Every finding on record at Lake Taylor Hosp

Number of residents sampled: 47Number of residents cited: 2 Based on record review, interview, and policy review, the facility failed to ensure residents' safety for two (Resident (R) 11 and R195) of two residents reviewed for accident hazards in the sample of 47 residents. Specifically, R11 fell to the floor during an assisted transfer by nursing staff from the commode to the bed, which resulted in a femur fracture and R195 rolled out of bed when nursing staff were providing incontinence care and fell to the floor which resulted in a femur fracture. This had the potential to affect residents who required staff assistance during care. Findings include: 1.Review of R11's Face Sheet in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, left knee prosthetic joint, and chronic kidney disease. Review of R11's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/28/25 in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was moderate cognitively impaired. Review of R11's Care Plan dated 08/26/25 and located in the EMR under the Care Plan tab revealed R11 was at risk for falls due to requiring assistance with transfers. Interventions in place were to monitor for steadiness and assistance as needed. Review of R11's Outpatient Consultation Record provided by the facility dated 05/06/25 revealed that patient was okay to increase weight bearing from 50% to 100% as tolerated. When ambulating the resident should wear knee immobilizer to prevent knee buckling due to weakness in knees. Review of R11's Physician Progress Note dated 05/13/25 and located in the EMR under Notes tab revealed that resident stated she felt weaker in therapy yesterday with possible buckling of the legs. She is 50% to 100% weightbearing as tolerated to left lower extremity with knee immobilizer per orthopedics. May remove knee immobilizer when in bed and not ambulating. Review of R11's Nurse's Note dated 05/13/25 and located in the EMR under the ''Notes'' tab written by Licensed Practical Nurse (LPN) 3 revealed that Certified Nurse Aide (CNA)1 reported that the resident had a fall when transferring. Resident stated that her leg felt like it would give out. Resident not wearing knee immobilizer. Review of R11's Radiology Note dated 05/14/25 and located in the EMR under the ''Notes'' tab revealed suspicious for mid femur fracture. During an interview on 09/25/25 at 9:56 AM, LPN3, who was a former charge nurse, revealed that R11 was considered a fall risk. On 05/13/25 she was notified by CNA1 that the resident had fallen and went into the resident's room and the first thing she noticed was R11 wasn't wearing her knee mobilizer. She said it was placed inside the bag on the back of R11's wheelchair. She said CNA1 had not put her knee immobilizer on her prior to getting her up and out of bed. She asked CNA1 why the resident didn't have her leg immobilizer on, CNA1 stated what immobilizer. CNA1 was under the impression that R11 did not use it anymore and didn't know that it was in the room. LPN3 stated that she didn't ask CNA1 if she looked for it prior to the transfer. During an interview on 09/25/25 at 11:05 AM, CNA1 stated that on 05/13/25 around 8:30 PM to 9:00 PM, R11 rang her call light and was ready to get ready for bed. She said she assisted R11 from the chair onto the bedside commode and then was attempting to assist R11 to bed when R11 started sliding down. She helped R11 onto the floor and called for assistance. She was unaware that R11 required a leg immobilizer during ambulation or transfers and never observed one in the resident's room. During an interview on 09/25/25 at 6:45 PM the Director of Nursing (DON) said she expected to have better communication in place when there was a change in orders, and agreed there was a breakdown in communication regarding expectation for R11 to wear a knee immobilizer during transfers and when ambulating. The DON stated that she expected the CNAs to look at the resident's fact sheet at the start of every shift to ensure they were aware of what type of care each resident required. 2.Review of R195's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, age related osteoporosis, chronic kidney disease, and kidney transplant status. Review of the EMR revealed that R195 had a hip fracture at home. R195 was admitted to the facility from home due to pressure sores. Review of R195's admission MDS with an ARD of 05/21/24 and located in the resident's EMR under the MDS tab revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. R195's MDS indicated she was a one person assist for bed mobility including turning and repositioning. Review of R195's Care Plan dated 07/01/24 and located in the EMR under the Care Plan tab revealed R195 was at risk for complications related to Osteoporosis to include pain and bone fracture. Interventions in place were to identify any injury or fracture and render treatment. The care plan also included decreased ability to perform activities of daily living (ADLS). R195 required one-person physical assist with all ADLS including bed mobility. Review of R195's Nurse's Note dated 06/06/24 and located in the EMR under the ''Notes'' tab written by LPN 2 revealed, resident rolled over and fell during personal care by assigned CNA 8, resident assessed with left hip and knee pain. R195 did not want to go to the hospital, however x-rays were ordered and revealed a fractured left hip. She was sent to the emergency room via ambulance and underwent left hip repair. Review of R195's Incident Report dated 06/06/24 completed by LPN2 revealed, assigned CNA8 was yelling for help in R195's room at 6:04 AM. LPN2 went to the room, and the resident was found lying on the floor, complaining of pain in her left hip and left knee, CNA8 stated resident rolled out of bed while he was turning her over during incontinent care. Further review revealed a statement by CNA8 that indicated, I was turning [R195] during personal care, her leg was sliding off the bed and I went to the other side, and she fell off the bed onto the floor. During an interview on 09/23/25 at 4:10 PM, CNA8 said he was providing care for R195 when her right leg was sliding off the bed. He said he went to the other side of the bed but was unable to catch her before she fell to the floor. CNA8 said she was a one person assist, and he had not had any issues with turning her in the past. He was asked what he could have done differently, and he said he could have called for assistance, but everything happened so fast. He did not call for assistance. During an interview on 09/24/25 at 1:57 PM, the DON stated she expected staff to try and identify root cause of falls, especially during care with staff. She stated after reading the incident report she did not feel there was anything that could have been done differently. Review of the facility's policy titled Fall Risk Assessment and Prevention dated 04/2025 revealed to protect and safeguard residents from injury and decrease the incidents of falls.

Based on interview and record review, the facility failed to ensure ongoing communication and collaboration with the dialysis facility for one resident (Residents (R)11) reviewed for dialysis out of a total sample of 47. This had the potential to effect the continuity of care for residents who receive dialysis treatment. Findings include:Findings include: Review of R11's Face Sheet in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included congested heart failure and chronic kidney disease. Review of R11's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/28/25 EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of three out of 11, which indicated the resident was moderate cognitively impaired. R11 was documented as receiving hemodialysis. Review of R11's Care Plan dated 08/26/25 and located in the EMR under the Care Plan tab revealed R11 was not care planned for dialysis treatment. Review of R11's Physician Orders located under the Orders tab in the EMR dated 08/22/25 revealed hemodialysis every Tuesday, Thursday, and Saturday. Review of R11's Treatment Details Report forms dated 07/26/25 through 09/18/25 revealed thirteen out of nineteen days that did not have any documentation provided by the dialysis center after treatment. During an interview on 04/30/25 03:45 PM, Nurse Manager (NM)1 stated on dialysis days nursing staff completed the dialysis communication log and send it along with the resident's binder to dialysis. She said it has been a challenge receiving the post communication information from the dialysis center. In those instances, the unit secretary reached out to the dialysis company, but there wasn't a lot of feedback from them. NM1 stated that she was unaware if this concern had been reported to any administrative staff. During an interview on 09/25/25 at 12:37, the Unit Secretary (US) said it has been a challenge getting post dialysis information sent back to the facility after R11's dialysis. She has reached out to the dialysis center and reported it to her supervisor, but it is still an ongoing issue. She stated she has spoken with the nurses at the dialysis center, but she has never spoken with anyone in management. During an interview on 09/25/25 at 6:45 PM, the Director of Nursing (DON) said she felt if there was information, the dialysis center needed to communicate with the facility.

Based on observation, interview, record review, and review of the manufacturer's manual, the facility failed to maintain air loss mattresses at the proper setting for two of three residents (Resident (R)9 and R15) observed for patient care equipment. This failure could lead to increased risk of skin breakdown.Findings include:Review of the facility's mattress manual dated 2018 provided by the facility revealed instructions to Turn the Pressure Adjust Knob to set a comfortable pressure level by using the weight scale as a guide. The manual illustrated the pressure adjust knob was to be set to the weight of patient.1. Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 09/17/25 and located in the MDS tab of the electronic medication record (EMR) revealed an admission date 07/09/18 and a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated R9 was cognitively intact. The MDS indicated that R9 had two unstageable pressure ulcers and diagnoses of quadriplegia and multiple sclerosis.Review of R9's order dated 05/10/25 provided by the facility revealed, Low air loss mattress Every Shift, Request Type: Routine.Review of R9's Care Plan dated 05/12/25, provided by the facility, revealed [R9] has pressure area to Lt. [left] gluteal fold/buttocks and sacrum. Potential for further skin breakdown, infection and deterioration of wounds. An intervention included, Pressure relief device on bed and chair.Review of R9's Weekly Wound Progress Update dated 09/22/25, provided by the facility, revealed R9 had a pressure injury to her sacrum Stage 4- Unstageable and Wound Prevention Intervention: Low Air Loss Mattress.Review of R9's Treatments Orders dated 09/25/25, provided by the facility, revealed R9 weighed 123.6 pounds.During an observation and interview on 09/25/25 at 8:28 AM, R9 was asked if she had sores on her body and R9 stated, Yes. R9 then complained that her mattress was Going down. R9's mattress was noted to be flat and the air mattress setting on 50.During an interview on 09/25/25 at 8:32 AM, Certified Nurse Aide (CNA)9 stated that she was assigned to R9.CNA9 was asked about R9's mattress and the setting at 50. CNA9 entered R9's room and observed the mattress and the setting at 50. CNA9 confirmed the setting and how flat the mattress was. CNA9 then stated she would report the mattress. CNA9 stated that CNAs have nothing to do with the mattress setting.During an interview on 09/25/25 at 9:26 AM, Licensed Practical Nurse (LPN)4 was asked about R9's mattress setting at 50 and R9 was complaining it was too flat. LPN4 stated setting of 50 was incorrect and it should be set at the resident's weight. LPN4 was asked who set the mattress setting. LPN4 stated either the CNA or the Nurse. LPN4 was told CNA9 stated she doesn't touch the setting. LPN4 was asked if the CNA would know the resident's weight. LPN4 didn't comment.During an interview on 09/25/25 at 12:33 PM, LPN5 was asked if she was aware R9's air mattress was set at 50 and R9 complained that the mattress was flat the morning of 09/25/25. LPN5 stated she wasn't aware, but they had difficulty with the air mattress not holding pressure. LPN5 stated the mattress should be adjusted according to the resident's weight. LPN5 stated R9's setting should be between 120 and 150.2. Review of R15's quarterly MDS with an ARD date of 08/20/25 and located in the MDS tab of the EMR, revealed an admission date 05/37/23 and a BIMS score of nine out of 15, which indicated R15's cognition was moderately impaired. The MDS indicated that R15 had two pressure ulcers and diagnoses of diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, osteomyelitis, ankle, and foot.Review of R15's Care Plan dated 04/28/25, provided by the facility, revealed, Pressure ulcer- at risk for altered skin integrity and pressure ulcers. Related to decreased in ADL abilities, poor PO [oral] intake, decreased mobility, incontinence. An intervention included Provide low air loss mattress on bed.Review of R15's Order dated 04/28/25, provided by the facility, revealed Low air loss mattress Every Shift, Request Type: Routine.Review of R15's weight dated 09/05/25, provided by the facility, indicatedR15 weighed 144.4 pounds.On 09/23/25 at 9:15 AM and 1:13 PM, and on 09/25/25 at 9:20 AM, R15 was observed asleep in bed with an air mattress in use. The mattress was set at 180.During an interview on 09/25/25 at 9:26 AM, LPN4 was asked about R15's air mattress setting and if it should be set at 180 LPN4 stated it shouldn't be at 180 and should be set at her weight. LPN4 then walked into R15's room and confirmed the setting was at 180 and reset it between 120 and 150.During an interview on 09/25/25 at 12:40 PM, LPN5 was asked about R15's wound and about the air mattress setting. LPN5 stated the purpose of the air mattress was to promote healing and should be at the appropriate setting.

Based on observation, interview, record review, and policy review, the facility failed to provide appropriate meal assistance for two of two residents (Resident (R)9 and R85) reviewed for activities of daily living (ADLs) in a sample of 47 residents. This failure could cause residents to become malnourished, aspirate, or an exacerbation of health conditions.Findings include:Review of the facility's policy titled Activities of Daily Living dated 11/22, provided by the facility revealed, To provide care for residents that give them a sense of comfort and wellbeing. Residents are provided assistance with all activities of daily living by clinical staff as desired and based on the individual care needs.1. Review of R85's face sheet, provided by the facility revealed R85 was admitted on [DATE] and had diagnoses of dementia, epilepsy, and gastro-esophageal reflux disease.Review of R85's nurse notes, dated 09/10/25 provided by the facility revealed, pt [patient] admitted for anxiety, COPD [chronic obstructive pulmonary disease], depression, dementia, macular degenerative disorders . Pt have hard to see vision problem .Review of R85's Diet Order dated 09/10/25 provided by the facility, revealed, liquid consistency: thin liquids, consistency: Mech [mechanical] Soft Chopped, comments: dysphagia advanced texture.Review of R85's Care Plan dated 09/10/25 provided by the facility revealed Decreased ability to independently complete ADLs and functional mobility, related to Decrease in Range of Motion, Weakness or deconditioning. An intervention included Set up [R199] ADL supplies and encourage or allow [R199] to complete care as able and then assist with completion. Interventions included, Silverware w/ [with] built up handles mealtimes.Divided plates mealtimes.On 09/22/25 at 4:50 PM and 5:15 PM, R85 was in bed and served dinner on an overbed table across her lap. R85 was observed touching the items on her tray and noted to be vision impaired. A bowl of soup still had a cover over the top as well as a cover over the plate of food. No staff assisted her or set her tray up. On 09/22/25 at 5:25 PM, R85 received no staff assistance, and her intake was poor, little consumed.Review of R85's Meal Acceptance History, provided by the facility revealed for dinner on 09/22/25 it was blank.On 09/24/25 at 8:30 AM and 8:55 AM, R85 was asleep in bed and her breakfast tray next to her. The food was untouched and included scrambled eggs, pancakes, milk, open yogurt, ground sausage, and apple juice.On 09/24/25 at 9:03 AM, the Hospitality Aide (HA)1 removed R85's breakfast tray.HA1 confirmed the food on R85's tray was not consumed. On 09/24/25 at 12:08 PM, R85 was seated in a wheelchair in the dining room. R85 was being fed her lunch meal by HA3 while standing.On 09/24/25 at 12:17 PM, HA3 was still feeding R85in the dining room. Licensed Practical Nurse (LPN)4 was asked should HA3 be standing while feeding R85. LPN4 stated, some stand and some sit depending on the situation.During an interview on 09/25/25 at 2:03 PM, Certified Nurse Aide (CNA)3 was asked about R85's eating status. CNA3 stated R85 was not on the feeding list that was kept at the nurse's station. CNA3 stated they fed her sometimes and other times R85 fed herself as R85 was still new to them. CNA3 was asked if R85 had vision problems. CNA3 stated she thought so.During an interview on 09/25/25 at 6:39 PM, LPN4 was asked about R85's feeding ability and why she wasn't on the feeding list at the nurse's station. LPN4 stated she didn't know but R85 ate better if she was fed. LPN3 stated thatR85 didn't do well if she was left to feed herself, LPN3 confirmed R85 was vision impaired.2. Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 09/17/25 and located in the MDS tab of the electronic medication record (EMR) revealed an admission date 07/09/18 and a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated R9 was cognitively intact. The MDS indicated that R9 required supervision or touching assistance with eating, had two unstageable pressure ulcers and diagnoses of quadriplegia, multiple sclerosis, and dysphagia.Review of R9's diet order dated 10/17/24, provided by the facility revealed a Thin Liquids, consistency: Regular, Comments: Ensure daily with meal-staff to assist with set-up PRN [as needed] indications: dysphagia resolved.Review of R9's care plan provided by the facility did not include a care plan for activities of daily living and eating ability.On 09/23/25 at 12:02 PM, R9 was served her lunch in bed on an overbed table, and her room door closed. R9's lunch includes beef/macaroni casserole, green beans, gelatin, a side of macaroni, coffee, a supplement, and ice cream.On 09/23/25 at 12:19 PM and 12:36 PM, R9 was in bed with her meal and her door closed. No assistance was observed with her meal.On 09/23/25 at 1:16 PM, R9 was in bed with her lunch tray, and her consumption was poor. R9's door remained closed, and no assistance was provided. R9 was asked if she received assistance with her meal and R9 stated, No.Review of R9's Meal Acceptance History provided by the facility revealed 09/23/25 for lunch was documented as 25%.On 09/23/25 at 4:51 PM and 5:00 PM, R9 was served her dinner in bed, and her tray was covered. R9's door remained closed, and no assistance was provided.On 09/23/25 at 5:21 PM, R9 was asleep in bed with her dinner tray unconsumed and sitting at her bedside.Review of R9's Meal Acceptance History provided by the facility revealed 09/23/25 for dinner was documented as refused.During an interview on 09/25/25 at 12:33 PM, LPN5 was asked why R9 hadn't received feeding assistance for two meals on 09/23/25. LPN5 stated R9 could feed herself.During an interview on 09/25/25 at 2:01 PM, CNA3 confirmed that she was assigned to R9.CNA3 was asked how she would know who needed assistance with eating. CNA3 stated they get information from the family or the previous nursing home on meal intake, and they also follow a feeding list at the nurse's station. CNA3 provided the list which indicated that R9 was to receive queueing/supervision. CNA3 confirmed R9 was to receive queueing/supervision.During an interview on 09/25/25 at 2:08 PM, the Nurse Manager (NM)3 was asked about the feeding list and R9 listed as queueing/supervision which was different from her diet order instructions. UM3 stated it was the same as queuing/supervision.During an interview on 09/25/25 at 2:14 PM, the Speech Therapist (ST) was asked about R9's diet order. The ST stated, Someone should be with R9 to cue/supervise. ST stated R9 would accept someone feeding her. ST confirmed R9 had poor meal consumption and had a pressure sore.

Number of residents sampled: 47Number of residents cited: 1Based on observation, interview, record review, and policy review, the facility failed to ensure residents received alternative measures prior to the installation of side rails; documented discussion related to risk versus benefits; and signed informed consent prior to bed rail use for one of four residents (Resident (R)89 reviewed for side rails out of 47 sampled residents. The lack of alternate side rail measures and proper assessment/consent could lead to potential restraint or side rail entrapment.Findings include Review of R89's admission Record in the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnosis of hemiplegia. Review of R89's admission Minimum Data Set (MDS) assessment under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 09/15/25 revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating severe cognitive impairment. Review of R89's Care Plan located under the Care Plan tab of the EMR dated 09/09/25 revealed R89 did not have a care plan for side rail use. Review of R89's Physician Orders located under the Orders tab in the EMR dated 09/08/25 revealed, 1/2 rails every shift to assist with bed mobility and repositioning. Review of R89's Nursing admission Assessment located under Assessments tab in the EMR dated 09/08/25 revealed no documentation that alternates were explored prior to bed rail/side rail use; risk and benefits were discussed; and that informed consent was obtained prior to bed rail use. Observation on 09/23/25 at 11:40 AM, R89 was in bed with side rails up on both sides. During an interview on 09/25/25 at 9:56 AM, Licensed Practical Nurse (LPN)3, who was a former charge nurse, said all residents were admitted with side rails already on the beds for use. She said staff would ensure there was not a restraint, but they did not look at alternatives. Most of the residents wanted side rails. She said they go over the risks and benefits related to side rail use, but they don't have the resident or family sign anything. She was also unsure how often side rails were reassessed after admission. During an interview on 09/25/25 at 11:18 PM, LPN2 said after residents were admitted to the facility and wanted side rails they would educate them on the risk and benefits. She said most residents were more comfortable with having side rails. But they did not look at alternates prior to use, because bed rails were already on the beds. She said they have a consent form, but nobody signed them. During an interview on 09/25/25 at 6:45 PM, the Director of Nursing (DON) said she was unaware that there needed to be documentation that alternates were explored prior to bedrail use; discussion of risk and benefits of bedrail use and that there needed to be signed consent in the medical record.

Based on a complaint investigation, medical record review, staff interviews and facility document review the facility staff failed to implement documented fall interventions to ensure a resident was not left alone and unsupervised for approximately 6 minutes during toileting that resulted in an unwitnessed fall with a nasal bone fracture and a facial laceration requiring sutures on 5/1/21, which constitutes harm for 1 of 3 residents in the survey sample, Resident #3. The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses to include but not limited to Status Post Pacemaker Implantation, Legal Blindness, Weakness/Deconditioning, Anemia and Need for Assistance for Personal Care. The most recent comprehensive Minimum Data Set (MDS) was an Admission 5 Day assessment with an Assessment Reference Date (ARD) of 4/24/21 for Resident #3. Under Section B Hearing, Speech and Vision; B1000 Vision, Resident #3 was coded as a 4 Severely Impaired- no vision or sees only light, colors or shapes; eyes do not appear to follow objects. Under Section G Functional Status, Resident #3 was coded as requiring Extensive-resident involved in activity, staff provide weight bearing support/One person physical support for transfers and toilet use. Under G0300 Balance During Transitions and Walking Resident #3 was coded as a 2, indicating she was not steady and was only able to stabilize with staff assistance. For Section G0400 Functional Limitation in Range of Motion (code for limitation that interfered with daily function or placed resident at risk of injury) the resident was coded as a 1, indicating upper extremity impairment on one side. Resident #3's Brief Interview for Mental Status (BIMS) was coded as a 14 out of a possible 15 indication the resident cognitively intact and capable of daily decision making. Resident #3's Hospital Discharge Summary dated 4/17/21 was reviewed and indicated the resident was legally blind, had a fall 6 months prior and was a high fall risk. The discharge summary also stated Resident #3 had an unsteady gait and required assistance or supervision for mobility, transfer, and ambulation. Resident #3's admission nursing assessment dated [DATE] was reviewed and describe the resident as being moderately impaired visually with no history of falls. The nursing assessment identified Resident #3 as a low fall risk of a 5 with fall precautions such as non-skid socks an, call light and fall risk identification bracelet applied. Resident #3's Comprehensive Care Plan dated 4/19/21 was reviewed and is documented in part, as follows: Date: 4/19/21 Problem: 1. At Risk for Falls due to requires assist with transfers, ambulation and locomotion related to visual deficit, Use of devices. Date: 5/1/21 Weakness or deconditioning s/p (status/post) implantation of pacemaker as evidenced by 5/1/21: Name (Resident #3) was assisted to toilet by CNA (Certified Nursing Assistant), given call bell and told by staff to call when finished. Name (Resident #3) fell on to the floor after attempting toileting hygiene without call for assistance. Interventions: 3. Provide hands on assist of one during transfers and ambulation with use of walker. Date: 4/19/21. 4. Monitor for steadiness and balance, if name (Resident #3) appears unable to stabilize self, assist as needed. Date: 4/19/21. 7. Assist Name (Resident #3) by toileting routinely and do not leave in the bathroom unattended. Date: 4/19/21. 9. Keep assistive devices and call light within reach. Answer call light promptly to discourage Name (Resident #3) from getting impatient and transferring without assist. Date: 4/19/21. 12. Close and frequent monitoring for unmet needs, do not leave Name (Resident #3) in bathroom unattended. Date: 5/1/21. Resident #3's Progress Notes were reviewed and are documented in part, as follows: 4/18/21 at 5:08 a.m.: The daughter called and voiced her concerns with the issue of the call bell. She stated that her mom is blind and has neuropathy. 4/25/21 at 10:07 p.m.: PT (patient) is assist x1 with ADL's (activities of daily living) and q2hr (every 2 hours) checks for safety. 4/28/21 at 10:17 p.m.: PT is assist x1 with ADL's and transfers, pt. is blind with q2hr checks. 5/1/21 at 7:10 p.m.: Patient heard calling out from room, staff entered room to find patient lying face down on floor in the bathroom. Patient stated she called for assistance and was trying to wipe herself when she fell . Patient assisted to wheelchair by staff, eyes perl (pupils equal and reactive to light), able to move all limbs. Large bruise with open cut to right center of forehead, bridge of nose noted with bruise and left cheek. Skin care given. Daughter called, 911 called. 5/1/21 at 7:49 p.m.: Patient remained up in wheelchair with staff constantly observing patient neuro status. Patient remain alert and oriented x3. Ambulance transport arrived to room, transport arrived to room, transported patient via stretcher to Name (hospital). 5/1/21 at 11:06 p.m.: Received call from Name ER (emergency room ). Patient has three sutures above her right eye, nose broken. Resident is being discharged back to facility. 5/2/21 at 1:48 a.m.: Resident returned to Name (facility) via stretcher, resident is alert and oriented x 3. Final diagnosis at discharge is two facial lacerations and closed fracture of nasal bone. Resident has 4 stitches total between two lacerations, one laceration over right eye and the second one at the beginning bridge of nose both approximately 0.1 x 0.5 in size. Resident has packing in left nose. The packing needs to be removed in two days and stitches need to be removed in 9 days. Resident #3's Situation, Background, Assessment and Recommendation (SBAR) Tool dated 5/1/21 at 5:35 p.m. was reviewed and is documented in parts, as follows: .Situation/Current Complaint/Concern: Resident observed on floor. Pain level: 6 out of 10 Nurse's Note: During change of shift, resident heard calling out from room. This writer and off going nurse responded, resident observed lying face down on floor in the bathroom. When resident was asked what happened? Resident stated, She called for assistance and was trying to wipe herself and she fell . Resident noted to have a large bruise with open cut to right center of forehead, bridge of nose noted with bruise and left cheek. Supervisor came and assessed resident. Call place to on call Name (Nurse Practitioner) order given to send resident to ER. Daughter contacted and made aware of situation. Resident sent to ER via 911 . Resident #3's emergency room After Visit Summary dated 5/1/21 was reviewed and revealed the resident did receive a facial laceration and had a closed fracture of her nasal bone with a nose bleed from a fall. While in the emergency room Resident #3 told the physician that she fell when she was trying to wipe herself. Resident #3 did have to have 4 stitches to her 4 centimeter forehead laceration and was referred to see an ENT ((Ear, Nose and Throat Physician) because her septum was deviated and a fracture was suspected. Resident #3's Physician Progress Noted dated 5/3/21 was reviewed and stated the resident was being seen that day because of a status post unwitnessed fall with nasal bone fracture on 5/1/21.The progress noted also referenced Resident # 3's forehead laceration that required sutures due to the fall. In conclusion the physician recommended fall precautions be put into place. Resident #3's ENT Outpatient Consultation Record dated 5/5/21 determined the resident did have an acute non-displaced nasal fracture, however no intervention was indicated. Resident #3's facility Physician Discharge Summary dated 5/13/21 was reviewed and is documented in part, as follows: .Discharge Diagnoses: 12. Physical Deconditioning . .Hospital Course: Since the patient's admission to this facility, she has been followed closely by the medical staff. The patient has continued with physical therapy/occupational therapy as she has been able to tolerate. She had been tolerating physical therapy and occupational therapy and doing quite well, but she did start to have a progressive decline. The patient ultimately fell in the restroom, hitting her face, requiring sutures to the forehead, and she had a nasal fracture. The patient was on a steady decline after that point. Her balance and instability had decreased. The patient throughout her stay had some weakness. After her fall, we did request an occupational therapy evaluation for toileting. However, it was found that the patient required assistance with toileting and due to her vertigo that is occasional, it would not be safe for her to do these activities alone. The patient required 24-hour supervision Resident #3's Occupational Therapy Discharge Summary dated 5/4/21 was reviewed and is documented in part, as follows: Short Term Goal #3: Minimal assist with toileting routine through improved strength and reduced fatigue-Discharge 4/30/21 is CGA (contact guard assist). Long Term Goal #2: CGA with toileting routine to reduce fall risk and restore ADL (activities of daily living)-Discharge 4/3/21 is CGA. Summary of Care: She can walk to restroom safely with S (supervision) and verbal cueing for obstacles and complete clothing management and peri-care. The facility fall investigation completed by the Director of Nursing for Resident #3's unwitnessed fall on 5/1/21 was reviewed and it was determined that the CNA did leave the resident unsupervised in the bathroom for over 6 minutes based on camera footage and that the resident had experienced an unwitnessed fall which resulted in serious injury with fracture of her nose. Furthermore it was decided by the Director of Nursing that Resident #3 wound not be left unattended while using the bathroom forward On 4/27/22 at approximately 11:00 a.m. the Complainant arrived at the facility to speak with this surveyor and provide a copy of his documentation/investigation of Resident #3's unwitnessed fall on 5/1/21. The Complainant stated, The resident's family member called me and was very upset that her mother sustained facial injuries resulting from a fall. The resident was left alone in the bathroom and fell while in the toilet. The daughter said her mother was trying to wipe herself and fell face down on the floor. I called the facility and interviewed the Director of Nursing regarding the resident's fall. It was confirmed that the staff member left the resident in the bathroom unattended. I saw in the resident's care plan that she was not to be left alone in the bathroom. The Director of Nursing told me the resident had been left alone in the bathroom before without incident. On 4/27/22 at 12:17 p.m. a phone interview was conducted with CNA (Certified Nursing Assistant) #4. CNA #4 was asked about Resident #3's unwitnessed fall on 5/1/21 in the bathroom. CNA #4 stated, The whole entire day she was going to the bathroom. He routine was I would put her on the toilet and put the call-bell in her hand. I said Name (Resident #3) when you are finished pull the call light. It was time to leave, we were changing shifts and I was doing report at the nurse's station. I walked down the hall foe 2 seconds to give report, then we heard a scream. She was only in the bathroom alone for a minute, no more than 5 minutes. Everyone went running down, me too because she was my patient. The nurse said what happened and the resident said she was standing to wipe herself. She never pulled the call light. I put her in the bathroom by herself 5 to 6 times that same day and left her in their by herself. When we found her she was facedown. She was bleeding and above one eye there was a gash. More than likely she did fall on her face. She was upset. I usually work the other side of the hall. CNA #4 was asked how do you know how much assistance your residents require for adl's. CNA #4 stated, The nurses will report it to us or maybe in the system it will say it. I never go no report that she couldn't be left alone in the bathroom. No report that she was a fall risk. There was no fall risk sign on her door or in her room. If I had known she was a fall risk I would have never left her in the bathroom alone. On 4/27/22 at 12:25 p.m. an interview was conducted with CNA #5. CNA #5 was asked about Resident #3's unwitnessed fall on 5/1/21 in the bathroom. CNA #5 stated, It was at the end of the shift. Name (CNA #4) put her in the bathroom and she never told anyone that Name (Resident #3) was in the bathroom. I heard the charge nurse coming out of her room screaming I need some help. All of us went running and I got some towels. They turned her over and blood was all over her nose. I don't remember any cuts, but her nose was crooked. Someone said, looks like her nose is broken. She had a fall risk band on her arm, she was blind. CNA #5 was asked Resident #3 should have been left in the bathroom alone. CNA #5 stated, No ma'am, because if she has a fall risk band on you have to stay with her so she won't get up by herself and fall. I would have stayed where I could see her. On 4/27/22 at 1:20 p.m. an interview was conducted with CNA #3. CNA #3 was asked if she was familiar with Resident #3. CNA #3 stated, Yes, she was my lady, I took care of her a lot. I was not working on 5/1/21 when she fell . She was a fall risk because of her blindness. She had a yellow bracelet on her arm that said fall risk. When I take her to the bathroom, I sit on the shower bench in the bathroom while she is using the bathroom. She is in my sight the entire time. If she needs to have a bowel movement and wants privacy I come out pull a chair up to the bathroom door where I can see her. She is blind, she should not be left alone. On 4/27/22 at 1:50 p.m. an interview was conducted with Charge Nurse LPN (Licensed Practical Nurse) #1. LPN #1 was asked if Resident #3 was a fall risk and how do the CNA's know who is a fall risk. LPN #1 stated, Yes she was a fall risk, she had a yellow fall risk band on her wrist. She was unsteady at times and we had to keep a close eye on her. We have put her on the toilet prior to the fall for privacy and had her pull the call light when she was done. We would step out into the room, but stayed near the bathroom door. I wouldn't expect the CNA to leave the room and go down the hallway if she was in the bathroom. The CNA's get information about the residents from me or other nurses taking care of the patients. LPN #1 was asked if she was aware that Resident #3 was care planned to not be left alone in the bathroom prior to her unwitnessed fall on 5/1/21. LPN #1 stated, I was aware that it was in her care plan prior to her fall. On 4/27/21 at 2:45 p.m. an interview was conducted with Nurse Manager RN (Registered Nurse) #1. RN #1 was asked if Resident #3 was a fall risk and if she should have been left alone in the bathroom on 5/1/21. RN #1 stated, Yes she was a fall risk. She was blind, deconditioned, had mobility problems and was her for therapy. She had a yellow fall risk band on her wrist. OT (occupational therapy) had stopped working with her. If therapy says the person is able to perform the task themselves it relieves nursing of the task. RN #1 was asked if Resident #3 was care planned to not be left alone in the bathroom and if the care plan was revised after her fall on 5/1/21. RN#1 stated, Yes, she was care planned to not be left unattended in the bathroom. No, we didn't update the care plan after her fall because nothing changed. MDS updates the care plan. On 4/27/22 at 3:00 p.m. an interview was conducted with MDS Coordinator LPN #2. LPN #2 was asked when Resident #3's care plan was updated after her fall on 5/1/21. LPN #2 stated, When the MDS Director reported it to us after the morning meeting that Monday. She said that was the intervention from administration that they wanted for us to add. LPN #2 was asked if she was aware that Resident #3 already had an intervention dated 4/19/21 to not be left unattended in the bathroom. LPN #2 stated, I see it now, but I don't remember going back and seeing it before I added the new intervention on 5/1/21. It is basically the same intervention. On 4/28/22 at 11:25 a.m. an interview was conducted with the Director of Nursing (DON) regarding Resident #3's unwitnessed fall with a major injury on 5/1/21 and her fall investigation. The DON stated, She was a fall risk when she was admitted . Her new environment, requiring assist with ambulation and I believe she had a visual deficit. I don't remember if she had a fall risk band on or not. I reviewed her chart, talked to the resident, talked to the staff and reviewed the tape. I determined she had an unwitnessed fall with a major injury, she fractured her nose. The family was upset, falls happen. Oh my God, there was no neglect or abuse found. It was an unfortunate event. Accidents happen, it was unintentional and we apologized to the family. We left her in the bathroom and she fell . She should not have been left in the bathroom alone. I see the harm. At the time I thought I did a good investigation but now I see what I missed. I missed the care plan intervention from 4/19/21 that she was not to be left unattended in the bathroom. The DON was also asked if Resident #3's care plan was revised after her fall on 5/1/21. The DON stated, Care Plans are updated after standup meeting by the MDS Coordinators. The MDS Director comes to the morning standup meeting and we talk about everything that has happened the day before and they are to update the care plans. The DON was asked if Resident #3's care plan was revised after her fall on 5/1/21. The DON stated, No, because the intervention that was added was already in place for the resident prior to the fall. The DON was also asked if the facility put a plan of correction in place after Resident #3's fall. The DON stated, No we didn't because at the time I did not feel one was needed. On 4/28/22 at 1:42 p.m. a return call was received from LPN #3 and an interview was conducted regarding Resident #3's unwitnessed fall on 5/1/21 in the bathroom. LPN #3 stated, It was change of shift and I was coming on. Myself and the other nurse were counting narcotics. I was not aware Name (Resident #3) was alone in the bathroom, she is blind and was a fall risk. We heard a loud boom. Myself and the other nurse went running and we could hear Name (Resident #3) yelling out for help. When we got to her room Name (Resident #3) was face down on the floor in her bathroom. Blood was everywhere. The supervisor came and assessed her. We cleaned her up, did neuro checks, called the doctor and send her to the hospital via 911. The daughter was also called. If someone is a fall risk they are not to be left alone. Someone should stay in the room with them while they are in the bathroom. On 4/28/22 at 3:07 p.m. a return call was received from the Occupational Therapist and an interview was conducted. The Occupational Therapist was asked about Resident #3's occupational therapy discharge summary she completed on 5/4/21 indicating Resident #3 was CGA for toileting. The Occupational Therapist stated, If that is what I documented on the discharge summary then that was her level of assistance needed at discharge. The Occupational Therapist was asked what is CGA. The Occupational Therapist stated, CGA is basically supervision with stand by assist in case the resident would need added weight bearing assist for safety. The Survey also asked if Resident #3 should have been left alone in the bathroom on 5/1/21. The Occupational Therapist stated, No, not is she was CGA, someone should have been with her. The facility policy titled 11.3 Fall Risk Assessment and Prevention effective 11/2013 was reviewed and is documented in part, as follows: Purpose: To protect and safeguard residents from injury and decrease the incidence of falls. Procedure: 1. Resident's at risk will be provided and encouraged to wear a Fall Risk yellow arm band. 2. Upon completion of a comprehensive assessment, a care plan will be developed by the multidisciplinary team to assist in preventing falls and injury. A. Interventions to be considered are included, but not limited to: 7) Staff observation 8) Assistance with toileting 3. In the event a fall does occur: A. Complete and document a thorough assessment and determine if any injuries are present. 4. Review circumstances of the event to determine what additional interventions should be implemented. On 4/28/22 at 12:30 p.m. a pre-exit debriefing was conducted with the Administrator, the Director of Nursing and the [NAME] President of Patient Services where the above information was shared. The Administrator was asked what would he have expected from the staff in regards to Resident #3 prior to and after her fall with a major injury on 5/1/21. The Administrator stated, She was identified as a fall risk with a fall risk band on. The fall risk band is in place for the staff to let them know she is a fall risk and cannot be left alone on the commode or in the chair. We had a system in place for them. After the fall we should have reviewed and revised the care plan appropriately and communicated that information to the staff. Prior to exit no further information was shared. This is a Complaint Deficiency

Based on facility documented review and staff interviews the facility staff failed to ensure the Covid-10 Vaccination Policy included weekly testing for staff members who had been granted covid-19 vaccination exemptions and failed to weekly test 3 staff members who had been granted covid-19 vaccination exemptions. The facility staff failed to ensure their Covid-10 Vaccination Policy included weekly testing for staff members who had been granted covid-19 vaccination exemptions and failed to weekly test 3 staff members who had been granted covid-19 vaccination exemptions since February 2022. The findings included: During the survey 3 staff members who had been granted medical and or religious covid-19 vaccination exemptions documentation was reviewed. On 4/27/22 at 3:50 p.m. the surveyor asked for the weekly testing for these 3 staff members the Infection Control Nurse stated, I haven't tested them since February when our county transmission rate was high. One was last tested on [DATE], one on 2/11/22 and the third on was tested on [DATE]. We have been low since then. I follow the CMS(Center for Medicare/Medicaid Services) guidelines and we don't have to test weekly if the county transmission rate is low, that's why they weren't tested . The Infection Control Nurse was provided the CMS requirements for weekly testing of covid-19 vaccination exemption employees by the [NAME] President of Patient Services. After the Infection Control Nurse reviewed the CMS requirements for weekly testing of covid-19 vaccination exemption employees she stated, I wasn't aware they had to be tested weekly, I thought testing for all employees was based on the county transmission rate. The facility's Covid-19 Vaccination Policy was requested and provided to the surveyor for review. The facility's Covid-19 Vaccination Policy failed to address the weekly testing of Covid-19 Vaccination Exempt Employees. On 4/27/22 at approximately 4:25 p.m. an interview was conducted with the Director of Nursing regarding weekly covid testing for covid-10 vaccination exempt employees. The Director of Nursing stated, I was not aware our 3 employees that were exempt had to be tested weekly. I don't have a policy that says the exempt employees have to be tested weekly. We will have to update that policy. On 4/28/22 at 12:30 p.m. a pre-exit debriefing was conducted with the Administrator, the Director of Nursing and the [NAME] President of Patient Services where the above information was shared. The [NAME] President of Patient Services stated, We tested the 3 exempt employees this week and the expectation going forward is that the exempt employees will be tested at least weekly or more depending on the county transmission rate. The Administrator was asked why the Covid-19 vaccination policy had not been updated to include weekly testing of covid-19 exempt employees. The Administrator stated, It was an unintentional oversight. Prior to exit no further information was shared.

Based on interview, record review, and review of facility policy, the facility failed to ensure that one (Resident (R) 59) of eight residents reviewed for pressure ulcers out of a sample of 31 residents did not develop a pressure ulcer unless their clinical condition showed that it was unavoidable. R59, who had been wearing a splint for a fracture, developed a facility-acquired Stage IV pressure after the facility failed to follow physician orders for daily skin checks and wound care. Findings include: Review of R59's Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, indicated R59 was a long-term resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an emergency room Report, dated 04/27/21, located in the EMR under the hospital note tab, revealed that R59 sustained fractures of the distal shaft of the tibia and fibula. Review of an Outpatient Consultation Record, dated 05/12/21, located in the EMR under the Outpatient tab, revealed the resident had a follow-up from emergency room with fracture to left tib/fib .soft cast on leg . healing. Review of R59's significant change Minimum Data Set (MDS), located in R59's EMR under the MDS tab, with an Assessment Reference Date (ARD) of 05/05/21, indicated that the time of this assessment, the resident had moderate cognitive impairment, as evidenced by a Brief Interview of Mental Status (BIMS) score of 11/15. Per this MDS, R 59 did not exhibit behaviors, including rejection of care, and required extensive assistance with bed mobility and dressing. The MDS documented that, although at risk for their development, R59 did not have any pressure ulcers. Review of an Outpatient Consultation Record, dated 07/08/21, located in the EMR, revealed that, After splint removal, resident has a darkened area to the back of the calf which appears to be firm, most likely hematoma resolving . no skin breakdown is noted at this time . resident has a healing, stable fracture to the left tib/fib .multiple skin tears, pending ulceration to foot and calf .new orders to apply ace wrap daily, no weight bearing, may shower, cleanse area, skin checks daily, posey boot to offload pressure areas, and wound care three times a week. The plan of care in the same report revealed, At this time, this patient's skin tears, and areas of concern were treated with Xeroform .leg was wrapped in a soft dressing, and an Ace wrap .We will not re-splint her at this time, due to need for skin checks .I would Lake [NAME] to perform daily skin checks and wound care at least three times a week and as needed. Review of the entire EMR revealed no evidence that the new orders for daily skin checks and wound care three times per week were implemented from 07/08/21 until 07/21/21, when, per the wound assessment tab in the EMR, R59 was identified with a new, facility-acquired unstageable pressure ulcer to the mid/lateral left leg that measured 5.6 centimeters (cm) in length, 4.0 cm in width, and 0.2 cm in depth. On 08/02/21, the facility doctor debrided (removed) the necrotic (dead) tissue, and the pressure ulcer was measured at 5.0 cm x 4.0 cm x 0.5 cm. Review of an Outpatient Consultation Record, dated 08/05/21, located in the EMR, revealed the resident had a Decubitus ulcer, posterior lateral calf over musculature/no exposed bone /this is at the level of the top of the Posey boot that she was wearing .the plan of care with family discussion was that something surgically needed to be done very quickly or the resident was going to succumb to an infection .and amputation was recommended for consideration. On 08/16/21, the pressure ulcer was documented as being a Stage IV wound measuring 5.8 cm x 3.0 cm x 0.8 cm. Record review of a pain assessment dated [DATE] located in the EMR under the assessment tab revealed that R59 had severe, sharp pain to her leg with moaning and frowning. The last wound assessment, completed while during survey on 10/12/21, showed the facility-acquired Stage IV pressure ulcer was now 4.7 cm x 2.0 cm x 1.3 cm in size. Interview on 10/15/21 at 10:28 AM with the Wound Care Nurse (WCN), revealed that the ordered treatment was not started on R59's left leg until 07/21/21. She stated that the family asked her to check the resident's leg. The WCN did so and noted open areas on the left leg and notified the Unit Manager (UM 2). The WCN did not know the cause of the pressure ulcer other than she had previously had a splint on her left leg. Interview with UM2 on 10/15/21 at 10:46 AM confirmed that wound care treatment did not start until 07/21/21. On 07/08/21, after removal of the splint, skin tears were noted, with a darkened area pending ulceration. The orthopedic doctor ordered daily skin checks and wound care three times a week. The UM2 stated, The orders that came back to the facility from the orthopedic doctor were never transcribed over into system so nursing would know the new plan of care and treatment could begin. UM2 stated the facility doctor had read the orthopedic report and initialed the report; however, these orders were missed. An interview with UM2 and the Director of Nursing (DON) on 10/15/21 at 3:54 PM also confirmed that there was a lapse in time between when the orthopedic orders were written on 07/08/21 for wound care and daily skin assessments, until wound care started on 07/21/21. They stated that in order to assess the skin under a bandage, the bandage must be removed and a new one applied. However, the ace bandage was not removed for a skin assessment because bandage changes are completed by the day shift nurse, while skin assessments are completed on the night shift nurse who does not do bandage changes. Phone interview on 10/15/21 at 4:19 PM with the facility Medical Director revealed that he would expect orders to be addressed and the wound care to be started a lot sooner than 07/21/21. The Medical Director stated that the facility has a wound protocol and, I expect them to use it. I would expect the nurse during the skin assessments to remove a bandage to look at the skin. The Medical Director stated [ he was unaware that the wound had become a Stage IV pressure ulcer, and he expected that either he or the attending physician would be notified of the change in the pressure ulcer. Phone interview on 10/15/21 at 4:35 PM with the attending physician revealed that she remembered R59 developing a wound in her left lower extremity. She stated that the orders from the orthopedic doctor should have been followed by the nursing staff, adding, A consultant is another provider just like us and the orders need to be entered. She stated that she has not seen the wound but was made aware that it had went from unstageable to a Stage IV pressure ulcer after the wound care doctor debrided the wound. The attending physician was not aware that the orders not transferred into the system and stated that there was potential for deterioration because of the time gap. She also stated that when completing skin assessments, the bandage should be removed unless there was an order to not remove the wrap. The attending physician stated that she could not justify the gap in time from 07/08/21 to 07/21/21 when the orders were not initiated or followed until the identification of the facility-acquired pressure ulcer. Review of the facility policy Pressure Injury Prevention, with a review date of 01/21 revealed .residents will receive early identification, prompt evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .each resident will have a weekly skin assessment including measurements and description .notification of physician for specific treatment as indicated.

Based on observation and interview, the facility failed to ensure food, dishware, and cookware used for food preparation/service was stored in a sanitary manner. Food items were not labeled, dated when opened, and/or sealed closed. Dirty industrial fans were blowing on dishware which were clean and ready for use. Cookware was stacked wet. These failures had the potential to affect all 145 residents in the facility who were served food from the facility kitchen. Findings include: On 10/11/21 at 8:40 AM, the following observations were made with and verified by the Chef Manager: 1. The dry storage room contained one bag of egg noodles that was not sealed closed. There was one bag of spaghetti that was not labeled and dated after opening. The plastic flour bin was left open, with the lid sitting partially on the bin. 2. The walk-in refrigerator had a one container of chicken parmesan with no label or dating. A roll of ground beef in a plastic container with plastic wrap covering, had an expiration date of 10/09/21. The ground beef, which was not disposed of past its expiration date was a pale brown/gray color. There were four bags of raw chicken that were not sealed closed and had no labels or dates. 3. The walk-in freezer contained one bag of biscuits, and one bag of frozen pancakes that were not sealed closed. 4. The drying area contained one stack of loaf pans, baking sheets, and cake pans that were wet on the inside. 5. Two industrial fans that were visibly dirty with dust and black build-up, were blowing on clean dishes. An approximately three feet by three-foot area of the ceiling located directly above one of the two fans in the dish storage area was peeling. During an interview on 10/22/21 at 8:40 AM the Chef Manager stated, All opened bags of food should be sealed closed, labeled and dated . All opened bags of chicken in the refrigerator that had no labels and dates are going to be thrown out . and the fans are dirty and will be removed and cleaned. He also stated, The wet pans should not have been stacked until dried due to them harboring bacteria.

Based on observation, interview, record review, and review of facility program documents, the facility failed to ensure that a paid feeding assistant provided dining assistance only for residents who had no complicated feeding problems. In addition, the facility failed to ensure appropriateness for the paid feeding assistance program was reflected in the care plan. The facility's failure affected one of four units, potentially affecting the 53 residents residing on the Dogwood Unit, out of a total of 145 residents. Findings include: Review of the paid feeding assistance program titled Feeding/Hydration Training Program, reviewed 12/17, revealed the purpose of the program was to provide adequate training for non-licensed assisting residents with feeding and drinking. Review of the seven sections of the program revealed an assessment to determine the residents eligible for the program was not identified. Review of R23's Face Sheet found in R23's electronic medical record (EMR) under the Face sheet tab revealed the resident was admitted to the facility in 1994 with diagnoses that included [CONDITION(S)] and dysphagia. Review of R23's comprehensive Care Plan revised 10/30/20, found in R23's EMR under the Plan of Care tab indicated, [R23] receives diet of mechanically altered texture/thickened liquids with adaptive meal equipment and supplements as needed with the goal of not showing signs of aspiration. Review of R23's Care Plan revealed that it did not address the appropriateness of resident participation in a paid feeding program. Observation on 10/14/21 at 12:29 PM revealed Hospitality Aide 1 fed R23 pureed carrots with a small spoon. Review of the meal ticket dated 10/14/21 indicated R23 was on a pureed diet and had buildup utensils. The meal ticket did not address the appropriateness of R23 being fed be staff from the paid feeding program. Interview with Hospitality Aide 1 on 10/14/21 at 12:04 PM revealed she completed the paid feeding assistance training program last year and was assigned to the Dogwood Unit to assist in feeding residents. Hospitality Aide 1 stated she could feed any resident that needed assistance, including residents with swallowing issues on the unit. Review of the CMS 802 provided by the facility revealed that 53 residents resided on the Dogwood Unit. During this interview, Hospitality Aide 1 stated there was a list of residents that needed feeding at the nurse's station. Hospitality Aide 1 stated that she does not review the care plan to determine the resident's feeding assistance needs but reviewed the diet ticket which listed diet type and utensils needed to feed the resident. Interview with the Director of Quality Development on 10/14/21 at 12:32 PM revealed she oversaw the paid feeding assistance program since 2019 and verified that eligible residents were not identified for the program. The Director of Quality Development stated that any resident that needed feeding assistance could be fed by the hospitality aides, indicating the facility had no system in place to base resident selection on the interdisciplinary team's assessment and the resident's latest assessment and plan of care. Interview with Unit Manager (UM) 3 on 10/14/21 at 12:41 PM confirmed that although they could not perform care, hospitality aides could feed all residents. UM3 stated that the resident's dietary needs were listed on the meal ticket that came on the meal tray and that the hospitality aides were trained by the speech therapist on how to feed residents with swallowing difficulties. Interview with the Speech Therapist on 10/14/21 at 1:50 PM revealed that she trained the hospitality aides on basic feeding guidelines for the paid feeding assistance program. However, per the Speech Therapist, only licensed staff were allowed to feed residents with swallowing issues, not hospitality aides. The Speech Therapist stated that the unit managers were responsible for ensuring that the hospitality aides were feeding residents that were eligible for the program since they run their units. Interview with the MDS Coordinator on 10/15/21 at 7:35 PM revealed that the MDS Coordinators do not update the resident care plans to indicate that residents are appropriate to be fed by the hospitality aides or need dining assistance.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure the appropriate use of side rails for four cognitively impaired residents (Resident (R) 96, R125, R3, and R89) out of 31 sampled residents. The facility failed to ensure that prior to the installation of side rails (also known as bed rails), alternatives were attempted. The facility failed to assess each resident for the use of side rails, including a review of risks including entrapment; or obtained informed consent for the use of side rails from the resident and/or the resident representative. In addition, the facility failed to ensure that the bed was appropriate for the residents and that the side rails were routinely monitored for hazards and maintained in accordance with manufacturer specifications. Findings include: On 10/11/21 at 08:00 AM a recertification survey was initiated at Lake [NAME] Hospital. Observation revealed that the facility has four units and 145 residents. During the screening process conducted throughout the facility on 10/11/21, observation revealed that the facility currently uses three different types of beds. Although not in use for multiple residents, all beds had side rails attached. 1. Observation of R96 on 10/12/21 at 8:43 AM revealed the resident was in bed with three-quarter side rails up on both sides of the bed. The mattress failed to fit snuggly within the side rails and observation revealed a gap large enough for R96 to place her leg between the mattress and side rails. Review of R96's Face Sheet revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/16/21 revealed the resident was moderately cognitively impaired, as evidenced by a Brief Interview for Mental Status (BIMS) score of 8/15. Review of the both the electronic medical record (EMR) and hard-copy records provided by the facility chart revealed no evidence of any attempts to use other devices prior to side rails for R96's bed. There was no evidence in either record that the resident was assessed for the use of the side rails. There was no evidence that the facility considered the factors such resident's medical diagnoses, conditions, symptoms, and/or behavioral symptoms, size and weight, sleep habits, medication(s), acute medical or surgical interventions, underlying medical conditions, existence of [CONDITION(S)], cognition, communication, or mobility (in and out of bed) prior to the use of the side rails. There was no evidence that either R96 or their representative gave informed consent after being provided with the risks and the benefits of the side rail use. 2. Observation of R125 on 10/11/21 at 11:52 AM revealed she was laying in bed with three-quarter sized rails raised on both sides of the bed. Review of R125's Face Sheet found in R125's EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R125 required extensive assistance of staff of one-person physical assistance for bed mobility, transfers, dressing, and personal hygiene. Review of R125's EMR revealed no evidence that other devices had been attempted prior to siderails, no evidence of an assessment for the use of the siderails, and no evidence that the facility had identified risks and benefits of the siderails. Further, there was no evidence that the facility informed the resident's Responsible Party (RP) or obtained informed consent for the use of the siderails. 3. Observation on 10/14/21 at 5:56 PM revealed R3 lying in bed with two half-side rails up. Review of R3's Face Sheet located in the EMR revealed that the resident was admitted to the facility in 2019 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a quarterly MDS, with an ARD of 07/07/21, revealed that the resident was severely cognitively impaired, as evidenced by a BIMS score of 4/15. Per the MDS, R3 needed extensive assist for functional status. Further review of R3's EMR revealed no evidence of assessment for the use of the side rails or informed consent given after the risks and benefits of their use was explained to the resident and/or their representative. 4. Observation on 10/14/21 at 8:38 revealed R89 was in bed, with two half-side rails s up. During an interview on 10/13/21 1:12 PM, R89 stated that the side rails were on the bed when she came; the facility never asked if she needed them or wanted them, they were just there. Review of R89's face sheet in the EMR indicated that she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission MDS, with an ARD of 08/03/21 revealed the resident was moderately cognitively impaired, as evidenced by a BIMS of 8/15. Further review of R3's EMR revealed no evidence of assessment for the use of the side rails or informed consent given after the risks and benefits of their use was explained to the resident and/or their representative. Interview on 10/14/21 at 10:33 AM with the Director of Plant Maintenance revealed that all beds have side rails, and they are attached when they assemble the bed. The Director of Plan Maintenance stated that every Wednesday, nursing, and maintenance make rounds of all rooms and check lights, beds, and anything that may need fixed. A list is made, and the work is completed. The Director of Plant Maintenance indicated that there was no system for routine checks of the mattress and its fit within the side rails to assure there were no entrapment hazards. When asked who assessed the use of side rails for each resident, he stated, Nursing does all of that. Interview on 10/14/21 at 01:40 PM, the Director of Nursing (DON) stated that side rails come with the beds and residents are not assessed. The DON stated that residents can choose whether they want the side rails up or not. The DON added that, since the side rails are attached to the bed, an informed consent is not completed, and the side rails are not care planned. The DON stated that the risks and benefits of the side rails are not discussed with the resident or the resident representative. The DON thought that maintenance logs were kept on bed installations. When asked if there were risks to a resident not being assessed for side rails, she stated, I cannot answer that. Review of the policy titled, Use of Restraint/Bed Rails/Safety Device, revised on 10/21, indicated .that restraints/safety devices shall only be used for the safety and well-being of the residents and will only be implemented after least restrictive alternatives have been unsuccessful. Further review of the policy revealed that it failed to address maintenance requirements for routine checks of issues such as loose side rails and monitoring for gaps sufficient in size to create a risk of entrapment.

Based on observation, interview, and facility document review, the facility failed to ensure there was a sufficient supply of bath linens available on two of four units ([NAME] and Dogwood). This failure had the potential to affect 101 residents living on these two units, out of the total census of 145 residents. Findings include: 1. Interview on 10/11/15 at 11:11 AM with R84 revealed that the facility does not have enough washcloths and towels. R84 stated she likes to wash her face in the morning and most days when she asks for linens, none are available. The resident states that she does not get to wash her face before breakfast, and this is upsetting to her. 2. During a Resident Council Meeting held on 10/12/21 at 1:30 PM, seven of seven residents (Residents (R) 18, R35, R64, R75, R77, R131, and R134) who regularly attend resident council meetings expressed concerns about a shortage of washcloths/towels, specifically on the Camellia and Dogwood Long Term Care Units. During interview, R64 stated, There is a short supply of washcloths and towels every evening. There used to be a cart that was full of linen and now it's last minute. I doubt if there is anything in it today. R75 stated, Those that know your routine [staff], know how many washcloths you will need, but they are generally short. R134 (who resides on the Dogwood unit) stated, There is a closet in our hallway that stores everything and when I need something like an extra towel, I will open the door and help myself. There is not enough in there. The supply is generally low. R64 stated, The supply is generally low. All day it's low. I doubt there is [sic] any towels on the unit right now. About 3:30-4:00 PM, they will bring linens and lately, it is always short. During the Resident Council Meeting, R18, R35, R64, R75, R77, and R131, who all indicated they reside on the Camellia Unit agreed, There are not enough washcloths and towels. 3. Interview on 10/13/21 at 8:40 AM with Certified Nurse Aide (CNA) 25 revealed that she was having a hard time finding towels and washcloths for her morning rounds. CNA25 stated the linen closet had no towels and only a few washcloths. She added that the linen closet is not replenished until after 10:00 AM. Observation of the linen closet for Rooms 17-32 on the Dogwood Unit on 10/13/21 at 9:15 AM revealed there were no wash clothes and no towels in the closet. Interview with Linen Aide 2 on 10/13/21 at 9:28 AM revealed that he does not know how many towels and wash clothes should be available in each linen closet on each hallway, but he stocked the closet twice a day. Linen Aide 2 stated that there was a shortage of linens over the summer when they had more new admissions but was not aware of any recent issues. 4. Observation of the linen closet for Rooms 1-16 on the Dogwood Unit on 10/13/21 at 10:01 AM revealed there were 40 wash clothes and no towels available for use. Observation and interview on 10/13/21 at 10:20 AM with Linen Aide 1 revealed that he had just replenished the linen closet. Observation of the closet revealed there was a small stack of approximately 20 towels and approximately 40 washcloths. He stated that the laundry is outsourced and goes out daily and returns daily. He restocks what he has. Linen Aide 1 stated, Linen has been cut back and I have made numerous reports to the management that more linen is needed. 5. Interview with CNA4 on 10/13/21 at 10:23 AM revealed she was assigned to resident rooms 17-24 on the Dogwood unit and there were not enough wash clothes and towels to perform bed baths for the residents a couple of weeks ago. CNA4 stated she looked in the resident rooms and the closet on the other hallway for wash clothes, but none were found so CNA4 used a pillowcase to perform a bed bath for the resident. CNA4 stated that every resident was given at least a partial bed bath daily and she used a minimum of two wash clothes and one towel when performing the bed bath. Interview with Unit Manager (UM) 3 on 10/13/21 at 10:31 AM revealed there was one linen closet on each hallway on the Dogwood Unit and that the linen aides stock the closets at least twice daily. UM3 stated that she expected staff to check the other hallway closet for linens and then report to her if more were needed to perform their assignments. UM3 stated when the staff needed more linens, she would contact materials management and they would bring more linens to the unit. UM3 further stated she had only worked on the unit one week and was not aware of a time when no towels or wash clothes were available. Interview with CNA5 on 10/13/21 at 2:26 PM revealed she had worked at the facility six weeks and would use five wash clothes and three towels when performing a bed bath for a resident. CNA5 stated that there were not enough wash clothes and towels on the weekends and sometimes there were not enough during the week. CNA5 stated that when there were not any wash clothes and towels in the linen closet on her assigned hall, she would look in the other hall linen closet on the unit. Interview with the Director of Nursing (DON) on 10/14/21 at 3:40 PM revealed that it was important to have an adequate supply of linens available for staff use for resident care. The DON stated that linens were an ongoing issue because staff had been throwing them away and they were storing them in the resident's rooms. The DON also stated that all the staff had been trained on not throwing the linens away and storing them in the resident's rooms. Interview on 10/13/21 at 1:01 PM with the Director of Material Management revealed that linen is outsourced six days a week to an independent contractor who takes care of all linens for the facility. The Director of Material Management stated he would like to see more linen in the facility, adding they had an extra reserve this summer, but now it is low. The Director of Material Management noted that census increased, and the supply of linen went down. He stated, I am aware that the residents need linen, and we ensure that they have linen and provide what we can. He explained that if the linen supply gets low, the charge nurse will call down for linens and they pull from the next day's supply. Further interview revealed that that linen is listed by weight, and soiled linen weighs more than clean dry linen. Therefore, they never get back the same quantity of linen which they send out and there was no system in place to count or record the linen that goes out and the linen that is then returned. Record review of email documentation revealed 16 emails from 03/30/21 to 10/11/21 from the Director of Material Management to the linen company asking for various linen types because they were short.

Based on interview, record review, and review of facility policy, the facility failed to ensure that the resident and/or the resident's representative (RP) for two (Resident (R) 118, and R288) of 31 sampled residents were provided with a summary of the baseline care plan. The facility failed to provide written summaries of the baseline care plan that included, at a minimum, the initial goals of the resident; medications and dietary instructions; and services and treatments to be administered by the facility and personnel. Findings include: 1. Review of R118's undated face sheet located in the electronic medical record (EMR) under the demographic tab indicated the resident was admitted on [DATE] from the hospital. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R118's Interdisciplinary Notes provided by the Social Service Director (SSD), dated 05/14/21, revealed Baseline care plan was reviewed with resident to include summary of resident's medications, initial goals, services, and treatment to be administered, primary diagnoses, and discharge plan. However, review of R118's EMR and hard chart revealed no evidence the facility had provided the resident and/or resident representative with a written summary of the baseline care plan. Review of R118's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/28/21, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13/15, indicating the resident was cognitively intact. During an interview conducted on 10/11/21 at 3:24 PM, R118 stated, I don't know what my care plan is. I don't remember anyone speaking to me and giving me any papers to keep related to my care plan needs. 2. Review of R288's undated Face Sheet located in the EMR under the demographic tab, indicated the resident was admitted to the facility on [DATE] from the hospital. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R288's Interdisciplinary Notes provided by the SSD, dated 10/01/21, revealed Baseline care plan was reviewed with Resident/Family to include summary of resident's medications, initial goals, services, and treatments to be administered, primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R288's admission MDS with an ARD of 10/05/21, revealed the resident had a BIMS score of 5/15, indicating severe cognitive impairment. As a result, an interview was conducted on 10/12/21 at 10:59 AM with R288's RP, who stated, I don't recall getting a written care plan, I would really like to be part of the care plan meeting. During an interview conducted on 10/13/21 at 12:39 PM, the SSD was asked to provide any documentation verifying the facility provided a written summary of the baseline care plan to these residents and/or their representative. The SSD stated, We [social services] document that we discuss the care plan, but we don't give them [resident/resident representatives] a copy. I wasn't aware that was a requirement. Review of the facility's policy titled Care Planning dated 01/21 revealed the baseline care plan is developed and implemented within the first 48 hours of admission .The interdisciplinary team will meet with the resident and/or representative to discuss the baseline care plan.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure the care plan for one (Resident (R) 103) of 31 sampled residents was revised as needed. R103's care plan was not reviewed and updated when the resident developed a facility-acquired Stage II pressure ulcer. Findings include: Review of a facility policy titled, 8.25 Care Planning, dated 01/21, revealed, An appropriate individualized plan is developed, reviewed, and modified throughout the resident's stay to ensure optimum levels of function .Policy: The facility will develop an Interdisciplinary Care Plan for each resident that includes measurable goals and objectives to meet the resident's medical, nursing .needs. The policy further indicated, In cases of significant changes, in the resident's condition, the Care Plan must be updated. During an observation and interview on 10/11/21 at 2:26 PM, R103 was observed to be in bed in his room. At this time R103 stated, I have a sore on my butt, but they are treating it. I didn't have it at the hospital. Review of R103's Face Sheet, located in the electronic medical record (EMR) under the Document Storage tab revealed R103 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an 09/17/21 Nursing Admission Assessment, located in the EMR under the Clinical Documentation tab, revealed that upon admission, R103's skin was warm and dry, and the resident did not have a pressure ulcer. Review of an 09/17/21 Plan of Care, located in the EMR under the Plan of Care tab indicated, Pressure ulcer-at risk for altered skin integrity and pressure ulcers related to decreased mobility, decrease in Activities of Daily Living (ADL) abilities. The plan of care did not indicate that the resident had a pressure ulcer at that time. Review of an Admission Minimum Data Set (MDS) assessment, located in R103's EMR under the Skilled tab, with an Assessment Reference Date (ARD) of 09/22/21, revealed R103 had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating no cognitive impairment. The MDS indicated R103 had impairment on both sides of the lower extremities. The MDS further indicated R103 was at risk of developing pressure ulcers/injures but did not have any pressure ulcers upon admission. Review of a 10/08/21 Interdisciplinary Note, located in the EMR under the Notes tab indicated, CNA [Certified Nursing Assistant] let this writer know of patient's buttocks breakdown. R [Right buttock] has open area of 0.5cm [centimeter] x 0.5cm. Triad cream applied and alleyvn. Charge nurse notified. Review of a 10/08/21 Admission/New Wound Assessment located in the EMR under the Clinical tab indicated, Wound Assessment- Present on Admission- No. Shape is irregular. Size is length: 0.5cm x Width: 0.5cm. Stage 2. Wound Intervention: Triad Cream, Dressing: Allevyn. Wound Plan of care: Daily dressing change. Risk Level for Skin Breakdown: Mild. Skin Breakdown Prevention Interventions in Place: Resident is able to turn and re-position self. Review of a body diagram on the Wound Assessment indicated 10/08/21- Site: Buttocks Pressure Injury. Acquired. Further review of R103's Plan of Care, revealed no evidence that, as of 10/13/21, the care plan had been revised to indicate that the resident had developed a facility-acquired pressure ulcer. The care plan failed to indicate the interventions what interventions were needed to assist in healing the pressure ulcer which developed in the facility. During an interview on 10/13/21 at 8:48 AM, Licensed Practical Nurse (LPN)7 stated, It was acquired on the right buttock on 10/08/21 and it was a Stage II at 0.5cm x 0.5cm. For treatment, we were doing triad cream daily and the treatment was changed yesterday when I saw him. Yesterday the measurements were 0.00 and it was fully closed. It was first identified on his bottom on 10/08, and it is healed now. During an interview on 10/13/21 at 10:05 AM, the MDS Coordinator stated, I was not aware he had a new pressure ulcer. This is the first time I'm hearing of it. The 8th was Friday. Normally, we have a clinical meeting in the morning Monday through Friday. Our clinical team meets after we have a stand-up meeting. We have not had a clinical meeting today. The MDS Coordinator continued, Normally, a new pressure ulcer is reported to us in clinical stand-up meetings, then I jot it down and report it to the other MDS Coordinators. At that time, the other MDS Coordinators would be updating the care plan. Whoever has that particular group, will update it at that time. Had we met in our clinical meetings, I would have reported it to our team, and we could have updated it right then, but you all have been here since Monday, and we haven't had our meeting. At this time, the MDS Coordinator verified the care plan for R103 was not updated to reflect the Stage II pressure ulcer that R103 acquired on 10/08/21. During an interview on 10/13/21 at 11:41 AM, the Director of Nursing (DON) confirmed the care plan for R103 was not updated to reflect the Stage II pressure ulcer when it was acquired on 10/08/21, stating, I do not see there has been anything added. The DON stated, Our process is usually there is a QVR (Incident Report) that is done. The Unit Manager gets it and receives it, and she comes to the morning meeting. We have a stand-up huddle and review the QVRs. Then the MDS person reports back to the team there is a pressure ulcer, so it can be added to the care plan. But this Monday, we had you all come in for survey. I don't see anything on the care plan that has been added at this time. At this time, while the DON was reviewing R103's care plan in the EMR, the DON then stated, I do now see that on 10/13/21 [today] there was something added. Prior to today, I don't see anything added. It was added by the MDS person as of today. During a second interview with the MDS Coordinator on 10/14/21 at 1:51 PM regarding R103s care plan, the MDS Coordinator stated, I corrected and updated the care plan yesterday. When we spoke, that was the first time I found out about the wound. I put in interventions yesterday. It was identified on 10/08. After I talked to you, I updated the care plan to reflect the pressure injury to the right buttock.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that one (Resident (R) 50) of 29 current sampled residents received activities in accordance with the resident's assessed preferences. The facility failed to assist R50 so the resident could attend a religious activity, per the resident's choice. Findings include: Review of the facility policy titled Therapeutic Recreation Department, dated 02/10/17, revealed the mission of the department was to plan and provide an ongoing, comprehensive program of recreation services which empowered the residents toward increased independence, personal choice, and expression, and to improve or maintain their level of physical and cognitive functioning. The policy stated that based on their interests and functioning level, a care plan was created. This would include bedside, 1:1 visits, small and/or large group activities. The policy related that a variety of activities would include religious, creative, physical, cognitive, and social-type activities. Per the policy, an activity calendar was to be produced monthly, and each resident would receive a large copy that was posted in their room. Review of R50's Face Sheet found in R50's Electronic Medical Record (EMR) under the Face Sheet tab revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R50's Significant Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/29/21, found in R50's EMR under the MDS tab revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. The MDS also indicated that R50 stated it was very important to participate in religious services and practices. The MDS indicated R50 had limitations in range of motion (ROM) to the upper and lower extremities on both sides, and was totally dependent on staff for bed mobility, transfers, bathing, dressing and locomotion on and off the unit. Review of R50's comprehensive Care Plan, revised 08/17/21, found in R10's EMR under the Plan of Care tab indicated, Resident will engage in self-directed activities of interest (daily chronicle and bible) with assist from staff. The care plan also indicated Resident will attend worship or Bible Study two times a week when feasible to meet spiritual needs. Observation of R50's room revealed a recreation calendar dated 10/21 with Bible Study listed on 10/11/21 at 2:00 PM. Interview with R50 on 10/12/21 at 11:42 AM revealed that he wanted to go to the Bible Study activity on 10/11/21 at 2:00 PM. However, the nurse aide did not get him up to his chair. R50 stated the recreation assistant came by his room but he was not in his chair so she could not take him to the activity in the recreation room. R50 stated the nurse aide told him she had not put him in his chair because she was busy getting residents ready for their appointments and visits with family. Interview with Unit Manager (UM) 3 on 10/13/21 at 10:39 AM revealed she was not notified that the nurse aide did not get R50 up for his religious activity on 10/11/21. UM3 stated that it was a priority to get R50 up because Bible Study was one of his favorite activities. UM3 also stated she walked around the unit to ensure residents are ready for appointments and family visits. UM3 further stated she expected the nurse aides to ask for assistance with transfers from the bed to the chair from the nurse aide on their hall, team leader (nurse), or charge nurse on the unit. Interview with Certified Nursing Aide (CNA) 6 on 10/13/21 at 10:51 AM revealed that she was originally scheduled on the bath team on 10/11/21; however, another CNA called out that day, so she took their place. CNA6 stated R50 told her that he wanted to get up for Bible Study at 2:00 PM and she gave him a bed bath, but she did not get him up because she was still giving care to other residents. CNA6 stated she informed the oncoming CNA at 3:00 PM (after the activity occurred) but did not ask for assistance from other staff to get the resident up for the activity because they were also busy. Interview with the Director of Nursing (DON) on 10/15/21 at 12:04 PM revealed if a resident wants to go to something, then she expects staff to meet their needs to participate in that activity. The DON stated the Unit Managers were expected to manage their unit and prioritize the needs of the residents. The DON also stated she expected staff to complete their assignments, and work with the residents to meet their needs. Interview with Licensed Practical Nurse (LPN) 8 on 10/15/21 at 1:40 PM revealed she was the charge nurse on the unit on 10/11/21 and was responsible for ensuring that the nurse aides and nurses completed their assignments daily. LPN8 stated the nurse aide should have reported to the nurse or to her that she did not have time to get R50 up for the activity that day so she could have assured the resident received the needed assistance in attending his preferred activity Interview with LPN1 on 10/15/21 at 1:54 PM revealed she was assigned to R50 on 10/11/21. LPN 1 stated R50 mentioned he wanted to go to Bible Study at 2:00 PM but she did not have time to get back to him before the activity. LPN 1 confirmed that CNA6 failed to inform her that she needed assistance in transferring R50 to the chair so he could attend his activity that day.

Based on observation, interview, and document review, the facility failed to post all required nurse staffing data, including both total number and actual hours worked for each shift. In addition, the required data was not posted on two of four units ([NAME] and Beechwood) or in a common area to which all residents and visitors had access. Findings include: Observation on 10/11/21 at 12:56 PM revealed no evidence that the required staff data information was posted in a common area of the facility such as the lobby where visitors had access and were screened for COVID-19, or on two of the facility's four units ([NAME] or Beechwood). Nurse staffing data dated 10/11/21 was found to be posted in a glass case on the [NAME] and Dogwood Unit hallway by the Courtyard 4 sign. However, Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . The total number of hours, as well as the actual hours worked for licensed and unlicensed nursing staff for the second shift were not completed on the posting for the day. Interview on 10/13/21 at 8:25 AM with the Nursing Administration Office Manager revealed she had been employed at the facility for [AGE] years and nurse staffing data had always been posted on the [NAME] and Dogwood Unit hallway in the glass case. The Office Manager stated it used to be her responsibility to complete the nurse staffing data for the first (day) shift staff and it was then the Nursing Supervisor's responsibility to complete the data for the second [night] shift staff and post it in the same location when she came in at 3:00 PM daily. Continued interview revealed that she had trained the Nursing Administration Secretary how to complete the nurse staffing data and it was her responsibility to complete and post it for the day shift now. Interview on 10/13/21 at 8:30 AM with the Nursing Administration Secretary revealed she would review the daily schedule to determine the number of nursing staff that worked each day, multiply the number of hours they were working that day, and then enter the information on the posting. The Nursing Administration Secretary stated the purpose of the data posting was to inform the residents and visitors how many nursing staff were providing care to the residents on a daily basis. Interview on 10/14/21 at 3:16 PM with the Director of Nursing (DON) revealed the purpose of posting was to inform the visitors and staff of the numbers of unlicensed and licensed nursing staff. The DON stated there was no formal process for this and no written procedure on how to the update the system. Further interview with the DON revealed the facility did not have a policy that addressed the requirement for posting data regarding licensed and unlicensed nursing staff at the facility. Continued interview with the DON confirmed that the staffing data was not posted in a manner which assured it was accessible to all visitors and residents, as it was not posted in either the lobby where all visitors were screened for COVID-19 or on the side of the facility where the [NAME] and Beechwood Units were located.

Based on observations, staff interviews and facility documentation, the facility staff failed to ensure social distancing and/or facial coverings for the residents were in use when out of their rooms on two of four units to prevent potential transmission of infection. The findings include: On 6/16/20 at 6:35 p.m., fourteen residents were observed positioned in the Dayroom on the Dogwood unit, either at tables, geri-loungers or in wheelchairs. None of the residents were observed to be socially distanced at six feet apart, nor were they wearing facial coverings. Some of the residents at the rectangle tables could reach out to touch one another. Three residents were ambulating in wheelchairs on the unit passing and stopping in proximity of the residents in the Dayroom without masks. During the aforementioned observation, Unit Manager, Registered Nurse (RN) #1 stated ten residents leave the unit at designated times for activities and for any other reason wear masks, but not on the unit because the staff ensure social distance between each resident. All nursing staff were observed wearing masks. On 6/16/20 at 6:55 p.m., twelve residents were observed positioned in the Dayroom on the Camellia unit, either at tables or in wheelchairs. None of the residents were observed to be socially distanced at six feet apart, nor were they wearing facial coverings. Some of the residents at the rectangle tables could reach out to touch one another. Two residents were ambulating in wheelchairs on the unit passing and stopping in proximity of the residents in the Dayroom without mask. During the aforementioned observation, Unit Manager, RN #2 stated the residents were positioned in the dayroom to maintain social distancing between each other at six feet. He stated, There is not much we can do with the residents that move about in their wheelchairs on the unit with regard to social distancing, but no resident leaves the unit without a face mask. All nursing staff were observed wearing masks. On 6/18/20 at 2:10 p.m., a phone interview was conducted with the Infection Control Preventionist, RN #3. When the aforementioned observations were shared with her, she stated she expected the nursing staff to position residents on the individual unit's dayrooms to maintain social distancing, but had not considered the residents that move about the unit whether they should wear face masks since social distancing with those residents were more challenging. On 6/18/20 at 2:38 p.m., a debriefing was conducted via phone with the Administrator, Director of Nursing, Infection Control Preventionist and the Minimum Data Set (MDS) Coordinator. The aforementioned observations of residents on the Dogwood and Camellia were discussed with the administrative group. No further information was provided prior to survey exit. The facility's COVID-19 Task Force Time Line of actions meeting dated 4/15/20 indicated that the Dayroom was being used on all Long Term Units and face masks given to patients to wear when off unit to rehab, doing laundry in rehab, or leaving unit to be in front lobby or walking front hallway . Practice social distancing 6 feet if patient isn't wearing mask. The facility's policy and procedure titled in Section D-page 43, Prevention and Control of Corona-virus, COVID-19 Residents indicated transmission of COVID-19 can be person-to person between people who are in close contact with one another (within about 6 feet) through respiratory droplets when a person speaks, coughs or sneezes. Droplets can land in mouths, noses, or eyes of people who are nearby or possibly inhaled into the lungs of those in close proximity. Another source of control included placing a mask on the patient.

Based on clinical record review, staff interviews, and facility document review, the facility staff failed to notify the office of the State Long-Term Care Ombudsman in writing of applicable discharges for 4 of 48 residents (Residents #164, #163, #147 and #164 B) in the survey sample. 1. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #164's discharges to the hospital on [DATE] and 8/15/18. 2. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #163's discharge to the hospital on [DATE]. 3. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #147's discharges to the hospital on [DATE] and 8/30/18. 4. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #164B's discharge to the hospital on [DATE]. The findings included: 1. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #164's discharge on 8/2/18. Resident #164 was admitted to the nursing facility on 7/26/18 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment was an admitted d 7/30/18 and coded the resident on the Brief Interview for Mental Status (BIMS) with a 15 out of a possible score of 15 which indicated the resident was cognitively intact with the necessary skills for daily decision making. During a discussion with the Administrator on 11/1/18 at 2:15 p.m., he stated they reported 30 day discharges to the Ombudsman, but no other discharges to include the emergency room , the local hospital or discharges to the community. There was no policy or procedures in place that detailed a process on reporting facility discharges to the Ombudsman. No further information was provided by the facility staff prior to survey exit on 11/1/18 at 7:30 p.m. 2. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #163's discharge on 9/24/18. Resident #163 was admitted to the nursing facility on 8/30/18 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment was an admitted d 9/6/18 and coded the resident on the Brief Interview for Mental Status (BIMS) with a 15 out of a possible score of 15 which indicated the resident was cognitively intact with the necessary skills for daily decision making. During a discussion with the Administrator on 11/1/18 at 2:15 p.m., he stated they reported 30 day discharges to the Ombudsman, but no other discharges to include the emergency room , the local hospital or discharges to the community. There was no policy or procedures in place that detailed a process on reporting facility discharges to the Ombudsman. No further information was provided by the facility staff prior to survey exit on 11/1/18 at 7:30 p.m. 3. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #147's discharge on 9/17/18. Resident #147 was admitted to the nursing facility on 11/25/17 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 6/28/18 and coded the resident on the Brief Interview for Mental Status (BIMS) with a 15 out of a possible score of 15 which indicated the resident was cognitively intact with the necessary skills for daily decision making. During a discussion with the Administrator on 11/1/18 at 2:15 p.m., he stated they reported 30 day discharges to the Ombudsman, but no other discharges to include the emergency room , the local hospital or discharges to the community. There was no policy or procedures in place that detailed a process on reporting facility discharges to the Ombudsman. No further information was provided by the facility staff prior to survey exit on 11/1/18 at 7:30 p.m. 4. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #164B's discharge on 12/15/17. Resident #164B was admitted to the nursing facility on with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] was a 5-day assessment and coded the resident on the Brief Interview for Mental Status (BIMS) with a 15 out of a possible score of 15 which indicated the resident was cognitively intact with the necessary skills for daily decision making. During a discussion with the Administrator on 11/1/18 at 2:15 p.m., he stated they reported 30 day discharges to the Ombudsman, but no other discharges to include the emergency room , the local hospital or discharges to the community. There was no policy or procedures in place that detailed a process on reporting facility discharges to the Ombudsman. No further information was provided by the facility staff prior to survey exit on 11/1/18 at 7:30 p.m.

Based on observations during medication pour and pass, resident statement, staff interviews, clinical record review, and review of the facility's policy, the facility staff failed to ensure the medication error rates was not 5 percent or greater for 3 of 48 residents (Resident #152, #314 and #27), in the survey sample. During the medication pour and pass observation conducted with several staff over different shifts. Twenty-six (26) medication opportunities were observed; five (5) medication errors occurred resulting in a 19.23% medication error rate. 1. The facility staff crushed Resident #152's Alfuzosin [MEDICATION NAME] (a medication to decrease [MEDICAL CONDITION]) (Hcl) Extended Release (ER) 24 hours, which is a do not crush medication. 2. The facility staff crushed Resident #314's Potassium Chloride Extended Release (ER), which is a do not crush medication. 3. On 10/31/18 at 10:00 a.m., during the morning medication pass, two medications were omitted ([MEDICATION NAME] 100 milligrams and Atrovent nasal spray) and a third medication was administered in the wrong route (Artificial tears drops instead of artificial tears ointment) for Resident #27. The findings included: 1. Resident #152 was originally admitted to the facility 8/1/18 and has not been discharged from the facility. The current [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/8/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. That indicated Resident #152's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 2 people with bed mobility and transfers, extensive assistance of 1 person with off unit locomotion, dressing, toileting, personal hygiene and bathing and total care with eating. In Section H0100A, the resident was coded as requiring use of an indwelling urinary catheter. The physician's orders [REDACTED]. The care plan revealed a problem dated 8/2/18 which read; (name of resident) receives 100% of nutritional needs via J/[DEVICE]; tube feedings and medications. The goal read; (name of resident) will tolerate tube feedings without residuals or signs of nausea, vomiting, diarrhea through 11/20/18. (name of resident) will show no signs of aspiration through 11/20/18. The interventions included; Monitor intake, weights, labs, medications for changes and adjust medical nutrition therapy as needed to meet nutrition needs. On 10/31/18, at approximately 4:00 p.m., Licensed Practical Nurse (LPN) #1 crushed the Alfuzosin Hcl ER 10 milligrams and mixed it with water to administer via Resident #152's G- tube. For 26 minutes LPN #1 mixed the crushed tablet in water but it congealed into a clump of white which couldn't pass from the syringe into the [DEVICE]. LPN #1 then discarded the white clump into the trash. An interview was conducted with Licensed Practical Nurse (LPN) #1, on 10/31/18 at approximately 7:00 p.m., LPN #1 stated she didn't understand why the medication clumped and wasn't capable of passing from the syringe in to the G- tube. LPN #1 further stated she wasn't aware the medication was a do not crush medication. An interview was conducted with on 11/1/18, at approximately 6:20 p.m., with the consulting Pharmacist. The Pharmacist stated she reviewed Resident #152's medications approximately 8/2/18 and the resident wasn't receiving the medication at that time and she missed crushing the medication during the 9/2018 and 10/2018 reviews. On 11/1/18; at approximately 6:20 p.m.,the facility staff presented a new order dated 11/1/18 at 10:10 a.m., to discontinue the Alfuzosin Hcl ER 10 milligrams and start Oxybutinin ER liquid via [DEVICE], everyday. The facility's Medication Administration Policy with a revision date of 1/17 read at #6; Drugs must be administered correctly as ordered and according to specific instructions. On 11/1/18, the above findings were shared with the Administrator and Director of Nursing. The Director of Nursing stated no extended release medications should be crushed. DEFINITIONS A jejunostomy tube is a tube inserted through the abdomen that delivers nutrition directly into the small intestine A gastrostomy tube is a tube inserted through the abdomen that delivers nutrition directly to the stomach. [MEDICAL CONDITIONS] is an enlargement prostate gland. 2. Resident #314 was originally admitted to the facility 10/22/18 and had not been discharged from the facility. The The current [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment had not been completed but the nursing admission assessment revealed Resident #314 was alert, and oriented to person, place, time and situation. The nursing admission assessment also revealed the resident short and long term memory was intact and she was capable of understanding what was said to her and making her needs known. The physician's orders [REDACTED]. The care plan revealed a problem which read; Potential for complications related to hypertension. The goal read; (name of resident) will be/remain free of signs and symptoms or complications related to hypertension through 1/24/19. The interventions included; Obtain and monitor labs/diagnostic work as ordered. Report results to physician and follow-up as indicated. Provide medications as ordered and monitor for side effects/effectiveness. On 10/31/18, at approximately 5:58 p.m., Licensed Practical Nurse (LPN) #1 crushed Resident #314's Potassium Chl ER and mixed it in applesauce. She stated that was how the resident liked to take it. Upon entering Resident #314's room the resident asked when I go home can I go back taking my small potassium pill? I don't like that big pill. LPN #1 handed the resident the cup and she accepted the crushed medicine as well as two other medication capsules in another cup. An interview was conducted with Licensed Practical Nurse (LPN) #1, on 10/31/18 at approximately 7:00 p.m., LPN #1 stated she didn't realize the potassium was an extended release medication, she just knew the resident didn't like the big pill and crushing it solved her concern. On 11/1/18 at approximately 6:20 p.m.,the facility staff presented a new order dated 11/1/18 at 10:10 a.m., to change the Potassium Chl ER tablet to a liquid form two times per day and to offer yogurt along with the liquid potassium. The facility's Medication Administration Policy with a revision date of 1/17 read at #6; Drugs must be administered correctly as ordered and according to specific instructions. On 11/1/18, the above findings were shared with the Administrator and Director of Nursing. The Director of Nursing stated no extended release medications should be crushed. 3. On 10/31/18 at 10:00 a.m., during the morning medication pass, two medications were omitted ([MEDICATION NAME] 100 milligrams and Atrovent nasal spray) and a third medication was administered in the wrong route (Artificial tears drops instead of artificial tears ointment). Resident #27 was admitted to the nursing facility on 2/12/14 with [DIAGNOSES REDACTED].*[MEDICAL CONDITION]. *[MEDICAL CONDITION] is a chronic arthropathy characterized by disruption and potential loss of joint cartilage along with other joint changes (https://www.merckmanuals.com/professional/musculoskeletal-and-connective-tissue-disorders/joint-disorders). *[MEDICAL CONDITION], also referred to simply as a chronic [MEDICAL CONDITION] brain disease that usually starts slowly and worsens over time (https://www.nia.nih.gov/health). The most recent Minimum Data Set (MDS) was a quarterly dated 8/9/18 and coded the resident on Brief Interview for Mental Status (BIMS) with a score of 13 out of a possible score of 15 which indicated she was intact in the skills needed for daily decision making. The resident was coded to have constipation, dry eye syndrome of unspecific lacrimal gland, as well as allergic rhinitis and [MEDICAL CONDITION]. The care plan dated as revised on 8/22/18 indicated the resident had altered discomfort related to eye irritation and the goal set for the resident by the staff was that she would not have any complication related to prescribed medication. One of the approaches the staff would take to accomplish this goal included administered eye medication as ordered by the physician. The care plan identified the resident was at risk for constipation as a result of side effects from medication. The goal the staff set for the resident was that she would have regular bowel movements 2-3 days per week. One of the approaches the staff would implement to accomplish this goal included to administer bowel protocol that included administering the bowel medications as ordered by the physician. The care plan identified episodes of dyspnea and upper respiratory allergic symptoms. The goal set for the resident by the staff indicated the resident would be free of any upper respiratory allergic symptoms. The approaches the staff would take to accomplish this goal included administer medication as ordered by the physician. Resident #27 had physician orders [REDACTED]. On 10/31/18 at 10:00 a.m., during the morning medication pass, Licensed Practical Nurse (LPN) #4 omitted [MEDICATION NAME] 100 milligrams and Atrovent nasal spray and a third medication was administered in the wrong form: Artificial tears drops instead of artificial tears ointment. Review of the Medication Administration Record [REDACTED] On 11/1/18 at 1:50 p.m., the aforementioned medication errors were reviewed with Unit Manager Registered Nurse #6. She stated LPN #4 was an agency nurse, floated all over the facility and was scheduled to work another unit for 11/1/18, thus she was not able to review the errors with her. On 11/1/18 at 6:15 p.m., a pre-exit meeting was conducted with the Administrator and Director of Nursing (DON). The medication errors were brought to their attention. No further information was provided prior to survey exit on 11/1/18 at 7:30 p.m. The facility's policy and procedures titled Medication Administration revised 1/17 included: the licensed nurse will observe the five rights of administration when passing medications: [REDACTED].

Based on observation, staff interviews and facility document review the facility staff failed to store food in accordance with professional standards for food service safety. The food service staff failed to ensure foods stored in the freezer and dry storage were sealed, labeled and dated when opened. The findings included: On 10/30/18 at 11:00 a.m., during the initial inspection of the kitchen with the Director of Food Services, the following were observed: 1. Inside the walk in freezer was 1 bag of corn on the cob, 1 bag of tilapia, 1 bag of baby shrimp, 1 bag of green beans, 1 bag of zucchini, 1 bag of meatballs, 1 bag of bagels and 1 bag of omelets; which were not sealed closed, labeled or dated. 2. Inside the dry storage was an opened bag of granola; not sealed closed, labeled or dated. On 10/30/18 at approximately 11:14 a.m., the surveyor asked the Director of Food Services, Should the open bag of corn on the cob, tilapia, baby shrimp, green beans, zucchini, meatballs, bagels and omelets and granola be labeled and dated once opened he replied, All food items should be dated after they are open. The Director of Food Services removed all frozen food from the freezer and the bag from dry storage that were open and not dated. The facility administration was informed of the finding during a briefing on 11/01/18 at approximately 5:45 p.m. The facility staff did not present any further information about the findings. The facility's policy titled Food Handling (Revision 09/27/17). -8.1.1. Labeling tools, uses, and required information -Refrigerated/Frozen food label - use for: -All refrigerated foods after opening, preparing, cooking, and cooling -Put this information on the label include but not limited to: -Product name -Open/Production/Freeze date -Initials of Associate

Based on observations, clinical record review, staff and resident interview, the facility staff failed to ensure care was provided to prevent complications for 3 out of 30 residents (Resident #5, #3 and #18), in the survey sample, with an indwelling urinary catheter. 1. The facility staff failed to provide care for a resident with an indwelling urinary catheter and recognize early, the development of a penile erosion that progressed to the extent of a tear from the tip of the penis, through the shaft to the base of the scrotal junction. In addition, the staff failed to follow physician's orders [REDACTED]. Harm was identified for this resident. 2. Resident #3 developed a penile erosion while a resident in the facility from an indwelling urinary catheter. The facility staff failed to ensure intervention with careful offloading to the urethra and securing the catheter, which placed the resident at risk of further urethral tearing and damage. 3. The facility staff failed to maintain indwelling urinary catheter in a manner that promotes urinary health in the following manner: improper anchoring of tubing to prevent further damage of a penile erosion, and improper assessment of surrounding tissue to detect changes in penile erosion, report, and obtain recommendations for needed care for erosion of underside of penis and care for altered skin integrity under anchor device and in the penile erosion for Resident #18. The findings include: 1. Resident #5 was originally admitted to the nursing facility 5/7/15 with [DIAGNOSES REDACTED].*indwelling urinary catheter. Subsequent readmission [DIAGNOSES REDACTED].**E.coli and *ESBL. The readmitted d 7/8/15 diagnosed another stroke. The resident's recent admission diagnosed ***SIRS, ****sepsis secondary to UTI. The most resent Minimum Data Set (MDS) assessment dated [DATE] coded the resident with a score of 15 out of a total score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was fully intact in the cognitive skills for daily decision making. The resident was not assessed with [REDACTED]. Resident #5 was coded to be totally dependent on one staff for bed mobility, dressing, personal hygiene and bathing. The resident was assessed to require extensive assistance from one staff for eating. He was impaired in range of motion of upper extremities. The resident was not able to move from a seated position, walk, turn around, move on and off the toilet or transfer. His mobility device was a wheelchair. The resident was coded always incontinent of bowel and had an indwelling urinary catheter. Resident #5's care plans dated 10/14/15, 1/15/16, 4/13/16 identified he had a Foley (brand name for indwelling urinary catheter) catheter secondary to [MEDICAL CONDITION]. The goal the staff set for the resident was that the resident would remain free of complications related to Foley catheter. Some of the approaches the staff would implement to accomplish this goal included Foley care would be provided per protocol or physician's orders [REDACTED]. On 1/9/16 the care plan was updated to reflect the resident had a split on the left side of his penis and that the area would heal within 90 days, monitor area as ordered and notify physician of any changes. On 1/11/16 the care plan was updated again to include anchoring the Foley catheter loosely to thigh as ordered. Nursing and Certified Nursing Assistants (CNA) were the responsible disciplines to ensure implementation of these approaches. The care plan also identified the resident was at risk for impaired skin integrity related to decreased mobility and stroke with right sided [MEDICAL CONDITION]. The goal the staff set for the resident was that he would not develop any skin breakdown. Some of the approaches that staff would implement to accomplish this goal included body and skin audit at least weekly and notify physician of any areas of breakdown, rash, abrasion, etc. The resident was not assessed on any of the Nursing Admission Assessments dated 5/7/15, 5/21/15, 7/8/15 or 9/28/15 with a penile erosion. Resident #5 had physician orders [REDACTED]. The nurses were scheduled to work 12 hour shifts, 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m. An event report dated 1/9/16 indicated on 1/9/16 at 10:00 a.m., a skin integrity problem was identified: Left side of penis, split open. The Physician/Nurse's Communication Form dated 1/9/16 indicated during care CNA noticed the open split to resident's penis. The licensed nurse assessed the split from tip of penis to the penile shaft, open, red with no bleeding and measured 4 centimeters (cm) in length by 3.5 cm wide. The Foley catheter was noted in place draining amber urine. The physician was called and orders were given to to monitor, call back if worsens and the physician would follow-up on Monday (1/11/16). The attending physician evaluated the resident on 1/11/16 while resident's wife was at the bedside. The resident was diagnosed with [REDACTED]. New orders dated 1/11/16 to current included, Anchor catheter loosely to right thigh-never (never was underlined) to left thigh and hang catheter bag on right side of the bed at all times. Consult Urologist this week-erosion of penis secondary to catheter. The attending physician's progress notes indicated the following: .Penile foreskin, glans and shaft eroded on left side-very large split. No drainage, no bleeding, no pain-somewhat [MEDICAL CONDITION] . The Treatment Administration Record (TAR) dated 1/11/19 through current (April 2016) evidenced the physician's orders [REDACTED]. The urologist evaluated the resident on 1/18/16 for urethral erosion. The notes indicated the resident had a ventral erosion from the tip of the penis to the scrotal junction. It was noted that the Foley catheter was found stretched, not secured; in diaper. The urologist indicated the catheter needed to be secured to leg and not on stretch. A telephone interview was conducted with the urologist on 4/21/16 at 12:45 p.m. The Urologist stated penile erosions could occur in men with chronic indwelling urinary catheters, but if not caught early with early intervention, they start unzipping. She stated early intervention included careful off loading of the pressure point to the urethra. She stated, (Resident #5's name) erosion probably began over a couple of months, but that staff should have seen the beginnings and progression with bathing and daily catheter care, not allowing it to get to this point. I don't usually see them to this extent. This is a severe one. She said if it was sudden, there would have been bleeding. She stated there was no recourse for the resident but a suprapubic catheter, but he was not medically a candidate for surgery. She said the area would not heal back together and the goal was to properly secure the catheter to prevent further urethral and scrotal pressure. She said, it was already known the resident had a history of [REDACTED]. On 4/21/16 at 1:30 p.m., the physician's assistant stated that residents with erosions were at risk for UTIs,[MEDICAL CONDITION] and skin infection. The following observations were made of Resident #5: On 4/19/16 at 12:30 p.m., the resident was observed in bed, positioned on his right side. He initiated and participated in conversation. A Foley catheter urine drainage bag was observed hanging on the left side of the resident's bed frame. The resident stated his Foley catheter had always been on his left side. The resident's bed was clearly visible from the hallway by all nursing staff that passed his room. The resident stated he liked his room door and his privacy curtain to be open. He stated he had two [MEDICAL CONDITION] and was not able to effectively use his hands, needed help from the staff with his meals, as well as the nurses providing his baths. He stated he could not walk or independently reposition himself in bed and never repositioned or pulled out his catheter. On 4/19/16 at 2:30 p.m. to 4:30 p.m. the resident was observed in bed and the catheter remained on the left side. The licensed nurses were observed administering medications to the resident and CNAs were seen in the room emptying the urinary drainage bag. On 4/20/16 at 9:30 a.m. and 10:30 a.m., Resident #5 was again observed in bed and the Foley catheter remained on his left side. An interview was conducted with the assigned CNA #2 at 10:30 a.m. When asked if she obtained a nursing report from the off going CNA about any special instructions on the positioning of the resident's Foley catheter and drainage bag she stated, No, there was nothing special told to me. When asked if the Foley catheter was on the resident's right side, she looked at the resident and said, Yes, it is on the right (as she pointed to the resident's left leg using her right hand). When asked if she saw a split on the resident's penis during the bed bath, she responded, I did not see anything. A skin assessment was made at this time where CNA #2 lowered the resident's head, removed the brief and exposed the resident's penis. When his penis was positioned to the right, a clean split was visible from the tip of the penis to the top of the scrotum with the catheter pressing on the scrotal junction, not in the penis at all. The CNA stated her bath consisted of sudsing up the front of his perineum with a wash cloth, rinsing and turning him over performing the same process to his rectum and buttocks. The catheter tubing was not secured in the Foley stabilization device, but stretched out pressing directly on the scrotal junction with the most narrow part of the catheter sliding in and out the retainer clamp. On 4/20/16 at 10:45 a.m., the unit's charge nurse (LPN #7) was asked if there any specific orders for the positioning of Resident #5's Foley drainage bag and catheter. She checked the chart and Treatment Administration Record (TAR) and stated the catheter should be anchored to his right leg and the drainage bag hanging off the right side of the bed. She immediately went to the resident's room and responded the Foley drainage bag was not hanging on the right side as ordered by the physician. On 4/20/16 at 10:55 a.m., another assessment was made along with another surveyor and assistance from the assigned Licensed Practical Nurse (LPN #8). She stated she was not aware of any split in the resident's penis and there was nothing on the report sheet about the positioning of the Foley drainage bag or Foley catheter. When asked what side the catheter was supposed to be positioned, she stated, No one told me a particular side. The resident stated he hurt from time to time from the tube in his bladder, especially when he is pulled up in bed, turned and repositioned. When asked how he felt about the split on his penis, he stated, There is nothing to feel at this time, I can't straighten or fix anything. The damage has already been done. On 4/20/16 at 11:15 p.m., the Unit Manager (LPN #1) was asked about the correct positioning and anchoring of the resident's Foley catheter and drainage bag, to which she checked the clinical record and responded, The physician ordered that it be on the right at all times because of the erosion. She proceeded to the resident's room, turned and stated, I can see from the hall, it is not on the right. While at the bedside, the UM was also asked if the catheter was anchored properly. She examined the resident and affirmed the catheter should have been on the right side, but did not notice the catheter was not correctly positioned in the Foley stabilization device, but did notice the tension on the catheter and the direct pressure to the scrotal junction. She said on 1/9/16, a traumatic injury occurred where the catheter split the resident's penis from the tip all the way down the shaft, but stated ironically there was no bleeding. On 4/20/16 at approximately 12:00 p.m., the Unit Manger LPN #1 and the Unit Charge Nurse LPN #7 proceeded to the resident's room. The Unit Manager stated, We are going to do Foley care, make a good assessment, anchor the catheter to the right leg and position the Foley drainage bag hanging on the right side per physician's orders [REDACTED]. His right hand was contracted with no functional use. The CNA (#1) who informed the nurse about her first observation of the tear, on 1/9/16, was interviewed on 4/20/16 at approximately 1:00 p.m. She stated she was providing morning care and saw the split when she performed perineum care, but there was no blood. She stated she had cared for him before and never saw it. She said she immediately reported her findings to a licensed nurse. She stated, I have had him since, but did not know about any special positioning of the drainage bag or catheter. It has been on the same side it's on now all along. The LPN (#6) that made the first assessment of the penile split was interviewed on 4/21/16 at 2:20 p.m. She stated she was called to the room by CNA #1 to look at a skin problem. She stated she measured the areas to be 4 centimeters (cm) in length and 3.5 centimeters in width, red with no odor and no bleeding. She stated she had provided Foley care to the resident many times since his admission to the nursing facility. LPN #6 initialed she provided Foley care in the month of January, on the 7 a.m. to 7 p.m. shift, January 4, 5, 8 and signed off there were no new skin integrity issues on the weekly body checks. She stated the weekly body checks encompassed a head to toe check and she would have seen it through them, but assuredly during Foley care. When asked how she performed Foley care she stated she always lifted and cleaned around the penis to include foreskin, shaft, base, as well as the scrotal area and the length of the Foley catheter tubing that lead into the urethra. She stated she did not see the split, nor was she told there was one by the 7 p.m. to 7 a.m. licensed nurses. She said, I found out since this survey that we were not using the anchoring device appropriately and I got inserviced this morning so the catheter does not slide and how to apply the pad on the resident's leg. On 4/21/16 at 1:54 p.m., an interview was conducted with LPN #4 who stated she was frequently assigned the resident to include some days in December 2015 and January 2016 and provided Foley care. She stated she provided Foley care in the same manner as noted above in the interview with LPN #6. She also had the resident frequently during November 2015, December 2015 and January 2016 and said she never saw any split in the resident's penis during Foley care or with skin checks. She stated, I have now learned in training, how we should put the [MEDICATION NAME] (brand name for the Foley stabilization device) on so it does not slide and pull on the resident. On 4/21/16 at 2:10 p.m., another LPN (#5) was interviewed via telephone and signed off she provided Foley catheter care and performed weekly skin checks in December 2015 and January 2016. She stated she did not see a split in the resident's penis, but if she saw one she would have reported to the Charge Nurse or Unit Manager. She stated, I have provided Foley care last month and I think this month for (Resident #5's name) and as far as I know there is no split. She described Foley care as was described by the aforementioned LPN #6, but added she also flushed the tubing with saline to ensure potency. She was not sure of any special positioning/anchoring of the Foley catheter or drainage bag. An interview was conducted with the Director of Nursing (DON) on 4/21/16 at 2:45 p.m. She stated, she too thought the injury to the resident's penis was a sudden injury that occurred on 1/9/16. She stated she had a problem with the extent of the injury and that physician's orders [REDACTED]. She stated she expected the nursing staff to have identified any skin problems early during bathing, Foley care and weekly skin assessments. The DON stated she was not aware and did not have a record of the resident ever pulling out his Foley Catheter and did not think he was capable of doing it. Another interview was held with the Unit Manager LPN #1 on 4/21/16 at approximately 3:00 p.m. She stated she expected her licensed nurses to be her eyes and ears and make accurate, honest skin assessments and provide Foley care according to the facility's standard. It was shared with the Unit Manager that it was determined from the urologist the erosion was gradual over at least a couple of months and didn't have to progress to this extent and nurses should have found it before 1/9/16 during bathing, skin assessments and proper Foley care. The Unit Manager was not aware that the area was at a point that it would not close. It was asked if she felt the nurse's actually washed the resident's perineum to include pulling back foreskin to clean, as well as cleaning around the penis and scrotal area each time Foley care was provided, she stated, Obviously not, but it will be monitored from here on out. It had been signed off on all weekly skin audits for November, December and January up to 1/9/16 that there were no new areas, other than a small Stage II (partial skin loss of outer layers) on the residents sacrum. The TAR indicated the Foley catheter had been changed on December 23, 2015 with no indication there was a penile erosion. The wound flow sheets indicated the penile erosion initially measured 4.0 cm by (x) 3.5 in width on 1/9/16. The flow sheets further indicated the length, on 3/14/16, to be 4.3 cm and smaller in width at 2.0 cm, deep red with bloody drainage. On 3/21/16 it measured 4.0 cm long and 1.5 cm wide. The documentation indicated the split widened on 3/28/16 to 1.8 cm with drainage. The last weekly measurement on 4/18/16 indicated the area was 4.0 long and 1.8 cm wide. The area was re-measured by the Unit Manager on 4/20/16 at 5:16 p.m. to be 4.0 cm long and 2.5 cm wide and the Foley catheter bag was now observed hanging off the right side of the resident's bed, as well as the Foley stabilization device pad secured on the top upper right thigh with the Foley catheter tubing loose, not stretched tight as previously observed, and no pressure observed on the scrotal junction from the catheter tubing. On 4/21/16 at approximately 3:30 p.m., the aforementioned observations and interviews were shared with the Administrator and re-shared with the DON. There was no additional information was provided prior to exit. The facility's policy and procedure entitled Foley Catheter Care revised 12/2015 indicated indwelling urinary catheters would be maintained in a manner that promotes urinary health and to comply with regulatory standards and best practices. The policy indicated that catheter care would be provided every shift by washing with soap and water or peri-care products. The policy indicated indwelling catheters should be anchored to the thigh to prevent trauma from pulling. The policy on skin integrity dated 12/2015 indicated residents would receive early identification, prompt evaluation and treatment of [REDACTED]. The policy indicated that each resident would have a weekly skin observation completed by a licensed nurse to assure timely identification and treatment of [REDACTED]. The Lippincott Manual of Nursing Practice, 10th edition 2014 for the management of a patient with an indwelling catheter and a closed drainage system, indicated the indwelling catheter needed to be secured to the patient's thigh using tape, adhesive anchor, or other securement device. Allow some slack of the tubing to accommodate the patient's movements to prevent catheter movement and traction on the urethra. Keep the tubing over the patient's leg which prevents kinking or forming loops of stagnant urine. In the male patient, the indwelling catheter is taped to the thigh to straighten the angulation of the penoscrotal junction, thus reducing pressure on the urethra exerted by the catheter. Adverse outcomes of long-term urethral catheterization include urethral erosion, ventral penile erosion, meatal erosion, and device-related necrosis of adjacent tissues. Indwelling bladder catheters are often placed when a patient requires voiding assistance. Long-term use of these catheters has been associated with significant morbidity. This case presentation describes a complete erosion of the glans, urethra, and penile skin, up to the penoscrotal junction, as an outcome from long-term use of an indwelling bladder catheter. Appropriate nursing interventions can prevent this devastating health care outcome. A case study concluded existing research suggests that negative outcomes associated with urethral and meatal erosions can be prevented by properly securing the indwelling catheter. Though this is one of the easiest and most effective practices, we found a low level of compliance with this preventive measure (http://www.ncbi.nlm.nih.gov/pubmed/ 017). According to information from the article Addressing the Challenge of Providing Nursing Care for Elderly Men Suffering From Urethral Erosion, Challenges in Practice, by, LeBlanc; Christensen, Dawn, BscN, RN, MN (c), IIWCC, Clinical Nurse Consultant with KDS Professional Consulting, Ottawa, Ontario Canada, Dawn Christenson, BScN, RN, ET, Grad, Dip Wd Mngmt, MHSc(N), IIWCC, Advanced Practice Nurse and Clinical Nurse Consultant with KDS Professional Consulting, Ottawa, Ontario Canada, 2005, by the Wound Ostomy and Continence Nurses Society, 2008, Lippincott Williams & Wilkins, Urethral erosion affects not only the complexity of the patients care, but also the patient's quality of life. There are associated problems that patients with indwelling catheters experience. One often overlooked but potentially psychologically and physically painful complication of urinary catheterization is urethral erosion. Urethral erosion on the distal urethra may be linked to .positioning of the catheter, repeated or continual pressure and movement of the catheter, can lead to full thickness wounds, which result in urethral erosion. Removal of the underlying cause (friction, moisture, and shear) is the first step towards closing the wound. Management Plan Prevent further erosion, protect the mucosa, prevent infection, reduce pain and maintain dignity. Prevention for this complication is important. Health care professional must recognize the potential risks associated with urinary catheterization. *Indwelling urinary catheter: Indwelling means inside your body, inside your bladder. This catheter drains urine from your bladder into a bag outside your body. Common reasons to have an indwelling catheter are urinary incontinence (leakage), [MEDICAL CONDITION] (not being able to urinate), surgery that made this catheter necessary, or another health problem (www.nlm.nih.gov/medlineplus/ency/patientinstructions/ 0.htm). **E.coli (Escherichia coli) urinary tract infections typically occur when bacteria enter the urinary tract from this type of bacteria commonly found in the gastrointestinal (GI) tract (from feces). Bacteria enter through the urethra and begin to multiply in the bladder. A urinary tract infection [MEDICAL CONDITION] is an infection in any part of your urinary system - your kidneys, ureters, bladder and urethra. Most infections involve the lower urinary tract - the bladder and the urethra. Although the urinary system is designed to keep out such microscopic invaders, these defenses sometimes fail. When that happens, bacteria may take hold and grow into a full-blown infection in the urinary tract (http://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/basics/causes/con- 892). ***ESBL (extended-spectrum ß-lactamases) are enzymes that are resistance to multiple antibiotics and difficult to treat to include extended-spectrum (third generation) cephalosporins (e.g., [MEDICATION NAME], cefotaxime, and [MEDICATION NAME]) and monobactams (e.g., aztreonam) but do not affect [MEDICATION NAME] (e.g., [MEDICATION NAME] and [MEDICATION NAME]) or carbapenems (e.g., meropenem or imipenem) (http://www.cdc.gov/HAI/settings/lab/lab_esbl.html). *****SIRS (systemic [MEDICAL CONDITION] Response Syndrome/Sepsis is the body's overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death. It is difficult to predict, diagnose, and treat. Patients who [MEDICAL CONDITION] have an increased risk of complications and death and face higher healthcare costs and longer treatment (http://www.cdc.gov/sepsis/index.html). 2. Resident #3 developed a penile erosion while a resident in the facility from an indwelling urinary catheter. The facility staff failed to ensure intervention with careful offloading to the urethra and securing the catheter, which placed the resident at risk of further urethral tearing and damage. Resident #3 was admitted to the nursing facility on 6/1/12 with [DIAGNOSES REDACTED].*indwelling urinary catheter. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 3/3/16 and coded the resident with a 12 out of a possible score of 15 on the Brief Interview for Mental Status Assessment (BIMS), which indicated the resident was moderately impaired in the skills necessary for daily decision making. The resident was not assessed for any behavioral or mood symptoms to include refusing care. Resident #3 was assessed to require extensive assistance from one staff for bed mobility and transfers. he was able to provide personal hygiene with set up and oversight by staff. He had no problems with his range of motion in upper and lower extremities. he was coded always incontinent of bowel and had an indwelling urinary catheter. The most recent revised care plan dated 3/16/16 identified the resident required extensive assistance to total assistance for Activities of Daily Living (ADL), was at risk for impaired skin integrity and he had an indwelling urinary catheter. Some of the goals set by the staff for the resident was that he would continue to allow the staff to assist and perform his ADLs, the resident would not develop any skin integrity problems during length of stay and that he would remain free of any complications related to the indwelling urinary catheter. Some of the approaches the staff would implement to accomplish these goals included: notify physician of any areas of breakdown, rash, abrasions etc for treatment orders, Foley (brand name of indwelling urinary catheter) care per protocol or physician's orders [REDACTED]. The Nursing Admission assessment dated [DATE] did not reference Resident #3 had a penile erosion. On 12/4/15 at 7:30 a.m., the nurse's note indicated the resident was seen standing at the doorway of his room bleeding from his penis, he was incontinent of stool, the Foley drainage bag was still on the side of the bed and the Foley catheter was in the floor. The nurse's notes indicated ADL care was given and his penis was wrapped. There was an event report generated for this incident and signed by the Unit Manager Licensed Practical Nurse (LPN) #1. Orders were obtained from the attending physician to monitor the area for signs and symptoms of infection around the tip of the penis secondary to traumatic catheter removal. The Foley catheter was re-inserted on 12/4/15 at 2:00 p.m. During an observation of the resident on 4/19/16 at approximately 12:30 p.m., he was observed out of his room, sitting in the activity/dining area. The large Foley Drainage bag with connecting tubing was observed at the resident's foot on the floor. The resident was wearing long pants and it was obvious the connecting tubing came down through the right pant leg. On 4/20/16 at approximately 1:30 p.m., the Unit Charge Nurse LPN #7 assisted with a skin check of the resident's penis and positioning of the Foley catheter. The resident was in his room sitting at the bedside in a chair. The large Foley drainage bag was observed in the same position a previously observed. He was able to follow directions well, unbuttoned and unzipped his pants. The LPN stood the resident, pulled down his pants and opened the brief. A small penile erosion was visible on the right back side of his penis and the Foley catheter tubing that led out of the bladder and urethra was not anchored to his thigh, but pull straight and tight, even more so held that way by the brief and the weight of the urinary drainage bag. The LPN stated, All our residents should have a Foley stabilization device and he will get one right away. When asked about the penile erosion, she stated she would have to check because she did not think he had one. The Urologist evaluated the resident on 12/11/15 and diagnosed the resident a ventral penile erosion from the chronic Foley catheter. During an interview with the Unit Manager on 4/21/16 at 2:20 p.m., she stated the Foley catheter should have been anchored to the resident's thigh. She further said, the nursing staff was inserviced 4/20/16 and continued on 4/21/16 on the used of [MEDICATION NAME] (brand name) Foley anchoring device. She stated the device was placed correctly on the thigh and a urinary drainage leg bag was applied to allow the resident to comfortably wear his pants without the large drainage bag hanging out of the end of his pant leg. The Unit manager stated, We are monitoring him and he seems to be tolerating the leg bag well. She stated she knew the resident had pulled out his Foley catheter, but did not know he had developed a penile erosion. An interview was conducted with the Director of Nursing (DON) on 4/21/16 at 2:45 p.m. She stated she expected the staff to anchor the Foley catheter to the resident's thigh to prevent pulling and pressure. She further said all nursing staff were receiving inservicing on the proper application of the [MEDICATION NAME] Foley stabilization device. On 4/21/16 at approximately 3:30 p.m., the aforementioned observations and interviews were shared with the Administrator and re-shared with the DON. There was no additional information was provided prior to exit. *Indwelling urinary catheter: Indwelling means inside your body, inside your bladder. This catheter drains urine from your bladder into a bag outside your body. Common reasons to have an indwelling catheter are urinary incontinence (leakage), [MEDICAL CONDITION] (not being able to urinate), surgery that made this catheter necessary, or another health problem (https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/ 0.htm) 3. Resident #18 was originally admitted to the facility on [DATE]. Resident #18 had multiple hospitalization s with readmissions back to the facility. The most recent readmission to the facility was on 5/25/15. The resident's [DIAGNOSES REDACTED].

Based on a complaint investigation, clinical record review, staff and family interview, the facility staff failed to ensure 1 of 31 residents (R#27) in the survey sample were free of accident hazards. The facility staff failed to use the assessed number of staff and safety devices to safely position Resident #27 in bed to prevent head injury. The findings included: R#27 was admitted to the Dogwood Unit of the nursing facility on [DATE] with [DIAGNOSES REDACTED]. Resident #27 was discharged to the local hospital on [DATE] at 9:54 am (time according to medical transport company document) and did not return. R#27's most recent Minimum Data Set (MDS) assessment in effect prior to her discharge was a quarterly dated [DATE]. This MDS assessment coded the resident with short and long term memory problems, as well as poor decision making. She was assessed as totally dependent on the physical assistance of two staff persons for bed mobility (how the resident moves to ad from lying position, turns side to side, and positions body while in bed) and transfers (how the resident moves between surfaces-to and from bed, chair, wheelchair, standing position). She as coded as totally dependent on staff during bathing. She was coded as limited in her range of motion (ROM) in both hands and legs. She was assessed unable to balance herself while standing. She lacked trunk control, was unable to balance self and/or follow directions for the test while in a sitting position without partial physical support. She was fully incontinent of bowel and bladder. The care plan for R#27 in effect at time of discharge was dated [DATE] and identified mobility impairments and was at risk for injuries/ falls and fractures secondary to weakness, end stage rheumatoid arthritis, osteoarthrosis and osteoporosis, degenerative joint disease (DJD), bilateral hand contractures, decreased mobility and history of left hip fracture. The goals included the resident would be assisted to reduce the risks for injuries and falls for the duration of staff in facility. Some of the approaches to accomplish these goals included providing assistance with all mobility activities, handle resident gently..., two half top side rails for bed mobility and to establish boundaries, and mechanical lift with two staff for transfers. The Risk for Falls form dated [DATE] scored the resident as 17 (greater than 10 or above deemed at risk), which made her at risk for falls. Device assessments were made for ? side rails times 2 for bed mobility and positioning and required staff monitoring and redirection. The last therapy screening was an Occupational Therapy (OT) Evaluation dated [DATE], which reflected the following upper body limitations: The OT evaluation indicated the attending physician made the referral for evaluation of bilateral hand [DIAGNOSES REDACTED]/contractures and positioning needs related to the same for R#27. The evaluation noted the resident required maximal assistance for bed mobility, had impaired sitting and standing balance and was substantially impaired bilateral gross motor coordination throughout upper extremities with hypertonicity and/or contractures present at multiple sites. She had significantly diminished range of motion throughout bilateral upper extremities severely impaired function for fine motor coordination and no appreciable function noted either upper extremity hand. Hands and digits of hands presented with moderate to severe flexor [DIAGNOSES REDACTED], posturing at rest in near closed fist position. Pain was identified through moans of discomfort with even gentle extensor ROM of joints and digits bilaterally. Tight bicep tendons were noted at bilateral elbow junctions. OT was unable to assess right and left upper extremity strength due to the presence of tonal abnormalities and contractures. Licensed Practical Nurse (LPN #6 who no longer worked for facility and was assigned to the resident at the time) wrote an entry the nurse's notes dated [DATE]. The note stated the assigned Certified Nursing Assistant (CNA #3) on [DATE] at 7:20 am called her to R#27's room stating the resident had a large bump on her head. LPN #6 noted the bump was located on the left side of the head. The nurse's notes further indicated the House Supervisor (RN #2) was called into the room to examine the resident and the Nurse Practitioner (NP) was made aware of the area. The nurse's note stated R #27 was assessed again by RN#2 at 8:00 am, at which time she had another RN (RN#1) examine the resident with no specific assessment documented at this time. The nurse's notes indicated the NP was paged at 8:20 am, awaiting a return call. The NP returned the page at 8:50 am, at which time she was updated on the resident's status. An order was given to send the resident out to the emergency room (ER) for evaluation and treatment. The House Supervisor (RN#2) was made aware. There was no documented assessment at this time by LPN #6 of what the resident's status was. It was documented a call was made to the Responsible Party (RP) and "made aware of the situation and new order to send out to eval (sic)." At 9:50 am a non-emergent transportation company transported the resident out of the facility via stretcher in route to the local hospital. RN #2 House Supervisor documentation, dated [DATE] at 7:30 am, under LPN #6's aforementioned nurse's note, indicated she received a call from the nursing unit to come check and examine R#27. She documented the resident lying in bed was noted to have a hematoma to the left side of her head with a knot/bump extending toward the left side of her forehead. It was documented the resident was unable to report pain and she also told the nurse (LPN #6) to call the MD/NP to inform them of the resident's status. The nurse's note indicated at 8:00 am, RN#2 re-checked the resident and asked the NP be paged and updated about her condition. Orders were received by LPN #6 to send out to ER for evaluation and treatment. On [DATE] at 10:00 am, Dogwood's RN#4 Unit Manager stated LPN#6 did not show up for work after the incident on [DATE]. She stated, "She worked here for over four years. To this day I have not heard from her. I assumed she resigned." She said R#27 had a raised area on the left side and was sent to the ER and did not return. On [DATE] at approximately 10:50 am, an interview was conducted with CNA #3 who was assigned to provide direct care for R#27 on [DATE] 7 am to 7 pm. The Director of Nursing (DON) was present during this interview. CNA #3 stated she went in to take care of R#27 first at 7:10 am because the charge LPN (LPN#6), who was in the room at the time, stated the resident was soaking wet the previous morning at the beginning of the shift. She stated LPN #6 left the room, after which she changed R#27's brief and turned her from side to side. She stated the resident was unable to help her in any way for positioning in bed because her hands, arms were stiff and contracted, as well as both legs. She said, "I do her by myself. I just press into her back to hold her over with one hand while I wipe or put the diaper on with the other hand. I use the draw sheet to turn her from side to side because she could not help me due to her contractures." CNA #3 said when she pulled up the bed spread on the resident; she noticed a bump on the left side of the resident's forehead. She was not able to approximate the size of the bump. She stated she did not see it when she first entered her room or during the brief change. She said LPN#6 told her she had not seen a bump on R#27's head when in the room morning around 7:00 am. She stated the resident's side rails were not padded and she did not use any pillows or wedges to hold the resident in place. CNA #3 stated the supervisor and other team leaders examined the resident. She said, "I did not see anything when I first came into the room, her eyes were open and she was awake. Even after I discovered the bump she was still awake. I might have bumped her head on the bed rail, but I don't know." She stated the bump increased in size and the resident was sent out to the ER around 9:30 am. The DON gave the name of another RN (RN#3) who measured the bump on the resident's head. On [DATE] at approximately 11:10 am, the DON continued the discussion of the incident after CNA #3 returned to her assigned shift duties. The DON stated there was discrepancy regarding the hip injury and the RP insisted the resident had sustained a fall, broke her hip, as well as hit her head. She stated during her investigation of the incident it was concluded a fall had not occurred, nor had the resident sustained [REDACTED].#27 had hit her head on the protruding metal gatches of the side rail. The mattress did not fully cover the areas the DON referred to upon observation of the side rail. The ? side rail was fully metal. She stated the side rails should have been padded for resident's protection, or pillows positioned against the rails before turning her so she wouldn't turn into any portion of the side rails. RN #3 was interviewed on [DATE] at approximately 2:00 pm. A second surveyor was present during the interview. She stated [DATE] around 8:15 am, LPN #6 asked her to come to the room and look at R#27's head. She stated breakfast trays had already been out and she had eaten her breakfast by the time she saw the resident. Delivery time schedule was between 7:,[DATE]:25 am. RN#3 stated the area measured to be approximately 10 centimeters (cm) with one half of it on the forehead and the other half inside the hairline. She stated the area was soft and appeared new and there was no bruising or outward bleeding. She said she marked it to track any increase in size. She said although she did not return to the resident, when she came back to the nurse's station later that morning, she was made aware the resident had been sent out the hospital. RN#3 stated the resident was total care, which her arms were totally contracted and her legs were stiff and she was not sure if she could be changed and re-positioned with one person. She stated she knew she did not attribute anything for positioning, but required pillows to stay on her side and she was heavy and required a mechanical lift for transfers in and out of the bed. On [DATE] at approximately 2:20 pm, the DON was interviewed again and presented documentation evidence of her investigation of the incident. A second surveyor was present during the interview. The DON stated the morning of the incident, RN#2 called and informed her R#27 had a bump on her head was swelling and they had sent her out to the ER. She stated when she asked RN#2 how it happened, the RN responded she did not know. The DON said she instructed the RN to start asking the staff. The DON stated she met with the RP on [DATE] regarding the results of her investigation related to the resident's Subarachnoid Hemorrhage (SAH), diagnosised in the ER. A subarachnoid hemorrhage is sudden bleeding occurs into the space (subarachnoid space) between the inner and middle layers of the tissue covering brain (The Merck Manual of Medical information, second edition). The DON said during the interview with the RP, he stated the medical transport team told him the resident was found on the floor, and she attempted to assure him it was not true. The DON stated she spoke with a representative of the medical transport team and asked if RP was told the resident was picked up from the floor. The DON said she was informed "floor" referred to the unit the resident resided on, not the actual floor. The transportation documentation did not indicate the resident was found on the floor. She stated after this interview, the Vice President of Patient Services (VPPS) called the local hospital wound/ostomy nurse assessed the resident's skin from head to toe, and informed the only bruising was of the left side of her head and forehead. The wound nurse told her the resident's hip was painful to touch. She stated it was also determined the resident's hip was not fractured, but dislocated. She said she found out the resident had died on [DATE]. The ER documentation placed the resident's arrival time in theER on [DATE] at 10:01 am. It was documented per EMS (rescue) personnel, the resident was found in bed in the am with a bruise, abrasion of the left frontal area with no history of fall. There was documentation the facility was called and received information by LPN#6 the resident was found in bed with the left forehead bruise the morning of [DATE]. Pain was elicited by the resident when moved her left leg and transferred to the ER, where x-rays confirmed left prosthetic hip dislocation. The head CT scan revealed left SAH, large left scalp hematoma and possible small subdural hematoma. The ER documentation noted the resident was admitted to the hospital on [DATE] at 6:51 pm. It was noted R#27 was not a candidate for surgery and conservative management ensued followed by palliative care and comfort care. The death summary dated [DATE] at 7:25 am indicated the resident expired on [DATE] at 12:30 am with the cause of death due to left SAH, scalp hematoma and possible subdural hematoma due to suspected closed head injury. An interview was conducted with an Environmental Service Worker (ESW) on [DATE] at approximately 2:50 pm. This ESW stated CNA#3 called her to the room the morning of [DATE], about 7:15 am, to check why the water was not working. She stated once she fixed the problem, she looked up and to her surprise saw a large knot on the left side of the resident's head. She stated she immediately turned to CNA#3 and asked her, "What's that big bump on her head. I could see it from ,[DATE] feet away. She (referred to CNA#3) said, 'I'm so scared; I think I hit her head'. I told her she needed to tell the nurse right away. I'm not a nurse, but I could not understand why she was telling me and had not told the nurse. I'm in environmental service. She kept saying over and over, 'I'm so scared'. She left out of the room behind me. I assumed she went to tell the nurse." A second surveyor was present during the interview. The interview with the DON was resumed on [DATE] at approximately 3:10 pm. She stated she reviewed the facility's surveillance tapes on [DATE] after the RP concerns the resident may have sustained a hip fracture on [DATE]. She provided the document where she had recorded all staff in and out of the room from ,[DATE] at 7:00 pm through ,[DATE] at 7:38 pm. She stated after analysis of the surveillance timeline, it gave her the impression the incident with the head occurred between 7:10 and 7:15 pm. The surveillance timeline showed LPN #6 and CNA#3 entering the room at 7:10 am and both exiting the room at 7:11 am. CNA#3 entered the room with a mechanical lift at 7:11 am and exiting the room at 7:14 am with the same lift. The ESW entered the room at 7:15 am, the assigned LPN #6 entered the room at 7:31 am and numerous nurses entered the room at 7:38 am. The DON stated no one was in the room long enough would have indicated the time needed to pick someone up off the floor. She stated she also ruled out there may have been an incident with the mechanical lift because CNA #3 told her she did not attempt to transfer her out of the bed because she could not find the help she needed for the transfer, so she brought the lift out of the room. The DON stated, "I counseled (CNA #3 name) regarding being aware of where the residents are in bed and whether needed padded side rails, pillows or blankets during a one person repositioning with a resident has no motor control to be able to stop themselves; which describes (resident's name). She had no upper body control or anything. Her legs were contracted, but the staff could straighten and flex her legs. She (CNA#3's name) was just scared." The DON stated the nursing staff was in-serviced regarding the same information imparted to CNA#3. The in-service sign in sheets were dated [DATE] entitled "Safe Positioning of Residents." The top of counseling document was dated [DATE] and the bottom was signed and dated by CNA#3 on [DATE]. It indicated she failed to adhere to facility Code of Conduct and safely provide assistance to the resident; thereby, the resident received a head injury during turning and repositioning. The corrective action the employee could take to prevent reoccurrence included the DON's aforementioned counseling. The DON also presented written statements and typed interviews she and the VPPS had conducted with the same staff had worked on ,[DATE]-,[DATE] including the ESW. The following additional interviews were conducted with nursing staff was assigned to the Dogwood Unit on [DATE] from 7:00 pm to 7:00 am on [DATE]: CNA #1 was interviewed via telephone on [DATE] at 6:00 pm. She stated she was the assigned aide on [DATE] from 7 pm to 11 pm and did not see any bruises on R#27's forehead during any of her rounds or during provision of incontinence care. She said the resident had no ability to help reposition herself; she used pillows between the resident's legs before turning and also pillow at the head of the bed when pulled up in the bed with another aide or nurse. She stated in a pinch she could turn and reposition her by herself, but without pillows next to the side rail; the resident may hit her head. CNA#2 was interviewed via telephone on [DATE] at 6:20 pm. She stated she was the assigned aide on [DATE] from 11 pm to 7 am and did not see any bruises. She said she gave the resident a bath around 4:00 am also combed her hair and did not see a bruise on her head. She said and another staff pulled her up in bed using the draw sheet. She stated if she was to only one to pull her up, she would raise the foot of the bed, use the draw sheet to roll her from side to side and gravity would cause the resident would end up at the head of the bed. She said the resident was total care and did not did help with anything; she (CNA#2) had to do everything. She stated the last time she saw the resident was at 6:45 am; she did not see any abnormalities of any kind included a bump or bruise on her head. She stated she did her charting and left at 7:15 am. She said, "The agency I worked for was called and they asked me if I knew about the resident's head contusion. I told them I did not see anything and I did not use the Hoyer lift (mechanical lift); she was never removed from the bed. I was also interviewed by the facility and both of them cleared me of everything." LPN#1 was interviewed via telephone on [DATE] at 8:10 pm. She stated she had her Friday night and was not told about, nor did she see a bump or bruise on the resident's head. She said she gave the resident her medications at between 5:30 and 5:45 am and saw nothing on her head. RN#1 was interviewed via telephone on [DATE] at 8:20 pm. She stated she was the RN supervisor for the shift and was about to leave around 7:25 am, when the unit called the nursing office to come and check out the bump on R#27's forehead. She stated the RN#2 day shift supervisor, as well as RN#3 all checked out the resident and wasn't able to say how the injury to her head happened. She stated it was after 7:30 am when she clocked out. She said she was off after the incident, but was interviewed about it. The following additional interviews were conducted with staff was assigned to the Dogwood Unit on [DATE] from 7:00 am to 7:00 pm: The RN supervisor was interviewed via telephone on [DATE] at 7:55 pm. She stated after she received report from the night supervisor, LPN #6 came to her to look at R#27's head. She observed the resident to have a bump with a slight bruise. The LPN stated she had her the previous day and there was nothing on her head. She said CNA#3 told her she was trying to get her ready for the morning and she did not know what happened. She stated she instructed the LPN to call the physician right away and went back to the nursing office. She said she told the previous shift RN supervisor what she suspected had happened; a fall out of bed, but they (all staff in the room) said she had not fallen. She stated, "I returned to check on the resident and could obviously see the bruise now. I told (LPN's name) to call the physician back because I was not comfortable with just saying it was a bump anymore. When (LPN #6) called the physician again, they stated she needed to be sent out. When I talked to (CNA#3 name) again, she said the resident was turned into the side rail, but could not confirm it. (R#27's name) should be turned in bed using 2 people for her safety; she is stiff and contracted." LPN#3 was interviewed on [DATE] at 10:05 am. She stated LPN#6 asked her to check the swelling on the resident forehead around 7:30 am, which she noted to be large and shiny in appearance. LPN #3 said she, the day shift RN supervisor, a second RN and LPN #6 were standing in the resident's room trying to figure out how the injury possibly happened. She stated, "We ended up sending her out day. There was some talk as to whether (CNA#3's name) had rolled her into the side rail, since the resident had no control." An interview was conducted with R#27's RP on [DATE] at 10:30 am. He stated he was told by the facility the head injury occurred from the resident hitting the side rail and they had no explanation for the resident's hip dislocation. On [DATE] at approximately 3:30 pm, the DON stated and the VPPS confirmed immediately after the incident, they did an audit of all the beds and specifically those residents in the type of bed R#27 (6 in the entire building) was in to ensure the safety of all residents. It was stated the Director of Maintenance had the results of the audit. On [DATE] at 3:55 pm, the Director of Maintenance stated he did not do any audits specifically for incident regarding the exposed metal hinges. He handed over several audits to the survey team were routinely done to ensure the safety of the beds, such as; brakes, wheels and the side rails go up and down properly. The VPPS was also in attendance during this interview. On [DATE] at 4:15 pm, an interview was conducted with the Administrator, VPPS and the DON. They stated R#27 was in the 670 model with the short bed side rails, but they looked at all the bed rails. They stated it was their belief the hinges on the side rail caused the head injury and it was a positioning issue. They stated they were not sure if other side rails could have caused the injury, but also said it could be any side rail and they were not sure what part of the side rail the resident hit, but speculated it probably was the hinges because they were at the level of the mattress. The Administrator stated there were probably more than six 670 model beds in the entire facility. On [DATE] at 4:50 pm, CNA#3 was re-interviewed to clarify some information the ESW and the DON gave. She was asked if the ESW was in the room the morning the head injury was discovered and did she encourage her to report the area on the resident's forehead. CNA#3 made the following statement: "I asked her to check the water in the resident's room, because it was not working. She did see the bump and told me I had better tell someone right away. So I did it after she told me to." When asked if she fed the resident morning with the bump evident on her head, she stated; "I did feed the resident and she ate everything, but I take back; I don't remember if I fed her or not, but she did eat." She voluntarily said, "I took the (Brand name of the mechanical lift) in the room to transfer her, but the trays were on the unit so I decided not to transfer her and I took it out." On [DATE] at 5:10 pm, the details of the aforementioned interview with the DON and she stated, "I did not tell (CNA#3) about what the ESW said. She did not know about ." She stated she had talked to the CNA and cleared her regarding using the mechanical lift or setting the resident up for the lift. She also said CNA#3 had been talked to before about one person mechanical lifts before. An interview was conducted with the Administrator, the VPPS and the DON on [DATE] at approximately 12:10 pm. The DON verified CNA #3 had not been challenged on the fact she had to be told by the ESW to report the obvious head injury; nor was it included her counseling. The DON stated she did not know until now the resident was assessed to require the assistance of two for bed mobility. It was also mentioned the head injury was not reported to the State Survey and Certification agency within 24 hours of the incident. Based on the documentation was presented during the survey, the investigation was ongoing for several days to determine how the injury occurred, as well as more investigation into the RP's concern on the [DATE] the resident may have potentially broken her hip on [DATE]. The incident was not reported to the State until [DATE], after the facility was aware the resident had expired. The letter from the facility reporting the incident to the State agency, faxed [DATE], indicated R#27 sustained the injury and SAH to the left side of the head while being repositioned during care. The letter explained CNA#3 turned the resident who's head hit the side of the rail causing a hematoma. The letter indicated the matter was referred to the local Medical Examiner and the DON had spoken with two detective from the local police department. COMPLAINT DEFICIENCY