Every finding on record at Lakewood Health System

Based on observation, interview and document review, the facility failed to provide routine shaving for 1 of 1 residents (R39) who was dependent on staff for assistance with personal hygiene.Findings Include: R39's quarterly Minimum Data Set (MDS) dated [DATE], identified R39 had moderate cognitive impairment and diagnoses which included; paraplegia (paralysis of lower body), Alzheimer's disease and multiple sclerosis (chronic neurological disorder that affects the nerve cell coverings and may cause numbness, weakness, vision changes and fatigue). R39's MDS identified R39 required substantial/maximal assistance with personal hygiene. R39's Functional Abilities Care Area Assessment (CAA) dated 6/27/25, identified R39 required substantial/maximal assistance with personal hygiene. R39's CAA identified R39 was able to verbalize, but staff also had to anticipate his needs. R39 needed and received staff assistance with all activities of daily living (ADL) tasks. R39's comprehensive care plan revised 12/10/25, identified R39 had an ADL self-care performance deficit related to impaired balance related to multiple sclerosis. R39's care plan interventions included touching assistance from wheelchair level for oral care and shaving. R39's medical record lacked documentation of R39 refusal of shaving. During an observation on 2/17/26 at 2:14 p.m., R39 had approximately one quarter inch long white facial hair across his lower face and neck area. At 4:53 p.m., R39 stated he would like to be shaven daily, but was unable to determine the last time he was shaved. During a phone interview on 2/17/26 at 5:31 p.m., family member (FM)-A stated R39 would like to be shaved every day but was not sure if the staff had the time to shave R39. During an observation on 2/18/26 at 9:15 a.m., R39 was seated in his wheelchair in the activity room doing exercises with other residents and staff. R39 continued to have white facial hair present across his lower face and neck. At 10:56 a.m., R39 was in wheelchair in sitting area with other residents, while they were watching television. R39 continued to have facial hair. R39 informed surveyor he needed to be shaved. During an interview on 2/18/26 at 11:06 a.m., nursing assistant (NA)-A indicated she had completed morning cares with R39, and R39 had whiskers today. NA-A stated the bath aides usually shaved R39 on Mondays. NA-A indicated she had offered to shave R39 at times, but did not offer to shave R39 today. NA-A stated her usual practice was to offer shaving to residents if facial hair was present and if refused to let the nurse know. During an interview on 2/18/26 at 1:37 p.m., licensed practical nurse (LPN)-A confirmed R39 had whiskers today, and stated she had shaved R39 about twenty minutes ago, because he needed to be shaved. LPN-A stated the nursing assistants were responsible to shave residents. LPN-A stated they did have a few residents the nurses were to document on the treatment administration records (TAR) that they were specifically shaved. LPN-A indicated she was unaware R39 wanted to be shaved daily, but would discuss with unit manager to possibly add R39 to the TAR to assure they offered R39 to be shaved daily. During an interview on 2/18/26 at 1:41 p.m., director of nursing (DON) indicated her expectation was to offer shaving daily, unless otherwise care planned. DON stated it was important to offer to shave residents to make them feel neat and clean, and possibly for infection prevention. On 2/18/26 at 3:48 p.m., DON e-mailed indicating the facility did not have a policy for shaving residents, but nursing staff were taught to offer shaving daily per resident preference.

Based on observation, interview, and document review, the facility failed to ensure nebulizer medications were administered safely for 1 of 1 resident (R44) who were observed to self-administer a nebulizer and had not been assessed as safe to self-administer medications. R44's quarterly Minimum Data Set (MDS) dated [DATE], indicated R44 had no cognitive impairment and had a diagnosis which included hemiplegia (one-sided weakness), and hypertension (high blood pressure). Furthermore, R5 required maximum assistance with bed mobility, transfers, toileting, and personal hygiene.R44's care plan revised 5/29/25, identified R44 had chronic obstructive pulmonary disease (COPD). Care plan interventions were to elevate head of bed to 30 degrees or propped on pillows or out of bed upright in a chair during episodes of difficulty breathing. Care plan lacked information regarding self-administration of medications.Review of R44's electronic health record (EHR) lacked a self-administered medication (SAM) assessment.R44's Order Review History Report signed 2/16/26, directed staff to administer Ipratropium-Albuterol inhalation solution 0.5-2.5 3 milligrams (mg)/3 milliliters (ml), inhale via nebulizer three times a day related to other specified chronic obstructive pulmonary disease (COPD) and 3 ml inhale orally via nebulizer every 24 hours as needed for wheezing, shortness of breath, rinse mask and allow to air dry after each use.R44's Order Review History Report lacked an order to self-administer medication.R44's electronic medical administration record (EMAR) for February 2026, lacked directions to self-administration medications. During an observation on 2/17/26 at 5:17 p.m., R44 was sitting in room in a wheelchair with a nebulizer mask on his face and no steam coming out of the mask with no staff present. At 5:18 p.m., R44 turned on the call light and stated he had to use the bathroom, with no staff present in the room, nebulizer mask on his face and no steam coming out of the mask. At 5:19 p.m., trained medication aid (TMA)-A went into the room, and R44 told TMA-A that his nebulizer was done and he had to use the bathroom. TMA-A took off the nebulizer mask and sat it on the dresser and informed R44 she would rinse the mask out later and was going to find a nursing assistant to help him to the bathroom.During an interview on 2/17/26 at 5:45 p.m., TMA-A verified she had placed the nebulizer mask on R44, turned on the machine, and left the room. TMA-A identified her normal process was to put the medication in the nebulizer, place the mask on R44, and set a timer for ten minutes. TMA-A indicated she does not sit with R44 during his nebulizer treatments. TMA-A stated if a resident was able to self-administer a medication, it would be identified in the EMAR. TMA-A pulled up R44 EMAR and was unable to find information regarding self-administration of medications.During an interview on 2/18/26 11:31 a.m., registered nurse (RN)-A indicated for a resident to self-administer medications, a registered nurse would do an assessment and then reach out to the provider for an order. RN-A verified R44 did not have a self-administration of medication order. RN-A indicated it was important to do the self-administration of medication assessment to ensure a resident does not pull off the nebulizer mask, and ensure the resident get the medication in the nebulizer treatment. If a resident does not have a self-administration assessment done, she would have expected staff to sit with the resident during the nebulizer treatment.During an interview on 2/18/26 at 2:24 p.m., director of nursing (DON) indicated a resident needed to have a self-administration assessment completed to self-administer medication. After a resident was assessed and was deemed safe to self-administer medications, staff would identify in the care plan the resident was safe to self-administer medications and would obtain orders from the provider. DON verified R44 did not have a SAM assessment completed. DON stated this is important to ensure the resident received the medication as ordered. A facility policy titled Self-Administration of Medications reviewed 6/13/25, identified if the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual abilities to carry out this responsibility, during the care planning process. The licensed nurse will determine resident's ability to self-administer medications by a means of a skill assessment, which is conducted on a quarterly basis. The results of the licensed nurse's assessment are recorded on the medication self-administration assessment, which is placed in the resident's medical record. If a resident has orders for nebulizers the nurse may assess that the resident is able to deliver the nebulizer after set up and then will go back after nebulizer has run and shut off the machine and take care of the equipment.

Based on interview and document review, the facility failed to ensure adequate supervision to prevent wandering to unsafe places and falls for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm to R1 when she fell and sustained a fracture to the right leg. The facility implemented corrective action so the deficient practice was issued at past non-compliance. Findings include: R1's annual Minimum Data Set (MDS), dated [DATE], identified R1 required supervision with eating, oral hygiene, toileting, and shower/bathing, partial to moderate assistance personal hygiene, roll left to right, sit to lying, lying to sitting, and toilet transfers. Substantial to maximum assistance to transfer from chair to bed and sit to stand machine. R1 was frequently incontinent of bladder and always continent of bowel. R1's diagnoses included non-traumatic brain dysfunction, arthritis, osteoporosis, Alzheimer's, and dementia. R1's medications include diuretics (increased urine output). R1's Fall risk assessment dated [DATE], identified intermittent confusion, incontinent, balance problem with standing and walking and required the use of assistive devices (i.e. cane wheelchair, walker, furniture). R1 was at risk for falls. R1's elopement evaluation dated 6/24/24, identified R1 wandered and identified at risk for elopement. R1's bowel and bladder assessment dated [DATE], no falls in past three months, intermittent confusion, ambulatory and incontinent. R1 had balance problems while standing and while walking and required use of assistive devices (i.e. cane, wheelchair, walker, furniture). R1's care plan dated 6/24/24, directed staff to anticipate unmet needs, cue, reorient, and supervise as needed. R1 was at high risk for falls, unaware of safety needs, gait/balance problems, incontinence, and the potential to fall down and hurt herself. Staff were directed to follow urinary toileting schedule every two hours and monitor/provide reminders/assistance to turn/reposition at least every two hours, or more often as needed or requested due to potential for pressure ulcer development. R1's care plan lacked evidence of a revision following implementation of hourly safety checks on 7/4/24, though hourly checks were added to the NA tasks sheet at that time. A facility reported incident (FRI) report submitted to the State Agency (SA) on 7/4/24, at 10:40 p.m The report identified R1 fell at 9:35 p.m., R1 was found on the floor beside the bed lying on right side. R1 was unable to state what happened. R1 had a small amount of emesis. R1's electronic medical record identified the following: - Task of: MONITOR - Complete Hourly Safety Check every shift related to fall risk. Staff to ensure R1 had gripper always socks on. R1's hourly safety checks documentation for 7/4/24, revealed staff signed off the safety checks were completed at 2:41 p.m., 3:53 p.m., 4:41 p.m., 5:00 p.m., 6:00 p.m. 7:00 p.m. Staff did not document the safety check was completed at 8:00 p.m. or 9:00 p.m. and then at 10:47 p.m. documented R1 not available. R1's safety checks were documented to acknowledge R1 was located on 7/4/24, at 2:41 p.m., 3:53 p.m., 4:41 p.m., 5:00 p.m., 6:00 p.m. 7:00 p.m. and documented R1 was not available at 10:47 p.m. Staff did not document R1 was located after 7:00 p.m. until 10:47 p.m. (3 hours and 47 minutes). Task of: B & B (bowel and bladder): Bladder elimination - Toilet every two hours, while awake, during AM (morning) and PM (evening). First, third, and last rounds during the night. Toilet after dinner each day. R1's bladder elimination documentation on 7/4/24, revealed staff signed off at 1:00 p.m. continent, 3:41 p.m. continent, 5:00 p.m. incontinent, 9:35 p.m. incontinent. Staff did not document bladder elimination after 5:00 p.m. until 9:35 p.m. (4 hours and 35 minutes). At 10:47 p.m. staff documented R1 was not available. R1's progress notes dated from 6/25/24, to 7/5/24 were reviewed and identified the following: -6/25/24, at 6:54 a.m. staff were unable to complete brief interview for mental status (BIMS), memory problem identified and severely impaired decision making. -6/30/24, at 11:08 p.m. R1 self-transferred in room, attempted to put herself to bed, and had an unwitnessed fall. No injuries identified. -7/1/24, at 2:45 a.m. R1 was found sitting on floor next to bed at 1:10 a.m. R1 stated she was getting in her chair. Second fall within 12 hours. R1 was assessed, assisted into her chair, and brought to nurse's desk. -7/1/24, at 7:01 a.m. post fall evaluation indicated fall was not witnessed, occurred in R1's room, and reason for fall was not evident. Contributing factors note: R1's bedtime routine was disrupted as R1 had company. -7/4/24, at 9:40 p.m. orders obtained to send R1 to emergency room (ER) for evaluation and treatment following fall. -7/4/24, at 9:48 p.m. Post fall evaluation: R1's fall on 7/4/24, at 9:11 p.m. was found on the floor was not facility sleep study room at 9:10 p.m., complained of right leg pain, and had an emesis. R1's fall was unwitnessed and appeared she attempted to get into a bed that was very elevated and resulted in a fall. R1 sustained an injury of the right medial leg with pain. Physical findings noted R1 had a sensory impairment of her sight and displayed right leg pain. R1 was sent to ER and evaluated. -7/4/24, at 10:56 p.m. communication with provider: staff completed the 9:00 p.m. safety check and located R1 on the floor beside the bed in sleep study room. R1 laid on her right side and complained of right leg pain. -7/5/24, at 1:26 p.m. updated R1's daughter, vulnerable adult was filed with the state agency. R1 was transferred to another local hospital for surgery then would return to facility. -7/8/24, at 2:28 p.m. R1 returned to facility via wheelchair. R1 experienced signs of short-term memory loss, was disoriented, confused, and required cues. R1 had dressing on right hip, poor balance, impairment of lower extremity on one side, and an indwelling catheter. R1's Emergency Department (ED) triage notes dated 7/4/24, at 10:41 p.m. identified brought to ED after R1 encountered an unwitnessed fall and was found in sleep study on the ground on her right side. R1 had a lot of pain will wince and say ouch with range of motion (ROM) to her lower right extremity. R1's hospital history and physical dated 7/4/24, at 10:53 p.m. was found wandering into the sleep lab in another part of the care center and found down on the ground. R1 refused to move right leg at all. R1 had swelling/deformity noted in right femur which was location of prior fracture in the past. R1 had dementia at baseline but seemed to be more confused than usual. R1's physical examination showed deformity/edema noted in lateral upper leg. R1's x-ray showed distal femur fracture that was displaced just past rod from prior surgery. R1's discharge summary from hospital dated 7/8/24, at 11:05 a.m. identified R1 had a comminuted periprosthetic supracondylar femur fracture right leg and received surgical repair ORIF (open reduction and internal fixation) of right femur fracture with bone grafting. R1 was discharged back to skilled nursing facility at 1:18 p.m. on 7/8/24, and all transfers non-weight bearing on the right leg/foot. Right knee immobilizer was expected to be worn full-time until follow up in two weeks with orthopedics for x-rays and staple removal. A facility five-day report submitted to the SA on 7/8/24, at 1:12 p.m., identified R1's care plan was not followed regarding toileting and rounding. R1 was care planned to have been toileted every two hours, last toileted at 4:00 p.m. due again at 6:00 p.m. and not completed. R1 was brought to the dining room at 5:30 p.m. where R1 was last seen finishing her dinner at 6:15 p.m. At 8:30 p.m. staff were unable to locate R1, initiated a missing person alert and found R1 at 9:10 p.m. R1 was unable to explain what happened due to dementia/memory problems. R1's x-rays showed a right femur distal femur fracture and was surgically repaired. Both staff involved were immediately removed from the schedule and disciplinary actions were completed for R1's care not followed. Staff were new, acknowledged, and understood expectations moving forward. Audits were put into place for close monitoring of care and care plans. R1 would be assessed upon return from hospital for a wander guard or memory care placement due to new recent wandering behavior. R1's primary physician visit dated 7/11/24, identified R1 had a history of recurrent falls, cognitive impairment, remote right superior and inferior pubic ramus fractures, intertrochanteric fracture of the right hip post-surgical repair on 1/9/23, via right hip internal fixation of intertrochanteric fracture using cephalomedullary nail. R1 was admitted to facility on 1/25/23, unable to care for herself at home and had falls due to confusion and attempts to transfer without assistance. R1's cognitive decline continued at a slow pace. R1 was admitted to hospital on 7/4/24, after she sustained a fall and suffered a comminuted right femur fracture. R1's surgical procedure included an open reduction internal fixation of the right periprosthetic femur fracture with bone grafting. R1's significant change MDS dated [DATE], identified R1 was dependent on staff for bed to chair transfers and had an indwelling catheter. R1's elopement evaluation dated 7/12/24, identified R1 wandered, wandering behavior was a pattern, goal directed (i.e. specific destination in mind, going home etc.) and likely to have affected the safety or well-being of self/others. R1 was identified at risk for elopement. R1's physician orders dated 7/14/24, identified a wander guard every shift for elopement risk and ensure the device was working. R1's Kardex dated 7/16/24, identified Fall Prevention: after meals, ask resident if she wants to sit on the couch and watch TV (television) or place her near the TV in her wheelchair so she was able to see people as they came in and out of the facility. R1 required monitoring/reminders/assistance to turn/reposition at least every two hours, more often as needed or requested. R1 was non-weight bearing to right leg. R1 used wander guard for elopement prevention. R1 was dependent of two staff and the total mechanical lift. HS (evening) routine: go to bed between 8:00 p.m. and 9:00 p.m. R1 had wander guard for elopement precaution. During continuous observations on 7/17/24, from 9:00 a.m. through 10:00 a.m.: -9:00 a.m. R1 sat was observed sitting in her wheelchair in the dining room at a table by herself. R1 drank coffee and looked around. R1 appeared to have eaten approximately 50 percent of her breakfast, had gripper socks on both feet, feet were placed on footrests, and right leg elevated. R1's wander guard was observed to be hung on lower back side of wheelchair and lift sheet remained underneath R1. -9:03 a.m. an unidentified staff asked R1 if she was done eating, pushed her down to hallway one where R1 lived, and left her in the wheelchair where staffed continuous walked by to check on R1. -9:09 a.m. physical therapy assistant (PTA) approached R1 and asked if she was ready for physical therapy this morning. R1 stated yes. PTA pushed R1 in wheelchair down the hallway and into her room. PTA completed R1's physical therapy at 9:25 a.m. then asked if R1 wanted to stay in her room or go out and watch the birds. Registered nurse (RN)-B located outside R1's room in hallway stated out loud that R1 needed to be outside her room in either hallway or out by the birds, and not left in her room. PTA stated, well that answers my question and pushed R1 down the hallway to the central lounge area by the birds. -9:35 a.m. R1 sat in wheelchair in commons/lounge area in front of the birds. -9:50 a.m. R1 sat in wheelchair awake in commons/lounge area in front of the birds. Numerous staff walked by. R1's feet both remained on the footrests and no attempt to get up out of wheelchair. -9:59 a.m. R1 remained in wheelchair in commons/lounge area in front of the birds. NA-D walked up to R1 and sat down next to her in a chair. NA-D asked R1 if she wanted to remain sitting up or lay down, R1 stated lay down. NA-D pushed R1 down hallway to outside of her room, while NA-D located a lift machine. NA-D pushed lift machine into R1's room then R1 in wheelchair. NA-D placed call light on to signal staff for assistance with transfer from wheelchair to bed. NA-E entered R1's room and together they transferred R1 from wheelchair to bed with total lift machine. NA-D and NA-E checked R1's incontinent product, positioned her onto her back with pillow under both legs from knees to ankles so that heels were off bed mattress, then placed bed in lowest position. R1 had on right leg immobilizer during entire observation. NA-E placed call light within reach, moved bedside table next to the bed, and wheel chair on other side of room unreachable by R1. During a telephone interview on 7/17/24, at 1:30 a.m. licensed practical nurse (LPN)-A stated on 7/4/24, the last time she saw R1 was in the dining room at 6:15 p.m. LPN-A stated according to R1's care plan R1 was to be taken to the commons area after meals to be distracted by TV and other people but that night the intervention never happened. LPN-A stated R1 spent a lot of time in her wheelchair, attempted to self-transfer, and forgot she was unable to walk by herself. On 7/4/24, at 8:30 p.m. LPN-A noticed R1's roommate was in bed but R1 was not in her room. R1 was usually in bed by that time and a search was initiated. At 9:10 p.m. LPN-A noticed the sleep study room light was on and entered that room. R1 was sitting on the floor next to the bed with her right leg placed under the left leg. LPN-A placed a pillow behind R1, touched the right leg, tried to move R1's right leg but felt it was not in the correct position. LPN-A indicated registered nurse (RN)-A assisted with lifting R1 off the floor with a full mechanical lift and into her wheelchair. LPN-A stated the assessment of the right leg identified the leg was swollen, very painful, as R1 moaned, and when moved R1 yelled out ohhhhh, winced, and grimaced. R1's provider was notified and R1 was sent to ER via ambulance. R1 was diagnosed with a fracture of the right femur and had surgery to repair it. R1 was on a toileting plan, but was not sure when the last time she was taken to the bathroom. R1 was incontinent of urine and had a small emesis at the time of the fall. R1 told LPN-A she had been hollering out for a long time and knew someone would eventually come. R1 was supposed to have been on hourly safety checks, and the care plan was not followed; otherwise R1 would have not of been found half-way across the building. LPN-A stated had received education on monitoring, repositioning, hourly rounding, toileting and following the care plan on 7/8/24, right after incident. During a telephone interview on 7/17/24, at 10:16 a.m. registered nurse (RN)-A stated R1 was at high risk for falls and was to be toileted every two hours and have hourly safety checks. Staff were expected to document the hourly checks and when R1 was toileted accurately. R1's cognition and memory were poor, R1 had fallen two weeks prior and was then placed on hourly checks. R1 frequently tooled herself around the facility and often tried to stand up by herself. It was after 9:30 p.m. when RN-A was made aware R1 fell . Staff placed R1 in a full total lift and lifted her off the floor of the sleep study room. RN-A stated it was obvious R1 favored her right leg and once her pants were removed they observed two swollen areas on the right thigh. RN-A stated both NA's involved were educated the evening incident happened and audits were started right after incident. RN-A stated all nurses were expected to have completed audits every shift on NA's to assure the care plans were being followed and education provided. RN-A stated those audits continued to be completed on every shift. RN-A also stated at any given time would check the NA's documentation in the resident's electronic medical record and at a glance would have known if cares and checks been completed and/or if they were behind in their cares and checks. RN-A stated she had sent out an email to all nursing staff regarding R1's fall regarding fall interventions and following the care plan right after R1 had fallen. During a telephone interview on 7/17/24, at 1:19 p.m. patient care attendant (PCA) verified she worked on wing one with a nursing assistant (NA)-A on 7/4/24. R1 was on hourly checks and both staff (PCA and NA-A) checked on her and worked as a team. Last time PCA toileted R1 on 7/4/24, was at 4:00 p.m. and after that the NA-A told her she had placed R1 in bed. PCA stated looked at the documentation on R1 and it looked like NA-A signed off she had checked on her every hour so figured R1 was taken care of. PCA was in the dining room assisting another resident when she saw R1 leave the room at about 6:00 p.m., and figured she headed down to her room. PCA found out later R1 was missing and had fallen and possibly injured herself. PCA stated they received education the following day after incident on 7/9/24, prior to start of next shift regarding falls, hourly, checks, transfers, and toileting. During an interview on 7/17/24, at 2:00 p.m. NA-A stated R1 was on hourly safety checks and was to be toileted every two hours on 7/4/24. R1 was toileted was at 4:00 p.m. that day. NA-A stated from 2:00 p.m. to 4:00 p.m. R1 visited in cafe with her family. NA-A informed PCA she planned her break from 5:00 p.m. to 5:30 p.m. NA-A stated once she returned from her break at 5:30 p.m., she checked with PCA in the dining room, and saw R1 sat at a table in dining room. PCA stayed in dining room and assisted residents, and NA-A returned back to wing one, and answered call lights. NA-A was really busy answering resident call lights and then ended up in resident's rooms. NA-A verified hourly checks and every two-hour toileting on R1 were not completed as they were too busy. Call lights were crazy busy and NA-A asked PCA to complete the checks on R1. At 9:00 p.m. NA-A looked for R1 to get her ready for bed but was unable to find her. NA-A and PCA were expected to have completed the hourly checks on R1 and document in the electronic medical record. The building was searched and R1 was found by a staff nurse in the sleep study room. R1 had fallen and was sent over to ER. NA-A felt she may have been able to prevent that fall if the hourly checks would have been completed as care planned. NA-A stated she had received education the night R1 had fallen on 7/8/24, on documentation, falls, toileting, and hourly rounding. During an interview on 7/17/24, at 4:00 p.m. social worker designee (SWD) completed R1's elopement assessment on 6/24/24. SWD documented R1 did wander and scored one point on the assessment. SWD also verified a score of one or higher the resident would have been considered a risk. SWD stated her thought process was when R1 was taken out of her room and wandered back into her room she considered that would be wandering. SWD stated mostly likely was an error and that question should have been answered no instead on 6/24/24. SWD stated R1 was re-assessed on 7/12/24, for her risk of elopement and identified at risk and a wander guard was placed. During an interview on 7/17/24, at 4:30 p.m. director of nursing (DON) stated on 6/13/24, at 7:35 a.m. R1 had a drop in blood pressure and fell and that's they initiated hourly safety checks as an intervention. Nursing staff were expected to follow the care plan in entirety for each resident and there were no exceptions. If it was not charted then the task was not completed. DON stated falsification of documentation was not allowed and would not be tolerated. DON indicated education was provided to the staff directly involved in incident; NA-A the evening of the incident, PCA the next day prior to shift worked, and additional education was provided to NA's while audits were completed by the staff nurse every shift initiated approximately one week ago. DON stated audits continued so that all staff were monitored for frequent checks and residents toileted according to their care plan. DON stated her expectation for staff would be the care plan followed in it's entirety and was made very clear in during audits. DON stated rounded with NA's and they were very clear on scope of practice and expectations. DON hourly rounding was not included on the care plan but was on the tasks list to be completed by NA's to help keep R1 safe and staff were aware of that. During interview, the DON identified the following was observed on video: R1 ventured down a total of three hallways to get to the education room (previously known as the sleep study room), two and 1/2 hallways (a total of up to approximately 400 feet total). At 6:45 p.m. R1 ventured up the hallway and wheeled herself out of the main area where she sat by the bird cage. At 6:49 p.m. R1 was down just past her office (almost 2 hallways from main area) and that was the last R1 was seen on the video. DON stated R1 was in the education room approximately two hours before she was found and unsure when she fell . Staff headed down the hallway past her office at 9:04 p.m. and found R1 on the floor with right leg bent and tucked underneath the left thigh. DON indicated when the staff nurse moved R1's leg to straighten them out she said ouch ouch, noted swelling on the right upper leg, and then held her legs straight during the transfer with a total mechanical lift. R1 was then transferred to ED via ambulance and had surgery on her right hip. Review of staff education documents and shift audits identified the facility implemented corrective action and was determined to be in compliance before survey entrance. The facility policy Resident Assessment for Bowel and Bladder Retraining or Management dated 9/6/23, identified purpose was to ensure residents were maintaining the highest level of continence. The facility policy Fall/Injury Risk dated 1/17/24, revealed purpose of policy was to identify resident's risk for falling and risk from a fall, and develop an individualized plan of care to reduce falls and injury. Staff were responsible to initiate the appropriate interventions related to safety and fall prevention. Residents who have fallen will be appropriately managed. All staff member were responsible for implementing the intent and directives contained within this policy and for creating a safe environment of care. Resident maybe placed on fall precautions. The facility policy Nursing Documentation dated 3/20/24, identified all nursing documentation must be completed both accurately and timely in order to enhance patient care. All nursing documentation was expected to be completed within the shift care was completed unless otherwise designated. Documentation should have displayed handling of the data and should influence the plan of care. The facility policy Hourly Rounding dated 5/15/24, identified it was the responsibility of each department director/manager to establish a method of hourly rounding practice within their department to reduce resident safety/risk issues, enable nursing staff to be proactive in their resident care, and evaluate resident for a change in condition. Staff would be expected to meet the resident personal needs such as bathroom assistance, personal hygiene, reposition to provide comfort, and respond to any resident concerns.

Based on observation, interview and document review, the facility failed to ensure grievance procedures were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously if desired, for 5 of 5 residents (R2, R40, R46, R49, R27) reviewed for grievances. This deficient practice had the potential to affect all 74 residents residing in the facility. Findings include: During a resident council meeting on 11/7/23 at 2:02 p.m., five residents attended. All five residents, R2, R40, R46, R49, R27, confirmed they were not aware of how to file a grievance at the facility. During an interview on 11/7/23 at 4:00 p.m., social service assistant (SSA)-A indicated the grievance procedure was reviewed upon admission with the residents and a copy of the procedure was included in the admission packet. SSA-A stated three facility staff members were listed on the grievance procedure form for residents or representatives to contact if they had a concern, or they could contact the ombudsman. SSA-A indicated if residents wished to file a grievance, they could talk to social services or the charge nurse who could provide them information on who they could contact. During an interview on 11/7/23 at 4:07 p.m., director of nursing (DON) stated residents in the facility could report grievances to any staff member or charge nurse. DON indicated she understood residents who attended resident council meetings were informed they could contact social services if they had concerns and they would assist them with the grievance process either by addressing their concerns internally or assisting with filing a grievance. DON and surveyor observed the eight by eleven inch framed grievance procedure located on the wall across from the chapel office, approximately five feet off the ground. DON indicated the facility had recently reviewed the grievance process and posting and had discussed whether the height of the posting and location were adequate. DON confirmed the grievance procedure was not posted in any other prominent locations in the facility. DON verified the facility had not identified how residents could file a grievance anonymously. DON stated the facility did not have any forms for residents to file anonymous grievances. During an interview on 11/8/23 at 11:50 a.m., administrator indicated the facility used a formal grievance process that was used for all campuses. Administrator confirmed the only location of the grievance procedure was in the facility's main corridor across from the chapel/activity room. Administrator confirmed the facility's procedure for grievances, including how to file anonymously, was to contact one of the three staff members listed on the procedure. The facility posting titled Grievance Procedure, undated, identified if concern or suggestions, the facility encouraged them to notify the nurse in charge. If the matter could not be resolved by the charge nurse, they could contact the director of nursing, director of programs and operations, or the grievance officer, whose names, phone numbers and e-mails were listed. The procedure identified grievances may be filed orally or in written format, and may be done so anonymously. The facility policy titled Lakewood Health System (LHS) System Grievance Policy revised 3/20/23, identified its purpose was to provide all customers of LHS a procedure to follow for reporting concerns and grievances with services, care, or other elements of their experience within LHS, and whom to contact to file a grievance. The policy indicated concerns excluded from being defined as grievances included; billing concerns, patient satisfaction survey comments unless a written and signed complaint was included with the survey requesting resolution, and post-care verbal communication that would routinely have been handled by staff present if the communication had occurred during the stay, and anonymous concerns. The policy identified all customers were encouraged to notify any front line staff or charge nurse of their concern. If the concern was unable to be resolved promptly, the concern would be documented within the department as a point-of-care concern. Concerns that were unable to be resolved would be forwarded to director of nursing, director of social services, vice president of senior services, or customer experience, and would be logged as a grievance. The policy identified grievances may be received in person, phone, voicemail, e-mail or in writing, or attached to patient satisfaction survey as a signed document requesting resolution.

Based on interview and document review, the facility failed to ensure resident mail was delivered on Saturdays for 5 of 5 residents (R2, R40, R46,R49, R27) who voiced concerns with mail delivery. This deficient practice had the potential to affect all 74 residents residing in the facility. Findings include: During a resident council meeting on 11/7/23 at 2:02 p.m., five residents attended. All five residents, R2, R40, R46, R49, R27, confirmed mail was not delivered on Saturdays at the facility, and they had to wait until Monday to receive their mail. During an interview on 11/7/23 at 3:09 p.m., activity assistant (AA)-A indicated activity staff delivered mail to residents. AA-A stated they did not deliver mail to residents on Saturday and indicated mail had not been delivered to the facility on Saturdays. During an interview on 11/7/23 at 3:15 p.m., business office assistant (BOA)-A indicated she sorted the mail the residents received on Monday through Fridays and placed the mail activity mail box for resident delivery. BOA-A indicated she was unsure if mail was delivered on Saturdays. During an interview on 11/8/23 at 11:50 a.m., administrator confirmed mail was not delivered to residents on Saturdays and indicated it did not get delivered to the facility on Saturdays. The facility policy titled Resident Mail, dated 4/17/22, identified residents had the right to send and promptly receive mail. The policy identified facility staff would deliver resident's personal mail to their room, unopened.

Based on interview and document review the facility failed to notify the ombudsman of a facility initiated transfer for 1 of 1 residents (R9) reviewed for hospitalization . Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R9 was cognitively intact, and had diagnoses which included: stroke, hemiplegia (one sided paralysis or weakness) and peripheral vascular disease (blood circulation disorder). Indicated R9 required assistance with self care and mobility. Review of R9's progress notes from 8/28/23 to 8/30/23, identified the following: - on 8/28/23 at 1:17 p.m., nurse was notified from nurse at vascular appointment, that the procedure went well, but R9's blood pressure dropped significantly. R9 was being admitted for observation, with plan to return to facility the next day. Family notified and verbal bed hold completed. - on 8/30/23 at 12:20 p.m., R9 returned to the facility. During an interview on 11/7/23 at 10:49 a.m., social service designee (SSD)-A indicated her usual process was to send the transfer notification to the Ombudsman* When did she do this and how?* and place the form into the resident's medical record. During a follow-up interview on 11/7/23 at 1:02 p.m., SSD-A confirmed the Ombudsman had not been notified of R9's hospital transfer. SSD-A indicated it was important to notify the Ombudsman of hospital transfers, so if concerns existed regarding returning to the facility, the Ombudsman would be aware of the transfer. During an interview on 11/8/23 at 2:00 p.m., director of programs and operations (DPO)-A confirmed she oversaw the social service department. DPO-A indicated the usual facility process for hospital transfers included the nurses would complete a transfer form, which was then provided to social service, which would trigger them to notify the Ombudsman. DPO-A stated it was her expectation social services notified the Ombudsman by fax of all transfers. DPO-A indicated it was important for resident advocacy and to protect the residents right to come back to the facility. DPO-A confirmed the above findings. A policy was requested however was not provided.

Based on observation and interview, the facility failed to ensure the posting of conspicuous signage of employee rights related to retaliation against the employee for reporting a suspected crime. This deficiency has the potential to affect all 74 residents currently residing in the facility. Findings include: During an observation on 11/8/23, a tour of the facility revealed the facility lacked signage of employee rights related to retaliation prohibition for reporting suspicions of a suspected crime posted within the facility. During an interview on 11/8/23 at 1:25 p.m., licensed practical nurse (LPN)-A reported that no retaliation was not addressed in the abuse policy online and staff reviewed it annually. Could not identify where employee rights related to retaliation were posted. During an interview on 11/8/23 at 1:30 p.m., director of program and operations verified employee rights related to retaliation prohibition for reporting suspicions of a suspected crime were not posted. During an interview on 11/8/23 at 2:00 p.m., administrator verified employee rights related to retaliation were not posted. Review of the facility policy titled Vulnerable Adult Policy dated 9/28/23, identified the facility was prohibited from retaliating against a person who reported suspected maltreatment in good faith.

Based on interview, observation and document review, the facility failed to implement assessed intervention to prevent reoccurrence following a respiratory care incident and facility failed to develop a respiratory care plan for 1 of 4 residents (R2) reviewed for respiratory care. Findings include: R2's admission Minimal Data Set (MDS) dated [DATE], identified R2 had diagnoses which included paraplegia, chronic obstructive pulmonary disease (COPD), and respiratory failure. Further MDS identified required the use of oxygen (O2) therapy. R2's Order Summary dated 8/14/23, indicated R2 required O2 between 0-2 liters as needed to keep 02 saturation about 90% and nurse to check O2 tank prior to meals and change promptly if needed. R2's care plan dated 8/10/23, lacked evidence of a respiratory plan of care or any respiratory interventions which included: type of O2 delivery system, when to administer O2, equipment settings for prescribed flow rates, monitoring O2 levels and resident risks and monitoring for complications. Review of facility report to the state agency (SA) dated 7/27/23, included nursing assistant (NA) reported to the licensed practical nurse (LPN)-A prior to breakfast R2 need more oxygen in her portable tank. R2 was brought into the dining room and tablemate asked a trained medication assistant (TMA) to get R2 oxygen. R2 was upset she did not get her oxygen right away. R2 reported LPN-A was not friendly and was crying and visibly upset. Review of facility's 5-day investigation submitted to the SA on 7/28/23, identified investigation verified R2 was out of oxygen however R2's saturations were at an acceptable level per physician orders and R2 appeared clinically stable. Further, investigation identified there were interventions put into place to prevent further issues. Review of an email sent by director of nursing (DON) sent to all nursing staff dated 7/31/23, directed staff to do the following: - only a nurse or a TMA can change O2 tanks over and do anything with them. A NA cannot move oxygen from tanks, adjust tanks, ect. - Nurses and TMAs need to check the O2 fill level to ensure it has O2 in it prior to changing the resident over to the tank. Staff can't put someone on O2 when there isn't any oxygen in it. - The order is for continuous O2 for a reason, so the resident cannot have a gap in O2 - If staff note the resident is running low, please bring them to a nurse and have them sit with the nurse to avoid them running out or the nurse forgetting to fill their tank. - If they are in their room and need to be changed over, use the nurse light system so the nurse is reminded that they need to change the resident over. On 8/10/23 at 3:27 p.m., R2 was observed in her room in wheelchair and was hooked to the portable O2 tank on the back of her wheelchair by nasal cannula. R2 stated on 7/27/23, the NA that assisted with morning cares hooked her up to the portable O2 tank and brought her to the nurses cart and reported to the nurse she needed more O2 and then the NA took her to the dining room. R2 stated she ate breakfast and waited a while when another nurse noticed she did not have her O2 on and got her a new tank. R2 stated she felt the nurse has it in for me. On 8/10/23 at 3:58 p.m., registered nurse (RN)-D stated only licensed nurses or TMAs can switch and/or touch O2, the NAs were expected to notify the nurse to switch a resident's O2 source. On 8/10/23 at 5:57 p.m., NA-A indicated on the day of 7/27/23, NA-A confirmed she had switched R2 from the room concentrator to the portable tank and brought R2 out of her room with the empty tank, notified LPN-A R2's tank was empty, and then brought R2 into the dining room, however R2's tank was never changed by LPN-A. Further, NA-A stated if a resident required O2 it would be identified in their care plan along with if the resident required O2 continuously or as needed. In addition, NA-A stated NAs were allowed to change O2 source, turn on/off O2, and set the concentrator or portable tank to flow rate, which NA-A would compare what it was previously set at, but NAs were not allowed to increase the flow rate. On 8/10/23 at 6:16 p.m., RN-A indicated R2 was admitted to the facility on hospice care with orders for O2 as needed related to diagnosis of respiratory failure with hypoxia. RN-A indicated R2 did wear her O2 almost continuously for comfort. Further, RN-A stated on 7/27/23, R2 was brought into RN-A's office by TMA-A and R2 appeared to be upset she didn't have oxygen and crying and R2 reported the nurse has it out for me. RN-A reported R2 was not in respiratory distress and upon assessment revealed R2's O2 saturation was 96% and lung sounds were clear. In addition, RN-A stated only licensed nurses or TMAs were allowed to do anything with O2 since O2 was considered a medication/treatment and NAs should not do anything with O2. On 8/11/23 at 8:35 a.m., RN-C stated only licensed nurses or TMAs were able to touch O2, switch O2 sources, or adjust O2 flow rate but sometimes the NAs forget and would bring residents out of their rooms and notify the nurse the resident needed oxygen and continue to bring them to the dining room. Further, RN-C indicated a big education was sent to all nursing staff directing staff to leave the residents in their rooms and notify the nurse when they were ready to leave their room and they need their oxygen. On 8/11/23 at 8:56 a.m., LPN-A residents who required O2 had orders and were monitored as well as ensuring their portable tank were full before switching O2 sources and would be completed by either the licensed nurse on duty or TMA the NAs were not allowed to touch the O2. LPN-A indicated on 7/27/23, in the morning it was busy, and NA-A notified LPN-A R2 needed a new O2 tank as hers was empty while passing by and NA-A brought R2 into the dining room. LPN-A indicated R2 became upset she did not have oxygen on and the NA-A had left her with no oxygen. Further, LPN-A indicated there was a failure that occurred, and this incident could have been prevented had the NA alerted LPN-A while R2 was still in room hooked up to room concentrator. LPN-A indicated education was sent out to all nursing staff related to NAs not touching O2 and to alert licensed nurse or TMA prior to moving the resident out of the room as well as checking R2's tanks more frequently to ensure it is full. On 8/11/23 at 11:26 a.m., TMA-A stated on 7/27/23, R2 was in the dining room at a table with another resident who got TMA-A's attention and reported R2 needed her oxygen. TMA-A went and got a new portable O2 tank and brought R2 into RN-A's office. TMA-A reported R2 was upset but did not appear to be in repertory distress. Further, TMA-A indicated since this incident the DON had sent an email to all nursing staff related to only licensed nurses or TMAs were allowed to change O2 sources or adjust O2 and NAs were not allowed to touch the O2. On 8/11/23 at 11:44 a.m. NA-B indicated she was allowed to switch O2 sources for residents as well as turn on/off oxygen. Further, NA-B will ask a verbal resident if they require oxygen and if they are unable to tell staff NA-B would ask a nurse. On 8/11/23 at 12:19 p.m., NA-C indicated NAs were allowed to turn on/off O2 and change O2 sources for example if a resident was on the room concentrator NA-C would assist with transferring to the wheelchair and turn on the O2 portable tank which was typically already set to 2 liters. On 8/11/23 at 12:23 p.m., TMA-B indicated if a resident required O2 it would be listed on their care plan and the care plans are posted in each resident's closet. Further, TMA-B stated only licensed nurse and TMAs were allowed to touch O2 and the NAs were not supposed to be changing O2 sources. On 8/11/23 at 2:52 p.m., RN-B indicated due to the incident with R2, DON sent out education to all nursing staff on the recent changes which were only licensed nurses and TMAs would be able to do anything with O2. On 8/11/23 at 2:41 p.m., RN-A stated on 7/27/23, R2 was brought into her office and appeared to be upset with tears coming down her face and appeared to be gasping from crying (not in respiratory distress). Through the investigation, RN-A stated it was determined R2 had been without O2 for approximately 20 minutes. Further, RN-A stated anxiety with or without respiratory distress could cause someone to hyperventilate or have air hunger. In addition, RN-A stated each resident who required O2 should have a care plan within 30 days of admission with respiratory inventions for staff direction that are placed on the Kardex as well, but confirmed R2 did not have a respiratory care plan due to miscommunication of staff when R2 switched care coordinators. On 8/15/23 at 10:40 a.m., DON indicated the NA-B reported to LPN-A R2's tank was almost empty and brought R2 into the dining room and left R2 at the table where the tank eventually went empty. DON stated NA-B should have alerted another nurse regarding R2's tank being close to empty if LPN-A was busy. Further, DON stated following the incident the interdisciplinary team met and implemented the licensed nurse would check the tank before each meal. DON stated there was a miscommunication regarding the email that was sent to all staff on 7/31/23 and stated the facility did not change their process and NA's were able to switch O2 sources but were not trained to adjust the O2 flow rate. In addition, DON stated RN care coordinators and MDS nurse would be expected to collaborate and complete a comprehensive assessment for each resident which would include a respiratory care plan. Review of facility policy titled Oxygen administration, long term revised 11/28/22, lacked direction on which staff were allowed to assist with O2 as well as implementing a respiratory care plan and interventions required.

Based on observation, interview, and document review, the facility failed to ensure food items were properly stored and dated in 1 of 1 kitchens and 2 of 2 kitchenettes in the facility to prevent food borne illness. This deficient practice had the potential to affect 73 of 74 residents who were served food from the main kitchen and kitchenettes. Findings include: During the initial kitchen tour with the baker-cook (BC) on 6/26/22, at 1:40 p.m. the following observations were made: The walk-in refrigerator storing milk and dairy products was noted to have: A crate containing approximately five half pint non-fat milk cartons with a use-by-date of 6/18/22, and approximately 15 cartons with a use-by-date of 6/20/22. A crate containing approximately eight pint-sized heavy whipping cream bottles with a use-by-date of 6/25/22. During an interview on 6/26/22, at 1:50 p.m. the BC stated she was not certain why the outdated items listed above were still in the refrigerator. BC immediately disposed of the outdated items from the walk-in refrigerator. During the second kitchen tour with the dietary manager (DM) on 6/28/22, at 10:00 a.m. the following observations were made: The freezer compartment of the refrigerator located in the kitchenette on the memory unit was noted to have three bags of food products without labels or dates and inside the bags the food items were covered in a heavy layer of ice. The food items included a bag containing three waffles, a bag of French toast sticks, and a bag with a single egg omelet. The DM stated the items should have had labels. DM commented the items were freezer burnt and immediately disposed of them. The multi-door refrigerator located in the main dining room kitchenette was noted to have food products that were beyond the use-by-date. Those products included: One single size yogurt container had a use-by-date of 6/20/22. The DM immediately threw the container away in the trash receptacle. One half pint size non-fat milk carton had a use-by-date of 6/16/22, and five more half pint sized non-fat milk cartons with use-by-dates noted to be 6/22/22. The DM immediately threw the cartons away in the trash receptacle. During an interview on 6/28/22, at 10:00 a.m. the DM stated she had been informed outdated food products were also found during the initial kitchen tour completed on 6/26/22. During a follow-up interview on 6/29/22, at 11:35 a.m. DM stated her expectation for her staff would be to check the use by dates of the food upon food deliveries. Additionally, DM indicated she expected staff to properly seal and date food products once they had been opened. Review of the facility kitchen's policy titled Food Storage revised 3/17/19, revealed foods with expiration dates were to be used prior to the date on the package. The policy indicated all foods would be covered, labeled, and dated. The policy identified refrigerated foods would be checked to assure that foods (including leftovers) would be consumed by their safe use by dates, or frozen (where applicable) or discarded. The policy indicated frozen foods would be covered, labeled, dated and all foods would be checked to assure that foods would be consumed by their safe use by dates or discarded.

Based on observation and interview, the facility failed to ensure proper containment of garbage in the outside dumpsters to prevent harboring pests and rodents. This had the potential to affect all 74 residents residing in the facility. Findings include: On 6/28/22, at 10:20 a.m. during the kitchen sanitation tour, the facility's two outside dumpsters were observed located at the end of the back parking lot next to an area of vegetation and wildlife. The dumpster on the left had one lid open, exposing the interior of the dumpster. The Dietary Manager (DM) stated at the time the dumpsters were used for recycling. DM stated housekeeping staff disposed of dietary's refuse, such as cardboard boxes from food deliveries, into the dumpsters. On 6/29/22, at 9:50 a.m. the two dumpsters were observed and both dumpster lids were open. During an interview on 6/29/22, at 10:00 a.m. the Maintenance Supervisor (MS) confirmed the dumpster lids were open and stated housekeeping or any staff using the dumpsters should have ensured the lids were closed. During a telephone interview on 6/29/22, at 1:00 p.m. Housekeeping Director (HKD) stated the facility did not have a policy for proper containment of refuse in the dumpsters. HKD stated housekeeping staff disposed of the refuse once daily and were expected to ensure the lids were closed after the task was completed. HKD indicated the dumpsters were located next to an area where active wildlife had been observed.

Based on interview and document review, the facility failed to ensure incidents of potential abuse were immediately reported to the State Agency (SA), no later than 2 hours after knowledge of the allegation of abuse, for 1 of 1 residents (R60) reviewed for allegations of abuse. Findings include: R60's Significant Change of Status Assessment (SCSA) Minimum Data Set (MDS) dated [DATE], identified R60 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R60 had intact cognition, and required extensive assistance with activities of daily living of bed mobility, transfers, toileting and was dependent for all locomotion. R60's undated nursing assistant care plan, revealed R60 had situational stressors and identified interventions of reapproaching R60 at a later time, provide reassurance, anticipate her needs and record any behaviors. The facility SA report reviewed identified the allegation of abuse occurred on 6/22/22, at 5:42 am. The SA report was submitted by the facility on 6/22/22, at 9:04 a.m., three hours and 22 minutes after the incident occurred. R60's medical record lacked documentation of her allegation of staff abuse. During a telephone interview on 6/28/22, at 1:18 p.m. nursing assistant (NA)-A stated on 6/22/22, at approximately 5:45 a.m. NA-B had requested assistance with providing cares to R60. NA-A indicated when she entered R60's room, R60 was lying on her back in bed, an inch from the end of the bed. NA-A stated R60 was screaming, crying about how poorly she had been treated by NA-B shortly before NA-A entered the room. NA-A stated she had never seen R60 so upset and indicated R60 had told her she felt she had been treated like a dog. NA-A indicated at that time; NA-B began to verbally disagree with R60 about her reports of poor treatment. NA-A stated she told NA-B to leave the room and provided cares to R60 by herself. NA-A indicated R60 was calm when she left the room at approximately 6:15 a.m. NA-A stated she did not report R60's concerns to the night charge nurse. However, NA-A indicated she reported R60's complaints of poor treatment by NA-B to registered nurse (RN)-A when she started her shift at approximately 6:55 a.m. During an interview on 6/28/22, at 12:58 p.m. the director of nursing (DON) stated she had been notified on 6/22/22, R60 had reported rough treatment by an NA. The DON stated she was aware the SA report was submitted past the two-hour reporting requirement. The DON stated, upon learning of the incident, RN-A went to R60's room and spent time with her to ensure she felt safe prior to submitting a vulnerable adult report to the SA. During an interview on 6/28/22, at 1:34 p.m. RN-A stated on 6/22/22, at approximately 6:30 a.m. she was notified of R60's report of staff-abuse by NA-A. RN-A stated she immediately went to R60's room to gather information and to ensure R60 felt safe and comfortable. RN-A indicated it had taken awhile to get R60 to calm down and she had been in her room with her for approximately 30-45 minutes. RN-A stated after she met with R60, she notified the social worker, the DON, and the facility administrator and then submitted a report to the SA at approximately 9:00 a.m. During an interview on 6/29/22, at 10:02 a.m. the facility administrator stated the facility policy and protocol for reports of abuse would be to report to the SA immediately, no later than two hours. The administrator stated she had been made aware of R60's report on 6/22/22, and was aware the SA report was submitted later than the two-hour timeframe. She indicated she felt it was more important to ensure R60 felt safe, and her emotional needs were met prior to submitting the SA report. Review of facility policy titled, Vulnerable Adult Policy effective 6/20/22, revealed the facility would provide a system of protected services to adults, who may show reasonable, cause of incidence of abuse, neglect, misappropriation of property or injuries of unknown source. The policy identified the facilty had the responsibility of safeguarding the rights and welfare of the physically, mentally, and emotionally vulnerable adults. The policy indicated all alleged violations would have been reported immediately but not later than two hours, if alleged violation involves abuse, or results in serious bodily injury, serious bodily injury -immediately but not later than two hours after forming the suspicion.

Based on observation, interview and document review, the facility failed to ensure staff were donning the appropriate personal protective equipment (PPE) for 1 of 3 residents (R222) observed on preventative admission droplet precautions for COVID-19. This had the potential to affect 16 of 16 residents, currently residing on the unit containing the new admission quarantined residents. In addition, the facility failed to ensure properly disinfected mechanical lift equipment (i.e. standing lift) between each resident, for 1 of 2 residents (R18), requiring use of the standing lift for transfers. This had the potential to affect two residents residing on the memory care unit who required the use of a standing lift for transfers. Findings Include: During entrance conference on 10/19/20, at 1:45 p.m. the director of nursing (DON) and the assistant director of nursing (ADON) reported there had been no confirmed COVID-19 positive residents, but have had staff test positive. Further, the DON and ADON reported a portion of the 300 unit was used for new admissions or suspected COVID-19. On 10/21/20, at 8:01 a.m. there was an isolation station observed outside of R222's room that contained gowns, gloves, disinfecting wipes, and alcohol based hand rub (ABHR). There was a sign posted on the wall next to R222's room identifying R222 was on droplet and enhanced barrier precautions. The Droplet precaution sign directed staff to wear mask and eye protection and the Enhanced Barrier precaution sign directed staff to wear gown and gloves in addition to mask and eye protection when performing high contact resident care activities (i.e., dressing and transferring). On 10/21/20, at 8:10 a.m. nursing assistant (NA)-B entered R222's room wearing a surgical mask and eye protection. NA-B provided assistance with dressing and transferring R222. Licensed practical nurse (LPN)-C entered R222's room to assist maneuvering the full mechanical lift during R222's transfer. LPN-C was wearing a surgical mask and eye protection, but did not provide any direct patient care. NA-B was not wearing gown or gloves during direct patient care. R222's vitals signs were reviewed from 10/15/20, through 10/21/20, and R222 did not have any current signs or symptoms of COVID-19. R222's COVID-19 test was reviewed from 10/12/20, and confirmed that it was a negative test result. On 10/21/20, at 8:18 a.m. NA-B stated staff only need to wear a gown and gloves when cares are being provided. NA-B confirmed that providing assistance with dressing and transferring was providing cares but continued to state that she did not need to wear a gown or gloves during that interaction with R222. On 10/21/20, at 8:20 a.m. LPN-C stated staff must wear a gown, gloves, surgical mask and eye protection when providing cares, any direct touching of resident, or if staff will be within six feet for more than 15 minutes of the quarantined residents. LPN-C confirmed that NA-B should have had on a gown and gloves along with her mask and eye protection during that resident interaction but did not feel it was her place to correct NA-B. Further LPN-C stated the importance of wearing the PPE directed on the precaution signs was for the safety of the residents and the staff. On 10/21/20, at 2:24 p.m. DON stated her expectation of all staff were to wear full PPE (gown, gloves, surgical mask, and eye protection) with any close contact with new admissions and/or quarantined residents. Review of the facility policy, Infection Prevention Precautions, dated 3/26/20, indicated standard precautions and transmission based precautions were to reduce the risk of passing infectious agents from individuals with known or suspected infections to non-infected individuals. Further, the policy indicated droplet precautions prevent transmission caused by pathogens in droplets that are transmitted from the host source by coughing, sneezing, talking or during procedures. Also, gown and gloves to be worn for personnel caring for patients for all interactions that may involve contact with the patient and potentially contaminated areas in the patient's environment. Further, the policy indicated during the COVID-19 pandemic Lakewood will follow the Centers for Disease Control (CDC) guidance for droplet and airborne precautions for suspected and confirmed COVID-19 cases. R18's significant change Minimum Data Set (MDS), dated [DATE], indicated R18 required physical assist from one for transfers and toileting. R18's care plan, revision date 10/10/20, indicated R18 transferred with the help of one person, bearing part of his weight with use of a standing lift. On 10/21/20, at 7:35 a.m. registered nurse (RN)-A was observed providing perineal care (cleaning private areas of a resident) to R18 following a continent bowel episode. RN-A did not doff her gloves or perform hand hygiene after assisting R18 with perineal care. RN-A performed the following tasks before doffing her gloves and performing hand hygiene: pulled up R18's clean incontinent product, pulled up R18's clean pants, used the plastic control on the standing lift to assist R18 to stand from the toilet, used the metal handle on the standing lift to move R18 and the standing lift from the bathroom and position R18 in front of his wheelchair, used the plastic control on the standing lift to lower R18 into his wheelchair, unbuckled the plastic buckle on the cloth sling, removed the cloth sling from R18, placed the cloth sling on a hook on R18's closet, removed R18's feet from the metal platform on the standing lift, removed cloth gripper socks from R18's feet, put R 18's leather shoes on his feet, tied the shoe laces on each shoe, assisted R18 to don a fleece jacket, adjusted R18's clothing, cleaned R18's glasses with water, dried R18's glasses with paper towel, assisted R18 to place glasses on his face, and removed used towels and wash clothes from the bathroom and placed in hamper in R18's room. On 10/21/20, at 8:03 a.m. RN-A removed the standing lift from R18's room and placed it in a storage area. RN-A did not clean the lift after using it for R18's transfer. On 10/21/20, at 9:11 a.m. RN-A confirmed she did not doff her gloves or perform hand hygiene after assisting R18 with perineal care. RN-A stated she was aware she needed to perform hand hygiene after removing her gloves after she assisted R18 with perineal care and coming into contact with R18's bodily fluids. RN-A indicated the standing lift should have been cleaned after use with R18. RN-A confirmed she did not clean the lift after she used it with R18. On 10/21/20, at 9:18 a.m. RN-B stated staff should have cleaned any part of the standing lift touched by staff or resident, between each resident. RN-B indicated staff needed to perform hand hygiene after removing gloves and having contact with bodily fluids, after assisting with perineal care, and after touching soiled items used for resident care. On 10/22/20, at 11:38 a.m. the assistant director of nursing (ADON) stated staff were required to clean the lift, all areas the resident and staff touch, after each use. ADON indicated staff were required to doff gloves and perform hand hygiene after contact with bodily fluids, after assist with perineal care and after touching soiled items used for resident care. On 10/22/20, at 12:41 p.m. Licensed Practical Nurse (LPN)-A indicated there are two residents on the memory care unit who require staff physical assistance with the standing lift for transfers. A facility policy and procedure regarding cleaning of mechanical lifts was requested but was not received.

Based on observation, interview, and document review, the facility failed to provide routine grooming and personal hygiene to 3 of 4 residents (R13, R19, R69) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care. Findings include: R13's quarterly Minimum Data Set (MDS), dated [DATE], identified R13 had intact cognition, had no behaviors or rejection of care, and required extensive assistance for personal hygiene. Further, R13's care plan dated 9/22/20, identified R13's mobility was affected due to having surgery and could not complete cares on her own, and required extensive assistance with hygiene grooming tasks with help of one staff. During an observation on 10/20/20, at 8:52 a.m. R13 had several 1/4 to 1/2 dark colored facial hairs, across her upper lip, and under her lower lip, across her chin. When asked about the facial hairs R13 indicated she had her hair cut a couple weeks ago, and stated, My hairdresser usually does it but didn't this time, as she used her hand to cover her mouth and chin. R13 stated staff have not offered to shave facial hair. On 10/21/20, at 7:37 a.m. R13 was sitting in her wheelchair, with her breakfast tray on the bedside table. Facial hair remained to face. During an observation on 10/22/20, 8:55 a.m. R13's facial hair remained. R13 stated, Yes, they bother me. They get irritating. I wish I had a scissor to clip them off, as she covered the hairs with her hand. R13 stated staff have not offered to take them off for her. When interviewed on 10/22/20, at 10:01 a.m. licensed practical nurse (LPN)-B stated, It is their preference. We encourage, promote. (R13) does have a razor in her top drawer .If they ask, we are more than happy to help. During an interview on 10/22/20, at 12:34 p.m. nursing assistant (NA)-A stated she didn't get R13 up today, but did get her up yesterday, and doesn't remember if she saw any facial hair or not. NA-A stated, Usually I ask them if they have a razor, and if they have one, I ask if they want to use it. I think she has her own (razor), however, indicated she had not offered to assist R13 to remove the facial hair. R19's quarterly MDS, dated [DATE], identified R19 had severe cognitive impairment, had no behaviors or rejection of care, and required extensive asssitance for personal hygiene. Also, R19's care plan, dated 8/11/20, identified R19 could not complete cares on her own due to having muscle weakness and stroke affecting her right side, and required the help of staff to complete hygiene and grooming tasks. R19's face sheet, dated 11/20/19, identified [DIAGNOSES REDACTED]. During an observation of medication administration on 10/19/20, at 6:49 p.m. R19 had several curly, white hairs, approximately 1/2-3/4 inches long, on her chin and along her jaw line. When interviewed on 10/20/20, at 9:18 a.m. the facial hair on R19's chin remained. R19 indicated staff did not offer to help to remove the chin hairs, and put her hand over her chin and held it there to cover the hair. R19 stated, What can I do? Can't do anything about it. I can't make it change. During an observation on 10/22/20, at 9:12 a.m. R19 was in her room, sitting in the wheelchair, and the facial hair remained. When interviewed on 10/22/20, at 9:36 a.m. NA-C stated some residents have razors and ask for help to remove facial hair, some don't really care and aren't as particular with that as others. NA-C stated she helped R19 get ready for breakfast this morning, but didn't offer to remove the facial hair, because, (R19) just wanted to have breakfast. During an interview on 10/22/20, at 1:01 p.m. the director of nursing (DON) stated, It's hard with residents, because we don't always ask their preference .if that was something they want to do or not. The DON indicated her expectation would be to ask the resident if they are alert and oriented, and to assist the resident to remove the facial hair if that is their preference. R69's quarterly MDS, dated [DATE], identified R69 had severe cognitive impairment, impaired communication ability to express herself, and required total dependence for personal hygiene. Further, R69's care plan, dated 10/7/20, identified R69 had limited mobility to her right wrist and hand and her left hand and knuckles, and required total assistance with hygiene grooming tasks with help of one staff. R69's [DIAGNOSES REDACTED]. R69's medical record was reviewed and lacked any evidence R69's facial hair had been reviewed with her or her family regarding their desired preferences for facial hair removal. An observation on 10/19/20, at 2:43 p.m. identified R69 had numerous white hairs, approximately 1/8-1/4 inches long, on her chin and along her upper lip line. A subsequent observation was made on 10/20/20, at 9:52 a.m. and R69 continued to have visible facial hair on her chin and upper lip regions. R69 lacked verbal response during attempted interviews. Observation during R69's bed bath on 10/21/20, at 7:22 a.m. identified the bath aide NA-D failed to remove R69's facial hair after NA-D completed R69's bed bath that morning. NA-D stated when R69 was provided with her bed bath NA-D would typically leave R69 laying in bed once the bed bath had been completed and the nursing assistants who worked the unit that day would then complete any of the remaining grooming/hygiene tasks needed for R69 such as hair care and oral care. During telephone interview on 10/21/20, at 9:39 a.m. family member (FM)-A stated R69 would not want facial hair on her chin or upper lip region. When interviewed on 10/21/20, at 1:08 p.m. NA-E denied having provided R69 with any of her grooming/hygiene tasks that morning. NA-E explained because NA-D had provided R69 with her bed bath that morning NA-D had been responsible for providing R69 with all her grooming/hygiene needs after the bed bath. During interview on 10/21/20, at 1:21 p.m. RN-D stated the bath aide would have been responsible for R69's full morning cares, except for oral cares, due to the bath aide having had provided R69 with her bed bath that morning. When interviewed on 10/21/20, at 2:12 p.m. NA-D stated the facial hair should have been removed. NA-D explained she usually left shaving and oral cares to the nursing assistants but would manage any residents facial hair as needed if concerns were noted during bathing. NA-D stated not knowing if R69 had a razor. NA-D shaved R69's chin and upper lip hair afterfinding R69's razor. During follow-up interview on 10/21/20, at 2:16 p.m. RN-D stated she expected the bath aide that morning would have shaved R69's facial hair if it had been present. Further, RN-D explained if R69's preference for facial hair managment was unknown, staff would be expected to follow up on such resident preferences. When interviewed on 10/21/20, at 2:36 p.m. the social services assistant (SSA) stated preferences are asked on admission and during care conferences. SSA reviewed R69's care plan and denied the care plan indicated any preferences towards facial hair management. SSA explained if a resident does not want facial hair removed then it is usually care planned otherwise I would think it should be taken care of. During interview on 10/21/20, at 3:01 p.m. the DON stated R69's facial hair shaving could have been done by either the bath aide who gave the bath or the nursing assistant who worked that day; however, further stated if the bath aide had provided the bath during the morning hours, she would expect any shaving to have been done by the bath aide that day in accordance with R69's preferences. In addition, the DON explained if R69's shaving preferences had been unknown, staff would have been expected to follow up on determining this preference. A facility policy on grooming and hygiene was not provided.

Based on observation, interview, and document review, the facility failed to follow the plan of care for the use of no straws, as identified for 1 of 1 resident (R19), who was observed to have a straw, and was at risk for choking and aspiration (inhalation of food and fluids into the lungs). Findings include: R19's quarterly Minimum Data Set ((MDS) dated [DATE], identified R19 had severe cognitive impairment, had no behaviors or rejection of care, and required supervision and oversight while eating. R19's face sheet, dated 11/20/19, identified [DIAGNOSES REDACTED]. R19's physician orders, printed 10/22/20, indicated R19 received a NDD3 diet (level 3 national dysphagia diet-moistened foods in bite sized pieces) and nectar thickened liquids. R19's care plan, dated 8/11/20, identified R19 eats with the help of one person to provide reminders to tuck her chin, and, no straw. R19's care plan also identified, I need dietary staff to provide me with my food preferences and my diet as ordered. I should not have straws. Review of R19's medical record, included a Speech Language Pathology Swallowing Evaluation, dated 1/7/20, which included reports from R19's daughter of concerns regarding R19 struggling with coughing on foods/liquids in meals. Findings included delayed swallow initiation and risk for aspiration, [DIAGNOSES REDACTED]. Review of speech therapy notes, dated 5/26/20, included R19 demonstrated cough immediately following trial of thin liquids via straw. On 6/25/20, speech therapy note included recommendation for thickened liquids, however, family signed diet waiver to allow thin liquids. Assessment summary included, Precautions: regular textures, nectar thick liquids; Confusion, risk of aspiration with thin liquids. Long term goal included, In order to facilitate safety with oral intake, patient will use alteration of liquid/solids, no straws, chin tuck and rate modification 75% of opportunities in order to decrease s/s (signs and symptoms) of oral/pharyngeal dysphagia. During an observation on 10/19/20, at 3:00 p.m. R19 was sitting in her wheelchair in her room, reading a book. A pink sign, posted on the wall by the nightstand, and another posted on the wall by R19's bed, directed, NO STRAWS. Another sign posted on the wall directed, May have thin liquids in room, nectar thick liquids for meals and medications. R19 had a large plastic water jug on the nightstand, containing thin water, and a straw. On 10/19/20, at 6:49 p.m. trained medication assistant (TMA)-A entered R19's room to administer medications she had mixed with pudding. R19 was lying on her side in bed, and TMA-A asked her to sit up. R19 raised herself up onto her right elbow, and opened her mouth to receive the medications. TMA-A gave her the spoonful of medications mixed in pudding, and offered R19 a drink of thin water from the plastic water jug, with the straw. R19 drank some water from the straw, and was observed to cough three times before lying back down. TMA-A left the room. On 10/20/20, at 9:21 a.m. R19's plastic water jug on the nightstand, contained a straw. During an observation on 10/21/20, at 7:29 a.m. the plastic water jug on R19's nightstand, contained a straw. During an observation on 10/21/20, at 8:30 a.m. R19 was eating breakfast in the dining room. The meal ticket on the tray included, NO STRAWS across the top. R19's tray had two thickened beverages and no straws. On 10/21/20, at 8:55 a.m. licensed practical nurse (LPN)-D administered medications to R19, mixed in pudding, and offered R19 sips of thickened water in a small plastic glass that was on the nightstand. When asked to explain the signs on the wall in R19's room, LPN-D stated, This shouldn't be in here, and picked up the plastic water jug with the thin water and straw. LPN-D stated, (R19) could aspirate, and stated R19 should not have a straw. LPN-D went out into the hallway to look at R19's electronic medical record, and stated, It looks like she can have thin liquids in her room, but only thickened liquids with medications, and no straw, so that's pretty obvious. LPN-D stated she needed to investigate this further. During an interview on 10/21/20, at 2:48 p.m. TMA-A verified she gave R19 medications in her room, and followed with thin water from the plastic water jug, with a straw. TMA-A stated she would usually go to get a cup of thickened water because she is to follow medications with nectar thick water and no straw. TMA-A stated she was, Just nervous I guess. During an interview on 10/22/20, 1:08 p.m. assistant director of nursing (ADON) stated therapy recommendations needed to be followed, unless the resident refused, and then a waiver risk and benefits would be discussed. A facility policy was requested, but not provided.

Based on interview and document review, the facility failed to ensure the required nurse staffing information was posted daily. This had the potential to affect all 71 residents residing in the facility. Findings include: When reviewing the facility's daily nursing staffing postings for 10/19/20-10/21/20, the daily postings were noted to be displayed on the wall at eye level on 10/19/20-10/21/20. However, the information provided did not include the total number of staff scheduled. On 10/22/20, at 12:04 p.m. Assistant Director of Nursing (ADON) stated she wasn't aware of what direction was provided to the staff completing the daily staff sheet. ADON indicated it was the responsibility of the scheduler or possibly the health unit coordinator to complete the form and post it. ADON confirmed the posting did not include the number of staff for each position. The facility procedure for staff posting was requested, but there was not one available.

Based on observation, interview, and document review, the facility failed to implement interventions to minimize the risk of falls for 1 of 3 residents (R4) reviewed for falls. This resulted in actual harm for R4 when she was transferred without the use of her walker and experienced a fall which resulted in a nasal fracture. Although noncompliance was present at the time of the event, the facility had implemented appropriate corrective action prior to the survey, resulting in a finding of past-noncompliance for R4. Findings include: R4's Physician order [REDACTED]. R4's quarterly Minimum (MDS) data set [DATE], indicated R4 was cognitively intact and required extensive assistance of one person for all activities of daily living (ADL) except was independent with eating. The MDS also indicated R4 was not steady with transfers or walking. The MDS further indicated R4 had experienced one fall with major injury since the previous assessment. R4's Falls Care Area Assessment indicated R4 was at risk for falls related to her disease process, medication use, history of falls, advanced age and immobility. R4 triggered for a significant change assessment due to now being able to ambulate, and with improvement in transfers and eating. R4 has a [DIAGNOSES REDACTED]. She is able to verbalize and use the call light, but staff were to anticipate her needs. R4 required staff assistance for all her ADLs. R4's undated Care Plan indicated R4 had physical challenges, a history of falling, and required staff assistance with all mobility. The Care Plan also indicated R4 had a history of [REDACTED]. The Care Plan further indicated R4 was unsteady with transfers and demonstrated an inability to safely transfer independently. The Care Plan directed staff to keep an eye on behaviors, request a therapy screen if needed, remind to ask for help, make sure important items are within reach, use the following assistive devices: FWW (front wheeled walker) or wheelchair, to observe for unmet needs (such as pain, toileting, hunger and thirst), use non-skid footwear, encourage to use assistance, report signs of pain to nurse, assist with transfers or when walking, attempt to anticipate needs, and attempt to keep bedside table within reach when in recliner. The Care Plan also indicated R4 required assistance of one person with a FWW for transfers from all surfaces in room and used a PAL (a sit to stand lift) to get into bed at night. On 1/30/20, at 9:44 a.m. R4 was observed in her room, seated in recliner in her room with the foot of the recliner elevated. A bedside table was next to the recliner and the call light was within reach. R4 rested with eyes closed -At 10:21 a.m. remained quietly seated in the recliner, fully reclined. No attempts to self transfer observed. -At 10:37 a.m. R4 was seated fully upright in the recliner. Nurse entered room to administer medications. On 1/30/20, at 1:23 p.m. R4 was observed in the therapy department doing exercises with physical therapy assistant (PTA)-[NAME] -At 1:25 p.m. PTA-A prompted R4 to stand and R4 started on her own before PTA-A assisted. PTA-A cued R4 to wait for assistance. R4 stood up between the parallel bars and worked on standing exercises with PTA-A -At 1:48 p.m. R4 finished exercises and wheeled over to the bike area. R4 transferred with assist of one and the use of a FWW and gait belt. PTA-A cued R4 to keep the walker close and turn and step back, reach for the chair, and sit on the seat of the bike. PTA-A assisted R4 to position feet on the pedals and hands on grips. R4 began to pedal on the bike. -At 2:02 p.m. R4 completed the bike exercise and transferred with assist of one and the FWW back to the wheelchair. PTA-A wheeled R4 from the therapy room to her own room, and assisted to transfer to recliner with use of gait belt and FWW. R4 transferred well but required cues to keep walker close to her body. PTA-A removed the gait belt and cued R4 to sit back in the chair, raised foot of recliner, placed call light on R4's lap, a pillow under R4's feet and a blanket on her lap. Review of R4's Progress Notes from 11/1/19 to 12/3/19, revealed R4 experienced a fall on 11/8/19, at 8:20 p.m. in her room. The note indicated staff was assisting R4 from the recliner to the wheelchair when the fall occurred. R4 sustained a laceration to the nose and a nasal fracture. A Nursing Home Incident Report (NHIR) submitted to the State Agency (SA) dated 11/11/19, indicated on 11/8/19, nursing assistant (NA)-A was transferring R4 to her recliner after R4 requested to go to the bathroom and go to bed. NA-A had a transfer belt on R4, and was standing next to her. The chair was at an angle. R4 was wearing gripper socks. When R4 started to pivot, she lost her balance and fell down to the ground. NA-A also went down to the ground with R4. R4 hit her head on the floor, neuros's were started and she was sent to the ER. R4 had a laceration to her nose and received five sutures. R4 also received a closed [MEDICAL CONDITION] bone. In further review of event, it was discovered that a FWW had not been used during the pivot transfer. Care plan was updated to use a PAL lift until further evaluation. Will review footwear. Staff education provided to all staff related to falls and pivot transfers. The 5-Day Investigation submitted to the SA dated 11/12/19, included an investigation summary which indicated after further investigation it was discovered that NA-A did not go to the ground with R4. NA-A stated that the transfer belt had loosened up after R4 stood up and that was when R4 started to lose her balance. NA-A tried to stop R4 from falling but was not able to do. It was verified with at least three staff that R4 did have a transfer belt on when she fell . Family did mention R4's preference was for staff to use the PAL lift instead of a pivot transfer at bedtime because it helped her get further back on the bed. This was not in R4's care plan at the time of the fall. Family also stated R4 should wear shoes with transfers and not gripper socks. This was also not in R4's Care plan at the time of the fall. The investigation concluded R4's care plan was not followed as R4 had been transferred with one assist and gait belt and the care plan directed assistance with one to pivot and the FWW. On 1/30/20, at 2:07 p.m. PTA-A stated R4 did not have good safety awareness. PTA-A indicated R4 was improving on transitions from sitting to standing but needed cuing and assistance with her walker as she tended to push it out too far in front of her and could not get it into position with verbal cues. PTA-A stated she had to move the walker for her. PTA-A further stated based on today's session, R4 would not be safe to transfer without a walker. On 1/30/20, at 3:29 p.m. R4 verified she had had a fall and broke her nose. R4 stated the NA who was helping her did not use her walker and she fell . R4 stated the NA's at night used a PAL lift to transfer her and that went well, however, the NA's in the daytime did not use the PAL. R4 verified she was supposed to use a walker with transfers and indicated sometimes they (the NA's) used it and sometimes they did not. R4 stated she tries to tell them, but they (staff) do not listen to her. On 1/30/20, at 3:46 p.m. NA-B stated R4 usually used a FWW and assistance with transfers and ambulation in the daytime and then on the evenings used a PAL lift. NA-B stated R4 was more tired in the evening and needed the extra assistance. He stated they would use the walker versus the PAL depending on how R4 was doing that day. NA-B verified R4 needed to use the walker for transfers and was not to be transferred without it. On 1/30/20, at 4:01 p.m. registered nurse (RN)-A verified R4 had a fall on 11/8/19, at 8:20 p.m. when she fell /lost balance during an assisted transfer from recliner to the wheelchair. RN-A indicated it had been determined upon investigation that R4's walker was not used at the time of the fall. RN-A also indicated they had found a discrepancy in communication between nursing and physical therapy (PT) related to when PT directed a pivot transfer, it meant to use a device to stabilize the resident such as a walker, but to nursing, a pivot transfer just meant to stand and pivot with no device needed. RN-A stated therapy had been working with R4 at the time of the fall. RN-B referenced R4's care plan on the computer and indicated, at the time of the fall, the care plan directed R4 required transfer with assist of one and the FWW which had been initiated 10/7/19. RN-A verified R4 was not safe to transfer without the walker per therapy and indicated R4 had one leg longer than the other subsequent to hip surgery. RN-A indicated they were working on getting R4 a built up shoe with the hopes that she would have increased function. RN-A and RN-B confirmed if staff had used the walker as directed, it was possible R4 may not fallen and broken her nose. On 1/30/20, at 4:23 p.m. the director of nursing (DON) verified NA-A had not followed R4's care plan and received education regarding this after the fall. DON confirmed NA-A should have transferred R4 with the assistance of a FWW as directed on her care plan. The Fall/Injury Risk policy dated 6/20/18, indicated all patients would be assessed upon admission (and re-assessed every quarter, after a fall or with a significant change) using the Fall Assessment & Re-evaluation Tool. An individual plan of care related to safety and fall prevention would be completed. Family would be consulted for individualizing fall prevention interventions, if available. Appropriate interventions would be initiated. The patient and family would be educated about the safety interventions in place. The past non-compliance that began on 11/8/19, was verified during the 1/28-1/29/20, onsite visit and reviewed to be corrected by 11/12/19. Verification of corrective action was confirmed by interviews with a variety of nursing staff, observations, and document review. Training and education was completed for all staff. On-going monitoring of resident cares implemented in order to prevent future incidents. The action plan implemented included: -review of resident care plans -PT/T involvement which identified the discrepancy related to the definition of a pivot transfer. Educated all staff in the definition of a pivot transfer -included R4's family with the development of interventions -incorporated the use of standing lifts into facility skills fair. -referred R4 to Speech therapy in an attempt to improve speech/communication related to disease process. -reviewed and/or revised policies and procedures. Reviewed with staff and educated the staff on changes made. -implemented plan for staff on all shifts to review care plans to ensure accuracy related changes in resident ability as it related to the time of day. -Educated all staff on implementation of the care plan. -implemented a monitoring system to ensure compliance.

Based on interview and record review the facility failed to ensure residents were free of significant medication errors which resulted in loss of consciousness, critically low blood sugar with risk for serious harm or death for 1 of 3 residents (R1) reviewed for medication errors. The immediate jeopardy began on [DATE], when R1 was administered 80 units of [MEDICATION NAME] before bed, instead of R1's prescribed 8 units of [MEDICATION NAME]. R1 was found on the floor of his room and had lost consciousness on [DATE], at 5:44 a.m. with a blood sugar of 13, (normal range ,[DATE].) R1 required immediate emergent care and had an extended emergency room visit as a result of his critically low blood sugar. The immediate jeopardy was corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Findings include: Review of R1's admission Minimum Data Set (MDS) dated , [DATE], identified R1 had [DIAGNOSES REDACTED]. The MDS identified R1 had moderate cognitive impairment and required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, ambulation and toileting. Further, the MDS revealed R1 had received insulin injections daily during the look back period. Review of R1's admission Care Area Assessment (CAA) dated [DATE], identified R1 had short and long term memory loss, moderately impaired cognition and had problem solving deficits. The CAA identified R1 required extensive assistance with ADL's. The CAA's identified R1 had a [DIAGNOSES REDACTED]. Review of R1's physician orders [REDACTED]. -[DATE], [MEDICATION NAME] Flex Pen (insulin [MEDICATION NAME] 100 units/ml) 8 units three times a day at breakfast, lunch and dinner. -[DATE], [MEDICATION NAME] (insulin [MEDICATION NAME] 100 units/ml) 8 units before bed -[DATE], check R1's blood glucose (blood sugar) levels four times a day (qid) R1's emergency room notes dated [DATE] revealed the following: -emergency room history and physical identified R1 arrived at the emergency department by ambulance due to symptomatic low blood sugar. The history and physical revealed R1 had inadvertently been given 80 units of [MEDICATION NAME] last evening before bed instead of his prescribed 8 units of [MEDICATION NAME]. The H&P identified R1 had been found on the floor with a blood glucose of 13 and had been given a dose of [MEDICATION NAME] (emergency intramuscular medication given to rapidly increase blood sugar,) and his blood sugar had increased up to the range of the high 20's. The H&P revealed R1's blood sugar was 38 while in the ambulance and he had been given intravenous (IV) D 50 ([MEDICATION NAME] solution given to increase blood sugar) 10 milliliters (ml) and then 150 ml of D 10 (another [MEDICATION NAME] solution given to increase blood sugar) by the paramedics in route to the emergency department. -emergency department course note revealed R1 was lucid and hungry upon arrival to the emergency department. The note revealed R1's blood glucose levels were checked periodically throughout his emergency room visit and the following values were noted; 151, 149 and 149. The note revealed R1 continued to receive D10 by IV at 25 milligrams (mg) an hour while he was in the emergency department and was monitored closely. R1's emergency department course note identified the hospitals pharmacist and poison control had been consulted as to the best course of treatment for [REDACTED]. The hospital pharmacist had noted the peak effect for [MEDICATION NAME] was ,[DATE] hours and was excreted through the kidneys. -emergency room provider note dated [DATE], identified R1 continued to be closely monitored for further signs of [DIAGNOSES REDACTED] and R1 had been monitored for four hours after the IV D10 was discontinued. The note revealed R1 was encouraged to continue to sip on sugary beverages for the next 24 hours, and R1's [MEDICATION NAME] and [MEDICATION NAME] insulin's were to be held for the next 24 hours. Further, the note identified R1 would be discharged back to the facility with orders to check his blood sugars every four hours on a scheduled basis and as needed. Review of R1's facility incident report dated [DATE], identified at 5:44 a.m. R1 had been found on the floor of his room unresponsive with a blood glucose level of 13. The incident report revealed at that time, R1 received intramuscular [MEDICATION NAME] (emergent medication given to increase blood sugar) injection and he was sent to the hospital emergency department via ambulance. The incident report identified R1 had an order for [REDACTED]. The report indicated on [DATE], the facility's electronic medical record system (EMR,) Medication Administration Record [REDACTED]. On [DATE], at 11:17 a.m. licensed practical nurse (LPN)-A stated he had received verbal education within the last week regarding safe insulin administration and the seven rights to safe medication administration. LPN-A stated he had received safe medication administration education as a result of a significant medication error where R1 had received the wrong dose of insulin. LPN-A stated he routinely checked all insulin doses with the residents physician orders [REDACTED]. LPN-A further stated the facility had recently implemented a communication system of placing magnets on the door frame of residents rooms who were diabetic in order to make all nursing staff aware of who was diabetic and to observe for signs and symptoms of [DIAGNOSES REDACTED]. On [DATE], at 11:26 a.m. LPN-B stated she had recently received verbal education within the last few days regarding the seven rights of safe medication administration and insulin administration. LPN-B stated she had been reminded to triple check insulin doses with the physician orders [REDACTED]. Further, LPN-A stated within the last week the facility had implemented a magnet system of which residents who were diabetic had a magnet placed on the door frame of residents rooms who were diabetic in order to observe for signs and symptoms of [DIAGNOSES REDACTED]. LPN-B also indicated the facility had increased the font size of their EMR and had made insulin orders easier to read. On [DATE], at 11:47 a.m. LPN-C stated she routinely attended the facility's skills fair in May, 2019, which she would return demonstrate insulin administration. LPN-C stated within the past week she had received verbal education to triple check all insulin doses with the residents physician orders [REDACTED]. LPN-C stated she routinely checked residents insulin orders and the amount drawn up three times prior to administration due to the risk of [DIAGNOSES REDACTED]. LPN-C stated within the last week the facility had implemented a magnet system of which residents who were diabetic had a magnet placed on the door frame of residents rooms who were diabetic in order to observe for signs and symptoms of [DIAGNOSES REDACTED]. On [DATE], at 11:57 a.m. the director of nursing (DON) stated she was called on [DATE], in the early morning and was notified R1 had been found on the floor of his room, unresponsive with a blood sugar of 13. She stated R1 was sent to the emergency department by ambulance and had been notified RN-A had given 80 units of [MEDICATION NAME] instead of 8 units of [MEDICATION NAME] the night prior. The DON stated RN-A was immediately suspended while she completed an investigation to determine the root cause of the error. The DON stated the facility's staff development coordinator (LPN)-D, herself, nurse manager and assistant director of nursing had met with RN-A and it was determined RN-A had not double checked R1's insulin order before she had administered the 80 units of [MEDICATION NAME]. The DON stated they had determined RN-A had not followed facility policy for insulin administration and had not completed the seven rights of safe medication administration. She indicated the facility's policy for insulin administration had not been revised as it mirrored Lippincott's nursing manual for insulin administration. The DON stated LPN-D had also provided safe insulin/medication administration education to the facility's licensed staff to ensure all staff were aware and had been following the facility's policy and standards of practice. She stated the facility was also looking at their medical record system to see what safety measures could be put in place and indicated they facility had already implemented clarifying insulin orders on residents medications administration record which included having the units of insulin in parenthesis. On [DATE], at 12:13 p.m. during an interview with R1's nurse manager (NM)-B she was aware of a significant medication error had occurred when R1 had received 80 units of [MEDICATION NAME] versus 8 units of [MEDICATION NAME]. NM-B stated the facility's DON and assistant director of nursing (ADON) had met with RN-A following the medication error. She indicated RN-A had been suspended immediately following the significant medication error and an investigation was conducted. NM-B stated at that time, RN-A had returned to work on the night shift. She stated RN-A was required to have a second licensed nurse check all high risk injectable medications, which included insulin. NM-B stated the facility also implemented a cupcake magnet system, whereas residents who were diabetic and at risk of [DIAGNOSES REDACTED] had a magnet in the shape of a cupcake on the frame of the residents doorway to alert staff to routinely observe residents for signs and symptoms of [DIAGNOSES REDACTED]. Further, NM-B indicated the facility had contacted their electronic medical record (EMR) systems information technologist and were currently working on safety measures for insulin administration, such as an alert to double check insulin doses. On ,[DATE], at 1:49 p.m. during a follow up interview, the DON stated the facility's staff development coordinator, LPN-D, had previously worked with RN-A on [DATE], following a medication error and LPN-D had again completed competency training with RN-A on [DATE], and [DATE]. Further, the DON stated LPN-D had observed RN-A throughout her medication pass on [DATE] and had a plan to observe RN-A's medication pass when she worked again. Further, the DON stated RN-A was required to have another licensed nurse double check all high-risk injectable medications prior to administration, which included insulin. In addition, she stated during the facility's investigation into R1's significant medication error, it was noted the font size of the nurses laptops used during medication administration was set at 8, which is smaller than average newspaper print. The DON stated all laptop font sizes had been changed to 12. On [DATE], at 2:44 p.m. the facility's staff development coordinator, LPN-D, confirmed she had been working with RN-A regarding safe insulin administration and the seven rights to safe medication administration since [DATE]. LPN-D stated she planned to observe RN-A for a minimum of three entire medication administrations to ensure compliance with the facility's policy and current standard of practice. LPN-D indicated she had met with RN-A following the significant medication error with R1 and stated RN-A had confirmed she had not double checked R1's physician order [REDACTED]. She indicated RN-A had verified she had not followed standard of practice and gave no other explanation as to what other factors were involved when she made the error, though LPN-D stated she was under the impression RN-A was interrupted during her medication pass on [DATE]. LPN-D stated at present RN-A was required to have another licensed staff member verify all high-risk injectable medications, which included insulin. LPN-D further stated she planned in the future to complete random audits of medication administration for all licensed staff to ensure safe medication administration practices continued to be followed. On [DATE], at 3:11 p.m. the ADON stated all licensed nursing staff had attended the facility's skills fair in April, 2019, in which they covered insulin administration, the seven rights of safe medication administration and indicated nursing staff had returned demonstrated administration of insulin pens, and multi-use vials. The ADON stated since the time of the incident with R1, RN-A had been monitored and was not able to administer injectable medications, such as insulin, without another nurse present. The ADON stated as of that day, they have added a safety measure to the facility's EMR (electronic medical record), Medication Administration Record, [REDACTED]. During a telephone interview on [DATE], at 10:30 a.m. R1's primary physician, (MD)-A indicated he had been made aware R1 had received the wrong dose of insulin and had been sent to the emergency room department for treatment. MD-A stated he was not aware of the particulars, such as how much insulin he received and how low his blood sugar had gone. MD-A was notified from the facility's documentation, R1 had received 80 units of [MEDICATION NAME], instead of his prescribed 8 units, and R1's blood sugar had dropped to 13. MD-A stated he felt R1 could have died , had he not landed on the floor the following morning and indicated he felt the medication error could have been completely avoided if the nurse would have followed standards of practice and the facility's policy. MD-A stated he felt it was an asinine thing to do, and stated, it is nursing 101 to double check injectable medications, especially high-risk medications such as insulin. MD-A stated he expected the facility's nursing staff to double/triple check all insulin and injectable mediations. Further, MD-A stated he would expect the facility to provide education, skills training and to monitor RN-A following the egregious medication error. Review of a facility policy titled, Safe Medication Administration Practices, general, revised [DATE], identified safe medication practices to prevent medication errors which included the five rights of medication administration; right patient, right medication, right dose, right time and right route. The policy listed four additional rights to safe medication administration which included; right documentation, right action, right form and right response. The policy directed facility nursing staff to verify medication orders and dosage prior to administration. Review of a facility policy titled, Subcutaneous Injections, revised [DATE], indicated it was the facility's policy to make sure the type of insulin, unit dosage and syringe were correct prior to administration. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and the deficient practice corrected by [DATE], after the facility implemented a systemic plan that included the following actions: - immediately removed the involved employee from the work schedule, re-educated the employee on the standards of practice of safe medication administration, administering high risk injectable medications, such as insulin and when employee returned to work, required the employee to double check all high risk medications with a second nurse prior to administration. -re-educated all facility licensed nursing staff regarding insulin administration and the seven rights to safe medication administration. -implemented changes to licensed staff computers which included font size modification. -implemented and educated all facility staff on a system to identify diabetics in the facility using cupcake magnets, to increase awareness of symptoms of [DIAGNOSES REDACTED].

Based on interview and document review, the facility failed to ensure an alleged violation of staff to resident physical and verbal abuse was immediately, no later than two hours, reported to the State agency (SA) for 2 of 3 residents (R15, R60) reviewed for allegations of abuse. Findings include: R15's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R15 had moderately impaired cognition and [DIAGNOSES REDACTED]. The MDS identified R15 required extensive assistance of two staff with bed mobility, transfers and toileting as well as extensive assistance of one with grooming, bathing and dressing. R15's MDS further indicated verbal and other behavioral symptoms displayed by R15 which occurred one to three days during the assessment period. Review of untitled incident report # 6, dated 1/27/19, 8:40 p.m. identified the alleged incident was witnessed by nursing assistant (NA)-A. The report indicated nursing assistant (NA)-D was rough and rude to R15 when interacting with her. NA-A reported R15 cried and NA-A reported the incident to registered nurse (RN)-A. RN-A discussed with registered nurse (RN)-B and NA-D was removed from care and sent home. Review of the untitled investigation report # 6, dated 1/28/19, indicated the facility reported to the SA on 1/28/19, at 12:34 a.m. an allegation of physical abuse of rough handling which occurred on 1/27/19, at 8:40 p.m. from NA-D to R15. The SA was notified of the alleged staff to resident abuse three hours 54 minutes after the alleged incident. On 2/28/19, at 10:43 a.m. NA-A confirmed she was present in R15's room at the time of the incident and stated NA-D was very rough when turning R15 in her bed. Additionally, NA-A stated NA-D was yelling while talking to R15. NA-A stated R15 became upset and cried after the incident. NA-A stated RN-A was out in the hallway at the time of the incident and NA-D reported the incident to RN-A and RN-B. NA-A further stated she assumed cares of R15 and offered reassurance and support to R15 after the incident. On 2/28/19, at 11:32 a.m., RN-A confirmed NA-D reported the allegation of abuse to her. RN-A stated the allegation was discussed with RN-B and NA-D was removed from the schedule and sent home. RN-A stated RN-B completed the report to the SA and was not able to recall the time frame from receiving the report of alleged physical abuse to the reporting of the alleged abuse to the SA. R60 R60's quarterly MDS dated [DATE], indicated R60 had moderately impaired cognition and [DIAGNOSES REDACTED]. The MDS indicated R60 required extensive assistance of two staff with bed mobility, transfers, dressing and toileting. The MDS futher indicated R60 required extensive assistance of one staff with locomotion, grooming and bathing. R60's MDS identified R60 had not displayed any verbal or physical behaviors during the assessment period. Review of untitled incident report # 6, dated 1/27/19, at 8:40 p.m. identified the alleged incident was witnessed by NA-A. While assisting R60 onto the toilet, NA-D used foul language at R60 while telling her to move further back onto the toilet seat. R60 made a comment to NA-D about the foul language she had used and NA-D again used foul language at R60 when responding. Further, NA-D was heard by NA-A to say to R60, God you are so heavy. Review of the untitled investigation report # 6, dated 1/28/19, indicated the facility reported to the SA on 1/28/19, at 12:34 a.m. an allegation of verbal abuse which occurred on 1/27/19, at 8:40 p.m. from NA-D to R60. The SA was notified of the alleged staff to resident abuse three hours 54 minutes after the alleged incident. Reports to the SA were completed simultaneously for R15 and R60. The director of nursing (DON) confirmed the reports for R16 and R60 had been completed for the same times since the staff were not aware of the specific times each incident had occurred. On 2/28/19, at 11:32 a.m. RN-A confirmed the allegation of verbal abuse to R60 had been reported to her and RN-B. RN-A was not able to recall the time frame of when it was reported to her and RN-B. On 2/28/19, at 1:29 p.m. DON confirmed the allegations of physical and verbal abuse for R15 and R60 met the criteria for abuse. DON further confirmed allegations of abuse were to be reported to the SA immediately, within two hours. On 2/28/19 at 2:28 p.m. during a follow up interview, DON stated RN-B indicated she wasn't able to confirm the exact time frame however felt the incidents had been reported to her a little after 10:00 p.m. DON further confirmed the reporting to the SA had not occurred within the two hour time frame. Review of the facility's policy titled Vulnerable Adult Policy, last reviewed on 2/21/18, revealed the facility staff were to report all alleged violations involving abuse to the SA immediately but not later than two hours after an allegation was made.

Based on interview and document review, the facility failed to ensure residents current wishes for resuscitation status were accurately documented in the clinical record for 2 of 2 residents ( R53, R75) reviewed for advanced directives. Findings include: R53 R53's Significant Change Minimum Data Set (MDS) assessment dated [DATE], indicated R53 was cognitively intact and had [DIAGNOSES REDACTED]. R53's Provider Orders for Life Sustaining Treatment (POLST) form located in R53's paper medical record, dated [DATE] and last reviewed on [DATE], indicated R53 was DNR (do not resuscitation) (Allow Natural Death). Review of R53's electronic record revealed the current Physician order [REDACTED]. Further, R53's current care plan revised on [DATE], indicated R53 was a full code (cardiopulmonary resuscitation CPR attempt resuscitation). R53's clinical record did not accurately reflect R53's current wishes for advance directives. On [DATE] at 1:50 p.m. department secretary (DS)-A confirmed R53 code status was identified differently in various locations of the clinical record and was referred to the social service designee (SSD)-A. On [DATE] at 1:50 p.m. SSD-A verified R53 currently was a DNR (do not attempt resuscitation) (Allow Natural Death). She confirmed R53 code status was identified differently in various locations of the clinical record and indicated the electronic record should match the paper record. SSD-A indicated the usual practice was for staff to look in the electronic record to identify a resident's current wishes for advanced directives. On [DATE] at 1:58 p.m. registered nurse (RN)-B indicated R53's advanced directives were processed incorrectly and verified R53 was currently was a DNR RN-B confirmed R53 code status was identified differently in various locations of the clinical record. She indicated staff were to look in the electronic record for the most current code status and follow the orders in the computer. On [DATE] at 9:42 a.m. licensed practical nurse (LPN)-A indicated staff were to look in the electronic record (computer) or the care plan located in the closets of the residents rooms. LPN-A indicated she would look in the electronic record first to know the residents advanced directives before anything else. R75 R75's Admission Minimum Data Set (MDS) assessment dated [DATE], indicated R75 was cognitively intact and had [DIAGNOSES REDACTED]. R75's Provider Orders for Life Sustaining Treatment (POLST) form signed and dated [DATE], located in R75's paper copy medical record indicated R75's current code status was Do Not Resuscitate (DNR) (Allow Natural Death). Review of R75's electronic record revealed R75's current Physician order [REDACTED]. care plan revised on [DATE], indicated R75 had no indicated code status and R75's current medication administration record (MAR) indicated R75 had no indicated code status. Further review of R75's paper medical record under Advanced Directive tab included an Honoring Choices Minnesota Health Care Directive form dated [DATE], which indicated R75 requested cardiopulmonary resuscitation(CPR) under certain circumstances. R75's clinical record did not accurately reflect R75's current wishes for advance directives. On [DATE], at 2:22 p.m. registered nurse coordinator (RNC)-A stated prior to [DATE], R75 had an order for [REDACTED]. He confirmed R75's current code status was DNR according to the signed POLST. RNC-A confirmed R75's code status was identified differently in various locations of R75's clinical record. He stated the usual facility process when a code status order was received was to process the order into the electronic health record as a physician order. From there the code status order would show on the resident's physician orders, MAR and care plan. RNC-A confirmed R75's physician orders, MAR and care plan lacked R75's current code status of DNR. RNC-A and R75's new order for DNR was not processed in the electronic health record correctly. On [DATE], at 3:20 p.m. RNC-A stated R75's DNR order was processed into R75's electronic health record on [DATE], but the electronic health record was not showing the DNR order on R75's physician orders, MAR or care plan due to a computer error. RNC-A stated presently information technology (IT) found the error and had corrected it. On [DATE], at 3:36 p.m. assistant director of nursing (ADON) stated when a signed POLST was received, the code status would be entered into the electronic health record like a medication order. From there the code status order would show on a resident's physician orders, MAR and care plan. ADON stated the licensed nurses would look at the resident's MAR if they were required to know a resident's code status. ADON confirmed R75's physician orders, MAR and care plan had not reflected R75's current code status. On [DATE], at 3:40 p.m. director of nursing (DON) stated she would expect the correct code status information for residents would be available for staff in the electronic medical record. On [DATE], at 3:17 p.m. registered nurse (RN)-C stated the usual practice for licensed staff was to look at the residents MAR when they needed to know an individual resident's wishes for resuscitation. RN-C stated as a charge nurse in the facility, she would look at the resident's physician orders. A facility policy titled Advance Directives approved on [DATE], indicated any advance directives on file will be considered valid, unless the client revokes them. If more than one advance directive existed, the most current (dated) advance directive would be considered the valid document and would be included in the electronic health record.

Based on observation, interview and record review the facility failed to ensure nebulizer medications were administered safely for 1 of 1 resident (R78) who was observed to self administer a nebulizer and had been assessed as not safe to self administer medications. Findings include: R78's quarterly Minimum Data Set ((MDS) dated [DATE], identified R78 had [DIAGNOSES REDACTED]. R78's MDS also indicated she had severe cognitive impairment and required extensive assistance with activities of daily living (ADLs). R78's Care Area Assessments (CAA) dated 8/15/17, identified R78 had [DIAGNOSES REDACTED]. The CAAs further identified R78 was not a candidate for self administration of medications. R78's self medication administration assessment dated [DATE], identified R78 remained an inappropriate candidate for self administration of medications. She would continue to receive all medications, as ordered, from licensed staff on the unit. R78's care plan dated 2/28/18, revealed R78 had potential for alteration in self medication administration related to [DIAGNOSES REDACTED]. The care plan revealed R78 was unable to self administer her medications, and directed the nurses to administer all medications as ordered. R78's current physician orders [REDACTED]. Dose ordered: 1 ml BID (two times a day) AM PM for [MEDICAL CONDITION]. On 2/28/18, at 3:21 p.m. R78 was observed lying on her right side in her bed in her room. She had a nebulizer mask on her face, and the nebulizer machine was running. R78's door was partially open, and she was not visible from the hallway. No staff members were in R78's room, and the nurse was not in the hallway. On 2/28/18, at 3:23 p.m. nursing assistant (NA)-A entered R78's room and removed her nebulizer mask and shut off the machine and exited the room. NA-A confirmed she had just taken off R78's nebulizer mask and shut the nebulizer off. On 2/28/18, at 3:46 p.m. registered nurse (RN)-A confirmed he had initiated R78's Duo Neb ([MEDICATION NAME][MEDICATION NAME] medications that relax the muscles in the airways and increase air flow to the lungs) medication via nebulizer. He indicated he removed R78's nebulizer equipment from her closet, put the medication in the nebulizer cup, placed the mask on R78, turned on the nebulizer machine then left the room. RN-A indicated R78 had not been observed to ensure she had been administered the entire dose of the medication. RN-A confirmed he instructed NA-A to stop the nebulizer treatment for [REDACTED]. RN-A indicated R78 was at risk of removing the nebulizer mask before her treatment was done, and stated she had removed her nebulizer mask herself at times in the past. RN-A reviewed R78's Medication Administration Record [REDACTED]. On 3/01/18, at 2:19 p.m. during a follow up interview RN-A confirmed he had started administration of R78's [MEDICATION NAME] nebulizer medication by putting on her mask, turning the machine on then left the room. RN-A indicated the nebulizer machine ran for about 6 minutes before he instructed NA-A to remove it. RN-A indicated this was the time it took for R78's nebulizer medication to finish. RN-A indicated he had asked his supervisor prior to administering the medication how to know if R78 could self administer the medication. RN-A indicated the supervisor informed him R78's Medication Administration Record [REDACTED]. RN-A indicated he could not remember if he saw a note at the top of R78's MAR indicated [REDACTED]. RN-A indicated it was not his usual practice to start nebulizer medications then leave the room. RN-A indicated his usual practice was not to instruct nursing assistants to stop nebulizer medications for residents. RN-A indicated the reason he instructed NA-A to stop R78's nebulizer medication was he got distracted with another resident and did not want R78 to have the mask on too long. On 3/01/18, at 2:46 p.m. NA-A confirmed she had stopped R78's nebulizer machine and removed her mask. NA-A indicated RN-A had asked her to do it. NA-A confirmed she had removed nebulizer masks for residents at other times, but not very often. NA-A indicated in the past she had removed them just to be helpful, but that the only time she had been asked by a nurse to take a residents nebulizer mask off and stop the treatment was when RN-A asked her to remove R78's. On 3/01/18, at 2:50 p.m. director of nursing (DON) indicated the facility practice for self administration of medications was to do an assessment on admission, annually and it was reviewed quarterly. DON confirmed nebulized medications were included on that decision. DON indicated the facility process was to put an FYI notice on the top of the residents MAR indicated [REDACTED]. DON confirmed R78's MAR indicated [REDACTED]. DON indicated her expectation would be that a nurse or trained medicaiton aide (TMA) would be in sight and watching while administering nebulized medication for residents who could not self administer medication. The facility policy tilted Self Administration of Medications reviewed 5/2/16, identified residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that he practice would be safe for the resident and other residents of the facility.