports, and review of the facility's Root Cause Analysis forms it was determined that the facility failed to re-evaluate the effectiveness of current fall protective measures and failed to implement Fall Prevention Protocol II, per facility policy, and put new measures in place to prevent additional falls for one Resident (R) (#1) who experienced seven falls in three months. This resulted in actual harm for R#1, who fell on [DATE], while ambulating and sustained a laceration to the back of the head which required transfer to the emergency room for treatment. The sample size was 3 residents with a history of falls. Findings include: Review of the facility's policy titled, Fall Management in pertinent part as specified in the Procedure section, that the resident will be considered high risk for falls if their total score on the fall risk assessment is 10 or above. If the score is 10-14, implement Protocol I which includes the following: Frequently orient and repetitively reinforce use of call bell and ensure it is within reach. Reassess for safe footwear, institute bowel and bladder routine as appropriate, conduct a medication review, evaluate the need for an adjustment in resident's daily activity schedule, educate resident's family regarding those interventions and encourage family assistance and support. If the score is 14-18, implement Protocol II, in addition to all interventions noted in Protocol 1. Fall Prevention Protocol II interventions to be intiated, in pertinent part: implement chair or bed alarm as appropriate, initiate half-hour hourly checks and/or placement of resident at nursing station, as needed. Implement use of protective equipment (helmets, hip pads), as indicated. Record review for R#1 revealed the resident had the following [DIAGNOSES REDACTED]. The facility had completed a Quarterly Minimum Data Set (MDS) assessment on 12/15/16. Section C- Cognitive Patterns documented that the resident as having severe cognitive impairment. Section G- Functional Status of this MDS documented that the resident was independent with walking/locomotion in the room and required supervision while walking in the corridor. Review of the Quarterly MDS assessment dated [DATE] revealed Section G- Functional Status, the resident required supervision with walking in corridor as well as locomotion on and off the unit. The facility Incident Details report documented that on 2/2/17 at 8:30 a.m., the resident was found on the floor in her room. Nursing staff noted that there were no apparent injuries. The Incident Details report further noted to continue to monitor for any complaints of pain. Further review revealed that there was not any documentation in the section titled Details of Corrective Measures Taken by Facility. The facility Incident Details report documented that on 2/7/17 at 11:30 a.m., the resident was found on the floor in the dining room with no apparent injuries. The Corrective Actions section of the report documented, unable to redirect because she is combative. The facility completed a Fall Risk Assessment for the resident on 2/3/17 and 2/8/17 with a score of twelve (12) which indicated that the resident was at risk for falls. Review of the 2/2/17 Physical Therapy (PT) screen noted the Registered Nurse reports a decrease in mental status and needs careful monitoring to prevent falls or dangerous behavior. Review of the 2/9/17 PT screen revealed documentation that PT was unable to make recommendations to address the falls from a skilled PT intervention. The facility Incident Details report and the Progress Notes documented that on 2/14/17 at 8:20 p.m., revealed that the resident was ambulating through the dining room with an unsteady gait. The resident fell against the corner of the wall and hit head. The resident had a small opening to back of head to the right side. The physician was notified and the resident was sent to the emergency room and received four staples to the area. Further review revealed that the resident was admitted to the hospital for closer observation and returned to the facility on [DATE]. The facility completed a Fall Risk Assessments on 2/28/17 and scored the resident as an 18 which indicated that the Fall Prevention Protocol II should have been implemented according to the facility's policy titled, Fall Management which documented that the facility should implement interventions which included, but were not limited to, implement chair or bed alarm, as appropriate, initiate half-hour hourly checks and/or placement of resident at nursing station, as needed, implement use of protective equipment (helmets, hip pads), as indicated. Review of the facility Incident Details report documented that on 3/30/17 at 4:30 p.m. that the resident fell while ambulating and sustained a skin tear to the right hand. There was no documentation in the section titled Details of Corrective Measures Taken by Facility. The facility completed a Fall Risk Assessment on 4/3/17 and scored the resident at a 15 which again indicated the Fall Prevention Protocol II should have been implemented according to the facility's policy titled, Fall Management. The facility Incident Details report documented that on 4/14/17 at 3:20 p.m. a visitor reported seeing resident on the floor in the lobby. The resident was disoriented and sitting up on floor with only socks on, took shoes off. No apparent injuries. Will continue to monitor. Further review revealed that there was not any documentation in the Corrective Measures section of the report. The facility Incident Details report documented that on 4/16/17 at 8:45 a.m., the resident was found on the floor next to bed with legs crossed. Noted with no socks or shoes on. No apparent injuries. Corrective measures taken were skid free socks applied and the resident in dining room with staff. The facility Incident Details report documented that on 4/17/17 at 10:05 a.m., the resident was noted by the certified nursing assistant (CNA) in the solarium staggering and fell to floor on bottom. Resident noted with skid free socks on. No apparent injuries. The Corrective measures section of this report documented that staff assisted from floor to chair in solarium for supervision per staff. It further noted that the resident was assisted to the dining room in a Geri- chair recliner for closer supervision per staff. During an interview with the MDS nurse Registered Nurse CC, and the Assistant Director of Nursing (ADON) on 4/17/17 at 10:45 a.m., revealed that there were not any new interventions to the falls care plan after the 2/2/17 and 2/7/17 falls. Further interview revealed that the only new intervention put in place after the 2/14/17 fall was: gather information on past falls and attempt to determine the cause of falls and to anticipate and intervene to prevent future recurrence. The MDS nurse Registered Nurse CC also confirmed that the care plan was not revised to include the Fall Prevention Protocol II to include half-hour hourly checks and/or placement of resident at the nursing station. She stated that she was not sure if staff knew to check on resident every half hour. Review of the Root Cause Analysis forms dated February 2017 and March 2017 revealed that an analysis was conducted for R#1 and that the February 2017 analysis revealed that the contributing factor for the resident's falls was the resident's cognitive status. The March 2017 Root Cause Analysis revealed that the contributing factors for the residents falls was the residents cognitive status with resolutions/corrective actions noted to be, close observation by staff. During an interview with Licensed Practical Nurse (LPN) AA on 4/17/17 at 12:45 p.m., revealed that she has to check on the resident every two hours. She also stated that when they bring the resident to the nursing station, that the resident won't stay there. During an interview with Certified Nursing Assistant (CNA) BB on 4/17/17 at 1:15 p.m., she revealed that she tries to check on the resident every hour or every chance she gets. Despite the resident experiencing multiple falls, there was not any indication that the facility had re-evaluated the effectiveness of the fall interventions and there was not any indication that the facility put any new measures in place to prevent falls. There was also not any indication that after the resident was assessed to be an 18 on the 2/28/17 Fall Risk Assessment and assessed to be a 15 on 4/3/17 Fall Risk Assessment, that the facility implemented the Fall Prevention Protocol II, per facility policy, that included every half-hour checks and/or placement of the resident at the nursing station as needed or implemented the use of protective equipment (helmets, hip pads), as indicated.

Based on observation, clinical record review, facility Incident Details report review, hospital Imaging Service Consult Report review, and staff interview, the facility failed to review the Care Plan, regarding the evaluation of existing Care Plan Approaches for fall-prevention to assess their effectiveness and/or to determine the need to identify additional Approaches for fall-prevention, for one (1) resident (#72), who had been assessed to be at risk for falls and sustained additional falls, of three (3) sampled residents having falls, from a total survey sample of twenty-eight (28) residents. This resulted in actual harm for Resident #72 when the resident experienced a subsequent fall and sustained a left shoulder dislocation. Findings include: Resident #72's 03/11/2014 Admission Minimum Data Set assessment documented an admission date of [DATE]. Section I - Active [DIAGNOSES REDACTED]. Section G - Functional Status documented that Resident #72 required staff supervision for walking, and Section J - Health Conditions documented a history of falls. Review of the Current Care Plan for Resident #72 revealed a Problem Category having a Start Date of 03/10/2014 which identified the resident to be at risk for falls related to impaired cognition, short term memory, and an unsteady gait. Resident #72's Care Plan identified the following Approaches, all having a Start Date of 03/10/2014, related to her risk for falls: anticipate and meet the resident's needs; assess the resident after each fall; be sure the call light is within reach, encourage the resident to use the call light for assistance as needed and respond promptly to all requests for assistance; place the bed in the lowest locked position at all times; encourage activities that promote exercise and physical activity for strengthening and improved mobility; ensure the resident is wearing appropriate footwear, to include shoes, bedroom slippers, and non-skid socks when ambulating or up in the wheelchair; keep the floors even and free from spills or clutter; notify the physician and family of falls; use side rails as indicated; and Physical Therapy/Occupational Therapy to evaluate and treat the resident as ordered or as-needed. A subsequent Approach having a Start Date of 03/18/2014 was added, reiterating for staff to encourage Resident #72 to wear skid-free socks or shoes. A 04/19/2014 facility Incident Details (ID) report documented Resident #72 had been found on the floor in her room near the bed, and noted a new order for the use of [REDACTED] Review of Resident #72's Care Plan referenced above revealed an entry of 04/19/2014 which documented the resident's unwitnessed fall of that date, as noted on the 04/19/2014 ID report referenced above, and also documented a revision to the Care Plan noting the implementation of a bed alarm as ordered. A 04/28/2014 facility ID report documented that Resident #72 fell when the walker slipped away from her while ambulating. Review of Resident #72's Care Plan revealed an entry of 04/28/2014 which documented the resident's fall of that date, as noted on the 04/28/2014 ID report referenced above. However, further review of this Care Plan revealed no evidence to indicate that the facility reviewed the Care Plan to evaluate the Care Plan Approaches listed above, which existed prior to this resident's 04/28/2014 fall while ambulating, to determine the effectiveness of these Approach interventions, to determined the need to modify these interventions, or to determine the need to identify additional interventions to address the resident's fall-potential. The Care Plan only documented that on 04/28/2014, Resident #72 (who was diagnosed with [REDACTED]. A 05/18/2014 facility ID report documented that Resident #72 had fallen while ambulating down the hallway when she picked an item up from the floor. Review of Resident #72's Care Plan revealed an entry dated 05/18/2014 which documented the resident's fall, as noted on the 05/18/2014 ID report referenced above. However, further review of this Care Plan revealed no evidence to indicate that the facility evaluated the Care Plan Approaches referenced above, which existed prior to this 05/18/2014 fall, to determine their effectiveness or the need to modify the existing interventions, or to determine the need to identify additional interventions. The Care Plan only documented that on 05/18/2014, Resident #72, who was cognitively impaired, had been instructed by nursing staff to call for assistance from staff when trying to retrieve items from the floor. A 05/20/2014 facility ID report documented that Resident #72 had fallen while walking down the hallway with her walker, resulting in a small bruise on the left hand. Review of Resident #72's Care Plan revealed an entry dated 05/20/2014 which documented the resident's fall as noted on the 05/20/2014 ID report referenced above. However, further review of the Care Plan revealed no evidence to indicate that the facility evaluated the Care Plan Approaches referenced above, which existed prior to this 05/20/2014 fall, to determine their effectiveness, to determine the need to modify the existing interventions, or to determine the need to identify additional interventions. The Care Plan only documented that on 05/20/2014, Resident #72 had been instructed on the importance of wearing non-skid socks (an Approach which was already referenced on the Care Plan, originally dating from 03/10/2014, prior to this current fall of 05/20/2014), and that staff had demonstrated to the resident the importance of walking slowly with her head up while ambulating (an intervention already referenced on the Care Plan related to the 04/28/2014 fall, as referenced above). A facility ID report of 06/02/2014 at 10:42 a.m. then documented that Resident #72 had fallen while ambulating in the hallway via walker. A 06/02/2014 Progress Notes (PN) entry documented that Resident #72 complained of left shoulder pain and that an order was obtained for an X-ray, and the ID report documented Resident #72's hospital transfer. A 06/02/2014 hospital Imaging Service Consult report documented X-ray results which revealed an anterior dislocation of the left humeral head and that Resident #72 had undergone a reduction for the dislocated left shoulder. During an interview with the Minimum Data Set Coordinator conducted on 06/27/2014 at 11:45 a.m., she was unable to provide evidence to indicate that the facility had evaluated the effectiveness of the existing Care Plan Approach interventions related to Resident #72's falls, or had evaluated to determined the need for new interventions to address the resident having subsequent falls. Based on the above, despite Resident #72 having been assessed to be at risk for falls with Care Plan Approaches developed to address this fall-risk, the resident experienced subsequent falls, but the facility failed to review the resident's Care Plan to evaluate the effectiveness of the existing interventions and to determine the need to identify additional interventions. The facility thus failed to ensure the necessary Care Plan revision to address the resident's continued falls. Cross refer to F323 for more information regarding Resident #72.

Based on observation, clinical record review, facility Incident Details report review, hospital Imaging Service Consult report review, and staff interview, the facility failed to ensure that services related to fall-prevention were provided in accordance with the Care Plan of one (1) resident (#72), of three (3) sampled residents at risk for falls, and failed to ensure that services related to the prevention and/or treatment of [REDACTED].#91 and #55) who had pressure ulcers, from a total survey sample of twenty-eight (28) residents. This failure resulted in actual harm for Resident #72, who sustained a fall which resulted in a dislocated left shoulder requiring reduction. Findings include: 1. Resident #72's 03/11/2014 Admission Minimum Data Set (MDS) assessment documented [DIAGNOSES REDACTED]. Section J - Health Conditions documented Resident #72 to have a history of falls. Review of Resident #72's Current Care Plan revealed a Problem Category dated 03/10/2014 which identified the resident to be at risk for falls related to impaired cognition, short term memory, and an unsteady gait. This Current Care Plan identified multiple Approaches to address Resident #72's risk for falls, with one Approach dated 03/10/2014 specifying that the resident was to be evaluated and treated by the Physical Therapist/Occupational Therapist as ordered or as-needed related to fall-prevention. A facility Incident Details (ID) report for Resident #72 documented that on 04/19/2014, Resident #72 was found sitting on the floor in her room, with no noted injuries. A facility ID report for Resident #72 documented that on 04/28/2014, the resident fell when the rolling walker slipped while she was ambulating in the dining area, and she was assessed with [REDACTED]. A facility ID report for Resident #72 documented that on 05/18/2014, she fell when she was ambulating down the hallway and attempted to pick an item up from the floor, with an assessment noting no injuries. A facility ID report for Resident #72 documented that on 05/20/2014, the resident had fallen while walking down the hallway with the walker, with an assessment noting a small bruise on the resident's left hand. A facility ID report for Resident #72 documented that on 06/02/2014, the resident had fallen while ambulating in the hallway using a walker. A 06/02/2014 Progress Notes entry documented that Resident #72 complained of left shoulder pain after this fall, and the facility ID report referenced above documented the resident's emergency room transfer for a shoulder X-ray. A 06/02/2014 hospital Imaging Service Consult report for Resident #72 documented the X-ray results revealed an anterior dislocation of the left humeral head, and documented a reduction for repair of the resident's dislocated left shoulder. Further record review for Resident #72, however, revealed no evidence to indicate that the resident had been evaluated by the Physical Therapist or Occupational Therapist in relation to the falls of 04/19/2014, 04/28/2014, 05/18/2014, 05/20/2014, or 06/02/2014, even though the resident's Current Care Plan for her risk for falls specified, via the 03/10/2014 Approach for fall-prevention, that the resident would be evaluated and treated by the Physical Therapist/Occupational Therapist as ordered or as-needed. During a 06/26/2014, 8:45 interview, the Director of Nursing (DON) acknowledged that Resident #72 had not been referred to the physical or occupational therapy department after having fallen, and acknowledged that the resident should have been evaluated by the therapist. Cross refer to F323 for more information regarding Resident #72. 2. Resident #91's Admission MDS assessment of 05/12/2014 documented diagnoses, in Section I - Active Diagnoses, that included, but were not limited to, [MEDICAL CONDITION], Heart Failure, Hypertension, Arthritis, [MEDICAL CONDITIONS] and Dementia. Section M - Skin Conditions documented a Stage 2 pressure sore. Review of Resident #91's Current Care Plan revealed a Problem Category originally dating from 05/20/2014 which documented that the resident had an alteration in skin integrity related to the presence of a Stage 2 pressure sore to the right lower buttocks. Approaches dated 05/20/2014 listed on Resident #91's Current Care Plan related to the altered skin integrity specified to apply dressings as ordered to the break in the resident's skin, and also directed staff to apply heel protectors while the resident was in bed. A 05/06/2014 physician's orders [REDACTED].#91's gluteal ulcer every three (3) days until healed, and a 06/10/2014 order specified to apply triple antibiotic ointment to the buttocks with the dressing change. During a 06/25/2014, 11:40 a.m. observation, the Treatment Nurse applied a [MEDICATION NAME] dressing to Resident #91's right buttock, but failed to apply triple antibiotic ointment as ordered. The facility thus failed to ensure that Resident #91 received pressure sore treatment in accordance with the Care Plan Approach which specified that staff apply dressings as ordered, by failing to apply triple antibiotic ointment as ordered by the physician. In addition, even though Resident #91's Care Plan Approaches specified the application of heel protectors while in bed, observations of 06/25/2014 at 8:00 a.m. and 4:00 p.m., 06/26/14 at 8:30 a.m. and 12:45 p.m., and 06/27/2014 at 9:00 a.m. revealed Resident #91 to be in the bed but wearing no heel protectors. During interview on 06/27/2014 at 10:30 a.m., the Treatment Nurse acknowledged the absence of heel protectors for Resident #91. Cross refer to F314, example 1, for more information regarding Resident #91. 3. Resident #55's Annual MDS of 06/16/2014 documented diagnoses, in Section I - Active Diagnoses, that included, but were not limited to, [MEDICAL CONDITION], Dementia, and [MEDICAL CONDITION]. Section M - Skin Conditions documented the presence of a Stage 2 pressure sore. Review of the Current Care Plan of Resident #55 revealed a Problem Category originally dating from 08/14/2012 which identified the risk for altered skin integrity. A Current Care Plan revision dated 04/17/2013 identified that Resident #55 had an alteration in skin integrity related to a decline in condition, and an Approach was added specifying that the resident wear heel protectors while in bed. However, even though Resident #55's Care Plan Approach specified that the resident wear heel protectors while in bed, observations on 06/25/2014 at 7:30 a.m. and 9:40 a.m., and 06/26/2014 at 7:30 a.m. revealed Resident #55 in bed but with no heel protectors in place. During a 06/27/2014, 10:40 a.m. interview, the Treatment Nurse acknowledged the absence of heel protectors for Resident #55. Cross refer to F314, example 2, for more information regarding Resident #55.

Based on observation, clinical record review, facility Policies and Procedures for Fall Management review, facility Incident Details report review, hospital Imaging Service Consult Report review, Physical Therapist interview, and staff interview, the facility failed to evaluate the need for additional interventions for fall-prevention, to include interventions included as part of the Policies and Procedures for Fall Management, for one (1) resident (#72) after the resident sustained [REDACTED]. This failure resulted in actual harm for Resident #72, who experienced multiple falls without the facility evaluating the need for additional fall-prevention interventions. This resulted in actual harm for Resident #72, who then experienced a fall while ambulating and sustained a left shoulder dislocation. Findings include: Review of the facility's Policies and Procedures for Fall Management revealed, as specified in the Procedure section, that for residents assessed to be at risk for falls, a "falling star" would be placed above the head of the resident's bed and an orange circle with a silver star would be placed on the name tag outside the resident's door. These Policies and Procedures for Fall Management also specified that if a resident had repeated falls or falls with injury, the Fall Prevention Protocol (part of the Policies and Procedures for Fall Management) would be implemented. The Fall Prevention Protocol section of these Policies and Procedures identified interventions which included, but were not limited to, contacting the Therapy Department as appropriate and initiating half-hourly checks as needed for residents who were at risk for falls, had who had repeated falls, or had falls with injuries. Record review for Resident #72 revealed an Admission Minimum Data (MDS) set assessment having an Assessment Reference Date of 03/11/2014 which documented a facility Entry Date of 02/28/2014. Section C - Cognitive Patterns documented Resident #72 to have a Brief Interview for Mental Status (BIMS) Summary Score of 10, indicating that the resident had moderate cognitive impairment, and Section I - Active [DIAGNOSES REDACTED]. Section G - Functional Status of this MDS documented that Resident #72 required the supervision of staff with walking/locomotion and utilized a walker as a mobility device, and Section J - Health Conditions documented a history of falls. The Care Plan for Resident #72 contained a Problem dated 03/10/2014 which identified that the resident was at risk for falls and identified multiple Approaches to address this risk. A facility Incident Details (ID) report for Resident #72 documented that on 04/19/2014 at 4:15 p.m., the resident had been found sitting on the floor in her room near the bed. Nursing staff assessed Resident #72 and noted no injuries. This facility ID report further documented that the physician was notified of the fall, and that the use of a bed alarm was implemented at that time for Resident #72 to address the resident's falls. A facility ID report for Resident #72 then documented that on 04/28/2014 at 5:10 a.m., the resident fell when the rolling walker slipped away from her while ambulating in the dining area. The Corrective Measures section of this ID report documented that nursing staff provided instruction and demonstrated to the resident to slow both herself and the walker down while ambulating, to step further into the walker, and to keep her head upright while ambulating. A facility ID report for Resident #72 documented that on 05/18/2014 at 6:58 am, the resident was ambulating down the hallway and fell while picking an item up off the floor, with an assessment noting no injuries. The Corrective Measures section of this facility ID report documented that nursing staff had instructed the resident to call for assistance from staff when trying to retrieve items from the floor. A facility ID report for Resident #72 documented that on 05/20/2014 at 2:00 a.m., the resident had fallen to the floor while walking down the hallway with her walker. This facility ID report documented that an assessment at that time noted a small bruise on Resident #72's left hand, with no lacerations or skin tears noted. The facility ID report further documented, in the Corrective Measures section, that nursing staff had instructed Resident #72 on the importance of wearing her nonskid socks while ambulating, and had demonstrated the importance of walking slowly with her head up while ambulating. Further record review, however, revealed no evidence to indicate that after Resident #72 sustained the 04/28/2014 fall while ambulating in the dining area, and the 05/18/2014 and 05/20/2014 falls while ambulating in the hallway as referenced above, the facility had placed a "falling star" above the resident's bed and an orange circle with silver star on the name tag outside of the resident's room, had evaluated the need to consult with the Therapy Department, or had evaluated the appropriateness of half-hourly checks for this resident. This was despite the facility's Policies and Procedures for Fall Management referenced above which indicated the evaluation of these interventions for residents, such as Resident #72, who were at a high risk for falls, who had repeated falls, or who had falls with injury. Then, a facility ID report for Resident #72 documented that on 06/02/2014 at 10:42 a.m., the resident was ambulating in the hallway using the rolling walker. A Progress Notes entry of 06/02/2014 documented that, upon assessment after this fall, Resident #72 complained of left shoulder pain, and that when notified, the Nurse Practitioner ordered an X-ray. The facility ID report documented Resident #72 was then transferred to the emergency room to obtain the X-ray of the shoulder. A hospital Imaging Service Consult report of 06/02/2014 for Resident #72 documented the X-ray results of the left shoulder revealed an anterior dislocation of the left humeral head, with no obvious fracture observed. This Imaging Service Consult report documented that Resident #72's had undergone a reduction for repair of the dislocated left shoulder, and the 06/02/2014 facility ID report documented the resident's return to the nursing facility. A 06/02/2014 Episodic Note by the Nurse Practitioner documented that he had been called to the facility to examine Resident #72's due to the resident's complaint of left shoulder pain, and referenced the X-ray which revealed a left shoulder dislocation. The Nurse Practitioner further documented that the resident's shoulder was satisfactorily reduced, and that the resident was doing fine. During an interview with the Director of Nursing (DON) conducted on 06/26/2014 at 8:45 a.m., the DON acknowledged that despite having multiple falls, Resident #72 had not been referred to the Therapy Department for the evaluation related to these falls. The DON further acknowledged that Resident #72 should have been evaluated by the therapist due to her multiple falls, and stated that a referral would be made for a therapy evaluation. During an interview with the Physical Therapist (PT) conducted on 06/26/2014 at 10:05 a.m., the PT stated she had not been informed of Resident #72's falls. The PT stated she would have expected to have been contacted regarding Resident #72's falls, and stated that the resident would receive a therapy screen on the 06/26/2014 date of this interview. Additionally, during an observation conducted on 06/26/2014 at 10:00 a.m. in the room of Resident #72, it was noted that no "falling stars" had been placed above the head of the resident's bed, and no orange circle with silver star had been placed on the resident's name tag outside of the room door, as outlined in the facility's Fall Management Policy referenced above.