Every finding on record at Newark Manor Nursing Home

Based on record review and interview, it was determined that for one (R6) out of four residents reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to coordinate with the PASRR program under Medicaid and refer the resident for an assessment. Findings include:Review of R6's clinical records revealed:12/9/24 - A PASRR Level 1 Screen was completed prior to R6's admission to the facility. The PASSR Level 1 documented that No mental health diagnosis is known or suspected.2/4/25 - R6 was admitted to the facility with diagnoses including but not limited to unspecified dementia, unspecified severity, without behavioral disturbance and major depressive disorder.2/17/25 - R6's admission Minimum Data Set (MDS) assessment documented that R 6 had no serious mental illness and/or intellectual disability.5/20/25 - R6's Quarterly MDS assessment documented that R6 's active diagnoses Non-Alzheimer's Dementia and Depression.6/23/25 1:21PM - A nurse progress note documented Resident became physically aggressive towards staff when attempting to provide AM care. 6/23/25 - R6 had the following new physician orders:1. Rexulti Tablet 1 milligram, Give 1 tablet by mouth at bedtime for 14 days for depression.2. Ativan Tablet 0.5 milligram, Give 1 tablet by mouth every six hours as needed for anxiety for 14 Days. 6/23/25 1:00 AM - An encounter note by P1(NP) documented Plan: 1. Dementia with behaviors, continue to monitor moods and behaviors, will initiate Rexulti and consult psych for evaluation. 2. Depression with insomnia, will decrease trazodone from 100 mg to 50 mg, continue to monitor moods and behaviors encourage good sleep habits and follow-up with psych as needed.6/24/25 1:00 AM- An encounter note by P2(DO) documented Assessment. Psychosis. Associated with behavioral abnormalities Appears to be secondary to underlying neurocognitive disorder (sic) Continue medical therapy with Rexulti, trazodone and as needed lorazepam (sic) Attempt gradual dose reduction as tolerated Psychiatry evaluation and follow-up as indicated. 6/24/25 - R6 was diagnosed with Unspecified Psychosis Not Due To A Substance Or Known Physiological Condition8/20/25 - R6's Quarterly Minimum Data Set (MDS) documented Active Diagnosis. Non-Alzheimer's Dementia. Anxiety Disorder, Depression.Psychotic Disorder7/11/25 9:19 PM - A psychiatry note by P3 (MD) documented Patient seen for Initial Evaluation mood and medications management. Patient is very angry and delusional that people on the building killing Dogs. Patient is argumentive (sic) and threatening towards staff. Patient is alert and oriented self but confused about time and place. A/P (Assessment/Plan) Dementia Alzheimer's Type Late Onset. Mood Disorder. Patient will benefit with Depakote 125mg PO (by mouth) TID (three times a day) for Mood and Will follow up for mood and medications.11/20/25 - R6's Quarterly MDS documented that R6 had Non-Alzheimer's Dementia, Anxiety Disorder, Depression and Psychotic Disorder. In addition, R6 received antipsychotics on a routine basis,2/17/26 R6's Significant change MDS documented that R6 had Non-Alzheimer's Dementia, Anxiety Disorder and Psychotic Disorder. R6 continued to receive antipsychotics on a routine basis. 3/10/26 3:23 PM - A review of R6's clinical record lacked evidence of an updated PASRR evaluation when R6 was diagnosed with anxiety and psychotic disorders after her admission to the facility on 2/4/25. 3/12/26 2:22 PM - In an interview, E4 (SW) confirmed that he did not request an updated PASSR evaluation to the State PASRR authority.3/13/26 at 1:00 PM- Finding was reviewed with E1 (NHA) and E3 (ADON) during the exit conference.

Based on interview and review of clinical record and facility documentation, it was determined that for two (R1 and R2) out of three residents reviewed for accidents, the facility failed to ensure each resident received adequate supervision to remain free of accident hazards. For R1, the facility failed to identify that R1's left bed rail was a potential hazard. R1, a dependent resident with dementia, was identified with a change of condition on 7/18/25 and diagnosed with a left upper extremity fracture. The facility's investigation documented that R1 sustained the injury as an accidental contact with the bed enabler during care. As a result, R1 was harmed. R2, a severely cognitively impaired resident and dependent resident sustained a scalp laceration, and a subtle sacral fracture from a fall when she was left in the bathroom unsupervised. Findings include: An undated facility document entitled, Falls included, . The nurse and charge nurse are to be notified immediately, and the resident is not to be moved until assessed by a nurse unless otherwise directed. 2/28/22 - R2 was admitted to facility with diagnoses including but not limited to dementia, left eye absolute glaucoma (permanent vision loss), and difficulty walking. 3/2/22 – R2's fall care plan (revised 7/18/24) included, .At high risk for falls r/t [related to] gait/balance problems/ambulatory dysfunction. The interventions included, Anticipate and meet [R2's] needs. 1/16/24 – R2's fall care plan documented, Resident with poor safety awareness and impulse control. A review of R2's clinical record revealed the following history of falls: 2/24/25 – R2 sustained a fall in her room next to the bed. 3/12/25 – R2 sustained an unwitnessed fall in the lounge. 4/26/25 – R2 was found sitting on the floor of her room. 4/30/25 – R2 was found sitting on the floor next to her bed. 5/16/25 – R2 was found sitting on the floor next to her bed. 6/2/25 – R2 fell while walking unassisted out of the dining room. 6/14/25 – R2's quarterly fall assessment document a score of 80, indicating a high fall risk. R2's fall care plan lacked evidence of a person-centered care plan and interventions for the high fall risk. 8/3/25 – R2's quarterly MDS assessment documented a BIMS score of 00, indicating the inability to complete a cognitive assessment. This assessment also documented that R2 required minimum assistance with eating and was completely dependent on staff for all other activities of daily living. 8/30/25 2:41 PM – R2's clinical record documented, .S/P [status post] fall hit head, has a superficial laceration to the back of the right side of head that is 0.5cm. 8/30/25 7:40 PM – A facility reported incident submitted to the Division documented, Resident found on the floor in the bathroom of the third-floor day room. 8/30/25 7:47 PM – E8 (LPN) documented in R2's clinical record, At approximately 1400 [2:00 PM], staff reported an unwitnessed fall in the dining room immediately after lunch. Resident was noted on the floor in a seated/side-lying position with active bleeding from the head. This nurse arrived at 1402 [2:02 PM], activated post-fall protocol, and assessed the resident in place. Linear laceration to scalp. approximately 0.5 cm length, bleeding scant. 8/30/25 4:50 PM – R2's clinical record documented, On-call doctor called back, and new order received. Send to ER for evaluation.The resident was sent to the ER [emergency room.] The facility failed to implement appropriate emergency interventions in a timely manner for R2's unwitnessed fall with obvious head injury. R2 fell at approximately 2:00 PM and was sent to the emergency room at 4:50 PM, 2 hours, 50 minutes later. 8/31/25 1:15 AM – R2 returned from the hospital with a diagnosis of a head laceration and a subtle non-displaced vertical fracture to the right of the sacrum. 10/21/25 1:30 PM – A review of the facility's post-fall investigative record revealed, During the multidisciplinary care conference for [R2] on 9/11/25, it was brought to the attention of staff that the fall occurred in the bathroom after the resident was left unattended by the CNA [E7.] The CNA misrepresented the location and details of the incident. The facility's new investigation revealed that R1 was left unattended in the bathroom while the CNA went down the hall to obtain an incontinent brief. When she returned, R2 had fallen to the floor. E7 put R2 into the wheelchair and told the supervisor that [R2] had fallen in the dining room. The facility failed to thoroughly investigate the location of the fall until 12 days after the event. 10/21/25 12:30 PM – During an interview, the Surveyor asked E8 (LPN) if she had seen or assessed R2 post fall, E8 stated, No, I was on break, and I did not see her on the floor after the fall. The RN supervisor [E5] told me that she had fallen. 10/21/25 1:00 PM – During an interview, the Surveyor asked E5 (RN supervisor) how she was she became aware that R2 had sustained a fall. E5 stated, The aide [E7] came to the second floor and told me that the resident had fallen. I went up to the third floor and saw [R2] sitting in the wheelchair in the common area. The Surveyor asked E5 about emergency intentions for R2's obvious head injury, E5 stated, I started neuro checks and waited for the on-call doctor to call back. The facility failed to have R2 assessed by a registered nurse after the unwitnessed fall prior to getting back into the wheelchair 10/21/25 2:00 PM – During an interview E3 (ADON) stated, All of the aides know that any resident who is an assist of one with transfers should not be left alone in the bathroom. It's documented on the care plan and on the resident's care sheet in the closet. The Surveyor asked E3 if the aides had access to the residents' care plans in the electronic records, E3 stated, No, but they can ask the nurse. A review of R2's care plan and care sheet lacked evidence of documentation for staff to remain the bathroom with her to prevent falls. The facility failed to ensure that R2 had adequate supervisor to prevent falls with injuries despite the extensive history of falls. 10/24/25 12:00 PM - Findings were confirmed with E2 (DON). 10/24/25 2:30 PM – Finding was reviewed during the exit conference with E1 (NHA) and E2 (DON). 1. Cross refer to F580, F657 example 1, F700 example 1, and F776 Review of R1's clinical record revealed: 3/7/23 – R1 was care planned for left bed enabler for assistance to change position while in bed. Interventions included: -Document that the enabler is being used to help assist resident to change position in bed; -Ensure a valid consent is on chart prior to initiating enabler; and -Obtain order for enabler. 10/26/23 – A physician's order stated, TRANSFER STATUS: resident is a Hoyer lift with 2 staff assist with transfers BED MOBILITY: resident is a 1 assist with bed mobility. 7/3/24 – A physician's order stated, May use a left sided bed enabler to assist with turn and repositioning. 5/1/25 3:19 PM – R1's side rail assessment documented by C1 (contracted PT): 1. Has Resident expressed a desire to have side rails raised while in bed for their own safety and/or comfort? Yes. rolling and positioning. 2. Does the resident have fluctuations in levels of consciousness or a cognitive deficit? Yes. dementia. 3. Does the resident have any visual deficits? Yes. glaucoma, legally blind. 4. Is the resident able to get in/out of bed safely? Yes. 7. Is the resident having problems with balance or poor trunk control? Yes. enabler for sitting balance. 8. Does the resident use the side rails for positioning or support? Yes 9. Does the side rail help the resident rise from a supine position to a sitting/standing position? Yes. 14. Is there a risk to the resident if side rails are used? No 16. Is the resident alert and oriented? Yes 17. Is the resident currently using a side rail for positioning or support? Yes 18. Would a side rail improve independence for transfers in/out of bed? Yes 18b. Side Rail Type and Location: Left side enabler. 5/17/25 – The quarterly MDS assessment documented that R1's vision was severely impaired; BIMS score of 3/15 (cognitively impaired); functional limitation in range of motion revealed no impairments of upper and lower extremities; was dependent for toileting hygiene/upper body dressing/roll left and right/sit to lying/lying to sitting on side of bed/chair to bed transfer/shower transfer; always incontinent of bowel and bladder; no pain presence in the last 5 days; and used bed rail daily. This assessment documented that only the resident participated in the assessment process, and not R1's POA. 7/16/25 11:00 AM – R1's Multidisciplinary Care Conference form documented that R1 was alert and oriented x1, able to communicate her needs, incontinent of bowel and bladder, dependent on staff for all ADLs (activities of daily living), required Hoyer lift for transfers, wheelchair bound, legally blind, and complaining of pain often. and to schedule Tylenol for pain management. R1's POA attended by phone on 7/17/25. 7/17/25 – A physician's order was entered to administer Tylenol two times a day for pain. R1 received her first dose at 8 PM on 7/17/25. 7/17/25 and 7/18/25 – The CNA Documentation Survey Report revealed that R1 was dependent for rolling left and right, incontinent of bowel and bladder and turned and repositioned every two hours. 7/18/25 1:29 AM – A nursing note documented that R1 had no complaint of bodily (sic) pain at present. 7/18/25 12:48 PM – A nursing note documented, Resident noted with increased pain in L [left] elbow and decreased range of motion to LUE [left upper extremity]. No obvious swelling or deformity noted at this time. NP [Nurse Practitioner] & [and] POA made aware. X-ray of L elbow ordered. 7/18/25 – A physician's order stated, Elbow X-ray: Including the humerus, radius, and ulna, for fractures, dislocations, or deformities R/T [related to] increased pain and decreased movement. STAT for Increased pain and decreased movement of LEFT arm. 7/18/25 5:49 PM – A nursing note documented, X-ray of left arm completed. Awaiting results to come back. The following nursing notes revealed: 7/19/25 3:32 AM - No complaints of pain this shift. Still waiting for xray (sic) results of left arm. 7/19/25 10:05 AM - LATE ENTRY. This RN called [name of x-ray company] at 1000 [10 AM], and was told that the X-ray results still pending. They stated that they are running late, once they get the results, and they'll fax the results to the facility. Family made aware. 7/19/25 3:48 PM - PRN Tylenol administered for pain level of 10/10. 7/19/25 8:57 PM - Resident still continues with pain to L arm, slightly swollen. Pain relieved with Tylenol, given around 1545 [3:45 PM] and 2045 [8:45 PM]. Xray results still pending as of this time. 7/20/25 1:34 AM - . Xray of left arm results still pending. 7/20/25 9:45 AM - The nurse called [name of x-ray company] at 0945 [9:45 AM], and they stated that the X-ray result is not available yet. They will let us know in 2 to 3 hours. 7/20/25 4:22 PM - This RN got a phone call from [name of x-ray company] at 1610 [4:10 PM], and was told that the X-ray results are still not available. They stated that they hoped to get the result by 9 PM today. 7/20/25 6:40 PM – A nursing note documented, The resident's [name of POA] came in to see the resident this afternoon. was very upset to know the X-ray results still pending. was so concerned. asked to send the resident to ER to get the X-ray. MD made aware. New MD order received at 1650 [4:50 PM]. Send to ER for evaluation and treatment for left elbow pain and decreased range of motion to LUE [left upper extremity]. The resident was sent to ER by ambulance at 1710 [5:10 PM]. 7/20/25 8:20 PM – While R1 was in the ER, the mobile x-ray results were faxed to the facility and documented acute nondisplaced fracture of the left humeral neck and no acute abnormality at the elbow. According to the facility's investigation, when the ER called to report that R1 was going to return and there was no elbow fracture, the facility informed the ER about the fracture identified in the mobile x-ray results. The ER cancelled R1's transfer back to the facility and conducted further x-rays, which revealed a fracture. 7/21/25 12:20 AM – The ER's x-ray of R1's left humerus revealed that there was an impacted fracture of the surgical neck of the humerus. 7/25/25 – The facility's five-day follow-up to the State Agency documented that .based on the review of staff statements, timing, and the location/pattern of the injury, it is feasible that the resident sustained the injury as an accidental contact with the bed enabler during care. 10/22/25 12:58 PM – During an interview, E9 (LPN) stated that staff have to move/roll the resident in bed. E9 stated that R1 would always have her left elbow bent and would rest her left hand on her stomach. E9 stated that R1 would ask for Tylenol for knee pain or body aches and never complained about her left arm before the fracture. E9 confirmed that R1 was unable to get out of bed independently. 10/22/25 3:30 PM – During an interview, E10 (CNA) stated that she was assigned to provide care for R1 on 7/18/25 day shift. E10 stated that when she touched R1's left arm, the resident screamed and told her that it hurts. E10 stated that she immediately knew something was wrong as this was an unusual response of R1. E10 stated that she immediately reported this complaint of pain to the assigned nurse. 10/24/25 11:00 AM – During an interview, E11 (CNA) stated that R1 could not turn in bed. E11 stated that R1 always kept her hands together and left elbow bent. The facility failed to identify R1's right sided bed rail as a potential accident hazard. 10/24/25 2:30 PM – Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).

Based on interview and review of clinical record, it was determined that for one (R1) out of three residents reviewed for accidents, the facility failed to notify the on-call provider of R1's delayed STAT x-ray results ordered 7/18/25. Findings include:Cross refer to F689, example 1 Review of R1's clinical record revealed: 7/18/25 - A physician's order stated to obtain a STAT elbow x-ray for R1's increased pain and decreased movement of left arm. A nursing note, at 5:49 PM, documented that the x-ray was completed in the facility. 7/20/25 8:20 PM - R1's mobile STAT x-ray results were finally read and faxed to the facility revealing a left humeral neck fracture. 10/23/25 11:00 AM - During an interview, E6 (RN) stated that she called the mobile x-ray company on 7/19/25 and was told they were running behind. E6 stated that she did not notify the on-call provider. E6 stated that when she returned to work on 7/20/25 evening shift and found out the results were still not received. E6 stated R1's POA was very upset and requested R1 to be sent to the ER. E6 stated that the on-call provider was notified and an order to send R1 to the ER (emergency room) for an x-ray was obtained. R1 was sent to the ER at 5:10 PM. The facility lacked evidence that R1's physician or an on-call provider was notified that the physician ordered STAT x-ray results were not received until approximately 48 hours later. 10/24/25 2:30 PM - Finding was reviewed during the exit conference with E1 (NHA) and E2 (DON).

Based on observation, interview, record review and other facility documentation, it was determined that for one (R2) out of three residents sampled for falls, the facility failed to thoroughly investigate an allegation of neglect when R2 was left unattended in the bathroom and had a fall. Findings include: An undated facility document entitled, Falls included, . The nurse and charge nurse are to be notified immediately, and the resident is not to be moved until assessed by a nurse unless otherwise directed.2/28/22 - R2 was admitted to facility with diagnoses including but not limited to dementia, left eye absolute glaucoma (permanent vision loss), and difficulty walking.1/16/24 - R2's fall care plan documented, Resident with poor safety awareness and impulse control.8/30/25 2:41 PM - R2's clinical record documented, .S/P [status post] fall hit head, has a superficial laceration to the back of the right side of head that is 0.5cm.8/30/25 7:40 PM - A facility reported incident submitted to the Division documented, Resident found on the floor in the bathroom of the third-floor day room.8/30/25 7:47 PM - E8 (LPN) documented in R2's clinical record, At approximately 1400 [2:00 PM], staff reported an unwitnessed fall in the dining room immediately after lunch. Resident was noted on the floor in a seated/side-lying position with active bleeding from the head.10/21/25 1:30 PM - A review of the facility's post-fall investigative record revealed, During the multidisciplinary care conference for [R2] on 9/11/25, it was brought to the attention of staff that the fall occurred in the bathroom after the resident was left unattended by the CNA [E7.] The CNA misrepresented the location and details of the incident. The facility's new investigation revealed that R2 was left unattended in the bathroom while the CNA went down the hall to obtain an incontinent brief. When she returned, R2 had fallen to the floor. E7 put R2 into the wheelchair and told the supervisor that [R2] had fallen in the dining room.10/21/25 2:30 PM - During an interview, the Surveyor asked E8 (LPN) if she had seen or assessed R2 post fall, E8 stated, No, I was on break, and I did not see her on the floor after the fall. The RN supervisor [E5] told me that she had fallen.10/22/25 2:45 PM - During an interview, the Surveyor asked E6 (3-11RN supervisor) how she became aware of the location of R2's fall. E6 stated, The day shift supervisor [E5] told me that the aide said that the resident had fallen in the bathroom. The location was on the report that I submitted to the state.The facility failed to thoroughly investigate the location of the fall until 12 days after the event. 10/24/25 12:00 PM - Findings were confirmed with E2 (DON).10/24/25 2:30 PM - Finding was reviewed during the exit conference with E1 (NHA) and E2 (DON).

Based on interview and review of clinical record, it was determined that for one (R1) out of three residents reviewed for accidents, the facility failed to ensure a person-centered care plan was initiated and implemented that included measurable objectives and timeframes to meet R1's medical need with respect to the resident's pacemaker. Findings include: Review of R1's clinical record revealed: 1/31/23 - R1 was admitted to the facility with diagnosis that included, but was not limited to, dementia, legal blindness and sick sinus syndrome. 1/31/23 2:15 PM - The Resident Assessment-Data Collection Form documented that R1 had a pacemaker on her left upper chest. 1/31/23 - R1 was care planned for a pacemaker r/t [related to] sick sinus syndrome with goals and interventions that included: Goals:-will remain free from s/sx [signs/symptoms] of pacemaker malfunction or failure through the review date.Interventions:-Monitor vital signs monthly and as needed. Notify MD (medical doctor) of significant abnormalities. Notify MD of significant abnormalities.-Monitor/document/report PRN (as needed) any s/sx of altered cardiac output or pacemaker malfunction: dizziness, syncope (fainting), difficulty breathing (dyspnea), pulse rate lower than programmed rate, lower than baseline B/P (blood pressure). The facility failed to ensure that R1's pacemaker care plan was person-centered. Specifically, the care plan lacked R1's pacemaker's function information (type, settings/rate, battery status); education for the resident/family on the purpose and function of the pacemaker, signs and symptoms of pacemaker complications and the importance of follow-up appointments with R1's Cardiologist; and monitoring of skin integrity at location site. 10/23/25 approximately 3:00 PM - During an interview, surveyor reviewed that R1's pacemaker care plan was not person-centered with E2 (DON). 10/24/25 2:30 PM - Finding was reviewed during the exit conference with E1 (NHA) and E2.

Based on observation, interview and review of clinical record, it was determined that for three (R1, R4 and R5) out of seven residents reviewed for bed rails, the facility failed to review and revise each resident's bed rail care plan to ensure they were person-centered to meet their medical needs and included, but were not limited to, ongoing assessment and monitoring of the bed rail usage. Findings include:1. Review of R1's clinical record revealed: 3/7/23 - R1 was care planned for left bed enabler for assistance to change position while in bed. Interventions included:- Document that the enabler is being used to help assist resident to change position in bed;-Ensure a valid consent is on chart prior to initiating enabler; and-Obtain order for enabler. R1's bed rail care plan lacked evidence of the monitoring and supervision to be provided during the use of the bed rail; ongoing assessment to make sure that the bed rail was used to meet the resident's needs; ongoing evaluation of risks; identification of the person who will determined when the bed rail will be discontinued, and the identification and interventions to address any adverse effects of the bed rail use. 10/23/25 approximately 3:00 PM - During an interview, finding was reviewed with E2 (DON). 2. Review of R4's clinical record revealed: 5/17/24 - R4 was care planned for right side rail enabler to assist with changing position while in bed. Interventions were:- anticipate and meet the resident's needs;-document the rail is being used to help assist the resident in changing position;-ensure a valid consent is in the chart prior to initiating rail;-obtain order for rail enabler; and-PT referral as ordered by MD. R4's bed rail care plan lacked evidence of the monitoring and supervision to be provided during the use of the bed rail; ongoing assessment to make sure that the bed rail was used to meet the resident's needs; ongoing evaluation of risks; identification of the person who will determined when the bed rail will be discontinued, and the identification and interventions to address any adverse effects of the bed rail use. 10/23/25 approximately 3:00 PM - During an interview, finding was reviewed with E2 (DON). 3. Review of R5's clinical record revealed: 7/3/24 (last revised) - R5 was care planned for . right sided bed enabler for assistance to change position while in bed. Interventions were:- anticipate and meet the resident's needs;-document the rail is being used to help assist the resident in changing position while in bed; and-ensure a valid consent is in the chart prior to initiating rail. R5's bed rail care plan lacked evidence of the monitoring and supervision to be provided during the use of the bed rail; ongoing assessment to make sure that the bed rail was used to meet the resident's needs; ongoing evaluation of risks; identification of the person who will determined when the bed rail will be discontinued, and the identification and interventions to address any adverse effects of the bed rail use. 10/23/25 7:20 AM and 11:38 AM - Despite R5's care plan for a right sided bed enabler, observations of R5 in bed revealed that bilateral bed rails in the up position were still being used. 10/23/25 approximately 3:00 PM - During an interview, finding was reviewed with E2 (DON). 10/24/25 2:30 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2.

Based on observation, interview and review of clinical records and facility documentation, it was determined that for three (R1, R4 and R5) out of seven residents reviewed for bed rails, the facility failed to ensure that each residents' bed rail was used appropriately with ongoing monitoring. Additionally, the facility lacked evidence that preventive maintenance/safety checks were being done for bed rails being used in the facility. Findings include: The facility's policy and procedure entitled Bed Enabler, last updated 10/28/23, stated, Objective: 1. To assist with bed mobility. 2. To assist with transfer from bed to chair. Procedure:1. Physical therapy will determine the potential benefit of bed enabler use for bed mobility and/or transfers.2. Obtain an order for bed enablers from the physician.3. Obtain informed consent from the resident and/or resident representative.4. The Maintenance Department will be asked to install a bed enabler on the side/sides of the bed as specified by the physician order in Point Click Care.5. Update the care plan.6. The resident will be reassessed at least every six months for continued bed enabler use by physical therapy.7. If the bed enabler is discontinued, the bed enabler will be removed from the bed, cleaned with disinfectant, dry thoroughly and placed in a designated storage area by the Maintenance department. 1. Cross refer to F689, example 1 Review of R1's clinical record revealed: 3/7/23 - R1 was care planned for left bed enabler for assistance to change position while in bed. Interventions included:- Document that the enabler is being used to help assist resident to change position in bed;-Ensure a valid consent is on chart prior to initiating enabler; and-Obtain order for enabler. 7/3/24 - A physician's order stated, May use a left sided bed enabler to assist with turn and repositioning. 5/1/25 3:19 PM - R1's side rail assessment documented by C1 (contracted PT):1. Has Resident expressed a desire to have side rails raised while in bed for their own safety and/or comfort? Yes. rolling and positioning.2. Does the resident have fluctuations in levels of consciousness or a cognitive deficit? Yes. dementia.3. Does the resident have any visual deficits? Yes. glaucoma, legally blind.4. Is the resident able to get in/out of bed safely? Yes.7. Is the resident having problems with balance or poor trunk control? Yes. enabler for sitting balance.8. Does the resident use the side rails for positioning or support? Yes9. Does the side rail help the resident rise from a supine position to a sitting/standing position? Yes.14. Is there a risk to the resident if side rails are used? No16. Is the resident alert and oriented? Yes17. Is the resident currently using a side rail for positioning or support? Yes18. Would a side rail improve independence for transfers in/out of bed? Yes18b. Side Rail Type and Location: Left side enabler. Despite the 5/1/25 Side Rail Assessment, R1's 5/17/25 quarterly MDS assessment documented that R1 was dependent for toileting hygiene/rolling left and right/sitting to lying/lying to sitting on side bed/chair to bed transfers. 7/16/25 11:00 AM - The Multidisciplinary Care Conference form documented that R1 was dependent on staff for all ADLs and required a Hoyer lift for transfers. There was no evidence that R1's bed rail was reviewed to ensure it was still appropriate for the resident. 2. Review of R4's clinical record revealed: 8/19/24 - A physician's order stated, May use right side bed enabler to assist with turn and repositioning. 8/23/24 - A physician's order stated, . Bed Mobility: resident is an assist of 1 with bed mobility. 9/21/25 - The quarterly MDS assessment documented that R4 had a BIMS of 15/15 (cognitively intact); was dependent for toileting hygiene/upper body dressing/roll left and right/sit to lying/lying to sitting on side of the bed/sit to stand/chair to bed transfer/shower transfer; and daily use of bed rail. Review of the October 1-21, 2025 CNA Documentation Survey Report revealed that for 56 out 63 shifts, staff documented that R4 was dependent for rolling left and right in bed. 10/23/25 1:15 PM - An observation during care revealed that R4 had a right sided bed rail in the up position. E10 (CNA) was observed removing the therapy carrot device from R4's left contracted hand. During incontinent care, R4 required two staff assist for rolling left and right in bed. R4 was observed and the resident stated that he was not able to grab the right bed rail with his left contracted hand to roll in bed. Immediately after the observation, E10 confirmed that R4 required staff assistance for turning in bed. 3. Review of R5's clinical record revealed: 7/3/24 - A physician's order stated, May use right side bed enabler to assist with turn and repositioning. 10/23/25 7:20 AM - Despite having a physician's order for only one bed rail, an observation of R5 in bed revealed bilateral bed rails in the up position and head of bed elevated approximately 30 degrees. R5 was sleeping with the right elbow bent and laying on top of the right sided bed rail and right hand under his head. The left hand was in a fist and laying on his chest. 10/23/25 11:05 AM - During an interview, E12 (ES) confirmed that the facility did not have evidence of preventive maintenance/safety checks of the bed rails that are currently being used in the facility. E12 provided the manufacturer's guidelines for the bed rails being used. 10/23/25 11:38 AM - An observation during incontinent care revealed that R5 had bilateral bed rails in the up position. R5 was observed in bed with the right elbow bent and laying on top of the right-sided bed rail. During incontinent care, R5 required two staff assist. R5 was observed grabbing and holding onto the left bed rail with his right hand during incontinent care. However, R5 was not able to use the right sided bed rail for turning during care with his left hand and required two staff assist for turning and repositioning. The facility failed to ensure each residents' bed rail(s) were used appropriately with ongoing monitoring. In addition, the facility lacked evidence that preventive maintenance/safety checks were being completed of all bed rails being used in the facility. 10/24/25 2:30 PM - Findings were reviewed during the exit conference with E1 (NHA) and E2 (DON).

Based on interview and review of clinical records and facility documentation, it was determined that for one (R1) out of three residents reviewed for accidents, the facility failed to meet the acute medical needs of R1 with regard to obtaining the timeliness of STAT x-ray results on 7/18/25. Findings include: Review of R1's clinical record revealed: 7/18/25 - A physician's order stated, Elbow X-ray: Including the humerus, radius, and ulna, for fractures, dislocations, or deformities R/T [related to] increased pain and decreased movement. STAT for Increased pain and decreased movement of LEFT arm. 7/20/25 8:20 PM - Approximately 48 hours later, R1's mobile x-ray results were faxed to the facility and documented an acute nondisplaced fracture of the left humeral neck. 10/23/25 12:18 PM - During an interview, C2 (Representative with X-ray company) stated that STAT x-ray results are usually completed in two hours on the same day ordered. C2 confirmed that on the weekend of 7/18/25 through 7/20/25, the company had limited staff coverage for reading x-rays. C2 stated that the x-ray company notified the facility on 7/20/25 at 2:28 PM that the next available reading would be on 7/20/25 approximately 8:30 PM. 10/24/25 2:30 PM - Finding was reviewed during the exit conference with E1 (NHA) and E2 (DON).

Based on interview, record review and review of other documentation as indicated, it was determined that for one (R462) out of three residents reviewed for abuse, the facility failed to ensure that R462 was free from physical abuse by R461 resulting in harm when R462 obtained a broken nose and laceration to the bridge of nose. Due to the facility's corrective measures completed on 5/28/24, the facility was notified that R462's incident was a harm past non-compliance. Findings include: Cross refer F684 The facility's undated policy, titled, Freedom from Abuse, Neglect, Mistreatment, Serious Injury, Misappropriation of Property, Exploitation, Injury of Unknown Origin and Crime documented, .Definitions: 1. Abuse - the infliction of injury .with resulting physical harm, pain or mental anguish .and includes .a. Physical abuse - the unnecessary infliction of pain or injury . to a . resident . includes hitting, kicking, slapping . Review of R462's record revealed: 3/6/24 - R462 was admitted to the facility with diagnoses including dementia. 3/15/24 - R462's admission MDS assessment revealed that R462's cognition was severely impaired with a BIM's score of 6. R462 had no mood or behavioral symptoms exhibited during the review period. Review of R461's record revealed: 5/6/24 - R461 was admitted to the facility with diagnoses including depression, insomnia and adult personality and behavior disorder. 5/6/24 - R461 had a physician's order for safety checks every 2 hours every shift. 5/7/24 - R461 was care planned for impaired thought process related to dementia with interventions including administering medications as ordered, cuing, reorienting and supervising as needed. 5/10/24 - R461 was care planned for verbal and physical aggressive behavior towards staff related to dementia. R461's interventions included: - R461's triggers for physical aggression are night shift hours .R461's behaviors are de-escalated by snacks and activities like using fidget books; - analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; - assess and address for contributing sensory deficits; - assess and anticipate R461's needs for food, thirst, toileting needs, comfort level, body positioning, pain, etc. - give the resident as many choices as possible about care and activities; - modify environment such as adjusting room temperature to comfortable level, reducing noise, dimming lights, placing familiar objects in room, keeping door closed, etc. and; - assess resident's coping skills and support system. - assess R461's understanding of the situation .allow time to express self and feelings towards the situation 5/10/24 - R461's care plan interventions for behavioral problems of paranoia and making false accusations included: - anticipate and meet the resident's needs; - assist R461 to develop more appropriate methods of coping and interacting . encourage the resident to express feelings appropriately; - caregivers to provide opportunity for positive interaction, attention .stop and talk with him when passing by; - explain all procedures to R461 before starting and allowing the residents a few minutes to adjust to changes; - if reasonable, discuss the resident's behavior . explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; - intervene as necessary to protect the rights and safety of others .approach/speak in a calm manner. divert attention .remove from situation and take to alternate location as needed. - praise any indication of the resident's progress/improvement in behavior and; - provide a program of activities that is of interest and accommodates residents' status. 5/16/24 - R461's Admission MDS revealed that R461 had a BIMS score of 6 with severe cognition impairment, was feeling down and depressed, tired and having little energy for 7-11 days. In addition, R461 displayed physical and verbal behavioral symptoms occurring 1-3 days and had significant risk of physical illness or injury interfering with his care, putting others at significant risk of physical injury and intrusion on the privacy or activity of others during the review period. 5/16/24 - R461 had a physician's order for safety checks every 30 minutes while in bed . If resident awakes, allow him to exit room and offer preferred activities. 5/16/24 - R461's physical aggression care plan intervention was updated to include safety checks every 30 minutes while resident is in bed .if [R461] wakes (sic), allow [R461] to get dressed if he desires to do so and allow [R461] to enter common area with preferred activities. 5/18/24 11:20 PM - A nurse progress note documented, . (Registered Nurse) called (sic) to (room #) for resident [R462] altercation and noted to be seated in chair actively bleeding from face with roommate [R461] in front of him. Residents easily separated and this resident (sic) assessed. No c/o (complaints of pain) nose very swollen and bruised and lacerations noted on bridge of nose and below left eye . 5/19/24 3:04 AM - A facility incident report submitted to the State Agency documented that on 5/18/24 at 11:20 PM, .found residents in altercation . CNA called for help and residents were separated. Both residents were sent to ED (Emergency Department) for further evaluation. 5/19/24 12:25 AM - A hospital ED (Emergency)Teaching Physician Note documented, 82 - year old white male with dementia .now status post traumatic injury to his face by a punch from his roommate .has an injury to the nose .he did feel somewhat woozy (dizzy) . Impression: Laceration to the bridge of the nose/nasal fracture. 5/23/24 - A facility 5 day follow up summary submitted to the State Agency documented, .the alleged perpetrator [R461] was striking the alleged victim and stated, 'You were stealing my stuff' .Upon assessment .[R461] was actively bleeding from his face .Lacerations noted to the bridge of the nose and under the left eye. 2/18/25 2:00 PM - In an interview, E2 (DON) stated that some information about R461's aggressive behaviors from outside facility was not relayed to them prior to R461's admission on 5/6/24. The facility failed to ensure that R462 was free from physical abuse by R461 when R461 struck 462 on the face which resulted in R462's broken nose and laceration to the bridge of nose. 2/18/25 3:00 PM - During interview, FM1 (Family Member) stated, They (facility) advertised that they have a memory care unit. We checked the place before [R461's] admission and we were told that they will have somebody sit outside of the room and leave the door open to keep an eye on him specially when [R461] gets up and goes near the roommate. I don't know what the circumstance was when the hitting happened but I guess nobody was out there to keep an eye on him when he got up and became physically aggressive to his roommate . 2/19/25 10:00 AM - Findings were discussed with E1 (NHA) and E2 (DON). 2/19/2 3:47 PM - In an email correspondence, E1 submitted to the Surveyor documentation of the corrective action plan with correction completed 5/28/24 at 3:00 PM. Corrective Actions: 1. Education for staff began on 5/20/24 on Resident - to - Resident Mistreatment (RRM), which included risk factors of RRM, ways to de-escalate residents, documentation of behaviors, monitoring and provider notification. 2. QAPI 2nd quarter review. 3. Strengthen of the admission screening process: Evaluating each potential resident for: - History of aggression, violence and other behavioral issues. - Psychiatric diagnosis and treatments. - History of substance abuse or withdrawal symptoms. - Prior incidents of resident - to - resident aggression in other facilities. Interdisciplinary Review Process: - Admission team (including DON and social services) must review hospital discharge summaries, psychiatric evaluations, and legal history before approval or the last 6 months, or if potential admission has been in their current facility for < (less) 6 months, all notes available. - History of assault, involuntary psychiatric hospitalization s require further discussion before acceptance. Enhanced Admission Documentation and Communication - Improved Handoff Communication: Require detailed behavioral history reports from referral sources before admission approval, at least 6 months of notes or all notes available if resident at current facility < 6 months. -Admission Care Plan Implementation: Within 48 hours of admission, develop an individualized care plan that includes safety interventions for at - risk residents. Monitoring and Compliance - Admission Audits: Review 100% of admission, focusing on behavioral risk assessments and compliance with the new process. No immediate action required related to facility correction and no further occurrences after the incident on 5/18/24. This was verified by interviews with staff about resident - to - resident physical abuse education, spot inspection for resident interactions and inspection of the facility abuse incident reports. 2/19/25 10:30 AM - Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference.

Based on record review and interview, it was determined that for one (R461) out of one sampled resident, the facility failed to ensure the physician's order to administer tamsulosin HCL, aripiprazole and escitalopram oxalate. Findings include: Cross refer F600 5/6/24 - R461 had a physician's order for tamsulosin HCL give 2 capsules to equal 0.8 mg in the evening for enlarged prostrate. 5/6/24 (discontinued 5/13/24) - R461 had a physician's order for aripiprazole 5 mg give 2.5 mg (1/2 tablet) in the evening for depression. 5/7/24 - R461 had a physician's order for escitalopram oxalate 10 mg 1 tablet in the morning for depression. 5/13/24 - R461 had a physisian's order for aripiprazole 5 mg 1 tablet by mouth at bedtime for depression. 2/18/25 10:00 AM - A review of R461's May 2024 Medication Administration Record revealed the following missing medication doses: 6 pm - tamsulosin HCL 0.8 mg - one out of 12 missed dose on 5/8/24; 6 pm - aippirazole 2.5 mg - four out of seven missed doses on 5/6/24-5/9/24; 8 pm - aripiprazole 5 mg - five out of six missed doses on 5/13/24 - 5/17/24; 8 am - escitalopram oxalate - two out of 11 missed doses on 5/15-17/24. 2/18/25 10:20 AM - A review of nurse progress notes from 5/6/24 through 5/19/24 revealed the following: - 5/6/24 7:39 PM - awaiting delivery from pharmacy, pharmacy notified; - 5/7/24 7:45 PM - awaiting pharmacy delivery; - 5/8/24 7:26 PM - awaiting delivery; - 5/8/24 7:29 PM - awaiting delivery; - 5/9/24 6:14 PM - awaiting delivery; - 5/13/24 7:55 PM - awaiting delivery; - 5/14/24 8:00 PM - awaiting delivery; - 5/15/24 8:57 AM - not available; - 5/15/24 10:08 PM - unavailable; - 5/16/24 8:58 AM - none available, attempted to order; - 5/16/24 6:05 PM - on order; - 5/17/24 7:35 PM - awaiting order. 2/18/25 10:47 AM - In an interview, E3 (ADON) confirmed that R461 missed all those doses on the dates and times identified by the surveyor. E3 further stated that R461's son [FM1] signed a facility Pharmacy Services Agreement on 5/6/24 that R461's medications will be filled by the facility and that the facility pharmacy provider was not able to fill the medications as indicated. 2/18/25 1:18 PM - During interview, E5 (RN, SW) stated that during R461's admission to the facility, .We were not aware that [R461's] prescriptions were to come from [Pharmacy 2], another provider with insurance issues which caused the delay in obtaining the scripts and availing the medications. I was calling [Pharmacy 2] almost everyday to follow up on [R461's] prescriptions because [Pharmacy 1], our facility pharmacy provider, could not fill due to insurance . [Pharmacy 2] finally sent the prescriptions to us by mail on 5/15/24 .When asked if the facility notified the attending physician regarding the delay in R461's medication delivery and that R461 was missing multiple doses, E5 stated, I spoke to the NP (E9) about it for the first time on 5/8/24. I asked her to write a script for [R461's] meds to be faxed to [Pharmacy 2]. When her script was sent over, we learned from the (Pharmacy 2] that the scripts were not accepted because the meds had to be prescribed by their [Pharmacy 2] physician [Physician 1] - so it was another cause of the delay because we had to look for [Physician 1] to write the scripts. 2/19/25 10:00 AM - Findings were discussed with E1 (NHA) and E2 (DON). 2/19/25 10:30 AM - Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference.

Based on interviews, record review, review of facility reported incidents (FRI), and review of the facility's policy, the facility failed to ensure residents were free from abuse for one of two residents reviewed for abuse (Resident (R) 2) out of a total sample of 26 residents. Findings include: Review of facility's policy titled, Freedom from Abuse, Neglect, Mistreatment, Serious Injury, Misappropriation of Property, Exploitation, Sexual Abuse, Injury of unknown origin and crime, dated ,d+[DATE], revealed [name of the facility] affirms that all persons admitted to the facility shall be treated with dignity and respect. Each resident is entitled to and shall receive appropriate and quality care, free of adverse preventable risks, consistent with their assessed needs and available resources. Staff shall be assured that resident care and treatment is administered in a safe, professional, and humane manner. Any instances of suspected, alleged, or witnessed resident abuse neglect mistreatment, serious injury, misappropriation of property, exploitation, sexual abuse, injury of unknown origin, and reasonable suspected crime must be reported by the covered individuals (owner, operator, employee, manager, agent or contractor of such long term care (LTC) facility) to facility administration or State survey agency and local law enforcement agency in the jurisdiction of the facility. Furthermore, not later than two hours after forming the suspicion if the event that causes the suspicion results in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. The nurse on duty at the time of the incident, or supervisor will submit an incident report to the office of long-term care residents' protection (OLTCRP) via their online portal. 1. Review of R312's undated Face Sheet, located in the resident's electronic medical record (EMR) under the Profile tab revealed R312 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and anxiety. Review of an Incident Note (facility provided) dated [DATE] revealed Called to R312's room because he was very agitated, and staff reported he struck his roommate [R2] on the right side of his cheek. R312 continued to strike out at staff who finally calmed R312 and removed his roommate [R2] from the room. Review of the facility provided Incident/Accident Report dated [DATE] revealed R312 noted with aggression and was reported that he hit his roommate [R2] on the face. 2. Review of R2's undated Face Sheet, located in the resident's EMR under the Profile tab revealed R2 was readmitted to the facility on [DATE] with a diagnosis including dementia and major depressive disorder (MDD). Review of R2's Progress Note (facility provided) dated [DATE] revealed R2 was struck by R312 on the right cheek while sitting in his wheelchair at 07:15 AM [7:15 AM]. Staff immediately moved R2 to a safe location. Right cheek is reddened but R2 denied pain at the time. Team health notified through voicemail and are awaiting a call back. Review of facility provided Incident/Accident Report dated [DATE] revealed R2 was sitting in his wheelchair when R312 became agitated and struck him on right cheek. Area was reddened. Interview with R2 on [DATE] at 09:00 AM, alert yet confused, said that nobody has hit him while he has been at the facility. He had no evidence of bruising on his skin. Review of Incident Reporting Application (initial reporting) dated [DATE] revealed Received report R312 noted with physical aggression towards R2. R312 noted hitting R2 on his right cheek and mouth. Residents were separated, redirected, and given snacks to calm down. R312 was later sent to the hospital for further evaluation and treatment. R2 was noted with abrasion on the right check and bruise to the lip. First aid administered, R2 denied pain and stated he was okay. Review of Witness Statement for Registered Nurse (RN) 1, dated [DATE], revealed Called to resident's room after resident hit R2 on left cheek. R312 very agitated and trying to hit staff who were trying to calm him down. Review of Witness Statement for Certified Nursing Assistant (CNA) 1 dated [DATE] revealed At 07:15 AM [7:15 AM], I was in the dining room when I heard the R2 from room [R2's room] calling for help, help me, help me. I ran to see what was going on with the resident. As I got to the room door, I saw the nurse and another CNA trying to calm and redirect R312 who was being aggressive hitting his roommate [R2] in the face. I asked R2 why he was calling for help and he said that his roommate [R312] was hitting him. R312's face was read (sic). I, the nurse, and another CNA redirected R312 to his bed and offered him snacks while we took his R2 to the dining room for breakfast. The charge nurse/supervisor was notified. Review of Investigation Follow-Up dated [DATE] revealed R2 was dressed and ready to be sent to the dining room when R312 struck him on his face. R2 was asked what happened he stated I do not know, R312 just hit me. R312 is noted with a red mark on right cheek, no other injuries observed. R2 denied pain and stated that I am fine. Separate R312 from R2 and room change. Review of Follow Up (5-day report) dated [DATE] revealed Resident altercation between R312 and R2-not issues prior to the incident-one resident hit another with a one two punch. R312 who punched other R2 had behavior concerns and had demonstrated aggressive, hitting behaviors. R312 with aggressive behaviors sent to the hospital for evaluation and medical management (remains in the hospital at this time). R2 who was hit in face has no complaints of discomfort or pain. Currently investigating room change to separate the two residents. Resident rounding and rooms change when necessary. Interview with Administrator on [DATE] at 10:30 AM, he said that R312 was sent out to the hospital for further evaluation after he hit R2 in the face. While R312 was at the hospital, R312 expired. Interview with CNA1 on [DATE] at 3:08 PM, she said that she did witness the incident when R312 hit R2. Said that R312 was walking on R2's side of the bedroom, staff redirected him several times without success, and R312 hit R2. Unable to recall where R2 was hit at. Said that R312 had a history of aggressive behavior toward staff, but not residents. During an interview on [DATE] at 3:15 PM, the Director of Nursing (DON) stated if there was a resident-to-resident altercation, she expected staff to intervene and separate the residents. After separating the residents, she expected staff to assess residents and give treatment to any resident that is hurt. The DON also stated she expected staff to send out the aggressive resident for evaluation. The DON further stated staff would notify her, so she could notify the appropriate agencies within two hours.

26190 Based on record review, interview and facility policy review, the facility failed to provide the resident and/or their responsible party a written transfer notice at the time the resident was transferred to the hospital; and failed to send a copy of the notice to the Long Term Care (LTC) Ombudsman for two residents (Resident (R) 54, and R312) of two reviewed for hospitalization s in a total sample of 26 residents. Findings include: Review of facility's updated policy titled, Discharge to Hospital/Another Long-Term Care (LTC) Facility, revealed To assure that comprehensive information regarding a resident's plan of care is communicated between facilities. Policy: 1. Obtain transfer or discharge order from the physician. 2. Notify the family and administration. 3. Complete Interagency Form B. Place in an envelope with the resident's name and the name of the receiving facility. When a resident is being transferred to another LTC facility. Send a copy of the immunization record. 4. Arrange for transport (unless accepting facility has arranged). 5. Notify the receiving facility of the resident's transfer and explain the resident's condition. 6. When determination is made that the resident is to be admitted to another facility: a. Notify administration b. Notify dietary c. Notify pharmacy d. Notify housekeeping 7. Contact the business office: a. Bed being held-put resident's belongings away neatly in room b. Bed not being held-Certified Nursing Assistant (CNA) to pack resident's belongings and check with the clothing sheet. Label all boxes, bags, suitcases with the resident's name and have maintenance put in storage until the family comes for the items. The policy did not entail being given written notices. 1. Review of R54's undated Face Sheet, located under the Profile tab of the electronic medical record (EMR) revealed R54 was admitted to the facility on [DATE]. Review of R54's Progress Notes located in the Progress Notes tab of the EMR revealed R54 was sent to the hospital on 10/15/23. Review of R54's EMR revealed no documented evidence that written notification regarding R54's transfer to the hospital was sent to R54's responsible party or sent to the Ombudsman. During an interview on 01/10/24 at 12:03 PM, the Long Term Care Ombudsman confirmed she had not received any notifications of the resident's transfer from the facility or any other resident transfer for the past year. During an interview on 01/10/24 at 1:00 PM, the Social Services Director (SSD) confirmed residents and/or resident's responsible party were not provided a written notice of transfer upon transfer to the hospital. During an interview on 01/10/24 at 1:50 PM, the Director of Nursing (DON) was asked about written notification of transfer being provided to R54's responsible party and the Ombudsman. The DON stated, upon resident transfer, nursing notified the resident's responsible party by telephone. The DON stated she was not aware of written resident transfer notifications being sent to the ombudsman. The DON said she did not know written notification of transfer needed to be completed and provided to the residents' responsible party and the ombudsman. 2. Review of R312's undated Face Sheet, provided by the facility, revealed R312 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and anxiety. Review of Incident Reporting Application (initial reporting) dated 12/09/22 revealed Received report R312 noted with physical aggression towards R2 .R312 was later sent to the hospital for further evaluation and treatment. Review of R312's electronic medical record (EMR) and thinned medical record revealed no documented evidence that a written transfer notice was provided to R312, R312's family, and/or Ombudsman. During an interview on 01/10/24 at 1:00 PM, the Social Service Director (SSD) confirmed the resident, family, and/or resident representative (RP) were not given a written notice of transfer. The SSD also indicated the Ombudsman is not notified of residents' transfers to the hospital. During an interview on 01/10/24 at 1:50 PM, the Director of Nursing (DON) confirmed that the facility's policy did not address providing written notification of transfer to the resident, family and/or RP. The DON also confirmed the policy did not address notification to the Ombudsman.

Based on record review, interview, and facility policy review, the facility failed to provide written information regarding the facility's bed hold policy to the resident and the resident's responsible party at the time of transfer or within 24 hours of the transfer for two of three residents (Resident (R) 54 and 312) reviewed for hospitalization s of a total sample of 26 residents. Findings include: Review of facility policy titled, Bed Hold (BH) Policy, (admission package) undated, revealed, A. Medical Assistance/Medicaid Residents. If the resident is transferred to a hospital by the order of a physician, [name of facility] will hold resident's bed for up to seven days commencing on the first day of leave, in accordance with Medicaid bed-hold policy. If a patient or resident is transferred out of a facility to an acute care facility or other specialized treatment facility, the facility must accept the patient or resident back into the facility when the resident no longer needs acute or specialized care and there is space available in the facility. If no space is available, the resident shall be accepted into the next available bed. B. Private Pay Residents. BH payment will be $150.00 per day. 1. Review of R312's undated Face Sheet, provided by the facility revealed R312 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and anxiety. Review of Incident Reporting Application (initial reporting) dated 12/09/22 revealed Received report R312 noted with physical aggression towards R2 .R312 was later sent to the hospital for further evaluation and treatment. No evidence in the electronic medical record (EMR) and/or thinned chart revealed that a bed hold notice was given to R312 and/or R312's family upon transfer to the hospital on 12/09/22. 2. Review of R54's undated Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed R54 was admitted to the facility on [DATE]. Review of R54's Progress Notes located in the Progress Notes tab of the EMR revealed R54 was sent to the hospital on 10/15/23. Review of R54's EMR revealed no documented evidence that the facility provided written information regarding the facility's bed hold policy to the resident and the resident's responsible party at the time of transfer or within 24 hours of the transfer. During an interview on 01/10/24 at 12:03 PM, the Long-Term Care Ombudsman stated she had concerns regarding the facility not sending her bed hold notices for the past year. Interview with Social Services Director (SSD) on 01/10/24 at 1:00 PM, confirmed no bed hold notices were given at time of transfer or within 24 hours of the transfer. During an interview on 01/10/24 at 1:50 PM, the Director of Nursing (DON) stated residents and their responsible parties were provided written information regarding the facility's bed hold policy upon admission. The DON stated information about the facility's bed hold policy had not been provided to residents and their responsible parties upon the resident's transfer to the hospital. At 2:30 PM, the DON stated the facility was using the bed hold policy for 30 days, not seven. 26190

Based on observation, record review, interviews, review of the facility's policies and procedures, and review of the police report, it was determined that the facility failed to provide adequate supervision and an environment as free of accident hazards as possible for one (R1) out of four (4) sampled residents. R1, a resident known with a behavior of wandering and assessed as an elopement risk was identified as missing on [DATE] at approximately 11:55 AM. At 2:07 PM, R1 was found outside, unresponsive, stiff, skin cold to touch, without a pulse, and was pronounced deceased at 2:43 PM. The facility failed to provide adequate supervision to ensure that R1 did not leave the facility unattended; she was found approximately two hours and 12 minutes later outside on the facility grounds without a pulse. The lack of established preventative maintenance measures for the wander management system and the exit alarms, in addition to the lack of trained staff on the timely implementation of the facility's elopement response posed an immediate jeopardy (IJ) for R1 and other residents who were assessed as elopement risks. This deficient practice placed R1 in IJ as it resulted in a serious adverse outcome as evidenced by R1 being found unresponsive without a pulse deceased . The IJ was identified on [DATE] at 6:00 PM and was abated on [DATE] at 4:00 PM. Findings include: The facility's Code Alert and Wander Guard use policy, dated [DATE], stated, .Procedure: 1. All residents will be assessed for elopement potential on admission and quarterly. 2. Any resident that is found to be an elopement risk will be placed on one of the lock units . The facility's policy and procedure titled Missing Person Policy (undated and followed by E3 [ADON] during the search of R1 on [DATE] ), stated, .B. Purpose: To find patient/resident as quickly as possible .D. Equipment: 1. Nurse in charge of patient/resident directs search or consults with director of nurses (sic), registered nurse, or administrator. 2. Missing patient/resident to be treated with same sense of immediacy as if it were a fire alarm code .E. Procedure: 1. Inform the nurse in charge of patient/resident when discovered missing. 2. Nurse's responsibility: a. Alert staff in building that a patient/resident is missing. b. Staff on all units immediately look for patient/resident making sure that all areas within building are searched. c. On telephone, call unit from which the patient is missing after area is thoroughly searched and report completed search .e. Direct search to facility grounds if it is determined that the patient/resident is not in (sic) building; remain in building and coordinate search (spend only few minutes searching the grounds). f. If patient/resident is not found immediately, call fire department or police and report that a patient/resident is missing. g. Notify family that patient/resident is missing . Review of R1's clinical record revealed the following: [DATE] - R1 was originally admitted to the facility with a diagnosis of dementia and she resided on the 3rd floor of the facility, a secured unit with a key pad entry for elevators and emergency exits. [DATE] - The facility initiated a care plan for elopement risk/wanderer related to R1's impaired safety awareness and as R1 wanders aimlessly. The goal was that R1 would not leave the facility unattended. Interventions included to monitor location of R1 multiple times throughout the shift, to place a Wander Alert bracelet on R1's right wrist and to check placement and function every shift. [DATE] - The Elopement Risk Assessment documented that R1 was at risk for elopement. [DATE] - The quarterly Minimum Data Set assessment stated that R1's daily decision making skills were severely impaired with a BIMS score of 3 and that R1 required the supervision of one staff person for transfers and walking on and off the unit. [DATE] through [DATE] day shift (7 AM to 3 PM) - Review of the Treatment Administration Record revealed that R1's Wander Alert bracelet was checked for proper placement and function. [DATE] - The facility's Incident Follow-up documentation, in addition to written staff statements revealed that at 11:00 AM on [DATE], R1 was observed in her room by E9 (LPN). At 11:55 AM on [DATE], E6, the assigned RN to R1 was unable to locate R1. E6 subsequently notified the charge nurse for the shift, E3 (ADON). E3's statement documented that E3 was notified at approximately 12:20 PM of a Code W (missing resident) by E6 and all staff began searching the building and the grounds. E3 contacted E2 (DON) at 1:06 PM and E1 (NHA) at 1:09 PM. E3 conducted a second search of the building. 911 was called at 1:40 PM and R1's family member (FM1) was notified that R1 was missing. During a search of the facility grounds, E3 (ADON) was met by Police Officer (PO1). R1 was found outside in the generator area leaning on a fence without a pulse. [DATE] 1:35 PM - The Police Report documented that the facility notified the Police Department that R1 was missing. Although R1 was at risk for elopement, the facility failed to provide adequate supervision to prevent R1 from eloping from the facility. It is unknown how R1 eloped from the facility. [DATE] 9:38 AM - An email from E1 (NHA) revealed that the facility did not have a written expectation for preventative maintenance of the Wander Alert and the emergency exit alarm systems to include how often functional testing and monitoring would be performed. E1 stated . We do fix things when an exit alarm is found to not function properly, but no written policy driving that practice. In response to this incident [[DATE]] we will be adding monthly function checks of the alarm doors with documentation . [DATE] 1:15 PM - An interview with E4 (Environmental Health Services Director/EHSD) revealed that he began employment as the EHSD on [DATE] and there was no formal orientation to his role. E4 stated that he was not responsible for periodically checking the Wander Alert system or any of the exit alarms in the facility. [DATE] 2:30 PM - An interview with E5 (Staff Educator) was conducted and revealed that prior to the [DATE] incident in which R1 eloped from the facility, routine missing resident drills were not performed and after the [DATE] incident, the facility had not conducted an inservice related to elopement and/or a mock missing resident drill. [DATE] 6:00 PM - During an interview, E1 (NHA) was advised that the lack of a system to ensure the safety of residents with wandering behavior and/or were assessed to be at risk for elopement was an Immediate Jeopardy. Findings were confirmed by E1. [DATE] 7:00 PM - The facility's abatement plan included: - Development and implementation of a policy and procedure for preventative measures of the facility's wander management and the emergency exit alarms to include how often functional testing and monitoring will be performed. - Education of all staff on the newly developed Elopement Response Guideline (Missing Resident) procedure. - Conduct Missing Resident drills with all staff. - Evaluate all exits and update systems to prevent elopement. [DATE] 12:30 PM - An interview with E3 (ADON) revealed that she was the charge nurse during the day shift on [DATE] and worked from approximately 6 AM to 8 PM. E3 stated that E6 (RN) came to her at 12:20 PM to advise her that R1 was missing. E3 stated that Code W was not called over the facility's paging system. After the initial search of the facility and the outside grounds, R1 remained missing, thus, E3 proceeded to independently conduct a second search of the facility and outside grounds. E3 stated that R1 was not found and subsequently, a call to 911 was placed. At the conclusion of the interview, E3 provided a copy of the facility's policy titled Safety & Emergency Protocol Missing Person Policy that E3 stated she followed during the [DATE] incident. E3 stated that she received education on Missing Person protocol during orientation approximately two years ago, however, E3 had not participated in a missing person drill until [DATE] during the survey, after R1's elopement. E3 stated that she was aware of the new Elopement written guideline and the mock drill will include paging Code W (missing resident) in their facility wide paging system. [DATE] 9 AM - The facility provided evidence of the following: - Policy and procedure for preventative measures of the facility's wander management and the emergency exit alarms to include how often functional testing and monitoring would be performed and E4 (EHSD) was educated. - Education of the newly developed Elopement Response Guideline (Missing Resident) with 89% of current staff and a plan to educate the remaining staff prior to working the next time they were working at the facility. - Evaluation of all exits and systems to prevent elopement was completed, including the process to secure an active locking system on the front door when approached by a resident with a Wander Alert bracelet. - A written lesson plan for the missing resident drill utilizing the Elopement Guideline developed during the survey. [DATE] 1:15 PM - The Surveyor observed a missing resident drill in which the resident was located inside of the building. The drill failed to incorporate when the resident was not found. [DATE] 1:20 PM - During an interview with E1 (NHA), the Surveyor advised that the missing resident drill must incorporate when a resident was missing. [DATE] 3:55 PM - The Surveyor verified the missing resident drill was completed with 61% of the current staff and there was a plan to complete the training with the remaining staff prior to the next time they were working at the facility. [DATE] 4:00 PM - During an interview, E1 (NHA) revealed that the facility received a proposal for an active securing device for the front door and until the system was implemented, the facility would continue to ensure staff visual monitoring of the front door 24 hours a day, 7 days a week. E1 was advised that the IJ was removed. [DATE] at 2:45 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).

Based on observation, interview and review of the facility's policy and procedure (P & P), it was determined that the facility failed to develop and implement a P & P that included requirements for the reporting of reasonable suspicion of a crime. In addition, the facility failed to ensure that notice of employee rights for the reporting of reasonable suspicion of crime was posted. Findings include: Review of the facility's P & P titled Freedom From Abuse, Neglect, Mistreatment, Serious Injury, Misappropriation of Property, Exploitation, Sexual Abuse, and Injury of Unknown Origin, dated 1/18/18, lacked evidence of requirements for the reporting of reasonable suspicion of a crime. 2/25/22 Beginning at approximately 1:15 PM - A joint observation with E2 (DON) of the 2nd floor and the 1st floor employee break room lacked evidence of a posting of employee rights for the reporting of reasonable suspicious crime which included the prohibition and prevention of retaliation. 2/25/22 1:40 PM - An interview with E1 (NHA) confirmed that the facility failed to develop and implement a policy and procedure for the reporting of suspicion of a crime and the required posting for employees to report reasonable suspicion of a crime. 2/25/22 at 2:45 PM - Findings were reviewed during the Exit Conference with E1 (NHA and E2 (DON).

Based on interview and review of the facility's policy and procedure (P & P), it was determined that the facility failed to develop and implement a P & P which included requirements for staff COVID-19 vaccinations. Findings include: Review of the facility's P & P titled COVID-19 Immunization for Staff, dated 12/16/21, lacked evidence that the components of §483.80(i)(3) were incorporated into the facility's P & P. 2/25/22 1:30 PM - An interview with E1 (NHA) confirmed that the facility failed to develop a P & P for Staff COVID-19 vaccination which incorporated the requirements. 2/25/22 at 2:45 PM - Findings were reviewed during the Exit Conference with E1 and E2 (DON).

Based on record review and interview it was determined that for three (R19, R40 and R55) out of 31 residents reviewed for care plans, the facility failed to ensure that care plan meetings included the required IDT (interdisciplinary team) attended. Findings include: 1. Review of R19's clinical record and interviews revealed: There were three quarterly MDS assessments completed for R19 on 3/17/21, 6/17/21 and 9/17/21. 12/15/21 12:34 PM - During an interview, FM2 stated that I have never been involved in any care plan meetings, they notify me of changes in condition or medications either over the phone or in person when I'm visiting my (R19). 12/18/21 10:12 AM - During an interview with E2 (DON), it was confirmed that the facility has not been holding care plan meetings for some time. Per E2 We are focused on resident care. The facility was unable to provide evidence that R19's care plan meetings were attended by the required IDT members. 2. Review of R40's clinical record and interviews revealed: 1/14/21 - R40 was admitted to the facility. 12/15/21 11:00 AM - Record review lacked evidence that care plan meetings were held following the annual MDS assessment on 1/27/21 and three quarterly MDS assessments on 4/29/21, 7/30/21, and 10/30/21. The facility lacked evidence that R40's care plan meetings were attended by the required IDT members. 3. Review of R55's clinical record and interviews revealed: R55 had an annual MDS assessment on 2/18/21 and quarterly MDS assessments on 5/21/21, 8/21/21 and 11/21/21. 12/15/21 11:45 AM - During an interview with FM1, it was revealed that they had never participated in any care plan meetings. 12/18/21 10:12 AM - During an interview with E2 (DON), it was confirmed that the facility has not been holding care plan meetings for some time. Per E2 We are focused on resident care. The facility was unable to provide evidence that R55's care plan meetings were attended by the required IDT members. Findings were reviewed during the exit conference on 12/22/21 at 4:10 PM with E1 (NHA) and E2 (DON).

Based on observation, interview and record review it was determined that for one (R19) out of five residents for medication review, the facility failed to monitor and have an adequate indication for use of an antipsychotic drug [MEDICATION(S)]. Findings include: 12/2/19 - R19 was admitted to the facility. 12/15/20 - An annual MDS assessment did not document any behaviors of wandering or delusions (misconceptions or beliefs that are firmly held, contrary to reality) present. 1/4/21 - A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3/17/21 and 6/17/21 - A quarterly MDS assessment did not document any behaviors of wandering or delusions. 7/7/21 - A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, last revised on 11/30/21, did not include any delusional behaviors or monitoring of antipsychotics. 12/16/21 - Random observations of R19 did not include any delusional behaviors. 12/17/21 10:28 AM - R19 was observed in bed with no behaviors present. 12/17/21 11:28 AM - R19 was observed in the dining room with no behaviors present. 12/17/21 11:52 AM - The Surveyor requested the facilities documentation of R19's monitoring of delusional behaviors and monitoring of side effects for the antipsychotic medication. 12/20/21 1:55 PM - During an interview with E5 (MDS Coordinator), a document was provided that only included R19's wandering behavior that was being monitored by the facility. E5 further revealed that the delusional behaviors and side effects might be in the chart. 12/20/21 3:24 PM - A review of Psychiatric notes from December of 2020 through September of 2021 did not include any delusional behaviors. 12/20/21 - A review of the chart and the progress notes from March to December 2021 lacked evidence that R19 was having delusions. Also, during the review there was a lack of evidence that the facility was doing the required side effect monitoring on R19 for the antipsychotic medication [MEDICATION(S)]. 12/21/21 - The facility was not able to produce any documentation that R19 experienced delusional behaviors for which the antipsychotic drug was prescribed. Furthermore, the facility failed to monitor R19 for side effects when taking [MEDICATION(S)]. 12/21/21 12:20 PM - During an interview, E7 (Medical Director) revealed that R19 probably had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . E7 told this Surveyor she would check her records to confirm. 12/22/21 5:02 PM - An email communication revealed that E7 (Medical Director) did not have any additional information on R19's antipsychotic [MEDICATION(S)] that was ordered by E18 (Psychiatric MD). E7 said she thought it was more for a behavior disorder/dementia than delusions. The facility used an antipsychotic medication without an adequate indication for use and in the absence of side effect monitoring. Findings were reviewed during the exit conference on 12/22/21 at 4:10 PM with E1 (NHA) and E2 (DON).

Based on interview and record review, it was determined for two (R19 and R44) out of nine residents reviewed for the sample, the facility failed to complete an accurate MDS assessment. Findings include: 1. Review of R44's clinical record revealed: 1/20/21 - R44 was admitted to the facility on an antipsychotic medication which remains actively prescribed. 2/1/21- An admission MDS assessment documented that R44 did not receive antipsychotic medications. 11/3/21- A quarterly MDS assessment documented that R44 did not receive antipsychotic medications. During an interview on 12/20/21 at 12:07 PM, E5 (RNAC) confirmed the facility failed to accurately assess R44 for taking antipsychotic medication. 2. Review of R19's clinical record revealed: 12/2/19 - R19 was admitted to the facility. 12/4/19 - Review of R19's inventory list documented that R19 had a partial denture on admission. 12/2/19 - An admission MDS assessment documented no missing teeth and no full or partial dentures. 9/17/21 - A quarterly MDS assessment documented R19 did not have a full or partial denture or difficulty chewing. 12/17/21 12:25 PM - Interview with E5 (MDS Coordinator) revealed that she had no knowledge that R19 had a partial denture. E5 comfirmed that the facility failed to accurately assess R19 as having a partial denture. Findings were reviewed during the exit conference on 12/22/21 at 4:10 PM with E1 (NHA) and E2 (DON).

Based on record review and interview, it was determined that for two (R19 and R363) out of two residents reviewed for neglect, the facility failed to ensure that R363 received treatment and care in accordance with professional standards of practice when a prescription for R363 was not given until three days after being ordered. R19 was reviewed for dental services and the facility failed to identify that the plan of care for a partial denture was not being implemented when the facility failed to identify the missing denture. Findings include: 1. Review of R363's clinical record revealed: 12/11/19 11:32 - A progress note documented, Resident noted with redness to abdominal folds [stomach] charge nurse made aware, and put in MD book for further evaluation. 12/14/21- An order was written for R363 to receive an antifungal cream to the stomach and breast. 12/14/19 12:13 PM - A note regarding R363's antifungal medication documented, Waiting to arrive from pharmacy. 12/14/19 8:45 PM - A note regarding R363's antifungal medication documented, On order. 12/15/19 12:14 PM - A note regarding R363's antifungal medication documented, Waiting for cream from pharmacy. 12/15/19 4:20 PM - A note regarding R363's antifungal medication documented, Medication on order. 12/16/19 10:00 PM - A note regarding R363's antifungal medication documented, Medication not available, waiting for delivery from pharmacy. Review of progress notes from 12/14/19, the date of the prescription through 12/16/19 lacked evidence that the pharmacy was contacted regarding delivery of the antifungal cream and that R363's physician was aware that the medication was not being given. 12/17/19 9:14 AM - A progress note documented, Called pharmacy to get antifungal cream order filled. Pharmacy stated it had been filled at another pharmacy and they were unable to process it. Spoke with resident's daughter. Called ordering physician's office to clarify that we used facility designated pharmacy . and to notify that the cream had not been started yet . 12/17/19 9:52 AM - A note regarding R363's antifungal medication documented, Followed up with pharmacy, antifungal will be delivered this afternoon. 12/17/19 11:30 AM - A note regarding R363's antifungal medication documented, Medication not available. pharmacy made aware. Medication in transit. December 2019- Review of R363's electronic treatment administration record revealed the first administration of the antifungal cream prescribed for R363 on 12/14/19 was 12/17/19. During an interview on 12/21/21 at 9:00 AM , E3 (RN) explained a New order generally as long as it's put in before 2:00 PM or 3:00 PM, we get it towards the same evening, if late, it would come the next day. The nurse world see it on the EMAR (electronic medication administration record) and if not available, we reorder then call the pharmacy and make sure they can deliver it. We have a secondary pharmacy that is close by and we would also notify the MD as well. E3 confirmed that staff should have Documented that they reorder or contacted them [the pharmacy] about the delivery. 2. Review of R19's clinical record, interview and observation revealed: 12/2/19 - A facility inventory list documented R19 had a partial denture on admission. 12/2/19 - An admission MDS assessment documented R19 did not have a partial denture. 12/2/19 - A care plan for oral care documented that R19 had a partial upper denture and had the potential for oral dental health issues related to the partial denture and some of her own natural teeth. Monitor, document and report any signs and symptoms of oral or dental problems . missing teeth. 12/2/19 - A care plan for ADL's (activities of daily living) documented that R19 had an ADL self-care performance deficit related to Alzheimer's. R19 was to have teeth and mouth care twice a day and as needed, assist with setup and cue for completion, has own bottom teeth and a partial upper. 12/15/20 - An annual MDS assessment documented R19 did not have a partial denture. 9/17/21 - A quarterly MDS assessment documented R19 did not have a partial denture. 12/15/21 1:07 PM - During an interview with FM3 it was revealed that R19 was missing a partial denture and FM3 could not recall the date that the partial denture went missing. 12/17/21 12:25 PM - During an interview, E5 (MDS Coordinator) stated, I am not aware of a missing partial denture. 12/17/21 12:30 PM - During an interview, E15 (CNA) stated, I didn't know she had a denture. 12/21/21 3:30 PM - An observation of R19's room confirmed there was not a partial denture. R19 allowed this Surveyor to look in her mouth which revealed no partial denture, but upper molars were missing. During the survey it was identified that R19's partial denture was missing for an undetermined amount of time, yet it went unrecognized despite a plan of care that included caring for R19's partial denture. Findings were reviewed during the exit conference on 12/22/21 at 4:10 PM with E1 (NHA) and E2 (DON).

Based on clinical record reviews, interviews, observations and review of other facility documentation, it was determined that the facility failed to ensure that three (R25, R62 and R68) out of 23 Stage 2 sampled residents, who were incontinent of bladder, received appropriate treatment and services to restore as much normal bladder function as possible. All three residents experienced a decline in continence. For R25, R62, and R68, the facility failed to comprehensively assess the urinary continence; failed to complete voiding diaries; failed to individualize toileting plans, resulting in the decline of their urinary continence. Findings include: The facility's Bowel and Bladder Incontinence Program Nursing Policy and Procedure issue date 4/15/2009 stated, If resident is incontinent .6. The resident will also be evaluated for . Bladder incontinence patterns by staff completion of the .Bladder Schedule for 7 consecutive days. Additionally, the facility's Plan of Correction for the Recertification survey dated 08/17/15 for F315 (compliance date of 10/12/15) stated, 3. A new bladder incontinence policy implemented. A nurse will complete a continence assessment on admission, quarterly and after any significant change in condition. A 3-day voiding diary will be initiated to establish the resident's individual voiding pattern . 1. R 25's [DIAGNOSES REDACTED]. Review of R25's record revealed the following: The facility originally initiated a care plan dated 1/10/13 entitled, Potential for complications related to urinary incontinence. The care plan goals included, Will be clean and dry with use of incontinence products and prompt incontinence care through review date. The care plan lacked goals that included restoration toward R25's normal bladder function or prevention of a decline. The care plan approaches included, Assess incontinence to determine if there is a pattern. Assess for potentially reversible causes, cognitive function, motivation .Offer/assist to toilet/bedpan or urinal at scheduled intervals during the day: q 2 hours, Before and after meals. Activities staff: notify nursing if incontinent during activities. 11/11/15 Quarterly MDS assessment stated that R 25's cognitive skills for daily decision making were severely impaired. R25 was assessed as occasionally incontinent of bladder. R25 did not ambulate and used the wheelchair as her mobility device. R25 needed staff assistance in all activities of daily living except eating. There was no documented evidence that the facility followed the care plan by assessing R25's incontinence to determine a voiding pattern. The CNA ADL Flowsheet documentation on bladder function for the month of 11/15 showed the following: 8 continent episodes out of 49 opportunities on the 7-3 shift, total continence on the 3-11 shift, total incontinence (35 episodes) on the 11-7 shift. The CNA ADL Flowsheet documentation on bladder function for the month of 12/15, showed the following: was always continent on the 7-3 PM shift, always incontinent on the 3-11 PM shift , 1 continent episode and 30 episodes of incontinence on 11-7 AM shift out of 31 days. There was no documented evidence that the facility initiated/completed a 3-day voiding diary to establish R25's voiding pattern for the variances in R25's bladder function or that they initiated an individualized toileting program based on a voiding diary result. Additionally, on 2/01/16, R25 was prescribed the [MEDICATION NAME] medication to control her overactive bladder. 2/11/16 Quarterly MDS assessment stated that R25's bladder function/urinary continence had declined to always incontinent. The care plan was not reviewed and revised to include/initiate facility's plan of correction that stated, A nurse will complete a continence assessment on admission, quarterly and after any significant change in condition. A 3-day voiding diary will be initiated to establish the resident's individual voiding pattern . 4/11/16 Annual MDS assessment stated that R25's Urinary continence remained as was always incontinent. However, despite the facility's knowledge of her continued decline in urinary incontinence since the 2/11/16 assessment, there was lack of documented evidence in the clinical record that a Voiding Diary was implemented for R25 to determine her voiding pattern or that a toileting program was scheduled based on her pattern. 6/25/16 - R25 was admitted to the hospital for rectal bleeding (an unrelated condition) and was readmitted back to the facility on [DATE]. 6/28/16-An Admission Bladder Assessment was completed for R25 with a total score result of 15. According to the scoring code, 15-20 means to reassess in 2 weeks. The assessment also indicated that R25, was continent of urine when out of bed, calls for toileting assistance when in bed; and was able to understand instructions to participate in a bladder management/retraining program. 7/21/16 - a two week Bladder Assessment was completed and R25 scored 35. According to the scoring code, 25-35 means, attempt active retraining; if unsuccessful in 90 days, develop a management plan. However, there was no documented evidence that a 3-day Voiding Diary to determine R25's voiding pattern was initiated and completed and that an attempt to actively retrain R25 for bladder management was done. 8/03/16 Quarterly MDS assessment stated that R25's Urinary Incontinence assessment remained as always incontinent. The facility failed to ensure that : 1) a Voiding diary was completed when R25 showed variance in episodes of incontinence; 2) a toileting schedule was put in place for R25 in accordance with the result of a 3-day voiding diary. During the survey period, R25 was observed independently propelling her wheelchair in the room and the corridor. However, she needed help to stand up and needed supervision to be told not to get out of the wheelchair on her own. During an interview with E4 (RN) on 8/25/16 at approximately 3:00 PM, she stated that she was unable to locate documentation of a voiding diary assessment for R25. Also, E3 (RN-SW) and E9 (MDS Coordinator) were unable to find documentation of a voiding diary assessment from 11/2015 through 8/2016. In an interview with E 12 (CNA) on 8/29/16 at 2:20 PM, she stated that R25 sometimes did not realize that her pad was wet. At times she would tell staff she needed to go to the bathroom or would attempt to go by herself. Occasionally, she would not make it to the bathroom and would wet herself. The facility's Plan of Correction from the recertification survey dated 8/17/15 with a completion date of 10/12/15 stated that a new bladder continence policy was implemented. A nurse will complete continence assessment on admission, quarterly and after any significant change in condition. A 3-day Voiding Diary will be initiated to establish the resident's individual voiding pattern. The facility failed to ensure that this system was implemented for R25. The facility failed to analyze R25's voiding patterns via a 3 day voiding diary and failed to establish a toileting schedule in accordance with the result of the 3-day voiding diary, to restore as much normal bladder function as possible. R25's urinary function declined from occasionally incontinent to always incontinent in accordance with the MDS assessments dated 2/11/16 through 8/03/16. In an interview with E2 (DON) on 8/29/16 at approximately 2:00 PM and during the exit conference on 8/30/16 at approximately 4:00 PM with E1 (NHA), E3, and E9 (MDS Coordinator), this finding was confirmed. 2. Review of R68's clinical record revealed the following: 3/28/16 - Accompanied by family members, R68 was admitted to the facility with [DIAGNOSES REDACTED]. 3/28/16 - The Resident Assessment - Data Collection Form stated that R68 used the toilet and was both incontinent and continent of bladder. Incorrectly dated 3/24/16 admit (Admission) - The Admission Bladder Assessment revealed R68 scored a total of 10 points. The assessment stated that for a score of 0 - 10, the resident was not a candidate for retraining, may respond to management program. Despite R68's bladder assessment stating in handwritten form cont/incont, it was unclear how the facility accurately assessed R68's bladder function when it stated that R68 was not continent of urine when out of bed; R68 was always incontinent 24 hours a day; R68's general state of health did not enable her to participate in a bladder management or retraining program; and R68 had a history of [REDACTED]. 3/28/16 - The admission nursing note, timed 6:30 PM, stated the resident was continent and incontinent of bladder. 3/29/16 through 3/31/16 - R68's 3-day Voiding/Fluid Record form was incomplete. 3/29/16 through 3/31/16 - The Activity of Daily Living Flow Record, completed by CNAs, documented that R68 was both continent and incontinent of bladder. 3/30/16 - The physician's admission H&P did not identify any urinary incontinence. 4/1/16 through 4/30/16 - The Activity of Daily Living Flow Record documented that R68 was both continent and incontinent of bladder. 4/8/16 - R68's admission MDS assessment stated she was severely impaired for daily decision making; required extensive assist of 1 staff person for toilet use, bed mobility and transfers; required total assistance of 1 staff person for personal hygiene; was not on a toileting program trial; and was frequently incontinent of bladder. 4/10/16 - A nurse's note, timed 3:45 AM, stated that R68 was toileted two times during the shift and was continent. 4/12/16 - R68 was care planned for urinary incontinence with approaches that included: .assess incontinence to determine if there is a pattern. Assess for potentially reversible causes, cognitive function, motivation .check at least every 2 hours (between toileting) for any incontinence, change .as needed .offer/assist to toilet/bedpan .at scheduled intervals during the day .provide adult briefs/pullups/pads and change prn . The facility failed to follow R68's plan of care by the lack of evidence that she was comprehensively assessed to determine her voiding patterns and potentially reversible causes. 4/15/16 - A nurse's note, timed at 9 PM, stated that R68 was incontinent of bladder. The note also stated, Some time if you put her on the toilet she can use it. 5/1/16 through 5/31/16 - The Activity of Daily Living Flow Record documented that R68 was always incontinent of bladder. 5/5/16 - R68's urinary incontinence care plan was revised. The care plan specified to offer or assist R68 to the toilet every 2 hours during the day. The facility failed to comprehensively assess R68 upon admission to determine her voiding patterns so that an individualized toileting plan could be implemented to attempt to maintain or improve her bladder function. 6/1/16 through 6/30/16 - The facility started R68 on a standardized Prompted Voiding Program (PVP) despite the lack of being comprehensively assessed for urinary incontinence upon admission including completion of a 3-day diary to determine her voiding patterns and lack of an individualized toileting program based on R68's voiding patterns. The prompted voiding sheet stated R68 was to be prompted as follows: Day Shift - AM care-1st void, 2nd void, 3rd void; Evening Shift - 1st void, 2nd void, and PM care-3rd void; Night Shift - 1st Round (if awake), Last Round. Review of R68's June 2016 Prompted Voiding sign off sheet revealed multiple episodes of both continent and incontinent of bladder. 6/1/16 through 6/30/16 - The Activity of Daily Living Flow Record documented that R68 was always incontinent of bladder. This record does not reflect what the CNAs were documenting on the prompted voiding sign off sheet. 6/17/16 - A nurse's note, timed at 9:30 PM, stated that R68 was incontinent and occasionally continent of bladder. 7/1/16 through 7/31/16 - Review of R68's Prompted Voiding sign off sheet revealed multiple episodes of both urinary continence and incontinence. 7/1/16 through 7/31/16 - The Activity of Daily Living Flow Record documented that R68 was always incontinent of bladder. This record does not reflect what the CNAs were documenting on the Prompted Voiding sign off sheet. 7/7/16 - R68's urinary incontinence care plan was reviewed and revised. The care plan stated that she was on a PVP and was occ (occasionally) incontinent. 7/9/16 - R68's quarterly MDS assessment stated she was moderately impaired for daily decision making; required extensive assist of 1 staff person for toilet use, bed moblity and transfers; required total assistance of 1 staff person for personal hygiene; was on a current toileting program or trial; was always incontinent of bladder; and was receiving a medication to eliminate excess fluid from the body. The facility failed to identify that R68 remained both continent and incontinent of bladder function during the 7-day look back period during this assessment and inaccurately coded R68 as always incontinent when she was frequently incontinent. The two facility forms completed by CNAs, the Prompted Voiding sign off sheet and Activity of Daily Living Flow Record, contradicted each other. 8/1/16 through 8/28/16 - Review of R68's Prompted Voiding sign off sheet revealed multiple episodes of both urinary continence and incontinence. 8/1/16 through 8/28/16 - The Activity of Daily Living Flow Record documented that R68 was always incontinent of bladder. This record does not reflect what the CNAs were documenting on the Prompted Voiding sign off sheet. 8/29/16 - In an interview at 2:37 PM, E8 (CNA) stated that sometimes R68 can tell staff that she needs to use the toilet. E8 stated that R68 was both incontinent and continent of bladder. 8/29/16 - In an interview at 3:17 PM, E2 confirmed findings. The facility failed to ensure that R68, a resident who was both incontinent and continent of bladder upon admission, received the appropriate treatment and services to restore as much normal bladder function as possible. The facility failed to comprehensively assess R68 upon admission including completion of a 3-day voiding diary; failed to implement an individualized toileting program based on R68's voiding diary; failed to identify the contradiction with CNA documentation on two facility forms regarding R68's urinary incontinence; and failed to reassess when the quarterly MDS assessment revealed a decline in urinary incontinence. 3. Review of R62's clinical record revealed the following: 4/13/16 - R62 was admitted to the facility with [DIAGNOSES REDACTED]. 4/13/16 - The Resident-Data Collection Status Upon Admission stated R62 was continent of bladder, had no dribbling of urine and used the toilet and/or a urinal. 4/13/16 - Review of the Admission Bladder Assessment revealed R62 scored a total of 45 points. The assessment stated that for a score of 40 to 45 - resident is continent. He or she may need assistance toileting; develop a plan to meet resident needs. Reassess annually and when a significant change MDS is done. 4/13/16 - The admission nursing note, timed 3:30 PM, stated the resident was continent of bladder. 4/13/16 - The physician's admission orders [REDACTED]. 4/14/16 - The physician's admission H&P stated R62 had [MEDICAL CONDITION], but did not identify any urinary incontinence. An undated and incomplete Voiding/Fluid Record found in R62's clinical record had only two (2) entries completed for Day 1. The remainder of the voiding/fluid record was blank. 4/13/16 through 4/30/16 - Review of a prompted voiding sign off sheet for R62 revealed multiple episodes of urinary incontinence. This prompted voiding sheet stated the resident was to be prompted as follows: Day Shift - AM care-1st void, 2nd Void, 3rd Void; Evening Shift - 1st Void, 2nd Void, and PM Care-3rd Void; Night Shift - 1st Round (if awake), Last Round. There was no evidence that the facility completed a voiding diary to establish R62's voiding patterns. 4/13/16 through 4/30/16 - The Activity of Daily Living Flow Record, completed by CNAs, documented that R62 was continent of bladder. This record did not reflect what the CNAs were documenting on the prompted voiding/fluid record. 4/26/16 - R62's admission MDS assessment stated that during the seven (7) day review period: - daily decision making skills were moderately impaired (decisions poor; cues/supervision required); - required extensive assist of two (2) staff for bed mobility; - was totally dependent on two (2) staff for transfers; - required limited assist of one (1) staff for toilet use and hygiene; - was on a trial of a toileting program; the response was unable to be determined or the trial was still in progress; and was on a current toileting plan; - was continent of bladder. The CAA portion of the 4/26/16 admission MDS assessment triggered incontinence as a potential problem area and was checked off to proceed with care planning. 4/29/16 - A care plan was developed for potential for discomfort, complications related to [DIAGNOSES REDACTED]. 4/29/16 - A care plan was developed for self-care deficit. Approaches included uses urinal PRN, wears brief. 4/29/16 - A care plan for potential for altered skin integrity was developed related to decreased mobility and incontinence. Approaches included to provide incontinence care every two (2) hours as needed. The facility failed to develop an individualized toileting plan based on R62's established voiding patterns (voiding diary) and physical needs. 5/1/16 through 5/3116 - The Activity of Daily Living Flow Record, completed by CNAs, documented that R62 was continent of bladder. 6/1/16 through 8/25/16 - The Activity of Daily Living Flow Record, completed by CNAs, documented that R62 was incontinent of bladder on multiple occasions. 7/20/16 - A quarterly MDS assessment stated that during the seven (7) day review period R62: - was cognitively intact and independent for daily decision making skills; - was occasionally incontinent of bladder (three (3) episodes of urinary incontinence during the review time period). After completion of the 7/20/16 MDS assessment, the facility failed to identify R62's decline in urinary continence, failed to re-assess R62, and failed to develop an individualized toileting plan based on established voiding patterns (voiding diary). Additionally, the facility failed to revise R62's plan of care to address the decline in urinary continence. 8/24/16 at 2:45 PM - During an interview, E5 (CNA) stated that R62 uses a sliding board for transfers to/from bed to w/c and is continent during the day using a urinal. E5 also stated R62 asks to use the bathroom where he can lift himself from the w/c using a grab bar. E5 stated that when she assists him with morning care, his brief is wet so she documents him as incontinent. 8/24/16 at 3:00 PM - During an interview, R62 stated he always knows when he needs to urinate and uses a urinal while in bed. However, at times it is difficult to manage the urinal with one hand and spillage occurs. 8/25/16 at 12:12 PM - During an interview, E6 (LPN) stated that R62 does ask to use the bathroom and uses a urinal during the day, but is occasionally wet. 8/25/16 at approximately 2:00 PM - During an interview, E7 (CNA) stated when assisting R62 that morning his brief was slightly wet, but that he did request to be taken to the bathroom during the day where he voided and his brief was dry. 8/25/16 at 3:15 PM - During the exit conference on 8/30/16 at 4:00 PM findings were reviewed with E2.

Based on record review, observation, interview and review of other facility documents, it was determined that the facility failed to ensure that three (3) residents (R18, R46 and R51) out of 36 sampled Stage 2 residents remained as free of accident hazards as is possible and received adequate supervision to prevent accidents. The facility failed to adequately supervise R46 and failed to ensure that staff did not create an accident hazard when staff left their own hot beverage in reach of the resident (R46) which resulted in second degree burns to her bilateral inner thighs. Additionally, the facility failed to follow the facility policy regarding burns which caused a delay in treatment. On another note, R46 was left in a high raised bed following a perineal care observation on 7/17/14. The facility failed to ensure that R18 received adequate supervision and an assistance device per the plan of care. The facility failed to adequately supervise and ensure a safe environment for R51 who was left unsupervised in the 3rd floor dining room on 6/22/14 during dinner and fell out of her wheelchair. Findings include: Cross refer F309, example #1 1A. Review of the facility policy, dated 6/3/08 entitled, "Burns", stated, "... 2. Assess resident and situation ... 3. Signs and symptoms: a. Extreme pain at site of injury. b. Swelling that develops rapidly. c. Redness around the burn. d. Small bubbles of fluid (blisters) under the top layer of skin ... 5. If possible, hold the burned part under cold running water for 10-20 minutes. 6. At the same time ... remove ... clothing from the burned area before the swelling begins ... 8. Protect the injury with a sterile dressing large enough to cover the burned area completely ...". The Mayo Clinic's web site, at <http://www.mayoclinic.org/first-aid/first-aid-burns/basics/art- 649> stated, "To distinguish a minor burn from a serious burn, the first step is to determine the extent of damage to body tissues. The three burn classifications ...will help you determine emergency care." ... First-degree burns are those in which only the outer layer of skin is burned, but not all the way through. The skin is usually red, often with swelling, and pain sometimes is present. When the first layer of skin has been burned through and the second layer of skin (dermis) also is burned, the injury is called a second-degree burn. Blisters develop, skin takes on an intensely reddened, splotchy appearance and there is severe pain and swelling. If the second-degree burn is no larger than 3 inches (7.6 centimeters ) in diameter , treat it as a minor burn. If the burned area is larger or if the burn is on the hands, feet, face, groin or buttocks, or over a major joint, treat it as a major burn and get medical help immediately. For minor burns, including first-degree burns and second-degree burns limited to an area no larger than 3 inches in diameter, take the following action: ? Cool the burn. Hold the burned area under cool (not cold) running water for 10 or 15 minutes or until the pain subsides. If this is impractical, immerse the burn in cool water or cool it with cold compresses. Cooling the burn reduces swelling by conducting heat away from the skin. Don't put ice on the burn. ? Cover the burn with a sterile gauze bandage " ... Bandaging keeps air off the burn, reduces pain and protects blistered skin. ? Take an over-the-counter pain reliever. These include ... acetaminophen (Tylenol) ... Minor burns usually heal without further treatment ... Watch for signs of infection, such as increased pain, redness, fever, swelling or oozing ...". R46 had [DIAGNOSES REDACTED]. The following documentation was contained in R46's incident report, investigation and clinical record: 5/14/14 - significant change MDS assessment coded R46 as moderately impaired for daily decision making; May 2014 Medication Administration Record (MAR) pain assessments, done every shift, were negative for complaints of pain. R46 was routinely medicated with "Arthritis pain relief 650 mg (milligrams) three times daily" for a [DIAGNOSES REDACTED]. 6/7/14 at 12:30 PM - R46's incident report stated, "This nurse (E29/LPN) heard a scream and noticed that resident (R46) had poured or dropped a hot liquid (coffee) into her lap. L (left) inner thigh redness: 12 cm X (times/by) 10 cm R (right) inner thigh redness: 12 cm X 14 cm"; 6/7/14 - an untimed doctor's telephone verbal order for "Silvadene (antibacterial, used to treat burns) cream to both inner thighs and apply non-stick pad and wrap c (with) CDD (clean, dry dressing) BID (twice a day) 2 (secondary to) burn"; 6/7/14 at 2 PM - E6's (CNA) witness statement for the incident report,"burn, coffee spill" stated, "I had just finished feeding resident, went to assist another resident when I heard a scream. I turn (sic) around to find out the resident spilled a cup of coffee on themselves (sic), then I took resident to room put resident in bed and took pants off and nurse was present"; 6/7/14 at 2:30 PM - R46's nurse's note stated, "...in the main dining room...I heard a yell. I.... noticed that resident had spilled a hot liquid into her lap... noticeable redness noted to bilateral inner thighs. Resident was in discomfort... "; 6/7/14 at 10 PM - R46's nurse's note stated, " ...Applied dressing per MD (doctor) order to Res's (resident's) (B) (bilateral) inner thigh continue to monitor." 6/7/14 - Review of the June 2014 MAR, for 6/7/14, incorrectly documented R46 as having no pain despite the witness statement and nurse's note (described above). R46 was only medicated with routine "Arthritis pain relief 650 mg (milligrams) three times daily." R46 also had orders for Tylenol 325 mg every 4 hours as needed for pain and Roxanol (Morphine) as needed every 6 hours for shortness of breath/pain. Review of the MAR on 6/7/14 lacked evidence that any PRN (as needed) pain medications were administered to R46 and only the routinely ordered Arthritis pain relief medication was given. 6/8/14 - 6/23/14 - Review of the June 2014 MAR revealed that R46 was assessed with [REDACTED]. On 6/14/14, R46 was observed to be "crying/agitated" with "severe pain" to the inner thighs. Additionally, on 6/18, 6/19 and 6/22/14, R46 was documented as "pushing away/guarding"; 6/8/14 - 6/29/14 - Review of the June 2014 MAR revealed that R46 was medicated with Roxanol for complaints of increased pain multiple times on 6/8 - 6/9, 6/11 - 6/14, 6/16 - 6/19, 6/22, 6/25 and 6/29 with positive effects; 6/11/14 -The five day follow up incident report stated, "Blistered areas (indicative of second degree burns) to residents inner thighs... Pain assessments (sic) done on a regular basis and medicated as needed. Staff inserviced on use of food and liquids in common areas where residents might be injured". 7/15/14 - At 3:36 PM, in an interview, R46's daughter stated that when she visited on 6/7/14, about 1 - 1.5 hours after the burn incident, R46 had blisters on both inner thighs. She stated that no first aid had been done, E29 (LPN) told her that the staff's action was removal of her clothing and placing the resident in bed. 7/16/14 - At 2:11 PM, during an interview, E30 (RN) stated that she worked the evening shift on 6/7/14 and during the change of shift, E29 reported R46's burn incident and told her to watch for blistering. E30 denied examining R46's bilateral inner thighs at the beginning of the shift. Instead, she stated that she just peeked into the resident's room, saw R46 in bed, and then began her medication administration to the resident's on the unit. E30 stated that around 5 PM, dinnertime, blisters were noted on both of R46's thighs. E30 gasped and stated the thighs were blistered ... she was surprised when she first looked, "I didn't know it was that big" (referring to the burned, blistered thighs). E30 stated that she placed a call to the doctor (E33) and that E33 called back about 6 - 6:30 PM, at the same time that the Silvadene cream arrived. E30 denied having knowledge of the facility's burn policy, she denied that she provided first aid, other than placing a 4 inch X 4 inch gauze pad over the burns to keep them clean and she placed a pillow between R46's legs to keep them apart. More than 6 hours elapsed before R46 received treatment for [REDACTED]. She stated, "we know when it blisters ... there's pain ..." Review of E30's nurse's notes failed to mention R46's burns, including any measurements or description of R46's blisters that were visualized by her. 7/17/14 - At 8:39 AM, during a telephone interview, E31 (Pharmacist/manager) confirmed that an order for [REDACTED]. E31 stated that E32 (pharmacist) filled the order just before the end of his shift (which ended at 2 PM) on 6/7/14. E31 stated that this order was treated as a STAT (immediate) order and at 2:22 PM, the invoice was printed and the medication given to their driver. The time of delivery to the facility is unclear, as the nurse receiving the medication failed to sign the time the Silvadene was received, but instead only signed the date of "6/7/14". 7/17/14 - At 3 PM, during an interview, E6 (CNA) stated, "When I heard her scream, I knew immediately what happened ... E29 (LPN) was there. (R46's) legs were red and kind of blistering ...". E6 stated that it was her coffee ... and knew R46 was a "grabber". E6 acknowledged that she should not have left her hot coffee within R46's reach. 7/21/14 - At 8:13 AM, in an interview, E29 (LPN) stated that during the lunch hour on 6/7/14, he heard R46 scream and saw a cup in her lap, something had spilled in her lap, lower pants had "vapors like something from being hot." E29 stated that R46 was brought to her room, placed in bed and with the help of E6, R46's clothes were removed from her lower body (waist down) and left open to air. E29 then did his assessment. E29 stated that R46 had redness noted to her bilateral thighs and was screaming "like in some pain." E29 stated that when he removed R46's brief, he observed coffee coming out of the brief. E4 (RN/Supervisor) got an order from E33 for Silvadene cream at about 1 PM. E29 denied knowledge of the facility's burn policy and denied providing first aid treatment. On 7/21/14 at 3 PM, during an interview, E6 stated that R46 had been seated to her left. She stated, that none of the residents at that table drank coffee... that the coffee was hers (E6's) and that staff would have to supervise or serve the resident any hot beverages at that table. E6 stated, "I had a cup of coffee that I set in the middle of the table... I went to help someone at another table... not more than a minute... When I heard her scream, I knew immediately what happened..." E6 stated that R46 was known to be a "grabber" and she knew immediately that R46 must have grabbed her (E6's) coffee cup and spilled it on herself. 7/22/14 - At 10:41 AM, in an interview, E3 (ADON) confirmed findings. E3 stated although there was no written policy, it was facility practice that there was to be no eating or drinking in the patient care areas by staff. E3 stated that since this incident, the policy was now formally in writing. E3 confirmed that the facility failed to provide complete first aid as per their policy, they incorrectly documented on R46's MAR that there was no pain and they failed to provide as needed pain medication on 6/7/14. There was approximately a 6 hour delay before R46 received treatment (Silvadene) for her burns other than basic removal of her clothing, a loose covering of gauze on the burns, a pillow between the resident's legs and routine medications. The facility failed to provide cool compresses or take measures to reduce swelling and conduct heat away from the skin when the burns occurred, they failed to bandage the burns appropriately to keep air off of the burns and they failed to provide pain relief other than routinely ordered arthritis medication until the next day. Additionally, the facility failed to do a complete assessment with measurements and a description of R46's blisters that were visualized by E30, the 3-11 shift nurse, on 6/7/14. The facility failed to ensure that R46's environment remained as free of accident hazards as is possible and failed to ensure that this resident received adequate supervision on 6/7/14 at lunch time resulting in second degree burns to R46's bilateral thighs. Additionally once R46 sustained the burns the facility failed to ensure a complete assessment was performed and the facility failed to ensure pain interventions were implemented. 1B. Review of the undated policy entitled, "Perineal care for a male and female resident" stated, "... Lower bed if it was raised..." R46's care plan, dated 6/18/13 and entitled, "High risk for falls related to ambulatory dysfunction (difficulty walking), confusion and inability to transfer without total staff assistance" included the intervention, dated 6/21/13, "Fall mat; Low bed". R46 was assessed as a high risk for falls. On 7/17/14 at approximately 11:45 AM, an observation was made of E20 (CNA) and E21 (CNA) providing incontinence care (cleansing of genitals and surrounding area due to loss of control of bladder and/or bowel). When they completed incontinence care for R46, E20 and E21 left R46 in a high, raised bed unattended, while they went to wash their hands at the resident's sink, across the room, with their backs turned toward the resident. Immediately following this observation, findings were confirmed by both E20 and E21. They acknowledged that they should have lowered R46's bed. The facility failed to ensure that R46 received adequate supervision based upon the plan of care which resulted in a potential accident hazard for a resident who was high risk for falls. 2. R18's fall care plan, dated 9/13/12, included an intervention, dated 1/30/13, that stated a tab alarm was to be in place while the resident was in bed at night. Review of R18's fall incident report, dated 7/7/14 and timed 5 AM stated that during second rounds, E23 (CNA) responded to a resident's scream for help. E23 found R18 out of bed on the floor mat with no injuries. The investigation included written statements by E22 (LPN) and E23, who both wrote that the tab alarm was not in place at the time of the fall. On 7/22/14 at 8:30 AM, E2 (DON) was interviewed regarding R18's use of a tab alarm. E2 denied knowing if R18 used a tab alarm and asked E24 (assigned CNA) if R18 was supposed to have a tab alarm. When E24 stated she did not know, she was directed to check R18's care plan. R18's fall care plan stated that R18 was to have a tab alarm on when in bed at night. E24 denied knowing that and went to R18's room to find the tab alarm. E24 found it in the top drawer of the bedside table. On 7/22/14 at 8:33 AM, during an interview, E24 denied placing the alarm in the drawer and stated that R18 did not have a tab alarm in place when she got the resident up. On 7/22/14 at 9 AM, in an interview with E25 (RN/Supervisor), findings were confirmed for both R18's 7/7/14 fall incident and the 7/22/14 failure to ensure that R18 had the correct assistance device in place. 3. R51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R51's significant change MDS assessment, dated 5/12/14, stated this resident was cognitively impaired (abnormal mental processes; thinking), constantly delirious (acutely disturbed state of mind), rejected care daily and exhibited physical behaviors daily and verbal behaviors less frequently. This assessment also stated that R51's change in behavior worsened since the last assessment on 4/26/14. R51 was care planned for at risk for falls, dated 6/18/11, and approaches included, "... Anticipate and intervene to prevent future recurrence ... Anticipate and meet needs ... Coordinate with appropriate staff to ensure a safe environment ... Tab alarm (clip attached to the resident that alarms when the resident attempts to rise out of her chair/bed) at all times ...". R51 was also care planned for potential for behavior problems related to a [DIAGNOSES REDACTED]. Approaches included: "Monitor behavior episodes and attempt to determine underlying cause ... Document behavior and potential causes ... Intervene as needed ... Remove from situation and take to another location as needed ... Anticipate and meet needs ... Administer medications as ordered and monitor for side effects, effectiveness ... Monitor for (increased) confusion and redirect as needed ...". A nurse's note, dated 6/21/14 and timed 3:30 AM, stated, "R51 agitated at start of shift. R51 kicking and hitting at nurse and CNA. Unable to assist to bathroom or into bed. 1:1 (one staff person assigned to one resident) ineffective ... PRN (as needed) Ativan (anti-anxiety medication) given at 11:00 PM c (with) R51 spitting part of (it) out. Placed in supervised area until ready to lay down to sleep at 11:30 PM ...". It is unclear what interventions were changed when 1:1 and medications were not successful. A nurse's note, dated 6/22/14 and timed 1:55 PM, stated "(Increased) anxiety this AM X3 staff to assist to calm and transfer to chair. Combative and grabbing everything in front of her such as: roommates walker, the door handle, end of bed, tab alm (alarm). Unable to redirect, (increase) anxious continued until around 9 AM ...". Review of the facility Incident/Accident Report stated that on 6/22/14 at 5:55 PM," ... R51 was in dining room when E8 (CNA) had (to) leave area to help another resident. E8 comes back to the dining room where she finds R51 on the floor ...recommend tilt (recline) chair for R51 ...". According to the assigned nurse's written statement, E5 (RN) stated that at 5:35 PM she "checked the residents before she went off the floor". E5 also stated that R51 leaned in her chair and was combative during care (hitting, kicking, yelling and swinging). According to the assigned CNA's written statement, E8 stated she "was in the bathroom providing care for another resident and when I went back in the dining room to get R51 to put her in the day room I noticed she was on the floor and notify (sic) nurse". E8 also stated that R51 leaned in her chair and was combative during care (swinging arms, biting, hitting and kicking). A nurse's note, dated 6/22/14 and untimed, stated "R51 had increase (sic) agitation at 4:55 PM. PRN Ativan given. Result negative. Resident continued to want to get out of chair unassisted. Resident had fall at 5:55 PM. No injury ...". Despite documented evidence of R51's agitation, multiple attempts to get out of and leaning in her wheelchair, the facility failed to provide adequate supervision and a safe environment by leaving R51 unsupervised in the 3rd floor dining room during dinner that resulted in a fall. Findings were confirmed with E2 (DON) on 7/22/14 at 11:20 AM.

Based on record review, observation and interview, it was determined that the facility failed to ensure that one (R12) out of 13 sampled residents received adequate supervision and assistive devices to prevent avoidable accidents and injuries. R12 was assessed as having severe cognitive (relating to thinking and reasoning) impairment (never/rarely made decisions) with intermittent confusion. R12 also had balance problems with walking, transfers and moving on and off the toilet. In addition, the facility identified that R12 had insomnia (sleep disturbance problem), a "general awareness problem" (lack of safety awareness), and had a high risk for falls. R12 had a history of [REDACTED]. The facility failed to analyze the fall pattern of R12, failed to establish and implement fall prevention interventions such as fall mats, physical therapy (P.T.) and the implementation of a bed in the lowest height position. The facility failed to establish a system to provide adequate supervision for R12 on the evening and night shifts consistent with R12's needs and plan of care to reduce her risk of falls. On 10/13/14 at 8:50 PM, R12 had an unwitnessed/unsupervised fall in her room and sustained an Occipital Condyle Fracture (broken bone situated at the back and lower part of the skull) that required hospitalization . Findings include: The facility's Policy and Procedure on Fall Prevention Program stated, "...The nursing home facilitates resident safety through identifying who may be at risk for falls and or injury due to falls. The facility establishes, implements and maintains an identification system for best-practice care intervention, options for fall prevention, and implements fall protocols designed to reduce and/or prevent the risk of resident falls and related injury...Post Fall Assessment Interventions (included)... may initiate another review of P.T., O.T.(Occupational Therapy)...for possible rail enablers, mobility devices and/or floor mats, and/or low beds... Bed Position: Keep the beds in the lowest height position for the geriatric population to reduce distance of a potential fall". R12 had [DIAGNOSES REDACTED]. Record review of nurse's notes and incident reports revealed the following examples of some of R12's history of multiple unwitnessed, unsupervised fall incidents. The following documentation was contained in R12's clinical record and incident report investigation: 7/8/13 at 1:50 AM - R12 was found in her bathroom holding onto her roommate's bedside table. She stated that she had fallen and denied hitting her head. Her walker was on the floor in her room. There was no documented PT evaluation or treatment services provided after the fall for strengthening and to improve R12's mobility. 12/3/13 at 2:30 AM - R12 was found on the floor next to her bed lying on her left side on her bed spread. R12 did not sustain any injury but was sent to the ER (emergency room ) for evaluation and treatment. 12/7/13 at 11:30 PM - The roommate of R12 put on the call bell. R12 was found sitting on the floor in front of her closet. R12 did not sustain injury. 12/8/13 (time unknown) - R12 was found on the floor between the bathroom and hallway. R12 sustained a skin tear on her left arm and two bruises on the left side of her back. 12/29/13 at 3:45 AM - R12's roommate rang the call bell and R12 stated that she rolled off the bed. R12 did not sustain any injury. There was no PT evaluation or treatment provided for strengthening and to improve R12's mobility after any of the falls (prior to 10/18/14) that R12 sustained. 12/29/13- the following care plan was reviewed. The Care plan entitled, "High Risk for Falls related to dementia and ambulatory dysfunction (disorder that affect walking, running, including crawling) ". The care plan goal stated, "Will remain free of falls and/or injury related to falls...". The approaches included: "Gather information on past falls and attempt to determine cause of falls; Anticipate and intervene to prevent future recurrence; call light within reach; anticipate and meet needs; ensure a safe environment with... bed in low position at night; PT evaluate and treat as ordered or prn (as necessary); provide activities that minimize potential for falls while providing diversion and distraction; physical activity for strengthening and improved mobility; Ensure that resident is wearing appropriate footwear (shoes, bedroom slippers, non-skid socks) when ambulating; Remind resident to inform staff before removing tag alarm to get up and (sic) Resident advise to use call bell for assist" 5/7/14 at 10:20 PM - R12 was found on the floor in her room. R12 stated that the room went black and when she awoke she was on the floor. R12 complained of right shoulder pain. 6/6/14 at 3:35 AM - CNA found resident sitting on the floor in the hallway outside of her room. R12 stated that she was not sure what happened. R12 sustained skin tear to her left elbow. 6/16/14 - The tab alarm was discontinued 8/09/14 - The quarterly MDS assessment coded R12 as severely impaired for daily decision making. This same MDS assessed that R12 ambulated independently, had unsteady balance but was able to stabilized herself (with a walker if used), and had balance problems while standing, walking and surface to surface transfer; 8/11/14 - In the fall risk assessment R12 was assessed as a high risk for falls due to intermittent confusion and with a history of multiple unwitnessed falls (with and without injuries); 10/13/14 at 3:00 PM - R12 was found sitting on the floor in her room. R12 complained of pain on her "butt". 10/13/14 at 8:30 PM - Five and a half (5 1/2) hours later, another incident report stated that R12 was found on the floor outside her room, blood was on the floor near her bed and the resident "scooted" out to the hallway. 10/18/14 -After the 10/13/14 fall, the care plan was reviewed. When the care plan entitled, "High Risk for Falls related to dementia and ambulatory dysfunction" was reviewed the only intervention added was to walk with contact guard (therapist places one or two hands on resident to help with balance). 10/18/14-Initial PT evaluation completed with recommendation for bed mobility and transfer with supervision. Also walking with rolling walker with supervision. 10/21/14 - Incident report investigation follow-up (to the fall of 10/13/14) stated, At 8:50 PM on 10/13/14, the resident was found on the floor near her room in hallway sitting on buttocks with back against the wall. Blood on floor near bed. The resident "scooted" out to hall. Right forehead with bruise, left forehead with skin tear and left hand with skin tear...The resident stated, "I fell out of bed"...The resident was sent to ER for evaluation and was found to have an Occipital Condyle Fracture...The resident returned to the facility on [DATE] with a "Miami J. Collar (a neck brace to keep the neck and spine straight and to help healing by supporting the neck bones) on". 11/6/14 at 10:00 AM - E10 (PT Director) was interviewed. She stated that R12 had a private insurance that would not reimburse for PT and R12's family refused to pay for PT services. 11/6/14 at approximately 10:41 AM - Interview with E2 (DON) confirmed that there was no attempt made by the facility to call any other outpatient PT or other alternative resources for R12's PT needs. Despite all of her past unsupervised multiple falls, R12 was not provided the treatment needed to strengthen and improve her mobility by PT. 11/6/14 at 4:34 PM - In a telephone interview with E10 (LPN) who wrote the incident report, she stated that R12 was a "pacer" (walks up and down nervously) and that she used to have a tag alarm at night but it was discontinued before she had this (10/13/14) fall. There was no fall mat on the floor next to her bed and R12 was in a regular low bed (height of 24 inches from the mattress to the floor). This bed could not be adjusted to the lowest position when R12 fell on [DATE] at 8:50 PM. Also, there was blood on the frame of the bed and the floor. 11/7/14 at 10:45 AM - E11 (CNA) showed the surveyor the regular low bed that R12 was in when she fell . According to E11, that bed was the only bed in the facility that could not be lowered to the lowest position. The height of the regular low bed (that R12 was in) measured 24 inches from the mattress to the floor as per E13's (Maintenance) measurement, and the lowest position that was observed on R12's roommate's bed ( a real low bed) was 13 inches from the mattress to the floor. According to E11, after R12's fall with injury on 10/13/14, R12's bed was replaced with a low bed that could be lowered to the lowest position of 13 inches from the floor. R12's bed was in the lowest position with pressure alarm on the mattress and another tab alarm at the head of the bed. The facility failed to evaluate R12's pattern of falls and failed to establish and implement a systematic approach that included adequate supervision and assistive devices to reduce her risks for injury which resulted in harm when R12 fell and sustained a fracture on 10/13/14 at 8:50 PM. On 11/7/14 at approximately 2:00 PM, findings were discussed with E2 (DON). On 11/7/14 at approximately 4:30 PM, findings were discussed with E1 (NHA), E2, E3(ADON) and E7 (RNAC).

Based on closed record review, interview and review of other facility documentation and hospital record, it was determined that the facility failed to ensure that one resident (R1) received adequate supervision and assistance devices to prevent accidents and injury. The facility had no system to monitor and ensure that interventions are implemented correctly and consistently, and failed to evaluate the effectiveness of the interventions and to modify or replace interventions as needed. R1 had an un-witnessed fall in the 2nd floor bathroom on [DATE] and sustained an " odontoid fracture " (a fracture caused by sudden forward and backward movement of the head with respect to the trunk/C2 -cervical fracture). Findings include: R1 had [DIAGNOSES REDACTED]. According to R1 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE], this resident ' s cognitive skills in daily decision-making were impaired; decisions poor; cues/supervision required. R1 was non-ambulatory and for mobility device used a walker and a wheelchair. R1 ' s standing balance was not steady and she was only able to stabilize with staff assistance. R1was totally dependent on staff for bed mobility, surface to surface transfer, dressing, toilet use, personal hygiene and needed extensive assistance in bathing. R1 was always incontinent of bladder and bowel (coded 3). R1 was assessed as a high risk for falls due to intermittent confusion ([DIAGNOSES REDACTED]. The facility established a care plan dated [DATE] (reviewed quarterly) entitled " ...at risk for falls related to decreased mobility " with interventions such as : gather information on past falls and attempt to determine cause of falls; anticipate and intervene to prevent future recurrence; anticipate and meet needs; be sure call light is within reach and encourage using it for assistance as needed; respond promptly to all requests for assistance; coordinate with appropriate staff to ensure a safe environment; when patient stands for care make sure there is a chair behind her for support; remind the patient to always ask for help if she needs it; accompany patient when she ambulates to provide back - up in case her knees buckle. R1 had fallen 4 times on [DATE], [DATE], [DATE] and [DATE]. Two were un-witnessed and two were witnessed. 1.)The [DATE] fall occurred because the bed was not in a lower position as per the resident care plan. The facility ' s corrective actions/response to this fall was to " redirect staff to have resident ' s bed in a lower position at all times;" 2) [DATE] resident was in the dining room with E3 (CNA). E3 had observed another resident in the dining room trying to get up. E3 left R1, went to E4 (CNA) to tell her to put the resident to bed and as E3's back was turned from R1, E3 saw R1 as she was approximately 4 inches off the floor but could not catch her. R1 fell out of her chair. The facility ' s corrective action to this fall was " Remind patient every shift that if call bell not available, patient must ask for staff assist " ; 3) [DATE] resident was found sitting on her buttocks between the bed and wheelchair. The facility's corrective action was " Remind resident to use call light " ; 4) [DATE], resident was transferring from wheelchair to bed independently. R1 was not wearing shoes and slipped and fell on buttocks. The facility ' s corrective action was " remind resident to wear non-slip shoes when transferring. Encourage and remind her to ask for assistance from staff ". R1 experienced pain. R1 did not sustain injuries to all these falls. A nurse ' s note dated [DATE] stated, " Actual Fall. Pt (patient) being sent to hospital for confusion, non-coherence + pain. Pt. will not answer questions about pain when asked. She is crying. Palpable bump felt on back left side of pt. head. Pt fell against wall with neck bent sharply. MD (Medical Doctor) and family aware". Additional information obtained verbally from E2 (DON-Director of Nursing) on [DATE] revealed that R1 was in her wheelchair in the Dining/Activity lounge and wheeled herself into the bathroom adjacent to the area unsupervised by the staff. According to the facility's incident report dated [DATE], R1 was found under the bathroom sink, alert but could not verbalize what happened. According to the resident, she was in pain and her head was hurting. The facility's Incident Follow-up Information dated [DATE] stated, " Resident was a fall (sic) in second floor bath room which result (sic) in being sent to emergency room and a [DIAGNOSES REDACTED]. R1 is a resident who uses a wheelchair and propels her wheelchair by herself. She needs help going to the bathroom, but because of her dementia she tries to go by herself. She was admitted to (hospital)". The facility's corrective action for this incident was, " Remind patient to ask for assistance when transferring self ". The facility failed to make a clinical decision that determined the best fall prevention interventions for R1 who was evaluated to have impaired expressive and receptive communication related to her dementia. The care plan of [DATE] said anticipate and meet needs but most corrective actions gave R1 (with a [DIAGNOSES REDACTED]. The facility failed to provide adequate supervision and assistive device to prevent serious injury related to a fall. According to the hospital Emergency Department's (ED) Primary Assessment, R1 " was stuck between the toilet and sink, possibly hit head on the sink ". R1 was diagnosed with [REDACTED]. R1 returned to the facility on [DATE] with neck collar (Miami J collar). A nurse ' s note dated [DATE] (9:15 PM) stated, " Staff heard tab alarm, staff entered room, resident on floor, head on floor next to fall mat, upside down (in relation to head of bed), resident rolling on floor ....sent via 911 to hospital for evaluation." The facility's corrective action for this fall was " Remind resident to call for assistance prior to transferring". The facility failed to add any new interventions such as a plan for supervision or a toileting program. R1 was admitted to the hospital for a change in mental status and expired in the hospital on [DATE]. The facility failed to ensure that R1 received adequate supervision and assistance devices to prevent accidents and injury. This finding was acknowledged by E2 (DON-Director of Nursing) on [DATE].

Based on observation, interview, record review and review of other documentation as indicated, it was determined that the facility failed to ensure that acceptable parameters of weight were maintained for one (R67) out of 29 sampled residents. R67 experienced a severe weight loss of 20 lbs. (14.6%, although incorrectly recorded by the facility as 17%) in one month after being admitted to the facility. A nutritional supplement was ordered by the MD on 1/17/11 when R67 lost 5 lbs., however, there was no evidence that the facility monitored the weights and reassessed the effectiveness of their intervention until 2/10/11 when R67 lost another 15 lbs. and E14 (registered dietitian) was notified. On 2/10/11, E14 ordered the nutritional supplement to be increased, ice cream to be given between meals and R67's diet was changed to pureed. There were no assessments or interventions implemented by E14 from the initial evaluation done on 1/5/11 in which R67's weight was stable until 2/10/11 after R67 lost 20 lbs. The facility additionally failed to follow their policy regarding notification of the MD and dietician of weight loss of 5 lbs. or greater. R67's weight declined from 129.5 lbs. to 115 lbs. on 2/4/11 in approximately one week, yet E14 and the MD were not notified until 2/10/11. In the interim, R67 was being evaluated for mental status changes by the MD and R67's weight loss was not being addressed. R67 was hosptalized on [DATE] for mental status changes. Findings include: The facility policy (undated) entitled "Weekly Weights" stated, "Objective: To assure... resident's weight is assessed accurately and in a timely manner each week. Policy: 1) All new admissions... weighed every week for four weeks to obtain a baseline. 2) Any resident with a gain or loss of 5 lbs will be placed on weekly weights for four weeks. 3) If weight is a gain or loss greater than 5 lbs the nurse must verify the weight. 4) Dietitian will be notified. 5) The physician will be notified... 6) make sure weight is documented on the chart." R67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her admission weight on 12/30/10 was 136.5 lbs. Review of R67's admission MDS assessment, dated 1/10/11, listed R67 as severely cognitively impaired and she required set-up help by staff for eating with oversight, encouragement or cueing. R67 was observed in the dining room feeding herself lunch on 5/23/11. Weights for R67 were found in multiple places- on the monthly weight record, weekly weight records (usually only indicated as week #1, #2, etc. for specific month), and on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Weights were as follows: 12/30/10 (admission)- 136.5 lbs. 1/4/11- 136.5 lbs. 1/13/11- 131.5 lbs. (5 lb. loss) 1/20/11- 128.5 lbs. (8 lb. loss) week #3 Jan.- 125 lbs. (11.5 lb. loss) week #4 Jan.- 129.5 lbs. 2/4/11- 115 lbs. (21.5 lb. loss) 2/7/11- 115 lbs. with re-weight of 116.5 lbs. (20 lb. loss) 2/11/11- to hospital R67's weight was 136.5 lbs. on 1/4/11 and 116.5 lbs. for a re-weight done on 2/7/11, reflecting a severe weight loss of 20 lbs. (14.6%) in one month. Monthly weight record instructions included "... Identify weight gain or loss in the appropriate WT. CHANGE column by specifying the difference (in pounds) between "new" weight and previous weight. The DATE NOTIFIED columns need only be completed when it is necessary to notify the individuals listed (family, doctor and dietary). Refer to the bottom of this form for undesired weight loss parameters. Each entry must be signed by a nurse...". There was no information recorded in the WT CHANGE and DATE NOTIFIED columns indicating that the facility failed to monitor R67's weight loss. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R67 drank 100% more often during the day than in the evening. Review of the MAR for % of meal consumption from 12/30/10 to 1/15/11 revealed variable intakes from 0-100% with an average of about 50% and from 1/16/11 to 2/10/11 0-75% with an average of about 25%. A care plan was developed on 1/5/11 for variable oral intakes and history of hydration issues. Interventions included, "monitor weights". On 1/17/11 a care plan was developed for weight loss for R67. The goal listed was to maintain weights weekly for 2 months. Interventions included monitoring and recording of weekly weights and report to MD as needed. The care plan was not revised until 2/21/11 when R67 returned from the hospital. A physician's progress note, dated 1/17/11, stated that R67 was seen for back pain and it was noted that R67 had a 5 lb. weight loss. The MD ordered a Med pass (nutritional supplement) 4 ounces 2 times a day. On 2/1/11, a physician's progress note, stated that R67 was seen for recent falls and "... wt loss: cont Med pass, follow [MEDICATION NAME] (test used to detect and diagnose protein-calorie [MEDICAL CONDITION])...". A [MEDICATION NAME] was not ordered, however. On 2/4/11, a physician's progress note, stated that R67 was seen for lethargy (fatigue) and her [MEDICATION NAME] (antipsychotic) was discontinued and urine studies were ordered. On 2/8/11, a physician's progress note, stated that R67 was seen due to continued lethargy despite the discontinuation of [MEDICATION NAME]. Multiple laboratory tests (did not include [MEDICATION NAME]) were ordered as well as a CT scan of the head. There was no mention of R67's continued significant weight loss in the progress notes on 2/4/11 or 2/8/11. A nurse's note, dated 2/10/11, stated, "The pt.'s wt. in Jan. 2011 was 136. 5 lbs. and wt. in Feb. 2011 was 116.5 lbs. The pt. lost 20 lbs (14.6%) in one month. MD, RD (registered dietician) and family made aware." Although R67's weight was identified at 115 lbs. on 2/4/11, the MD, RD, and family were not notified until 6 days later, despite ongoing evaluation by the MD during this time. R67 experienced a severe weight loss of 14.6% in one month. E14 (dietician) was in to evaluate R67 on 2/10/11 and after consultation with an MD, she wrote orders to increase the Med Pass to 3 times a day, ice cream with all meals and document % consumed on MAR, offer 4 oz. water 3 times a day between meals with % on MAR, and change R67'(s diet to pureed. Despite R67's continued weight loss (additional 15 lbs.) after the initial loss of 5 lbs. in which an MD ordered Med pass 2 times a day on 1/17/11, there were no other interventions ordered in an attempt to improve R67's to ensure acceptable parameters of weight. Review of R67's initial Nutrition Risk Assessment (completed by E14- registered dietician), dated 1/5/11, stated that R67's daughter stated that the resident was "not a big eater". R67's weights were stable at 136 lbs. and R67 was assessed as no/low risk for weight loss. R67's weight on 1/4/11 was 136.5 lbs., the same as it was on admission. Review of E14's dietary notes revealed that the facility failed to ensure that E14 monitored, evaluated and implemented appropriate interventions for R67's weight loss until she was notified by nursing of R67's 20 lb. weight loss on 2/10/11. There was no documentation by E14 from 1/5/11 until 2/10/11. A physician's progress note, dated 2/11/11, stated, "Seen & examined secondary to abn labs. Pt. has decreased po (oral) intake last week or two & increased lethargy... also had 20 lb weight loss in last mth... wt was 129.5 last week in Jan & on 2/7 weight is 115 lbs... Problem List: 1) [MEDICAL CONDITION] (sodium was 156 on 2/9/11, was 147 on 1/4/11; normal is 135-145) 2) lethargy/change in ms (mental status) 3) wt loss...". R67 was sent to the ER for evaluation of [MEDICAL CONDITION] and lethargy on 2/11/11 and she was hospitalized until 2/21/11. R67 was additionally diagnosed with [REDACTED]. On 5/24/11, E25 (LPN) was interviewed. E25 stated that when weight loss occurs, Med pass is started, the family and MD are to be notified of any weight changes, and weekly weights are to be done on bath days (Monday and Thursday for R67). E26 (charge nurse) was interviewed on 5/25/11. E26 confirmed findings and stated that R67 was not a hospice resident. E14 (dietitian) was interviewed on 5/25/11 via telephone. E14 confirmed that she could see why we (DLTCRP) had concerns by what was in the record. She stated that R67's daughter and she "talked all the time" and "could not figure out what was going on." E14 stated that she should have written down her conversations with R67's daughter. When asked how she monitored weights, E14 stated that when in the facility 2 times a week she first checks for new admissions, who went out to the hospital, and anyone with skin issues. After that, she stated that she walked around observing residents eating a meal and she talked to them. If she noticed something, E14 stated she would then go to the nurse and ask if there were any changes and she also talked to families. Despite these practices, the facility failed to ensure that R67's weight was monitored resulting in a severe weight loss of 14.6% in one month.

Based on observation, record review and interview, it was determined that the facility failed to provide nutritional interventions for two (R1 and R7) out of 7 sampled residents in accordance with assessed needs and per physician orders. The facility failed to consistently provide ice cream at all meals for R1 and R7, both of which had experienced weight loss. Findings include: 1. R7 was originally admitted to the facility 5/12/11 and re-admitted to the facility on [DATE], post hospitalization for pneumonia. Additional [DIAGNOSES REDACTED]. The initial MDS (Minimum Data Set) assessment, dated 5/21/11 stated R7's BIMS (Brief Interview for Mental Status) score was 9 (8-12: moderately impaired) and that she was independent for eating. Record review revealed that R7's re-admission weight on 6/8/11 was 139.8 pounds (lbs.). On 6/9/11, a physician's orders [REDACTED]. On 6/14/11, the order was changed to [MEDICATION NAME] 20 mg every other day. On 6/15/11, R7's weight was 125.5 and a re-weight completed on 6/16/11 noted her weight as 127 lbs. Orders were written on 6/16/11 for R7 to receive Med Pass (nutritional supplement) 2 ounces three times a day and ice cream with all meals. On 7/1/11, R7's weight had increased to 134.9 lbs. A "Nutritional Progress Note," dated 7/4/11 stated the resident's appetite was improved and that the supplement would be cut back. An order was written to decrease the Med Pass 2 ounces to once a day, but to continue the ice cream with all meals. Review of physician's orders [REDACTED]. On 8/1/11, R7's weight was 128 lbs., with a re-weight on 8/2/11 of 128.5 lbs. On 8/4/11, R7 was seen by the physician for the 6 lb. weight loss. The physician's progress note, dated 8/4/11 stated, "weekly wts x 4. (Continue) [MEDICATION NAME] (antidepressant which can act as appetite stimulant) 15 mg (every day). May be (secondary) to fluid loss (secondary) to [MEDICATION NAME] (increased) in July and (patient) also has (urinary tract infection)..." R7 was observed on 8/4/11 throughout breakfast, of which she consumed 100%. The facility staff did not give R7 any ice cream at this meal as per physician's orders [REDACTED]. R7 shook her head and said "no." R7 was again observed on 8/4/11 from 11:45 AM until approximately 1:30 PM during the midday meal. R7 did not eat her lunch and refused an offer of an alternate. Although E7 (CNA) brought the resident a container of pudding, which the resident ate, ice cream was not given or offered as per orders. In an interview with R7 immediately after lunch, she stated she wasn't hungry and did not want anything else. At 2:10 PM on 8/4/11, the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with E13 (nurse-had signed off on the MAR indicated [REDACTED]. E13 stated that it was given by dietary with meals. When E13 was informed that R7 had been observed during both meals on 8/4/11, she then stated that in the morning the resident told her she ate half (yet she had documented 100%), and that the resident told her she had pudding so she documented that in the place of the ice cream. On 8/4/11 at 2:20 PM, E12 (dietary) was interviewed with E2 (Director of Nursing) present. When asked how the ice cream that is to be given with meals is distributed, E12 stated that she brings up the ice cream but it is not labeled for the specific residents who are to receive it. E12 stated that whoever clears their plates should give the ice cream.The facility failed to have a system in place to ensure that residents who were ordered ice cream for nutritional needs (e.g.weight loss) received it as ordered. On 8/5/11 at 8:20 AM, E16 (Food Service Director) was interviewed regarding the facility's system to ensure that ice cream was provided to the residents as ordered. E16 stated that it would be delivered labeled with names and the time they are to get it. She also stated that it would be given with the main entree to ensure that the residents received it as ordered. On 8/5/11, the ADL (activities of daily living) Flow Record (completed by CNA) was reviewed for documentation of meal consumption for 8/4/11. R7's intakes on 8/4/11 for breakfast and lunch documented 25% for both meals. Surveyor observation on 8/4/11 revealed the intakes were 100% for breakfast and less than 25% (pudding consumed) at lunch. These findings were reviewed with E2, who acknowledged the inaccuracy. In summary, the facility failed to consistently provide ice cream for R7 per physician's orders [REDACTED]. 2. R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS (Minimum Data Set), dated 1/10/11 and a quarterly MDS, dated [DATE], stated R1's cognitive skills for daily decision making were moderately impaired and that she had short and long term memory problems. These same MDS' stated R1 was independent for eating with setup help only. A care plan for "Alteration in nutrition and hydration- ...has Alzheimer's c (with) variable po (oral intake), h/o (history of) decrease hydration status, sig wt.(significant weight) loss for 6 mos (months), but improved over 4 mos - now 121# (121 lbs.) was developed on 1/5/11 and last revised on 6/21/11. This care plan included the approaches: diet as ordered; liquids as ordered; monitor weights; assist with meals as needed; supplements as ordered; ...ice cream as ordered; milk as ordered... R1's 7/11 POS (Physician order [REDACTED]. Review of the physician's orders [REDACTED]. Review of R1's clinical record revealed that she had experienced a severe weight loss of 20 lbs. (14.6%) in one month after being admitted to the facility. A dietary progress note, dated 6/7/11 stated, " Wt stable x (times) 5 months - now 119.5#, remains significant for 6 mos. PO has stabilized and is slightly improved..." Another note, dated 6/21/11 stated, " Wt increased to 121# this week... Pureed diet, ice cream at all meals. Med pass 120 ml (milliliters) 3 x/day... Significant wt loss for 6 mos but improved since February..." A dietary note, dated 7/12/11, stated, "wt improved to 123# - now on regular diet. ice cream c (with) meals adds ~ (approximately) 450 kcal, 12 gm protein. Med Pass (supplement) adds another ~ 720 kcal, ~20 gm protein..." Review of the "2nd Floor Diets" sheet, which was kept in a drawer in the second floor dining room and updated on 8/2/11, listed R1's diet as, "Regular" and that she received "Med Pass 4oz 3 X a day- Ice cream all meals". Breakfast and lunch meal observations on 8/4/11, revealed that R1 ate her meals in the dining room. R1 ate 100% of the food served on her plate, however, she was never served nor offered any ice cream with these meals. At 2:10 PM on 8/4/11, R1's 8/11 MAR indicated [REDACTED]. During an interview on 8/4/11, E13 (nurse assigned to R1) confirmed that she had not given any ice cream to R1. When questioned regarding the blanks on the MAR, she confirmed that she missed it because she had not flagged R1's MAR indicated prn" (as needed) and was unaware that R1 was to receive ice cream with all meals, despite the written order on the MAR. At 2:45 PM, R1's 8/11 MAR indicated 0%" of ice cream was consumed for breakfast on 8/1/11 through 8/4/11, "50%" was consumed at lunch on 8/1/11 through 8/3/11 but "0%" on 8/4/11 and "100%" of ice cream was consumed with dinner for 8/1/11 through 8/4/11. There was no documentation on the back of the MAR indicated 0%" , no consumption of ice cream . During an interview on 8/4/11 at 3:25 PM, E2 (Director of Nurses) stated that they did not have a system or policy/procedure to ensure that the residents received their ordered ice cream. E2 stated that they probably needed to have the ice cream labelled with the resident's name and time or meal to be given, on each ice cream when it is brought up to the floors. E2 stated that they would work on that right away. The facility failed to consistently implement the intervention, "ice cream with all meals", as ordered for R1 who had a known significant weight loss, despite it being included on the 2nd floor diet sheet, R1's MAR, and POS.