Every finding on record at Madonna Manor Nursing Home

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Ensure the main kitchen grout and coving was maintained in a sanitary and safe condition; and2. Ensure ready to eat foods (food which does not require cooking or further preparation prior to consumption) were handled utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another) during tray line service. Findings include:1. Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised January 2023, indicated but was not limited to the following:1-2 Definitions 1-201 Applicability and Terms Defined1-201.10 Statement of Application and Listing of Terms.Easily Cleanable.(1) Easily cleanable means a characteristic of a surface that: (a) Allows effective removal of soil by normal cleaning methods; (b) Is dependent on the material, design, construction, and installation of the surface; and (c) Varies with the likelihood of the surface's role in introducing pathogenic or toxigenic agents or other contaminants into food based on the surface's approved placement, purpose, and use.Smooth means:(3) A floor, wall, or ceiling having an even or level surface with no roughness or projections that render it difficult to clean.6-201.12 Floors, Walls, and Ceilings, Utility Lines. Floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned. Requirements and restrictions regarding floor coverings, utility lines, and floor/wall junctures are intended to ensure that regular and effective cleaning is possible and that insect and rodent harborage is minimized.6-201.13 Floor and Wall Junctures, Coved, and Enclosed or Sealed. (A) In FOOD ESTABLISHMENTS in which cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures shall be coved and closed to no larger than 1 mm (one thirty-second inch). On 9/9/25 at 8:20 A.M., the surveyor made the following observations in the main kitchen:- Peeling paint on the ceiling above the air conditioner and prep sink.- Dirty floor tiles under the sinks in the food prep area.- Chipped/peeling paint on the ceiling and walls in the first walk-in refrigerator.- Chipped/peeling paint on the ceiling and walls in the second walk-in refrigerator. The ceiling and walls were also noted to have a white/brown powdery substance.- Black, fuzzy buildup on the tile coving in the second walk-in refrigerator.- Chipped/peeling paint on the ceiling and walls in the third walk-in refrigerator. The ceiling was also noted to have black splotches.- The perimeter of the floor in the third walk-in refrigerator had a buildup of crumbs and other food residue.- Grout in the dish room was noted to be crumbling in many areas. During an interview on 9/10/25 at 1:40 P.M., the Food Service Director (FSD) said the floors in the main kitchen areas are mopped twice a day by staff. The FSD said the floors in the main kitchen area had not been professionally washed or maintained since she started at the facility. The FSD said there were multiple areas of peeling paint in the walk-in refrigerators which will need to be addressed. The FSD when the paint peelings drop into the grout on the floor it is hard to get out. During an interview on 9/10/25 at 2:16 P.M., the Administrator and the surveyor reviewed the findings in the main kitchen areas. The Administrator said he expected the kitchen areas to be kept clean and sanitary. 2. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following:- 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT.- 3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. On 9/10/25 at 11:26 A.M., the surveyor made the following observations during the lunch tray line service:- At 11:33 A.M., Dietary Staff #1 touched the top of the trash can with a gloved hand and then used the same gloved hand to flip a grilled cheese sandwich cooking on the stove top.- At 11:42 A.M., Dietary Staff #1 went into the walk-in refrigerator to grab food items for the line service. Dietary Staff #1 did not change his gloves and returned to prepping foods on the tray line.- At 11:46 A.M., Dietary Staff #1 took a hot dog out of the warmer with gloved hands and continued to plate food items on the tray line without changing his gloves.- At 11:47 A.M., Dietary Staff #1 touched the broccoli, placing it in a bowl, and did not change his gloves.- At 11:50 A.M., Dietary Staff #1 adjusted his pants with his gloved hands and did not change them prior to continuing to plate food items during the tray line service.- At 11:53 A.M., Dietary Staff #2 touched his gloved hand to his face to just above his mouth. Dietary Staff #2 did not change his gloves and remained on the tray line placing items onto resident trays.- At 11:59 A.M., Dietary Staff #1 used his gloved hands to slide a grilled cheese onto a plate that he removed from the warmer.- At 12:00 P.M., Dietary Staff #1 used his gloved hands to plate French fries from the warmer onto a plate.- At 12:03 P.M., Dietary Staff #1 used his gloved hands to move a piece of meatloaf from a regular plate to a lipped plate.- At 12:15 P.M., Dietary Staff #3 touched her gloved hands to her face and adjusted her glasses and remained on the tray line without changing her gloves.- At 12:17 P.M., Dietary Staff #1 reached into a pot on the stove with his gloved hand and mixed the food item with his gloved hands. Dietary Staff #1 then plated the food item and delivered it to the tray line. During an interview on 9/10/25 at 1:40 P.M., the FSD said staff should be changing their gloves when they break away from a task or start something new. The FSD said dietary staff should change their gloves and perform hand hygiene if they touch their face or body. The FSD said gloves should have been changed when Dietary Staff #1 touched the top of the trash can.

Based on employee record review and interview, the facility failed to ensure the new hire employee records contained evidence of the 2024-2025 COVID-19 vaccination for two of five newly hired employees. Specifically, the facility failed to ensure the employee record contained evidence of the COVID-19 vaccination or proof the newly hired employees were offered an updated COVID-19 vaccine when he/she was eligible. Findings include: Review of the facility's policy titled COVID-19 Personnel Vaccination Requirement, dated as revised 5/2023, indicated but was not limited to:-All nursing homes must ensure that all personnel are up to date with vaccination against COVID-19, unless such administration is medically contraindicated or on the basis of a sincerely held religious belief-Vaccinations against COVID -19 will be made available to staff as arranged by the infection control nurse Review of the Centers for Disease Control and Prevention (CDC) guidance, Staying up to date with COVID-19 vaccinations, dated as revised June 6, 2025, indicated but was not limited to the following:- CDC recommends a 2024-2025 COVID-19 vaccine for most adults ages 18 years and older. This includes people who have received a COVID-19 vaccine, people who have had COVID-19, and people with long COVID.Importance of staying up to date:- Getting the 2024-2025 COVID-19 vaccine is important because protection from the COVID-19 vaccine decreases with time; Immunity after COVID-19 infection decreases with time; COVID-19 vaccines are updated to give you the best protection from the currently circulating strains.- Administer recommended vaccines if vaccination history is incomplete or unknown.- Routine vaccination: age [AGE]-64 years:a. Unvaccinated: 1 dose 2024-25 Moderna or Pfizer-BioNTech; 2 doses 2024-25 Novavax at 0, 3-8 weeksb. Previously vaccinated before 2024-25 vaccine with: 1 or more doses Moderna or Pfizer-BioNTech: 1 dose 2024-25 Moderna or Novavax or Pfizer-BioNTech at least 8 weeks after the most recent dose. 1 dose Novavax: 1 dose 2024-25 Novavax 3-8 weeks after most recent dose. If more than 8 weeks after most recent dose, administer 1 dose 2024-25 Moderna or Novavax or Pfizer-BioNTech. 2 or more doses Novavax: 1 dose 2024-25 Moderna or Novavax or Pfizer-BioNTech at least 8 weeks after the most recent dose. 1 or more doses [NAME]: 1 dose 2024-25 Moderna or Novavax or Pfizer-BioNTech.- Routine Vaccination: age [AGE] years and older:a. Unvaccinated: follow recommendations above for unvaccinated persons ages 19-64 years and administer dose 2 of 2024-25 Moderna or Novavax or Pfizer-BioNTech 6 months later (minimum interval 2 months).b. Previously vaccinated before 2024-25 vaccine: follow recommendations above for previously vaccinated persons ages 19-64 years and administer dose 2 of 2024-25 Moderna or Novavax or Pfizer-BioNTech 6 months later (minimum interval 2 months).- Unvaccinated persons have never received any COVID-19 vaccine doses. There is no preferential recommendation for the use of one COVID-19 vaccine over another when more than one recommended age-appropriate vaccine is available. Administer an age-appropriate COVID-19 vaccine product for each dose. Nurse #1 was hired on 6/25/25. Review of the employee file failed to indicate evidence of his/her COVID vaccination status. Further review of the employee file failed to indicate he/she had been provided education regarding the benefits, risks, and potential side effects associated with the COVID vaccine; and had been offered the most recent COVID vaccination. Activities Assistant #1 was hired on 6/18/25. Review of the employee file failed to indicate evidence of his/her COVID vaccination status. Further review of the employee file failed to indicate he/she had been provided education regarding the benefits, risks, and potential side effects associated with the COVID vaccine; and had been offered the most recent COVID vaccination. During an interview on 9/1/25 at 9:31 A.M., the Assistant Director of Nurses (ADON)/ Staff Development Coordinator (SDC) said newly hired staff should bring a copy of their vaccine history with them at the time of hire and the information should be in the employee files. The ADON/SDC said the most recent COVID vaccine should also be offered to those who have not received it and it should be documented in their employee file. The ADON/SDC said if an employee did not want the vaccination a signed declination should be completed and kept in their employee file. During an interview on 9/11/25 at 1:16 P.M., the ADON/SDC said she could not find evidence of COVID vaccination or that the vaccination had been offered to Nurse #1 or Activities Assistant #1.

Based on observation and interview, the facility failed to ensure medications were accurately labeled and stored in accordance with acceptable professional standards. Specifically, in one of three medication carts reviewed the facility failed to ensure medications were stored in their original packaging. Findings include: Review of the facility's policy titled Medication Storage in the Facility, dated March 2021, indicated but was not limited to:-The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United State Pharmacopeia (USP). Medications are kept in these containers. Nurses may not transfer medications from one container to another.-All medications dispensed by the pharmacy are stored in the container with the pharmacy label. On 9/10/25 at 12:48 P.M., the surveyor observed a medicine cup containing several unlabeled medications, in the 2nd floor [NAME] Unit medication cart third drawer. The medicine cup included eight pills:-one red oval caplet-one dark red round tablet-one pink oval tablet-one white and blue capsule-two white round tablets-one dark (black) round pill -one white/yellow tablet During an interview on 9/10/25 at 12:51 P.M., Nurse #4 said the medications were for Resident #70 who refused to take the prescribed medications at 9:00 A.M. Nurse #4 said she should have destroyed the medications after refusal and should not have left the medications in the cart in a medicine cup unlabeled. During an interview on 9/11/25 at 2:20 P.M., the Director of Nursing (DON) said medications should not be left without identifiers, unlabeled, in a cup inside of the medication cart. The DON said if a resident refused medications those medications should be destroyed.

Based on observation and interview, the facility failed to ensure residents received food prepared by methods that conserve nutritive value, flavor and appearance and was palatable, attractive and at a safe and appetizing temperature for one of two test trays. Findings include:Review of Resident Council Minutes indicated the following resident concerns and facility solutions:- 7/3/25: food trays are warm, but not hot and meals are delivered at incorrect times. The Food Service Director (FSD) is training new staff, and the metal plate warmer was not functioning and was being fixed.- 8/7/25: FSD attended meeting and explained to residents the piece of equipment (metal plate warmer) that was not working in the main kitchen. On 9/10/25 at 11:00 A.M., 10 of 17 residents in attendance of the Resident Council Meeting said food was cool or lukewarm and that trays were coming later than scheduled. On 9/11/25 at 8:00 A.M., the surveyor requested a test tray to the second floor unit and made the following observations:- The food truck containing resident trays left the main kitchen at 8:13 A.M. and arrived at 8:14 A.M. on the unit and was placed across from the unit dining room.- At 8:15 A.M., nursing staff were observed on the [NAME] portion of the unit delivering meal trays to residents from the first meal truck sent to the unit. The second meal truck remained positioned across from the unit dining room, unopened.- At 8:21 A.M., a Certified Nursing Assistant (CNA) was observed to place a meal tray from the first meal truck into the second meal truck across from the unit dining room. The CNA then continued to deliver meal trays to residents from the first meal truck.- At 8:28 A.M., 14 minutes after the second meal truck arrived on the unit, nursing staff began delivering meal trays into the unit dining room from the second meal truck.- At 8:49 A.M., 35 minutes after the second meal truck arrived on the unit, nursing staff delivered the last meal tray from the meal truck. On 9/11/25 at 8:50 A.M., the surveyor and Nurse #3 completed the test tray together and the food temperatures were as followed:- Bacon: 100.5 Fahrenheit (F); bacon was crispy but cold to taste and touch- Scrambled Eggs: 113.2 F; eggs were cold and lacked flavor- Milk: 54.3 F; lukewarm temperature to taste and warm to touch- Orange Juice: 55.9 F; lukewarm to taste and touch-Hot Cereal: 125.8 F; warm to taste-Coffee: 135.1 F; hot, no concerns noted. During an interview on 9/11/25 at 8:51 A.M., Nurse #3 said she was not sure what temperatures should be when they arrive on the unit to residents. During an interview on 9/11/25 at 11:45 A.M., the FSD and the surveyor reviewed the observations and test tray results from the breakfast service. The FSD said cold items, such as milk and orange juice, should be around 40F when residents are consuming them on the unit. The FSD said hot food items should be around 150-155F when served to residents on the unit. The FSD said she would expect the hot food temperatures to be higher and the drink temperatures to be lower.

Based on interview and record review, the facility failed to ensure one Resident (#9), out of a total sample of 18 residents, was referred to see a Neurologist as recommended by the Psychiatrist and the Primary Physician.Findings include:Resident #9 was admitted to the facility in October 2022 with a diagnosis of history of bipolar disorder and anxiety.Review of the Minimum Data Set (MDS) assessment, dated 7/2/25, indicated Resident #9 scored 10 out of 15 on the Brief Interview for Mental Status, indicating the Resident had a moderate cognitive impairment. Review of Section S indicated Resident #9 was their own healthcare decision maker. Review of the medical record indicated Resident #9 had a telehealth visit with the Psychiatrist on 6/16/25. The Subsequent Nursing Facility Visit summary indicated Resident #9 became weepy while talking about his/her condition of involuntary movements/tremors. The Recommendations section indicated Due to {his/her} concerns that tremors have been depressing for {him/her}, consider referral to Neurology for consultation and recommendations to follow-up on Parkinsonian tremors and clarify re: whether {he/she} has primary Parkinson's vs. neuroleptic-induced Parkinsonian tremors. The visit form was signed by the primary physician on 6/17/25 with a handwritten note okay with me.During an interview on 9/10/25 at 2:15 P.M., Resident #9 said the Psychiatrist had recommended he/she see a Neurologist about the tremors, but he/she had never heard anything after that and had not seen a Neurologist but would like to.Review of the Nursing Progress Notes included a note written on 6/17/25 which indicated Resident #9 was seen by the Psychiatrist with no new orders other than labs (blood work).Review of the medical record on 9/10/25, almost three months after the visit, failed to indicate Resident #9 had been referred to a Neurologist.During an interview on 9/11/25 at 12:24 P.M., Unit Manager #1 said she had not read the part of the Psychiatrist's recommendation that indicated Resident #9 should be referred to a Neurologist and that the physician had signed it and agreed. She said the referral to a Neurologist had not been made for Resident #9.

Based on observation, record review, and interviews, the facility failed to ensure infection prevention and control measures were implemented to prevent the potential transmission of infections for one Resident (#33), out of a total sample of three residents observed for medication administration. Specifically, the facility failed to ensure staff followed safe injection standard practices, by recapping used needles after the administration of insulin.Findings include:Review of the facility's policy titled Specific Medication Administration Procedures, dated March 2021, indicated but was not limited to the following:-Injectable medication administration: To administer medications via subcutaneous route in a safe and effective manner.-Discard syringe and needle in designated area.-Activate needle safety feature.-Do not recap needleReview of the Occupational Safety and Health Administration (OSHA) Fact Sheet (DSG FS-3519) titled Protecting Yourself When Handling Contaminated Sharps, dated 1/2011, indicated sharps are objects that can penetrate a worker's skin, such as needles If blood or other potentially infectious materials (OPIM), as defined in the OSHA Bloodborne Pathogens standard (29 CFR 1910.1030), are present or may be present on the sharp, it is a contaminated sharp and appropriate personal protective equipment must be worn. A needlestick or a cut from a contaminated sharp can result in a worker being infected with human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and other bloodborne pathogens. The standard specifies measures to reduce these types of injuries and the risk of infection. Careful handling of contaminated sharps can prevent injury and reduce the risk of infection. Employers must ensure that workers follow these work practices to decrease the workers' chances of contracting bloodborne diseases. Resident #33 was admitted to the facility in April 2025 with diagnoses including Type II Diabetes.Review of Resident #33's Physician's Orders included the following:-Basaglar KwikPen U-100 Insulin 35 units subcutaneous (SQ) once a day-Novolog U-100 Insulin 4 units SQ with breakfast in addition to sliding scale. Hold for blood sugar under 100.On 9/10/25 at 9:11 A.M., the surveyor observed Nurse #1 prepare and administer medications to Resident #33 which included the following:-Nurse #1 stated she had already taken Resident #33's blood sugar, and it was 107. She prepared both insulin injections at the medication cart as ordered and walked down the hallway and entered Resident #33's room, leaving her medication cart across from the nursing station.-Nurse #1 cleansed Resident #33's left lower abdomen with an alcohol swab and injected the Novolog insulin syringe.-Nurse #1 did not activate the needle safety feature leaving the used needle exposed, placed the cap over the used needle and placed it on Resident #33's overbed table.-Nurse #1 cleansed Resident #33's left upper abdomen with an alcohol swab and injected the Basaglar insulin pen.-Nurse #1 placed a cap over the used insulin pen and placed it on Resident #33's overbed table. The needle safety feature was activated, and no exposed needle was observed.-Nurse #1 then picked up the used insulin syringe and insulin pen, exited Resident #33's room, and walked down the hallway to her medication cart. She removed the needle tip from the insulin pen and disposed of it along with the insulin syringe in the sharp container located on the side of her medication cart.During an interview on 9/10/25 at 2:50 P.M., Nurse #1 said after administering injections, she should never recap a used needle. She said the insulin syringes should retract into the barrel after use and she does not know why it did not. Nurse #1 said she usually brings her medication cart into the doorway to dispose of the needles after use but was nervous and forgot. Nurse #1 said she recapped the used needles to carry them down the hallway to dispose of them in the sharp container located on her medication cart.During an interview on 9/11/25 at 1:52 P.M., the Director of Nursing (DON) said her expectation is for needle safety guidelines to be always followed, as a standard of practice. She said used needles are never recapped whether the needle is exposed or not. DON said the nurse should never carry used needles down the hallway.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required physical assistance from staff for positioning, the Facility failed to ensure they maintained a complete and accurate medical record, related to Certified Nurse Aide (CNA) Positioning Sheets, when daily documentation by CNA's (for all three shifts) was not consistently completed and positioning sheets were often left completely blank. Findings Include: Review of the Facility's Policy tilted CNA Documentation, dated as revised 10/05/2021, indicated the Certified Nurses' Aides will provide accurate documentation daily on each shift using the Electronic Medical Record (EMR). Resident #1 was admitted to the Facility in May 2023, diagnoses included Parkinson's disease, spinal stenosis (narrowing of space within the spine) of cervical region, muscle weakness, contracture (tightening of muscles, and tendons causing joints to become stiff) of unspecified joint, and hypertension, Review of Resident #1's Significant Change in Status Minimum Data (MDS) Assessment, dated 07/18/24, indicated that Resident #1 had impaired functional range of motion on both sides of his/her lower extremities and that he/she required the assistance of two staff members to roll from lying on his/her back to his/her left and right side in bed. Review of Resident #1's Positioning Sheet, completed by CNA's, dated 07/01/24 through 07/31/24, indicated for the following shifts, documentation on the positioning sheets was incomplete: -7:00 A.M. to 3:00 P.M.- 16 days (out of 21) positioning every two hours was left blank -3:00 P.M. to 11:00 P.M.- 20 days (out of 21) positioning every two hours was left blank -11:00 P.M. to 7:00 A.M.- 9 days (out of 21) positioning every two hours was left blank This does not include dates and shifts when Resident #1 was a Medical Leave of Absence (MLOA) from 07/01/24 through 07/10/24. Review of Resident #1's Positioning Sheet, completed by CNA's, dated 08/01/24 through 08/31/24, indicated for the following shifts, documentation on the positioning sheets was incomplete: -7:00 A.M. to 3:00 P.M.- 27 days (out of 29) positioning every two hours was left blank -3:00 P.M. to 11:00 P.M.- 14 days (out of 29) positioning every two hours was left blank -11:00 P.M. to 7:00 A.M.- 10 days (out of 29) positioning every two hours was left blank This does not include dates and shifts when Resident #1 was MLOA from 08/06/24 through 08/07/24. Review of Resident #1's medical record indicated there was no Positioning sheet for September 2024 or documentation to support that he/she was turned and positioned every two hours on all three shifts from 09/01/24 through 09/06/24. During an interview on 12/02/24 at 1:11 P.M., Certified Nurse Aide (CNA) #1 said they document turning and repositioning of residents on handwritten positioning sheets. CNA #1 said all documentation has to be completed by the end of the shift and said she tries her best to document care provided to residents. CNA #1 said if she does not have time or forgets to document, she informs the Nursing Supervisor. During an interview on 12/02/24 at 1:54 P.M., CNA #3 said positioning sheets are handwritten and are kept in a binder for all residents. CNA #3 said they have to document all care provided by the end of the shift and said she has forgotten to document on the positioning sheets, and she tries to remember to document the next day of work. During an interview on 12/02/24 at 2:22 P.M., CNA #4 said documentation for ADL care has to be done daily before her shift ends. CNA #4 said the positioning sheets are not in the computer system, they are in a binder, and are handwritten. CNA #4 said sometimes they (CNAs) forget to document on the positioning sheets and can be overlooked because they are trying to get all the other documentation done in the Matrix computer system. During an in-person interview on 12/02/24 at 4:11 P.M. and a telephone interview on 12/04/24 at 2:49 P.M., the Director of Nursing (DON) said she was not aware that Resident #1's CNA Positioning sheets were not being filled out, that they were left blank and said they were not able to find Resident #1's positioning sheet for September 2024. The DON said the Facility did not have a specific policy for handwritten documentation and said her expectation is that CNAs should be documenting all care provided to residents every shift and flow sheets should not be left blank.

Based on interview and document review, the facility failed to notify the physician of an ongoing and significant weight loss for one Resident (#26), out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Weight Loss Policy, dated as reviewed 2/2024, indicated but was not limited to the following: - all confirmed weight loss of 5 pounds (lbs.) or more within one month is reported to the dietician, the weight information is recorded in the chart - staff must also report any continuing trends of monthly weight loss, even if it is below 5 lbs. - the dietician is responsible for determining if weight loss is significant, unplanned (weight loss greater than (>) 5% in one month, 10% in 6 months) - the physician is to be notified by nursing staff of any significant weight loss Resident #26 was admitted to the facility in December 2023 and has diagnoses including: Hypothyroidism and dysphagia (difficulty swallowing). The Brief Interview for Mental Status (BIMS), dated 6/14/24, indicated the Resident was cognitively intact with a score of 15 out of 15. Review of the current Physician's Orders, dated 8/21/24, indicated but were not limited to the following: - Weekly weight to be obtained: notify MD/NP of any significant weight loss/gains over past week and any trends, once a day on Thursdays (12/14/23) During an interview on 8/15/24 at 8:09 A.M., Resident #26 said he/she had lost at least 20 pounds since being admitted to the facility. During an interview on 8/15/24 at 4:13 P.M., Nurse #2 said Resident #26 has had a weight loss but has recently started to gain a little back. She said she does not know the exact amount of weight loss. Review of Resident #26's weight monitoring report from 12/2023 to 8/15/24 indicated but was not limited to the following: 2/29/24- 119.0 lbs. 3/28/24- 112.8 lbs. (significant weight loss in one month (2/29/24) of 5.21%) 4/04/24- 113.9 lbs. 4/25/24- 110.8 lbs. 5/02/24- 106.8 lbs. (significant weight loss in one month (4/4/24) of 6.23%) 5/09/24- 104.6 lbs. Review of the Minimum Data Set (MDS) assessment for Resident #26 indicated the following weights were used on the following MDSs: - 12/14/23 - MDS recorded a weight of 125 lbs. - 03/07/24 - MDS recorded a weight of 115 lbs. - 06/14/24 - MDS recorded a weight of 104 lbs. In the three months from the December 2023 MDS to the March 2024 MDS the Resident had a significant loss of 8.12%. In addition, in the three months between the March 2024 MDS and the June 2024 MDS, the Resident had another significant weight loss of 9.88% (significant weight loss is = > 7.5% in 3 months). Review of the MDS assessment, dated 6/14/24, indicated, but was not limited to the following: SECTION K (Swallowing/Nutritional Status): K0200: Height = 66 inches Weight = 104 lbs. (most recent and measured in the last 30 days) K0300: Weight loss: Loss of 5% or more in the last month or 10% or more in the last 6 months: YES, not on a physician prescribed weight loss regimen The MDS indicated that from the 12/14/23 MDS recorded weight of 125 lbs. to the 6/14/24 MDS recorded weight of 104 lbs. Resident #26 experienced a significant weight loss of 16.8% over 6 months. Review of the progress notes for Resident #26 from 1/2024 to 8/21/24 failed to indicate the physician was made aware of the significant and ongoing weight loss. During an interview on 8/21/24 at 12:57 P.M., Nurse #3 said the Resident had been losing weight and has only started gaining weight in the last few weeks. She said the Resident was admitted at 125.6 lbs. and was currently 111 lbs. She reviewed the progress notes for the Resident from admission to 8/21/24 and said she could not find any evidence that the physician was made aware of the weight loss that had occurred. Review of the Registered Dietitian's (RD) documentation for Resident #26 from 12/2023 to 8/21/24 indicated but was not limited to the following: - 12/21/24: Comprehensive dietary assessment and note: weight = 125.6 lbs.; BMI = 20.1; stable when compared to hospital weights; reported a poor to fair appetite; goal to maximize intake to maintain current weights and heal skin integrity (related to recent surgery) - 3/14/24: Quarterly assessment and note: weight = 115.4 lbs., ideal body weight is 125 - 132 lbs.; intake fair to good; previous goals achieved; weight decline of 3% in 30 days and 8% since December 2023. Add: 240 milliliters (ml) fortified apple juice supplement to all meals to promote weight maintenance - 4/11/24: Note: discontinue fortified juice at breakfast, lunch and dinner due to resident not drinking; continue to monitor weights - 6/6/24: Quarterly assessment and note: weight 104 lbs., this is a weight loss; intake mostly variable; stable weights in 30 days with a significant loss since admission Further review of the RD's documentation failed to indicate that the RD notified the physician of the significant weight loss. During an interview on 8/21/24 at 1:28 P.M., the RD said Resident #26 has an ideal body weight of 125 - 132 lbs. and currently weighs 111 lbs. She said she does not typically notify the physicians of weight loss or significant weight loss and she believes that is done by nursing. She said, on review of the nursing progress notes for Resident #26, she could not find any evidence that the physician was made aware of the significant weight loss for the Resident. During an interview on 8/21/24 at 2:08 P.M., Physician #1 said he did not recall being made aware of Resident #26's progressive and significant weight loss and therefore no further evaluation of the situation had been completed at this time. He said he is unaware of any medical reason for Resident #26 to have an ongoing or significant weight loss and the loss was unplanned. During an interview on 8/21/24 at 2:22 P.M., the Director of Nurses reviewed the medical record of Resident #26 and said she could not find any evidence that the physician was aware of the ongoing and significant weight loss for Resident #26. She said the process is for the physician to be notified of changes to a resident's condition and there is no evidence that had occurred. See F692

Based on record review, interviews, and documentation review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one Resident (#26), out of 18 sampled residents. Specifically, the facility failed to ensure ideal or usual body weight was maintained and interventions implemented and re-evaluated to prevent significant and ongoing weight loss for the Resident which was unplanned and undesired. Findings include: Review of the facility's policy titled Weight Loss Policy, dated as reviewed 2/2024, indicated but was not limited to the following: - all confirmed weight loss of 5 pounds (lbs.) or more within one month is reported to the dietician, the weight information is recorded in the chart - staff must also report any continuing trends of monthly weight loss, even if it is below 5 lbs. - the dietician is responsible for determining if weight loss is significant, unplanned (weight loss greater than (>) 5% in one month, 10% in 6 months) - if the dietician determines weight loss is significant, an interim note is written documenting the weight loss and including suggested approaches for prevention of further loss - the dietician is responsible to ensure the interdisciplinary care plan is updated for weight loss prevention as warranted Review of the facility's policy titled Meal Replacement, dated as reviewed 10/2023, indicated but was not limited to the following: - every possible effort will be made to maintain meal satisfaction and intake by residents - as soon as nursing or dietary staff discover the resident has consumed less than 50% of a meal, they will offer additional forms of nourishment - nursing and dietary staff should encourage residents to accept the alternate to the prepared meal - if the resident refuses the alternate selection to the menu, he/she should be offered food items on the additional readily available food list - if a resident refuses all alternate foods available a commercial supplement may be offered and is a last resort of meal replacement Review of the facility's policy titled Selective Menu Policy, dated as reviewed 10/2023, indicated but was not limited to the following: - every possible effort will be made to maintain meal satisfaction and intake by residents - menus are posted on floors for reference - a representative from dietary meets with all new residents within 24 hours for an initial interview to discuss food preferences, likes and dislikes in accordance with the resident's diet restrictions - cycle menus will be individually reviewed with the resident until they are completed - main dining room is open for all meals, menus are posted, residents in the main dining room make their choices Resident #26 was admitted to the facility in December 2023 with diagnoses which included hypothyroidism and dysphagia (difficulty swallowing). Review of the Brief Interview for Mental Status (BIMS), dated 6/14/24, indicated Resident #26 was cognitively intact with a score of 15 out of 15. During an interview on 8/15/24 at 8:09 A.M., Resident #26 said he/she had lost at least 20 pounds since being admitted to the facility. The Resident was observed to have breakfast of scrambled eggs and toast in front of them and consumed about 25% at that time. He/She said the coffee is like an oil slick. He/She said people have talked to him/her about the food and weight loss and he/she thinks the food is overall not bad but prefers other things brought in by their family. The Resident said he/she has always been a picky eater. During an interview on 8/15/24 at 4:13 P.M., Nurse #2 said Resident #26 was not a good eater and will decline meals at times, adding that the Resident's family will bring in food and snacks because the Resident is a picky eater. She said she knows the Resident has had a weight loss but has recently started to gain a little back. She said she does not know the exact amount of weight loss or if there are any interventions in place to prevent the weight loss, but she offers the Resident ice cream in the afternoons and it is usually accepted. She said the Resident doesn't get any type of supplements and is not offered any other meals if he/she doesn't eat well unless they request something else. She said the Resident needs lots of encouragement to eat. She said the Resident will usually accept foods brought in by the family. Review of the current Physician's Orders, dated 8/21/24, indicated but were not limited to the following: - DIET: NAS (No added salt diet) (1/23/24 and 4/12/24) - May omit diet restrictions on special occasions (12/14/23) - Snack offered at bedtime (12/14/23) - Speech therapy evaluation and treatment as indicated (1/9/24) - Weekly weight to be obtained: notify MD/NP of any significant weight loss/gains over past week and any trends, once a day on Thursdays (12/14/23) - Aspiration precautions: Resident is an aspiration risk monitor for signs and symptoms (s/s) such as: cough, congestion, fever, runny nose, etc., monitor lung sounds, oxygen saturation, and temperature every shift (1/8/24) Review of the Certified Nurse Assistant (CNA) care plan Kardex currently in use by the facility indicated but was not limited to the following: NUTRITION: Diet/Texture: Regular; Ability to eat: Independent During an interview on 8/21/24 at 8:17 A.M., CNA #3 said Resident #26 eats independently after meal set up. She said the Resident's intake fluctuates and sometimes the Resident eats well and sometimes not so good. She said the Resident is weighed weekly and she knows the Resident has a history of weight loss but had a gain this past week and is up to 111 pounds (lbs.). She said she is not aware of any interventions for the staff to provide to help the Resident not lose any more weight, but the Resident has told her he/she prefers sandwiches with tomatoes for lunch and pancakes for breakfast. During an interview on 8/21/24 at 8:31 A.M., the surveyor observed Resident #26 eating breakfast consisting of scrambled eggs and toast with jelly. The meal ticket on the tray indicated the Resident was supposed to have a hard-boiled egg. The Resident said the breakfast was fine but they wished it was pancakes or waffles; they are sick of eggs everyday. The Resident said he/she gained weight this past week because he/she can't resist the treats and ice cream in the afternoons. The Resident said there are foods that they like but the facility has not offered them to him/her and he/she likes to have options with his/her meals and may change his/her mind on the meal daily depending on what might be available. The Resident said he/she was offered milkshakes and juice drinks to purposely get fat but the use of those are against his/her beliefs. Resident #26 said he/she enjoys sandwiches but only gets them when his/her family brings them in because the facility sends him/her whatever they want for meals and he/she doesn't have any options. During an interview on 8/21/24 at 9:22 A.M., the Food Service Director (FSD) said the process for selective menus and meal preferences for the unit Resident #26 resides on is for staff to call for a meal replacement if necessary. She said she learns different resident preferences as time goes on and the nursing staff, residents, and dietitian will also communicate items of preference to her so she can update the meal tray tickets. She said residents should get what their tickets say are their preferences with each meal because the kitchen staff will automatically follow the ticket and make the substitution and she does not keep any other system to track preferences. She said she would provide the surveyor with a copy of Resident #26's meal tickets for the day which would reflect the daily preferences. Review of the 8/21/24 meal tickets for Resident #26 indicated but were not limited to the following: BREAKFAST: Hard-boiled egg, cereal, toast, juice, coffee, milk, jelly, sugar LUNCH: Meatloaf, brown gravy, broccoli, mashed potatoes, bread, peach cobbler, milk, coffee, sugar, tomato slices (Serve sliced tomatoes when ordering a sandwich) DINNER: Glazed ham, mixed vegetables, sweet potato, fruit cocktail, milk, coffee, sugar, tomato slices (Serve sliced tomatoes when ordering a sandwich) During an interview on 8/21/24 at 10:02 A.M., the FSD said Resident #26 only gets tomatoes if he/she orders a sandwich, but he/she gets a hard-boiled egg each morning. When she was informed the Resident had scrambled eggs this A.M., she said scrambled eggs were available this morning but the Resident should have gotten a hard-boiled egg and she does not know how that error occurred. She said the process is for the Resident to get their preferred foods according to their meal tickets. Review of Resident #26's weight monitoring report from 12/2023 to 8/15/24 indicated but was not limited to the following: 2/29/24- 119.0 lbs. 3/28/24- 112.8 lbs. (significant weight loss in one month (2/29/24) of 5.21%) 4/04/24- 113.9 lbs. 4/25/24- 110.8 lbs. 5/02/24- 106.8 lbs. (significant weight loss in one month (4/4/24) of 6.23%) 5/09/24- 104.6 lbs. Review of the Minimum Data Set (MDS) assessments for Resident #26 indicated the following weights were used: - 12/14/23 - MDS recorded weight of 125 lbs. - 3/7/24 - MDS recorded weight of 115 lbs. - 6/14/24 - MDS recorded weight of 104 lbs. In the three months from the December 2023 to the March 2024 MDS assessments the Resident experienced a significant loss of 8.12%. In addition, in the three months between the March 2024 MDS and the June 2024 MDS the Resident had another significant weight loss of 9.88% (significant weight loss is = > 7.5% in 3 months). Review of the MDS assessment, dated 6/14/24, indicated but was not limited to the following: SECTION K (Swallowing/Nutritional Status): K0100: Signs and symptoms of swallowing disorders: None K0200: Height = 66 inches Weight = 104 lbs. (most recent and measured in the last 30 days) K0300: Weight loss: Loss of 5% or more in the last month or 10% or more in the last 6 months: YES, not on a physician prescribed weight loss regimen K0520: Nutritional approaches: Therapeutic diet while a resident The MDS indicated that from the 12/14/23 MDS recorded weight of 125 lbs. to the 6/14/24 MDS recorded weight of 104 lbs. Resident #26 experienced a significant weight loss of 16.8% over 6 months. Review of the Speech Language Pathology (SLP) evaluation and treatment notes for Resident #26 in May 2024 indicated but were not limited to the following: - 5/16/24 Evaluation: Reason for referral: This patient was noted to have a significant weight loss as follows: 4/4/24 - 113.9 lbs., 4/25/24 - 110.8 lbs., 5/2/24 - 106.8 lbs., 5/9/24 - 104.6 lbs. [sic] Patient goals: He/She would like to get foods he/she likes so they'd have an appetite to eat them Clinical bedside assessment: Regular solids with mild clinical s/s of dysphagia characterized by poor attention to task Recommendations: distant supervision for intake - 5/16/24 Treatment note: has particular interest in eating certain foods and aversion to others; realizes he/she is losing weight and would like to improve intake if they get the foods they like - 5/24/24 Treatment note: no complaints of dysphagia; patient stated: I ate all that I wanted, don't make me eat anything else - 5/28/24 Treatment note: patient states he/she eats the food they like and denies any difficulties with trouble chewing or swallowing - 5/28/24 Discharge Summary: Previous goal met (5/16/24): patient appetite was sufficient to maintain his/her weight and remain stable but currently has a significant weight loss; current goal met: patient demonstrated safe intake of regular solids and thin liquids consuming at least 50-75% per meal over three consecutive meals without dysphagia. Review of the Meal and Snack intake report for Resident #26 from 3/1/24 through 8/20/24 indicated but was not limited to the following: MARCH 2024: Out of 93 meal opportunities: 20 meals were not documented and out of 31 bedtime snack opportunities 9 snacks were undocumented Of the meals received, the Resident consumed an average of 26-50% of breakfast; 26-50% of lunch; 51-75% of dinner and 51-75 % of bedtime snacks. APRIL: 2024 Out of 90 meal opportunities: 14 meals were not documented with 2 additional meals refused; and 9 out of 30 bedtime snack opportunities undocumented with an additional 10 refused Of the meals received, the Resident consumed an average of 51-75% of breakfast; 26-50% of lunch; 25-50% of dinner and 25-50% of bedtime snacks. MAY 2024: Out of 93 meal opportunities: 22 meals were not documented with 4 additional meals refused; and 14 and out of 31 bedtime snack opportunities were undocumented with an additional 12 snacks refused Of the meals received, the Resident consumed an average of 26-50% of breakfast; 26-50% of lunch; 1-25% of dinner and 1-25% of bedtime snacks. JUNE 2024: Out of 90 meal opportunities: 21 meals were not documented with an additional 2 meals refused; and 6 out of 30 bedtime snack opportunities were undocumented with an additional 9 snacks refused Of the meals received, the Resident consumed an average of 26-50% of breakfast; 26-50% of lunch; 26-50% of dinner and 1-25% of bedtime snacks. JULY 2024: Out of 93 meal opportunities: 13 meals were not documented with an additional 2 meals refused; and 7 out of 31 bedtime snack opportunities were undocumented with an additional 11 snacks refused Of the meals received, the Resident consumed an average of 26-50% of breakfast; 26-50% of lunch; 26-50% of dinner and 26-50% of bedtime snacks. AUGUST 2024: Out of 60 meal opportunities: 4 meals were not documented with an additional one meal refused; and 1 out of 20 bedtime snack opportunities were undocumented Of the meals received, the Resident consumed an average of 26-50% of breakfast; 26-50% of lunch; 26-50% of dinner and 1-25% of bedtime snacks. Review of the Registered Dietitian's (RD) documentation for Resident #26 from December 2023 to 8/21/24 indicated but was not limited to the following: - 12/21/23: Comprehensive dietary assessment and note: House diet with HS (hour of sleep) snacks; weight = 125.6 lbs.; BMI = 20.1; stable when compared to hospital weights; reported a poor to fair appetite; goal to maximize intake to maintain current weights and heal skin integrity (related to recent surgery) - 3/14/24: Quarterly assessment and note: NAS diet with HS snacks; weight = 115.4 lbs., ideal body weight is 125 - 132 lbs.; intake fair to good; previous goals achieved; weight decline of 3% in 30 days and 8% since December 2023. Add: 240 milliliters (ml) fortified apple juice supplement to all meals to promote weight maintenance - 4/11/24: Note: discontinue fortified juice at breakfast, lunch and dinner due to Resident not drinking; continue to monitor weights - 5/23/24: Note: please add a plate of sliced tomatoes to lunch and dinner meals per resident preference; resident states he/she will eat any sandwich with tomato on it; likes hard boiled (HB) eggs only - no other kind of eggs; notice provided to kitchen - 6/6/24: Quarterly assessment and note: NAS diet with HS snacks and aspiration precautions; weight 104 lbs., this is a weight loss; intake mostly variable; stable weights in 30 days with a significant loss since admission, self-reported picky eater; Resident declines supplements and will accept sandwiches with tomato slice, provide encouragement at meals During an interview with observation on 8/21/24 at 12:12 P.M., the surveyor observed Resident #26 having lunch in his/her room. The meal on the plate consisted of meatloaf with gravy, broccoli, a piece of bread, and a scoop of mashed potatoes. No sandwich or tomato were observed on the tray or in the Resident's room. He/She was not eating the meatloaf but was consuming the bread and mashed potatoes. The Resident said he/she did not like the meatloaf and would love to get sandwiches at lunchtime with tomato but has not gotten them in a few weeks. Resident #26 said he/she does not have the capability of picking their meals and has not been given a large selective menu to complete in ages. The Resident said he/she would not call and bother the nursing staff for a replacement meal since no one cares enough to provide him/her with a menu. Resident #26 said he/she would complete a weekly menu if that was still an option but it was not. The Resident said if the meal was something he/she liked, he/she would eat it. He/She said the facility did try to give him/her supplement drinks a few months ago but he/she would not drink them; he/she preferred real food. During an interview on 8/21/24 at 12:31 P.M., the FSD said Resident #26 doesn't do a selective menu and gets whatever the kitchen has as the meal for the day and can have someone call down if he/she wants something different. She said she could not recall the last time the Resident had completed a selective menu, but said they follow the meal ticket for preferences. During an interview on 8/21/24 at 12:57 P.M., Nurse #3 said she was unsure if Resident #26 had a significant weight loss or any weight loss and would need to review the record. She said the Resident had been losing weight and has only started gaining weight in the last few weeks. She said the Resident was admitted at 125.6 lbs. and currently weighed 111 lbs. She reviewed the assessments, progress notes, orders and care plans for the Resident and said she does not see any interventions currently in place to reflect what the staff should be doing to prevent further weight loss for the Resident. She said she did see that the Resident had attempted to take supplements for a short time in March but did not like them. She said, There are so many types of real foods we could use, I don't know why that's not an option shown in here. She said the facility had the ability to attempt fortified foods and even additional snacks like ice cream in the afternoon to help with weight loss prevention but she did not see any documentation in the record that these things were attempted and said the care plan does not reflect any interventions at all except for providing the Resident with a meal. She said as far as the Resident preferences she noticed the Resident had scrambled eggs this morning and was surprised since the ticket said hard-boiled egg, but the Resident told her, They just send what they want anyway and declined a replacement meal or food item. She said they would only offer any resident a supplement or replacement meal if they ate less than 50% if they had orders to do so, and this Resident did not. She said if the Resident requested an alternate meal the staff would accommodate that, but that had not happened at either meal today. She said she could not find anything on the care plan that would indicate the Resident had weight loss or required any interventions to prevent weight loss so she wasn't aware the concern existed until it was brought to her attention by the surveyor. Review of the care plan currently in place for Resident #26 indicated the following: PROBLEM: Nutritional status, Nutritionally related medical diagnoses: hypertension (HTN), hypothyroidism, hyperlipidemia, and Vitamin D deficiency; requires a therapeutic diet at this time related to HTN. Supplementation in place and accepted by Resident to promote weight maintenance. (6/25/24) GOAL: Maintain current status; prevent exacerbation of medical diagnosis (6/25/24) APPROACHES: House diet (6/25/24) The care plan failed to indicate the Resident experienced any weight loss or provided any interventions to prevent further weight loss for the Resident. During an interview on 8/21/24 at 1:28 P.M., the RD said Resident #26 is a self-admitted picky eater and resistant to any creamy supplements so she recommended the juice supplement, but the Resident did not consume it and it was discontinued. She said she did send a preference update to the kitchen in May alerting them to the Resident's preference to eat sandwiches with sliced tomato. She said once the information is sent to the kitchen they place it on the tray ticket. She said this Resident has an ideal body weight of 125 - 132 lbs. and is currently 111 lbs., but that is an increase from previous and at one point the Resident got as low as 103 lbs. so she is happy with the weight coming back up. She said the Resident remains below ideal body weight at this time because they are very particular about what they will eat. She said the FSD is the person that would provide a selective menu to residents, but only to those who are willing to complete them and want to select their own foods and she doesn't know if the Resident does those menus but thinks it would likely benefit Resident #26 to have this option so they can receive foods they are more interested in. She said she was aware of the significant weight loss for the Resident but when reviewing the care plan said she realizes the care plan is not specific to the Resident losing weight, and does not have any interventions on it that may help prevent further weight loss and only indicates a current diet order for the Resident. She said the Resident has had a continual weight loss since admission until just recently and she would need to reevaluate the Resident and the documentation since it appears to be lacking. During an interview on 8/21/24 at 2:08 P.M., Physician #1 said he is not aware of any medical reason for Resident #26 to have an ongoing or significant weight loss and it was unplanned. He said he doesn't recall being made aware of the situation and therefore no further evaluation of the situation had been completed and the issue has not been documented by him in the medical record. During an interview on 8/21/24 at 2:22 P.M., the Director of Nurses reviewed the medical record of Resident #26 and said there were no interventions she could find documented anywhere, except for the juice supplement in March that was discontinued, to prevent further weight loss for the Resident. She said it did not appear by viewing the current and history of the nutritional care plan that any interventions were ever attempted to prevent weight loss and the care plan does not indicate the Resident had experienced any weight loss and inaccurately reflected the Resident's use and acceptance of supplements. She said she could not find any documentation that a medical work up had occurred in an attempt to rule out any cause of the progressive weight loss, nor could she find any evidence the physician was aware of the situation. She said the expectation is that the Resident be evaluated and provided with interventions in an attempt to prevent undesirable ongoing weight loss, especially when a significant weight loss occurs, but also prior to reaching that level. She said the Resident should have been receiving his/her preferences at mealtimes and receiving alternate meals as needed. She said it appears the process for managing weight loss and providing interventions to prevent further weight loss were not followed.

Based on record review, interview, and document review, the facility failed to evaluate the use of a one-piece jumpsuit as a restraint for one Resident (#67), to ensure it was the least restricted device and necessary, out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Physical Restraint Policy, dated as reviewed 4/2024, indicated but was not limited to the following: - restraints will only be used in circumstances in which the resident has medical symptoms that warrant the use of the restraint - the need for restraint use if assessed by the interdisciplinary team as needed, quarterly and with any significant changes for residents with restraints - the facility follows a systematic process of evaluation and care planning prior to using restraints Resident #67 was admitted to the facility in February 2023 and had diagnoses including: dementia without behavioral disturbance and late onset Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment for Resident #67, dated 7/17/24, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicating he/she was not cognitively intact. The MDS also indicated the Resident used a restraint daily, exhibited no behaviors in the look back period and had no mood disturbance based on their PHQ-9 score in the look back period. Review of the current Physician's Orders, as of 8/20/24, indicated but were not limited to the following: - one piece clothing jumpsuit to be worn at all times except personal hygiene - remove jumpsuit for hygiene only (3/25/24) - behaviors: monitor every shift for depression - document behaviors in resident progress notes (2/6/23) Review of the assessments for Resident #67 in the medical record as of 3/15/24 failed to indicate a restraint assessment had been completed to determine if the one-piece jumpsuit was a restraint and the least restrictive device for the management of the Resident's behaviors. Review of the Certified Nurse Aide (CNA) Care plan card on 8/16/24 for Resident #67 indicated but was not limited to the following: - Behavior/Cognitive Section: Target behaviors: wandering and smearing feces; Interventions: redirect and offer snack - Restraint section: Blank - Special care/needs: 3/25/24 one piece clothing - Resident information: maintain adequate bowel movements, toilet for good fecal evacuation, prompt care related to smearing feces, one piece clothing added secondary to this behavior Review of the CNA Behavior analysis report for Resident #67 from 3/1/24 through 8/20/24 indicated but was not limited to the following: - Behavior of throwing/smearing bodily waste not at others: occurred 6 times out of 173 opportunities, and four times prior to the order for the one-piece jumpsuit on 3/25/24 Review of the nursing and social service progress notes from 3/1/24 through 8/20/24 indicated but were not limited to the following behaviors: - 3/1/24 at 9:20 P.M., routinely defecates and smears feces, toileted every two hours, can be resistive to care - 3/5/24 at 2:30 P.M., smearing feces times 3 [sic] - 3/8/24 at 10:44 P.M., in the last seven days the resident has had behaviors of smearing feces, redirected with some effect - 3/25/24 at 10:31 A.M., Resident is to wear a one-piece jumpsuit at all times except for hygiene, the plan was initiated due to smearing of feces to maintain resident dignity, healthcare proxy (HCP) in agreement and purchased outfits - 3/29/24 at 7:59 P.M., tolerating jumpsuit well, have been a few instances when the Resident got into his/her brief but all was contained in the jumpsuit - 5/3/24 at 9:49 A.M., since the introduction of the jumpsuit bodily waste is better contained, dignity and hygiene have been improved - 7/26/24 at 10:58 A.M., in the last seven days the resident has had behaviors of smearing, one piece set of clothes effective - 8/1/24 at 5:25 P.M., wearing a jumpsuit continues to assist in managing bodily waste The surveyor made the following observations of Resident #67: - 8/15/24 at 7:58 A.M., the Resident was sitting in a rocking recliner, appeared calm and easily engaged in conversation with the surveyor, pleasantly confused, well-groomed and dressed in a one piece outfit which zipped up the back and appeared to be two separate clothing pieces - 8/16/24 at 7:40 A.M., Resident was smiling and easily engaged with surveyor, well-groomed and dressed in one piece clothing with zipper on the back - 8/20/24 at 10:40 A.M., Resident well-groomed and dressed in one piece clothing, appeared comfortable Review of the current care plans for Resident #67 indicated but were not limited to the following: PROBLEM: ADLs functional: I have a diagnosis of Alzheimer's with subsequent cognitive loss. I am unable to initiate and sequence tasks to completion and require assist with most efforts. APPROACH: One piece jumpsuit to be worn at all times except for hygiene, HCP aware and in agreement with plan to prevent smearing of feces and maintain dignity for Resident, toileting schedule for bowel movements failed to correct this and it was becoming an infection control issue (3/25/24), no agitation or anxiety related to jumpsuit use (5/15/24) During an interview on 8/16/24 at 7:48 A.M., Nurse #2 said the Resident wore a one-piece jumpsuit, which is a restraint for him/her since they cannot remove it independently and it is in place to prevent them from smearing feces. She said the outfits started about five or six months ago and she can't be sure of the exact date. She said there is a doctor's order for the outfits but as far as other interventions that may have been attempted and the care plan or any assessments that would need to be completed, she would not be aware of those and that type of paperwork was completed at a management level. During an interview on 8/20/24 at 10:42 A.M., the Director of Nurses (DON) said the Resident wore a one-piece jumpsuit, which was a restraint. She said on review of the record she could not locate any evidence that prior devices or interventions were attempted to ensure the jumpsuit restraint was the least restrictive device and there was no restraint assessment completed at the time the restraint was initiated or for a re-evaluation of the device in July. She said she was aware that the guidelines were not followed and the process needed to be looked at.

Based on interviews, document review, and observations, the facility failed to have information on how to file a grievance in resident care and public areas and have forms accessible, so residents and/or visitors were able to anonymously notify the facility of their concerns. Findings include: Review of the facility's policy titled Resident/Staff/Family Member Grievances, dated as reviewed 4/2023, indicated but was not limited to the following: - any resident/staff/family member or designated representative who has a complaint or suggestion, shall report to the charge nurse or social worker on the unit involved, or complete a grievance form - the nurse or social worker will respond appropriately, after assessing the nature of the complaint and will complete the grievance form if one has not already been completed - the grievance report itself will be submitted to the Administrator/Department head as soon as possible - grievances, actions taken and results are to be documented on the grievance report and kept on file in the Administrator's office Review of the facility Grievance Book for 2024 indicated four grievances were completed throughout the year. Of the four completed grievances on file, three were reported by families using e-mail and all four forms were completed by facility staff for tracking purposes. During a Resident Group Meeting on 8/16/24 at 11:00 A.M., 11 of the 13 residents in attendance said they were unaware of how to file a grievance. During a tour on 8/16/24 at 11:41 A.M., of the first floor including the main lobby, community rooms and first floor nursing unit there was no evidence observed of the procedure for a family or resident to file a grievance or the availability of grievance forms for a grievance to be completed anonymously. During an interview on 8/16/24 at 11:42 A.M., Nurse #2 said grievance forms are not available for residents or families to complete on their own and if she was made aware of a grievance or concern, she would direct the person to the Administrator or nursing supervisor. She said there are grievance forms available in the filing cabinet behind the nurses' station if neither of those people were available. During a tour on 8/16/24 at 11:51 A.M., of the second floor nursing unit there was no evidence observed of the procedure for a family or resident to file a grievance or the availability of grievance forms for a grievance to be completed anonymously. During an interview on 8/16/24 at 11:52 A.M., Nurse #4 said she was not aware and has never seen any grievance forms or information posted for residents or families. She said if a resident or family voiced a concern to her that she couldn't fix immediately she would direct them to the nursing supervisor, Administrator or Director of Nurses (DON). She checked the filing cabinet and form storage areas behind the nurses' station and said she could not locate a grievance form to supply the family or resident with and would have to direct them to someone else for assistance. During a tour on 8/16/24 at 11:54 A.M., of the third floor there was no evidence observed of the procedure for a family or resident to file a grievance or the availability of grievance forms for a grievance to be completed anonymously. During an interview on 8/16/24 at 11:55 A.M., Certified Nurse Aide (CNA) #1 said if a resident or family informed her they had a concern or grievance they wanted to report, she would direct them to the posted information for the Ombudsman office. She said if they wanted it to be dealt with in the facility, she would alert a Nurse or Nursing supervisor to try and assist them. She said she was not aware that there were any grievance forms they could provide or what the grievance process entailed. During an interview on 8/16/24 at 12:15 P.M., the Activity Director said she was not aware of where any grievance forms may be available for residents or families to complete without notifying the staff of a concern. She said the process for filing a grievance if one is voiced is to obtain a form from the Administrator and to assist a resident or family with completing one. During an interview on 8/16/24 at 12:42 P.M., the Social Worker said the Administrator is the grievance official for the facility but they have open communication if any concerns are brought forward. She said if a grievance should occur the staff will direct the resident or family member to the Administrator or DON if they are available and in the facility at the time and if not a nursing supervisor so the resident or family member can be assisted in completing a grievance form. She said the facility does not keep grievance forms available in public areas. She said grievance forms are stored in the management offices and behind the nurses' stations in filing cabinets. She said if a family or resident wanted to place a grievance anonymously within the facility, they would not have the capability of doing so because the forms are not available to them without speaking with a staff member and the facility does not have a process for that to occur at this time. She said residents and families have the right to make grievances anonymously and not having a process in place for them to do that does not meet the regulatory requirements for grievances. During an interview on 8/16/24 at 1:19 P.M., the Administrator said he was not aware that residents and families had the right to formulate grievances anonymously and that the facility should have a mechanism in place for them to do so. He said grievance forms are not available in any public area that would make it possible for a family member or resident to formulate a grievance without notifying a staff member and the process would need to be looked at for improvement to meet the regulatory guideline.

Based on a resident group meeting, staff interviews, and document review, the facility failed to ensure concerns from the Resident Council were documented to ensure they were acted upon timely and included the facility response. Findings include: Review of the facility's policy titled Resident Council, dated as reviewed 9/2023, indicated but was not limited to the following: - the home will listen to and follow up on residents' complaints and grievances through Resident Council meetings and individual resident requests - distribute minutes of the last meeting to the administrator and resident council president - notify department heads of complaints when presented - schedule department head to answer complaints of residents at the next council meeting or immediately, if required - each facility shall have a resident council consisting of representatives elected by facility residents elected annually Review of the Resident Council Meeting Minutes from February 2024 through July 2024 indicated the residents in attendance at those meetings had no concerns for any department for the entire six months reviewed. On 8/16/24 at 11:00 A.M., the surveyor held a Resident group meeting with 13 residents in attendance, including the Resident Council President and [NAME] President. The following concerns were discussed: - 9 of the 13 residents said they were told not to discuss what happened in Resident council with anyone not in the council meeting but the facility's Activity Director (AD) - 9 of 13 residents said that concerns voiced are only responded to if the AD feels the concern rises to the level of requiring a response and not all their concerns are followed up on - 7 of 13 residents said the Resident council meeting is supposed to be for them but is run by the AD who takes the minutes and directs them in what is to be discussed - the President and [NAME] President said they have never seen the meeting minutes, been offered to review the minutes, or offered a copy of the minutes and they felt that would be helpful in knowing what issues were addressed and documented as being brought up as a concern - 5 of 13 residents said missing clothing has been discussed at the resident council meeting in the last two months - 3 of 13 residents said concerns of housekeeping not filling the bathrooms with paper goods has been brought up in the last one to three months - all of the residents in attendance agreed the food service director (FSD) had been present in the last few meetings to discuss food questions and concerns that had been brought up over the last few months The last six months of meeting minutes were shared with the Resident Council and failed to include any of the concerns the residents discussed in this meeting, 6 of the 13 residents said the Resident Council meeting minutes were inaccurate and did not include information they have brought forward in the last few months that they expected to be documented and followed up on. During an interview on 8/16/24 at 11:58 A.M., the AD said she runs the Resident Council meeting, organizes inviting all the residents and inviting any department heads she thinks the residents would like to see for a check-in even when there are no concerns or issues for that department head. She said she also writes the minutes of the meeting and keeps attendance records. She said if a concern is brought forward it is written on a separate piece of paper for Resident Council response and provided to the department head that would be responsible for addressing the concern. She said the department head is then required to respond with a plan within about 48 hours and the Resident Council is made aware of the response and the department head would usually attend the next meeting. She said there have been no concerns or issues brought forth by the Resident Council in the last six months or so but wanted to verify that in her records and offered to supply the survey team with any response forms she may have. During a follow up interview on 8/16/24 at 12:15 P.M., the AD provided the surveyor with two Resident Council response forms dated in December 2022. She said there had been no voiced concerns for the Resident Council since that time and she did not have any more recent response forms. She said she documents any information or concerns brought forward in Resident Council on the meeting minutes. She said she doesn't recall any of the residents discussing issues with missing clothing, housekeeping not filling paper products in the bathrooms sufficiently, or any food concerns. She said she invited the FSD to the council meeting in the last few months to discuss changes to the menus and adding additional cookouts to the activity schedule. She reviewed the Resident Council meeting notes and said although the dietary section indicated no concerns because there were no issues and she didn't feel the information needed to be in the meeting minutes and said she feels the meeting minutes reflect all discussions in the Resident Council meetings. She said the majority of the Resident Council meetings are discussing activity programs and any activities they would like to see or events they would like planned. She said she can see how the residents may feel that the meeting isn't centered around them based on this and her need to refocus them on things that need to be discussed. During an interview on 8/16/24 at 1:16 P.M., the FSD said she attended the last three or four Resident Council meetings after being invited by the AD. She said they did not discuss menu changes but she was asked to assist with holding a cookout. She said when she attended not many issues were brought up at the meetings, and what was, she considered to be minor and she addressed them. This last month, there were no concerns at all communicated. She said she did not keep any notes or minutes on what concerns the residents voiced and cannot specifically remember what the issues were. She said she believed the process was that the AD would put the concerns and resolution information in the Resident Council meeting notes and she was not required to maintain separate records. She said she was surprised the information was not in the Resident Council meeting minutes and did not know why it would not be documented in there. During an interview on 8/16/24 at 1:19 P.M., the Administrator said the expectation is that the Resident Council meeting minutes reflect all discussions the residents have in the meeting both good and bad to ensure any concerns are followed up on. He said he was not aware of any recent concerns the Resident Council had and the meeting minutes should have reflected them and did not. He said he was not aware the Resident Council President or [NAME] President were not reviewing the meeting minutes for accuracy and the process would need to be looked at.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases. Specifically, the facility failed: 1. For Resident #51, to ensure staff wore PPE as required for Isolation/Droplet Precautions (infection control precautions used for residents who are infected with certain infectious agents including COVID-19 for which additional precautions are needed to prevent infection transmission) while entering the room to provide care; and 2. For Resident #13, to ensure staff wore the appropriate personal protective equipment (PPE) while providing high contact care to the Resident who was on enhanced barrier precautions (EBP - infection control intervention that involves wearing gowns and gloves during high contact care to reduce the spread of multi-drug resistant organisms) related to chronic wounds and a Foley catheter device. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions, dated 3/2024, indicated but was not limited to the following: -Purpose: to prevent the spread of multi-drug resistant organisms (MDROs) (germs that are resistant to many antibiotics) -Residents with wounds or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO -Wounds include chronic wounds such as pressure ulcers and diabetic foot ulcers -Indwelling medical device examples include urinary catheters -The use of gown and gloves for high-contact care activities is indicated with EBP -High contact care includes dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting and device care -EBP are intended to be in place for the duration of a resident's stay in the facility or resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk Review of the facility's policy titled Caring for long term residents during the COVID-19 outbreak, dated 4/2024, indicated but was not limited to the following: -Diocesan Health Facilities follow the guidelines that the Department of Public Health (DPH) and Center for Disease Control (CDC) regarding COVID-19. Review of the Centers for Disease Control (CDC) guidance titled: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated: March 18, 2024, indicated but was not limited to the following: Personal Protective Equipment: Healthcare providers who enter the room of a patient with suspected or confirmed SARS-CoV-2 (COVID-19) infection should adhere to Standard Precautions and use an approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). 1. Resident #51 was admitted to the facility in October 2021. Review of the medical record including progress notes, physician orders, and care plan indicated but were not limited to the following: -He/she tested positive for COVID-19 on 8/6/24 -Isolation Precautions for COVID-19 every shift. On 8/15/24 at 8:40 A.M., the surveyor observed the following: -A RED sign posted outside of Resident #51's doorway that indicated but was not limited to the following: -Isolation Precautions STOP: ISOLATION In addition to Standard Precautions Staff and Providers MUST: -Clean Hands when entering and exiting -Gown: Change between each Resident -N95 Respirator (respiratory protective device designed to achieve a very close facial fit to filtrate airborne particles; the edges form a seal around the nose and mouth) -Eye Protection (goggles or face shield) -Gloves: Change between each Resident - A 3-drawer plastic bin outside of the Resident's door containing PPE -Two Certified Nursing Assistants (CNA) #2 and #6 approaching the 3-drawer plastic bin outside of Resident #51's room, both wearing surgical masks for source control -CNA #2 opened the drawer and removed a protective gown and gloves. She donned (put on) the gown and gloves, leaving her surgical mask in place (not an N95 respirator) -CNA #6 then opened the drawer and removed a protective gown, gloves and N95 respirator. She donned the gown and gloves, discarded her surgical mask, and donned an N95 respirator -CNA #2 and #6 entered Resident #51 room together -CNA #2 did not don an N95 respirator or eye protection prior to entering Resident #51's room -CNA #6 did not don eye protection prior to entering Resident #51's room 2. Resident #13 was admitted to the facility in May 2023 with diagnoses including pressure ulcer of left heel and sacral region (portion of your spine between your lower back and tailbone). Review of the medical record including progress notes, physician's orders, and care plans indicated but were not limited to the following: -He/she had an indwelling urinary catheter (a thin, flexible tube that drains urine from the bladder into a collection bag, outside of the body) -Enhanced Barrier Precautions related to Chronic wounds and urinary catheter -Clean hands when entering and exiting. Gloves and gown for high contact care (see room sign). During an observation with an interview on 8/20/24 at 3:23 P.M., the surveyor observed the following: - An ORANGE sign posted outside of Resident #13's doorway that indicated but was not limited to the following: Enhanced Barrier Precautions STOP Everyone must: Clean hands before entering and when leaving the room Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities: dressing, transferring, changing linens, providing hygiene, device care or use: urinary catheter, wound care: any skin opening requiring a dressing. -A 3-drawer plastic bin outside of the Resident's door containing PPE -CNA #1 entered Resident #13's room wearing a surgical mask and gloves -CNA #1 then repositioned Resident #13, moving the Resident to the left side, then to the right side removing and reapplying bilateral heel booties. -At no time did CNA #1 wear a protective gown while performing a high contact care activity -CNA #1 said Resident #13 is on EBP precautions, and she should have worn a gown to reposition the Resident but did not. During an interview on 8/21/24 at 2:30 P.M, CNA #7 said if a resident has a sign outside of their door that says Enhanced Barrier Precautions, she would wear a gown and gloves for any hands on care. She said if a resident has a sign that says Isolation Precautions, she would put on an N95, gown, gloves and goggles anytime she had to enter the room. During an interview on 8/21/24 at 4:14 P.M., the Infection Preventionist said her expectation is for all staff to follow the PPE guidelines posted on the signage outside of the resident's doors. She said when a resident is on EBP precautions, staff must use a gown and gloves for all high contact care, to reduce the risk of transmission of MDROs. She said when a resident is on Isolation/droplet precautions for COVID-19 everyone needs full PPE to enter the room including eye protection and an N95 respirator.

Based on observation and interview, the facility failed to maintain sanitary conditions of continuous positive airway pressure (CPAP- respiratory machine used to assist in keeping airways open to ease breathing while sleeping) respiratory tubing and equipment for one Resident (#3), out of a total sample of 18 residents. Findings include: Review of the Lippincott Nursing Procedure, eighth edition, indicated but was not limited to the following in regard to the use and storage of CPAP tubing: - When the CPAP therapy has been completed, follow these steps: remove the headgear and appliance from the patient; clean and disinfect the equipment using a facility-approved disinfectant according to the manufacturer's instructions, and store it properly. Resident #3 was admitted to the facility in June 2011 with a diagnosis of respiratory failure with hypercapnia (abnormally high levels of carbon dioxide in the blood). Review of the most recent Brief Interview for Mental Status (BIMS), dated 7/1/24, indicated the Resident was cognitively intact with a score of 14 out of 15. During an observation with interview on 8/15/24 at 1:12 P.M., Resident #3 said he/she uses a CPAP machine. The surveyor observed the machine and associated tubing and mask at the bedside, unlabeled and undated. The machine was laden with dust and the tubing and mask were lying on top of a plastic bag beside the air conditioner open to air and potential contamination by germs and environmental debris. The Resident said that since they are totally blind they cannot see where the staff puts the mask and tubing once it is removed, but hears them throw it, he/she said the machine and tubing are supposed to be wiped down every day and the mask is supposed to be changed weekly but they do not know if that happens since they cannot see. The surveyor observed the following: - 8/16/24 at 7:54 A.M., CPAP mask and tubing lying on the windowsill, appeared dry and was not stored in a plastic bag, open to potential contamination by germs and environmental debris; the machine was on the bedside table laden with dust. - 8/19/24 at 8:57 A.M., CPAP machine was laden with dust, and the mask and tubing were no longer connected. - 8/20/24 at 12:18 P.M., CPAP machine appeared dirty and a fingerprint could be made in the dust and dirt on the machine, there was tubing and a mask in a storage bag labeled 8/18/24. During an interview on 8/20/24 at 12:59 P.M., Nurse #1 said the process for caring for CPAP equipment is to store the mask and tubing in a plastic respiratory equipment bag when not in use to protect it from dirt and germs. She said she would think the machine was wiped down on Thursdays or weekly by the respiratory therapist, but she couldn't be sure. She viewed the photographs the surveyor took of the CPAP mask and tubing and dirty machine and said the machine was dusty and dirty and the mask and tubing should have been stored in the respiratory bag and not left out in the open touching other items in the environment because it was unsanitary. During an interview on 8/20/24 at 2:13 P.M., the Director of Nurses said the expectation is that respiratory equipment be kept clean and free of environmental debris and when any tubing is not in use it is to be stored in a respiratory storage bag to protect it from potential germs. She said the machines should be wiped down and kept clean routinely. She viewed the photographs of Resident #3's CPAP mask, tubing and machine and said the mask and tubing were not stored appropriately and the machine should have been cleaned and the expectation for maintaining this Resident's respiratory equipment was not met.

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services for the care of an indwelling catheter (tube inserted into the bladder to drain urine into a collection bag outside the body) for one Resident (#13), out of total sample of 18 residents. Specifically, the facility failed to ensure the Resident's indwelling Foley catheter device was maintained in a sanitary manner. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance titled Summary of Recommendations, Guideline for Prevention of Catheter-Associated Urinary Tract Infections, dated March 2024, indicated but was not limited to the following: -Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Resident #13 was admitted to the facility in May 2023 and had diagnoses including urinary tract infection, bacteremia, difficulty in walking, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 7/18/24, indicated Resident #13 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, had an indwelling Foley catheter (tube inserted into the bladder to drain urine), and was dependent on staff for personal hygiene and showering/bathing. Review of current Physician's Orders indicated the following: -Foley catheter care: Provide Foley catheter hygiene every shift. Add to POC instructions: Click on select POC charting category and pick miscellaneous tasks from the list every shift; 7:00 A.M. - 3:00 P.M., 3:00 P.M. - 11:00 P.M., 11:00 P.M. - 7:00 A.M., 7/10/24 -Foley to collection device at all times, ensure leg bag or overnight bag is connected and containing output every shift, 7:00 A.M. - 3:00 P.M., 3:00 P.M. - 11:00 P.M., 11:00 P.M. - 7:00 A.M., 7/10/24 Review of the Indwelling Catheter care plan, initiated 7/21/24, indicated the goal was to not contaminate or be contaminated. During an observation with interview on 8/20/24 at 3:23 P.M., the surveyor and Certified Nursing Assistant (CNA) #1 observed Resident #13 lying in bed. A Foley catheter was observed hanging from the side of the bed draining yellow urine into a urinary drainage bag. The bag was fully resting on the floor without a protective barrier underneath and was potentially exposed to environmental contaminants. CNA #1 said it was the first thing she saw upon entering the room then placed a protective barrier underneath. On 8/21/24 at 1:52 P.M., the surveyor observed Resident #13 lying in bed. A Foley catheter was observed hanging from the side of the bed draining yellow urine into a urinary drainage bag. The bag was partially touching the floor without a protective barrier underneath potentially exposing it to environmental contaminants. During an interview on 8/21/24 at 4:41 P.M., CNA #5 said the catheter bag shouldn't ever be on the floor because of germs. During an interview on 8/21/24 at 4:45 P.M., Nurse #5 said catheter bags should never be on the floor. During an interview on 8/21/24 at 4:50 P.M., the Infection Preventionist said the catheter bag should not be on the ground as it increases the risk of contamination.

Based on observation and interview, the facility failed to ensure one Resident (#13), out of a total sample of 18 residents, was treated with respect and dignity. Specifically, the facility failed to ensure staff provided a privacy cover for Resident #13's Foley catheter (tube inserted into the bladder to drain urine) drainage bag when the bag was exposed, containing urine, and visible for others to see. Findings include: Resident #13 was admitted to the facility in May 2023 and had diagnoses including urinary tract infection. Review of the Minimum Data Set (MDS) assessment, dated 7/18/24, indicated Resident #13 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, had an indwelling Foley catheter, and was dependent on staff for personal hygiene and showering/bathing. Review of current Physician's Orders indicated the following: -Foley catheter care: Provide Foley catheter hygiene every shift. Add to POC instructions: Click on select POC charting category and pick miscellaneous tasks from the list every shift; 7:00 A.M. - 3:00 P.M., 3:00 P.M. - 11:00 P.M., 11:00 P.M. - 7:00 A.M., 7/10/24 -Foley to collection device at all times, ensure leg bag or overnight bag is connected and containing output every shift, 7:00 A.M. - 3:00 P.M., 3:00 P.M. - 11:00 P.M., 11:00 P.M. - 7:00 A.M., 7/10/24 On 8/20/24 at 10:17 A.M. and 11:28 A.M., the surveyor observed Resident #13 sitting in a recliner chair in his/her room. A Foley catheter was observed hanging from the side of the chair draining yellow urine into a urinary drainage bag. The Foley catheter was not stored in a privacy bag and was fully visible to the surveyor from the doorway and to anyone passing by. During an observation with interview on 8/20/24 at 3:23 P.M., the surveyor and Certified Nursing Assistant (CNA) #1 observed Resident #13 lying in bed. A Foley catheter was observed hanging from the right side of the Resident's bed, closest to the doorway, draining yellow urine into a urinary drainage bag. The Foley catheter was not stored in a privacy bag and was fully visible to anyone entering the room. CNA #1 said it was the first thing she saw when she entered the room as it was resting on the floor but did not place the drainage bag into a privacy bag after placing a protective barrier underneath it. On 8/21/24 at 1:52 P.M., 2:32 P.M., and 4:41 P.M., the surveyor observed Resident #13 lying in bed. A Foley catheter was observed hanging from the right side of the bed draining yellow urine into a urinary drainage bag. The drainage bag was not stored in a privacy bag and was fully visible to the surveyor from the doorway and to anyone passing by. During an interview on 8/21/24 at 4:41 P.M., CNA #5 said no one should be able to visualize the urine in the bag. During an interview on 8/21/24 at 4:45 P.M., Nurse #5 said catheter bags should be covered so the urine cannot be visualized. During an interview on 8/21/24 at 4:50 P.M., the Infection Preventionist said to maintain dignity, urine should be covered and not visualized while in the bag.

Based on records reviewed and interviews for three of three residents (Resident #1, Resident #2, and Resident #3), who developed rashes and/or had changes in their skin conditions, the Facility failed to ensure they maintained complete and accurate medical/clinical records including but not limited to documentation related to weekly skin assessments which included completion of a wound management assessment as needed, and the monitoring of treatments and progress towards healing. Finding Include: Review of the Facility Policy titled Wound (any type of damage or breakage on the surface of the skin) and Skin Care Protocol, dated as last revised 1/2009, indicated that the purpose is to identify outcomes-based approaches for the care of residents identified at risk and those with existing wounds. Review of the Facility Protocol titled, At-Risk Residents, dated 6/2013, indicated that a weekly skin assessment is to be performed by a licensed nurse. 1) Resident #1 was admitted to the Facility in June 2023, diagnoses included cerebral vascular accident, multiple falls, vascular dementia, diabetes mellitus, anxiety, and depression. Review of Resident #1's Physicians Orders, dated 9/01/23, indicated that a weekly skin check was to be completed by a licensed nurse and if a skin issue is noted, a Wound Management Assessment is to be completed in Point Click Care (PCC, electronic medical record system) to record findings and to notify the wound nurse. Review of Resident #1's Nurse Progress Note, dated 9/24/23, indicated that Resident #1 complained of itchy skin and the nurse noted flat, red spots on his/her lower back, scabs and redness to his/her upper arm and his/her lower extremities. Review of Resident #1's Nurse Progress Note, dated 9/26/23, indicated he/she complained of itchiness to his/her upper arm, lower extremities, back, and these areas had noted scabs and redness. Review of Resident #1's Nurse Progress Note, dated 10/11/23, indicated his/her red itchy spots remain. Review of Resident #1's Nurse Progress Note, dated 11/15/23, indicated his/her rash appears to be worsened. Review of Resident #1's Wound Progress Note (written by the Wound Physician's Assistant), dated 12/07/23, indicated he/she had a cluster of open wounds (trauma full thickness wound) to his/her right lower extremity and an open wound (trauma, full thickness wound) to his/her left posterior lower leg. Review of Resident #1's Treatment Administration Records (TAR) dated 9/27/23, indicated the weekly skin check was initialed by nursing as being completed, however, there was no documentation to support that the Wound Management Assessment was completed. Review of Resident #1's TAR, dated 10/01/23 through 10/31/23, indicated the weekly skin checks on 10/04/23, 10/11/23, 10/18/23, and 10/25/23 were initialed by nursing as being completed, however, there was no documentation to support the Wound Management Assessments were completed. Review of Resident #1's TAR, dated 11/01/23 through 11/30/23, indicated the weekly skin checks on 11/01/23, 11/08/23, 11/15/23, 11/22/23 and 11/29/23 were initialed by nursing as being completed, however, there was no documentation to support the Wound Management Assessments were completed. Review of Resident #1's TAR, dated 12/01/23 through 12/31/23, indicated the weekly skin checks on 12/06/23, 12/13/23, 12/20/23, and 12/27/23 were initialed by nursing as being completed, however, there was no documentation to support the Wound Management Assessments were completed. 2) Resident #2 was admitted to the Facility in December 2020, diagnoses included Alzheimer's type dementia, hypertension, anxiety, and depression. Review of Resident #2's Physicians Orders, dated 12/01/23, indicated that a weekly skin check was to be completed by a licensed nurse and if a skin issue is noted, a Wound Management Assessment is to be completed in PCC to record findings and to notify the wound nurse. Review of Resident #2's Nurse Progress Note, dated 12/01/23, indicated he/she had open scratch marks up and down his/her left arm and lower back. Review of Resident #2's Nurse Progress Note, dated 12/04/23, indicated he/she had scattered small scabs on his/her left arm from mid bicep to wrist with red marks all the way down the arm. Review of Resident #2's Nurse Progress Note, dated 12/15/23, indicated he/she had scattered marks all over bilateral arms. Review of Resident #2's Nurse Progress Note, dated 12/21/23, indicated he/she had rashes on his/her bilateral arms, back, and buttocks. Review of Resident #2's TAR, dated 12/01/23 through 12/31/23, indicated the weekly skin checks on 12/01/23, 12/08/23, 12/15/23, and 12/22/23 were initialed by nursing as being completed, however, there was no documentation to support the Wound Management Assessments were completed. 3) Resident #3 was admitted to the Facility in March 2022, diagnoses included Alzheimer's type dementia, anemia, hypertension, and anxiety. Review of Resident #3's Physicians Orders, dated 11/01/23, indicated that a weekly skin check was to be completed by a licensed nurse and if a skin issue is noted, a Wound Management Assessment is to be completed to record findings and to notify the wound nurse. Review of Resident #3's Nurse Progress Note, dated 11/05/23, indicated he/she has scattered scratch marks and petechiae (tiny round brown-purple spots due to bleeding under the skin) to both ankles and feet. Review of Resident #3's Nurse Progress Note, dated 12/16/23, indicated he/she had some bleeding to his/her right lower extremity due to scratching. Review of Resident #3's TAR, dated 11/01/23 through 11/30/23, indicated the weekly skin checks on 11/04/23, 11/11/23, 11/18/23, and 11/25/23 were initialed by nursing as being completed, however, there was no documentation to support the Wound Management Assessments were completed. Review of Resident #3's TAR, dated 12/01/23 through 12/31/23, indicated the weekly skin checks on 12/01/23, 12/08/23, 12/15/23, and 12/22/23 were initialed by nursing as being completed, however, there was no documentation to support the Wound Management Assessments were completed. During an interview on 12/28/23 at 3:47 P.M., Nurse #1 said she had noticed Resident #1 had a rash over his/her body for quite some time (quite a few months) and said she first documented the findings in her nursing progress note on 9/24/23 and said she should have started a Wound Management Assessment as soon as the rash was identified. Nurse #1 said the policy is that if anything is observed during a resident's weekly skin assessment (or any other time), including but not limited to, bruises, abrasions, pressure injuries, and rashes, she said nursing staff are instructed to begin a Wound Management Assessment in Point Click Care (PCC, electronic medical record system) to document he abnormal findings. During an interview on 12/28/23 at 12:28 P.M., Nurse #2 said that if an abnormal area is found when completing a resident's weekly skin assessment, or at any time, the nurse must write a progress note and then complete a Wound Management Assessment in PCC. During an interview on 12/28/23 at 12:56 P.M., the Charge Nurse said if a nurse finds an open area, bumps, bruises, pressure ulcers, or rash while doing a weekly skin assessment, or at any other time, it is the Facilities expectation for nurses to document findings in a progress note, notify the physician, family member (if applicable) and then document the findings on the Wound Management Assessment in PCC. During an interview on 12/28/23 at 2:57 P.M., the Assistant Director of Nurses (ADON) said she was unaware that the nurses had not completed Wound Management Assessments for all three residents, despite all having some sort of skin condition. The ADON said a wound is to be considered anything abnormal found on the skin, including but not limited to, bruises, skin tears, cuts, rashes, and pressure ulcers. The ADON said all three residents should have had Wound Management Assessments completed due to the finding of their skin conditions. The ADON said it is the Facility's expectation for nurses to perform, at minimum, a weekly skin assessment for each resident (according to individual schedules) and if any skin issues are identified, that Wound Management Assessments must be completed and nurses are to report the findings to the Wound Nurse (ADON).

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), whose Plan of Care indicated he/she required physical assistance of one staff member with toileting which included assistance with hygiene care needs, utilized bed/chair alarms for safety and was assessed by nursing at high risk for falls, the Facility failed to ensure nursing staff consistently implemented and followed interventions from his/her Plan of Care while meeting his/her care needs. On 08/30/23, Certified Nurse Aide (CNA) #1 brought Resident #2 into the bathroom, transferred and positioned him/her onto the toilet (which was not alarmed), CNA #1 then exited the bathroom and Resident #2's room, leaving him/her unattended and unassisted by a staff member. A short time later Resident #2 was heard calling out for help, and was found lying on his/her back on the floor near the recliner in his/her room complaining of left hip pain. after he/she had transferred him/herself off of the toilet and ambulated unassisted by staff. Upon assessment, Resident #2's left leg was noted to be externally rotated, he/she was transferred to the Hospital Emergency Department for evaluation, where he/she was diagnosed with a left hip and left elbow fracture from the fall. Findings include: Review of the Facility's Policy, titled Comprehensive Care Plan, dated July 2023, indicated the Facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident right set forth, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Resident #2 was admitted to the Facility in February 2021, diagnoses included wedge compression fracture of the first thoracic vertebrae, fracture of second thoracic vertebrae, osteoporosis, vascular dementia, muscle weakness and difficulty in walking. Review of a Physicians Order, dated 9/26/22, indicated nursing to assist Resident #2 with all aspects of toileting. Review of Resident #2's Activity of Daily Living (ADL) Care Plan, dated 06/07/23, indicated he/she required staff assistance with all aspects of toileting, interventions included staff assistance with transfers on and off the toilet, and assistance with hygiene care. Review of Resident #2's Physician's Order, dated 6/17/23, indicated nursing to use a chair and bed alarms for his/her safety. Review of Resident #2's Care Plan related to Risk for Falls, dated 06/20/23, indicated interventions included the use of alarms (bed and chair) for safety. Review of the Quarterly Minimal Data Set Assessment (MDS), dated [DATE], indicated Resident #2 was moderately cognitively impaired, required limited physical assistance from staff with transfers, extensive physical assistance of one staff member with toileting and hygiene care needs. The MDS indicated Resident #2 was unsteady when he/she moved from a sitting to a standing position, unsteady with ambulation, unsteady with turns, and unsteady when moving on/off the toilet and was only able to stabilize him/herself with human (staff) assistance. Review of Resident #2's CNA Care Plan, (used as a reference guide by CNA's), undated, indicated Resident #2 was at risk for falls, required physical assistance with transfers and toileting, and utilized bed and chair alarms. Review of CNA #1's Written Witness Statement, dated 8/30/23, indicated that at approximately 9:20 A.M., she heard an alarm go off, went into Resident #2's room and helped him/her into the bathroom and then left the room. During an interview on 09/06/23 at 1:00 P.M., Certified Nurse Aide (CNA) #1 said that on 08/30/23 at 9:35 A.M., she heard Resident #2's chair alarm sound. CNA #1 said that Resident #2 requested to go to the bathroom, so she walked Resident #2 to the bathroom, assisted him/her onto the toilet and then left his/her room to assist another resident. CNA #1 said that she left Resident #2 unassisted on the toilet and left him/her alone in the bathroom. CNA #1 said that Resident #2 required staff assistance with toileting and transfers and used a chair alarm for safety. CNA #1 said she should not have left Resident #2 alone on the toilet in the bathroom and said she did not follow his/her plan of care. CNA #1 said that she did not review Resident #2's Care Plan, but said she knew what level of care he/she required and said she had taken care of Resident #2 many times. Review of a Nurse Progress Note, dated 08/30/23, indicated Nurse #2 heard Resident #2 yelling out for help. The Note indicated that Resident #2 was found lying on the floor (in his/her room) next to his/her recliner complaining of left hip pain with his/her left lower extremity externally rotated. The Note indicated that Resident #2 was transferred to the hospital for evaluation. During an interview on 9/11/23 at 10:19 A.M., Nurse #2 said that on 8/30/23 at 9:35 A.M., she was standing at the medication cart when she heard Resident #2 call out for help. Nurse #2 said that when she entered Resident #2's room, she found him/her lying on his/her back near his/her recliner in his/her room complaining of left hip pain. Nurse #2 said that Resident #2 had transferred him/herself off the toilet and exited the bathroom unassisted by staff. Nurse #2 said that upon assessment, Resident #2's left lower extremity was externally rotated. Nurse #2 said that she called 911 and Resident #2 was transferred to the hospital for evaluation of his/her injuries. Nurse #2 said that Resident #2 was at high risk for falls, utilized bed and chair alarms for safety, required assistance of one staff member with toileting and should not have been left alone and unattended on the toilet. Nurse #2 said Resident #2 is confused at baseline, has a history of getting up and transferring him/herself without calling for staff assistance, and that was why he/she needed safety alarms. Nurse #2 said that CNA #1 did not follow Resident #2's plan of care. Review of the Hospital Discharge Summary, dated 09/03/23, indicated Resident #2 had sustained a fall at the Facility on 8/30/23 and presented at the hospital with a left hip deformity and left elbow pain. The Discharge Summary indicated Resident #2's x-rays confirmed a left distracted (force applied to the forearm or hand with the arm extended can allow the radial head to slip out of the collar) intra-articular ulnar volcano process fracture with joint effusion (the pointy segment of bone that is part of the ulna, one of the three bones that come together to form the elbow joint) and a comminuted impacted and angulated left intertrochanteric hip fracture. The Discharge Summary indicated that Resident #2 underwent an open reduction internal fixation (ORIF) surgery of his/her left hip and conservative management of the left elbow fracture. During interview on 09/06/23 at 3:15 P.M., the Director of Nurses (DON) said that Resident #2 is at high risk for falls, has a physician's order for nursing staff to assist with all aspects of toileting. The DON said that Resident #2 requires physical assistance of one staff member with toileting and transfers, is confused, gets up by him/herself and that was why he/she required alarms. The DON said residents requiring alarms for safety should not be left alone in the bathroom. The DON said that CNA #1 should not have left Resident #2 alone on the toilet in the bathroom and said that CNA #1 did not follow Resident #2's plan of care. The DON said that as a result of being left alone on the toilet in his/her bathroom, Resident #2 fell and sustained a left elbow and left hip fracture.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who was assessed by nursing at high risk for falls, whose Plan of Care indicated that he/she required physical assistance with toileting care needs, including transfers on and off the toilet, the Facility failed to ensure he/she was provided with the required level of staff assistance to maintain his/her safety, in an effort to prevent incidents/accidents resulting in an injury. On 08/30/23, Certified Nurse Aide (CNA) #1 brought Resident #2 into the bathroom, assisted with transferring and positioning him/her on the toilet (which was not equipped with an alarm) and then left the bathroom and Resident #2's room leaving him/her unattended by a staff member. A short time later, Resident #2 was heard calling out for help, and was found lying on his/her back on the floor in his/her room near the recliner complaining of left hip pain. Upon assessment, Resident #2's left leg was noted to be externally rotated. Resident #2 was transferred to the Hospital and x-rays revealed he/she had a left hip and left elbow fracture from the fall. Findings include: Review of the Facility's Policy, titled Fall Prevention Program, dated October 2022, indicated the following: -each resident will be assessed for risk factors and predisposition for falling using the facility Fall Risk Assessment Form; -residents having a history of falls or who score high on the Fall Risk Assessment will have an active problem included in their interdisciplinary plan of care; -residents who experience a fall will have a Fall Risk Assessment completed and immediate interventions will be implemented; -all falls will have an initial review by the Fall Risk Committee and recommendations will be added to the resident care plan; -the nurse manager will review the staff education form with all staff on their units; -new interventions are added to the resident's care plan; -interdisciplinary care plans will be established, revised and/or reviewed each time a resident falls; -appropriate interventions to maintain a resident's safety will be included. Resident #2 was admitted to the Facility in February 2021, diagnoses included wedge compression fracture of the first thoracic vertebrae, fracture of second thoracic vertebrae, osteoporosis, vascular dementia, muscle weakness and difficulty in walking. Review of Resident #2's Physicians Order, dated 9/26/22, indicated nursing to assist with all aspects of toileting. Review of Resident #2's Activity of Daily Living (ADL) Care Plan, dated 06/07/23, indicated he/she required physical assistance of one staff member with all aspects of toileting, interventions included staff to assist with transfers on and off the toilet and staff to assist with hygiene care. Review of Resident #2's Physician's Order, dated 6/17/23, indicated to use chair and bed alarms for safety. Review of Resident #2's Risk for Falls Care Plan, dated 06/20/23, indicated interventions included the use of bed and chair alarms for safety. Review of Resident #2's Fall Risk Assessment, dated 8/03/23, indicated that he/she was at high risk for falls. Review of the Quarterly Minimal Data Set Assessment (MDS), dated [DATE], indicated Resident #2 was moderately cognitively impaired, required limited physical assistance from staff with transfers, and extensive physical assistance of one staff member with toileting and hygiene care needs. The MDS indicated Resident #2 was unsteady when he/she moved from a sitting to a standing position, unsteady with ambulation, unsteady with turns, and unsteady when moving on/off the toilet and was only able to stabilize him/herself with human (staff) assistance. Review of Resident #2's CNA Care Plan, (used as a reference guide by CNA's), undated, indicated Resident #2 was at risk for falls, interventions included staff to provide physical assistance for transfers and with toileting, and that he/she utilized bed and chair alarms. Review of CNA #1's Written Witness Statement, dated 8/30/23, indicated that at approximately 9:20 A.M., she heard an alarm go off and went into Resident #2's room and helped him/her into the bathroom and then left the room. During an interview on 09/06/23 at 1:00 P.M., Certified Nurse Aide (CNA) #1 said that on 08/30/23 at 9:35 A.M., she heard Resident #2's chair alarm sound. CNA #1 said that Resident #2 requested to go to the bathroom, said she walked Resident #2 to the bathroom, assisted him/her onto the toilet and then left his/her room to assist another resident. CNA #1 said that she left Resident #2 unassisted on the toilet and left him/her alone in the bathroom. CNA #1 said that Resident #2 required staff assistance with toileting and transfers and used a chair alarm for safety. CNA #1 said she should not have left Resident #2 alone on the toilet in the bathroom. CNA #1 said that she did not review Resident #2's Care Plan, but said she knew what level of care he/she required and said she had taken care of Resident #2 many times. Review of a Nurse Progress Note, dated 08/30/23, indicated Nurse #2 heard Resident #2 yelling out for help. The Note indicated that Resident #2 was found lying on the floor (in his/her room) next to his/her recliner complaining of left hip pain with his/her left lower extremity externally rotated. The Note indicated that Resident #2 was transferred to the hospital for evaluation. During an interview on 9/11/23 at 10:19 A.M., Nurse #2 said that on 8/30/23 at 9:35 A.M., she was standing at the medication cart when she heard Resident #2 call out for help. Nurse #2 said that when she entered Resident #2's room, she found him/her lying on his/her back near his/her recliner in his/her room complaining of left hip pain. Nurse #2 said that Resident #2 had transferred him/herself off the toilet, exited the bathroom, and was found lying on his/her back on the floor near his/her recliner in his/her room complaining of left hip pain. Nurse #2 said that upon assessment, Resident #2's left lower extremity was externally rotated. Nurse #2 said that she called 911 and Resident #2 was transferred to the hospital for evaluation of his/her injuries. Nurse #2 said Resident #2 is confused at baseline, at high risk for falls, has a history of getting up and transferring him/herself without calling for staff assistance, and that he/she required bed and chair alarms for safety. Nurse #2 said Resident #2 required assistance of one staff member with toileting and should not have been left alone and unattended on the toilet. Review of a Resident Incident Report, dated 8/30/23 at 9:35 A.M., indicated that Resident #2 was found lying on the floor next to his/her recliner with his/her left lower extremity noted to be externally rotated, pain noted with movement and a skin tear was also noted to Resident #2's left elbow. The Report indicated that Resident #2 was transferred to the hospital. Review of the Hospital Discharge Summary, dated 09/03/23, indicated Resident #2 had sustained a fall at the Facility on 8/30/23 and presented at the hospital with a left hip deformity and left elbow pain. The Discharge Summary indicated Resident #2's x-rays confirmed a left distracted (force applied to the forearm or hand with the arm extended can allow the radial head to slip out of the collar) intra-articular ulnar olecranon process fracture with joint effusion (the pointy segment of bone that is part of the ulna, one of the three bones that come together to form the elbow joint) and a comminuted impacted and angulated left intertrochanteric hip fracture. The Discharge Summary indicated that Resident #2 underwent an open reduction internal fixation (ORIF) surgery of his/her left hip and conservative management of the left elbow fracture. During interview on 09/06/23 at 3:15 P.M., the Director of Nurses (DON) said that Resident #2 is at high risk for falls, has a physician's order for nursing staff to assist with all aspects of toileting and that his/her plan of care indicates that he/she utilizes a bed and chair alarm for safety. The DON said that Resident #2 requires physical assistance of one staff member with toileting and transfers, is confused, gets up by him/herself and that was why he/she required alarms. The DON said residents requiring alarms for safety should not be left alone in the bathroom and said CNA #1 should not have left Resident #2 alone on the toilet in the bathroom. The DON said that as a result of being left alone on the toilet in his/her bathroom, Resident #2 fell and sustained a left elbow and left hip fracture.

Based on observation, record review, policy review, and interviews, the facility failed to ensure its staff provided each resident an environment free of accident hazards and adequate supervision and assistance devices to prevent potential accidents or injuries. Specifically, the facility failed: 1. For one Resident (#48), out of a total sample of 19 residents, to ensure effective interventions were implemented to prevent three falls, including one with injury, requiring transfer to an acute care hospital; and 2. To ensure the Treatment Room door was closed and locked, exposing wandering residents to an environment with medication and medical supply hazards, on one of three units. Findings include: 1. Review of the facility's policy titled Fall Prevention Program, last reviewed 10/2022, included but was not limited to: -Residents who experience a fall will have an incident report and resident incident investigation follow up. -Immediate interventions will be implemented. -The nurse manager or shift supervisor will trigger a rehab request. -All falls will have an initial review by the Fall Risk Committee to identify and eliminate any environmental factors and add further recommendations. -The physical therapist will make recommendations for interventions to the Fall Risk Committee. -A Fall Prevention/Incident Interventions/Staff Education form will list the intervention(s) to be added, changed, or deleted in the resident's care plan. -The nurse manager or designee will review the Fall Prevention/Incident Interventions/Staff Education form with all staff on the unit. -Interdisciplinary care plans will be established, revised, and/or reviewed each time a resident falls. -Residents with potential fall risk problems will be re-evaluated at their quarterly care planning meeting. Resident #48 was admitted to the facility in October 2018 with diagnoses including dementia, arthritis, cerebral infarction (stroke), and anxiety. Review of the Minimum Data Set (MDS) assessment, dated 4/18/23, indicated Resident #48 had severe cognitive impairment and was rarely/never understood, required assistance of staff for bed mobility, transfers, toileting, hygiene, and dressing, utilized a wheelchair and had a history of two or more falls. Review of the medical record indicated Resident #48 had five falls from January 2023 to July 2023. Review of the Resident Incident Reports indicated: -1/24/23 at 3:10 A.M., Resident had un unwitnessed fall out of bed and was found sitting on the floor against the bed. The Resident could not tell staff what he/she was trying to do. Bed alarm was sounding. No injury was noted. The follow-up assessment and recommendations section of the Incident Report was signed by Unit Manager #2 and failed to indicate any intervention was implemented or staff education was provided. The Fall Committee Review indicated Rehab was to screen the Resident. Fall Committee Review and Weekly Review sections were signed by the Assistant Director of Nurses (ADON). The Fall Prevention/Incident Interventions/Staff Education form was requested and not provided. The Rehab screen was requested and not provided. Further review of the medical record failed to indicate Rehab had screened the Resident. Review of the interdisciplinary care plan for falls indicated purposeful rounding per policy and Rehab screen were added to the electronic care plan. -3/28/23 at 11:55 P.M., Resident had a witnessed fall out of bed. Bed was in low position and bed alarm was sounding, staff was with roommate and observed Resident roll out of bed, landing on his/her right side. The Resident could not tell staff what he/she was trying to do. No injury was noted. The follow-up assessment and recommendations section of the incident report was signed by Unit Manager #2 and failed to indicate any intervention was implemented or staff education was provided. Fall Committee Review indicated Rehab was to screen the Resident and a defined perimeter mattress (mattress with raised sides to enhance fall prevention by cradling resident in the bed) was to be added to the Resident's plan of care. Fall Committee Review and Weekly Review sections were signed by the ADON. The Fall Prevention/Incident Interventions/Staff Education form was requested and not provided. Rehab screen indicated an evaluation was not needed because reasonable expectation for improvement was not elicited. Review of the interdisciplinary care plan for falls indicated defined perimeter mattress and rehab screen were added to the electronic care plan. Review of the medical record indicated no order was written for a defined perimeter mattress. -4/27/23 at 12:40 A.M., Resident had an unwitnessed fall out of bed and was found kneeling by his/her bed. Bed was in low position and bed alarm was sounding when staff entered the room. The Resident could not tell staff what he/she was trying to do. No injury was noted. The follow-up assessment and recommendations section were left blank and not signed by a Unit Manager or Supervisor. It failed to indicate any intervention was implemented or staff education was provided. The Fall Committee Review indicated Rehab to screen the Resident and a defined perimeter mattress was to be added to the Resident's plan of care (was supposed to be done after 3/28/23 fall). Fall Committee Review and Weekly Review sections were signed by the ADON. The Fall Prevention/Incident Interventions/Staff Education form was requested and not provided. Rehab screen indicated the Resident was currently on caseload. Review of the interdisciplinary care plan for falls indicated to continue the defined perimeter mattress and Rehab screen was added to the electronic care plan. Review of the medical record indicated no order was written for a defined perimeter mattress. -6/1/23 at 1:30 A.M., Resident had an unwitnessed fall out of bed and was found lying on the floor by his/her bed. Bed was in low position and bed alarm was sounding when staff entered the room. The Resident could not tell staff what he/she was trying to do. No injury was noted. The follow-up assessment and recommendations section were signed by Unit Manager #2 and failed to indicate any intervention was implemented or staff education was provided. The Fall Committee Review indicated Rehab to screen the Resident. Med Review for dose reduction of antipsychotic medication. Fall Committee Review and Weekly Review sections were signed by the ADON. The Fall Prevention/Incident Interventions/Staff Education form was requested and not provided. The Rehab screen was requested and not provided. Review of the medical record failed to indicate Rehab had screened the Resident. Further review of the medical record failed to indicate a physician's order had been obtained for the defined perimeter mattress or that the mattress had been put on the Resident's bed at the time of this fall. Review of the interdisciplinary care plan for falls indicated medication review and continue all interventions was added to the electronic care plan. -7/12/23 at 7:30 A.M., Resident had a witnessed fall out of bed. Bed was in low position and bed alarm was sounding. Nurse #2 entered the room and observed the Resident roll off the right side of the bed. The Resident could not tell staff what he/she was trying to do. The Resident had a hematoma and laceration over his/her right eye. Resident was transferred to the Hospital. The follow-up assessment and recommendations section indicated staff education on fall mats but failed to indicate any staff education was provided and was not signed by a Unit Manager or Supervisor. The Fall Committee Review indicated fall mats and defined perimeter mattress added (defined perimeter mattress was to be implemented previously after 3/28/23 fall and again after 4/27/23 fall). It did not indicate a Rehab screen was sent. Fall Committee Review section was not signed, and the Weekly Review section was signed by the Director of Nurses (DON). The Fall Prevention/Incident Interventions/Staff Education form was requested and not provided. The Rehab screen was requested and not provided. Review of the interdisciplinary care plan for falls indicated fall mats and defined perimeter mattress were added to the electronic care plan. Review of the medical record indicated an order was written for a defined perimeter mattress on 7/13/23. Further review of the medical record indicated Resident #48 was transferred on 7/12/23 after a fall. Diagnoses on discharge paperwork include brain concussion, elderly fall and laceration of right eyebrow. The laceration was closed with glue/skin adhesive. On 7/13/23 surveyor observed a defined perimeter mattress on Resident #48's bed. During an interview on 7/18/23 at 2:56 P.M., Nurse #2 said she does not recall what mattress was on the Resident's bed on 7/12/23 when he/she rolled out of bed. Additionally, Nurse #2 said the Resident now has floor mats and a defined perimeter mattress on the bed. During an interview on 7/18/23 at 1:45 P.M., Unit Manager #2 said she did not know when the defined perimeter mattress was put on the bed. During an interview on 7/18/23 at 2:03 P.M., the ADON said the Rehab screen request goes to the Rehab department, but the form doesn't come back to the office. The ADON said every resident that falls will have a Rehab screen done. Additionally, the ADON said she would expect a new intervention to be added to the care plan and implemented with every fall. After the fall on 3/28/23, the defined perimeter mattress should have been put on the bed. The ADON said the usual process is not to double check interventions were implemented. The ADON said she would expect the unit manager to address the interventions written on the incident report review, write the orders if needed and update the care plan. The ADON said she doesn't know why it was not done. In regard to the fall on 4/27/23, the ADON said she did not know why the same intervention was noted for the defined perimeter mattress, because it should have already been in place and it was not. The ADON said a defined perimeter mattress requires a physician's order and it was not put in place until 7/13/23. During an interview on 7/18/23 at 2:37 P.M., Rehab Staff #1 said sometimes the screens get missed. Additionally, Rehab Staff #1 said when the screen is complete it does not go back to nursing, the form stays in the rehab office. Rehab screens were requested for Resident #48's five falls in 2023 and Rehab Staff #1 was unable to provide them for 3 of the 5 falls. Rehab Staff #1 said he did not have all of them and did not know if they were done. During an interview on 7/18/23 at 3:10 P.M., the DON said after every fall the incident report is completed by the nurse and reviewed by the Interdisciplinary Team (IDT) for interventions to be implemented to prevent future falls. Additionally, the DON said the intervention for the defined perimeter mattress should have been implemented in March and was not done until 7/13/23. The DON said the defined perimeter mattress was not on Resident #48's bed at the time of the fall on 7/12/23. The DON said her expectation is that when the incident report is signed by the Unit Manager, Supervisor and/or the ADON, the intervention is put in place, however in this case the order for the mattress was not written until 7/13/23 and that is when the mattress was actually put on the bed. During an interview on 7/18/23 at 3:30 P.M., Unit Manager #1 said Resident #48 did not have a defined perimeter mattress on his/her bed on 7/12/23 when the fall with laceration occurred. Additionally, Unit Manager #1 said the intervention was added to the care plan, physicians order was written, and mattress was put on the bed on 7/13/23 after the Fall Committee Review. Unit Manager #1 said she does not know why it was not done previously. During an interview on 7/19/23 at 8:28 A.M., Nurse #3 said Resident #48 did not have a defined perimeter mattress on his/her bed until after the fall last week. During an interview on 7/19/23 at 12:34 P.M., the ADON said she did not have the Fall Prevention/Incident Interventions/Staff Education Forms for any of these five falls. The ADON provided a blank copy of the form referenced in the facility Falls policy and said, but we do not use it. 31830 2. Review of the facility's policy titled Medication Storage in the Facility, dated February 2019, indicated but was not limited to the following: - Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the suppliers. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. The surveyor made the following observations on the third floor [NAME] Unit where long-term residents, some with cognitive deficits, resided: On 7/13/23 at 2:54 P.M., the surveyor observed the Treatment Room door unlocked and slightly opened and easily accessible to residents residing on the third floor [NAME] Unit. The Treatment Room was located down an L shaped hallway and was not in view of the nurses' station which was located at the opposite end of the L shaped hallway. The surveyor observed the following treatments which were on top of the treatment cart and on the shelving unit in the Treatment Room: - Diclofenac Sodium Topical Gel 1% (nonsteroidal anti-inflammatory) - DermaGinate/Ag Calcium Alginate Wound Dressing with Antibacterial Silver - Idosorb Cadexomer Iodine Gel (antiseptic) - Calcium Alginate Dressing: (highly absorbent, can reduce bacterial infections) - Triamcinolone Acetonide Ointment 0.05%: (corticosteroid) - DermPhor Ointment - Triple Antibiotic Cream - Xeroform Gauze Dressing - Allevyn Gentle Border - Alcohol Prep Pads On 7/13/23 at 2:58 P.M., the surveyor observed a wandering resident ambulate down the hallway past the Treatment Room. At 3:00 P.M., the surveyor observed a resident ambulate with a walker down the hallway past the Treatment Room. During an interview on 7/13/23 at 3:03 P.M., Nurse #7 observed the opened Treatment Room door with the surveyor. Nurse #7 said she was most likely the last nurse into the Treatment Room at approximately 2:30 P.M. and was responsible for not closing the self-locking door. Nurse #7 said the Treatment Room door should never be left opened and unlocked. During an interview on 7/13/23 at 3:37 P.M., the Director of Nurses said there were many residents on the unit and the expectation was the Treatment Room door should never be left opened and unlocked.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), the facility staff failed to prevent Resident #1 from sustaining a bilateral (both) mandibular (jaw) fracture. Findings include: Resident #1 was admitted to the Facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. An Activities of Daily Living (ADL) and Falls Care Plan, dated 12/21/17, indicated Resident #1 required two staff persons assist for transfers. A Pre-Restraining Assessment, dated 12/29/17, indicated Resident #1 used two top quarter side rails to assist with positioning and transfers. The physician's orders [REDACTED].#1 was on 15 minute checks for restlessness since 12/8/17. A Fall Risk Assessment, dated 2/3/18, indicated Resident #1 was a high risk for falls. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #1 was non-ambulatory, dependent on staff for transfers and eating, and required assist of two staff persons for bed mobility. The Certified Nurse Aide (CNA) Flowsheet, dated (MONTH) (YEAR), indicated Resident #1 was verbally and physically abusive towards staff on 2/14/18 during the 3:00 P.M. to 11:00 P.M. shift. A Nurse's Note, dated 2/14/18 at 11:00 P.M. indicated Resident #1 was kicking his/her legs, rolling side to side in bed, climbing out of bed and combative with incontinence care. The Note indicated Resident #1 was administered Tylenol (a medication used to treat mild pain). A Nurse's Note, dated 2/15/18, for the 11:00 P.M. to 7:00 A.M. shift, indicated Resident #1 slept in long naps, was cooperative, and less resistive to care. A Resident Incident Report, dated 2/15/18 at 11:55 A.M., indicated Resident #1 was noted by his/her spouse to have a 1.5 centimeter (cm) by 1.5 cm purple bruise under his/her left side of chin, of unknown etiology, that was tender to touch. A Nurse's Note, dated 2/15/18 at 2:05 P.M., indicated Resident #1 was to see the dentist for discomfort and bruising at jaw area. A Nurse's Note, dated 2/15/18 at 2:50 P.M., indicated Resident #1 was seen by the dentist with no new orders. A Dental Consult, dated 2/15/18, indicated Resident #1 had bilateral bruising under chin and that he/she may have hit his/her jaw on something. A Nurse's Note, dated 2/15/18, for the 3:00 P.M. to 11:00 P.M. shift, indicated Resident #1 had no discomfort, light purple bruise remained on left side of chin, appetite was poor, was restless at times and combative with care. A Nurse's Note, dated 2/16/18, for the 11:00 P.M. to 7:00 A.M. shift, indicated Resident #1's neck on both sides of the Adam's apple was irregular shaped with a dark purple bruise noted. The Note indicated Resident #1 slept in long naps and was less resistive to care. A Situation Background Appearance Review (SBAR) and Notify Communication Form, dated 2/16/18, indicated Resident #1 had mouth and jaw discomfort, difficulty swallowing, left jaw swelling, and bilateral neck bruising. The SBAR indicated the Physician was notified and ordered Resident #1 to be transferred to the Hospital Emergency Department for evaluation. A Physician's Interim Telephone Order, dated 2/16/18, indicated to send Resident #1 to the Hospital Emergency Department for evaluation. A Hospital Report, dated 2/16/18, indicated Resident #1 is combative with end-stage [MEDICAL CONDITION]. The Report indicated Resident #1 had bruising to his/her neck. The Report indicated a CT scan was performed and showed bilateral mandibular fractures with no dislocation. The Surveyor interviewed Physician #2 at 11:11 A.M. on 7/6/18. Physician #2 said he examined Resident #1 on 2/15/18 and noted bruising under his/her chin that appeared to have been caused by hitting or banging your chin on something. The Surveyor interviewed the Director of Nurses (DON) at 1:06 P.M. on 6/29/18. The DON said Resident #1 has a history of being combative with care, was on 15 minute checks for restlessness. The DON said a complete investigation was conducted and that she was unable to determine the cause of Resident #1's jaw fracture.

Based on records reviewed and interviews for one of three sampled residents (Resident #4), the facility failed to prevent Certified Nurse Aide (CNA) #12 from physically abusing Resident #4, when two staff members witnessed CNA #12 hit Resident #4 on his/her left arm. Findings include: The Facility Policy titled Resident Abuse, Mistreatment, and Neglect Policy and Procedure, revised (MONTH) (YEAR), indicated the facility will not permit residents to be subjected to abuse by anyone, including staff members. Resident #4 was admitted to the Facility in (MONTH) (YEAR) with a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #4 was moderately cognitively impaired and required assistance with eating. The Facility's Investigation, dated 5/22/18, at approximately 12:00 P.M., indicated CNA #9 and CNA #10 witnessed CNA #12 feeding Resident #4 lunch. CNA #9 and CNA #10 said Resident #4 became agitated and refused to eat. CNA #9 and CNA #10 said when CNA #12 continued to attempt to feed Resident #4, he/she hit CNA #12's arm. CNA #9 and CNA #10 said CNA #12 then hit Resident #4 back on his/her left arm and said that's what you get for being mean to me or words to that effect. The Surveyor interviewed CNA #12 at 12:13 P.M. on 6/29/18. CNA #12 said Resident #4 was refusing to eat his/her lunch, became agitated, and hit her on the arm. CNA #12 said she did not hit Resident #4 back but did say to him/her don't hit me, you're not my father, these old people don't like to eat when you try to feed them or words to that effect. The Surveyor interviewed CNA #9 at 1:35 P.M. on 6/28/18. CNA #9 said Resident #4 was mad and didn't want to eat lunch anymore. CNA #9 said CNA #12 tried to continue to feed him/her and he/she slapped CNA #12's arm. CNA #9 said CNA #12 slapped Resident #4 back on his/her left arm and said don't hit me, you're not my father or words to that effect. The Surveyor interviewed CNA #10 at 1:51 P.M. on 6/28/18. CNA #10 said Resident #4 was being resistive to CNA #12 feeding him/her. CNA #10 said Resident #4 slapped CNA #12's arm and CNA #12 slapped him/her back on his/her left arm and said that's what you get for being so mean or word to that effect. The Surveyor interviewed the Director of Nurses (DON) at 12:29 P.M. on 6/29/18. The DON said the Facility found that CNA #12's actions were abusive towards Resident #4.

Based on record review and staff interview, the facility staff failed to ensure a tooth abscess was treated, following a dental consult for 1 Resident (#9) out of a total of 25 sampled residents. Findings include: Resident #9 was admitted to the facility in 1/2013 and had [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set Assessment, dated 12/6/16 and the Quarterly MDS, dated [DATE], indicating moderate cognitive loss, scoring an 8 out 15 and 9 out of 15 on his/her Brief Interview of Mental Status, and required assistance in transfers and hygiene. The MDS indicated the Resident was responsible for self. Clinical record review indicated that the Resident had episodes of pain and swelling in the left side of his/her face since 11/2015. Review of the pain indicated that the physician was uncertain of the cause and documented in a progress note that it was either dental pain or an injury. The physician treated the pain Resident with an antibiotic. On 8/14/16, 8/15/16 and 8/16/16, the nurse's note indicated the Resident's left side of his/her face was swollen and painful. On 8/16/16, the physician examined the Resident and indicated in his progress note that it was either an injury or dental pain. His note indicated that staff should monitor. There were no subsequent notes about the area until 12/6/16, when the nurse's note indicated the Resident had pain, swelling and jaw and teeth pain. The physician ordered the Resident be seen by a dentist. On 12/7/16, the Resident was transported to the dentist office and the dentist diagnosed the Resident with a tooth abscess. The recommendations were to remove the tooth after treatment of [REDACTED]. On 12/8/16, the staff developed a written care plan for an infected tooth. The goal was to manage the pain, infections and to have the tooth removed. The medical record indicated that staff treated the Resident's abscess with antibiotics and pain medication for 12/8/16 through 12/29/16. Nursing notes and the Medication Administration Record [REDACTED]. On 12/29/16, the Resident was sent to the dentist for removal of the tooth, however, due to allergies [REDACTED]. The dental consult requested that the staff clarify with the physician what the Resident's allergic reaction was to these medications in order for the procedure to be done. Record review indicated that staff documented that the Resident complained of tooth pain and had swelling on 1/3/17, 1/5/17, 1/7/17, 1/8/17 and 1/10/17. The staff administered pain medication and applied ice packs to the swollen left of side of his/her face. On 1/14/17, more than 2 weeks after the request from the dentist for clarification, the nurse's note indicated that she spoke with the Resident about tooth pain and that the Resident was unsure of . left side tooth pain ? possible right lower molar. The note indicated that the Resident said . his/her teeth do not hurt at this time. The nurse indicated she spoke with the physician about the dentist's request for clarification. The note indicated that the physician deferred back to the dentist. The dental extraction was then deferred until the Resident had another complaint of a toothache in the future. The note made no mention that the physician was made aware of the Resident's complaint of right molar pain and/or if the Resident was agreeable in the decision to the delay dental treatment and no referral was made to the dentist following the new complaint of right molar pain. During interview on 4/10/17 at 10:00 A.M., Unit Manager (UM) #3 said the Facility had not obtain any further dental services or made arrangements for the Resident. She said that they (the facility) had never been sure of the cause of the pain. She said that they had thought at one point it was from a blocked gland, but did state that the dentist had confirmed on 12/7/16 that the pain and swelling was diagnosed as an abscess. UM #3 said she had not followed up with the dentist, because they were waiting for the Resident to have another episode of pain and swelling.

Based on observations, record reviews and interviews, the facility failed to: a.) ensure that effective interventions were initiated and put in place to provide adequate supervision/oversight to prevent falls with injury for 2 Residents (#4 and #2 ), b.) to provided adequate supervision to prevent Resident to Resident and Resident to Staff altercations and injuries of unknown origin; and failed to ensure appropriate safety measures were developed, monitored for effectiveness, and consistently implemented to maintain safety of the Resident and others at risk. (#5) c.) the facility failed to ensure that before installing 4 half side rails that the risk and benefits of 4 bed rails were reviewed with the Resident and/or Resident representative and an attempt to use appropriate alternatives were assessed for 1 Resident (#9) from a total sample of 25 Residents. Findings include: 1. For Resident #4, the facility failed to implement effective interventions to prevent 6 falls in a 6 month period (10/2016 through 3/2017), one of which resulted in an injury requiring sutures. Resident #4 was admitted to the facility in 9/2015 with [DIAGNOSES REDACTED]. Review of the facility fall policy, incident reporting policy, fall risk assessment and Fall Prevention Program indicates that a fall assessment and incident report are to be completed after each fall. *The fall risk assessments completed by the facility on the Resident indicated that the Resident consistently scored over 10 which indicated the Resident was a high risk for falls. The Investigation Report included, but not limited to: * Fall Occurrence (what happened) * Interdisciplinary review * Care Plan updated * Current preventative measures/interventions already in place * Recommendations *The CNAs who are providing care to the Resident, are responsible for the alarm checks, in regards to what type of alarm is in place, and to check placement and functioning of the alarms (7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.) The interventions of the bed/chair alarm was put into place 10/10/16 at which time it was added to the Resident's care plan. The Resident also had a physicians order for Bed and chair alarms for safety. Check placement and function (7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.). There were no indications that the intervention was in place at the time of the fall with injury on 2/15/17. No new interventions were identified or implemented. The Resident had the following falls; - The facility incident report, dated 10/5/16 at 1:35 P.M., indicated that the Resident was found lying on floor. The Resident stated that he/she hit the back of the head. At this time, the intervention for the Resident was to add alarms. The Residents care plan was updated with the intervention to place bed and chair alarms, and a physicians order was obtained. -The facility incident report, dated 12/21/16 at 7:00 P.M., indicated that it was a visitor in the facility that said a Resident had fallen in the other room (small dining room on the unit). Resident #4 stated he/she was transferring from the wheel chair to another chair in the room. Chair pad noted to be in place, but the alarm noted not to be sounding. The resident sustained [REDACTED]. No new interventions were identified and implemented. The facility incident report dated, 12/28/16 at 12:15 A.M.,indicated that a Certified Nursing Assistant (CNA) responded to the alarm sounding in the Residents room. Resident #4 was observed kneeling next to the bed, No injury. No new interventions were identified or implemented. -The facility incident report dated, 2/15/17 at 3:30 P.M., indicated that the Resident was found lying on the floor crying by a CNA who was in the next room providing care to another Resident and heard the Resident crying. 911 was called due to the Resident sustaining a head injury that was bleeding from an unknown area. The facility incident report did not indicate that an alarm (chair/bed) was sounding. At 8:00 P.M. the Resident returned to the facility with 4 sutures above right eyebrow, 8 steristrips to right forearm and 2 steri strips to left knee. Clinical record review indicated that there was not an alarm in place nor sounding at the time of the fall with injury on 2/15/17. -The facility incident report, dated 3/14/17 at 7:00 P.M., indicated that the Resident was found lying on right side in his/her room by a CNA walking by the Resident's room. Facility incident report indicated that although the alarms were in place, they were not sounding. At this time the Resident denied hitting his/her head but did complain of severe right hip pain. The Resident was sent to the emergency room at the local hospital. Upon return it was indicated that the X-Rays were negative, however the Resident did have a urinary tract infection and was begun on an antibiotic. No new interventions were identified or implemented. -The facility incident report, dated 3/27/17 at 5:30 A.M., indicated that the CNA responded to the Resident's alarm sounding and found the Resident sitting on the floor of his/her room vomiting into the wastebasket. No injury noted. No new interventions were identified or implemented. -The documentation by the CNAs for the checking of the alarms was consistently incomplete, with no indication of what type of alarm the CNAs were checking for functioning and numerous dates without initials that the alarms were checked (11/2017 through 3/2017). The above interventions were never comprehensively evaluated for their effectiveness, plan of care was not changed to ensure Resident safety and the Resident had continued falls, with one fall resulting in injury. On 4/6/17 at 12:05 P.M., the Director of Nurses (DON) said that the investigations failed to consistently indicate that all interventions were in place (chair/bed alarms) and the interventions never comprehensively evaluated for their effectiveness to prevent the Resident from falling resulting in injury. 2. For Resident #5, the facility failed to ensure they provided adequate supervision to prevent Resident to Resident altercations and injuries of unknown origin; and failed to ensure appropriate safety measures were developed, monitored for effectiveness, and consistently implemented to maintain safety of the Resident and others at risk. Resident #5 was admitted to the facility in 3/2016 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 10/6/16, indicated that Resident #5 had moderate impairment in decision making, had behaviors toward others, took antipsychotic medication and had an activated health care proxy. Review of the current physician's orders [REDACTED]. Further review of physician's orders [REDACTED].#5 did not take anticoagulant medication. Further review of the medical record and Resident Incident Reports indicated 8 Resident to Resident altercations (which included choking another Resident) between 10/18/16 to 1/7/17 (while under 1:1 supervision at all times), and 17 Resident to Employee altercations from 10/4/16 to 1/20/17 with no effective interventions implemented to prevent recurrence Further review of the medical record indicated that an interdisciplinary care plan for behaviors was not developed until 1/19/17 (more than 9 months after admission and after 22 documented incidents of assaultive behavior toward Residents and staff). The care plan for behaviors indicated that Resident #5 was verbally and physically abusive, had a short temper and was easily annoyed. Approaches identified on the care plan included: approach calmly, provide support and reassurance, keep Resident at a safe distance from other Residents and notify the physician, psychiatrist and social worker with concerns. There were no individualized interventions identified for when the Resident became physically assaultive to other Residents and staff. Review of CNA (certified nursing assistant) Flow Sheets from 9/2016 through 3/2017 indicated the following: 9/2016: behaviors (including physical abuse and spitting) were identified on 32 occasions over 30 days documented; interventions (including 1:1 attention, diversion, redirection) were documented as ineffective on 22 occasions. 10/2016: behaviors were identified on 17 occasions over 19 days documented; interventions were documented as ineffective on 11 or 17 occasions. 11/2016: behaviors were identified on 14 occasions over 11 days documented; interventions were documented as ineffective on 10 of 14 occasions. 12/2016: behaviors were identified on 29 occasions over 31 days documented; interventions were documented as ineffective on 28 of 29 occasions. 1/2017: behaviors were identified on 40 occasions over 31 days documented; interventions were documented as ineffective on 25 of 40 occasions. 2/2017: behaviors were identified on 25 occasions over 28 days documented; interventions were documented as ineffective on 25 of 25 occasions. 3/2017: behaviors were identified on 35 occasions over 31 days documented; interventions were documented as ineffective on 17 occasions. During interview with CNA #1 on 4/6/17 at 8:30 A.M. and 4/20/17 at 8:50 A.M., she said that she had not been educated on techniques of how to de-escalate or intervene with Resident #5 when he/she becomes physically abusive to other Residents or staff. The Surveyor asked CNA #1 what she would do if the Resident became abusive to another Resident or staff. She said she would yell for help. During interview with the Director of Nursing (DON) on 4/6/17 at 12:00 P.M., she said that no new interventions had been implemented after each incident of physical assault toward other Residents and staff to prevent recurrence. Resident #5's physician was interviewed on 4/7/17 at 10:00 A.M. He said that he defers to the psychiatric consultant regarding any interventions to address Resident #5's behaviors. During interview with the Director of Social Services on 4/10/17 at 11:10 A.M., she said that she does not participate in the education of staff regarding behavioral interventions to address Resident #5's physically abusive behavior. The facility's psychiatric consultant was interviewed on 4/20/17 at 10:35 A.M. The psychiatrist said that she meets with the Resident on a quarterly basis, conducts a review of the Resident's psychotropic medication, and makes recommendations for medication changes to the Resident's physician as needed. She indicated that it is not within her scope of practice to develop a behavior plan or educate staff about behavioral strategies to manage Resident #5's behaviors. She said multiple times during the interview that she defers to the Resident's attending physician for everything except for psychotropic medication review. During interview with CNA #2 on 4/20/17 at 2:00 P.M., she said that she works with Resident #5 as a 1:1 on a regular basis. She said that she has not been trained by the facility on specific strategies to use when the Resident becomes agitated or physically abusive. During interview on 4/20/17 at approximately 3:00 P.M., the Administrator said that the facility does not have a resource available to identify and educate staff about individualized strategies for staff to utilize in the management of Resident #5's physically abusive behaviors. 3. For Resident #2, the facility failed to implement effective interventions to prevent 7 falls in a 6 month period (5/2016 through 12/2016), one of which resulted in fractured hip. Resident #2 was admitted to the facility in 6/2015 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) with a reference date of 1/31/17, indicated that Resident #2 was alert and oriented and capable of making his/her decisions. The MDS indicated the Resident required assistance in his/her activities of daily living, did not ambulate and had falls with injury in the past. Review of the facility policies related to falls, incident reporting, fall risks, Fall Prevention Program indicates that a fall assessment and incident report are to be completed. The Fall Prevention Program indicates the following: Policy statement -To prevent falls and injuries related to falls Fall Risk assessment -To be completed on admission, quarterly, annually, with any significant change of status and after a fall. The Investigation Report included, but not limited to: * Fall Occurrence (what happened) * Interdisciplinary review * Care Plan updated * Current preventative measures/interventions already in place * Recommendations *The CNAs are responsible for the alarm checks, in regards to what type of alarm is in place, and to check placement and functioning of the alarms (7:00 A.M.-3:00 P.M., 3:00 P.M.-11:00 P.M. and 11:00 P.M.-7:00 A.M.). Resident #2 had the following falls; - On 5/30/16 at 3:20 P.M., the Resident was found lying on his/her left side on floor. Resident stated that he/she was trying to pick something up. At this time, the intervention for the Resident was check on the Resident every 15 minutes and remind the Resident to ask for help should he/she drop something. - On 6/3/16 at 7:30 P.M, the staff was answering Resident #2's call bell and was found sitting on the floor. The Resident said he/she was reaching for something on a shelf and when he/she went to sit back down, the brakes of the wheelchair went out from under him/her. The intervention that were in place was transfer with assist according the the report, and the new interventions were to remind the Resident to call for assistance and to have maintenance check the Resident's wheelchair brakes. - On 6/26/16 at 4:50 A.M., the staff heard someone calling for help and Resident #2 was found sitting on the floor in front of the commode. The preventative measures that had been in place include call bell in place, hourly rounds, low bed and toilet every 2 hours. The review indicated that the Resident was alert and oriented and able to make voice needs . is assist with toileting, however is noncompliant at times with call light. - On 7/1/16 at 11:30 P.M., the Certified Nursing Assistant (CNA) responded to the call light and found the Resident on the floor. The Resident stated he/she was dreaming. No new interventions were identified or implemented. - On 7/15/16 at 4:0 A.M. the Resident was found lying on the floor. The Resident stated he/she was trying to transfer to commode and slipped on floor mattress. There were no changes to the plan of care. - On 9/27/16 at 1:30 A.M. the CNA was answering the call light and found the Resident had fallen off the commode. The Resident had several abrasions to his/her lower and mid back. No new interventions were implemented. - On 10/21/16 at 9;00 P.M, the staff found Resident #2 on his/her left side on the floor. The resident sustained [REDACTED]. The Resident was transferred to the hospital for treatment and care. The Facility investigation indicated the Resident was on the commode and attempted to self transfer while reaching for his/her walker. The interventions following his/her readmission included re-education regarding call light use and importance of safety. In addition, he/she has proper foot wear and his/her room was safe from environmental hazards. Further review, indicated the facility never comprehensively evaluated the Resident and subsequently failed to develop and implement effective interventions until 11/23/16, a month after a fall with significant injury and 6 months after the Resident's fall on 5/30/16. During interview on 4/10/17 at 11:00 A.M., Resident #2 said that he/she tried to do his/her best. The Resident said that staff are helpful, but often has to wait for help. The Resident said that he/she has tried to maintain safety but that sometimes the waits are too long. 4. For Resident #9, the facility failed to ensure that before installing 4 half side rails that the risk and benefits of 4 bed rails were reviewed with the Resident and/or Resident representative and an attempt to use appropriate alternatives were assessed. Resident #9 was admitted to the facility in 1/2013 and had [DIAGNOSES REDACTED]. During the initial tour of the Facility on 4/4/17 at 8:00 A.M., Resident #9 was observed in bed with 4 half side rails up. During the tour Unit Manager #3 said that there were no residents on the unit with a restraint device. During record review there was no assessments for side rails. Review of the Annual Minimum Data Set Assessment, dated 12/6/16 and the Quarterly MDS, dated [DATE] the Resident scored an 8 out 15 and 9 out of 15 on his/her Brief Interview of Mental Status indicating moderate cognitive impairment and required assistance in transfers and was nonambulatory. Neither MDS indicated that side rails were used for this Resident. On 4/11/17 at 6:20 A.M. and 9:00 A.M., Resident #9 was observed with 4 half side rails up while he/she was in bed. During the 9:00 A.M. observation a Certified Nursing Assistant (CNA) was feeding the Resident. The Surveyor asked the CNA about the siderails. The CNA said the Resident had tried to get out of bed, so they were up to keep him/her from getting out of the bed. The Resident joined the conversation and said that staff did not want him/her to get up out bed and that was why they were up. During interview on 4/11/17 at 10:00 A.M., Unit Manager #3 said that the 4 half side rails had not been fully assessed.

Based on record review, staff and consultant interviews, the facility failed to ensure that 1 Resident (#5), from of a total sample of 25 Residents, received treatment and services to attain the highest mental and psychosocial well-being to prevent ongoing physically abusive behaviors and avoid mental deterioration. Findings include: Review of the contract agreement between the facility and the psychiatric consultant service initiated 12/19/88, indicated the primary functions of the consultant included: -review of patients' status regarding the need for mental health services with nursing, social services, medical and other personnel of the facility -meet with professional personnel of the facility to assist in treatment planning and behavioral management -request psychological and/or neuropsychological screening and/or studies of patients in order to assist in [DIAGNOSES REDACTED].>-liaison with hospital staff regarding admissions and discharge planning when hospitalization s occur under the auspices of the consultant psychiatric service Resident #5 was admitted to the facility in 3/2016 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) with a reference date of 10/6/16, indicated that Resident #5 had unclear speech, is sometimes understood and sometimes understands what is said to him/her, had moderate impairment in decision making, exhibited behaviors toward others, took antipsychotic medication and had an activated health care proxy. Review of the medical record indicated that Resident #5 had a history of [REDACTED]. Review of the physician's admission orders [REDACTED]. Review of the psychiatric consultant's notes indicated that a psychiatric evaluation was conducted on 4/2/16 which included a review of the Resident's medical and psychosocial history. No recommendations were made by the psychiatrist. There was no behavioral plan developed by the psychiatric consultant to meet the Resident's psychosocial needs. Review of 4/2016 physician's orders [REDACTED]. On 4/30/16, the psychiatrist saw Resident #5 for a follow-up evaluation of behaviors such as resistance to care, agitation, and manic behaviors. The note indicated that the Resident was started on 1:1 supervision by the facility due to wandering and aggressive behaviors. The clinician made a recommendation to change dosages of several [MEDICAL CONDITION] medications. There was no behavioral plan developed by the psychiatric consultant to meet the Resident's psychosocial needs identified in the psychiatrist's note. On 5/13/16, the psychiatrist saw Resident #5 for a follow-up evaluation of intermittent agitation, difficulty of staff to redirect the Resident, and aggressive behaviors with attempts to hit staff. The clinician noted that the Resident continued on 1:1 supervision for wandering and aggressive behaviors. The clinician recommended an increase in an antianxiety medication and the implementation of an antidepressant. There was no behavioral plan developed by the psychiatric consultant to meet the Resident's psychosocial needs identified in the psychiatrist's note. On 8/7/16, the psychiatrist saw Resident #5 for a follow-up to evaluate increased sedation and decreased oral intake resulting in weight loss. Medication changes were recommended. The clinician noted that the Resident continued to have 1:1 supervision for behaviors. There was no behavioral plan developed by the psychiatric consultant to meet the Resident's psychosocial needs identified in the psychiatrist's note. On 2/18/17, the psychiatrist saw Resident #5 for a follow-up visit after the Resident had been sent out to the hospital for psychiatric evaluation on 3 occasions (10/19/16, 11/3/16, and 11/10/16) over the previous 4 months due to aggression and assaultive behaviors. Review of the medical record failed to indicate that that the psychiatric consultant was notified of, and acted as a liaison with the hospital staff regarding admission and discharge planning when hospitalized for [REDACTED]. The clinician noted that the Resident continued to have 1:1 supervision for behaviors. There was no behavioral plan developed by the psychiatric consultant to meet the Resident's psychosocial needs identified in the psychiatrist's note. Further review of the medical record and Resident Incident Reports indicated 17 Resident to Employee altercations from 10/4/16 to 1/20/17, and 8 Resident to Resident altercations between 10/18/16 to 1/7/17 (while under 1:1 supervision at all times) which included: Review of social services notes indicated that since admission, Resident #5 was easily angered, combative with caregivers, and had unpredictable and unsafe behaviors. The Resident was unable to engage in conversation, unable to make needs known and had no insight or awareness of boundaries. The social worker noted three hospitalization s for psychiatric evaluation. However, there was no evidence of an interdisciplinary approach to address the Resident's behavioral needs. Review of CNA (certified nursing assistant) Flow Sheets from September 2016 through March 2017 indicated repetitive behaviors of physical and verbal abuse with interventions including 1:1 attention, diversion, and re-direction which were ineffective as follows: 9/2016: behaviors such as physical abuse, verbal abuse and spitting were identified on 32 occasions over 30 days documented; interventions (including 1:1 attention, diversion, redirection) were documented as ineffective on 22 occasions. 10/2016: behaviors such as physical abuse, verbal abuse and spitting were identified on 17 occasions exhibited by the Resident over 19 days documented; interventions were documented as ineffective on 11 or 17 occasions. 11/2016: behaviors such as physical abuse and verbal abuse were identified on 14 occasions exhibited by the Resident over 11 days documented; interventions were documented as ineffective on 10 of 14 occasions. 12/2016: behaviors such as physical abuse and verbal abuse were identified on 29 occasions exhibited by the Resident over 31 days documented; interventions were documented as ineffective on 28 of 29 occasions. 1/2017: behaviors such as physical abuse and verbal abuse were identified on 40 occasions exhibited by the Resident over 31 days documented; interventions were documented as ineffective on 25 of 40 occasions. 2/2017: behaviors such as physical abuse and verbal abuse were identified on 25 occasions exhibited by the Resident over 28 days documented; interventions were documented as ineffective on 25 of 25 occasions. 3/2017: behaviors such as physical abuse, verbal abuse and spitting were identified on 35 occasions exhibited by the Resident over 31 days documented; interventions were documented as ineffective on 17 occasions. Further review of the medical record indicated that an interdisciplinary care plan for behaviors was not developed until 1/19/17 (more than 9 months after admission and after 22 documented incidents of assaultive behavior toward Residents and staff). Resident #5's physician was interviewed on 4/4/17 at 10:00 A.M. He was unable to identify specific behaviors the Resident has, but that he/she becomes agitated at times. He went on to say that he defers to the facility's psychiatric consultant for the development of a behavioral treatment plan, although he could not say what the treatment plan entails. The facility's psychiatric consultant was interviewed on 4/20/17 at 10:35 A.M. The psychiatrist said that she meets with the Resident on a quarterly basis, conducts a review of the Resident's [MEDICAL CONDITION] medication, and makes recommendations for medication changes to the Resident's physician as needed. She indicated that it is not within her scope of practice to assess the Resident's behavioral needs, develop a behavior plan or educate staff about behavioral strategies to manage Resident #5's behaviors. She said multiple times during the interview that she defers to the Resident's attending physician for everything except for [MEDICAL CONDITION] medication review. During interview on 4/20/17 at approximately 3:00 P.M., the Administrator said that the facility does not have a resource available to identify and educate staff about individualized strategies for staff to utilize in the management of Resident #5's physically abusive behaviors.

Based on record review and interviews, for one of three sampled residents, (Resident #1), the Facility failed to ensure that Resident #1's safety alarm sounded as he/she required a safety alarm at all times per the plan of care. The Director of Nurses (DON) said Resident #1 had a history (13 months) of disconnecting safety alarms, and on 10/11/13 Resident #1 got out of bed, his/her bed alarm failed to sound because he/she disconnected the safety alarm, he/she fell and sustained an impacted fracture of the right humerus and a minimally displaced fracture of the right hip. Findings include: The Face Sheet indicated that Resident #1 was admitted to the Facility October of 2011, and [DIAGNOSES REDACTED]. The Surveyor interviewed the Director of Nurses (DON) at 6:45 A.M. and 1:15 P.M. on 11/4/13. The DON said Resident #1 was at high risk for falls and between admission and 12/30/12, Resident #1 had five falls at the Facility. The DON said Resident #1 had no falls during 2013. The DON said she reviewed all falls and had not recalled that Resident #1 had a long past history of disconnecting his/her bed alarm The Surveyor interviewed Nursing Supervisor #1 at 12:15 PM on 11/4/13. The Surveyor interviewed Nursing Supervisor #2 at 8:15 AM on 11/5/13. The Surveyor interviewed Nursing Supervisor #3 at 12:10 PM on 11/6/13. Nursing Supervisor #1, Nursing Supervisor #2, and Nursing Supervisor #3 said the nurse assigned to Resident #1's unit was also the night shift working supervisor. Nursing Supervisor #1, Nursing Supervisor #2, and Nursing Supervisor #3 said they were routinely assigned to Resident #1's unit during the night shift (11:00 P.M. on 10/11/12 to 7:00 A.M. on 10/12/12). Nursing Supervisor #1, Nursing Supervisor #2, and Nursing Supervisor #3 said Resident #1 had a history of [REDACTED]. The Surveyor interviewed Nurse #1 at 3:20 P.M. on 11/4/13. Nurse #1 said she was assigned to Resident #1's unit during the day shift. The Surveyor interviewed Nurse #2 at 4:00 P.M. on 11/4/13. Nurse #2 said she was assigned to Resident #1's unit during the day shift and during the evening shift. Nurse #1 and Nurse #2 said they knew about Resident #1's history of disconnecting the bed and chair safety alarms, and the concern was reported to Unit Manager #1. The Surveyor interviewed Unit Manager #1 at 8:00 A.M and at 11:00 A.M. on 11/4/13. Unit Manager #1 said she was aware that Resident #1 had disconnected his/her safety alarms. The nurse's note, dated 7/28/12, 8/1/12, 10/12/12, 5/12/13, 7/20/13, 7/25/13, 7/30/13, 8/6/13, 9/2/13, 9/5/13, and 9/15/13 indicated that Resident #1's safety alarm was found disconnected. The night shift (11:00 P.M. on 7/27/12 to 7:00 A.M. on 7/28/12) nurse's note, indicated that Resident #1 had learned how to disconnect his/her bed safety alarm even when the alarm box was hidden under the bed. The night shift nurse's note indicated that Resident #1 was found coming out of his/her bathroom unassisted after he/she had disconnected the bed safety alarm. The night shift (11:00 P.M. on 7/31/12 to 7:00 A.M. on 8/1/12) nurse's note, indicated staff responded to Resident #1's bed safety alarm that sounded briefly. The night shift nurse's note indicated that Resident #1's bed safety alarm box was found turned off and disconnected. The night shift (11:00 P.M. on 10/11/12 to 7:00 A.M. on 10/12/12) nurse's note, indicated that staff responded to Resident #1's bed safety alarm that sounded briefly. The night shift nurse's note indicated that Resident #1's bed safety alarm box was found turned off and he/she was attempting to get out of bed to turn the television on. The night shift nurse's note indicated that there was a concern that Resident #1 was able to shut the bed safety alarm off. Nursing Supervisor #2 said the nurse assigned to Resident #1's unit was also the night shift working supervisor. Nursing Supervisor #2 said she was occasionally assigned to Resident #1's nursing care needs during the night shift (11:00 P.M. on 10/11/12 to 7:00 A.M. on 10/12/12). Nursing Supervisor #2 said when she was assigned as Nursing Supervisor during the night shift she routinely gave a verbal report for the entire Facility to the DON before leaving duty. Nursing Supervisor #2 said she recalled that during shift report to the DON on 10/12/12 she expressed a concern that Resident #1 was able to shut off the bed safety alarm. The night shift (11:00 P.M. on 5/11/13 to 7:00 A.M. on 5/12/13) nurse's note, indicated that Resident #1 had self transferred out of bed to his/her wheelchair after disconnecting his/her safety alarm. The night shift (11:00 P.M. on 7/19/13 to 7:00 A.M. on 7/20/13) nurse's note, indicated that Resident #1 ambulated to the nurses' station to request a drink after disconnecting his/her safety alarm. The night shift (11:00 P.M. on 7/24/13 to 7:00 A.M. on 7/25/13) nurse's note, indicated that Resident #1 was found several times wandering around in his/her bedroom after he/she had disconnected the bed safety alarm. The day shift nurse's note, dated 7/30/13, indicated that Resident #1 was found ambulating out of his/her bedroom while using his/her rolling walker after he/she had shut the safety alarm off. The night shift (11:00 P.M. on 8/6/13 to 7:00 A.M. on 8/7/13) nurse's note, indicated that Resident #1 ambulated with his/her rolling walker to the nurses' station for a snack after he/she had shut the bed safety alarm off. The day shift nurse's note, dated 9/2/13, indicated that Resident #1 was found ambulating in the hallway in an attempt to enter the elevator after he/she had shut off the safety alarm and was successfully re-directed. The night shift (11:00 P.M. on 9/4/13 to 7:00 A.M. on 9/5/13) nurse's note, indicated that Resident #1 kept shutting off the safety alarm during attempts to self transfer. The Minimum Date Set Assessment nurses' note, dated 9/5/13, indicated that Resident #1's behaviors included many attempts to go outside after shutting off his/her safety alarms. The MDS note indicated that Resident #1 was taken outside by staff and attended activities, but continued to attempt to go outside after shutting off safety alarms. The day shift nurse's note, dated 9/15/13, indicated that Resident #1 was found ambulating in the hallway in an attempt to enter the elevator after he/she had disconnected the safety alarm box and hid the safety alarm box, which was replaced. The care plan, updated 10/9/13, indicated that Resident #1 required: safety alarms at all times, a wanderguard alarm due to a history of exit seeking behavior, a bedside safety mat, a low bed, a clutter free room, and assistance with toileting and incontinence care as needed The certified nurse aide (CNA) flow sheet, dated 10/1/13 to 10/10/13, indicated that Resident #1 required physical assistance during transfers, was toileted every two hours, and required continual supervision/cueing while out of bed in his/her wheelchair. The Surveyor interviewed Unit Manager #1 at 8:00 A.M and at 11:00 A.M. on 11/4/13. Unit Manager #1 said Resident #1's plan of care for falls included safety alarms at all times and once awake he/she required continual supervision/cueing while out of bed in his or her wheelchair or assistance with ambulation. The DON said Resident #1's usual routine included visual supervision while awake, he/she was observed by staff as he/she was seated in a wheelchair in the dayroom or was physically assisted when he/she ambulated on the unit with a rolling walker. The Surveyor interviewed Certified Nurse Assistant (CNA) #1 in person at 6:50 A.M. on 11/4/13. CNA #1 said she was assigned to Resident #1's nursing care needs during the night shift (11:00 P.M. on 10/11/13 to 7:00 A.M. on 10/12/13). CNA #1 said Resident #1 was offered toileting during 11:00 P.M. shift rounds on 10/11/13. Nursing Supervisor #1 said she was assigned to Resident #1's nursing care needs during the night shift (11:00 P.M. on 10/11/13 to 7:00 A.M. on 10/12/13). Nursing Supervisor #1 said Resident #1 was left resting comfortably in bed with his/her bed safety alarm on and functioning during shift rounds. CNA #1 said she routinely placed the alarm box beneath the bed because Resident #1 routinely disconnected the bed alarm. CNA #1 said Resident #1 was able to pull the alarm cord, raise the alarm box up off the floor, and disconnect the alarm box. CNA #1 said she routinely made the night shift Nursing Supervisors aware of the problem. Nursing Supervisor #1 said she was aware that Resident #1 was able to disconnect the bed safety alarm and made the day shift nurses aware of the concern during shift report. Nursing Supervisor #1 said on 10/11/13 Resident #1 was sleeping in bed with the bed safety alarm that did not sound because he/she disconnected the alarm when he/she got out of bed without assistance. Nursing Supervisor #1 said Resident #1fell in his/her bedroom. The night shift (11:00 P.M. on 10/11/13 to 7:00 A.M. on 10/12/12) nurse's note, indicated that Nursing Supervisor #1 heard Resident #1 yell for assistance from his/her bedroom, and Resident #1 was observed on his/her bedroom floor. The nurse's note indicated that Resident #1 was assessed, he/she was complaining he/she was unable to move his/her right arm and unable to move his her right leg. The nurse's note indicated that the covering Physician was notified and Resident #1 was transferred to the Hospital, per physician's orders [REDACTED]. The DON said on 10/11/13 Resident #1 was sleeping in bed with the bed alarm that did not sound because he/she disconnected the larm when he/she got out of bed without assistance. The DON said Resident #1 fell in his/her bedroom. The DON said she reviewed all falls and was not aware that Resident #1 had a long past history of disconnecting his/her bed alarm because his/her previous 5 falls were not the result of his/her disconnecting the alarm. The DON said Resident #1 was transferred to the Hospital where it was determined he/she sustained an impacted fracture of the right humerus and a minimally displaced fracture of the right hip. The Hospital History and Physical, dated 10/12/13, indicated that Resident #1 fell at the Facility and recommendations included a hospital admission, xrays, and an orthopedic consult. The orthopedic consult, dated 10/12/13, indicated Resident #1 fell at the Facility and x-rays were reviewed and indicated Resident #1 sustained a right impacted proximal humerus fracture and a minimally displaced fracture of the right hip. The orthopedic consult included recommendations to discharge Resident #1 back to the Facility for rehabilitation. The Surveyor interviewed Physician #1 at 12:20 P.M. on 11/5/13. Physician #1 said Resident #1 sustained a fractured right humerus and a minimally displaced fracture of the right hip that required hospitalization and orthopedic consult.