Every finding on record at Lutheran Convalescent Home

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) with a diagnosis of dementia received appropriate treatment and services to attain or maintain his/her highest psychosocial well-being. The sample size was three. The census was 130. The administrator was notified on 08/12/26, of the past non-compliance. The facility responded appropriately when the incident occurred. Certified Nursing Assistant (CNA) A was suspended pending an investigation and then terminated. The facility provided training and in-services for all staff regarding abuse and neglect. The deficiency was corrected on 08/11/26. Review of the facility's Caring for Residents Experiencing Aggressive Expressions policy, dated 01/29/2024, showed:-Policy: Facility staff will be proactive in working with residents who demonstrate aggressive expressions toward others. Facility will provide staff training and ongoing communication regarding how to care for residents with aggressive expressions;-Policy implementation: Safety is the first priority when a resident experiences aggressive expressions. Staff should focus on protecting the resident experiencing aggressive expressions and the recipient of the aggressive expressions, as well as other people who may be nearby such as residents, staff, and visitors in the neighborhood. Attempt to guide the resident to a quiet area and assist the resident in regaining self-control. Maintain calm manner in word and action. Try not to express anger or impatience either verbally or through gestures. 1. Review on 08/12/2026, of the facility's investigation, dated 08/10/2026, showed:-On Sunday 08/09/2026 CNA C reported to Nursing Supervisor G that employee CNA A admitted to popping (slapping), the resident. CNA C reported that CNA A said whenever the resident hit him/her that he/she popped the back of the resident's hand. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/11/2026, showed:-Diagnoses included vascular dementia, anxiety, and major depressive disorder;-Section E (behaviors): resident has physical and verbal behaviors;-Severe cognitive impairment. Review of the resident's care plan, in use at the time of the investigation, showed:-Focus: The resident has potential to be physically aggressive;-Goal: The resident will demonstrate effective coping skills through the review date;-Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, or pain. Give the resident as many choices as possible about care and activities. During an interview on 08/12/2026 at 10:16 A.M., CNA C said during his/her shift on 08/09/2026 at approximately 1:30 P.M., he/she and CNA A went to the resident's room to provide care. The resident was angry and attempted to hit him/her. He/She said he/she was able to get the resident calmed down and CNA A told him/her that when the resident tried to hit him/her, he/she slapped the resident on the hand to get him/her to stop. He/She said all employees had abuse training and training on working with residents who have behaviors. He/She said CNA A should know how to work with residents who have behaviors. During an interview on 08/12/2026 at 10:35 A.M., CNA A said he/she was a new employee and had only been working for three days. He/She said he/she had to fight the impulse to hit residents back when they tried to hit him/her. He/She said it was an instinct to hit back when someone tried to hit him/her. He/She said he/she did have abuse training and dementia training during orientation. He/She said during his/her shift on 08/09/2026, he/she and CNA C went to the resident's room to provide care. The resident was angry and attempted to hit CNA C. He/She said he/she told CNA C that when the resident tried to hit him/her he/she tapped the resident on the hand or swatted the resident's hand to get him/her to stop. During an interview on 08/12/2026 at 11:38 A.M., Nursing Supervisor G said CNA A was a new employee and he/she did not know him/her as well. He/She said CNA A received abuse training, dementia care training, and behavior training during orientation. He/She would expect the CNA to have used appropriate de-escalation techniques when working with any resident who had behaviors. During an interview on 08/12/2026 at 12:15 P.M., the Administrator said he would expect staff to have the knowledge to appropriately handle residents who were displaying behaviors. If a resident was attempting to hit a staff member, he would have expected the staff member to step back and reapproach the resident at a different time when they were calm. He said training on abuse, dementia care, and resident behaviors was provided during orientation and was ongoing.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 27 opportunities observed, four errors occurred resulting in a 14.81% error rate (Residents #31, #10, #12 and #88). The census was 123 with 99 residents in certified beds. Review of the facility's Administering Medications policy, review date 1/30/24, showed: -Purpose: Medication shall be administered in a safe and timely manner and as prescribed. The community shall provide resident with the necessary medication(s) when they leave the community temporarily; -Policy Interpretation and Implementation: 1. Medications must be administered in accordance with the orders, including any required time frame. 2. Medications must be administered within one hour of their prescribed time, unless otherwise specified. 3. If a medication is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall indicate in the medication administration record that the medication was not given and the reason. Review of the facility's Crushing Medications policy, review date 1/30/24, showed: -Policy statement: Medication shall be crushed only when it is appropriate and safe to do so and consistent with physicians orders; -Policy Interpretation and Implementation: 1. The following guidelines shall be followed when crushing a medication, the medication administration record (MAR) must indicate it is necessary to crush the medication. Crush medications in paper cups or folded plastic sheets to prevent contact between the drug and the crushing device. Use only the approved crushing device in the drug preparation area to crush medications. Crushed medications should be administered with liquids or soft foods to ensure that the resident receives the entire dose ordered. 1. Review of Resident's #31's medical record, showed: -Diagnoses included diabetes, depression, kidney disease, low thyroid hormone level, and stroke; -An order dated 11/15/23, for fluticasone propionate (nasal spray used to treat allergies) 50 micrograms (mcg)/actuation nasal spray, one spray into each nostril one time daily. Observation on 11/6/24 at 8:33 A.M., showed Certified Medication Technician (CMT) R assisted the resident to place the bottle with the spray into each nostril. While CMT R held the bottle, the resident pushed the pump device and two sprays went into each nostril. 2. Review of Resident #10's medical record, showed: -Diagnoses included elevated cholesterol, low thyroid hormones, and stroke; -An order dated 9/10/21, for Deep Sea Nasal 0.65% spray aerosol two drops (gtts) in each nostril, two times daily for nasal dryness; Observation on 11/6/24 at 8:57 A.M., showed CMT R inserted the nasal spray bottle in each nostril and administered one drop into each nostril. 3. Review of Resident's #12's medical record, showed: -Diagnoses included high cholesterol, depression, high blood pressure, seasonal allergies, and low thyroid hormone; -The following medications: -An order dated 11/29/19, for lisinopril 10 milligrams (mg) by mouth daily for high blood pressure; -An order dated 12/8/19, for citalopram 10 mg by mouth daily for depression; -An order dated 10/23/20, for loratadine 10 mg by mouth daily for sinus drainage; -An order dated 3/2/23, for Mucus DM 30 mg-600 mg, two tablets by mouth twice daily for cough; -An order dated 2/15/24, for Senna 8.6 mg by mouth twice daily for constipation; -An order dated 10/3/23, for diltiazem CD 120 mg capsule, extended release one time daily for high blood pressure; -An order dated 9/4/24 for vitamin D3 125 mcg (5,000 unit) tablet by mouth one time daily; -No orders for crushing the lisinopril, citalopram, loratidine, mucus DM, Senna or vitamin D3. Observation on 11/6/24 at 9:17 A.M., showed CMT R pulled the medication strip from the medication cart, opened the individual packets and emptied lisinopril, citalopram, loratadine, lisinopril, mucus DM, Senna, and vitamin D3 into a folded plastic envelope and crushed the medications using a pill crushing device. CMT R verified that the contents of the plastic envelope were crushed into a powder form and he/she poured the contents into a 30 milliliter (ml) cup. CMT R opened the capsule of diltiazem and emptied the contents into the 30 ml cup with the other medications. Using a spoonful of yogurt, CMT R mixed the powder of medication and administered the medication to the resident. 4. Review of Resident #88's medical record, showed: -Diagnoses included high blood pressure, arthritis, anemia, anxiety, and high blood pressure; -An order dated 9/23/24, for acetaminophen (pain reliever) extended release 650 mg one time a daily at 7:00 A.M. Observation on 11/6/24 at 9:24 A.M., showed CMT R administered acetaminophen 650 mg to the resident, that was due at 7:00 A.M. 5. During an interview on 11/7/24 at 8:58 A.M., Licensed Practical Nurse (LPN) I said physician's orders for medication administration should be followed to prevent medication errors and injuries to the residents. Medications should not be crushed unless ordered by the physician. 6. During an interview on 11/7/24 at 9:05 A.M., CMT R said he/she should administer medications as ordered by the physicians. If a resident refuses a medication or does not want to follow the physician's order, he/she would hold the medication and contact the nurse immediately. Medication should be given at the time listed on the MAR. It is important to follow physician's orders for medication administration to prevent a medication error. 7. During an interview on 11/7/24 at 2:21 P.M., the Director of Nursing (DON) said that nurses should follow the policy and procedure for medication administration. Medications should only be crushed when there is an order from the physician. 8. During an interview on 11/7/24 at 2:21 P.M., the Administrator said that the nursing staff should follow the policies on medication administration.

Based on observation, interview and record review, the facility failed to ensure dietary staff used proper hand hygiene during meal service and failed to ensure the kitchen ceiling was free from dust accumulation. The sample was 20. The census was 123 with 99 residents in certified beds. Review of the facility's hygiene and sanitary practices policy, revised 2/16/24, showed: -Policy statement: Dining services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness; -Policy implementation: Employees must wash their hands after personal body functions, after using tobacco, eating or drinking, whenever entering or re-entering the kitchen; before coming in contact with any food surfaces, after handling raw meat, poultry or fish and when switching between working with raw food and working with ready-to-eat food, after handling soiled equipment or utensils, during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or after engaging in other activities that contaminate the hands. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing. Review of the facility's kitchen cleaning schedule, dated 1/9/20, showed: -Ceiling tiles and ceiling vents are to be cleaned weekly. 1. Observation of the Forest Park dining room on 11/4/2024 at 11:46 A.M., showed Dietary Aide (DA) L prepping plates of food in the kitchen with no gloves. DA L left the kitchen to propel residents to their tables, locking brakes on the wheelchairs. He/She returned to the kitchen, grabbed a plate from the top of the stack, and began prepping the plate with food, not wearing gloves. He/She returned to the dining room and assisted residents with setting up their food, touching the resident's utensils, with no hand hygiene between residents. DA L returned to the kitchen, picked up a piece of paper from the floor, placed it in the garbage receptacle, and continued to prep plates with ungloved hands. 2. Observation of the Forest Park dining room on 11/5/2024 at 11:31 A.M., showed DA L propelled residents in wheelchairs to their tables. DA L returned to the kitchen and did not wash his/her hands. He/She pulled back the clear covering to the hot food container and took the temperatures of each container of food. DL A did not perform hand hygiene or wear gloves between resident interaction and checking the temperatures of the large containers of cooked food. 3. Observation of the Forest Park dining room on 11/5/2024 at 12:07 P.M., showed DA M wore gloves while washing dishes. He/She collected a plate of prepared food and delivered it to a resident while wearing the same pair of gloves. 4. Observation of the Forest Park dining room on 11/6/2024 at 6:11 A.M., showed DA L prepped the kitchen for breakfast by wiping counters, gathering serving utensils, checking water in a bucket with a chemical strip, preparing resident plates with food, and assisting residents, without wearing gloves or performing hand hygiene in between tasks. 5. Observation on 11/5/24, of the main kitchen, showed: -At 7:34 A.M., a light fixture and the five surrounding ceiling tiles, above the main food prep station, had dark dust accumulation and build up. An uncovered pot of gravy was on the prep station counter; -At 8:33 A.M., a light fixture above the second food prep station had dust accumulation. 6. Observation on 11/6/24, of the main kitchen, showed: -At 8:40 A.M., a light fixture and the five surrounding ceiling tiles, above the main food prep station, had dark dust accumulation and build up; -At 8:41 A.M., a light fixture above the second food prep station had dust accumulation. There were opened cans of fruit on the prep station below the light. 7. During an interview on 11/7/2024 at 8:47 A.M., DA N said he/she washes his/her hands about four to six times during a meal service, and gloves should be worn while prepping a plate of food to prevent cross contamination. 8. During an interview on 11/7/24 at 12:15 P.M., the Manager of Dining Services said he would expect the main kitchen ceiling to be free from dust accumulation and build up. He said the ceiling should be cleaned as necessary. He would except for hand hygiene to be performed during meal service. He would expect the dietary staff to be frequently washing their hands and wearing gloves. 9. During an interview on 11/7/24 at 2:33 P.M., the Director of Nursing (DON) and Administrator said they would expect for proper hand hygiene to be performed during meal service. They would expect for the main kitchen ceiling to be clean and free from dust accumulation and build up. 49992

Based on observation, interview, and record review the facility failed to follow enhanced barrier precautions (EBPs) to prevent risks of infection for three of 20 sampled residents (Residents #29, #40, and #74) and failed to provide direct care following acceptable infection control procedures for another resident (Resident #39). This failure had the potential to affect all residents in the facility. The census was 123 with 99 residents in certified beds. Review of the facility's Enhanced Barrier Precautions policy, revised on 4/9/24, showed: -Enhanced barrier precautions are used as an infection prevention control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents; -EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply; -EBPs are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with the following: Vancomycin (antibiotic)-resistant Enterococci (VRE, a drug resistant chronic infection process), drug resistant streptococcus pneumonia (a gram-positive bacterial infection in the lungs), and carbapenemase-producing drug resistant organisms (an enzyme produced by bacteria making carbapenem antibiotics ineffective); -Signs are posted in the door or wall outside the resident room indicating the type of precautions and Personal Protective Equipment (PPE) required. Review of the facility's Hand Hygiene policy, revised on 1/30/24, showed: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Staff should use an alcohol-based hand rub containing at least 60% alcohol, or soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents, before and after handling an invasive device (urinary catheters (thin tubing that empties the bladder), IV (intravenous, a small line placed into the vein of the patient to deliver medication or fluids) access sites), after contact with a resident's intact skin, before entering isolation precaution settings and after leaving isolation precaution settings, before and after eating or handling food, and before and after assisting a resident with meals. 1. Review of Resident #29's medical record, showed diagnoses included dementia, personal history of Methicillin (antibiotic)-resistant staphylococcus (bacteria that is resistant to many antibiotics) infection, and unspecified abnormal findings in urine. Review of the resident's urine culture results, dated 8/24/24, showed positive results for Vancomycin resistant enterococcus. Review of the resident's physician order summary (POS), showed an order, dated 8/26/24, for enhanced barrier precautions. Notes: VRE urine - wear gowns/gloves for high contact resident care activities. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident has an activities of daily living (ADL) self-care deficit related to decreased mobility, decreased cognition, and muscle weakness; -Interventions included, VRE in urine - wear gowns/gloves for high contact resident care activities. Observation on 11/4/24 at 12:24 P.M., showed a cart outside of the resident's room containing gowns. A sign posted on the front door of the resident's room to Stop, see nurse for instructions. A sign posted on the inside of the resident's door for EBP. Licensed Practical Nurse (LPN) J and Certified Nurse Aide (CNA) K entered the resident's room and donned gloves. LPN J positioned a mechanical lift in front of the resident, who was seated in his/her Broda (recliner) chair. LPN J and CNA K positioned a sling around the resident's waist, and the staff members' torsos and forearms touched the resident's upper body while LPN J and CNA K positioned the sling and adjusted the resident. LPN J operated the mechanical lift while CNA K used his/her hands to adjust the resident's positioning during the transfer. Neither LPN nor CNA K wore gowns during the resident's transfer. Observation on 11/5/24 at 11:20 A.M., showed Certified Medication Technician (CMT) A entered the resident's room and put a glove on his/her right hand. He/She used his/her left hand to pull the collar of the resident's shirt away from the resident's body, and inserted his/her right hand inside the collar of the resident's shirt to rub the resident's left arm. CMT A said the resident just had a shot and his/her arm was itchy. CMT A's forearm brushed against the resident's skin while he/she rubbed the resident's arm. During an interview on 11/7/24 at 10:50 A.M., CMT A said the resident is on EBP. EBP means staff should wear gowns and gloves when providing personal care or bathing assistance. Gowns are not required when assisting residents on EBP with transfers. He/She did not need to wear a gown when he/she rubbed the resident's arm after his/her shot the other day because CMT A was not assisting the resident with personal care or bathing. During an interview on 11/7/24 at 10:07 A.M., LPN C said the resident is on EBP. Staff should wear gowns and gloves when providing care to residents on EBP, including dressing, transfers, and any activity that requires direct contact. 2. Review of Resident #40's medical record, showed: -Diagnoses included: Diabetes, anxiety, right side heart failure, and liver disease; -Severe cognitive impairment. Review of the resident's POS, in use at the time of survey, showed: -An order, dated 7/31/24, for EBP. Wear gloves and gown for high contact resident care activities due to a non-pressure related wound on the resident's left lower leg. Review of the resident's care plan, in use at the time of the survey, showed: -Problem: Resident is at risk for developing impaired skin integrity related to mobility and incontinence. Left lower leg wound that is treated at wound clinic, started as a skin tear complicated by lymphedema (a chronic condition causing swelling due to increased lymph fluids) and cardiac (heart related) status; -Goal: Resident will have no new alteration in skin integrity and demonstrate progressive wound healing/improvement through next review; -Interventions: Complete weekly skin assessments. Enhanced barrier precautions due to wounds. Observation on 11/4/24 at 4:45 P.M., of the resident's room, showed: -A sign on the back of the resident's door indicating the resident is on Enhanced Barrier Precautions. The sign indicated that everyone who enters the resident's room must wash their hands before entering and when leaving. The sign also indicated that staff should wear a gown and gloves when providing high contact care for the resident; -No PPE in the resident's room or outside the resident's room. During an interview on 11/4/24 at 4:54 P.M., the resident said he/she has a vascular wound on his/her left leg. When staff come into his/her room to provide care, they do not wear gowns. Observation on 11/5/24 at 11:37 A.M., showed CMT F and CNA E in the resident's room. The resident lay on his/her bed with the mechanical lift sling underneath his/her body. Both CMT F and CNA E touched the resident's arms and sides to assist the resident to turn on his/her left side. CMT F pulled up the resident's shirt, repositioned the lidocaine (a local anesthetic that prevents pain by blocking pain receptors at the location) patch on the residents back, and then pulled the resident's shirt back down. CNA E positioned the mechanical lift next to the bed and then both CNA E and CMT F connected the mechanical lift sling to the lift. CNA E operated the mechanical lift while CMT F used his/her hands to adjust the resident's positioning during the transfer. CMT F had on gloves and no gown. CNA E had no gown or gloves on. During an interview on 11/7/24 at 8:18 A.M., CNA H said EBP was a medical cream. He/She then identified EBP as the sign on the door of any resident's room that indicated a gown and gloves should be worn during care. PPE should be kept either in the resident's room or outside the resident's room at the door. During an interview on 11/7/24 at 8:24 A.M., CMT F said the resident used to be on EBP but is not now because the resident's wound healed. A gown and gloves should be worn when providing high contact care when the resident is on EBP. During an interview with the Administrator and Director of Nursing (DON) on 11/7/24 at 2:22 P.M., the DON said the resident is currently being treated at a wound clinic outside of the facility for his/her vascular wound on his/her left lower leg. The Administrator and DON expected for a gown and gloves to be worn by staff when providing care to the resident. 3. Review of Resident #74's medical record, showed diagnoses included dementia, hardening of the vessels that carry blood to the heart, high blood pressure, and depression. Review of the resident's care plan, in use at the time of survey, showed: -Problem: The resident has an indwelling suprapubic urinary catheter (urinary catheter inserted through the lower abdomen into the bladder) due to being unable to urinate; -Interventions: Enhanced Barrier Precautions due to presence of the suprapubic urinary catheter. Observation on 11/5/2024 at 9:32 A.M., showed CNA P entered the resident's room, provided perineal care (peri care, washing of the genital and anal area), dressed the resident, and assisted the resident to transfer without wearing gown or gloves. During an interview on 11/7/24 at 9:10 A.M., CNA P said that Enhanced Barrier Precaution is the cream that is used for the residents. If a resident has a urinary catheter, staff should wear gown and gloves to provide care. He/she admitted that during the observation, he/she was in a hurry and did not stop to put on a gown or gloves. 4. Review of Resident #39's medical record, showed diagnoses included dementia, long term use of blood thinners, high blood pressure, depression, and stroke. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident is unable to complete activities of daily living due to a stroke and depression; -Interventions: To provide substantial/total assistance of one staff member to complete my dressing, grooming/hygiene, and toileting needs. Observation on 11/6/24 at 8:25 A.M., showed CNA O in the resident's room, standing at the bedside. The resident lay on his/her back with the lower half of the body covered. CNA O assisted the resident to roll onto his/her side, applied a protective skin cream and placed a clean brief under the resident. CNA O removed his/her gloves and continued to apply the brief to the resident with no hand hygiene or gloves. During an interview on 11/7/24 at 9:10 A.M., CNA P said staff should wear gloves when providing peri care to the residents. Gloves protects the employees as well as the residents. During an interview on 11/7/24 at 8:58 A.M., LPN I said staff should wear gloves when providing care, such as toileting and showering, to the residents. Gloves prevent the spread of germs. 5. During an interview on 11/7/24 at 9:55 A.M., CNA B said when there is a sign on a resident's door to see the nurse, it means staff should wear PPE when providing any touching care activity with the resident. Touching care activities include transfers, personal care, and any activity in which staff touches the resident. Staff know what type of PPE to wear by looking at the PPE placed outside of the resident's room. 6. During an interview on 11/7/24 at 11:04 A.M., LPN D said residents are placed on EBP when they have wounds, catheters, or anything that could increase their potential for infection. EBP means staff should wear gowns and gloves when providing direct, hands-on care with a resident. Gowns and gloves should be worn during transfers, including transfers using a mechanical lift, and any time staff are going to touch the resident. This is to protect the resident from possible infection from staff. 7. During an interview on 11/7/24 at 9:21 A.M. the facility Infection Preventionist said residents in the facility are placed on enhanced barrier precautions for current health conditions such as open wounds, urinary catheters, IV lines both peripheral and central, or anyone with a current or latent Multi-Drug Resistant Organism infection. Staff are instructed to wear personal PPE appropriate for the condition during high care, including but not limited to gowns and gloves stored in bins outside the resident's door. A sign on the door should indicate to staff what PPE to use for any high-contact care provided, including care that could expose them to bodily fluids or exposure to the wound or indwelling medical device. The Infection Preventionist would expect staff to follow the facility policy for enhanced barrier precautions and would expect staff providing high-contact care including routine hygiene care such as replacing a brief, to wear gloves and other PPE as indicated. 8. During an interview on 11/7/24 at 2:25 P.M. the facility DON said the facility Infection Preventionist is in charge of staff inservicing and education regarding infection control policies and the facility's policy on enhanced barrier precautions. The DON would expect staff to follow the facility's policies on enhanced barrier precautions and hand hygiene in the appropriate circumstances, and would expect any transmission or enhanced precautions signage to be placed outside the room per CDC (Centers for Disease Control and Prevention) recommendations and guidelines. The DON expected all nursing staff to follow the facility's policy on enhanced barrier precautions when selecting PPE to use during high-contact care situations. 9. During an interview on 11/7/24 at 2:25 P.M. the facility Administrator said staff are expected to don and doff PPE per CDC guidelines and recommendations. All facility staff are expected to follow the facility's policy on hand hygiene for resident care to reduce the spread of infection within the facility among the community. 46888 49992

Based on interview and record review, the facility failed to ensure services provided met professional standards of practice when staff failed to complete neuro checks (neurological assessments) following unwitnessed falls or falls in which the resident hit their head, for two residents (Residents #44 and #35). The sample was 20. The census was 123 with 99 residents in certified beds. Review of the facility's Neurological Evaluation policy, revised 5/25/21, showed: -Purpose: The purpose of this procedure is to provide guidelines for a neurological assessment: 1) upon physician order; 2) when following an unwitnessed fall; 3) subsequent to a fall with a suspected head injury; or 4) when indicated by resident condition; -Steps in the procedure included: -Perform neurological checks with the frequency as ordered or per falls protocol; -Determine resident's orientation to time, place and person; -Observe resident's patterns of speech and speech clarity; -Take temperature, pulse, respirations, blood pressure; -Check pupil reaction; -Determine motor ability. Review of the facility's Clinical Documentation Standards - Care Center policy, -Electronic medical record (EMR) process for Adverse Event - Fall: -Completed for each adverse event fall; -Complete Post Fall Observation form and follow up is every shift for 72 hours. Residents should have increased monitoring for the first 72 hours after a fall. Each shift, the nurse should record in the medical record a review of systems, noting any worsening or improvement of symptoms as well as the treatment provided. 1. Review of Resident #44's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/2/24, showed: -Short and long term memory problem; -Cognitive skills for daily decision making: Severely impaired; -Inattention behavior present, fluctuates; -Altered level of consciousness behavior present, fluctuates; -Diagnoses included Alzheimer's disease, dementia, anxiety, depression, restlessness and agitation; -Two or more falls with injury (except major) since last assessment. Review of the resident's progress note, dated 9/20/24 at 11:09 P.M., showed resident found on floor at 8:00 P.M. this evening. No apparent injury. Unwitnessed. Full range of motion, denies pain, no discomfort observed. Assisted resident back into bed. Returned to resident's room at 8:10 P.M. and found the resident on the floor again. Neuro checks within normal limits (WNL). Review of the resident's post fall observation, dated 9/20/24 through 9/23/24, showed neuro checks not documented as completed as follows: -Two consecutive four-hour checks on 9/21/24; -One eight-hour check on 9/22/24. Review of the resident's progress note, dated 9/26/24 at 10:13 P.M., showed resident was found lying on his/her right side near the bathroom. Resident unable to tell staff what happened. Resident has full range of motion in all extremities. Skin tear to left elbow. Review of the resident's post fall observation, dated 9/26/24 through 9/29/24, showed neuro checks not documented as completed as follows: -One eight-hour check on 9/28/24; -One eight-hour check on 9/29/24. Review of the resident's progress note on 10/14/24 at 4:00 A.M., showed at 3:00 A.M., resident was found by staff in the doorway to his/her bathroom on his/her back on the floor. His/her head was in the bathroom and his/her torso was in the doorway to his/her room. Resident denied hitting his/her head, although he/she told the supervisor that he/she hit his/her head. No injuries noted. Review of the resident's post fall observation, dated 10/14/24 through 10/16/24, showed neuro checks not documented as completed as follows: -One four-hour check on 10/14/24; -Two consecutive eight-hour checks on 10/15/24; -One eight-hour check on 10/16/24. Review of the resident's progress note, dated 11/2/24 at 4:37 A.M., showed at 1:00 A.M., resident was found in the doorway to his/her bathroom on his/her back on the floor. When asked what happened, resident was silent. Resident denied hitting his/her head. No injuries noted. Review of the resident's post fall observation, dated 11/2/24 through 11/4/24, showed neuro checks not documented as completed as follows: -Three consecutive four-hour checks on 11/2/24; -Two consecutive eight-hour checks on 11/3/24; -Three consecutive eight-hour checks on 11/4/24. During an interview on 11/7/24 at 10:07 A.M., Licensed Practical Nurse (LPN ) C said the resident is confused and needs staff assistance with transfers. He/She falls frequently from trying to get up on his/her own. Due to his/her cognitive status, the resident would not be able to tell staff what happened in the event of a fall. 2. Review of Resident #35's significant change MDS, dated [DATE], showed: -Moderate cognitive impairment; -Upper and lower extremity impairment on one side; -Diagnoses included Alzheimer's disease, dementia, seizure disorder, anxiety, and depression; -One fall without injury, two or more falls with injury (except major), and one fall with major injury since last assessment. Review of the resident's progress note, dated 10/3/24 at 9:16 P.M., showed at 8:45 P.M., staff went to the resident's room to check on him/her and found the resident on his/her bathroom floor. Resident lying on his/her left side with his/her head under the sink. Resident assessed and neuro checks WNL. Review of the resident's post fall observation, dated 10/3/24 through 10/6/24, showed neuro checks not documented as completed as follows: -One hourly check on 10/3/24; -Two consecutive four-hour checks on 10/4/24; -One eight-hour check on 10/5/24. Review of the resident's progress note, dated 10/13/24 at 3:12 P.M., showed upon taking another resident to the restroom, Resident #35 was yelling, Help, get me off my hip, please. Upon going into resident's room, resident was on floor laying on right side near the sink. Vital signs within normal limits. Resident did not hit head. Skin tear to right elbow, both knees red. Review of the resident's post fall observation, dated 10/13/24 through 10/16/24, showed neuro checks not documented as completed as follows: -One hourly check on 10/13/24; -One four-hour check on 10/13/24; -Two consecutive eight-hour checks on 10/15/24. Review of the resident's progress note, dated 10/21/24 at 11:40 P.M., showed resident was found on the floor on the side of the bed by oncoming staff. Resident did not have any injuries. Resident did not recall what happened. Neuro checks WNL. Review of the resident's post fall observations, dated 10/21/24 and 10/22/24, showed: -Hourly neuro check completed 10/21/24 at 11:00 P.M.; -Hourly neuro checks missed at 12:00 A.M., 1:00 A.M., and 2:00 A.M.; -Neuro checks completed 10/22/24 at 6:00 A.M.; -On 10/22/24 at 7:00 P.M., staff started a new post fall observation document with neuro checks starting over on 10/22/24 at 7:00 P.M., and no neuro checks documented in between 6:00 A.M. and 7:00 P.M. that day. During an interview on 11/7/24 at 10:07 A.M., LPN C said the resident is very confused and his/her health has recently declined a lot. He/She falls frequently and he/she has no sense of safety and will try to stand on his/her own, but he/she needs assistance from staff to stand. Due to his/her cognitive status, the resident would not be able to tell staff what happened in the event of a fall. 3. During an interview on 11/7/24 at 10:07 A.M., LPN C said neuro checks must be initiated for all unwitnessed falls. Neuro checks are performed to assess residents for internal head injuries. Neuro checks should be completed at various intervals for the 72 hours following a resident's fall. Nurses should document neuro checks in the EMR. Once neuro checks are triggered in the EMR, it pops up as an order for staff to follow at all shifts until the conclusion of the 72 hour period. 4. During an interview on 11/7/24 at 11:04 A.M., LPN D said neuro checks should be initiated following all unwitnessed falls. Immediately following a fall, the nurse completes a full assessment of the resident and documents it in the EMR. After entering the fall in the EMR, it should trigger staff to continue neuro checks hourly, then every four hours, then every eight hours for 72 hours following the resident's fall. Neuro checks are completed to assess residents for injury. 5. During an interview on 11/7/24 at 2:21 P.M., the Director of Nurses (DON), Interim Administrator, and Administrator said Residents #35 and #44 are confused, disoriented, and have frequent falls. It would be expected for staff to complete neuro checks following falls for Residents #35 and #44, and any unwitnessed fall for residents who are not alert and oriented. Neuro checks should also be completed for any fall in which the resident hits their head. Neuro checks are performed to make sure residents do not have head injuries. They are documented as post-fall assessments in the EMR and should be performed in accordance with the times on the post-fall assessment flow sheets. 46888

Based on interview and record review, the facility failed to ensure the pharmacist reported any irregularities to the attending physician and the facility's Medical Director and Director of Nursing (DON), and failed to ensure these reports were acted upon for two residents (Residents #47 and #52). The sample was 20. The census was 123 with 99 residents in certified beds. Review of the facility's Drug Regimen Review policy, provided as the facility's policy and procedure for the required monthly medication review for residents, revised February 2019, showed: -Policy Statement: It is the policy of the community that a licensed pharmacist will review the resident drug regimen including the resident chart at least once a month. The consultant pharmacist may need to conduct the medication regimen review more frequently depending on the resident condition, review of short stay resident and risk of adverse consequences. The licensed pharmacist will report in writing, any irregularities to the attending physician, the community's Medical Director and the Director of Nursing to be acted upon; -Policy Interpretation and Implementation: 1. The pharmacy consultant will perform a monthly drug regimen review on each resident unless the resident condition/risk will indication a more frequent schedule that is individualized and communicated between the community clinical staff and the pharmacy consultant. 2. Irregularities identified will be documented on a separate, written report and sent to the physician, Medical Director, and Director of Nursing, listing the resident's name, relevant drug and irregularity the pharmacist has identified. If in the professional judgment of the Pharmacy Consultant that an irregularity requires urgent action, the Pharmacy Consultant will immediately report the irregularity to the Director of Nursing and or charge nurse and the attending physician by phone. 3. The physician will document in the resident record that the identified irregularity has been reviewed and any action taken to address it. If the physician chooses not to act upon the Pharmacy Consultant recommendations, the physician must document the rationale as to why the change is not indicated in the resident record. 4. All medication regiment review documents will be maintained in the resident medical record. 1. Review of Resident #47's medical record, showed: -Diagnoses included dementia, healed traumatic fracture and high blood pressure; -An order dated 4/30/20, for acetaminophen (used to treat pain or fever) 325 milligram (mg). Administer 650 mg by mouth every 4 hours as needed for pain; -An order dated 8/8/24, for oxycodone-acetaminophen (to treat pain) 5 mg/325 mg tablet, one tablet every eight hours as needed for severe pain. Review of the resident's Consultant Pharmacist Recommendation to Physician, dated 9/26/24, showed: -Recommendation Category: Potential High Dose Therapy; -Please add the following warning to current order(s) for acetaminophen 1. oxycodone-acetaminophen 5 mg/325 mg tablet, one tablet every eight hours as needed for severe pain; 2. acetaminophen 325 mg. Administer 650 mg by mouth every 4 hours as needed for pain. Maximum dose is 3 grams (GM) in 24 hours from all sources. Please update the Medication Administration Record (MAR) to reflect this change. -There is no record the recommendation was addressed, and the physician's orders do not reflect a change in the medications. 2. Review of Resident #52's medical record, showed: -Diagnoses included diabetes, stroke, dementia, high cholesterol, poor appetite, depression, and high blood pressure; -An order dated 1/9/24, for escitalopram (to treat depression) 5 mg. Administer 15 mg by mouth every day; -An order dated 9/18/23, for mirtazapine (to increase appetite) 7.5 mg tablet, by mouth every day. Review of the resident's Consultant Pharmacist Recommendation to Physician, dated 8/28/24, showed: -Federal nursing facility regulations require that consideration be given to the gradual does reduction (GDR) for psychopharmacologic therapies unless documentation exists which GDR in contraindicated; -Please consider a GDR for the following 1. Escitalopram 15 mg by mouth daily; 2. Mirtazapine 7.5 mg daily by mouth daily; -There is no record that the recommendation was addressed, and the physician's orders do not reflect a change in the medications. 3. During an interview on 11/7/24 at 8:58 A.M., Licensed Practical Nurse (LPN) I said the Medication Management Review (MRR) reports are sent the supervisor and then each charge nurse will address the recommendations assigned to their unit. He/She expected staff to address the recommendations within a week. 4. During an interview on 11/7/24 at 2:21 P.M., the Director of Nursing (DON) said she distributes the MRRs to the Unit Managers to have the nurses address the recommendations. Some of the recommendations are addressed in person at the facility and the remainder are done via fax or by phone. The MRR should be addressed within 30 days. After several attempts, if a physician does not address the MRR, the recommendations are forwarded to the Medical Director. She does not currently have a system in place to follow up on the recommendations. 5. During an interview on 11/7/24 at 2:21 P.M., the Administrator said she expected nursing staff to follow the facility's policy on pharmacy recommendations.

Based on observations, interviews, facility document and policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to label and date perishable and non-perishable food items in 1 of 2 walk-in refrigerators, 1 of 3 walk-in freezers, and 1 of 1 dry storage area. The facility also failed to label and date perishable items in the refrigerators and freezers in 2 out of 8 satellite unit kitchens. Findings included: Review of a facility policy titled, Food Flow-Storage, revised on 11/01/2023, revealed, Discard ready-to-eat foods that are not date marked or that exceed the 4-day time period. The policy indicated under the heading, Date Marking Ready-to-Eat, Potentially Hazardous Foods, that 1. The best practice for a date marking system is to label the item with the product name, the date, and the time it is prepared or opened. 2. Label ready-to-eat, potentially hazardous foods that are prepared on site and held for more than 24 hours. The policy further revealed, 6. Indicate with a separate label the date prepared, the date frozen, and the date thawed of any refrigerated, ready-to-eat, potentially hazardous foods. 1. During an observation of walk-in refrigerator #1 on 07/31/2023 from 10:16 AM to 10:23 AM with Manager of Dining Services #1, the following meat items did not have a date recorded or expiration date included: six sealed packages of beef ribs, one pork loin, one bottom round corned beef, one beef top round, and one smokehouse pit ham. Manager of Dining Services #1 stated the process for meat storage was assigned to two dietary staff members. If a meat item arrived at the facility frozen, then it was placed in either of the two walk-in refrigerators. All other items were placed in the walk-in refrigerators and rotated accordingly. The labels on the shipping boxes had expiration dates. If a box was discarded, then the items removed should be dated. He stated he pulled the pork loin from a freezer on 07/28/2023 and it would be prepped on 07/31/2023 for the following day. Manager of Dining Services #1 indicated the smokehouse pit ham was used for the dinner meal on 07/30/2023. During an observation of the dry storage area on 07/31/2023 at 10:32 AM with Manager of Dining Services #1, the following items were found opened without a date recorded: half a bag of egg noodles, half a bag of penne pasta, and half a bag of elbow macaroni. Manager of Dining Services #1 stated any open item in dry storage should be sealed and have a date written on the package. During an observation of walk-in freezer #1 on 07/31/2023 at 10:37 AM with Manager of Dining Services #1, the following items were found on a metal rack without a label or date: one shotgun pan of crab rangoon, one shotgun pan of chicken fingers, one shotgun pan of chicken breast, and one shotgun pan of egg rolls. Manager of Dining Services #1 stated these food items were from the restaurant and should have been labeled. During an observation of walk-in refrigerator #1 on 08/01/2023 at 2:17 PM with the Executive Chef, one package of andouilles sausage did not have a date on it. The Executive Chef stated that if meat was pulled out of the shipped box that included the ship date, then all packaged meat outside the shipping box should have a date on it. An interview was conducted on 08/03/2023 at 11:15 AM with the Cook. She stated that meat was stored in shipping boxes in the refrigerators or freezers. If there was only one item left in the shipping box, then she would take it out and follow the first-in-first-out (FIFO) procedure. She stated she labeled the single item with a paper label as well as marker that included the date when it was received and the use-by date. If prepared foods needed to be stored in the refrigerator or freezer, then she would place it in a container, cover it properly, and label and date the item. An interview was conducted with the Registered Dietitian (RD) on 08/03/2023 at 11:26 AM. She stated perishable items needed to be covered and wrapped, labeled, and dated, and discarded in three days. She would expect that all perishable and non-perishable food items be labeled and dated when opened and stored. All food items that were not labeled and dated should have been discarded. An interview was conducted on 08/03/2023 at 11:34 AM with the Supply Coordinator. He stated his responsibility was to ensure proper rotation of stored meats. He also received, maintained, and distributed foods to all the satellite kitchens. The Supply Coordinator indicated foods were delivered twice weekly, and the meats came in a sealed box with shipped and use-by/freeze-by dates. If the meats needed to be placed in the freezer, a label of when it was initially frozen would be included. If one meat item was left outside the shipping box, he was supposed to write the use-by date on the single meat item. He stated that once food items were opened, then they would need to be labeled and dated as well. An interview was conducted on 08/02/2023 at 2:31 PM with the Dining Services Director. He stated all perishable and non-perishable food items should be labeled and dated unless there was a predated stamp on the packaging. All opened items transferred to another container had a three-day shelf life. An interview was conducted with the Director of Nursing (DON) on 08/03/2023 at 10:17 AM. She stated all foods in refrigerators and freezers should be labeled and dated, and if the item was questionable, it should have been discarded. An interview was conducted on 08/02/2023 at 3:06 PM with Administrator #20 and she stated her expectations were that all perishable and non-perishable food items should be labeled and dated. Any items removed from the shipping box with a labeled date should be dated as well. 2. During an observation of satellite kitchen #1 on 08/02/2023 at 9:10 AM, the following items were found without a label or date: - Freezer #1: two press-sealed plastic bags of bread rolls, five press-sealed plastic bags of French toast, three press-sealed plastic bags of pancakes, one press-sealed plastic bag of croissants, and one press-sealed plastic bag of pepperoni. - Refrigerator #1: one metal container of pear slices in liquid, one press-sealed plastic bag of lettuce, one press-sealed plastic bag of sliced tomatoes, one press-sealed plastic bag of bread rolls, one press-sealed plastic bag of sliced pepperoni, one press-sealed plastic bag of sliced red onion, one press-sealed plastic bag of one tomato sliced in half, one cling-wrapped stack of sliced yellow cheese, and two unopened peach yogurt containers. - Freezer #2: one tray of biscuits, two trays of cinnamon rolls, and one tray of croissants. During an interview with Manager of Dining Services #2 on 08/02/2023 at 9:23 AM, he stated that each of the satellite kitchens were managed by him. All food stored in the satellite kitchens should be labeled and dated. During a follow-up interview with Manager of Dining Services #2 on 08/02/2023 at 9:28 AM, he stated satellite kitchen #1 was managed by nursing staff and was not part of the skilled nursing area. Manager of Dining Services #2 indicated that nursing staff were expected to label and date all opened or unpackaged foods. The food that was not dated or labeled was discarded by Manager of Dining Services #2. During an observation of satellite kitchen #2 on 08/02/2023 at 9:54 AM, the following items were not labeled or dated: - Refrigerator #1: fourteen bowls of cut pineapple and two bowls of mixed fruit covered by meal trays. - Freezer #1: one opened bag of two hoagie rolls and one opened bag of hamburger patties with date not legible. - Freezer #2: one press-sealed plastic bag of biscuits. An interview was conducted on 08/02/2023 at 9:57 AM with the Dietary Aide (DA). She stated all foods in the refrigerators and freezers should be labeled and dated. The DA indicated all bread did not have to be labeled and dated because it was used so quickly. She indicated the fruit bowls were prepared earlier in the day and would be used for the lunch meal. An interview was conducted on 08/02/2023 at 10:08 AM with Nurse Manager #3. She stated certified nursing assistants and certified medical technicians were expected to label and date all foods when opened and stored in the kitchen area. Nurse Manager #3 indicated that if full-time nursing staff were not present, the labeling and dating of foods was challenging. An interview was conducted on 08/02/2023 at 2:31 PM with the Dining Services Director. He stated all perishable and non-perishable food items should be labeled and dated unless there was a predated stamp on the packaging. All opened items transferred to another container had a three-day shelf life. The Dining Services Director indicated that satellite kitchen #1 was overseen by nursing, and Manager of Dining Services #2 performed quality control checks twice weekly and sent necessary corrections to nursing services. An interview was conducted with the Director of Nursing (DON) on 08/03/2023 at 10:17 AM. She stated nursing would be responsible for maintaining satellite kitchen #1 because a dining staff member was not assigned to that kitchen. All foods in refrigerators and freezers should be labeled and dated, and if the item was questionable, it should have been discarded. An interview was conducted on 08/02/2023 at 3:06 PM with Administrator #20. She stated her expectations were that all perishable and non-perishable food items should be labeled and dated. Any items removed from the shipping box with a labeled date should be dated as well.

Based on interview, record review, and facility policy review, it was determined that the facility failed to provide the required bed hold notification at the time of transfer for 2 (Resident #209 and #219) of 3 residents reviewed for hospitalization . Findings included: A review of a facility policy titled, Bed holds and Returns, with a revised date of 09/14/2022, revealed, All residents/representatives are provided written information regarding the facility bed hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice: a. well in advance of any transfer (e.g. [for example], in the admission packet); and b. at the time of transfer (or, if the transfer was an emergency, with 24 hours). 1. A review of a Face Sheet indicated the facility admitted Resident #209 on 07/06/2023 with diagnoses that included acquired absence of other specified parts of digestive tract, polyp of colon, and anemia in chronic kidney disease. The Face Sheet indicated Resident #209 was discharged from the facility on 07/10/2023. A review of a Clinical Notes Report, dated 07/10/2023, revealed Resident #209 was transported via stretcher to the hospital. The progress note did not address the bed hold notification. 2. A review of a Face Sheet indicated the facility admitted Resident #219 on 03/13/2023 with diagnoses of complete atrioventricular block and presence of pacemaker. The form indicated Resident #219 was discharged from the facility on 03/28/2023. A review of a Clinical Notes Report, dated 03/28/2024, revealed Resident #219 was transported via private vehicle, at the family member's request, to the emergency room . The note revealed the face sheet, medication list, recent labs, chest x-ray results, and a signed code status sheet were sent with the resident. The progress note did not address the bed hold notification. During an interview on 08/03/2023 at 10:20 AM, the Director of Nursing (DON) indicated it was facility policy that Medicare A (skilled) residents did not get to hold a bed. During an interview on 08/03/2023 at 1:43 PM, Nurse Manager (NM) #8 indicated the facility never held a bed but placed the resident on leave of absence to the emergency room . NM #8 indicated the resident might be in a different room when they returned, but they could return when they were ready. During an interview on 08/03/2023 at 1:58 PM, the Director of Nursing (DON) indicated the residents on skilled services did not pay to hold the bed. The DON indicated the resident or responsible party signed an agreement on admission about bed hold. During an interview on 08/03/2023 at 2:19 PM, the Social Services Coordinator (SSC) indicated short-term rehabilitation residents were told they may get a different room when they returned to the facility rather than having them pay to hold the room. The SSC indicated she did not follow up when the residents discharged to see if they wanted to hold the bed. The SSC indicated the stays were so short that she did not have to remind residents or families about the bed hold. During an interview on 08/03/2023 at 2:28 PM, Administrator #19 was asked if she was aware a bed hold agreement was required even for Medicare residents, and she indicated that was not something specifically that was done. During an interview on 08/03/2023 at 3:02 PM, Administrator #20 indicated it was facility policy to allow a resident to pay privately for bed hold. Administrator #20 indicated that on the short stay unit the procedure was if someone went out, they were put on leave of absence to the hospital, and once the facility received confirmation that the resident was admitted then they would be discharged . Administrator #20 indicated the facility did not send documentation addressing bed holds with the resident when they left to go out to the hospital.

Based on interview, record review, and facility policy review, it was determined that the facility failed to ensure the physician was notified of a change in condition for 1 (Resident #209) of 3 residents reviewed for change in condition. Specifically, the facility did not notify the physician when Resident #209 complained to staff of rectal bleeding. Findings included: A review of the facility's policy titled, Change in Resident Condition, originated on 01/25/2017, revealed, Except in medical emergencies, notification will be made no later than 12 hours of a change occurring in the resident's medical/mental condition. A review of a Face Sheet indicated the facility admitted Resident #209 on 07/06/2023 with diagnoses that included acquired absence of other specified parts of digestive tract, polyp of colon, and anemia in chronic kidney disease. The 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/10/2023, revealed Resident #209 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The resident required limited assistance with bed mobility, transfer, and toilet use. The resident was occasionally incontinent of urine and always continent of bowel. Review of Resident #209's Care Plan Report, dated 07/07/2023, revealed the resident was at risk for bleeding related to anticoagulant use. Interventions directed staff to monitor for signs of bleeding in stool and report any abnormal bleeding or new bruising to health care provider and monitor their vital signs as indicated. Review of a hospital Inpatient Discharge Summary, dated 07/06/2023, indicated Resident #209 was discharged from the hospital after receiving a laparoscopic assisted right colectomy (a surgical procedure that involves removing a segment of the colon). A review of a Clinical Notes Report addendum note, entered on 07/10/2023 at 3:53 PM with an effective date of 07/09/2023 at 9:50 PM and signed by Licensed Practical Nurse (LPN) #9, revealed Resident #209 was alert and oriented to person, time, place, and situation, required assistance of one staff, and was continent of bowel. The note indicated the resident reported blood in the stool and when the nurse went to the room, the toilet had been flushed. The note indicated no blood was seen in or around the toilet. LPN #9 told Resident #209 to let her know the next time the resident had a bowel movement (BM). During a telephone interview on 08/02/2023 at 2:03 PM, LPN #9, who worked 07/08/2023 and 07/09/2023, indicated on Sunday 07/09/2023, Resident #209 reported a bloody stool and that the resident flushed before she could see it. LPN #9 indicated she told Resident #209 that she needed to observe the stool and the resident voiced understanding. LPN #9 stated there had been no change in vital signs and the resident was up walking around. During a telephone interview on 08/03/2023 at 1:22 PM, LPN #9 indicated the reason she did not call the doctor about the resident reporting a bloody stool was because the physician usually wanted a guaiac (a test of the stool to determine the presence of blood), and she did not see the stool to do the test. LPN #9 indicated she obtained the resident's vital signs and asked about pain. LPN #9 indicated there was usually residual blood observed in the toilet if a resident were bleeding but there was none for Resident #209. LPN #9 indicated Resident #209 reported that morning that they thought there was blood in the BM. LPN told the resident to save the next BM. LPN #9 indicated later that day, the certified nurse assistant (CNA) answered the call light and Resident #209 told the CNA they were having a BM. LPN #9 said when she entered the resident's bathroom to look at the stool, the resident was washing their hands and had flushed the toilet. LPN #9 indicated that was on Sunday, 07/09/2023. A review of hospital laboratory results of a complete blood count (CBC), dated 07/10/2023 at 5:33 PM, revealed a hemoglobin level of 3.6 grams per deciliter (g/dL), which indicated a critical lab value. The reference range was 11.9 - 15.5 g/dL. A review of H&P [history and physical] Notes, dated 07/11/2023 at 12:00 AM, indicated the chief complaint for Resident #209 was rectal bleeding. The note indicated the resident previously underwent a right colectomy for adenomatous polyp. The note indicated that in the emergency room the resident's hemoglobin level was 3.6 g/dL and Resident #209 received two units of blood. The repeated hemoglobin was 5.6 g/dL and the resident received one more unit of blood. The hemoglobin was then 6.6 g/dL. The note indicated Resident #209 received the fourth unit of blood at the time of the note. The note indicated Resident #209 had active gastrointestinal bleeding at the level of the colonic anastomosis (the site where the two ends of the colon were joined). The note indicated the resident would be transferred to the intensive care unit (ICU) due to ongoing active bleeding. During a telephone interview on 08/02/2023 at 4:58 PM, LPN #12, who worked on 07/08/2023, indicated the resident had reported that they had bloody stools and the resident was told by other staff that staff needed to see the BM. LPN #12 indicated the resident did not report another stool to her. LPN #12 stated the BM needed to be observed for color and consistency before it could be treated. LPN #12 indicated Resident #209 was without symptoms and was fine. During a follow-up telephone interview on 08/03/2023 at 1:14 PM, LPN #12, indicated if the resident had reported the bloody stool to her then she would have called the doctor. LPN #12 indicated Resident #209 did not report anything to her the evening of 07/08/2023. During a telephone interview on 08/03/2023 at 12:39 PM, LPN #13, who worked 07/08/2023 and 07/09/2023 on the night shift, stated no CNA had reported bloody stool to him. LPN #13 indicated he did not recall that Resident #209 had reported any bloody stool. During a telephone interview on 08/02/2023 at 2:29 PM, the Nurse Practitioner (NP) indicated she came to see Resident #209 on 07/10/2023 because there was concern about Resident #209 having rectal bleeding all weekend that no one notified the physician or NP about. During a telephone interview on 08/03/2023 at 12:50 PM, the NP indicated she would expect staff to notify her of the report of bloody stools. The NP stated she expected the nurses to assess and follow up if bloody stool was reported. During a telephone interview on 08/03/2023 at 12:55 PM, the Physician indicated she was not notified of the bloody stool. The Physician indicated she could see why the nurses waited since they had not seen the stool. During an interview on 08/03/2023 at 1:43 PM, Nurse Manager (NM) #8 indicated she expected the nurses to assess a resident and report to a physician if there was BM in the toilet or brief. NM #8 indicated she did do some coaching with LPN #9 after 07/09/2023 to assess bowel sounds, assess the stomach, and call the physician. During an interview on 08/03/2023 at 1:58 PM, the Director of Nursing (DON) indicated she expected the nurse to obtain vital signs, do an assessment for abdominal distention, and notify the physician if an alert and oriented resident (like Resident #209 was) had reported bloody stools. The DON indicated the expectation was to notify the physician with their findings of blood, vital signs, and their assessment of the resident. She also indicated that it would be logical to ask the resident what they had seen or if there was any pain. During an interview on 08/03/2023 at 2:28 PM, Administrator #19 indicated she would expect the nurses to assess the resident, obtain vital signs, ask the resident questions about color, and amount and then reach out to the doctor, even though they did not see the bloody BM. Administrator #19 indicated best practice was to notify the physician and family. During an interview on 08/03/2023 at 3:02 PM, Administrator #20 indicated if an alert and oriented resident reported bloody stools to the nurse she would expect them to see the stool. If the stool was flushed, she would ask the resident for consistency and color, get vital signs, listen and check the abdomen for distention, in order to gather as much information as possible. She would also ask if it turned the water red, or if it was only when they wiped. The expectation was to notify the doctor of what the resident reported.

Based on interview and record review, the facility failed to ensure newly hired employees were screened to determine the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry, for two of 10 sampled employees hired since the last survey. The facility hired at least 300 new employees since the last survey. The census was 164. Review of the facility's Abuse/Neglect Prevention and Response Policy, dated 7/29/21, showed the following: -Policy Statement: Residents and client of the facility campuses and programs will live and be served in an environment that promotes dignity, respect and strived to be free from abuse, neglect and exploitation. Allegation of potential or actual abuse, neglect or exploitation will be immediately reported to the appropriate leadership and government agency(ies), the resident protected and the allegation investigated; -Screening: The facility conducts a criminal background check and conducts other checks as applicable for the state in which the community operates: -For Missouri, review the Missouri Employee Disqualification List; -A check is completed on each potential facility employee. The facility will hire only individuals who successfully complete this process. The facility also completes reference and licensure checks prior to hiring. Periodically, all employees will be checked to insure that they continue to remain off the Missouri Employee Disqualification List. 1. Review of Maintenance Associate A's employee file, showed the following: -Hire date: 1/17/23; -No CNA registry check performed. 2. Review of Dietary Aide B's employee file, showed the following: -Hire date: 3/28/23; -No CNA registry check performed. 3. During an interview on 8/10/23 at 11:40 A.M., the Human Resource Generalist said she was new to the position and was not sure if the CNA registry needed to be checked for all staff members. 4. During an interview on 8/10/23 at 11:55 A.M., the Administrator said the Human Resource Manager should check the CNA Registry for the federal indicator. It is possible this issue was overlooked.

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the residents' highest practicable well-being when staff failed to conduct and or document neurological checks after a fall. In addition, the facility failed to notify the physician for further guidance when a resident experienced lethargy (a pathological state of sleepiness or deep unresponsiveness and inactivity) and neurological changes after the fall occurred (Resident #1). The sample was three. The census was 98. Review of the facility's fall policy, dated 4/26/19, showed the following: -Policy Statement: -Base on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; -Fall Definition: An incident in which the resident unintentionally comes to rest on the ground, floor, or other lower level, but not a result of overwhelming external force. An episode where a resident lost their balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred; -Policy Interpretation and Implementations: -Prioritizing Approaches to managing falls and fall risk; -Each resident will be assessed for the risk factors for falling on admission, quarterly, with change of condition, upon return from a health care facility and after a fall; -The staff with the input from the physician, will identify appropriate interventions to reduce the risk of the falls; -In conjunction with the physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling; -Monitoring subsequent falls and fall risk; -The staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling; -If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the physician will help the staff reconsider possible causes that may not previously have been identified; -The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Review of the facility's neurological evaluation policy, dated 7/1/19, showed: Purpose: -The purpose of this procedure is to provide guidelines for a neurological assessment: 1. Upon a physician's orders [REDACTED]. 3.) Subsequent to a fall with a suspected head injury. 4.) When indicated by resident condition; -Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure: -Flashlight; -Stethoscope and sphygmomanometer (instrument used to take a blood pressure); -Thermometer; -Timepiece to measure seconds; -Steps in the procedure: -Perform hand hygiene; -Perform neurological checks with the frequency as ordered per falls protocol; -Determine the resident's orientation to time, place and person; -Observe the resident's pattern of speech and speech clarity; -Take temperature, pulse, respirations, and blood pressure; -Check eye pupil reaction; -Darken room. Open eyelid with your fingers. Turn on flashlight and observe size and reaction of pupil; and repeat for the other eye; -Determine motor ability: -Have resident move all extremities. Ask resident to squeeze your fingers; Note strength bilaterally (both sides). Have resident plantar and dorsiflex (movement of the feet); Note strength bilaterally; Ask resident if they have any numbness or tingling in extremities and document accordingly; -Perform hand hygiene. Review of the facility's change in resident condition policy, dated 5/6/19, showed the following: -Policy Statement: -The community will promptly notify the resident's physician and representative of changes in the resident's medical/mental condition; -Policy Interpretation and Implementation: -The nurse will notify the resident's physician or on-call physician and representative when there has been: -An accident or incident involving the resident. A significant change in the resident's physical/emotional/ mental condition. A need to alter the resident's medical treatment significantly. A need to transfer the resident to the hospital/ treatment center; -Except in medical emergencies, notification will be made no later than 12 hours of a change occurring in the resident's medical/mental condition; -Regardless of the resident's current mental or physical condition, staff will inform the resident of any change in their medical care or nursing treatments; -Staff will record in the in the residents' medical record information relative to changes in the resident's medical/mental condition or status; -If a significant change in the resident's physical or mental conditions occur, an assessment of the resident's condition will be conducted. A significant change of condition is a decline or improvement in the resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Impacts more than one area of the residents' health status. Requires interdisciplinary review and/or revision to the care plan. Ultimately is based on the judgement of the clinical staff and/or guidelines outlined in the Resident Assessment Instrument. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/9/20, showed: -Clear speech, makes self-understood and understands; -Brief interview for mental status (a screening tool used to determine cognitive status) not conducted and not indicated as unable to be conducted; -Is there evidence of an acute change in mental status from the resident's baseline: No; -Inattention: Behavior not present; -Disorganized thinking: Behavior not present; -Altered level of consciousness: Behavior not present; -Extensive assistance required for bed mobility, transfer, dressing, toilet use and personal hygiene; -Moving from seated to standing position, moving on and off the toilet and surface-to-surface transfer: Not steady, only able to stabilize with human assistance; -Use of a wheelchair; -[DIAGNOSES REDACTED]. -Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months: No; -Fall history on admission: Yes; -Did the resident have a fall any time in the last 2 to 6 months prior to admission: No; -Received oxygen therapy. Review of the resident's care plan, in use during the time the resident resided in the facility, showed: -Focus: Resident is at risk for falls/injury as evidenced by: history of falls, cognition, medications, incontinence, vision and balance. On 6/29/20, fall transferring self from bed to wheelchair; -Goal: Resident will not sustain a major injury related to falls through next review; -Interventions: Continence- see Alteration in Urinary Care Plan. Provide environmental adaptations- Resident's call light within reach; adequate, glare free lighting; area free of clutter. Provide/monitor use of adaptive/assistive devices- wheelchair. Side rail(s) as an enabler to assist with transfers and bed mobility- 1/2 side rails, grab bars. Encourage/assist the resident when rising from a lying position, sit on side of bed for a few minutes before transferring/standing. Report the following possible drug side effects or symptoms to nurse - increased weakness, sedation, lightheadedness, dizziness, and change in mental status; -Focus: Urinary Continence: Resident is frequently incontinent of urine: -Goal: Resident will not have any moisture related skin breakdown, falls or urinary tract infections [MEDICAL CONDITION] related to incontinence through next review; -Interventions: Notify nurse of any signs or symptoms of UTI including blood in urine, increased urinary frequency or pain with urination. Resident requires one person assist with toileting. Check for incontinence; change if wet/soiled. Implement safety measures (keep path to bathroom clear and well lit, select clothing that is easily removed for toileting, answer call bell quickly). Assist resident to the bathroom in the morning upon rising, between meals, before activities, at bedtime and per his/her request. Review of the resident's medical record, showed: -[DIAGNOSES REDACTED]. -A Morse fall scale, dated 7/28/20, showed low fall risk. Review of the resident's physician order [REDACTED]. -An order dated 6/26/20, Regular Diet. Oxygen (O2) 3 liters per nasal cannula. O2 via pulse oximetry (the measurement of the percentage of oxygen in the blood). Keep O2 saturation at 90%; -No orders for any fall preventive measures. Review of the resident's progress notes, showed: -On 7/28/20 at 10:29 P.M., resident on the floor yelling for help. Once Licensed Practical Nurse (LPN) A arrived, he/she was laying on his/her left side. When asked what happened, the resident said he/she fell while trying to pull up his/her pants. LPN A asked did he/she have any pain or hurt anywhere, he/she denied it. Upon assessment, LPN A noted some dried scratches to his/her elbow, no injuries to his/her head, he/she denied hitting his/her head as well. The resident begin turning lethargic, oxygen was applied, LPN A set him/her up on floor until his her 02 raised back to his/her normal limits. Nursing assistant arrived and assisted LPN A with resident's transfer. During the transfer he/she begin screaming his/her hip. LPN A assessed the area, nothing but old bruising on his/her skin. LPN A practiced range of motion, the resident complained of pain when he/she flexed his/her lower extremity. LPN A asked about the pain, he/she did ask for pain medications due to the progression of his/her pain. The resident's right grips and pushes were stronger than his/her left side. He/she was oriented to self and situation. His/her brief was dry, wheelchair was positioned closer to his/her bed when he/she was found on the floor. His/her vitals appear to be stable. LPN A began neurological (neuro) checks, notified physician of painful hip, new orders for x-ray to the resident's left hip and femoral (upper leg bone) area. LPN A also noted a resurfaced skin tear to resident's lower knee cap on his/her left leg. Power of attorney has not been notified; -The note did not specify if the resident was on oxygen at the time of the fall, how many liters of oxygen the resident was placed on or his/her oxygen saturation (O2 sats, percentage of oxygen in the blood) before or after the application of oxygen. No documentation the physician was notified of the resident's lethargic episode. No specification of the vital signs obtained. During an interview on 10/15/20 at 1:39 P.M., Physician I said he/she was the physician for the resident and had ordered the x-ray due to the resident's fall. If the resident had turned lethargic, he/she was not aware. When the facility had called they said the resident was hurting. He/she knew the resident fairly well. The resident had a lot of medical problems. He/she was pretty frail. When staff called, he/she told them to get an x-ray STAT (immediately). If the resident was indeed lethargic, he/she would have expected to be notified. But this would be for any resident. Lethargy comes in different levels. If the resident's vital signs, for example O2 sats or respirations, were decreasing he/she would have expected for the resident to be sent out 911. During an interview on 10/19/20 at 1:18 P.M., the Director of Nursing (DON) said the resident's fall was at 9:00 P.M., based off the fall investigation. LPN A completed and signed his/her notes at 10:29 P.M., but this was not the time of the fall. Review of the resident's neurological check flow sheet, dated 7/28/20, showed neuro check to be completed every 15 minute (min) x 4, every 30 min x 2, every hour x 2, and every 8 hours x 72 hours. This checklist should be completed at the following intervals for follow up for all unwitnessed falls or falls in which head is struck. Any changes in resident condition requires a phone call to the primary care physician: -Baseline at 9:30 P.M. (no documentation of vital signs or neuro checks at 9:00 P.M., the alleged time of the fall): -Blood pressure 154/60 (normal 90/60 through 120/80), pulse 82 (normal 60 through 100), respiratory rate 24 (normal 12 through 22), temperature 98.5 (normal 97.8 through 99.1), no O2 sats indicated; -Level of consciousness (LOC): Lethargic; -Pupils equal; -Right pupil response: Sluggish; -Left pupil response: Sluggish; -Every 15 min x 4: -9:45 P.M.: -LOC: Drowsy; -Pupils equal; -Right pupil response: Sluggish; -Left pupil response: Sluggish; -10:00 P.M.: -LOC: Alert; -Pupils equal; -Right pupil response: Brisk; -Left pupil response: Brisk; -10:15 P.M.: -LOC: Alert; -Pupils equal; -Right pupil response: Brisk; -Left pupil response: Brisk; -10:30 P.M.: -LOC: Alert; -Pupils: Right greater than the left; -Right pupil response: Brisk; -Left pupil response: Brisk; -Every 30 minutes x 2: -11:00 P.M.: -LOC: Drowsy; -Right pupil react: No; -Left pupil react: No; -Pupils: Not documented as assessed; -Right pupil response: Sluggish; -Left pupil response: Sluggish; -Motor function upper extremity: Unable; -Motor function lower extremity: Unable; -Hand grasp: Unable; -11:30 P.M.: -LOC: Alert; -Pupils equal; -Right pupil response: Brisk; -Left pupil response: Brisk; -Motor function upper extremity: Yes; -Motor function lower extremity: Unable; -Hand grasp: Not documented as assessed; -Every 1 hour x 2: -12:30 A.M., no documentation of neuro checks and or vitals for this time period; -1:30 A.M., no documentation of neuro checks and or vitals for this time period. Further review of the resident's medical record, showed not documentation the resident's physician or family was notified of the changes in the resident's neurological status. During an interview on 10/15/20 at 1:39 P.M., Physician I said he/she did not recall if facility contacted him/her about the 10:30 P.M. change in neurological status. This was back in July. If there was change in neurological signs, he/she would have expected the facility to notify him/her. If there were acute changes, he/she would have expected the facility to send the resident out to the hospital urgently. The resident had multiple medical complications, so it could be a variety of things going on. Review of the resident's x-ray results, showed: -Date of service, 7/28/20; -The resident suffered an impacted fracture thru femoral neck (fracture caused when bones fragments are driven into each other, broken hip); -It appears to be new when compared to the prior study. Clinical correlation and follow-up are recommended; -Electronically signed by the laboratory company physician on 7/29/20 at 1:44 A.M. Further review of the resident's progress notes, showed on 7/29/20 at 2:33 A.M., x-ray results show resident has an impacted left femoral neck fracture. Notified Physician D, send to emergency room . Notified family. He/she agrees with sending the resident to the hospital. Called Ambulance Company and scheduled pick up for resident. Waiting their arrival: -No documentation of further assessment of the resident's status. Review of the resident's ambulance report, showed: -Call received: 1:56 A.M.; -Dispatched: 2:37 A.M.; -Enroute: 2:38 A.M.; -At scene: 2:55 A.M.; -At the resident's side: 3:00 A.M.; -Transport: 3:15 A.M.; -Dispatch information: -Response Mode: No lights and siren (indicated when the transport was not called in as an emergency); -Transportation mode: Downgraded no lights/sirens; -Upon arrival: -Found the resident laying semi fowlers (positioned with the head if the bed raised) in bed, gasping for air. The resident is alert to painful stimuli and non-verbal. The LPN states the resident fell from a standing position at approximately 10:30 P.M., the resident has a broken hip confirmed via x-ray, the resident is normally alert and oriented times four, and the resident's breathing status is new for the resident; -The resident was placed on a monitor showing sinus rhythm (regular heart rhythm). O2 sat showing 88% on 3 liters per minute, 02 via nasal cannula; -The resident lifted from the bed to stretcher via sheet, then secured with rails and straps; -The resident was placed on emergency services (EMS) 02 at four liters per minute via nasal cannula; -While walking to the ambulance, the resident became apneic (stopped breathing) and pulseless; -Resuscitation was not initiated due to the resident being a do not resuscitate (DNR); -Primary Impression: Respiratory- respiratory arrest; -Secondary Impression: Cardiac- [MEDICAL CONDITION]; -Factors impacting care: Unconscious. Review of the facility's fall investigation, showed: -Type of adverse event: Fall with major injury- [MEDICAL CONDITION]; -Date and time of event on 7/28/20 at 9:00 P.M.; -Notifications completed: -Supervisor: at 9:30 A.M.; -Physician: at 9:45 A.M.; -Daughter: at 10:00 P.M.; -New orders received: Yes -Event description: The resident stood up to pull his/her own pants and lost his/her balance and fell directly on his/her left side. The resident said he/she should have just asked for help; -Location of event: bedroom; -Brief description of injury: The resident has been complaining of pain, left hip/femoral area. Skin tear to left knee; -Immediate medical care provided: The resident was administered oxygen, then assessed, then skin tear on left knee was cleaned and dressing was applied to the area. The resident was also administered as needed pain medication for pain; -Describe immediate interventions taken after event occurred: Nothing noted; -Witness to event: No; -Fall investigation does not state who found the resident. During an interview on 10/2/20 at 1:26 P.M., LPN A said he/she is familiar with the resident and worked with him/her the day he/she had had his/her major fall with injury. He/she worked the 3:00 P.M. through 11:00 P.M. shift. The resident had suffered a major fall. He/she could not remember the certified nursing assistant (CNA) who had found the resident. The resident was lying on the floor on one of his/her sides. He/she asked the resident what happened and the resident said he/she was trying to get up and take him/herself to the bathroom. The resident was able to communicate his/her needs but, at times, he/she would be confused. He/she was on continuous oxygen. At times he/she would remove his/her oxygen. He/she had a habit of trying to do things on his/her own. His/her gait was very unsteady. Standby assistance was needed to transfer. He/she did not have his/her oxygen on at all at the time he/she was found on the floor. He/she could not remember what time the resident was found, but thinks it was about nine o'clock. The CNA who found the resident was the one who came and got him/her. Once he/she got the resident up to the wheelchair, the resident complained of pain, so he/she called the physician. He/she was unsure if the family had been notified that night. He/she was not there when they called for ambulance transport to take the resident to the hospital. Neuro checks were done on his/her shift. Anytime a person has an unwitnessed fall, neuro checks are automatically done. It does not matter if they are alert or not. The resident was a little confused, but again he/she did not have his/her oxygen on. He/she did not recall if he/she informed the physician of the status of the neuro checks. During an interview on 10/7/20 at 9:53 A.M., CNA C said he/she has been working at the facility for about a year and worked the 3:00 P.M. to 11:00 P.M. shift. He/she is familiar with the resident. The resident was a fall risk. The resident ambulated via wheelchair and he/she transferred via one person assist with a gait belt. He/she did not know if the resident had a history of [REDACTED]. When he/she is assigned to the resident, he/she would always remind the resident to ring the bell. They do rounds on the residents. He/she couldn't say how often because they have other residents they have to take care of. On 10/15/20 at 7:39 P.M., CNA C said that he/she had worked with the resident that night. The resident was found on the floor. He/she did not remember who saw or found the resident on the floor. The resident was awake when the nurse was asking him/her did he/she hurt anywhere. He/she could not remember if the resident had his/her oxygen and/or nasal cannula on when he/she was assisting the resident. During an interview on 10/16/20 at 12:36 P.M., LPN J said he/she was the supervisor on the night shift after the resident's fall. He/she is not really familiar with the resident. Once the x-ray results came in thru the fax, Certified Medication Technician (CMT) K gave them to him/her and he/she read the results and discovered there was a broken hip. He/she called the physician and gave him/her the x-ray results. The physician said go ahead and send the resident to the emergency room . He/she called the resident's family member to inform them the resident was going to the hospital. He/she called the ambulance direct line, not 911. For 911 calls, these are for if the resident was going out on them, if his/her mental status had changed, or if his/her vitals were changing. If he/she showed any signs of distress then a 911 call would have been made. The resident became lethargic once the emergency medical technicians (EMTs) got there. He/she did not know what the resident's normal base line alert and orientation status was. The CMT was doing the vitals and he/she was doing the neuro checks. There was no change in condition at any point. If the resident had experienced a change in condition, he/she would have called the ambulance and told them, he/she needed them stat. When the ambulance got there, he/she was at the desk. He/she showed them where the resident's room was and when they went in to check the resident. They asked if he/she was always like that? His/her breathing was labored. He/she told them no. He/she was on oxygen and his/her nasal cannula was in. The evening shift nurse, LPN A, would have been the last nurse to check on the resident as far as nurses' go. He/she left at about 11:30 P.M., because he/she came by the office and gave report, telling him/her to expect x-ray results and told him/her about the fall. The CNAs do rounds at change of shift, and do walking rounds at 1:00 A.M., 3:00 A.M., and 5:00 A.M. During an interview on 10/19/20 at 9:04 A.M., CNA M said he/she was the CNA that was assigned to the resident on the 11:00 P.M. to 7:00 A.M. shift on the night of the fall. He/she is familiar with the resident. He/she got report and did his/her rounds. The resident was alert a lot of times and independent. He/she checked in on the resident and he/she was awake. He/she checked on the resident frequently. During his/her very last observation of the resident, he/she could see pain in the resident's face. He/she had his/her nasal cannula in. The resident did not say anything but you could see the pain. During an interview on 10/19/20 at 1:18 P.M., the DON said as a safety measure, staff start neuro checks after an unwitnessed fall. Nurses should see the residents every couple of hours during their shift, routinely. The resident should have been seen more often than that because staff would be doing neuro checks repetitively for the next several hours. That first baseline neuro check would have been done before the physician's call. The nurse can make the decision to call 911 without the physician order, if it is necessary. The resident's neuro checks showed he/she was more alert and his/her responses were better. The nurse who is assigned to the community where the resident is at, is responsible for doing the neuro checks. During an interview on 10/20/20 at 9:13 A.M., CMT K said LPN A told him/her that the resident had a fall. He/she would have done the vitals on the resident, documented them on a sheet and given the vital sheets to the nurse. The nurse would put them into the computer. When he/she was making rounds on the resident, the resident was alert. In between the EMTs getting into the building and them getting to the resident, it would have been five minutes since he/she had last seen the resident, because he/she was going in and out the room helping as much as he/she could while the nurse was getting paperwork ready. When the resident left with the ambulance, he/she was stable and alert. During and interview on 10/21/20 at 12:13 P.M., the administrator said the resident was not a high fall risk. According to the Morse fall risk scale, he/she was a low fall risk. The expectations is that staff would be checking on the resident as frequently as the neuro checks were required. Neuro checks should be completed and documented. She would expect for the neuro checks to be completed as scheduled. MO 105

Based on observation, interview and record review; and in accordance with Centers for Disease Control and Prevention (CDC) guidelines for 2019 Novel Coronavirus Disease (COVID-19), the facility failed to protect all residents in the facility by not following acceptable infection control practices for COVID-19. The facility failed to ensure staff wore personal protective equipment (PPE) as indicated for one resident on transmission based precautions upon entering the resident's room (Resident #1). Staff failed to properly dispose of used PPE out of reach of one resident with dementia, failed to offer a mask to a resident in common areas and denied a resident a mask when requested (Resident #4). In addition, nursing and housekeeping staff failed to consistently wear a mask and performed proper hand hygiene when in common areas and around residents (Residents #6 and #7) and dietary staff failed to wear a mask during food preparation. The sample was 8. The census was 181 with 113 residents in certified beds. Review of a list of residents provided by the facility on 7/17/20, showed a total of 32 residents had been diagnosed as having COVID-19. Review of the facility census, showed on 7/16/20, seven residents had active cases of COVID-19. During an interview on 7/16/20 at 9:10 A.M., the administrator said the most recent facility COVID-19 case was on 7/6/20. The facility tests all residents weekly and results have been taking about a week to get back. Review of the CDC.gov website, Preparing for COVID-19 in Nursing Homes, updated June 25, 2020, showed: -Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 and other pathogens. As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP); -This guidance has been updated and reorganized according to core IPC practices that should remain in place even as nursing homes resume normal practices, plus additional strategies depending on the stages described in the Centers for Medicare and Medicaid Services (CMS) Reopening Guidance or at the direction of state and local officials. This guidance is based on currently available information about COVID-19 and will be refined and updated as more information becomes available; -Implement Source Control Measures: -HCP should wear a facemask at all times while they are in the facility. When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Guidance on extended use and reuse of facemasks is available. Cloth face coverings should not be worn by HCP instead of a respirator or facemask if PPE is required; -Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility; -Care must be taken to avoid touching the respirator, facemask, or eye protection. If this must occur (e.g., to adjust or reposition PPE), HCP should perform hand hygiene immediately after touching PPE to prevent contaminating themselves or others. Review of the CDC.gov website, Responding to Coronavirus (COVID-19) in Nursing Homes, updated April 30, 2020, showed: -This guidance is intended to assist nursing homes and public health authorities with response and cohorting decisions in nursing homes. This guidance supplements but does not replace recommendations included in the Interim Additional Guidance for Infection Prevention and Control for Patients with Suspected or Confirmed COVID-19 in Nursing Homes; -Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19: -All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Review of the facility's Management of Pandemic policy, revised 3/10/20, showed: -The facility will follow the recommendations of the CDC, the state and regional health departments and Center for Clinical Excellence team in order to most effectively manage an actual or potential outbreak of infection for employees and residents; -CDC website will be monitored on a regular basis by the director of clinical compliance and others in order to remain abreast of the current status of any pandemic and recommendations related to preventing, diagnosis, treatment and other necessary precautions. Review of the facility's Isolation Precautions policy, revised 3/10/20, showed: -Standard precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-based precautions shall be used when caring for a resident who is documented or suspected to have a communicable disease or infection that can be transmitted to others; -All necessary equipment and supplies will be maintained near the resident's room; -A sign will be posted on the resident's door explaining the type of isolation. Nursing will update the resident's care plan; -Droplet Precautions: -In addition to standard precautions, implement droplet precautions for an individual infected with or suspected to be infected with microorganism transported by droplets that can be generated by the individual coughing, sneezing and talking or by performance of procedures such as suctioning; -Examples of infections requiring droplet precautions, include, but are not limited to: Coronavirus; -Mask and eye protection: in addition to standard precautions, put on a mask and eye protection when entering the room; -If transport or movement from the room is necessary, place a mask on the infected individual and encourage the resident to follow respiratory hygiene/cough etiquette to minimize dispersal of droplets. 1. Review of Resident #1's electronic medical record, showed: -admitted [DATE]; -[DIAGNOSES REDACTED]. -A Nursing Admission Assessment, dated 7/11/20 at 4:10 P.M., admitted from acute hospital. Services Provided: Isolation management. Presence of active infection: Yes active infection. Isolation, droplet. Infection status: Biliary obstruction. Oriented to place, person, time and event; -An order dated 7/11/20, isolation precautions (specify in notes); -An order dated 7/12/20, monitor for COVID-19 symptoms three times a day; -A care plan dated 7/15/20, showed: -Problem: Poor appetite; -Goal: Adequate food/fluid intake; -Interventions included to eat all meals in room related to isolation due to COVID; -A progress note dated 7/16/20 at 10:35 P.M., collect stool sample, check for [MEDICAL CONDITION] ([MEDICAL CONDITION], a bacterium that causes diarrhea). Continues on antibiotics due to biliary obstruction, collection of stool to check for [MEDICAL CONDITION] remains pending. Observation on Reach East hall, used as the quarantine area for newly admitted residents that have a COVID-19 status unknown, on 7/16/20 at 9:39 A.M., showed Certified Nursing Assistant (CNA) A entered the resident's room. He/she only wore a mask, and no gown, eye protection or gloves; and emptied the resident's trash and linen bags. CNA A exited the room, held the soiled linen and trash bags directly against his/her clothing and held the bags with his/her bare hands. He/she did not perform hand hygiene before entering or after exiting the room. He/she carried the bags down the hall, past the nurses station, resident television area and dining area; and entered the soiled linen room by touching the door handle with his/her soiled hands. He/she exited the soiled linen room and entered the trash chute room by touching the door handle with his/her soiled hands. He/she exited the trash chute room, adjusted his/her pants and then entered the laundry area to wash his/her hands. Observation of the resident's room, showed the closest supply of PPE located several rooms down, approximately 48 feet from the resident's room. No gloves, gowns or eye protection available outside the resident's room. Two signs hung on the resident's room door. The first read: Stop, droplet precaution. To prevent the spread of infection, anyone entering this room must: Hand hygiene, surgical mask, glove, and gown. The second sign read: Stop, droplet precautions. Everyone must clean their hands, including before entering and when leaving the room. Make sure the eyes, nose and mouth are fully covered before room entry. The sign showed a picture of a person wearing a mask and face shield or a picture of a person wearing goggles and a mask. During an interview on 7/16/20 at 10:42 A.M., CNA A said when providing care to residents on droplet precautions, gloves, gown, mask and face shield are required. Handwashing is completed. Staff are to follow the directions provided on the signs posted outside the resident rooms. There is sufficient PPE provided by the facility to do his/her job. CNA A identified the resident as a resident on droplet precautions. During an interview on 7/20/20 at 12:19 P.M., with the Director of Nursing (DON) and Assistant DON D, they said the resident's floor was transitioned into the observation area on 6/9/20. Residents who are newly admitted or have been out to the hospital or to procedures are placed on this floor for their 14 day quarantine. Resident #1 was on droplet precautions because he/she was in his/her 14 day window after admission. If a resident has a droplet precaution sign posted, staff should don the PPE as indicated on the sign. Soiled trash and linen should be bagged and removed from the room. It is not preferable for staff to hold the bag against their clothing. 2. Review of Resident #4's electronic medical record, showed: -admitted [DATE]; -[DIAGNOSES REDACTED]. -A care plan, in use at the time of the survey, showed: -Problem: Risk of psychosocial well-being concern related to medical and visitation restrictions secondary to COVID-19; -Goal: No decline in psychosocial well-being; -Interventions: Educate about COVID-19 symptoms and precautions; -Problem: Impaired cognition; -Goal: Participate in decision making with activities of daily living; -Interventions: Give verbal reminders as needed; -Problem: Altered thought process, at risk for self-care deficit and at risk for injury; -Goal: Monitor for safety; -Interventions: At risk for fall and elopement, initiated appropriate interventions. Observation on Reach East hall, used as the quarantine area for newly admitted residents that have a COVID-19 status unknown, on 7/16/20 at approximately 10:00 A.M., showed CNA A assisted the resident to walk into the television area and sit in a recliner. The resident wore no mask. At 10:04 A.M., CNA A approached the resident. The resident sat with a mask over his/her face. CNA A removed the mask and threw it in the trash can that sat next to the recliner. CNA A said the resident got the mask from the trash can. He/she told the resident he/she could not wear a mask he/she got out of the trash. CNA A failed to move the trash can, full to the top with PPE, from the resident's reach. The resident asked CNA A for a mask and CNA A told the resident he/she did not need a mask. CNA A walked away from the resident. Observation on 7/16/20 at 10:55 A.M., showed Licensed Practical Nurse (LPN) B assisted the resident to walk to his/her room. The resident asked LPN B for a mask. LPN B said no, you don't need one. During an interview on 7/20/20 at 12:19 P.M., with the DON and Assistant DON D, they said the resident is being transitioned off of the observation unit and no longer required transmission based precautions. When removing PPE, staff should dispose of the PPE inside the resident's room. It is then taken to the trash chute. If a resident has taken a mask from the trash, staff should make sure the trash can is removed from the area the resident could reach it. All residents should be offered a mask when they leave their room, but they have the right to refuse it. If a resident asks for a mask, one should be provided. 3. Observation on 7/16/20 at approximately 10:00 A.M., on Ball Park Village hall, showed Certified Medication Technician (CMT) J stood outside of a resident's room at a medication cart. He/she wore his/her mask below his/her nose. He/she looked up at the surveyor and used his/her bare hands to adjust the mask so it covered the nose completely. He/she continued to prepare medications without sanitizing his/her hands and brought them to a resident. 4. Observation on 7/16/20 at 10:27 A.M., showed Housekeeper Associate F in the dining area. He/she cleaned without a mask that covered his/her nose and mouth. Two residents sat in the dining room at the time. Another staff member instructed Housekeeper Associate F to wear a mask and said state. Housekeeper Associate F stopped cleaning at this time and walk past the State Surveyor and said let me get a mask. Housekeeper Associate F exited the dining area and returned with a mask that covered his/her nose and mouth. During an interview on 7/16/20 at 9:30 A.M., the housekeeping supervisor said housekeeping staff wear a mask in all places in the facility and wear PPE as indicated for residents on isolation. During an interview on 7/1/20 at 10:37 A.M., Housekeeping Associate F said all employees are required to wear a mask at all times in all areas of the facility. They have access to face masks daily. 5. Review of Resident #6's medical record, showed [DIAGNOSES REDACTED]. Review of Resident #7's medical record, showed [DIAGNOSES REDACTED]. Observations and interview on 7/1/20, showed: -At 10:39 A.M., CNA G walked down Ballpark Village hall with his/her mask under his/her chin. CNA G's mask hung on both ears, sat under his/her chin, and exposed his/her nose and mouth. As CNA G walked down the hallway, he/she place a food item in his/ her mouth. Before he/she made it to the exit doors, he/she pulled the mask up on his/her face then, without sanitizing his/her hands, used his/her hands to push the door open and walked off the unit into the stair well; -At 10:45 A.M., CNA G returned to the unit with his/her mask under his/her chin. As he/she walked down the hallway, he/she place a food item in his/her mouth. CNA G's mask hung on both ears, sat under his/her chin, and exposed his/her nose and mouth. He/she walk down the hallway past three residents. CNA G entered and exited a closet without first sanitizing his/her hands. CNA G then approach a resident that stood in his/her doorway and talked with the resident. The resident wore no mask and CNA G stood within two feet of the resident. CNA G's mask was positioned under his/her nose; -At 11:05 A.M., CNA G stood behind the kitchenette in the dining area and talked to another staff person. His/her mask positioned under his/her nose. CNA's G mask fit loosely and moved up and down, repeatedly covering and uncovering his/her nose, as he/she talked; -At 11:37 A.M., CNA G sat at a portable computer in the hallway outside Resident #6 and #7's room. The room door open and the residents sat next to their beds. CNA G's mask positioned under his/her chin and exposed his/her nose and mouth. CNA G took a sip of his/her drink from a cup. At 11:39 A.M., CNA G remained in the hallway outside of Resident#6 and #7's room with his/her mask under his/her chin. During an interview on 7/16/20 at 10:58 A.M., CNA G said staff are required to wear a mask. The facility provides masks to the staff. Staff do not really have access to them. They can't just go and get them. They can go and ask for a one. A mask must be on upon entry into the building and must be worn the entire shift. The facility requires this. CNA G said he/she worked at the facility on an as needed basis and was not full or part time. 6. Observation on 7/16/20, on Ballpark Village hall, showed: -At 12:14 P.M. and 12:17 P.M., Dietary Aide I stood in the kitchenette area behind the steam table, and prepared meal trays with his/her mask under his/her nose; -At 12:28 P.M., Dietary Aide I stood in the kitchenette area behind the steam table. His/her mask hung on both ears, sat under his/her chin, and exposed his/her nose and mouth. Dietary Aide I talked and laughed with other staff members as he/she prepared meal trays. Dietary Aide I looked up at the State Surveyor, walked over to the left side of the coffee maker and then returned to the steam table with his/her mask on his/her face, but positioned under his/her nose with the nose exposed. He/she put on gloves and resumed making meal trays. During an interview on 7/16/20 at 10:22 A.M., Dining Service Associate C said dietary staff are required to wear their masks in the kitchen and kitchenettes. During an interview on 7/16/20 at approximately 12:45 P.M., the dietary supervisor said masks should be worn at all times. The mask should cover the nose and mouth. 7. During an interview on 7/16/20 at 9:10 A.M., with the administrator and DON, they said staff are required to wear a mask at all times. On Reach East, new admissions are housed for 14 days on quarantine. They are placed on droplet precautions. In this area, staff are to wear a mask in the halls and should wear a mask, gown and face shield in resident rooms. The facility currently has no PPE needs. 8. During an interview on 7/20/20 at 12:19 P.M., with the DON and Assistant DON D, they said staff should wear masks at all times. This includes nursing staff, housekeeping and dietary staff. Masks should cover the mouth and nose.

Based on interview and record review, the facility failed to ensure a final accounting of and/or the remaining funds in the resident trust account were sent to the individual or probate jurisdiction administering the resident's estate, in accordance with Federal law for four of four accounts reviewed (Residents #179, #180, #181 and #182). The census was 240 with 132 in certified beds. 1. Review of Resident #179's resident trust account, showed he/she expired on [DATE], with $143.12 in the account. The facility did not send the letter to the state regarding the balance until [DATE]. 2. Review of Resident #180's resident trust account, showed he/she expired on [DATE], with $619.86 in the account. The facility did not send the letter until [DATE]. 3. Review of Resident #181's trust account, showed he/she expired on [DATE], with $196.31 in the account. The facility did not send the letter to the state until [DATE]. 4. Review of Resident #182's trust account, showed he/she expired on [DATE], with $978.38 in the account. The facility did not send the letter until [DATE]. 5. During an interview on [DATE] at 1:20 P.M., the business office manager said she waited for the family to let her know if they needed any money for funeral expenses and other adjustments to come through before she sends the letter to the state. She did not know she had to send the letter off within 30 days. She has always waited for information from the family.

Based on interview and record review, the facility failed to issue written transfer notices to residents and/or their representative upon discharge to a hospital when their return to the facility was expected. Of the 26 residents sampled, four had been recently discharged to a hospital for various medical reasons, all were expected to return, and none of those four had been issued a written transfer notice upon leaving the facility (Residents #60, #21, #41 and #58). The census was 240 with 132 in certified beds. 1. Review of Resident #60's progress notes dated 5/4/18 at 4:31 A.M., showed the resident discharged to the hospital due to [MEDICAL CONDITION] and neurological issues. Staff called the physician for orders and notified the responsible party. The resident returned to the facility on [DATE]. Review of the resident's medical record, showed no transfer notice. 2. Review of Resident #21's nurse's notes, showed the on 6/30/18, staff sent the resident to the hospital due to a fall. Staff notified the physician and responsible party regarding the resident's fall and obtained orders to send the resident to the hospital for an evaluation and treatment. The resident was admitted to the hospital and returned to the facility on [DATE]. Review of the resident's medical record, showed no transfer notice. 3. Review of Resident #41's progress notes, showed the resident discharged from the facility to the hospital on [DATE], for a change in condition and readmitted on [DATE]. Staff called the physician for orders and notified the responsible party. Review of the resident's medical record, showed no transfer notice. 4. Review of Resident #58's progress note, dated 7/19/18 at 1:54 P.M., showed the nurse discussed the resident's condition with the resident's representative and made a decision to send the resident to the hospital. Review of the resident's progress note, dated 7/19/18 at 11:03 P.M., showed the hospital confirmed the resident's admission with a [DIAGNOSES REDACTED]. 5. During an interview on 10/10/18 at 7:51 A.M., Nurse C said when he/she sends a resident to the hospital, he/she sends a copy of the resident's physician's orders [REDACTED]. He/she had not been instructed to give the resident or resident representative a transfer notice. 6. During an interview on 10/10/18 at 10:22 A.M., the Assistant Director of Nurses D said he/she had not been instructed to issue a transfer notice to a resident or resident representative when the resident is sent to the hospital. 7. During an interview on 10/11/18 at 10:00 A.M., the administrator verified no discharge notice letters are sent when residents are discharged from the facility to the hospital and she was unaware the facility is required to issue a discharge notice letter.

Based on observation, interview and record review, facility staff failed to follow their puree recipes during two of two meals observed, which affected nine of nine residents receiving puree diets. The census was 240 with 132 in certified beds. 1. Observation on 10/5/18 at 6:26 A.M., showed Cook E prepared pureed eggs. He/she said he/she is preparing 22 puree meals. While preparing to puree the eggs, Cook E said he/she is making it a mashed potato consistency. He/she then placed 7 spoons (unmeasured amount) of eggs, 1 1/2 scoops of hot milk (using a 4 ounce (oz) ladle), and 1/2 of a big spoon (unmeasured amount) of thickener into the blender and pureed the items for approximately 10 seconds. The pureed eggs mixture had a smooth fluffy consistency. He/she placed the eggs in a metal container, covered it with plastic wrap and placed it in the oven. Cook E did not have the facility's recipe book out or opened in front of him/her while preparing the pureed eggs dish. Review of the pureed eggs recipe, showed the following for five servings: -1 ½ cups of pasteurized liquid egg mix; -½ cup of 2% milk; -2 tablespoons of solid margarine; -Place in the food processor. 2. Observation on 10/11/18 at 10:00 A.M., showed Cook F prepared pureed fried rice. He/she said he/she is preparing 15 puree meals. He/she placed five (3 oz) scoops of fried rice and an unmeasured amount of hot milk into the blender. Cook F said he/she would add milk until he/she got the consistency needed. He/she pureed the items for approximately 20 seconds, then added an unmeasured amount of hot milk and pureed the items again for approximately 20 seconds. Cook F said that since he/she is pureeing a starch, he/she is leaving the pureed fried rice a little thinner because when it sits and is heated, it will thicken up. He/she added an additional unmeasured amount of hot milk, pureed the items for approximately 10 seconds, added an additional unmeasured amount of hot milk and pureed the items for approximately 10 seconds, added an additional unmeasured amount of milk, and pureed the items for an additional 10 seconds. The pureed fried rice was smooth yet a little thick in consistency. Cook F did not have the facility's recipe book out or opened in front of him/her while preparing the pureed fried rice dish. Review of the pureed rice recipe, showed the following for fifty servings: -3 pounds of rice; -1 gallon of water; -4 ounce of Chicken Soup Base -Place in the food processor. 3. Observation on 10/11/18 at 10:24 A.M., showed Cook F prepared the pureed soup of the day (RS Lemon Chicken Orzo Soup). He/she said he/she was preparing 15 puree meals. While preparing to puree the soup, Cook F said he/she would pour all of the soup from the metal container into the blender, blend the items together, then pour it all back into the metal container, so all of the ingredients are mixed together. Cook F said he/she would have to puree the soup in parts. Cook F poured the soup from the metal container into the blender, pureed the soup for approximately ten seconds, then poured the pureed soup mixture back into the metal container. Cook F poured an unmeasured amount of the pureed soup mixture and an unmeasured amount of thickener from a big spoon into the blender. He/she added an unmeasured amount of thickener again into the blender and pureed the items for approximately 10 seconds. Cook F then added an unmeasured amount of thickener once again into the blender and pureed the items for an additional 10 seconds. Cook F poured the pureed soup mixture into a metal container. The pureed soup mixture had a smooth consistency. Cook F did not have the facility's recipe book out or opened in front of him/her while preparing the pureed RS Lemon Chicken Orzo Soup dish. Review of the pureed RS Lemon Chicken Orzo soup recipe, showed the following for ten servings: -10 (6 oz) ladles of RS Lemon Chicken Orzo Soup; -5 packets Saltine Crackers, 2 count; -Place in the food processor. 4. Observation on 10/11/18 at 10:33 A.M., showed the Cook F prepared pureed oriental mixed vegetables. He/she said he/she is preparing 15 puree meals. He/she placed 4 (4 oz) scoops of cooked oriental mixed vegetables into the blender and pureed the vegetables for approximately 20 seconds. Cook F then poured 4 (4 oz) scoops of vegetable juice into the blender and pureed the items for an additional 10 seconds. He/she poured the pureed vegetable mixture into a metal container and placed plastic wrap over it. The pureed vegetable mixture had a smooth yet slightly thin consistency. Cook F did not have the facility's recipe book out or opened in front of him/her while preparing the pureed mixed vegetables dish. Review of the pureed vegetables recipe, showed the following for ten servings: -2 cups of Oriental blend vegetables; -2 tablespoons of food thickener; -Place in the food processor. 5. Observation on 10/11/18 at 10:46 A.M., showed the cook F prepared pureed Chicken a la Orange. He/she said he/she is preparing 15 puree meals. He/she placed 4 (4 oz) chicken fillets into the blender, then added an unmeasured amount of orange sauce from a small pot. Cook F said he/she would only add sauce in pureed mixture based on the consistency. He/she pureed the items for approximately 30 seconds. The pureed Chicken a la Orange had a smooth consistency. Cook F did not have the facility's recipe book out or opened in front of him/her while preparing the pureed Chicken a la Orange dish. Review of the Chicken a la Orange recipe, showed the following for five servings: - 5 (4 oz) of raw boneless skinless chicken breast - 1 (1/2 oz) of all purpose flour - 2 (1/3) tablespoons of brown sugar - 2 (3/8) teaspoon of margarine - 1/4 teaspoon of dry mustard seed - 1/8 teaspoon of ground allspice - 1/4 teaspoon of salt - 1/4 teaspoon of pepper - 5 (1/2) cup of steamed rice - 5 oz of thickener -Place in the food processor. 6. During interviews on 10/11/18 at 11:50 A.M., the dining manager said when preparing pureed meals, he/she uses a spreadsheet, which tells what each puree item needs. He/she also uses the recipe book, which gives instructions on how to prepare the puree meals. 7. The Director of Dining Services, said he/she tells the cooks, that he/she wants to see the recipe book opened while preparing the puree meals. He/she would expect the cooks to follow the recipes when preparing the puree meals to ensure the puree meals are prepared correctly. It is important to follow the recipes as written. The number of puree meals prepared can vary from day to day depending on discharges, transfers, expiration of residents and diet changes.

Based on interview, the facility failed to ensure cardiopulmonary resuscitation (CPR, initiate life sustaining measures in the the event the heart stops beating) certified staff accompanied all residents with a full code (initiate CPR in the event the heart stops beating) status, when transported to and from appointments by the facility van. The census was 242 with 135 in certified beds. During an interview on [DATE] at 11:20 A.M., the administrator said the facility had four van drivers that took residents to and from appointments. A life enrichment employee always accompanied the resident and van driver to an appointment. Some residents going to appointments were full codes. None of the four van drivers were CPR certified and since the facility did not require all staff to be CPR certified, the life enrichment employees were not CPR certified either.

Based on observation and interview, the facility failed to ensure potentially hazardous chemicals and sharp knifes were secured in one of four kitchenette areas, accessible to residents. The facility identified 15 of the 46 residents residing on the third floor, as wanderers. The census was 242 with 135 in certified beds. Observation of the third floor kitchenette on 11/9/17 at 5:50 A.M., showed the kitchenette had multiple cabinets and/or drawers. Seven of the cabinets/drawers had locks and all seven were unlocked. No staff members were present in the kitchenette or dining room at that time. The unlocked cabinet under the sink, capable of locking, contained a one gallon container, 1/8 full, of Multi Quat Sanitizer. The label showed the word danger and instructions to keep it out of the reach of children and if swallowed to call poison control. A second one gallon container, full, of Eco-San Liquid Sanitizer, was located in the same cabinet. The label showed the chemical should be kept out of the reach of children and poison control should be contacted if swallowed. A third one gallon container of Lime-A-Way, 1/8 full, was located in a different unlocked cabinet, but capable of locking, below the steam table. That label showed the word danger along with instructions to keep out of the reach of children. Further warnings showed it could cause severe skin burns and eye damage. If swallowed rinse mouth, do not induce vomiting. One unlocked drawer, capable of locking, showed a sharp serrated knife with a blade approximately 4 inches long. Observation of the third floor kitchenette on 11/14/17 at 6:40 A.M., showed no staff members were present in the kitchenette or dining room and the Multi Quat Sanitizer and the Eco-San Liquid Sanitizer remained in the unlocked cabinet, but capable of locking, under the sink, the Lime-A-Way remained in the unlocked cabinet under the steam table and the serrated knife remained in the unlocked drawer. During an interview at on 11/14/17 6:55 A.M., Dietary Staff C said the cabinets containing the chemicals and the sharp knife should be locked. He/she did not have a key to lock any of the cabinets. He/she normally worked on the second floor where they kept chemicals and sharp knives locked up. Observation on 11/14/17 at 8:15 A.M., showed an approximately 6 inch long steak knife in an unlocked drawer in the third floor kitchenette. During an interview on 11/14/17 at 10:15 A.M., the Director of Dining Services said the keys to lock the third floor kitchenette were kept in the dining office and the Dietary Manager had access to them. Kitchen staff were responsible for ensuring chemicals and sharp knives were locked up when not in use. He did not know why they had not been. Review of the facility material safety data sheets, showed the following: -Effective date 8/6/13, Multi-Quat Sanitizer: Harmful if swallowed. Causes severe skin burns and eye damage; -Effective date 1/26/17, Eco-San: If swallowed rinse mouth do not induce vomiting. Causes severe skin burns and eye damage; -Effective date 1/29/16, Lime-A-Way: Potential health effects - causes serious eye damage, severe skin burns, digestive tract burns and may cause nose/throat/lung irritation.

Based on observation, interview and record review, facility staff failed to follow facility policy and relieve an employee of duty, immediately following an allegation he/she verbally abused a resident. The employee was allowed to remain on duty until the shift ended. This affected one of 21 sampled residents. (Resident #10). The census was 242 with 135 in certified beds. Review of Resident #10's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/7/17, showed the following: -Brief Interview for Mental Status score: 5 of 15 (a score of 0 - 7 indicates severe cognitive impairment); -Disorganized thinking: Behavior continuously present, does not fluctuate; -Independent for walking in room and corridor; -Mobility device: Walker; -[DIAGNOSES REDACTED]. Review of a report received from the facility on 11/3/17 at 4:34 P.M., showed the Department of Health and Senior Services was made aware that on 11/3/17 at around 2:30 P.M., the resident was trying to get into the kitchen area and Dietary Staff D told the resident to stay the f--- out of the kitchen. Dietary Staff D had been removed and suspended from the facility. Observation and interview on 11/7/17 at 10:25 A.M., showed the resident sat in his/her room with a wheeled walker next to him/her. The resident said he/she had not had any problems with any staff and did not recall an incident that occurred on 11/3/17. At 10:40 A.M., the resident used a wheeled walker to ambulate into the dining room. The resident did not recognize the surveyor and did not remember the conversation from earlier that day. During an interview on 11/7/17 at 10:15 A.M., Certified Medication Technician (CMT) E said on 11/3/17, at around 1:00 P.M. to 1:30 P.M., he/she saw the resident walking toward the kitchenette. It was not uncommon for the resident to wander into the kitchenette area and start touching food items. Dietary Staff D came out of the kitchenette, walked up to the resident and in a loud voice told the resident to get the f--- back. Nurse F intervened at that time. CMT E reported what had happened to the second floor Nurse Manager K. Dietary Staff D worked until the end of his/her shift which was over at 3:00 P.M. During an interview on 11/7/17 at 10:50 A.M., Certified Nurse Aide (CNA) G said he/she worked on 11/3/17, and was down the hall at around 1:30 P.M., when he/she heard a loud commotion and saw Dietary Staff D tell the resident he/she better take his/her funky a-- home or he/she would beat the s--- out of him/her. Dietary Staff D appeared hostile and his/her voice was elevated. The resident, by his/her body language, appeared to react in anger as well. During an interview on 11/7/17 at 12:00 P.M., CNA H said about 30 to 45 minutes after lunch on 11/3/17, he/she saw Dietary Staff D come out of the kitchenette and cut the resident off by standing in front of the resident's walker. The resident was angry and began shaking his/her walker. Dietary Staff D started telling everyone they better get the resident. He/she had an angry tone when he/she said it. During an interview on 11/7/17 at 12:20 P.M., Nurse F said on 11/3/17, after lunch and at about 1:30 P.M., Dietary Staff D got aggravated with the resident for going into the kitchenette area. He/she heard Dietary Staff D yelling but did not hear what he/she was yelling because the double doors to the dining room were closed. When he/she went through the doors Dietary Staff D was yelling at the resident to get the h--- out and he/she was tired of the resident's a--. The resident had his/her walker lifted off the floor and as if he/she was going to hit Dietary Staff D with it. Nurse F removed the resident from the area immediately and walked with him/her to his/her room. By the time they got to the room, the resident did not seem to know anything had happened and seemed fine. Nurse F went back to the dining room and Dietary Staff D told him/her the resident was trying to hit him/her with his/her walker. The nurse tried to explain to Dietary Staff D that the resident was confused, but Dietary Staff D said he/she did not give a d---. Dietary Staff D went back to work in the kitchenette and he/she called Dietary Manager J and the second floor supervisor. Nurse F stayed in the dining room until Dietary Manager J arrived about five minutes later, told him/her what happened and left the dining room. He/she thought Dietary Staff D continued to work because he/she saw him/her at the time clock at around 3:00 P.M. He/she also called and reported the incident to Assistant Director of Nurses (ADON) L who was on duty. During an interview on 11/9/17 at 7:30 A.M., Housekeeping Staff I said on 11/3/17, at around 2:30 P.M., he/she was cleaning in the dining room and heard Dietary Staff D yell loudly at the resident to get out of there. Dietary Staff D and the resident were face to face. After Nurse F took the resident out of the dining room, Dietary Staff D continued to work in the kitchenette. Nurse F returned and spoke to Dietary Manager J. Nurse F left and Dietary Manager J walked right by Dietary Staff D who was in the kitchenette. He/she did not see Dietary Manager J speak to Dietary Staff D before leaving the floor. During an interview on 11/9/17 at 11:50 A.M., Dietary Manager J said on 11/3/17, at around 2:10 P.M., he/she spoke to Nurse F in the dining room area. Nurse F told him/her that Dietary Staff D told him/her to get the resident the h--- out of his/her kitchen. He/she did not know who Dietary Staff D said it to, a resident or another staff member and he/she did not ask Nurse F to clarify. He/she went back downstairs after speaking to Nurse F. He/she was not sure if Dietary Staff D was still in the kitchenette or not, he/she might have been. He/she did not see Dietary Staff D again until he/she came downstairs. Another Dietary Manager had Dietary Staff D write a statement and told him/her he/she was suspended pending an investigation. It was not until Monday, 11/6/17, when he/she saw the statements from staff that he/she was aware of the severity of the situation. Had he/she known all of the facts, when he/she spoke to Nurse F, he/she would have removed Dietary Staff D from the floor immediately. During an interview on 11/13/17 at 10:00 A.M., Nurse Manager K said everything was over by the time he/she got there. As far as he/she knew, the incident had occurred five to 10 minutes prior to the time he/she arrived on the floor, which was about 2:45 P.M. CMT E told him/her Dietary Staff D had cursed at the resident. He/she asked Nurse F who verified Dietary Staff D had cursed at the resident. He/she did not know where Dietary Staff D was at that time. He/she asked staff that witnessed the incident to begin writing statements and went to ADON L. They contacted Dietary Manager J and told him/her he/she needed to get Dietary Staff D off the floor. During an interview on 11/13/17 at 10:20 A.M., ADON L said Nurse F was the first person to contact him/her, but he/she was not sure of the time. Nurse F told him/her the resident was trying to get into the kitchenette and they were mopping the floors. Dietary Staff D did not want the resident in the kitchenette and became upset. Nurse F did not tell him/her Dietary Staff D had cursed or yelled at the resident. He/she had no idea it was as bad as it was, at that time. It was not until Nurse Manager K called him/her later, that he/she knew about the yelling and cursing. He/she did not know where Dietary Staff D was during that time. During a telephone interview on 11/14/17 at 8:30 A.M., Dietary Staff D said lunch started around 12:30 P.M. and was usually finished a little after 1:00 P.M. After serving lunch, he/she buses the tables. On 11/3/17, at around 2:00 P.M. to 2:30 P.M., the dining room floor was being mopped. He/she saw the resident walking into the area with a wheeled walker. The resident started coming to the kitchenette area and he/she was trying to stop the resident from getting on the wet floor. The resident tries to go into the kitchenette a lot and no one tries to stop him/her. He/she had told the nurses this several times. After he/she stopped the resident, the resident tried to hit him/her with the walker. He/she probably did yell at the resident and he/she may have cursed. If he/she cursed, he/she was sorry. He/she remained on the floor and finished his/her shift. He/she did not see the resident again after that and clocked out at 3:00 P.M. The incident with the resident occurred quite sometime before he/she clocked out. After clocking out, he/she was asked to write a statement and told not to return until an investigation had been completed. During an interview on 11/14/17 at 10:00 A.M., the administrator said she thought the incident on 11/3/17, occurred closer to 2:30 P.M. to 3:00 P.M. Nurse F should have taken Dietary Staff D off the floor immediately. He/she should have escorted Dietary Staff D down to the dietary managers. She expected staff to follow the abuse policy. Review of the facility Abuse/Neglect Prevention and Response policy, dated 5/17/00 and revised on 3/27/17, showed the following: -Investigation: It is the facility's responsibility to investigate each concern that is raised and it is the administrator who is responsible for overseeing the investigation; -Protection: Staff shall immediately see to the safety of an alleged resident victim upon an allegation of abuse. This includes, but is not limited to, removing accused staff from contact with all residents.

Based on observation, interview and record review, the facility failed to ensure staff followed acceptable infection control standards during a treatment and incontinence care for two expanded sampled residents. The sample size was 21. (Residents #26 and #25) The census was 242 with 135 in certified beds. 1. Review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 9/26/17, showed the following: -[DIAGNOSES REDACTED]. -Short term memory loss; -Required extensive assistance of staff for bed mobility, transfers, dressing, toilet use and personal hygiene; -Required total assistance of staff for bathing; -Pressure ulcers: Yes. Observation on 11/14/17 at 7:57 A.M., showed the resident lay in bed. Nurse A washed his/her hands, applied gloves and moved the trash can, with a gloved hand, closer to the bedside. Without changing gloves, he/she pulled the resident's covers back, reached into his/her pocket for a pair of scissors and cut the old dressing from the resident's left foot. The nurse removed his/her gloves and without washing his/her hands, applied new gloves and cleaned the wounds with normal saline. With the same gloves, he/she applied medication to the wounds with a cotton swab and applied clean dressings. During an interview on 11/14/17 at 8:20 A.M., Nurse A said he/she should have washed his/her hands after touching the trash can and after cleaning the resident's wounds. During an interview on 11/14/17 at 10:15 A.M., the Director of Nurses (DON) said the nurse should have washed his/her hands and changed his/her gloves after touching the trash can. Review of the facility's policy on Infection Control Guidelines for all Nursing Procedures, dated 10/30/15, showed the following: -Purpose: To provide guidelines for general infection control while caring for residents; -General Guidelines: In most situations, the preferred method of hand hygiene is with alcohol-based gel hand rub. If hands are not visibly soiled, use an alcohol- based hand rub containing 60 - 95% [MEDICATION NAME] or [MEDICATION NAME] for the following situations: Before and after direct contact with residents, before handling clean or soiled dressings, gauze pads, etc., before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's skin, after handling used dressings, contaminated equipment and after removing gloves. 2. Review of Resident #25's care plan, dated 6/7/17, showed the following: -Problem: Urinary incontinence; -Approach: Assist the resident to the bathroom in the A.M., between meals, at bedtime and per request. Check for incontinence, change if wet or soiled. Clean skin with mild soap and water. Apply moisture barrier. Review of the resident's quarterly MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Short/long term memory loss; -Required extensive staff assistance for bed mobility, transfers, dressing, toilet use and personal hygiene; -Incontinent of urine. Observation on 11/9/17 at 5:18 A.M., showed the resident lay on a wet incontinence pad. After providing perineal care, Certified Nurse Aide (CNA) B changed his/her gloves, washed the resident's buttocks, applied barrier cream, applied clean brief, pulled the resident's gown back down and covered the resident without changing his/her gloves. During an interview on 11/9/17 at 5:40 A.M., CNA B said he/she should have changed gloves before applying barrier cream and touching clean items. During an interview on 11/14/17 at 10:15 A.M., the DON said she expected staff to change gloves prior to applying ointment and touching clean items. Review of the facility's Perineal Care policy, dated 4/1/08, showed it failed to instruct staff to change gloves after washing the buttocks, before applying protective ointment and touching clean items.

Based on observation, interview, and record review, the facility failed to use proper hand washing and glove changing techniques when going from soiled to clean and when handling food, properly wash and sanitize utensils prior to use, ensure the food contact surfaces of equipment were clean and allow dishes to air dry for five of five days of kitchen observations. The census was 207 with 143 in certified beds. 1. Observation of the main kitchen on 11/1/16 at 11:20 A.M., showed Dietary Aide F walked into the kitchen, without washing his/her hands, donned a pair of gloves, lifted the garbage can lid with his/her left hand and threw away the empty glove box. He/she then picked up a knife which sat on the bottom of the sink and placed the knife on a cutting board positioned next to the sink. The dietary aide reached into an opened container of cooked chicken breasts with his/her right gloved hand, picked up a chicken breast and placed it on the cutting board. He/she then picked up the knife he/she had placed on the cutting board and cut the chicken breast into small pieces and placed them into an open container. During an interview on 11/2/16 at 10:58 A.M., Dietary Aide H said knives should never be used to cut food once it had touched the bottom of a sink. During an interview on 11/4/16 at 8:15 A.M., Dietary Aide I said it would never be acceptable to use utensils which were laying on the bottom of the sink and hands should always be washed before touching food. During an interview on 11/4/16 at 10:00 A.M., the director of dining services said kitchen staff should always wash their hands before putting on gloves and touching food. Review of the facility's undated Dining Services: Employee Health and Personal Hygiene policy, showed the following: -Handwashing: wash hands, including under the fingernails and forearms vigorously and thoroughly with soap and water for a period of 20 seconds with water temperature being at least 100 degrees Fahrenheit; -Wash hands when entering facility before work begins, immediately before preparing food or handling equipment, as often as necessary during food preparation when contamination occurs, between each task performed and before wearing disposable gloves, any other time an unsanitary task has been performed, such as taking out the trash/garbage, sweeping, handling cleaning chemicals, etc; -Glove and utensil use: The facility has a no bare hand contact policy when handling ready to eat foods; therefore, utensils such as deli-paper, spatulas, tongs and gloves should always be used. 2. Observation of the main kitchen on 10/31/16 at 9:15 A.M., 11/1/16 at 11:20 A.M., 11/2/16 at 6:50 A.M., 11/3/16 at 5:50 A.M. and 11/4/16 at 8:30 A.M., showed rust and debris on the large blender, on the sides of the blade attachment and above the food mixing bowl. During an interview on 11/4/16 at 8:22 A.M., Cook G said the blender had rust and dried food on it which could fall into the food and the blender should be cleaned thoroughly prior to use. He/she said the rusty areas on the blender would not be able to be sanitized. 3. Observation of the preparation table adjacent to the entrance of the kitchen, on 10/31/16 at 9:34 A.M., 11/1/16 at 8:15 A.M. and 11/2/16 at 6:00 A.M., showed an assortment of stored, stacked serving pans. The pans had visible wet droplets of water running down the interior of the pans when lifted apart. Observation in the kitchen on 11/3/16, showed the following: -At 7:24 A.M., Dietary Aide J removed two wet pans from the preparation table next to the kitchen doorway. He/she placed the pans on a different preparation table and filled one with cooked bacon and the other with cooked biscuits; -At 7:28 A.M., Cook G removed eight wet pans from the preparation table next to the kitchen doorway, placed them on the preparation table in front of the stove and filled each pan with cooked gravy. Review of the facility's undated Dining Services: Employee Health and Personal Hygiene policy, showed pots and pans should be cleaned and sanitized, allowing to air dry before use. During an interview on 11/3/16 at 7:30 A.M., Cook G said the dishwashing staff normally bring the pans from the dishwashing room and place them on the preparation table, just inside the kitchen doorway. They are stacked on the counter for use and the ones that have not been used are later moved under the counter in the back of the kitchen. 4. During an interview on 11/4/16 at 10:00 A.M., the director of dining services said kitchen staff were to clean the kitchen on a daily basis and all staff were responsible for cleaning the kitchen. All pots and pans should be stacked in a manner to allow them to air dry prior to use.

Based on observation, interview and record review, the facility failed to investigate or thoroughly investigate, implement corrective interventions and update care plans for resident falls, incidents, accidents, bruises and resident elopement attempts. The facility identified 26 residents who fell and 29 residents who had abrasions/bruises. A total of 11 of those residents were sampled (seven from the survey sample of 18, four from an expanded sample), and problems were found with all 11. In addition, the facility failed to ensure the most appropriate mechanical lift was used for one of four observations of resident transfers and failed to ensure staff kept potentially hazardous chemicals locked up in two separate resident shower rooms. (Residents #9, #28, #13, #40, #29, #2, #41, #8, #12, #14, #1 and #17) The census was 187 with 105 in certified beds. 1. Review of Resident #9's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/29/12, showed the following: -[DIAGNOSES REDACTED]. -Short/Long term memory loss; -Cognitively impaired; -Limited assistance of staff for transfers and walking in room/corridor; -Extensive assistance of staff for bed mobility, dressing, toilet use and personal hygiene; -Total assistance of staff for bathing; -Unable to transfer from seated to standing position and from bed to wheelchair without the assistance from staff; -Incontinent of bowel and bladder; -No falls. Review of the resident's care plan, updated on 6/11/12, showed the following: -Memory impairment, required cues from staff; -Able to transfer with limited assistance of staff; -Fall Precautions: At risk for falls due to unsteady transfers; -Used a walker or the back of the wheelchair for support when walking; -Staff to make sure bed was at the height of the resident's knees for easy self transfer; -Keep light on in bathroom at night and offer assistance to the bathroom; -Incontinent of bowel and bladder. Review of the resident's electronic progress notes, completed by nursing staff, showed the following: -8/26/12 at 7:07 P.M.: Noted to have a hard area on the back of the left calf, diminished pedal (foot) pulses, complained of pain when area moved, call placed to the resident's physician. Tylenol given for pain at 4:00 P.M., left calf area reassessed after dinner and noted to be discolored with an increase in redness. Repeat call placed to the resident's physician; -8/26/12 at 10:50 P.M.: Notified the physician of a large 6 by 6 inch hematoma (an area of localized swelling that is filled with blood caused by a break in the wall of a blood vessel). Not sure if caused by a fracture or a blood clot. New order received for an X-ray of the left leg from the knee to the ankle and a venous (vein) Doppler (an ultrasound test used to search for blood clots); -8/27/12 at 10:18 A.M.: In bed at this time with a baseball size firm area noted to the back of the calf, green and purple in color. The resident's physician in to evaluate the area and stated he was glad he ordered the X-ray of the left leg and the venous Doppler study. Review of the resident's Left Lower Extremity (Leg) Venous Study, dated 8/26/12, showed the following: -Clinical Indication: Pain in soft tissues; -Findings: No thrombus (blood clot) is identified within the blood vessel. The area of concern is an area in the muscle of the left calf, probably a hematoma; -Impression: No evidence of deep venous thrombosis in the left lower extremity. Review of the resident's X-ray of the left tibia/fibula (bones in the lower leg), dated 8/27/12, showed the following: -Exam: Left tibia/fibula; -Results: No fracture or dislocation seen. Diffuse soft tissue swelling noted. Review of the resident's annual History and Physical, dated 8/27/12, showed the following: -[DIAGNOSES REDACTED]. -Physical exam: Musculoskeletal: stiff legs, left calf hematoma, large. Review of the resident's electronic progress notes, completed by nursing staff, showed the following: -8/27/12 at 2:49 P.M.: Results of the venous Doppler: negative, the resident remains in bed with legs elevated; -8/27/12 at 10:21 P.M.: In bed for evening meal. Tylenol 650 milligram (mg) given twice for complaints of pain; -8/29/12 at 8:37 A.M.: X-ray results negative for fracture, continued to have a baseball size green/purple area to the left calf. Review of the resident's electronic progress note, completed by the nurse practitioner, showed the following: -8/30/12 at 12:10 P.M.: Medical Progress Note: Chief complaint/reason for visit: History of present illness: Left calf is worse today per nurse, seen by the resident's physician on 8/27/12. X-ray's of left lower leg are negative and venous Doppler negative for blood clot, shows hematoma; -New sign or symptom: left calf swelling; -Physical exam: Large raised hematoma present to left calf, with a large fluid filled blister. Edema present: left calf 3+ swelling; -Assessment and Plan: Impression: Left calf hematoma, resident unsure of the source of the hematoma. Left calf has a dark purple firm hematoma with a fluid filled blister. 50 cubic centimeters (cc) of golden brown fluid removed per sterile needle. High risk for infection, new order for Keflex (antibiotic) 500 mg for ten days. Review of the resident's electronic progress notes, completed by nursing staff, showed the following: -8/30/12 at 1:01 P.M.: Left back of calf hematoma is larger in size and red/purple in color. Nurse Practitioner drained the hematoma, stating it was an infected hematoma and ordered Keflex 500 mg for ten days. During an interview on 9/5/12 at 8:15 A.M., during the initial tour of the facility, Nurse B, said the following, about the resident: -Alert and oriented to person and place; -Transferred with the assistance of one staff; -Ambulated to meals by holding onto the back of his/her wheelchair; -No recent falls; -Had a infected hematoma to the back of the left leg, discovered two weeks ago, may have been pinched, cause of injury unknown. Observation on 9/6/12, showed the following: -7:15 A.M.: the resident lay in bed reading. He/She showed this surveyor a dressing to his/her left calf and said he/she didn't know what happened to his/her leg but hoped it would get better soon. He/She said it hurt "bad" at times; -8:45 A.M.: the resident sat in his/her wheelchair, self propelling with his/her feet. A large dressing noted to the left lower leg. Review of the resident's History and Progress Note, completed by the Nurse Practitioner, dated 9/6/12, showed the following: -Follow up for left lower leg hematoma; -Complaint of tenderness with palpation (examine by touch/pressure); -Left calf, increased swelling with increased purple (dark) discoloration in localized area; -Area tender, firm and covers the entire calf; -Plan: Elevate the calf, continue Keflex and monitor. During an interview on 9/7/12 at 7:00 A.M., Certified Nurse Aide (CNA) D said he/she didn't work the weekend staff discovered the hematoma, when he/she returned the following Monday, the resident had the hematoma. The resident received a shower twice a week on Wednesdays and Saturdays and needed help with transferring from the bed to the wheelchair and in the bathroom. He/She didn't know how the resident developed the hematoma to the left calf and no one interviewed him/her about it or asked for a statement. Observation on 9/10/12 at 7:40 A.M., showed the resident lay in bed. Nurse B said he/she didn't know how the hematoma occurred. He/She worked, on the day shift of 8/26/12, and remembered the resident saying at the change of shift his/her left leg hurt. Both nurses, day and evening shift, looked at the resident's leg and the evening nurse asked if he/she knew what happened. He/She did not know, no one informed him/her of any problems with the resident's leg. Nurse B removed the dressing to the resident's left leg revealing a large discolored area covering the entire calf with a smaller black area in the center. The nurse said the hematoma measured 15 centimeter (cm) by 11 cm and the smaller black area measured 5.5 cm by 11 cm. When asked if the physician had been notified of the current condition of the resident's calf, Nurse B said they notified the Nurse Practioner. The resident then complained, his/her leg hurt "so bad" at times. Review of the resident's history and progress note, dated 9/10/12, completed by the Nurse Practitioner, showed the following: -Follow up of left calf hematoma, over the weekend the hematoma opened and drained; -[DIAGNOSES REDACTED]tous (redness of the skin, sign of inflammation) area raised about 1 centimeter, felt warm to touch; -Area measured 17.5 cm by 14 cm, the center of the wound has old dark blood and measured 7 cm by 6.5 cm. Review of the resident's electronic progress note, completed by nursing staff, showed the following: -9/10/12 at 10:00 A.M.: Hematoma on back of left calf is no longer raised, large amount of dark red thin drainage, area remains tender to touch; -Red/purple area measures: 17.5 cm by 14 cm and the hematoma measures 7 cm by 6.5 cm., order received to extend the antibiotic order for seven more days. Review of the resident's electronic progress notes, dated 8/30/12 through 9/10/12, failed to show an investigation regarding the hematoma to the resident's left calf. During an interview on 9/12/12, at 9:50 A.M., the Director Of Nurses (DON) said they discussed the resident's hematoma but failed to document. She said she did not have an investigation regarding the hematoma to the resident's left calf. During an interview on 9/14/12 at 11:56 A.M., the Medical Director said the resident had been sent to the hospital on [DATE], for the infected hematoma. He said the hematoma was a soft tissue injury that involved the entire left calf. He did not know what caused the hematoma but felt it was caused some type of trauma or injury. He said the resident had Alzheimer's type dementia and was unable to describe what happened. He would have expected the facility to investigate to determine what caused the injury. 2. Review of Resident #28's admission MDS, dated [DATE], showed the following:-admitted on [DATE]; -Understood/Understands; -No mood or behavior problems; -Limited assistance of one person required for bed mobility, transfers and walking in room/corridor; -Moving from seated to standing position: Not steady, but able to stabilize without human assistance; -Surface-to-surface transfer: Not steady, but able to stabilize without human assistance; -Impairment of one upper and one lower extremity; -Mobility devices: Walker and wheelchair; -[DIAGNOSES REDACTED]. -Fall within the last month prior to admission; -No falls since admission. Review of the resident's electronic progress notes, dated 9/2/12 at 11:23 P.M., showed staff found the resident on the floor in the dining room with his/her wheelchair approximately 8 feet from where he/she fell . He/She said his/her left elbow was sore but could move it without difficulty. Just before the fall, the resident had been at the nurse's station wanting to go with staff to the bus stop. Review of the resident's "Incident Details" form, completed by facility staff on 9/2/12, showed the following corrective measures: -Observe resident frequently to check for safety; -Keep resident within sight of staff. Review of the "Resident Care Information", used by the CNAs, undated, showed the following:-Full weight bearing; -Wheelchair; -High risk for falls; -Assist of one staff for transfers; -Nap after lunch; No mention of the corrective measures identified on the "Incident Details" form dated 9/2/12. Review of the resident's electronic progress notes, from 9/2/12 through 9/5/12, showed no investigation regarding the resident's fall on 9/2/12. Review of the resident's "Fall Risk Assessment", dated 9/2/12, showed the following: -History of falls: one to two falls in the last 90 days; -Last fall on 9/2/12; -Change in cognitive status in the last 90 days; -Does the resident display any of the following: Easily distracted, periods of altered perception or awareness of surroundings, episodes of disorganized speech, periods of restlessness or lethargy, mental function varies of the course of the day, wanders - YES; -Required assistance with bowel or bladder continence; -Ambulated with devices/assistance; -Balance while standing: Not steady, only able to stabilize with human assistance; -Age: greater than 85; -Three or more health conditions that may contribute to falls; -Three or more medications, that may be contributing factors to falls, taken currently or in the last seven days; -Total risk for falls score: 24 (A resident whose score is over nine is at risk for falls, consider environment risk factors in the resident's interventions or addition or removal of balance mobility devices). During an interview on 9/5/12 at 9:25 A.M., MDS Coordinator J said the resident was confused and forgetful. He/She had been admitted to the Medicare unit on 8/31/12 for skilled therapy. The resident used a wheelchair independently and had fallen on 9/2/12. The resident did not use an alarm on his/her bed or wheelchair. Observation on 9/5/12 at 1:20 P.M., showed the resident sat in a wheelchair at the nurse's station. Nurse A stood next to the resident holding a pressure dressing and ice pack to the right side of the resident's forehead. During a conversation with another staff member, Nurse A said the resident fell to the floor in the dining area. Staff called 911 and sent the resident to the hospital. Review of the resident's electronic progress notes, dated 9/5/12 at 7:55 P.M., showed the following: At 12:45 P.M., the physical therapy assistant heard a noise, turned and found the resident on the dining room floor. The resident was unresponsive for approximately 45 seconds and had two lacerations above the right eye. One laceration was approximately 2 cm long and one was approximately 4 cm long. The lacerations had a moderate amount of bleeding and bleeding was also noted coming from the resident's mouth. Resident assisted to the wheelchair with assistance of three staff, 911 called and resident was transported to the hospital. Review of the resident's hospital notes, dated 9/5/12, showed admission to the hospital with [DIAGNOSES REDACTED]. During a telephone interview on 9/19/12 at 1:20 P.M., Nurse A said he/she remembered the resident's fall on 9/5/12, and thinks he/she remembered something about the resident falling on 9/2/12, but he/she was not sure. After a resident falls, they try to monitor them more closely. The resident could wheel himself/herself in the wheelchair. During an interview on 9/12/12 at 9:50 A.M., the DON said she did not have an investigation for the resident's falls. 3. Review of Resident #13's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Wheelchair for mobility; -Extensive assistance of one with transfers, dressing and toileting; -Ambulation did not occur; -Unsteady and only able to stabilize with human assistance when moving from seat to standing, turning around, moving on or off of the toilet and surface-to-surface transfers. Review of the resident's electronic progress notes, showed the following: -On 3/25/12 at 2:13 P.M., staff found the resident on the floor, in front of his/her toilet, lying on his/her back after an attempt to transfer without assistance; -On 3/29/12 at 2:15 P.M., staff notified the resident's family of a roll out of bed which resulted in a 0.5 cm abrasion above the resident's right ear, after he/she landed on a trash can; -On 4/12/12 at 7:15 P.M., staff discovered the resident lying on the dining room floor on his/her back with both legs extended and his/her wheelchair across the room. Review of the resident's electronic physician's orders [REDACTED]. -An order dated 4/22/12, for assist of one with transfers; -An order dated 4/22/12, for bed in low position; -An order dated 4/22/12, for fall risk precautions; -An order dated 4/22/12, for tab alarm (features a magnetic pull string that sounds an alarm if the resident to whom it was attached attempted to rise) when in bed; -An order dated 4/22/12, for a wheelchair for mobility; -An order dated 4/22/12, for a physical therapy evaluation related to Parkinson's disease; -Orders dated 4/23/12, for physical therapy (PT) and occupational therapy (OT) evaluations. Review of the resident's care plan, showed no update for fall interventions. Review of the resident's electronic progress notes, showed the following: -On 5/7/12 at 7:25 P.M., a nurse observed the resident lying on his/her left side on the dining room floor; -On 5/22/12 at 1:45 P.M., staff constantly had to reposition the resident due to him/her and the cushion sliding forward in his/her wheelchair; -On 5/20/12 at 11:00 P.M., staff observed the resident sitting at the edge of his/her bed with the right knee leaning against the footboard of the bed. Staff assisted him/her with repositioning twice but he/she sustained a 2 cm, round abrasion to the right knee. Review of the resident's electronic progress notes, showed the following: -On 6/5/12 at 2:22 P.M., he/she kept sliding to the front of his/her wheelchair and staff had to continually remind him/her to position self to keep from sliding out of wheelchair. Review of the resident's care plan, showed no update for fall interventions. Review of the resident's electronic fall risk assessment, dated 6/9/12, showed the following: -Confined to chair; -Not able to attempt balance without physical help; -Three or more falls; -Last fall on 6/7/12; -Total score of 20; -A score over nine indicates fall risk; -Environmental risk factors should be considered in resident interventions; -Consider addition or removal of balance mobility devices. Review of the resident's progress notes and incident logs did not show a fall on 6/7/12. Review of the resident's electronic progress notes, showed the following: -On 6/24/12 at 11:15 A.M., staff found the resident lying on his/her back on the dining room floor in front of his/her unlocked wheelchair. The resident had a small raised area and skin tear on the center, rear of his/her head. Review of the resident's electronic fall risk assessment, dated 6/24/12, showed a total score of 18. Review of the resident's electronic POS, printed on 9/7/12, showed an order dated 6/25/12, for transfers via a stand up lift every shift daily. Review of the resident's electronic progress notes, showed the following: -On 7/1/12 at 10:49 P.M., a housekeeper found the resident lying flat on the floor with blood flowing from a "T" shaped laceration in the center of the resident's forehead for which he/she went to the hospital and received treatment. The resident remained under observation at the hospital until the next day; -On 7/2/12 at 2:12 A.M., it was documented that hospital staff closed the abrasion on the resident's forehead with steri-strips, and discovered a small reddened area to the right lower leg and rug burn to the right knee sustained during the fall on 7/1/12. Review of the resident's electronic fall risk assessment, dated 7/2/12, showed a total score of 24. Review of the resident's care plan, updated on 8/6/12, showed: -Exhibited short term memory problems and confusion resulting in episodes of wandering; -At risk for getting dizzy from all of the different medications taken; -Fall risk posed by resident's tendency to remove the cushion from his/her wheelchair and slide to the floor; -Handwritten note dated 7/4/12, resident provided with a Broda chair (a reclining chair on wheels used for positioning) due to frequent falls. Review of the resident's care plan and medical record did not show fall intervention updates or changes after the resident's falls. Review of the resident's electronic progress notes, dated 8/14/12 at 5:20 A.M., showed staff found the resident lying on his/her back. He/She did not know how he/she fell out of the low bed. Review of the resident's electronic fall risk assessment, dated 8/14/12, showed a total score of 26. Review of the resident's POS, printed 9/17/12, showed the following: -An order dated 8/23/12, for a PT evaluation for a new stroke diagnosis; -An order dated 8/23/12, for an OT evaluation for a new stroke diagnosis; -An order dated 8/27/12, for a skilled OT evaluation or treatment for [REDACTED]. -An order dated 8/28/12, for OT evaluation and treatment for [REDACTED]. Review of the resident's undated physician's progress note, showed the following: -Skin tears to bilateral shins with serous (pale, benign fluid) weeping; -New irregular heart rate, electrocardiogram (EKG) pending; -Limited passive and active range of motion (ROM); -New, leaning to the right side. Observations showed the following: -On 9/6/12 at 7:11 A.M., the resident slept in a bed not in low position; -On 9/6/12 at 12:55 P.M., the resident ate lunch leaning to the right side; -On 9/7/12 at 9:32 A.M., the resident slept at the breakfast table, leaning slightly to the right side; -On 9/10/12 at 12:23 P.M., the resident ate lunch leaning slightly to the right side. 4. Review of Resident #40's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -No cognitive impairment; -History of falls; -Limited assistance with transfers. Review of the resident's care plan, dated 7/24/12, showed the following: -Fall precautions: I am at risk for falls because I will on occasion have a shuffling (shaky) gait. I am able to walk at least 200 feet but I tend to tire easily and will have to sit for a rest; -Because I am up ad lib independently, please monitor me for unsteady gait; -When I have episodes of shuffling my feet, remind me to ask for assist for transfers and ambulation with assist. Review of the resident's incident report, showed the following: -Falls on 6/19/12, 7/16/12, 8/1/12 and 8/20/12. Review of the resident's progress notes, showed the following: -6/19/12, resident fell in his/her room while trying to transfer himself/herself into his/her wheelchair. Reopened a skin tear to posterior (back) upper left arm; -7/16/12, no progress notes documented; -8/1/12, the nurse observed the resident lying on his/her back with his/her head toward the door with legs extended towards the toilet in his/her bathroom. The resident was assessed and assisted into his/her wheelchair. The resident had excoriation (rash) to the left shoulder blade measuring 5 cm by 0.5 cm, a 4 cm by 10 cm skin tear on the posterior aspect of the armpit and a 18 cm by 5 cm skin tear to the posterior bicep area of the left arm. The resident complained of bilateral shoulder and neck pain and said he/she hit his/her head. The resident had cataract surgery in the past. The right pupil was 4 millimeters (mm) and slow to react to light. The left pupil was 2 mm and brisk to light; -8/20/12, found on the floor on his/her back in his/her room. The resident said he/she got dizzy and lost his/her balance. The resident had a 7.5 cm by 7.5 cm abrasion with excoriation and slightly bleeding on his/her back. Review of the resident's care plan showed the following: -No updates for the falls on 6/19/12, 7/16/12, 8/1/12 and 8/20/12. Observations on 9/17/12, showed the following: -9:40 A.M., the resident sat quietly in his/her wheelchair in the second floor dining area; -10:30 A.M., the resident sat in his/her wheelchair visiting with a family member in his/her room. 5. Review of Resident #29's admission MDS, dated [DATE], showed the following: -admitted 6/4/12; -Moderate cognitive impairment; -Limited assistance with activities of daily living (ADLs); -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 6/21/12, showed the following: -Fall precaution: I have a history of falls which is why I moved here from the Assisted Living; -History of dizziness related to inner ear problem. I usually fall to the left side; -Please toilet me routinely. Review of the resident's nurse's notes, showed the following: -6/20/12, the resident was in the bathroom. He/She stood up from the toilet and his/her leg was hurting and he/she felt dizzy. He/She held onto the arm rail in bathroom and eased him/herself to the floor. Resident told staff he/she did not hit his/her head or any other area of the body; -6/22/12, the care companion reported finding resident on floor in room, sitting with his/her back against side of the bed. Resident explained he/she was trying to turn off radio and lost his/her balance. Denied hitting his/her head; -6/29/12, the resident was found on the floor in the bathroom. The resident had taken him/herself to the toilet, got up without locking the his/her wheelchair and sat down in front of the toilet. Denied any pain; -7/1/12, the resident was found on floor next to his/her bed, between the bed and his/her wheelchair. The resident said he/she went to the restroom and when he/she came back the bed started acting crazy and that is when the resident hit the floor; -7/28/12, the CNA found the resident on the bathroom floor. The resident said his/her left side of his/her head hurt and was fading in and out of consciousness. The physician was notified and the resident was sent to the hospital for evaluation; -7/30/12, the resident's roommate came to the nurse's station and informed staff the resident was on the floor. Staff entered the room and saw the resident on the floor next to his/her bed wrapped in a blanket with his/her back and head against the side rail. The resident said he/she did not know what happened and his/her back and left arm hurt. Staff did upper and lower range of motion. There were no open areas or bruising; -7/30/12, nurse's order for a tab alarm at all times; -8/2/12, the resident was found by care companion on the floor leaning against his/her bed. The resident's back was to the bed and his/her legs were in front of him/her. The resident denied hitting his/her head, but complained the back of his/her head hurt. There was no raised areas or bruising on the resident's head; -8/2/12, nurse's order for fall risk; -8/6/12, staff heard a tab alarm sound, went into the resident's room and found the resident lying on his/her side, with right his/her shoulder and head on mat. The resident apparently got out of bed. The resident said he/she was looking for his/her daughter and attorney. Staff did ROM to all extremities without problem. The resident's right shoulder had some limitation of movement due to history of a fracture; -8/8/12, the resident was found on floor by the bed lying on his/her right side. ROM done without difficulty and resident denied any pain or discomfort; -8/13/12, the care companion was helping the resident get his/her night gown on and asked if the resident needed to go to the bathroom. The resident said yes and the care companion started to take him/her in his/her wheelchair. The resident stood up and sat down on his/her right side and lowered his/her right shoulder down to the ground. The resident said he/she had pain in his/her right and left hip. The resident was swearing and yelling at the care companion and said he/she did not want anymore help. There was no sign of rotation of the resident's legs; -8/14/12, the nurse was called into the resident's room by a staff member who found the resident on the floor. The resident was lying on his/her right side, awake and able to speak. The resident's speech was unclear and the resident was confused; -8/23/12, the resident got out of his/her wheelchair unassisted and landed on the floor. The resident denied any pain and there was no apparent injury noted; -8/30/12, the resident was found on the floor, in a fetal position on his/her right side, in front of his/her bed. The resident was able to roll with assistance, denied pain and denied hitting his/her head. The resident was able to move upper extremities. Observations of the resident on 9/17/12, showed the following: -9:45 A.M., the resident sat in his/her Broda chair in the second floor dining area. The resident's tab alarm was attached; -10:50 A.M., resident sat in his/her Broda chair in the second floor dining area participating in an activity. The resident's tab alarm was attached. Review of the resident's care plan, showed no updates regarding the falls on 6/22/12, 6/29/12, 7/1/12, 7/28/12, 7/30/12, 8/2/12, 8/6/12, 8/8/12, 8/13/12, 8/14/12, 8/23/12 and 8/30/12. During an interview on 9/17/12 at 11:40 A.M., the DON said there was an expectation for the care plan to be updated to show the progression of the resident and the interventions that are put into place. During an interview on 9/17/12 at 12:55 P.M., the DON said investigations are not done for falls. The information should be documented in the progress notes and on the care plan. Investigations are done for unexplained skin tears. 6. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -admission date of [DATE]; -Severe cognitive impairment; -Total assist with ADLs; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 6/20/12, showed the following: -No care plan for bruising and skin tears. Review of the resident's incident log, selected for injury type, showed the following: -7/7/12, skin tear and minor injury to right elbow; -7/21/12, bruise and minor injury to right eye; -8/17/12, skin tear and minor injury to lower back forearm. Review of the resident's nurse's notes, showed the following: -7/9/12, a call placed to physician's office to notify him of the bruise and skin tear on right elbow (size not documented). Requested a call back. Awaiting a return call; -No return call from the physician documented; -8/17/12, observation of a skin tear on left forearm, 1 cm "V" shape. Cleansed with normal saline and dry dressing applied. Notified the resident's physician and responsible party. Review of the resident's "Incident Details" report, dated 7/7/12, showed the following corrective measures: -Protect extremities, especially when transferring into the bed and using the mechanical lift. Review of the resident's incident investigation report, dated 7/12/12, showed the following; -A 1 cm skin tear on right elbow with a 3.1 cm bruise surrounding the skin tear and dried blood noted; -Resident unable to say what happened; -CNA reported the skin tear to the charge nurse at the beginning of the shift. Review of the resident's incident investigation report, dated 7/24/12, showed the following: -A 1.5 by 1 cm bruise under the right eye; -The resident was in bed when the bruise was found; -The resident unable to say what happened. Observations on 9/6/12, showed the following: -8:30 A.M., the resident lay in a low bed with a mat on the floor; -12:10 P.M., the resident sat quietly in his/her wheelchair in the third floor dining room. Review of the resident's medical record, showed the following: -No updated care plan for bruising and skin tears. During an interview on 9/11/12 at 9:04 A.M., the DON said she could not find any further investigative information regarding the resident's incidents. 7. Review of Resident #41's "Resident Care Guide", dated 6/11/2008 and last updated on 1/17/12, showed the following: -Safety: Resident is at risk of getting dizzy from medication side effects, so make sure he/she has his/her wheeled walker with him/her and try to be with the resident during transfers. Resident requires help to get through the tables and wheelchairs in the dining room; -Mobility: History of a fractured hip in 2008. Resident is usually up in a wheelchair propelling self, but after supper, he/she is tired and may need someone to push him/her back to his/her room. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Understood/Understands; -Extensive assistance of one person required for bed mobility, transfers, walking in room/corridor and locomotion on the unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self sufficiency once in chair); -[DIAGNOSES REDACTED].