Every finding on record at Mechanicsville Specialty Care

Based on observations, clinical record review, staff interviews, and facility policy review the facility failed to provide dignity with cares for 1 out of 3 residents reviewed (Resident #2). The facility reported a census of 29 residents. Finding include:1. The Minimum Data Set (MDS assessment for Resident #2 dated 6/8/25 revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderate cognitive impairment. The MDS assessment for Resident #2 dated 8/22/25 listed diagnoses of neurogenic bladder, spastic quadriplegic cerebral palsy, and urinary tract infection. The Care Plan for Resident #2 dated 4/10/25 identified a urinary catheter related to neurogenic bladder. On 9/03/25 at 9:58 AM, Resident #2 laid on his bed while the catheter drainage bag hung uncovered on the left side of his bed. The catheter bag held amber colored urine. On 9/04/25 at 9:11 AM, Resident #2 laid in his bed while his uncovered catheter bag hung on the left side of his bed. The empty dignity bag hung beside the uncovered drainage bag. On 9/04/25 at 12:57 PM, the Director of Nursing (DON) reported she expected the resident's catheter drainage bags kept in a dignity bag. On 9/04/25 at 2:00 PM, Staff C, Certified Nurse Aide (CNA) reported she floated all over the building today. She reported the catheter bags go in the blue (dignity) bag on the side of the bed. The facility provided a policy titled Dignity dated 2/2021. The policy directed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.The policy revealed, Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example:a. helping the resident to keep urinary catheter bags covered;b. promptly responding to a resident's request for toileting assistance; andc. allowing residents unrestricted access to common areas open to the public, unless this poses a safetyrisk for the resident.

Based on observation, clinical record review, staff interview and facility policy review the facility failed to administer the correct amount of water flush before the administration of the tube feeding for 1 of 1 resident reviewed (Resident #2). The facility reported a census of 29 residents. Finding include: The Minimum Data Set (MDS) assessment for Resident #2 dated 6/8/25 revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderate cognitive impairmentThe Minimum Data Set (MDS) assessment dated [DATE] listed diagnoses of spastic quadriplegic cerebral palsy and urinary tract infection. The Care Plan for Resident #2 dated 2/24/25 directed he will remain free of side effects or complications related to tube feeding.The Physician's Orders Review History Report dated 8/4/25 directed enteral feed order every shift flush feeding tube with at least 70 milliliters (ML) of water before and after administration of feedings.The Medication Administration Record (MAR) for Resident #2 dated 9/25 directed every shift flush feeding tube with at least 70 ML of water before and after administration of feeding.On 9/03/25 at 11:18 AM, Staff B, Licensed Practical (LPN) flushed the tube feeding with 30 ML water and hooked up the gravity bag to the feeding tube. Staff B pushed Resident #2 into the lobby.On 9/04/25 at 12:12 PM, Staff B, LPN reported she thought she gave 30 ML as the per tube feeding flush yesterday at the 11:00 feeding. She opened the electronic record and reported he got 70 ML a shift so she gave 40 in the morning and 30 ML with the 11 feeding. On 9/04/25 at 12:57 PM, the Director of Nursing (DON) reported the MAR directed the water flushes for Resident #2 were scheduled 70 ML before and after each feeding. She reported she expected the nurses to administer the water flush as ordered on the MAR. The facility provided a policy titled Enteral Tube Feeding Via Gravity Bag dated 2018, directed at point #9 to administer at least 30 ML of water or the prescribed amount.

Based on observations, staff interviews and facility policy review, the facility failed to prevent exposure for cross contamination during meal service and failed to follow safe food handling practices. The facility identified a census of 33 residents. Findings include: On 08/06/24 at 12:19 PM, observed Staff C, [NAME] leave the meal serving area to go to the dining room. The cook left the serving scoops in the potatoes, corn, rice casserole and the tongs in the chicken and did not cover any of food items on the steam table before leaving. At 12:23 PM Staff C returned to the kitchen, scratched her face and resumed plating resident's food without washing her hands. On 08/07/24 at 12:35 PM, The Dietary Manager advised the test tray would be the last tray on the cart with the room trays and then placed the thermometer and alcohol wipes on the test tray. The cook took the thermometer off the test tray to check the temperature of the chicken noodle soup. The thermometer was not cleaned before or after temping the soup and being placed back on the test tray. Staff D, Dietary aid then took the thermometer outside the kitchen doorway to the beverage preparation area and checked the temperature of the white milk. The thermometer was then placed on the stainless steel prep table. It was not sanitized before or after testing the milk. The dietary aid then placed the thermometer back on the test tray, beside the alcohol wipes and delivered the room trays. The dietary aid then temped all food items on the test tray without sanitizing the thermometer and served the test tray to the surveyor. On 08/07/24 at 01:28 PM Staff C was queried regarding cross-contamination and hand sanitation. Staff C advised hands should be washed frequently and anytime going from one task to another or different area. Staff C advised she was not aware she had scratched her face upon returning to the kitchen and agreed she should have washed her hands. When queried about sanitizing the thermometer Staff C advised it should have been sanitized between food items to prevent cross contamination. On 08/07/24 01:43 PM The dietary manager was interviewed regarding hand sanitation and cross contamination. The dietary manager articulated appropriate hand hygiene and cross-contamination prevention. She advised the facility conducts random hand washing audits and all workers are required to have yearly refresher training. In addition it is her expectation the thermometer is sanitized before and after each use and stored in the protective sleeve between use. On 08/07/24 at 02:15 PM The facility administrator was queried regarding hand hygiene and cross-contamination. It is her expectation that all workers practice appropriate hand hygiene at all times. She advised the worker should have washed her hands when she returned to the kitchen. She also advised it is her expectation the thermometer be kept in the sleeve whenever not is use and sterilized before and after each use. The undated facility policy titled Handwashing/Hand Hygiene informed that the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The undated facility policy titled Food Preparation and Service informed food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Appropriate measures are used to prevent cross contamination. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness. Food thermometers used to check food temperatures are clean, sanitized and calibrated for accuracy.

Based on observations, clinical record review, resident, and staff interviews, the facility failed to treat a resident with respect and dignity for one reported interaction with a nurse for one out of one residents reviewed (Resident#7). The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) Assessment for Resident # 7 dated 7/5/24, included diagnoses of Parkinson's disease, and non Alzheimer's dementia. The Brief Interview for Mental Status (BIMS) reflected a score of 13, intact cognition. The MDS identified Resident#7 independent with toileting, transfers, ambulation, and dressing. The Care Plan for Resident#7 listed an intervention dated 7/18/24, at times I can have an outburst and yell at my family or staff. Attempt to redirect me when I have an outburst or give me some alone time so I can settle down and proceed with my day. Resident #7's Nurses Behavior Progress Note dated 7/31/2024 at 11:15 PM, reflected Resident#7 wanted Staff A, Registered Nurse (RN) to send her to emergency room (ER) after Staff A found her slipping out of her recliner she sat in. Resident #7 told Staff A I am sick I am dying I need ER Resident #7 called the sheriff and kicked the Staff A, called staff vulgar disgusting names. The Nurses Behavior Note dated 7/31/2024 at 11:47 PM, read Resident#7 called her daughter and wanted out, her daughter then called Staff S and directed do anything you can to calm her down . Resident#7 refused to take her 10:00 PM medication Oxycodone when offered. Nurses Behavior Note dated 7/31/2024 at 11:52 PM, reflected Staff A will let Resident#7 simmer down, Resident#7 reported that this is her home. Staff A thought Resident #7 may calm down. The Nurses Progress Note dated 8/1/2024 at 12:14 AM, revealed Resident #7 left via Ambulance cart. Resident#7 packed 3 bags and held her purse, blanket Resident#7 walked to the ambulance cart to get secured in left in stable condition. The investigation file provided by the Administrator included: a statement from Resident #7 taken by the Director of Nursing (DON) undated, revealed Resident #7 failed to remember calling her daughter or the sheriff. Resident #7 stated she failed to understand why the nurse kept yelling at her to go to bed. Resident #7 told the nurse to leave her room. The Witness Statement by Staff A, RN dated 7/31/24, reflected she entered the room and Resident#7 sat almost off the recliner. She asked Resident#7 to go to bed. The statement reflected the Staff B, Certified Nurses Aid (CNA) told Staff A, Resident#7 doesn't need to go to bed. Resident#7 asked to go to ER stated I was sent to hospital in March and they said there was nothing more they can do I was going to die. Resident#7 called Staff A vulgar names kicked Staff A on the right calf, bruising her, told Staff A she was going to call the police, and her daughter. Resident#7 called her daughter, the sheriff and her physician. The physician called back with orders to send Resident#7 to the ER for evaluation. The statement reflected Staff B, heard Staff A state rather loudly to Resident#7 exactly what Resident#7 told her that nothing more could be done and sent to the nursing home to live out her life. The Statement by Staff B dated 8/1/24 at 12:50 AM, identified she saw Resident#7 in her chair asleep. Staff B reported Resident#7 looked slouched some but after she looked further she saw one of the legs on the chair was up 30-40 degrees keeping her in the chair. The statement continue Staff B left her there because sometimes she sleeps there and she fell a few days before getting out of her bed and into her chair in the night. The Statement revealed Staff A told her Resident#7 needed to go to bed. Staff B told Staff A Resident#7 slept in the chair at times and she's sound asleep so she continued to help others. Staff B wrote she heard screaming and shouting from Resident#7's room, Resident#7 asked Staff A to leave and kicked at her shin. Staff A argued, told Resident#7 she needed to get out of the chair. Staff B said Staff A told her she's just a CNA and cant tell her what to do. Staff B removed herself from the situation. The Statement revealed the screaming continued so she went back to check on Resident#7 and saw the nurse wheeled herself back and forth on the resident's walker as Resident#7 walked around her room shaking upset looking for phone numbers. Resident#7 said it's her right to call an ambulance as she sat back down. Staff A abruptly got up from the walker stood over Resident#7 and said you are here to die, you are at this facility to die. Staff B's statement reflected she told the nurse she shouldn't talk to residents like that. Before Staff A could say anything the Sheriff called and ended the conversation. The facility interview undated reflected Staff E, CNA reported Staff B told her on 7/31/24 at 11:29 PM, Staff A's upset because she wanted Resident#7 to go to her bed. The facility Investigation reflected on 7/31/24 around 10 PM, Staff B saw Resident#7 asleep in her chair, which she occasionally did. At around 10:30 PM Staff A entered Resident#7's and noticed she appeared as if she may slide off the recliner. Staff A asked the Resident#7 to go to bed. Staff B went back to Resident#7's room and told the nurse she doesn ' t have to go to bed. Staff B told her Resident#7 looked like she may slid out of her chair. Resident#7 became irritated and started to call Staff A names and kicked at the nurse on the calf. Resident#7 stated she wanted to go to ER. Staff A tried asking what she wanted to go to hospital for and Resident#7 said nobody cared and does nothing for her and she is going to die. Resident#7 stated she was sent to the hospital in March, and they told her there was nothing more they could do for her, and she was going to die. Staff A repeated what Resident#7 said to her that nothing more could be done and sent to the nursing home to live out her life. Staff B went back to the resident room due to it being loud and overheard Staff A repeating what Resident#7 said. Staff B told Staff A she shouldn ' t say that to Resident#7. Resident#7 reported the need to call the sheriff, daughter and her physician. Staff A tried asking what she wanted to go to hospital for and she said nobody cares and does nothing for her and she is going to die. Resident#7 called the police, physician while nurse and CNA were in room. The physician called facility and ordered the Resident#7 sent to ER. The Investigation continued to reflect Staff B called the DON around 11 PM but didn ' t get a hold of her so she sent her a couple text messages. On 8/6/24 at 1:30 PM, Staff B reported Staff A wanted Resident#7 put to bed. Staff B said she didn't want to wake Resident#7. Staff B revealed while she worked 3 rooms down the hall, she heard yelling. Resident#7 told Staff A she didn't want to to go to bed Resident # 7 told the nurse she was a fat cow. Staff B said Resident#7 walked around her room upset and shaking looking for her phone numbers. Resident#7 wanted Staff A to call 911 and Staff A told Resident #7 she's here to die. Staff B reported she went answered the phone and the sheriff wanted to know if they were needed or if it was an accidental call or of they wanted them to come to the facility. Staff B stated she asked Staff A if they were sending Resident#7 out and the nurse yelled at her because she took the phone call. On 8/6/24 at 5:36 PM, Staff A reported she got to Resident#7 at about 11:20 PM She looked about ready to slip off the chair. Resident#7 needed the neurological assessment from after a fall the other night. Staff A reported she asked Resident#7 to get into bed and had a pain pill for her. Staff B came in the room and said she didn't need to go to bed, she's fine. Resident#7 woke up, reported her pain high and she needed to go to the ER. Staff A stated Resident#7 wanted to got to ER, and wouldn't let her do the neurological assessment, just wanted wanted her cell phone to call her daughter, sheriff and her physician. Staff A said the Sheriff, the Physician and Resident#7's daughter called her. Staff A indicated Resident#7 didn't like her tone of voice, Staff A said something like Resident#7's placement here at the facility for end of life care. Staff A stated her comment scared Staff B, who thought she was abusive by saying such thing. Staff A confirmed she told Resident#7 she's here for the rest of her life. On 8/07/24 at 8:08 AM, Resident #7 walked in her room independently with her walker. Resident#7 reported on 7/31/24 she didn't feel well Staff A told her to get into the bed, said she was fine, no reason to go to the ER in the night. Resident#7 reported she kicked at the nurse because the nurse grabbed at her shoulder, gave a little push to get up. Resident#7 said she was yelled at the nurse she was sick and needed to go to the hospital, the nurse told her she was fine and to go to bed. She said the nurse left the room and she called the sheriff and he brought the ambulance her. Resident #7 reported Staff A didn't want to call the physician in the night and said she needed to sleep till the am. Resident#7 said Staff A seemed mean, bossy, pushy, aggressive interactions to her. Resident #7 said she was scared at the time, not sure the authority she had if she would get tied down to the bed. On 8/06/24 at 10:58 AM the Administrator revealed the Physician won't say Resident#7 can't make her own decision with the BIMS of 13. 08/08/24 at 11:05 AM the Administrator reported she expected the staff to treat the residents with respect and dignity. The Administrator provided the policy titled Dignity dated 2/2021 Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation 1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident ' s facility stay. 3. Individual needs and preferences of the resident are identified through the assessment process. 4. Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility. 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: a. groomed as they wish to be groomed (hair styles, nails, facial hair, etc.); b. encouraged to attend the activities of their choice, including religious, political, civic, recreational, or social activities; c. encouraged to dress in clothing that they prefer; d. allowed to choose when to sleep, eat and conduct activities of daily living; and e. provided with a dignified dining experience. 6. Residents ' private space and property are respected at all times. Staff do not handle or move a resident ' s personal belongings without the resident ' s permission. 7. Staff are expected to knock and request permission before entering residents ' rooms. 8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. 9. Staff inform and orient residents to their environment. Procedures are explained before they are performed and residents will be told in advance if they are going to be taken out of their usual or familiar surroundings. 10. Staff protect confidential clinical information. Examples include the following: a. Verbal staff-to-staff communication (e.g., change of shift reports) are conducted outside the hearing range of residents and the public. b. Signs indicating the resident ' s clinical status or care needs are not openly posted in the resident ' s room unless specifically requested by the resident or family member. Discreet posting of important clinical information for safety reasons is permissible (e.g., taped to the inside of the closet door). continues on next page (C) 2001 MED-PASS, Inc. (Revised February 2021) c. In the interest of public health, posting the resident ' s isolation status or transmission-based precautions is permissible as long as the type of infection remains confidential. d. The display of the resident ' s name on the door or the presence of memorabilia among the resident ' s belongings is not considered a violation of the resident ' s privacy or dignity. 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered; b. promptly responding to a resident ' s request for toileting assistance; and c. allowing residents unrestricted access to common areas open to the public, unless this poses a safety risk for the resident. 13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example: a. addressing the underlying motives or root causes for behavior; and b. not challenging or contradicting the resident ' s beliefs or statements.

Based on observations, test tray, resident and staff interviews, the facility failed to provide food at an appropriate temperature to ensure the food was safe and appetizing. The facility also failed to serve pureed food that was attractive in appearance. The facility reported a census of 37 residents. Findings Include: On 9/26/23 at 9:45 AM, Resident #10 reported the food on his room trays were cold most of the time. Resident #10 stated he doubted the facility would do anything about the food being cold. On 9/26/26 at 1:00 PM, Staff C, Dietary Manager served two pureed meals that consisted of fish, wax beans, and potatoes. The pureed food items were white in color, appeared bland and served together on the same plate, with the pureed food items blending into each other on the plate. On 9/26/23 at 1:29 PM, Staff C reported there was one resident (Resident #10) that complains all the time that his food was not warm enough. On 9/26/23 at 1:31 PM, a test tray was received from Staff C. The test tray consisted of crumb topped fish, oven browned potatoes, green peas and apple crisp. Staff C completed a temperature check on the fish, potatoes and green peas. Staff C used the facility thermometer to conduct the temperatures. Staff C reported the following temperatures: a. Fish- 129 degrees Fahrenheit. b. Potatoes- 128 degrees Fahrenheit c. Peas- 132 degrees Fahrenheit The items on the test tray were tasted and revealed the food was lukewarm. On 9/26/23 at 3:05 PM, Staff C stated prior to serving, she would expect the temperatures of the vegetable to be at 135 degree Fahrenheit and the temperatures of the meat to be at 165 Fahrenheit. On 09/26/22 at 4:00 PM, the Administrator stated she would expect the hot food to be at 135 degrees Fahrenheit when serving. On 9/27/23 at 9:45 AM, Resident #10 reported lunch on 9/26/23 was an hour late and was cold. Resident #10 stated supper on 9/26/23 was 40 minutes late and his cold salad was served on a warm plate. Resident #10 stated breakfast was usually on time but always cold. The facility policy titled Food Preparation and Service revised April 2019 documented food and nutrition services employees are to prepare and serve food in a manner that complies with safe food handling practices. The policy revealed the danger zone for food temperatures are between 41 degrees Fahrenheit and 135 degrees Fahrenheit. The policy further documented that during food distribution the proper hot and cold temperatures are to be maintained during food service.

Based on observations, staff and resident interviews and facility policy review, the facility failed to ensure food was discarded after product expiration date, that leftovers were discarded after 3 days, prevent cross contamination during meal service and serve the meal on time. The facility identified a census of 37 residents. Findings include: 1. An initial kitchen tour conducted on 9/25/23 at 11:00 AM, revealed the following items were stored in the refrigerator ready for service: a. Vanilla Yogurt 32 ounces- best by date 9/18/23. b. Leftovers covered and dated: - Green beans - prepped/dated 9/21. - Baked beans - prepped/dated 9/15. - Noodle for Resident's Name - prepped/dated 9/17. - Egg Salad - prepped/dated 9/20. - Spaghetti sauce - dated 9/17. On 9/25/23 at 11:45 AM, Staff C, Dietary Manager reported she had left a note for the night cook to go through the refrigerators and throw away outdated items. Staff C stated her expectation was for leftovers to be thrown away after three days. Staff C acknowledged and verified the leftovers identified needed to be discarded. On 9/26/23 at 12:30 PM, Staff C washed her hands and brought a loaf of bread over to the counter. Staff C placed a glove on her left hand and went to the refrigerator with the glove on and got out a container of ham and a container of cheese and brought the containers over to the counter. Staff C removed the glove from her left hand and did not wash her hand. Staff C then put a glove on her right hand and made multiple ham and cheese sandwiches, touching the cheese, meat, and the bread with her gloved hand. After the sandwiches were made, Staff C removed the glove and did not wash her hands. On 9/26/23 at 12:50 PM (start of meal service), Staff C placed a glove to her right hand and placed two loaves of bread on top of the steam cart. Staff C did not wash her hands prior to putting on the glove to her right hand. Staff C ripped open the plastic bread package with her bare hand and gloved hand. Staff C then took off the glove to her right hand and did not wash her hands. Staff C obtained a container of butter and a knife, placed them next to the bread on the steam table. Staff C put a glove on her right hand without washing her hands. Staff C prepared multiple plates to be served and touched the utensils on the steam table while wearing the glove to her right hand. While preparing the plates to be served, Staff C buttered pieces of bread with the gloved hand. Staff C opened a cupboard with the gloved hand and took out bowls to be used to serve apple crisp. After removing the bowels from the cupboard, Staff C removed the glove and did not wash her hands. Staff C put on a new glove to her right hand and scooped apple crisp into the bowls. Staff C placed the scoop for the apple crisp directly on the stainless steel cart multiple times without a barrier and continued to use the scoop to dish out the apple crisp. Staff C took the glove off her right hand, did not wash her hands and continued to prepare the plates to be served. On 9/26/23, observed the lunch meal service started at 12:50 PM and ended at 1:25 PM. An undated facility form titled Meal Times documented the meal service was to begin at 12:00 PM. On 9/26/23 at 3:05 PM, Staff C reported she felt she was using her gloves appropriately. Staff C stated she felt the utensils on the steam table were clean and stated she used her pinky of the gloved hand to open up the cupboard. Staff C stated she was trying to be conscious of the glove usage. Staff C acknowledged and verified she did not wash her hands when applying or removing her gloves. On 9/26/23 at 4:00 PM, the Administrator reported she expected handwashing to occur when gloves were removed. The Administrator stated she would prefer gloves not to be worn in the dietary department but if the gloves are worn she would expect the gloves to be used for one task at a time. The Administrator stated leftover food items should be discarded after three days. On 9/27/23 at 9:45 AM, Resident #10 reported lunch on 9/26/23 was an hour late and was cold. Resident #10 stated supper on 9/26/23 was 40 minutes late. The facility policy titled Food Preparation and Service revised April 2019 documented food and nutrition services employees are to prepare and serve food in a manner that complies with safe food handling practices. The policy revealed bare hand contact with food is prohibited. The policy further documented gloves are worn when handling food directly and changed between tasks. The policy directed that disposable gloves are single-use items and are discarded after each use. The facility policy titled Food Receiving and Storage revised October 2017 documented foods shall be received and stored in a manner that complies with safe food handling practices. The policy directed all food stored in the refrigerator to be covered, labeled and dated (used by date).

Based on clinical record review, document review, resident and staff interviews, the facility failed to set up resident funds over $50 in an interest bearing account and failed to provide the resident or their legal representative with quarterly balance statement for 1 of 4 residents sampled (Resident #25). The facility documented a census of 37 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. On 9/25/23 at 1:50 p.m., Resident #25 reported he had money locked up in the front business office that he could access whenever he wanted. Resident #25 didn't recall getting any quarterly statements detailing his balance of funds at the facility. During an interview on 9/26/23 at 9:43 a.m., the Business Office Manager (BOM) reported Resident #25's daughter leaves money in the front office for him for hair cuts and outings. He can come to the office and get money whenever he wants. She reported he signs a slip every time he takes money out. She verbalized Resident #25 had more than $50 in the front office and the facility did not provide him or the family with any statements. The money was not in an interest bearing account. An untitled roster with the Resident's name documented the date, deposit/withdrawal, reason money withdrawn, amount withdrawn, staff member involved in transaction and the running balance. The Roster showed Resident #25 had a balance of #111.72 as of 9/23/23. During an interview on 9/26/23 at 1:07 p.m., the BOM reported they had kept Resident #25 cash in a separate envelope in the business office safe. She stated she had him sign a roster each time he came to take money out of his funds. She reported she had just talked to him this morning after the Surveyor had questioned his account and she had taken his money to the bank and opened an interest bearing account. She verbalized he did not receive a copy of the roster each time he took money out of his account and had not received monthly statements. The BOM provided a copy of a checking deposit slip for$111.72 and a Trust Transaction History report dated 9/26/23 detailing the resident account balance. On 9/28/23 at 10:55 a.m., the Administrator reported she expected residents with funds in excess of $50 would have the money placed in an interest bearing account and receive quarterly statements. The Accounting and Records of Resident Funds Policy revised April 2001 provided by the facility detailed the following: 1. The business office maintains a record of all financial transactions involving the resident's personal funds on deposit with the facility. 2. Individual accounting ledgers are maintained in accordance with generally accepted accounting principles and include: a. The resident's name and medical record number; b. The name of the resident's representative (sponsor); c. The date of the resident's admission; d. The date and amount of each deposit and withdrawal; e. The name of the person who accepted or withdrew funds; f. The balance after each transaction; g. receipts for charges imposed by the facility; and interest earned, if any. 3. Records include copies of the resident's or representative's written permission for any non-covered items or services charged. 4. Resident funds are maintained separately from the facility operating funds and from the funds of any other person other than another resident. 5. Individual accounting records are made available to the resident through quarterly statements and upon request. Quarterly statements include the following information: the resident's balance at the beginning and end of the statement period; the total of deposits and withdrawals by the resident for the quarter; interest earned on the resident's funds; resident funds available through petty cash; and the total amount of petty cash on hand.

Based on clinical record review, staff interviews and facility policy review, the facility failed to provide a notice of bed hold for 2 of 2 residents reviewed (Resident #32 and #139) for discharge to the hospital. The facility reported a census of 37 residents. Findings include: 1. Resident #32's Minimum Data Set (MDS) dated [DATE] assessment identified Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Resident #32's MDS included diagnoses of cancer, coronary artery disease, end stage renal disease and malnutrition. The Clinical Census revealed Resident #139 was admitted to the facility on [DATE]. A Progress Note dated 8/29/23 at 4:10 PM, revealed Resident #32 was transferred to the emergency room (ER) from the cardiovascular clinic due to low blood pressure. A Progress Note dated 8/29/23 at 9:00 PM, documented Resident #32 was admitted to the hospital for hypokalemia (low potassium) and hypotension (low blood pressure). The Clinical record lacked documentation the facility provided a bed hold notice to Resident #32 and/or resident representative upon discharge to the hospital. On 9/27/23 at 4:56 PM, the Administrator reported she did not have bed hold notice for Resident #32 hospitalization on [DATE]. 2. Resident #139's MDS dated [DATE] assessment identified BIMS score of 15 out of 15, indicating intact cognition. Resident #139's MDS included diagnoses of hypertension (high blood pressure), depression, schizophrenia, post traumatic stress disorder and obsessive compulsive disorder. The Clinical Census revealed Resident #139 was admitted to the facility on [DATE] for a Medicare Part A Skilled stay. A Progress Note dated 12/18/22 at 2:35 PM, revealed Resident #139 was transferred to the ER due to acute psych and being a threat to others. A Progress Note dated 12/19/22 at 4:10 AM, documented Resident #139 remained in the ER with a pending admission to the hospital related to mental health issues. A Progress Note dated 12/20/22 at 2:08 AM, documented Resident #139 was admitted to the hospital for agitation. The Clinical record lacked documentation the facility provided a bed hold notice to Resident #139 and/or resident representative upon discharge to the hospital. On 9/27/23 at 11:04 PM, the Administrator acknowledged and verified she could not locate a bed hold for Resident #139 hospitalization on [DATE]. On 9/27/23 at 12:30 PM, the Administrator reported her expectation was for the nurses to start the bed hold process when a resident was sent to the hospital and to follow up on the bed hold in 24 hours if the resident was admitted . The facility policy titled Bed Holds and Returns revised March 2017 documented prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed hold and return policy. The policy further documented the written information given to the resident and the resident representative will explain in detail the following: a. The rights and limitations of the resident regarding bed holds. b. The reserve bed payment policy as indicated by the state plan (Medicaid residents). c. The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed hold period (Medicaid residents); and d. The details of the transfer.

Based on clinical record review, electronic census record, document review, Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) Assessment across multiple MDS assessments for 1 of 2 residents reviewed for Hospice services (Resident #15). The facility identified a census of 37 residents. Findings Include: A Order Review History Report signed by the Provider on 9/01/23 documented a physician order for Hospice care services for pancreatic cancer effective 2/21/22. A Medicare Hospice Election form detailed Resident #15 signed himself into hospice care on 2/21/22. A review of the Electronic Census Record on 9/26/23 revealed Resident #15 resided on Hospice care at the facility since 2/21/22. A review of the Care Plan on 9/26/23 documented Resident #15 had chosen hospice care and directed to coordinate his care with hospice. The Care Plan had an initiation date of 3/09/22. A review of the Hospice documentation on 9/26/23 revealed the following: a. Hospice Interdisciplinary Group Meeting Note dated 1/19/23 detailing the Hospice Plan of Care from 12/18/22 to 2/15/23. b. Hospice Interdisciplinary Group Meeting Note dated 5/11/23 detailing the Hospice Plan of Care from 4/17/23 - 6/15/23. c. Hospice Interdisciplinary Group Meeting Note dated 8/03/23 detailing the Hospice Plan of Care from 6/16/23 - 8/14/23. A review of the completed MDS records on 9/26/23 revealed the following: a. Quarterly MDS assessment dated [DATE] section O coded Hospice care services while a resident. b. Quarterly MDS assessment dated [DATE] section O failed to have Hospice care services while a resident coded. c. Annual MDS assessment dated [DATE] failed to have Hospice care services while a resident coded accurately. On 9/27/23 at 8:17 a.m., the Administrator reported the Point Click Care Census showed Resident #15 changed to Hospice care on 2/21/22. A Review of the Hospice Nursing Facility Communication Notes available for review in the Hospice book showed documentation of Hospice discipline visits documented from 11/19/22 - 9/25/22. On 9/27/23 at 8:22 a.m., the MDS Coordinator reported she didn't know why the coding got missed across multiple MDS assessments. The nurse consultant had just reviewed some of her MDS assessments. She felt since she had been working the floor, the coding got missed on the MDS. She reported if a resident admits to hospice care a significant change MDS is to be completed within 14 days. She confirmed Resident #15 resided on Hospice care. During an interview on 9/27/23 at 4:40 p.m., the Director of Nursing (DON) reported she expects the MDS to be completed accurately. The MDS Completion and Submission Time frames Policy revised July 2017 provided by the facility documented a Policy Statement detailing the facility would conduct and submit resident assessments in accordance with current federal and state time frames. The Policy did not address MDS accuracy of assessments. The LTC RAI 3.0 User's Manual Version 1.17.1 October 2019 page 1-7 documents the RAI process has multiple regulatory requirements. Federal regulations at 42 CFR (Code of Federal Regulations) 483.20 (b)(1)(xviii), (g), and (h) require that the assessment accurately reflects the resident's status.

Based on observations, clinical record review, staff interview and facility policy review, the facility failed to develop a Care Plan to address pressure reduction interventions for a chronic left heel pressure ulcer for 1 out of 13 residents (Resident #36) reviewed for Comprehensive Care Plans. The facility reported a census of 37 residents. Findings Include: Resident #36's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS identified Resident #36 required extensive assistance of two persons with bed mobility, transfer and toilet use. The MDS documented Resident #36 did not walk during the assessment period. The MDS identified Resident #36 at risk for developing pressure ulcer and indicated that he had an unhealed pressure ulcer during the seven day lookback period. The MDS also identified the facility had placed a pressure reducing device in the resident's chair, provided pressure ulcer care, applications of medication and dressing to his feet. The MDS included diagnoses of diabetes mellitus, non-Alzheimer's dementia, malnutrition, hyperlipidemia, and transient ischemic attack (stroke). A Hospital Consult Note dated 9/11/23 at 4:11 PM, documented Resident #36 to have a Stage 3 pressure injury to the left lateral heel. The Hospital Consult Note recommended offloading with a heel elevation boot. A Hospital After Visit Summary dated 9/13/23 documented Resident #36 was discharged to the facility with a Stage 3 pressure injury to left heel. Review of the Initial Skin Integrity Baseline Care Plan dated on 9/13/23 documented Resident #36 had a pressure injury. The Pressure Injury Baseline Care Plan directed staff to do the following: a. Assess, record, and monitor wound healing (specific, frequency). b. Measure length, width and depth where possible. c. Assess and document status of wound perimeter, wound bed and healing process. d. Report improvement/declines to physician. The Initial Pressure Ulcer Care Plan lacked pressure reduction interventions such as offloading the heels and/or heel elevation boots. Review of the Comprehensive Care Plan dated 9/13/23 document Resident #36 had a pressure injury to his left heel upon admission with potential for delayed healing due to diabetes mellitus and medication use. The Care Plan directed staff to do the following: a. Assess, record, and monitor wound healing (specific, frequency). Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing process. Report improvement/declines to physician- 9/13/23. b. Pressure relieving /reducing device bed/chair- 9/16/23. c. Monitor for pain related to pressure injury- 9/16/23. d. Monitor/document/report any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length, width, and depth), stage-9/16/23. Review of the Comprehensive Care Plan dated 9/13/23 lacked pressure reduction interventions such as offloading the heels and/or heel elevation boots. Review of the Certified Nursing Assistant (CNA) Kardex/Task in the clinical record lacked direction on pressure reduction for Resident #36 heels. On 9/26/23 at 7:27 AM, observed Resident #36 sitting in his room in a wheelchair, gripper socks on both feet and feet resting on the hard foot pedals. On 9/27/23 at 7:00 AM, observed Resident #36 sitting up in the dining room in a wheelchair, gripper socks on both feet and feet resting on the hard foot pedals. On 9/27/23 at 9:18 AM, observed Resident #36 lying in bed on his back, gripper socks in place, bilateral heels resting on the bed. Observed no pillows or heel lift devices in the room. On 9/27/23 at 9:20 AM Staff D, Restorative Aide reported Resident #36 had worn heel boots the last time he was at the facility. Staff D stated she would go get some pillows to help elevate Resident #36 heels. On 9/27/23 at 9:40 AM, the Director of Nursing (DON) reported the staff found Resident #36's heel boots in the shower room. The DON stated she would expect the heel boots to be in place when Resident #36 was in bed or elevate Resident #36's heels off the bed with a pillow. On 9/27/23 at 9:45 AM, observed Resident #36 lying in bed on his back with heel boots in place to bilateral feet with pillows underneath elevating the heels off the bed. On 9/27/23 at 10:30 AM, Staff E, Certified Medication Aide (CMA) reported she was aware that Resident #36 had a pressure ulcer on the left heel. Staff E stated she recalled he wore boots but was not sure if it was during his current stay or the previous stay. Staff E acknowledged and verified on the CNA Kardex for Resident #36 there were no directions to apply boots or off load heels when in bed. On 9/27/23 at 11:00 AM, the DON acknowledged and verified the Initial Baseline Pressure Ulcer Care Plan, current Comprehensive Care Plan and the CNA Kardex/Tasks did not address pressure reduction intervention for the heels such as heel boots or offloading the heels when in bed. The facility policy titled Care Plans- Baseline revised 12/2016 documented a Baseline Plan of Care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. The policy further directed the Baseline Care Plan will be used until the staff can conduct the Comprehensive Assessment and develop an Interdisciplinary Person-Centered Care Plan. The facility policy titled Care Planning- Interdisciplinary Team revised September 2013 documented the facility Care Planning/Interdisciplinary Team was responsible for the development of an individual Comprehensive Care Plan for each resident. The policy further documented the Comprehensive Care Plan was based on the resident's Comprehensive Assessment.

Based on observation, clinical record review and staff interview, the facility failed to have physician insulin orders that matched insulin administration and failed to follow the manufacturer's directions regarding safety for product use for administration for 1 of 2 residents observed for insulin administration (Resident #15). The facility identified a census of 37 residents. Findings Include: Resident #15 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no cognitive loss. The MDS listed a diagnosis of diabetes mellitus, hyperlipidemia and detailed Resident #15 received insulin injections seven days a week. The Care Plan revised [DATE] documented a focus problem of diabetes mellitus and directed Resident #15 had chosen to have his blood sugars assessed per medical doctors orders and receive diabetes medications for treatment for better control and comfort while on Hospice services. The Order Review History Report signed by the Provider on [DATE] documented a physician order for Humalog [NAME] Kwik Pen Solution Pen-injector 100 units/milliliter (ml). Inject 4 units subcutaneously three times a day related to type 2 diabetes mellitus without complications. During an observation on [DATE] at 11:26 a.m., Staff A, Registered Nurse (RN)/MDS Coordinator performed hand hygiene, read Resident #15 order from the Medication Administrative Record (MAR), pulled out a vial of Humalog insulin with an open date of [DATE] and drew up 4 units of insulin from the vial. At 11:28 a.m., Staff A locked the medication cart and proceeded to walk halfway down the east hallway toward the resident's room. Staff A reported being prepared to administer the resident's insulin. The Surveyor stopped Staff A from administering the resident's insulin. Staff A reported she should not give Humalog insulin dated [DATE]. At 11:35 a.m., Staff A prepared and administered the correct insulin to resident #15. On [DATE] at 10:13 a.m. Staff B, Licensed Practical Nurse (LPN) reported they are transitioning from insulin pens to the insulin vials. She reported it is happening, but she doesn't know the circumstances behind it. She thinks the change may have been in the last month or so from the Director of Nursing (DON). She doesn't know why some residents have insulin pens and some have the vials. They were told it was the same medication and dosages. Sometimes they get a vial and the next time the pharmacy delivers an insulin pen. The communication with the pharmacy is not always easy. On [DATE] at 10:33 a.m., Staff B explained nurses are to check the open date on the insulin vial or pen to ensure the insulin can be administered as part of preparing the insulin for administration according to the physician orders. An observation of the Resident's Humalog from the pharmacy revealed the bag label directed the contents expired 28 days after the first use. During an interview on [DATE] the DON reported she expected the nurses to follow the manufacturers directions for use for insulin administration. She reported they are transitioning from the insulin pens to the vials as part of a corporate wide change in the past month. She expects during medication rights the nurses will check the open date on the insulin as part of insulin administration. She had not thought about getting the physician orders to match the insulin vial versus the pen. They had not talked about that. The Insulin Administration Policy revised [DATE] provided by the facility directed under Steps in the Procedure to check the expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening). The Manufacturer's Highlights of Prescribing Humalog under Storage and Handling directed not to use the insulin after the expiration date. Humalog 10 ml vial and Flex pen should be stored at room temperature below 86 Fahrenheit and must be used within 28 days or be discarded, even if the vial or pen still contains Humalog insulin.

Based on clinical record review, document review and staff interview the facility failed to correctly fill out and serve the resident or the legal representative a beneficiary notice of the ending of Medicare skilled services for 3 of 3 resident reviewed (Resident #39, #40, and #90). The facility identified a census of 37 residents. Findings include: 1. An Electronic Census Record showed Resident #39 readmitted to the facility on skilled care services and discharged from the facility on 7/10/23. A Center for Medicare and Medicaid Services (CMS) Detailed Explanation of Non-Coverage (DENC) of Skilled Services dated 7/06/23 detailed Resident #39 had reached their maximum potential and the condition of the beneficiary was not expected to improve materially in a reasonable and predictable period. The CMS Notice of Medicare Non-Coverage (NOMNC) documented the Resident's skilled nursing service coverage would end 7/09/23. The Social Service Coordinator documented she contacted the resident on 7/06/23 and explained the non-coverage and appeals rights ending on 7/09/23. The NOMNC signed by the Resident contained a signature date of 7/08/23. The CMS Skilled Nursing Advanced Beneficiary Notice of Non-Coverage (SNF ABN) documented the Resident may have to pay out of pocket expenses as of 7/10/23 as the Resident had reached their maximum potential. The SNF ABN contained the following options: A. Option 1: I want the care listed above. I want Medicare to be billed for an official decision on payment which will be sent to me on a Medicare Summary Notice (MSN). I understand if Medicare doesn't pay, I'm responsible for paying, but I can appeal to Medicare by following the direction on the MSN. B. Option 2: I want the care listed above, but don't bill Medicare. I understand that I may be billed now because I am responsible for payment of the care. I cannot appeal because Medicare won't be billed. C. Option 3: I don't want the care listed above. I understand that I'm not responsible for paying and I can't appeal to see if Medicare would pay. The SNF ABN lacked documentation Resident #39 had chosen an option. Resident #39 signed the SNF ABN which contained a date of 7/08/23. 2. A CMS DENC form dated 5/12/23 detailed Resident #90 had reached her maximum potential and no longer required skilled nursing or therapy services. A CMS NOMNC Form detailed the Resident's skilled nursing coverage would end on 5/16/23. The Social Service Coordinator documented she contacted Resident #90 on 5/12/23 to explain the notice of non-coverage and appeal rights and make the resident aware of the ending of skilled services on 5/16/23. The CMS NOMNC form contained Resident #90's signature with a 5/16/23 date. Resident #90's CMS SNF ABN form detailed beginning on 5/17/23 the Resident would have to start paying out of pocket if they did not have other insurance that may cover the cost. The SNF ABN showed Resident #90 signed the form with a date of 5/16/23. 3. Resident #40's Electronic Census Record showed he admitted into skilled care services at the facility on 8/18/23 and discharged from the facility on 8/31/23. A review of the Minimum Data Set (MDS) assessments on 9/26/23 revealed the following: A. MDS Entry Record dated 8/18/23. B. Admission/Medicare 5 Day assessment dated [DATE]. C. Discharge Return Not Anticipated/End of PPS Part A Stay dated 8/31/23. On 9/26/23 at 12:41 p.m., the Social Services Coordinator reported she received a webinar training on how to completed the beneficiary notices and she has some print out tools that she follows. She stated it had been hard to serve Resident #39 notices as he had been in and out of the hospital. She reported that she had met with him as she documented on 7/06/23 on the generic notice but she did not see that he had not chosen an option on the SNF ABN. He had not dated the beneficiary notices when he signed them so she signed the date on the beneficiary notice for him on 7/08/23. For Resident #90 she had met with her and explained her benefits on 5/12/23. The Resident had not dated the beneficiary forms when she signed the forms so she dated for her on 5/16/23. During an interview on 9/26/23 at 12:46 p.m., the Social Service Coordinator reported she remembers serving Resident #40 beneficiary notices (SNF ABN and NOMNC), but she had not been able to locate the notices. She is still looking for them. On 9/27/23 at approximately 9:45 a.m., the Social Service Coordinator reported she did not find any beneficiary notices for Resident #40. During an interview on 9/27/23 at 12:10 p.m., the Administrator reported she expected the beneficiary notices to be completed appropriately, be served within 48 hours and copies of the notices to be retained by the facility. The Advanced Medicare Beneficiary Notice Policy dated April 2021 directed the following process: 1. If the admissions coordinator or business office manager believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee-for-Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). The facility issues the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (CMS form 10055) to the resident prior to providing care that Medicare usually covers, but may not pay for because the care is considered not medically reasonable and necessary, or custodial. The resident (or representative) may choose to continue receiving the skilled services that may not be covered, and assume financial responsibility. 2. If the resident's Medicare Part A benefits are terminating for coverage reasons, the admissions coordinator or business office manager issues the Notice of Medicare Non-Coverage (NOMNC) (CMS form 10123) to the resident at least two calendar days before Medicare covered services end (for coverage reasons). The Notice of Medicare Non-Coverage informs the resident of the pending termination of coverage and of his/her right to an expedited review of service determination. The Notice of Medicare Non-Coverage is not indicated when the resident's Medicare covered days are exhausted; nor is it used to notify the resident of potential liability for payment.

Based on observation, clinical record review, resident and staff interviews, the facility failed to follow proper infection control practices by failing to ensure proper placement of indwelling catheter tubing for one of two residents reviewed (Resident #26). The facility reported a census of 29 residents. The Minimum Data Set (MDS) dated [DATE] identified Resident #26 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 and with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also identified he required extensive staff assist with most activities of daily living and had an indwelling urinary catheter. The Care Plan with the last revision date of 2/7/22 identified the resident with the problem of an indwelling catheter and failed to direct staff to keep the catheter tubing off the floor to help prevent urinary tract infections. Observations of the resident revealed the indwelling catheter tubing on the floor on 3/30/22 at the following times: a. At 7:55 AM, now sitting in wheelchair in the main dining room and no staff noted nearby. b. At 8:05 AM, the Foley catheter tubing remains on floor, while Staff B, Licensed Practical Nurse (LPN) stood in front of the medication cart by the nurse's station. c. At 8:20 AM, the Foley catheter tubing remains on floor while the Director of Nursing (DON) spoke to another staff member standing in front of resident, and did not pick up tubing off floor before she walked down East hall. d. At 8:24 AM, the Foley catheter tubing remains on floor while the DON and another staff member walked past the resident without picking up tubing off the floor. e. At 8:30 AM, assessment unchanged, Staff B, LPN and the DON, stood at the Nurse's Station nearby, neither one repositioned the catheter tubing. f. At 8:35 AM, assessment unchanged. g. At 8:40 AM, assessment unchanged. h. At 8:44 AM, resident now able to self propel from the main dining room to his room with catheter tubing dragging on the floor. i. At 9:46 AM, sitting up in wheelchair with both feet on foot rests, in his room watching TV, catheter tubing remained on floor. j. At 9:47 AM, Staff A, Temporary Nurse Aide (TNA) entered the resident's room, closed door to the room, washed hands, donned gloves, checked the resident's catheter and repositioned the tubing up off the floor A review of the urinalysis (UA) with culture and sensitivity completed 3/15/22 identified the resident with >100,000 cFu (colony forming units) of Serratia Marcescens and had documentation of 3/18/22 [MEDICATION(S)] 250 mg PO (orally) daily for 3 days A review of the Nurse's Notes revealed the following: a. On 3/15/2022 10:11 AM, Resident reported low back and hip pain. Urine is dark and cloudy. Received order from the doctor for UA (urinalysis) with culture and sensitivity and to change the catheter. Catheter changed. UA obtained. b. On 3/18/2022 1:53 PM, the resident received order from the Nurse Practitioner regarding urine culture. New orders received for [MEDICATION(S)] (an antibiotic) 250 milligrams (mg) once daily for 3 days. Interviews with the staff revealed the following: a. In an interview on 3/31/22 at 8:50 AM, the DON reported catheter tubing should be placed off the floor. b. In an interview on 3/31/22 at 10:20 AM, Staff C, Certified Nurse Aide (CNA) reported catheter tubing should not be left on the floor. c. In an interview on 3/31/22 at 10:34 AM, Staff D, Restorative Aide (RA) reported catheter tubing should be kept off the floor. d. In an interview on 3/31/22 at 10:55 AM, Staff A, TNA reported if she saw catheter tubing on the floor, she would pick it up off the floor. A review of the facility policy titled: Catheter Care, dated January 2015 failed to direct Nursing Staff to ensure the catheter tubing should be kept off the floor at all times.

Based on clinical record review and staff interview, the facility failed to identify personal property for one of three residents reviewed on the personal inventory form. (Resident #2) The facility census was 37 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #2 had no cognitive impairment. During interview on 1/26/18 at 9:15 a.m., the resident reported the lock box was removed from their room and contained two hundred dollars in cash and an anniversary ring valued at five hundred dollars, as well as medical cards, driver's license and a credit card. The resident still had the key to the lock box. The facility submitted to the department an investigation regarding a missing lock box belonging to Resident #2 that contained personal possessions including an anniversary ring and approximately two hundred dollars in cash. A review of the resident's clinical record failed to reveal an inventory list completed on admission. The facility had no policy regarding the completion of resident inventory. During interview on 1/26/18 at 12:30 p.m., the Director of Nursing reported the facility failed to complete inventory lists on admission. During interview on 1/26/18 at 12:30 p.m., the Corporate Nurse said the facility went by what the resident reported, though they could not provide an inventory list. During interview on 2/20/18 at 4:30 p.m., the Administrator indicated the facility completed a Concern Form and the facility completed inventory sheets since the investigation.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to provide adequate Foley catheter care for two of two residents observed. The facility census was 34 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 had [DIAGNOSES REDACTED]. Observation on 11/14/17 at 7:00 a.m., revealed the resident in bed with a catheter bag laying on the floor. Observation on 11/14/17 at 7:40 a.m., revealed Staff D, Certified Nurse Aide, CNA entered room but did not remove the catheter bag from floor. Staff D completed catheter care by utilizing a washcloth to cleanse the residents abdominal folds and center of the residents perineum in a back to front motion and failed to cleanse the tubing of catheter at all. Staff D rolled the resident onto their side and utilized the same washcloth to cleanse the buttocks and rolled the resident onto their back. After catheter care was complete Staff D changed the Foley catheter bag to a leg bag. Staff D cleansed the connection of leg the bag with a alcohol wipe, but failed to cleanse the catheter tubing the leg bag was placed into with alcohol wipe. The care plan dated 11/3/17, revealed an intervention to ensure the catheter tubing was free of kinks and off of the floor. During interview on 11/15/17 at 2:05 p.m., Staff A, Certified Nurse Aide, CNA stated the catheter bag should not be on the floor and she used disposable wipes for each area and cleansed using a front to back motion and cleansed the tubing of the catheter. During interview on 11/15/17 at 2:33 p.m., the Director of Nursing (DON) stated the catheter bag should not be on the floor. 2. The MDS assessment dated [DATE], documented Resident #2 had [DIAGNOSES REDACTED]. During observation on 11/14/17 at 8:26 a.m., Staff A, CNA failed to cleanse the end of the catheter tubing with an alcohol swab after disconnecting it from the drainage bag and prior to connecting it to the leg bag. During observation on 11/14/17 at 8:28 a.m., Staff A failed to cleanse the resident's front peri area and around the catheter tubing. Staff A failed to cleanse down the catheter tubing. During interview on 11/15/17 at 2:08 p.m., Staff C, CNA reported when changing over catheter bags, both connection points must be cleansed with an alcohol swab before connecting them together. Staff C continued to report peri care includes washing every surface that was contaminated with incontinent material. Staff C stated catheter care includes washing around the catheter entry point and down the catheter tubing away from the body. The facility provided guidelines for catheter care titled Catheter Care dated January 2015, directing staff cleanse tubing using downward motion. Wash perineum well, taking care to wash from front to back. Wash all areas that were potentially soiled or wet. The facility provided guidelines for Leg Bag (applying) dated January 2015 from the Nursing Guidelines and Procedure Manual with direction to Remove the cap from the top of bag, handling only outer portion cap. Cleanse top connection with an alcohol swab. Cleanse connection at tubing with an alcohol swab. Pinch catheter and disconnect from tubing. Attach to top of connection leg bag, Apply cap from leg bag.

Based on record review and staff interviews, the facility failed to provide adequate nursing supervision to prevent accidents and failed to revise the Care Plan with interventions for 1 of 4 residents reviewed with a recent fall history (Resident #1). The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) Assessment with a reference date of 08/01/2016 documented Resident #1 with active [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMS (Brief Interview for Mental Status) score of 10 out of 15 indicating moderately cognitive impairment. The MDS indicated the resident required extensive physical assist of 2 or more staff members for bed mobility, transfers to and from bed and chair, dressing, toileting and personal hygiene. The MDS indicated the resident admission date of [DATE]. The resident's nursing Initial Care Plan dated 07/19/16 identified the resident required assistance of two staff for ambulation, the resident independent with positioning, used a wheelchair, required assistance of staff for dressing and oral care. The care plan documented Resident #1 had short term memory loss. The resident continent and wears incontinent pads. The care plan revealed the resident with a fall risk and to keep bed in low position. Review of the Nurse's Notes dated 7/19/16 at 10:00 a.m., documented Resident #1 arrived to the facility and the nurse identified the resident alert and oriented but had short term memory loss. The note documented Resident #1 would need the assist of two staff for transfers and the facility was awaiting for therapy to evaluate. Review of the Nurse's Notes dated 7/19/16 at 10:05 a.m., documented Resident #1 ' s bed in low position for safety while in room. Staff updated on plan of care. Review of the Nurse's Notes dated 7/19/16 at 9:00 p.m. revealed it being reported to the nurse the resident self-transferred one time this shift. The resident's record lacked indication of additional interventions implemented for the safety of the resident to prevent self-transfers. Review of the Nurse's Notes dated 7/21/16 (no time documented) indicated resident witnessed up walking without assistance three times this evening. Staff applied a personal alarm on resident. Review of the Nurse's Notes dated 7/19/16 at 3:00 p.m. revealed Resident #1 confused and believed he/she was going home. The CNA found the resident standing in his/her room and the CNA went to assist the resident when the resident slipped in his/her non-slip socks. The CNA lowered the resident to the floor. Review of Incident/Accident/Unusual Occurrences Form dated 7/21/16 at 3:00 p.m. staff responded to resident as resident up to his/her closet without assist. Staff went to assist resident and resident's feet slipped and staff lowered to the floor. No injuries noted. Staff notified resident's physician and family. The resident's record lacked indication of additional interventions implemented for the safety of the resident to prevent further falls. Review of the Nurse's Notes dated 7/21/16 at 10:10 p.m. indicated the resident calling out help at the same time resident's roommate call light came on. Staff went into resident's room and found resident lying on the floor right side of his/her bed with upper body on roommates side of room and lower half of body on his/her side with dividing room curtain hanging above resident. Appears resident removed own personal alarm. Walker noted to not be near resident and located on the other side of the resident's bed. Resident lying on right side and turned self almost onto his/her back. Resident able to move upper extremities and left lower extremity without difficulty but complains of pain to right groin area. Resident's physician and family notified and resident transferred via ambulance to the emergency room . At 3:00 a.m. staff contacted the hospital and was informed the resident being admitted with a right femoral neck fracture treatment. Review of Incident/Accident/Unusual Occurrences Form dated 7/21/16 at 10:10 p.m. indicated staff heard a call for help from resident at the same time resident's roommate call light came on. Staff found resident on the floor at the foot of resident's bed half on roommate's side of the room. Resident with active range of motion to upper extremities and to left lower extremity, resident could not move right lower extremity and complains of right inner groin pain. Resident's physician and family notified and resident transferred to the emergency room for further evaluation. Review of Consult hospital notes dated 7/22/16 revealed resident suffered a closed fracture of the right femur neck fracture after a fall. The resident had been living with family member, sustained two falls and family determined it best to place resident in a nursing home. Resident suffered another fall on 7/21/16 while at the nursing home and sustained a femoral neck fracture. Plan is surgical repair today. Procedure right hip hemiarthroplasty on 7/22/16. The Discharge Summary documented Resident #1 had been taken for right hip hemiarthroplasty (hip surgery) on the day of admission. Resident #1 had an uneventful postoperative course with some dehydration as evidence by mild elevated creatinine, mild hypotensive and low urine output. Resident #1 would be discharged back to the nursing home on 7/25/16. Interview conducted on 8/9/16 at 12:50 p.m. with Staff A, Certified Nurse Aide (CNA). Staff A reported taking care of the resident prior to his/her falling. Staff A reported during that time the resident would remove his/her alarm and also would remove gown that the alarm was attached to. Interview conducted on 8/10/16 at 9:48 a.m. with Staff B, Certified Nurse Aide (CNA). Staff B stated taking care of the resident prior to his/her falling. Staff B indicated the resident confused about the alarm and would attempt to put the string of the clip to the alarm on as a piece of clothing. Staff B reported the resident removing the alarm/clip no matter where it was placed at on him/her. Staff B stated she reported to the oncoming shift of resident removing alarm/clip. Staff B indicated staff were doing frequent checks on the resident before the resident fell , however no documentation of the checks done. Review of statement of Staff E, Certified Nurse Aide (CNA) of 7/21/16, indicated she found resident sitting up on edge of bed and had removed alarm around 9:15 p.m. - 9:30 p.m. Staff E reported she assisted the resident to the bathroom and back to bed and reapplied the alarm out of the resident's reach. Interview conducted on 8/10/16 at 11:12 a.m. with Staff C, Certified Nurse Aide (CNA). Staff C stated staff aware that the resident could and did remove alarm/clip as this was passed on in report at shift change. Staff C indicated on 7/21/16 prior to resident falling, staff were doing frequent checks of every 15 to 20 minutes to check if the resident is in bed or not. Staff C reported checking on the resident around 9:45 p.m. the night of 7/21/16 and the resident sitting up on the edge of the bed and had removed the alarm/clip. Staff C stated she assisted the resident to the bathroom and back to bed and placed the alarm/clip to the middle back of resident, attempting to place it out of reach for the resident. Staff C stated the next time she seen the resident it was at 10:10 p.m., he/she had removed the alarm and fell on to the floor. Interview conducted on 8/11/16 at 2:03 p.m. with Staff D, Registered Nurse, and (RN). Staff D reported on 7/20/16 she place a personal alarm/clip on the resident due to the resident getting up unassisted from the wheelchair. Staff D stated she expected resident to have the alarm/clip on while in wheelchair and in bed. Staff D stated on 7/21/16 staff reported to her, prior to resident falling, that Resident #1 was removing the alarm/clip. Staff D indicated she looked for a pressure alarm to apply to the resident due to resident removing the clip alarm; however she could not locate one in the facility. Staff D stated the resident increased anxiety and confusion the evening of 7/21/16, and attempting to get out of bed unassisted and removing alarm, she instructed staff to do frequent checks of every 15-30 minutes on resident, but staff did not document this as being done. Staff D stated at 10:10 p.m., she and two other staff members were at the nurse ' s station when they heard the resident yelling out. Staff D stated she responded with other staff members to the resident's room and found the resident on the floor, alarm/clip lying perfectly in the resident's bed, as resident had removed alarm prior to falling. Staff D stated she assessed the resident and noted resident unable to move right lower extremity and complained of pain to right groin area. Staff D stated she called the resident's physician and family and transferred the resident via ambulance to the emergency room .

Based on clinical record review and staff interviews, the facility failed to review and revise one of four resident care plans in order to ensure the residents safety. The facility census was 35 residents. (Resident #1) Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], document Resident #1 had [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive physical assistance for bed mobility, transfers, dressing, toileting and personal hygiene needs. The MDS indicated the resident was admitted to the facility on [DATE]. The residents Initial Care Plan dated 7/19/16, identified the resident as requiring assistance of two for ambulation, was independent with positioning and used a wheelchair. The resident required assistance of staff for dressing and oral care and had short term memory loss. The resident was continent and wore incontinent pads and was a fall risk and was to have the bed in a low position. Nurse Notes dated 7/19/16 at 9:00 p.m., revealed the resident self-transferred one time that shift. The resident's record lacked indication of additional interventions implemented for the safety of the resident to prevent self-transfers. Nurse Notes dated 7/20/16 (no time documented) indicated the resident was up walking without assistance three times that evening. Staff applied a personal alarm on resident. An Incident/Accident/Unusual Occurrences Form dated 7/21/16 at 3:00 p.m., documented staff responded to the resident being up to his/her closet without assistance. Staff went to assist the resident and residents feet slipped and staff lowered the resident to the floor. No injuries noted. The resident's record lacked indication of additional interventions implemented for the safety of the resident to prevent further falls. Nurse Notes dated 7/21/16 at 10:10 p.m., indicated the resident was calling out help at the same time the residents roommate call light came on. Staff went into the residents room and found resident lying on the floor on the right side of his/her bed with their upper body on the roommates side of room and lower half of body on his/her side with dividing room curtain hanging above the resident. The resident removed the personal alarm. Walker noted to not be near resident and located on the other side of the residents bed. Resident able to move upper extremities and left lower extremity without difficulty but complains of pain to right groin area. Residents physician and family notified and resident transferred via ambulance to the emergency room . At 3:00 a.m., staff contacted the hospital and was informed the resident being admitted with a right femoral neck fracture treatment. During interview on 8/11/16 at 2:03 p.m., Staff D, Registered Nurse, RN reported on 7/20/16 she placed a personal alarm/clip on the resident due to the resident getting up unassisted from the wheelchair. Staff D stated she expected the resident to have the alarm/clip on while in the wheelchair and in bed. Staff D stated on 7/21/16 staff reported to her, prior to the resident falling, that the resident was removing the alarm/clip. Staff D indicated she looked for a pressure alarm to apply to the resident due to resident removing the clip alarm; however she could not locate one in the facility. Staff D stated the resident had increased anxiety and confusion the evening of 7/21/16, and was attempting to get out of bed unassisted and removing the alarm, she instructed staff to do frequent checks every 15-30 minutes on resident, but staff did not document the checks.

Based on clinical record review, staff and resident interview, the facility failed to ensure one of four residents reviewed had a plan of care that included the residents refusal to complete cares and how staff were to approach the resident after a refusal. (Resident #4) The facility census was 30 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #4 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required supervision to walk and required assistance for dressing, toilet use and personal hygiene needs. The AccuNurse Documentation (Certified Aide Charting) for the time period 2/4-2/11/16, revealed the aides documented the resident had 8 episodes of refusals for bathing, snacks and hygiene needs. During interview on 2/10/16 at 2:10 p.m., the resident stated he/she was pleased with the care from facility, but does not want to be awakened during the night for cares. The resident stated he/she refused cares during the night and early mornings. During interview on 2/11/16 at 10:00 a.m., the Director of Nurses (DON) stated the resident refused to allow staff to complete incontinence cares during the night and directed staff to continue offering cares. The DON stated the resident does as they want when they want and there is no changing the residents mind. The DON stated the facility does use agency staff and they would be directed to use the resident Care Plan to identify needs and approaches used. During interview on 2/10/16 at 2:30 p.m., Staff B, indicated the resident would initially refuse cares when offered but stated they could talk to the resident and the resident would consent to staff help. The residents Care Plan dated 10/12/15, indicated the resident had diabetic circulation problems with a potential to develop pressure ulcers, experienced pain in their legs, had a risk of falls due to weakness, had a risk for side effects due to anti-depressant medications, required assistance with Activities of Daily Living due to weakness, had a potential for low socialization and a potential for occasional urinary incontinence due to weakness. The Care Plan failed to indicate the resident had frequent refusal of cares and failed to give direction to the staff on how to approach the resident when refusals occurred.

Based on observation and clinical record review, the facility failed to follow professional standards of practice during observation of eye drop installation on two occasions for one resident. The facility census was 34 residents. Findings include: 1. Review the the clinical record revealed a physician order [REDACTED].#8's left eye 3 times daily. The facility's drug reference, the Nursing 2016 Drug Handbook, 36th edition, directed staff to apply light finger pressure on the lacrimal sac (tear duct) for 1 minute after the medication instilled to minimize systemic absorption of the medication. Observation of medication administration on 11/10/15 at 6:44 a.m., revealed Staff A, registered nurse, RN, instilled the [MEDICATION NAME] medication into the resident's left eye, dabbed the lower eyelid area with a tissue, but failed to apply pressure to the lacrimal duct. Observation on 11/10/15 at 3:19 p.m., Staff B, licensed practical nurse, LPN, instilled the [MEDICATION NAME] medication into the resident's left eye, dabbed the lower eyelid area with a tissue, but failed to apply pressure to the lacrimal duct.

Based on observation, facility policy review and clinical record review, the facility failed to ensure staff followed proper infection control practices during observation of one residents dressing change. (Resident #4) The facility census was 34 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 had [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Change ABD's as needed related to drainage. Observation of Resident #4's dressing change on 11/10/15 at 1:13 p.m. revealed Staff A, registered nurse donned gloves and removed the rolled gauze and ABD pads visibly soiled with serous (yellow colored) exudate from the right lower leg. Staff A did not change gloves or sanitize their hands and went on to open packages of ABD pads and rolled gauze dressings and applied the dressings to the resident's right lower leg. Staff A sanitized hands and applied new gloves and removed the rolled gauze and ABD pads visibly soiled with serous drainage from the residents left lower leg. Staff A failed to change gloves or sanitize their hands and went on to open packages of ABD pads and rolled gauze dressings and applied the dressings to the resident's left lower leg. The facility's Infection Control policy dated September 2012 directed the following hand hygiene practices: 1. Improved adherence to hand hygiene (handwashing or use of alcohol-based hand rub) has been shown to terminate outbreaks in health care facilities, to reduce transmission of antimicrobial resistant organisms and reduce overall infection rates. 2. The use of gloves does not eliminate the need for hand hygiene. Gloves reduce hand contamination by 70 to 80 percent, prevent cross-contamination and protect patients and health care personnel from infection.

Based on observation, record review, and interviews with resident, family and staff, the facility failed to provide adequate supervision and implement care plan interventions identified to prevent accidents for 2 of 4 residents reviewed (Residents #1 & #4). The facility reported a current census of 37 current residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) test revealing no cognitive impairments. The assessment identified the resident had [DIAGNOSES REDACTED]. Resident #1 required two staff to assist with bed mobility, transfers, and for assistance to use the toilet. The test for balance identified Resident #1 unable to maintain his/her balance and only able to stabilize with staff assistance when moving from seated to standing position, when walking, when moving on and off the toilet and during surface to surface transfer ( for example from wheelchair to bed). The assessment identified Resident #1 had impaired range of motion on one side of his/her body and had no falls since the prior assessment. The Resident Assessment Protocol (RAP) dated [DATE], indicated the resident had no falls for the quarter and had a fall risk score of 16. A score greater than ten represented a high risk for falls. The RAP dated [DATE], reported the resident had a pressure alarm on the wheelchair and bed discontinued on ,[DATE], deemed no longer needed and a fall score of 15. A Physical Therapy Plan of Care dated [DATE], revealed therapy received a referral due to the resident's decline in ambulation, curling of toes with weight bearing and pain. Nursing noticed a decrease in self-care ability for three weeks resulting in decreased safety and an increased need for assistance, skilled therapies needed to improve safety and function. The Care Pan initiated on [DATE] identified Resident #1 at risk for falls related to impaired mobility, left sided weakness, medication use, incontinence and a history of falls. The care plan directed staff to complete the following: toilet the resident routinely, administer medications as ordered, assure safe, dry footing and shoes and apply a non-slip device in his/her wheelchair and use a pad cushion in the wheelchair. The care plan directed one staff assist the resident to ambulate to the dining room table utilizing a gait belt and a quad cane. A pressure alarm had been used (without knowing when initiated) but then discontinued on ,[DATE]. On ,[DATE](2013), the care plan noted to ensure the wheelchair foot pedals are out of foot path prior to ambulation and on ,[DATE] (2013) the care plan identified the resident needed to wear his/her brace to left foot before transfers. The Care Plan also addressed the resident had a potential for bleeding related to aspirin use and directed staff to monitor for bleeding, obtain laboratory tests and provide the resident with added skin protection if needed. During interview on [DATE] at 5:00 p.m., Staff F, RN, registered nurse (care plan coordinator) reported being responsible for resident Care Plans. The facility used Dycem,(a product name), as the non-slip device listed on the resident ' s care plan. Staff F reported interventions are added on the computer and CNA's can access it and review it. An Incident/Accident/Unusual Occurrences Form dated [DATE] at 4:00 p.m., documented staff found the resident on floor in the room after the roommate pulled the call light. Staff observed the resident lying prone with left side of face on floor with a pool of blood on floor from nose. The resident had confusion and wanted to sit up, and wanted to know what happened. The roommate identified he/she did not see the fall, just heard it. Nurse notes dated [DATE] at 4:30 p.m., revealed staff found the resident lying prone with the side of the resident's face in a 12 inch pool of blood on the floor. Staff assessed the resident's vitals and neurological examination revealed sluggish pupils and swollen left eye. The resident transferred to the emergency department via ambulance. Staff notified the physician and family. Nurse notes dated [DATE], reported the resident remained in the hospital. The Hospital Course documented the resident had a history of [REDACTED]. The CT (computed tomography) dated [DATE] showed increased intraventricular hemorrhage, though otherwise stable, with no intervention recommended. The resident had further tests that showed no aneurysm or vascular abnormality. The resident received palliative care. A hospital Discharge Summary of a deceased Patient documented the resident passed away on [DATE]. The resident was admitted with traumatic subarachnoid and subdural hemorrhage diagnosis (hemorrhage of brain). The report documented respiratory failure as the primary cause of death. Conditions directly contributing to death were subarachnoid, intraventricular and subdural hemorrhage with altered mental status, pulmonary edema, history of prior hemorrhagic stroke with significant deficit. Other pertinent [DIAGNOSES REDACTED]. During interview on [DATE], the resident's family member reported the resident had declined physically but remained sharp cognitively and used the call light or called out for help. The facility always called with changes in condition, and the resident recently received therapy services. The family indicated they left the resident's wheelchair at the facility, but removed other personal belongings after the resident passed away. The facility investigation reported submitted [DATE] included the resident fell on [DATE]. Staff found the resident lying on the left side with a facial laceration and pupils sluggish. The resident transferred to the hospital and had [DIAGNOSES REDACTED]. Staff previously saw the resident 10 minutes prior sleeping in the wheelchair. The roommate watched television and saw the resident on the floor. The resident had two other falls, one where a CNA (certified nurse aide) transferred him/her without an AFO and staff had to lower the resident to the floor, and another where the CNA tripped over the foot pedal while ambulating the resident and landed in the wheelchair with the resident on his/her lap. During interview on [DATE] at 2:50 p.m., the Administrator reported being on vacation at the time the resident fell on [DATE]. The director of nursing (DON) did the investigation on [DATE] and reported it to DIA (Department of Inspections and Appeals). The Administrator heard Staff A answered the call light and found the resident on the floor. On [DATE], the Administrator revealed Staff B, LPN, licensed practical nurse saw the resident approximately 10 minutes prior to the incident. During interview on [DATE] at 12:00 p.m., the DON reported she investigated the fall beginning the day after the incident occurred on [DATE]. The resident's roommate, Resident #2, indicated he/she slept in the recliner and failed to witness the fall. Resident #2 woke when the resident fell and saw the resident's call light on and the resident on the floor. Resident #2 put the call light on and Staff A, CNA responded to the call light. The resident had a chair alarm in the past, however upon review staff removed it since the resident had no attempts to stand independently. The resident recently finished physical therapy due to a decline in ambulation. The resident had previous falls. In May of 2013, a CNA lowered the resident to the floor during a transfer without an AFO boot on as the care plan directed. The DON reported the family took the resident's wheelchair. When he/she arrived at the facility the next day, he/she failed to observe the resident's wheelchair. The resident had no falls due to self-transfer attempts since 2012. On [DATE] at 4:38 p.m., the DON indicated the resident had Dycem (anti-slip device) in the wheelchair, most of the time. The Dycem may have been between the soaker pad and the wheelchair cushion. The DON indicated the Dycem needed to be placed between the resident and the cushion. The DON confirmed the facility used Dycem when needing a non- slip device according to the (resident ' s) Care Plan. When they re-enacted the scene, Staff A and Staff B reported everything had been in place. On [DATE] at 4:40 p.m., the nurse consultant indicated the facility used Dycem to prevent the resident from sliding. During interview on [DATE] at 10:45 a.m., Resident #2 with no cognitive impairment reported when the resident fell , he/she heard a "kaboom". The resident's wheelchair faced Resident #2. Prior to that Resident #2 observed the resident in the wheelchair facing the opposite wall snoring, so he/she knew the resident slept. After the resident fell , Resident #2 put his/her call light on, but observed the resident had the call light already on. Staff A responded to the call light and summoned assistance. On [DATE] at 3:40 p.m., Staff B, LPN reported working second shift on [DATE]. Staff B heard a call from Staff A for help and found the resident on the floor on their left side, conscious with a pool of blood under their head. Staff B said the resident received no pills on second shift prior to the fall, and he/she failed to visualize the resident that shift, prior to the fall. Staff B peeked into the room to say "Hi" to Resident #2, but found him/her asleep in the recliner. After the resident fell , Staff B never saw the wheelchair and never removed it from the scene. Staff B did not recall if the resident had Dycem in the chair. On [DATE] at 2:22 p.m., Staff A, CNA reported working second shift on [DATE]. At approximately 3:00 p.m., Staff A passed ice to the resident and saw the resident asleep in the wheelchair facing the wall next to the bed and Resident #2 slept in the recliner near the room entry door. At approximately 4:00 p.m., Staff A assisted another resident on another hall and saw the West wing light on, indicating call lights were on for approximately ,[DATE] minutes. Staff A walked in the room and found the resident on the floor and called for help. The wheelchair faced the bed, and the resident asked why he/she "was on the floor". Staff A said the resident failed to have a Dycem in the wheelchair, he/she moved the wheelchair and saw the seat without the Dycem. During interview on [DATE] at 4:05 p.m., Staff C, CNA reported working second shift on [DATE], on another hall. Staff C got a page from Staff A reporting call lights on the West wing were sounding "like crazy" and a resident fell and needed help. Two residents fell that night. When Staff C entered the room, he/she saw the resident on the floor, Staff E cleaned up blood, Staff A got extra towels and Staff B did the resident assessment. Staff C observed the resident's wheelchair with no Dycem, but a cushion and soaker pad. They had a five minute meeting and reviewed resident falls and interventions. At the time, Resident #1 had no fall interventions; no alarms. Staff C reported assisting the resident transfer from one surface to another often, at least once a shift. Staff C failed to recall ever seeing Dycem in the wheelchair. The resident had difficulty standing and required assistance of one to two staff to stand upright. Staff C said AccuNurse informed them if a resident had Dycem. Staff C did not recall ever hearing the resident had Dycem. During interview on [DATE] at 5:20 p.m., Staff E, CNA reported working on [DATE]. At the time the resident fell , Staff E assisted residents with showers. Staff E heard Staff A call for help and asked someone to call 911. Staff E denied touching the resident's wheelchair and did not recall if the resident had Dycem in the wheelchair. During interview on [DATE] at 8:00 a.m., Staff G, CNA reported working the night shift for seven months. Staff G indicated during the night they assisted the resident to the bathroom, or performed incontinence cares. The night shift cleans resident wheelchairs in the shower. Staff G said they remove the alarms, cushions and anything on the chair and place it in a pile, wash and dry the chair and put everything on the seat. Staff G said they put the wheelchair back where they got it from and day shift staff put everything back together. Staff G said the resident's wheelchair sat in the room for a week after he/she fell . During interview on [DATE] at 4:20 p.m., Staff H, CNA reported working at the facility on the day shift. Staff H stated the resident made no attempt to stand up independently recently. At one point the resident had an alarm, and then they discontinued it. The resident required Dycem in the wheelchair because he/she scooted down. Staff H had no knowledge of the resident's Dycem the day of the fall. Staff needed to remind the resident to sit up straight. Staff H indicated staff knew not to put soaker pads in the wheelchairs. AccuNurse failed to include the Dycem in resident care plan. During interview on [DATE] at 3:46 p.m., Staff I, CNA reported working the night shift. Third shift washed resident wheelchairs, and put them back. Only one resident had Dycem in the wheelchair and it was not Resident #1 or Resident #4. 2. The MDS assessment dated [DATE], revealed Resident #4 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had no cognitive impairment. The resident transferred with extensive assistance of two staff and had an unsteady balance and was only able to stabilize with staff. The MDS assessment reported the resident had one fall since admit/reentry/prior assessment with no injury. The Care Plan identified the resident had a potential for falls due to a cognitive disorder, dementia and Parkinson's disease. The Care Plan instructed staff to apply a non-skid pad in the wheelchair. The Care Plan noted to remind the resident to ask for assistance and he/she participated in the walk to dine program. The care plan directed staff to place an alarm on the bathroom door and assure the use of safe, comfortable foot wear (non-slick soled shoes or slippers). On ,[DATE]/(2014), staff hand wrote an intervention: non-skid pad placed in wheelchair. The Care Plan identified the resident had problems including potential for bleeding secondary to daily Aspirin use, had self-care deficit related to need for assistance with activities of daily living and use of psychotropic medications. The RAP dated [DATE], reported the resident slid on the floor on [DATE] from the wheelchair without injury and to place a non-skid pad in the wheelchair. Primary mobility via wheelchair propelled by self/staff assistance as needed and non-skid pad placed in wheelchair. Nurse notes dated [DATE] at 8:00 p.m., revealed the resident slid from the wheelchair to a sitting position on the floor, with no injuries noted. The Incident/Accident/Unusual Occurrences Form dated [DATE] at 10:00 p.m., revealed the resident slid to the floor from the wheelchair when stiffening in the wheelchair at 9:00 p.m. During interview on [DATE] at 12:15 p.m. the DON reported the resident transferred with the assistance of one staff. In January, the resident slid out of his/her chair and staff added Dycem to the chair as the intervention to prevent further incidents. The facility completed training on [DATE] titled " 5 Minute Meeting for Employees". The summary mentioned the list of interventions on the care plan for residents and to ensure all the interventions are in place. For Resident #4, the training document: walk to dine with the assist of 1 (staff) and follow with wheelchair, Dycem in wheelchair, pull alarm on bathroom door. Observation on [DATE] at 12:30 p.m., revealed the Resident #4 sitting in a wheelchair, eating independently, with no Dycem observed in his/her wheelchair. The DON reported she did not observe the Dycem either. At 1:15 p.m., Staff J assisted the resident to the room via wheelchair, transferred the resident from the wheelchair to bed with a gait belt. Observation revealed the wheelchair had no Dycem. At the time, the DON placed a Dycem on the wheelchair on top of the cushion. On [DATE] at 1:25 p.m., Resident #4 reported not knowing where the Dycem went, but had not seen it for a while. Last month staff placed the " blue stuff" in the wheelchair after he/she scooted to the front of the wheelchair and slipped out. On [DATE] at 1:30 p.m. Staff K, CNA reported assisting the resident in getting up from bed that morning. The resident had no Dycem in the chair and AccuNurse failed to identify the resident had it. Staff relies on AccuNurse for instructions. Staff K never observed the Dycem. On [DATE] at 1:35 p.m., the DON indicated AccuNurse documents Dycem under "Custom Notes". Custom Notes failed to be revealed via the AccuNurse head set. Resident alarms had a separate section in the AccuNurse. CNA's rely on AccuNurse for instructions and they hang notes in resident rooms. The DON indicated he/she put interventions related to falls in the AccuNurse. On [DATE] at 1:40 p.m. the Administrator indicated when staff sign on to AccuNurse, they hear a "ding" symbolizing an update or change to the Care Plan.