Every finding on record at Legend Oaks Healthcare and Rehabilitation - Ennis

Based on observation, interview and record review, the facility failed to ensure that 3 residents (Resident's #34, #61, and #64) out of 6 residents reviewed for activities of daily living received care and services for nail care. The facility failed to ensure that Residents #34, #61, and #64's fingernails were cleaned. This failure placed residents at risk for not receiving adequate care and services to prevent infection, injury, and diminished quality of life.Findings include: Record review of Resident #34's face sheet dated 05/06/26 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: metabolic encephalopathy (a broad term for brain dysfunction caused by non-traumatic, systemic issues like chemical imbalances, organ failure, or infections, rather than direct brain injury), acute respiratory failure (a serious condition where the lungs fail to adequately oxygenate the blood, leading to low blood oxygen levels), chronic obstructive pulmonary disease (COPD) (a lung disease characterized by chronic respiratory symptoms and airflow limitation), and dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities). Record review of Resident #34's Significant Change MDS assessment dated [DATE] reflected a BIMS score of 06 indicating Resident #34 had severe cognitive impairment. MDS assessment reflected resident required partial/moderate assistance for eating and was dependent on staff for toileting, showering, and personal hygiene. Record review of Resident #34's Comprehensive Care Plan dated on 07/22/25 reflected a focus Resident #34 had osteoarthritis and gout. Goal: will maintain acceptable level of comfort (as expressed by resident) through review date. Interventions included: monitor and report to Nurse any change in level of activity or ability to perform ADL's. Resident #34's care plan reflected a focus ADL self-care performance deficit r/t arthritis, BPH with lower urinary tract symptoms, and Gout. Goal: will maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene; ADL Score through the review date. Interventions included: Encourage to participate to the fullest extent possible with each interaction. Record review of Resident #34's progress notes dated 05/06/26 reflected Resident dependent on ADLs'. In an observation on 05/05/26 at 12:07 PM, Resident #34 was in bed with his blankets pushed to the side. Resident #34 awakened to name call but only mumbled in response to questions. Resident appeared pleasantly confused. Resident #34 was without odors or signs of pain or distress. Resident #34's hands were crossed and laid across chest. Resident #34's fingernails were dirty with dirt and brown debris under the nails. Record review of Resident #61's face sheet dated 05/05/2026 reflected a [AGE] year-old-female admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD)(a long-term progressive lung disease that causes difficulty breathing due to obstruction of airflow in the lungs), paroxysmal atrial fibrillation (A-Fib) (irregular and rapid heartbeat),vascular dementia(a decline in memory, thinking, and reasoning skills caused by reduced blood flow to the brain, often due to strokes or damage blood vessels), and muscle weakness (a reduced strength in one or more muscles, making it difficult to move, lift objects, walk, or perform daily activities). Record review of Resident # 61's admission MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severely impaired cognition. Section GG reflected Resident #61 required substantial/maximal assistance with personal hygiene. The MDS reflected that the resident did not reject care. Review of Resident #61's care plan dated 03/24/2026 reflected the following: Resident has an ADL self-care performance deficit related to decreased mobility, weakness, A-fib, pulmonary edema, pain, chronic obstructive pulmonary disease (COPD), depression, and refusal to get out of bed at time. Nail care was not addressed in care plan.Goals: Resident #61 will safely perform through the review date.Interventions included: Encourage to discuss feelings about self-care deficit. Encourage to participate to the fullest extent possible with each interaction. In an interview/observation on 05/05/2026 at 11:17 AM Resident #61 showed her fingernails, which had a yellowish discoloration present to all fingernails. Several nails were thick with dark yellowish-brown dirt or debris underneath fingernails along the nail beds and nail edges. Resident #61 stated she wished she could get her nails cleaned but she did not know who to ask for assistance. In an observation on 05/06/2026 at 1:12 PM revealed Resident #61's fingernails had a yellowish discoloration present to all fingernails. Several nails were thick with dark yellowish-brown dirt or debris underneath fingernails along the nail beds and nail edges. Record review of Resident #64's face sheet dated 05/05/26 reflected a [AGE] year-old-male admitted on [DATE] with diagnoses of unspecified dementia, mild without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety(mild cognitive impairment affecting memory and thinking abilities that affect daily functioning), type 2 diabetes (condition where the body does not properly use insulin causing blood sugar levels to become elevated), need for assistance with personal care (requires help from another person to complete daily self-care activities such as bathing, dressing, grooming, toileting, eating, or hygiene task), hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated). Record review of Resident # 64's quarterly MDS assessment dated [DATE] reflected a BIMS score of 05 which indicated severely impaired cognition. Section GG reflected Resident #64 required partial/moderate assistance with personal hygiene. The MDS reflected that the resident did not reject care. Review of Resident #64's care plan dated 01/01/2026; revised date 01/15/2026 reflected the following: Resident #64 has an ADL self-care performance deficit related to weakness, decreased mobility, and cognitive deficit. Goals: Resident #64 will maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene through the review date. Interventions: Staff will provide the appropriate level of physical assistance with ADL's as needed due to his self-ability may fluctuate throughout the day. In an interview/observation on 05/05/2026 at 11:47 AM Resident #64 showed his fingernails, which had a yellowish discoloration present to all nails. Dark brown debris or dirt was observed underneath fingernails along the nail beds and nail edges. Resident #64 stated his nails are always dirty and never cleaned. In an observation on 05/06/2026 at 2:55 PM Resident #64's fingernails had a yellowish discoloration present to all nails. Dark brown debris or dirt was observed underneath fingernails along the nail beds and nail edges. In an interview on 05/06/26 at 12:44 PM, LVN A stated she had worked in the facility for about 13 years. She stated she had been in-serviced on ADL's and grooming/nail care. She stated residents' fingernails should have been cleaned at least weekly on Sundays and on shower days. She stated if a resident's fingernails were dirty with dirt or debris under the nails, it could have resulted in an infection for the resident or it could have affected their self-esteem. In an interview on 05/06/26 at 12:50 PM, LVN B stated she had worked in the facility for about 12 and a half years. She stated she had been in-serviced on ADL's and grooming/nail care. She stated resident's fingernails should have been cleaned anytime they are soiled, on shower days, and on Sundays. She stated she cared for a resident that she had to do his nails daily. She stated if a resident's fingernails were dirty with dirt or debris under the nails, it could have resulted in an infection for the resident and it could have affected their dignity or self-esteem. In an interview on 05/06/26 at 12:58 PM, CNA D stated she had worked in the facility for about a year. She stated she had been in-serviced on ADL's and grooming/nail care. She stated resident's fingernails should have been cleaned in the shower on their shower days and anytime their nails were dirty. She stated if a resident's fingernails were dirty with dirt or debris under the nails, it could have resulted in a resident feeling embarrassed. In an interview on 05/06/26 at 1:03 PM, CNA E stated she had worked in the facility for about 4 years. She stated she had been in-serviced on ADL's and grooming/nail care. She stated resident's fingernails should have been cleaned every day. She stated if a resident's fingernails were dirty with dirt or debris under the nails, it could have resulted in the resident to have had interference with their feeding and could have been a risk of infection or it could have been a dignity issue. In an interview on 05/06/26 at 1:30 PM, the DON stated staff had been in-serviced on ADL's and grooming/nail care. She stated resident's fingernails should have been cleaned daily, on shower days, and as needed. She stated if a resident's fingernails were dirty with dirt or debris under the nails, it could have resulted in a dignity or infection control issue for the resident. In an interview on 05/06/26 at 1:44 PM, the ADM stated staff were in-serviced on ADL's and grooming/nail care. She stated resident's fingernails should have been cleaned depending on the resident and after meals or as needed when dirty. She stated if a resident's fingernails were dirty with dirt or debris under the nails, it could have resulted in a resident feeling uncomfortable or it could be a risk of bacteria being spread. Record review of facility policy dated 11/2007 and revised 07/2013 titled Policy/ Procedure - Nursing Services - Section: Quality of Care - Subject: ADL, Services to carry out. Policy: It is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. Procedures: 2. If a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal oral hygiene will be provided by qualified staff.

Based on observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 5 residents (Resident #25) reviewed for resident rights. The facility failed to ensure Resident's #25 call light was within reach on 05/05/26. This failure could place residents at risk of needs not being met.Findings included: Record Review of Resident #25's face sheet dated 05/06/26 reflected the resident was a [AGE] year-old male admitted on [DATE]. His diagnoses included dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), dysphagia (difficulty in swallowing), muscle wasting and atrophy (the loss of muscle tissue and strength, typically caused by inactivity, malnutrition, aging (sarcopenia), or diseases affecting nerves or muscles), and history of falling (indicates a patient is at high risk for future falls). Record Review of Resident #25's Significant Change MDS assessment dated [DATE] reflected Resident #25 had a BIMS score of 04 which indicated Resident #25 was severely cognitively impaired. The MDS reflected Resident #25 had no impairment in functional limitation in range in motion for upper extremity (shoulder, elbow, wrist, hand). Resident #25 required partial/moderate assistance for eating, substantial/maximal assistance for toileting, and was dependent on staff for showering and personal hygiene. Record review of Resident #25's care plan dated 10/27/25 reflected: Resident was at risk for falls r/t decreased mobility, weakness, left femur fracture S/P surgical repair, dementia, HTN, depression, anxiety, and syncope with collapse (a sudden, temporary loss of consciousness and muscle control, typically lasting a minute or two, followed by a spontaneous return to normal).Goal: Resident #25 would minimize risk of injury with target date: 07/26/26.Interventions included: Be sure the call light is within reach and encourage to use it to call for assistance as needed. In an interview and observation on 05/05/26 at 11:54 AM, Resident #25 was in bed with his blankets pulled to his chest area. Resident #25's eyes were closed and he was showing no signs of pain or distress. Resident #25 awakened to name call and stated he was ok and staff treated him well. He stated he did not know about his call light. Resident #25 appeared pleasantly confused and did not answer for how he would have called for help if needed. Resident #25's call light was hanging beside his bed on the right side and stuck between the bed rail and the bed. Resident #25 could not demonstrate if he could have reached for or used the call light. In an interview on 05/05/26 at 12:13 PM, CNA C stated it was the third day she had worked at the facility. She stated Resident #25's call light was not in a place where he could reach it. She stated the call light should have always been within residents' reach and he had liked to push things off him like his blankets and stuff. She stated Resident #25 had not liked anything on him. She stated she was trained on call lights having to be within residents' reach and the management staff trained her good at the facility. She stated if a call light was not in reach, a resident could have fallen or needed to be changed and could not call for help. In an interview on 05/06/26 at 12:44 PM, LVN A stated she had worked in the facility for about 13 years. She stated she had been in-serviced on call light placement and resident rights. She stated residents call lights should have always been within their reach. She stated if a resident's call light was not within their reach, it could have resulted in injury to the resident. In an interview on 05/06/26 at 12:50 PM, LVN B stated she had worked in the facility for about 12 and a half years. She stated she had been in-serviced call light placement and resident rights. She stated residents call lights should have always been within their reach. She stated if a resident's call light was not within their reach, it could have resulted in someone trying to get up by themselves and possibly falling. In an interview on 05/06/26 at 12:58 PM, CNA D stated she had worked in the facility for about a year. She stated she had been in-serviced on call light placement and resident rights. She stated residents call lights should have always been within their reach. She stated if a resident's call light was not within their reach, it could have resulted in a resident falling trying to reach their light or they may have needed emergency help, and staff would not have known. In an interview on 05/06/26 at 1:03 PM, CNA E stated she had worked in the facility for about 4 years. She stated she had been in-serviced on call light placement and resident rights. She stated residents call lights should have always been within their reach. She stated if a resident's call light was not within their reach, it could have resulted in a resident falling or they could have dropped something and needed help. In an interview on 05/06/26 at 1:30 PM, the DON stated staff had been in-serviced on call light placement and resident rights. She stated residents call lights should have always been within their reach. She stated if a resident's call light was not within their reach, it could have resulted in a delay in care. In an interview on 05/06/26 at 1:44 PM, the ADM stated staff were in-serviced on call light placement and resident rights. She stated residents call lights should have always been within their reach. She stated if a resident's call light was not within their reach, it could have resulted in delayed care. Record review of facility policy titled Policy/Procedure - Nursing Clinical: Subject: Call Light/Bell and dated 08/03/21 reflected Policy: It is the policy of this facility to provide the resident a means of communication with nursing staff. Procedures: Leave the resident comfortable. Place the call device within resident's reach before leaving room. If the call light/bell is defective, immediately report this information to the unit supervisor.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 out of 2 residents (Resident #6 and Resident #43) observed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions (EBP) was followed and hand hygiene was performed when CNA E and CNA M provided peri care for Resident #43. The facility failed to ensure aseptic technique and hand hygiene was performed when IFP L provided wound care for Resident #6. These deficient practices could place residents at risk for cross contamination and the spread of infection. Findings included: 1.Record review of Resident #43's undated face sheet reflected an admission date of 04/23/2026 with diagnoses of Sepsis due to MRSA (Life-threatening, emergency condition where a drug-resistant bacterial infection enters the bloodstream, damaging organs), Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (cognitive decline when the specific type or stage is not documented, and no associated behavioral issues are present), and Unspecified obstructive and reflux uropathy (a structural or functional blockage in the urinary tract that causes urine to back up, potentially damaging the kidneys, without a specific cause or exact location documented). Record review of Resident #43's undated care plan reflected: Resident has bowel/bladder incontinence r/t obstructive and reflux uropathy- Date Initiated: 04/10/2026. Goal included- Will remain free from skin breakdown due to incontinence and brief use through the review date- Date Initiated: 04/13/2026. Interventions included- Monitor/document for s/s UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns- Date Initiated: 04/10/2026 Resident has surgical wound to the abdomen with staples present- Date Initiated: 03/26/2026. Goal- Will be free from injury through the review date-Date Initiated: 03/26/2026. Interventions included - Use Enhanced Barrier Precautions-Date Initiated: 03/26/2026. Record review of Resident #43's admission MDS assessment, dated 03/30/2026, reflected a BIMS score of 13 indicating he was cognitively intact. The MDS reflected Resident #43 was always incontinent of both bladder and bowel. He had indwelling catheter. Resident #43 was dependent on helper for: toileting hygiene, shower/bath, upper body dressing, lower body dressing and putting on/taking off footwear. Record review of Resident #43's order summary report reflected: Monitor/Record/Report to MD for any s/s of UTI: Pain/discomfort, burning, blood-tinged urine, cloudiness, scanty or no urine output, dark urine color, high temperature, chills, altered mental status, changes in behavior, changes in eating pattern, foul smelling urine every shift-Start date: 03/25/2026. Secure catheter with a leg strap/leg band or anchor to minimize catheter related injury and accidental removal or obstruction of urine outflow. Check placement every shift-Start date: 03/25/2026. Enhanced barrier precautions required for high resident contact care activities. Indication: wounds, indwelling medical device, every shift- Start date: 03/25/2026 During an observation on 05/05/2026 at 1:40 p.m. of peri care with catheter revealed CNA E did conduct handwashing/hand hygiene prior to putting gloves on and started providing peri care. There was a sign indicating Enhanced Barrier Precautions on the door to Resident #43's room and there was a supply of PPE available outside the door/room; CNA E and CNA M did not put on or wear gowns while performing peri care with catheter for Resident #43. CNA E pulled out a wipe from container and placed it on her left wrist to fold it before cleaning resident's genital area; CNA E repeated this step four times while cleaning Resident 43's genital area. CNA M lifted and held Resident #43's Foley bag above his bladder while CNA E was assisting resident to reposition him on his left side. The Resident #43's Foley bag was placed on the left side of resident's bed frame. Both CNAs did wash hands after finishing providing resident's peri care. 2.Record review of Resident #6's undated face sheet reflected an original admission date 01/05/2018 and readmission date of 11/06/2025 with diagnoses of Acquired absence of other right toe (the loss of any right toe excluding the great toe), Acquired absence of the left foot (surgical removal or traumatic loss of the left foot), Type 2 Diabetes Mellitus with unspecified complications (a chronic condition characterized by high blood sugar resulting from the body's inability to use insulin properly), Dependence on renal dialysis (a life-sustaining treatment for kidney failure (typically below 10% function), removing waste and excess fluid from the blood), and need for assistance with personal care (requiring help with daily activities like bathing, dressing, and toileting due to aging, illness, or disability). Record review of Resident #6's undated care plan reflected Resident #6 has potential for pressure ulcer development r/t Diabetes, antidepressant use, Lower Limb Ischemia. Has Impaired Skin Integrity related to Left Arm Fistula-Date Initiated: 04/06/2025. Goal included - Will have intact skin, free of redness, blisters or discoloration by/through review date-Date Initiated: 04/06/2025. Interventions included - Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD - Date Initiated: 04/06/2025. Use Enhanced Barrier Precautions-Date initiated: 10/09/2025 Record review of Resident #6's quarterly MDS assessment, dated 02/19/2026 reflected a BIMS score of 07 indicating severe cognitive impairment. The MDS reflected Resident #6 has infection of the foot and surgical wound(s) Record review of Resident #6's order summary report reflected: Cleanse diabetic wound of the right, dorsal foot with NS, pat dry, apply xeroform, cover with dry dressing, everyday shift for Wound Care -Start date:04/09/2026 Observation of Resident #6's wound care on 05/06/2026 at 8:50 a.m., revealed IFP L gathered her supplies and placed them on a piece of wax paper. IFP L applied PPE then took the wax paper with her treatment supplies into Resident #6's room and placed them on an overbed table. She did not clean the table prior to placing the treatment supplies. IFP L, without washing her hands before starting the wound care donned gloves and started providing wound care while his foot was lying on Resident #6's blanket. She cut Resident #6's dressing on his left foot using scissors and then she placed the scissors next to the dressing supplies. IFP L finished providing wound care to Resident #6 and moved the scissors and a bottle of hand sanitizer to Resident #6's spare over the bed table. She then picked up the wax paper with the remaining of supplies and placed it in a trash can. She removed her gloves and donned gloves after sanitizing her hands. IFP L moved over the bed table she used for wound supplies next to the table with scissors and then she picked up the scissors and exited Resident #6's room. IFP L did not sanitize surfaces of the two over the bed tables before exiting the room. She placed the scissors and a bottle with hand sanitizer on the top of the treatment cart. She removed her gown and sanitized the scissors before placing them inside of the treatment cart. IFP L sanitized surface of the treatment cart, she then removed her gloves and sanitized her hands. IFP L did not perform hand washing after providing wound care to Resident # 6. In an interview on 05/06/2026 at 1:07 p.m. with CNA M when asked to describe the meaning of EBP, CNA M stated, I forgot to wear a gown. CNA M stated PPE is required when providing direct care to a resident in EBP rooms. Not following this requirement may cause transmission of infection between residents. CNA M stated that she sanitized her hands before, between and after providing peri care to the resident. CNA M stated that she was trying to use the cuff of a glove on her hand to fold and manage the wipes. In an interview on 05/06/2026 at 1:19 p.m. with CNA E she stated she has been working in the facility for over two years. She stated that she had an infection control training a long time ago. CNA E stated that she had hand hygiene in-service training not too long ago. She stated that she knows that she must wash her hands and put gloves on before providing peri care and if resident is in EBP room then staff must put gowns on before providing direct care with wounds, Foley bags to prevent spread of infection. CNA E stated that she had forgotten to put a gown on before entering Resident 43's room. She stated that if resident has a Foley bag, the bag must be kept below resident's knees just in case the bag had a whole and the urine could leak out of the bag. She stated that this measure is needed to prevent transmission of infection. In an interview on 05/07/2026 at 8:15 a.m. with Resident #6's FM she stated that she has not been to facility to visit Resident #6 since 2018. She stated she has no concerns about the care provided to Resident #6. She stated the facility's staff is calling and texting her all the time. In an interview on 05/07/2026 at 8:21 a.m. with DON she stated she has been working here for 2.5 years. She stated that she has infection control training every month. These trainings cover hand hygiene, when to wear PPEs and the way of infection transmissions. She stated that it is expected for staff to sanitize hands before and after going to the residents' rooms. She stated it is also expected for staff to wash hands before, between and after providing direct care to the residents such as wound care, peri care, to any residents with G-tubes, foley bags. DON stated that it is not acceptable to be folding wipes on the staff's wrist during peri care because it is cross contamination issue and may cause resident to get infection and UTIs. DON stated that Foley bag must be kept below the resident's kidneys; lifting a foley bag and holding it above the kidneys may cause back up flow of urine to the bladder and resident potentially can get UTI. In an interview on 05/07/2026 at 8:54 a.m. with ADM she stated that she has been working in the facility for about 4 years. She stated that her last infection control training was on 02/23/26. This training covered current Covid situation and requirements, different types of isolations, and hand hygiene. She stated that staff had hands-on training which covered requirements for staff providing direct care to the residents in EBP rooms and how to Identify the EBP rooms. Staff had check-off training on putting PPE on, proper hand washing and hands sanitizing protocols. She stated she expects staff to follow the EBP protocols such as staff to put PPE on before providing direct care to the residents in the EBP rooms, to wash hands before and after providing peri care, hand sanitizing between changing gloves and washing hands if gloves become visibly soiled. ADM stated she is not a clinical nurse to know anything about providing wound care or providing care for residents with foley catheters/bags. In an interview on 05/07/2026 at 9:20 a.m. with IFP L she stated she has been working in the facility since September of 2023. She stated she had been trained in infection control. The training covered proper hand hygiene, infectious diseases in this type of setting, different types of precautions such as contact precautions, air born precautions, and EBP. IFP L stated that staff is expected to sanitize their hands when providing direct care to the first two residents and to wash their hands before providing care to the third resident FP L stated that hand washing is also expected when they are visibly soiled. She stated that staff expected to use PPE when providing direct care to the residents in EBP rooms. IFP L stated that she did not notice putting the contaminated scissors on Resident #6's over the bed table and not sanitizing both over the bed tables until this interview. She stated that not performing proper hand hygiene and not following aseptic techniques may potentially cause spread of infection among the residents and make them very ill. She stated that resident's foley bags must be kept as low as possible because the urine in the catheter and bag can get back into bladder and resident can get UTI. In an interview on 05/07/2026 at 11:37 a.m. with Resident #43's FM she introduced herself as resident's FM she stated that Resident #43 had UTI's and Sepsis (life-threatening medical emergency caused by the body's extreme, toxic response to an infection) in the past. She stated that Resident #43's health condition is not in good shape, so she is worried about Resident #43 getting any infection again. FM stated that the facility's staff is excellent; they take great care of Resident #43. She did not voice any other concerns at this time. Record review of facility policy titled Indwelling Urinary Catheter Care with the original date: 05.2007. Revision dates: 7.2012; 7.2013; 7.2015; 7.2017; 7.2019; 7.2022; 7.2023; 7.2025; 7.2026 reflected: 7. Perform hand hygiene, using soap and water. 8. [NAME] gloves. Record review of facility policy titled IPCP Standard and Transmission-Based Precautions with original date: 06.2021 Revision/Review Date(s): 7.2022; 10.2022; 12.2023; 3.2024; 4.2025; 1.2026 reflected: a. PPE: The use of gowns and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with: Indwelling medical devices include, but are not limited to central lines, peripherally inserted central catheter (PICC) lines, urinary catheters, feeding tubes, and tracheostomies. Record review of facility policy titled Indwelling Urinary Catheter Care original date 05.2007. Revision/Review date(s) dates: 7.2012; 7.2013; 7.2015; 8.2017; 12.2019; 1.2022; 12.2023; 4.2025; 1.2026. 13. Maintain the drainage tubing below the level of the bladder. Record review of facility policy titled Infection Prevention and Control Program with original date: 06.2021 Revision/Review Date(s): 6.2021; 1.2022; 10.2022; 12.2023; 4.2025; 1.2026 reflected: 2. Process Surveillance is the review of practices by staff directly related to resident care. Some considerations for this process may include, but are not limited to: b. Appropriate use of personal protective equipment (PPE) g. Cleaning and disinfection production and procedures for environmental surfaces and equipment i. Linen management (handling, storage, processing, and transport) 3. The facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection. b. Facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. 4. Facility personnel will handle, store, process, and transport linens to prevent the spread of infection. 6. The facility will provide areas, equipment, and supplies to implement its infection Control program with the goal of: b. Safe use of disposable and single use supplies and equipment. c. Effective cleaning and disinfecting equipment as needed, to include bathing areas between each resident's use. d. Chemicals and equipment used for cleaning and disinfecting will be used in accordance with manufacturer's directions and recommendations.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents for four of four residents (Residents #12, #19, #58, and #171) reviewed for accidents and hazards. The facility failed to properly maintain wheelchairs and anti-pressure cushions for Residents #12, #19, #58, and #171 . These failures could place residents at risk for equipment that is in unsafe operating condition, which could cause injury. Findings included: 1. Record review of Resident #12's quarterly MDS assessment, dated 02/10/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #12 had diagnoses which included CVA (Stroke), hemiplegia (partial weakness on right side of the body) and difficulty walking. Record review of Resident #12's plan of care, dated 01/10/2025, reflected goals and approaches to include wheelchair mobility for locomotion. Observation and interview on 02/25/2025 at 10:00 a.m. revealed Resident #12 was lying in the bed, waiting to get up, and had no skin problems. The wheelchair's left armrest was an open metal piece with sharp edges, a piece of foam that was loose and was folded backwards with duct tape around the foam piece. The right-side arm rest was missing. Resident #12 stated the arm rest did not work. Resident #8 said that was his wheelchair he used it the way it was. Resident #8 did not seem to be bothered by the condition of the wheelchair . In the seat of the wheelchair was blue anti-pressure cushion which was cracked and the foam was exposed on the front and top of the cushion. Resident #12 stated it made the wheelchair easier to sit in . 2. Record review of Resident #19's quarterly MDS assessment, dated 01/25/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #19 had diagnoses which included Cerebral Vascular Accident (stroke), difficulty walking, and generalized weakness. Record review of Resident #19's plan of care, dated 01/05/2025, reflected goals and approaches to include wheelchair mobility. Observation on 02/25/2025 at 12:23 p.m. revealed Resident #19 was in her wheelchair in the dining area, and the wheelchair's right armrest was cracked with exposed foam. Resident #19 stated, the armrest was rough. There were noted ecchymosis (bruise) to both of the resident's arms, no skin tears. 3, Record review of Resident #58's MDS assessment, dated 01/31/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #58 had diagnoses which included Hip fracture (broken hip), dementia (confusion), muscle weakness, and age-related osteoporosis (bone weakness). Record review of the Resident #58's, plan of care, dated 01/08/2025, reflected goals and approaches to include wheelchair mobility. Observation on 02/25/2025 at 10:00 a.m. revealed Resident #58 was in her wheelchair in the activities area, and the wheelchair's left armrest was cracked with the foam exposed. There were no skin tears on arms . 4. Record review of Resident #171's MDS assessment, dated 02/19/2025. Reflected the MDS was in progress and dated 02/21/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #171 had diagnoses which included fracture of left femur closed (closed left hip fracture) and left artificial hip joint. Record review of Resident #171's plan of care, dated 02/19/2025, reflected goals and approaches to include wheelchair mobility . Observation and interview on 02/25/2025 at 12:30 p.m. revealed Resident #171 was in his wheelchair, in the dining room and with no skin problems. The wheelchair's right armrest was cracked with the foam exposed. Resident #171 was asked about the wheelchair, and he shook his head and smiled . In an interview on 02/26/2025 at 12:30 p.m., CNA A stated when a resident's wheelchair needed repair the staff were to enter it into the electronic maintenance system in the computer. CNA A stated she never wrote anything in the computer though she usually told the maintenance supervisor . In an interview on 02/27/2025 at 10:30 a.m., LVN B stated when a resident's wheelchair needed repair the staff were to write it in the electronic maintenance system, tell the maintenance man, who would tell them to place the information in electronic maintenance system . In an interview on 02/27/2025 at 8:30 a.m., the DON revealed if the staff saw wheelchairs needed repair, the staff was to place a ticket in the electronic system. The Maintenance Supervisor would then know to repair the wheelchair. In an interview on 02/27/2025 at 11:02 a.m., the Maintenance Supervisor stated he repaired the wheelchairs when there was needed repairs. He stated staff were to place the needed repairs in the electronic maintenance system. The Maintenance Supervisor was informed about the residents' wheelchairs condition, and he stated if the wheelchairs' issues had not been placed in the electronic maintenance system for repair he would not know. The Maintenance Supervisor stated all staff could place information about needed repairs in the system. The Maintenance Supervisor reviewed in his phone for tickets, in the electronic maintenance system, concerning repairs, there were none found for wheelchair repairs. A record review of the facility's policy and procedure Maintenance, dated July 2018, reflected It is the policy of this community to maintain all equipment provided by the facility, in good working order to ensure the safety and wellbeing of all residents and staff . Equipment provided by the community will be: 1. Maintained in working order.

Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one of four residents (Resident #20) reviewed for resident rights. The facility failed to ensure CNA A did not stand over Resident #20 while assisting the resident with her meal in her room on 02/26/2025. This failure could place residents at risk of feeling rushed to eat or not interested in eating, which could result in weight loss and decreased psycho-social well-being of anguish or frustration. The findings included: Record review of Resident #20's MDS Assessment, dated 01/31/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #20 had a staff assessment BIMS score of 06, which indicated the resident was severely impaired. She had partial to moderate assist with eating and active diagnoses which included: Dementia (confusion), malnutrition (not nourished), anxiety disorder (nervous), and muscles weakness. She had a mechanically altered and therapeutic diet and no issues with swallowing food and drinks. Record review of Resident #20's Care Plan, dated 01/08/2025 and revised, revealed, The resident has potential nutritional problem r/t GERD (gastrointestinal reflux disease) , dementia, hypokalemia (high potassium): Goals - The resident will maintain adequate nutritional status as evidenced by maintaining weight with no S/Sx of malnutrition through review date: 01/08/2025 and intervention: Eating - The resident requires set up assist of (1) staff for eating. Observation on 02/26/2025 at 8:40 a.m. in Resident #20's room revealed CNA A was standing at the bedside next to Resident #20 who was lying in the bed . There was 90% of Resident #20's breakfast on her plate and CNA A had a spoon in her hand with food on it. CNA A lifted the food and was telling Resident #20 she needed to eat her food and to try and take just a few more bites. Resident #20 said she would try but was not really hungry. Observation and interview on 02/26/2025 at 12:30 p.m. in Resident #20's room revealed CNA A was standing at the bedside next to Resident #20 who was lying in the bed . There was 75% of Resident #20's lunch on her plate and CNA A stated to the State Surveyor she was going to try and get her to at least take a couple of more bites of her lunch. Interview on 02/26/2025 at 1:00 p.m., CNA A stated they were supposed to sit down to feed the residents. CNA A stated she knew she was supposed to have gotten a chair and she had just forgotten. CNA A said she was trained this was not correct and was against the resident rights to stand over her and assist her to eat. CNA A stated she was sorry. The CNA stated she had in-service training on resident rights and she knew this was a part of not dignifying their rights . In an interview on 02/26/2025 with CNA C revealed if a staff member was assisting a resident to eat, they were to sit next to them, whether they were sitting up or lying down . CNA C stated all staff were trained on resident rights in the past 6 months and that was a part of the residents right. Interview on 02/27/2025 at 8:30 a.m., the DON stated the staff should be feeding the residents sitting down at eye level with the residents. She stated sitting down while feeding the residents was good for the staff to see how the resident swallowed. She stated feeding the residents standing up was a dignity issue. Record review of the facility's policy and procedure titled Resident Rights, dated 11/28/2017, reflected Policy Statement Residents shall receive assistance with meals in a manner that meets the individual needs of each resident . 2. Facility staff will serve resident trays and will help residents who require assistance with eating. 3. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. not standing over residents while assisting, them with meals

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 (Resident #1) of 5 resident reviewed for care plans in that: The comprehensive care plan did not reflect the facility's use of a Velcro stop sign door banner on Resident #1's bedroom and bathroom door. These failures could result in residents at risk of receiving inadequate interventions not individualized to their care needs. Findings include: Review of Resident #1's face sheet dated 06/30/24 revealed an [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of unspecified atrial fibrillation (abnormal heart rhythm), cognitive communication deficit (a problem with one or more cognitive skills involved in communication, such as attention, memory, or reasoning), dysphagia-oropharyngeal phase (difficulty in swallowing food or liquid), schizophrenia-unspecified (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), unsteadiness on feet, unspecified anxiety disorder (fear characterized by behavioral disturbances), and unspecified hyperlipidemia (high cholesterol). Review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 08 indicating moderate cognitive impairment. The MDS assessment also revealed the resident was on hospice care. Review of Resident #1's clinical physicians orders revealed an order with a start date of 03/14/24 may have door guard stop sign strip (Velcro) across door as reminder not to go in room unattended. Review of Resident #1's care plan last updated 05/14/24 revealed no care plan for the Velcro door banner stop sign implemented after the order dated 03/14/24. Review of Resident #1's nursing progress note revealed a nurse note entered by ADON A, [RN B], RN with [hospice facility] notified of residents fall, no injuries noted. Order given for door guard stop sign strip (Velcro) across door as a reminder not to go in room unattended. The note which was entered by the ADON was created and effective 03/14/24. An observation and interview on 06/29/24 at 12:12 PM revealed a white banner with a red stop sign was observed outside of Resident #1's room secured via Velcro to each end of the door. Resident #1 was observed near the nurses' station located in the hall next to his room in his wheelchair. CNA D stated that she believed it was the family who requested the stop sign banner to prevent Resident #1 from going to his room as a fall precaution. She stated they would have the banner up to redirect him when there was nobody available to sit in his room with him to ensure he didn't get hurt. An interview on 06/29/24 at 01:09 PM with the ADM she stated the banner was requested by the family and hospice as a joint effort in developing interventions that would redirect Resident #1 from going into the room and having a fall. An interview on 06/29/24 at 04:53 PM with RN B she stated the banner was implemented 03/14/24 and it was developed by the IDT in response to the residents' frequent falls as an intervention to redirect him. RN B stated that Resident #1 had a habit of returning to his room after meal services and attempting to transfer himself which he was not able to do resulting in frequent falls. RN B stated Resident #1 was still able to knock down the sign with his hand, but they hoped it would delay him enough to get a staff members attention to assist him or just redirect him to an area where staff were present. RN B said that she understands the resident has a right to fall but they were doing everything they can to prevent those falls because some have led to abrasions and bumps on the head. RN B stated Resident #1 was confused at times and has what is called terminal restlessness (a set of symptoms that occurs at the end of a person's life such as agitation, confusion, and unusual behaviors) which causes him to try to get up and move around when he is unable to on his own. An interview on 07/01/24 at 02:28 PM with the DON she stated she did not see that the care plan was updated after the IDT meeting where it was implemented 03/14/24. She stated it would have been nursing (DON/ADON) to ensure it got updated. The DON stated she did not see a potential negative outcome of not having it in the care plan because staff have been trained on the proper way to use it. The DON stated the order entered into the system was vague and did not specify when to use it, it only said may have- she then stated it should have been in the care plan. An interview on 07/01/24 at 03:03 PM with RN C she stated care plans were used in everything she does on a daily basis. RN C said care plans were used to know the residents individualized care and goals. RN C said care plans were 100% important to giving the resident optimum care. She stated it was important to have updated information on the care plans so that they knew how to care for the residents' current needs. An interview on 07/01/24 at 03:08 PM with the ADM she stated it was her expectation that care plans were updated quarterly and as needed when assessments show there is change. The ADM stated care plans were important because care staff use it to know how to care for a resident. She stated if someone came in from the outside they would need to know how to care for the residents and the care plans are that guide. Review of the facility Care Planning policy last revised 07/2020 revealed: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. - The residents plan of care- focus, goals, and interventions- are communicated and implemented by the members of the health care continuum accordingly. - The residents plan of care is reviewed and revised on an ongoing basis, quarterly at minimum and/ or as needed with changes of condition.

Based on interview, and record review the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for residents for 1 of 5 (Resident #1) residents reviewed for environment. The facility failed to keep Resident #1's room clean and free of bed bugs. This was determined to be past non-compliance at potential for more than minimal harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. This failure could place the residents at risk of unsanitary and uncomfortable conditions. Findings include: Review of Resident #1's face sheet dated 06/30/24 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of unspecified atrial fibrillation (abnormal heart rhythm), cognitive communication deficit (a problem with one or more cognitive skills involved in communication, such as attention, memory, or reasoning), dysphagia-oropharyngeal phase (difficulty in swallowing food or liquid), schizophrenia-unspecified (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), unsteadiness on feet, unspecified anxiety disorder (fear characterized by behavioral disturbances), and unspecified hyperlipidemia (high cholesterol). Review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 08 indicating moderate cognitive impairment. The MDS assessment also revealed the resident was on hospice care. Review of Resident #1's nursing progress note dated 06/24/24 revealed, Insect reported in resident's room on end of bed. Resident in the hall in his wheelchair with sitter at side. This nurse went to room to assess. Insect at the foot of bed and appeared to be dead AEB no movement upon touching and disposing. Resident transitioned from 200 hall and placed in room [ROOM NUMBER] with new bedding. Body assessed with no signs of bites or skin alterations. Maintenance informed of insect in room and notified exterminator for assessment in the am. Maintenance provided resident with temporary air mattress in new room until hospice is able to replace air mattress in room tomorrow. Resident given pain medication and PRN anxiety medications to assist with back pain, change in mattress and anxiety with being in new environment. Bed is in lowest position, call light in reach, fall mats in place, and hydration provided. Sitter remains at bedside. Nursing to monitor frequently for comfort. Nursing to continue skin assessments throughout follow-up. Spoke with resident's [family member]to give update. [family member] reports that she has updated resident's [family member]. NP at facility and informed with no concerns at this time. Review of facility pest sighting services log dated 06/24/24 revealed bed bugs, [Resident #1's room]. Review of pest service inspection report dated 06/24/24 revealed tech comments: treated room [Resident #1's room] for bed bugs, live activity found. It also revealed 1 gallon of product was applied to treat the room for target pests: bed bugs. Review of Resident #1's skin assessment dated [DATE] revealed, no open skin areas. Review of Resident #1's skin assessment dated [DATE] revealed, resident noted skin warm, dry, and intact. Skin turgor appropriate for age. No signs of bites, redness or swelling noted. An interview on 06/29/24 at 12:21 PM with Resident #1's family member stated she was first made aware of the bed bugs in Resident #1's room by the hired agency sitter 06/24/24. The Family member stated that the agency sitter took a picture of the bed bug that was on the bed while she was getting Resident #1 ready for bed. She stated the facility removed him from the room and then relocated him back after treatment of the room. An interview on 06/29/24 at 12:45 PM with the agency sitter, she stated that she saw the bed bug on Resident #1's bed on 06/24/24 and she took a picture of it and sent it to the family member. The agency sitter stated she did not see any others and did not see any noticeable bites. An interview on 06/29/24 at 04:53 PM with RN B with the hospice agency, she stated she was notified by Resident #1's family member on 06/24/24 about bed bugs in Resident #1's room. RN B stated when she tried to question the ADM about the bed bug concerns the ADM would neither confirm or deny there was bed bugs. RN B stated a potential negative outcome to bed bug bites was uncomfortable itching, allergic reaction, or secondary skin infection. RN B did not note any bite marks on Resident #1. An interview on 06/30/24 at 12:50 PM with the pest services technician he stated aside from Resident #1, there was an inspection done in another room which was negative for activity, he stated he also inspected the nurse's station, the lobby, and common areas were residents congregate and there was no evidence of additional bed bugs in those areas. The Pest services technician stated he did find live activity in Resident #1's room and they treated the area and cleared the bugs and removed/ disposed of the mattress. He stated that protocol was followed, and they treated the room where live activity was found but are unable to apply additional treatment through other rooms/ halls without evidence that they have spread. He stated that to his knowledge it appeared to have been confined to Resident #1s room. He stated bed bugs were hitchhikers and were carried by people and their items. He stated an additional inspection was performed 06/29/24 in Resident #1's room and it was negative for bedbugs, so he believed treatment was effective. An interview on 06/30/24 at 01:30 PM with MD E, (Resident #1's physician and facility medical director) he stated that the facility was timely in notifying them of Resident #1s exposure to bed bugs. He stated it was his expectation that staff notify him or his proxy (NP) when things like this occur. He said on 06/24/24 the NP was in the building so the facility was able to make the report to her. He stated a potential negative outcome to bed bug bites would be the potential for discomfort and infection he said, skin integrity becomes the issue. MD E said he expects that the facility would have followed their pest control policy and did not believe there was a negative outcome to Resident #1 from this exposure. An interview on 06/30/24 at 02:43 PM with Hospice ADM, she stated that on skin assessments completed by the hospice LVN and notes in the hospice shower aides from 06/25/24 through 06/27/24 there were no abnormal findings on Resident #1's skin such as bite marks noted. An observation on 07/01/24 at 12:30 PM nurse surveyor, conducted observations of 5 resident rooms on Resident #1's hall that included Resident #1. The five rooms examined were negative for pest activity at the time of the investigation. Skin assessments completed by nurse surveyor did not reveal any healing spots to confirm bed bug bites. An interview on 07/01/24 at 02:28 PM with the DON she stated after the bed bug was found they completed a skin assessment on 06/25/24 which was negative for bite marks. The DON stated that in the last month and a half Resident #1 has had 7 different agency sitters which makes it difficult to determine how or who brought the bed bugs in. The DON said that they followed the policy and removed Resident #1 from the room in order to shower him and assess, and they called pest control to treat the room and inspect other areas of the facility. The DON said skin assessments were completed on all the other residents and no bite marks were observed or bugs noted in the rooms. An interview on 07/01/24 at 03:08 PM with the ADM she stated she did not know how many bed bugs were found in Resident #1's room she just knows there was one seen on the curtain and one on the bed. The ADM said she believes they followed their policy which was to remove the resident and assess him and other residents and treat the area where live activity was found. The ADM said the room was deep cleaned and linens and items were bagged separately and washed and dried separately. The ADM said they did attempt a root cause analysis to determine where this came from but were unsuccessful because Resident #1 has had 6 to 7 sitters and there had been a lot of traffic to his room. She stated the sitters that do come will sometimes bring bags with a blanket or other items while they are here caring for the resident. The ADM stated she has reached out to the agency and let them know she wants consistency with the sitters being sent over that way they can limit exposure to those items. The ADM stated assessments to Resident #1 and other residents revealed no bites or negative outcomes and she believes it was contained to Resident #1's room. Review of facility Pest Control policy last revised 05/2020 revealed: It is the policy of this facility to utilize pesticides and rodenticides in a safe an efficient manner to control pests with the least amount of contamination to the environment. Responsibilities: Facility staff will: l. Report any pest sightings to supervisor. 2. Advise staff on preventive measure and the steps needed to ensure safety. Differs case by case. This includes room changes, isolation, or any other preventative measures. 3. Secure services of a Pest Control company for routine and PRN services to control pests with the least amount of contamination to the environment. Pest Identification: The following guidelines for pest identification: 1. When pests are sighted, determine why the infestation is occurring and advise department on preventive measures 2. Use pesticides only after all other channels of control are exhausted 3. Use pesticides only as a preventive measure and in conjunction with proper mechanical controls 4. Report insect or pest sightings to the housekeeping/maintenance supervisor immediately. Include the following information: a. Type of problem b. Location Pest Prevention: The following are guidelines for pest prevention: 1. All storage and food preparation areas are to be kept clean. This includes walls, floors, shelving, cabinet tops, sinks, equipment, etc. 2. Keep grounds free of trash and brush. 3. Keep the dumpster area clean. 4. Food stored in resident rooms will be in covered containers. 5. Clean up food spills. 6. Screen foundation areas with mesh.

Based on observation, interview and record review, the facility failed to ensure all assistive devices were maintained and free of hazards for five (Residents #8, #28, #33, #35, and #47) of 18 residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #8, #28, #33, #35, and #47. These failures could place residents at risk for equipment that is in unsafe operating condition, that could cause injury. Findings included: Review of Resident #8's quarterly MDS assessment, dated 10/18/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of CVA (Stroke) and hemiplegia (partial weakness on same side of the body) and hemiparesis (partial weakness on one side of the body) effecting the nondominated side. Review of the Resident #8's plan of care dated 12/18/23 with updates reflected goals and approaches to include wheelchair mobility for locomotion. Observation and interview on 01/10/24 at 1:00 p.m. revealed Resident #8 was sitting in his wheelchair and had no skin problems. The wheelchair's left armrest was taped down with silk tape, that was frayed and dirty around the edges. Resident #8 stated the arm rest did not work. Resident #8 said that was the wheelchair he had been provided when he came to live at the facility and the staff just taped it down since he could not use that side of his body anyway. Resident #8 stated he did not know why they did not take arm rest off of the wheelchair. Review of Resident #28's quarterly MDS assessment, dated 12/14/23, reflected she was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses Gastroenteritis (inflammation of the esophagus), Colitis (inflammation of the colon), and Parkinson (instability and neuromuscular disease) Review of the Resident #28's plan of care dated 12/09/23 with updates reflected goals and approaches to include wheelchair mobility. Observation on 01/09/24 at 1:16 p.m. revealed Resident #28 was in her wheelchair, and the wheelchair's left and right armrests were cracked with exposed foam. Resident #28 was asked about her wheelchair, and she stated, It was needing some work. There were no skin tears on arms. Review of Resident #33's quarterly MDS assessment, dated 12/18/23, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of Cardiovascular disease (stroke) hemiplegia (partial weakness on same side of the body), Hemiparesis (partial weakness on one side of the body), difficulty in walking, and muscle weakness. Review of the Resident #33's updated plan of care dated 12/02/23 with updates reflected goals and approaches to include wheelchair mobility. Observation on 01/09/24 at 1:25 p.m. revealed Resident #33 was in her wheelchair, and the wheelchair's right and left armrests were cracked with the foam exposed. There were no skin tears on arms. Review of Resident #35's quarterly MDS assessment, dated 12/10/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of Parkinson (instability neuromuscular disorder) and lack of coordination and weakness. Review of the Resident #35's updated plan of care dated 11/07/23 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 01/09/24 at 1:30 p.m. revealed Resident #35 was in his wheelchair and with no skin problems. The wheelchair's right armrest and the left armrest were cracked with the foam exposed. Resident #35 was asked about the wheelchair, and he stated the handles were rough. Review of Resident #47's quarterly MDS assessment, dated 11/12/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of epilepsy (seizures), abnormality of gait and mobility, and instability of left knee. Review of the Resident #47's updated plan of care dated 10/08/23 with updates reflected goals and approaches to include wheelchair mobility and skin not being in contact with hard surfaces since she has thin skin and a history of skin tears on her hands. Observation on 01/09/24 at 1:45 p.m. revealed Resident #47 was in her wheelchair and had no skin problems. The wheelchair's left and right armrests were cracked with the foam exposed. Resident #47 was unable to be interviewed. In an interview on 01/10/24 at 12:27 p.m. CNA E stated when a resident's wheelchair needed repair the staff were to enter it into electronic maintenance system in the computer. CNA E stated she had never written anything in the computer though she usually told the nurse in charge. In an interview on 01/10/24 at 12:30 p.m. LVN A stated when a resident's wheelchair needed repair the staff were to write it in electronic maintenance system, tell the maintenance man, who would tell them to place the information in electronic maintenance system and try to find a new wheelchair that was not being used. In an interview on 01/11/24 at 9:46 a.m. the Maintenance Supervisor stated he repaired the wheelchairs when there was needed repairs. He stated staff were to place the needed repairs in TELs. The Maintenance Supervisor was informed about the residents' wheelchairs condition, and he stated if the wheelchairs' issues had not been placed in TELs for repair he would not know. The Maintenance Supervisor stated that all staff could place information about needed repairs in TELs. A review of the electronic maintenance system with the Maintenance Supervisor on 01/11/23 reflected there were no entries that indicated residents' wheelchairs needed the armrest repaired for the October -December 2023. A review of the facility's policy and procedure Maintenance dated July 2018 reflected It is the policy of this community to maintain all equipment provided by the facility, in good working order to ensure the safety and wellbeing of all residents and staff Equipment provided by the community will be: 1. Maintained in working order. A review for the facility's policy and procedure Maintenance and subject maintenance services dated July 2018 reflected: It is the policy of the facility to maintain a clean and safe facility and grounds. A Maintenance problems or concerns must be reported to the office and work order will be generated. Procedure: 1. When a maintenance issue arises, the resident, staff member or family member must put in a work order 2. The maintenance department will complete the work order within 72 hours from the time it was reported .

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for five (Residents #6, #8, #9, #28 and #50) of 7 residents reviewed for infection control. MA C failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #50, #9, and #28. MA D failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #8, and #6. The failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review of Resident #8's EHR revealed the resident was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including Hypertension, with diagnoses of CVA (Stroke), hypertension (increased blood pressure), hemiplegia (partial weakness on same side of the body) and hemiparesis (partial weakness on one side of the body) effecting the nondominated side. Review of Resident #8's quarterly MDS assessment, dated 10/18/23, reflected a BIMs score of 14, indicating the resident was alert and oriented, capable of making decisions. His functional status indicate he needed one staff to complete his activities of daily living. Record review of Resident #8's physician orders dated 12/24/23 reflected, Amiodarone HCL tabs 200 mg one time a day for arrhythmia. Take Blood pressure every day. Review of Resident #6's EHR revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including Hypertension (increased blood pressure) and coronary artery disease (coronary arteries blocked). Review of Resident #6's quarterly MDS, dated [DATE] revealed a BIMs score of 14, indicating she was alert and oriented not impaired for decision making, her functional status indicated she needed assist of one staff with her activities of daily living. Record review of Resident #6's physician orders dated 01/03/24 reflected, Bumex oral tab 1mg every day, Doxazosin mesylate (blood pressure) tab 8 mg two times as day, and hydralazine 100 mg (blood pressure) three times a day. Review of Resident #9's EHR revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE], with diagnosis including essential Hypertension (elevated blood pressure). Review of Resident #9's quarterly MDS, dated [DATE] revealed a BIMs score of 11, indicating she was alert and oriented and not impaired for decision making, her functional status indicated she needed assist of two staff with her ADLs. Record review of Resident #9's physician orders dated 12/11/23 reflected, metoprolol ER (blood pressure) 25 mg every day and lisinopril (blood pressure med) 1-tab 5 mg every day. Checking blood pressure prior to administration. Review of Resident #28's EHR revealed the resident was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including elevated blood pressure without a diagnosis of hypertension and Parkinson. Review of Resident #28's quarterly MDS, dated [DATE] revealed a BIMs score of 15, indicating she was alert and oriented, not impaired for decision making, her functional status indicated she needed assist of one staff with her ADLs. Record review of Resident #28's physician orders dated 12/01/23 reflected, Amlodipine Besylate (blood pressure) 10 mg every day and hydralazine (blood pressure) 100 mg three times a day. Checking blood pressure prior to administration. Review of Resident 50's EHR revealed the resident was a [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including hypertension (elevated blood pressure). Review of Resident #50's quarterly MDS, dated [DATE] revealed a BIMs score of 9, indicating she was confused and impaired for decision making, her functional status indicated she needed assist of one staff with her ADLs. Record review of Resident #50's physician orders dated reflected, Cozaar (blood pressure) 100 mg every day and nifedipine ER (blood pressure) 60 mg every day. Checking blood pressure prior to administration. Observation on 01/10/24 at 8:17 a.m. revealed MA C performing morning medication pass, during which time she checked the blood pressure of Resident #50. MA C failed to sanitize the blood pressure cuff before or after using it on Resident #50. Observation on 01/10/24 at 8:20 a.m. MA C performing a medication pass, during which time she checked the blood pressure of Resident #9. MA C failed to sanitize the blood pressure cuff before or after using it on Resident #9. Observation on 01/10/24 at 8:36 a.m. revealed MA C performing a medication pass, during which time she checked the blood pressure of Resident #28. MA C failed to sanitize the blood pressure cuff before or after using it on Resident #28. Observation on 01/10/24 at 8:59 a.m. revealed MA D performing morning medication pass, during which time she checked the blood pressure of Resident #8. MA D failed to sanitize the blood pressure cuff before or after using it on Resident #8. Observation on 01/10/24 at 9:13 a.m. revealed MA D performing a morning medication pass, during which time she checked the blood pressure of Resident #6. MA D failed to sanitize the blood pressure cuff before or after using it on Resident # 6. Interview on 01/10/24 at 8:42 a.m., MA C stated she always cleaned the blood pressure cuff with the purple top before and after each use. MA C stated she had used the purple top wipes that were on her medication cart to clean the blood pressure cuff and stated, you must have missed that part. She stated there had been in-services on infection control and cleaning equipment, but she could not recall when that had occurred. MA C stated that if the cuff was not cleaned appropriately, it could spread germs. Interview on 01/10/24 at 9:15 a.m., MA D stated blood pressure cuffs should be sanitized with wipes between each resident use to prevent transmitting an infection from one resident to another. She stated she was supposed to cleanse the blood pressure cuff in-between each usage. MA D stated she had been nervous because she had never had to perform her medication pass in front of a state surveyor. MA D stated that if the equipment that was used on the residents was not cleaned correctly it could cross contaminate causing a spread of infection. Interview on 01/10/23 at 4:19 p.m. with the DON she stated that her expectation was that staff would sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. She stated there was plenty of supplies for the nursing staff to have the sanitization wipes that were EPA-registered disinfectant, on all the medication carts. The DON stated there had recently been an in-service for the staff on infection control and cleaning equipment. Review of the in-service records dated 10/16/23 reflected in service training topic cleaning essential equipment: blood pressure cuffs, glucometers, treatment supplies disinfection MA C's and MA D's names were on the list and further review reflected follow-up activity with competencies review there was no presented follow-up competencies reports. Review of facility's Policies and Procedure titled: Infection control and Sanitation, revision date October 2022, reflected the following: The infection control prevention and control program is a facility -wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program . The program will be carried out by the facility infection control preventionist. It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers based on acceptable standards . Goals: decrease the risk of infection to resident and personnel, recognize infection control practices while providing care, identify and correct problems relating to infection control, ensure compliance with state and federal regulations related to infection control 6. c. effective cleaning and disinfecting equipment as needed .

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one (200, 300,400Hall) of two halls and 1 of 1 dining room reviewed for environment. The facility failed to ensure windows, floors, and ceilings were in good repair for halls 200, 300,400, dining room, and the 200-300 hall shower room. This failure could affect residents and the staff by placing them at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: An observation on 01/10/24 at 9:00 AM revealed that the ceiling in the hallway near the entrance to room [ROOM NUMBER] had a 5-inch by 2-inch section of paint and ceiling material hanging down. An observation on 01/10/24 at 9:04 AM revealed that the faux wood flooring at the entrances to the 300 and 400 halls had a black gummy build up between the joints and along the edges of the faux wood tiles. An observation on 01/10/24 at 9:08 AM revealed that 8 panes in the windows on the left side of the dining area were cracked and the entire cabinet unit at the back of the dining room had pulled away from the wall revealing a 2-inch gap between the cabinetry and the wall. An observation on 01/10/24 at 9:14 AM revealed that the left-hand shower stall of the two shower stalls in the 200-300 hall shower room was missing a handle to activate and control the water temperature of the shower. An observation on 01/10/24 at 9:26 AM revealed spiderwebs and various small debris behind the fire doors of the 200, 300, and 400 halls. Interview on 01/10/24 at 12:45 PM, RN F revealed that any broken equipment or facility fixtures had to be logged into the TEL's system, electronic maintenance system, and that all personnel in the facility had access to and had been trained on using the TEL's system. Interview on 01/10/24 at 1:00 PM, LVN A revealed that the staff would tell the Maintenance Supervisor about when they found a problem and he always instructed them to log the problem into the TEL's system. LVN A further stated that she was unaware of the broken handle in the shower room, or the broken windowpanes in the dining room. Interview on 01/11/24 at 9:49 AM, the Maintenance Supervisor revealed that the facility mandated the use of the TEL's system to report maintenance problems in the facility. The Maintenance Supervisor stated that the nursing staff were required to put information about maintenance issues in the TEL's system all the CNAs and Med Aides had access to the TEL's system and that the staff may not be reporting all maintenance issues in the TEL's system. The Maintenance Supervisor further stated that he was aware of the windowpanes in the dining room but had no reports about the shower handle in the shower room or the gummy build up on the floors at the entrances to the 300 and 400 halls. The Maintenance Supervisor was aware of the ceiling issue near room [ROOM NUMBER] but just had not gotten to fix it. He did not indicate how long he was aware of these issues. Interview on 01/11/24 at 12:36 PM, the DON revealed that having outstanding maintenance issues in the facility could have an ill effect on the residents' sense of wellbeing and that the staff would be re-instructed to be better report maintenance issues in the TEL's system. Interview on 01/11/24 at 1:27 PM, the Administrator revealed that the facility had no policy and procedure for physical environment. He stated they used TELs for guidance on repairs and communication.

Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as was possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards, in that: The facility failed on [DATE] to ensure Resident #1 remained free of hazards and had adequate supervision in that she suffered a fall that resulted in a pool of blood around her head, a skin tear to her left elbow, and bruises on all extremities which lead to her subsequent hospitalization with 3 fractured ribs on the left (8th, 9th, and 10th rib). An immediate jeopardy existed from [DATE] - [DATE]. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This deficient practice placed residents at risk for falls, injuries, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, repeated falls, anxiety, and depression. Review of Resident #1's annual MDS assessment, dated [DATE], reflected a BIMS of 99, indicating the resident could not complete the assessment. Section E (Behavior) reflected she had not shown signs of wandering. Section P (Restraints and Alarms) reflected a wander/elopement alarm was used daily. Section G (Functional Status) reflected she could ambulate in her room with supervision, and she did not ambulate in the corridor. Section J (Health Conditions) reflected she had not had any falls with major injury since admission/reentry or prior assessment. Section N (Medications) reflected she took daily antianxiety medications, antidepressant medications, anticoagulants and opioids. Review of Resident #1's undated care plan reflected she was at risk for mood problems due to dementia that was last revised [DATE]. The care plan further reflected that Resident #1 was an elopement risk due to being disoriented to place and impaired safety awareness, so a wander guard was placed on the right ankle ([DATE]). The care plan further revealed that Resident #1 was dependent on staff for activities, cognitive stimulation, and social interaction due to cognitive deficit, immobility and physical limitations. The care plan also revealed that Resident #1 was at risk for falls due to weakness, history of falls, dementia, anxiety, and bowel/bladder incontinence, and the following dates and falls were documented: [DATE] - fall with left hip and low back pain [DATE] - fall with skin tear [DATE] - fall with no injuries [DATE] - fall with hematoma (swollen bruise) to forehead [DATE] - fall no injuries [DATE] - fall with skin tear to left lateral (outside) upper arm, bruise to left lateral (outside) antecubital (inside of elbow) area, abrasion (scratch) to left posterior (back) ribs/flank area [DATE] - fell , hit head, left rib area The care plan was updated for falls on the following dates: [DATE] PT working with resident on strength training [DATE] nursing staff will keep door open for better monitoring [DATE] floor mats at bedside Interventions included re-orient resident to call light ([DATE]), appropriate footwear ([DATE]), safe environment with clean floor, free of clutter, adequate light, bed in low position, side rails on bed, hand rails on walls, personal items in reach ([DATE]), physical therapy to strengthen resident ([DATE]), keep door open ([DATE]). Review of Resident #1's order history printed [DATE] revealed the following orders: 'Scoop mattress on bed due to frequent falls and impaired safety awareness, start date [DATE], no end date Monitor placement and functioning of wander guard every shift, start date [DATE], end date [DATE] BusPIRone HCl Tablet 15 MG Give 1 tablet by mouth three times a day for anxiety, start date [DATE], no end date Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day related to DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, SEVERE, WITH PSYCHOTIC DISTURBANCE, start date [DATE], no end date Cymbalta Capsule Delayed Release Particles 60 MG (DULoxetine HCl) Give 1 capsule by mouth one time a day related to OTHER RECURRENT DEPRESSIVE DISORDERS, start date [DATE], no end date Haloperidol Lactate Concentrate 2 MG/ML Give 0.5 ml by mouth every 6 hours as needed for agitation, start date [DATE], end date [DATE] LORazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for anxiety for 14 Days, start date [DATE], end date [DATE] LORazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for anxiety, start date [DATE], end date [DATE] LORazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for anxiety for 30 Days, start date [DATE], end date [DATE] tiZANidine HCl Tablet 2 MG Give 1 tablet by mouth at bedtime for muscle spasm, start date [DATE], no end date TraMADol HCl Tablet 50 MG Give 1 tablet by mouth two times a day related to OTHER MUSCLE SPASM, start date [DATE], no end date Vistaril Oral Capsule (Hydroxyzine Pamoate) Give 10 mg by mouth every 12 hours as needed for anxiety/agitation, start date [DATE], end date [DATE] Vistaril Oral Capsule 25 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth every 24 hours as needed for anxiety related to ANXIETY DISORDER, UNSPECIFIED (F41.9) for 30 Days, start date [DATE], end date [DATE] Vistaril Oral Capsule 25 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth two times a day related to ANXIETY DISORDER, UNSPECIFIED (F41.9), start date [DATE], end date [DATE]. Vistaril Oral Capsule 25 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth two times a day related to ANXIETY DISORDER, UNSPECIFIED (F41.9); DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, SEVERE, WITH PSYCHOTIC DISTURBANCE, start date [DATE], no end date' 'Cipro Oral Tablet 500 MG Give 1 tablet by mouth every 12 hours related to urinary tract infection, for 7 Days, start date [DATE], end date [DATE] Ertapenem Sodium Injection Solution Inject 1 gram intramuscularly every 24 hours for infection related to urinary tract infection for 7 Days, start date [DATE], end date [DATE].' Review of the list of Resident #1's fall incidents for the last 12 months revealed 14 falls on the following dates: [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] [DATE] Record review of Resident #1's fall incident reports revealed: [DATE] Resident #1 was found prone at the foot of room mate's bed; Resident #1 stated she was exiting the restroom; no injuries noted [DATE] Resident #1 was found laying face down leaning on her right shoulder, unable to describe what occurred; had a hematoma to top of right forehead. [DATE] Resident #1 was sitting on buttocks on the floor between wheelchair and closet; no injuries found; unable to decribe incident [DATE] crshign noise heard, Resident #1 found on ground moaning and grimacing; no head injury, skin tear to upper arm; left side tender to touch; x-ray of spine and left pelvis done without injries; resident unable to verbalize incident [DATE] Sound was heard, Resident #1 was found lying on her right side with a pool of blood around her During an interview and observation on [DATE] beginning at 10:00 am with Resident #1, she was sitting in a wheelchair across from the nurses station and smiled and said hi. She did not appear in pain, but a healing cut to the right forehead was visible as were several bruises to both of her arms and a few small cuts/scratches were visible on both arms as well. The resident was not interviewable due to her dementia. During an interview on [DATE] at 4:28 pm RP, stated that in July Resident #1 was having an increase in her falls, so she asked the facility to discontinue the Vistaril because she thought it was causing the falls; the facility told RP that the doctor made the Vistaril PRN but did not want it discontinued. RP stated that Resident #1 went to the hospital because of a fall with a knot on her head on [DATE], and then Resident #1 was confused and had altered mental status on [DATE] and was diagnosed with a urinary tract infection. RP said that Resident #1 had a bad fall on [DATE] and was admitted to the hospital because the facility couldn't stop the bleeding and were concerned about head trauma; Resident #1 was diagnosed with 3 broken ribs on the left. During an interview on [DATE] at 12:30 pm ADM, stated that Resident #1 was having altered mental status, so psychiatry was consulted and started the resident on Depakote on [DATE]. She stated the resident was sent to the emergency room [DATE] and was diagnosed with a urinary tract infection and started on one antibiotic (cipro), and then it was switched to a stronger antibiotic when sensitivities returned (Ertapenem). She stated that psychiatry was aware of the falls that Resident #1 suffered and did not want to discontinue Vistaril. During an interview on [DATE] at 3:23 pm Psych MD, stated that Depakote could cause falls and dizziness, as could Vistaril. He stated he would discontinue any medication if the RP requested it because it was the withdrawal of consent for the medication. He denied knowledge of the request to discontinue Vistaril but did change it to PRN because the RP was concerned about the falls. He was informed the resident would not stay in the wheelchair and was having falls, so he added Depakote and resumed scheduled Vistaril. He stated that he was not aware that Resident #1 was diagnosed with a UTI on the same day as the Depakote was started and that Resident #1's confusion and agitation could have been caused by the UTI and not progression of disease and he would have discontinued the Depakote if he had known. He also stated he complied with recommendations from the pharmacist, for dose reductions. During an interview on [DATE] at 5:51 pm ADON stated that on [DATE] she and RP saw Resident #1 was agitated and looking for her deceased husband, so she saw Psych MD and got order for Vistaril 10 mg twice a day PRN and that RP gave verbal consent. She stated that Resident #1's diagnosis of UTI was discussed at the morning meeting, but that she did not use her clinical judgement to consider discontinuing the new psychotropic medications that were added due to the altered mental status of the resident. Record review of Resident #1's progress notes dated [DATE] revealed a note at 9:34 am that stated resident with increased anxiety and pressured speech; aggressive behaviors with staff redirected with difficulty, NP present and new order for Depakote 125 mg bid for psychosis and mood disorder, RP aware and gave verbal consent. Further review revealed a progress note dated [DATE] at 12:35 pm that stated that Resident #1 was sent to the emergency room due to altered mental status and agitation and returned with a diagnosis of UTI. Record review of the manufacturer's guidelines for Depakote, accessed on [DATE] at https://www.depakote.com/hcp/important-safety-information revealed: In a clinical trial, somnolence was associated with valproate in some elderly dementia patients along with reduced nutritional intake; weight loss; and a trend to have a lower baseline albumin concentration, higher BUN, and lower valproate clearance. Discontinuation occurred in some patients. It further revealed that the most common adverse reactions (reported >5%) included accidental injury, blurred vision, amnesia, anorexia, depression, dizziness, dyspepsia (indigestion), emotional lability (rapid mood changes), insomnia, nausea, nervousness, rash, somnolence (drowsiness), thinking abnormal, tremor, vomiting, and weight loss. Record review of the [DATE] Beers Criteria for Potentially Inappropriate Medication Use in Older Adults published by the American Geriatrics Society, accessed on [DATE] at https://www.guidelinecentral.com/guideline/340784/ , revealed that Cymbalta (duloxetine) should be used with caution, haloperidol should be avoided except in some situations (bipolar, schizophrenia, and short term chemotherapy), Vistaril (hydroxyzine) should be avoided for strong anticholinergic properties (impaired memory, reduced cognitive function, behavioral disturbances, anxiety, and insomnia), Lorazepam should be avoided, and tramadol should be used with caution. Record review of the Admission Drug Regimen Review performed [DATE] for Resident #1's readmission from the hospital revealed: No use of medication(s) without evidence of adequate indication for use; No history of recent adverse reactions to any medication; No duplicate therapy and was signed by LVN A. Record review of the hospital records of Resident #1's (hospital) admission on [DATE] revealed a right forehead laceration; a CT of the abdomen and pelvis with contrast revealed acute minimally displaced nonsegmental fractures of the left 8th, 9th and 10th ribs. Record review of the Pharmacist recommendation for [DATE] to review Cymbalta (duloxetine) and buspirone for reduction in dose revealed the Psych NP declined GDR on [DATE] because a decrease would result in return of symptoms. Record review of the [DATE] Psych NP visit summary revealed no mention of diagnosis of urinary tract infection on [DATE], nor change of antibiotics on [DATE]. Record review of the facility's Falls Prevention Policy dated [DATE] revealed: . a review of all falls will be completed, with the purpose of . investigating the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury . discussions may include: .Recent medication changes . Lab studies . Medical status

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of care within 48 hours of the resident's admission for three (Resident #10, Resident #62 and Resident #171) of three residents reviewed for base line care plans. The facility failed to complete Resident #10, Resident #62, and Resident #17 baseline care plan within 48 hours of admission that included the minimum required healthcare information of initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. This failure placed residents at risk of not receiving effective and person-centered care. 1. Review of Resident #10's undated Face Sheet, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included fracture of the right femur, hypertension, retention of urine, type 2 diabetes, muscle weakness, neuromuscular dysfunction of bladder, unsteadiness on feet, hypothyroidism (underactive thyroid), hyperlipidemia (high cholesterol), depression, and sleep apnea. Review of Resident #10's Baseline Care Plan, dated 11/03/22 reflected it did not address physician orders, dietary orders, therapy services, and social services. 2. Review of Resident #62, undated Face Sheet, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included sepsis, moderate protein-calorie malnutrition, muscle weakness, difficulty in walking, dysphagia, dementia, hypertension, and need for assistance with personal care. Review of #62's Baseline Care Plan, dated 10/24/22 reflected did not address physician orders, dietary orders, therapy services, and social services. 3. Review of Resident #171's undated Face Sheet, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnosis included fluid overload, congestive heart failure, type 2 diabetes, hyperlipidemia, chronic pain, hypertension, repeated falls, weakness, and reduced mobility. Review of Resident #171's Baseline Care Plan, dated 11/28/22 reflected it did not address physician orders, dietary orders, therapy services, and social services. In an interview on 12/01/22 at 10:00 am with the DON, he revealed he was solely responsible for the initiation and completion of all baseline care plans within 48 hours upon a resident's admission into the facility. The DON stated he was aware that Resident #10, Resident #62, and Resident #171 baseline care plans were not completed timely. He stated most new admission occur on a Friday and the baseline care plans would need to be completed over the weekend, which would require him to work seven days a week. The DON stated going forward he would have the weekend RN complete the baseline care plans that would be due over the weekend. The DON stated in his review of the baseline care plans for Resident #10, Resident #62, and Resident #171, the plans were not specific to each resident's need. He stated that he did not personalize the care plans, but instead the interventions were chosen from computer generated options. The DON stated not having a personalized care plan would not allow for the most appropriate care to be given to the resident which could lead to harm, injury, and death. Review of the facility's Comprehensive Person-Centered Care Planning policy dated 2017 reflected .within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions to provide effective and person-centered care. The baseline care plan will include the minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and PASARR recommendations, if applicable .

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling service by failing to maintain essential equipment for two of two hand washing sinks in the kitchen area reviewed for safe and sanitary water temperatures. Hand Washing, Gloves, and Antimicrobial Gel - Employees should never use bare hand contact with any foods, ready to eat or otherwise. Since the skin carries microorganisms, it is critical that staff involved in food preparation, distribution and serving consistently utilize good hygienic practices and techniques. Staff should have access to proper hand washing facilities with available soap (regular or anti-microbial), hot water, and disposable towels and/or heat/air drying methods. The facility failed to regularly check the water temperature of the kitchen handwashing sinks and failed to document and report the water was not getting hot. This failure could affect residents at risk for illness due to unsafe hand washing practices. Findings included: Observation on initial tour of the kitchen on 11/29/22 at 9:31 AM revealed that water in hand washing sink #1 was cold to the touch when surveyor washed her hands. Surveyor proceeded to hand washing sink #2 and it was also cold to the touch. Interview on 11/29/22 at 9:36 AM the Dietary Manager stated that they have been having issues with the two sinks not getting hot for about a week. The dietary manager stated it was verbally reported to Maintenance Supervisor but was not formally documented in a work order. The dietary manager stated water in both sinks have been sporadically getting hot water over the past few days. Observation and interview on 11/29/2022 at 9:50 AM with Maintenance Supervisor check the water temperature in sink #1 and it was 59 degrees and sink #2 was also at 59 degrees. The Maintenance Supervisor revealed that he was aware that the water in the kitchen has not been producing hot water in the hand washing sinks. He stated that there was a problem with the tankless water heater, and he would have to call a plumber to fix it. He stated that it was working 11/28/2022 but he had not checked the temperature today. The Maintenance Supervisor stated a plumber had not been called about the hand washing sinks. Interview with Dietary Aide on 11/29/2022 at 10:23AM revealed that she did use sink #1 in the kitchen to wash her hands when she entered the kitchen. She stated she did not recall if the water was hot or cold but did know that it has been having issues. Interview with Cook B on 11/29/2022 at 10:27AM revealed that she did use sink #1 in the kitchen to wash her hands when she entered the kitchen. She stated she remembered the water being kind of chilly but she still used it. She stated that she did not report it to anyone because she did not know it was a problem and thought it could've been because it was cold outside. Interview with Cook A on 11/29/2022 at 11:00AM revealed that she was aware of the issue with the kitchen hand washing sinks and washed her hands in an alternative sink located in the dining room area. She was unsure how long the hand washing sinks in the kitchen have been malfunctioning. Record review of Facility Monthly Heater and Boiler Log revealed there were no accurate temperatures documented from January- November. The log revealed that only check [NAME] were used which had no indication of date or actual temperature that was recorded. There was no other documentation to review including nothing being recorded in the Maintenance log addressing the water temperatures in the hand washing sinks. Interview with Maintenance Supervisor on 11/29/2022 at approximately 11:15AM revealed that a plumber has been called and was expected at the facility on 11/29/2022 between 2PM-2:30 PM. Observation and interview on 11/30/2022 at 9:40 AM revealed the water in both hand washing sinks in the kitchen are still producing water that was cold to the touch. The Maintenance Supervisor revealed that the plumber will return today to replace the tankless hot water system that produces hot water for the two hand washing kitchen sinks as it was deemed unfixable by the plumber yesterday. Observation and interview on 11/30/2022 at 3:05 PM revealed that Kitchen hand washing sink #1 temperature was at 111 degrees. Kitchen hand washing sink #2 was at 110 degrees. The Life Safety Facility Coordinator revealed that the tankless water heater had been replaced and the kitchen hand washing sinks had been fixed. Interview with the Administrator on 12/01/2022 at 1:30PM revealed that she was unaware of the issue in the kitchen until it was brought to her attention on 11/29/2022. She expected the Maintenance Supervisor to conduct temperature checks throughout the building including the kitchen sinks on a weekly basis and those temperatures should be clearly documented, dated and signed. She also stated that it was her expectation that any issues should be reported immediately so that they can be addressed timely. Going forward she revealed that her Life Safety Facility Coordinator will be setting up a QR code in the kitchen and other areas around the facility that can be scanned to report maintenance issues. She stated that the QR code will alert the Maintenance Supervisor and Life Safety Facility Coordinator of the issue and can be tracked in real time. She also was now requiring Maintenance Supervisor to turn in Temperature check logs into her on a weekly basis and she will sign and keep them in a logbook. Record Review of a facility in-service dated 11/30/2022 indicated that Life Safety Facility Coordinator trained the Maintenance Supervisor on water temperature expectations and how to properly document temperatures. All areas in the building were checked and verified for appropriate water temperatures. Record review of invoice from [NAME] Service LLC dated 12/01/2022 indicated that tankless water system was replaced with a new tankless water system. Review of the facility's Reporting Malfunction/Error Reporting Policy Number 2G dated 6/2017 stated: Policy: It is the policy of this facility to report all equipment malfunction to the maintenance supervisor so that they may ensure that all equipment is maintained in an operable state. Procedure: 1. When a piece of equipment is observed to be malfunctioning or operating incorrectly, advise the maintenance director of the situation. 2. If maintenance director is unavailable put item in maintenance log. 3. Maintenance director shall facilitate repair/replacement of equipment as soon as possible and notify the department head and administrator when repairs are complete. 4. If equipment must be replaced and will fall under CAPEX criteria, maintenance director shall coordinate with administrator to properly order equipment. Record review of the facility's Hot Water System Policy which was not dated: 1. The temperature will be recorded on the water temperature log daily and maintained by the Maintenance Supervisor weekly. 2. There will be random water temperature checks throughout the facility accessible to the residents. 3. Water temperature should be maintained at 100 degrees F at a minimum, and 110 degrees F at a maximum. 4. The laundry and kitchen areas should be maintained at a temperature of 140 degrees F. 5. Temperature readings will be recorded on the water temperatures log weekly. 6. The hot water tanks should be adjusted accordingly with the readings that are too high or too low. Adjustments will be noted on the water temperature log. 7. The facility will make provisions to repair the hot water problem as soon as possible. Use to the areas affected by the malfunctioning unit will be restricted until repairs are completed. FDA Food Code Chapter 5 [Plumbing, Water and Waste] Section 5-202.12, Handwashing Sink, Installation, paragraph (A), recommends that, A handwashing sink shall be equipped to provide water at a temperature of at least 43 C (110 F) through a mixing valve or combination faucet . A handwashing lavatory shall be equipped to provide water at a temperature of at least 43 C (110 F) through a mixing valve or combination faucet. A steam mixing valve may not be used at a handwashing lavatory. A self-closing, slow-closing, or metering faucet shall provide a flow of water for at least 15 seconds without the need to reactivate the faucet. https://www.fda.gov/food/fda-food-code/food-code-2017

Based on observation, interview and record review the facility failed to develop a care plan for interventions for removal of facial hair for one (Residents #23) of eight residents reviewed for comprehensive care plans. The facility failed to develop a care plan Resident #23's care plan for interventions for removal of facial hair. This failure could place residents at risk for possible decreased quality of life, isolation and embarrassment. Findings include: Record review of Resident #23's quarterly MDS dated [DATE], revealed an [AGE] year-old female admitted to the facility 10/02/2020, readmitted on [DATE] with diagnosis of diabetes mellitus, cerebrovascular accident, and dementia with a BIMs of six severely confused. She requires total care with bathing and personal hygiene of one staff assistance. Review of Resident#23's care plan undated reflected resident had a self-care performance deficit. The care plan did not address Resident #23's ADL interventions for removal of facial hair. Observation on 11/29/22 at 10:27 a.m. revealed Resident #23 was sitting in her wheelchair neat and clean. She had long white and gray facial hair approximately 0.5 inches in length on her [NAME] area, her upper lip and underneath her [NAME]. When asked if she would like for the facial hair to be removed, she replied yes, its, embarrassing. Hospitality Aide stated she would get her care giver to took care of Resident #23's [NAME] hair that she was a hospitality aid. Resident #23's facial hair was removed shortly after it was brought to the CNAs attention. In an interview with CNA D on 11/30/22 at 10:02 a.m. she revealed there was nothing on the bathing sheet to inform the CNAs when to shave the female residents. The CNAs just use their judgments when to shave a female's facial hair depending on how long it is because if it's too short it will cause skin irritations. Residents should be shaved at the same time of their showers. Review of the facility's undated Care Plans, Comprehensive Person-Centered policy: A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, Psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview and record review, the facility failed to ensure each resident received food that accommodates resident preferences for one resident (Resident #59) of eight residents reviewed for food preferences. The facility failed to ensure Resident#59's likes, and dislike food preferences were honored by combining her food together. This failure could cause residents who ate meals from the kitchen at risk of not having their choices and food preferences accommodated, possible weight loss, and a diminished quality of life. Findings included: Record Review of Resident #59's undated face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her diagnoses included Type two Diabetes, protein-calorie malnutrition, and cognitive communication deficit. Record Review of Resident #59's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 indicating severe cognitive impairment. Observation on 11/30/22 at 8:40 a.m. revealed breakfast was being served to Resident #59 in the dining room. CNA D set the residents breakfast tray on the table in front of her. She proceeded to set -up the resident's food by opening the jelly container and added the jelly to residents' cream of wheat. CNA D then she took the scrambled eggs and added them in with the jelly and cream of wheat. CNA D never asked Resident #59 if she would like for her jelly and eggs to be combined in the cream of wheat. Resident #59 stated she did not like the jelly in her cream of wheat. Review of the breakfast and lunch meal tickets dated 11/30/22 for Resident #59 revealed her likes and dislikes was blank and did not indicate to combine residents' foods at meals. In an interview on 12/01/22 at 10:20 a.m. with CNA D she combined Resident #59's breakfast food together because that was what the therapy staff were doing, and she just done what she had seen. She stated the purpose of the meal tickets were to give instruction on how and what type of food the resident was allowed to eat and their likes and dislike. In an interview on 12/01/22 at 10:02 a.m. with the Dietary Supervisor revealed she was not aware the CNAs were combining Resident #59's foods. She stated the meal tickets was to inform the staff of residents likes and dislikes preferences. His expectations were to follow the meal ticket instructions and to ensure residents eat and enjoy their meals to get the proper nutrition. The risk factors were that the resident could lose weight and not eat their meals. The facility did not provide a food preference policy at the time of exit.

Based on observation, interview and record review, the facility failed to ensure a resident, who is unable to carry out activities of daily living, receives the necessary services to maintain grooming, and personal hygiene for two (Resident #6 and Resident #23) of eight residents reviewed for personal hygiene and bathing. The facility failed to ensure staff provided consistent showers/baths to Resident #6. The facility failed to ensure staff removed Resident #23's facial hair. These failures could affect the residents who require assistance with care from facility staff by placing them at risk for social isolation, loss of dignity and self-worth. Findings included: 1. Review of Resident #6's MDS re-admission assessment, dated 10/22/22, revealed an [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease ( respiratory disease) . Further review revealed the resident was alert and oriented to person, place, and time and required total assistance with two-person assistance for bathing. Review of Resident #6's Comprehensive Care Plan, undated, revealed her shower days were three times a week on Tuesdays, Thursdays and Saturdays. She required assistance with personal hygiene. Observation and interview on 11/29/22 at 10:27 a.m. Resident #6 were setting in wheelchair well groom at bedside. When asked if he had received her showers. She stated, I have not had a shower since I've been here. Record review of Resident#6's Bathing record dated from 11/17/22 through 11/28/22. The record reflected no showers on were provided on the following days: 11/17/22, 19th, 22nd, 24th, 26th, and 28th. In an interview on 12/01/22 at 9:00 a.m. with LVN C, she revealed a shower list was made out each morning of residents receiving a shower that day. She stated hall 200 did not schedule showers/baths the same as the other halls. Showers were rotated by room numbers. They used to have several residents that were heavy care and required mechanical lift. It was likely that Resident#6 was not put on the shower list. She revealed the CNAs were to document on the residents bathing record if a resident received or refused a shower/bath. If a resident refuses a shower, they are supposed to report to the charge nurse. The charge nurse will talk with the resident and try to encourage him/her to take a shower, then the nurse is to chart in the resident's record. In an interview on 11/30/22 at 11:45 a.m. with CNA E revealed she was the shower aid that assisted with showers on the 6 am-2 PM and 2 PM-10 PM shifts. She stated she gets a list of the residents that are scheduled to receive a shower for that day, and she starts going down the list giving showers. She was not aware Resident #6 had not received a shower which meant she must not have been on her list to shower her. She stated she was supposed to chart the showers and if a resident refuses a shower that she will verbally report to the CNA on that hall. In an interview with the DON 11/30/22 1:27 p.m., he revealed the facility's expectation was all residents to be well groomed including facial hair. He stated if a resident refused a shower then the CNA should report to the charge nurse so she can talk and encourage the resident to take a shower and/ or document the refusal. He stated the risk of for not bathing a resident were body odor, skin breakdown, loss of dignity and isolation. 2. Record review of Resident #23's quarterly MDS dated [DATE], revealed an [AGE] year-old female admitted to the facility 10/02/2020, readmitted on [DATE] with diagnoses of Diabetes mellitus, Cardiovascular accident and dementia. The resident had a BIMs of six which indicated the resident was severely impaired with decision making. She required total care with one person assistance with bathing and personal hygiene. Review of Resident#23's care Plan undated reflected resident had a self-care performance deficit. The care plan did not address Resident #59's ADL interventions for removal of facial hair. Observation on 11/29/22 at 10:27 a.m. revealed Resident #23 setting in her wheelchair neat and clean. She had long white and gray facial hair approximately 0.5 inches in length on her [NAME] area, her upper lip and underneath her [NAME]. When asked if she would like for the facial hair to be removed, she replied yes, its, embarrassing. The Hospitality Aide stated she would get her care giver to take care of Resident #59's [NAME] hair. Residents' facial hair was removed shortly after it was brought to the CNAs attention. In an interview with CNA D on 11/30/22 at 10:02 a.m. she revealed there was nothing on the bathing sheet to inform the CNAs when to shave the female residents. The CNAs just used their judgment when to shave a female's facial hair depending on how long it was because if it's too short it will cause skin irritations. Residents should be shaved at the same time of their showers. Record review of the facility's policy for bath, tub/shower undated reflected, bathing by tub or shower is done to remove soil, dead epithelial cell and microorganism from the skin, and body to promote comfort, cleanliness, circulation and relaxation. The policy did not address shaving of residents.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 20 staff (NA A, Laundry Staff B and OTR C) reviewed for infection control during a COVID-19 outbreak. NA A, Laundry Staff B and OTR C failed to wear their masks pulled over their mouths or noses while in the presence of residents and other facility staff. These failures place residents at an increased risk of exposure to infections to include COVID 19, decreased quality of life or hospitalization s. Findings include: Review of Resident # 1's undated Face Sheet reflected she was an [AGE] year-old female who was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 1's Comprehensive MDS, dated [DATE], reflected she had a BIMS score of 8 indicating moderate cognitive impairment and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 1's Care Plan dated 09/08/2021 reflected she is at risk for contracting infections due to [CONDITION(S)]. Keep the environment clean and people with infection away. 03/16/2020 Is at risk for s/sx of COVID 19. Educate staff of signs and symptoms and precautions. Review of Resident # 2's undated Face Sheet reflected she is a [AGE] year old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 2's Quarterly MDS, dated [DATE], reflected she was unable to participate for a BIMS and her cognition could not be assessed. Review of Resident # 2's Care Plan dated 07/26/2021 reflected she is at risk for signs and symptoms of COVID-19. Educate staff of COVID 19 signs, symptoms and precautions. Observation and interview on 01/06/2022 at 8:37 AM revealed NA A at the entrance of the Nurses Station with her mask under her nose. Interview with NA A revealed she had worked at the facility for 2-3 months and had training two weeks ago on handwashing and wearing PPE. She stated it is to protect you and others from airborne diseases. When asked if there were any COVID-19 positive residents in the facility she stated Yes . Interview on 01/06/2022 at 8:39 AM with the Administrator revealed there are two COVID Positive residents at the end of Hall 300. Observation and interview on 01/06/2022 at 9:32 AM revealed Laundry Staff B with her mask under her chin, nose and mouth exposed, while standing over and talking to the Receptionist. She stated her mask was down Because I thought she couldn't hear me. She stated this was not appropriate because coughing and sneezing can spread COVID. We had a training on infection control last week. Observation and interview on 01/06/2022 at 9:42 AM revealed OTR C was observed in the therapy room filled with other staff and residents . OTR C had her mask under her chin, nose and mouth exposed, and was drinking a beverage. She stated she had been at the facility for two months and had received in-services on COVID-19 prevention weekly. When asked if she should always keep her mask above her nose and under her chin while in the building she stated, Yes ma'am. She stated, without prompting, Those residents are farther than six feet from me. Observation reflected Resident # 1 was within approximately six feet of OTR C and Resident # 2 was nearby. Interview on 01/06/2022 at 9:49 AM with the Director of Rehabilitation revealed he had worked at the facility for eight years. He stated there should be 100% staff masking in patient areas. In the warm or hot zone, we wear an N-95 mask and otherwise mask at all times around residents. Interview on 01/06/2022 at 12:00 PM with the DON revealed, All staff should be wearing masks while around residents and other staff . Review of an Infection Control and Prevention Policy, revised on 04/12/2021, reflected Implement Source Control Measures, use of well-fitting facemask or respirators. HCP should wear well fitting source control at all times while they are in the facility.

Based on observation, interviews, and record review, the facility failed to ensure the resident's right to be free from any physical imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 8 of 22 residents (Residents #1, #2, #3, #4, #5, #6, #7, and #8) whose care was reviewed for, in that: 1. Residents #2, 6, 7, and 8 had PSA on their beds with no physician orders in place prior to survey entry. 2. Residents #1, 2, 3, 4, 5, 6, 7, and 8 had PSA on their beds with no documentation of alternative interventions attempted prior to PSA installation. 3. Residents #2, 3, 5, 6, 7, and 8 had PSA on their beds and no indication of monitoring/re-evaluation for the need for use of the bed or chair alarms. The findings were: Review of face sheet dated 12/04/2021, reflected Resident #1 was a 93- years- old, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that she was discharged from the facility on 12/1/2021. Review of the quarterly MDS assessment dated [DATE] reflected Resident #1 had severe cognitive impairment with BIMS of 99. Review of incident reports for Resident #1 reflected: 1/28/2021: Fall no injury 4/5/2021: Fall no injury 12/5/2021: Fall with injury PSA applied and Care Plan Initiated: 01/28/2021 PSA: check placement and function every shift on 02/01/2021 Observation on 12/03/2021 at 2:15 PM , of Resident #1's room indicated resident had a fall mat between bed and window. There was no PSA observed, and Resident #1 was not in the facility. Interview on 12/03/2021 at 2:31 PM , the family member for Resident #1 revealed was aware of one fall mat between bed and window. Review of a face sheet dated 12/04/2021, indicated Resident #2 was an 85- years- old, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE] indicated Resident #2 had severe cognitive impairment with BIMS of 99. PSA ordered 12/3/21. PSA care planned 8/30/2018 No falls in last 3 months on incident report dated 12/03/2021. 9/16/2019: Fall with injury - right orbital fracture Observation on 12/05/2021 at 12:50 PM, Resident #2 was sitting outside her room by nurse's station . Record review of a face sheet dated 12/04/2021, indicated Resident #3 was 82- years- old, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS assessment dated [DATE] indicated Resident #3 had severe cognitive impairment with a BIMS of 04. Review of physician orders for Resident #3 reflected that the PSA ordered and care planned 4/14//21 and no evidence of fall mat or medication review interventions ordered prior to applying PSA. Review of care plan for Resident #3 reflected that the PSA was care planned 4/14/21 and no evidence of fall mat or medication review interventions care planned prior to applying PSA. Review of incident reports for Resident #3 reflected: 9/14/21: Fall no injury 1/20/2021: Fall no injury 3/16/2021: Fall with bruise 4/5/2021: Fall with Injury 4/11/2021: Fall with fracture to right hip 5/2/2021: Fall no injury 5/21/2021: Fall no injury 5/24/2021: Fall with hematoma 5/27/2021: Fall no injury 5/29/2021: Fall no injury 7/13/2021: Fall no injury 9/14/2021: Fall no injury During an interview on 12/05/2021 at 1:10 PM, Resident #3 revealed she did not know what the alarm was hanging on the top side rail. Resident #3 pointed to the alarm and states, I don't know why that box keeps blinking green there. Record review of a face sheet dated 12/04/2021, indicated Resident #5 was 89- years- old, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS assessment dated [DATE] indicated Resident #5 had severe cognitive impairment with BIMS of 99. Review of physician orders for Resident #5 reflected that the PSA ordered and care planned 11/16/19 and no evidence of fall mat or medication review interventions ordered prior to applying PSA. Review of care plan for Resident #5 reflected that the PSA was care planned 11/16/19 and no evidence of fall mat or medication review interventions care planned prior to applying PSA. Review of incident reports for Resident #5 reflected: 10/08/2021: Fall 10/11/2019: Fall no injury 10/18/2019 no injury 11/16/2019 no injury 11/30/2019 No injury 11/30/2019 No injury (2nd fall of day) 1/15/2020: Fall no injury 2/10/2020 Fall no injury 5/3/2020 Fall no injury 5/4/2020: Fall no injury x2 6/28/2020 Fall no injury 8/23/2020: Fall no injury 8/28/2020: Fall no injury 9/30/2020: Fall no injury 12/5/2020: Fall no injury 2/10/2021: Fall no injury Observation on 12/05/2021 at 1:09 PM , Resident #5 was sleeping in bed with PSA on, bed was in low position. Review of the face sheet dated 12/04/2021, indicated Resident #6 was a 93- years- old, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS annual assessment dated [DATE] indicated Resident #6 had severe cognitive impairment with BIMS of 99. Review of physician orders for Resident #6 reflected that the PSA ordered and care planned 7/6/20 and no evidence of fall mat or medication review interventions ordered prior to applying PSA. Review of care plan for Resident #6 reflected that the PSA was care planned 7/6/20 and no evidence of fall mat or medication review interventions care planned prior to applying PSA. Review of incident reports for Resident #6 reflected: 11/4/2021: Fall no injury 6/19/2020: Fall no injury 7/6/2020: Fall no injury Observation on 12/05/2021 at 12:54 PM , Resident #6 was sitting in her wheelchair in her room by the window with PSA on and no fall mats in room. A face sheet, dated 12/04/2021, indicated Resident #7 was an 81- years- old, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS quarterly assessment dated [DATE] indicated Resident #7 had severe cognitive impairment with BIMS of 99. Review of physician orders for Resident #7 reflected that the PSA ordered 12/3/21 and no evidence of fall mat or medication review interventions ordered prior to applying PSA. Review of care plan for Resident #7 reflected that the PSA was care planned 5/6/20 and no evidence of fall mat or medication review interventions care planned prior to applying PSA. Review of incident reports for Resident #7 reflected: 5/6/2020: Fall no injury 5/12/2020: Fall no injury 5/22/2020: Fall no injury 9/19/2020: Fall no injury 9/28/2020: Fall no injury 4/24/2021: Fall no injury Observation on 12/05/2021 at 12:32 PM of Resident #7 revealed wearing a PSA alarm while sitting in hallway outside her room and no fall mats in room. During an interview on 12/05/2021 at 12:32 PM Resident #7 stated, I'm not wearing an alarm and My chair makes a beep or noise sometimes when I get up . Record review of Resident #8 A face sheet, dated 12/04/2021, indicated Resident #8 was a 75- years- old, admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .), dementia with behavioral disturbance, muscle weakness, difficulty in walking, unsteadiness on feet, lack of coordination, abnormalities of gait and mobility. MDS quarterly assessment dated [DATE] indicated Resident #8 had severe cognitive impairment with BIMS of 99. Review of physician orders for Resident #8 reflected that the PSA ordered 12/3/21 and no evidence of fall mat or medication review interventions ordered prior to applying PSA. Review of care plan for Resident #8 reflected that the PSA was care planned 10/6/20 and no evidence of fall mat or medication review interventions care planned prior to applying PSA. Review of incident reports for Resident #8 reflected: 10/3/2020: Fall no injury 10/6/2020: Fall no injury 10/22/2020: Fall no injury Observation on 12/05/2021 at 12:43 PM, Resident #8 was lying on the PSA in low positioned bed and no fall mats in room. During an interview on 12/05/2021 at 12:43 PM, CNA D confirmed Resident #8 had a PSA on bed under her bedspread and stated, She has her bed alarm and it's working. During an interview on 12/04/2021 at 6:20 PM, the DON stated, There hasn't been any residents exhibiting physical or psychosocial changes related to the use of a PSA device. Each resident was care planned with interventions to address the individual's changes by linking the PSA to the fall or whatever incident triggered the care plan. The determining factor of when a resident uses a PSA is if they fall multiple times and dependent on their cognitive level. The DON states the interventions tried before applying a PSA are reeducating the resident, relocating their room closer to the nurse stations, reeducating the staff to more frequent rounds, use of fall matts, low beds, involve therapy department. The DON stated the MD provided standing orders for the use of a PSA if the resident meets the criteria for them . The DON stated residents were evaluated and reassessed quarterly or when there was a change in cognition or if cognition improves to determine the ongoing need for the use of PSA. DON stated, The plan for reducing the use of a PSA was person centered and what the resident's individual needs were to keep them safe. The DON stated they removed the PSA if it were agitating the resident more than it was helping, when residents are observed trying to pull, pick, twist, or remove the device, verbalized anger/anxiety, or kept calling out for help to take the device off. The DON stated they replaced the use of the PSA with low beds, fall mats, provided education, had medications evaluated and used psych services. When DON was asked weren't these the same interventions used prior to the PSA being applied, DON stated, Yes but it depends on the resident and their cognitive level because a lot of cognitively impaired residents don't retain education. DON states, I do not consider using a PSA as a restraint. During an interview on 12/04/2021 at 11:27 AM, the MD revealed standing orders are always provided with admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MD stated, I have standing orders, so the staff do not have to call me with every need. To use a PSA, it depends on a resident's cognitive level, dementia, high risk of falls, and debility or the facility has residents with mental disorders. The MD stated, I don't feel a facility using 16 PSAs out of 69 residents is a high number because you can't institute using a PSA according to numbers. It's hard to go by typical number of institute because it depends on the person. MD stated, With the terminology of restraint, under the state law it could be considered a restraint, but under my law it's not because I tried to help them. I don't consider PSAs restraints because residents can still get up and a restraint is where its ties up the resident and prevents them from getting up or out . MD stated, The PSA sounds off at the resident room or under them while they are sitting or lying down and it is very loud. MD stated, The shrill doesn't matter to the residents. It doesn't bother them at all. They still try to get up and that's why staff have to run to the room. The PSA doesn't bother them all psychosocially. It would be better if did. Safety is everything because you don't want them to fall and crack their head or get hurt. MD stated, We have to abide by the laws to keep them from getting hurt. I have been doing this for [AGE] years and I can tell you this isn't harmful in anyway. When advising MD that under federal/state regulations a PSA is considered a restraint, MD asks, Really Really??? Really it's a restraint? MD stated, It doesn't affect them psychosocially at all because it doesn't affect them from getting up. The alarm goes off and staff run to try to sit them down and the resident becomes more irritated from that. MD states, You guys have rules, but we have saved more people than harming them by using a PSA. My job is to protect and not injure. MD stated, A wrist restraint is a real restraint but not a posey vest because it helps them be comfortable and they can still move around in their chair and not having everyone grab them every 5 seconds. A PSA is big deal to state, but I'm protecting the resident. MD states, I have my NP reevaluate the continued use of the PSAs when it's needed. MD states, Some residents haven't had falls because of the PSA. I think we have done a great service using the PSA because they haven't fallen. The prevention of falls was more important for their safety. If you take the PSA away, then you're experimenting on if residents will fall or not. During an interview on 12/05/2021 at 12:36 PM, RN C stated, PSAs are supposed to be checked every two hours and at shift changes by the CNA, and during each shift at no specific time by nurses and documented in the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/05/2021 at 2:30 PM, the DON stated, Not at all care plans include fall mats as interventions because they are specific to the residents needs and whether they're appropriate or not for that particular resident. Record review of Policy/ Procedure - Nursing, Section: Resident Assessment, Subject: Fall Management System dated 06/2018 revealed: Policy: It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Procedures: 2. Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that included measurable objectives and timeframes . The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food was properly stored in the facility's refrigerator and freezer. 2. The facility failed to ensure expired foods were discarded. These failures could place all residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on [DATE] at 9:30 AM revealed: - 1 box dated [DATE] contained 18 cantaloupes with fuzzy white and black spots; and - 1 bag dated [DATE] contained 7 cabbages with fuzzy white and black spots; Observation of the facility's freezer on [DATE] at 9:55 AM revealed: - 1 box of biscuit dough open and exposed to air; - 1 box of garlic bread open and exposed to air; - 1 box of cobbler crust dough sheets open and exposed to air; - 1 box of pizza with fat reduced pepperoni open and exposed to air; - 1 bag of fully cooked flame broiled beef steak burgers open and exposed to air; - 1 box of chicken textured vegetable protein product enchiladas open and exposed to air; and - 1 box of fully cooked portioned chicken breast meat fritter chunks open and exposed to air. In an interview with Dietary Manager on [DATE] at 11:10 AM she stated she and the dietary staff (cook and dietary aides) were responsible for getting rid of expired food. She stated her expectation was for food in the refrigerator to be checked daily for spoilage. She stated the food should be checked daily but was not checked as often as needed. She stated she checked the bags and boxes of food in the freezer every other day while rearranging items. She stated residents were at risk of food borne illnesses and bacteria from expired food in the refrigerator and unsealed food in the freezer. A policy was requested on [DATE] regarding food items being sealed properly and removal of expired or rotten foods. The facility did not provide a food storage policy prior to exit on [DATE]. Review of U.S Department of Health and Human Services Food Code 2017 ,d+[DATE].15 Package Integrity reflected: Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants.

Based on interview and record review, the facility failed to obtain from hospice the most recent plan of care specific to each resident, obtain the hospice election form, physician certification of terminal illness, and implement a communication process for 1 (Resident #48) of 4 residents reviewed for hospice services. The facility failed to document any communication for Resident #48's hospice visits, obtain Resident #48's current Hospice plan of care from Hospice, obtain the hospice election form, and physician certification of terminal illness . This failure could affect residents on hospice services at risk for services and treatments not being coordinated. Findings included: Review of Resident #48's Comprehensive MDS assessment dated [DATE] reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was moderately impaired with no behaviors observed. Resident #48 was also receiving Hospice care while a resident. Review of Resident #48's physician orders, dated 09/08/21, reflected, Admit to [facility name] under the care of [Hospice Company] on 08/01/21. Resident #48's hospice binder was requested on 09/08/21 at 8:39 AM. Review of provided hospice material for Resident #48, received on 09/08/21 at 11:30 AM, revealed, the hospice plan of care was received and printed by the facility on 09/08/21 at 9:53 AM, the client coordination notes report was received and printed by the facility on 09/08/21 at 9:22 AM, the hospice election form and physician certification of terminal illness forms were not included in the provided material. Interview with the DON on 09/08/21 at 11:45 AM, revealed, that Resident #48 did not have a hospice binder onsite at the facility, she stated the resident was supposed to be on respite care. She stated respite care was for a few days but the resident had been at the facility for over a month. She stated that she believes that the resident was on long term care now. She stated that she does not understand the purpose of the forms being in the binder and onsite. She stated that they should be onsite. She stated that she was in charge of ensuring the hospice information gets onsite. Review of facility policy, Quality of Care: Administration. End of Life Care: Hospice, dated 12/2019, revealed, .4. Hospice services will be offered as appropriate and as ordered by the physician. These services will be integrated into the overall individualized, interdisciplinary care plan. Collaboration with hospice will include processes for orienting staff to facility policies and procedures which may include: resident rights, documentation and record keeping requirements.

Based on observation, interview and record review, the facility failed to ensure residents received appropriate supervision to prevent accidents for one (Resident #1) of 11 residents reviewed for elopement. The facility failed to provide adequate supervision to Resident #1 during a facility activity. Resident #1 exited the building on 04/19/18 with alarms sounding which were not heard by staff due to loud music. She was found outside on the ground by facility visitors. An Immediate Jeopardy (IJ) was identified to have occurred on 04/19/18 to 04/20/18. This was determined to be an IJ of past noncompliance due to the facility having implemented actions that corrected the noncompliance prior to the investigation. This failure could affect 11 residents identified as elopement risk and who were ordered Wander Guards by placing them at risk for injury, severe injury and even death. Findings included: Review of Resident #1's MDS assessment dated [DATE] revealed she was an 86- year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She required extensive assistance with ADL's. Resident #1's Care Plan dated 03/26/18 reflected Resident #1 Was at risk for wandering due to impaired safety awareness. The identified goal was to maintain safety for Resident #1 through the next review date. Interventions included placement of a Wander Guard with monitoring every shift for placement and function. Observation and interview with Resident #1 on 05/08/18 at 2:55 PM in her recliner in her room revealed she was alert. She was oriented to general time and place. She was confused about events but did state she 'should have gone to bed when asked about her bruise. Her Wander Guard was in place. Resident #1 was observed and interviewed on 05/16/18. Wander Guard in place. Review of Resident #1's Elopement/Wandering Evaluation dated 04/14/18 at 9:36 PM reflected she was a high risk for wandering. The evaluation was completed by LVN A (No longer employed by facility). The evaluation reflected predisposing diseases: dementia; ambulation: independent in wheelchair; mental status: intermittent confusion; history of elopement last 6 months: one or two episodes; makes statements about going home: no; place the resident at risk: yes; intrude on privacy of others: no; how does wandering compare to previous, same. Interview with the DON, ADON and LVN E on 05/16/18 at 11:10 AM revealed they could not identify the previous one or two episodes identified in the assessment. They were not able to identify or provide documentation of previous events. They stated they thought she said something about going out to see about her car. The nurse who completed the report was no longer employed by the facility. Review of the facility's Provider Investigation Report (PIR) dated 04/19/18: Resident #1 was assumed to have exited the 400 Hall door as she was found on the ground outside the 400 Hall door by a family member. An account in the Provider Investigation Report of the security video of 04/19/18: The Resident #1 self-propelled her wheelchair at 7:10 PM down the 300 Hall after leaving the dining room during the Polka Night with a live band. Resident #1 turned around and headed back up the hall toward the front of the building. The report reflected staff could be seen in the background. Resident #1 then rounded the corner to the 400 Hall and staff were no longer visible. Resident #1 passed through the double door (located one-third of the way down Hall 400 where no residents were located (as observed on 05/08/18 at 11:00 AM and 05/16/18 at 10:40 AM) and self-propelled down 400 Hall. According to the tape Resident #1 was now out of view of the camera at 7:14 PM. At 7:38 PM a white SUV pulled to the side of the building. A man came down the sidewalk and into the building summoning CNA A. CNA A was seen stopping at the front desk telephoning and running outside to the side of the building. Other staff members were also seen running outside to the side of the building. Now the events were out of camera range. According to the Provider Investigation Report, Resident #1 was found outside on the ground near the exit to the 400 Hall. Resident #1 was assisted back in the building to her room and received first aid treatment for [REDACTED]. She was then monitored every 15 minutes for three days following the event. The investigation identified that staff failed to hear the door alarm due to a polka band playing loud music. The report reflected Resident #1 had a Wander Guard and was identified as high risk for wandering. Observation of the area outside the door at the end of the 400 Hall on 05/16/18 at 11:55 AM revealed a walkway with a rail which turned immediately to the right toward the front of the facility and the parking lot. This was not a secured area. Interview with LVN B at 2:25 PM on 05/16/18 revealed on Polka Night, she was summoned by CNA C who was running to the front door and LVN B ran to the front door as well. At that time, the band stopped playing and she could hear the alarms. LVN B found Resident #1 on the ground with her wheelchair on its side with the pressure sensitive alarms sounding. Resident #1 was on her left side with a bruise and skin tear to the left hand, a bruise to the left shoulder and a bruise above her left eye. LVN B assessed Resident #1, assisted into her wheelchair and took her to her room. The family who saw her and reported her on the ground according to LVN B was at the facility for Polka Night and left early to avoid the traffic in the parking lot. She stated the man who came in was dispatched by his wife who was a CNA and used to work at the facility. LVN B revealed the man's wife went to the resident. She stated when she (LVN B) arrived, they (the family who noticed Resident #1) left. She stated staff checked her Wander Guard as well and it was working. She said the physician and family were notified and orders were received from the physician for x-rays and laboratory urinalysis due to her change in behavior. LVN B revealed the urinalysis indicated she had a urinary tract infection and she was started on antibiotics. The x-rays were negative. LVN B stated LVN P who was the nurse for Resident #1 was already looking for Resident #1 when she finished care for another resident. When CNA C knocked on the door to the 300 Hall, LVN P came out to help. Resident #1 wheeled herself to the Polka Night. She was not noticed leaving the venue. Resident was last seen around 7:00 PM at the start of the band. On 05/16/18 at 3:45 PM, an attempt was made to contact the man and woman who found Resident #1 outside on the ground, but they were not available. On 05/16/18 at 3:50 PM an attempt was made to contact CNA A via telephone, but she was not available. CNA A's written statement attached to the PIR reflected; at about 7:45 PM a family member came up to me while I was helping another resident the family said we have a res.(resident) on the ground. And his wife is with her. I looked down the hall didn't see any nurse. I went to the main nursing station and page. But the music was loud due to be Polka Night. I saw (LVN B) and we ran with the man. I saw (Resident #1) laying on the ground on her left side. And I told (LVN B) to stay with her. I went and banged on the 300 Hall door. And open it saying I need help (Resident #1) was on the ground. ( CNA A, CNA C, and CNA D picked her up.) Interview with the DON on 05/16/18 at 10:10 AM revealed that she had watched the security camera footage and confirmed that the report contained in the PIR was written by her. DON revealed she had not known the video tape was written over in a few days so they could not submit the tape. She stated that the Administrator and Chief of Operations also reviewed the tape. According to the DON on 05/16/18 at 10:10 AM, the physician ordered x-rays and a urinalysis (changes in mentation frequently indicate a UTI) due to her change in behavior. She stated the resident's x-rays were negative however, she did have a UTI. Bactrim DS 800/160 mg (antibiotic) by mouth twice daily for seven days was ordered and administered for the UTI. There were no aberrations in her behavior noted during the three day she was monitored. There were no verbal cues to exit seeking and she did not approach a door to go outside. Review of Medical Record on 05/16/18 at 5:10 PM noted urinalysis with E. coli. Physician order [REDACTED]. Continued interview with the DON on 05/16/18 at 10:10 AM revealed Resident #1 stated she was going to look for her car that was parked outside. I should have gone to bed instead of going outside. The DON stated the door Resident #1 exited did not have a Wander Guard alarm system but did have an alarm when the door was opened. Staff was unable to hear the alarm due to the polka band music. The DON revealed they knew the alarm sounded because the control panel on the wall in front of the nurse's station was flashing. She stated the alarm on the door sounded when someone touched the bar (on the door). The door locked initially but opened after 15 seconds which was a Life Safety Code requirement in the event the building needed to be evacuated. She stated staff was usually able to hear the alarms and respond, but due to the music, the sounding alarm was overpowered and not heard by staff. New alarms which were much louder and could only be turned off at the door were installed. During an interview with the Administrator on 05/17/18 at 8:45 AM, he revealed he had watched the video and agreed with the written summary submitted in the Provider Investigation Report. Resident #1 had not demonstrated exit seeking behaviors. She did wander about the facility in her wheelchair in a slow non-purposeful manner. He stated the facility was not able to retain exit seeking residents. The Administrator revealed Resident #1 just wanted to check on her car, but she was not trying to get away. Interview with the Operations Manager on 05/16/18 at 4:30 PM revealed he reviewed the video camera events as well. He stated he was not aware that the video would be deleted after a few days. His notes of his review match the DON's account of the video review. Review of facility Care Guidelines Elopement Management effective date of 07/27/17, reflected; .to provide a safe environment for residents who are at risk to wander. Elopement is the ability of the resident who is not capable of protecting himself or herself from harm to successfully leave the facility unsupervised and unnoticed and who may enter into harms way. The Best Practice Guidelines identify interventions which may be used for high risk residents: frequent monitoring of residents whereabouts to assure he or she remains in the facility, promote activities that are in full view of staff members, alternative activities to maintain interest level of the wanderer, implementation of wander bracelet or other electronic alert system, transfer to a more suitable or more secured facility if necessary . Responding to an actual elopement a. It is the responsibility of all staff, regardless of the department they work in, to respond to activated door alarms and return residents to their units. b. Charge Nurse will activate Code Green c. Each charge nurse will verify census on their hall. It was determined that the above failures put Resident #1 in an IJ from 04/19/18 to 04/20/18. An IJ was identified at past non-compliance and the Administrator was notified of this on 05/17/18 at 11:10 AM. The facility took the following actions to correct the deficient practice prior to the investigation: An interview with the DON on 05/16/18 at 10:10 AM revealed all residents who were previously identified as at risk for wandering and had Wander Guards were checked immediately to ensure placement and function of the Wander Guard and location of resident. She stated at that time, their Elopement/Wandering Assessment was reviewed, and they were evaluated for any changes in behavior. The DON said all orders were in the system and care plans were in place. The Wander Guards were checked each shift for placement and function, and it was documented on the TAR. She stated all other facility residents were evaluated utilizing the Wandering/Assessment tool. Continued interview with the DON on 05/16/18 at 10:10 AM revealed in-services were initiated with staff and included: elopement, missing residents, the Elopement Management Care Guidelines as well as the Elopement /Wandering Evaluation Tool and the new alarms. She stated the new protocol for monitoring during large (or loud) facility events was introduced. The DON revealed 100% of the staff were in-serviced by the end of 04/20/18. She stated in-services were conducted by herself and the ADON. The DON stated in-service conducted included information related to the elopement risk assessment which was completed on all residents on admission, quarterly, and upon change of condition. the in-service included information including: initial assessment should be conducted within eight hours of admission: actual wandering behaviors included: shadowing (following staff or another resident), self-stimulatory (wandering due to boredom or lack of activity), akathisia (motor restlessness characterized by pacing, standing and sitting, rocking back and forth which may be caused by [MEDICAL CONDITION] and antidepressant medications), exit seeking (resident is intent on leaving the facility, looking for exits, and hovering at exits waiting for the opportunity to leave with someone or pushing on a door.) The facility did not accept or keep exit seeking residents because they could not meet their needs for a secure unit. If a resident became exit seeking, they were placed on increased supervision until arrangements could be made for transfer to a secure unit. During large or loud events when the possibility of residents exiting doors unsupervised could be increased, facility doors and the alarm panel would be monitored by a staff member designated by management for the duration of the activity. She revealed the staff member could not leave the desk area. There was a check off list to be completed every 15 minutes by the monitor and co-signed at random intervals by on duty management staff. She stated the monitor obtain relief from on duty management as necessary. The DON further stated during the interview on 05/16/18 at 10:10 AM that a total of seven elopement drills were conducted from 04/19/18 to present (05/16/16) involving all staff on all three shifts and weekends. She stated the drills included, elopement as well as lost resident trapped in the closet. All in-service material and sign in sheets were provided by DON and content reviewed on 05/16/18 at 11:30 AM. All elopement drills were provided and reviewed on 05/16/18 at 11:30 AM. The DON also revealed immediately following the elopement, all exit doors alarms in the facility were checked. The doors were checked by the staff every shift for the next six days to ensure the doors were locked and the alarms were functioning. There were no issues. She stated the maintenance director continued to check all outside doors weekly. New door alarms were obtained on 04/20/18 which required they be shut off at the door source and only then should the keypad be reset at the nurse's station. The DON revealed these alarms were significantly louder than the previous alarms. In addition to the alarms continuing to sound until someone physically turned them off, they have a big red stop sign which hopefully would also stop people from exiting the door. The DON revealed the Wander Guard vendor was contacted for pricing for Wander Guard alarms on exterior doors. She said this information was received and submitted to their corporate office. Observation and verification of operation of exterior doors on Hall 100, 200, 300 and 400 as well as the wander guard on the front door was conducted on 05/08/18 at 4:20 PM. Door alarms were extremely loud. Observation on 05/16/18 at 11:05 AM, of all the facility doors revealed the alarms were very loud and operational. The Wander Guard alarm was operational at the front entrance. Wander Guards were on Residents #1, #2, #3, and #4 and were operational as verified with a tester unit. Documentation of Wander Guard checks was on the TAR. All the alarms could be heard in all parts of the facility as verified by moving into different parts of the facility and different rooms away from the alarm being tested . Review of the elopement risk resident book on 05/16/18 at 12:30 PM, revealed there were 11 residents identified with Wander Guards. All residents identified had current pictures as well as information sheets available for each of the residents. Observation on 05/16/18 at 1:25 PM revealed a door alarm was activated accidentally on the 400 Hall at the double doors. Staff members headed rapidly in the direction of the alarm. Four staff members were headed in that direction of the alarm, the other staff headed toward their respective halls where they verified their resident's location. They then reported to the central nursing station to report resident status and if needed to review a photograph of missing resident. Even though staff were aware there was a high probability this was a drill, they responded with urgency. Review of in-service records reflected 100% of the staff were in-serviced on Wander Risk Assessment, location of book with resident photos in the event of missing resident Elopement Management Best Practice Guidelines, new door alarms and event monitoring. Review of Resident #2, #3 and #4 who were identified as wanders and had Wander Guards included; observation of the Wander Guards for presence and function as well as documentation of checks every shift, observation of wandering and evaluation for exit seeking behavior, observation of staff intervention/redirection for wandering, observation of staff awareness of wanderers and frequency of contact with residents identified as wanders and clinical records for care plans, orders and every shift checks of Wander Guards documentation. Interviews with CNA D, CNA F, LVN E, LVN F, MA G, MA L, CNA H, CNA I, CNA J, LVN K, LVN M, LVN N, CNA O, HAQ, HA R, DM S ON 05/26/18 between 1:15 PM and 4:45 PM. Interviews revealed staff members were able to identify the code name for elopement, locate the notebook with wander risk residents pictures, state the process for a door alarm and verbally describe an exit seeking wanderer, they knew of the monitoring plan during facility events and the need to know the whereabouts of their at risk assigned residents. They were aware that oversight of the program was provided by the DON and ADON. They had participated in a Code Green Drill. Review of Resident Roster provided by the DON dated 05/16/18 highlighted 11 residents with Wander Guards.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #7) of nine residents reviewed for falls. CNA A transferred Resident #7 with no assist and left Resident #7 sitting up in a chair without her personal safety alarm and/or supervision. Resident #7 had an unwitnessed fall resulting in a skin tear to the left elbow, laceration to the left eyebrow and an acute right mid partial subdural hematoma (brain bleed) measuring 10 mm in thickness and 6 cm in diameter. The facility did not report the incident. These failures could place the 50 residents identified by the facility who utilize personal safety alarms at risk for falls with injuries. Findings included: Review of the comprehensive MDS assessment for Resident #7, dated 04/25/16, revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7 had severely impaired cognition and required extensive assistance of two staff members for transfers and was total dependent for locomotion. Review of the fall history revealed there had been no falls prior to admission or since admission to the facility. Review of the Interim plan of care dated 04/12/16 reflected Resident #7 had the potential for falls. One of the approaches was to assist the resident with transfers and mobility. Further review of the updated plan of care dated 04/19/16 reflected Resident #7 was at risk for falls, as she was unaware of safety needs, confusion, wandering and gait/balance problems. One of the interventions was a pressure sensitive alarm at all times. Review of the Incident Report dated 04/16/16 revealed Resident #7 was on the floor in her room. Resident #7 was lying face down on the floor, the assessment revealed a skin tear to the left elbow, a laceration above the left eyebrow, and complaining of shoulder pain. The resident was asked how that happened and the reply was I don't know. Resident #7 was assessed, and transferred to the hospital. The physician, family and the DON was notified. Review of the Hospital History and Physical dated 04/16/16 reflected Resident #7 was admitted for continuums monitoring of her acute subdural hematoma. Further review reflected a review of systems was negative, except for ongoing recurrent falls Review of the Computed Tomography (CT) scan of Resident #7's head. dated 04/16/16 reflected a 1 cm by 6 cm acute right mid partial subdural hematoma. Review of the nurse's notes dated 04/16/16 revealed Resident #7 was on the floor. Upon entering the room the resident was lying face down on her stomach. The resident was assessed for any injuries and noted a minor skin tear to left elbow, laceration above left eyebrow, and complaining of shoulder pain. The nurse notified the physician, family and transferred the resident to the emergency room . Review of the nurse's note dated 04/17/16 revealed Resident #7 remained hospitalized for [REDACTED]. Review of the nurse's notes dated 04/17/16 revealed Resident #7 returned to the facility. Resident #7 was admitted to Hospice services for comfort care Residents laceration above her left eyebrow was glued at hospital and had five steri-strips, measuring at 1.2 cm. Resident was diagnosed with [REDACTED]. Review of in-services dated 04/20/16 regarding Fall/Alarm education revealed if a resident has an alarm it needs to be on at all times. Transfer alarms between chair and bed. Ensure alarms were functioning . An interview on 05/11/16 at 1:00 p.m. with the DON revealed she was aware of Resident #7's fall. The facility had called me and she had the CNA in-serviced concerning the appropriate use of the personal safety alarms. The DON said the CNA was disciplined and a follow-up in-service concerning personal safety alarms was completed on 04/20/16 for other staff working on the hall. An interview on 05/11/16 at 2:21 p.m. with CNA A revealed Resident #7 was a two person transfer with a gait belt. The resident could bear weight when she stood up. CNA A said the morning Resident #7 fell she had gone into the room and gotten Resident #7 up, by herself. CNA A said she was in a hurry because she was running behind with her duties. CNA A said she sat the resident in a wheelchair with her bed side table and her breakfast; CNA A left the room without placing and turning on the personal safety alarm. CNA A said it was about 30 to 45 minutes later she found out Resident #7 had fallen. CNA A said it was the CNAs responsibility to make sure the personal safety alarm was on and in place. An interview on 05/11/16 at 9:45 a.m. with LVN B revealed Resident #7 walked with a walker. LVN B said Resident #7 scared her because she was very unsteady with the walker. LVN B said after the fall Resident #7 was on Hospice services transferred with a Hoyer Lift and placed in a Geri-chair. An interview on 05/11/16 at 3:15 p.m. with LVN C revealed she was the nurse that had admitted Resident #7. LVN C said Resident #7 was a pleasant, but confused resident who walked with a walker. LVN C said the daughter reported to her, that her mom had given her walker a name and she was never to be without the walker. The daughter told LVN C Resident #7 was unsteady at times with the walker and had fallen at home, because she would go off and forget her walker. LVN C said Resident #7 was unsteady on her feet and the staff had tried to keep her sitting near the nurse ' s station. LVN C said Resident #7 would wander around looking for her daughter, and that is why the resident had a personal safety alarm, so the staff would just know when she got up. An interview on 05/11/16 at 3:30 p.m. with the Administrator and the DON revealed the DON said she had been called and told concerning the fall on 04/16/16. When the DON was made aware of the diagnosis, she called and spoke to the facility's consultant concerning reporting the incident. The DON was told not to report the incident. The DON said she should have gone with my gut and reported it anyway, because she was the person responsible for investigating and reporting. The DON said it was the nurses responsibility to document on the MARs if the personal safety alarms were working, but the CNAs were the staff that where made aware of what interventions to use. The Administrator said he was the abuse coordinator in the building and he understood the concerns of not reporting that incident. Review of the MARs dated 05/01/16 revealed Resident #7 had personal safety alarm initiated on 04/12/16 to bed and wheelchair to alert the staff. Review of the facility's current Abuse/Neglect Policy dated June 2009 reflected: The facility will prohibit abuse, neglect . for all residents though implementation of seven components: .D. Identification of possible incidents or allegations which need investigation .G. Reporting of incidents, investigations and facility response to the results of the investigation .Reporting and response: All allegations and substantiated occurrences of abuse, neglect are reported to the state agency .Identification/Reporting . the Administrator/and or designee will document on the Providers Investigation Report when it meets the reportable incident guidelines, and fax to DHS LTC-R . methods of identification include incident reports. A list provided by the DON on 04/12/16 identified 50 residents in the facility that utilized personal safety alarms.

Based on observation, interview and record review, the facility failed to implement the written policies and procedures, which prohibit neglect for one (Resident #7) of nine residents reviewed for falls. The facility failed to report an incident of neglect to DADS when CNA A failed to apply the personal safety alarm and/or provide supervision for Resident #7 which resulted in an unwitnessed fall. The fall resulted in a skin tear to the left elbow, laceration to the left eyebrow and an acute right mid partial subdural hematoma (brain bleed) measuring 10 mm in thickness and 6 cm in diameter. These failures could place the 50 residents identified by the facility who utilize personal safety alarms at risk for falls with injuries. Findings included: Review of the facility's current Abuse/Neglect Policy dated June 2009 reflected: The facility will prohibit abuse, neglect . for all residents though implementation of seven components: .D. Identification of possible incidents or allegations which need investigation .G. Reporting of incidents, investigations and facility response to the results of the investigation .Reporting and response: All allegations and substantiated occurrences of abuse, neglect are reported to the state agency Identification/Reporting .the Administrator/and or designee will document on the Providers Investigation Report when it meets the reportable incident guidelines, and fax to DHS LTC-R .methods of identification include incident reports. Review of the comprehensive MDS assessment for Resident #7, dated 04/25/16 , revealed she was a [AGE] year-old-female admitted to he facility on 04/12/16 with [DIAGNOSES REDACTED]. Resident #7 had severely impaired cognition and required extensive assistance of two staff members for transfers and was total dependent for locomotion. Review of the fall history revealed there had been no falls prior to admission or since admission to the facility. Review of the Interim plan of care dated 04/12/16 reflected Resident #7 had the potential for falls. One of the approaches was to assist the resident with transfers and mobility. Further review of the updated plan of care dated 04/19/16 reflected Resident #7 was at risk for falls, as she was unaware of safety needs, confusion, wandering and gait/balance problems. One of the interventions was a pressure sensitive alarm at all times. Review of the Incident Report dated 04/16/16 revealed Resident #7 was on the floor in her room. Resident #7 was lying face down on the floor, the assessment revealed a skin tear to the left elbow, a laceration above the left eyebrow, and complaining of shoulder pain. The resident was asked how that happened and the reply was I don't know. Resident #7 was assessed, and transferred to the hospital. The physician, family and the DON was notified. Review of the Hospital History and Physical dated 04/16/16 reflected Resident #7 was admitted for continuums monitoring of her acute subdural hematoma. Further review reflected a review of systems was negative, except for ongoing recurrent falls Review of the Computed Tomography (CT) scan of Resident #7's head dated 04/16/16 reflected a 1 cm by 6 cm acute right mid partial subdural hematoma. Review of the nurse's notes dated 04/16/16 revealed Resident #7 was on the floor. Upon entering the room the resident was lying face down on her stomach. The resident was assessed for any injuries and noted a minor skin tear to left elbow, laceration above left eyebrow, and complaining of shoulder pain. The nurse notified the physician, family and transferred the resident to the emergency room . Review of the nurse's note dated 04/17/16 revealed Resident #7 remained hospitalized for [REDACTED]. Review of the nurse's notes dated 04/17/16 revealed Resident #7 returned to the facility. Resident #7 was admitted to Hospice services for comfort care Residents laceration above her left eyebrow was glued at hospital and had five steri-strips, measuring at 1.2 cm. Resident was diagnosed with [REDACTED]. Review of in-services dated 04/20/16 regarding Fall/Alarm education revealed if a resident has an alarm it needed to be on at all times. Transfer alarms between chair and bed. Ensure alarms were functioning. An interview on 05/11/16 at 1:00 p.m. with the DON reveaeld she was aware of Resident #7's fall. The facility had called me and she had the CNA in-serviced concerning the appropriate use of the personal safety alarms. The DON said the CNA was disciplined and a follow-up in-service concerning persoanl safety alarms was completed 04/20/16, for staff working on the hall. An interview on 05/11/16 at 2:21 p.m. with CNA A revealed Resident #7 was a two person transfer with a gait belt. The resident could bear weight when she stood up. CNA A said the morning Resident #7 fell she had gone into the room and gotten Resident #7 up, by herself. CNA A said she was in a hurry because she was running behind with her duties. CNA A said she sat the resident in a wheelchair with her bed side table and her breakfast; CNA A left the room without placing and turning on the personal safety alarm. CNA A said it was about 30 to 45 minutes later she found out Resident #7 had fallen. CNA A said it was the CNAs responsibility to make sure the personal safety alarm was on and in place. An interview on 05/11/16 at 9:45 a.m. with LVN B revealed Resident #7 walked with a walker. LVN B said Resident #7 scared her because she was very unsteady with the walker. LVN B said after the fall Resident #7 was on Hospice services transferred with a Hoyer Lift and placed in a Geri-chair. An interview on 05/11/16 at 3:15 p.m. with LVN C revealed she was the nurse that had admitted Resident #7. LVN C said Resident #7 was a pleasant, but confused resident who walked with a walker. LVN C said the daughter reported to her, that her mom had given her walker a name and she was never to be without the walker. The daughter told LVN C Resident #7 was unsteady at times with the walker and had fallen at home, because she would go off and forget her walker. LVN C said Resident #7 was unsteady on her feet and the staff had tried to keep her sitting near the nurse ' s station. LVN C said Resident #7 would wander around looking for her daughter, and that is why the resident had a personal safety alarm, so the staff would just know when she got up. An interview on 05/11/16 at 3:30 p.m. with the Administrator and the DON revealed the DON had been called and told concerning the fall on 04/16/16. When the DON was made aware of the diagnosis, she called and spoke to the facility's consultant concerning reporting the incident. The DON was told not to report the incident. The DON said she should have gone with my gut and reported it anyway, because she was the person responsible for investigating and reporting. The DON said it was the nurses responsibility to document on the MARs if the personal safety alarms were working, but the CNAs were the staff that where made aware of what interventions to use. The Administrator said he was the abuse coordinator in the building and he understood the concerns of not reporting that incident. Review of the MARs dated 05/01/16 revealed Resident #7 had a personal safety alarm initiated on 04/12/16 to bed and wheelchair to alert the staff. A list provided by the DON on 04/12/16 identified 50 residents in the facility that utilized Personal safety alarms.

Based on interview and record review, the facility failed to ensure each resident received adequate assistive devices to prevent accidents for one (Resident #7) of eight residents reviewed for falls. CNA A failed to provide proper level of supervision by not placing the personal safety alarm on Resident #7 on 04/16/16 resulting in the resident being injured, with a laceration to the left eyebrow area and acute right mid partial subdural Hematoma (brain bleed.) This failure could affect the facility's 50 residents, who had personal safety alarms, placing them at risk for falls, lacerations, fractures and the need for hospitalization . Findings included: Review of Incident Report dated 04/15/16 revealed Resident #7 had fallen while using her walker with staff in the room. No injuries were assessed. Resident #7 was to be assessed by therapy due to losing balance while using walker and the resident already had a pressure sensitive alarm for bed and chair. Review of the Incident Report dated 04/16/16 revealed Resident #7 was on the floor in her room. Resident #7 was lying face down on the floor; the assessment revealed a skin tear to the left elbow, a laceration above the left eyebrow, and complaining of shoulder pain. The resident was asked how that happened and the reply was I don't know. Resident #7 was assessed, and transferred to the hospital. The physician, family and the DON was notified. Review of the comprehensive MDS assessment for Resident #7, dated 04/25/16, revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7 had severely impaired cognition and required extensive assistance of two staff members for transfers and was total dependent for locomotion. Review of the fall history revealed there had been no falls prior to admission or since admission to the facility. Review of the MARs dated 05/01/16 revealed Resident #7 had a personal safety alarm initiated on 04/12/16 to bed and wheelchair to alert the staff. Review of the Interim plan of care dated 04/12/16 reflected Resident #7 had the potential for falls. One of the approaches was to assist the resident with transfers and mobility. Further review of the updated plan of care dated 04/19/16 (no update for 04/15/16 incident /fall) reflected Resident #7 was at risk for falls, as she was unaware of safety needs, confusion, wandering and gait/balance problems and using was a pressure sensitive alarm at all times. Review of the Hospital History and Physical dated 04/16/16 reflected Resident #7 was admitted for continuums monitoring of her acute subdural hematoma. Review of the Computed Tomography (CT) scan of Resident #7's head dated 04/16/16 reflected a 1 cm by 6 cm acute right mid partial subdural hematoma. An interview on 05/11/16 at 1:20 p.m. with the Director of Therapy revealed the therapy department was not aware Resident #7 was unsteady when using her walker, until she fell . The DOT said the department was unable to assess Resident #7 when she came back from the hospital because she was on Hospice services. The DOT said Resident #7 was not assessed on 04/15/16 and then fell on [DATE] and went to the hospital. Review of the nurse's notes dated 04/16/16 revealed Resident #7 was on the floor. Upon entering the room the resident was lying face down on her stomach. The resident was assessed for any injuries and noted a minor skin tear to left elbow, laceration above left eyebrow, and complaining of shoulder pain. The nurse notified the physician, family and transferred the resident to the emergency room . Review of the nurse's notes dated 04/17/16 revealed Resident #7 returned to the facility. Resident #7 was admitted to Hospice services for comfort care Residents laceration above her left eyebrow was glued at hospital and had five steri-strips, measuring at 1.2 cm. Resident was diagnosed with [REDACTED]. Review of the in-service dated 04/20/16regrading Fall/Alarm education revealed, if a resident had an alarm it needed to be on at all times. Transfer alarms between chair and bed. Ensure alarms were functioning. Review of the Fall Risk Evaluation dated 04/12/16 revealed a score of nine placing Resident #7 as a low risk for falls. Further review revealed a Fall Risk assessment dated [DATE], a score of 13 placing Resident #7 as a high risk for falls. An interview on 05/11/16 at 2:21 p.m. with CNA A revealed Resident #7 was a two person transfer with a gait belt. The resident could bear weight when she stood up. CNA A said the morning Resident #7 fell she had gone into the room and gotten Resident #7 up, by herself. CNA A said she was in a hurry because she was running behind with her duties. CNA A said she sat the resident in a wheelchair with her bed side table and her breakfast; CNA A left the room without placing and turning on the personal safety alarm. CNA A said it was about 30 to 45 minutes later she found out Resident #7 had fallen. CNA A said it was the CNAs responsibility to make sure the personal safety alarm was on and in place. An interview on 05/11/16 at 9:45 a.m. with LVN B revealed Resident #7 walked with a walker since admission on 04/12/16. LVN B said Resident #7 scared her because she was very unsteady with the walker. LVN B said she had not thought to report this to therapy and have Resident #7 assessed, LVN B said the staff tried to monitor the resident and keep her safe. LVN B said after the fall Resident #7 was on Hospice services transferred with a Hoyer Lift and placed in a Geri-chair. An interview on 05/11/16 at 1:00 p.m. with the DON revealed she was aware of the fall that Resident #7 had. The DON said she had one of the nurses in-service the CNA in-serviced concerning the appropriate use of the personal safety alarms. The DON said the CNA was disciplined and a follow-up in-service concerning personal safety alarms was completed on 04/20/16, for other staff working on the hall. Review of the In-service Training Report dated 04/16/16 revealed CNA A was in-serviced concerning the use of the chair/bed alarms. CNA A was in-serviced concerning always turning on the alarm and assuring that the alarm worked. An interview on 05/11/16 at 2:23 p.m. with MA D revealed MA D was not aware Resident #7 had a previous fall. MA D said she was passing medications on the hall the morning Resident #7 fell . MA D said she was just in the room for a few moments, asked if they required any assistance, but then went on passing morning medications. MA D said the resident was lying in the floor face down when she was in the room. An interview on 05/11/6 at 2:30 p.m. with CNA E revealed she had been walking past Resident #7's room when she saw her on the floor. CNA E said she went and told MA D to get help and stayed with Resident #7. CNA E said Resident #7 was lying on her stomach bleeding from her head. CNA E said Resident #7 was not responsive, but she was breathing. CNA E said Resident #7 had a personal safety alarm, but she did not hear it. CNA E said Resident #7 used a walker, was very unsteady and the staff tried to keep her sitting in a wheelchair. An interview on 05/11/16 at 3:15 p.m. with LVN C revealed she was the nurse that had admitted Resident #7. LVN C said Resident #7 was a pleasant, but confused resident who walked with a walker. LVN C said the daughter reported to her, that her mom had given her walker a name and she was never to be without the walker. The daughter told LVN C Resident #7 was unsteady at times with the walker and had fallen at home, because she would go off and forget her walker. LVN C said Resident #7 was unsteady on her feet and the staff had tried to keep her sitting near the nurse's station. LVN C said Resident #7 would wander around looking for her daughter, and that is why the resident had a personal safety alarm, so the staff would just know when she got up. Review of the Fall Management Policy Procedure dated December 2005 revealed: Policy: The facility will identify each patient who is a risk for falls and will plan care to manage falls by providing a safe and hazard free environment. Procedure: identify preventive interventions and record in the patient's plan of care Review of the Fall Prevention Program dated January 2016 revealed: .4. Implement preventative measures . including alarms . A list provided by the DON on 04/12/16, revealed a census of 102 residents, and 50 residents that utilized personal safety alarms.

Based on observation, interview and record review, it was determined the facility failed to implement policies and procedures, which prohibit neglect for one (Resident #1) of five residents reviewed for neglect who required the use of a mechanical lift for transfers. LVN A and CNA B failed to transfer Resident #1 with a mechanical lift multiple times, including on 08/21/15, which resulted in the resident being injured and receiving 35 staples to her left leg from a laceration. LVN A and CNA B failed to transfer Resident #1 with a mechanical lift as care planned. This failure could affect the facility's 14 residents, who required the use of a mechanical lift for transfers and placed them at risk for falling, lacerations, fractures and the need for hospitalization . Findings included: Review of Resident #1's MDS assessment, dated 08/16/15, revealed she was an [AGE] year-old female who was readmitted to the facility on [DATE], [DIAGNOSES REDACTED]. The MDS reflected Resident #1's Brief Interview for Mental Status score was eight which indicated she was moderately impaired. Resident #1 was totally dependent on two or more persons for physical assist with transfers, and had impairment on one side of her lower extremity (hip, knee, ankle, foot). The resident used a wheelchair (manual or electric) for mobility. Review of Resident #1's comprehensive care plan, dated 08/06/15, revealed .The resident has an ADL (Activities of Daily Living) Self-Care Performance Deficit Transfer: The resident requires (total) staff participation with transfers. mechanical lift with assist of 2 . Review of Resident #1's Injury Report, revised on 08/25/15, revealed the following: . Person Preparing Report: (ADON D) . Incident Description Nursing Description: While transferring resident from chair to bed residents (sic) left leg received a laceration from the grab bar connected to the side of bed Resident Description: I guess I scraped it. I was getting into the bed, standing up and I hit my leg. Immediate Action Taken Description: Edges approximated and pressure bandage applied to stop bleeding. sent to (hospital) for evaluation . Review of the facility's Provider Investigation Report pertaining to Resident #1, dated 08/24/15, revealed . On 08/21/15 at 1350 (1:50 p.m.) (LVN A) and (CNA B) transferred the resident from her wheelchair to her bed. She sustained a laceration to her left lower leg measuring approximately 14 cm (centimeters) x (by) 8 cm. She was subsequently sent to the emergency room for evaluation where they repaired the laceration with staples Laceration to left lower leg measuring 14 cm x 8 cm, requiring 35 staples Training was provided to nursing staff regarding how the resident was to be transferred and on how to access information regarding transfers via the Care Binders that are on every unit Per (LVN A) and (CNA B)'s statements they transferred the resident using 2 assist. The resident is to be transferred via mechanical lift per the care binder (kardex) and her care plan. Both employees state they were aware of how she transferred with a mechanical lift but the resident requested to stand up from the chair (LVN A) and (CNA B) have received in-services on transfers and use of the care binders (LVN A) and (CNA B) were both reinstated and received counseling as well as training regarding the care binders, assist levels, transfer techniques and following facility policy. Transfer training was initiated with nursing staff and will continue with the Therapy Department completing a transfer training on 09/10/2015 at the monthly in-service Review of Resident #1's Nurses Notes revealed . 08/21/2015 14:30 (2:30 p.m.) . called to resident's room, assessed left leg laceration approximately 14 x (by) 8cm (centimeters) (sic), moderate amount of blood on floor and on sheet as well as some skin tissue on sheet. sent to (hospital) for possible stitches (emergency medical transportation) transferred resident at 1445 (2:45 p.m.) Author: (DON) . 08/21/2015 15:58 (3:58 p.m.) . resident returning with 35 staples to laceration as well as dissolvable internal sutures Author: (DON) . 08/21/2015 21:27 (9:27 p.m.) . Resident returned from (hospital) @ (at) 1700 (5:00 p.m.) with 35 staples to left leg r/t (related to) skin tear . Author: (LVN E) . Observation on 09/04/15 at 10:51 a.m. with the Treatment Nurse and ADON D revealed Resident #1's wound to her leg measured 19 cm in length and was half-moon shaped. The resident had staples covering the length of the wound, as well as light bruising. Observation on 09/04/15 at 11:09 a.m. revealed no concerns regarding Resident #1's mechanical lift transfer from her bed to her wheelchair. Interview on 09/04/15 at 9:41 a.m. with Resident #1, who the facility identified as interviewable, revealed staff had helped her stand to transfer from her bed to her wheelchair and then from her wheelchair to her bed. She stated her leg was injured as she was transferring back to her bed from her wheelchair. Resident #1 further stated a staff member was helping her stand and as she turned to sit down on the bed her leg bumped into the grab bar attached to the bed. She then stated she immediately sat down on the bed. Interview on 09/04/15 at 9:35 a.m. with the DON revealed Resident #1 had to be transferred using a mechanical lift. She stated Resident #1 had asked CNA B if she could stand up to transfer on the day of the incident. She then stated CNA B and LVN A transferred the resident to and from her bed without using the mechanical lift. She stated the resident received a skin tear from the assist bar that was attached to her bed and folded down at the time as she was transferring back to her bed. The DON stated Resident #1 was a larger person and had swollen legs which made her skin fragile. She further stated LVN A and CNA B both made a poor decision to transfer the resident without a mechanical lift. Interview on 09/04/15 at 9:49 a.m. with LVN A revealed CNA B had asked him to help transfer Resident #1 from her bed to her wheelchair on 08/21/15. LVN A stated Resident #1 required a mechanical lift for transfers. He then stated Resident #1 had finished therapy services and did not want to lose the use of her legs. He stated the Resident constantly asked him to help her stand to transfer. He further stated he had been helping the resident stand to transfer with the help of a CNA who was on duty three to four times a week for about two months prior to the incident on 08/21/15. LVN A then stated he and CNA B helped Resident #1 stand to transfer without incident from her bed to her wheelchair on the day of the incident. He stated the resident's injury occurred when she was transferred back to her bed from her wheelchair. He then stated he was standing with the resident facing him and had one leg between the resident's legs. LVN A further stated the resident's leg was next to the grab bar on her bed when she turned. He stated the resident screamed out, but he was already in the process of moving her, so she was placed on the bed. He then stated he applied pressure to the resident's wound and sent CNA B for help. He stated first aid was provided to the resident and she was then transported to the hospital. He further stated he was suspended pending the investigation and subsequently returned to work. Interview on 09/04/15 at 10:06 a.m. with CNA B revealed Resident #1 asked her to get LVN A so that she could stand to transfer on 08/21/15. CNA B then stated she and LVN A helped Resident #1 stand to transfer without incident from her bed to her wheelchair on 08/21/15. CNA B stated she and LVN A helped the resident stand to transfer back to her bed from her wheelchair and in the course of the transfer the resident's leg got caught on the grab bar that was attached to the bed. She stated at the time of the incident, she held the wheelchair while LVN A helped Resident #1 stand to transfer. CNA B stated there had been no other times that she had transferred Resident #1 without a mechanical lift. CNA B further stated she had never transferred other residents outside of their care plan guidelines. She then stated she was suspended pending the investigation and subsequently returned to work. Interview on 09/04/15 at 12:33 p.m. with CNA B revealed she knew Resident #1 required a mechanical lift for her transfers, but the resident was insistent that she stand to transfer on 08/21/15 and LVN A was okay with it. Interview on 09/04/15 at 12:38 p.m. with CNA C revealed Resident #1 was adamant about getting stronger and not losing the abilities in her legs. CNA C stated she and LVN A had tried about a month ago to transfer Resident #1 without a mechanical lift, but the Resident was unable to bear enough weight and it was a no-go. Interview on 09/04/15 at 12:57 p.m. with the DON revealed she was unaware of any other times that Resident #1 had been transferred without the mechanical lift. She stated she watched Resident #1 very closely and never recalled seeing the resident without a mechanical lift sling while up in her wheelchair. During an interview on 09/04/15 at 1:10 p.m. with the DON and LVN A, LVN A confirmed he had transferred Resident #1 in the two months prior to the incident on 08/21/15. He stated he transferred the resident, without the mechanical lift, three to four times a week during that time. Interview on 09/04/15 at 1:21 p.m. with the DON revealed she was not aware of any other times that Resident #1 or any other resident in the facility had been transferred inappropriately. Review of the facility's Abuse Prevention Policy, dated June 2009, revealed .The facility will prohibit abuse, neglect . The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect . for all patients, and to treat all patients at the facility with dignity and respect at all times Neglect Failure to provide goods and services necessary to avoid harm, mental anguish or mental illness Review of the facility's in-services, provided on 09/04/15, regarding the incident with Resident #1 revealed the following: Transfers (Follow care plan and care binder for transfer and assist information. If a resident transfers mechanical lift, you must transfer via lift. No exceptions.) was discussed on 08/21/15. Transfers for (Resident #1) ((Resident #1) must transfer via mechanical lift with two staff assisting her. No exceptions.) was discussed on 08/21/15. Transfers (Care binder, assist levels, transfer techniques and following (facility) policy regarding transfers) were discussed on 08/24/15. Review of the facility's in-services, provided on 09/11/15, regarding the incident with Resident #1 revealed the following: Transfers (pivot transfer with gait belt and mechanical lifts - Pivot transfer with gait belts (one - two to assist) with return demonstration, mechanical lift transfers, care binders to determine transfer status, what to do if a resident becomes weak during a transfer and when does a resident qualify for mechanical lift use) was discussed on 09/10/15. Review of the resident (room) roster, dated 09/03/15 and provided on 09/04/15, revealed the facility identified 14 residents who required transfers with a mechanical lift.

Based on observation, interview and record review, it was determined the facility failed to implement written policies and procedures, which prohibit neglect for one (Resident #1) of five residents reviewed for neglect who required the use of a mechanical lift for transfers. LVN A and CNA B failed to transfer Resident #1 with a mechanical lift multiple times, including on 08/21/15, which resulted in the resident being injured and receiving 35 staples to her left leg from a laceration. LVN A and CNA B failed to transfer Resident #1 with a mechanical lift as care planned. This failure could affect the facility's 14 residents, who required the use of a mechanical lift for transfers and placed them at risk for falling, lacerations, fractures and the need for hospitalization . Findings included: Review of the facility's Abuse Prevention Policy, dated June 2009, revealed .The facility will prohibit abuse, neglect . The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect . for all patients, and to treat all patients at the facility with dignity and respect at all times Neglect Failure to provide goods and services necessary to avoid harm, mental anguish or mental illness Review of Resident #1's MDS assessment, dated 08/16/15, revealed she was an [AGE] year-old female who was readmitted to the facility on [DATE], [DIAGNOSES REDACTED]. The MDS reflected Resident #1's Brief Interview for Mental Status score was eight which indicated she was moderately impaired. Resident #1 was totally dependent on two or more persons for physical assist with transfers, and had impairment on one side of her lower extremity (hip, knee, ankle, foot). The resident used a wheelchair (manual or electric) for mobility. Review of Resident #1's comprehensive care plan, dated 08/06/15, revealed .The resident has an ADL (Activities of Daily Living) Self-Care Performance Deficit Transfer: The resident requires (total) staff participation with transfers. mechanical lift with assist of 2 . Review of Resident #1's Injury Report, revised on 08/25/15, revealed the following: . Person Preparing Report: (ADON D) . Incident Description Nursing Description: While transferring resident from chair to bed residents (sic) left leg received a laceration from the grab bar connected to the side of bed Resident Description: I guess I scraped it. I was getting into the bed, standing up and I hit my leg. Immediate Action Taken Description: Edges approximated and pressure bandage applied to stop bleeding. sent to (hospital) for evaluation . Review of the facility's Provider Investigation Report pertaining to Resident #1, dated 08/24/15, revealed . On 08/21/15 at 1350 (1:50 p.m.) (LVN A) and (CNA B) transferred the resident from her wheelchair to her bed. She sustained a laceration to her left lower leg measuring approximately 14 cm (centimeters) x (by) 8 cm. She was subsequently sent to the emergency room for evaluation where they repaired the laceration with staples Laceration to left lower leg measuring 14 cm x 8 cm, requiring 35 staples Training was provided to nursing staff regarding how the resident was to be transferred and on how to access information regarding transfers via the Care Binders that are on every unit Per (LVN A) and (CNA B)'s statements they transferred the resident using 2 assist. The resident is to be transferred via mechanical lift per the care binder (kardex) and her care plan. Both employees state they were aware of how she transferred with a mechanical lift but the resident requested to stand up from the chair (LVN A) and (CNA B) have received in-services on transfers and use of the care binders (LVN A) and (CNA B) were both reinstated and received counseling as well as training regarding the care binders, assist levels, transfer techniques and following facility policy. Transfer training was initiated with nursing staff and will continue with the Therapy Department completing a transfer training on 09/10/2015 at the monthly in-service Review of Resident #1's Nurses Notes revealed . 08/21/2015 14:30 (2:30 p.m.) . called to resident's room, assessed left leg laceration approximately 14 x (by) 8cm (centimeters) (sic), moderate amount of blood on floor and on sheet as well as some skin tissue on sheet. sent to (hospital) for possible stitches (emergency medical transportation) transferred resident at 1445 (2:45 p.m.) Author: (DON) . 08/21/2015 15:58 (3:58 p.m.) . resident returning with 35 staples to laceration as well as dissolvable internal sutures Author: (DON) . 08/21/2015 21:27 (9:27 p.m.) . Resident returned from (hospital) @ (at) 1700 (5:00 p.m.) with 35 staples to left leg r/t (related to) skin tear . Author: (LVN E) . Observation on 09/04/15 at 10:51 a.m. with the Treatment Nurse and ADON D revealed Resident #1's wound to her leg measured 19 cm in length and was half-moon shaped. The resident had staples covering the length of the wound, as well as light bruising. Observation on 09/04/15 at 11:09 a.m. revealed no concerns regarding Resident #1's mechanical lift transfer from her bed to her wheelchair. Interview on 09/04/15 at 9:41 a.m. with Resident #1, who the facility identified as interviewable, revealed staff had helped her stand to transfer from her bed to her wheelchair and then from her wheelchair to her bed. She stated her leg was injured as she was transferring back to her bed from her wheelchair. Resident #1 further stated a staff member was helping her stand and as she turned to sit down on the bed her leg bumped into the grab bar attached to the bed. She then stated she immediately sat down on the bed. Interview on 09/04/15 at 9:35 a.m. with the DON revealed Resident #1 had to be transferred using a mechanical lift. She stated Resident #1 had asked CNA B if she could stand up to transfer on the day of the incident. She then stated CNA B and LVN A transferred the resident to and from her bed without using the mechanical lift. She stated the resident received a skin tear from the assist bar that was attached to her bed and folded down at the time as she was transferring back to her bed. The DON stated Resident #1 was a larger person and had swollen legs which made her skin fragile. She further stated LVN A and CNA B both made a poor decision to transfer the resident without a mechanical lift. Interview on 09/04/15 at 9:49 a.m. with LVN A revealed CNA B had asked him to help transfer Resident #1 from her bed to her wheelchair on 08/21/15. LVN A stated Resident #1 required a mechanical lift for transfers. He then stated Resident #1 had finished therapy services and did not want to lose the use of her legs. He stated the Resident constantly asked him to help her stand to transfer. He further stated he had been helping the resident stand to transfer with the help of a CNA who was on duty three to four times a week for about two months prior to the incident on 08/21/15. LVN A then stated he and CNA B helped Resident #1 stand to transfer without incident from her bed to her wheelchair on the day of the incident. He stated the resident's injury occurred when she was transferred back to her bed from her wheelchair. He then stated he was standing with the resident facing him and had one leg between the resident's legs. LVN A further stated the resident's leg was next to the grab bar on her bed when she turned. He stated the resident screamed out, but he was already in the process of moving her, so she was placed on the bed. He then stated he applied pressure to the resident's wound and sent CNA B for help. He stated first aid was provided to the resident and she was then transported to the hospital. He further stated he was suspended pending the investigation and subsequently returned to work. Interview on 09/04/15 at 10:06 a.m. with CNA B revealed Resident #1 asked her to get LVN A so that she could stand to transfer on 08/21/15. CNA B then stated she and LVN A helped Resident #1 stand to transfer without incident from her bed to her wheelchair on 08/21/15. CNA B stated she and LVN A helped the resident stand to transfer back to her bed from her wheelchair and in the course of the transfer the resident's leg got caught on the grab bar that was attached to the bed. She stated at the time of the incident, she held the wheelchair while LVN A helped Resident #1 stand to transfer. CNA B stated there had been no other times that she had transferred Resident #1 without a mechanical lift. CNA B further stated she had never transferred other residents outside of their care plan guidelines. She then stated she was suspended pending the investigation and subsequently returned to work. Interview on 09/04/15 at 12:33 p.m. with CNA B revealed she knew Resident #1 required a mechanical lift for her transfers, but the resident was insistent that she stand to transfer on 08/21/15 and LVN A was okay with it. Interview on 09/04/15 at 12:38 p.m. with CNA C revealed Resident #1 was adamant about getting stronger and not losing the abilities in her legs. CNA C stated she and LVN A had tried about a month ago to transfer Resident #1 without a mechanical lift, but the Resident was unable to bear enough weight and it was a no-go. Interview on 09/04/15 at 12:57 p.m. with the DON revealed she was unaware of any other times that Resident #1 had been transferred without the mechanical lift. She stated she watched Resident #1 very closely and never recalled seeing the resident without a mechanical lift sling while up in her wheelchair. During an interview on 09/04/15 at 1:10 p.m. with the DON and LVN A, LVN A confirmed he had transferred Resident #1 in the two months prior to the incident on 08/21/15. He stated he transferred the resident, without the mechanical lift, three to four times a week during that time. Interview on 09/04/15 at 1:21 p.m. with the DON revealed she was not aware of any other times that Resident #1 or any other resident in the facility had been transferred inappropriately. Review of the facility's Abuse Prevention Policy, dated June 2009, revealed .The facility will prohibit abuse, neglect . The purpose of this policy is to ensure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect . for all patients, and to treat all patients at the facility with dignity and respect at all times Neglect Failure to provide goods and services necessary to avoid harm, mental anguish or mental illness Review of the facility's in-services, provided on 09/04/15, regarding the incident with Resident #1 revealed the following: Transfers (Follow care plan and care binder for transfer and assist information. If a resident transfers mechanical lift, you must transfer via lift. No exceptions.) was discussed on 08/21/15. Transfers for (Resident #1) ((Resident #1) must transfer via mechanical lift with two staff assisting her. No exceptions.) was discussed on 08/21/15. Transfers (Care binder, assist levels, transfer techniques and following (facility) policy regarding transfers) were discussed on 08/24/15. Review of the facility's in-services, provided on 09/11/15, regarding the incident with Resident #1 revealed the following: Transfers (pivot transfer with gait belt and mechanical lifts - Pivot transfer with gait belts (one - two to assist) with return demonstration, mechanical lift transfers, care binders to determine transfer status, what to do if a resident becomes weak during a transfer and when does a resident qualify for mechanical lift use) was discussed on 09/10/15. Review of the resident (room) roster, dated 09/03/15 and provided on 09/04/15, revealed the facility identified 14 residents who required transfers with a mechanical lift.

Based on observation, interview and record review, it was determined the facility failed to ensure each resident received adequate assistance devices to prevent accidents for one (Resident #1) of five residents reviewed who required a mechanical lift for transfers. LVN A and CNA B failed to transfer Resident #1 with a mechanical lift multiple times, including on 08/21/15, which resulted in the resident being injured and receiving 35 staples to her left leg from a laceration. LVN A and CNA B failed to transfer Resident #1 with a mechanical lift as care planned. This failure could affect the facility's 14 residents, who required the use of a mechanical lift for transfers and placed them at risk for falling, lacerations, fractures and the need for hospitalization . Findings included: Review of Resident #1's MDS assessment, dated 08/16/15, revealed she was an [AGE] year-old female who was readmitted to the facility on [DATE], [DIAGNOSES REDACTED]. The MDS reflected Resident #1's Brief Interview for Mental Status score was eight which indicated she was moderately impaired. Resident #1 was totally dependent on two or more persons for physical assist with transfers, and had impairment on one side of her lower extremity (hip, knee, ankle, foot). The resident used a wheelchair (manual or electric) for mobility. Review of Resident #1's comprehensive care plan, dated 08/06/15, revealed .The resident has an ADL (Activities of Daily Living) Self-Care Performance Deficit Transfer: The resident requires (total) staff participation with transfers. mechanical lift with assist of 2 . Review of Resident #1's Injury Report, revised on 08/25/15, revealed the following: . Person Preparing Report: (ADON D) . Incident Description Nursing Description: While transferring resident from chair to bed residents (sic) left leg received a laceration from the grab bar connected to the side of bed Resident Description: I guess I scraped it. I was getting into the bed, standing up and I hit my leg. Immediate Action Taken Description: Edges approximated and pressure bandage applied to stop bleeding. sent to (hospital) for evaluation . Review of the facility's Provider Investigation Report pertaining to Resident #1, dated 08/24/15, revealed . On 08/21/15 at 1350 (1:50 p.m.) (LVN A) and (CNA B) transferred the resident from her wheelchair to her bed. She sustained a laceration to her left lower leg measuring approximately 14 cm (centimeters) x (by) 8 cm. She was subsequently sent to the emergency room for evaluation where they repaired the laceration with staples Laceration to left lower leg measuring 14 cm x 8 cm, requiring 35 staples Training was provided to nursing staff regarding how the resident was to be transferred and on how to access information regarding transfers via the Care Binders that are on every unit Per (LVN A) and (CNA B)'s statements they transferred the resident using 2 assist. The resident is to be transferred via mechanical lift per the care binder (kardex) and her care plan. Both employees state they were aware of how she transferred with a mechanical lift but the resident requested to stand up from the chair (LVN A) and (CNA B) have received in-services on transfers and use of the care binders (LVN A) and (CNA B) were both reinstated and received counseling as well as training regarding the care binders, assist levels, transfer techniques and following facility policy. Transfer training was initiated with nursing staff and will continue with the Therapy Department completing a transfer training on 09/10/2015 at the monthly in-service Review of Resident #1's Nurses Notes revealed . 08/21/2015 14:30 (2:30 p.m.) . called to resident's room, assessed left leg laceration approximately 14 x (by) 8cm (centimeters) (sic), moderate amount of blood on floor and on sheet as well as some skin tissue on sheet. sent to (hospital) for possible stitches (emergency medical transportation) transferred resident at 1445 (2:45 p.m.) Author: (DON) . 08/21/2015 15:58 (3:58 p.m.) . resident returning with 35 staples to laceration as well as dissolvable internal sutures Author: (DON) . 08/21/2015 21:27 (9:27 p.m.) . Resident returned from (hospital) @ (at) 1700 (5:00 p.m.) with 35 staples to left leg r/t (related to) skin tear . Author: (LVN E) . Observation on 09/04/15 at 10:51 a.m. with the Treatment Nurse and ADON D revealed Resident #1's wound to her leg measured 19 cm in length and was half-moon shaped. The resident had staples covering the length of the wound, as well as light bruising. Observation on 09/04/15 at 11:09 a.m. revealed no concerns regarding Resident #1's mechanical lift transfer from her bed to her wheelchair. Interview on 09/04/15 at 9:41 a.m. with Resident #1, who the facility identified as interviewable, revealed staff had helped her stand to transfer from her bed to her wheelchair and then from her wheelchair to her bed. She stated her leg was injured as she was transferring back to her bed from her wheelchair. Resident #1 further stated a staff member was helping her stand and as she turned to sit down on the bed her leg bumped into the grab bar attached to the bed. She then stated she immediately sat down on the bed. Interview on 09/04/15 at 9:35 a.m. with the DON revealed Resident #1 had to be transferred using a mechanical lift. She stated Resident #1 had asked CNA B if she could stand up to transfer on the day of the incident. She then stated CNA B and LVN A transferred the resident to and from her bed without using the mechanical lift. She stated the resident received a skin tear from the assist bar that was attached to her bed and folded down at the time as she was transferring back to her bed. The DON stated Resident #1 was a larger person and had swollen legs which made her skin fragile. She further stated LVN A and CNA B both made a poor decision to transfer the resident without a mechanical lift. Interview on 09/04/15 at 9:49 a.m. with LVN A revealed CNA B had asked him to help transfer Resident #1 from her bed to her wheelchair on 08/21/15. LVN A stated Resident #1 required a mechanical lift for transfers. He then stated Resident #1 had finished therapy services and did not want to lose the use of her legs. He stated the Resident constantly asked him to help her stand to transfer. He further stated he had been helping the resident stand to transfer with the help of a CNA who was on duty three to four times a week for about two months prior to the incident on 08/21/15. LVN A then stated he and CNA B helped Resident #1 stand to transfer without incident from her bed to her wheelchair on the day of the incident. He stated the resident's injury occurred when she was transferred back to her bed from her wheelchair. He then stated he was standing with the resident facing him and had one leg between the resident's legs. LVN A further stated the resident's leg was next to the grab bar on her bed when she turned. He stated the resident screamed out, but he was already in the process of moving her, so she was placed on the bed. He then stated he applied pressure to the resident's wound and sent CNA B for help. He stated first aid was provided to the resident and she was then transported to the hospital. He further stated he was suspended pending the investigation and subsequently returned to work. Interview on 09/04/15 at 10:06 a.m. with CNA B revealed Resident #1 asked her to get LVN A so that she could stand to transfer on 08/21/15. CNA B then stated she and LVN A helped Resident #1 stand to transfer without incident from her bed to her wheelchair on 08/21/15. CNA B stated she and LVN A helped the resident stand to transfer back to her bed from her wheelchair and in the course of the transfer the resident's leg got caught on the grab bar that was attached to the bed. She stated at the time of the incident, she held the wheelchair while LVN A helped Resident #1 stand to transfer. CNA B stated there had been no other times that she had transferred Resident #1 without a mechanical lift. CNA B further stated she had never transferred other residents outside of their care plan guidelines. She then stated she was suspended pending the investigation and subsequently returned to work. Interview on 09/04/15 at 12:33 p.m. with CNA B revealed she knew Resident #1 required a mechanical lift for her transfers, but the resident was insistent that she stand to transfer on 08/21/15 and LVN A was okay with it. Interview on 09/04/15 at 12:38 p.m. with CNA C revealed Resident #1 was adamant about getting stronger and not losing the abilities in her legs. CNA C stated she and LVN A had tried about a month ago to transfer Resident #1 without a mechanical lift, but the Resident was unable to bear enough weight and it was a no-go. Interview on 09/04/15 at 12:57 p.m. with the DON revealed she was unaware of any other times that Resident #1 had been transferred without the mechanical lift. She stated she watched Resident #1 very closely and never recalled seeing the resident without a mechanical lift sling while up in her wheelchair. During an interview on 09/04/15 at 1:10 p.m. with the DON and LVN A, LVN A confirmed he had transferred Resident #1 in the two months prior to the incident on 08/21/15. He stated he transferred the resident, without the mechanical lift, three to four times a week during that time. Interview on 09/04/15 at 1:21 p.m. with the DON revealed she was not aware of any other times that Resident #1 or any other resident in the facility had been transferred inappropriately. Review of the facility's in-services, provided on 09/04/15, regarding the incident with Resident #1 revealed the following: Transfers (Follow care plan and care binder for transfer and assist information. If a resident transfers mechanical lift, you must transfer via lift. No exceptions.) was discussed on 08/21/15. Transfers for (Resident #1) ((Resident #1) must transfer via mechanical lift with two staff assisting her. No exceptions.) was discussed on 08/21/15. Transfers (Care binder, assist levels, transfer techniques and following (facility) policy regarding transfers) were discussed on 08/24/15. Review of the facility's in-services, provided on 09/11/15, regarding the incident with Resident #1 revealed the following: Transfers (pivot transfer with gait belt and mechanical lifts - Pivot transfer with gait belts (one - two to assist) with return demonstration, mechanical lift transfers, care binders to determine transfer status, what to do if a resident becomes weak during a transfer and when does a resident qualify for mechanical lift use) was discussed on 09/10/15. Review of the resident (room) roster, dated 09/03/15 and provided on 09/04/15, revealed the facility identified 14 residents who required transfers with a mechanical lift.

Based on observation, interview and record review, it was determined the facility failed to ensure six (Residents #2, #6, #10, #11, #12 and #13) of 13 residents reviewed for falls received adequate supervision and/or services to prevent falls and accidents with injuries. 1. The facility failed to provide assistance for toileting to Resident #6 who was admitted to the facility with history of falls. Resident #6 fell and fractured her left shoulder. 2. The facility failed to assess Resident #12 in a timely manner for toileting assistance. The facility identified Resident #12 as a fall risk on 3/28/11, and failed to provide her with toileting assistance. 3. The facility failed to provide Resident #11 with toileting assistance. Resident #11 fell on [DATE] at 2:10 p.m. while transferring herself to the bathroom. Resident #11 was found on 05/17/11 at 1830 (6:30) p.m. on the floor, between her bed and her wheelchair, while transferring herself. 4. Resident #10 was removed from the "Falling Star Program" in March 2011 when she had her wheelchair alarm. Resident #10 fell on [DATE] and again on 05/11/11. Resident #10's fall on 04/22/11 resulted in a nose and facial fracture. 5. Resident #2 was removed from the "Falling Star Program" in March 2011. Interventions were not implemented according to the resident's care plan. The personal alarm was not provided until 05/12/11, the scoop mattress and the floor mat were not provided until 05/17/11. The resident sustained [REDACTED]. 6. Resident #13 was cognitively impaired, hard of hearing and blind. The resident sustained [REDACTED]. The resident's care plan was not revised with interventions in an attempt to prevent falls. These failures resulted in resident falls and injuries that produced pain, mental anguish, lacerations, bruises and fractures to Residents #2, #6, #10, #11, #12 and #13. These failures could affect the facility's forty-four (44) cognitively impaired residents and the twenty five (25) residents who were incontinent of bladder and bowel who might also require assistance with transfers. Findings included: 1) Resident #6 was observed during the initial rounds with LVN A on 05/16/11 at 9:17 a.m. LVN A stated Resident #6 was alert but confused, Resident #6 was incontinent of bowel and bladder. Resident #6 required total assistance with all her activity of daily living needs, she had an alarm and fed herself in the dining room area. LVN A stated Resident #6 fell three weeks ago in her room, sustaining a compound fracture to her left shoulder. Resident #6 was observed in her room watching television with an arm sling observed to her left shoulder area. Review of the physician orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the nurse's notes dated 05/06/11 at 3:45 p.m., revealed the nurse was called into Resident #6's room. On entry the nurse found Resident #6 on the floor by her bed with her walker next to her feet. The resident was also observed laying to her left side. The nurse's note reflected when the nurse questioned Resident #6 about the fall, the resident stated to the nurse, "I was going to the bathroom." The resident complained of pain with movement of her left hand. Review of the Incident/Accident (A/I) report dated 05/06/11 at 1545 (3.45) p.m. revealed Resident #6 was in her wheelchair in her room, she "got up with walker (stated she was going to bathroom)- Res found on floor on left side with walker at feet-Res assessed, neuron check within normal limit-handgrips R>L. Pupils ERTL (equal reactive to light) - MD office notified - Res c/o (complained of) (L) shoulder pain - Shoulder immobilized, X rays ordered." The A/I report reflected in column "(B) Charge nurse investigation-intervention after accident/incident:" that Resident #6, whom the facility had identified as confused, was encouraged to ask for help with transfers and toileting. The charge nurse also placed a personal alarm on Resident #6's wheelchair. The column "C" section of the A/I report dated 5/10/11 reflected the "DON/Nurse follow-up/change in care plan:" The DON stated in this report that Resident #6, "was self transferring at time of incident when she fell fractured her left arm per X ray to Orthopedic- sling on until next visit." The report further revealed "Resident #6 continues to be at risk for injury due to Dementia, no safety awareness, and alarm initiated." Review of the fall risk assessment dated [DATE] revealed a score of twelve (12). The assessment reflected a total score of 10 or above "represented HIGH RISK." A bowel and bladder evaluation dated 3/28/11 was reviewed. This assessment revealed Resident #6 had a total score of ten (10). The assessment revealed the following score categories: 0-6, 7-14, 15-18 and 19 or above. Resident #6 had the score of ten, placing her between the 7-14 score. The score that was between 7-14 revealed the resident required "prompted or schedule voiding program." The entire clinical records also revealed Resident #6 was not assessed for assistance to toileting and was not listed on the facility's list of residents on the B/BP. Review of the care plan dated 04/05/11 revealed Resident #6 was "at risk for falls related injury." The approaches identified for this problem were: 1) use fall risk screen to identify risk factors, "... provide / monitor use of adaptive devices: wheelchair. Remind resident and reinforce safety awareness; lock brakes on bed, chair, etc. before transferring." Review of the most recent Minimum Data Set assessment dated [DATE] revealed Resident #6 did not have a trial of a toileting program instituted. The X-ray report dated 5/6/11 reflected Resident #6 sustained a "comminuted slightly impacted fracture, left humeral head and neck." The report also reflected there were several small fragments seen superolaterally. The report reflected the fracture probably also extends to the margin of the articular surface of the humeral head. The report for the left humerus reflected "impacted transcervical fracture of the left humerus." Resident #6 was observed in bed on 05/17/11 at 2:45 p.m. The surveyor observed an alarm string on the bed. A thorough observation of the string revealed it was not clipped onto the resident. On arousal, Resident #6 complained of pain to her left shoulder. The surveyor inquired of Resident #6 what happened to her shoulder. Resident #6 stated she had called for assistance to the bathroom, and when she could not find help, she started to transfer herself to the bathroom and then fell . The surveyor interviewed CNA B on 05/17/11 at 3:00 p.m. The interview revealed Resident #6 could stand and ambulate depending on her mood. CNA B stated Resident #6 was also on the low/high bed before her fall, and it was after the fall that the facility placed a mat on the floor to cushion any falls. CNA B told the surveyor when Resident #6 fell , she found the resident on the floor, and she picked the resident up off the floor. CNA B further stated she observed the resident's adult briefs/pull ups down to her feet. CNA B stated after this incident, the facility placed an alarm on Resident #6. The DON was interviewed on 05/17/11 at 3:20 p.m. The interview revealed that all residents on fall risk were placed on the "Falling Star Program." The DON stated the falling star program was a program that identified residents at risk for falls, a yellow star was placed at the residents door, and on their wheelchairs and/or walking devices. The DON continued that if Resident #6 was identified as at risk on admission, she should have had the star on her door, a blue band (not sure if still used) and a star on her wheelchair. The DON stated that after a fall, a wheelchair alarm was placed, to ensure the falling star was on the door, and the resident should be placed on a bowel and bladder program. The surveyor informed the DON that the B/B program notebook on the floor was reviewed and Resident #6 was not listed on the program, and there was no voiding trials evaluation observed in her records. On the same day, at 4:00 p.m., the DON came back to the surveyor stating the facility had not assessed Resident #6 for the three-day B/B trial program. She however stated she would immediately initiate the assessment to ensure Resident #6 was assisted to the bathroom to prevent falls. 2) The surveyor observed Resident #11 during the initial rounds in her room on 05/16/11 at 9:28 a.m. LVN A on rounds stated Resident #11 was ambulatory (but not sure), incontinent of bowel and bladder, alert and confused, LVN A stated the resident required assistance with activities of daily living and was fed by staff. LVN A also stated Resident #11 was at a high risk for falls, she had a pressure sensitive alarm on her wheelchair cushion, and she had a wander guard to prevent elopement. Review of the May 2011 physician's orders [REDACTED]. Review of the face sheet for Resident #11 revealed she was a "fall risk." Review of the nurse's notes dated 04/02/11 at 2:00 p.m. revealed Resident #11's roommate reported to the facility staff Resident #11 was on the floor in the bathroom. Review of the A/I report dated 04/02/11 at 2:10 p.m., revealed Resident #11's roommate had reported Resident #11 was on the floor in the bathroom. The report did not identify an alarm was in use at that time. The incident report dated 04/07/11, under column "C" DON/Nurse Manager Follow-up/Change in care plan reflected a statement from the facility DON. The DON wrote in the statement Resident #11 had Dementia, and the resident tried to transfer herself to the bathroom when she was found on the floor. The DON continued in the statement Resident #11 had history of frequent falls, and the resident was currently on a toileting schedule for her safety and to remain continent. The statement reflected the facility was to continue monitoring Resident #11 frequently, toilet, and continue the use of a chair alarm. However, review of the facility B/B program work sheet for hall 100 did not include Resident #11 on the list. Interview with CNA B on 05/17/11 at 2:45 p.m. revealed Resident #11 was not on the facility B/B program, but she was assessed and changed as needed. The surveyor observed an incomplete fall risk assessment dated [DATE] after Resident #11 fell . The total undocumented score per this assessment was 16 with the total score of ten or more being high risk for falls. The care plan dated 05/17/11 for at risk for falls reflected Resident #11 had: cognitive impairment, physical impairment, unsteady gait and actual falls. The approaches identified for this problem were: 1) Encourage resident to ask for assistance of staff. 2) Ensure call light is in reach, answer promptly 4) Anticipate needs, provide prompt assistance 5) Assure adequate lightening and 7) falling star program The care plan dated 11/08/10 and revised 05/04/11 reflected Resident #11 was at risk for fall related to injury. Some of the approaches identified for this problem were: Use fall risk screen to identify risk factors. Remind resident and reinforce safety awareness. Educate/remind resident to request assistance prior to ambulation. Appropriate footwear. Invite, encourage, remind, escort to activities programs consistent with resident's interest to enhance physical strengthening needs. The care plan for Resident #11's incontinence reflected the following approaches: Provide prompt peri-care PRN (as needed) for incontinent episodes between regular scheduled toileting times. However, review of the 100 hall list of residents assisted with a scheduled toileting did not include Resident #11. The most recent MDS dated [DATE] revealed Resident #11 was continent of bowel and bladder. In an interview with the DON on 05/19/11 at 1:30 p.m. it was revealed Resident #11 was demented and had no safety awareness. The DON stated facility had tried everything to keep her safe and free of injury. The interview revealed she was not aware if Resident #11 was on a B/B program. The surveyor informed the DON at that time that Resident #11 was not in the list on the B/B program book in hall 100. The surveyor and DON also reviewed the current MDS dated [DATE] and pointed to the DON Resident #11 might not have been on the B/B program as the MDS reflected she was continent of bowel and bladder. 3) Resident #12 was observed during the initial rounds by the surveyor on 05/16/11 at 9:15 a.m. LVN D on rounds stated Resident #12 was alert, forgetful, non-interviewable, ambulates with a walker, was frail and thin, has unsteady gait and eats in the dining room. Resident #12 was incontinent of bowel and bladder and required assistance with activities of daily living. Review of the May 2011 physician's orders [REDACTED]. Review of the nurse's note dated 04/09/11 at 1900 (7:00 p.m.), revealed Resident #12 was found sitting on the floor in her room between the bed and the recliner chair. Resident #12 sustained some redness to her lower back area. The note dated 04/10/11 at 6:00 a.m. to 2:00 p.m. reflected Resident #12 had bruising to her left lower buttocks and non tender. Review of the April and May's A/I for Resident #12 revealed Resident #12 has had a couple of falls. The Accident/Incident reports reflected the following: The A/I report on 04/09/11 at 1900 (7:00 p.m.) reflected Resident #12 was found sitting on the floor between her bed and the recliner chair in her room. The DON statement of findings in column C reflected Resident #12 stated she slipped. The care plan action was to encourage this demented resident to call for assistance to avoid injury. The A/I report dated 04/12/11 at 1800 (6:00 p.m.) reflected Resident #12 was in the dining room getting up from chair to walker and she slid to the floor. The A/I report dated 04/29/11 at 1:30 a.m., revealed Resident #12 was found on the floor by the foot of her bed by a CNA who reported the incident to the nurse. The column "B" the charge nurse investigation-intervention after incident reflected Resident #12 told the nurse she was attempting "maybe to go to the bathroom" when she fell . The report also revealed Resident #12 complained of Left Shoulder pain that was tender to touch. Column "C" reflected Resident #12 was "confused at times, uses a walker, encourage use, resident voices understanding continue fall prevention program." The incident report reflected on 04/30/11 Resident #12 sustained a 4.0 centimeter left posterior shoulder bruise. Review of the fall risk assessment dated [DATE] revealed a score of 9. The assessment dated [DATE] revealed a score of 12. The assessment dated [DATE] revealed a score of 18 and the assessment dated [DATE] revealed a score of 11. According to the instructions on the assessment form if the total score was 10 or greater, the resident should be considered at high risk for potential falls. The bowel and bladder assessment dated [DATE] reflected a total score of 24 for Resident #12 placing her in the category between 19 and above which meant she was continent and did not require a toileting program. Review of the care plan dated 04/12/11 revealed Resident #12 had a history of [REDACTED]. The care plan also revealed the problem has been resolved on 04/15/11, no injuries. The most current care plan for falls dated 05/17/11 revealed Resident #12 was at risk for falls as evidenced by: cognitive impairment, Physical impairment, unsteady gait and actual fall. The care plan approaches identified the following approaches for this problem: (1) Encourage resident to ask for assistance of staff. (6) encourage socialization and activity attendance as tolerated. (7) "Falling Star Program." There were no care plans in her clinical records addressing her incontinent needs. The charge nurse LVN D was interviewed on 05/18/11 at 4:40 p.m. The interview revealed Resident #12 was not on the toileting program because she can toilet her self and is continent. LVN D stated resident does her toileting by herself. The surveyor interviewed Resident #12 in her room on 05/19/11 at 10:50 a.m. with her roommate in the room laying in her bed. Resident #12 told the surveyor she needed some assistance to the bathroom and cannot attend properly to her self in the bathroom. Resident #12 stated staff does not have a set time or set schedule they assist her to the bathroom. Resident #12's roommate stated Resident #12 was not always able to make it to the bathroom on time and does need assistance in and out of the bathroom as she was unsteady in her feet. At 1:00 p.m. on 05/19/11, the surveyor observed CNA E walking beside Resident #12 from the dining room. CNA E walked the resident to her room leaving her in the middle of the room standing with her walker. Resident #12 unsteadily ambulated close to her recliner chair and fell into it and cried, "oh my God." Resident #12 denied injury at that time but did state she needed to go to the bathroom. The surveyor went to the nurse's station and found CNA E bringing back another resident from the dining room. After surveyor informed her of the residents need, she told the surveyor she was going to assist Resident #12 to the bathroom after bring other residents back from the dining room. After the surveyors brought it to the facility attention that there were issues with fall assessments, falls and assistance to toileting on 05/17/11 the facility started Resident #12 on the three days trial B/B incontinence pattern for toileting assessment. 4) According to the undated Face Sheet Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Resident #2 was initially observed during rounds with LVN C on 05/16/11 at 10:00 a.m. The resident was resting in bed. LVN C described the resident as being incontinent of bowel/bladder, requiring assistance with all activities of daily living and having experienced a decline in mental and functional abilities within the past two weeks. A nurse's note dated 03/10/11 reflected the High Risk committee evaluated Resident #2 and deemed the resident not at risk for falls. According to the note the resident had experienced no recent fall and the Falling Star Program would be discontinued. The note further reflected Resident #2 would be reassessed quarterly and as needed for changes in condition. A physician's telephone order dated 03/10/11 reflected an order to discontinue the Falling Star Program for Resident #2. An interview with the DON and the ADON on 05/16/11 at 12:40 p.m. revealed Resident #2 was discontinued from the Falling Star Program because he had not experienced any falls prior to 03/10/11. The DON was queried during this time about the resident being assessed to be at high risk for falls. The DON stated the decision to discontinue the Falling Star Program for Resident #2 did not necessarily depend on the fall risk scores. The DON was queried during this time about what interventions had been implemented to address the resident's high risk for falls after the Falling Star Program had been discontinued. The DON stated "none, monitoring." Resident #2's admission fall risk assessment dated [DATE], reflected the resident was at high risk for falls. According to the instructions on the assessment form if the total score was 10 or greater, the resident should be considered at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Resident 2's fall risk assessment score was 10. The subsequent fall risk score dated 02/14/11 was still 10. An interview with LVN C on 05/16/11 at 12:20 p.m. revealed Resident #2 had experienced a fall the past weekend (05/15/11) and two falls the previous week. Resident #2's most recent MDS assessment was dated 03/14/11 and coded as a quarterly assessment. The assessment reflected the resident used a wheelchair, required extensive assistance of staff for ambulation and weight bearing support. Review of fall tracking logs revealed Resident #2 had experienced falls on 03/24/11, 05/04/11, 05/05/11 and 05/15/11. According to the summary/conclusion/plan section of the tracking log Resident #2 was "Placed back on the fall program" after the fall on 05/05/11. There were no documented interventions on the form related to the falls on 03/24/11, 05/04/11 or 05/15/11. Review of Accident/Incident reports revealed Resident #2 had experienced five falls since admission to the facility on [DATE]. The reports reflected the following: (1) On 03/24/11- Resident #2 was observed sliding form the wheelchair to the floor but sustained no injury. The fall risk score at this time was 14. According to the report the resident was currently receiving therapy services. There was no care plan developed prior to this fall. However, the care plan developed after the fall was dated 03/24/11. Interventions were generic in nature and not individualized for Resident #2. They included encouraging the resident to ask for assistance, ensuring the call light was in reach, answered promptly and the falling star program. (2) On 05/04/11- Resident #2 was observed sliding from the bed to the floor. The resident sustained [REDACTED]. A care plan dated 05/04/11 included interventions of encouraging the resident to ask for assistance, ensuring the call light was in reach, answered promptly and the falling star program. (FYI- the Falling Star Program was not re-initiated until after a fall on 05/05/11). A faxed communication form to the physician dated 05/04/11 reflected Resident #2 was experiencing weakness and confusion. The care plan further reflected "P T (physical therapy) to screen." A therapy screen addressing the resident's fall was dated 05/06/11 and reflected the resident refused to work with therapy and did not follow safety precautions. The screen further reflected no skilled therapy intervention was indicated for Resident #2. There were no recommendations addressing fall prevention for Resident #2. (3) On 05/05/11 - Resident #2 was observed on the floor of his room face down next to the bed. The resident's legs were tangled in the wheelchair and blood was coming from his right eyebrow. The resident was transferred to the emergency room for evaluation. A care plan dated reviewed on 05/05/11 reflected interventions remained the same as previous care plans, with the addition of providing a bed alarm for the resident. A physician's telephone order dated 05/05/11 reflected the Falling Star Program would be re-instated for the resident. A fall risk score dated 05/07/11 reflected a score of 18. According to hospital physician's orders [REDACTED]. A therapy screen dated 05/11/05 addressing Resident #2's fall on 05/05/11 reflected the resident continued to raise the bed too high despite instructions against doing so. The therapy screen further reflected a recommendation for a bed alarm, 1-2 hour monitoring and bedside mats to both sides of the resident's bed. (4) On 05/12/11- Resident #2 was observed on his knees next to the bed. The resident was assisted back to bed and assessed with [REDACTED]. According to this report an alarm was not in use at the time of the fall but was put into place at this time. The care plan dated reviewed on 05/12/11 reflected an additional intervention of providing a scoop mattress for Resident #2. (5) On 05/15/11- Resident #2 was found hanging onto the side of the bed. According to the report the bed alarm was sounding and the resident was assessed with [REDACTED]. According to the care plan dated reviewed on 05/16/11 a sensor pad (alarm) would be provided for the resident's wheelchair and bed. Observation of Resident #2 in bed on 05/17/11 at 9:30 p.m. revealed a scoop mattress had been placed on the bed, and a mat had been placed on the floor on one side of the bed. A pressure sensitive (sensor) bed alarm was attached to the resident and the bed. However, it was switched to the off position. An interview with LVN C during this time revealed the mattress and the mat had not been provided for Resident #2 until earlier in the day on 05/17/11. According to LVN C the bed alarm had not been provided for the resident until 05/12/11 after his fall. Observation of the resident in bed on 05/17/11 at 1:00 p.m. and again at 1:45 p.m., with the DON revealed the alarm remained off and non-functional. During this time the DON turned the alarm on. 5) Resident #13 was initially observed resting in bed during rounds on 05/16/11 at 9:45 a.m. with LVN C. LVN C described the resident as incontinent of bladder at night, legally blind and having a history of falls. Resident #13 was utilizing a personal alarm. Review of Resident #13's face sheet printed on 03/22/11 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Resident #13's admission fall risk assessment dated [DATE], reflected the resident was at high risk for falls. According to the instructions on the assessment form if the total score was 10 or greater, the resident should be considered at high risk for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Resident 13's fall risk assessment scores for 02/21/11 and 05/18/11 were 23. Care plans dated 03/03/11 reflected Resident #13's was at risk for falls due to previous fall, fall risk factors present as determined by the fall risk screen. Interventions included using the fall risk screen to identify risk factors, reporting fall to the physician, providing wheelchair locks, breaks on bed and chair before transferring. A physician's telephone order dated 02/25/11 reflected an order for [REDACTED]. Review of Accident/Incident reports for Resident #13 revealed the resident had experienced three falls in March 2011. The reports reflected the following: (1) On 03/19/11- Resident #13 was found on Hall 100 sitting on the floor. The resident sustained [REDACTED]. The fall risk assessment score on 03/19/11 was 22. A care plan dated 03/19/11 reflected Resident #13 was at risk for falls due to cognitive impairment, unsteady gait and physical impairment. Interventions included encouraging the resident to ask for assistance, falling star program, ensuring the call light was in reach and answered promptly. An additional intervention documented on the bottom of the care plan was " PT/OT." (Physical Therapy/Occupational Therapy). A therapy screen dated 03/22/11 addressed the resident's fall on 03/19/11. The resident was currently receiving occupational therapy and no other skilled therapy interventions were indicated. The use of an alarm was not reflected on this care plan. (2) On 03/23/11 - Resident #13 was found lying on her right side on the floor between the roommate's bed and the air conditioning unit. The resident sustained [REDACTED]. According to this report a bed alarm was clipped to the resident after she was assisted off the floor. The fall risk assessment score dated 03/23/11 was 24. A care plan dated 03/23/11 addressed the resident's risk for falls due to cognitive impairment, unsteady gait, physical impairment and blindness. Interventions included encouraging the resident to ask for assistance, falling star program, ensuring the call light was in reach and answered promptly. (3) On 03/26/11 - Resident #13 was found hanging onto the support bar on the side of the bed. The resident was assessed and no injuries were noted. However, bruising from past fall remained on the resident's arms, hands and legs. The fall risk assessment score dated 03/26/11 was 20. According to the nurse's notes dated 03/26/11 Resident #13 required frequent observation due to attempts to transfer form bed to wheelchair and to the bathroom without calling for assistance. The note further reflected the resident was confused and often disoriented, blind and hard of hearing. A care plan dated 03/26/11 reflected the resident was at risk for falls due to cognitive impairment, unsteady gait, physical impairment and blindness. Interventions included encouraging the resident to ask for assistance, falling star program, ensuring the call light was in reach and answered promptly. An additional intervention documented on the bottom of the care plan was PT/OT services. A therapy screen dated 03/28/11 addressed the resident's fall on 03/26/11. According to the screen Resident #13's therapy had been discontinued on 03/25/11. The resident had demonstrated poor carry over with locking brakes. The recommendation was that room checks be provided. The screen reflected no skilled therapy intervention was indicated. (4) On 03/31/11 - Resident #13 was found on the floor of her bathroom. The resident was on the floor on her right knee holding onto the commode. No injuries were noted. According to the report the wheelchair alarm was in place and functional. The fall risk assessment score dated 03/31/11 was 18. A care plan dated 03/31/11 reflected the resident was at risk for falls due to cognitive impairment, unsteady gait, physical impairment and blindness. Interventions included encouraging the resident to ask for assistance, falling star program, ensuring the call light was in reach and answered promptly. A therapy screen dated 04/4/11 addressed the resident's fall on 03/31/11. According to the screen Resident #13's therapy had been discontinued. The resident had demonstrated poor carry over with locking brakes. The screen reflected no skilled therapy intervention was indicated. A care plan dated 05/17/11 reflected Resident #13 was at risk for falls due to cognitive impairment, unsteady gait and physical impairment. Interventions included encouraging the resident to ask for assistance, ensuring the call light was in reach and answered promptly. Additional interventions documented on the bottom of the care plan included using a bed/chair alarm and mats beside the bed. There were no dates to indicate when these interventions had been added. An interview with the DON on 05/19/11 at 12:00 p.m. revealed Resident #13 had utilized a bed/chair alarm since admission. During this interview the DON was queried about any other interventions that had been implemented for the resident. The DON stated the resident sat and watched television for hours and interventions had been divisional. 6) Resident #10 was observed on 5/18/11 at 9:30 a.m. sitting in a Gerichair in Hall 100 hallway. The surveyor while working near the hall observed Resident #10 had a yellow purple bruise on her right cheek area that extended to her neck. On initial rounds, 05/16/11 at 9:30 a.m.LVN A told the surveyor Resident #10 alert and confused, uses the Gerichair, was incontinent of bowel and bladder requiring total care from staff. LVN A also stated Resident #10 was fed by the facility staff, was a fall risk, she can ambulate a short distance but was not safe and she was legally blind. Review of Resident #10's Face Sheet dated 02/02/11 revealed an initial admitted a current admission date of [DATE]. [DIAGNOSES REDACTED]. Record review of facility Nurses Notes on 03/09/11 at 1220 r