Every finding on record at Kennybrook Village

Based on observation, staff interview, and policy review, the facility failed to maintain sanitary practices by touching food with contaminated, gloved hands during food service for one of one meal services observed. The facility reported a census of 39 residents.Findings include:On 1/20/2026 at 11:17 AM, a continuous meal service observation revealed Staff A, Culinary Aide (CA) placed his right oven mitt covered thumb inside the pan of peas and directly touched the food.At 11:34 AM, Staff A put on gloves, packed up a food thermometer, grabbed the temperature logbook, placed them both on the back counter, and returned to serving resident food. During service, he grabbed Tostitos chips with the same gloved hands and put them on a resident's plate.At 11:46 AM, Staff B, CA put on gloves, handled plates, ladles, and scoops then returned to serving resident food. During food service, she grabbed Tostitos chips with the same gloved hands and put them on a resident's plate. She did it four (4) times.At 11:15 AM, Staff A stated he received Infection Prevention training upon hire in March 2025. He confirmed hand hygiene and proper glove use were included in the training. He stated he was not aware his thumb touched the peas and admitted he should have changed his gloves before touching the Tostitos chips.On 1/22/26 at 1:47 PM, the Dietary Manager (DM) stated staff should have been more aware of food handling equipment when handling food items and staff should've used appropriate equipment to serve food, such as tongs.A policy titled Food Preparation and Service revised October 2018 directed staff to adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. It also indicated bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks.

Based on observation, staff interview, and policy review, the facility failed to serve food within appropriate temperature ranges for one of one meals observed. The facility reported a resident census of 39.Findings include:On 1/21/26 at 12:05 PM, a lunch food check revealed the following preservice temperatures:Chicken parmesan - 142.3 deg FSpaghetti noodles - 149 deg FVegetables - 177 deg FBread - 153.4 deg FSpaghetti sauce - 173.6 deg FBeef pot pie - 161 deg FChicken noodle soup - 196 deg FMechanical soft (MS) chicken parmesan - 159.1 deg FMechanical soft (MS) beef pot pie - 173 deg FPureed chicken parmesan - 189 deg FPureed noodles - 175.8 deg FPureed bread - 179 deg FPureed vegetables - 154.5 deg FAt 1:06 PM, the food temperatures revealed the MS chicken parmesan temperature was 125.2 deg F and the Pureed chicken parmesan temperature was 126.3 deg F which indicated they did not maintain a safe temperature of at least 135 deg F throughout lunch service. All other food items' post-service temperatures exceeded 135 deg F.At 1:10 PM, the Dietician stated the MS and pureed foods are routinely placed on the steam table but the facility had to place them in the warming oven due to the number of items being served for lunch.On 1/22/26 at 1:47 PM, the Dietary Manager (DM) stated staff should have checked the food temperatures periodically since it was being served from a warming location that was different than usual.A policy titled Preventing Foodborne Illness - Food Handling revised October 2018 indicated the facility recognized that the critical factors implicated in foodborne illness are:Poor personal hygiene of food service employees;Inadequate cooking and improper holding temperatures;Contaminated equipment; andUnsafe food sources.A policy titled Food Preparation and Service revised October 2018 indicated the danger zone for food temperatures is between 41 deg F and 135 deg F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness.

Based on observation, clinical record review, staff interviews, and policy review the facility failed to maintain infection control practices for 2 of 3 residents reviewed (Resident #35 and Resident #4). The facility failed to ensure use of Enhanced Barrier Precautions (EBP) when required for Resident #35 and failed to perform hand hygiene and infection control practices during wound care for Resident #4. The facility reported a census of 39 residents. Findings include: 1.The Minimum Data Set (MDS) for Resident #35, dated 12/31/2025, included diagnoses of Non-Alzheimer's Dementia and pressure- induced damage of sacral region (buttocks). The MDS identified the resident was dependent on staff for transfers. The MDS identified the resident had a Stage 2 pressure ulcer (partial thickness loss of skin presenting as a shallow open ulcer). The MDS indicated the resident had a BIMS score of 5, indicating severe cognitive impairment. The Care Plan with initiated date of 10/24/25 for Resident#35 documented a Deep Tissue Injury (IDT) to the buttock. Observation on 1/20/2026 at 12:41 PM, Staff C, Certified Nurse Aide (CNA) and Staff D, CNA entered Resident #44's room, applied gloves only and transferred the resident from the wheel chair to the recliner with a stand-up lift. Interview on 1/20/2026 at 1:15 PM, Staff E, Licensed Practical Nurse, stated Resident #35 had a wound on her right buttock. Interview on 1/21/2026 at 11:15 AM, Staff F, stated Resident #35 is on EBP for a wound and need to wear gown and gloves with transfers, cares, and bedding changes for the resident. Interview on 1/21/2026 at 11:23 AM, Staff G stated need to wear gown and gloves for cares or transfers with Resident #35, as the resident has an EBP sign posted outside her door. Interview on 1/22/2026 at 10:38 AM, the Infection Preventionist stated Resident #35 is on EBP due to her wound and expectation for staff to wear gown and gloves when transferring the resident. The facility Enhanced Barrier Precautions policy dated 3/7/2024, directed EBP are used in conjunction with standard precautions and expand the use of personal protective equipment to donning of gown and gloves during high-contact resident care activities. EBP are indicated for residents with wounds. 2. The MDS dated [DATE] for Resident #4 documented a BIMS score of 2, indicating severe cognitive impairment. The MDS included diagnoses of heart failure, renal insufficiency, respiratory failure and pressure ulcer of the sacral region, stage 3. The MDS indicated the resident was at risk of developing pressure ulcers/injuries and had unhealed pressure ulcers/injuries. The Order Summary Report for Resident #4 documented the following physician orders; Start date 1/20/26 left forearm, clean with wound cleanser, apply a single layer of Xeroform to open wound, cover with a gauze roll one time a day and as needed for abrasion. Start date 1/6/26 Right forearm clean with wound cleanser of choice, apply a single layer of Xeroform to open wound, cover with gauze roll one time a day for skin tear, and as needed. Right shin clean with wound cleanser, apply a single layer of Xeroform to open wound, cover with gauze roll one time a day for abrasion and as needed. During a continuous observation 1/22/2026, beginning at 11:30 AM, Staff H, LPN, completed wound care for Resident #4 for both forearms and the right shin. Staff H sanitized hands before getting the supplies ready, washed her hands and then donned a gown and gloves. The supplies were placed on a barrier. Staff H began with wound care for Resident #4's right forearm. Taking a pair of scissors, Staff H cut the old dressing off of the resident's right forearm, placed the scissors on the barrier and removed the dressing and pad. Staff H removed her gloves, did not sanitize hands, retrieved a gauze pad and cleaned the wound with wound cleanser, there was blood on the gauze and a spot of blood on Staff H's glove. Staff H removed her gloves, did not sanitize her hands and placed new gloves on her hands. Staff H used the same scissors she had used to cut the old gauze off of the resident's arm, without sanitizing the scissors, to cut the Xeroform to fit the wounds on the right forearm and placed the Xeroform on the wounds. Staff H put a clean pad over the Xeroform and wrapped the wound with a clean gauze roll. Staff H washed hands and put on new gloves. Staff H then began wound care for the left forearm. Staff H used the same scissors, without sanitizing them before or after, to cut the old gauze off and removed the gauze and pad and Xeroform. Staff H changed her gloves and cleaned the wound with wound cleanser. Staff H removed her gloves, did not sanitize her hands, and placed a new pair of gloves on her hands. Staff H used the same scissors to cut the Xeroform to fit the wound and applied this to the wound and covered with a pad. Staff H then used the same scissors to cut a piece of gauze from the roll and wrapped this around the wound. Staff H removed her gloves and washed her hands. Staff H put on a new pair of gloves and then began wound care for the resident's right shin. Staff H used the same scissors, without sanitizing before or after, and cut the old gauze off of the right shin. Staff H removed the old pad and old Xeroform from the wound. Staff H removed her gloves, did not sanitize hands, placed new gloves on and cleaned the wound with wound cleaner. Staff H used these same gloved hands to open the lid of the trash can, touching the trash can, then using the same gloved hands, continued to clean the wound. Staff H changed gloves, she did not sanitize her hands. Staff H used the same scissors, without cleaning them before or after, to cut a section of the Xeroform from the package to fit over the wound. The Xeroform was placed on the wound and a clean pad over the wound. Staff H used the same scissors to cut a strip of clean gauze to wrap around the wound. During an interview 1/22/2026 at 12:15 PM, the Director of Nursing (DON) stated an expectation the scissors are cleaned/sanitized between clean and dirty use and for staff to use appropriate hand hygiene with sanitizing hands between clean and dirty and changing gloves, and sanitizing after touching a dirty surface such as a trash can lid. Review of the facility policy Handwashing/Hand Hygiene, revised August 2024, documented indications for hand hygiene included after contact with blood, body fluids or contaminated surfaces, before moving from work on a soiled body site to a clean body site on the same resident and immediately after glove removal. The use of gloves does not replace handwashing/hand hygiene.

Based on staff interview, review of the facility's Provider History Profile reports, and facility policy review, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies. This resulted in multiple repeat deficiencies identified on the facility's current recertification and complaint survey. The facility reported a census of 35 residents. Findings include: Review of the facility's Provider History Report revealed the facility received the same deficiency for three (3) consecutive recertification surveys. The deficiency category was for failing to accurately follow resident menus. On 1/09/25 at 2:50 PM, the Certified Dietary Manager (CDM) stated she assigned all staff to watch a video on diet portion sizes as part of the QAPI Performance Improvement Plan (PIP). At 2:55 PM, the Administrator stated the CDM held monthly in-services and the administrative team held a skills fair twice yearly. She stated the video was provided to staff on 4/30/24 and 5/02/24. She stated all staff should be done as it was mandatory. She stated the facility's internal program contained the detailed information of the PIP. At 3:38 PM, the administrator stated there was no documentation of follow-up to the efficacy of the aforementioned PIP. The facility policy, titled Quality Assurance and Performance Improvement (QAPI) Manual revised 1/2024, indicated ongoing monitoring will be achieved by using tools specifically developed to monitor desired outcomes. It also indicated the Quality Assessment and Assurance (QAA) committee will monitor progress, provide input, and ensure the individuals involved in the project have the resources they need.

Based on observation, menu review, clinical record review, staff interviews, and policy review, the facility failed to follow the appropriate diet and serve the appropriate portions for (2) residents (#11, #18) who received pureed diets and failed to follow the menu diet for all residents who received gravy. The facility reported a census of 35 residents. Findings include: On 1/08/25 at 10:40 AM, Staff B, Cook, began making the pureed pork. He placed six (6) small pieces of pork into the blender and added 2 ounces (oz) of beef base. He blended the contents. He emptied the contents into a steam table bowl. Some of the contents was observed still in the blender when rinsed. The total volume was not measured and the Dishers Scoop Sizes, Colors and Yields chart was not used to determine the appropriate serving size prior to being served. At 11:37 AM, Staff C, Dietary Aide (DA), placed serving utensils in each menu item pan. She stated a #20 disher (1.6 fluid oz) was used for the pureed pork and pureed vegetable serving sizes, and a black handled scoop was used for gravy. She was not able to identify the black handled scoop size. A continuous meal service observation revealed every resident who received gravy got one (1) scoop of gravy with the black handled scoop. At 1:55 PM, Staff A, Cook, stated he did not puree egg rolls. He stated he just didn't think about it. He also stated he made the pureed vegetables and based the serving size on the combined individual amounts of vegetables and tomato juice used during the pureed process. He stated he did not measure the total volume and used the facility Disher Scoop Sizes, Colors and Yields (DSSCY) conversion chart to determine the disher size. At 2:15 PM, the Certified Dietary Manager (CDM) stated the facility used the facility specific conversion chart. A review of the menu indicated a #6 scoop (5.33 fluid oz) was the appropriate pureed pork serving size which resulted in a -3.73 oz serving. It also indicated a #12 scoop (2.67 fluid oz) was the appropriate pureed vegetable serving size which resulted in a -1.07 oz serving. and 2 oz was the appropriate gravy serving size. The menu also identified 2 oz of gravy was the appropriate serving size. The black handled serving scoop used was later identified as a one (1) oz serving size which resulted in a -1 oz serving. An Electronic Health Record review revealed both Resident #11 and Resident #18 were ordered pureed diets without portion restrictions. A policy titled Kitchen Weights and Measures revised 10/2018 indicated cooks and staff plating food for meal service will follow the portion sizes per menu and will use appropriate utensil. On 1/09/25 at 2:01 PM, the Administrator stated staff should follow the scoop diagram (pureed disher conversion chart) and menu items serving sizes.

Based on observation, staff interview, and policy review, the facility failed to provide food served by a method to maintain a safe and appetizing temperature for one of one meal service observed. The facility reported a census of 35 residents. Findings include: On 1/08/23 at 11:37 AM, a continuous lunch service observation revealed Staff C, Dietary Aide (DA), obtained the temperature of one (1) food item, Salmon croquettes, prior to service and noted the temperature of 123.5 Fahrenheit (F). All other lunch menu items met acceptable temperatures. At 12:20 PM, Staff C obtained the temperatures of remaining lunch menu items after meal service ended. The results were: 1) Salmon croquettes - 117 F 2) Mashed potatoes - 124.8 F 3) Vegetable egg rolls - 122 F 4) Pureed pork - 124 F 5) Mechanical Soft egg rolls - 120 F A policy titled Food Preparation and Service revised 10/2018 indicated food held at temperatures between 41 F and 135 F promoted the rapid growth of pathogenic organisms that cause foodborne illness and must be maintained above 135 F. On 1/09/25 at 2:03 PM, the Administrator stated staff should bring menu items to appropriate temperatures before serving. She also stated staff should have reported the low temperatures to the CDM and implemented corrective procedures to ensure the food maintained correct temperatures.

Based on observation, staff interview, and facility policy review, the facility failed to maintain sanitary practices by improperly storing and serving food. The facility reported a census of 35 residents. Findings include: On 1/06/25 at 10:20 AM, an initial kitchen observation identified the following findings: A [NAME] refrigerator contained: 1) Two (2) undated, unlabeled, sealed packs of long, round, hot-dog looking items. 2) Three (3) opened, undated bags of grapes in a single labeled box. 3) One (1) undated, previously opened 2-liter bottle of A&W root beer. 4) Three (3) undated, unlabeled, clear dispensers with a clear liquid and round, orange, disk shaped items. 5) Four (4) unlabeled, loaf shaped packages of a dark pink substance. A [NAME] freezer 1) One (1) undated, unlabeled, clear plastic bag with round, yellow items. 2) One (1) undated, unlabeled, clear plastic bag with a pink, meat-looking item on a cookie pan. The kitchen area contained: 1) A white bin labeled sugar had 1 sealed bag of sugar, 1 opened bag of sugar, and a plastic scoop lying on top of the sugar at the bottom of the bin. 2) An undated, unlabeled clear plastic container with a blue lid had a white flaky product. The dry goods storage contained: 1) Multiple unlabeled bags of brown, flaky items. 2) Multiple unlabeled bags of tan, donut-shaped items. On 1/08/25 at 7:06 AM, a follow-up kitchen visit revealed: 1) One (1) undated, previously accessed plastic container of strawberries. 2) Two (2) pans of unlabeled, red, gelatin-like substance with orange colored chunks. 3) Three (3) opened, undated bags of grapes in a single labeled box. 4) One (1) undated 2-liter bottle of A&W root beer. 5) Three (3) undated, unlabeled, clear dispensing containers with clear liquid and round, light green disk-shaped items. A [NAME] freezer contained: 1) One (1) undated and unlabeled clear plastic bag of rounded, rectangular shaped items. 2) Multiple bags of multicolored vegetable-like items. The kitchen contained one (1) white bin labeled sugar that had 1 sealed bag of sugar, 1 opened bag of sugar, and a plastic scoop lying on top of the sugar at the bottom of the bin. The dry goods storage contained: 1) One (1) bag of undated, unlabeled jug of white liquid beside a Frymax container. 2) One (1) bag of unlabeled tan grain-shaped items. On 1/08/24 at 10:35 AM, Staff A, Cook, grabbed a can of spray butter with his gloved hand and sprayed the inside of a steam table bowl. He then grabbed the egg rolls with the same gloves and placed them in 3 steam table bowls. No hand hygiene or glove change was performed between touching the spray can and eggs rolls. At 10:37 AM, Staff B, [NAME] opened the walk-in freezer door with gloved hands. He then grabbed a bread loaf with the same gloves and positioned it on the food preparation table. After cutting the bread, he grabbed several different utensils and a mustard container. He took two (2) slices of lunch meat from a package and placed them on the bread. No hand hygiene or glove change was performed throughout the process. At 10:55 AM, Staff B performed hand hygiene and donned gloves. He opened a large container of pickles, grabbed a knife, opened the stack of cheese, stuck his gloved hand inside the pickle container and grabbed and handful of pickles. On 1/09/25 at 2:10 PM, the Administrator stated staff should follow the facility's policies regarding food storage, hand hygiene, and prevention of cross-contamination. A policy titled Food Receiving and Storage revised 10/2018 indicated dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). It also indicated all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing, preparing, and serving food. The facility reported a census of 39 residents. Findings include: During an initial kitchen observation on 9/25/23 at 9:35 AM, the following findings were identified: -Observed all of the Heating, Ventilation, and Air-Conditioning diffusers (HVAC vents) missing and two (2) ducts blowing air directly on a pan of barbeque (BBQ) chicken located on the food preparation table. Another exposed duct blowing air directly on the area designated for newly washed dishware. -Observed a serving scoop stored inside a bin of flour in direct contact with the contents. -Observed Staff A, Cook, did not have his facial hair covered while preparing food and Staff B, Dietary Aide (DA), did not cover the back of her hair while handling food. -The [NAME] refrigerator contained an undated bag of previously opened dinner rolls, a partially covered tray of vegetable lasagna, and a partially covered block of butter. -The [NAME] freezer contained an undated, unlabeled, open brown bag of food, an undated bag of mixed vegetables, and a partially covered carton of Blue Bunny sorbet. A sealed bag and round package of meat were stored on the floor between two (2) storage racks and a stack of boxes were stored on the floor in the middle of the freezer. A dining observation on 9/25/23 at 11:33 AM revealed, Staff C's, (DA), hairnet did not cover the lower back of his hair. While serving food, Staff C picked up a plate with no gloves and his thumb touched a part of the inside of the rim of the plate then he put a piece of BBQ chicken on the plate where his finger touched. While Staff C was putting chips on another plate, the sandwich came in direct contact with the outside of the potato chip bag that Staff C opened with his bare hands. At 11:59 AM, Staff C put on gloves, served a plate of food, then opened a drawer to get another serving scoop, placed the scoop in the mashed potatoes then grabbed a slice of bread with same gloves. On 9/28/23 at 9:10 AM, the Dietary Manager stated the expectation was food should be labeled and dated when stored; staff should wear a hairnet properly; and staff should wash hands after touching nonfood items while serving food. A policy titled Food Receiving and Storage revised 10/2018 indicated all foods stored in the refrigerator or freezer will be covered, labeled and dated and opened containers must be dated and sealed or covered during storage. A policy titled Food Preparation and Service revised 10/2018 directed staff to wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. It further directed staff to wear gloves when food is handled directly and to change gloves between tasks.

Based on observations, staff interview, and facility policy review, the facility failed to provide food served by a method to maintain a safe and appetizing temperature. The facility reported a census of 39. Findings include: During a continuous observation on 9/27/23 beginning at 11:33 AM, Staff C, Dietary Aide (DA), obtained the temperatures of two (2) foods that were noted to be below the acceptable holding temperature. The mechanical soft turkey had a temperature of 131.4 Fahrenheit (F) and the pureed turkey had a temperature of 93 F. At 12:32 PM, Staff C prepared a resident plate containing the mechanical soft turkey but was asked to recheck the temperature of the mechanical soft turkey before serving it. The temperature observed to be 129 F and it was subsequently reheated to 190 F before being served to a resident. The pureed turkey was served to the resident without rechecking the temperature or being reheated. A policy titled Food Preparation and Service revised 10/2018 indicated food held at temperatures between 41 F and 135 F promoted the rapid growth of pathogenic organisms that cause foodborne illness and must be maintained above 135 F. On 9/28/23 at 10:25 AM, the Dietary Manager confirmed the temperatures were below acceptable limits for serving meals.

Based on clinical record review, resident interview and staff interviews, the facility failed to provide restorative activities for 1 of 1 sampled resident in order to maintain a functional range of motion and prevent a decline in activities of daily living (Residents #3). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 had diagnoses that included anemia (low blood count), arthritis, Alzheimer's Disease, muscle weakness, and abnormal gait and mobility. The MDS revealed the resident required limited assistance of one for bed mobility, transfers, dressing, personal hygiene, and toileting. The MDS indicated no range of motion (ROM) impairment to the upper and lower extremities. The MDS revealed the resident had Occupational Therapy (OT) services from 4/10/23 - 5/31/23 and was actively receiving Physical Therapy (PT) services that began 7/2/23. The Electronic Health Record (EHR) for the resident recommended for Restorative Aide (RA) program services by OT on 5/31/23 focused on bilateral upper extremity (BUE) exercises two to three (2-3) times per week. The MDS assessment dated [DATE] included significant changes to Resident #3's functional status which required extensive assistance of one for bed mobility, transfers, dressing, personal hygiene, and toileting. The MDS indicated no ROM impairment to the upper and lower extremities. It also indicated the resident received one (1) day of restorative nursing program training and skill practice in transfer and walking in the seven (7) day look-back period. The EHR for the resident recommended restorative program services by PT on 8/18/23 focused on lower body exercises 2-3 times per week. The Progress Notes included RA documentation dated 8/31/23 indicating the resident received restorative program BUE exercise. The resident's Care Plan included Restorative Nursing exercises and directed staff to have the resident perform Upper Body tasks 2-3 times per week. The Lower Body restorative exercises 2-3 times per week were marked as resolved on 7/28/23. During an interview on 9/25/23 at 2:50 PM, Resident #3 stated that she was not getting around as easily as she used to. On 9/26/23 at 1:10 PM, the Rehabilitation Director stated the resident should be on RA program services for BLE & BUE through PT and OT respectively. On 9/26/23 at 3:30 PM, a therapy assistant stated the facility did not have a routine Restorative Aide. On 9/26/23 at 3:43 PM, the Assistant Director of Nursing (ADON) stated the resident had not received restorative program services 2-3 times per week due to staffing shortages. She stated a Performance Improvement Plan was being done as the facility was aware of the problem. The EHR included the restorative program BUE and BLE tasks. The subsequent Point-of-Care (POC) response history documentation revealed the resident had not received scheduled restorative program exercises. On 9/26/23 at 3:58 PM, Staff D, Certified Nurse Aide (CNA) stated the resident had not received dedicated restorative services within the previous three to four weeks. A policy titled Restorative Nursing Services revised 7/2017 indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence.

Based on observation, menu review, clinical record review, staff interviews, and policy review, the facility failed to serve the appropriate portions for the last five (5) residents who received green beans or mashed potatoes. The facility reported a census of 39 residents. Findings include: On 9/27/23 at 12:53 PM, observed Staff C, Dietary Aide (DA) partially fill a #8 (4-oz) scoop for a serving of potatoes and a 4-oz ladle for a serving of green beans for the last 5 resident servings. At 12:59 PM, the Registered Dietician stated the serving size of vegetables is 4 oz. but less dense starches required larger portion servings. A review of the Week 5 Wednesday menu indicated a serving size of mashed potatoes was a #8 scoop and a serving size of green beans was four (4) ounces. A document titled Diet Type Report provided by the Dietary Manager revealed no resident was ordered half-portion sizes for meals. On 9/28/23 at 10:25 AM, the Dietary Manager stated staff should provide serving sizes according to the guidelines. A policy titled Kitchen Weights and Measures revised 10/2018 directed staff to follow the portion sizes per the menu and to use appropriate utensils.

Based on observation, staff interviews, and facility policy review, the facility failed to maintain a clean, comfortable and homelike environment for 2 out of 8 resident rooms. The facility reported a census of 39 residents. Findings include: 1. On 09/25/23 at 11:00 AM observation of the carpeted floor in room [ROOM NUMBER] revealed excessive stains of various sizes and colors. A urine odor noted in the room. A second observation on 09/26/23 at 09:00 AM of room [ROOM NUMBER] revealed no changes to the stained carpet and continued to have a strong urine odor. A third observation on 09/27/23 at 10:00 AM of room [ROOM NUMBER] showed stained carpet and urine odor remained unchanged. During an interview on 09/27/23 at 12:20 PM the Housekeeping Supervisor and the Maintenance Supervisor both confirmed the carpet was excessively stained and the urine odor noted but could not provide a date of the last time the carpet was shampooed. 2. On 09/26/23 at 10:10 AM observation of the carpeted floor in room [ROOM NUMBER] revealed 2 red color stains of approximately 4 inches in diameter in front of a recliner. The room noted to be excessively warm. The thermostat on the wall was not functioning and the temperature was not displayed. The maintenance department confirmed the room temperature measured using an infrared thermometer was 86 degrees fahrenheit. During an interview on 09/26/23 at 12:20 PM the Maintenance Supervisor stated the expectation for the room temperature ranged between 70-80 degrees fahrenheit. He further stated he wasn't aware the room temperature was outside the expected range and that the thermostat on the wall wasn't functioning. The facility policy review on 09/28/23 at 2:30 PM titled Quality of Life-Home Environment undated, documented residents are provided with safe, clean, comfortable homelike environment, comfortable and safe temperatures (71 degrees fahrenheit - 81 degrees fahrenheit).

Based on observation, record review, and staff interviews, the facility failed to ensure staff served the proper serving size for 2 of 2 residents with a pureed texture diet (Resident # 26 and Resident # 32). The facility reported a census of 40 residents at the time of the survey. Findings include: The facility's document titled, Pivotal SS 2022 for Week 4 lunch Tuesday listed the food items planned for lunch on 6/21/22: apple butter pecan crusted pork loin chops, rice pilaf, buttered zucchini, dinner roll/margarine , bread pudding, milk. The document titled, Diet Spreadsheet directed staff to serve 1 serving of each of the apple butter pecan crusted pork loin chops, rice pilaf, buttered zucchini, dinner roll/margarine, bread pudding, and 8 oz of milk to residents on a pureed diet for lunch on 16/21/22 . During preparation of the pureed food on 6/21/22 at 10:40 AM, Staff A (dietary cook) said the facility had 2 residents on a pureed diet, but he planned to prepare 3 serving sizes for each kind of food. Staff A used 4 1/2 scoops to measure and prepare the vegetables (veggies), which resulted in a total of 15 ounces (oz). Staff A said the 15 ounces of veggies would make up for 3 servings of 5 oz portions. Staff A labeled the container for the prepared veggies as veggies 3 5 oz and then set aside. Staff A took 3 pieces of porkchops and added chicken broth to make 12 oz of pureed meat. Staff A said that to make 3 serving sizes, it would be 4 oz each serving, so he labeled the container to indicate 3 serving sizes of pork at 4 oz. However, on 6/21/22 at 12:45 PM, when Staff B (dietary aide) who worked at the kitchen/dining area measured the pureed food, he used a smaller scoop of 3 1/4 oz for the porkchop instead of 4 oz and also used a smaller scoop of 4 oz for the veggies instead of 5 oz. The pureed food were then served to Resident # 26 and Resident # 32. Staff B verified the size of the scoops used and the amount of food served to the 2 residents. Staff B verbalized that those were the correct scoops for each serving size, saying that 1 serving of meat equals 3 oz. On 6/21/22 at 12:50 PM the Dietary Director (DD) also identified the sizes of the scoops sitting on the countertops as 3 1/4 oz and 4 oz, which were used for the pureed meat and veggies served to the residents on pureed diet. The clinical records of the 2 residents on pureed diet showed the following: 1. Resident # 26's medical diagnoses include [CONDITION(S)] reflux disease, dementia, deficiency of other specified B group vitamins, [CONDITION(S)] obstruction, and [CONDITION(S)]. Resident # 26's diet orders indicated regular diet, and pureed texture. Resident # 26's care plan showed potential for nutritional problem related to history of dysphagia (difficulty or discomfort in swallowing) and needed mechanically altered diet. The care plan also indicated a goal for Resident # 26's weight to remain stable. 2. Resident # 32's medical diagnoses include Alzheimer's disease, irritable bowel syndrome, protein-calorie malnutrition, and type 2 diabetes mellitus. The orders for Resident # 32 identified a regular diet with pureed texture. Resident # 32's care plan showed a potential for nutritional problem. The care plan indicated that Resident # 32's nose runs a lot while eating which can be a sign of aspiration. The care plan also indicated an occasional weak cough while eating and drinking. The care plan documented ed Resident # 32's risk for malnutrition. The care plan directed staff to provide general/pureed diet, to offer and encourage snacks and juice between meals, to offer and select a balanced meal, and to provide feeding assistance. During an interview on 6/22/22 at 11:32 AM, the Administrator was talking on the phone with the DD who reportedly verified that Staff B was correct in using the smaller-sized scoops to measure the serving amount of food given to the residents. The Administrator acknowledged that there was a need to educate dietary staff members to ensure knowledge and consistency on measurements and correct serving size of food being provided to residents with mechanically altered diet. The facility's policy titled, Kitchen Weights and Measures with revision date of October 2018, provides, Cooks and staff plating food for meal service will follow the portion sizes per menu and will use appropriate utensil. The policy also indicates that staff will be trained in the appropriate measurement and type of serving utensil to use for each food. The policy further noted, The Culinary Director will ensure cooks prepare the amount of food for the number of servings required.

Based on clinical record review and staff interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for one of twelve residents reviewed in the sample (Resident #14). The facility reported a census of 40 residents. Findings include: The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS section A1500 revealed the state level II PASRR (pre-admission screening and record review) process identified Resident #14 did not experience a serious mental illness or a related condition. The care plan dated 12/30/14 revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan documented the PASRR directed the facility to provide rehabilitative services and other supports to address her rehabilitation, such as a physician to monitor the resident's mental health diagnosis, managed her medications, and monitored any new or problematic behaviors related to her diagnosis. The PASRR dated 3/10/14 revealed the resident's had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] and transmitted on 6/22/22 revealed staff had coded 1 under Section A1500 which indicated the state level II PASRR currently identified that Resident #14 had a serious mental illness or a related condition. The MDS section X revealed the MDS assessment dated [DATE] contained a modification due to an item coded in error and an attestation by the Assistant Director of Nursing (ADON) dated 6/22/22. During an interview on 6/22/22 at 11:23 AM, the ADON verified she had initially coded Resident #14's MDS incorrectly under Section A regarding the level II PASRR. She also verified she had modified (corrected) the MDS information on 6/22/22 after the surveyor requested Resident #14's MDS and care plan after she reviewed it more closely. The ADON reported the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON reported she obtained information to complete the MDS assessment from the resident and from the resident's chart.

Based on clinical record review and staff interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) assessment in 14 days for a resident placed on hospice care for one (#21) of sixteen residents reviewed. The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #21, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified the resident required extensive assistance of one staff for personal hygiene and dressing and extensive assistance of two staff for bed mobility, transfers, and toilet use. A Brief Interview for Mental Status (BIMS) score of 8 indicated moderate cognitive impairment for decision-making. Review of resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident's clinical record revealed a Significant Change MDS completed 5/17/21 and a Quarterly MDS in progress dated 8/17/21. During an interview on 7/22/21 at 11:32, the Assistant Director of Nursing confirmed a significant change MDS was not completed when the resident was placed on hospice as required.

Based on clinical record review and staff interview, the facility failed to complete a Level I Preadmission Screening and Resident Review (PASRR) within 30 days of admission and refer a resident to the appropriate state-designated authority for a Level II PASRR evaluation and determination who was identified with a newly evident mental disorder for one of one residents reviewed (Resident #35). The facility reported a census of 38 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #35 dated 6/24/21, with resident admitted on [DATE], included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of PASRR Level I Screen Outcome completed and dated 7/20/21, 33 days after admission, documented no mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 7/20/21 at 3:51 PM, the Admission Coordinator stated she completed the PASRR on 7/20/21 and acknowledged it was not completed within 30 days of admission as required.

Based on clinical record review, resident, and staff interview, the facility failed to update the comprehensive care plan for one (#21) of sixteen residents reviewed and failed to include a resident in the care plan conference meeting for one (#25) of sixteen residents reviewed. The facility reported a census of 38 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #21, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified the resident required extensive assistance of one staff for personal hygiene and dressing and extensive assistance of two staff for bed mobility, transfers, and toilet use. A Brief Interview for Mental Status (BIMS) score of 8 indicated moderate cognitive impairment for decision-making. Review of the Non Pressure Skin Record for Resident #21, dated 7/4/21 documented a 1.0 centimeter (cm) X 1.0 cm wound to the coccyx/gluteal cleft(tailbone/split between buttocks). The form described the wound as superficial, wound bed with dark pink granulation (surface of skin as part of healing process), dry with no drainage or odor, rolled wound edges and reoccurring. Review of Resident #21's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply skin prep around wound and triad paste (absorbs liquid present in the wound) to the wound. Cover with [MEDICATION(S)] dressing ( dressing that has a silicone adhesive border and waterproof backing) and change every other day and as needed (PRN) - 14 days and re-evaluate every 48 hours for altered skin integrity for 14 days. An observation on 7/21/21 at 1:45 PM revealed the coccyx/gluteal cleft wound had a superficial area that measured approximately 2 cm X 2 cm with red excoriation. During an interview on 7/21/21 at 2 PM , the Quality Assurance Nurse stated they coded the wound as a pressure ulcer due to the area having granulation tissue after a verbal consultation with a wound care specialist Resident #21's care plan with target date 8/17/21 lacked documentation that addressed the wound and treatment on coccyx/gluteal cleft. During an interview on 7/22/21 at 1:10 PM, the Executive Director stated she expected staff to address skin impairment and related treatments on the resident's care plan. 2. The MDS dated [DATE] documented Resident #25 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A BIMS score of 14 indicated the resident demonstrated no cognitive impairment problems. During an interview on 7/20/21 at 11:05 AM, Resident #25 stated he did not remember attending a care plan meeting. Review of the facility document titled Care Plan Conference Attendance Signature Page documented a care plan conference date of 7/9/21 for Resident #25 with resident not in attendance. During an interview on 7/21/21 at 4:21 PM, the Admission Coordinator stated they did not invite the resident to the care conference because they discussed different issues regarding the resident. During an interview on 7/26/21 at 12:19 PM, the Executive Director stated she expected staff to invite residents to the care plan meeting.

Based on observations, facility policy and staff interviews, the facility failed to maintain staff hair in a hair net and provide a clean and sanitary environment for residents during a dining observation. Findings included: 1. During a lunch dining observation 7/19/21, Staff A, dietary aide, served plates to residents while wearing a hat that allowed at least three inches of hair to hang outside the hat not contained by a hair net or the hat. During an interview on 7/21/22, the administrator reported staff should restrain their hair under a hair net or hat. Review of the facility policy for food preparation and service revealed staff are to wear hair restraints (hair net, hat, beard restraint) so hair does not contact food. 2. During an observation on 7/21/21 at 12:15 pm, Staff B, dietary aide, washed her hands and laid the paper towel she used to dry her hand on the countertop. As she served resident trays she moved the damp paper towel to a different location on the counter top. During the observation, the paper towel touched Resident #2 and at 12:25 pm, the paper towel touched the plate for Resident #14. A policy for food preparation and service directed staff to adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness during food preparation.

Based on observations, review of facility policies and staff interviews the facility failed to provide a sanitary environment for four of four residents observed that received water pitchers. The facility also failed to ensure an environment free of possible infections when staff failed to follow proper mask hygiene. The facility to provide a sanitary environment for one of three residents (#9) observed for perineal cares. The facility reported a census of 37 residents. Findings included: 1. A dining observation on 7/19/21 at 12:30 pm revealed a staff member touched her mask and then touched a cupboard in the kitchenette area. A 2nd staff member touched her mask and then assisted a resident with his wheelchair and pushed his wheelchair for him. A third staff member, Staff C, activity assistant, wore her mask below her nose throughout the dining process and served multiple residents during lunch. A personal protective equipment policy for face masks directed staff to cover their mouths and noses while wearing a facemask during treatment and services for residents, to not remove their mask while providing treatment or services for patient cares, and not to touch the mask while it is in use. Staff should handle masks by the string ties. In an interview on 7/27/21 at 1:12 pm, the infection preventionist reported she educated staff to hold each other accountable with regard to PPE use, especially to make sure everyone is wearing their masks correctly. 2. Review of the Minimum Data Set, dated dated dated [DATE] documented Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident required extensive assistance of two staff for bed mobility and toilet use and experienced incontinence of both bowel and bladder. The care plan identified the resident displayed self-care deficits and required assistance of one to two staff for toilet use and hygiene. The care plan revealed the resident to have impaired urinary and bowel elimination. An observation on 07/22/21 at 1:50 pm revealed Staff D, certified nurse's aide assistant (CNA) and an agency staff CNA assisted the resident after an episode of stool incontinence. The agency staff CNA provided incontinence care and Staff D applied ointment to the resident's bottom. Staff D failed to remove her gloves and then assisted the resident to position himself on his back, gave him his foam footrest for his feet, and rolled his blanket over him. Staff D then removed her gloves to wash her hands. Staff D failed to remove her gloves after placing the cream on the resident's bottom before touching his personal belongings. The Hand Hygiene policy directed staff to wash their hands in the following circumstances: a.) before and after direct contact with residents b.) before moving from a contaminated body site to a clean body site c.) after contact with the resident's intact skin d.) after contact with blood or bodily fluids e.) after contact with the objects in the immediate vicinity of the resident f.) after removing gloves Review of a personal protective equipment policy for gloves revealed staff are to wash their hands after removing their gloves. 3. During an observation on 7/19/21 at 2:52 PM, in room [ROOM NUMBER]-A, Staff C, Activities Assistant sat next to a resident painting their nails. Staff C's face mask sat just below her nose and only covered her mouth. 4. During an observation on 7/21/21 at 9:30 AM, Staff D, pushed a cart down the hallway that contained 12 mugs filled with ice and not covered with lids. Staff D took a mug into a resident's room, filled it with water, removed the lid from the mug already present in the resident's room, placed the lid on the mug filled with water, and placed a new straw in the mug. Staff D continued down the hallway and passed 3 more mugs from the cart to 3 different residents while repeating the same process. During an interview at the time of the observation, Staff D she knew the process the mugs required covers, but the facility staff told her to pass the mugs in that manner because they did not have enough lids for all the mugs. Review of the facility's Assistance with Meals policy revised on October 2018 directed staff to cover all food and fluids during delivery to residents' rooms. During an interview on 7/22/21 at 1:07 PM, the Executive Director stated she expected staff to cover water mugs whey they transport them through hallways and also expected staff to wear their masks over their noses and mouths.

Based on observation and staff interview, the facility failed to post nurse-staffing data in a prominent location visible to residents and visitors. The facility reported a census of 37 residents. Findings included: Observation on 7/20/21 at 11 a.m. and again on 7/27/19 at 1:00 p.m. revealed no visible daily staff posting found anywhere throughout the health center unit. An interview with the RN admissions coordinator on 7/21/21 at 1:47 p.m. revealed the facility recently painted the walls. They usually posted the nurse staffing sheets on the bulletin board, which also contained the ombudsman notification information by the RN admissions office.

Based on record review, staff interviews, review of policy and procedures and viewing of the facility surveillance camera, the facility failed to provide an intervention of an advanced directive for 1 resident that requested CPR (Cardiopulmonary resuscitation). The facility reported a census of 31 residents and 4 of the 31 residents requested CPR (Resident #1, #6, #7, #8). Findings include: Resident #1 had a quarterly Minimum Data Set (MDS) assessment with a reference date of [DATE]. The MDS identified the resident had a BIMS (Brief Interview for Mental Status) score of 15. A score of 15 indicated the resident had no cognitive problems. The MDS noted the resident required extensive assistance of 2 staff members for bed mobility and totally dependent with transfers. The resident's [DIAGNOSES REDACTED]. The Care Plan with an initiated date of [DATE] identified the resident requested to have a full code (CPR). The goal of the plan identified the resident's wishes would be respected. The interventions directed the staff that the resident did not want to be intubated but wanted CPR, medications and electro shock. Review of a form titled CPR/DNR Authorization Form dated [DATE], indicated in the event that the resident should stop breathing or his/her heart stops beating, he/she chose the following: perform CPR, which means cardiopulmonary resuscitation will be administered. Review of the form titled Nurse to Nurse Pre-Admission Report, dated [DATE], indicated Resident #1, was admitted with [DIAGNOSES REDACTED]. Review of the Progress Nurses Note dated [DATE] at 4:00 pm indicated the resident returned from the hospital via a wheelchair. The note indicated the resident to be alert to whereabouts, made direct eye contact when talking with staff and followed directions. The resident appeared tired so the nurse suggested he/she lie down for a while rather than staying up in the wheelchair and the resident agreed to this. The nurse documented the resident's skin pale warm and dry, pulses palpable of arms and feet, but weak in feet. The nurse noted the resident had chronic vascular discoloration throughout the lower extremities. Review of the Progress Nurses Notes dated [DATE] at 10:09 pm indicated evening medications administered and resident complaining of mild pain. Staff administered Tylenol ([MEDICATION NAME]). The resident received and completed a menu. At meal time, the resident was sleeping so the meal tray was placed in refrigerator to reheat later when awake. At 6:00 pm the north hall nurse, Staff B, closed Resident #1's door due to the resident sleeping and peers wanted to visit. At 7:15 this nurse (Staff A, Licensed Practical Nurse, LPN) entered the room and described the resident's condition as: not responding to verbal or tactile stimuli. Staff A called for Staff B to affirm the initial assessment. The note identified the resident's body as: cool to touch; skin jaundiced, palpable pulses, blood pressure and respirations absent. Staff B advised Staff A to call the physician immediately. The physician gave verbal order not to initiate CPR. The physician accepted the assessment of death and ordered to call the Funeral Home of the resident's choice. The nurse notified the family and medical examiner. On [DATE] at 2:56 pm Staff A was interviewed and stated she saw the resident when he/she arrived from the hospital and completed an assessment. Staff A stated the resident complained of pain and she administered the scheduled and the PRN Tylenol to the resident around 4:00 pm. Staff A stated she went back into the resident's room around 4:,[DATE]:00 pm and applied [MEDICATION NAME] Cream to the resident's lower legs for complaints of pain. Staff A stated she gave the resident a supper menu and he/she completed the menu form. Staff A stated she did not see the resident again until 7:15 pm. At that time, Staff A described the following: The resident skin noted to be ashen, jaundice, mouth open with dentures falling out, stomach bloated, extremities cold, body cool to touch, knees down appeared purple/red. Staff A described no rigor mortis had set in, and the resident's extremities to be flexible. Staff A stated she knew the resident to be a full code but per her assessment at 7:15 pm, she decided not to perform CPR, as she stated nothing she could have done to bring the resident back. Staff A stated she stands by this choice, resident was her friend and nothing she could do to bring him back. Staff A stated her assessment of the resident took her 5 to 10 minutes to complete. Staff A stated she left the resident's room to get Staff B, RN, to assess the resident. Staff A stated Staff B came to the resident's room and assessed the resident and told her to call the resident's physician immediately. Staff A stated she called the physician and answered right away. Staff A stated she informed the physician of her assessment and the physician instructed her not to start CPR. On [DATE] at 3:51 pm and [DATE] at 4:26 pm Staff B was interviewed and stated she saw the resident around 5:00 pm at supper time in bed and complained of being tired. Staff B stated she next saw the resident around 6:,[DATE]:15 pm and the resident refused a room tray. Staff B stated she went to the resident's bedside and he/she requested his door shut. Staff B stated she instructed dietary to put the tray in the refrigerator for later. Staff B stated the next time she saw the resident was 7:15 pm after Staff A came to get her. Staff B stated she immediately went to the resident's room and described the resident as: absence of breathing, pulse, hand and feet cold. The resident's arms laid on abdomen and felt warm. The resident's skin appeared jaundice with a blue color around the mouth; abdomen distended and felt fluid present. The resident's mouth open with dentures falling out and slumped over the left side. Staff B stated due to her assessment and her clinical experience, the resident was too far gone for CPR. Staff B stated her assessment took her 1 to 2 minutes to complete. Staff B stated she had never had a resident code ([MEDICAL CONDITION]) under her care. Staff B reported she instructed Staff A to call the resident's physician and give assessment of the resident's condition. Staff B stated the physician immediately answered the phone and after Staff A gave her assessment of the resident, the physician told them to not initiate CPR. Further interview and facility surveillance review revealed Staff B entered Resident 1's room at 5:29:20 and in room for 5 seconds. When Staff B was asked about this she stated she went into the resident's room to say hello and the resident was still alive, covers pulled up over her/him up to abdomen area, lying on back with arms over abdomen, awake, talking to her. Review of the facility surveillance video dated [DATE] revealed the following: - At 5:16 pm the hair dresser entered Resident #1's room and exited at 5:17 pm. -At 5: 29:20 pm Staff B entered resident's room and exited 5 seconds later. -At 5:46 pm Resident #9 entered Resident #1's room and exited 30 seconds later. -At 5:49:36 pm a resident ambulated towards the resident's room. Staff B closed the door without entering and the resident went the other direction. -At 7:08:10 pm Staff C, Certified Nurse Aide (CNA) entered the resident's room and exited 36 seconds later. -At 7:14:03 pm Staff A, LPN, entered the resident's room twice -At 7:15:43 pm Staff A and Staff B entered the resident's room and left at 7:16:08 p.m. -At 7:37:48 p.m., Staff G entered the room and exited at 7:40 p.m. -At 7:43:40, Staff G returned to the resident's room. -At 7:47:04, Staff A and what appeared to be family, entered the room. NOTE: The video did not show a supper tray delivered to the resident's room on [DATE]. An interview was conducted on [DATE] at 11:20 am with Staff B. Staff B was asked about the facility surveillance on [DATE] at 5:49:36. The surveillance identified she did not enter Resident #1's room but blocked a visiting resident from entering the room, and closed the room door. Staff B replied I'm sorry; well I did go all the way into the resident's room, to the resident's bedside. An interview was conducted on [DATE] at 11:28 am with Staff D, hair dresser. Staff D stated she stopped to see Resident #1 after she/he returned to the facility. Staff D stated when she entered the resident's room; she/he slept soundly with eyes closed and covers on. Staff D stated she did not go all the way into the room to the resident's bed side. Staff D stated she did not speak to the resident and the resident did not say anything to her. Staff D stated she then left the room. An interview was conducted on [DATE] at 2:45 pm with Staff C, CNA. And stated after reviewing the video surveillance, she did go into Resident #1's room at 7:08:10 pm. Staff C stated she was working on the other side of the facility and looked for gowns when Staff B told her to check in the resident's room. Staff C stated she went to the resident's room and found the resident lying in bed, and had one eye open. Staff C stated she did not say anything to the resident nor did the resident say anything to her. Staff C stated she did not go up to the resident's bedside and did not find any gowns. During a second interview on [DATE] at 2:35 p.m. with Staff C, she stated she did not recall if Resident #1 laid on his/her back in bed or on side when she entered the room looking for gowns. Staff C stated the resident had 1 eye open and mouth open but don't recall if dentures came out of mouth. Staff C stated the resident probably laid on back. Staff C stated Staff B had sent her to the room to look for gowns as she thought maybe gowns were in that room. On [DATE] at 1:30 p.m. Staff G, CNA, was interviewed and stated she worked the day Resident #1 returned from the hospital. The staff assisted the resident in transferring to the bed and positioned the resident on back with pillows on side. The resident had oxygen per a concentrator. At 5:,[DATE]:00 p.m. Resident #1 asked her to rub ointment on legs so she informed Staff A. Staff G stated around 7:15 p.m. she saw Staff A coming out of the resident's room and she appeared worried, and she could tell something was wrong. Staff G stated she asked Staff A if the resident was okay and Staff A did not reply. Staff G stated she could see the resident from the hall and the resident laid on his/her back with blanket pulled up to abdomen. Staff G stated she saw Staff A and Staff B at the nurse's station looking in the resident's chart. Staff G stated she was asked later to give Resident #1 post mortem care. The resident was cold but not too cold, a little warm, not stiff, his mouth opened with dentures protruding out and skin pale. Staff G stated she did not see CPR performed. On [DATE] and [DATE] the DON (Director Of Nursing) was interviewed and stated the staff follow the AHA (American Heart Association) for CPR. The DON stated she stood behind Staff A and Staff B decision to not perform CPR on Resident #1 as the resident had signs of lividity and rigor mortis and dependent lividity. The DON stated the time discrepancy of Staff A's assessment time of Resident #1 of ,[DATE] minute assessment is not correct per video surveillance, and Staff A is not very good at estimating time. The DON stated the AHA guidelines indicated to do CPR if the body is warm with no pulse or respiration. The DON stated staff should not do a blood pressure check before initiating CPR. The DON stated she did educate the staff of the facility CPR policy starting on [DATE] to ensure staff are all on the same page, just in case something would come up. On [DATE] at 7:35 am the Assistant Director of Nursing (ADON) was interviewed and stated she would perform CPR on a full code resident if the resident showed signs of life. If not would not do CPR per AHA. The ADON stated Resident #1 was a full code. Review of the letter dated [DATE] and signed by the physician, indicated she was called at 7:16 p.m. on [DATE] by the facility nurse. The nurse shared with her the resident was gone and found to have no pulse and not breathing, cold to touch and very pale. The letter indicated the nurse informed the physician she had seen the resident an hour and 15 minutes before finding the resident pulseless and the nurse felt the resident had been dead a while. The physician ordered CPR not to be given based on the conditions and the description already cool, suggesting pulseless for perhaps an hour. Review of the facility's Resuscitation Policy (not dated) included: -Cardiopulmonary Resuscitation (CPR); refers to a range of procedures used to attempt to restore heartbeat and breathing following a cardiopulmonary arrest. Basic CPR refers to a means of opening and maintaining an airway, providing ventilation through rescue breathing and providing artificial circulation through the use of external cardiac compression. - Upon determination that a resident is in cardiopulmonary or respiratory arrest (note time), CPR will be immediately initiated by nursing staff and 911 called for advance cardiac life support unless one of the exceptions applies: a) When the resident or surrogate has indicated that resuscitation is not desired and the attending physician has issued a written do not resuscitate (DNR) order that is maintained in the facility's clinical record; or b) When there is the presence of obviously clinical signs of irreversible death (defined as rigor mortis or dependent lividity); or c) There are no physiologic benefit can be expected because the vital functions have deteriorated despite maximal therapy for such conditions such as progressive septic shock or cardiogenic shock. d) When attempts to perform CPR would place the rescuer at risk of personal injury. - If CPR is required, it will be immediately initiated by any staff member currently certified to perform CPR, pursuant to current American Heart Association guidelines. 2. The quarterly MDS assessment for Resident #6, dated [DATE], revealed the resident had a BIMS score of 8. A score of 8 identified the resident moderately cognitive impairment. The MDS noted the resident to be independent for bed mobility, transfers, ambulation, and required assist of one staff member for toilet use, and personal hygiene. The resident's [DIAGNOSES REDACTED]. Review of Resident #6's face sheet identified the resident requested CPR code status. 3. The quarterly MDS assessment for Resident #7, dated [DATE], revealed the resident had a BIMS score of 12. A score of 12 identified the resident had moderate cognitive impairment. The resident's [DIAGNOSES REDACTED]. Review of Resident #7's face sheet indicated the resident requested CPR code status. 4. The quarterly MDS assessment for Resident #8, dated [DATE], revealed the resident had a BIMS score of 8. A score of 8 indicated the resident had a moderate cognitive impairment. The resident's [DIAGNOSES REDACTED]. Review of Resident #8's face sheet indicated the resident requested CPR code status. Note: The Director of Nursing provided inservices to the staff about the resuscitation policy/procedures on [DATE]. This was determined past noncompliance and the facility had corrected the immediate jeopardy on [DATE], following the inservices provided to the staff.

Based on record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self and elements in the environment (Resident #1). The sample consisted of 9 residents and the facility reported a census of 31 residents. Resident #1 went on an outing to a restaurant with 3 other residents, the activity director and van driver. The resident attempted to enter through a door and the threshold was raised and not accessible. The resident rammed the threshold and fell out of the chair. The resident did not receive supervision or assistance getting through the door. Findings include: 1. Resident #1 had a quarterly MDS (Minimum Data Set) assessment with a reference date of 1/7/17. The MDS identified the resident had a BIMS (Brief Interview for Mental Status) score of 15. A score of 15 indicated the resident had no cognitive impairments. The MDS noted the resident required extensive assistance of two staff members for bed mobility, dressing and toilet use, total dependence on assistance of two staff members for transfers, set up assist for eating and for locomotion off the unit. The MDS indicated the resident had functional impairment of both lower extremities that placed resident at risk for injury. The resident's [DIAGNOSES REDACTED]. The resident's Care Plan identified a focus area with an initiated date of 1/15/16. The focus area identified the resident at risk for falls related to debility and paralysis. The care plan identified a focus area on 8/27/14 and revised on 1/18/16 that the resident used a power wheelchair for independent mobility in and out of the facility. The interventions included and directed staff that the resident is independent with the use of the power chair and can go independently when the weather is nice. The staff are to educate the resident of safety Review of a form titled Witness Fall dated 3/30/17 at 11:58 a.m. indicated staff received a phone call from the Activities Director, Staff E. Staff E reported Resident #1 out on outing to a local restaurant in motorized wheelchair. Per report, resident slid out of wheelchair onto the floor inside of the restaurant. Resident reported no pain or problems at the time and requested to be allowed to stay at the restaurant to eat meal before returning to the facility. Resident denied injury to the Activity Director who was present and the resident asked that they (non-facility personnel) get him/her up from the floor and put him/her back into the motorized wheelchair. The resident assisted by non-facility personnel back into motorized wheelchair and maintained his/her wish to stay at the restaurant to eat although Activities Director strongly encouraged return to facility for further assessment. Resident returned to facility around 1:00 pm in his/her wheelchair and voiced complaints of right hip/knee pain and rubbing the right upper leg. Resident recounted events, stating him/her having trouble getting wheelchair through the threshold of the restaurant. Resident reported having to move his/her wheelchair backward and forward to get a run at the doorway and the wheelchairs back wheels went over the threshold and the wheelchair hit the building causing resident to fall to floor. Resident reports legs being bent underneath him/her and at the time having no pain. Resident asked people to help him/her back into wheelchair so he/she could proceed with eating at the restaurant. Resident stated about 15 minutes into the meal, started to have pain in the upper right leg but wanted to stay at meal before returning to facility to be assessed. The Progress Nurses Notes dated 3/30/17 at 1:06 pm indicated Resident #1 reported he/she arrived at the restaurant and was moving motorized wheelchair through doorway when wheel got hung up on lip of doorway. Resident reported he/she then backed wheelchair up and floored it and got through the doorway and causing him/her to fall out of wheelchair landing forward onto floor with legs folded underneath him/her. Resident reported he/she insisted on people to get him/her off the floor and back into wheelchair because he/she wanted to eat at the restaurant. The resident reported developing pain about 20 minutes later to the knee and thigh area. Upon return to facility resident transferred from wheelchair to bed via Hoyer lift (mechanical lift) per his/her normal with right leg supported, and ice applied to right leg. Resident had scheduled Tylenol while eating. The nurse notified the physician and received order to have x-ray's done. The x-rays completed at 2:40 pm and the physician ordered for resident to be transferred to the emergency room for further evaluation and treatment. Review of the Operative/Procedure Report dated 4/3/17 indicated Resident #1 was in a motorized wheelchair 4 days ago and fell out of wheelchair. Resident brought to emergency room due to pain and deformity of leg. Resident diagnosed with [REDACTED]. The x-rays identified chronic severe osteoarthritic changes of the right hip and femoral head and neck (hip). The right hip had comminuted (pieces) fracture of the femoral shaft (femur-thigh bone). The surgery consisted of repair with rod and nail to the right femur. Review of Staff F's statement, volunteer bus driver for the facility, reported when entering the restaurant, the entrance had about a 1 inch threshold at the bottom of doorway. Resident first tried to go in forward in motorized wheelchair and could not get in. Then resident tried to go in backwards and still not able to get into building. Staff F then told the resident the threshold keeping him/her from getting in and resident said let me try going through forward again. The resident did get in the first door after several attempts. The resident's wheelchair got caught on the second door and stopped the wheelchair causing him/her to slide out of wheelchair on to floor and legs. After this, the resident said we need to get him/up off the floor to wheelchair because of leg hurting from being bent. Staff F reported he and the owner of the restaurant picked resident up of the floor by lifting him/her under the arms and placing the resident onto wheelchair. Staff F reported after getting the resident back into wheelchair he asked resident if he needs to transport him/her back to facility and resident said no, and Staff F asked resident if his/her leg still hurting and resident replied no. Staff F reported assisting the other residents from the bus into the restaurant and then sat across the table from Resident #1. Staff F stated the resident then reported his/her knee hurts and Staff F asked resident if it hurt enough for him to transport resident back to facility and resident said no. Staff F than asked resident if his/her motorized wheelchair had a seatbelt and resident said yes but he/she does not use it. Staff F reported the resident continued to eat dinner okay and took home leftovers. Staff F stated no problems were encountered for the resident leaving the restaurant and retuning to the facility. Further review of the Incident Fall Report dated 3/30/17, indicated facility reviewed events with the emergency department and resident. Feel that when resident does go out on outings he/she should place motorized wheelchair into manual mode and have staff assist him/her over difficult passages/thresholds to avoid this from happening again. The report indicated the therapy are to reassess resident's safety with operating motorized wheelchair. The facility Incident Report on Witnessed Fall dated 3/30/2017, indicated a statement from the restaurant server. The restaurant server reported she witnessed the fall of Resident #1 and reported the resident rammed his/her wheelchair into the doorway and slid out of the wheelchair onto the floor. The server stated the resident wanted to get up off the floor and she went to go get assist from another restaurant worker. The server stated Staff F and another restaurant worker assisted the resident off the floor and back into wheelchair and the resident went to a table in the restaurant. Review of the Fall Scene Investigation Report dated 3/30/17 at 11:15 to 11:30 am, indicated staff who witnessed the resident's fall from the facility to be Staff E, Activity Director and Staff F, bus driver, and from the restaurant personnel to be the female server. Factors observed during the time of fall indicated environmental factors of motorized wheelchair forced over lip of doorway on floor causing resident to be tipped out of wheelchair to floor. The resident got his/her wheelchair caught on the lip of doorway and resident backed up and took a run for it and dumped self out of wheelchair. The resident reported got caught on lip of doorway in wheelchair, I backed up and floored it and hit the lip of doorway and dumped myself onto right side. The cause was a mechanical fall due to running into static object. Resident lost control of wheelchair. Feel this is isolated event. Resident not in a familiar place and forced his/her wheelchair through doorway which made the wheelchair out of control for resident, hitting wall/doorframe causing fall from wheelchair. Interventions included for the resident to not speed through lipped doorway, therapy to reassess resident's safety with driving motorized wheelchair, resident not using best judgement or technique with use of wheelchair. Spoke with Activities Director about turning off wheelchair into manual mode for assisting resident through difficult passageways. An interview on 4/13/17 at 9:04 am Staff E, Activity Director, stated she always calls first to a restaurant to ensure they are handicap accessible and she did this prior to the outing on 3/30/17. The restaurant said they were accessible. Staff E stated this is the first she has taken residents to this restaurant for an outing. Staff E stated Resident #1 was the first off the bus and she remained on the bus with the other residents. Staff E stated the bus driver, Staff F, went ahead of the resident and opened the front door for him/her. Staff E stated the doorway was narrow and there was immediate decline slope once inside the doorway to the second doorway that was very close. Staff E stated they left the facility around 10:45 am to the restaurant that is only a couple miles away from the facility. Staff E stated there was a total of 4 residents attending the lunch outing, 1 motorized wheelchair, one manual wheelchair, and 2 resident independent with ambulation. Staff E stated she could see the resident attempting to go through doorway several times and said we are going to have to go back as resident not able to get through doorway. Staff E stated the resident insisted and she got out of the bus and went to doorway as Staff F held door open. Staff E stated she did not offer help to the resident and neither did Staff F, nor did the resident ask for help. Staff E indicated the resident backed up wheelchair to get a running start to get through doorway and when doing this the resident hit the threshold causing him/her to bounce up in wheelchair and losing control of his/her motorized wheelchair, and hitting the second doorway door and causing the resident to fall to floor. Staff E stated Staff F kept telling the resident to slow down before he/she fell out of wheelchair, but the resident did not listen. Staff E stated the resident landed on his bottom with legs bent towards his/her right side and wheelchair behind him/her. Staff E stated the resident requested to lifted back up into his/her wheelchair and denied any injury. Staff E stated Staff F and a male restaurant worker lifted the resident up, from the floor, from under his/her arms into wheelchair. Staff E stated she told the resident we needed to go back to the facility so he/she can be assessed but the resident refused. Staff E stated she called the facility and reported this incident and they told her it was ok to stay and complete the lunch outing. Staff E stated after the resident finished his/her meal, he/she complained of knee pain. Staff E stated the resident always went out on outings and would operate his/her motorized wheelchair in high mode, very fast, and Staff F would always tell the resident to slow down. Staff E stated she assumed the facility knew the resident operated the wheelchair in fast mode as she saw the resident also doing it in the facility. An interview was conducted on 4/13/17 at 10:55 am with Staff F, volunteer bus driver. Staff F stated Resident #1 went out on outings often and when he enters the van he goes very fast causing him/her to bump into bracket on the lift. Staff F states he tells the resident to slow down and sometimes he/she will and other times not. Staff F stated he did not know the resident had a seat belt in wheelchair until after this incident. Staff F stated when they arrived at the restaurant for lunch outing, Resident #1 was first off the bus and he held the first door open for the resident and the second door was propped open. Staff F stated before the resident attempted to enter the doorway he asked the restaurant for a ramp to get into first doorway and they said they don't have one. Staff F stated he told the resident to try going into doorway forward and a wheel of his/her wheelchair got stuck on the threshold. Staff F stated he told the resident to try going in backward and again he got stuck on the threshold. Staff F stated he told the resident then that he/she was not going to get into restaurant and resident said let me try one more time. Staff F stated the resident backed up about a foot and with wheelchair in high and ran up over the threshold causing the resident to pop up from wheelchair and losing control of wheelchair, hitting the second door frame and causing resident to come to an immediate stop and falling forward to floor. Staff F stated the resident did not ask for help to get into doorway and he did not offer due to the wheelchair being heavy and he did not want to hurt his back and known the resident does not like wheelchair touched. Staff F stated he did not know the wheelchair could be put into manual and push assist be provided. Staff F stated the resident requested to be picked up off the floor and he and a restaurant worker picked the resident up from under his/her arms back into wheelchair. Staff F stated the resident told him he/she was fine and wanted to eat at the restaurant. Staff F stated the restaurant, after being picked up of the floor and back into wheelchair, proceeded to the table in the restaurant and did not want to leave to return to facility until after the meal. Interview with Resident #9 on 4/13/17 at 3:45 pm revealed the resident had been to the restaurant before and the doorway is bad. The doorway is dangerous and had a very hard time getting his/her motorized wheelchair into the restaurant. Photographs of the door threshold appeared raised and not acceptable for a person not supervised and without assistance in a wheelchair.

Based on record review, resident and staff interviews, the facility failed to provide adequate supervision to ensure against hazards when assisting a resident with transfers and ambulation (walking) for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 31 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 9/18/16, Resident #1 had [DIAGNOSES REDACTED]. The MDS revealed the resident experienced no problems with cognitive impairment and required extensive assist of two staff with transfers and ambulation. The Care Plan dated 12/11/15 identified the resident displayed difficulty with mobility and directed two staff to assist with transfers and ambulation using a gait belt, and to follow behind the resident with a wheelchair when staff and he/she walked together. Progress notes dated 10/8/16 at 10:06 a.m. documented facility staff summoned Staff E, licensed practical nurse (LPN) to the resident's room. The resident lay on the floor in an upright position. Staff I, a certified medical assistant (CMA) reported she had been between the resident and a chair and when she stopped to remove items from the chair and throw them on the bed, the resident fell . Resident #1 complained of right hip pain, which he/she rated as a 6 out of 10 on a 1 - 10 pain scale. The resident's right leg was externally rotated and appeared to be shorter than the left leg. The progress notes revealed Resident #1 had experienced a recent fracture of the right hip. The resident's physician ordered staff to send the resident to a local hospital for evaluation and treatment. Progress notes dated 10/8/16 at 2:09 p.m. revealed the resident returned from the hospital. The resident's family member reported the resident sustained [REDACTED]. In the Progress notes dated 10/9/16, the nurse documented Resident #1 rested in bed and was alert and oriented to person, place, and time. The resident reported he/she broke his/her hip again and he/she would baby the hip for now. A witnessed fall report dated 10/8/16 at 3:08 p.m. revealed Staff I reported the resident had finished breakfast and wanted to return to his/her room, so the resident proceeded to stand up and ambulate. Staff I reported she assisted the resident back to his/her room. Staff I also reported she had called for assistance, but no one came to assist. Upon entering the resident's room, Staff I stated she cleared the recliner of items while maintaining support of the resident by holding onto the gait belt. The resident then lost his/her balance, Staff I lost her grip on the gait belt, and the resident fell to the floor. The fall report revealed Staff E reviewed the resident's care plan with Staff I and noted the resident required two staff for transfers. Staff I acknowledged the resident's care plan indicated two staff are to assist with transfers and ambulation. Staff I reported the resident had been anxious and wanted to leave the table, so she walked the resident back to his/her room without another staff member. She held the gait belt and leaned away from the resident. The resident fell on his/her right hip. During an interview dated 11/1/16 at 10:00 a.m. the resident reported he/she didn't remember the specific date or time when the fall occurred, but remembered the fall because only one staff (Staff I) helped him/her back to his/her room from the dining room. The resident stated Staff I had been moving stuff from the recliner and that is when he/she fell . The resident reported he/she didn't know how he/she fell , but remembered landing on the floor and hurting his/her leg. During a phone interview dated 11/1/16 at 2:39 p.m. Staff I reported she and another staff assisted the resident to a standing position, but she couldn't find the resident's wheelchair. The other staff went to look for the wheelchair, but never returned. Staff I reported she couldn't remember who the other staff person was that left to find the resident's wheelchair. The resident was impatient and wanted to go back to his/her room. Staff I reported once in the room, the resident wanted to sit down in a chair. The chair contained several articles of clothing and a blanket. She stated she kept one hand on the gait belt, used the other hand to remove the items, and that was when the resident fell and broke his/her right hip. Staff I reported she had called for assistance but no one answered because the two way radio did not work and staff did not hear her call for help. During an interview dated 11/1/16 at 3:00 p.m., the Interim Director of Nursing (IDON)reported at the time of the resident's fall the resident had required two staff to assist with transfers and ambulation - no exceptions. The resident could bear weight at that time only with two staff, one on each side of the resident, and they also needed to use gait belt and a walker and wheelchair behind the resident when he/she ambulated. The IDON stated she expected staff to follow the resident's care plan, and Staff I should not have transferred and ambulated with the resident by herself; she should have waited for additional staff to assist.

Based on clinical record review and staff interview, the facility failed document the effectiveness of fall interventions and develop new interventions after a fall for 1 of 4 current residents reviewed (Resident #5). Additionally, based on observation, facility product review and staff interview, the facility failed to ensure potential hazards were not accessible to confused and wandering residents. The facility reported a census of 30 residents. Findings include: 1. The MDS (Minimum Data Set) assessment dated [DATE] documented Resident #5 had a BIMS (brief interview for mental status) score of 9, indicating moderate memory and cognitive impairment. Resident #5 required the assistance of one staff member with bed mobility, transfers, walking, dressing and toilet use. Resident #5 exhibited unsteady balance with all activities, but could stabilize without assistance. The assessment documented Resident #5 fell twice without injury since the previous assessment. The MDS identified Resident #5 used a wheelchair and walker for mobility. According to the MDS Resident #5 ' s [DIAGNOSES REDACTED]. The care plan dated 11/7/14 listed the following fall interventions: - Initiated 7/30/14 - Bed in low position with call light within reach. - Initiated 7/30/14 - Care conference to be scheduled with family as needed. - Initiated 7/30/14 - Physical/Occupation therapy if indicated. - Initiated 7/30/14 - Staff to encourage to use call light and ask for staff assistance with transfers/activities of daily living - Initiated 10/8/14 - Urinalysis and laboratory test obtained and physical therapy to screen. - Initiated 10/8/14 - Medication list faxed to the nurse practitioner for review as requested. - Initiated 7/30/14 - Physical therapy involved in plan of care The progress note dated 10/30/14 at 10:52 a.m. documented Resident #5 fell and received a small abrasion to the left knee. The incident report dated 10/30/14 identified Resident #5 stated she/he got up to put on pajamas. The incident report dated 10/30/14 lacked evaluation of current interventions to determine if the interventions continued to be effective. The progress note dated 12/1/14 at 11:00 a.m. documented staff witnessed Resident #5 lowering self to the floor and then laying on the floor. Resident #5 stated she/he missed the chair and sat down. The incident report dated 12/1/14 lacked evaluation of current interventions to determine if effective. The progress note dated 1/3/15 at 12:49 p.m. documented Resident #5 fell at 9:30 a.m. Blood noted on the floor in the shower area. Staff performed an assessment and Resident #5 tolerated transfer from the floor without complaints of pain. Staff noted a skin tear to the right elbow a hematoma and small skin tear to the right hand and a bruise to the left lower lip. The progress note documented Resident #5 had no complaints of pain at the time of the fall until 12:30 p.m. when Resident #5 complained of right rib pain. Staff contacted the on-call doctor and received an order for [REDACTED]. The incident report dated 1/3/15 at 12:06 p.m. for Resident #5 revealed an observation of Resident #5 found on the floor at 9:30 a.m. in his/her bathroom. A skin tear to the right elbow area with bruising noted around the skin tear and a large hematoma noted to the back of Resident #5 ' s right hand. Family and physician notified. The X-ray report dated 1/3/15 revealed Resident #5 had acute rib fractures of ribs 4, 5, 6, 7, 8 and 9. The X-ray documented Resident #5 had no apparent, pleural effusion or pneumothorax. The report documented diffuse osteopenia for Resident #5. The Physician visit note dated 1/6/15 documented Resident #5 ' s rib fractures and directed staff members to continue with pain management. The note directed use of a Lidoderm patch to the right sided thoracic region for improved pain management and incentive spirometer 10 times each hour while awake. The care plan dated 1/4/15 documented Resident #5 sustained rib fractures from a fall and listed the following interventions: - Initiated1/4/15 - Staff to consult nurse practitioner and/or medical doctor as needed - Initiated1/4/15 - Extensive staff assists with transfers/activities of daily living - Initiated 1/4/15 - Incentive spirometer as ordered - Initiated 1/4/15 - Rest/reposition as tolerated for comfort - Initiated1/4/15 - Tramadol (pain medication) for pain as ordered by the medical doctor - Initiated1/7/15 - Request for speech therapy evaluation if indicated - Initiated1/6/15 - Nurse practitioner expects resident will return to prior level of function. Determined not a major injury The Progress notes dated 1/13/15 at 12:38 p.m. revealed staff walked by Resident #5 ' s room and located him/her on the floor kneeling in front of the dresser. Resident #5 waved to staff for help following an unwitnessed fall. Resident #5 fidgety and refused to wait for staff to transfer with a gait belt and assistance. Resident #5 declined pain at the time. (However previous x-ray report revealed 6 fractured ribs.) The progress note failed to contain documentation of lung sounds with the review of Resident #5 following the unwitnessed fall. The incident report dated 1/13/15 lacked evaluation of current interventions to determine if these continued to be effective. The most current care plan, dated 5/27/15, included the following interventions: - Initiated 7/30/14 - Bed in low position with call light within reach; - Initiated 7/30/14 - Care conference to be scheduled with family as needed; - Initiated 7/30/14 - Physical/Occupation therapy if indicated: resolved 1/10/15; - Initiated 7/30/14 - Staff to encourage to use call light and ask for staff assistance with transfers/Activities of daily living; - Initiated10/8/14 - Medication list faxed to the nurse practitioner for review as requested, resolved 1/10/15; - Initiated10/8/14 - Orthotic consult in progress, resolved 10/8/14; - Initiated12/30/14 - Assess environment for safety, hazards, lighting, pathways, absence of aids; - Initiated12/30/14 - Physical therapy if indicated, resolved 12/30/14; - Initiated12/30/14 - Urinalysis and lab work obtained, physical therapy will screen; - Initiated1/4/15 - X-ray as ordered, resolved 1/31/15; - Initiated1/7/15 - Rearranged room, resolved 1/13/15; - Initiated1/10/15 - Medication review faxed to pharmacy if indicated, resolved 1/10/15; - Initiated1/13/15 - Resident moved to a new room today closer to the care base, resolved 3/24/15; - Initiated 2/6/15 Occupational therapy to evaluate and treat for wheelchair mobility/safety. Anti-lock brakes to be ordered and placed, resolved 4/28/15; - Initiated1/31/15 Pharmacy fall review faxed to pharmacy, resolved 3/24/15; The MDS assessment dated [DATE] documented Resident #5 had a BIMS of 15, indicating intact memory and recall. Resident #5 required extensive assistance of one staff member with bed mobility, transfers, walking and toilet use. The MDS documented Resident #5 experienced two falls since the previous assessment that resulted in injuries. The progress note dated 1/31/15 at 9:45 a.m. documented staff observed Resident #5 on the floor with the wheelchair laying on the right side. Resident #5 sat backwards to the bed and voiced no pain. Resident #5 reported no apparent injury. The incident report dated 1/31/15 lacked evaluation of current interventions to determine if these continued to be effective. During an interview on 5/28/15 at 9:13 a.m. the Director of Nursing stated staff should document the effectiveness of the interventions in place and stated an intervention should be implemented after a fall to include implementation of alarms and effectiveness of the alarms or interventions used. During an interview on 5/28/15 at 11:20 a.m. Staff E, administrative assistant, stated the certified nurse aides have hall sheets directing the resident's care but these are destroyed after the shift ended. 2. Observation on 5/26/15 at 10:25 a.m. revealed the Maintenance Supervisor's utility cart left parked, unsecured and unattended in the hallway between the beauty shop and the employee lounge. Observation revealed the following items located on the utility cart and accessible to confused and independently mobile residents: a. The top counter contained piles of screws, drill bits and tacks. b. One can of W-D 40. The Material Data Safety Sheet (MSDS) for the WD-40 identified it can be extremely flammable and may be fatal if swallowed and enters the airways. c. A 21.5 fluid ounce, 1/4 full, bottle of Oxy-Clean. The MSDS for the product documented it can be harmful if swallowed and can irritate the skin and eyes. d. A full 8 ounce container of Goof Off solvent. The MSDS for the product documented it causes serious eye and skin irritation and may cause damage to the lungs or central nervous system. e. A over 1/2 full bottle of Tuff Stuff commercial cleanser used for stainless steel equipment. The product ' s MSDS documented it causes serious eye and skin irritation, it may cause respiratory irritation and may cause damage to the central nervous system. The product could also be harmful if swallowed. f. Seven boxes of drywall nails and screws and 1 box of nails and screws together. g. The unlocked enclosed cabinet side of the cart contained a hammer, 2 putty knives, a electric saw, a pair of channel locks wrenches, 2 vice grips, 2 pliers , a snatch all and 5 screwdrivers. The Maintenance Supervisor came out of the employee lounge after the observation and stated he had been fixing a lock. The Maintenance Supervisor stated, you name it, it ' s like a hardware store. The facility provided a resident list that documented two residents resided in the facility who experienced cognitive impairment and who had independent mobility.