Every finding on record at Marian Home

Based on clinical record review, staff interviews, and facility policy, the facility failed to notify the physician of a condition change for 1 of 1 residents reviewed (Resident #66). Resident #66 had complaints of shortness of breath with low oxygen saturation of 79% on 3 liters (L) of oxygen and a new productive cough with crackles in bilateral lower lungs. The facility reported a census of 72 residents.Findings include:Resident #66's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS also documented diagnoses of Alzheimer's disease, respiratory failure, a seizure disorder, malnutrition, anxiety, and depression. A review of the facility's progress notes on 5/14/26 at 4:41 PM revealed a nurse documented an assessment of Resident #66 regarding complaints of shortness of breath (SOB), difficulty breathing, and nausea. Resident #66 stated she felt dizzy and lightheaded. Staff noted the resident appeared diaphoretic (sweating heavily due to illness) and was shaking her legs, and Resident #66's hands appeared cyanotic (turning blue from lack of oxygen). Her vital signs were a temperature of 98.6, a pulse of 104 (average 60-100), a blood pressure of 153/65 (average 120/80), and an oxygen (O2) saturation of 79% (expected to be greater than 90%) on 3 liters via nasal cannula (NC). The nurse instructed Resident #66 to take deep breaths, and after 15 minutes, her O2 saturation returned to 90% and her pulse dropped to 84. Resident #66 returned to bed and reported no further nausea or dizziness. Resident #66 reported she didn't eat that day because she felt like crap. Resident #66 presented with a new productive cough (movement of fluids out of the lungs or airway) that started that morning, and crackles (abnormal sounds in the lungs) were heard in the bilateral lower lungs. A review of the facility's progress notes on 5/15/26 at 2:00 AM revealed a nurse documented an assessment of Resident #66's complaints of nausea. Resident #66's skin was noted to be pale; her pulse was 102, her blood pressure (BP) was 171/70, and her O2 saturation was 75% on 3 liters (L) via nasal cannula (NC). Resident #66's O2 saturation came up to 88% after 15 minutes. A review of the facility's clinical records revealed the facility failed to notify the physician of the change in condition for Resident #66. A review of the facility's progress notes on 5/15/26 at 6:58 AM revealed a nurse documented that at 5:30 AM, staff summoned her to the room due to the resident's complaints of SOB. Resident #66 had an O2 saturation of 70% on 3L of O2, and wheezes (abnormal lungs sounds due to decreased room in the airway) were noted throughout her lungs. The resident stated her cough was worse, noted she had not felt well for the last two days, and requested to go to the emergency room. A review of the facility's progress notes on 5/15/26 at 1:10 PM revealed a nurse documented the hospital admitted Resident #66 with an exacerbation of chronic obstructive pulmonary disease (COPD). On 6/18/26 at 9:00 AM, the Administrator acknowledged that there was no notification made to the physician. The facility policy titled Physician Notification, dated 10/10/23, revealed the facility is to inform the physician of a resident's change in condition: Physicians will be notified promptly of the following:Any accident or incident which results in injury which may require physician intervention.ii. A significant change in resident condition which is life-threatening.A significant change in resident condition which has potential for clinical complication.A change in condition which requires a significant alteration in treatment.Death of a resident.Discharge or transfer of a resident.Any change in condition which requires immediate attention should be called to the physician immediately.Same-day written notification may be utilized for condition changes, accidents and incidents, and other events which do not require immediate attention. During an interview on 6/18/26 at 10:24 AM, Staff A, Licensed Practical Nurse (LPN), stated she expected the staff to notify the physician of the assessment.

Based on observations, clinical chart review and staff interview the facility failed to check placement for gastrostomy tube for 1 of 1 residents (Resident #66). The facility reported a census of 72 residents. Findings include: Resident #66's Minimum Data Set (MDS) (standardized clinical assessment tool) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS also documented diagnoses of Alzheimer's disease, respiratory failure (inability of lungs to exchange gases), a seizure disorder, malnutrition, anxiety, and depression. The MDS further documented Resident #66 received nutrition through a gastrostomy feeding tube (tube through abdomen for feeding). Resident #66's Care Plan dated 6/3/25 directed staff to check and record tube placement per facility protocol. On 6/16/26 at 2:20 PM observed Staff B, Registered Nurse (RN), flushed and administered an enteral feeding (feeding through a digestive tract tube) through the gastrostomy feeding tube. Staff B failed to check tube placement prior to the feeding. The facility policy titled Enteral Feeding Via Nasogastric or Gastrostomy, or Jejunostomy Tube, revised on 11/5/22, directed the following: Tube Placement Requirement: Tube placement shall be checked before each feeding, per physician order.Verification Procedure: Check for tube placement and residual gastric contents, as ordered: Using an appropriately sized syringe (20-60 mL), gently aspirate gastric contents and note the quality and quantity of any return. During an interview on 6/18/26 at 10:24 AM, Staff B, Licensed Practical Nurse (LPN), stated they expected the staff to check placement by checking the residual prior to the feeding.

Based on record review and staff interview, the facility failed to assure each resident received adequate assistance to prevent a fall with injury for 1 of 3 residents reviewed (Resident #31). The facility reported a census of 76 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #31 scored 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident had functional limitation in range of motion (ROM) of 1 side, upper extremity. The resident required supervision or touching assistance with transfer and ambulation. The resident's diagnoses included rheumatoid arthritis (RA). The Care Plan identified the resident had an activity of daily living (ADL) self-care performance deficit related to Alzheimer's, disease process, RA, chronic back pain, osteoporosis, hypothyroidism, chronic urinary tract infections (UTI's), depression, impaired balance, but able to stabilize self with walker, and increased risk for falls. The resident had limited ROM of the left hand. The interventions included: a. On 12/8/23 the resident ambulated with a walker to all destinations. The resident ambulated with guidance and direction from staff. Staff were at the resident's side at times. On occasion the resident would walk independently for short distances. The intervention resolved 4/11/24. b. On 4/11/24 the resident ambulated as tolerated to destinations with 1 assist and walker. The resident's bilateral hands had rheumatoid arthritis knuckle contractures, assisted with the walker as needed. The Progress Notes dated 4/23/24 at 11:37 a.m. documented staff were summoned for help in the main nurses station due to the resident on the ground. Staff stated they were assisting the resident up to go to the dining room for lunch. After the resident was in a standing position from the chair she grabbed her walker with her right hand and staff tried to assist the resident's contracted left hand to the walker but the resident let her right hand go from the walker. The resident was lowered to the ground but did end up on her right hip. Vital signs were taken. No shortening noted to bilateral lower extremities. Assisted the resident to a sitting position, then assisted into a standing position with a gait belt and 3 staff members. The resident was wheeled into the dining room in a wheelchair. The resident showed signs of pain by facial expressions and verbally. Interventions included: Updating the Advanced Registered Nurse Practitioner (ARNP), received orders for x-ray of the right hip, sent out via emergent ambulance for x-ray, would no longer use the walker for ambulation. A hospital History and Physical dated 4/23/24 at 12:43 p.m. documented Resident #31 presented to the emergency room (ER) with hip pain following a fall. Hip X-ray results dated 4/23/24 documented an acute appearing right femoral neck fracture in mild varus malalignment. Orthopedic surgery was contacted per their documentation and discussion with the resident's power of attorney (POA). They decided to proceed with surgery the following day. The physical exam revealed the resident's right lower extremity shortened and externally rotated. A Post-hospitalization visit dated 5/1/24 at 10 a.m. documented the resident had right hip hemiarthroplasty (surgery to treat hip fracture) on 4/24/24. Staff reported the resident had increased pain since returning to the facility, noticed with transfers, assisting the resident with daily cares, in the mornings, and in the middle of the night. The resident was cognitively impaired at baseline. Given the resident's cognitive impairment, there was concern she would be unable to express the pain she truly experienced. The resident reported no pain, but even with light palpation over the right hip, she grimaced and stated ouch. New orders included increasing Hydrocodone-Acetaminophen to 7.5/325 mg 3 times a day, and Hydrocodone 5 mg as needed every 6 hours for breakthrough pain. The Progress Notes dated 5/7/24 at 8:42 a.m. documented the resident readmitted on ,d+[DATE] post right hip hemiarthroplasty. Appetite very poor, required cues and assistance during meals. Required maximum assist of 2 for transfers, toileting, and bed mobility. Assist of 1 for ADL's and showering. Weight bearing as tolerated to right lower extremity but resident did not allow leg to bear any weight. Left hand remained contracted and painful to the resident. The resident complained of pain in the right lower extremity during any attempts of movement. On 5/14/24 at 10:35 a.m. Staff A Certified Nursing Assistant (CNA) stated (on 4/23/24) she went to assist the resident to go to the bathroom before going to lunch. She said she helped the resident stand up to her walker and one hand was on the walker holding it and the other hand was closed. She opened the hand to put it on the walker and the resident let go of the walker with the one hand, lost her balance and she went to the ground. Staff A was able to hold on to her to ease her down. Staff A stated she did not know they needed to have a gait belt on. She had not seen other staff use a gait belt on the resident. The Director of Nursing (DON), present during the interview, stated the resident had recently changed from independent to a 1 assist prior to the incident. The resident should have had the gait belt on when assisting her. A note dated 4/23/24, Gait belt use, documented discussion of the importance and mandate to use a gait belt with any resident when required an assist of 1 or 2 with any and all transfers and ambulation. Caregivers had to have on their person or within reach a gait belt at all times while on the floor. Failure to follow the protocol could result in disciplinary action. A Summary of the self report on Resident #31: When transferring the resident from the recliner chair the CNA did not have a gait belt on the resident. The resident stood up from the chair, and the CNA was guiding the resident's arthritic hand to grip the walker and the resident's opposite hand, her right hand, let go of the walker. The resident's knees began to buckle, and the CNA slowly guided her to the floor. The resident's Care Plan had recently changed to assist of 1 from independent. Prior to the change the resident had been transferring and ambulating independently. Employee education done with all CNA's and Nurses regarding gait belt use on all residents that were assist of 1 or greater, when not using a manual lift. Education of all nursing staff started on 4/24/24 and completed on on 4/26/24. Each individual CNA or Nurse was given the education on a 1 to 1 basis. Going forward Nursing Administration would conduct audits on all shifts to make sure all were using gait belts properly.

Based on interviews and record review, the facility failed have a system in place to track antibiotic use as part of their antibiotic stewardship program. The facility failed to provide documentation of ongoing tracking and trending of antibiotic use. The facility reported a census of 72 residents. Findings include: On 1/24/21 at 10:04 p.m., the Infection Control task for the facility's recertification survey was conducted with the Nursing Home Administrator (NHA) and Staff B, Unit Manager. They reported they have an infection control module that is filled out with resident symptoms or complaints. Staff B stated she checks the antibiotic use daily but did not run or do a monthly report of antibiotic use. The NHA and Staff B stated they would provide more information. On 1/24/22 at 11:55 AM, the NHA and Staff B showed they completed peri care and handwashing audits in May. They stated there were 6 infections in April, but they could not provide a report. Both concurred that audits done related to the infections but it was done as the annual training. The NHA stated she tracked and trended antibiotic use prior to the change over to PCC (electronic health record) and although they discuss daily they were not discussing results from each month. Both stated understanding that infections and antibiotics should be tracked and then trends should be documented with appropriate follow up from the results of tracking and trending. Both stated that follow up would involve education. They both stated it is a learning experience and they will get better at this. An undated Antibiotic Stewardship Policy, directed staff that the facility's antibiotic stewardship program promoted the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and reduce antibiotic resistance. The policy diredted that the facility practiced the Core Elements of Antibiotic Stewardship, outline by the Centers for Disease Control and Prevention to optimize the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy directed that the Infection Preventionist(IP) would track antibiotic use and monitor adherence to evidence based criteria, including: a. documentation related to antibiotic selection and use b. tracking antibiotics used to review patterns of use and determination of the impact of the antibiotic stewardship interventions. c. monitoring for clinical outcomes d. reporting of communicable disease per State Law e. assist prescribing practitioners in choosing the right antibiotic antibiogras f. provide reports related to monitoring antibiotic usage and resistance data to the QAA (Quality Assessment and Assurance) committee. This policy directed that during the quarterly QAA committee meeting, the pharmacies, medical director, IP, would analyze the antibiotic use in the facility to collaborate with nursing and clinical leaders for identification of potential QAPI (Quality Assurance and Process Improvement). A process action plan related to analysis of the tracking and trending of data for quality outcomes.

Based on clinical record review and staff interview the facility failed to complete a follow-up Preadmission Screening and Resident Review for one out of one residents reviewed in the current sample who had a change in mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #2). The facility reported a census of 72 residents. Findings include: 1. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #2 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessed the resident with a BIMS (Brief Interview Mental Status) score of 15 indicating no cognitive impairment. The assessment documented Resident #2 entered the facility on 3/13/15. The MDS indicated the resident received antipsychotic and antidepressant medications for 7 or 7 days during the look-back period. The care plan updated on 1/5/22 revealed the resident with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan had a goal for mood to remain stable on her current medications. The care plan indicated she was at risk for side effects from her antipsychotic and antidepressant medications. The care plan directed staff to monitor and report any risk for harming others (including possession of weapons or objects that could be used as weapons), increased anger, labile mood or agitation, or feeling threatened by others. The care plan directives revealed Resident #2 could be critical of staff and felt they were doing something wrong if it was done differently than another staff person. Staff were to provide emotional support and adaptive coping skills to resident. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] 2 milligrams (mg) by mouth one time a day started 9/3/19 for major depressive disorder b. [MEDICATION(S)] 75 mg by mouth one time a day for major depressive disorder c. [MEDICATION(S)] 7.5 mg by mouth at bedtime for major depressive disorder The medical record revealed a PASSR (Preadmission Screening and Resident Review) completed on 3/13/15 to screen for mental illness/intellectual disability by Ascend. The record revealed the resident had not been prescribed psychoactive (mental health) medications at the time or in the past 6 months and had no major metal illness or disorder. On 120/22 at 02:34 PM, the Social Worker reported the facility has a process for ensuring level 1 PASARR screenings are correct when the resident admits to the facility or there is a change in their mental health status but that Resident #2 must have been missed. After she reviewed the file she stated there should have been a Level II PASARR submitted.

Based on clinical record reviews and staff interviews, the facility failed to revise the comprehensive care plan for 2 of 18 residents reviewed (Residents #43 and #70). The facility did not remove information regarding transmission based precautions for Resident #43 , and did not add information regarding antianxiety medication and a wound for Resident #70. The facility reported a census of 72 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], identified Resident #43's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview for Mental Status (BIMS) score for Resident #43 was 13 out of 15, which indicated intact cognitive functioning. The resident was independent for transfers and required supervision of 1 staff for toileting and personal hygiene. A Care Plan with a Focus area dated 3/17/2, identified the resident with C. Difficile ([CONDITION(S)] difficile) related to antibiotic (ATB) therapy. A goal dated 2/26/21 identified the resident would not have any complications related to c. difficile through the review date. The following interventions with a revision date of 2/26/21, contained the following directives:: a. Resident #43 was in Contact Isolation. Staff to wear gowns and masks when changing contaminated linens, place soiled linens in bags marked biohazard, bag linens and close bag tightly before taking to laundry b. disinfect all equipment used before they left the room. c. encourage good nutrition and hydration. d. monitor for symptoms of weakness, dehydration, fever, nausea and vomiting and blood in stool. e. place Resident #43 in private room with contact isolation precautions. f. assist with hand washing after toileting and before and after meals. On 1/19/22 at 12:15 PM, Resident #43 walked to the bathroom independently without an assistive device. The resident shared a room with another resident and was not in isolation. On 1/19/22 at 12:47 PM, Staff B, Unit Manager stated she removed the c diff focus area, goal and interventions from the care plan on that day She concurred that it should have been removed when resident came off of isolation for c diff and that they failed to revise the care plan. 2. The MDS dated [DATE] revealed Resident #70 entered the facility on 9/27/21. Resident #70's MDS assessed the resident with a BIMS of 15 (no cognitive impairment) and listed active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress notes identfied a wound to resident's right lower extremity as follows: a. On 12/13/21 at 02:12 PM, resident reported she stood up and bumped her leg on the recliner lever. Immediate bruise and swelling noted to area. Measurement was 10.5 centimeters (cm) long by 4 cm in width. Placed sheepskin over the lever of the recliner to prevent further contusions. b. On 12/27/21 at 11:45 AM, wound center informed of the right lower extremity wound. c. On 12/29/21 at 03:59 AM wound center notes indicated resident could shower without wound dressing. Staff to apply conforming stretch gauze bandage and secure with transparent tape to left lower extremity and right lower extremity. Cleanse the wounds with normal saline moistened gauze, squeeze out excess and pack in to the wound. Cover with absorbent pad and secure. d. On 1/5/22 at 02:41 PM, received order to not use Adaptec on wounds with dressing ordered for the right lower leg. Treatment to right lower leg changed to cleanse with soap and water and Normal Saline daily. Apply [MEDICATION(S)] Ag Rope 2x45 cm daily. (Cut [MEDICATION(S)] ribbon to size and apply to wound). Apply large roll gauze daily. Cover with absorbent pad daily and secure with transparent tape. e. On 1/13/22 at 9:39 AM resident was seen by wound center for wound on bilateral lower extremities. No changes in treatment. The current Order Summary Report dated 12/21/21 revealed the following orders related to Resident #70's right lower extremity wound: a. Cleanse the wound anterior right lower extremity with saline. Apply [MEDICATION(S)] ribbon to wound. Apply conforming stretch gauze bandage, cover with absorbent pad, secure with transparent tape daily. b. Make sure to put in wound center measurements from wounds on bilateral lower extremities when return from appointment every Wednesday c. Measure right lower extremity wound weekly and as needed on Wednesday d. Remove bandages before showering every Tuesday, and Friday. e. Make sure large leg protector in place over right lower extremity unitly bruising is resolved. Check placement three times per day. f. Avoid standing for long period. Elevate legs to level of heart or above for 30 minutes daily or when sitting three times per day. The Care plan dated 12/29/21 revealed a problem/need for a risk for impaired skin integrity related to fragile skin with a goal to have the venous ulcers to left lower leg heal without signs and symptoms of infection. Staff directives included to administer medication and completed treatments as ordered, encourage good nutrition and hydration to promote healthier skin, monitor bruises weekly until resolved, skin treatments per physician orders, use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface, weekly wound documentation including measurements, and wound clinic prn. The care plan dated 12/29/21 failed to address an actual skin integrity problem nor did it address the wound to the right lower extremity from an injury on 12/13/21. Review of current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated 12/29/21 failed to address the need for an antidepressant medication. On 1/24/22 at 02:32 PM, Staff C RN (registered nurse) reported she was responsible to complete and update the care plans for nursing. She acknowledged there should have been an actual skin impairment problem on the care plan instead of risk for skin impairment and it should have addressed the wound on the resident's right lower extremity. Staff C also acknowledged the lack of a problem/need for antidepressant medication. She stated the social worker normally identifies the need for a problem related to mental health medications and ensures a problem is placed on the care plan. She stated there should have been a problem on the care plan for the antidepressant that was initiated in October 2021.

Based on observation, facility policy review and staff interviews, the facility failed to maintain a safe environment by leaving a medication cart unlocked with the keys hanging from the lock on the cart unsupervised in a resident care area. The facility reported a census of 72 residents. Findings include: Observation 1/20/22 07:25 AM, Staff A, Certified Medication Aide (CMA), went into room 315 to administer medication to Resident #58. Staff A, CMA failed to lock the medication cart and had the medication cart keys hanging from the open lock unsupervised from 7:25AM until 7:31AM. A staff member and an ambulatory resident walked passed the medication cart during this time. At 7:31AM, Staff A, CMA returned to the medication cart and acknowledged she left the cart unlocked with the keys hanging from the unlocked lock. On 1/20/22 at 1:34 PM, Staff A, CMA, revealed the narcotic key for the medication cart is kept on the same key ring as the medication cart key. Observation of the narcotic box revealed there were 13-50mg [MEDICATION(S)] tablets and 65 5-325mg [MEDICATION(S)] tablets in the narcotic box. Review of facility policy titled, Medication Administration, effective 10/10/19 revealed the medication cart must be locked when not in line of sight. On 01/20/22 at 9:18 AM, Staff B, Unit Manager, revealed it is an expectation staff keep the medication cart locked when it is not is their line of sight.

Based on observation, policy and inservice review and staff interview, the facility failed to handle food to minimize the risk of foodborne illness and utilize proper hand washing technique during one meal service. Observation of the meal service in 200 Hall kitchenette at 11:50 AM on 2/18/20, revealed improper handwashing, improper glove use, and contamination of residents' food. The facility reported a census of 77 residents. Findings include: Observation of the meal service in 200 Hall kitchenette at 11:50 AM on 2/18/20, revealed Staff C dietary aide turn the water on and wash her hands. Staff A then got paper towels from the dispenser and turned the water off with the paper towel and used the same paper towel to dry her hands. The dietary aide then donned gloves, obtained 2 slices of bread from the wrapped loaf and placed the bread on a plate. While still wearing the gloves, Staff C went to the refrigerator and got butter and buttered the 2 slices of bread, touching the bread with the contaminated gloves. Still with the same gloves on, she returned to the refrigerator to obtain a slice of cheese, which she then placed on the bread. The dietary aide then placed the cold lunch meat on the prepared bread with the same contaminated gloves. The dietary aide then cut the sandwich touching the bread with the same contaminated gloves. Once she completed the sandwich she removed her gloves and washed her hands. Again, after she washed her hands she shut the water off with paper towels and then used those same paper towels to dry her hands. Observed the dietary aide wash her hands with the same technique a total of 4 times. The dietary aide began preparing trays for the dining room, she placed the Reuben sandwich on the plate with tongs and then used her bare hands to hold the sandwich to cut in half. Once this was completed she went to the refrigerator to get out the cucumbers and then opened the kitchenette door for staff to get the tray. The dietary aide returned to the steam table to prepare the next plate, proceeded with the same routine. Staff C did not wash her hands after holding the Reuben, opening the refrigerator, or opening the kitchenette door and then proceeded with making 4 additional plates in that same manner. The dietary manager entered the kitchenette at that time to assist with delivering meals to residents and informed the dietary aide she could not touch the residents' food without using gloves or tongs to hold the food while cutting. The dietary aide then began using tongs to cut the Reuben sandwiches. An undated facility policy titled Inspection Report Item 8 Hands Clean and Properly Washed, instructed staff to wash their hands after handling soiled equipment or utensils, during food preparation as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, and after engaging in activities that contaminate hands. Review of Monthly Dietary in-services dated 12/2/19 and 1/31/20, revealed Staff C attended both and hand washing was reviewed at both of these in-services. During an interview with the Dietary Manager at 12:28 PM on 2/18/20, she stated not touching food with bare had reviewed several times The Dietary Manager stated she would not expect staff to use the same gloves and touch numerous things. The Dietary manager stated staff received instruction on correct hand washing. During an interview with the Administrator at 9:45 AM on 2/19/10, she stated she expected staff to use gloves or utensils while holding food to cut and to perform proper handwashing. The Administrator stated the Dietary Manager consistently reviewed handwashing and not to touch residents' food with bare hands with kitchen staff .

Based on observations, interviews, and record review, the facility failed to revise the care plan to accurately reflect the resident for two of 19 residents reviewed (Resident #175 and Resident #59). The facility reported a census of 77 residents. Findings included: 1. The Minimum Data Set (MDS) completed for Resident #175 with an Assessment Reference Date (ARD) of 1/24/20 showed a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Review of the care plan revealed the following: Mattress Observation showed on 2/17/20 at 2:53 PM a mattress on the floor beside the resident's bed. A review of the current care plan revealed lack of documentation regarding placement of a mattress beside the resident's bed. Diet texture A review of the care plan dated 1/17/20 showed an intervention for the resident's diet as a general diet with pureed texture and thin consistency liquids. The progress note dated 1/21/20 at 11:10 AM stated the facility received feeding recommendations from the Speech Therapist (ST) for the recommended diet of a mechanical soft diet with thin liquids (with dentures ), and to eat with supervision when needed. The progress note dated 1/22/20 at 12:36 PM stated the facility received a fax from the provider approving the mechanical soft diet with ground meat and thin liquids. A review of the resident's orders dated 1/23/20 showed a diet order for a regular diet with a soft mechanical texture and thin liquid consistency. On 2/19/20 at 10:56 AM, the Director of Nursing (DON) stated the care plan should reflect the resident's current diet recommendations and that if a resident's diet orders changed, then staff should update the care plan. She also stated the care plan should contain information regarding the mattress lying next to the resident's bed. The DON said they don't specifically care plan the medications but the care plan would say refer to the Medication Administration Record [REDACTED]. 2. The MDS completed for Resident #59 with an ARD date of 1/25/20 showed a BIMS score of 4, indicating severe cognitive impairment. The resident [DIAGNOSES REDACTED]. The resident utilized opioids three days of the seven day lookback period. A review of the resident's MAR indicated [REDACTED]. A review of the resident's MAR indicated [REDACTED] a. [MEDICATION NAME] (Concentrate) Solution 20 MG/milliliters (ML) dated 2/11/20 with the direction to give 0.5 ml by mouth every four hours as needed for shortness of breath or pain. b. [MEDICATION NAME]-[MEDICATION NAME] Tablet 7.5-325 MG dated 2/11/20 with the instruction to provide one tablet by mouth every six hours as needed for pain. c. [MEDICATION NAME]-[MEDICATION NAME] Tablet 7.5-325 MG dated 1/30/20 with the direction to provide one tablet by mouth in the morning for pain. A review of the resident's MAR indicated [REDACTED]. A review of the resident's care plan showed a lack of documentation related to the use of anticoagulants, opioids, or diuretics. During an interview on 2/19/20 at 10:56 AM, the Director of Nursing (DON) said they don't specifically care plan the medications but that the care plan would direct staff to refer to the MAR. The DON stated the care plan should have instructions to monitor for adverse effects. During an interview on 2/19/20 at 12:15 PM, the Administrator stated she would expect the care plan to contain a directive to monitor for side effects for the medications.

Based on observations, record review, staff and resident interviews, the facility failed to utilize resident wheelchair pedals for 2 out of 2 residents reviewed (Resident # 34 and Resident #58). The facility reported a census of 77 residents. Findings include: 1. The Minimum Data Set (MDS) completed for Resident #34 with an Assessment Reference Date (ARD) of 12/4/19 showed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The resident had [DIAGNOSES REDACTED]. The resident required extensive assistance of one staff for locomotion. Observation showed on 2/17/20 at 2:48 PM, Staff B, Certified Nurses' Aide (CNA) push the resident without pedals on the wheelchair. Observation showed on 2/18/20 at 12:32 PM Staff B push the resident from the resident's room down the hall and park the resident in the wheelchair next to other residents in the hallway without foot pedals on the wheelchair. 2. The MDS completed for Resident #58 with an ARD date of 1/19/20 showed a BIMS score of 15, indicating intact cognition. The resident had [DIAGNOSES REDACTED]. Observation showed on 2/17/20 at 11:15 AM, Staff A, CNA, push the resident in the wheelchair without foot pedals. On 2/19/20 at 10:56 AM, the Director of Nursing (DON) stated that she expected staff to pull the residents from the front of the wheelchair if the resident did not have foot pedals on the wheelchair. She said that some of the residents prefer to have their foot pedals off so they can propel themselves when they wish to leave. The DON said the care plan should contain the information if the resident did not want to have foot pedals on their wheelchairs. She reported that the resident should have foot pedals on when the staff pushed them from behind.

Based on observations, record review, and staff interviews, the facility failed to ensure appropriate infection control procedures related to the transportation of uncovered linens and completion of incontinence cares. The facility reported a census of 77 residents. Findings include: 1. Observation revealed on 2/17/20 at 12:08 PM, linen transported in a laundry cart, clothing hanging covered with bath blanket exposing bottom part of clothes, and a basket that contained folded clothes uncovered. Observation near the central nurses' station revealed, on 2/18/20 at 12:12 PM , laundry in a wire basket covered with a blanket without staff present. The sides of the basket were not covered, exposing clothes. During an interview on 2/19/20 at 12:25 PM, the Administrator stated that the laundry did have a covered linen cart and would expect the laundry department to use that cart. 2. The Minimum Data Set (MDS) completed for Resident #59 with an assessment reference date (ARD) of 1/25/20 showed a brief interview for mental status (BIMS) score of 4, indicating severe cognitive impairment. The resident had [DIAGNOSES REDACTED]. The resident required extensive assistance of two staff for toileting. Observation revealed on 2/17/20 at 10:49 AM, Staff B, Certified Nurses' Aide (CNA) provide pericare to Resident #59. Staff B wiped the resident's perineum by removing wipes from the package five times from the wipes package with contaminated gloves without completing hand hygiene. Staff B then placed a new brief on the resident with the same gloves and no hand hygiene. Then Staff B removed her gloves, and without completing hand hygiene, placed the mechanical lift sling under the resident before pulling up the resident's pants. Staff B, then connected the mechanical lift without completing hand hygiene then used the mechanical lift controller to raise the resident out of bed. Staff A, CNA, then directed the resident to the wheelchair. After completing the task, both CNAs washed their hands. During an interview on 2/19/20 at 11:13 AM, the DON stated she would not expect the CNA to take wipes out of the package without completing hand hygiene. She said the expectation is to prepare the wipes before completing the incontinence cares.

Based on observation, record review and staff interview the facility failed to implement interventions to prevent avoidable accidents resulting in a fall with fracture for 1 of 5 residents reviewed (Resident #70). The facility reported a census of 80 residents. Findings include: According to the Minimum Data Set (MDS) with an assessment dated of 10/10/18 Resident #70 had [DIAGNOSES REDACTED]. The MDS showed the resident had a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognition. The resident required extensive assistance of two (2) staff for bed mobility, transfer, walking in room, and extensive assistance of one (1) staff for locomotion on/off unit. The MDS identified the resident not steady when moving from seated to standing position, walking, moving on/off the toilet and surface to surface transfer between bed, and chair/wheelchair. The resident used a walker and wheelchair for mobility and had a history of [REDACTED]. The MDS also identified the resident wandered/an elopement risk and used an alarm daily. In review of Event Report history showed: a. Fall in room [ROOM NUMBER]/5/18 resulted in abrasion to knee b. Fall in dining room [ROOM NUMBER]/21/18 with no injury c. Fall in room [ROOM NUMBER]/25/18 resulted in transfer to emergency room for evaluation d. Fall in room [ROOM NUMBER]/26/18, pain with transfer after fall, intervention to keep resident in high traffic area when not in bed implemented. X-ray from 9/26/18 showed possible nondisplaced [MEDICAL CONDITION] right pubic ramus. The resident's Active Care Plan dated with a review date of 9/5/18, and Target date of 12/5/18 identified the resident at risk for falls related to cognitive impairment, impaired gait, impaired balance, and refuses to use walker or cane. Interventions included: Vision aid: glasses PT/OT evaluation and treat. Keep walker next to resident's table during meals to allow the resident to see and take with her when leaving the dining room. Addition interventions added on 9/26/18 included: Keep in high traffic area when not in bed. Offer reading material when sitting up during awake hours as needed. Review of the Event Report dated 10/28/18 revealed the resident transferred self, self ambulated and fell . The resident did not use her walker, she was holding a cat when ambulating and fell . The resident complained of pain in the shoulder, hip and leg. The resident was sent to the emergency room . The assessment documented the resident's call light was not on, no mobility alarms were attached, turned on, functioning or removed by the resident at the time of the fall. In review of the nursing Progress Notes dated 10/28/18 at 1:10 PM documented nurse at the nurse's station heard a loud noise come from room [ROOM NUMBER] where resident was. Entered room and observed the resident laying on the floor. Resident stated she got up to go back to her room and fell . The resident was in the room with other resident watching TV. The resident self transferred, not using her walker and fell . The resident reports not hit her head and complained of pain to her right shoulder. The resident is unable to raise her right upper extremely, grips to her right hand are weaker than the left. The resident complains of pain to the right hip and leg. The resident is able to move without difficulty. The nursing Progress Notes dated 10/28/18 at 1:15 PM documented the resident transferred to the hospital emergency room for evaluation. The nursing Progress Notes dated 10/28/18 at 7:23 PM documented the resident transferring to different hospital to have hip pinned. The nursing Progress Notes dated 11/1/18 at 4:04 PM documented the resident returned to the facility from hospital with a [DIAGNOSES REDACTED]. Hospital X-ray reports. 10/28/18 hip and pelvis X-ray showed resident with minimally displaced [MEDICAL CONDITION] femur. 10/28/18 right shoulder X-ray showed resident with mildly displaced right humeral neck fracture. In review of written statement from Staff G dated 11/1/18 related to fall on 10/28/18 showed resident observed walking into room [ROOM NUMBER]. Staff G pulled chair up for resident then went to get Staff H. In review of written statement from Staff H LPN showed Staff H aware resident ambulated into another resident's room prior to fall on 10/28/18 and resident left unattended by staff. When interviewed on 1/18/19 at 1:56 PM Staff G (Housekeeper) reported on 10/28/18 she walked out of the housekeeping storage room to find Resident #70 walking from her room (#317) into room [ROOM NUMBER] across the hall. The resident looked unsteady so she pulled a chair close for her sit on. Staff G stated she informed Staff H Licensed Practical Nurse (LPN) to assist the resident. Staff G confirmed her written statement dated 11/1/18 related to the resident fall on 10/28/18 and incorrectly identified room [ROOM NUMBER] as room [ROOM NUMBER]. When interview on 1/18/19 at 4:11 PM Staff H LPN stated on 10/28/18 Resident #70 self transferred and self ambulated to another resident's room, sat in a chair with her cat and was watching TV with the resident in room [ROOM NUMBER] across the hall to room [ROOM NUMBER]. The resident appeared comfortable and content in room [ROOM NUMBER] so she returned to the nurse station. Staff H reported the resident was in room [ROOM NUMBER] for 5-10 minutes and could not be seen from the nurse's station. She heard a loud noise from room [ROOM NUMBER] and the resident had fallen. Staff H confirmed Resident #70 was to be in a common space when out of bed so staff could visualize resident. In an interview on 1/19/18 at 8:35 AM the Director of Nursing stated expectation is for staff to follow all fall prevention strategies implemented for resident. Observation on 1/18/19 at 2:24 PM revealed room [ROOM NUMBER] not visible from nurse station.

Based on observation, staff interview and record review the facility failed to provide appropriate catheter care for 1 of 1 residents reviewed (Resident #36). The facility identified a census of 80 residents. Findings include: 1. Resident #36's Minimum Data Set (MDS) assessment dated [DATE] showed the resident had memory intact, required extensive staff assistance for daily cares, and had an indwelling catheter. The MDS showed the resident had [DIAGNOSES REDACTED]. The resident's Active Care Plan dated 2/27/19 identified the resident had an indwelling urinary catheter with a [DIAGNOSES REDACTED]. Interventions included to use standard care for indwelling urinary catheter and ensure perineal care is performed using proper technique with morning and evening cares and after toileting and incontinence. A nursing Progress Note dated 10/25/18 documented the resident admitted to the hospital Intensive Care Unit (ICU) for urinary tract infection (urosepsis) and pneumonia. On 1/18/19 at 07:01 AM observation revealed Staff A and B Certified Nursing Aides (CNA's) performed morning cares in the bathroom. Staff B cleansed each side of the resident's groin, Staff B took an alcohol wipe and cleansed from the catheter insertion site (urinary meatus) and down the tubing a few inches. Staff B failed to pull back the resident's foreskin and cleanse the area thoroughly. In an interview on 1/18/19 at 11:40 AM Staff C CNA reported to clean each side of the resident's peri area, pull back the foreskin in the male, and cleanse that area. She noted for each swipe, use a clean wet wipe, then use another wet wipe down from the catheter (urinary meatus) site and down the catheter tubing a few inches. Staff C noted, you do not not use an alcohol wipe from the urinary meatus site, nor down the catheter tubing, but a wet wipe or cloth. When interviewed on 1/18/19 at 1:00 PM Staff D Registered Nurse (RN) reported to pull back the resident's foreskin and cleanse the area. She noted staff can use an alcohol wipe or a cleansing (wet) wipe for cleaning from the catheter insertion site (urinary meatus) down the tubing, and noted the entire male genital organ is expected to be cleansed. In an interview on 1/18/19 at 2:00 PM the Unit Manager (RN) reported they have always used alcohol wipes for cleansing the catheter tubing, but staff should not touch the meatus with the alcohol wipe. She reported when cleaning the male genital area one should always pull back the foreskin and cleanse the entire area, as it is standard procedure. When interviewed on 1/19/19 at 7:20 AM the Director of Nursing (DON) acknowledged the concern and the observation did not follow facility policy. The Skills Checklist (#28), undated, to Provide Incontinent Care showed for male residents if uncircumcised, cleanse the male genital by pushing back the foreskin and gently washing, wash around the male genital and scrotum, and return the foreskin back to its natural position. The facility's Policy for Urinary Catheters undated, under Proper Techniques for Urinary Catheter Maintenance, (# G), directed staff not to clean the periurethral area with antiseptics to prevent Catheter Associated urinary Tract Infection while the catheter is in place. Routine hygiene, such as cleansing of the male genital organ is expected during daily bathing or showering is appropriate.

Based on record review, observation and staff interview the facility failed to assess bed side rails for risk of entrapment and obtain consent for use of side rails from resident or their representative for 2 of 2 residents reviewed (Resident #70 and #376). The facility reported a census of 80 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #70 had [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) score of 4, indicated the resident had severely impaired cognition and the MDS documented the resident required extensive assistance of two (2) staff for bed mobility, transfers and toilet use; and required extensive assistance of one (1) staff person for locomotion off unit, dressing, personal hygiene and bathing. The MDS Section P Restrains and Alarms identified the resident used a bed alarm and chair alarm the Physical Restraints Section remained blank for the use of bed rails, trunk retrain, and limb restraint. On 1/18/19 at 2:22 PM observation revealed Resident #70 in bed with the upper bed side rails in the upright in use, position. The resident's Active Care Plan dated 1/9/19 with a Target date of 4/10/19 identified the resident with cognitive impairment but not totally dependent with mobility, impaired gait, impaired balance, at risk for falls and at risk for serious injury. The resident's Active Care Plan failed to identify the use of the bed side rails. Review of the resident's clinical record revealed no bed side rail assessment completed or consent for use of the bed side rails. When interview on 1/18/19 at 2:28 PM the Director of Nursing (DON) stated Resident #70 has no bed side rail assessment completed or signed consent for the use of the side rail. 2. According to the MDS assessment dated [DATE] Resident #376 had [DIAGNOSES REDACTED]. The MDS documented the resident had a BIMS score of 8, indicating moderately impaired cognition. The MDS assessment identified the resident required extensive assistance of two (2) staff for bed mobility, transfer, walk in room, walk in corridor and toilet use, and totally dependent on staff for locomotion on and off unit. The resident requires extensive assistance of one (1) staff for dressing, personal hygiene and bathing. Review of MDS Section P, Restraints and Alarms revealed the areas coded with (0's) indicating not used. Observation on 1/18/19 at 11:16 AM revealed Resident #376 in bed with upper bed side rails in the upright, in use, position. Review of the resident's Active Care Plan revealed the care plan failed to identify the use of bed side rails. Review of the resident's clinical record revealed no bed side rail assessment completed or consent for use of bed side rails documented. When interviewed on 1/18/19 at 11:17 AM Staff F stated the facility did not do bed side rail assessments for use of half length side rails. When interview on 1/18/19 at 11:45 AM the DON stated, the facility has no bed side rail policy and bed side rail assessment is not completed for this resident. The DON stated maintenance [MEDICATION NAME] each bed and mattress combination to make sure gaps are appropriate but does not keep a log of beds and mattresses. In an interview on 1/18/19 at 1:50 PM the DON stated the facility will be implementing side rail assessments, consents for use of side rails and maintenance will be tracking logs of resident mattress and bed frame fitment.

Based on observation, record review and staff interview the facility failed to place signage in a conspicuous place outside of resident room identifying category of transmission based precautions or post instructions to see the nurse prior to entering resident room for 1 of 1 residents reviewed (Resident #64). The facility reported a census of 80 residents. Findings include: According to the Minimum Date Set (MDS) assessment dated [DATE] Resident #64 had [DIAGNOSES REDACTED]. The MDS documented the resident with a Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired cognition, dependent on staff for all activities of daily living and frequently incontinent of bowel. Review of the Nursing Progress Note dated 12/21/18 at 3:14 PM revealed new orders received and noted to obtain a stool sample for[DIAGNOSES REDACTED]icile. ([DIAGNOSES REDACTED] ([MEDICAL CONDITION]) a bacteria passed in feces and spread to food, surfaces and objects when people who are infected don't wash their hands thoroughly.[DIAGNOSES REDACTED]icile is contagious, microorganisms can be spread from person-to-person by touch or by direct contact with contaminated objects and surfaces (for example, clothing, cell phones, door handles). Nursing Progress Notes dated 12/22/18 at 9:54 AM documented stool sample obtained and sent to the lab, mucous stool with foul odor. At 1:37 PM lab results returned positive for C- Difficile. Review of the resident's Nursing Progress Notes revealed the resident had loose stools on (MONTH) 21, 22, 23, 24, 25, 26, 28, 29 and (MONTH) 9,10, 11, and 15, 2019. Nursing Progress Notes dated 1/17/19 at 1:24 PM documented the resident continues on antibiotic [MEDICATION NAME] for [MEDICAL CONDITION]. Observation on 1/17/19 at 2:29 PM showed resident room without transmission based precaution signage posted. Observation on 1/18/19 at 8:27 AM showed resident room without transmission based precaution signage posted and red biohazard bags present in both garbage cans in resident room. In review of facility procedure related to Standard Precautions and Transmission based precautions showed no direction to staff to post signage for a resident in transmission based precautions. When interviewed on 1/18/19 at 10:25 AM the Director of Nursing stated the facility does not post any type of signage related to transmission based precautions. CDC Guidelines for residents with[DIAGNOSES REDACTED]icile in long term care facilities include but not limited to the following: Contact Precautions Education healthcare providers, housekeeping, administration, residents, and families and visitors about [DIAGNOSES REDACTED] and the proper use of Personal Protective Equipment (PPE). C. diff infected residents should be placed under contact precautions for the duration of their diarrhea and for a minimum of 48 hours after the last episode of diarrhea. Implement soap and water for hand hygiene before exiting room of a resident with[DIAGNOSES REDACTED]icile. Residents with active[DIAGNOSES REDACTED]icile diarrhea should not attend group dining or activities. Place resident with[DIAGNOSES REDACTED]icile in a private room or in a cohort with other CDI residents when possible. All Health Care Providers and visitors should wear proper personal protective equipment (PPE) and wash hands vigorously with soap and water for 20 seconds.

Based on record review and staff interview, the facility failed to notify the resident or their representative of the bed hold option for 1 out of 4 residents reviewed for hospitalization s (#7). The facility reported a census of 80 residents. Findings include: The Minimum Data Set ((MDS) dated [DATE] documented the resident as being discharged with return anticipated. Review of the Nurse's Progress Note dated 10/1/18 documented the resident was transported to the emergency room and admitted for [MEDICAL CONDITION]. Documentation of notification of resident or their representative regarding the bed hold policy is absent from the resident's health record. A review of a document Admission and Agreement defined that if a resident is temporarily absent from the facility for medical treatment, the Facility shall provide written information to the Resident specifying (1) the duration of the bed hold policy under applicable governmental regulations, if any, during the which the Resident shall be permitted to return and resume residence in the facility and (2) the Facility's policies regarding bed hold periods. The Facility shall then ask the Resident or the Resident's Representative if he or she wished the Facility to hold open the bed. The Facility shall document in the Resident's records the fact that such information was given and the response of the Resident or the Resident's Representative. Review of a letter written by the Office Manager dated 10/1/18 directed the Resident's Representative to indicate on the enclosed Private Pay Reserve Form whether the bed was to be held or not. During an interview with the Director of Nursing (DON) at 4:20 PM on 1/18/19 the DON stated they were unable to find documentation related to the bed hold notification for Resident #7. During an interview with Staff I, Office Manager, at 4:35 PM on 1/18/19, Staff I stated she looks at the census daily to see who was sent out of the facility and sends the resident or their representative a letter, a blank copy of the bed hold option form, and an envelope addressed to the facility. Staff I stated she did not document the sending of the form or the return of the form to the facility in the resident's health record. The Office Manager stated the nurse that transferred the resident out would be responsible for reviewing the bed hold policy with the resident or representative and documenting in the health record.

Based on record review and staff and family interview, the facility failed to promptly report a resident's change of condition to a family member or designee for 1 of 4 residents reviewed. (Resident #1) The facility identified a census of 75 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 1/10/18 indicated Resident #1 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, sometimes made self understood and understood others, as dependent on 2 staff with bed mobility, required extensive assistance of 2 staff with transfers and as non-ambulatory. A Care Plan with a start date of 2/25/15 indicated the resident had a potential for activities of daily living (ADL'S) decline/safety and falls and a rehab potential. The interventions included the following: a. Stand pivot for transfers with 2 staff assist. An Event Report dated 1/6/18 at 8:30 a.m. documented staff was getting Resident #1 ready for bed and notified the nurse the resident had a large yellow area across her chest, right breast and under the right arm. The Event Report Section 1, to be completed by the nurse directed the nurse to; Describe Injury (size, depth, color, pain, bleeding, limitation in Range Of Motion (ROM) results of head-to-toe assessment and vitals. The nurse documented the following: Unable to measure the bright yellow area with no dark areas. The resident expressed no pain and revealed no limitation with ROM. The form indicated a message had been left for a family member on 1/8/18. An X-ray report form dated 1/10/18 indicated the resident suffered from a non-displaced 6th rib and possibly 7th rib fracture. When interview on 2/2/18 at 2:10 p.m., Staff E, Licensed Practical Nurse (LPN) stated she did not call the resident's family because it was too late in the evening on 1/6/18 when the bruise was discovered. When interviewed on 2/2/18 at 3:50 p.m., the Director of Nursing (DON) reported the staff failed to call the resident's family member the evening of 1/6/18, when the bruise had been first observed because it was late and non-emergent. The nurse on duty at the time planned to call the family on 1/7/18 when she returned to work however she got pulled to work another hall and forgot to notify the family. During an interview on 2/6/18 at 12:40 p.m., Staff B, LPN confirmed on 1/8/18 she called the resident's family member and left a message to return call related to the bruise but was unaware why the family had not been notified at the time the bruise first observed. The staff member confirmed nurses called family and/or a resident representative right away following a change of condition which included the resident's bruise. During an interview 2/6/18 at 12:50 p.m., Staff C, LPN stated the resident's bruise should have been reported to the family and/or family representative within 24 hours. During an interview 2/6/18 at 12:12 p.m., Staff A, Registered Nurse (RN) indicated the facility had no policy on family notification but she felt it appropriate to notify family 2 days following a change of condition. During an interview 2/6/18 at 12:56 p.m Staff D, LPN stated family and/or a representative should be notified of a condition change as soon as possible. If unable to contact family, continued to call until contact is made. During an interview 2/6/18 at 11:22 a.m., a family member stated he/she absolutely had a concern related to the facilities failure to notify him/her of the resident's bruising until 2-3 days later. The family member stated he/she had not received a message on 1/8/18 as stated by the facility staff and that he/she became aware of the bruised area on 1/9/18 when a staff member asked him/her what he/she thought of the resident's bruise. At this time he/she observed the bruised area. The family member reported visiting the facility everyday and felt there should be no reason the facility staff failed to notify him/her of the bruise.

Based on record review, observation, and staff interviews, the facility failed to properly assess and implement adequate interventions in order to prevent the development of avoidable pressure sores for 2 of 6 residents reviewed with pressure sores (Resident #2 and #5). The facility reported a census of 74 residents. Findings included: 1. Resident #2 had a MDS (Minimum Data Set), significant change assessment with a reference date of 8/16/17. The MDS indicated the resident had a BIMS (Brief Interview for Mental Status) score of 4. A score of 4 identified the resident with severely impaired cognition. The MDS indicated the resident required extensive assistance from 2 staff members for bed mobility, transfers, dressing, and toilet use and had not walked. The MDS indicated the resident required staff assistance to balance during transitions and had not walked or turned around, the resident without any upper and lower extremity range of motion impairment, and used a wheel chair for locomotion. The MDS identified Resident #2 at risk for pressure ulcer development. The MDS indicated no presence of pressure ulcers and the resident had a surgical incision. The MDS indicated the resident used a pressure reducing device on the bed and chair and did not identify a turning and repositioning program. The MDS revealed the resident's [DIAGNOSES REDACTED]. The CAA (Care Area Assessment) completed with the 8/16/17 MDS identified the resident triggered for pressure ulcers. The CAA documented the resident had a recent [MEDICAL CONDITION] resulting in a decline in condition and an increase in potential for skin breakdown and the resident had a pressure reduction cushion for the chair and an alternating air overlay on the bed. The MDS revealed the resident required staff to assist the resident with position changes before meals, at bed time, and when needed, to keep the heels elevated off the bed surface, and the resident frequently repositioned self to the back. The notes indicated the resident received patient education but ineffective due to cognitive impairment and the staff educated to reposition the resident frequently to prevent coccyx pressure. A Braden Scale For Predicting Pressure Sore Risk identified the resident scored a 14 on 7/29/17. A score of 13 to 14 identified the resident at a moderate risk for pressure sore development. An Active Care Plan with a problem start date of 4/21/17, a review date of 7/5/17, and a target date of 10/4/17, identified the resident had the potential for skin break down due to thin, fragile skin, and limited mobility due to a fractured pubis ramus (pelvis) fracture. The interventions included and directed the staff members to do the following: Dietary supplements per order. See The Standard Of Care For Risk For Skin Breakdown (dated 4/13) that included: a. Use a pressure reduction device on the resident's bed and chair if bed or chair bound. b. Turn and encourage the resident to reposition every 2 to 3 hours. c. Moisture barrier according to facility protocol. d. Encourage oral intake including fluids. e. Prevent friction and shearing. f. Encourage maximal mobilization Half side rails on the resident's bed for positioning and bed mobility. Keep the resident clean and dry, try to minimize the resident's exposure to excess moisture, use a barrier when needed, and moisturize the skin well daily with morning and bed time cares. Use caution with transfers and repositioning. Check bruises weekly until healed when needed. Skin treatments according to physician orders. The Care Plan lacked documentation that directed staff to keep pressure off of the resident's heels until 8/22/17. A Treatments record documented an alternating air overlay mattress added to the resident's bed on 8/15/17. A form titled Interdisciplinary Progress Notes identified a late nurse's entry dated 8/21/17 at 4:01 p.m. The entry documented the resident returned to the facility on [DATE] at 4:00 p.m. after a podiatry appointment. The podiatrist documented the resident had a pressure ulcer to the left posterior heel. Documentation directed the staff to keep pressure off the heel at all times, place 2 pillows under the calf to offload the heel, and no compression socks to the left heel. The Centers for Medicare and Medicaid Services (CMS) identify the following stages of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Eschar is a thick black, brown, tan leathery consistency and made from slough (dead tissue). The IPN note identified a late entry nurse's entry dated 8/21/17 at 4:30 p.m. documented the resident had a 4 cm (centimeters) x (by) 4 cm bluish colored area under the heel. The note indicated the resident is to return to the wound center on 8/23/17. An event completed (incident report) and the CNAs (Certified Nurse's Aides) were directed to place pillows under the resident's left lower extremity when in bed. An Event Report, dated 8/21/17 at 4:00 p.m. documented the resident developed a pressure sore, that measured 4.0 x 4.0 cm, bluish in color on the left heel, area closed, and the resident without pain. The report lacked documentation of an investigation about how the pressure sore developed. A Podiatrist Progress Note, dated 8/18/17, identified the podiatrist saw the resident at the clinic due to left foot pain and accompanied by family members. The note indicated the resident had a fall on 7/25/17, ORIF (repair of hip) on 7/26/17 and the resident bed bound a great deal of the time. The note indicated the resident experienced increasing foot pain with pain level of 7 out of 10 (0 no pain and 10 extreme pain). The resident verbalized numbness and tingling in the both lower extremities. The resident had x-rays completed 3 days before the clinic visit that revealed diffuse osteopenia (low bone density) and arthritic changes throughout the foot and ankle but no fractures and no soft tissue deformities or ulcerations. The resident's dorsalis pedis (artery running on top of foot) and posterior tibial pulses (by ankle and heel) faintly palpable in the feet, skin cool with good capillary refill of the toes, skin temperature, tone, and turgor within normal limits, the resident without varicose veins, without swelling, and there were no ischemic changes or [MEDICAL CONDITION]. The notes identified the resident's light touch, sharp, dull, and vibratory sensations diminished to the lower legs and feet and gross motor function to the calf and foot musculature intact. The resident had normal skin color without rashes, ulcers or pigmentation changes and had hair growth. The podiatrist documented the resident had a 3.2 cm x 3.5 cm pressure ulcer on the left posterior heel with stable intact black epithelium overlay, no drainage or redness. Documentation revealed the resident had very limited strength or range of motion in the bilateral lower extremities, muscle movement intact, and the resident seemed frail. The podiatrist documented the pressure likely happened due to the resident's immobility after hip surgery. Orders for the facility included to stop the compression stocking to the left lower leg, the left heel should have no pressure at any time and place to pillows under the calf to suspend the heel. The podiatrist requested to see the resident return to the wound healing center in 1 week. CNA Activities of Daily Living Summary sheets, dated 8/12/17 to 8/19/17, documented the resident required extensive staff assistance or dependence on staff for mobility, transfers and toileting. The resident's Active Care Plan identified a new problem for a pressure ulcer, dated 8/22/17. The interventions directed the staff to keep the left heel free from pressure when in bed and the wheel chair with the use of 2 pillows. A Wound Healing Center report, dated 8/23/17, identified the resident had been bedridden, developed a pressure ulcer on the left heel, and the heel has improved since suspended. The report directed the staff the resident needed to wear an EZ boot (suspends heel) on the left foot at all times. Record review revealed the resident was seen at the Wound Healing Center or by the wound nurse from the wound center every week. On 10/10/17 the wound nurse saw the resident at the facility. The left heel unstageable pressure sore measured 3.0 cm x 4.0 cm x 0.1 cm, the wound base black/brown in color, no drainage, the wound edges adhered, the wound appeared stable, and measured smaller than the previous week (3.0 x 4.3 cm x 0.1 cm on 10/3/17). The report documented the resident had a full thickness tissue injury to the left heel, and the pedal pulses palpable. The report lacked any wound measurements. A Wound Nurse Notes sheet from a facility visit, dated 8/29/17, revealed the pressure wound measured 3.2 cm x 3.8 cm x 0.1 cm, the wound bed dry, stable, and without redness, drainage, and signs of infection. The resident denied pain in the left foot. Record review revealed a physician's Telephone Order, dated 7/10/17 that directed staff to discontinue the resident's vitamin and calcium due to previous non-compliance. A Nutrition note, dated 6/12/17, documented a house Supplement 120 cc (cubic centimeters) twice daily initiated. A note written, dated 7/3/17, documented the resident received a general diet and continued on the supplement. On 7/5/17 the dietitian documented the supplement discontinued due to the resident's dislike, the resident had a poor appetite, weighed 105.8 pounds and stable, and staff would offer food and fluids according to the resident's likes. A note written 8/24/17, documented the resident had a new skin impairment to the left heel, refused house supplement in the past, had increased needs for healing, had been accepting ice cream, pudding, and yogurt at meals, and planned to monitor the resident. A note written 10/9/17, revealed the resident's weighed 110.2 pounds, a 7% increase in 30 days, appropriate, and the resident now eating well. The resident's high calorie foods intake remained in place. Observation on 10/9/17 at 9:35 a.m. identified the resident sitting in the hallway in a wheel chair with a pressure relief boot on the left lower leg. Observation revealed the boot allowed a space in the heel for pressure relief. Observation throughout the survey identified the resident wore the boot at all times. During an observation on 10/10/17 at 9:40 a.m., the wound nurse assessed the left heel and had no new orders. The wound black/brown in color, wound bed dry, and had no drainage. The resident denied pain in the heel. The treatment to leave the wound open to air and the resident to wear the boot was continued. On 10/10/17 at 6:27 a.m., Staff C and Staff E, CNA's (Certified Nurse's Aide), was interviewed and state they provided care for the resident. The staff stated the resident started wearing a boot on the left heel after the pressure sore started. The staff thought the resident possibly had the heels floated with a pillow before the pressure ulcer developed and believed the pillow stayed in place. The staff stated they were unaware how the pressure sore developed if the resident had pressure relief. On 10/11/17 at 7:58 a.m., Staff F, LPN (Licensed Practical Nurse) was interviewed and verified the resident returned from the hospital on [DATE] without any pressure sores and the podiatrist first identified the left heel ulcer on 8/18/17. On 10/11/17 at 9:30 a.m., Staff F and the DON (Director of Nursing) was interviewed and stated the resident had been able to move his/her left leg alone at times. The staff stated they observed the resident's left leg slightly off the side of the bed at times and the resident had moved the left leg independently. The staff stated the 8/22/17 CAA and Care Plan documented pressure relief for the resident's heels and the documentation covered the entire assessment period for the 8/16/17 MDS. The DON stated the CNA that bathed the resident on 8/16/17 stated the resident had no signs of any heel skin impairment on that day. A note hand written by Staff C on 10/12/17 documented the resident had no skin impairment to the heels when bathed on 8/16/17. The DON presented a typed signed note by the ARNP (Advanced Registered Nurse Practitioner) on 10/11/17. The ARNP wrote the facility had assessed the resident's pressure ulcer risks after returning to the facility on [DATE], interventions to minimize the risk of pressure ulcer development had been implemented, and the resident developed an unavoidable pressure ulcer to the left heel on 8/18/17. On 10/25/17 at 9:50 a.m., the ARNP was interviewed and stated she had never seen the pressure sore during visits to the resident. The ARNP stated the resident wore an abductor pillow, and had seen heels floated. The resident did not wear shoes. The ARNP stated she spoke with the resident's nurse and she said the abductor pillow was approximately 4-6 inches above the ankle area. The ARNP stated the abductor pillow did not always appear properly aligned and the resident would move the leg some at times because of being uncomfortable. On 10/25/17 at 9:40 a.m., the Wound Center registered nurse was interviewed with the physician present. In presence of the physician, the nurse stated the heel pressure sore was avoidable following the [MEDICAL CONDITION]. 2. Resident #5 had a MDS assessment with a reference date of 5/2/17. The MDS identified an admission date of [DATE]. The MDS indicated the resident had severely impaired cognitive function and required staff assistance for bed mobility and transfers. The MDS and the 4/25/17 Interim Plan of Care documented the resident had a pressure relieving mattress on the bed but no pressure relieving cushion in the chair. On 5/31/17, the staff documented in the IPN notes that the staff found the resident's bilateral inner buttocks red with a dime sized calloused area to the right inner buttock. On 6/6/17 the Wound Nurse documented a Stage II pressure wound to the right buttock measuring 0.5 x 0.5 x 0.1 cm. The nurse documented the wound bed red and granular with scant drainage and directed the area be cleaned daily with normal saline, apply wound gel and then cover with bordered foam dressing. The nurse recommended a cushion to the chair at all times and an air overlay on the bed mattress. On 6/13/17, the nurse documented the Stage II right buttock wound healed.

Based on observation and staff interview, the facility failed to prepare and serve food in a manner to prevent foodborne illness during one of one observations. The facility reported a census of 74 residents. Findings include: 1. During observation on 10/10/17 at 11:25 a.m., Staff A, Dietary Cook, checked the food temperatures of foods planned to be served at the lunch meal. Turkey salad sandwiches food temperature had not been checked with the other foods. At 12:03 p.m., Staff A, obtained a plate of turkey salad sandwiches from the cooler, and placed 1 sandwich on a plate for a resident who requested the sandwich. Per surveyor request Staff A checked the temperature of the sandwich and recorded the temperature 48.8 degrees Fahrenheit (F) at 12:04 p.m. At 12:04 p.m., the dietician stated the turkey salad sandwich temperature needed to be at 45 degrees or less when served. At 12:15 p.m., final temperature at the end of meal service revealed temperature at 52.8 degrees (F). In an interview, 10/11/17 at 1:40 p.m., the dietary manager reported turkey salad sandwiches had been made on 10/10/17 at 9:30 a.m., and placed in the cooler. The dietary manager reported cold food should be 40 degrees or below when served. If temperature over 48 degrees, there would be a risk for food borne illness. The facility Diet Orders and Special Equipment Marian Home sheet dated 10/6/17, identified 12 residents received general mechanical soft diets. The 10/5/17, noon menu identified residents on a mechanical soft diet were to receive a Turkey salad sandwich.

Based observation, record review and interviews with resident and staff the facility failed to assess and implement care plan interventions for 1 of 13 active residents reviewed who preferred privacy when bathing (Resident #11).The facility reported a census of 74 residents. Findings included: Resident #11's 9/27/17 Minimum Data Set (MDS) documented the resident had intact cognitive function. The resident required physical assistance only for transfers when bathing. During observation on 10/11/17 at 6:52 a.m. the resident sat in the whirlpool tub in the 500 hall Spa room. Staff B, Certified Nursing Assistant (CNA) stated the resident had been left unattended in the tub. During interview on 10/11/17 at 7:57 a.m. Staff C, CNA, stated she had left the resident alone to soak for a while because the resident requested to do so. During interview on 10/11/17 at 8:37 a.m. Resident #11 stated she had asked to be left alone in the tub. The resident stated she liked to soak in the tub and liked privacy when bathing and rinsing. The resident stated she had almost always been left alone to rinse. The resident's care plan lacked any plan to leave the resident unattended in the tub or to honor the resident's wish for privacy when bathing. During interview on 10/11/17 at 8:51 a.m. the Director of Nursing (DON) stated it had never been the policy of the facility to leave residents alone in the tub. She stated if staff had told her or the Care Plan team the resident wanted to be left alone in the tub they would have requested an Occupational Therapy assessment to determine if the resident could be safely left in the tub alone in the tub and developed care plan interventions for that.

Based on observation, record review, physician and staff interviews, the facility failed to provide adequate supervision to protect one of four residents (Resident #1) from hazards. Record review identified Resident #1 required one staff assistance for transfers and ambulation (with a front wheeled walker). The resident's care plan directed staff to keep Resident #1 in a-lounge between meals for supervision to reduce the risk of falls. On 2/16/16 Resident #1 had an unwitnessed fall in a-lounge that resulted in a fracture when the staff left him/her alone for five minutes. Staff interviews revealed inconsistencies regarding supervision of Resident #1 when in a-lounge. The facility identified a census of eighty-four (84) residents. Findings include: 1. A Minimum Data Set with assessment date of 2/3/16, assessed Resident #1 with a Brief Interview for Mental Status (BIMS) score of 7 (severe cognitive impairment). A score of 7 identified the resident's cognition as severely impaired. The resident had no behavior symptoms identified. The resident required extensive assistance of two staff with bed mobility, transfers and toileting. The resident required extensive assistance of one staff with ambulation, dressing, eating, personal hygiene and bathing. A balance during transitions and walking test revealed the resident was not steady and only able to stabilize with staff assistance in all areas of testing. The resident used a walker for ambulation. The resident was frequently incontinent of bladder. The resident had [DIAGNOSES REDACTED]. The resident had one fall without injury since the previous assessment. History of Falls: A therapy recommendations form dated 10/21/15, revealed therapy identified the resident could walk independently with 4 wheel walker in facility. An event report dated 10/31/15 at 7:15 p.m., revealed staff attempted to open the resident's door and observed the resident on the floor laying on his/her right side next to the door. The resident bore weight without difficulty and stated he/she hit their head. Staff did not observe injury. The preliminary intervention/action plan completed by the charge nurse revealed staff should keep the resident in a supervised area at all times unless in bed, frequent room checks throughout night, continue pressure alarm throughout night and stand by assistance with ambulation, encourage and remind the resident to use walker and keep door open. On 11/2/15 the Director of Nursing (DON) also wrote that staff should sit the resident in the lounge area when up to facilitate increased supervision. An event report dated 12/9/15 at 1:50 p.m., revealed the resident walked by the nurses station and got his/her walker caught on another resident's walker. The resident fell on the carpeted area onto the right side. The resident did not sustain injury. The preliminary intervention/action plan completed by the charge nurse identified physical therapy would evaluate and treat. A physical therapy (PT) evaluation dated 12/11/15 revealed the resident required supervision from staff during mobility in the facility with 4 wheel walker due to impaired cognition. An event report dated 12/19/15 at 2:15 p.m., revealed staff found the resident laying on his/her right side/back when they entered the resident's room. Observation revealed clothing scattered on the floor of the resident's room. The walker was by the window in the room and out of reach of the resident. The resident had one shoe off with sock partially off. The assessment revealed a 2.5 centimeter (cm.) by 3.7 cm. bruise on the right outer wrist. The event report identified that the resident frequently left the walker and walked without it. The preliminary intervention/action plan completed by the charge nurse revealed staff assisted the resident to A lounge and that staff should keep the resident in a supervised area and provide assistance of one. Staff would check a UA (urinalysis) and have physical therapy evaluate the resident. A PT evaluation dated 12/23/15 identified the resident continued to require assistance from staff in the room and in the facility. A multistix urine test, dated 12/20/16 did not identify an infection. A care plan with status date of 12/7/15 contained an addendum dated 12/30/15 that revealed the resident could ambulate independently in the facility. An event report dated 1/17/16 at 11:15 a.m. revealed the resident fell while walking to the dining room for lunch. The resident's walker got too far ahead of the resident and the resident fell to the floor. Staff witnessed the fall. The preliminary intervention/action plan completed by the charge nurse revealed staff would remove the 4 wheel walker and give the resident a 2 wheel walker to keep the resident from walking too fast. Following the fall a therapy recommendations to staff form, dated 1/18/16 revealed the resident should transfer, ambulate and toilet with assistance of one with front wheel walker and gait belt. An interdisciplinary progress notes dated 2/6/16 included the following documentation: Staff reported Resident #1 had increased confusion and had forgotten how to ambulate. The interdisciplinary progress notes dated 2/7/16 documented, the resident had an increase (in) confusion, not oriented, unable to follow simple commands. An event report dated 2/16/16 at 5 p.m. and documented by Staff A licensed practical nurse (LPN), revealed staff found the resident lying on his/her right side in the floor in front of the chair the resident sat in with walker next to the resident. The location of the incident was A-lounge. In the event section of the event report it read alleged fall, unattended. The resident could not extend or bear weight to the right leg. The resident transported to the emergency room (ER) for evaluation. The care plan prior to the fall, with status date of 12/7/15 and identified as the care plan in place prior to the 2/16/15 fall, directed staff to keep the resident in A-lounge between meals for supervision. The resident ambulated to all destinations with rolling walker and assist of one. The resident used a wheelchair as needed (PRN). A toileting intervention directed staff to toilet the resident before and after meals, at bedtime and as needed. An addendum dated 2/16/16 revealed the resident fell with fracture to right femoral head. The facility would reassess for interventions upon return to facility. An activities of daily living summary for 2/16/16 revealed the last toileting documented as 2:09 p.m. Hospital Records: A 2/16/16 hospital history and physical identified that a resident with end stage dementia presented to the emergency room (ER) with unwitnessed fall. An x-ray performed on that date identified the resident with a displaced transverse fracture of the right femoral neck. An orthopedic consultation dated 2/16/16 identified the resident with an injury to the right hip. The resident did not have pain prior to 2/16/16. The physician discussed the risks and complications of surgery to repair the fracture with the resident's family. The physician documented that the resident had limited ability to ambulate and following surgery, the resident would continue with severe limitations. The physician told the family that surgery would relieve pain. An operative report identified the resident underwent [REDACTED]. An after visit summary with encounter date of 2/16/16 revealed the resident discharged from the hospital on [DATE]. The current care plan with status date 12/7/15 contained interventions that included the resident would use a pressure alarm in bed and chair at all times and keep resident in A-lounge between meals for supervision. Observation on 3/14/16 at 9:30 a.m.: Observation of the A-lounge revealed it was a lounge in the A-hallway. It was located in the middle of the west side of the hall. Staff walked by going to resident rooms up and down the hallway. The nurse kept the medication cart in the A-lounge. Observation showed on 3/14/16 at 9:56 a.m., the resident in A-lounge seated in a wheelchair. Staff B LPN cued the resident to eat a snack. The resident used a pressure alarm in the wheelchair. On the same date at 10:04 a.m. Staff B LPN unit manager and Staff C LPN assisted the resident to the toilet. Staff positioned the resident outside the bathroom. The two staff stood the resident with a gait belt and the resident walked into the bathroom with a front wheel walker. Following toileting, staff placed the resident in a recliner in A-lounge at 10:20 a.m. On the same date at 10:33 a.m. 2 therapy staff walked the resident and the resident went to the therapy room. The resident returned from therapy at 10:55 a.m. and staff transferred the resident into a recliner in A-lounge. Staff applied the pressure alarm and put the foot rest of the recliner up. Staff C LPN was present in the A-lounge. At 11:18 a.m. Staff C LPN left the A-lounge and Staff D certified nurse aide (CNA) was in the lounge. On the same date at 11:40 a.m. the DON, Staff B LPN and a CNA stood the resident. The resident took a few steps. At 11:55 a.m. the resident was in the dining room with a staff seated beside him/her. Observation on the same date at 12:20 p.m. revealed the resident remained at the dining room table with staff assisting him/her. On the same date at 12:52 p.m. the resident sat outside Staff B LPN's office under supervision of Staff B. The resident remained with Staff B LPN until Staff D CNA took the resident to A-lounge with a staff present. At 2: 45 p.m. the resident sat with staff at the Kiosk work area in his/her wheelchair. On the same date at 3:40 p.m., the resident was with Staff B LPN. At 4:10 p.m. of the same date, the resident's family member took the resident outside in the wheelchair. On the same date at 5:12 p.m. the resident sat at a table in the dining room with staff circulating in the dining room. Observation showed the resident's pressure alarm in place and functioning. Medical Director : On 3/9/16 the facility medical director documented in a typed note that she reviewed the resident's case history and medical history. She wrote the resident had a low impact fall (found at the base of the chair) that resulted in a femoral neck fracture. The resident had documented osteopenia and did not receive Vitamin D or calcium supplements. Given the significant risk factors, the medical director thought the osteopenia contributed to the fracture. On 3/14/16 at 4 p.m. the medical director stated the fall was a low impact fall and a fracture would not have necessarily occurred without osteopenia. Staff Working When the Incident Occurred: On 3/14/16 at 2:33 p.m. Staff A LPN stated she looked over physician facsimile notes and noted orders while the resident sat in A-lounge. She stated she went to the Kiosk computer to put labs in, leaving no staff in the A-lounge to supervise residents. She identified the Kiosk area as a short distance from the A-lounge. She stated the resident was out of her view when she went to the Kiosk area. She put 2 sentences in the computer and Staff E walked by and saw the resident on the floor. Staff A stated she didn't think she was gone from A-lounge over 5 minutes. She stated she did not hear the resident fall. She stated the resident's feet remained in the front of the chair. She stated she did not recall the resident as unduly restless prior to the fall. Regarding the supervised A-lounge area, Staff A stated it was an area where people are and they come and go. Staff go by the area frequently. Staff A stated the resident did try and get up a lot per self. Staff A identified herself and Staff E CNA and Staff F CNA working when the resident fell . On 3/14/16 at 7 p.m. Staff F CNA stated she thought she left that day prior to the incident at 6:30 p.m. (Review of Staff F's hours by the facility showed Staff F worked 1 p.m. to 4:02 p.m. on the day of the incident.) She stated prior to leaving, she sat with the resident who tried to get up on his/her own a few times. Staff F stated when she left, the resident was OK and she felt it was safe to leave the resident. She identified the supervised area as the A-lounge. A staff is not always present. Staff walks by a lot and the nurse is usually out there. She stated staff toileted the resident right before she left. On 3/15/16 at 2:10 p.m. Staff E CNA stated she transferred residents to the dining hall when the resident fell . She stated she toileted the resident at 4:20 p.m. She stated she did see the resident try and stand on his/her own that day. The resident tried to stand while the nurse was there. Staff E stated Staff F sat with the resident before she left because the resident was trying to stand. Staff E stated after Staff F left, Staff G certified medication aide (CMA) and Staff B LPN floated and tried to help. Staff E stated they try to keep the resident in a high traffic area. The nurse is out there and if the nurse is on break staff keeps by the area. A staff is usually sitting there. On 3/15/16 at 2:29 p.m. Staff G CMA stated she didn't get down A-hall right away. She took one person from A-hall to supper and when she came back to answer a light, she saw Staff F and Staff A working with the resident who had fallen. On 3/14/15 at 3:05 p.m. Staff G stated the resident never waits for help and tries to get up per self. She stated the residents with alarms sit in the supervised area so staff can run to them. In A-lounge, the nurse parks the medication cart there and if the nurse is not right there one of the other staff is. Staff may not be present if they leave to answer a light. On 3/14/16 at 2 p.m. Staff B LPN and unit manager stated she came upon the resident around 5 p.m. Staff B went to the hall to ensure residents were getting out to the meal. She stated Staff A was the charge nurse and just started to get the resident's vitals when Staff B arrived. The resident complained of pain right away. Staff B identified the fall as unwitnessed because Staff A left the lounge for a couple minutes. Staff B stated the resident would try and get up. Prior to using a chair alarm, staff kept the resident in the lounge and sometimes at the nurses station. She stated it is not required to have a staff in the supervised area. Staff are frequently out there or going by. After the resident returned from the hospital, they placed a chair alarm and have someone with the resident almost all the time. Staff B stated she did not like leaving the resident alone. On 3/15/16 at 12:05 p.m. Staff D CNA stated she works A hall day shift. She stated the resident would try and get up on his/her own all the time. Regarding the supervised lounge, Staff D stated the nurse parks the medication cart there and when the nurse steps away, the other staff keep an eye on A-lounge. On 3/14/16 at 1:03 p.m. the DON stated the A-lounge supervised area was a high traffic area where staff sits the resident when the resident is up. Sometimes the resident sits in the main area by the fish tank. The DON stated it was not necessary for staff to be in the lounge all the time. There is a high probability that someone would be there since the nurse positions the medication cart there. On 3/15/16 at 12 p.m. the Administrator stated there was no policy for the A-lounge supervised area. On 3/16/16 the Administrator documented everyone knows people in the high traffic area are there on purpose because they may need more watching. Resident #1 was seen 5 minutes or less prior to the fall.

Based on record review, staff and resident interviews, the facility failed to ensure the resident ' s environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 3 of 6 residents reviewed (Resident #1, Resident #2 and Resident #3). Facility census was eighty-six (86) residents. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #2 with a brief interview for mental status (BIMS) score of 4 (severe cognitive impairment). Resident #2 ' s admitted to the facility identified as 9/10/15. The MDS identified Resident #2 exhibited signs of disorganized thinking delirium and the following behavior symptoms one to three days out of 7: physical and verbal behaviors directed towards others. Resident #2 required supervision for bed mobility, transfer, ambulation, dressing and toilet use. Resident #2 utilized a walker for mobility. Resident #2 ' s [DIAGNOSES REDACTED]. A palliative care history dated 9/10/15 and documented by the physician, identified Resident #2 lived independently at the facility apartments. Resident #2's memory declined and exhibited inappropriate behavior so family made the decision to move Resident #2 from the independent living situation to long term care. Resident #2 exhibited difficulty accepting the change. The history failed to identify what inappropriate behaviors occurred. Care Plan: The interim plan of care dated 9/10/15 identified Resident #2 with impaired cognition. In the area of other safety needs, staff documented to monitor Resident #2's behavior towards his/her child (Resident #1) and remind Resident #2 that staff will take care of Resident #1. Resident #1 and #2 Incidents: Interdisciplinary progress notes revealed the following information 9/16/15 at 9:00 a.m. Resident #2 assisted Resident #1 towards the facility Chapel area. Staff explained to Resident #2 that only staff should assist Resident #1 to activities. Resident #2 stated Resident #1 was his/her child and he/she would take Resident #1 wherever he/she wanted to. At 10:45 a.m. of the same date, Resident #2 attempted to transfer Resident #1. Staff gave one to one explanation to Resident #2 that staff would assist Resident #1. At 2:30 p.m. of the same date, Resident #2 appeared agitated and aggressive with Resident #1 and staff. One to one failed to change Resident #2's behaviors. At 2:45 p.m. staff notified Resident #2's responsible party who stated they would come to the facility. At 3:00 p.m. Resident #2 flicked Resident #1 ' s arm and grabbed his/her arm telling Resident #1 to obey Resident #2 and not staff. Staff phoned Resident #2's daughter and Resident #2 spoke to the daughter on the phone. At 3:45 p.m. Resident #2 grabbed and squeezed Resident #1's arm and wrist. Resident #2 picked up Resident #1's walker and moved toward Resident #1 in a thrust motion and instead of throwing the walker at Resident #1, he/she threw the walker at staff's feet. At 7:00 p.m. of the same date staff observed Resident #2 checking Resident #1's brief for incontinence and attempted to take him/her to the bathroom. Staff intervened. Review of the clinical record revealed staff sent a facsimile (fax) to the physician on 9/16/15 informing the physician that Resident #2 was hostile towards Resident #1 and staff. Staff requested a urinalysis (UA) and the physician agreed. On 9/17/15 at 5:50 p.m., the physician discontinued Resident #2's current antidepressant and ordered Lexapro 20 milligrams (mg.) per day (antidepressant) and Alprazolam (antianxiety medication) 0.25 mg. every four hours as needed for anxiety. At 9:20 p.m. staff informed Resident #2's daughter about the new orders and also that the physician ordered an antibiotic for a urinary tract infection (UTI). On 9/18/15 at 10:10 a.m. urine results showed the urine sample (UA) as contaminated. Staff phoned the physician to ask if they should send another UA. The physician directed staff to continue the antibiotic. On 9/18/15 at 4:15 p.m. staff documented Resident #2 with negative behaviors with both Resident #1 and staff. Redirection failed and the facility required extra staff to assist to control the situation. Staff administered an as needed (PRN) antianxiety medication and provided one to one until calm. At 6:20 p.m. Resident #2 continued to attempt to care for Resident #1. Resident #2 put Resident #1 to bed according to staff progress note documentation. On 9/22/15 at 12:10 p.m. a Certified Nursing Assistant (CNA) reported Resident #2 struck Resident #1 during lunch because Resident #1 refused to take a bite of food and Resident #2 wanted Resident #1 to eat. On 9/23/15 at 6:50 p.m. Resident #2 checked Resident #1's brief in the TV lobby at started to change him/her with other residents present. Staff redirected Resident #2 who initially refused redirection. On 9/25/15 at 1:00 p.m. staff spoke with Resident #2's family about behaviors and concerns. The family refused a psychiatric consultation. At 4:30 p.m. Resident #2 attempted to take Resident #1 to bed. Staff educated Resident #2. At 4:40 p.m. Resident #2 told Resident #1 to get up right now. Resident #1 refused and Resident #2 hit Resident #1. Staff educated the resident. Resident #2 stated Resident #1 was his/her child and he/she could do whatever he/she wanted if Resident #1 didn't listen. At 5:20 p.m. staff called the charge nurse Staff A to the dining room to talk to Resident #2 and to allow Resident #1 to eat independently because Resident #2 kept trying to feed Resident #1. Review of the active care plan interventions dated 9/23/15 identified Resident #2 got upset when staff attempt to assist Resident #1 with activities of daily living (ADLs) and yelled at staff and pushed things around. The goal was for Resident #2 not to interfere with Resident #1's care. Care plan interventions for the problem are listed as follows: avoid over stimulation, redirect resident as needed, provide cueing as needed, redirect as needed and able, approach in a calm, slow, friendly manner, keep family informed as needed, 1 to 1 as necessary, document behaviors every shift and with medication changes and re-approach if agitated. An addendum dated 9/25/15 directed staff to refer to psychiatric nurse practitioner as needed, an addendum dated 10/5/15 directed the following: staff to perform every 15 minute location checks, keep separated from former roommate (Resident #3), keep Resident #2 and Resident #1 in supervised area when together, enlist family to help with one to one and referral to another facility. An intervention dated 10/28/15 was corrected on 1/5/16 by the Director of Nursing (DON) to the date 9/28/15 directed staff to monitor interaction with Resident #1. On 9/28/15 at 3:00 p.m. Resident #2 made numerous attempts to assist Resident #1 to get up. Resident #1 resisted and did not want to get up. Staff encouraged Resident #2 to leave Resident #1 alone. Resident #2 got angry and said he/she would take care of Resident #1. Staff redirected the resident by calling the resident's daughter. At 3:30 p.m. Resident #2 returned after speaking with daughter and got Resident #1 up and walked him/her holding onto Resident #1's hand. Staff redirected Resident #1 back to a chair in the lobby. On 9/30/15 at 4:00 p.m. staff observed Resident #2 double hand jerk Resident #1 forward, thrusting Resident #1 forward 12 inches from the back of the chair in an attempt to ambulate Resident #1. Staff yelled no stop and explained Resident #2 could hurt him/herself or Resident #1 by yanking on his/her arms. Resident #2 stepped away with a frown and stated he/she wanted Resident #1 to listen and Resident #1 needed to listen because Resident #1 was his/her Child. Staff documented contact to inform the Director of Nursing of the incident. At 6:10 p.m. Resident #2 approached Resident #1 while he/she ambulated and grabbed Resident #1's right wrist firmly and scolded Resident #1 for not listening to Resident #2. Staff requested Resident #2 release Resident #1's wrist due to color changes and Resident #1 trying to pull away. Resident #2 shook a fist at the staff. Staff took Resident #2 to a private area with one to one supervision until calm. On 10/2/15 at 1:00 p.m. Resident #2 attempted to walk Resident #1 into Resident #1's room. Staff instructed Resident #2 not to walk Resident #1 and he/she got angry and verbally abusive to Resident #1 and staff. Redirection failed to change Resident #2's behavior and staff administered PRN antianxiety medication as ordered. At 7:00 p.m. Resident #2 attempted to get Resident #1 ready for bed. Staff educated Resident #2 about safety concerns and Resident #2 stated he/she didn't care. On 10/4/15 at 8:00 p.m. staff observed Resident #2 smacking Resident #1 on the head. Resident #1 then appeared angry and staff advised Resident #2 that Resident #1 did not like it when he/she did that. Resident #2 stated Resident #1 was his/her son and Resident #1 needed to go to bed now. Staff provided one to one. On 10/5/15 at 1:30 p.m. Resident #2 moved to another hall. On 10/8/15 Resident #2 transferred to another facility. 2. Review of the MDS assessment reference dated 10/14/15 revealed Resident #1 ' s BIMS score of 2 (severe cognitive impairment). The MDS failed to identify behavior symptoms. Resident #1 required extensive staff assistance with transfers, ambulation, dressing, toileting and personal hygiene. Resident #1 required limited eating assistance from one staff member. Resident #1utlized a walker for mobility. According to the MDS Resident #1 was frequently incontinent of bladder and occasionally incontinent of bowel. Resident #1 ' s [DIAGNOSES REDACTED]. Resident #1's care plan dated 8/5/15 contained an addendum dated 9/21/15 that directed staff to remove Resident #1 from Resident #2 if he/she showed increased agitation or appeared upset with Resident #2's behavior. The care plan identified Resident #1 as a fall risk and to ambulate with a front wheeled walker and one staff member assistance to all destinations. 3. Resident #3 Incident: Review of Resident #3 ' s MDS dated [DATE], revealed a BIMS score of 15 that indicated intact cognition. The MDS lacked behavior symptoms or indicators of psychosis. Resident #3 required limited staff assistance with transfers and ambulation and extensive staff assistance with bed mobility, Dressing, toilet use and personal hygiene. Resident #3 noted as occasionally incontinent of urine. The MDS indicated Resident #3 utilized a walker and wheelchair for mobility. According to the MDS Resident#3 ' s [DIAGNOSES REDACTED]. An event report dated 10/5/15 at 9:00 a.m., revealed Resident #3 reported that Resident #2 got upset with Resident #3 and grabbed Resident #3's arm and left an approximate 2 (cm) centimeter purple bruise on the right upper arm. The residents were roommates. The incident allegedly occurred 10/2/15 or 10/3/15. The event report identified that after the report of the incident on 10/5/15, the facility moved Resident #2 out of the A-hall where the residents resided. On 10/5/15 at 10:55 a.m. the social worker sent an email to the Director of Nursing reporting that Resident #3 came to her office that morning and said over the weekend Resident #2 grabbed his/her arm. The social worker observed a small bruise on Resident #3's upper arm. Resident #3 informed the social worker that Resident #2 grabbed Resident #3 before but left no bruises in the past. On 1/4/15 at 9:16 a.m., observation showed Resident #3 in bed. Resident #3 stated Resident #2 always seemed mad when staff wanted to do something with Resident #1. The resident stated Resident #2 grabbed his/her arm and grabbed on other occasions. The resident stated she told staff about it but couldn't recall who. The resident identified the right upper arm as the area where the other resident grabbed and bruised him/her. Staff Interviews: On 1/4/16 at 8:50 a.m. the Director of Nursing (DON) stated Resident #3 came to the social worker and reported Resident #2 got upset and grabbed his/her arm leaving a small bruise. The DON stated Resident #2 and Resident #3 resided in the same room. Resident #1 also lived down the same hall. Resident #1 admitted to the facility first and then Resident #2 came later from independent living. Resident #1 has Downs Syndrome and Resident #2 cared for Resident #1 his/her whole life. The DON stated she found out about the incidents between Resident #1 and Resident #2 after Resident #3 reported his/her incident. Resident #1 would act stubborn when Resident #2 came around. Resident #2 thought he/she could do a better job of caring for Resident #1. The DON stated the 9/16/15 incident involved Resident #2 tapping Resident #1's wrist when Resident #1 had his/her hand on a walker. Resident #2 tried to get Resident #1 to listen to him/her. A 9/22/15 incident involved Resident #2 trying to feed Resident #1 when Resident #1 already had a mouthful of food. Resident #2 tapped Resident #1 on the shoulder. A 9/25/15 incident involved a nurse documenting that Resident #2 hit Resident #1. Resident #2 slapped Resident #1's hand. A 10/4/15 incident involved Resident #2 tapping the other resident on the head twice to get the resident to go to bed. The DON stated she just found out about the other incidents following the 10/5/15 report from Resident #3 and that is why she reported the information to the State Agency on that date. On 1/4/16 at 5:19 p.m. Staff C LPN (licensed practical nurse) stated Resident #2 forgot Resident #1 was an adult and demanded response ' s from Resident #1 like a toddler. Resident #1 did not like it. Resident #2 would try to undress Resident #1 in the lounge to get Resident #1 ready for bed. Regarding the 9/16/15 incident Staff C stated that Resident #2 swung at Resident #1's face. Resident #2 got near the other resident's face and stopped short. Resident #2 also grabbed and squeezed the Resident #1's arm hard. On 9/18/15 Resident #2 wanted Resident #1 to go to bed and checked the brief of Resident #1. Staff needed to separate the residents. Regarding the 9/30/15 incident, Staff C stated she applied a gait belt to Resident #1 and then heard another resident yell so she left Resident #1 to check on the resident that yelled. When she returned, she observed Resident #2 with both hands on Resident #1's gait belt as Resident #1 sat in the recliner. Resident #2 gave Resident #1 a good jerk. Staff C stated she yelled at Resident #2 and the resident stopped. Resident #2 stated that Resident #1 was supposed to do as he/she said. Staff C stated Resident #1 was mad. Staff C stated she always let the DON or Staff D LPN (unit manager) know when incidents occurred. Later that same day (9/30/15), Resident #2 grabbed Resident #1's hand/wrist so tightly it changed color. Staff C stated they would try to politely and respectfully redirect Resident #2. Staff C stated Resident #3 accused Resident #2 of grabbing and bruising his/her arm. She stated she observed a small yellowing bruise to the upper left forearm. On 1/5/16 at 12:02 p.m. Staff E CNA (certified nurse aide) stated one time Resident #3 got her when Resident #2 picked up his/her walker and motioned to throw a walker at Resident #1. Staff D LPN came to help with that incident. Staff E CNA stated Resident #2 grabbed Resident #1's forearms tightly and Resident #1 tried to get away. Staff E CNA stated she observed bruising to Resident #1's arms on a couple of occasions but no one could verify where the bruising came from. Staff E CNA described the bruises as small and all under 2 cm. At times Resident #1 would show disgust with Resident #2 by covering his/her eyes. Staff E CNA stated she observed Resident #2 squeezing Resident#1 on the arm about every other day for a couple months and a couple times Resident #2 would grab Resident #1's upper arms and shake the resident and say why aren't you listening? Staff E CNA stated she told Staff C LPN about the incidents and a couple times she informed Staff D LPN. Staff E CNA stated another time Resident #3 informed her that Resident #2 grabbed his/her arm. Staff E CNA stated she observed the incident and it appeared as just a touch and not done in a mean way. On 1/4/16 at 11:35 a.m. Staff D LPN (unit manager) stated she only observed Resident #2 escalated a couple times and she called the resident's son and daughter to come to the facility. Resident #2 got angry when Resident #1 failed to do as he/she requested. Staff D LPN stated she was aware of incidents prior to Resident #3's reporting on 10/5/15. Staff would come and get Staff D because she had a good rapport with Resident #2. She stated she told staff to keep Resident #1 in the A hall lounge because staff was usually in the area. She stated staff monitored A hall lounge closely because staff kept the medication cart there. Staff might leave the area for short periods to go in resident rooms. Staff D stated the intervention following the 9/16/15 incident was: to still keep the resident in the lounge or activity areas. The intervention following the 9/22/15 incident was: to watch the residents and maintain supervision between them. Staff D LPN stated Resident#2's family would visit approximately 3 times a week. The intervention following the 9/25/15 and 10/4/15 incidents was: to reassure Resident #2 who would reply that Resident #1 was his/her child. Staff D LPN stated she spoke with the family of Resident #2. The behavior of flicking his/her finger on Resident #1 was not a new behavior. This was how Resident #2 disciplined his/her children if they acted out. On 1/4/16 at 11:00 a.m. Staff F RN (registered nurse) stated she was the nurse on 9/22/15 when the lunchroom incident occurred between Resident #2 and Resident #1. Resident #1 would not eat so Resident #2 slapped the resident with his/her open hand on Resident #1's back. She stated she did not report the incident to management and since that time she learned she is supposed to tell management. Staff F RN stated she assessed the resident after the incident and did not see any in jury. Resident #1 did not seem bothered. She stated Resident #3 informed her that Resident #2 pinched his/her arm. She observed a bruise on Resident #3's upper left forearm. The bruise was yellowing and almost faded. On 1/5/16 at 11:20 a.m. the surveyor showed Staff F that the DON documented there was a 2 centimeter purple bruise on Resident #3's upper right arm. Staff F RN stated that is not where Resident #3 showed her where Resident #2 grabbed him/her or where she saw a bruise. She saw a bruise on the left arm. She stated she did not document the bruise she observed on the left forearm. On 1/5/16 at 9:38 a.m., Staff A LPN stated she worked when the 9/25/15 incident occurred. Staff A LPN stated she stood in A-lounge and saw Resident #2 try to stand Resident #1 and take Resident #1 to his/her room. Staff A told Resident #2 it was mealtime and left to deliver a medication. When Staff A LPN returned she observed Resident #2 hit Resident #1 really hard by the shoulder with a closed fist. Resident #1 stated no. Staff A LPN stated she was the only staff member in the area. Resident #2 stated he/she would do what he/she wanted with Resident #1. Staff A LPN intervened and the residents went to the dining room. Staff A stated she did not observe any injury on Resident #1 following the incident. Staff A stated that was the only time she observed Resident #2 really hit the other resident. She stated she reported the incident to Staff J (unit manager). Staff A LPN stated the DON wanted her to change her story about what occurred but Staff A LPN refused and said what she documented in the nurses notes is what she saw and she wasn't going to change it. The DON documented in a typed note dated 9/28/15 that she interviewed Staff A about Staff A's documentation of Resident #2 hitting Resident #1. The DON documented that Staff A described a light slap in an effort to get Resident #1 to go to the dining room. On 1/5/16 at 9:55 a.m. Staff J (unit manager) stated she did not recall Staff A reporting the incident to her. On 1/5/16 at 3:52 p.m. the Administrator stated it was questionable if Staff A's report was reliable because Staff A LPN quit without notice. On 1/4/16 at 2:15 p.m. Staff K CNA stated she observed Resident #2 get mad at Resident #1 and bring his/her hand up and then down forcefully on the arm of Resident #1. Staff K stated Resident #2 controlled the slap and it came down lightly on Resident #1's arm. She stated Resident #1 laughed about it. Staff K stated she reported the incident to the DON when the DON called her. The DON called her one day after the actual incident occurred. According to DON typed note, the DON documented that she spoke with Staff K on 9/28/15. On 1/13/15 at 1:45 p.m. when questioned if she knew about the incidents on 9/28/15, the DON stated she found out about them after Resident #3 reported his/her incident on 10/5/16. On 1/5/16 at 3:11 p.m. the DON denied trying to get Staff A LPN to change her story. She stated they always kept Resident #1 in the A hall lounge area, which she indicated was an area with increased staff supervision, from day one even before Resident #2 admitted to the facility. On 1/4/16 at 2:40 p.m. Staff I LPN stated she observed the 10/4/15 incident between Resident #1 and Resident #2. Staff I LPN stated she noticed Resident #2 standing in front of Resident #1 and tap him/her on the head twice. Resident #2 used her fingers to hit Resident #1's head. Staff I LPN heard a noise when Resident #2 tapped Resident #1's head. Staff I LPN stated Resident #1 did not like it when Resident #2 did that. Staff I told Resident #2 not to do that and Resident #2 stated Resident #1 needed to go to bed. Staff I LPN stated she did not know Resident #2 did things like that. Staff I LPN stated Resident #2 did not harm Resident #1 but Resident #1 acted frustrated with Resident #2. Staff I LPN stated she did not report the incident to anyone. On 1/5/16 at 2:40 p.m. Staff B CNA stated Resident #2 treated Resident #1 like a child and wanted Resident #1 to go with him/her and Resident #1 refused to go. Staff B stated she observed Resident #2 try to get Resident #1 up from the recliner and hit Resident #1's hand. Staff B stated it was a hit like when you tell your kid hey. The incident occurred in the A hall lounge. Staff B tried to supervise the residents but it was hard with them both on the same hallway. After the incident, Staff B saw Resident #1 rub his/her cheeks and make a moan/whine noise. On 1/4/16 at 12:45 p.m. Staff G CNA stated she observed Resident #2 grab Resident #1 when Resident #2 got agitated. Resident #2 tried to make the other resident go to bed. Staff G stated Resident #2 grabbed Resident #1 pretty hard. Resident #1 frowned and snatched his/her hand away. Staff G CNA stated she could tell it hurt Resident #1 by the expression on his/her face. Staff G stated she told the nurse what she observed. Staff G CNA observed the grabbing twice and then Resident #2 struck out at Resident #1. On 1/4/16 at 1:27 p.m. Staff H LPN stated Resident #2 always grabbed Resident #1's arms. Resident #2 also grabbed Resident #1's wrist to get the resident to stand. Staff H stated staff documented the information in the nurse ' s notes. Resident #1 got upset and refused to go with Resident #2. Resident #1 seemed afraid to go with Resident #2. Resident #1 looked at Staff H with a look like help me so Staff H intervened. Staff H never observed injury from the grabbing.

Based on record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazards from self (Resident #3, #4). The sample consisted of 4 residents and the facility identified a census of 82 residents. Upon staff interview and review of the fall assessment, the facility had failed to accurately identify Resident #3 and Resident #4 as a risk for falls. The facility did not adequately implement safety measures to keep Resident #3 safe. Findings include: 1. According to the Minimum Data Set (MDS) assessment, with a reference date of [DATE], Resident #3 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. Resident #3 required limited assistance with activities of daily living (ADLs) including bed . Resident #3 was not steady, but able to stabilize self without staff assistance when moving from a seated to a standing position, walking, turning around, moving on and off the toilet, and surface to surface transfer. Resident #3 used a walker and a wheelchair. Resident #4's [DIAGNOSES REDACTED]. The MDS documented Resident #3 had shortness of breath with exertion (e.g. walking, bathing, transferring). A Physician Transfer Order Report dated [DATE] documented Resident #3's problem list included orthostatic hypotension, coronary artery disease, peripheral vascular disease, acute on chronic congestive heart failure, pelvic fracture, rib fracture, weakness, and fall. An Active Care Plan dated [DATE] identified Resident #3 with occasional incontinence and limited mobility. The interventions included: a. Provide assistance with toileting related personal hygiene. Resident #3 needed assistance of 1 staff member for transfers. The care plan dated [DATE] identified weakness and the interventions included: a. Minimal assist/supervision with transfers, bed mobility, hygiene, ambulation, toileting as needed, crossed through [DATE]. b. Ambulate with roller walker independently to all destinations. Assist PRN (as needed). c. On [DATE], assistance of 1 staff person with dressing and toileting. d. On [DATE], may be independent with bed mobility and transfers after up for the day and evening. Monitor for increased assist during the night. The care plan dated [DATE] identified the problem of congestive heart failure. The interventions included: a. Frequent rest periods, Resident #3 laid down in bed in between meals. The care plan dated [DATE] identified Resident #3 with a history of falls, impaired balance, medications with known risk, risk for falls, and risk for serious injury. The interventions included: a. Ambulation aid: used walker and assist of 1 person, and wheelchair for long distances. b. Place ambulation aid at bedside or chair side. c. On [DATE], assistance of 1 staff person with the gait belt and front wheeled walker in the room and hallway. d. On [DATE], toilet Resident #3 before and after meals and prn, anticipate needs, and check on frequently. A facsimile (fax) dated [DATE] notified the physician that Resident #3 had increased weakness; balance and gait poor with a fall that a.m. The facility requested a Physical Therapy (PT) evaluation and treatment as indicated. The physician responded yes. A Physical Therapy Discharge Summary dated [DATE] documented a short term goal for Resident #3 to ambulate using a front wheel walker for 200 feet with stand by assist (SBA) to be able to walk to dine with increased safety awareness upon turning and changing direction without loss of balance, met (full filled) on [DATE]. A short term goal to decrease Resident #3's risk of falls as evidenced by an increase in Tinetti Assessment to ,[DATE] was not met. The goal was discontinued at a score of ,[DATE] which indicated Resident #3 at risk for falls. The long term goal was to increase dynamic standing balance to good minus/fair plus spontaneously righting self when needed and with good safety awareness in order to facilitate safe functional mobility without loss of balance and reduce the risk of falls was discontinued [DATE] and remained at fair minus. A Quarterly Nursing assessment dated [DATE] documented Resident #3 transferred with the assistance of 1 staff person. Resident #3's gait unsteady at times. Resident #3 ambulatory with the gait belt and front wheeled walker in his/her room and hallway. On [DATE] the facility added assistance of 1 staff person with dressing, and independent ambulation with roller walker. The Interdisciplinary Progress (IDP) Notes dated [DATE] at 11:50 a.m. documented an update from therapy for Resident #3 to be assistance of 1 staff person with a gait belt and front wheeled walker in the hallway and room. At 8:30 p.m. staff reminded Resident #3 he/she needed to call for assistance when up in his/her room. Resident #3 voiced an understanding. The Interdisciplinary Progress (IDP) Notes dated [DATE] at 9:30 a.m. documented Resident #3 self- transferred. Staff educated the resident about pulling the call light and waiting for assistance. At 12:30 p.m. they would toilet Resident #3 before and after meals, and staff would anticipate needs and check frequently. The Interdisciplinary Progress (IDP) Notes dated [DATE] at 10:30 a.m. documented Resident #3 self- transferred. Staff educated the resident and a physical therapy screen (request) was sent to the Restorative Nurse. The Medication Administration Record dated [DATE] revealed Resident #3's medications included: a. Amitriptyline (antidepressant) 10 mgs at bedtime, b. Losartan potassium (lowers blood pressure) 50 mg every day, c. Bumetadine (diuretic)1 mg every day, d. Clonazepam (anti-seizure and anti-panic drug) 0.5 mg 3 times a day. A Fall Risk assessment dated [DATE] scored Resident #3 at 7 with a score of 10 or more identifying the resident at a high risk for falls. The instructions directed to have the resident stand on both feet without any type of assistance, then have the resident walk forward, through a doorway, then make a turn (mark all that apply): a. 0 points of normal/safe gate and balance. b. 1 point for balance problem while standing/balance while walking (1 point each). c. 4 points for complaints of dizziness. d. 1 point for decreased muscular coordination. e. 1 point for a change in gait pattern when walking through the doorway. f. 1 point for jerking or instability when making turns. g. 1 point if required assistance (person, furniture/walls or device). The resident had the potential of scoring 10 points. The assessment scored Resident #3 with 0 points which reflected a normal/safe gait and balance. During an interview on [DATE] Staff G, LPN (licensed practical nurse) stated she did not do the assessment as directed (see interview). The assessment reflected Resident #3 took ,[DATE] of the type of medications listed. Resident #3 took 4 of the medication types listed (Bumetadine/diuretic, Losartan potassium/antihypertensive, clonazepam/benzodiazepine and amitriptyline/psychotropic). The assessment failed to identify oxygen tubing under equipment issues. The Interdisciplinary Progress (IDP) Notes dated [DATE] at 3:30 p.m. documented Resident #3 continued with the assistance of 1 staff person and encouraged to use the call light. At 5:00 p.m. the physical therapy screen was completed. The Physical Therapy Assistant advised continued assistance in the room for dressing due to a loss of balance. The resident could be up independently with roller walker for ambulation (signed by the Restorative Nurse). An Indications for Therapy form dated [DATE] documented staff requested a PT/OT (physical therapy/occupational therapy) screen for poor balance and difficulty dressing. The comments were Resident #3 was presently the assistance of 1 staff person. Resident #3 showed poor posture when dressing. When ambulating, gait slow and steady. The screen completed on [DATE] documented Resident #3 could be independent in his/her room, but still required assist in the room for dressing due to loss of balance (noted by the Restorative Nurse). A note dated [DATE] documented Resident #3 could be up independently throughout the facility for ambulation, assistance of 1 staff person for dressing and toileting, and monitor peri-care (cleansing of the perineal area). A service data form (not titled) and received from the Unit manager and hand dated on [DATE], documented the following: a. On Page 2 of 7, Resident #3 had a fall on [DATE] at 9:30 a.m. Resident #3 now independent in the hall with ambulation and required staff assistance with dressing and toileting. Resident #3 ambulated with a slow steady gait but able to stabilize self with the walker. Resident #3 would become unbalanced with dressing but showed no sign of orthostatic hypotension, and denied dizziness. b. On Page 3 of 5, Resident #3 was identified as alert and oriented, and able to make needs known. Resident #3 had a fall on [DATE] without injury. Therapy services picked up for muscle weakness (see Fall CAA). Resident #3 went from assist of 1 to independent during the quarter, with ambulation in the hall. Resident #3 required extensive assistance with dressing and toileting as he/she were unsafe doing these tasks him/herself. Resident #3 would try to ambulate with his/her pants around his/her ankles to and from the bathroom. Staff now assist with this. The staff anticipate Resident #3's needs and Resident #3 received education on the call light for assistance. Resident #3 voiced an understanding and aware of possible consequences of not having assistance. c. On Page 2 of 6, Staff assisted Resident #3 with bed mobility during the assessment period. Resident #3 improved from limited assistance to independent with bed mobility. Resident #3 required more assist after a fall and worked with therapy with noted improvement. Resident #3 was now independent in the hallway with staff assisting with dressing and toileting. An Active Care Plan dated [DATE] identified Resident #3 with weakness, need for assist or supervision with ADL's (Activities of Daily Living), walker with ambulation, wheelchair as needed, shortness of breath with exertion, need for oxygen as needed, and potential for increased pain. Interventions included: a. Assist of 1 with dressing, toileting, and assist with hygiene/pericare as needed. b. May be independent with bed mobility and transfers after up for the day and evening. Monitor for increased assistance of 1 staff person during the night. c. Ambulate with roller walker independently throughout facility, assist as needed. The Care Plan dated [DATE] identified Resident #3 with chronic congestive heart failure, shortness of breath, fatigue, weakness. The interventions included: a. Frequent rest periods, Resident #3 laid down in bed between meals. The Care Plan dated [DATE] identified Resident #3 with a history of falls in the past 6 months, impaired balance, medications with known risk, risk for falls, and risk for serious injury. The interventions included: a. See standard of care for fall risk. b. Place ambulation aid at bedside/chair side, A Range of Motion Record dated [DATE] documented Resident #3 participated 1 time that week. Resident #3 voiced the inability to participate 2 times due to nausea and fatigue. Resident #3 stated he/she just couldn't. The record reflected Resident #3 refused on [DATE] and [DATE]. The clinical record lacked documentation of an assessment of Resident #3's complaints of fatigue and nausea, or any follow-up. An event report dated [DATE] at 11:15 a.m. documented Resident #3 became dizzy when standing up. Resident #3 had an unattended fall in the lobby (area near the dining room). The Interdisciplinary Progress (IDP) Notes dated [DATE] at 11:15 a.m. documented the nurse was called to the lobby. Resident #3 laid on his/her right side next to the walker. No one witnessed the fall. Resident #3 voiced trying to get out of the chair, stood up and became dizzy. Resident #3 didn't know if he/she hit his/her head on the floor. At 1:30 p.m. Resident #3 went to the emergency room . At 9:45 p.m. staff at the hospital stated Resident #3 was admitted to the hospital with [REDACTED]. A hospital Admission History and Physical dated [DATE] documented Resident #3 fell at the nursing home with a right hip fracture. Resident #3 fell at the care facility while walking. Resident #3 vomited while in the emergency department. The hospital staff did a CT (computerized tomography) scan of the head with no acute pathology. While in the ED, Resident #3 was hypoxic, and required more oxygen. The Assessment/Plan included: a. Hip fracture due to a fall at the facility and would require surgery for [REDACTED].#3 was a poor surgical candidate due to his/her multiple co- morbid conditions and new incidental pulmonary findings. b. Hypertension, high at present since having emesis and pain from fracture. c. Pneumonia, organism unspecified, possibly aspiration pneumonia or lung mass, or showing of clot due to [DIAGNOSES REDACTED] atrial fibrillation. d. Weakness. e. Pain severe due to fall and fracture, for pain control and supportive measure. f. Lung mass right paratracheal region. The Discharge plan was Hospice for comfort care. The Interdisciplinary Progress (IDP) Notes dated [DATE] at 11:15 a.m. documented Resident #3's family called and stated Resident #3 had just died . During an interview on [DATE] at 2:38 p.m. Staff A Licensed Practical Nurse, stated she worked on Resident #3's hall the day he/she fell . She noted nothing unusual that morning. Resident #3 ambulated independently which he/she was allowed to do. Staff A heard something like a walker falling and looked in the lobby and saw Resident #3 on the floor. Resident #3 stated he/she was getting out of a rocking chair to go to lunch. Resident #3 laid on the floor on his/her right side. Then everyone came to him/her. No one witnessed the fall. Staff A and Staff E Registered Nurse (RN) did an assessment. Resident #3 did range of motion independently. Resident #3 voiced it hurt, but not like sharp pain, in the right buttock. The staff performed neuros (neurological checks) because of an unwitnessed fall. Resident #3 wanted to go to lunch, so they got him/her up, and he/she could bear weight. Resident #3 wanted to walk, but staff obtained a wheelchair. Staff A was not in the dining room during lunch. When Resident #3 came back from lunch he/she grabbed his/her leg and said it really hurt. Staff A called the physician and reported and the physician stated Resident #3 had a history of [REDACTED].#3 stayed in the wheelchair and they took him/her (to the ER) by van. The staff did not move him/her again. Staff A stated Resident #3 ambulated with a slow and steady gait and took her/his time. Staff A stated Resident #3 was right beside the chair, maybe took a few steps. Resident #3 liked to be independent, and would ask for help if needed. During an interview on [DATE] at 2:55 p.m. Staff B Certified Nursing Assistant (CNA) stated she did not assist Resident #3 with getting up that day. When Staff B came back from break, Resident #3 sat in the wheelchair. Resident #3 said it didn't hurt when sitting, but when she bent forward she complained of pain. Staff B stated Resident #3 was normally up and around on his/her own, very independent. Staff B did not observe Resident #3 ambulate to the lobby. During an interview on [DATE] at 9:05 a.m. Staff D CNA stated she did work Resident #3's hall the day he/she fell . Staff D stated they (staff) pretty much just awake Resident #3 and the resident would get ready independently (care plan directed assist of 1 for dressing and toileting). Resident #3 would ask for assist if needed. Resident #3 didn't need any help that morning. Staff D stated Resident #3 came and went as he/she pleased. She said Resident #3 resided at the end of the hall. Staff D stated Resident #3 was steady, but did not walk with him/her to the lobby. Staff D did not witness the fall or assist after the fall. During an interview on [DATE] at 9:25 a.m. Staff E RN (registered nurse) stated she worked D hall the day Resident #3 fell . She did not witness or hear the fall. She happened to get to the fall site about the same time as Staff A. Resident #3 laid in the front lobby to the right of the sitting area, lying on the floor on his/her right side. She asked Resident #3 if he/she could move his/her extremities and he/she did without pain. Resident #3 rolled to his/her back. Resident #3 wanted to get up so they assisted him/her off the floor with the gait belt. Resident #3 could bear weight without complaints. They did get Resident #3 in a wheelchair because he/she was shaken up. Staff E didn't recall Resident #3 at lunch. Staff E didn't work B hall so she didn't know Resident #3's status, but she had seen him/her walking in the hall with a walker. Resident #3 had a steady gait, but was slow. She didn't know if Resident #3 had been sitting prior to the fall. During an interview on [DATE] at 10:18 a.m. the Unit Manager stated it would be about 200 feet from the end of the hall to the dining room. She stated Resident #3 ambulated with a slow, steady, gait. The Unit Manager stated Resident #3 pretty much insisted upon being independent. She thought the therapy gave an okay to be independent in the facility; may have been verbal, and they were looking for an e-mail. During subsequent interview on [DATE] at 8:24 a.m. the Unit Manager stated she remembered having a conversation with the Physical Therapy Assistant (PTA) about Resident #3 ' s ambulation. The Unit Manager stated when she saw the paper saying Resident #3 could be independent in his/her room, she asked if she could be independent in his/her room or everywhere, and the PTA said everywhere. During an interview on [DATE] at 8:38 a.m. the PTA stated she did not recall anything about the situation. She thought she would have the recommendation written or sent an email. The PTA stated she had seen e-mails in resident's charts. She could not remember why she recommended (the resident being) independent in the room, but assist with dressing. During an interview on [DATE] at 8:51 a.m. the Physical Therapist stated they used the Tinetti assessment tool for gait and balance. She stated Resident #3's score of 19 indicating a risk of falls was mostly due to balance. Resident #3's ability varied. Sometimes he/she did good and then the next time he/she didn't do well. She stated when Resident #3 discharged from PT she had him/her supervised. She stated Resident #3 needed observation when walking to the dining room because it was a long distance, about 200 feet. The Physical Therapist stated Resident #3 needed someone to walk with him/her if he/she wasn't feeling well. She said the PTA did discuss screens with her, but she didn't recall them discussing Resident #3 being independently ambulatory in the hall. She stated Resident #3 could be independent in his/her room because it was a short distance to the bathroom. She thought they had Resident #3 as an assist of 1 staff person and the gait belt after therapy discharge because he/she did need someone with him/her when not feeling well. During an interview on [DATE] at 10:45 a.m. the Restorative Nurse stated she thought Resident #3's therapy ended [DATE], but that was the date the physical therapist electronically signed the discharge. She thought Resident #3 wanting to be independent prompted the change to independent in the facility. The Restorative Nurse stated she did not assess Resident #3 in regard to the documentation [DATE] (on the Range of Motion Record). She said they report to the floor nurse. During an interview on [DATE] at 10:56 a.m. Staff F CNA stated she did restorative at times. She looked at Resident #3's Range of Motion Record and said Resident #3 refused therapy (,[DATE] and [DATE]) because she wasn't feeling well and had nausea. Staff F stated when someone didn't feel well they usually gave them a day and if still not feeling well, reported to the Restorative Nurse and the (floor) nurse. Staff F stated she would have reported [DATE], but she didn't know to who. Staff F stated Resident #3 walked in the hall and they made him/her independent. Resident #3 was slow, but he/she did okay (alright). During an interview on [DATE] at 11:35 a.m. the Director of Nursing stated their fall risk assessment showed Resident #3 not at high risk and had a normal safe gait/balance. A discussion with the Director of Nursing identified inaccuracy of the fall risk assessment tool. During an interview on [DATE] at 2:05 p.m. the DON stated they had identified Resident #3 a fall risk. She stated Resident #3 had been on the same medications for a while. Resident #3 was independent for nearly a month without a fall. During an interview on [DATE] at 11:39 a.m. Staff G LPN stated she performed the (quarterly) assessment on [DATE]. When she marked unsteady at times she wasn't sure what she meant by that, it had been 2 months. She said regarding the fall risk assessment, she did not have the resident walk through the door as described on the form. She just observed Resident #3 walking. Resident #3 did not walk without the walker, he/she needed the walker. She said prior to the change to independent throughout the facility, staff would walk Resident #3 to the dining room or he/she would eat in his/her room. When she documented Resident #3 self-transferred it would have been in his/her room. During an interview on [DATE] at 2:59 p.m. Staff H RN stated Resident #3 self- transferred in his/her room so she asked for a PT screen to see if he/she could be deemed safe to be up independently in his/her room. She said she usually worked 6 a.m. to 6 p.m. and Resident #3 usually went to the dining room for lunch. She stated Resident #3 did not have a problem with staff walking him/her to the dining room. She stated since they made Resident #3 independent throughout the facility, he/she did pretty well. During an interview on [DATE] at 8:12 a.m. Staff I, CNA stated she worked in restorative and she had worked with Resident #3. Sometimes Resident #3 would refuse therapy if tired or didn't feel like it. Staff I stated Resident #3 did not complain of nausea. She didn't walk with Resident #3 a lot, but he/she was steady and slow. She said she would notify the nurse if Resident #3 didn't feel well. During an interview on [DATE] at 8:17 a.m. Staff J CNA stated she worked restorative and with Resident #3 at times. Sometimes Resident #3 didn't do therapy, if he/she didn't feel well. Resident #3 never complained of nausea. If Resident #3 didn't feel well she would notify the nurse so she could do whatever she had to. She stated Resident #3 ambulated with a walker, slow, but okay (alright). During an interview on [DATE] at 3:00 p.m. a family member stated he/she thought Resident #3 still had assistance to walk due to unsteadiness. During an interview on [DATE] at 2:26 p.m. the physician's office staff relayed Resident #3's physician stated the hip fracture contributed to Resident #3's death, but the resident was at the end of life with end stage lung disease. 2. According to the Minimum Data Set (MDS) assessment, dated [DATE], Resident #4 scored a 4 on the Brief Interview for Mental Status (BIMS). A score of 4 identified the resident had a severe cognitive impairment. Resident #4 required limited assistance with activities of daily living (ADLs) including bed mobility, transfer, ambulation in his/her room, and toilet use. A Social History & assessment dated [DATE] documented Resident #4 alert and oriented to person. Resident #4 had poor long and short term memory. The assessment included Resident #4 was friendly, pleasant, cooperative, confused, wandered, and could get agitated. An Interim Plan of Care dated [DATE] identified Resident #4 with mental impairment factors: Alert and oriented to person, very confused, poor short/long term memory problems. The admission orders [REDACTED] a. Citalopram 10 mg every day, b. Fexofenadine 180 mg daily, c. Lisinipril 20 mg daily, d. Risperidone 0.5 mg 2 times a day. A Fall Risk assessment dated [DATE] scored Resident #4 at a 4, with 10 or above indicating high risk for falls. The assessment failed to identify Resident #4's level of consciousness/mental status, with a potential for 4 points. The medications section identified Resident #4 took 1 to 2 of the type of medications listed, underlining anti-hypertensive (Lisinopril) and psychotropics (Citalopram, Risperidone). Resident #4 also took an antihistamine (Fexofenadine) which would increase the score by 2 points. Resident #4 had a potential of an increase in score by 6 which would equal 10, and identify the resident at high risk. The facility Standard of Care for Fall Prevention included the following interventions: a. Monitor gait, balance, and tolerance with ambulation. b. Report mental and physical changes to the nurse.