Every finding on record at Meadow Brook Medical Care Facility

Based on observation, record review, and interviews, the facility failed to prevent staff to resident abuse for one Resident (#27) of two residents reviewed for abuse. This deficient practice resulted in untreated physical pain and psychosocial harm based on the reasonable person concept.Findings include: Resident #27 (R27)Review of R27's Electronic Medical Record (EMR) indicated R27 was admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (A progressive disease that destroys memory and other important mental functions), dementia (a general term for a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life) with agitation, anxiety, chronic pain syndrome, abnormalities of gait and mobility, restlessness and agitation. R27 had a Brief Interview for Mental Status (BIMS) of 3 indicating severe cognitive impairment.The facility failed to recognize R27 was suffering from unrecognized and uncontrolled chronic pain from a prior motor vehicle accident. CNA P and CNA Q placed R27 unnecessary distress by placing hands on R27 in an attempt to control movement and push them down, causing feelings of frustration and unresolved pain based on the reasonable person concept.Per review of a facility reported incident (FRI) on 8/12/25 the FRI documentation stated during review of the security camera footage regarding another incident, two staff members were interacting with R27 who was in their wheelchair in the dining area of the Glacier Hill Household on 7/29/25. It appeared Certified Nursing Assistant (CNA) P attempted to tie R27 to their wheelchair at 8:52 PM with a bath blanket to prevent R27 from rising, with another bath blanket used to tuck around R27's legs and firmly under the thighs in an attempt to prevent R27 from rising from their wheelchair. CNA Q was present at the resident's side as the incident was occurring. Review of security camera footage for 7/29/25 collaborated the FRI information. While viewing the security footage both CNAs were observed exhibiting agitated behaviors with R27 with expansive movement of the CNAs arms and arms resting on their hips or crossed over their bodies with observable jerky movements. On 7/29/25 at 8:50 PM, CNA Q placed their hand on R27's chest prior to the blanket placement and had used observable force to push R27 back into the wheelchair when they lifted themselves from the wheelchair. CNA Q had placed their hands on both shoulders of R27 and used observable force to push R27 down into the wheelchair when they stood up out of their wheelchair on 7/29/25 at 9:04PM.The review of R27's orders did not indicate any order for any type of restraint and R27 was not care planned for any type of restraint.On 9/24/2025 at 9:02 AM, an interview was conducted with the Director of Nursing (DON) regarding the incident on 7/29/25. The DON stated R27 was in the dining room of Glacier Hall in their wheelchair with CNA Q who was making a broccoli salad for themself. R27 was at the bar area right by the front area of the kitchen where R27 had a salty snack that the CNA's wanted R27 to eat, in hopes that R27 would drink water with medications later. The DON verified the care plan did not have a plan of care for restraints. The DON stated both CNAs in question had received training on restraints and abuse prior to this incident. The DON noted the facility's annual abuse education covered restraints, but not specific restraint education. The DON stated after interviewing the CNA who placed the blanket around R27, the CNA did not view the act as a physical restraint. The DON stated CNA Q's body language was clearly agitated with R27 in the security camera footage.On 9/25/2025 at 11:15 AM, an interview was conducted with LPN J regarding R27 since the incident. LPN J felt that the incident although it was not a good thing did lead to the facility finding out more about the resident, so they could accommodate R27 more. LPN J stated that now the facility has a recliner for R27 that can be used in the afternoon. LPN J stated the afternoon is when R27 tends to get antsy in the wheelchair and stand up a little. When staff notice R27's antsy behavior they put R27 in the recliner as the staff learned R27 had a previous motor vehicle collision and may have back and hip pain. LPN J stated the change of position to the recliner seems to help R27 who then gets very calm. LPN J also stated that the scheduled medication has helped change R27's demeanor as well. LPN J stated that R27 is a mover and if R27 can do that safely it's in the resident's best interest. The staff keep an eye on any changes in R27 motoring around the floor and address it. Facility's Plan of Correction:For resident R27 the resident's care plan has been reviewed. There is no order present for a physical restraint, the resident demonstrates motor agitation at times especially in the late evening. A physician order for physical therapy evaluation and treatment was ordered in conjunction with another diagnosis this resident has. A discussion with the physician resulted in an occupational therapy evaluation and treatment for potential seating needs related to comfort has been initiated effective 8/15/25. The resident is offered individualized items to touch or interact with during times of increased motor agitation. The resident finds comfort in the kitchen/dining area related to her past history of home making. The resident will be able to maneuver her wheelchair in the cleared dining area during the evening when she has increased motor agitation. Items can be placed on the tabletops for R27 to interact with decreasing R27's anger or frustration by being sat in one place. The pressure alarm will remain on R27's wheelchair for safety to alert the staff of the resident's attempts to rise so that staff can intervene for her safety.For all residents, the Director of Nursing or designee will complete a random review of resident interactions utilizing the security camera system. Looking specifically for staff interaction with residents. This will occur at various times of the day and night on all the households. This review of the security camera system will be completed by 8/27/25. Residents on each household will be surveyed by the social services department to ask about interactions with staff asking if the residents' needs are being met, if they feel that there are any issues related to abuse, mistreatment, or neglect. This survey will be completed by 8/29/25. Any concerns noted of abuse, mistreatment, or neglect in review of the camera footage or in response to the survey will be immediately reported to the Director of Nursing and Administrator for immediate action.A quality assurance study will be initiated utilizing the results of the in-person survey and any results of concern noted on the random review of the security camera footage. This review will be completed by 9/5/25. The in-person survey asking about issues relating to abuse, mistreatment, or neglect will be repeated in September of 2025 and a second random review of camera footage on each household looking for concerns related to abuse, mistreatment, or neglect will be completed and documented as a quality assurance study by 9/30/25. If any concerns regarding abuse, mistreatment, or neglect are documented the in-person survey and review of the security camera system will continue until both survey results indicate no identified concerns with abuse, mistreatment, or neglect.The Director of Nursing reviewed and revised the Facility Restraint policy to include definitions of physical restraints, chemical restraints, and mechanical restraints. All nursing staff receive education regarding restraint use, the Facility policy and State and Federal regulation. All staff will receive training on the Facility policy and on abuse reporting and requirements and protecting residents from abuse. This will be accomplished by 9/1/25.Past Non-Compliance accepted as of 9/12/25 for the facility.

Based on observation, interview, and record review, the facility failed to provide adequate supervision per the plan of care during functional transfers and mealtimes for two Residents (#38 and #106) of eight residents reviewed for accident hazards and supervision. This deficient practice resulted in actual harm when Resident #38 experienced a fall with fracture and head contusion. Findings include: Resident #38 (R38) Review of R38's face sheet, revealed original admission to the facility on 5/2/25 with medical diagnoses including diabetes mellitus, hypertension, muscle weakness, and gout. Review of R38's Minimum Data Set (MDS) assessment dated [DATE], revealed in section GG, Functional abilities and goals; toileting hygiene, dependent on staff, and sit to stand and toilet transfer, supervision or touching assistance. Review of a pocket care plan, dated 7/3/25, revealed R38 required a one person assist with a gait belt for transfer, SBA [stand-by assistance] for room ambulation, and wheelchair use in the hallway with assistance. On 9/23/25 at 2:35 PM, an interview was conducted with R38 who was resting in her bed and was asked if she had a fall and replied, Yes. R38 was unable to give any details of the fall or when the fall had occurred. Review on R38's incident and accident report, dated 7/3/25 at 6:16 PM, read in part, .Incident Description: Nursing description: Staff assisting resident to restroom with walker. Bathroom door open, with door touching resident bed and resident wheelchair positioned next to the wall outside the bathroom. Resident took a few steps with her slippers on. CNA (certified nurse aide) and resident state her foot got tangled in the wheelchair and she fell to floor, hitting head on bathroom door frame/door. Resident description: Resident states she was walking to bathroom, lost her balance and fell on the floor. Denies pain and discomfort to back of head. Did rate lower back pain 7 out of 10. Review of progress note, dated 7/3/25 at 7:00 PM, read in part, Staff assisting resident to restroom with walker. Bathroom door open, with door touching resident bed and resident wheelchair positioned next to the wall outside the bathroom. Resident took a few steps with her slippers on. CNA and resident state her footgot (sic) tangled in the wheelchair wheel and she fell to the floor hitting head on the bathroom door frame/door.resident does have a contusion to back of her head and a small bruise area to left elbow noted. Review of progress note, dated 7/5/25 at 6:31 PM, read in part, .TOP OF LEFT FOOT IS BRUISED, RESIDENT BELIEVES IT IS FROM FALL. Review of progress note, dated 7/5/25 at 9:12 PM, read in part, resident being monitored for recent fall.resident left foot top does have bruising to base of 2nd toe and top of foot, bilateral feet are slightly swollen.the bruise area is sensitive to touch will continue to monitor. Review of radiology report, dated 7/8/25 at 4:24 PM, read in part, .Conclusion: Possible acute non-displaced fracture at medial base of 3rd proximal phalanx (toe). Consider more sensitive imaging evaluation with CT (computer tomography) as clinically directed. Review of CT scan, dated 7/17/25 at 12:37 PM, read in part, .History: X-ray LT (left) foot possible third toe FX (fracture).Findings.Intra-articular fracture at the medial base of 3rd digit proximal phalanx, involving the MTP (metatarsophalangeal, a bone in the toes of the foot that is connected between the metatarsal bones [in the foot] and the phalanges [toes]) joint, with valgus alignment (a condition where the foot deviates outward, causing the heel to turn out and the toes to rotate outwards, leading to abnormal weight distribution and an abnormal appearance) at the 3rd MTP.Impression: 1. Intra-articular fracture at the medial base of 3rd digit proximal phalanx, involving the MTP joint, with valgus alignment at the 3rd MTP. On 9/24/25 at 3:23 PM, an interview was conducted with Registered Nurse (RN) O who was asked about R38's fall and how R38 transferred and replied, (R38) transfers with one staff from her wheelchair with a gait belt around her to allow staff to assist with the transfer. RN O was asked if a gait belt was used on 7/3/25 when R38 fell in her bathroom and replied, I am not sure. (R38) hit her foot on the bottom of the wheelchair and stumbled and then fell. RN O was asked for the witness statements. RN O was asked if R38 had a care plan for how she transfers and fall risk interventions and replied, She should. I think I put on in place when she was admitted in May. RN O stated that she thinks everyone is a fall risk, R38 had a potential for falls, and that R38 did not ambulate by herself that she was a one staff assist for transfers with a gait belt. Review of witness statement from CNA N, dated 7/3/25, read in part, .Approx. (approximately) 6:10 PM I grabbed her pants to stand up from her wheelchair, lost balance forward to walker I caught her. Stood her up. Regained balance. I asked if she was ok. She said yes. Ok, let's head into the bathroom. I turned to get out of her way. When facing back to her she was on her way down. I noticed her foot was caught on her wheelchair wheel. On 9/25/25 at 9:00 AM, an interview was conducted with RN A in lieu of the Director of Nursing (DON), who confirmed R38 did not have a care plan for how they transferred or have fall risk interventions until 27 days after falling and sustaining a fracture and head contusion. RN A confirmed on 6/2/25 R38 transferred with one staff assist and a gait belt. RN A stated it was unclear if a gait belt was used on 7/3/25 when R38 fell and should have been included in the incident and accident report and the witness statement. On 9/25/25 at 10:30 AM, an interview was conducted with CNA N who confirmed her witness statement regarding R38's fall. CNA N stated she turned her back on R38 to get out of her way and noticed R38 was off balance, then grabbed R38's pants and not the gait belt because R38 was a 'bigger lady'. CNA N stated R38 was a standby assist of one with a gait belt. CNA N confirmed she should have used the gait belt but thought she would have been able to assist her better by grabbing R38's pants. Review of R38's care plan, dated 5/2/25, read in part, .Focus: The resident has an ADL (activities of daily living) self-care performance deficit.ensure that resident has her equipment 4 wheeled walker and quad cane. R38's care plan lacked any indications for how to transfer and interventions for prevention of falls. R38's care plan was not updated for fall interventions until 7/30/25 which was 27 days after her fall with a fracture and head contusion. Review of R38's fall risk assessment, dated 6/1/25, revealed a score of 19 which indicated R38 was at risk for falls. The fall risk assessment indicated a score of 10 or greater, constituted high-risk for falls. Review of policy titled, Falls Risk Policy and Procedure, dated 9/2025, read in part, Standard: The facility will ensure that the Resident environment remains as free of accident hazards as is possible and that each Resident receives adequate supervision and assistive devices to prevent accidents.Procedure: The facility will identify Residents at risk for falls and implement procedures to prevent accidents/falls and update Care Plans to incorporate interventions. Protocol(s): 1. A Fall Risk Assessment will be completed upon admission / readmission, quarterly, or upon significant change in the electronic medical record. The Fall Risk Assessment includes the use of the Morse Falls Risk Scale completed in the EMR (point click care). 2. If the Resident is assessed to be at Moderate or High Risk for falls the following shall be implemented per the nursing staff.Update the computerized care plan.The fall interventions are imbedded into the ADL [activities of daily living] Care Plan. Review of policy titled, Falls Risk Policy and Procedure, dated 9/2025, read in part, Standard: The facility will ensure that the Resident environment remains as free of accident hazards as is possible and that each Resident receives adequate supervision and assistive devices to prevent accidents.Procedure: The facility will identify Residents at risk for falls and implement procedures to prevent accidents/falls and update Care Plans to incorporate interventions.3. Resident Falls Fall or Found on Floor #1:.C. Investigation: 1. Review incident report, interview staff and review documentation.G. Review Care Plan / Revise Care Plan. Resident #106 (R106) Review of R106's EMR revealed initial admission to the facility on 9/17/25 with diagnoses including fracture of the lumbosacral spine and pelvis, dementia, and dysphagia (difficulty swallowing). Review of R106's EMR revealed a Health Status Note, dated 9/18/25 at 11:36 AM, that read, in part: .While eating bkfst [breakfast] resident was noted to be pocketing (the act of storing food or liquid in the mouth, typically in the cheeks or on the roof of the mouth, instead of swallowing it promptly) her waffle and scrambled eggs. Resident given oatmeal and continued to pocket. Orders entered for ST [speech therapy] evaluation. Review of R106's Speech Therapy Evaluation, dated 9/18/25, read, in part: How often does the patient require supervision/assistance at mealtime d/t [due to] swallow safety? = 91-100% of the time. .What modified diet is recommended for the patient to swallow solids safely? = Pureed Review of R106's EMR revealed a diet order, initiated 9/22/25, which read, Pureed texture, regular consistency, follow swallow precautions on her care plan. On 9/24/2025 at 8:49 AM, R106 was observed eating breakfast in the common dining area. No clinical staff were observed in the vicinity of the dining room. R106's meal ticket was placed on the table next to her and read, in part, follow swallow precautions on her care plan. Review of R106's care plan revealed the following nutritional goal, initiated 9/22/25: Safe swallow free from clinical s/sx [signs and symptoms] of aspiration. Resident will have no choking episodes through the review date. The following intervention was initiated on 9/22/25: .Supervision during all oral intake*Sit upright for all oral intake (including snacks & meds [medications])*Remain upright for @ least 30 minutes following meals*Take small bites & sips*Eat/drink slowly, taking a break after each bite/sip*Swallow @ [at] least 2 times per bite of food/sip of liquid*Alternate bites of food w/ [with] sips of liquids (remind her to sip liquids between bites) *Check of pocketing*. On 9/24/2025 at 2:58 PM, an interview was conducted with Speech Language Pathologist (SLP) L who confirmed she was treating R106 for a swallowing dysfunction. SLP L stated R106 was downgraded to a level II (pureed) diet due to concerns of pocketing which could lead to choking and aspiration. SLP L confirmed she recommended R106 receive supervision with all oral intake in the event R106 required cues for things like pacing, taking small bites, and monitoring for pocketing in order to decrease the risk for aspiration. When SLP L was asked her expectation for supervision, she responded the resident should be in a common area and within the line of sight of clinical staff. On 9/25/2025 at 8:56 AM, R106 was again observed eating breakfast in the dining room with no staff supervision. On 09/25/2025 at 9:21 AM, an interview was conducted with Certified Nursing Assistance (CNA) M regarding R106's nutritional needs. CNA M stated R106 required a pureed diet due to a history of pocketing food. When asked if R106 required a specific level of oversight, CNA M stated R106 should eat in common areas so staff could, keep an eye on her, but did not require direct supervision. On 9/25/25 at 11:45 AM, an interview was conducted with Clinical Care Coordinator (CCC) H regarding her expectations from clinical staff if a resident required supervision for a specific activity of daily living or functional task. CCC H stated supervision would require visual contact with the resident. CCC H understood the choking and aspiration risk as a result of not providing the recommended level of assistance for R106 during mealtimes. Review of the facility policy titled, Fall Risk Policy and Procedure, revised 0/2025, read, in part: The facility will ensure that the Resident environment remains as free of accident hazards as is possible and that each Resident receives adequate supervision and assistive devices to prevent accidents.

Based on observation, interview, and record review, the facility failed to ensure a restraint assessment, physician's order, risk-associated education, consent, and medical justification for the use of a pommel cushion were in place for one Resident (#100) of one resident reviewed for restraints. Findings include: Resident #100 (R100)On 9/23/25 at 1:51 PM, R100 was observed in a wheelchair sitting on a pommel cushion (a cushion with a large raised, center protuberance on the front of the cushion). R100 said the pommel cushion prevented her from picking things up if something falls on the floor because it kept her from being able to lean forward in her wheelchair.The electronic medical record (EMR) for R100 documented admission to the facility on [DATE] with a primary diagnosis of cerebral infarction (stroke). R100 also had an activated Durable Power of Attorney designated in the EMR (DPOA - a designated individual to handle medical decisions). The EMR did not include a physician's order for a pommel cushion, and there was no documentation identifying the medical symptom for which the pommel cushion was to be utilized for. The EMR did not contain an assessment for the use of the pommel cushion or a consent with potential identified risks associated with the use of a pommel cushion. There was no evidence the DPOA was informed of potential risks and benefits associated with the use of the pommel cushion and no consent was able to be located in the EMR. During an interview on 9/24/2025 at 12:24 PM, Certified Nurse Aide (CNA) B said the pommel cushion prevented R100 from standing independently from the wheelchair and was also utilized to prevent R100 from leaning forward and potentially falling from the wheelchair. CNA B confirmed R100 was unable to independently remove the pommel cushion from the wheelchair. The Occupational Therapist (OT) C was interviewed on 9/24/25 at 12:54 PM. OT C said R100 did not have positioning concerns in the wheelchair. When asked why R100 had a pommel cushion, OT C said the pommel cushion was implemented to prevent R100 from falling forward from the wheelchair. When asked if R100 could stand from the wheelchair with the pommel cushion in place, OT C said the resident could stand with assistance from therapists during skilled therapy sessions but was unable to do so with nursing.The Director of Nursing (DON) was not available during the survey on 9/24/2025. The Administrator (NHA) said Registered Nurse (RN) A would be the acting DON for the duration of survey. RN A was interviewed on 9/24/25 at 1:30 PM. RN A was asked if a restraint assessment was completed for the use of the pommel cushion for R100. RN A reviewed the EMR of R100 and said, I do not see one. RN A said a physician's order was required to utilize a restraint, and a restraint assessment and a signed consent [by the DPOA] were required. When asked why the pommel cushion was being used, RN A reviewed the EMR of R100 and said she did not know why the pommel cushion was put in place. RN A suggested Clinical Care Coordinator (CCC) D, the nurse who managed the unit where R100 resided, may have completed a restraint assessment. On 9/24/2025 at 1:36 PM, CCC D was interviewed regarding R100. When asked if any restraint assessments were completed for the resident, CCC D replied, I know she has a pommel cushion. CCC D indicated there was previous discussion regarding the pommel cushion potentially being a restraint, but no restraint assessment was completed. CCC D was asked if the pommel cushion prevented R100 from leaning forward to get items from the floor as she was doing prior to placement of the pommel cushion. CCC D said, yes - It keeps [R100] in an upright position and keeps her from falling forward onto her face. When asked why an assessment wasn't completed if there was a concern about the pommel cushion potentially restraining R100, CCC D said a restraint assessment was not completed because she didn't think it was a restraint. When asked the definition of a restraint, CCC D replied, Something that keeps them from doing something they can normally do. CCC D said the pommel cushion did not require a physician's order because R100 was working with therapy. The policy Restraint Policy dated as effective 8/2025 read, in part: .Residents shall be provided an environment that is restraint-free, unless a restraint is necessary to treat a medical symptom.A physician's order is required. a physical restraint shall be used only after the interdisciplinary team in conjunction with the physician, has performed an assessment .A restraint is defined by the Centers for Medicare and Medicaid Services (CMS) as follows: A restraint is any manual method, physical or mechanical device, material, or equipment that is attached to or near the resident's body that the individual cannot remove easily, and that restricts freedom of movement, normal access to one's body, or normal activities of daily living.4. The family or responsible party will be notified of the need for restraints. 5. Prior to application of the physical restraint, informed consent using the Physical Restraint Consent is to be obtained from the resident and/or responsible party. The clinical risk factors are to be explained, as well as the decision-maker's / residents right to refuse the restraint. 6. A Physical Restraint Consent must be signed by the family / responsible party for each type of restraint and each episode of restraint.

Based on observation, interview, and record review, the facility failed to ensure use of Enhanced Barrier Precautions (EBP) during high-contact resident care activities, according to current professional guidelines, for one Resident (#2) of two residents reviewed for infection control.Findings include:Resident #2 (R2)Review of R2's Electronic Medical Record (EMR) revealed initial admission to the facility on 8/13/25 with diagnoses including fracture around the right prosthetic knee joint, urinary tract infection, and need for assistance with personal cares. Review of R2's most recent Minimum Data Set (MDS) assessment, dated 8/29/25, revealed R2 required maximum assistance for both lower body dressing and functional transfers. Review of R2's EMR revealed a physician order, initiated 8/13/25, which read: Enhanced Barrier Precautions for foley catheter care and appliance replacement.On 9/24/25 at 9:24 AM, R2 was observed undergoing an extended skilled therapy session in her private room. Physical Therapy Assistant (PTA) F was observed assisting R2 in transfer training between R2's wheelchair and the edge of bed. During the process of the transfers, the clothing of PTA F was observed to be in direct contact with R2's clothing. PTA F was not wearing personal protective equipment (PPE) although EPB signage was posted on the outside of R2's door.On 9/25/25 at 8:58 AM, R2 was observed undergoing an extended skilled therapy session with Certified Occupational Therapy Assistant (COTA) G in her private room. R2 was observed working on lower body dressing tasks with COTA G. During the dressing task, COTA G was observed handling R2's catheter bag and tubing without gloves. COTA G was not wearing PPE for the duration of the session. The EPB signage continued to be posted on the outside of R2's door. On 9/25/25 at 9:14 AM, an interview was conducted with COTA G regarding EPB expectations. COTA G stated she would only be required to don PPE if she was directly changing or emptying R2's catheter. On 9/25/25 at 11:45 AM, an interview was conducted with Clinical Care Coordinator (CCC) H regarding PPE expectations in regard to EPB. CCC H stated PPE should be donned when care is provided that directly involves R2's catheter such as toileting assistance or providing catheter care. CCC H stated gloves are expected to be worn whenever a catheter bag or catheter tubing is handled.Review of guidance by the Center for Disease Control and Prevention (CDC) titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html), released 4/2/25, read, in part: .The use of gown and gloves for high contact resident care activities is indicated, when contact precautions do not otherwise apply, for all nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions Include: Dressing . Transferring .Review of the facility policy titled, Enhanced Barrier Precautions, revised 10/2024, read, in part: [Facility Name] will implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced Barrier Precautions refer to the use of gloves and gowns for use during high-contact resident care activities for residents with colonized or active MDROs as well as those residents with indwelling devices such as central lines, urinary catheters, and feeding tubes. Gloves will still be worn at all times of direct care and ADLs [activities of daily living] as part of our standard practice and precautions.

Based on observation, interview, and record review, the facility failed to complete and update a comprehensive care plan for one resident (Resident #38) of twenty residents reviewed for care plans. Findings include:Resident #38 (R38)Review of R38's face sheet, dated 9/24/25, revealed original admission to the facility on 5/2/25 with medical diagnoses including diabetes mellitus, hypertension, muscle weakness, and gout. Review of R38's Minimum Data Set (MDS) assessment, dated 6/20/25, revealed in section GG, Functional abilities and goals, toileting hygiene, dependent on staff, and sit to stand and toilet transfer, supervision or touching assistance. On 9/23/25 at 2:35 PM, an interview was conducted with R38 who was resting in her bed and was asked if she had a fall and replied, Yes. R38 was unable to give any details of the fall or when the fall had occurred. Review on R38's incident and accident report, dated 7/3/25 at 6:16 PM, read in part, .Incident Description: Nursing description: Staff assisting resident to restroom with walker. Bathroom door open, with door touching resident bed and resident wheelchair positioned next to the wall outside the bathroom. Resident took a few steps with her slippers on. CNA (certified nurse aide) and resident state her foot got tangled in the wheelchair and she fell to floor hitting head on bathroom door frame/door. Resident description: Resident states she was walking to bathroom, lost her balance and fell on the floor. Denies pain and discomfort to back of head. Did rate lower back pain 7 out of 10. Review of R38's care plan, dated 5/2025, read in part, .Focus: Resident request to sleep in a reclining chair states unable to tolerate use of bed.Interventions/Task: Obtain a reclining chair by family that will suit resident.Focus: Resident sleeps only in reclining chair requesting furniture removal Bed removal.Focus: The resident has an ADL (activities of daily living) self-care performance deficit.ensure that resident has her equipment 4 wheeled walker and quad cane. R38's care plan lacked any interventions for prevention of falls. R38's care plan was not updated for fall interventions until 7/30/25 which was 27 days after her fall with a fracture and head contusion. R38's care plan was not updated after her fall to reflect her current use of a bed. Review of R38's fall risk assessments revealed the following: - On 5/2/25 an admission fall risk assessment with a score of 11, which indicated R38 was at risk for falls. The fall risk assessment indicated a score 10 or greater constituted high-risk for falls. - On 6/1/25 a reentry fall risk assessment revealed a score of 19. On 9/24/25 at 11:50 AM, an observation was made of R38 resting in her bed and not in a reclining chair. On 9/24/25 at 3:23 PM, an interview was conducted with Registered Nurse (RN) O who was asked if R38 had a care plan for how she transfers and fall interventions and replied, She should. I think I put one in place when she was admitted in May. RN O stated she thinks everyone is a fall risk, R38 had a potential for falls, and R38 did not ambulate by herself. RN O disclosed R38 required the assistance of one staff member and a gait belt for transfers. RN O was asked why R38's care plan was not updated to reflect her current use of a bed and no longer a reclining chair and replied, She has been sleeping in the bed since this last Saturday, and I thought I updated it already. On 9/25/25 at 9:00 AM, an interview was conducted with RN A in lieu of the Director of Nursing (DON), who confirmed R38 did not have a care plan for how to transfer or fall risk interventions until 27 days after falling and sustaining a fracture and head contusion. RN A confirmed on 6/2/25 R38 transferred with one staff assist and a gait belt. RN A stated it was unclear if a gait belt was used on 7/3/25 when R38 fell and should have been included in the incident and accident report and the witness statement. RN A was asked if the residents' care plans should reflect their current needs and replied, Yes, absolutely they should. Review of policy titled, Comprehensive Care Plans, dated 10/2024, read in part, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines.3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.f. Resident specific interventions that reflect the resident's needs and preferences.

Based on observation and interview, the facility failed to transport two Residents (R39 and R41) in a safe manner and per standards of care out of 18 residents reviewed for accidents, hazards, and supervision. This deficient practice resulted in the potential for injury. Findings include: Resident #41 (R41) On 10/29/24 at 11:10 AM, Registered Nurse (RN) D was observed pushing R41 in their wheelchair without footrests from Orchard Hill dining area to R41's room halfway down the hall. Certified Nurse Assistant (CNA) E stopped RN D after noticing RN D was not using R41's wheelchair footrests. CNA E then put R41's footrests on their wheelchair. R41 was noted to have a plastic boot-like shoe to both their right and left feet that were barely off the floor during transport. On 10/30/24 at 10:35 AM, an interview was conducted with RN D who was asked about yesterday and pushing R41 back to their room from the dining area then to their room. RN D replied, Yes, we are supposed to use foot pedals, and I was just taking them back to their room to do a blood sugar check. I should have used the foot pedals. Resident #39 (R39) On 10/30/24 at 10:33 AM, CNA F was observed pushing R39 in their wheelchair without footrests from the Orchard Hill dining area down the hall to their room. R39 visibly had footrests stored on the back of their wheelchair readily available. On 10/30/24 at 10:34 AM, an interview was conducted with CNA F who was asked about propelling R39 in the wheelchair without footrests. CNA F replied, I am new down here. Yes, I should have used their [NAME] pedals to transport them back to their room. On 10/30/24 at 1:50 PM, an interview was conducted with the Director of Nursing (DON) who was asked about two different staff transporting residents without footrests. The DON replied, That is unacceptable. It is the standard of practice to use foot pedals.

Based on interview and record review, the facility failed to develop and implement care plans for three Residents (R24, R83, and R86) of 18 residents reviewed for care planning. This deficient practice resulted in the potential for unidentified and unmet individualized resident care needs. Findings include: Resident #24 (R24) A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R24 was always incontinent of bowel and bladder and was dependent on staff for toileting hygiene. A progress note dated 10/24/24 documented R24 was lethargic and had a 101.1 degrees Fahrenheit axillary (under arm) temperature. The Nurse Practitioner (NP) ordered lab tests including a urinalysis (UA). The UA resulted in a urine culture that revealed a urinary tract infection with the organism Escherichia coli (bacteria found in the intestine). A physician note dated 10/28/24 documented R24 had not had a bowel movement (BM) in 5 days and was experiencing abdominal pain. The physician documented R24 had a history of constipation. A review of the care plans for R24 revealed no care plan for the urinary tract infection and no care plan for the constipation to provide staff with appropriate interventions to address the individualized needs and care goals for R24. 40383 Resident #83 (R83) R83 was admitted on [DATE] with diagnoses which included a fracture of the left femur (leg), pain in the right shoulder, pain in the left shoulder, pain in the left knee, and other chronic pain. The admission MDS assessment dated [DATE] documented R83 was at risk of developing pressure ulcers (wounds caused by pressure), was taking an opioid (medication for pain), was on a scheduled pain medication regime and the verbal descriptor scale indicated very severe, horrible pain with indicators of pain or possible pain observed daily. The MDS assessment of 8/3/24 revealed the resident had a fall in the last month with a related fracture. The Care Area Assessment Summary (CAA) of the 8/3/24 MDS specified several care areas were triggered and would be addressed in the care plan including falls, pressure ulcers and pain. The care plan was reviewed and did not include a care plan for falls, pressure ulcers or pain to provide staff with appropriate interventions to address the individualized needs and care goals for R83. During an interview on 10/30/24 at 10:05 AM, Registered Nurse (RN) G agreed the care plan was not completed for R83. RN G stated R83 was scheduled to move to another unit and said, It is my intent to get that caught up before I pass them on (to the new unit). Resident #86 (R86) R86 was admitted on [DATE] with diagnoses which included metabolic encephalopathy (brain dysfunction), gastrostomy (tube feeding through the stomach), and pressure ulcer. The MDS assessment of 10/7/24 documented R86 had an unstageable pressure ulcer due to coverage of the wound bed by slough (dead tissue) and/or eschar (dry, black, crusty tissue). The physician orders indicated R86 was to have nothing by mouth and received all nutrition via the tube feeding. Pain medication had been ordered to be given as needed. The monthly medication administration record showed pain medication was given seven times during the month. The 10/7/24 MDS CAA specified several care areas were triggered and would be addressed in the care plan including pressure ulcers and pain. Upon review of the care plan for R86: - there were no care plans for pain, - it did not include nursing care interventions for the specialized tube feeding required, - it included a focus listed as The resident has (SPECIFY) pressure ulcer (SPECIFY LOCATION) or potential for pressure ulcer development r/t (related to) and was incomplete. - it had no goals or interventions listed for the existing pressure ulcer. During an interview on 10/30/24 at 11:00 AM, the Director of Nursing stated they would expect nursing interventions to be included with the tube feeding care plan and the other areas to be completed. The facility policy titled Comprehensive Care Plans and dated as effective 10/2024 read in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observation, interview and record review, the facility failed to treat three Residents (R4, R12, R31) with dignity and respect out of 18 residents reviewed for dignity. This deficient practice resulted in a lack of personal dignity and feelings of embarrassment based on the reasonable person. Findings include: On 10/29/24 at 12:15 p.m., the lunch meal observation was observed in the Glacier Hill Cottage. During this time, Certified Nurse Aide (CNA) A and CNA B were observed assisting two residents with their meals (later identified as R4 and R12). CNA B started to assist R12 by standing next to R12 with a spoon and continued to place food in their mouth. CNA A then replaced CNA B to assist R12 and continued to stand while quickly placing food in R12's mouth with the spoon. CNA B then walked over to R4 and began to assist R4 with lunch in a standing position, placing the spoon in her mouth. On 10/30/24 at 12:25 p.m., the lunch meal observation was observed in the Grass Creek Cottage. During this time, CNA C was observed assisting R31 with their meal by placing the meal in front of R31, sitting down, and donning gloves. CNA C continued to wear gloves during the meal observation with R31 and would make clicking noises to R31 or humming while assisting her with the meal. An interview was conducted with the Director of Nursing (DON) on 10/30/24 at 1:07 p.m. The DON confirmed that these observations were not providing the residents with a dignified dining experience. Review of the facility's Resident Rights Interpretation and Implementation Policy, undated, read in part, .Policy: It is the policy of this facility that all residents be treated with kindness, dignity, and respect. Policy Interpretation and Implementation: Our staff shall display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings .

Based on interview and record review, the facility failed to ensure required members of the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly, resulting in the potential for decreased quality of care for all 87 residents living in the facility. Findings include: Review of the QAPI committee meeting attendance logs with the Director of Nursing (DON) on 10/30/24 at 1:46 PM revealed meetings were held on 1/10/24, 3/13/24, 5/8/24, 7/10/24, and 9/11/24. Further review of the attendance logs revealed the following: 7/10/24: Director of Nursing not in attendance. 9/11/24: Director of Nursing not in attendance. On 10/30/24 at 1:50 PM, an interview was conducted with the DON who was asked the reason they were not in attendance for the July and September QAPI meetings. The DON replied, I was on vacation for the September 11th meeting, and they still give my reports. For the July 10th meeting I must not have been there if I am listed on the absent list. Review of policy titled, Quality Assurance and Performance Improvement (QAPI), dated 2023, read in part, .Quality Assessment and Assurance Committee .Procedures: 1. The facility will maintain a Quality Assurance Performance Improvement Committee that consists of: a.) Administrative b.) Director of Nursing c.) A physician designated by the facility d.) At least three other members of the facility staff. 2. The Quality Assurance Performance Improvement Committee: a.) Meets at least quarterly to identify issues with respect to which QAPI activities are necessary. b.) Develops and implements appropriate plans of action to correct identified quality deficiencies .

Based on observation, interview and record review, the facility failed to implement proper infection control measures during an outbreak of influenza on one household (Unit A). This deficient practice resulted in the potential for continued spread of influenza to the other residents residing within the household. Findings Include: Resident #9 Review of Resident #9's Electronic Medical Record (EMR) revealed an admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9's 9/30/22 Minimum Data Set (MDS) assessment revealed she required extensive one person assist for transfers, dressing and personal hygiene. Resident #9 scored a 3/15 on the Brief Interview for Mental Status (BIMS) score indicating she was severely cognitively impaired. Further review of Resident #9's EMR revealed she tested positive for influenza B on 11/12/22 and was placed in Transmission Based Precautions on that day. Upon entering Unit A household on 11/15/22 at approximately 11:30 a.m., there was no signage on the outside of the household doors to indicate there were positive influenza cases. On 11/15/22 at approximately 12:15 p.m., Resident #9 was observed lying in her bed watching television. Resident #9's door had posted signs indicating that it was a transmission-based precaution room with personal protective equipment (PPE) placed on the outside of the door. During this observation, Certified Nurse Aide (CNA) F was observed entering Resident #9's room wearing PPE which included a gown, gloves, face shield and N95. CNA F came out of Resident #9's room with a plastic cup and lid stating that Resident #9 did not want anything to eat or drink. CNA F was observed to sanitize her hands before grabbing the cup, walking it through the main common area, dump the contents of the cup into the sink, and then placed the cup in a used bin. There were no staff members that sanitized the handrail. On 11/17/22 at approximately 9:30 a.m., upon entering the Unit A household, a sign was observed on the outside of the doors to indicate positive influenza cases. An interview was conducted with Medical Director G on 11/17/22 at 12:05 p.m. Medical Director G stated he was informed of the positive influenza cases on 11/14/22 when there was already three residents who had tested positive. When asked what he advised to stop the spread of influenza throughout the household, Medical Director G indicated that the positive residents should remain in their rooms and staff were to wear the proper PPE which included: masks, gowns, gloves, face shield and N95's. Medical Director G confirmed that staff should be removing all of the PPE and placing a new face mask on before providing care to other residents. Resident #74 During an observation of the medication administration task on 11/15/22 at 12:25 p.m., Registered Nurse (RN) C prepared a 0.5 mg (milligram) tablet of [MEDICATION(S)] for R74 and mixed it in pudding in a small plastic 30 cc (cubic centimeter) medication cup. R74 was in droplet precautions for testing positive for influenza. RN C donned appropriate PPE (isolation gown, gloves, and the face mask and face shield she was already wearing during medication administration for all residents on the house). R74 refused the medication in the pudding and requested an individual pill. RN C threw the medication cup with pudding and the [MEDICATION(S)] in R74's bathroom garbage and exited the room after doffing (removing) the isolation gown and gloves at the resident's doorway. RN C sanitized her hands, and the same mask and face shield remained in place as she exited R74's room. RN C touched the front of the face shield with bare hands and placed the face shield on top of her head. Contact between the front of the face shield, and her bare hands was observed, with no hand sanitation performed before preparation of a second [MEDICATION(S)] tablet was retrieved from the medication cart for R74. RN C returned to R74's room and donned another gown and gloves, with no hand sanitation observed. RN C used both dirty, gloved hands to handle the face shield bows in her hair and pulled the potentially contaminated face shield down back over her face. No hand sanitation was performed as RN C entered R74's room with her dirty gloves in contact with the wooden gate blocking the door entrance. R74 refused the second [MEDICATION(S)] tablet, and RN C retrieved the medication cup filled with pudding and the first [MEDICATION(S)] tablet from the Residents bathroom garbage prior to exit from the room. RN C removed the isolation gown and gloves but did not change her mask or sanitize her face shield following either exit from R74's influenza isolation room. Review of R74's MDS assessment, dated 9/2/22, revealed R74 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R74 required extensive, two-person assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene, and was totally dependent upon one-person assistance for bathing. R74 scored 5 of 15 on the BIMS reflective of severe cognitive impairment. During an interview on 11/16/22 at 3:23 p.m., the Director of Nursing (DON) was asked about the expectation for doffing and/or sanitation of face shields after use in isolation rooms. The DON stated, The policy says that I need to sanitize my face shield. When again asked what the DON's expectation for staff would be about face shields being doffed, and the performance of hand hygiene when staff exited influenza isolation rooms, the DON stated, She needed to sanitize her hands between being in and out of the room. The DON confirmed there was a potential for environmental contamination and the transmission of infectious organisms. On 11/15/22 at 9:00 a.m., during the entrance to the facility the DON and Nursing Home Administrator (NHA) stated there were four Residents ( #9, #46, #74, & #6) who had been identified as positive for influenza on two separate households (A & B). On 11/15/22 at 2:15 p.m., during an interview, IP E stated staff were required to sanitize in and out of a room that is positive for influenza and must sanitize their face shield. IP E then stated staff were allowed to keep the same mask on when entering and exiting a droplet precaution isolation room. When asked what Personal Protective Equipment (PPE) staff were to use when entering a droplet isolation room, IP E stated, a pair of gloves, a gown, a mask, and a face shield were required for entry to a droplet isolation room. On 11/16/22 at 9:05 a.m., during a follow-up interview, IP E stated an additional case of influenza was identified that morning within household A. On 11/16/22 at 1:48 p.m., the infection prevention and control program (IPCP) was reviewed with IP E. During the review, IP E was asked to provide details regarding an outbreak of influenza at the facility which was ongoing during the survey time period. There were five Residents (#6, #9, #44, #46, & #74) who were identified as positive for Influenza at the time of this interview. The IP stated they resided on units A and B, all residents on unit A were screened and COVID-19 tested . IP E then stated residents with two or more symptoms consistent with influenza developed, residents are then tested for influenza. IP E was then asked to provide an outbreak summary for influenza. A review of the Influenza outbreak summary revealed the following: Resident #9 and Resident #46 tested positive for influenza 11/12/22 and resided on household A. Resident #74 then tested positive on the following day 11/13/22 who also resided on household A. Resident #6 tested positive for influenza on 11/14/22 who resided on household B. Resident #44 tested positive for influenza on 11/16/22 and resided on household A, where the first cases were identified. On 11/17/22 at 10:25 a.m., during an interview, IP E was asked how staff were to handle coming on and off the main outbreak area of household A. IP E stated she instructed the staff to limit the traffic on household A. When asked if activities were supposed to be conducted on the main outbreak household A, IP E stated, I hope not. On 11/17/22 at 11:10 a.m., during a follow-up interview, IP E was asked to confirm when the facility recognized the influenza outbreak on household A. IP E stated the influenza outbreak for household A had been officially identified on 11/13/22, when a third resident tested positive for influenza. When asked about signage for the outbreak, IP E acknowledged the signage for the outbreak should have been posted as of 11/13/22 and was not posted until the morning of 11/16/22. Based on the outbreak status of household A as of 11/13/22, IP E also confirmed group activities should not have been occurring on the unit. IP E then stated some of the residents were getting upset about the activity being canceled, so the activities staff went ahead with the activity. IP E confirmed the activities department did visit all of the units on 11/15/22 for a nerf gun hunting activity. When asked to confirm PPE requirements for 'Droplet Precaution' rooms, IP E stated staff were able to enter resident rooms who were influenza positive with a face shield covering their mask and exit only having to doff gown and gloves and sanitize the shield. IP E stated staff were not required to change their mask after leaving a Droplet Precaution' room. On 11/17/22 at 12:21 p.m., during an interview, Activities Director (AD) H stated there was no discussion in the morning meeting on 11/15/22 and acknowledged activities staff proceeded with group activities on 11/15/22 for a nerf gun hunting activity. AD H stated staff started on household B, moved to household A, and then in the afternoon went to household C. AD H stated activities being conducted in household A were restricted to one-to-one at the time of this interview and acknowledged small group activities should not have been held on 11/15/22 for household A. AD H stated no group activities would be held moving forward until the outbreak was over. There were concerns with staff not following CDC guidance with regard to PPE when entering and exiting 'Droplet Precaution' rooms for residents with confirmed influenza as stated below. On 11/17/22 at 1:09 p.m., CNA J was observed entering and exiting Resident #44's room who was currently positive for Influenza A as of 11/16/22. During the interaction, CNA J asked Resident #44 how his lunch meal was and Resident #44 responded. CNA J was observed within 3 feet of Resident #44 during this interaction and proceeded to remove the meal tray from Resident #44's room. CNA J was observed donning and doffing PPE properly except he failed to remove, discard, and replace his facemask before proceeding to non-outbreak areas. CNA J was then observed exiting the unit and traveled through the facility into the employee break room with the same mask worn in the isolation room. It was unknown if there were additional employees in the break room at that time. There was also no PPE station on the unit near the entrance to household A for donning and doffing the mask the facility required to enter the unit. Anyone exiting household A did not have ready access to change their mask upon exiting and at a minimum had to travel to the entrance of the facility approximately 50 feet away in order to change their mask to access the rest of the facility. A review of the facility policy, Standard Precautions, including donning and doffing PPE procedures, dated 10/2/20, read in part: . a. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, bodily fluids, or potentially infectious material is likely . Component Hand Hygiene . Practices After touching blood, bodily fluids, secretions, excretions, contaminated items; before and after removing PPE; between resident contacts . (CDC- [Document #CS 2-E]) HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) EXAMPLE 1 . . 4. MASK OR RESPIRATOR - Front of the mask/respirator is contaminated - DO NOT TOUCH - If your hands get contaminated during mask/respirator removal, immediately wash your hands or use an alcohol -based hand sanitizer - Grasp bottom ties or elastics of the mask/respirator, then the ones at the top, and remove without touching the front - Discard in a waste container . Example 2 . 3. MASK OR RESPIRATOR . - Discard in a waste container . A review of the facility policy, Outbreak of the Flu Activity Department, dated 7/8/20, read in part: .Will provide small group activities on units where flu is at a minimum . A review of the facility policy, Influenza and [CONDITION(S)] Respiratory Outbreak Policy, with a revised date of 11/14/22, read in part: Purpose: To prevent, recognize, and manage [CONDITION(S)] respiratory or influenza outbreaks in the Facility. I. Definitions of a Respiratory Virus Outbreak in (Facility Name): 1. More than two residents in a household (unit) develop a respiratory illness within 72 hours of each other or 2. Laboratory-confirmed positive case (e.g. influenza, respiratory syncytial virus, parainfluenza, adenovirus) or 3. A sudden increase over the normal background rate of acute respiratory illness cases, with or without documented fever II. Infection Control Procedures: 1. Institute standard and droplet precautions as appropriate, use of face masks if direct contact within 3 feet of residents . . 4. The Facility will implement by household: . . g. Post visitor signs alerting them to the outbreak/illness . A review of the facility policy Isolation Precautions, with a revised date of 11/15/22, read in part: . 5> Droplet Precautions: In addition to Standard Precautions, Droplet Precautions must be implemented for a resident documented or suspected to be infected with microorganisms transmitted by droplets (large particle droplets [Larger than 5 microns in size] that can be generated by the resident coughing, sneezing, talking, . a) Examples of infections requiring Droplet Precautions include, but are not limited to: . 5. Influenza . . c) Masks 1. In addition to Standard Precautions, wear a standard mask when working within 3 feet of the resident . A review of the facility policy Mask, with a revised date of 11/10/22, under Facility Outbreak and b. Resident Driven revealed no guidance to the staff on when to discard and replace a facemask after interaction with a droplet precaution resident. The policy only stated PPE requirements were .N95 mask, gown, gloves, and face shield or goggles . A review of the CDC website at, https://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm, web page last reviewed 5/13/21, read in part: Prevention Strategies for Seasonal Influenza in Healthcare Settings . .Fundamental Elements to Prevent Influenza Transmission Preventing transmission of influenza virus and other infectious agents within healthcare settings requires a multi-faceted approach. Spread of influenza virus can occur among patients, HCP (health care personnel), and visitors; in addition, HCP may acquire influenza from persons in their household or community. The core prevention strategies include: .adherence to infection control precautions for all patient-care activities . .Successful implementation of many, if not all, of these strategies is dependent on the presence of clear administrative policies and organizational leadership that promote and facilitate adherence to these recommendations among the various people within the healthcare setting, including patients, visitors, and HCP . 4. Adhere to Standard Precautions .During the care of any patient, all HCP in every healthcare setting should adhere to standard precautions, which are the foundation for preventing transmission of infectious agents in all healthcare settings. Standard precautions assume that every person is potentially infected or colonized with a pathogen that could be transmitted in the healthcare setting. Elements of standard precautions that apply to patients with respiratory infections, including those caused by the influenza virus, are summarized below . .5. Adhere to Droplet Precautions Droplet precautions should be implemented for patients with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a patient is in a healthcare facility . .HCP should don a facemask when entering the room of a patient with suspected or confirmed influenza. Remove the facemask when leaving the patient ' s room, dispose of the facemask in a waste container, and perform hand hygiene .

Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5% during the medication administration task. Two medications errors were observed for one Resident (R47) out of 26 medication administration opportunities for 11 total residents reviewed. This deficient practice resulted in a medication error rate of 7.69% and the potential for additional medication errors for facility residents. Findings include: During an observation on 11/16/22 at 8:44 a.m., Registered Nurse (RN) A attempted to prepare multiple medications, which included, but were not limited to: 1. [Name Brand] long-acting insulin, 18 units administered via insulin pen, and 2. [Name Brand] nasal spray, two puffs in each nostril one time daily for nasal congestion. 1. Insulin Administration Review of R47's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During preparation of the [Name Brand] long-acting insulin pen, RN A failed to cleanse the pen hub with alcohol prior to insertion of the insulin pen needle into the hub and failed to prime the pen prior to administration of 18 units of insulin to R47 via the insulin pen. Review of the facility Insulin policy, dated 11/11/2019, revealed the following, in part: Insulin Pens: 1. Swab the cartridge (cleanse hub with alcohol pad) and attach the pen needle. Remove cover. 2. Prime the needle until with 2 units, visualize the drop of insulin at the tip of the needle and then dial the correct dose. Prime the pen in a vertical position with the needle pointed upward . Review of the [Name Brand] long-acting insulin Instructions for Use, dated 7/2022, revealed the following, in part: .Routine Use: .Pull off pen cap . Wipe the rubber stopper with an alcohol swab . Prepare the Pen: Hold pen with needle pointing up. Tap cartridge gently with your finger a few times to bring any air bubbles to the top of the cartridge. Keep needle pointing up and press dose button until 0 mg lines up with pointer. Repeat . up to 6 times, until a drop of test medium appears at the needle tip. 2. Non-administration of [Name Brand] [MEDICATION(S)] Suspension 50 MCG/ACT (50 micrograms per actuation) nasal spray. During R47's medication administration observation on 11/16/22 at 8:44 a.m., RN A looked in the medication cart and the medication room refrigerator for the [Name Brand] nasal spray. RN A said the medication was not available, and the medication would not be administered that day as prescribed, and therefore was deemed a medication error. Review of R47's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Start Date: 11/16/2022 0900 (9:00 a.m.). Review of R47's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The number 9 Chart Code indicated Other/See Progress Notes. During an interview on 11/16/22 at 9:10 a.m., When asked if R47's insulin pen hub had been sanitized prior to application of the insulin administration needle, and if the insulin pen had been primed prior to insulin administration, RN A acknowledged neither step in preparation of the insulin pen for medication injection had been performed. When asked about the lack of the [Name Brand] nasal spray to administer to Resident #47, RN A confirmed the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/16/22 at 12:14 p.m., the Director of Nursing (DON) was asked to provide the [Name Brand] long-acting insulin pen Instructions for Use, and the facility policy regarding insulin administration. During an interview on 11/16/22 at 3:17 p.m., the DON confirmed the insulin pen hub should have been cleansed with an alcohol pad prior to application of the insulin administration needle and acknowledged the insulin pen should have been primed prior to insulin administration. The DON was unaware R47's [Name Brand] nasal spray was not available in inventory to administered on 11/16/22, as instructed per physician orders. Review of the facility Administration and Documentation of Medications/Treatments policy, dated 2022, revealed the following, in part: . Medications will be administered in accordance with order of the attending physician/NP (nurse practitioner)/PA (physician assistant) . Medication maybe administered one hour prior or after the prescribed time unless specific time(s) have been indicated for administration, such as before or after a meal .

Based on interview and record review, the facility failed to assure Advanced Directives were periodically reviewed and updated annually for six Residents (#10, #27, #39, #43, #71, #79) of 24 residents reviewed for advanced directives. This deficient practice resulted in the potential for inaccurate designation of residents' medical decisions pertaining to life-sustaining interventions. Findings include: Resident #10 Review of Resident #10's Electronic Medical Record (EMR) revealed an Advanced Directive form titled, Do-Not-Resuscitate [DNR] Order , signed by Resident #10, their Durable Power of Attorney (DPOA), and their physician on 8/11/17. Resident #27 Review of Resident #27's EMR revealed an Advanced Directive form titled, [DNR] Order , signed by Resident #27's DPOA on 1/27/18 and their physician on 2/03/18. Resident #39 Review of Resident #39's EMR revealed an Advanced Directive form titled, [DNR] Order, signed by Resident #39, their DPOA, and their physician on 7/11/17. Resident #71 Review of Resident #71's EMR revealed an Advanced Directive form titled [DNR] Order, signed by Resident #71's DPOA on 8/08/17 and their physician on 8/22/17. Resident #79 Review of Resident #79's EMR revealed an Advanced Directive form titled [DNR] Order, signed by Resident #79's DPOA on 9/23/19 and their physician on 9/24/19. Review of Residents' (#10, #27, #39, #71 and #79) facility paper charts with Clinical Coordinator, Registered Nurse (RN) A, on 8/25/21 revealed the same DNR forms dated 8/11/17, 2/03/18, 7/11/17, 8/22/17, 9/24/19, respectively. RN A confirmed they did not see any updated Advanced Directives for these residents in the facility charts. During an interview on 8/25/21 at 9:38 a.m., the Director of Social Work (SW) B was asked about the lack of updated Advanced Directive forms or documented periodic reviews in the EMR and paper charts for Residents #10, #27, #39, #71, and #79. SW B acknowledged they were unable to find evidence of any updated Advanced Directives or documentation in the medical record of periodic reviews for these five residents, including after their own record review and interviews with facility social workers. During an interview on 8/25/21 at 10:07 a.m., the Nursing Home Administrator (NHA) was asked about the lack of updated Advanced Directives for Residents #10, #27, #39, #71, and #79. The NHA acknowledged there was a process breakdown in updating the facility resident Advanced Directives annually, and staff were not documenting any periodic reviews. The NHA understood the need to document annual updates and periodic reviews. Resident #43 Review of Resident #43's EMR revealed an Advanced Directive form titled, [DNR] Order, signed by the DPOA, the physician and attested by two witnesses on 8/12/19. On 8/23/21 at 1:25 PM, RN G was asked about the current advanced directives for Resident #43. The most recent documents were dated 2019. RN G stated, I do not see anything scanned in. On 8/25/21, SW H discussed the Advanced Directive forms for the residents. Staff H said the quality assurance (QA) process reviewed charts to check for documentation without regard to the date activated. SW H stated, We review in QA to see if the forms are in the chart. We do not usually review this with family. Review of the policy, Advanced Care Planning, dated 4/16/14, received from SW B, revealed, Advanced Care Planning. Purpose: To provide residents/legal representative with information and opportunity to express wishes concerning end of life care. Protocol: Social Services will monitor, document, and review with residents/resident's legal representative wishes concerning the acceptance or refusal of medical/surgical interventions and life prolonging procedures based on disease progression and resident expressed (verbal or written) wishes. Initial discussion will take place in the first 14 days following admission, with review bi-annually, and PRN [as needed] based on disease progression .12. Social Worker will review Advanced Directive with family and resident at least bi-annually and document resident/family/responsible party of current disease progression and application of Advanced Directives .

Based on observation, interview and record review, the facility failed to appropriately use fall prevention measures for one Resident (#17) of five residents reviewed for accidents hazards. This deficient practice led to the potential for further falls and injury. Findings include: Resident #17 A review of the quarterly Minimum Data Set (MDS) assessment for Resident #17 dated 5/28/21 revealed admission to the facility on [DATE] with diagnoses including non-traumatic [CONDITION(S)], Alzheimer's disease, dementia, anxiety, depression, wandering, [CONDITION(S)], lumbago, chronic pain, restlessness and agitation, [CONDITION(S)], and history of falls. On 8/23/21 at 10:00 AM Resident #17 was observed resting in bed with floor mats laying on both sides of the bed. There was approximately a six inch gap from where the edge of the mattress stopped and the floor mats began on both sides of the bed, leaving room for Resident #17 to make contact with the hard floor if a rolling out of bed incident occurred. There was a motion sensor alarm (silent but alerts staff of resident movement) sitting on the night stand facing Resident #17. Resident #17's eyes were open and looking around. Resident #17 was still dressed in a hospital gown. Resident #17 displayed several full body jerking forward motions during this observation. There was a 2-3 centimeter (cm) hematoma (blood collection under the skin) noted on the left temporal (side of skull near forehead) area near the left orbit (eye socket). The area did not appear to have any green color in appearance yet, and was still dark purple. This Surveyor walked in front of the motion sensor alarm twice when initially entering the room. No staff entered the room for approximately 28 minutes. On 8/23/21 at 9:50 AM Visitor F was observed in the hallway and approached Clinical Care Coordinator Registered Nurse (RN) E to talk and then walked toward the unit exit with RN E. On 08/23/21 at 10:29 AM, Licensed Practical Nurse (LPN) C and Certified Nurse Aide (CNA) D were observed entering the room. When asked why 28 minutes had elapsed before staff entered the room, LPN C stated the motion sensor alarm had been turned off while Resident #17 had a visitor. On 8/23/21 at 10:40 AM, an interview was conducted with RN E. When asked why staff would turn off a motion sensor alarm designed to assist in prevention of falls, RN E stated the staff turn the sensor off while a visitor is in the room and ask the visitor to ring the call light when they are ready to leave so staff can turn the alarm back on. When asked who let Visitor F out of the unit, RN E stated they had let Visitor F out of the unit. The doors of the unit were secured magnetized doors, and required a code to exit and enter. RN E stated Resident #17 also had a pressure mat under her which was audible. When asked if the fall mats on both sides of the bed should have a gap of 6 inches from the bed edge to the edge of the mat, RN E stated the mats should be right next to the bed with no gap and stated it would be fixed. After determining Visitor F was the visitor for Resident #17, it was estimated approximately 38 minutes had passed where the motion sensor alarm was not on. On 8/25/21 at 12:01 PM during a follow-up interview, RN E stated Resident #17 was admitted to the facility on [DATE] with a bed and chair alarm in place due to fall history and when Resident #17 first admitted was quite ambulatory. RN E stated Resident #17 would pace the halls and staff would have to walk with Resident #17 because of a fast and unsteady gait (walk). RN E stated Resident #17 was on hospice at home and was always walking but had no destination. When asked how many fall incidents had occurred for Resident #17, RN E stated there were a total of three incidents. RN E stated the first incident was on 3/8/21 and Resident #17 was more agile at that time and would make attempts to turn off her alarms. RN E stated the pressure alarms for the bed and wheelchair had to be moved out of reach and the motion sensor alarm was added because of Resident #17's speed in moving from one place to another. RN E stated the second fall was on 6/28/21 when Resident #17 was sitting in a chair. RN E stated Resident #17 took a couple of steps and the pressure pad did ring but Resident #17 lost balance and fell . RN E stated the motion sensor alarm was moved from the bathroom area to across from Resident #17 to more quickly identify when Resident #17 was attempting to rise from the bed or chair. RN E stated there were no injuries from these falls. RN E stated the third fall was on 8/12/21 where Resident #17 sustained fractures. RN E stated per video review, Resident #17 was provided incontinence care approximately 15 minutes prior to being discovered laying on the floor. A review of the bed/chair alarm log showed the alarm was triggered at 6:09 PM on 8/12/21 and RN E stated this coincided with incontinence care being provided at the time, and then the log showed the alarm was triggered again by Resident #17 at 6:32 PM on 8/12/21 and was discovered on the floor approximately 1 minute later. RN E stated Resident #17 was experiencing advancing dementia symptoms with a steady decline over the last month. RN E stated, before the last fall Resident #17 was still trying to move independently to rise out of the bed and/or chair and attempt to ambulate independently. RN E stated Resident #17 has not been able to independently rise from the bed or wheelchair since the fall. RN E stated Resident #17 went from independently attempting to rise from the bed and chair before the fall, to extensive one assist from the bed and chair after the fall. RN E stated the facility was keeping the interventions in place just in case she becomes impulsive for any reason. When asked if the motion sensor alarm had a tracking tool for when it was triggered, RN E stated the facility did not have a log for that alarm. When asked if staff had checked to see if the motion sensor was on and functioning at the time of the incident, RN E did not know if anyone had checked. A review of the pelvis x-ray report following the fall at the facility for Resident #17, dated 8/12/21 at 11:59 PM, revealed the following: 1. Acute left superior and inferior pubic rami fractures with mild displacement. 2. Possible nondisplaced left hemi sacral fracture. A review of the 5-day incident report submitted to the State Agency (SA) revealed an unwitnessed fall incident with major injury for Resident #17 occurred on 8/12/21 at approximately 6:45 PM. Resident #17 was lying next to her room chair with a walker at her side. Resident #17 did have a chair alarm on which was triggered. Resident #17 was initially unresponsive to verbal stimuli. The facility was notified of the fractured left superior and inferior pelvis at approximately 6:30 AM. Resident #17 had a Brief Interview of Mental Status (BIMS) assessment of 3 and required one assist for transfers and use of a front wheeled walker. Resident #17 had been having a steady decline in cognition which appeared to increase her poor safety awareness. Resident #17 had both audible bed and chair alarm and a sensor (motion) alarm in her bathroom. Following the fall, Resident #17 had interventions put in place for bed in lowest position with fall mat and 1/2 hour checks for monitoring. A review of the facility care plan detail report for Resident #17 provided by the facility revealed the following: Focus- The Resident (#17) is a High risk for falls r/t (related to) [CONDITION(S)] (low blood pressure), Confusion, Gait/balance problems has had 4 falls in the last 2 weeks recent hospitalization and new admission. Poor Balance, Poor communication/comprehension, Psychoactive drug use, Unsteady gait. Will be HOSPICE care . Initiated on 2/22/21. Revised on 3/18/21. Interventions/Tasks- The Resident has chair/bed electronic alarm and senssor (sic) alarm. Ensure the device is in place and working properly. Initiated on 2/22/21, Revised on 2/22/21 . Focus- The Resident (#17) has a fracture to the pelvis left superior and inferior pubic rami r/t Fall resident is in Hospice care . Initiated on 8/13/21. Revised on 8/13/21. Interventions/Tasks- Modify environment as needed to meet current needs: Bed in lowest position with wheels locked, bilateral floor mats. check q (every) 1/2 hours and prn, usage of bed alarm and motion sensor . Initiated on 8/23/21. Revised on 8/23/21. A review of the Pocket Care Plan for Resident #17 revealed CNA interventions of bed in lowest position, audible bed and chair alarms, fall mats to both sides of the bed, non-skid footware (sic), and a sensor alarm in room place on dresser across from Resident #17.

Based on observation, interview, and record review, the facility failed to provide adequate assessment and/or monitoring of pressure ulcers for two Residents (#45 and # 62) of three residents reviewed for pressure ulcers. This deficient practice resulted in the potential for undetected and/or worsening pressure ulcers which could lead to pain, infection, and a decreased quality of life. Findings include: Resident #45 A review of the medical record for Resident #45 listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was on hospice and was at risk of developing pressure ulcers. The Skin and Wound Evaluation dated 8/10/21 for Resident #45 noted a wound abrasion located on the coccyx was In-House Acquired. The question of: How long has the wound been present? was answered as 2 weeks and measured 2.1 cm (centimeters) long by 1.2 cm wide. The wound Goal of Care was coded as Healable (and not as Manage: wound healing not achievable due to untreatable underlying condition). There was no Skin and Wound Evaluation the following week (8/17/21), but only a Nursing Progress Note dated 8/16/2021 which read: Resident (#45) has new open excoriated area on R (right) buttocks and small area on R heel. (Dressing name) placed on buttocks and heels floated (a practice whereby a pillow is placed under the calves, so the heels do not rest on the mattress to prevent pressure injury). No centimeter measurement of the wound's length, width, depth, tunneling and/or undermining was documented. No characteristics of the wound beds, wound edges, surrounding skin or exudate (pus) was documented. The Skin and Wound Evaluation dated 8/25/21 for Resident #45 noted the wound was now described as an open lesion on the coccyx with slough (a white or yellow covering on the base of the wound which can prevent a wound from healing properly.) The wound bed was described as pink or red but the area on the assessment for measurements was blank. The Progress section included notes of physician and CCC (Clinical Care Coordinator) aware of resident's status. Resident has a pink area on coccyx that has spread to a Kennedy Butterfly Type shape covering areas on both buttock cheeks and the crevasse between . The hospice Visit Note Report, dated 8/19/21, revealed an assessment section which read, (dressing name) on bilateral buttocks for red areas due to pressure, however, no measurements or wound characteristics were included. On 08/23/21 at 11:21 AM, Resident #45 was observed in bed lying on her back with her heels directly pressing on the mattress (not floating). On 8/24/21 at approximately 2:25 PM, Resident #45 was observed in bed lying on her back with her heels directly pressing on the mattress (not floating). On 8/24/21 at 3:07 PM, Resident #45 was observed to be in bed lying on her back with her heels directly pressing on the mattress (not floating). On 8/25/21 at 9:31 AM, RN M stated, (The floor nurse) did change the dressing (on Resident #45) but did not document on the wound. This was indicated on the Treatment Record for the dates of 8/13/21, 8/19/21, and 8/22/21. RN M indicated the wound care nurse RN J was also involved with the care of Resident #45. On 8/25/21 at 12:13 PM, RN J reviewed the wound picture and records for Resident #45 and stated, That got a little worse from when I first saw it on the 13th as open. RN J indicated the chart had been reviewed and no other wound documentation aside from the acknowledgment of dressing change was found. The medical record documentation did not acknowledge the existence of the wounds by the physician. There were two progress notes written by Physician Assistants dated 8/20/21 and 8/24/21. The PHYSICAL EXAM section of each note read: Skin: Adequate turgor. There were no measurements or description of wounds. Resident #62 A review of the medical record for Resident #62 listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS assessment dated [DATE] revealed Resident #62 was at risk of developing pressure ulcers. On 8/23/21 at 10:45 AM, Resident #62 was in his room sitting in his recliner and stated, I have a sore on my butt . They (nurses) put a patch and cream on it and it feels better . I have had it awhile. Resident #62 said that he always sits in his recliner and does not use his bed, and sleeps in that same recliner. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/9/21 a Skin and Wound evaluation documented an open lesion on the right ischial tuberosity (or sit bone/boney prominence) measuring 1.8 cm long by 1.4 cm wide with surrounding tissue fragile: skin that is at risk for breakdown and notes indicated a HISTORY OF OPEN [CONDITION(S)] TO LEFT BUTTOCK . No other documented centimeter measurements of the wound length, width, depth, tunneling and/or undermining were found. No other characteristics of the wound bed, wound edge, surrounding skin or exudate were documented. On 8/24/21, a nursing progress Skin/Wound Note read in part, Resident refusing early in this shift to allow this nurse to change his (Dressing name). (Dressing name) became wrinkled and resident agreed to allow nurse to do his treatment; however, refused a picture. There is no open area, no drainage, no sign of infection. Noted a superficial layer of skin missing. There were no documented centimeter measurements of the length, or width of the area of the superficial layer of skin that was missing. On 8/25/21 at 2:31 PM, RN M discussed the wound assessment for Resident #62 and said, The wound app (application) measures it. RN M explained since Resident #62 refused a picture, the wound was not measured. Other measuring devices were discussed, and RN M stated, For her to get a measuring tape to measure the spot . We don't do it. RN M said the area was last measured 8/9/21. When asked how the area was progressing, RN M said, It is hard for me to say these things because I personally didn't see it. There were no measurements available to assess the area. The SKIN CARE PROTOCOL PHILOSOPHY dated 8/24/18, was reviewed and read in part: Wound Assessment - All wounds will be assessed upon admission and when noted on assessment. Wounds will be reassessed at least weekly and PRN (as needed) . Wound assessments will include the following: Etiology, Anatomical location of the wound, Centimeter measurement of the wound length, width, depth, tunneling and undermining, and Characteristics of the wound bed, wound edge, surrounding skin and exudate.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered, comprehensive care plan for two Residents (#17, and #45) of 24 residents reviewed for care planning. This deficient practice resulted in the potential for unidentified and unmet care needs and the potential for injury. Findings include: Resident #45 A review of the medical record for Resident #45 listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was on hospice and was at risk of developing pressure ulcers. The Skin and Wound Evaluation dated 8/10/21 for Resident #45 noted a wound abrasion located on the coccyx was In-House Acquired. The question of How long has the wound been present? was answered as 2 weeks and measured 2.1 cm (centimeters) long by 1.2 cm wide. The wound Goal of Care was coded as Healable (and not as Manage: wound healing not achievable due to untreatable underlying condition). The Skin and Wound Evaluation dated 8/25/21 for Resident #45 noted the wound was now described as an open lesion on the coccyx with slough (a white or yellow covering on the base of the wound which can prevent a wound from healing properly.) Nursing Progress Notes dated 8/16/2021 read in part: Resident (#45) has new open excoriated area on R (right) buttocks and small area on R heel. (Dressing name) placed on buttocks and heels floated (a practice whereby a pillow is placed under the calves, thereby the heels do not rest on the mattress to prevent pressure injury). The hospice Visit Note Report dated 8/19/21 revealed in the assessment section, (dressing name) on bilateral buttocks for red areas due to pressure. On 8/24/21 at approximately 2:25 PM, Resident #45 was observed in bed lying on her back with her heels directly pressing on the mattress (not floating). On 8/24/21 at 3:07 PM, Resident #45 continued to be in bed lying on her back with her heels directly pressing on the mattress (not floating). The medical record for Resident #45 was reviewed and no care plan for the care and prevention of skin wounds was found. On 08/25/21 at 10:16 AM, Registered Nurse (RN) M was interviewed regarding the treatment and care of Resident #45's wound. RN M reviewed the care plan with goals and interventions for Resident #45 and said, I don't see a care plan for skin. On 8/25/21 at 9:23 AM, RN M presented the SKIN CARE PROTOCOL PHILOSOPHY dated 8/24/18, which read in part: If resident is at risk for impaired skin integrity (ISI) the following plan will be initiated and addressed on the care plan . 4.The nurse will perform the treatment and dressing changes prescribed by physician, and document . Care plan will be initiated . 5.The Skin Care Nurse will monitor . Update care plan as indicated . 6.Residents will be repositioned per the individualized care plan . Resident #17 A review of the quarterly Minimum Data Set (MDS) assessment for Resident #17 dated 5/28/21 revealed admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/23/21 at 9:50 AM Visitor F was observed in the hallway and approached Clinical Care Coordinator Registered Nurse (RN) E to talk and then walked toward the unit exit with RN E. On 8/23/21 at 10:00 AM Resident #17 was observed resting in bed with floor mats laying on both sides of the bed. There was approximately a six inch gap from where the edge of the mattress stopped and the floor mats began on both sides of the bed leaving room for Resident #17 to make contact with the hard floor if a rolling out of bed incident occurred. There was a motion sensor alarm (silent but alerts staff of resident movement) sitting on the night stand facing Resident #17 and Resident #17's eyes were open and looking around. Resident #17 was still dressed in a hospital gown. Resident #17 displayed several full body jerking forward motions during this observation. There was a 2-3 centimeter (cm) hematoma (blood collection under the skin) noted on the left temporal (side of skull near forehead) area near the left orbit (eye socket). The area did not appear to have any green color in appearance yet, and was still dark purple. This Surveyor walked in front of the motion sensor alarm twice when initially entering the room. No staff entered the room for approximately 28 minutes. On 08/23/21 at 10:29 AM, Licensed Practical Nurse (LPN) C and Certified Nurse Aide (CNA) D were observed entering the room of Resident #17. When asked why 28 minutes had elapsed before staff entered the room, LPN C stated the motion sensor alarm had been turned off while Resident #17 had a visitor. On 8/23/21 at 10:40 AM, an interview was conducted with RN E. When asked why staff would turn off a motion sensor alarm designed to assist in prevention of falls, RN E stated the staff turn the sensor off while a visitor is in the room and ask the visitor to ring the call light when they are ready to leave so staff can turn the alarm back on. When asked who let Visitor F out of the unit, RN E stated they had let Visitor F out of the unit. The doors of the unit were secured magnetized doors, and required a code to exit and enter. RN E stated Resident #17 also had a pressure mat under her which was audible. When asked if the fall mats on both sides of the bed should have a gap of 6 inches from the bed edge to the edge of the mat, RN E stated the mats should be right next to the bed with no gap and stated it would be fixed. After determining Visitor F was the visitor for Resident #17, it was estimated approximately 38 minutes had passed where the motion sensor alarm was not on. A review of the 5-day incident report submitted to the State Agency (SA) revealed an unwitnessed fall incident with major injury for Resident #17 occurred on 8/12/21 at approximately 6:45 PM. Resident #17 had a Brief Interview of Mental Status (BIMS) assessment of 3 and required one assist for transfers and use of a front wheeled walker. Resident #17 had been having a steady decline in cognition which appeared to increase her poor safety awareness. Resident #17 had both audible bed and chair alarm and a sensor (motion) alarm in her bathroom in place prior to the fall. Following the fall, Resident #17 had interventions put in place for bed in lowest position with fall mat and 1/2 hour checks for monitoring. A review of the facility care plan detail report for Resident #17 provided by the facility revealed the following: Focus- The Resident (#17) is a High risk for falls r/t (related to) [CONDITION(S)] (low blood pressure), Confusion, Gait/balance problems has had 4 falls in the last 2 weeks recent hospitalization and new admission. Poor Balance, Poor communication/comprehension, Psychoactive drug use, Unsteady gait. Will be HOSPICE care . Initiated on 2/22/21. Revised on 3/18/21. Interventions/Tasks- The Resident has chair/bed electronic alarm and senssor (sic) alarm. Ensure the device is in place and working properly. Initiated on 2/22/21, Revised on 2/22/21 . Focus- The Resident (#17) has a fracture to the pelvis left superior and inferior pubic rami r/t Fall resident is in Hospice care . Initiated on 8/13/21. Revised on 8/13/21. Interventions/Tasks- Modify environment as needed to meet current needs: Bed in lowest position with wheels locked, bilateral floor mats. check q (every) 1/2 hours and prn, usage of bed alarm and motion sensor . Initiated on 8/23/21. Revised on 8/23/21. A review of the Pocket Care Plan for Resident #17 revealed CNA interventions of bed in lowest position, audible bed and chair alarms, fall mats to both sides of the bed, non-skid footware (sic), and a sensor alarm in room place on dresser across from Resident #17.

Based on observation, interview and record review, the facility failed to prevent non-consensual sexual contact involving four Residents (#13, #194, #51 and #37) of six residents reviewed for abuse. This deficient practice resulted in inappropriate sexual contact and the potential for emotional distress and feelings of helplessness based upon the reasonable person standard. Findings include: This citation pertains to Intake MI 144. A Facility Reported Incident (FRI) investigation (MI 144) reported non-consensual sexual contact by Resident #13 on [DATE] at 4:27 a.m., when Resident #13 was found by certified nurse aid (CNA) L exiting from Resident #194's room. Resident #194 reported to CNA L that Resident #13 had entered her room and touched her breast. Resident #13 Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent Minimum Data Set (MDS) assessment for Resident #13, dated [DATE], revealed Resident #13 had scored eight out of 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating Resident #13 had mild cognitive impairment. Further review of Resident #13's MDS assessment, dated [DATE], revealed Resident #13 was physically independent for personal care and mobility. An observation on [DATE] at 9:56 a.m., revealed a motion alarm attached to the left side of Resident #13's doorway. The alarm had a green light blinking, indicating the motion alarm was activated. Further observation at that time revealed the light over the door lit up when the motion alarm was activated by this Surveyor. Within 15 seconds of activating the alarm, an unidentified staff person responded to Resident #13's room to verify Resident #13's presence. A review of Resident #13's electronic health record (EHR) for [DATE] through [DATE] revealed the following progress notes: [DATE] (6:11 a.m.): During checks tonight it was reported to this nurse that (Resident #13) told (CNA L) to come closer to his bed while she was standing in his doorway, she assumed he wanted to shake her hand, he grabbed her hand and would not let go, requesting to touch her all over. [DATE] (11:34 a.m.): CNA reported to this nurse that (Resident #13) had made some inappropriate sexual comments to her this a.m. while she was assisting him . CNA stated that resident told her that she has nice (breasts) and then asked her if he could touch them . [DATE] (10:10 p.m.): (Resident #13) touch(ed) the hand of another resident . no other behaviors noted other resident walked away and told staff what happened. [DATE] (11:23 a.m.): Staff reported to nurse that (Resident #13) was sexually inappropriate all through shower and asked if he could be made a two person assist for his bath. CNA informed this nurse that (Resident #13) stated I have never had such beautiful women wash me . I'm surprised I'm not getting (an erection) right now . Can I touch your breasts? [DATE] (11:11 p.m.): It was reported by (Resident #51) that (Resident #13) entered (her room) and asked if she had underwear on. [DATE] (1:48 p.m.): CNA reported to this nurse that the housekeeper told her that when she was cleaning (Resident #13's) room . he made inappropriate comment/question to her. (Resident #13) stated she has nice big soft breasts and then asked if he could touch them. [DATE] (7:36 p.m.): It was reported that (Resident #13) has approached two differed nursing staff members. (Resident #13) told that they have beautiful nursing bodies and asked (if) he could touch them. [DATE] (6:46 a.m.): At (approximately) 450am (4:50 a.m.), staff observed (Resident #13) coming out of a female resident's room. CNA asked female resident if anything happened when (Resident #13) was in her room and the (resident) reported that (Resident #13) had touched her nipple. This was reported to this nurse. I then saw female resident in her room and upon questioning, she indicated that (Resident #13) did touch her left breast. Staff reports that (Resident #13) also attempted to look in or enter other (resident's) rooms. A review of Resident #13's care plan revealed the following, in part: Focus: Behavior: This resident has a behavior problem of verbal sexual aggression toward female staff and sexually inappropriate to female residents. Date initiated: [DATE]. Revision on: [DATE]. Goal: Resident will not grab staff or other patients inappropriately through the next target date. Date initiated: [DATE]. Target date: [DATE]. Interventions: Resident touches staff or other patients inappropriately, tell him that moment those behaviors will not be tolerated. Date initiated: [DATE]. 15-minute checks at all times. Date initiated: [DATE]. Motion alarm outside his room/doorway to alert staff when the resident is exiting his room. Date initiated: [DATE]. Resident #13 and Resident #194 A review of an Investigation Summary, dated [DATE], revealed the following: Date/Time Incident Discovered [DATE] 4:30 AM. Date/Time Incident Occurred: [DATE] 4:17 AM . A review of the security camera system shows: . At (4:25 a.m.) (Resident #13) waves into (Resident #194's room. Unable to tell from the angle if (Resident #194) was awake in that room or not. (Resident #13) then is looking around the hallways for a few seconds. Then at (4:26 a.m.) (Resident #13) is seen on camera entering (Resident #194's room). Twenty seconds later (Resident #194's) motion alarm next to the bed turns on. (Resident #13) then stays in the room until 4:27 a.m. when (CNA L) comes out of the employee bathroom and finds (Resident #13) in (Resident #194's room) just inside the doorway . (Resident #194) . stated that (Resident #13) did touch her breast and then she told him to leave. A review of a written statement, signed and dated by CNA L on [DATE], revealed the following: I came out of the bathroom and seen (Resident #13) coming out of (Resident #194's room). I asked (Resident #194) if (Resident #13) had said anything and (Resident #194) told me (Resident #13) touched her nipple. Resident #194 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent, complete MDS assessment for Resident #194, dated [DATE], revealed Resident #194 had severe cognitive impairment. A review of Section E - Behavior of the MDS assessment, dated [DATE], revealed Resident #194 had not been experiencing hallucinations or delusions. A review of Resident #194's EHR revealed the following progress notes: [DATE] (7:06 a.m.): 0445 (4:45 a.m.) This nurse was returning from break and was notified by supervisor of an incident which occurred between (Resident #13) and (Resident #194). CNA reported (Resident #13) came out of (Resident #194's) room. Staff went to check on (Resident #194) and she reported a male coming into her room and grabbing her breast. This nurse and supervisor went to assess and interview (Resident #194). (Resident #194) again reported the same story (Resident #194) denied pain, stated it did not hurt but startled/scare her. (Resident #13) monitored (one to one) until further plan in place. [DATE] (11:42 a.m.): . (Resident #194's) daughter was updated on incident this am (morning) . (Resident #194's daughter) also stated that (Resident #194) does have a history of what was described . as inappropriately being fondled when she (Resident #194) was younger. Resident #194 expired on [DATE], therefore no observations of Resident #194 or interviews with Resident #194 could be obtained. In an interview on [DATE] at 9:22 a.m., Clinical Care Coordinator, Registered Nurse (RN) J, confirmed Resident #13 had exhibited sexually aggressive behaviors prior to the FRI involving Resident #13 entering Resident #194's rooms and touching her breast. When asked why Resident #13 had not been constantly supervised while out of his room, RN J reported she did not feel Resident #13 needed to be under constant supervision when out of his room because prior to the incident on [DATE], Resident #13 had only exhibited sexually inappropriate behaviors toward staff. Upon further inquiry, RN J confirmed that on [DATE], Resident #51 had reported Resident #13 entered her room and asked if she had underwear on. RN J reported Resident #51 was cognitively intact. Resident #13 and Resident #51 Resident #51 was admitted on [DATE]. A review of Resident #51's most recent MDS assessment, dated [DATE], revealed Resident #51 scored 15 out of 15 on the BIMS assessment, indicating Resident #51 was cognitively intact. An observation on [DATE] at 10:55 a.m., revealed a wooden gait blocking the doorway of Resident #51's room. Upon entering Resident #51's room, a motion alarm was observed to be attached to the left side of the doorway. In an interview at the time of the observation, Resident #51 reported the gait and motion alarm were to present due to alert staff if Resident #13 entered the room. Upon further inquiry, Resident #51 reported a few weeks ago, she had awakened in the night to find Resident #13 standing at her bedside and was lifting her nightgown. Resident #51 reported she shouted for staff after awakening to find Resident #13 at her bedside, at which time Resident #13 exited the room. When asked if Resident #13 had entered her room since that incident, Resident #51 reported Resident #13 had entered her room on other occasions but that she had been awake during those times and able to call for staff. A review of Resident #51's EHR revealed the following progress notes: [DATE] (10:08 p.m.): It was reported by CNA (Resident #13) came in (Resident #51's) room and asked if she had underwear on. [DATE] (10:45 p.m.): Resident #13) went into (Resident #51's) room and lifted her gown, (Resident #51) woke up and yelled don't and the other resident (#13) left. I talked to (Resident #51) and she stated (Resident #13) came in and she woke up to him lifting her gown and she yelled don't, he left, I asked her if she was okay, she stated that he did not touch her anywhere it just startle her because she was asleep. Notified the supervisor who also talked to her. Put in a work order to put a motion sensor in her doorway. A review of an incident investigation reported, dated [DATE] and provided by RN J revealed the following, in part: (RN J) was notified by charge nurse that (Resident #13) went into (Resident #51's) room and lifted up her (Resident #51's) gown. (Resident #51) woke up and yelled don't, (Resident #51) left and went back to his room. Shift supervisor interviewed (Resident #51), she stated she is fine she was just startled and that (Resident #51) did not touch her, add motion sensor to (Resident #51's doorway she already has a gait, and he has been in there before. Further review of the incident investigation report, dated [DATE], revealed the following: Camera was reviewed and (Resident #13) was only in (Resident #51's) room for less than a minute . motion sensor was added despite (Resident #51) stating she did not feel additional interventions were needed. A review of the 15-minute check log for Resident #13, provided by RN J, revealed on [DATE], Resident #13 had been checked on every 15 minutes, including the following times: 10:00 p.m., 10:15 p.m., 10:30 p.m., and 10:45 p.m. A review of Resident #13's EHR for [DATE] through [DATE], revealed the following progress notes: [DATE] (4:03 p.m.): . when this (social worker) asked if there was anything she could do to make his stay better (Resident #13) stated well you could take off all your clothes. [DATE] (11:12 a.m.): CNA reported to this nurse that (Resident #13) was inappropriate during cares. (Resident #51) requested to touch CNA's breasts. [DATE] (8:48 p.m.): (Resident #13) was seen coming out of (Resident #51's room). (Resident #51) stated (Resident #13) was in there and lifted her gown up which woke her up, she yelled at him, and he left . [DATE] (3:15 a.m.): (Resident #13) attempting to go into other resident's rooms this shift, was redirected by staff but became angry that he should be able to go where he pleases. Further review of the EHR revealed documentation of Resident #13's continued sexual inappropriateness on 11 days from [DATE] through [DATE], including the following progress note: [DATE] (2:12 p.m.): (Resident #13) made inappropriate comments during community circle . Staff asked residents if there was anything that they would like to do and (Resident #13) responded with have sex . staff then asked if the guys would like to play card games like poker, (Resident #13) responded strip poker. Resident #13 and Resident #37 In an interview on [DATE] at 9:22 a.m., RN J reported Resident #13 had inappropriately touched Resident #37 the prior evening, [DATE], and that the facility had reported the incident to the State Agency (SA). A review of an incident summary, dated [DATE] and provided by RN J, revealed the following, in part: (CNA L) . was assisting another resident when she noticed that (Resident #13) had approached (Resident #37), (CNA L) continued to assist the other resident into a safe position. (CNA L) then turned to check on other residents and she witnessed (Resident #13's) hand on (Resident #37's) chest. (CNA L) verbally told (Resident #13) to stop touching (Resident #37). (Resident #13) did not stop touching (Resident #37) therefore (CNA L) physically removed (Resident #13's) hand off (Resident #37's) breast. Further review of the incident summary, dated [DATE], revealed the following: (Resident #37) stated that she felt embarrassed because at first, I didn't know what he was doing. No one should touch me like that. I don't even let my boyfriends touch me like that. In an interview on [DATE] at 9:22 a.m., RN J reported Resident #13 would have constant supervision when out of his room and would continue to be under 15-minute checks when in his room. When asked why Resident #13 had not been under constant supervision prior to the event involving Resident #37 on [DATE], RN J reported Resident #13 had never approached residents in the open areas of the unit prior to the incident on [DATE], therefore, she did not feel it had been necessary to constantly supervise the Resident until then. On [DATE] at 9:22 a.m., an observation of video footage with RN J revealed on [DATE] at 7:17 p.m., Resident #13 approached Resident #37 in the living room of the Grass Creek Cottage unit (A-Hall). Resident #13 was observed to extend his hand toward Resident #27 and proceed to place his right hand on Resident #37's right breast. CNA L was observed to be in the hallway between the living room and dining room with her back to Resident #13 and Resident #37. No further video footage was provided. During the interview at the time of the video review, RN J reported CNA J immediately intervened after observing Resident #13 inappropriately touching Resident #37. In an interview on [DATE] at 10:50 a.m., the Director of Nursing (DON) reported since the incident on [DATE], Resident #13 had been placed on constant supervision while out of his room. The DON confirmed Resident #13 had been sexually inappropriate toward staff and residents on several different occasions prior to the event involving Resident #37. When asked why Resident #13 had not been placed on constant supervision prior to the incident on [DATE], the DON reported Resident #13 had never approached another resident in the common areas of the A-Hall prior to [DATE] and that motion alarms had been place on Resident #51's door to alert staff if Resident #13 entered. The DON reported prior the event involving Resident #13 and Resident #37 on [DATE], Resident #13 had only approached residents in their rooms. The DON acknowledged the threat of Resident #13's sexually aggressive behaviors to other residents in the facility and reported Resident #13 would be under constant supervision while out of his room, the motion alarm would remain in Resident #13's doorway and Resident #13 would be checked on every 15 minutes while in his room. A review of the facility policy titled Resident Abuse, Neglect, Mistreatment or Misappropriation Prevention Program, reviewed [DATE], revealed the following, in part: It is the policy of (facility) to maintain an environment free of abuse, neglect, mistreatment or misappropriation. The resident has the right to be free from abuse . Definitions: Abuse: (willful) infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. It includes . verbal abuse, sexual abuse, physical abuse and mental abuse . Verbal Abuse: defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident or their families . regardless of their age, ability to comprehend or disability . Sexual Abuse: is non-consensual sexual contact of any type with a resident. A review of the facility policy titled, Policy: It is the policy of the facility to protect and maintain our resident's safety. This includes protection from abuse and potential resident to resident conflicts. Guidelines: 1. Any aggressive/combative or verbally confrontational resident to resident confrontations. 2. Any aggress/combative or verbally confrontational resident to staff confrontations. 3. Any resident wander leading to entering other resident's room without permission. Procedure: 6. The clinical care coordinator and social worker will review incident types for patterns, trends, frequency of behaviors, triggers and develop interventions as needed for care plan development.

Based on observation, interview, and record review, the facility failed to ensure appropriate COVID-19 infection control practices were in place pertaining to restriction of entry into the facility and the staff screening process for two of four employees reviewed for employee screening. This deficient practice put staff and residents at increased risk for exposure to the COVID-19 virus. Findings include: On 1/25/21 at 11:33 a.m., the facility's main entrance door was observed to be open. This Surveyor was able to enter through the outer door and go into the vestibule. Employee screening forms were observed for employees to complete prior to starting their shifts. The vestibule door automatically opened, which allowed direct access to the facility. In the lobby of the facility, no staff were available to provide assistance to individuals who may enter. A phone at the front desk directed people to call for assistance. After this Surveyor dialed this number, staff did not appear for approximately five minutes. On 1/25/21 at approximately 11:45 p.m. the Director of Nursing (DON) explained the main entrance of the facility was not locked because it was the closest entrance for staff who had to work in some of the COVID-19 positive households. Staff were expected to complete the screening forms and take their own temperatures at the screening station. If staff were experiencing symptoms, they were to report to the nursing supervisor, return to their vehicles and await rapid COVID-19 screen testing. During an interview on 1/26/21 at 11:21 a.m., Household Assistant/Staff Member C reported the front door of the facility was unlocked when they came to work their 7 a.m.- 3 p.m. shift. Staff member C said sometimes there was staff available at the front desk to offer assistance and at other times there was not. On 1/26/21 at 11:36 a.m., Registered Nurse (RN) D said staff assigned to the COVID-19 units in the stacked households enter through the main entrance of the facility. RN D has found the door to be both locked and unlocked. Staff was not stationed at the desk to provide assistance. When asked if an unscreened person could enter the facility and enter the households, RN D said, Potentially. During an interview with Infection preventionist/RN A on 1/27/21 at 2:48 p.m., RN A explained staff were expected to fill out the screening forms at the screening stations prior to reporting to work. The ward clerk picked up the screening forms and went through them. If there were symptoms identified on the screening forms, the ward clerk notified RN A. During the night shift, nurses on duty were expected to collect the screening forms and identify any symptoms which were reported on the screening forms. When asked if there was a potential lag time in discovering staff who may have COVID-19 symptoms, RN A said yes, it was possible symptoms may not be detected until the screening forms had been reviewed. On 1/27/21 at 8:18 a.m., RN H reported they had came into work on 12/28/20 with some congestion but did not feel as though the congestion was significant because it had been mild. RN H had remained at work in the facility throughout the day on 12/28/20. RN H had been exposed to COVID-19 by their grandchildren earlier that week. RN H said they were COVID-19 tested on [DATE] and was notified of the positive results on 12/30/21. A Staff screening slip for RN H dated 12/28/20, revealed RN H had reported congestion, sneezing, and COVID-19 exposure. Section III, the Action/ Signature portion of the screening form revealed the following information, follow up work restricted, 'no', sneezing (+) grands (COVID-19 positive grandchildren) last week, monitor, test, wear PPE (personal protective equipment). This portion of the form was dated 12/28/20. A review of the facility's Employee Positive COVID tracking form revealed RN H had been COVID-19 tested on [DATE], positive test results date was 12/30/20 The documentation revealed RN H had been taken off work on 12/29/20. An absence slip dated 12/30/20 showed RN H had worked until 1:00 p.m. on 12/30/20 before leaving. The reason for absence on the form was COVID + During an interview with Infection preventionist/RN A on 1/27/21 at 2:48 p.m., RN A was asked about RN H's infection status on 12/28/20. RN A reported RN H did not show symptoms of COVID-19 and therefore did not meet the criteria to be taken off work. When asked about RN H's exposure to COVID-19 outside of the facility, RN A said this was not an issue because all staff had been exposed due to the residents having COVID-19 and this was no longer a factor. RN A stated, We have to trust their judgement when they are reporting symptoms. A review of the Facility's Testing and Screening for Coronavirus policy with the most recent revision date of 10/02/20, revealed the following information: All facility employees will perform a screen for symptoms of COVID-19 or other respiratory illness daily at the beginning of their shift. This screen will include travel questions, fever, shortness of breath, cough, sore throat, any known contact with a person who has had COVID-19 .Section I. If the employee answers yes to any of the screening questions, the employee is to exit the facility and return to their vehicle. They will call the Nursing Supervisor for further evaluation of the stated symptoms. Nurse Supervisor may conduct rapid COVID-19 test to rule out COVID-19. Section II The Nursing Supervisor will complete section II of the employee screening form and make the determination if the employee will be allowed to enter work. Section III The Supervisor will document and sign this section for the employee who had a positive screen .b. If the employee has had contact with a person who is known +COVID and the employee is now demonstrating symptoms, the employ will be referred to the local Health Department and will not be allowed to return to work until criteria are met .d. The supervisor may conduct a rapid COVID-19 test in house to rule out COVID-19 infection. If the employee's tests + COVID-19 the facility will notify the Health Department and the employee will be sent home. A review of January 2021 Infection Surveillance information revealed a total of 17 residents who had COVID-19. Four of seven households had positive COVID-19 residents.

This citation refers to Intake Number: MI 123. Based on interview and record review, the facility failed to provide adequate supervision for one Resident (#50) of three Residents reviewed for elopement risk. This deficient practice resulted in Resident #50 wandering through the stairwell and exiting the facility unsupervised and the potential for other Residents to exit the facility unsupervised putting them at risk for harm and/or injury. Findings include: Review of Resident #50's medical record revealed an admission to the facility on [DATE] with readmission on 6/25/20 and [DIAGNOSES REDACTED]. Resident #50 scored a 14/15 on the 6/29/20 Brief Interview for Mental Status (BIMS) score, indicating she was cognitively intact. According to the Facility Reported Incident (MI-FRI ID # 885) received by the State Agency (SA), Resident #50 eloped on 8/15/20 from the third floor of the facility through the stairwell at approximately 11:15 a.m. and exited the building to the outside front parking lot where she was found at approximately 11:45 a.m. On 8/20/20 at approximately 9:45 a.m. an interview was conducted with the Director of Nursing (DON) in regards to Resident #50's elopement from the facility on 8/15/20. The DON described the elopement incident stating Resident #50 was located on the third floor of the facility walking down the hallway and was last seen by staff heading towards the kitchen area. Resident #50 went to the main entrance of the third floor unit at 11:15 a.m. and pushed on the front door for 15 seconds activating the delayed egress system. Resident #50 was able to exit out of the unit undetected due to the front door alarm system malfunctioning. Resident #50 then made her way into the hallway towards the elevator and stairwell. Resident #50 again held the stairwell door for 15 seconds activating the delayed egress system. The stairwell door alarm system did function properly this time, however, the alarm sound did not transfer to the units and staff were not able to hear that the stairwell door had been breeched. Resident #50 then proceeded down the stairwell to the basement floor, then back to the main floor into the facility vestibule. Resident #50 manually opened the sliding front door of the facility, which had been disengaged to limit visitors due to the coronavirus pandemic, and exited the facility to the front main parking lot. Resident #50 was found by a staff member at 11:45 a.m. and was escorted back into the facility. On 8/20/20 at approximately 10:00 a.m. an interview was conducted with Maintenance Director A in regards to the malfunctioning door alarm system on the third floor unit. Maintenance Director A stated that he believed the magnetic system for the alarm may have been out of place at the time of the incident on 8/15/20. When asked how often the facility doors are checked for proper functioning, Maintenance Director A stated, 'We were on a monthly inspection for all facility doors at the time. That door (third floor main entrance) was last checked on August 10th, 2020 and it was functioning correctly. Maintenance Director A confirmed that although the stairwell door did function properly on 8/15/20, the sound was not loud enough for staff to hear on the third floor unit, and there was not a indicator inside the unit to notify staff that the stairwell door had been opened. On 8/20/20 at approximately 11:45 a.m. an interview was conducted with Resident #50 in her bedroom. Resident #50 was asked about the incident on 8/15/20 and she stated, I wanted to go find my son, so I opened the door and left. When asked if Resident #50 received any injuries on 8/15/20 she stated, No, I was fine.

Based on observation, interview and record review, the facility failed to properly maintain infection control practices during a COVID-19 Infection Control Survey by failing to screen employees for signs, symptoms, and exposure to COVID-19 (a highly transmissable infection), and failure to implement employee source control (masking), prior to entering the facility. This deficient practice resulted in the potential transmission of COVID-19 to all 110 residents living in the facility. Findings include: On 4/17/20 at 11:05 a.m., an observation at the designated employee entrance to the facility revealed a screening station equipped with a thermometer, hand sanitizer, bleach disinfectant wipes, and a green file folder containing yet-to-be-completed forms titled, Employee - Coronavirus Screening Form. An observation of the Orchard Hill Unit, on 4/17/20 at 11:50 a.m., revealed the following layout: upon entrance to the unit, the living area was on the left with the dining and kitchen areas on the right. The dining and kitchen serving areas were divided by a bar-type counter with seating which faced the kitchen serving area. A high counter separated the kitchen serving area from the hallway leading to the resident's rooms. Access to the high counter could be gained from both the kitchen serving area and hallway. Observed on the high counter was a bottle of hand sanitizer, a thermometer, surgical masks and a green file folder. Two residents were in the living area across from the kitchen at the time of the observation. An interview with Certified Nurse Aide (CNA) C, on 4/17/20 at 12:00 p.m., revealed they regularly worked on the Orchard Hill Unit. CNA C reported undergoing screening for COVID-19 upon presenting for work each day they was scheduled. When asked if they was screened for COVID-19 at the employee entrance to the facility, CNA C replied that they did not complete the screening at the entrance, but upon reporting to the Orchard Hill Unit to begin the work shift. CNA C reported they completed the screening at the station located on the unit by taking her temperature and answering the questions on the form, then returning the form to the green folder, and donning a mask. CNA C pointed to the high counter in the kitchen area previously observed by this Surveyor. When asked what they would do if they determined they had a fever upon taking her temperature and completing the screening form, CNA C reported they would take the form to the nursing office on the unit for review. When asked where the nursing office was located, CNA C pointed to a closed door approximately one-third of the way down the hallway toward the resident rooms. An observation on 4/17/20 at 12:20 p.m. in the Lakeshore Cottage unit revealed a similar layout as the Orchard Hill Unit. The high counter separating the kitchen serving area and the hallway held a small container of hand sanitizer, a thermometer and a green file folder containing unused Employee - Coronavirus Screening Forms. To access the screening tools, staff would be required to walk between the resident living and dining areas. There were five residents sitting at separate tables in the dining area at the time of the observation. One resident was seated at the low counter between the dining area and the kitchen serving area, within approximately five feet of the employee screening station. An interview with CNA E, on 4/17/20 at 12:25 p.m., in the Lakeshore Cottage Unit, revealed staff were instructed to screen for Covid-19 symptoms upon arriving on the unit they were assigned to work. When asked at what point upon arrival did they don a mask after arriving to work, CNA E replied they put on a mask after completing the COVID-19 screening on the unit. When asked if they walked through the building and into the care area before screening and donning a mask, CNA E reported, Yes, and stated they completed the screening by taking their temperature, recorded the reading on the screening form, answered the screening questions and donned a mask, all after entering the residential unit. An interview with Registered Nurse (RN) A, on 4/17/20 at 12:40 p.m., revealed staff had a choice of where to complete the employee screening for COVID-19. RN A stated the facility had employee screening stations located at the entrance to the building, the unit clerk's desk in the lobby and on each unit. When asked where the screening forms were placed after completion, RN A reported staff should deliver their screening forms to the nursing office on their respective units. An observation of the Antrim Lodge Unit, on 4/17/20 at 12:50 p.m., revealed the same layout and location of the employee COVID-19 screening tools as on the Orchard Hill and Lakeshore Cottage Units. There were three residents present in the dining area at the time of the observation. One resident was seated at the counter within close proximity to the employee screening station. An observation of the Cedar River Unit, on 4/17/20 at 1:30 p.m., revealed a COVID-19 employee screening station inside the entrance to the unit. An Interview with RN O at the time of the observation, revealed their understanding of the employee screening process was for clinical staff to screen themselves for infection on their assigned units, not at the screening station located at the designated employee entrance to the facility. RN O reported upon arriving for work, staff on the Cedar River Unit take their own temperatures, fill out the screening form and deliver the completed form to the nursing office on the unit. RN O reported housekeeping and dietary staff did not screen on the units but at the screening station located at the designated employee entrance. When asked how they knew that everyone on the unit had completed a screening prior to working, RN O replied, I just assume everyone is sticking to the policy. Further observation of the Grass Creek Unit, revealed to reach the unit's nursing office from the screening station, required travel through a portion of the unit's living area. One resident was present in the living area at the time of the observation. An interview with the Director of Nursing (DON), on 4/17/20 at 2:40 p.m., revealed clinical staff had been instructed to screen at the stations provided on their prospective units to help decrease the bottleneck at the employee entrance. When asked to clarify, the DON verified the process that clinical staff entered the building and traveled, unmasked, to the units on which residents resided, to complete the screening for COVID-19 symptoms and exposure. When asked about the disposition of the forms after completion by staff, the DON reported staff place the completed forms in the green folders located at each screening station and the forms are picked up by the unit clerk, sometime in the morning, and taken to the Human Resources Department. An interview with Staff N, on 4/17/20 at 3:28 p.m., revealed they worked at the front desk as a unit clerk. Staff N reported after morning shifts had begun, they picked up the completed, Employee - Coronavirus Screening Form(s) from the green folders at the screening stations, which included the designated employee entrance, the desk in the front lobby, and from each clinical unit. Staff N reported they then delivered the completed forms to the Administrative Assistant to be filed. During an interview with the Nursing Home Administrator (NHA) and the DON, on 4/17/20 at 3:40 p.m., the DON was asked if any employee screenings had resulted in having a staff member leave work due to risk of possible COVID-19 infection. The DON replied they had sent an employee home on 3/25/20 due to a positive screening. The screening document used to determine the positive screening for the employee was requested at that time. The DON was asked if there was concern that a staff screening may show symptoms of, or exposure to COVID-19 during the required screening, with the staff person entering the resident care unit, unmasked, to complete the screening. The DON stated they understood the concern. A review of the, Employee - Coronavirus Screen Form, dated 3/25/20, provided by the DON, revealed the staff member (will remain confidential to protect personal health information) had a low-grade fever, cough and sore throat. A telephone interview with the confidential staff member, on 4/21/20 at 9:11 a.m., revealed they had entered the building without at mask, travelled from the designated employee entrance to the lobby, screened themselves by taking their temperature and completing the screening form. The staff member reported upon completing the screening, they donned their mask and proceeded to report to their workstation, and awaited the arrival of the DON to discuss the results of their screening. Upon the DON's arrival, the staff member reported they took the screening form to the DON for review and were subsequently sent home due to symptoms of COVID-19 and instructed to seek guidance from their personal physician. The staff member was quarantined for 14 days after the positive screening was reported to the DON. An interview with the NHA on 4/21/20 at 11:08 a.m., revealed the process of having clinical staff travel through the building to screen in the resident care area was for staff to have access to nursing if screening indicated signs of, or exposure to, COVID-19. A review of the Centers for Disease Control (CDC), Infection Control Guidance, updated 4/13/20, revealed the following, in part: To address asymptomatic and pre-symptomatic transmission, implement source control (masks) for everyone entering the healthcare facility . Actively screen everyone for fever and symptoms of COVID-19 before they enter the healthcare facility.

Based on interview and record review, the facility failed to ensure that annual competency of nurse aide skills was completed for one Certified Nurse Aide (CNA) (CNA A) out of nine staff reviewed for competency. This deficient practice resulted in the potential for lack of quality of nursing care with the potential to effect all residents. Findings include: On 10/16/19 a review of the CNA education and competency for CNA A revealed that she was hired on 8/7/18. The facility was requested to provide the most recent annual competency. A review of the competency that was provided revealed it was a 90 day review dated 11/7/18, and did not include a review of nurse aide competency but only employee factors (Attendance, Punctuality, Attitude, Appearance, Dependability, etc). CNA A was documented as being 'marginal' for the following areas: Development ('does only the routine'), Knowledge of Work ('barely gets by'), Quantity of Work ('Does just enough to get by'), and Supervision ('Control of work force is inconsistent'). The 'Overall Evaluation' was marked as 'marginal - unsatisfactory but showing improvement). A review of the comments sections revealed, . (CNA A) had already one extension (with) orientation - (has) been verbally counseled regarding expectations. Per nurse/co-workers no improvement . Further review of CNA As record revealed she had not be reassessed for her employee factors despite being deemed as marginal in performance. The only assessment of CNA As skills titled C.N.[NAME] Skill Evaluation Record was completed on 8/7/18 (date of hire). A review of the comments revealed that many 'tasks' had only been discussed with CNA A, and no return demonstration was conducted to ensure that she could complete the task appropriately. Tasks that were only discussed included, 7. Assist the Resident having a [MEDICAL CONDITION] .9. Assist the Res. who is burned . 17. Fingernails/cleaning and trimming . 32. Application of physical restraints . 41. Assist with bedpan urinal . Other Task marked as no/not completed included, 11. [MEDICATION NAME] Maneuver . 43. Ostomy care . 46 Urine/stool spec. collection . 53. Range of Motion . The comments section of this evaluation revealed, Took class in (name of town). Needs to take test yet. New to caregiving. Weaknesses: brushing teeth and dentures, practice transfers, cath (catheter) (change), putting on clothes, [MEDICAL CONDITION] care. Needs to work with lifts more. On 10/16/19 at 10:42 a.m., an interview was conducted with Staff Educator/Registered Nurse (RN) E. When asked about the missing annual competency for CNA A, RN [NAME] stated, It's not due yet. They do the first form (90 day eval) at 90 days after they are done with probation, and then the full packet (assessment of CNA skills) is done a year later. RN [NAME] was asked to clarify that CNAs do not have their CNA skills assessed until 15 months after hire, and stated, Yes. On 10/16/19 at 11:02 a.m., a second interview was conducted with RN E. When asked how she thought CNA A was doing now after receiving a marginal review on the initial CNA Skills Evaluation and the 90 day employee evaluation, RN [NAME] stated, I don't know. When I did her initial one (on the day of hire) I thought she (seemed like) she wanted to do the right thing. When asked how she could know that CNA As performance had improved, RN [NAME] stated, Hopefully the nurses would tell me if she hadn't. I haven't worked with her. I only do the CNA form when they first come in. RN [NAME] was asked to provide a policy on CNA competency evaluation, but an appropriate policy was not provided.

Based on observation, interview, and record review, the facility failed to ensure appropriate fall interventions were initiated to prevent falls for one (Resident #101) of five residents reviewed for falls, from a total sample of six residents. This deficient practice resulted in Resident #101 sustaining major injuries as a result of the fall, delaying progress toward the resident's discharge goals, and jeopardizing existing health problems from expected normal resolution. Findings include: A review of Resident #101's Electronic Medical Record (EMR) revealed she was an [AGE] year old female, admitted on [DATE] with [DIAGNOSES REDACTED]. On 9/25/17 at 2:10 p.m. Resident #101 was observed in bed laying on her left side. An interview with Resident #101 at that time revealed she .had difficulty in getting staff to come using the call light, and I can only wait so long. Resident #101 also stated she had to use the bedside table to walk to the bathroom before. On 9/25/17 at 2:10 p.m., during an interview with Family Member (FM) J, she stated she had .told them (facility) right from the get go she's (Resident #101) highly independent and she's a fall risk . They (facility) didn't put down the fall mats and lower the bed until real recently (bitalteral floor mats and bed locked at low height added to care plan on 9/24/17). A review of Resident #101's Minimum Data Set (MDS) assessment dated [DATE] revealed she required total assist of one person for transfers, extensive assist with two people for dressing, hygiene, and toileting, and extensive assist of one person for bathing. Resident's pain was assessed as rarely occurring at a moderate level. The MDS assessment also indicated Resident #101 was admitted with an unstageable pressure ulcer (sacral region), and as a result of the fall had the potential to have delayed healing, was in bed more often, and in more pain (as stated in an interview with CNA H on 9/26/17 at 12:20 p.m.). A review of Resident #101's admission Morse Fall Scale assessment on 7/26/17 performed at 2:49 p.m. revealed she was categorized at 60.0, indicating high risk for falls. Review of Resident #101's comprehensive care plan revealed initial interventions to address falls were Maxi lift for all transfers with medium sling, non-ambulatory with floor staff on 7/28/17. Transfers without assistive device but gait belt and assist was added to the care plan on 8/7/17. Review of Health Status Notes documented on 8/10/17 indicated the Resident #101 had attempted .to get out of bed this AM .found foot on floor with body still on edge of bed .asked what resident was doing .'I need to go to the bathroom' .help pivot resident to w/c (wheelchair) to take to bathroom will continue to monitor. Non skid footwear at all times was not added to the care plan until 8/16/17. Offer bed pan when in bed, and assist with toileting & supervise on toilet was added on 8/24/17. A review of an incident report dated 8/29/17 at 8:35 a.m. revealed Resident #101 had sustained a fall without injury , and was found sitting on the floor near med cabinet. Immediate interventions were identified to .place bed and chair alarms . The incident report states Res very upset and crying .told (staff) that she stood up took a step and fell she had to go to the bathroom. A review of the incident report for the fall sustained on 9/10/17 (discovered at approximately 7:15 a.m.) revealed Resident #101 again was attempting to get to the bathroom. Resident #101 was found with her head leaning against the bathroom door, and she had been incontinent of bowel. Bowel incontinence was seen on the bed. Resident #101 was complaining of pain in her right hip, and had sustained a hematoma to her head. Review of notes section of the incident report dated 9/12/17 revealed Resident #101 had been receiving Physical and Occupational therapy five times a week prior, and had made progress, and was able to ambulate with therapy with front wheeled walker with assist. According to the incident report, Resident #101 was sent to the hospital for evaluation post fall. Review of Resident #101's CT scan of chest, abdomen , and pelvis with IV contrast performed on 9/10/17 at 11:27 a.m. revealed .subtle fractures of the anterolateral ( .between front and side on the right) and lateral (side) right 5th, 6th, 7th, and 8th ribs, fracture of the right pubic bone extending minimally into the pubic aspect of the right superior and inferior pubic rami, and moderate T12 compression with loss of approximately 50% anterior (front) body height. Review of Resident #101's x-ray of right hip complete minimum two views performed on 9/10/17 at 11:51 a.m. revealed .deformity with suggestion of acute fracture involving the right pubis and superior pubic ramus. According to the EMR, Resident #101 was re-admitted to the facility on [DATE]. A review of Resident #101's Morse Fall Scale re-evaluation on 9/14/17 continued to place her at high risk for falls with a score of 75.0. On 9/26/17 at 12:00 p.m. an interview with Licensed Practical Nurse (LPN) G revealed Resident #101 had Oxy IR (immediate release) 5 milligrams (mg), one or two tablets every four hours as needed added to her medication regimen for pain on 9/14/17 as a result of the fall. She hasn't been wanting to get up this week .last week (after readmission on 9/14/17) she was up 3 times and tolerated it well .ate meals in her wheelchair. On 9/26/17 at 12:05 p.m., during an interview with Resident #101 she stated, I can't bathe myself .before, I could if I had to .now, I can't right now. When Resident #101 was asked if her pain had changed at all since the fall on 9/10/17, she stated that the pain had become worse. On 9/26/17 at 12:20 p.m. an interview with Certified Nurse Aide (CNA) H revealed Resident #101 was was more active .up quite a bit .she still does (get up) but not as often .she also used to be out here (common living area/dining area) more, but now prefers to be in her room .obviously she is in more pain .(Resident #101) is not on a toileting schedule .but I do offer (to toilet) during turns (repositioning Resident #101 in bed). Review of Resident #101's CNA care delivery guide provided by RN C showed current flagged items in red (active items) for CNAs to perform or be aware of, which revealed Resident #101 was both continent and incontinent of bladder, continent of bowel, used medium incontinence pads, and needed supervision on the toilet. Toileting schedule was not added as an item for completion on Resident #101's CNA care delivery guide. On 9/26/17 at 12:25 p.m. an interview with Registered Nurse (RN) C revealed, (Resident #101) required more pain medication (since the fall) for dressing changes (unstageable coccyx wound) because of the pelvic fracture .she cannot walk right now .her activity varies .last week was better .she was up a few times .this week has been more difficult. When asked how Resident #101's high fall risk was addressed in the care planning process, RN C stated, I didn't recall her (Resident #101) being a fall risk, but we wouldn't necessarily go right to alarms .it's individualized (care planning). When RN C was shown Resident #101's fall risk assessment, she stated I still think I wouldn't have gone to alarms .she had a fall prior to admit (indicated on the 7/26/17 Morse Fall Risk Assessment) is vague. RN C also indicated Resident #101 was in the process of assessment for significant change in condition. Review of the comprehensive care plan revealed interventions of an audible alarm at upper torso height, and bed bolsters to define mattress perimeter added on 9/11/17. The care plan was modified to have Bed locked at low height, and bilat mats (floor mats on each side of the bed) on 9/24/17, two weeks after her fall with injury. An interview on 9/25/17 at 10:30 a.m. with CNA E revealed, .she (Resident #101) has a history of getting up independently and walking when she is not supposed to. CNA E also stated that she was on her way by the room of Resident #101 prior to the incident and no call lights were on in the hallway as staff was transporting another resident down to the dining area for breakfast. According to the 9/10/17 incident investigation submitted by the facility, CNA E was the one observed on camera passing by the room prior to the fall approximately 2 minutes prior to the call light attached to the bed alarm being triggered. Review of call light log for the pressure alarm (attached to the call system) provided by staff for 9/10/17 revealed a triggered time of 6:59:23 a.m. with an elapsed time of 23:20 seconds. On 9/25/17 at 10:05 a.m. an interview with CNA D revealed she was .on the way down the hall to another fall vulnerable resident's room responding to a call light and (heard moaning) notice Resident (#101) on the floor. CNA D stated she called for help when she discovered Resident #101 on the floor. According to the incident report dated 9/10/17 the CNA had ran to the nurses station at approximately 7:15 a.m. stating that she .needed a nurse. With the call light triggered at 6:59:23 a.m., and CNA D passing by the room responding to another light for a different resident (which required her to pass by Resident #101's room to notice her on the floor), CNA D indicated she was responding to a different resident, stating Resident #101's call light was not on at the time. Based on the events recorded, Resident #101 was potentially on the floor for 15 minutes before being discovered.

Based on interview and record review, the facility failed to honor the rights of one (Resident #101) of 5 residents reviewed for compliance with advance directives in the total sample of 5 residents, by not following the advanced directive requesting CPR (Cardiopulmonary Resuscitation) to be initiated when the resident was found unresponsive, without pulse or respirations. This deficient practice resulted in the lack of emergency medical procedure (CPR) as requested by Resident #101 prior to his death. Findings include: An abbreviated survey was conducted on [DATE] - [DATE] related to a facility reported incident involving Resident #101. Per the Facility Investigation Report Summary dated [DATE], on [DATE] at approximately 5:50 p.m., Resident #101 was found in his room (in bed) by Registered Nurse (RN) A, unresponsive, without pulse or respirations. RN A had contacted the Physician Assistant (PA) B and received an order to send Resident #101 to the Emergency Department for an elevated temperature of 103.8 degrees. Certified Nurse Aide (CNA) C had just been in his room [ROOM NUMBER] - 25 minutes earlier and checked his vital signs. Resident #101 was listed as a full code. RN A and Nursing Supervisor D, who also found him unresponsive, did not initiate CPR. A review of Resident #101's closed record face sheet dated [DATE], revealed a [AGE] year old man was admitted to the facility on [DATE] for sub-acute rehabilitation. A review of Resident #101's Physician order [REDACTED]. An interview was conducted on [DATE] at 10:00 a.m. with RN A pertaining to the advanced directive of Resident #101 not being followed. RN A reiterated the events which took place on [DATE] from 4:30 p.m., when Resident #101 was found to have an elevating temperature through 6:15 p.m., when she called the PA and reported Resident #101 had passed away. RN A said it went so fast, just over two hours from no signs of distress and then he was gone. RN A said yes.I knew (Resident #101) was a full code.it didn't hit me (to do CPR).he was that dead.I would have done it (CPR) if he had looked different.wasn't until (PA B) asked me about the code (when I called her).then I thought code.I didn't do a code (perform CPR). An interview was conducted on [DATE] at 4:18 p.m. with Nurse Supervisor D pertaining to the advanced directive of Resident #101 not being followed. Nurse Supervisor D explained, when she walked into Resident #101's room, .he (Resident #101) was dead.obvious signs of death. I knew (Resident #101) was a full code. he looked peaceful, white.no signs of life. Nurse Supervisor D said she knew the facility policy said, if a resident is a full code and you find them unresponsive with no pulse or respirations you are to initiate CPR. When asked why CPR was not initiated, Nurse Supervisor D responded, .I knew he was dead. A review was conducted of RN A and Nurse Supervisor D's personnel files. Neither of the two staff nurses had any disciplinary action prior to this event. Both had completed their annual CPR instruction on [DATE]. Both had good annual evaluations. Both of them had been in-serviced on the newly revised policy regarding when to perform CPR and the identifying of full code residents in the facility by way of the following: a blue wrist band, a red heart sticker on their picture next to their door, and their name highlighted on the list of neighborhood residents which was posted on the narcotics cupboard. (All of these identifying elements were in place for Resident #101, per the Director of Nursing (DON) interview on [DATE] at 3:15 p.m.) On [DATE], interviews were conducted with RN E at 4:10 p.m., RN F at 4:30 p.m., RN G at 4:40 p.m., RN H at 5:00 p.m., Licensed Practical Nurse (LPN) I at 5:15 p.m., RN J at 5:30 p.m., and RN K at 5:50 p.m. On [DATE] interviews were conducted with LPN L at 11:40 a.m., LPN M at 11:50 a.m., LPN N at 12:00 p.m., LPN O at 1:40 p.m., LPN P at 2:00 p.m., RN Q at 2:20 p.m., and RN R at 2:30 p.m. All 14 interviewed staff responded to the question asked by this Surveyor: What do you do if you walk in on a resident and they are unresponsive? by stating initiate CPR immediately as long as the resident has a blue bracelet on, a red heart on their picture by their room and their name is on the Full Code list in the nurses station. All of the above nurses interviewed said they had participated in an in-service about the facility's revised CPR policy, including how to recognize a 'Full Code' resident (resident who has indicated their wish for CPR). A review was conducted of the facility Policy, Cardiopulmonary Resuscitation-Emergency Procedure, revised ,[DATE]. The CPR-Emergency Procedure Policy read, .If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. A valid Do Not Resuscitate (DNR) order is in place, that prohibits CPR. b. Initiating CPR could cause injury or peril to the rescuer. On [DATE] at 12:35 p.m., an interview was conducted with Resident #101's wife, Family Member (FM) S. She said Resident #101 received very good care there and her husband told her everyone was good to him. She had talked to him earlier in the day of [DATE]. Resident #101 told her he just wanted to sleep and was very tired. FM S said Resident #101's death was very sudden for her and her family, and indicated she did not wish to further discuss the topic. On [DATE], the charts were reviewed of Resident #102, Resident #103, Resident #104 and Resident #105. They all had Full Code Status and were residing in different neighborhoods in the facility. The nurses in each of those neighborhoods knew, if the residents were found unresponsive, they would start CPR immediately. The four residents had blue bracelets on or in close proximity to them, red heart stickers were on their pictures and their names were highlighted and taped to the narcotic cupboard at the Nurses Station. On [DATE] at 3:15 p.m. an interview was conducted with the Administrator and the DON pertaining to the above facility incident report. The Administrator said when RN A and RN Supervisor D were asked if they had performed CPR, the two nurses said No they had not, and yes, they knew Resident #101 was a full code, they knew they should start CPR immediately if someone was unresponsive, but they were convinced Resident #101 was dead. Both the nurses were educated again about when to initiate CPR and there would be disciplinary action handed out. The DON said, before this event happened, she already had everyone signed up for a review course on the CPR Policy over the next two weeks and they were going to have mock drills on exactly how a 'Full Code' procedure was conducted. ( ) --

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION/ MONITORING AND ASSISTIVE DEVICES FOR ONE OF FIVE SAMPLED RESIDENTS (RESIDENT #1), OUT OF A TOTAL POPULATION OF 100, RESULTING IN RESIDENT #1 SUSTAINING A HARMFUL HEAD INJURY AFTER FOUR FALLS WITHIN A 72 HOUR TIME FRAME. FINDINGS INCLUDE: RESIDENT #1 IS AN [AGE] year-old FEMALE admitted to the facility on [DATE], WITH THE [DIAGNOSES REDACTED]. A FALL RISK ASSESSMENT WAS CONDUCTED ON 12/01/11, AND RESIDENT #1 SCORED 28, INDICATING RESIDENT #1 WAS AT HIGH RISK FOR FALLS. A CARE PLAN DATED 12/02/11, PLACED RESIDENT #1 AT RISK FOR FALLS RELATED TO: A HISTORY OF FALLS, DEMENTIA, AND BEING NEW TO THE ENVIRONMENT. A PROGRESS NOTE DATED 12/12/11, INDICATED RESIDENT #1 HAD "LESS THAN STEADY GAIT" WITH A QUAD CANE. A WHEELED WALKER WAS ADDED TO THE CARE PLAN FOR RESIDENT #1 TO USE DURING AMBULATION. IN ADDITION, STAFF WERE TO OBSERVE FOR ANY UNSTEADINESS AND ASSIST RESIDENT #1 AS NEEDED. ACCORDING TO THE INCIDENT/ACCIDENT REPORT DATED 2/23/12 AT 4:30 P.M., RESIDENT #1'S FIRST FALL WAS IN THE DINING ROOM WHILE CARRYING A CHAIR. THERE WERE NO INJURIES. ACCORDING TO THE INCIDENT/ACCIDENT REPORT DATED 2/25/12, AND VIDEO CAMERA IMAGES DATED 2/25/12 AT 11:24 P.M., RESIDENT #1 WAS SITTING ALONE AT A DINING ROOM TABLE WHEN SHE GOT UP, AND WALKED OVER TO THE NEXT TABLE (APPROXIMATELY 10 FEET) WHERE TWO CNAS (CERTIFIED NURSE AIDES) WERE SITTING. RESIDENT #1 THEN TURNED AROUND AND WALKED BACK TO HER TABLE WHERE SHE LOST HER BALANCE AND fell . UPON REVIEW OF THE VIDEO CAMERA IMAGES, THE TWO CNAS PRESENT DID NOT ASSIST RESIDENT #1 TO AMBULATE BACK TO HER CHAIR NOR DID THE TWO CNAS PROVIDE RESIDENT #1 WITH HER WALKER AS CARE PLANNED. RESIDENT #1 SUFFERED A LACERATION TO THE BACK OF HER HEAD. THIS FALL WAS THE SECOND FALL IN THE 72 HOUR PERIOD. AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 3/19/12 AT APPROXIMATELY 11:00 A.M., CONFIRMED THE TWO CNAS DID NOT ASSIST RESIDENT #1 BACK TO HER CHAIR OR PROVIDE A WALKER FOR HER AMBULATION SAFETY AS CARE PLANNED. THIS FAILURE RESULTED IN RESIDENT #1 GRABBING A WHEELED, OVER-BED TABLE AND FALLING TO THE FLOOR. ACCORDING TO THE INCIDENT/ACCIDENT REPORT DATED 2/26/12 AT 1:30 A.M., A CNA RESPONDED TO AN ALARM AND FOUND RESIDENT #1 ON THE FLOOR IN HER ROOM (FALL #3). A LACERATION FROM THE PREVIOUS FALL LOCATED ON THE BACK OF RESIDENT #1'S HEAD WAS OPENED UP AND BLEEDING. THE PHYSICIAN WAS NOTIFIED AND RESIDENT #1 WAS SENT TO THE EMERGENCY DEPARTMENT FOR EVALUATION. ACCORDING TO THE EMERGENCY DEPARTMENT REPORT DATED 2/26/12, RESIDENT #1 RECEIVED MULTIPLE SURGICAL STAPLES FOR REPAIR OF THE LACERATION TO THE BACK OF HER HEAD. A CAT SCAN OF THE HEAD WAS TAKEN AND WAS NEGATIVE FOR ACUTE PATHOLOGY. THE [DIAGNOSES REDACTED].#1 WAS RETURNED TO THE FACILITY AT APPROXIMATELY 6:00 A.M. THE SAME DAY. A REVIEW OF RESIDENT #1'S CARE PLAN REVEALED NO CHANGES IN THE PLAN OF CARE TO DECREASE THE RISK OF FALLS. DURING INTERVIEW WITH THE DON ON 3/20/12 AT APPROXIMATELY 11:00 A.M., SHE INDICATED RESIDENT #1 WAS NOT RE-ASSESSED BY STAFF AFTER RETURNING FROM THE emergency room FOR THE INCREASED NEED FOR MONITORING AND SUPERVISION RELATED TO THREE PREVIOUS FALLS. ACCORDING TO THE INCIDENT/ACCIDENT REPORT DATED 2/26/12 AT 11:10 A.M., RESIDENT #1 WAS FOUND ON THE FLOOR LYING FACE DOWN IN FRONT OF HER BED (FALL #4). RESIDENT #1 WAS BLEEDING FROM HER NOSE AND MOUTH. FIRST AID WAS ADMINISTERED CONSISTING OF PRESSURE TO STOP THE BLEEDING AND ICE PACKS APPLIED TO HER MOUTH AND NOSE. THE PHYSICIAN WAS NOTIFIED AND RESIDENT #1 WAS SENT BACK TO EMERGENCY DEPARTMENT FOR THE SECOND TIME ON 2/26/12. ACCORDING TO THE SECOND EMERGENCY DEPARTMENT REPORT DATED 2/26/12, RESIDENT #1 WAS NEGATIVE FOR ACUTE INJURY OR ABNORMALITIES. RESIDENT #1 WAS discharged BACK TO THE FACILITY FOR CONTINUED CARE ON 2/26/12. ACCORDING TO NURSE PROGRESS NOTES DATED 2/27/12, RESIDENT #1 COMPLAINED OF HEAD PAIN. IT WAS DOCUMENTED SHE HAD NAUSEA, DIZZINESS, AND GAIT DISTURBANCE. THE PHYSICIAN WAS NOTIFIED AND RESIDENT #1 WAS AGAIN SENT TO EMERGENCY DEPARTMENT FOR FURTHER EVALUATION. THE EMERGENCY DEPARTMENT DISCHARGE SUMMARY DATED 3/01/12, LISTED FINAL [DIAGNOSES REDACTED]." SHE WAS THEN discharged BACK TO FACILITY FOR CONTINUED CARE. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION FOR ONE RESIDENT (#1) AND IDENTIFY NON-FUNCTIONAL ALARM SYSTEMS FOR TWO RESIDENTS (#2 AND #3) OF FIVE RESIDENTS FROM A SAMPLE OF FIVE RESIDENTS WHO WERE REVIEWED FOR FALLS OUT OF A TOTAL RESIDENT CENSUS OF 105. THIS FACILITY DEFICIENT PRACTICE RESULTED IN FRACTURES REQUIRING MEDICAL EVALUATION BEYOND FIRST AID FOR RESIDENTS #1, #2 AND #3, AND IN A FRACTURE REQUIRING SURGICAL INTERVENTION FOR RESIDENT #2. FINDINGS INCLUDE: DURING THE ABBREVIATED SURVEY PERIOD OF 7/11/11 THROUGH 7/12/11, THE CLINICAL RECORD OF RESIDENT #1 WAS REVIEWED. ACCORDING TO THE FACE SHEET IN THE CHART, RESIDENT #1 IS A [AGE] year OLD MALE WHO WAS admitted to the facility on [DATE]. HIS [DIAGNOSES REDACTED]. A REVIEW OF THE ADMISSION MINIMUM DATA SET ((MDS) dated [DATE], REFLECTS RESIDENT'S LEVEL OF PAIN WAS SCORED AT A 2 ON A ZERO TO 10 PAIN SCALE WITH ZERO BEING NO PAIN. A REVIEW OF THE MDS assessment dated [DATE], REFLECTS A CHANGE/DETERIORATION IN THE LEVEL OF PAIN POST FALL WITH SUBSEQUENT FRACTURE FOR RESIDENT #1, SCORED AT A LEVEL OF 7 ON THE SAME SCALE. RESIDENT #1'S FALL RISK SCORE DATED 6/02/11, REVEALED HE WAS AT "HIGH RISK" FOR FALLS, SCORING 22 POINTS. THE "FALL RISK ASSESSMENT" DOCUMENT READS, "A RESIDENT WHOSE SCORE IS OVER 9 IS AT RISK FOR FALLS. CONSIDER ENVIRONMENTAL RISK FACTORS IN THE RESIDENT'S INTERVENTIONS." A REVIEW OF THE FACILITY'S UNDATED "FALLS RISK POLICY AND PROCEDURE" READS, "...THE INTENT OF THIS POLICY IS THAT THE FACILITY WILL PREVENT ACCIDENTS BY PROVIDING AN ENVIRONMENT THAT IS AS FREE FROM HAZARDS OVER WHICH THE FACILITY HAS CONTROL. THE FACILITY WILL... IMPLEMENT PROCEDURES TO PREVENT ACCIDENT/FALLS AND UPDATE CARE PLANS TO INCORPORATE INTERVENTIONS... IF THE RESIDENT IS ASSESSED TO BE HIGH RISK FOR FALLS THE FOLLOWING SHALL BE IMPLEMENTED PER THE NURSING STAFF... IF THE RESIDENT USES A W/C (WHEELCHAIR) OR LOUNGE CHAIR, A RESTRAINT FREE ALARM MAY BE IMPLEMENTED... A FALL MAT IS TO BE PLACED ON THE FLOOR AT THE BEDSIDE WHILE RESIDENT IS IN BED..." A REVIEW OF AN "AT RISK FOR FALLS" CARE PLAN FOR RESIDENT #1 DATED 6/02/11, REVEALED THIS INTERVENTION: "MAINTAIN A SAFE ENVIRONMENT FOR THE RESIDENT" AND "TRANSFER WITH ASSIST AND USES A FWW (FRONT WHEELED WALKER)". A REVIEW OF THE FACILITY'S INVESTIGATION SUMMARY OF AN INCIDENT REPORT DATED 6/10/11, REFLECTS THAT ON 6/10/11 AT APPROXIMATELY 11:00 A.M., RESIDENT #1 AND PHYSICAL THERAPIST (H) WERE IN THE RESIDENT'S ROOM. THEY WERE WORKING ON GAIT TRAINING WITHOUT DEVICE. PHYSICAL THERAPIST (H) NOTED RESIDENT #1'S PANTS TO BE FALLING DOWN AND TURNED AWAY FROM THE RESIDENT TO GET A BELT OUT OF THE CLOSET. UPON TURNING BACK AROUND, PHYSICAL THERAPIST (H) FOUND RESIDENT #1 ON THE FLOOR ON HIS RIGHT SIDE. RESIDENT #1 WAS ASSESSED BY A LICENSED PRACTICAL NURSE (LPN (F)) WHO FOUND HE COMPLAINED OF PAIN IN HIS RIGHT RIB AREA AT THAT TIME. AT APPROXIMATELY 3:30 P.M., RESIDENT #1 AGAIN COMPLAINED OF PAIN IN THE RIGHT RIB AREA WITH SOME SHORTNESS OF BREATH. THE PHYSICIAN WAS NOTIFIED AND an order for [REDACTED]. THE FACILITY SUMMARY INVESTIGATION SHOWS THE X-RAYS WERE COMPLETED ON 6/11/11, WITH THE RESULTS, "IMPRESSION: SLIGHTLY DISPLACED RIGHT SEVENTH AND NINTH RIB FRACTURES." COUGHING AND DEEP BREATHING WITH USE OF AN INCENTIVE SPIROMETER AND ACE WRAP FOR RESIDENT #1 WAS IMPLEMENTED. PHYSICAL THERAPIST (H) WAS NOT AVAILABLE FOR INTERVIEW REGARDING THIS INCIDENT, BUT HIS WRITTEN STATEMENT CONFIRMED THE EVENTS LEADING UP TO THE RESIDENT'S FALL ON 6/10/11. AN OBSERVATION OF RESIDENT #1'S ROOM WAS MADE ON 7/11/11 AT 11:35 A.M. IT WAS NOTED THE CLOSET WAS APPROXIMATELY 12 FEET AWAY FROM THE THE RESIDENT'S BED. RESIDENT #1 AND FAMILY MEMBER (FM I) WERE INTERVIEWED DURING THIS OBSERVATION. RESIDENT #1 WAS UNABLE TO RECALL THE DESCRIBED FALL. THE CLINICAL RECORD FOR RESIDENT #2 WAS REVIEWED DURING THE ABBREVIATED SURVEY CONDUCTED 7/11/11-07/12/11. RESIDENT #2 IS A [AGE] year OLD MALE admitted to the facility on [DATE] AND REadmitted on [DATE]. HIS [DIAGNOSES REDACTED]. THE MDS COMPLETED ON 7/11/11, SHOWED RESIDENT #2'S COGNITIVE ABILITY AS HIGHLY IMPAIRED, UNABLE TO MAKE DECISIONS FOR HIMSELF. HE NEEDED LIMITED TO EXTENSIVE ASSIST OF ONE STAFF PERSON FOR ALL HIS ACTIVITY OF DAILY LIVING (ADL) NEEDS. RESIDENT #2'S FALL RISK SCORE DATED 6/20/11, REVEALED HE WAS AT HIGH RISK FOR FALLS, SCORING A TOTAL OF 24 POINTS. THE FACILITY'S "FALL RISK ASSESSMENT SHOWED RESIDENT'S WITH A SCORE OF 9 OR GREATER 'AT RISK' FOR FALLS." A REVIEW OF THE FACILITY INCIDENT REPORT DATED 6/30/11, REVEALED AT 1:45 P.M. ON THAT DATE, RESIDENT #2 WAS OUT OF THE BUILDING FOR A FOLLOW UP VISIT TO THE ORTHOPEDIST FOR HIS PREVIOUS HIP FRACTURE. AN X-RAY OF THE LEFT WRIST WAS COMPLETED DUE TO THE PHYSICIAN NOTING SWELLING OF THE WRIST. DURING THIS VISIT, RESIDENT #2 WAS TAKEN TO A HAND SURGEON FROM THE ORTHOPEDIST'S OFFICE BECAUSE BONES WERE FOUND TO BE BROKEN IN HIS LEFT WRIST. THE FACILITY INCIDENT INVESTIGATION REPORT DATED 7/1/11, READS "ON 6/30/11 AT 2:00 A.M., RESIDENT (#2) WAS FOUND ON FLOOR IN ROOM NEXT TO BED SITTING ON HIS BUTTOCK FACING THE BED AND JUST OFF THE PERIMETER OF THE MAT. BED ALARM WAS SOUNDING, ALERTING STAFF OF RESIDENT OUT OF BED... AT APPOINTMENT... FOR FOLLOW UP ON RT (RIGHT) HIP ORIF (OPEN REDUCTION INTERNAL FIXATION), SWELLING NOTED TO LEFT WRIST. X-RAY OBTAINED AT APPOINTMENT AND NOTED TO HAVE DISTAL FRACTURE OF ULNA AND RADIUS. SPLINT APPLIED AT ORTHOPEDIC OFFICE AND RESIDENT THEN SENT TO HAND SPECIALIST... RESIDENT WILL HAVE SURGICAL INTERVENTION FOR LEFT WRIST FRACTURE ON JULY 8... RESIDENT CONTINUES TO WORK WITH THERAPY AND HAS SPLINT WITH ACE WRAP TO LEFT WRIST IN PLACE." A REVIEW OF RESIDENT #2'S CLINICAL RECORD REFLECTS THE SCHEDULED SURGICAL INTERVIEW FOR THIS FRACTURED WRIST OCCURRED. IT WAS LEARNED DURING AN INTERVIEW WITH REGISTERED NURSE (RN) (B) ON 7/12/11 AT 10:45 A.M., THAT BASED ON INFORMATION GATHERED UPON ADMISSION TO THE FACILITY, IF A RESIDENT HAS A HISTORY OF FALLS, THE FACILITY PUTS AN ALARM ON THE RESIDENT DURING THE INITIAL ASSESSMENT PERIOD. RN (B) STATED, "SOME ALARMS CAN HAVE A FOUR SECOND DELAY. THE SWITCH FOR THE DELAY IS UNDER THE BATTERY. MOST CERTIFIED NURSE AIDES DON'T KNOW THAT THE SWITCH EXISTS. THERE'S NO TIME WHEN WE GIVE SOMEONE A DELAY..." A TELEPHONE INTERVIEW WAS CONDUCTED WITH LICENSED PRACTICAL NURSE (LPN) (C) ON 7/12/11 AT 1:05 P.M. LPN (C) STATED SHE WAS CALLED TO RESIDENT #2'S ROOM. UPON ENTERING, FOUND RESIDENT #2 SITTING ON THE FLOOR FACING HIS BED. HIS LEGS WERE OUT IN FRONT OF HIM. LPN (C) STATED, "I COMPLETED A FULL BODY ASSESSMENT... MOVED HIS LEGS AND ARMS, I DIDN'T FIND ANY DEFORMITIES... I ASKED IF HE HURT AND HE SAID, 'YES' TO EVERY PLACE I TOUCHED HIM." WHEN ASKED ABOUT THE ALARM SOUNDING, LPN (C) STATED, "THE ALARM WENT OFF AFTER I ENTERED THE ROOM. NOBODY WAS NEAR THE ALARM WHEN IT WENT OFF... WE DID A TEST ON THE ALARM AND IT WAS ON DELAY. SOMETIMES THE ALARMS ARE NOT POSITIONED RIGHT." THE CLINICAL RECORD FOR RESIDENT #3 WAS REVIEWED DURING THE ABBREVIATED SURVEY ON 7/11/11-7/12/11. RESIDENT #3 IS AN [AGE] year OLD MALE admitted to the facility on [DATE] AFTER SUSTAINING A FALL WITH FRACTURES TO HIS LEFT SHOULDER BLADE AND RIBS AT HIS PREVIOUS RESIDENCE. HIS [DIAGNOSES REDACTED]. A REVIEW OF THE MDS dated [DATE], REVEALED RESIDENT #3 SCORED 6/15 ON THE BIMS (SEVERE MENTAL IMPAIRMENT). HE REQUIRED LIMITED TO EXTENSIVE ASSIST FROM ONE PERSON FOR ALL AREAS OF HIS ACTIVITIES OF DAILY LIVING NEEDS. HIS MAIN MODE OF TRANSPORTATION WAS BY WHEELCHAIR. A REVIEW OF THE INCIDENT REPORT DATED 6/29/11, REVEALED RESIDENT #3 WAS IN THE "RAINBOW ROOM" FOR BREAKFAST AT APPROXIMATELY 9:15 A.M. RESIDENT #3 STOOD UP FROM HIS WHEELCHAIR AND fell TO THE FLOOR, LANDING PRIMARILY ON HIS RIGHT HIP. STAFF WERE UNABLE TO GET TO HIM BEFORE HE fell . RESIDENT #3 COMPLAINED OF RIGHT AND LEFT HIP PAIN AT THAT TIME. HE WAS EVALUATED RIGHT AWAY BY THE PHYSICIAN IN THE FACILITY. THE IN-HOUSE X-RAY SHOWED INCOMPLETE RIGHT SUBCAPITAL FRACTURE WITHOUT DISPLACEMENT (RIGHT HIP FRACTURE). A CAT SCAN (COMPUTED AXIAL TOMOGRAPHY) WAS PERFORMED AT THE HOSPITAL AND REVEALED A "MINIMAL DISPLACED FRACTURE OF THE SUPERIOR PUBIC RAMI WHICH EXTENDS INTO THE INFERIOR PUBIC RAMI (BONES IN THE PELVIC GIRDLE)." RESIDENT #3'S FALL RISK SCORE DATED 5/23/11, REVEALS HE WAS AT HIGH RISK FOR FALLS. HE SCORED A TOTAL OF 24 POINTS AND THE "FALL RISK ASSESSMENT" DOCUMENT READS, "A RESIDENT WHOSE SCORE IS OVER 9 IS AT RISK FOR FALLS. CONSIDER ENVIRONMENTAL RISK FACTORS IN THE RESIDENT'S INTERVENTIONS." A REVIEW OF AN "AT RISK FOR FALLS" CARE PLAN DATED 5/23/11, REVEALED UNDER APPROACH, "BED AND CHAIR ALARM ON TO ALERT STAFF WHEN ATTEMPTING TO BE UP WITHOUT ASSIST." AN INTERVIEW WAS CONDUCTED ON 7/12/11 AT APPROXIMATELY 12:05 P.M. WITH CERTIFIED NURSE AIDE (CNA) (G). CNA (G) STATED SHE HAD JUST GOT TO THE DINING ROOM. CNA (G) STATED, "I WAS UP BY THE COOKS LINE AND I COULD HEAR TWO RESIDENTS YELLING, 'HE'S FALLING, HE'S FALLING'... I TURNED AROUND AND HE (RESIDENT #3) WAS STANDING UP BY THE TIME THE ALARM SOUNDED AND THEN HE fell ... HE'S QUICK, REALLY QUICK. I KNOW HIM A LITTLE BIT FROM THE DINING ROOM, BUT HE IS USUALLY GONE BY THE TIME I GET IN HERE... I THINK HE COULD USE A FASTER ALARM OR EVEN ONE WITH A CLIP...HE'S REALLY FAST." AN INTERVIEW WAS CONDUCTED WITH LPN (D) ON 7/12/11 AT 11:35 A.M. OUTSIDE ROOM 16 ON SUNSET LANE. LPN (D) WAS ASKED ABOUT THE DIFFERENT TYPES OF ALARMS THE FACILITY HAS, WHAT TYPES OF PREVENTATIVE MAINTENANCE CHECKS ARE PERFORMED ON THE ALARMS AND REQUESTED TO PROVIDE MANUFACTURERS' BOOKLETS FOR THESE ALARMS. LPN (D) BEGAN TO DEMONSTRATE A CHAIR ALARM. HE APPLIED PRESSURE TO THE CHAIR SEAT, ACTIVATED THE ALARM, HE THEN REMOVED THE PRESSURE FROM THE SEAT AND THE ALARM TOOK 2 SECONDS TO ALERT. LPN (D) OPENED THE BATTERY COMPARTMENT AND EXAMINED THE ALERT CONFIGURATIONS AREA. THE ALERT WAS SET TO THE "2 SECOND" DELAY POSITION. LPN (D) STATED, "SOMETIMES WHEN THE BATTERIES ARE CHANGED OUT THEY GET BUMPED INTO THE DELAY MODE. NOBODY IS SUPPOSED TO BE ON THE DELAY MODE." LPN (D) WENT ON TO SAY HE PERFORMS MONTHLY MAINTENANCE CHECKS ON THE ALERTS IN THE BUILDING STATING, "I CHANGE OUT THE BATTERIES, TEST THE SOUND, MAKE SURE THE ALARMS ARE NOT ON DELAY AND CHECK THE PRESSURE PADS FOR WEAR AND TEAR...WHEN A FALL OCCURS, I CHECK THE ALARM RIGHT AWAY, IF IT HAPPENS ON THE NIGHT SHIFT, I CHECK IT THE VERY NEXT DAY." WHEN LPN (D) WAS ASKED ABOUT CHECKING THE ALARMS FOR RESIDENTS #2 AND #3 AFTER THEIR FALLS, HE REPLIED, "I DIDN'T KNOW THEY DIDN'T SOUND RIGHT AWAY. IS THAT WHAT IT SAYS IN THE ACCIDENT REPORT?" ( )