Every finding on record at Mayflower Home

Based on clinical record review, policy review, and staff interview, the facility failed to notify the provider of abnormal blood sugars and of a weight loss for 1 of 5 residents reviewed for high risk medications(Resident #20). The facility reported a census of 31 residents. Findings included:The Minimum Data Set (MDS) assessment tool, dated 6/17/26, listed diagnoses for Resident #20 which included diabetes (a disease which caused abnormal blood sugars), heart failure, and high blood pressure and listed her Brief Interview for Mental Status (BIMS) score as 9 out of 15, indicating moderately impaired cognition. a. The June 2026 Medication Administration Record (MAR) listed a 6/11/26 order to administer insulin (an injectable medication which caused blood sugar to decrease) three times daily and to call the provider if blood sugars exceeded 400 milligrams (mg)/deciliter(dl). The order did not provide direction as to when staff should notify the provider regarding a low blood sugar. The July 2026 MAR also did not provide direction as to when staff should notify the provider regarding a low blood sugar.Resident #20's Weights and Vitals report included the following blood sugars:6/14/26 8:38 a.m. 537 mg/dl6/22/26 6:00 a.m. 56 mg/dl7/4/26 7:00 a.m. 42 mg/dl The facility lacked documentation of physician notifications of the above blood sugars.b. The resident's June and July MAR listed a 6/11/26 order for bumetadine (a potent diuretic, a medication which rid fluid from the body) 2 miilligrams (mg) three times daily.The residents Weights report listed the following weights:6/17/26 197 lbs6/24/26 188 lbsThe facility lacked documentation of physician notification of the resident's weight loss. The facility policy Hypoglycemia Management, revised 1/7/26, stated staff would test resident blood sugars per the provider's orders. If the reading was less than 70 mg/dl, the nurse would contact the provider for any new orders unless there were parameters previously specified by the provider. The facility policy Weight Monitoring, revised 3/2026, stated the facility would inform the provider of a significant change in weight.On 7/9/26 at 8:38 a.m., Staff A Registered Nurse (RN) stated if the resident did not have orders regarding when to call the physician for low blood sugars, she would follow the policy. She stated she would notify the provider of a blood sugar of 42 mg/dl and would call if over 500 mg/dl. On 7/9/26 at 8:51 a.m., the Director of Nursing (DON) stated staff should call the providers when blood sugars were less than 70 mg/dl or more than 500 mg/dl. On 7/9/26 at 10:08 a.m., the DON stated she was unable to locate any further provider notifications (related to the above blood sugars). She stated the Dietician tracked weights and notified the providers of weight losses.

Based on clinical record review, written resident statement, resident interviews, staff interviews and policy review, the facility failed to ensure residents were treated with respect and dignity for 2 of 6 residents reviewed for dignity (Residents #1 and Resident #9). The facility reported a census of 27 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, dated 1/9/26, documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS reflected the resident had diagnoses to include progressive neurological conditions, Parkinson's disease and anxiety disorder. The Care Plan, initiated 1/19/26, included a focus area the resident had Parkinson's affecting functional ability and mental thought process as evidenced by visual hallucinations and resident is at risk for impact on other functions such as constipation, urinary retention, vision, etc. The goal was the resident will remain free of further complications related to Parkinson's disease through the review date. The Interventions included: Adaptive devices as recommended by therapy, monitor for safe use. Administer psychotropic medications as ordered by the physician. Monitor/document side effects and effectiveness. Follow up with neurology as indicated. Continue discussing changes and medication management with facility provider/medical director to determine effective use and need.Monitor/document ability to perform activities of daily living (ADLs). Report any improvement or decline to medical director. Provide emotional support, encouragement. Encourage resident to vent feelings about disease. The Care Plan further included a focus area the resident had impaired functional ability with impaired range of motion to bilateral lower extremities and contributing diagnosis of Parkinson's disease. Resident needs assistance with self care and mobility tasks. The goal was for resident to improve current level of functional ability with participation in therapy services and activities of daily living (ADL's) through review period. The interventions included: Ambulation/transfers: Assist of 1, supervision with front wheeled walker. Bed mobility: Assist of 1 with completing tasks.Dressing: Assist of 1 with completing tasks. Allow the resident to attempt to complete independently prior to assisting. Personal hygiene: Assist of 1 with completing tasks. Toilet use/hygiene: Assist of 1 with completing tasks. During an interview 4/7/26 at 9:50 AM, Resident #1 reported Staff A, Certified Nursing Aide (CNA), had appeared frustrated with him while performing care for the resident. Resident #1 stated Staff A would appear frustrated when the resident told Staff A the resident was unable to perform a task on his own. Resident #1 stated Staff A worked the overnight shift and on several occasions Staff A would tell the resident to do tasks on his own, telling the resident Staff A had observed the resident do it before. Resident #1 stated he can do more during the day, but at night he cannot do as many things on his own given his diagnosis of Parkinson's disease. Resident #1 stated he tried to explain this to Staff A, the disease process, and Staff A would just tell the resident he observed him do it before. Resident #1 stated Staff A would help him, but would act like he didn't want to, and would ask the resident why he couldn't do the task on his own. Resident #1 stated when he would push his call light and if Staff A was working, Staff A would tell the resident he couldn't come in every 5 minutes and would ask the resident why he was using his call light. Staff A responded to the resident's call light one night and told the resident when he came into the room he was not dealing with this today. Staff A would have a frustrated tone of voice with the resident. Resident #1 stated he did not feel he should be treated that way. Resident #1 recalled an incident in January, on the night of the 22nd, when the resident pushed his call light, Staff A came into the resident's room and the resident told Staff A he needed changed, and Staff A said I am not dealing with you today. Resident #1 stated Staff A tossed the resident's blankets onto the resident and told the resident to straighten them out himself. The resident stated he felt like Staff A was frustrated with him every time he came in to respond to the resident's call light. Resident #1 stated he had stress and anxiety about Staff A working and coming in to help him, he had anxiety when Staff A worked. The resident stated he couldn't sleep well when Staff A worked. The resident stated he would have anxiety every time he pushed his call light and would hope it was not Staff A who responded. The resident advised he filed a grievance and reported these concerns with Administration, Staff A had not provided care to the resident since January 22nd of 2026. Resident #1 stated when Staff A provided care for him, Staff A would look at the resident with disdain. Resident #1 stated Staff A saw the resident in the hallway recently and looked at the resident with the same disdain and walked away. Resident #1 stated he reported his concerns to the Administrator on the 23rd of January, 2026. Review of the facility resident grievance form revealed Resident #1 completed a written grievance on 1/23/26. Resident #1 documented the reason for the grievance was disrespect of him or more residents by Staff A. When Staff A assisted him into bed, Staff A just threw the covers on him and said you cover yourself. If the resident has to use the bathroom in the middle of the night, Staff A begrudgingly gets up to help him. Staff A has answered the call light and when he sees it is Resident #1 he says he is not dealing with the resident tonight. Resident #1 wrote Staff A treats him with very little compassion. 2. The MDS assessment for Resident #9, dated 2/27/26, documented a BIMS score of 15, indicating intact cognition. The resident had diagnoses to include progressive neurological conditions, Multiple Sclerosis (MS), anxiety disorder and depression. The Care Plan for Resident #9, initiated 2/28/24, included a focus area the resident is at risk for psychosocial well-being problem and not meeting emotional, intellectual, physical and social needs due to requires assistance with self-care and mobility secondary to diagnosis of MS. The goal was the resident will identify coping mechanisms and increase out of room participation and prevent self-isolation problems through the review date. The interventions included: Allow the resident time to answer questions and to verbalize feelings, perceptions and fears.Encourage participation from resident who depends on others to make own decisions. Consult with: Social services, psych services; resident continues to decline. During an interview 4/6/26 at 2:35 PM, Resident #9 stated there is one staff member who is not kind to her and does not treat her well, this is Staff A, CNA. Resident #9 stated Staff A is rude to her. Staff A works the overnight shift usually. Resident #9 stated Staff A talks to her in a rude and obnoxious way. Staff A will make a face at her sometimes and say Yes (her name), or what do you want (her name). Resident #9 stated Staff A acts like he does not want to work here or be here. Resident #9 stated Staff A makes her feel he does not want to help her. Resident #9 stated Staff A has a bad attitude, he is rude and has rolled his eyes at her. During an interview 4/7/26 at 1:05 PM, Staff B, CNA, stated she had worked with staff who were not as respectful as they should be with residents, this is specifically one staff person, Staff A. Staff B stated she is aware of residents who do not want Staff A to provide care for them, Resident #1 and Resident #9 are two of these residents. Resident #9 advised Staff B that Staff A is rude to her, had made sarcastic comments to her and had tone in his voice. On the night of 1/22/26, Staff B worked with Staff A on the overnight shift, from 10 pm to 6 am. Staff B recalled during the shift she provided care to Resident #1 and then Staff A just came into the resident's room without being asked, Resident #1 was a 1 person assist. Staff A tossed Resident #1's blankets on his legs. Staff B stated she had not asked Staff A for assistance prior to Staff A coming into the resident's room. Staff B had helped Resident #1 back to bed and was getting him into his bed from the bathroom when Staff A walked into the room. When Staff A came in, Resident #1 looked upset, like he did not want Staff A in the room. When the resident saw Staff A, his face totally changed, he seemed upset. Staff B did not recall if Staff A said anything to the resident that night after he tossed the blanket on the resident. Staff A has commented to Staff B that the resident tried to kick him, however Staff B did not see the resident kick Staff A Staff B stated the resident had been aggressive with other staff. Staff B stated Staff A did not throw the blankets, he tossed them onto the resident. After that incident, Staff A cannot go into Resident #1's room. Staff B stated she had overhead Staff A at times have a tone in his voice. Staff A can sometimes be super nice to residents and sometimes he can have a tone. During an interview 4/7/26 at 2:15 PM, Staff C, Registered Nurse (RN) stated she worked an overnight shift with Staff A a while back and witnessed back and forth between Staff A and Resident #1. Staff A would tell Resident #1 something and the resident would say something back, it felt like it was children back and forth bickering. Staff C stated Staff A had a sarcastic tone with Resident #1. Staff C felt Staff A's tone was sarcastic and inappropriate with Resident #1. During an interview 4/8/26 at 8:40 AM, Staff D, RN, stated she recalled working the overnight shift on 1/22/26 and recalled working with Staff A and Staff B. Staff D stated when she first went in to meet Resident #1 and responded to a call light, he was very appreciative of her and told her thank you for being so nice to him. Resident #1 told Staff D there was a staff member, a CNA, Staff A, who was not nice to him. The resident said he thought Staff A did not like him. She recalled helping the resident to the bathroom with the other CNA working that night, Staff B. The resident was very kind, he was not combative or upset and did not display any behavioral concerns. He was kind and easy to redirect. She recalled helping the resident another time that night when he pushed his call light, she went in and then Staff A came in after her. When Staff A came into the room, there seemed to be tension between Staff A and the resident. Staff D could tell there was something between them or that something had happened between them. The resident was very kind to Staff A and thanked him for taking care of him, but Staff A did not respond and was quiet with the resident. Staff A did not really respond to the resident. The other CNA came in and Staff D left the room. During an interview 4/8/26 at 3:05, Staff E, Social Services, stated she did talk to other residents after Resident #1 filed his grievance. Staff E stated Resident #9 has said previously she did not like Staff A and said he is too sarcastic. Resident #9 is a two staff person assist with her care and stated although she would rather Staff A not provide care for her, she is okay with this taking place. Resident #9 did not give specific examples of Staff A being sarcastic. Staff E stated Staff A had not provided care to Resident #1 since 1/22/26, after Resident #1 filed the grievance with his concern regarding Staff A. During an interview 4/9/26 at 8:30 AM, Staff A, CNA, stated he began employment at the facility in July of 2025. Staff A stated he currently works the overnight shift and had for several months. Staff A stated he rarely had issues with the residents, other than three residents who have issue with him, including Resident #1 and Resident #9. Staff A stated Resident #9 does not like him. Staff A stated with Resident #1, he does not provide care to him anymore. Staff A stated Resident #1 was a resident with behaviors and with behavioral residents he can be stern and to the point. Staff A stated Resident #1 screamed loudly at night in January, and screamed loudly the first night Staff A worked with him. Staff A stated he did ask the resident at times what do you need, when the resident pushed the call light. Staff A stated he liked to have another staff in the room with him when he did care for Resident #1, even though Resident #1 was a one staff assist for care, this was due to what he felt was behavioral issues with the resident and he was not comfortable being in the room alone with him. Staff A stated Resident #1 would have some delusions and would use his call light often, sometimes 5-10 times in 20 minutes. Staff A stated he kept it strictly business with Resident #1. He would ask the resident to do things first, ask him to try, if he said no, would then help him. Staff A stated Resident #1 started getting rude with him and then told Staff A he was rude to the resident. Staff A stated the week of the incident of January 22nd, Resident #1 had behaviors during the night and did not sleep well and would be up most of the night. He would push his call light all the time. Staff A stated he would tell Resident #1 to give him a minute, that he had other residents to help. That week of the incident the resident lunged toward him, but not that night. The night of the 22nd, Staff A worked with Staff B, CNA. Staff A noted that Staff B went into the room by herself to help the resident, he went in to assist due to the resident's behaviors. Staff A stated he stood at the foot of the bed while Staff B helped the resident get in bed. Staff A stated he went to put the resident's sheet over him and the resident kicked at him and then lunged at him. Staff A put the sheet on his shins and said he could cover himself up and we are leaving. Staff A said he and Staff B left the room. Staff A stated he never told the resident he did not want to deal with him or stop pushing your call light. Staff A told the resident he had other residents to take care of and the resident might have to wait for a call light response. Staff A stated he might ask him what do you want or what do you need. Staff A stated it did get frustrating and taxing to have to deal all night with call lights. Staff A stated Resident #9 said he was rude to her. Staff A stated he had told Resident #9 that he had other residents to help when she used her call light over and over. Staff A stated he had been sarcastic with Resident #9 but felt it was in a joking manner. During an interview 4/9/26 at 1:30 PM, Staff E, Social Services, and the Administrator stated an expectation the residents are treated with dignity and respect. A staff member who shows frustration at a call light, asks a resident what do you want, rolls their eyes or is curt with a resident is not showing respect or treating a resident with dignity. Staff E and the Administrator stated Resident #1 in January of 2026, on the night of the 22nd, was a 1 staff member assist, they are okay if a staff member asks another staff member to accompany them for cares, but on that night, Staff B did not ask for assistance from Staff A. Review of the facility policy Resident Rights, revised 4/8/26, documented the resident has the right to a dignified existence and self-determination. The resident has a right to be treated with respect and dignity.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to follow physician's orders for 1 of 3 residents reviewed for pressure ulcers (Resident #32). The facility reported a census of 31 residents. Findings include: The Minimum Data Set assessment tool, dated 5/16/25, listed diagnoses for Resident #32 which included heart failure, diabetes, and obesity. The MDS listed the Brief Interview for Mental Status(BIMS) score as 14 out of 15, which indicated intact cognition. The MDS documented the resident had 1 unhealed pressure ulcer. A 5/27/25 Health Status Note stated the facility received a signed order from the primary care physician (PCP) which directed to apply betadine (an iodine solution used to treat wounds) to the left heel and cover with Optifoam (a type of foam dressing). During an observation on 5/28/25 at 9:06 a.m., Staff A Registered Nurse (RN) applied betadine to a dry, flaky scab-like area on the resident's left heel. Staff A stated that the provider told her last week that they did not want Optifoam applied and staff should keep the area open to air. Staff A did not apply Optifoam to the resident's heel. The May Treatment Administration Record (TAR) listed a 5/28/25 order for betadine to the left heel with Optifoam to cover, every other day until healed. The entry for 5/28/25 contained Staff A's initials and a check to indicate the completion of the treatment. During an interview on 5/29/25 at 10:08 a.m., Staff A stated she looked at orders prior to carrying out a treatment. She stated the Hospice provider did not want the Optifoam but the primary provider did. She stated the clinic failed to dispose of the order. During an interview on 5/29/25 at 10:41 a.m. the Director of Nursing stated nurses should look at the order prior to carrying out a treatment. Review of the facility policy Notification to Physician, Physician Assistant, Nurse Practitioner, revised May 2025, revealed the direction that staff would note and document physician treatments.

Based on clinical record review, facility policy review, and staff interviews, the facility failed to assess, intervene, and notify the physician as directed to ensure bowel regularity for 3 of 4 residents (Residents #2, #18, and #21) reviewed. The facility reported a census of 31 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment tool, dated 3/21/25, for Resident #2 revealed a list of diagnoses which included a seizure disorder, depression, and severe obesity. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, which indicated intact cognition. Review of the Bowel Elimination Report revealed a lack of documentation to indicate if Resident #2 had a bowel movement from 5/20/25 to 5/28/25. The report indicated Resident #2 had a bowel movement on 5/19/25 at 1:41 p.m. Review of the electronic health record revealed an Alert Note, dated 5/23/25 on 4:39 AM, which indicated the resident On list for intervention for No BM (bowel movement) in 3 days. Review of the May 2025 Medication Administration Record (MAR) revealed the following scheduled and PRN (as needed) medication orders: a. MiraLax (a laxative) Oral Packet 17 GM (grams)/SCOOP .Give 8.5 gms by mouth one time per day every other day for constipation. Mix with 4-8 ounces of fluid. Start Date: 2/8/24. Per the MAR the resident refused this on 5/13/25, 5/23/25 and 5/27/25. b. Dulcolax (a laxative) suppository 10 milligrams (mg). Insert 1 suppository rectally every 24 hours as needed for constipation. IF NOT RESOLVED WITHIN 48 HOURS CONTACT PHYSICIAN. Start Date: 11/29/24. The MAR lacked documentation the resident offered/refused or received the medication from 5/1/25 to 5/28/25. c. Milk of Magnesia (a laxative) Oral Suspension .Give 30 milliliters (ml) every 24 hours as needed for constipation. IF NOT RESOLVED WITHIN 48 HOURS CONTACT PHYSICIAN. Start Date: 11/29/24. The MAR documented the resident received the medication one time on 5/28/25 at 2:30 p.m. and it was unsuccessful. The MAR lacked documentation the resident offered/refused or received the medication at any other time in the month. d. MiraLax Oral Packet 17 GM (grams)/SCOOP .Give 17 gram by mouth every 24 hours as needed for promoting bowel movement. Mix with 4-6 ounces of fluid. IF NOT RESOLVED WITHIN 48 HOURS CONTACT PHYSICIAN. Start Date: 11/29/24. The lacked documentation the resident offered/refused or received the medication from 5/1/25 to 5/28/25. Review of the Progress Notes in the electronic health record from 5/20/25 until 5/28/25 at 2:30 p.m. revealed a lack of documentation regarding the status of Resident #2's bowel movements. The review also revealed a lack of physician notification of the lack of bowel movements during this period. During an interview on 5/29/25 at 10:08 a.m., Staff A Registered Nurse (RN) stated yesterday Resident #2 was on the list as having had no recent bowel movement so she administered Milk of Magnesia yesterday afternoon [5/28/25 at 2:30 PM] before she left. This morning [5/29/25] she found out that the resident had a bowel movement on 5/25/25 as this was noted on the calendar in her room. She stated she had the list yesterday morning. 2. Review of the MDS assessment tool, dated 3/7/25, for Resident #21 revealed a list of diagnoses which included heart failure, non-Alzheimer's dementia, and depression. The MDS stated the resident had problems with memory. Review the Care Plan, dated 4/23/24, revealed a Focus area to address The resident has constipation with contributing diuretic (medication used to rid the body of fluid) use for edema (swelling). He has impaired cognition and does prefer to perform toileting tasks himself. Interventions included, in part: a. Administer routine bowel medications, monitor effectiveness and report ineffectiveness. Date Initiated: 4/23/24 b. Follow facility bowel protocol for bowel management. Date Initiated: 4/23/24 Review of the Bowel Elimination Report revealed Resident #21 had a bowel movement on 5/23/25. The report listed no subsequent bowel movements as of 5/29/25 at 1:18 p.m. Review of the May 2025 MAR revealed the following scheduled and PRN medication orders: a. MiraLax Oral Power 17 GM/SCOOP .Give 1 scoop by mouth in the afternoon for constipation. Start Date: 4/30/25. Per the May 2025 MAR the medication administered daily from 5/1/25 to 5/29/25. b. Dulcolax suppository 10 mg. Insert 1 suppository rectally ever 24 hours as needed for constipation IF NOT RESOLVED WITHIN 48 HOURS CONTACT PHYSICIAN. Start Date: 12/4/24. Review of MAR's from 3/23/25 to 5/28/25 lacked documentation the resident offered/refused or received the medication. c. Milk of Magnesia, give 30 ml by mouth every 24 hours as needed for constipation. IF NOT RESOLVED WITHIN 48 HOURS CONTACT PHYSICIAN. The lacked documentation the resident offered/refused or received the medication from 5/1/25 until administered on 5/28/25 at 2:32 p.m. Review of the Progress Notes in the electronic health record from 5/23/25 to 5/28/25 at 2:32 p.m., revealed a lack of documentation regarding the status of Resident #21's bowel movements. The review also revealed a lack of physician notification of the lack of bowel movements during during this period. During an interview on 5/28/25 at 2:27 p.m., Staff D, RN stated nurses looked for BM documentation in the computer. She stated they had a paper list and stated there was only one resident on it currently and Resident #2 and Resident #21 were not on the list. Upon request, Staff D looked at Resident #21's electronic health record BM record and stated he had not had a bowel movement since 5/23/25. During an interview on 5/29/25 at 8:21 a.m., Staff C, Certified Nursing Assistant (CNA), stated the nurse informed staff if the resident is on on the BM list. She stated there was no one on the list currently. During an interview on 5/29/25 at 11:24 a.m., Staff E, Assistant Director of Nursing (ADON) stated the list generated from the computer was not congruent with the actual dates. She stated until they resolved the issue, the facility would complete paper lists. She stated when she worked on 5/16/25, the BM report sheets were not correct. She stated she directed staff not to rely on that report but stated if the resident's were not on the printed list, staff did not dig deeper to investigate. During an interview on 5/29/25 at 10:41 a.m., the Director of Nursing (DON) stated the facility had routine orders to follow if resident's had not had a BM. She stated she expected staff to notify the physician if they did not have a BM after 5 days. 3. Review of the MDS Assessment, dated 3/14/25, revealed a list of diagnoses for Resident #18 which included seizure disorder, anxiety disorder, and a mild cognitive impairment. The BIMS score of 11 out of 15 indicated a moderate cognitive impairment. Review of the Care Plan, Revision on: 7/15/24 revealed a Focus area to address [Name redacted] at risk for symptoms of constipation r/t (related to) decreased decreased mobility, need for assistance with toileting and transfers, hx (hx) of constipation. and a history of constipation. 7/12/24 Non compliant with interventions to promote normal bowel pattern and prevent complications related to constipation. Interventions included, in part: a. Follow facility bowel protocol for bowel management. UPDATED 7/12/24: [Name redacted] refusing to accept protocol for promoting normal bowel pattern. Report refusals if indicated and continues. b. Monitor the medications for side effects of constipation. Keep physician informed of any problems. Date Initiated: 4/27/23. Review of the Bowel Elimination Report revealed no documented bowel movement from 4/20/25 to 5/02/25 at 9:59 p.m.; from 5/3/25 to 5/19/25 at 1:01 p.m.; and from 5/20/25 to 5/26/25 at 9:54 p.m. Review of the electronic health record revealed the following a. Alert Note dated 4/25/25 at 6:32 a.m., On BM list for intervention No BM in 3 days b. No Type Specified dated 4/26/25 at 1:57 a.m., Resident refuses intervention for BM protocol. No documentation that physician notified of refusal. c. Alert Note dated 5/09/25 at 1:36 a.m., On BM list for intervention No BM in 3 days. d. Alert Note dated 5/16/25 at 1:00 a.m., LBM (last BM) updated to 5/12/25 -counseled res (resident, Resident #18) about regular bowel movements and available interventions. Res reports I am fine and I will poop when I'm ready. No documentation that physician notified of refusal. e. Health Status Note dated 5/18/25 at 2:14 p.m., Res refused any intervention for bowels at this time. No documentation the physician notified of refusal. f. Health Status Note dated 5/19/25 at 1:22 p.m., CNA was taking resident to bathroom and called this nurse to bathroom. Bright red blood noted small amount mixed in with B.M. Fax prepared to [physician name redacted]. Will continue to monitor. Follow up note entered at 10:00 p.m., documented Received response from PCF (primary care physician), no new orders received, no action needed. g. Health Status Note dated 5/25/25 at 9:31 p.m., Resident given prune juice to promote bowel movement. No BM noted during shift. No documentation that physician notifed of lack of bowel movement. During an interview on 5/29/25 at 9:23 a.m., Staff B, RN stated would often refuse bowel interventions and sometimes would go 5 days without bowel movement. Staff B stated that if more then 5 days with no bowel movement for Resident #18, the physician should be notified. Staff B revealed that nursing staff working overnights would run a bowel report in the facility's Electronic Health Records to determine which residents required bowel intervention or follow up. Staff B believed the bowel report may have recently had a system glitch. At 9:25 a.m., Staff B ran a bowel report which revealed no residents currently required intervention for facility bowel protocol. During an interview on 5/29/25 at 10:42 a.m., the DON stated Resident #18 would sometimes go 7 days with no bowel movement. The DON stated nursing staff should notify the physician by day 5 of no bowel movement, or determine accuracy of bowel movement documentation. Review of the facility policy, titled Notification to Physician, Physician Assistant, Nurse Practitioner revised May 2025, revealed the direction that staff would notify the provider of a resident change in condition in a timely manner. Review of the undated facility policy Bowel Management Program, revealed a Purpose section, which declared, in part: To ensure that the resident has adequate bowel movements to prevent problems. The policy directed staff to a. Administer Milk of Magnesia if no BM or only a small BM in 2 days. b. Administer a Dulcolax suppository if no BM by the end of the following shift. c. Administer a Fleets enema (a procedure where liquid was inserted into the rectum through the anus to empty the bowels) on that shift.

Based on daily staffing sheets, punch detail, policy review and staff interviews, the facility failed to have 8 hours Registered Nurse (RN) coverage. The facility reported a census of 28 residents. Findings include: The Daily Healthcare (HC) Schedule, dated 6/16/24, revealed Staff B, Registered Nurse, worked the night shift on 6/16/24. The review of the facility punch detail reflected on 6/16/24 Staff B clocked in at 10:07 PM and clocked out 6/17/24 at 6:37 AM. The facility couldn't provide additional information including Daily HC schedules or punch detail regarding RN coverage on 6/16/24. The Nursing Services and Sufficient Staff policy, revised 10/10/23 revealed except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. During an interview 7/10/24 at 2:00 PM the Director of Nursing acknowledged an RN didn't work 8 consecutive hours on 6/16/24 as expected.

Based on observation, policy reviews and staff interviews, the facility failed to follow manufacturer's recommendations while administering insulin utilizing an insulin KwikPen for 1 of 1 resident reviewed for insulin administration with an insulin pen (Resident #16). The facility reported a census of 28 residents. Findings include: Resident #16's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognition. The MDS included a diagnosis of diabetes mellitus. Resident #16's July 2024 Medication Administration Record (MAR) listed an order dated 5/30/24 for Basaglar KwikPen Solution Pen injector 100 UNIT/milliliter (ML) (insulin glargine). Inject 45 units subcutaneously in the morning for diabetes mellitus type 2. On 7/10/24 at 7:10 AM, observed Staff A, Licensed Practical Nurse (LPN), administer glargine insulin subcutaneously to Resident #16 utilizing the Basaglar KwikPen. Following administration, Staff A immediately removed the insulin pen from Resident #10. Review of the manufacturer's recommendation for Basaglar Temp Pen insulin glargine injection directed to insert the needle into the skin. Push the Dose Knob all the way in, continue to hold the dose knob in and slowly count to 5 before removing the needle. During an interview 7/10/24 at 12:09 PM Staff A reported she didn't receive training to keep the insulin KwikPen in place for a period of time following administration. During an interview 7/10/24 at 12:20 PM, Staff A acknowledged the manufacturer's recommendation is to hold the pen in place following administration and slowly count to 5 before removing the needle. In addition, Staff A explained she previously pulled the insulin pen out immediately after she heard the pen click following administration. The Insulin Pen policy, revised February 2023 instructed while still pressing the plunger, keep the needle in the skin following the manufacturer's protocol, then remove the needle. The Medication Administration policy, revised 10/19/23 directed the staff to administer medications as ordered in accordance with manufacturer specifications. During an interview 7/10/24 at 1:38 PM, the Director of Nursing (DON) reported they expected the staff follow manufacturer's recommendations when administering insulin.

Based on observations, interviews and record review, the facility failed to recognize and respect the psychosocial feedback and responses for 2 of 3 residents reviewed (Residents #4 and #10). Resident #4 and Resident #10 both had alarms that sounded when standing. Resident #4 reported the alarm made her anxious and like she needed to move when her alarm sounded. Resident #10 reported the alarm as jarring and it frightened her. The facility had a census of 27 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #4 required supervision or touching assistance with transfers, standing, and ambulation. The MDS included diagnoses of anxiety, depression, COPD (chronic obstructive pulmonary disease) and osteoarthritis. The MDS documented Resident #4 used a bed alarm daily. The Care Plan Focus revised 7/9/24 indicated Resident #4 had a risk for falls and fall related injuries due to her history of falls, increased weakness, use of oxygen per nasal cannula (O2/NC), contributing diagnoses, balance and gait deficits. Resident #4 continued to self-transfer, removed, or hid her alarms. The facility discontinued her chair alarm on 4/24/24. On 7/9/24, the facility placed a new alarm due to her noncompliance with requesting assistance with transfers resulting in falls and/or increased risk for falls. The Interventions directed the following: a. 1/9/24: Resident #4 needed an assistance from 1 staff with transfers, ambulation in room, and throughout the facility with use of a gait belt and walker. b. 12/1/23: Place a body pillow to the left side of Resident #4's bed to define edge of bed for Resident #4. c. 12/1/23: Check with Resident #4 between 9:00 a.m. and 9:30 a.m., to see if she is ready to get out of bed. d. 5/21/24: Educated Resident #4 that she was at risk for falls. Re-educate/remind further as needed. e. 5/21/24: Educated Resident #4 on the need for calling for assistance, questions, medications and/or concerns. The staff must assess Resident #4's compliance of the use of her call light to assist with above needs. f. 1/9/24: Ensure proper bed alarm placement and functioning while in bed. Resident #4 did remove her alarm at times. The staff should provide education on the importance of placement and the importance of requesting assistance prior to trying to self-transfer. Resolved 6/20/24. g. 1/9/24: Ensure chair alarm is in place when up and proper functioning. Resident #4 did remove chair alarm at times, Staff should educate on the importance of placement and need for requesting assistance prior to attempting to self-transfer. Resolved 4/24/24. h. 6/17/24: Listed the fall intervention as of 6/15/24: Ensure the use of the assistive device. Consult therapy as needed (PRN) to help with transfers and use of assisted devices. i. 6/20/24: Ensure placement and functioning of the floor alarm due to Resident #4 hiding the bed alarm (discontinued bed alarm due to noncompliant use). Cancelled 7/9/24. j. 7/9/24: Laser motion sensor alarm placed in room to alert staff when Resident #4 self-transferred. k. 6/11/24: Provide and encourage use of a reacher to pick up items off the floor. l. Revised 7/9/24: Provide education and counseling on the importance of using her call light for assistance. Keep Resident #4's door open. Resident #4 refused to use bedside commode attempted for safety. m. 6/13/24: Refer to Physical Therapy to evaluate and treat if indicated due to right lower knee weakness. n. 12/1/23: Remind Resident #4 to use call light and wait for staff assistance prior to attempting to self-transfer. o. 2/28/24: Remind Resident #4 to use the call light for assistance for all transfers and toilet use. The Care Plan Focus revised 2/16/24 identified Resident #4 had a risk for problems related to psychosocial wellbeing and participation due to her short-stay admission, but determined unsafe to return home. Resident #4 reported feeling isolated with diagnoses of depression and anxiety. The related Goal reflected she would participate in activities of daily living (ADLs), activities of her choice, her mood will not result in an overall decline through the next review date. The Interventions directed the staff the following: a. 11/24/23: Monitor and document Resident #4's for impact of medical problems on activity level. b. 11/24/23: Observe Resident #4 for changes in mood and participation, intervene and report if indicated. c. 2/16/24: Observe Resident #4 for signs of depression, such as isolating herself and decreased participation in self-care, report if indicated. d. 11/24/23: Resident #4 needed assistance/escort to activity functions. Resident #4's Clinical Record Review reflected Fall Incident Reports for the following dates: 11/22/23, 12/1/23, 12/9/23, 2/27/24, 4/27/24, 5/21/24, 5/25/24, 6/12/24 and 6/15/24. A Progress Note dated 6/17/24 at 11:41 a.m., documented that a nurse and the Administrator spoke with Resident #4. They reviewed her recent increased falls. They explained she needed interventions to mitigate the continued incidents. Due to the location of her room, staff couldn't hear her alarm effectively or pass by her room as it is at the end of the hall, the staff preferred she move closer to the staff area, but, that location didn't have rooms available. Resident #4 reported she usually didn't use her call light. They asked Resident #4 to start using her call light to prevent needing to move and having a possible roommate. Resident #4 stated she didn't want a roommate. They visited about keeping her door open, Resident #4 agreed to keep her door open. They discussed and Resident #4 agreed to having a commode beside her bed to use the bathroom in the middle of the night to decrease the distance and trip hazards. On 7/8/24 at 1:40 p.m., Resident #4 stated she did fall with injury but it had been awhile since she had fallen. Resident #4 stated she was good with ambulation and did not require further therapy. Resident #4 had an alarmed mat on the floor in front of her couch where she was sitting. This resident set the alarm off with her feet, turned it off, and scooted it under her couch with her feet. Staff responded. Staff C, Registered Nurse (RN), entered the room and pulled the mat back out from under the couch and turned it back on. Staff C explained to Resident #4 it was to let staff know when Resident #4 was up in her room. Resident #4 said okay and then rolled her eyes after the nurse left. Resident #4 set off her alarm again and rolled her eyes. Staff responded. On 7/10/24 at 10:19 a.m., Resident #4 did not have the mat under her feet while sitting on the couch. Staff E, Certified Nurse Aide (CNA), stated that now Resident #4 had an alarm on the wall. Staff E showed the censor and how it alarms. Staff E stated the alarmed censor basically will pick up movement in the room. The CNA stepped out in front of the alarm and it sounded. This resident rolled her eyes. When asked if her daughter wanted her to have an alarm, she stated she didn't know anything about that. When asked if she was worried about falling, she stated not anymore. When asked what she thought about the alarm she stated it can be annoying and she tolerates it. Following the above observation, Staff D, RN, and Staff E stated that Resident #4 transferred to the facility from Assisted Living related to continuous falling in her apartment. They stated that this resident does not like the alarm, but tolerated it. Staff E stated that Resident #4 agreed to have the alarm because her daughter wanted her to have it. Staff E stated that Resident #4's daughter wanted her mom to have some kind of an alarm. Staff D stated that Resident #4 was in a restorative program. Staff D said that Resident #4 liked to ride the bike (Nu Step) although many times she refused. On 7/10/24 at 11:52 a.m., the Licensed Nursing Home Administrator (LNHA) and Staff A, Licensed Practical Nurse (LPN), brought in documentation from progress notes regarding Resident #4's 'noncompliance' with call light use. They stated that Resident #4 was agreeable to use alarm and had stated back up on Physical Therapy. On 7/10/24 at 12:47 p.m., the Physical Therapist stated Resident #4 already had a floor alarm the first time this Physical Therapist saw Resident #4. The rest of the therapy team agreed that they did not make recommendations for Resident #4 to have alarms. On 7/10/24 at 12:56 p.m., when questioned about how the wall alarm made her feel, Resident #4 responded it made her anxious. Resident #4 described it as loud and made her feel like she needed to get up and move or something. She reported it as defective. When asked if anyone talked to her about it being an alarm to alert staff about her moving in her room, Resident #4 replied no one talked to her about that. She stated she can move around herself. When asked if staff talked to her about their concern of her falling, she stated no one talked to her about falling. On 7/11/24 at 9:11 a.m., Resident #4's Daughter (RR#4) stated she didn't love the alarms and didn't think the alarms prevented her mother from falling. RR#4 stated when the alarms sound, the staff come to her mom's room check on her and see that she fell . RR#4 stated in her opinion the alarm went off so often, that it could slow the staff's response to the alarm. RR#4 stated the alarms are loud, hard to turn off, and they end up waiting for the staff a while to respond to the alarm to turn them off. RR#4 said as they wait, they sit in the room waiting with a loud alarm sounding. When asked if she felt the alarms caused her mother any distress, RR#4 responded yes when an alarm went off, it caused her mom anxiety. RR#4 stated her mom did have short-term memory loss. 2. Resident #10's MDS assessment dated [DATE], identified a BIMS score of 15, indicating intact cognition. Resident #10 required supervision or touching assistance with chair/bed and toilet transfers, standing, and ambulation. The MDS included diagnoses of Parkinson's disease and cerebral infarction (stroke). The MDS documented that Resident #10 used a floor mat alarm daily. The Care Plan Focus revised 7/2/24 reflected Resident #10 had a potential to fall or have fall related injuries due to her needing assistance with self-care and mobility tasks due to admitting with impaired range of motion to her right lower extremity due to a previous fall with hip fracture that required repair. The connected Goal revised 7/1/24, indicated Resident #10 wouldn't sustain any additional falls related injuries by utilizing fall precautions through the next review date. The Interventions instructed the staff the following: a. 1/8/24: Anticipate and meet Resident #10's needs. b. 1/8/24: Be sure Resident #10's call light is within reach and encourage Resident #10 to use it for assistance as needed. Resident #10 needs prompt response to all requests for assistance. c. 5/19/24: Place chair alarm arm in wheelchair and recline. Observe placement and functioning. Cancelled 7/10/24. d. 1/8/24: Educate Resident #10, family, and caregivers about safety reminders and what to do if a fall occurred. e. 5/19/24: Encourage and remind Resident #10 to use her call light for assistance prior to attempting to self-transfers. f. 3/14/24: Ensure bed alarm placement and proper functioning. i. Revised 4/24/24: Will follow up with continued need of alarm on 5/7/24 if Resident #10 returned to full weightbearing status. iii. Intervention resolved 7/2/24. g. 1/8/24: Ensure Resident #10 wore appropriate footwear when ambulating or mobilizing in her wheelchair (w/c). h. 5/30/24: Floor alarm in front of chair (while up in chair) and at bedside (while in bed). i. 1/8/24: Physical Therapy to evaluate and treat as ordered or PRN. j. 6/14/24: Visual Reminder Note on closet to remind Resident #10 to not transfer without staff assistance. Resident #10's list of Fall Incident Reports listed she fell on [DATE]. A Progress Note dated 5/30/24 at 10:05 a.m., documented the staff discussed with Resident #10 about safety and need for staff to be by her when she is up with her walker. Staff found Resident #10 in the hall independently with her walker, no call light on, and no alarm sounding. Upon investigation, discovered alarm placed in different chair. Took a long walk with Resident #10, who visited with therapy about plans to do restorative exercises. Resident #10 reported a concern that no one would work with her anymore. Reassured Resident #10 that she would continue to get exercises with Occupational Therapy and she could ambulate with staff. When they returned to Resident #10's room, she avoided sitting in chair with alarm and asked, is it going to beep when I move my butt? In addition, Resident #10 avoided sleeping in her bed due to the bed alarm. When visited about an alternative option of a floor alarm, Resident #10 appeared more agreeable to that. Resident #10 stated what do I have to do to get rid of that?. Staff advised that Resident #10 would have to use her call light consistently for staff to be with her during ambulation and transfers. Resident #10 stated well I am done with therapy and at my best level so I can do whatever I want now. Advised that the staff's job required them to keep the residents safe from injury or otherwise. Additionally, the staff had facility rules they need to follow. Floor alarm placed, bed and chair alarms taken out. A Progress Note dated 5/30/24 at 10:18 a.m., documented a staff member reported Resident #10 crying in her room. The nurse visited with Resident #10 again and asked why she was upset. Resident #10 stated she couldn't go to a birthday party. The nurse explained the staff would make sure she could go to the birthday party. Resident #10 added she did not like the floor alarm and wanted to go home. Resident #10 stated What is the use of having legs if they won't let me use them? The nurse advised Resident #10 that she could ambulate with staff, they just needed to know when she would like to, as well as being able to walk to dining area and back to room for meals. Reiterated that staff needed to be present while she does so. Resident stopped crying, but continued to display some anxiousness about various things. On 7/8/24 at 2:57 p.m., observed an alarm mat at the foot of Resident #10's recliner. Resident #10 reported she HATES it. Resident #10 voiced she never fell and the staff wanted to make sure she called them before trying to take herself to the bathroom. On 7/10/24 at 10:47 a.m., Resident #10 looked asleep in her recliner, with the mat on the floor. The Director of Nursing (DON) and Staff D stated Resident #10 never refused the floor mat. They said Resident #10 told the staff she wanted the chair alarm removed and the bed alarm removed, so they removed those alarms. They acknowledged Resident #10 told staff she hated the mat, however they stated Resident #10 didn't refuse letting the staff to place it under her feet. They added that Resident #10 now refused to sleep in her bed, and slept in her recliner. They stated that Resident #10 got up to try to help her husband, she had slow gait and walked on her tip toes. The DON and Staff D described Resident #10 as a high fall risk. The DON stated Resident #10 currently worked in physical therapy (PT) as Resident #10 and her husband wanted to discharge back to their home. The DON stated Resident #10's children believed Resident #10 could take care of their father. The DON stated that Resident #10 and her husband had alarms at home and when/if they discharge they will take the alarm with them. On 7/10/24 at 12:46 p.m., the Physical Therapy Aide (PTA), stated she remembered having a conversation with nursing when Resident #10 ended therapy that maybe they could try a floor mat since she did not like the bed alarm or the chair alarm. Resident #10 didn't consistently use her call light but would go ahead and transfer herself. She needed to have 1 assist with a gait belt and walker for safety reasons. On 7/10/24 at 1:01 p.m., When asked how the floor alarm made her feel, Resident #10 reported the alarm as jarring and frightened her. When asked if she knew why she had the floor alarm, she stated it is there to keep a person in one place but that can't be good for the body. When asked if they had talked to her about their concern for her falling, she shook her head no. On 7/10/24 at 1:37 p.m., the DON, acknowledged the concern regarding psycho-social well-being for Resident #4 and Resident #10. This DON stated she would like the facility to be alarm free. On 7/10/24 at 4:01 p.m., the Executive Director acknowledged concerns with alarms. Stated she had a conversation with their call light company regarding other options that would send a signal to a phone instead without the loud noise sounding from the alarm. On 7/11/24 at 11:56 a.m., the DON stated each resident's alarm sounded differently and the staff could hear the alarms from all halls. The DON explained she expected the staff to answer the alarms immediately. A Facility assessment dated [DATE], directed the staff to do the following: a. Build relationship with resident/get to know him/her; engage resident in conversation b. Find out what resident's preferences and routines are; what makes a good day for Resident #10; what upsets him/her and incorporate this information into the care planning process. Make sure staff caring for Resident #10 have this information c. Record and discuss treatment and care preferences d. Support emotional and mental well-being; support helpful coping mechanisms e. Offer and assist resident and family caregivers (or other proxy as appropriate) to be involved in person-centered care planning and advance care planning. The Resident Alarms policy revised June 2024, directed the staff to utilize resident alarms in limited circumstances, in accordance with the resident's needs, goals, and preferences, so Resident #10 will be able to attain or maintain his or her highest practicable level of physical, mental, and psychosocial well-being. An alarm is any physical or electronic device that monitors the resident's movement and alerts the staff, by either audible or inaudible means, it detects when movement. a. The use of alarms does not eliminate the need for adequate supervision of the resident. Types of alarms include: i. Bed alarms - including devices such as a sensor pad on the bed or a device that clips to the resident's clothing ii. Chair alarms - including devices such as a sensor pad placed on the chair or wheelchair or a device that clips to the resident's clothing iii. Floor mat alarms - including devices such as a sensor pad placed on the floor beside the bed iv. Motion sensor alarms - includes infrared beam motion detectors. v. Other - includes devices such as alarms on Resident #10's bathroom and/or bedroom door, toilet seat alarms, or seatbelt alarms. b. The facility shall establish and utilize a systematic approach for the safe and appropriate use of resident alarms, including efforts to identify risk; evaluate and analyze risk; implement interventions to reduce risk; and monitor for effectiveness of the interventions and modifying interventions when necessary. c. Identification of risk: The facility should assess each resident for fall and elopement risk upon admission and periodically thereafter as part of the comprehensive assessment process. i. The medical record should have the medical symptoms identified and documented. The information may come from the resident's medical history, physical exam, or individual observation. ii. The facility should identify the adverse consequences related to alarm when using or considering the use of alarms. d. Evaluation and analysis of risk: The interdisciplinary team shall analyze each resident's unique risks and medical symptoms to determine the root cause(s) of each risk. i. The interdisciplinary team shall consider the severity of risks/symptoms, the immediacy of risks, and trends such as time of day, location, or stated reasons for the behavior/fall. ii. The facility should develop interventions to address the root cause(s) of each risk. e. Implementation of interventions i. The facility shall implement Resident-directed approaches in accordance with the resident's needs, goals, and preferences. ii. The facility should initiate alarms only to address a specific medical symptom or unique risk, when the benefit of the alarm outweighs the risk associated with its use. iii. The facility should implement and document on supervision and other resident-specific interventions prior to the use of alarms. iv. The facility should communicate the interventions to all relevant staff, including frequency/time frames and responsibility. f. Monitoring and modification: The facility should provide supervision to the resident in accordance with their plan of care. i. When a facility used an alarm, the facility should provide additional monitoring, including but not limited to: 1. Verifying using the alarm is in accordance with the resident's care plan. 2. Verifying alarms worked properly. 3. Monitoring for adverse consequences associated with the use of the alarms, including psychosocial concerns. ii. Ongoing assessment of the resident shall occur to identify changes in patterns, routines, or medical symptoms of the resident. The facility should modify interventions as needed, to address any changes. iii. Considerations for discontinuation of alarms include, but are not limited to: The medical symptoms or risks warranting the use of the alarms are no longer present. 1. The risks associated with the use of the alarm outweigh the benefit. 2. Evidence of adverse consequences associated with the use of the alarms. 3. Resident/family goals and preferences change. g. When the facility used alarms, the interdisciplinary team shall determine whether the alarm meets the definition of a restraint. The resident's assessment should include documentation to determine whether the alarm meets a definition of a restraint. i. If the facility considers the alarm a restraint for the resident, the facility should implement the procedures for restraints.

Based on clinical record review, observation, staff interviews, and facility policy review, the facility failed to ensure residents' tubing was changed on a weekly basis per standards practice for two of two residents reviewed who required oxygen therapy (Residents #7 and #30). The facility identified a census of 34 current residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident#7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented Resident #7 required supervision with all activities of daily living. The MDS also recorded the resident required oxygen therapy and an admitted [DATE] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's Care Plan contained a Respiratory category with a start date of 12/17/21. A listed intervention directed staff to change the resident's oxygen tubing per facility protocol. Observation on 12/20/21 at 11:27 a.m. revealed Resident #7 lying in bed with oxygen on at three liters, and the oxygen tubing showed a date of 9/16. Further observations on 12/21/21 at 1:24 p.m. and 12/22/21 at 8 a.m. revealed Resident #7 lying in bed with oxygen running at three liters and a continued date of 9/16 marked on his O2 tubing. During interview on 12/22/21 at 8:05 a.m. Staff A, Registered Nurse (RN) reported the facility's oxygen provider changes out the oxygen tubing and Staff A did not know if they document the change anywhere. Interview on 12/22/21 at 8:07 a.m. with Staff B, Certified Nurses Aide revealed the facility's oxygen provider changes the resident's oxygen tubing and checks out the equipment. If it looks like the tubing needs to be changed in the meantime, Staff B would tell the nurse, and the nurse would change it. During interview on 12/22/21 at 9:28 a.m. the Assistant Director of Nursing (ADON) reported the facility's oxygen provider changes out the oxygen tubing every week. The ADON reported they had reached out to the company to see if they had any documentation as to when they change out the oxygen tubing. The ADON stated she just changed Resident#7's oxygen tubing. 2. The MDS assessment dated [DATE] documented Resident#30 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required the assistance of two staff with bed mobility and the assistance of one with transfers, dressing and personal hygiene. The assessment recorded she required oxygen therapy while living at the facility and an admitted [DATE]. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #30's Care Plan, updated on 11/29/21, documented she had the risk for activity intolerance due to decreased cardiac output and increased respiratory effort with [CONDITION(S)]. The Care Plan identified Resident #30 as dependent on oxygen to maintain adequate oxygenation, but it did not address changing her oxygen tubing. Observation on 12/20/21 at 11:58 a.m. revealed the oxygen tubing in the resident's room connected to an oxygen concentrator without a date marked on the tubing. Observation on 12/21/21 at 1:59 p.m. revealed the oxygen tubing in Resident #30's room without a date marked on the tubing. Observation on 12/22/21 at 9:21 a.m. revealed Resident #30 sitting in the main dining room with portable oxygen set at two liters per nasal cannula, but no date marked on the oxygen tubing. During interview on 12/22/21 at 8:05 a.m. Staff A reported the resident had oxygen at two liters all the time. The facility's Oxygen Concentrator policy dated 9/20 documented the purpose of the policy as to establish responsibilities for the care and use of oxygen concentrators. The section on care of the concentrator, under nurse responsibilities, instructed change of a resident's oxygen tubing and mask/cannula weekly and as needed if it became soiled or contaminated (the facility's oxygen provider handled the weekly change).

Based on observations, document review and staff interview, facility staff failed to serve food under sanitary conditions in order to reduce the risk of contamination and food-borne illness. The facility identified a census of 42 residents. Findings include: During an observation on 11/13/19 at 9:24 a.m., Staff D, Cook, prepared the puree meals to serve the lunch meal. Staff D used a scoop to add Thick and Easy to food processor. Staff D placed the scoop into the tub of thick and easy and closed the lid. During an observation on 11/13/19 at 11:25 a.m. of meal service, Staff E, Cook, applied gloves. He opened the cooler under the grill, removed the top of the cheese container, took out a slice of cheese with same gloved hand, replaced top of the container, removed top of ham container, took out sliced ham, replaced top of the container. He placed the ham and cheese on bread and placed bread on the grill. He picked up a salad bowl, using same gloved hands, placed lettuce, tomatoes and cheese in bowl. He opened the cooler below the salad bar. He took out salad dressing and removed the lid. He picked up a small cup and poured salad dressing into the cup, placed lid on salad dressing and returned dressing to the cooler. Staff [NAME] removed gloves after touching multiple surfaces and food and then washed hands. During an observation on 11/13/19 at 11:37 a.m., Staff [NAME] applied gloves and took a handful of potato chips from bulk bag and placed chips in a bowl. He used tongs and a knife to remove bones from ribs, remove ribs from pan, cut meat and place meat on plate with tongs. He used the serving scoop to place corn on plate. He opened the cooler below the grill, removed a hamburger and placed the hamburger on the grill. Staff [NAME] then opened a package of buns, removed a bun with same gloved hand and placed the bun on the plate. He opened the cooler below the salad bar and removed lettuce, tomato slice and pickles from cooler and placed them on the plate. Staff [NAME] removed his gloves after touching multiple surfaces and food and washed hands. During an observation on 11/13/19 at 12:48 p.m., Staff [NAME] applied gloves. He then opened the cooler below the grill. He removed a hamburger from the cooler and placed it on the grill. He removed the top of the cheese container, removed a slice of cheese, placed the cheese on the hamburger, replaced top to the cheese container and closed the cooler. Staff [NAME] removed a bun from the package with his gloved hand and placed the bun on a plate. Staff [NAME] picked up a divided plate, removed the bun from the first plate and placed the bun on the divided plate. He opened the cooler below the salad bar, removed lettuce, pickles and onion and placed them on the plate. Staff [NAME] then removed his gloves after touching multiple surfaces and food items and washed hands. During an interview on 11/13/19 at 9:33 a.m., Staff D, Cook stated sometimes leaves the scoop in the tub of Thick and Easy, but probably shouldn't have done that. During an interview on 11/13/19, at 9:46 a.m., Staff F, Dietary Manager stated scoops are not to be left in the tub of the Thick and Easy. During an interview on 11/14/19 at 8:33 a.m., Staff F stated education recently provided to all staff during a Health Fair. A copy of the Health Fair In-Service was provided. A review of the Bulk Ingredient Bins and Scoops stated scoops, measuring cups, and utensils are not to be stored in the bulk food container. The Health Fair In-Service sheet states to wash hands before and after gloving. The In-Service sheet also states not to use gloves when using utensils. The 2013 Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry requires single-use gloves be used for only one task, such as working with ready-to-eat food and used for no other purpose and discarded when damaged or soiled or when interruptions occur in the operation.

Based on observation, interview, and record review, the facility failed to assess bed side rails for the risk of entrapment and failed to obtain consent for the use of bed rails after trying other alternatives and explaining the risks and benefits to the residents or the resident's representative for 5 of 42 (Residents #28, #4, #25, #9, and #26). The facility reported a census of 42 residents. 1. The Minimum Data Set (MDS) assessment dated [DATE], listed [DIAGNOSES REDACTED]. The MDS revealed the resident required assistance of staff for bed mobility, transfer, dressing and toilet use. The MDS documented the resident's Brief Interview for Mental Status (BIMS) as not able to be completed due to severe impairment. During an observation on 11/12/19 at 10:36 a.m., noted Resident #28 resting in bed with ¾ length side rails attached to the bed in the upright position on both sides of the bed. Both rails were padded on the inside of the rails. During this observation the openings between the slats on the bedrails from end to end appeared to be too wide. The Facility Administrator and Staff were notified of concern with the bed rails on Resident #28's bed. The Assistant Director of Nursing (ADON) measured the openings between the slats on the inside of the side rail and reported a measurement of 7 ¾ inches with the surveyor observing the measurement. During an observation on 11/12/19 on 12:50 p.m., Resident #28 resting in bed with both side rails in the upright position and again padded on the inside of the bed. During an interview on 11/12/19 at 3:30 p.m., the Facility Administrator acknowledged not aware of the regulation for the side rail. The Facility Administrator reported Staff G, Maintenance Staff, changed out all the ¾ side rails in the facility and the surveyor toured each room that had the ¾ rails to verify the side rails were taken off. During record review of Resident #28 no consent found related to the side rails. During an interview on 11/14/19 at 1:39 p.m., the Facility Administrator stated they had not been obtaining consents for the bed rails and acknowledged the facility did not have a routine maintenance plan for checking the side rails attached to the beds. 2. The MDS assessment dated [DATE], listed [DIAGNOSES REDACTED]. The MDS revealed the resident independent with bed mobility and transfer. The MDS documented the residents Brief Interview for Mental Status (BIMS) score was 2 out of 15, indicating severe cognitive impairment. On 11/12/19 at 3:00 p.m., during walk through with the Administrator she confirmed that Resident #4 had side rails with ¾ openings between the slats and did not meet the regulations. Facility took the side rails off of the bed. 3. The MDS assessment dated [DATE], listed [DIAGNOSES REDACTED]. The MDS revealed the resident required extensive assistance with bed mobility and transfer and the residents Brief Interview for Mental Status (BIMS) score was 3 out of 15 indicating severe cognitive impairment. On 11/12/19 at 3:00 p.m., during walk through with the Administrator she confirmed that Resident #4's side rails with ¾ openings between the slats and did not meet the regulations. Facility took the side rails off of the bed. 4. The MDS assessment dated [DATE] for Resident # 26, included [DIAGNOSES REDACTED]. During an observation on 11/12/19 at 11:33 a.m., noted Resident #26's bed with side rails in the down position on both sides of the bed. The bed rails had 6 vertical slats with 5 openings of 7 3/4 inches between the vertical bars. During an interview on 11/12/19 at 11:33 a.m., Resident #26 stated she uses both side rails every night. Resident #26's clinical record lacked documentation of a side rail consent. During a walk through of the facility on 11/12/19 at 3:30 p.m., the Administrator and Staff G, Maintenance Staff confirmed Resident #26 had bilateral bed rails (6 vertical bars with 5 openings of 7 3/4 inches between the bars) that did not meet regulations and had been removed. 5. The MDS assessment dated [DATE] for Resident #9, included [DIAGNOSES REDACTED]. Resident #9's clinical record lacked documentation of a side rail consent. During a walk through of the facility on 11/12/19 at 3:30 p.m., the Administrator and Staff G, Maintenance confirmed Resident # 9 had bilateral bed rails (6 vertical bars with 5 openings of 7 3/4 inches between the bars) that did not meet regulations and had been removed.

Based on record review and staff interview, the facility failed to limit as needed (PRN) [MEDICAL CONDITION] medication to 14 days per regulations for 1 of 5 residents reviewed (Resident #9) for un-necessary medications. The facility reported a census of 42 residents. Findings Include: The MDS assessment dated [DATE] for Resident #9, included [DIAGNOSES REDACTED]. The MDS documented a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. The Medication Administration Record [REDACTED]. A review of MAR for (MONTH) 2019 and (MONTH) 2019 revealed staff administered the PRN ABH gel on 10/25/19, 11/7/19, and 11/9/19. During an interview on 11/14/19 at 10:20 a.m.,, the Director of Nursing stated the expectation for PRN medication orders be for 14 days only.

Based on record review and staff interview the facility failed to accurately complete a Significant Change Minimum Data Set (MDS) for 1 of 13 residents reviewed (Resident #28).The facility reported a census of 42 residents. Findings Include; 1. The Minimum Data Set ((MDS) dated [DATE] for Resident #28 identified a Brief Interview for Mental Status (BIMS) not completed due to severe cognitive impairment. The MDS reported [DIAGNOSES REDACTED]. During the record review on 11/13/19 at 10:45 a.m., noted Resident #28 started on Hospice care on 6/14/19. Review of the MDS dated [DATE] section O did not indicate Hospice care for the Significant Change MDS. During an interview on 11/13/19 at 10:46 a.m., the MDS Nurse verified the Significant Change MDS for Resident #28 completed related to the initiation of Hospice care and acknowledged that Hospice care should have been identified in section O.

Based on clinical record review, policy review, and staff interviews, the facility failed to provide the resident/resident representative notice of the Bed Hold Policy at the time a resident transferred to the hospital for one of two residents reviewed (Resident #39). The facility reported a census of 42 residents. Findings include: A Minimum (MDS) data set [DATE] included [DIAGNOSES REDACTED]. A Brief Interview for Mental Status was unable to be completed due to severe cognitive impairment. Review of resident's clinical record revealed the resident transferred and admitted to the hospital on [DATE] and returned to the facility 11/4/19. Review of resident's clinical record lacked documentation of notification to the resident or resident's representative regarding the Bed-Hold Policy when the resident admitted to the hospital 11/2/19 thru 11/4/19. Review of the undated facility Bed Hold Policy documented to ensure that residents or responsible parties have information regarding the Bed Hold Policy prior to transfer to a hospital. During an interview on 11/13/19 at 3:43 p.m. Staff A, Registered Nurse (RN) acknowledged the facility unable to provide documentation a Bed Hold Policy provided to the resident/resident representative when the resident admitted to the hospital on [DATE]. During an interview on 11/14/19 at 8:30 a.m., the Director of Nursing (DON) acknowledged she expected the Bed Hold Policy to be provided to all residents/resident representatives upon transfer to the hospital.

Based on observation, dietary menu review, facility policy review and staff interview, the facility failed to ensure dietary staff utilized proper handling of ready to eat resident food items in order to prevent foodborne illness. The facility census was 42 residents. Findings include: 1. The dietary spreadsheet for the noon meal on [DATE], revealed the following to be served: a. catfish fillet or b. chicken and noodles c. baby red potatoes or d. mashed potatoes e. candied carrots or peas f. choice of salad g. bread basket h. pumpkin desert. Observation on [DATE] at 11:35 a.m., revealed Staff A, Cook wearing gloves touched the bread peanut/butter and jelly sandwiches directly and without changing gloves went on to touch the scoop handles and plates and served resident food items. Without removing the gloves Staff A again touched the sandwiches directly and continued to serve food items with no glove change. During interview on [DATE] at 8:00 a.m., the Food Service Director reported touching the bread without changing gloves was not acceptable, it was not the standard procedure or policy. The Director noted Staff A should have changed gloves after touching the bread. The Facility's Policy, undated, for Glove Use In Food Service showed in the Procedure (#4) to change gloves whenever you change activity (from making sandwiches to making change) or whenever you leave your workstation. Remove gloves and discard when not performing a food contact task and wash hands - wear gloves only when needed (handling ready-to-eat foods).

Based on observation, policy review, and staff interview, the facility failed to label resident's medication with identifying information and a date medication opened on 2 of 3 medication carts reviewed, and failed to assure expired medications were not available for resident use. The facility reported a census 47 residents. Findings include: 1. Observation of the North medication cart on 8/3/17 at 9:30 a.m., with Staff C, Licensed Practical Nurse (LPN), revealed the following concerns: a. One tube of voltaren 1% gel had no open date b. One tube of Theragesic cream had no open date c. Three bottles of Debrox ear drops had no label with resident's name on the bottle or medication box 2. Observation of the East medication cart 8/3/17 at 9:45 a.m., with Staff D, LPN, revealed the following concerns: a. One bottle of nystatin suspension had no open date b. One bottle of Phillips laxative caplets had no open date c. One bottle of hyoscyamine sublingual tablets had no open date d. One container of nitroglycerine ointment had no open date e. One bottle of Debrox ear drops had no label with the resident's name on the bottle or medication box f. One bottle of nystatin powder had no open date g. One bottle of lidocaine 5% had no open date h. One flovent inhaler had no label with the resident's name or an open date on the vial i. One bottle of humalog insulin stored in a plastic bag had no label with the resident's name on the vial. At the time, Staff D reported the vial may have been obtained from the emergency kit, and they hadn't received another vial from the pharmacy yet. The observations revealed a prescription label had been placed on the exterior of some of the medication boxes but the ear drop bottles, inhaler, and insulin contained no labels which identified the resident the medication belonged to. 3. Observation of the medication room [ROOM NUMBER]/3/17 at 10:00 a.m., revealed one bottle of magnesium citrate had expired on 6/2017. During an interview 8/3/17 at 9:35 a.m., Staff C, reported ear drops obtained from stock supply, and not from the pharmacy. Staff C reported she did not know the medication required a label on the bottle. During in interview 8/3/17 at 9:55 a.m., Staff D reported staff required to date a medication bottle or vial when opened. During an interview 8/3/17 at 11:55 a.m., the Director of Nursing (DON) reported the pharmacy and nurses checked medication and supply outdates. The DON reported when a new medication opened, the nurse had a responsibility to label the medication with the resident's name and the date when medication opened. In an undated policy, titled Medication Labeling and Storage, revealed labels should be typewritten and firmly affixed to the outside of the container. The label should contain the resident's name, room and bed number, and medication name. The policy revealed medication destroyed when a medication container had no label, in accordance with state and federal laws.

Based observation and facility policy review, the facility failed to keep all hair within the hair restraint and failed to wash hands properly to prevent the spread of microorganisms to the food. The facility reported a census of 47 residents Findings include: 1. Observation on 8/1/17 at 11:10 a.m. revealed Staff F, Dietary Aide, did not have all her hair in the hair restraint. At 11:16 a.m. Staff F handled dirty dishes, wash her hands for 10 seconds and turned the faucet off with bare hands. At 11:47 Staff F wash her hands then turned off the faucet with bare hands. At 11:55 a.m. Staff F washed her hands, turned the faucet with bare hands then dried her hands. Observation on 8/1/17 at 11:17 a.m. revealed Staff G, dietary cook, washed her hands, used a paper towel to turn off the water, then used the same paper towel to dry her hands. Observation on 8/1/17 at 12:00 p.m. revealed Staff H, dietary aide, washed her hands, turned off the faucet, and then dried her hands. Review of the undated Hand Washing for Food Service policy directed staff to do the following to insure safe food handling: · Turn on faucet, use running hot water · Wet hands and arms · Apply enough soap to build up a good lather · Scrub hand and arms vigorously for 20 seconds. Be sure to clean under fingernails and between fingers · Rinse hands and arms under running water, leave water running · Dry hands with a paper towel. Dispose of towel used to dry hands · With a second clean towel, turn off faucet and dispose of the towel. 2. An observation on 7/31/17 at 11:50 a.m. and 8/3/17 at 7:30 a.m. revealed Staff A, Dietary Aide did not have all of their hair covered, approximately, 2-3 inches of hair exposed outside of the hair net.

Based on clinical record review and observation, the facility failed to serve the appropriate portions for 4 pureed diets served. The facility reported a census 47 residents. Findings include: Review of an undated list of resident diets revealed the facility had 5 residents who required a pureed diet. Review of the 8/1/17 Tuesday lunch menu, the pureed meals consisted of the following: · 4 ounces grilled fish · 1/2 cup portion au-gratin potatoes · 1/2 cup portion creamed peas and onions · 2x2 deviled eggs · 2x2 jello cake · bread crumbs During observation on 8/1/17 at 9:12 a.m. the Staff E-Cook indicted he must pureed 5 servings of fish. The DM placed 5 servings of fish in robocoupe along with broth and shake en' serve, the total amount measured 3 1/4 cups. The DM stated staff will need to serve a #6 scoop (2/3 cup) at the meal. Staff E pureed 4 servings creamed peas/onion placing 1/2 cup of peas in blender ending with a total volume of 2 cups, Staff E stated the staff will need to serve #8 scoop (1/2 cup). Observation at 9:30 a.m. the Dietary Manager (DM) prepared the au gratin potatoes, he placed five 1/2 cups of potatoes, 1/2 cup of liquid and 1/2 cup puree appeal into a food processor, he explained 4 resident required a pureed diet. After measuring the total pureed mixture, 30 ounces, the dietary manger used a portion chart to calculate the portion size. It calculated each pureed resident would get a #8 ounce scoop (1/2 cup) and a #16 scoop (1/4 cup). The dietary manager wrote on a piece of paper the portion size and indicted they would send it up with the food items for the staff who serve the meal. Observation at 11:32 a.m. Staff G, dietary cook, served the pureed diets a #8 of the potatoes but failed to serve the #16 for the purred serving. The pureed fish was firm and Staff G had to add hot water and whisk the mixture which would add volume and would alter the serving size. Staff G stated no one sent the paper with the pureed portion sizes so she stated she just used the scoop she thought it would be. During an interview on 8/2/17 at 11:44 a.m. Staff G stated that most days she had to add water to the pureed items because the items could not be served due to the items were too hard.

Based on clinical record review, observation, and staff interview, the facility failed to wash their hands after providing care to a resident in contact isolation (Resident #9). The facility reported a census of 47 residents. Findings include: According to the Minimum Data Set ((MDS) dated [DATE], Resident #9 had a Brief Interview Score for Mental Status (BIMS) of 15 which indicated intact cognitive ability. The MDS revealed the resident required extensive assistance of 1 staff for transfers, dressing and hygiene. Review of Resident #9's Care Plan updated 11/4/16 informed staff the resident required assistance with the Activities of Daily living and required assistance of 1 staff for transfers. The resident has a history of recurrent left lower leg cellulitis Review of the June 2017 physician's orders [REDACTED].#9's left lower leg for signs of infection. According to the sign on the door, Resident #9 required contact isolation. Observation on 8/2/17 at 8:58 a.m. Staff D, Licensed Practical Nurse, entered the room to administer the resident's insulin. Staff D stated the resident required contact isolation due MRSA in the wound. Staff D left the room, failed to wash her hands, and continued to administer medications to other residents. During an interview on 8/3/17 at 12:25 p.m. the Assistant Director of Nursing stated staff must wash their hands after leaving a resident's room regardless if the resident required isolation. All staff must follow universal precautions. Review of an undated Infection Control Precautions/Guidelines directed staff in the fundamentals of isolation precautions. The procedure explains that microorganisms present on the hands of staff will be transmitted to residents during invasive or other resident care procedures.

Based on clinical record review and observation, the facility failed to complete incontinence care for 1 of 9 residents reviewed (Resident #8). The facility reported a census of 47 residents. The Minimum Data Set ((MDS) dated [DATE] documented Resident #8 had a [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of 2 staff for toilet use and had frequent urine and bowel incontinence. According to Resident #8's Care Plan dated 5/22/17 the resident had incontinence of bowel and bladder and directed staff to assist with toileting throughout the day and indicated the resident wore incontinence products. During observation on 8/2/17 at 12:04 p.m. Staff M, Certified Nurse Aide, and Staff N, Certified Nurse Aide, using the mechanical stand lift to take the resident to the bathroom. Staff M removed the resident's urine soaked incontinence product. Staff M used disposable wipes to clean the resident from the backside with 5 wipes but failed to cleanse the resident's front genital and front groin areas.

Based on clinical record review, staff, resident interview, and facility policy review, the facility failed to report allegations of abuse to the Department of Inspection and Appeals (DIA) for (2) two of (16) sixteen residents (Residents #8 & #10). The facility reported a census of 47 residents. Findings include: The Minimum Data Set ((MDS) dated [DATE] documented Resident #8 had a [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance for bed mobility, toilet use, and personal hygiene. The MDS dated [DATE] documented Resident #10 had [DIAGNOSES REDACTED]. The MDS documented the resident as independent for bed mobility, transfers, walking, toilet use, and personal hygiene. The progress notes for Resident #8 dated 5/14/17 at 5:55 p.m. documented: 2:30 p.m. (1430) investigation underway regarding roommate's allegation that this resident was abuse/neglected last evening (5/13/17). Resident is calm and denied feeling threatened. At 17:30 (5:30 p.m.) resident's family visiting and the nurse shared with them that an investigation was underway regarding concerns of roommate at treatment of [REDACTED]. The progress note dated 5/14/17 at 5:41 p.m. for Resident #10 documented at 1330 (1:30 p.m.) staff interviewed Resident #10 regarding allegations he/she made related to concerns over treatment of [REDACTED]. (about 5:00 p.m. last evening). The nurse documented Resident #10 reported he/she felt staff treatment of [REDACTED]. The nurse documented: investigation of allegation initiate at this time. Resident #10 denied fell ing threatened or in any danger. In a written document Staff L, registered nurse, wrote she learned about the allegation of abuse on 5/14/17 at 1:30 p.m. Staff L wrote, two (2) incidents occurred last evening (5/13/17) involving Resident #10 and Resident #8. Staff L identified at 5:00 p.m. on 5/13/17 Resident #10 stated he/she was concerned about his/her roommate (Resident #8) and the way he/she (self/Resident #10) was treated by Staff I. Staff L documented Resident #10 felt Staff I's actions constituted abuse and neglect. Staff L wrote Staff I demanded Resident #8 sit up in bed. Resident #10 told Staff I that Resident #8 needed two people to assistance but Staff I told the resident it was none of the resident's business and left the room. Resident #10 stated Staff I left Resident #8 in an unsafe position in his/her bed where the resident's head positioned against the side rail and feet dangled out of the bed. Resident #10 summoned another resident to sit in front of the resident's feet then summoned Staff J, certified nurse aide, to assist. Resident #10 spoke with Staff I about the incident, according to Resident #10, Staff I spoke loudly and aggressively to him/her; and pulled the privacy curtain so abruptly Resident #10 nearly lost his/her balance. Resident #10 denied fell ing threatened or in danger. During an interview on 8/2/17 at 2:55 p.m. Staff J, certified nurse aide, stated she could remember the exact date but Resident #10 summoned her to the room. Upon entering the room, Staff J observed Resident #8 lying crossways in the bed were the resident's head positioned against the side rail and the resident's feet dangling off the bed. Staff J stated Resident #8 could not get in the position herself/himself. Staff J assisted the resident back to bed. During an interview on 8/2/17 at 1:57 p.m. Staff K, licensed practical nurse, observed Resident #8 crossways in the bed with the feet dangling. Staff K stated the resident moved around in bed but could not get in that position without assistance. Staff K stated the resident's position made the resident a high fall risk. Staff J stated Staff I could be verbally abusive, rude, and harsh with the resident. Resident #8 told Staff K that Staff I had been mean to her and left her/him in that position in the bed. During an interview on 8/3/17 at 1:54 p.m. Staff I denied any abusive behavior. Staff I tried to get Resident #8 to sit up in bed but could not do it by herself so she went to get help. She did not leave the resident in an unsafe position. Staff I stated Resident #10 embellishes and unreliable. During an interview on 8/3/17 at 9:12 a.m. Resident #10 stated Staff I, licensed practical nurse, left Resident #8 in unsafe position. Resident #10 stated Resident #8's head had been up against the bed rail and the feet positioned on the floor. Resident #10 stated Resident #8 could have fallen out of bed. When asked if Staff I had been abusive to Resident #8, Resident #10 answered yes. During an interview on 8/2/17 at 9:10 a.m. Resident #8 could not recall the incident and denied any abusive treatment by staff. In a written statement by the Administrator dated 8/2/17 documented on 5/13/17 he received a phone call from Resident #10, who was agitated. Resident #10 had concerns regarding the treatment of [REDACTED].#8 and Staff I, licensed practical nurse, and concluded that Resident #10 had over-reacted. At the time the Administrator left the facility and thought the issue was resolved. During an interview on 8/2/17 at 11:00 a.m. the Administrator stated he knew now that allegations of abuse need to be reported the Department of Inspections and Appeals. The Abuse Investigation Procedure dated 3/3/16 directs staff to report any allegations of suspected or observed acts of abuse to the Department of Inspections and Appeal immediately. All complaints or allegations must be considered valid and an investigation completed. The policy identified as a mandatory reporter, if an employee suspects potential abuse of a resident, they must call DIA immediately after ensuring the safety of the residents.

Based on observation, record review and staff and resident interviews, the facility failed to provide adequate supervision to ensure against hazards from self or elements in the environment and failed to provide proper footwear (gripper slippers) to prevent slipping (Resident #1). The sample consisted of 4 residents and the facility reported a census of 45 residents. Findings include: 1. Resident #1 had a quarterly MDS (Minimum data set) assessment with a reference date of 12/9/2012, which identified [DIAGNOSES REDACTED]. The MDS documented the resident with a BIMS (Brief Interview for Mental Status) score of 14. A score of 14 indicates no problem with long or short term memory problems. The MDS reflected Resident #1 required the assist of one staff member for bed mobility, transfer, and extensive assistance of one staff member for ambulation in room, dressing, toilet use and personal hygiene. The MDS documented the resident had a prior fall that resulted in an injury. This MDS did not have verification of balance. The MDS with a reference date of 9/9/2013, identified a balance assessment had been performed. The MDS identified the resident has not steady, but able to stabilize without staff assistance. This assessment was in relationship to moving from a seated to standing position and surface to surface transfer. The resident was also assessed as not steady when turning around and facing the opposite direction while walking but able to stabilize without staff assistance. Review of the facility Fall Risk assessment dated [DATE] indicated the resident had a score of 10 which revealed a high risk range. Review of the care plan dated 3/28/12 included problems that resident required assist with ADL (activity of daily living) and history of falls. The care plan directed staff to assist with transfers and ambulation using a gait belt, walker and non-skid footwear to applied. The facility Internal Report dated 1/19/2013 at 2:45 a.m. revealed the staff answered the call light. When the CNA (Certified Nursing Assistant) untangled the oxygen tubing, the resident started to ambulate with the walker to the bathroom. The resident voiced he/she slipped and landed on the right shoulder and hip. The resident had no apparent injury as a result of the fall. The preventative measures put in place directed staff to apply non-skid socks and use gait belt with all transfers. The care plan identified a problem with a history of falls and on 2/5/2013, the approach directed staff to ensure the resident wore non-skid socks. Review of the facilities Internal Investigation dated 2/13/2013 at 7:15 a.m. reflected Resident #1 was in the bathroom with walker; oxygen tubing tangled up, Staff A, CNA, went to untangled tubing and the resident slipped and fell in the bathroom. The resident found lying on bathroom floor face up next to the toilet and sink. The resident has a rug burn to scalp, skin tear to left forearm and red bruise to middle of back. Resident complains of left rib pain and unable to lift left arm all the way up due to the pain, area is bulging on left side. Resident sent out (hospital) for x-rays. The investigation revealed the resident did not wear non-skid socks at the time of the fall. The preventative measures put in place directed the resident to be assisted with 2 staff persons. The Nurse's Notes dated 2/13/13 at 7:15 a.m. reflected Staff B, LPN (Licensed Practical Nurse) documented Staff A, CNA, reported she/he had assisted the resident to the bathroom and the oxygen tubing was tangled. Staff A left the resident by the toilet standing while she went to untangle the tubing. While Staff A had been out of the bathroom, the resident fell . The resident voiced complaints of left rib pain and wanting x-ray. The resident had a laceration to the tip of the scalp measuring 1 cm (centimeter) by 0.01 cm. Steri Strips applied after cleansing and Bacitracin (antibiotic) ointment applied. The resident had a skin tears to the left forearm which measured 5 cm by 2 cm, 4.5 cm by 0.1, and 1.5 cm by 0.01 cm. The resident had a bruised area in the small of the back which measured 3.5 cm by 3 cm which had a red appearance. The resident had a bulging area on the left back side. The Radiology Report dated 2/13/13 indicated x-rays of left ribs done for pain falling a fall. A non-displaced fracture of the left eighth rib is demonstrated, and there is an equivocal adjacent non-displaced of the left seventh rib. The Physician Ordered Vicodin 5/325 (analgesic) to be given every 6 hours as needed for pain. On 3/14/13 at 12:45 p.m., Staff A (CNA) stated she went to assist Resident #1 up out of bed the morning of 2/13/13 around 7:15-7:30 a.m. Staff A admitted she did not have her/his gait belt with her that morning. Staff A further stated she was trained and knows that she is to have a gait belt with them at all times as it is part of their uniforms and is the facilities policy. Staff A stated she assisted the resident to sit up on side of the bed and gave the resident their walker. Staff A stated that she assisted the resident to the bathroom without a gait belt or nonskid socks put on and when doing so the resident ' s oxygen tubing became tightly pulling on the resident. Staff A stated she left the resident alone in the bathroom standing in front of the toilet while She left the bathroom to pull on the oxygen concentrator to give more room to the tubing and the resident fell . Staff A stated she did not see the resident fall due to not being in the bathroom. Staff A stated the resident wore a gown, brief, and regular socks. Staff A stated she should have had a gait belt on the resident, non-skid foot wear, and should not have left the resident alone in the bathroom. Staff A stated after the resident fell , she summoned for the nurse. On 3/15/13 at 9:40 a.m., Staff B, LPN (Licensed Practical Nurse), was interviewed and stated she was the nurse on duty when Resident #1 fell . Staff B stated she was summoned to the resident's bathroom by Staff A and found the resident lying on the bathroom floor face up between toilet and sink. Staff B stated the resident had regular socks on, no gait belt, and had been left unattended. Staff B further reported she did write a disciplinary action on Staff A regarding this matter. The Nurse ' s Notes dated 2/13/2013 at 5:00 p.m. revealed the resident voiced complaints of rib pain. The staff administered analgesic medications for the pain (Ultram and APAP). At 10:50 p.m. the resident received Vicodin (narcotic analgesic).