Every finding on record at Majestic Oaks

Based on record review, staff interviews and facility policy review, the facility failed to maintain complete and accurately documented medical records in accordance with accepted professional standards of practice for three (Residents #329, #330, and #332) of 31 sampled residents, by failing to include medical diagnoses to the resident electronic medical record. The findings include: 1. A medical record review of Resident #329 revealed he was admitted on [DATE], with diagnoses including muscle weakness, difficulty walking, and other signs & symptoms involving skeletal system. A review of Resident #329's Agency for Healthcare Administration Form 5000-3008 revealed his medical diagnoses included atrial fibrillation, gastroesophageal reflux disease, cardio myopathy, alcohol cirrhosis, peripheral artery disease, coronary artery disease, hypertension, and asthma. A review of Resident #329's admission/Medicare minimum data set (MDS) assessment noted it was in progress showing a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. 2. A medical record review of Resident #330 revealed she was admitted on [DATE], with no diagnoses listed on the medical diagnosis page. A review of Resident #330's MDS assessment noted it was in progress with a BIMS score of 12, indicating the resident was cognitively intact. 3. A medical record review of Resident #332 revealed he was admitted on [DATE], with diagnoses including muscle weakness (generalized), difficulty in walking, not elsewhere classified, and other lack of coordination. A review of Resident #332's Agency for Healthcare Administration Form 5000-3008 revealed his medical diagnoses included severe anemia, diabetes mellitus, atrial fibrillation, chronic kidney disease, and pressure ulcer. A review of Resident #332's admission/Medicare 5-day MDS assessment noted it was in progress with no BIMS score indicated. On 12/11/24 at 10:07 AM, an interview was conducted with the MDS Coordinator/Registered Nurse (RN). She confirmed she was responsible for updating resident diagnoses in the electric medical record. She said, The DON will sometime add resident's initial and quarterly updates. When asked, how soon medical diagnoses were added to the electronic medical record. She replied, Within 24 hours of a resident's admission to the facility. The RN/MDS Coordinator confirmed that resident diagnoses needed to be added to the electronic medical record. On 12/11/24 at 10:14 AM, the MDS Coordinator/RN confirmed that only the therapy diagnoses had been added for Residents #332 and #329, and that Resident #330 had no diagnoses and stated the medical diagnoses would be added. She said, I was going back and forth between the pressure ulcer and the fracture. I hadn't had a chance to go back to update the electronic medical record. Diagnoses are pulled from the 3008 form, history and physical, physician progress notes, wound care notes, psych notes, and Dietitian notes. I try my best to add diagnoses within 24 hours of admission. Review of the facility's policy titled: Health Records Policies, date approved: 11/15/2018, read: II. Procedure: .5. The health records shall be maintained according to commonly-accepted standards. (Copy obtained)

Based on record review and staff and resident interviews, the facility failed to ensure adequate supervision to prevent a fall with fracture for one (Resident #1) of three residents sampled for falls. The findings include: A record review for Resident #1 revealed a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. She was alert and oriented, and required extensive assistance with activities of daily living. She required maximum assistance with transfers via the use of a mechanical lift and 2-person assistance. A review of the record revealed that on 9/25/20 at approximately 8:30 pm, Licensed Practical Nurse (LPN) B was informed by a Certified Nursing Assistant (CNA) that Resident #1 was on the floor. The LPN documented she was notified that Resident #1 was placed on the floor due to her knees buckling while transferring her in the sit-to-stand lift. The CNAs reported that the lift was tipping and the resident was unstable, so they lowered her to the floor and put blankets under her. The nurse observed Resident #1 sitting on blankets on the floor about five feet from the bed. Resident #1 was upset and crying about not being able to hold herself up, and said her right knee and ankle were hurting. The nurse examined Resident #1 and found no issue with range of motion to her right hip or knee, and no swelling or bruising. She did sustain a skin tear to her right arm and a dressing was placed. The daughter was notified of the incident. The note did not indicate that the physician was notified. Resident #1 was administered Tylenol, two tabs for pain. On 9/26/20 at 2:30 pm, the physician was notified that Tylenol was not effective for pain and a new order was given for [MEDICATION NAME] 600 mg (milligrams) every six hours as needed. On 9/26 at 11:05 pm, the resident's daughter called asking the nurse to give her mother something for pain, as her mother reported to her she had excruciating pain. The daughter wanted to know why x-rays were not taken and insisted the facility obtain x-rays of the resident's knees and ankles. The nurse administered [MEDICATION NAME] 600 mg for pain. Resident #1 reported pain at a level of 9 on a scale of 0 - 10, with zero representing no pain and 10 representing the worst possible pain. The physician was called and ordered x-rays. On 9/27/20, an x-ray showed the left ankle with an old and a new fracture. The old [MEDICAL CONDITION] fibula, treated with screws and cerclage wire, showed that moderate osteoarthritic changes were seen, probably related to post-traumatic arthropathy, a mildly displaced comminuted fracture involving the distal tibia metaphysis, soft tissue swelling, joint effusion and vascular calcification. The Advanced Registered Nurse Practitioner (ARNP) was notified, and said she preferred to treat pain at the facility and to make an immediate appointment with the orthopedic surgeon. A new order was given for [MEDICATION NAME] (narcotic pain medication) 5/325 mg every six hours. The family was notified and agreed to the plan and would accompany her to the appointment. An interview was conducted with the Director of Nursing (DON) on 11/23/20 at 12:45 pm. She was asked about the incident regarding Resident #1 on 9/25/20. She said that upon her investigation of the incident, the care plan showed that at the time of the incident, Resident #1 was a 2-person transfer using a sit-to-stand lift. Based on documentation and her staff interviews, it was determined that the CNA did not follow the care plan when transferring the resident in the bathroom. She said due to the resident's history of [MEDICAL CONDITION], along with a previous injury to same area, the facility was unable to determine whether the unassisted transfer contributed to the fracture, or whether it occurred during the sit-to-stand lift, or if a spontaneous fracture occurred that caused her knees to buckle. When asked what measures were taken after the fall, the DON said the CNA was provided with progressive discipline as it related to using the care plan. Additional education was provided to nurses to review accident and incident polices related to physician notification. A new process was implemented to include a paper copy of the care plan for each assignment that was centrally located, so that it would be a quick reference without having to get into the computer. An interview was conducted with Resident #1 on 11/23/20 at 10:15 am. She was observed sitting in a wheelchair in her room. She had a cast on her left lower leg. She was asked how she injured her leg. She said it happened in her bathroom a few weeks ago. She said she was being assisted by the certified nursing assistant (CNA) to go to the bathroom. When she stood up from the wheelchair, she became weak, her knees buckled and she went down on the floor. She was assisted back into the wheelchair and was taken out of the bathroom. Once out of the bathroom, the CNA went to get someone to help her get the resident into bed using the Sara lift (sit-to-stand lift). While in the sit-to-stand lift, her knees buckled again, leaving her hanging by her arms from the lift. The CNAs lowered her to the floor and went to get the nurse. She said she had pain to her right knee and both ankles. When the nurse came in, she and the CNAs used a Hoyer lift to get the resident off the floor and into bed. She was asked how many staff usually assisted her with transfers, and she said she always requested two CNAs because she would get weak. An interview was conducted with CNA C on 11/23/20 at 3:10 pm. She was asked if she was assigned to Resident #1 when she fell on [DATE]. She confirmed that she was. She said she had taken Resident #1, who was in a wheelchair, into the bathroom. She put a gait belt on her, stood her up, and she was holding onto the grab bar. When I attempted to move her to place her on the toilet, her knees buckled and she went down on her knees. The CNA was able to get her into the wheelchair. I took her out of the bathroom and had another CNA assist with the sit-to-stand lift to get her into bed. Again, her knees buckled, and she was hanging onto the lift. They put pillows on the floor and lowered her down to the floor. She said the other CNA went to get the nurse. She said the nurse and three CNAs put the resident into a Hoyer lift to get her off the floor and into bed. She was asked how the CNAs were informed of how much assistance a resident required, and she said the resident's needs were documented in the care plan. She said the evening of the incident was her first day working. She said the care plans were now printed and were available at the nursing station for easier access, instead of having to look them up in the computer, as was the case on the date of the incident. An interview was conducted with Licensed Practical Nurse (LPN) B on 11/23/20 at 3:30 pm. She was asked if she was assigned to Resident #1 at the time of the incident on 9/25/20. She confirmed that she was. She was asked what happened. She said she had not witnessed the event when the CNA came to get her and told her what happened. When she entered the room, Resident #1 was on the floor with her legs out and a CNA sitting behind her keeping her upright. She was asked how they moved her off the floor, and she said they used a Hoyer lift. There was herself and two CNAs. They put a sling under the resident and hooked her up to the lift and placed her in bed. The resident was upset and breathing heavily. She said her knees and ankles hurt. LPN B evaluated her and did not observe any injuries, bruising or swelling outside of normal ankle swelling. I gave her Tylenol for pain. LPN B notified the doctor and the resident's daughter. The daughter did not want her transferred to a hospital at the time. Resident #1 had an order for [REDACTED]. She was asked if she had documented that she notified the physician after the fall as well as her conversation with the daughter regarding not sending the resident to the hospital, and she replied that she did not but she should have. She also said that she came to find out that the CNAs had not told her everything that had happened prior to her being on the floor. She was not told that there had been an incident in the bathroom where she went down on her knees and she was put back in her wheelchair. She discovered that after the incident.

Based on record review and staff and resident interviews, the facility failed to follow the care plan developed to prevent falls, resulting in a fall for one (Resident #1) of three residents sampled for a review of falls. The findings include: A record review for Resident #1 revealed a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. She was alert and oriented, and required extensive assistance with activities of daily living (ADLs). She required maximum assistance with transfers via the use of a mechanical lift and 2-person assistance. A review of the care plan in place at the time of the fall on 9/25/20, revealed that Resident #1 was at risk for falls related to impaired balance. She required transfers with 2-person assistance and the use of a sit-to-stand mechanical lift. An interview was conducted with Resident #1 on 11/23/20 at 10:15 am. She was observed sitting in a wheelchair in her room. She had a cast on her left lower leg. She was asked how she injured her leg and she replied that it happened in her bathroom a few weeks ago. She said she was being assisted by the certified nursing assistant (CNA) to go to the bathroom. When she stood up from the wheelchair, she became weak, her knees buckled, and she went down on the floor. She was assisted back into wheelchair and taken out of the bathrooom. Once out of the bathroom, the CNA went to get someone to help her get into bed using the Sara lift (sit-to-stand lift). While in the sit-to-stand lift, her knees buckled again, leaving her hanging by her arms from the lift. The CNAs lowered her to the floor and went to get the nurse. Resident #1 said she had pain to her right knee and both ankles. When the nurse came in, she and the CNAs used a Hoyer lift to get Resident #1 off the floor and into bed. She was asked how many staff usually assisted her with transfers, and she replied that she always requested two CNAs because she would get weak. An interview was conducted with CNA C on 11/23/20 at 3:10 pm. She was asked if she was assigned to Resident #1 when she fell on [DATE]. CNA C confirmed that she was. She said she had taken Resident #1, who was in a wheelchair, into the bathroom. She put a gait belt on her, stood her up and the resident was holding onto the grab bar. When I attempted to move her to place her on the toilet, her knees buckled and she went down on her knees. CNA C was able to get Resident #1 into the wheelchair. I took her out of the bathroom and had another CNA assist with the sit-to-stand lift to get her into bed. Again, her knees buckled, and she was hanging onto the lift. CNA C stated they put pillows on the floor and lowered her down to the floor. The other CNA went to get the nurse. She said the nurse and three CNAs put the resident into a Hoyer lift to get her off the floor and into bed. She was asked how the CNAs were informed of how much assistance a resident required, and she said the care plan explained how much assistance the resident deeded. She said the evening of the incident was her first day working. She said the care plans are now printed and available at the nursing station for easier access, instead of having to look them up in computer as she would have had to have done on the day of the incident.

Based on record review, observation and staff interview, the facility failed to provide treatment and services, consistent with professional standards of practice, to promote healing of current pressure ulcers, by failing to ensure all pressure ulcers were assessed and documented upon admission for one (Resident #188) of two sampled residents with pressure ulcers from a total sample of 33 residents. The findings include: A record review for Resident #188 revealed a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. She was alert and oriented and required assistance with activities of daily living except for eating, for which she was independent. She was incontinent of bowel and bladder on admission. A review of the nursing admission note dated 6/22/19, revealed the following skin issues: skin tear of left leg and right hand. Blister noted on right lateral leg, back of left leg, right inner leg and pressure ulcer to buttock. There was no description, measurements or staging of the left buttock wound. The admission summary dated 6/22/19, revealed a large wound to the coccyx with a black wound bed. There were no measurements or indication of any other skin breakdown to adjacent areas surrounding the wound. An observation of the pressure ulcer to the left buttock was made on 6/26/19 at 1:10 pm with the registered nurse (Employee A). The wound was observed with a large black necrotic area in the center. An adjacent area above the necrotic area was noted with slough and redness surrounding the entire wound. In the fold of the buttocks, there was redness and an excoriated area on the right buttock. There was no drainage or odor detected. Employee A was asked if there had been any changes in the wound since admission. She stated the area above the necrotic area was open and red, but now it was covered with slough. When asked how often the wounds were measured, she stated they were measured weekly by the wound care physician. An interview was conducted with the Infection Control/Wound Nurse on 6/27/19 at 9:22 am. She was asked if she had seen the left buttock pressure ulcer on Resident #188. She stated she did observe the wound yesterday. She further stated the wound demonstrated much tissue damage with necrotic (dead) tissue. She was asked if the wounds had been measured and assessed upon admission. She stated the admitting nurse did not measure the left buttock wound or document other areas of breakdown. She also stated she had counseled the nurse regarding the lack of documentation. A review of the policy and procedure Pressure Injury Prevention and Care included the following: The nurse will assess/evaluate and measure new wounds and notify the wound care nurse, a pressure ulcer care plan will be initiated, documentation of the pressure ulcer should include: measurements, site, color, drainage and odor as well as treatment provided, wounds will be monitored routinely and documentation will be reflected on weekly wound assessment.

Based on observations and interviews, the facility failed to properly store medications on two (2) of four (4) medication carts. This placed residents receiving medication from those carts at potential risk for substandard treatment from decreased medication quality. The findings include: An observation of the medication cart identified as the 10-11 Cart on 3/22/18 at 5:40 PM, revealed one opened bottle of [MEDICATION NAME] (lactobacillus) tablets (50 tablets). This surveyor observed that the [MEDICATION NAME] was at room temperature, however the label stated that it should be kept refrigerated. (Photographic evidence obtained) Employee X, the Licensed Practical Nurse (LPN) responsible for the cart, confirmed in an interview at this time that the bottle was open, and was being stored at room temperature. She confirmed that the label on the bottle indicated it should be kept refrigerated. An observation of the 100 Hallway's medication cart on 3/22/18 at 5:53 PM, revealed one bottle of open [MEDICATION NAME] (lactobacillus) tablets (50 tablets) stored in the top drawer of the cart. When asked about the [MEDICATION NAME], Employee I, the LPN responsible for the cart stated, Well, they don't have to be refrigerated. The surveyor then showed Employee I the front label of the bottle. After reading the label, Employee I confirmed that the medication should be refrigerated, as per the manufacturer's instructions. (Photographic evidence obtained)

Based on observations and interviews, the facility failed to revise and then implement the revised dental care plan for 1 (Resident #117) of 31 sampled residents. The findings include: A record review revealed that Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/22/18 at 9:30 AM, an interview was conducted with Employee F, Certified Nursing Assistant (CNA), regarding the care she provided for Resident #117. Employee F stated that Resident #117 required a lot of time due to her difficulty breathing related to chronic respiratiry failure. Resident #117 got out of bed to eat breakfast, and required set-up only for her meals. She was otherwise independent while eating. Employee F confirmed that she set up the resident's breakfast tray at 9:00 AM. Employee F explained that there was no special care that she needed to provide for the resident, but that the resident just takes a lot of time, and I can't leave my other residents waiting while I am taking care of her. On 3/22/18 at 1:57 PM, an interview was conducted with Resident #117 regarding whether she had brushed her teeth after breakfast and/or lunch. Resident #117 stated, No, not yet. When she opened her mouth, food residue was observed in her teeth. On 3/22/18 at 2:21 PM, an interview was conducted with Employee E, Certified Nursing Assistant (CNA), regarding whether she brushed Resident #117's teeth after the meal. Employee E stated, No, I did not brush them. Employee E was asked whether she knew that the dental notes in the chart indicated that staff was to brush Resident #117's teeth after each meal, and she replied, No, I didn't realize that, but we never brush them, we just set her up with the supplies and she does it herself. A review of Resident #117's dental notes revealed the following: 2/1/18 Dentist Note: Generalized heavy plaque & bleeding, gingivitis moderate, decay rampant due to poor home care regimen, 10 areas of decay, will need 2 appointments to do restorative treatment, properly exam photos. 3/6/18 Dentist Note: Patient presented with rampant cavities cervically on multiple teeth. Silver Diamine [MEDICATION NAME] was applied on both the maxillary and mandibular teeth. This treatment arrests decay. Patient is not well enough to undergo extensive treatment at this time. So homecare by nursing healthcare professional and nurse home aides is very important!! You will see dark areas at gumline, that is expected with this arresting process. PLAN FOR FUTURE: Oral healthcare (brushing) after every meal. A care plan was in place to offer to brush the resident's teeth in the morning and evening. The facility failed to revise and implement the care plan following the dentist's recommendation of brushing Resident #117's teeth after every meal. On 3/22/18 at 2:46 PM, Employee C, Care Plan Coordinator, stated that the dental concerns were addressed under Resident #117's activities of daily living care plan. Employee C confirmed that the care plan stated to offer to brush Resident #117's teeth. There was no intervention in place for brushing Resident #117's teeth after every meal as per the 3/6/18 dentist's recommendation. Employee C stated that she would update the care plan to instruct teeth brushing after every meal. Employee A, Licensed Practical Nurse/Unit Manager intervened, and confirmed that she would enter an order requiring the nurses to follow up and sign off for toothbrushing after every meal.

Based on observations, interviews, and record reviews, the facility failed to provide an environment free of accident hazards for 1 (Resident #66) of 31 sampled residents. The findings include: A review of Resident #66's clinical record revealed an admission date of [DATE], and [DIAGNOSES REDACTED]. On 3/19/18 at 12:17 PM, Resident #66 was observed with a pair of suture removing scissors on the floor next to the wheelchair she was sitting in. Employee B, Licensed Practical Nurse (LPN), was immediately notified. Employee B stated, Those belong to the resident, and picked them up, placing them on Resident #66's bedside table. Employee B then exited the room. On 3/20/18 at 10:46 AM, Resident #66 was observed brushing her hair in the room, and two pairs of scissors were observed on top of the dresser. On 3/22/18 at 11:00 AM, an interview was conducted with Employee E, Certified Nursing Assistant (CNA). Employee E was asked about the scissors that were on Resident #66's dresser, and stated that she did not know why Resident #66 would have them. Employee E attempted to ask Resident #66 about the scissors, but was unable to understand what she was saying. Employee E confirmed there were two pairs of scissors on the dresser. (Photographic evidence obtained) Employee E stated, I thought they took them out of the room yesterday. You can ask the unit manager at the desk; she knows about it. On 3/22/18 at 11:12 AM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN), regarding the scissors on Resident #66's dresser. She stated, There were some in there, but the nurse took them out yesterday. On 3/22/18 at 12:38 PM, an interview was conducted with the Director of Nursing (DON) in conjunction with a review of the resident handbook. The DON confirmed that all residents received the book on admission, and verified the highlighted area on page 6, which read: Clothing/Personal Items: There are some items that are prohibited to include sharp objects (knitting needles, scissors, nail files, etc.), aerosol cans (room deodorizers, hair spray) and alcohol-based liquids. Please consult Administration, if you have any questions. The DON was asked if she was made aware that Resident #66 had scissors in her room, and she replied, Yes, I was made aware. When asked whether a resident should have scissors in their room, she stated, No, they shouldn't, and we make rounds to ensure that they do not have any sharp objects in their rooms. When asked how often rounds were conducted, she stated, Well, we do them everyday when we are in our survey window, but usually only weekly. The DON then confirmed that the scissors should have been removed during safety rounds.

Based on a review of resident records, and interviews with staff and families, the facility failed to notify the resident and the resident's representative(s) of a transfer and the reasons for the move in writing and in a language and manner they understood for 3 of 4 sampled residents reviewed for hospitalization (Residents #98, #122, and #136). The facility was required to provide a copy of this notice to a representative of the Office of the State Long-Term Care Ombudsman that included: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged ; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. The findings include: 1. A record review for Resident #98 revealed admission to the facility on [DATE], and re-admission on 1/30/18 following an 8-day hospitalization . Resident #98 had a discharge Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/22/18, that noted an unplanned discharge to acute hospital on [DATE], return anticipated. Resident #98 was assessed with [REDACTED]. The [DIAGNOSES REDACTED]. An electronic nursing progress note, dated 1/22/18, reflected abnormal laboratory results, with a BUN (blood urea nitrogen) of 59, and Creatinine (measures kidney function) of 5.0. The Advanced Registered Nurse Practitioner (ARNP) was alerted to the results, and requested the facility notify Resident #98's Nephrologist. As a result of the abnormalities, the Nephrologist sent Resident #98 to the emergency room for evaluation and treatment. That same day, the hospital called the facility to state the resident was being admitted for kidney issues. A history and physical, dated 1/23/18, from the hospital physician diagnosed Resident #98 with acute [MEDICAL CONDITION]. Further review of the resident's record found no written notification of the transfer to the resident or the representative prior to, or at the time of transfer, as required. There was no statement of the resident's appeal rights, or indication the resident was provided with the long-term care Ombudsman's contact information, per the regulatory requirement. An interview was conducted with the locked unit's Unit Manager (UM) on 3/22/18 at 10:10 a.m. She reviewed the chart, but was unable to locate any written notification of transfer. 2. During an interview with Resident #122's family member/power of attorney (POA) on 3/20/18 at 11:12 a.m., she stated the resident was recently re-hospitalized when sodium levels dropped. The resident remained in the hospital for 8 days. A record review for Resident #122 revealed admitted to the facility on [DATE], and a re-admission on 2/19/18. Resident #122 had a discharge return anticipated MDS assessment with an ARD of 2/12/18, which noted the resident was discharged to an acute hospital on this same day. The resident was assessed with [REDACTED]. [DIAGNOSES REDACTED]. An E-interact Transfer Form, dated 2/12/18, revealed Resident #122 was transferred to the emergency room for AMS (altered mental status). A history and physical exam, dated 2/13/18, revealed the resident was admitted to the hospital on [DATE], and presented with complaints of AMS and abnormal lab values. Further review of the record found no written notification to the resident or representative prior to, or at the time of the hospital transfer, as required. There was no statement of the resident's appeal rights, or indication the resident was provided with the long-term care Ombudsman's contact information, per the regulatory requirement. 3. A closed record review for Resident #136 revealed a discharge return anticipated MDS assessment with an ARD of 1/9/18. It noted the resident had an unplanned transfer to an acute hospital this same day. Resident #136 was assessed with [REDACTED]. Active [DIAGNOSES REDACTED]. An E-interact Transfer Form revealed Resident #136 was discharged on [DATE] to the hospital for AMS, and re-admitted to the facility on [DATE]. A second E-interact Transfer Form, dated 1/9/18, also noted a prior discharge to the hospital for AMS. A discharge, return anticipated MDS assessment with an ARD of 1/9/18 revealed Resident #136 had an unplanned discharge to an acute hospital. The resident was assessed with [REDACTED]. Active [DIAGNOSES REDACTED]. The discharge MDS assessment, dated 1/16/18, reflected an unplanned discharge to acute hospital, with no return to the facility anticipated. Further review of the record found no written notification of the transfer to the resident or representative prior to, or at the time of either transfer, as required. There was no statement of the resident's appeal rights, or indication the resident or a representative was provided with the long-term care Ombudsman's contact information, per the regulatory requirement. 4. An interview with the Director of Nursing (DON) on 3/22/18 at 12:00 p.m., revealed she did not provide residents with written notification of transfer when they went to the hospital. She only provided written notice if the discharge was a facility-initiated discharge for issues such as non-payment, or the resident met his/her therapy goals. In a second interview with the DON on 3/22/18 at 1:05 p.m., she reviewed the regulatory requirements regarding written notifications prior to transfers. The DON acknowledged that written notification was required prior to any resident transfer. She confirmed the requirements for written notification of transfer with appeal and Ombudsman information were required prior to any transfer and were not met by the facility. She stated she would correct this with the next resident transfer.

Based on observation and staff interviews, the facility failed to follow multiple care plans for Resident #66, 1 of 31 sampled residents regarding vision deficit. The findings include: A clinical record review revealed that Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Several observations of Resident #66 were conducted and revealed the following: On 3/21/18 at 9:41 AM, Resident #66 was sitting in the wheelchair in her room, brushing her hair with a little hand held mirror. She was not wearing glasses. On 3/22/18 at 9:32 AM, Resident #66 was observed sitting in the wheelchair in the room. She was having difficulty putting on a shirt. The shirt was twisted with one sleeve facing front and one facing backwards. Resident #66 was sitting in front of the dresser with a make-up drawer pulled out, and was not wearing glasses. On 3/22/18 at 10:58 AM, Resident #66 was observed sitting in a wheelchair in her room. Resident #66 was not wearing glasses, and there were no glasses visible in her room. On 3/22/18 at 10:59 AM, an interview was conducted with Resident #66 regarding her glasses. The surveyor pointed at her own glasses and asked the resident whether she had any of her own. Resident #66 shook her head and stated, No, I don't. On 3/22/18 at 9:39 AM, an interview was conducted with Employee D, Certified Nursing Assistant (CNA), regarding Resident #66's care and cognition status. Employee D stated that Resident #66 talked softly, but was able to make her needs known. Employee D was asked if Resident #66 had any vision impairment, and Employee D stated, No, (resident) does not wear glasses. Employee D stated that she was not a fall risk, and that she could stand up and transfer. Employee D then stated that Resident #66 liked to stay in her room, but would attend certain activities, and staff would assist with getting the resident to those activities. On 3/22/18 at 11:00 AM, an interview was conducted with Employee E, Certified Nursing Assistant (CNA), regarding Resident #66's care. Employee E stated that Resident #66 could make her needs known, but did not speak well, so it was hard to understand her. Employee E was asked whether Resident #66 wore glasses, and Employee E stated, No, (resident) does not have glasses. On 3/22/18 at 11:12 AM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN), regarding whether Resident #66 had any visula deficits or wore glasses, and Employee A stated, No, I don't see where she wears glasses. Employee A then reviewed Resident #66's care plans and confirmed that the activities of daily living (ADL) care plan did indicate that the resident wore glasses. A review of Resident #66's care plans revealed the following: 1) The resident had a visual deficit, but could see large print with glasses on. Intervention: keep glasses accessible and magnifier as needed. 2) Resident #66 prefers to be called by the first name, preferred activity setting is self initiated activities in room. Resident has vision and hearing impairment. Resident wears reading glasses, uses magnifying glass, and large print to read. Intervention: Provide room visits to resident 1-2 times weekly. Offer reading material, lotion hands, open/close blinds, assist as needed due to visual impairment. Resident wears reading glasses, and uses a magnifying glass and large print for reading. 3) Resident is at risk for falls related to history of falls, weakness, visual and hearing impairment. Intervention: Keep glasses accessible, and hearing aide in every morning and off at bedtime. 4) Resident is unable to manage activities of daily living (ADL's) independently. Resident wears glasses and has visual impairment. Intervention: WEARS GLASSES. The facility developed four (4) different care plans for Resident #66 that incorporated her visual deficit and need for corrective lenses, however the facility failed to ensure Resident #66 had glasses. Upon interviewing multiple staff members, they were unaware that Resident #66 required glasses.

Based on observations and interviews with staff, the facility failed to post the following required staffing information daily, at the beginning of each shift, and in a prominent place readily accessible to residents and visitors: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. The findings include: Multiple passes through the facility were made by the 6-member survey team between 3/19/18 and 3/22/18. Observations revealed that the required nurse staffing information, including the current date, total number of licensed nursing staff hours, and the resident census, were not posted at any location in the facility. An interview was conducted with the Director of Nursing on 3/22/18 at 5:02 p.m. When asked where the required posted information was, she went to look for it in the common area of the facility. She returned and confirmed the required daily staffing was not posted in any prominent location in the facility, as required. She acknowledged the requirement for daily posting.

Based on record reviews and staff interviews, the facility failed to ensure that each resident knew his or her rights and responsibilities prior to or upon admission for Resident #2, one out of 4 resident records sampled. The findings include: A record review for Resident #2 revealed a date of admission of 5/27/2017. Upon further review of the record, the facility's admission paperwork was not found. An interview with Employee F, Licensed Practical Nurse (LPN), on 6/1/2017 at 1:30 PM confirmed that Resident #2's record had no evidence that the facility's admission paperwork was reviewed and signed by the resident or his responsible party. There was no admission paperwork at all found in the record. An interview with Employee M on 6/1/2017 at 2:30 PM, confirmed the facility had not provided the admission paperwork for the facility to Resident #2 until this day, 6/1/2017, 5 days after admission.

Based on observation, record reviews, and staff interviews, the facility failed to notify a resident before transfer from the nursing facility of its bed hold policy for Resident #2, one of 3 resident records sampled. The findings include: An observation was conducted at 4:40 PM of Resident #2 being transferred out of the facility by transport service to a local hospital for treatment. A review was conducted of the paperwork that accompanied the resident, and no documentation was found notifying the resident before transport of the facility's bed hold policy. An interview with Employee G, Licensed Practical Nurse (LPN), on 6/1/2017 at 4:43 PM confirmed the facility's bed hold policy was not seen in the resident's discharge paperwork. She stated, We used to have packets with that included in the discharge paperwork, but since the facility went electronic, it's not included anymore. An interview with the Director of Nursing (DON) on 6/1/2017 at 4:45 PM confirmed the bed hold policy should have accompanied Resident #2 upon discharge to another facility. .

Based on record reviews and interviews, the facility failed to promptly notify a resident's physician related to a change in condition in which an existing treatment and medication needed to be changed or discontinued for Resident #1, one of 3 resident records sampled. The findings include: A record review conducted for Resident #1 revealed a date of admission of 4/18/2017, and a discharge date of [DATE]. Admitting [DIAGNOSES REDACTED]. A review of the admitting physician's orders [REDACTED].#1 revealed an order for [REDACTED]. A review of a nurse's progress note, dated 4/20/2017 at 3:20 PM, revealed, (Resident #1) on the 7-3 shift complained of being lightheaded while standing at Physical Therapy at 1 minute, sitting blood pressure was 79/49 with a heart rate of 63. (Resident #1) was back in bed, blood pressure is 115/57 with heart rate of 76. The physician was called and a new order was received to take Orthostatic blood pressures (blood pressures that are taken lying down, sitting up and standing) every shift for 3 days and labs to be drawn. A nurse's note, dated 4/21/2017 at 2:14 PM, read, (Resident #1) still complains of being lightheaded while standing, blood pressure dropping 69/37, denies chest pain. Physician was called to notify of the low blood pressure (B/P) and abnormal lab results and waiting for response - report given to oncoming nurse. No return call was noted from the physician. A therapy note, dated 4/24/2017 at 2:39 PM, read, During time with Physical therapy this am, it was noted (Resident #1)'s B/P was 95/53 sitting, 99/53 with exercise, 66/39 standing, and 100/58 sitting again. (Resident #1) was put back to bed. After vitals were rechecked, 128/83 lying down, 123/79 standing, 134/76 sitting down. Will report to oncoming shift to monitor. There was no evidence found in Resident #1's record that the physician was notified. A nurse's note, dated 4/25/2017 at 7:46 AM revealed Resident #1 was experiencing a 7 out of 10 pain and was requesting pain medication ([MEDICATION NAME]) to be increased for therapy. No documentation was found the resident's physician was called with this request. A nurse's note, dated 4/25/2017 at 12:48 PM read, (Resident #1) reported that he was hypotensive during his therapy today, blood pressure sitting is 107/58, standing 76/45, sitting again 99/55. (Resident #1) was also hypotensive during treatment but orthostatic blood pressure readings later on in the shift were within normal limits. Documentation was found the resident's Advanced Registered Nurse Practitioner (ARNP) was called with no answer, and a voice mail was left. A nurse's note, dated 4/25/2017 at 12:55 PM read, (Resident #1) states his pain in now a 7 out of 10 to his right hip. A call is placed to ARNP to increase his pain medication and waiting for return call. A nurse's note, dated 4/25/2017 at 4:13 PM read, (Resident #1)'s lab results faxed to physician and a note stating that resident has not been seen since his admission. A nurse's note, dated 4/25/2017 at 4:43 PM read, A 2nd call is placed to ARNP for (Resident 1) regarding his low orthostatic B/P's, and the resident wants to increase in his [MEDICATION NAME] and needs to be seen since he is a new admit. No documentation the physician or ARNP returned the facility calls or addressed the lab results that were faxed. A physician's orders [REDACTED].#1 called and gave a verbal order to discontinue [MEDICATION NAME] and to continue orthostatic blood pressures. A physician's verbal order dated 4/26/2017 at 8:30 PM, was to start [MEDICATION NAME] 500 mg, 1 daily for 7 days for urinary tract infection. A drug warning from the pharmacy, dated 4/26/2017, was given for the possible interactions [MEDICATION NAME] had with other medications the resident was receiving. There was no documentation found indicating the physician was notified of the drug warning from the pharmacy. LABS: U/A (urinary analysis), dated 4/27/2017, + (positive) for pseudomonas aeruginosa n.o. (new order) 4/29/2017 for [MEDICATION NAME] (antibiotic) 500 mg 1 po x 7 days, then d/c (discontinue) on 5/1/2017 and started on [MEDICATION NAME] and [MEDICATION NAME] (both antibiotics). A nurse's note, dated 4/29/2017 revealed Resident #1 was up with therapy and lowest b/p was in the high 90's and has continued dizziness. The documentation the resident's physician was notified. A nurse's note, dated 4/29/2017 revealed the facility obtained abnormal urine culture results for Resident #1 and a call was placed to the answering service for the physician, and facility was waiting for a return call. A nurse's note, dated 4/30/2017 at 10:42 am revealed Resident #1's urine culture sensitivity report was not addressed by the physician. A call placed to the physician was placed about 10 AM and a message was left to return the call. A call was placed to the answering service again at 10:35 AM, and confirmed they would put another call to doctor, and the facility is currently waiting on return call. A physician's verbal order, dated 4/30/2017 at 12:32 PM revealed Resident #1 was to start [MEDICATION NAME] 500 mg, 1 daily for 7 days. (Resident had a current drug warning for this medication from 4/26/2017.) Nurse's note, dated 5/1/2017 at 1 PM read the resident was put on [MEDICATION NAME] for urinary tract infection [MEDICAL CONDITION]. It was noted by the pharmacy on 4/26/2017 that this drug could possibly have an interaction with resident's medication [MEDICATION NAME]. [MEDICATION NAME] was held at this time and ARNP was called also to inform her of low b/p and waiting for return call. The ARNP returned the call to the facility on [DATE] at 6:19 to discontinue [MEDICATION NAME]. On 5/9/2017, a drug warning was given to the facility for Resident #1 in regards to Aspirin he was taking. No documentation could be found before the resident discharged home. The physician was not notified of the potential drug reaction with other medications the resident was taking. (Photographic evidence obtained) An interview was conducted with the Director of Nursing on 6/1/2017 at 1:17 PM, who confirmed she received a call from Resident #1's daughter around 4/26/2017 concerning his low blood pressures, and the DON informed the family member she would look into it. The DON confirmed she did no further follow up, and she knew the nurses were contacting the physician. She asked her Unit Manager to notify the physician and did not follow up with her to make sure it was done. The DON also confirmed the facility's nursing staff were to contact the physician and notify them of any Black Box drug warnings they received for a resident. She stated, We have given recent in-servicing to the nursing staff to make sure they notify the physician by phone and not leave in their box with any drug warning concerns. An interview with the DON 6/1/2017 at 3:30 PM confirmed the facility had no evidence the physician for Resident #1 was contacted on either 4/26/2017 or 5/9/2017 for the black box warnings for possible drug interactions and should have been called.

Based on observations and staff interviews, the facility failed to ensure 8 of 10 nourishment rooms, the satellite kitchenette, and its equipment were maintained and sanitary during the comprehensive tour observed on 2/23/2017, related to ice machines and microwaves which were not clean or maintained per the manufacturer's recommendations. The findings include: During the comprehensive tour of the nourishment rooms and the satellite kitchenette on 2/23/2017 at 7:30 a.m., the following concerns were observed and confirmed by the facility's Director at 8:20 a.m. 1. The 200, 400, 800, and 1000 hall nourishment rooms and satellite kitchenette ice machine dispensers were observed with black and gelatinous biological growth inside and along the entire chute and base of the dispensers. 2. The 100-hall microwave's entire bottom-lining of the door was covered with a gold/brown substance, and pieces of the plastic base were missing. 3. The 400-hall nourishment room's microwave door exhibited a gold/brown substance on the bottom and top of the back base. 4. The 700-hall nourishment room's microwave door had a gold/brown substance along the inside of the door and bottom of the back base. 5. The 800-hall nourishment room's microwave revealed along the bottom and top of the back base there was a gold/brown substance observed. 6. The 900 and 1100 hall nourishment rooms' microwaves had caked-on and built-up food debris along the inside top and back base of the units. An interview with the facility's Director on 2/23/2017 at 8:20 a.m. confirmed the condition of the ice machine dispensers and the microwaves that were in disrepair. He stated Maintenance was responsible for cleaning the ice machines that included inside the ice dispensers and chutes. He stated they were cleaned by a third party vendor on a quarterly basis, and he would contact the vendor immediately to get them serviced and would order replacement microwaves for the microwaves observed in disrepair. An interview with the Housekeeping Manager on 2/23/2017 at 1:00 p.m. revealed housekeeping was responsible for cleaning the nourishment rooms daily on the first shift. Housekeeping was responsible for cleaning the outsides of the ice machines and the insides of the microwaves daily. The preventive maintenance (PM) of cleaning inside the chutes of the ice machines and replacing the microwaves that were in disrepair were the responsibility of the Maintenance Department.

Based on observations and interviews, the facility failed to ensure that residents received services with reasonable accommodation of individual needs related to the independent use of bathrooms with emergency assistance readily available through the use of the emergency call lights for 11 resident rooms in the facility. This impacted the safety of of residents living in these rooms (rooms 301, 307, 323, , 325, 402, 409, 501, 505, 509, 511, and 515). The findings include: On 02/20/2017 at 12:39:52 PM, an observation was made of the bathroom in room [ROOM NUMBER]. In an interview with Employee N, Certified Nursing Assistant (CNA)), she stated the resident was independent. An observation was made of the bathroom emergency light pull cord tied around the hand rail on the wall at this time. This surveyor attempted to activate the emergency call system by pulling on the stem (farthest end from the call light switch). It tightened around the arm rail and did not activate the emergency call system. Employee N was interviewed on 02/20/2017 at 12:53:43 PM about how much assistance the resident in 505B required with toileting. She stated that the resident was alert and oriented and could express her need to go to the bathroom. The resident could do everything in the bathroom by herself, but the staff supervised, because the resident could fall. I take her to the bathroom; I say here you go, then I wait for her in the room. She can fall, but I give her privacy. On 2/22/2017 at 7:00 AM, a tour of the locked memory care unit revealed that call cords in multiple rooms were tied around the hand rail in the bathroom, preventing the appropriate operation of the call system. The following rooms were inspected and found to have call lights tied to the handrail in the bathrooms: room [ROOM NUMBER] - On 2/22/17 at 7:14 AM, the call light cord was observed tied around the hand rail in the bathroom. An interview was conducted with Employee A, CNA, who provided care to the residents residing in this room. On 2/22/2017 at 7:19 AM, she confirmed that the resident in the B bed could ambulate to use the bathroom. An observation was made of room [ROOM NUMBER], which revealed the emergency call light cord was tied around the hand rail in the bathroom on 2/22/17 at 7:16 AM. An observation made in room [ROOM NUMBER], revealed that the emergency call light cord was tied around the hand rail in the bathroom, and when tested by pulling the cord, it did not activate the call system. The cord only tightened around the handrail, and failed to activate the emergency call light and alarm. This impacted both residents in that room. Based on an interview with Employee A, CNA, during this observation on 2/22/2017 at 7:19 AM, she stated, The resident in room [ROOM NUMBER]-B could use the bathroom and walked everywhere. An observation made in room [ROOM NUMBER] revealed that the emergency call light cord was observed on 2/22/17 at 7:18 AM to be tied around the hand rail in the bathroom. The cord was pulled and failed to activate the emergency call system. An interview was conducted with Employee A, CNA, on 2/22/2017 at 7:19 AM. She stated, I work all over the facility; I float. She was asked about the call lights observed tied around the hand rails in the bathroom and stated, If the call light cord is tied around the hand rail, you would not be able to activate the call light, and a lot of people always do that. Employee A stated that a lot of people tied the call light cord around the hand rail. She also stated, Sometimes it could be the resident, but staff may do it too. We are supposed to untie it when we see it. An observation made of the emergency call light system in the bathroom for room [ROOM NUMBER] revealed the emergency call light cord was tied around the bathroom hand rail on 2/22/2017 at 7:21 AM. An observation made in room [ROOM NUMBER] revealed the call light cord in the bathroom was observed to be tied around the hand rail on 2/22/2017 at 7:25 AM. An observation was made in the bathroom of room [ROOM NUMBER], and revealed the bathroom emergency call light cord was tied around the hand rail on 2/22/2017 at 7:28 AM. An observation made in room [ROOM NUMBER] revealed the bathroom emergency call light cord was tied around the bathroom hand rail on 2/22/2017 at 7:30 AM. An observation made in room [ROOM NUMBER] on 2/22/2017 at 7:32 AM, revealed the bathroom emergency call light cord was tied around the hand rail. An observation was made in room [ROOM NUMBER] on 2/22/2017 at 7:35 AM, and the call light cord was tied around the hand rail in the bathroom. An interview was conducted with the resident in this room at 7:35 AM on 2/22/2017, and he stated, I cannot pull the call light from the bottom because it does not work like that. It is set up so I can only pull it from the top. I don't know why, but I have to pull it up here; see, it works like this. When asked to activate the call light by pulling from the bottom, the resident could not activate the emergency call light. The resident stated, You cannot pull it from there, because it is not going to work. On 2//22/2017 at 8:30 AM, while observing room [ROOM NUMBER], the Director of Nursing confirmed that the call cord was tied around the hand rail in the bathroom. She pulled it, and it would not operate the call system. She stated, The cord will not work like this, and it is not supposed to be wrapped around the hand rail. I will let everybody know through an in-service. We will have a sign in sheet for you tomorrow anyway. On 2/22/17 at 11:17 AM, the Director of Nursing arrived and stated, I am concerned about the resident in room [ROOM NUMBER]. He may be the one who ties the call light cords in resident rooms. We noticed today that when he enters another resident's room and comes out, we find the call light cord tied around the grab bar. On 2/22/2017, the Director of Nursing provided A Teachable Moment documentation of an in-service for facility staff related to In order to ensure proper accessibility and function, the bathroom call light must be free hanging and cannot be wrapped around the grab bar. On 2/23/17 at 10:00 AM, the Director of Nursing stated that there was no specific policy and procedure outlining management of the call light system. No additional information was provided.

Based on observations, record reviews, and staff interviews, the facility failed to provide an environment to keep 3 of 36 sampled residents free from accident hazards (Residents #174, #116, and #208). The findings include: 1. A record review for Resident #174 revealed a [AGE] year old female diagnosed with [REDACTED]. A review of Resident #174's Minimum Data Set (MDS) Quarterly assessment, dated 2/6/17, showed a Brief Interview for Mental Status (BIMS) score was unable to be obtained due to the resident's level of confusion. Resident #174's functional status (bed mobility, transfers, dressing, toileting, and personal hygiene) was coded as extensive assistance with 2 staff members required. On 2/23/17 at 9:02 AM, Resident #174 was observed being pushed down the hallway by Employee J, Certified Nursing Assistant (CNA), without the footrests on her wheelchair. Resident #174 was dragging her feet and not keeping them up. Employee J kept having to tell the resident to lift her feet. On 2/23/17 at 9:03 AM, an interview was conducted with Employee J, CNA, regarding Resident #174 being pushed down the hallway without footrests. Employee J was asked if Resident #174 self-propelled in the wheelchair, and she replied, No, she does not. We have to push her where she needs to go. Employee J was then asked about Resident #174 not having footrests on the wheelchair, and she stated, If she doesn't lift her feet, I have to get her footrest; but if she will lift them, I just push her. On 2/23/17 at 9:45 AM, an interview was conducted with Employee K, Occupational Therapist (OT), regarding residents in the memory care unit being pushed without using footrests. Employee K stated that residents that could self-propel did not need foot rests, but if a resident could not self-propel, they did need footrests. Employee K stated that you should never push a confused resident in a wheelchair without footrests for safety reasons. On 2/23/17 at 10:16 AM, an interview was conducted with the Director of Nursing (DON) regarding staff pushing residents in the memory care unit without footrests. The DON stated, If the residents can self-propel, then they don't need footrests, but if staff are pushing them, I would expect them to propel forward in a safe manner, at a safe rate of speed, and yes, I would expect them to use footrests. 2. A record review for Resident #116 revealed a [AGE] year old female diagnosed with [REDACTED]. A review of Resident #116's Minimum Data Set (MDS) Quarterly assessment completed on 2/1/17, revealed a Brief Interview for Mental Status (BIMS) score of 3 (indicating significant cognitive impairment). Functional status was coded to indicate that Resident #116 needed extensive assistance from 1-2 staff members with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #116 did not walk, and was dependent on staff for bathing. On 2/22/17 at 2:57 PM, Resident #116 was observed being pushed down the hallway by Employee F, CNA/ Restorative Aide. Resident #116 was in a wheelchair, and the wheelchair did not have any footrests on it. The resident was dragging her feet, and was not able to keep them up while being pushed. On 2/22/17 at 2:58 PM, an interview was conducted with Employee D, LPN, regarding the cognitive abilities of Resident #116 and whether the resident self-propelled in her wheelchair. Employee D stated that Resident #116 did not self-propel, and should have footrests if she was being pushed in the wheelchair. Employee D was asked what the facility's policy said about pushing residents in wheelchairs without footrests if they could not self propel. Employee D stated, If a resident is not self-propelling, they should have footrests, but if they can self-propel, they should not. On 2/23/17 at 9:45 AM, an interview was conducted with Employee K, OT, regarding residents in the memory care unit being pushed without using footrests. Employee K stated that residents that can self-propel did not need footrests, but if a resident could not self propel, they did need footrests. Employee K stated that you should never push a confused resident in a wheelchair without footrests for safety reasons. On 2/23/17 at 10:16 AM, an interview was conducted with the Director of Nursing (DON) regarding staff pushing residents in the memory care unit without using footrests. The DON stated, If the residents can self-propel, then they don't need footrests, but if staff are pushing them, I would expect them to propel forward in a safe manner, at a safe rate of speed, and yes, I would expect them to use the footrests. 3. A record review for Resident #208 revealed a [AGE] year old male with [DIAGNOSES REDACTED]. A review of Resident #208's MDS Quarterly assessment dated [DATE], revealed a BIMS score was not completed due to Resident #208's significant level of confusion. Resident #208's functional status was coded to indicate that he required limited to extensive assistance from 1-2 staff members with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. On 2/22/17 at 9:25 AM, an interview was attempted with Resident #208. He stated that he was trying to get up because he was hungry and he did not have any breakfast. Resident #208 was asking to please get him some food. On 2/22/17 at 9:25 AM, Resident #208 was observed lying sideways in bed with his legs hanging over the left side of the bed. The blanket and call light were wrapped around Resident #208's waist. Resident #208 had on white tube socks that were slippery on the bottom. Slippers were noted just out of Resident #208's reach on the left side of the bed on the floor. Resident #208 was lying in bed, but was attempting to get up when permission was asked to enter the room. On 02/22/2017 at 9:25 AM, and interview was conducted with Employee C, Memory Care Unit Manager, regarding Resident #208, and she stated that the resident walked independently and could get out of bed alone. Employee C was asked if the resident was cognitive enough to know to put shoes or slippers on before ambulating, and she stated, No, he is not. Employee C was then asked about the resident having on white tube socks that had not non-slip soles, and she stated, I don't know, I will have to ask his aide about that. Employee C was asked if Resident #208 should have on non-slip socks, and she stated, yes, he should. On 02/22/2017 at 9:32 AM, an interview was conducted with Employee G, CNA, regarding Resident #208 being capable of putting on slippers. Employee G stated, No, (Resident #208) would not be capable of putting slippers on. Employee G was then asked if Resident #208 could and would get out of bed on his own, and she stated, Yes, he will get up and walk on his own.

Based on record review and staff interviews, the facility failed to review and revise the care plan after a fall for 1 of 36 sampled residents (Resident #137). The findings include: A record review for Resident #137 revealed an [AGE] year old female admitted on [DATE]. Resident #137 had [DIAGNOSES REDACTED]. Resident #137 was a long-term care resident that resided in the locked memory care unit. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #137 required limited to extensive assistance with all activities of daily living; transfers, bed mobility, eating, toileting, and bathing. Resident #137 had a fall on Saturday, 1/28/2017, but no interventions were put into place until Monday, 1/30/17, when the Interdisciplinary Team (IDT) returned to work after the weekend. Staff nurses did not update the care plans if a resident fell over the weekend, and they waited until the IDT returned on Mondays to address the fall and update the care plans. On 02/22/2017 at 11:54 AM, an interview was conducted with Employee C, Unit Manager. She was asked about Resident #137's fall care plan not being updated until 1/30/17 when the resident had actually fallen on 1/28/17. Employee C stated that the floor nurses did not update the care plans, and they were not updated until the IDT returned on Monday. Employee C stated that floor nurses were allowed to get orders such as floor mats, low beds, skin tear treatments orders, etc., but they could not write them on the care plans. On 02/22/2017 at 1:07 PM, an interview was conducted with Employee H, Registered Nurse (RN) MDS/Care Plan Coordinator regarding Resident #137's fall care plan. Employee H was asked about Resident #137 falling on 1/28/17, and the care plan not being updated until 1/30/17. Employee H stated that it was because the resident fell over the weekend, and staff nurses were not to update the care plans. The IDT updated care plans during the morning meeting when they returned on Monday. Employee H was asked how the nurses and Certified Nursing Assistants (CNAs) knew what new interventions were put into place if the care plans weren't updated right away. Employee H stated that they were given the information during the shift change verbal report. Employee H was asked what happened if someone forgot to verbally give the information in a shift to shift report, and she replied, You have a point. On 2/22/17 at 3:04 PM, an interview was conducted with Employee D, Licensed Practical Nurse (LPN), regarding updating care plans. Employee D stated that the staff nurses did not update the care plans. On 2/22/17 at 3:06 PM, an interview was conducted with Employee E, Registered Nurse (RN), regarding updating care plans. Employee E stated, We never update care plans; we have someone who does that. On 2/23/17 at 8:46 AM, an interview was conducted with the Director of Nursing (DON) regarding care plan updates for Resident #137. The DON stated that care plans should have been immediately updated, and that education was initiated with the nursing staff the previous night related to updating the care plans immediately after a fall. The DON stated that not updating Resident #137's care plan immediately after the fall was inaccurate, and that it should have been updated immediately. The staff should not have waited for the IDT to return on Monday. The DON then stated, I concur that there was nothing on Resident #137's care plan after the fall until Monday 1/30/17.

Based on observations, record reviews, and staff interviews, the facility failed to treat and care for 2 of 36 sampled residents in a manner that promoted or enhanced his/her quality of life, recognizing each resident's individuality, and promoting dignity and respect (Residents #231 and #137). The findings include: 1. A record review for Resident #231 revealed a [AGE] year old female admitted on [DATE]. Resident #231 had [DIAGNOSES REDACTED]. Resident #231 was currently a long-term resident at the facility, and resided in the locked memory care unit. A review of Resident #231's Brief Interview for Mental Status (BIMS) score on the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #231 scored a 4 (indicating significant cognitive impairment). On 2/22/17 at 11:42 AM, Employee E, Registered Nurse (RN), was observed administering medication to Resident #231 during group activities. On 2/22/17 at 11:47 AM, an interview was conducted with Employee C, Unit Manager, regarding Employee E administering medications to Resident #231 during group activities. Employee C stated, We try to limit giving medications during activities, but since it's a memory care unit, it is okay to do that. On 2/23/17 at 8:52 AM, Employee I, Licensed Practical Nurse (LPN), was observed administering medication to Resident #231 in the hallway in front of the nurse's station at the entrance to the memory care unit. On 02/23/2017 at 1:36 PM, an interview was completed with Employee D, RN, regarding passing medication in the memory care unit without providing privacy to the resident. Employee D stated, You ask the resident if they want their medications and if they say 'yes', you give them their medications. You do not need to provide privacy unless it is an eye drop or something. Employee D was then asked if she worked in any other unit other than the memory care unit, and she stated, Yes, I work other floors. Employee D was then asked if it was okay to pass medication to residents anywhere throughout the building, and she stated, Yes, you don't need to provide any privacy for PO (medications given by mouth) medications. 2. A record review for Resident #137 revealed an [AGE] year old female admitted on [DATE]. Resident #137 had [DIAGNOSES REDACTED]. Resident #137 was currently a long-term care resident that resided in the locked memory care unit. A review of the MDS assessment dated [DATE], revealed that Resident #137 had a BIMS score of 4 (indicating significant cognitive impairment). On 2/23/17 at 8:54 AM, Employee I, LPN, was observed passing medication to Resident #137 in the hallway in front of the nurse's station at the entrance to the memory care unit. On 2/23/17 at 8:54 AM, an interview was conducted with Employee C, Unit Manager, regarding Employee I passing medication to residents in the hallway at the entrance to the memory care unit. Employee C stated after meals, residents came to the main sitting area, because residents did not spend much time in their rooms. Employee C was asked if nurses should be taking the residents to a private area to administer their medications, and she stated, Yes, nurses should be taking residents to a private area to administer their medications. On 02/23/2017 at 1:43:41 PM, an interview was conducted with the Director of Nursing (DON) regarding passing medication to residents in the common areas. The DON stated, We expect the nurses to provide privacy to all residents. Nurses have been educated time and time again, and know they are supposed to provide privacy. Sometimes we might have a resident that will request a medication with their lunch, and of course we will honor that, but for our everyday practice, we do not pass medications in common areas.

Based on observations, resident record reviews, and staff interviews, the facility failed to ensure residents were free from unnecessary medications by administering medication without a physician's order to 1 of 3 sampled residents (Resident #3) reviewed for medications. The findings include: A medication observation was conducted at 11:45 am on 10/3/16 in Resident #3's room. The Licensed Practical Nurse (LPN) assigned to Resident #3 gathered her supplies and took them into the resident's room. After making appropriate preparations for aseptic (free from contamination) techniques, she attached a 12 milliliter (ml) vial of normal saline to the red port of the PICC line (peripherally inserted central catheter; an intravenous catheter used for prolonged antibiotic or [MEDICAL CONDITION] use) in Resident #3's right upper extremity. She flushed the PICC line with the saline, removed the [MEDICATION NAME], and followed with a 50 iu (international units)/5 ml (milliliters) flush of [MEDICATION NAME] (an anti-coagulant medication). The LPN flushed the red port line with the [MEDICATION NAME]. After cleaning the purple port, she flushed it with a 12 ml vial of normal saline. The LPN then attached a self-contained antibiotic delivery system that contained an antibiotic, [MEDICATION NAME], to the purple PICC line port, and tucked the reservoir under Resident #3's shirt. An interview was conducted with Resident #3 at 12:00 pm on 10/3/16. He stated he had resided in the facility for 5 weeks, and was being treated for [REDACTED]. Resident #3 explained he had the PICC line for approximately 6 weeks. The facility nurses were responsible for his intravenous (IV) antibiotic administration of [MEDICATION NAME]. Record review found Resident #3 was admitted on [DATE]. The 14-day Medicare Minimum Data Set (MDS) assessment, with an assessment reference date of 9/6/16, revealed he had a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Resident #3 received antibiotics on 7 days over the assessment period, and IV medications while a resident and prior to his residency. Active [DIAGNOSES REDACTED]. Resident #3 was care planned for infections and IVs for a [DIAGNOSES REDACTED]. Resident #3 had a physician's order, dated 10/3/16, for normal saline (NS) 10 ml every shift, flush PICC line every shift before and after medication administration. An order dated 10/1/16 for [MEDICATION NAME] Hcl reconstituted solution instructed to use 1.25 grams IV in the afternoon related to extradural and subdural abcess until 10/10/16. Further review of the physician's orders for Resident #3 revealed there were no orders for the use of [MEDICATION NAME] in preparation for the [MEDICATION NAME] treatment. A review of the facility's Policies and Procedures (9.11) for Intermittent Administration of Medication through Central Venous Catheters noted the following: Policy: Intermittent administration of medications through central venous catheters is done in a safe and accurate manner. Guidelines: #1. A [MEDICATION NAME] lock flush will be ordered by the physician. Procedures: #8. Flush the catheter with [MEDICATION NAME] solution, according to the prescribed order. Review of the facility's Policy (9/23) Flushing PIC/ PICC/ Extended Peripheral Catheter also noted: Policy: Flushing PIC/PICC/ extended peripheral catheter with 0.9% NS and/or [MEDICATION NAME] is done in a safe and accurate manner. Guideline #4: Flush PICC line with 1-3 ml of normal saline and follow with [MEDICATION NAME] flush per specific MD (physician's) order. An interview was conducted with the Director of Nursing (DON) at 3:30 pm on 10/3/16. She reviewed the clinical record for Resident #3 and confirmed there was no physician's order for the use of [REDACTED]. The DON stated that old polices required that [MEDICATION NAME] was always given during PICC line use. She confirmed that the use of [MEDICATION NAME] required a physician's order.

Based on record review and family interview, the facility failed to notify the family member of a change in condition and change in treatment for 1 of 1 residents sampled for notification of change of a total sample of 35 residents. The findings include: Record review for Resident #54 revealed an [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. She was oxygen dependent and required assistance with transfers, bathing, dressing and toileting. On 9/17/15 the nurse documented Resident #54 was experiencing shortness of breath and labored breathing. The physician was notified and an antibiotic was ordered. There was no documentation the daughter was notified. On 9/20/15 she was observed with small white patches on the tongue. There was no documentation the daughter or physician were notified of the change in condition related to thrush. During an interview on 1/27/16 at 11:10 am, with the Resident #54's daughter, she reported that the staff had not informed her of changes in condition. She stated she visited frequently and was very involved in her mother's care, however, she was not able to visit for a week when she had some surgery. Upon her return to visit her mother on 9/21/15, she discovered her mother had been experiencing shortness of breath, labored breathing, had been started on antibiotics and had developed thrush in her mouth. She also found her mother with yellow crusty eyes and had eye infection. She stated she was very upset that the staff had not called to inform her of the changes. Upon arrival to the facility on [DATE] and observing her with respiratory distress, thrush and eye infection, she requested transfer to the hospital.