Every finding on record at Oceanside Skilled Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to implement water management control measures for hot water tanks, potentially exposing 104 residents to waterborne pathogens. The facility failed to implement policies and procedures for Enhanced Barrier Precautions (EBP) for 2 of 6 residents observed for EBP (Resident identifiers are #12 and #32.), The facility failed to implement Transmission Based Precautions (TBP) for 3 of 6 residents reviewed for TBP (Resident identifiers are #62, #109, and #110). The facility failed to perform hand hygiene and use proper glove use for 1 of 3 residents reviewed for pressure injuries (Resident identifier is #12). Findings include: Review on 1/29/26 of the facility's policy titled, Transmission Based Precautions, revision date 5/1/25, revealed .The Center will use standard approaches, as defined by the Center for Disease Control and Prevention (CDC), for Transmission Based Precautions: Airborne, Contact, and Droplet Precautions.8. Initiating Transmission Based Precautions: 8,1 Nursing staff may place patients with suspected or confirmed infectious diarrhea, influenza, or symptoms consistent with a communicable disease on Transmission Based Precautions/isolations empirically while awaiting confirmation.8.5 Signage that includes instruction for use of specific PPE will be placed in a conspicuous location outside of patient's room.9 Contact Precautions:.9.3 Healthcare personnel caring for patients on contact precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. 9.4 Donning PPE [Personal Protective Equipment] upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., vancomycin resistant enterococcus (VRE), Clostridium difficile, noroviruses and other intestinal tract pathogens, respiratory syncytial virus (RSV) . Review on 1/29/26 of the CDC website titled, Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Conditions, dated 2/7/25, revealed .Gastroenteritis C. [Clostridium] difficile.Type of Precaution.Contact + [plus] Standard.Precautions/Comments .Handwashing with soap and water preferred because of the absence of sporicidal activity of alcohol in waterless antiseptic handrubs.Gastroenteritis Noroviruses.Type of Precaution.Update: Contact + Standard.Precautions/Comments.Use of Contact Precautions for a minimum of 48 hours after resolution of symptoms or to control institutional outbreaks. Review on 1/27/26 of facility's policy titled IC310 Special Contact and Droplet Precautions, revised 2/24/25, revealed .4. Wear proper PPE [personal protective equipment] including respiratory protection (N95 respirator), gown, and gloves prior to entering the room of those who require Special Contact and Droplet Precautions.8. The duration of these transmission-based precautions will be determined per Centers for Disease Prevention & Control (CDC) guidance for discontinuing precautions for persons with COVID.Refer to:.Appendix A: Type and Duration of Precautions Recommended for Suspected Infections and Conditions. Review on 1/27/26 of CDC Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Conditions, revised 2/7/25, provided by the facility, revealed .Infection/ Condition: Severe acute respiratory syndrome (SARS), Type of Precautions: Airborne + [plus] Droplet + Contact + Standard, Duration of Precautions: Duration of illness plus 10 days after resolution of fever, provided respiratory symptoms are absent or improving. Resident #62 Review on 1/27/26 of Resident #62's SARS-CoV-2 (Severe Acute Respiratory Syndrome- Coronavirus-2) antigen report, collected date of 1/23/26, revealed a positive result, indicating COVID-19 infection. Observation on 1/27/26 at approximately 9:30 a.m. of Resident #62's room revealed a Special Contact and Droplet precautions sign at entry. Further observation revealed Staff A (housekeeper) inside Resident #62's room cleaning the room and bathroom while wearing an N95 respirator, without gloves and a gown. Staff A exited the room without performing hand hygiene and proceeded to the housekeeping cart in the hallway. Interview on 1/27/26 at approximately 9:30 a.m. with Staff D (Licensed Practical Nurse (LPN)) stated that Staff A did not speak English and they only had precaution signs in English. Staff D confirmed that Resident #62 was on special contact and droplet precautions for testing positive for COVID-19. Resident #109 Observation on 1/29/26 at approximately 9:23 a.m of Resident #109's room revealed a enteric contact precaution sign posted outside of the room indicating to wash hands with soap and water when leaving the room. Further observation revealed that Staff L (Registered Nurse (RN)) left Resident #109's room and performed hand hygiene with alcohol-based hand sanitizer and did not wash their hands with soap and water. Interview on 1/29/26 at approximately 9:25 a.m. with Staff L confirmed the above findings. Review on 1/29/26 of Resident #109's physician's orders revealed an order, dated 1/21/26, for Infection Precautions- Contact. Resident #110 Interview on 1/27/26 at approximately 8:30 a.m. with Staff H (Director of Nursing) revealed that the facility has a norovirus outbreak on the east unit. Observation on 1/28/26 at approximately 8:22 a.m. during Resident#110's medication administration revealed an enteric contact precaution sign posted outside of Resident #110's room that indicated to wear gown and gloves. Staff M (LPN) entered Resident #110's room without donning gown and gloves, then proceeded to give Resident #110's scheduled morning medications. Interview on 1/28/26 at approximately 8:40 a.m. with Staff M confirmed the above findings for Resident #110. Staff M revealed that Resident #110 was experiencing diarrhea the evening of 1/27/26. Review on 1/28/26 of Resident #110's medical record revealed an active physician order and care plan for contact precautions, dated 1/28/26. Review on 1/28/26 of the facility's norovirus outbreak list revealed that Resident #110 date of onset of diarrhea was on 1/27/26. Observation on 1/28/26 at approximately 2:16 p.m. in Resident #110's room revealed that Resident #110 was in the bathroom. Staff J (RN) entered the room wearing a mask but did not don a gown and gloves. Further observation revealed that Staff J was positioned less than two feet from Resident #110 while supervising Resident #110 back to their room. Staff J assisted the Resident #110 into bed by touching their back. Before exiting the room, Staff J used an alcohol-based hand rub and did not wash their hands with soap and water. Interview on 1/28/26 at approximately 2:20 p.m. with Staff J confirmed the above observation for Resident #110. Resident #32 Observation on 1/28/26 at approximately 1:00 p.m. revealed an EBP sign posted outside Resident #32's room. Staff M entered the room wearing a mask and gloves but did not don a gown. Staff M proceeded to prepare and administer IV Ampicillin (antibiotic) by connecting the IV bag to the tubing, priming the tubing, flushing the PICC (Peripherally Inserted Central Catheter) line with normal saline, confirming blood return, connecting the IV tubing, and setting up the IV pump for infusion. Interview on 1/28/26 at approximately with Staff M confirmed the above observation for Resident #32. Staff M revealed that Resident #32 was on EBP for their PICC line. Review on 1/28/26 of Resident #32's medical record revealed an active physician order and care plan for EBP related to the PICC line. Review on 1/29/26 of the facility's policy titled, Enhanced Barrier Precautions, revision date 5/1/25, revealed .Precautions.Enhanced Barrier Precautions.Applies To.All patients with any of the following:.Chronic wounds and/or indwelling medical devices (e.g., central line, urinary catheter, enteral feeding tube.PPE Used for These Situations.During high contact patient care activities:.Device care or use of central line, urinary catheter enteral feeding tube.Wound care; any skin opening requiring a dressing.Required PPE.Gown, gloves prior to high contact care activity (Change PPE before caring for another patient) (Face protection may also be needed if performing activity with risk of splash or spray). Resident #12 Observation on 1/28/26 at approximately 2:16 p.m. revealed an EBP sign posted outside Resident #12's room. Following the administration of medication via the PEG (Percutaneous Endoscopic Gastrostomy) tube, Staff M proceeded to replace the old gauze dressing at the PEG tube insertion site with a new gauze dressing. During this procedure, Staff M was wearing gloves, a mask, and no gown. Interview on 1/28/26 at approximately with Staff M confirmed the above observation for Resident #12. Staff M revealed that Resident #12 was on EBP for the PEG tube. Review on 1/28/26 of Resident #12's care plan revealed a care plan indicated that Resident #12 was at risk for MDRO (Multidrug-Resistant Organism) colonization or infection due to the presence of an indwelling device, specifically a PEG tube, and includes an intervention for EBP. Observation on 1/29/26 at approximately 11:30 a.m. with Staff N (LPN) revealed Staff donned a gown and gloves to change Resident #12's sacral dressing. Staff N did not perform hand hygiene when changing from used gloves to new gloves in between the following procedures: removing the old sacral dressing, cleansing the wound with saline spray, applying Triad cream, and covering the wound with a new sacral foam dressing. Further observation revealed that Staff N performed hand washing prior to changing Resident #12's left heel dressing and donned new gloves. Staff M did not change their gloves in between the following procedures: removing the left heel old dressing, cleansing the wound with saline spray, cutting and applying calcium alginate dressing to the left heel wound, covering the wound with heel foam dressing, and wrapping with Kerlix. Interview on 1/29/26 at approximately with Staff N confirmed the above Resident #12's wound dressing observation. Review on 1/29/26 of Resident #12's medical record revealed active physician orders for wound treatments to the pressure injuries located on the sacral area and left heel. Review on 1/29/26 of the facility's policy titled, Procedure Wound Dressing: Aseptic, revision date 2/24/25, revealed .10. Perform hand hygiene. 11. Apply gloves and other PPE as indicated.14. Discard soiled dressing in the appropriate receptacle. 12. Remove and discard gloves. 16. Perform hand hygiene. Open dressing(s) without contaminating. Keep dressing(s) within the open packet and place directly on top of the barrier. 18. Prepare medication ointment, if indicated, by placing on barrier. 19. Perform hand hygiene. Apply gloves. 20. Cleanse or irrigate wound and periwound gently, as ordered.24. Remove gloves and perform hand hygiene. 25. Apply gloves. 26. Using sterile swab or applicator, apply treatment medication as ordered.28. Apply and secure clean dressing. 29. Remove gloves and discard in the appropriate receptacle.31. Perform hand hygiene. Review on 1/29/26 of the facility's policy titled, Hand Hygiene, revision date 5/1/25, revealed .The use of gloves does not replace hand hygiene. If a task requires gloves, perform hand hygiene before donning gloves and immediately after removing gloves.Perform Hand Hygiene: 1,.1 Before patient/resident (hereinafter patient care; 1.2 Before aseptic technique; 1.3 After any contact with blood or other body fluids, even if gloves are worn; 1.4 After patient care; After contact with patient's environment. 2. Hand hygiene techniques: 2.1 To wash hands with soap and water.2.2 To decontaminate hands with alcohol based rub. Review on 1/29/26 of facility's Water Management Plan, revised 1/2025, revealed Control Measures & Corrective Action.Hot water tanks should be at or above 140 degrees. Check for build up of biofilm . Further review revealed that there was no frequency for the monitoring of temperatures for the hot water tank. Interview on 1/29/26 at approximately 11:15 a.m. with Staff B (maintenance director) revealed that they failed to monitor and document the temperatures at the hot water tanks.

Based on observation, interview and record review, the facility failed to follow physician's order for 1 resident in a final sample of 21 resident and for 1 of 5 residents observed for medication administration. (Resident Identifiers are #100 and #110.)Findings include:Resident #110 [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614, .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . Review on 01/28/2026 of Resident #110's Electronic Medical Administration Record during Resident #110's medication administration observation with Staff M (Licensed Practical Nurse) revealed an order for Fluticasone Propionate 100 microgram/activated (MCG/ACT) inhaler (inhaled corticosteroid) give one puff orally two times a day with an order date of 1/26/26. The Fluticasone Propionate 100 MCG/ACT inhaler, which was scheduled to be given at 9:00 a.m. that morning. Observation on 1/28/26 at approximately 8:22 a.m. during Resident #110's medication administration with Staff M revealed that Staff M obtained a Fluticasone Propionate 50 MCG/ACT nasal spray bottle from the medication cart. Staff M went in Resident #110's room and handed the Fluticasone Propionate nasal spray bottle to Resident #110. Resident #110 self-administered the Fluticasone Propionate 50 MCG/ACT nasal spray with Staff M supervision. Review on 1/28/26 of the Fluticasone Propionate 50 MCG/ACT nasal spray box revealed a pharmacy label with instruction to administer 1 spray in both nostrils at bedtime. Review on 1/28/26 of Resident #110's physician orders revealed an order for Fluticasone Propionate 50 MCG/ACT nasal spray box revealed a pharmacy label with instruction to administer 1 spray in both nostrils at bedtime with an order date of 1/21/26. Interview on 1/28/26 at approximately 8:40 a.m. with Staff M confirmed the above findings and that they gave the wrong medication to Resident #110. Review on 1/29/26 of the facility policy titled, Medication Administration, dated 1/2025, revealed, .Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record [MAR]. Compare the medication and dosage scheduled on the resident's MAR with the medication label .Medications are administered in accordance with written orders of the prescriber . Resident #100 [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th ed. St. Louis, Missouri: Mosby Elsevier, 2021. Page 994 Daily Weights and Fluid Intake and Output Measurement revealed, .Daily weights are an important indicator of fluid status (Flever, 2019c). Each kilogram (2.2.lb [pound]) of weight gained or losses indicate changes in the amount of total body fluid, usually ECF (extracellular fluid), but do not indicate shift between body compartments.Compare the weight of each day with that of the previous day to determine fluid gain or losses. Look at the weights over several days to recognize trends. Interpretation of daily weights guides medical therapy and nursing care . Review on 1/28/26 of Resident #100's physician's order, dated 12/31/25, revealed an order for daily weights for edema with a discontinued date of 1/9/26 and an order dated 1/10/26 for daily weights for edema and congested heart failure with a discontinued date of 1/23/26. Further review revealed an active order for daily weights. Review on 1/28/26 of Resident #100's January Medication Administration Record revealed that for 6 of 23 days weights were not documented (January 3, 4, 6, 7, 8, and 14). Interview on 1/29/26 at 10:24 a.m. with Staff H (Director of Nursing) confirmed that there was no documentation that the daily weights had been done on the above days. Staff H confirmed there was no documentation in Resident #100's record that the resident had refused to be weighed or that the physician had been notified of missing weights.

Based on observation, interview, and record review, the facility failed to ensure that residents have the appropriate equipment to prevent a decrease on Range of Motion (ROM) for 1 of 1 resident reviewed for Limited ROM in a final sample of 22 residents. (Resident identifier is #76.)Findings include: Observation on 1/27/2026 at approximately 1:53 p.m. at Resident #76's room revealed that Resident #76 was sitting in bed with their right hand clenched in a fist. Further observation revealed no hand splints or positioning devices on Resident #76's right hand or in their room. Interview on 1/27/26 at approximately 1:53 p.m. with Resident #76 revealed that he/she had a stroke and cannot move their right upper extremity. Resident #76 also revealed that he/she does not use a hand splint or positioning device for their right hand. Interview on 1/29/26 at approximately 9:30 a.m. with Staff J (Registered Nurse) revealed that Resident #76 does not currently have a hand splint, but they did before. Review on 1/29/26 of Resident #76's care plan, initiated date of 8/25/23, revealed the resident was at-risk for alteration in functional mobility with a goal to tolerate splints or palm guard on affected upper and lower extremity for ninety days and an intervention to wear splint on affected upper and lower extremity as ordered. Interview on 1/29/26 at approximately 9:28 a.m. with Staff I (Rehabilitation Director) revealed that Resident #76 had a palm protector and it should be worn daily when out of bed. Interview on 1/29/26 at approximately 11:42 a.m. with Staff K (Physician Assistant) revealed that Resident#76 should still have the hand splint applied as per the care plan.

Based on observation, interview and record review it was determined that the facility failed to arrange for the provision of rehabilitative services for 1 of 2 residents reviewed for rehabilitation in a final sample of 22 residents. (Resident identifier is #25.) Findings include:Interview on 1/27/26 at approximately 10:42 a.m. with Resident #25 revealed that he/she was receiving injections for contractures and was told that he/she would have therapy after the injections. Resident #25 further revealed that he/she has not received therapy following his/her most recent injection.Review on 1/27/26 of Resident #25's care plan meeting note, dated 12/30/25, revealed that Resident #25 would be re-evaluated by PT/OT (Physical Therapy/Occupational Therapy) after his/her Botox injection.Review on 1/27/26 of Resident #25's consultation report, dated 1/15/26, revealed that Resident #25 was seen for left spastic hemiplegia. Further review revealed recommendations for Dysport (Botox) injections every three months and physical therapy to address range of motion, standing, stretching, and bracing.Interview on 01/29/26 at approximately 8:24 a.m. with Staff I (Rehabilitation Director) confirmed that Resident #25 had not been seen by therapy after Resident #25's consultation appointment on 1/15/26.

Based on interview and record review, it was determined that the facility failed to ensure that grievances from Resident Council were acted upon (Resident identifiers are #16, #21, and #99). Findings include: Review on 12/16/24 of the Resident Council Meeting Minutes dated 8/19/24, facilitated by Staff E (Regional Activities Director), in the section titled Dietary, revealed: Residents are concerned snacks aren't consistently available when they ask for them. Interview on 12/16/24 at approximately 11:00 a.m. with Resident Council (13 residents attended the group meeting) revealed that they had a food committee and no changes ever happen after they voice their concerns about snacks. Interview on 12/18/24 at 8:00 a.m. with Resident #99 revealed that he/she was not provided snacks when they would like at bedtime. Interview on 12/18/24 at approximately 9:07 a.m. with Resident #16 revealed snacks were not always available. Resident #16 also stated that on the evening of 12/15/24, he/she requested a cookie, which was unavailable, and that the staff left without offering an alternative snack. Interview on 12/18/24 at approximately 1:00 p.m. with Resident #21 revealed that he/she was not provided snacks when they would like at bedtime.

Based on interview and record review, it was determined that the facility failed to ensure that the provider reviewed irregularities identified by the pharmacist during the monthly Pharmacy Medication Regimen Review (MRR) timely for 1 of 8 residents reviewed for unnecessary medications (Resident Identifier #62). Findings include: Review on 12/18/24 of the facility's policy titled, Medication Regimen Review and Reporting, dated 1/24, revealed: .The nurse care center follows up on the recommendations should be acted upon within 30 calendar days or per facility specific protocols. a. For those issues that required physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendations is rejected in the resident's record . Review on 12/18/24 at approximately 10:00 a.m. of Resident # 62's Pharmacy MRR, dated 8/22/24, revealed a recommendation to adjust the total daily dose of Gabapentin to stay within recommended dosing guidelines. Further review of the MRR revealed that the physician did not address the recommendation until 10/2/24 (more than 30 days from the MRR recommendation of 8/22/24).

Based on record review, interview, and policy review, it was determined that the facility failed to follow the established smoking policy for 1 out of 1 resident reviewed for smoking in a final sample of 23 residents (Resident Identifier #92). Findings include: Review on 12/18/24 of the facility's policy titled, OPS137 Smoking, revision date 5/01/24, revealed: Policy .Patients/Residents will be assessed on admission, quarterly, and with change in condition for the ability to smoke safely . Review on 12/18/24 of Resident #92's medical record revealed that Resident #92 was a smoker. Further review of the medical record revealed that the most recent smoking assessment was a smoking evaluation on 6/17/24. Interview on 12/18/24 at 11:00 am with Staff A (Director of Nursing) confirmed the above findings. Interview with Staff A confirmed that smoking evaluations were completed upon admission, quarterly, and with a change in condition. Staff A stated that Resident #92 was due for a quarterly smoking evaluation to be completed in September of 2024.

Based on interview and record review, it was determined that the facility failed to ensure residents received adequate supervision when a door alarm sounded resulting in a resident elopement for 1 of 2 residents reviewed for elopement (Resident Identifier #1). Findings include: Interview on 8/23/24 at approximately 8:30 a.m. with Staff C (Administrator) revealed that on 7/28/24, Resident #1 left the premises through the front door with a wanderguard on. The door alarm sounded and was deactivated by Staff B (Recreational Assistant) at approximately 5:15 p.m. Staff were looking for Resident #1 to go out on a smoking break around 6:30 and Staff D (Licensed Nursing Assistant) reported that he/she had seen the resident at a nearby gas station. Interview on 8/23/24 at approximately 10:30 a.m. with Staff A (Nurse Practice Educator) revealed he/she was on-call the evening of 7/28/24 and learned of the elopement at approximately 6:30 p.m. The facility discovered that Resident #1 took a taxi from the gas station to a homeless shelter approximately an hour away. The police department and hospitals near the shelter were notified. Resident #1 went to a fire station instead of the shelter with a complaint of abdominal pain and was taken to a nearby hospital. The resident has returned to the facility. Interview on 8/23/24 at approximately 11:05 a.m. with Staff B revealed he/she heard the front door alarm going off when he/she entered the lobby from a unit. Staff B did not know how long the alarm had been sounding. Staff B checked the parking lot for residents and did not see any residents in the vicinity. Staff B re-entered the facility lobby, turned the door alarm off, did not notify a nurse the alarm had sounded and Staff B left for the day. Review on 8/23/24 of the facility's in-service staff education sheet revealed all staff had been educated on the facility's elopement policy and what to do when a door alarm is going off was reviewed and completed between 7/29/24 through 7/30/24. Review on 8/23/24 of the facility's mock elopement drills revealed the drills had been completed weekly since 8/2/24. Review on 8/23/24 of the facility's Root Cause Analysis (RCA) completed on 7/29/24 revealed the system failures and assigned various managers to oversee different areas for improvement in keeping the staff aware of the elopement process. This RCA was submitted to the Quality Assurance Committee for review on 7/29/24. This RCA included the following areas: immediate actions, (elopement risks, book) what changes were made to the system, (increase sensitivity, what happens when alarm goes off, re-education) and what needed to be maintained (assess function of secure care system monthly, and audits). Review on 8/23/24 of the facility's policy titled: Elopement of Patient, last revised 10/24/22, revealed: Elopement is defined as any situation in which a patient leaves the premises or a safe area without the facility's knowledge and supervision, if necessary . 2. Witnessed Attempted or Actual Elopement: 2.1 Staff witnessing a confused patient or an identified elopement risk patient attempting to leave the Unit and/or Center accompanied (sic) will intervene as appropriate to redirect the patient to a safe area and prevent elopement. 3. Unwitnessed Elopement 3.1 Notify the supervisor that the patient is missing. 3.2 Supervisor will alert all staff of missing patient with an announcement to activate missing patient protocol .

Based on interview, observation, and record review, it was determined that the facility failed to ensure that residents with pressure ulcers had necessary treatment and services, which includes documentation of weekly assessments that contained measurements and descriptions of the pressure ulcer and treatment orders, for pressure ulcers for 2 out of 2 residents reviewed for pressure ulcers (Resident Identifiers are #1 and #2). Findings include: Resident #1 Interview on 7/2/24 at approximately 8:45 a.m. with Resident #1 revealed Resident #1 had wounds to their bottom and their heels. Review on 7/2/24 Resident #1's medical record revealed a clinical admission note dated 6/25/24 that stated: .Skin note: Skin issues noted. Coccyx open area and bilateral back heels black . Further review of the medical record revealed that there were no treatment orders for the above identified pressure injuries until 6/29/24. Review on 7/2/24 of Resident #1's Skin and Wound section of Resident #1's medical record revealed that there were no descriptions or assessments of wounds. Interview on 7/2/24 at approximately 1:00 p.m. with Staff A (Director of Nursing) confirmed the above findings. Resident #2 Interview on 7/2/24 at approximately 8:10 a.m. with Resident #2 revealed Resident #2 had a pressure injury on their left heel with a dressing in place. Review on 7/2/24 of Resident #2's medical record revealed the following weekly skin and wound evaluations completed for Resident #2's left heel pressure injury: 5/13/24 6/12/24 6/20/24 6/26/24 Interview on 7/2/24 at approximately 12:00 p.m. with Staff A confirmed the above findings and revealed there were no assessments between 5/13/24 and 6/12/24 (approximately 30 days). Review on 7/2/24 of facility policy titled, Skin Integrity and Wound Management, revised on 5/1/24, revealed: .6.5 Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with unanticipated decline in wounds .

Based on observation, interview and record review, it was determined that the facility failed to maintain infection control practices in regards to hand hygiene, changing gloves and cleaning equipment during pressure ulcer care in 1 out of 1 observations of pressure ulcer care observed (Resident Identifier #2). Findings include: Review on 7/2/24 of Resident #2's Skin and Wound Evaluation, dated 6/26/24, revealed that Resident #2 had a Stage 3 Pressure Injury to the left heel, measuring 5.1 by 2.8 centimeters. Review on 7/2/24 of Resident #2's July 2024 Treatment Administration Record revealed the following treatment orders: Wound care: left heel: cleanse with wound cleanser, pat dry, apply Betadine to eschar area, allow to dry, cover with ABD [Abdominal] Pad and secure with Kerlix [gauze wrap] every day, with a start date of 6/14/24. Observation on 7/2/24 at approximately 9:45 a.m. of Staff C (Registered Nurse) providing wound care to Resident #2's left heel area revealed the following: Staff C donned a protective gown but did not tie it at the waist, which allowed for the ties to drag on the floor. Resident #2 was sitting at the bedside in his/her wheelchair. Staff C removed a pair of surgical scissors from his/her pocket and began to cut the intact bandaged roll on the left foot without disinfecting the scissors. Staff C placed the dirty scissors directly on to Resident #2's bed. Staff C placed the multi-use wound cleanser bottle directly on to Resident #2's bed after cleaning the wound. Without changing his/her gloves and without performing hand hygiene Staff C applied the new dressing to Resident #2's left foot wound. After completing the dressing change, Staff C removed their gloves, but did not perform hand hygiene. With ungloved hands Staff C retrieved the dirty scissors and bottle of wound cleanser off the bed and without disinfecting them, placed the two items on top of the treatment cart outside of Resident #2's room. Staff C then used hand sanitizer to clean their hands and placed the dirty wound cleanser bottle in a drawer labeled with Resident #2's name without disinfecting and proceeded to take the scissors down the hall. Interview on 7/2/24 at approximately 10:15 a.m. with Staff C confirmed that they did not remove their gloves or wash their hands during the dressing change at any time, that they did not disinfect the multi-use items before returning them to clean areas and they did not disinfect the top of the treatment cart after placing dirty items on top of it. Interview on 7/2/24 at approximately 12:00 p.m. with Staff A (Director of Nursing) confirmed that he/she would expect that gloves would be changed and hand hygiene would be performed between the dirty and clean dressing change, that multi-use items would be disinfected after use and before placing in or on a clean area. Staff A was unable to provide a policy regarding infection control and dressing changes. Review on 7/2/24 of the Centers for Disease Control and Prevention's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 4/12/24, retrieved on 7/2/24 from https://www.cdc.gov/infection-control/hcp/core-practices/index.html, revealed: .Adherence to infection prevention and control practices is essential to providing safe and high quality patient care across all settings where healthcare is delivered .The practices outlined in this document are intended to serve as a standard reference and reduce the need to repeatedly evaluate practices that are considered basic and accepted as standards of medical care .The core practices in this document should be implemented in all settings where healthcare is delivered. These venues include both inpatient settings (e.g., acute, long-term care) .5a. Hand Hygiene References and resources .Use an alcohol-based hand rub or wash with soap and water for the following clinical indications: a. Immediately before touching a patient b. Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices c. Before moving from work on a soiled body site to a clean body site on the same patient d. After touching a patient or the patient's immediate environment e. After contact with blood, body fluids or contaminated surfaces f. Immediately after glove removal .5f. Reprocessing of Reusable Medical Equipment References and resources .Clean and reprocess (disinfect or sterilize) reusable medical equipment . Maintain separation between clean and soiled equipment to prevent cross contamination .

Based on record, policy, and interview, the facility failed to provide Cardiopulmonary Resuscitation (CPR) in accordance with the American Heart Association guidelines and/or the facility's policy for 1 resident in a survey sample of 11 residents who expired at the facility. (Resident identifier is #1.) Findings include: Review on [DATE] of Resident #1's physician orders revealed an order written on [DATE] for full code, meaning CPR is to be initiated in the event their heart or breathing stops. Registered Nurse (RN) #1 Interview on [DATE] at approximately 11:09 a.m. with RN #1 revealed on [DATE] that he/she was assisting with the care of Resident #1 with Licensed Nurse Assistant (LNA) #1. RN #1 further revealed that after assisting with care, LNA #1 said that Resident #1 didn't look right. RN #1 left the room to check the code status and call emergency medical services. RN #1 saw Licensed Practical Nurse (LPN) #1 in the hallway he/she asked LPN #1 if they knew how to do CPR because RN #1 felt like Resident #1 was declining. RN #1 further revealed that he/she continued to get paperwork and call emergency services before returning to Resident #1's room. LNA #1 Telephone interview on [DATE] at approximately 11: 35 a.m. with LNA #1 revealed that Resident #1 had loose bowels during their shift and that he/she informed RN #1. RN #1 asked for LNA #1's assistance in administering an enema to Resident #1. LNA #1 further revealed while administering the enema, Resident #1's breathing was off. When RN #1 completed administering the enema, he/she went to Resident#1's bathroom to wash his/her hands. LNA #1 informed RN #1, that Resident #1 was no longer breathing and had no pulse. RN #1 then left the resident's room. LNA #1 went to get a non-rebreather [mask used to administer high concentrations of oxygen] and when he/she returned to the room, there was no other staff present. LNA #1 took Resident #1's pulse again manually and there was no pulse felt. LNA #1 revealed that LPN #1 arrived approximately ,d+[DATE] minutes later and started CPR. Then LPN #2 arrived to assist. LPN #1 Telephone interview on [DATE] at approximately 1:10 p.m. with LPN #1 revealed that he/she was walking to the East Unit when they saw RN #1 approaching. LPN #1 went to ask RN #1 a question about one of their residents when RN #1 stated that he/she could not answer him/her because I'm in the middle of a code, do you know CPR? LPN #1 responded yes. RN #1 told him/her to get the crash cart and respond to Resident#1's room. LPN #1 further revealed upon entering Resident #1's room, LNA #1 told LPN #1 that Resident #1 had passed. LPN #1 stated they attempted to get the air mattress to deflate and to put down the head of the bed. LPN #1 stated they could not deflate the mattress or get the head of the bed down flat, so he/she initiated CPR without the mattress deflated or bed flat. LPN #1 stated they brought the code cart to Resident #1's room but did not bring the automated external defibrillator (AED) that was located next to the code cart. LPN #2 Telephone interview with LPN #2 revealed that RN #1 went to get LPN #2 to assist with a resident who needed CPR at approximately 9:30 p.m. LPN #2 went to Resident #1's room with RN #1 and started suctioning because Resident #1 had a brown fluid coming out his/her mouth. LPN #2 stated they suctioned about 400 cc [cubic centimeters] of fluid. Review on [DATE] of RN #1's Basic Life Support (BLS) Certificate, issue date [DATE], revealed that he/she was a BLS Instructor. Review on [DATE] of the In-Service sign in sheet with the topic of Mock Code Sign In was completed between [DATE] thru 23, 2023 with the licensed nursing staff. Review on [DATE] of the facility Quality Assurance Plan Improvement (QAPI) agenda identified that CPR has been added to the agenda between October thru January. The first QAPI meeting in which CPR was identified was on [DATE] as an ongoing project in which the facility will implement mock CPR drills. Review on [DATE] the facility had completed a full house audit of the resident's code status on [DATE]. Interview on [DATE] at approximately 9:30 a.m. with the Director of Nursing (DON) revealed that he/she was unable to piece together a timeline during their investigation and could not say how long it took to start CPR. It was estimated that Resident #1 was found deceased and unresponsive at 9:05 p.m. and CRP was started between 9:15 p.m. and 9:20 p.m. Interview confirmed that in response to the incident, the facility completed a house audit of resident code status, conducted mock codes, and started a QAPI project. Review on [DATE] of the facility's procedure titled Cardiac and/or Respiratory Arrest, with a revision date of [DATE], revealed the following: 1. Upon discovery of a patient in cardiopulmonary arrest (e.g., no apparent pulse, blood pressure, or respiration), staff will immediately: 1.1 Call for assistance; 1.2 Alert the licensed nurse and CPR/automated external defibrillator (AED) certified staff. 1.3 Prepare the patient for CPR/AED while determining the presence of a Do Not Resuscitate order (DNR) . 2. Witnessed Arrest: 2.1 If there is no visual identification of DNR status or no DNR order on the patient's medical record: 2.1.1 CPR/AED certified staff will initiate CPR/AED application. 2.1.1.1 If an AED is immediately available, begin defibrillation using the AED rather than starting compressions. 2.1.1.2 If an AED is not immediately available, initiate CPR while the AED is being retrieved and applied, and begin defibrillation as soon as the device is ready for use . 7. For all cardiac/respiratory arrests, documents: 7.1 Time patient was found without pulse or spontaneous respirations in the patient's medical record; 7.2 Any significant clinical events preceding the events; 7.3 Patient's DNR status; 7.4 Presence of any end-stage, terminal, or advanced medical condition(s); 7.5 Description of patient's condition upon discovery (e.g., absence of blood pressure, pulse, respiration, skin color, skin temperature, body stiffness, etc.); 7.6 reason for the decision to withhold CPR; 7.7 Notification of physician and time notified; 7.8 Notification of family and time notified; 7.9 Transfer order/information on the transfer sheet, if transferred; 7.10 Death pronounced by licensed nurse or physician called, if applicable; 7.11 Name of funeral home and date and time of the release of the body, if applicable. 8. If CPR/AED was performed, document the event on the CPR/AED flow sheet. Review on [DATE] of the facility's policy titled, Cardiopulmonary Resuscitation (CPR), effective date of [DATE] with a revision date of [DATE] revealed, An automated external defibrillator (AED) will be used, if available, to treat persons who experience sudden cardiac arrest. Use of the AED is authorized only for personnel certified in CPR and use of the AED . If a patient does not have a DNR (Do Not Resuscitate) order, CPR certified staff will initiate CPR, and emergency medical services (EMS) will be activated. CPR is to be provided in the location where the patient is discovered as long as the location is safe for the responder and the patient. If the location is not safe, the patient will be moved to the nearest safe location for resuscitation.

Based on observation and interview, it was determined that the facility failed to ensure a clean homelike environment for 2 of 4 units observed (West Unit and Tuck Unit). Findings include: Observation on 12/28/23 at approximately 12:45 p.m. with Staff J (Maintenance Director) and Staff H (Administrator), revealed the following on [NAME] Unit: Resident room [ROOM NUMBER] had chipped sheet rock exposing a corner metal edge outside the bathroom approximately 5 inches in length on the wall. Resident room [ROOM NUMBER] bathroom contained a brown urine stain around a leaking toilet base and cracked urine stained floor tiles around the toilet. Resident room [ROOM NUMBER] bathroom had a wet urine soaked towel wrapped around a leaking toilet base and cracked urine stained floor tiles around the toilet. Resident room [ROOM NUMBER] bathroom had a brown wet and sticky urine puddle around the base of a leaking toilet base and cracked urine stained floor tiles around the toilet, causing a urine mal-odor. Interview on 12/28/23 at approximately 12:55 p.m. with Staff J and Staff H confirmed the above findings. Observation on 12/28/23 at approximately 1:00 p.m. with Staff J and Staff H revealed the following on Tuck Unit: Resident room [ROOM NUMBER] had worn and cracked floor tiles throughout the room. Interview on 12/28/23 at approximately 1:00 p.m. with Staff J and Staff H confirmed the above finding. Review on 12/29/23 of the facility's policy titled, Sanitization, last revised 3/1/12, revealed: All bathrooms and areas which have hand washing facilities must be maintained in a clean and sanitary condition.

Based on observation, interview, and record review, it was determined that the facility failed to follow physician orders for 4 residents in a final sample of 26 residents (Resident Identifiers are #51, #55, #94, and #95). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 - Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #55 Review on 12/29/23 of Resident #55's December 2023 Electronic Medication Administration Record (EMAR) revealed that Resident #55 had an order for Morphine 20 milligram/milliliter (mg/ml) . give 0.25 ml by mouth every 1 hour as needed for mild pain 1-3 or shortness of breath. Review also revealed that Resident #55 had an order for morphine 20 mg/ml . give 0.5 ml for moderate pain 4-6 and an order for morphine 20 mg/ml . give 1 ml for severe pain 7-10. Further review of Resident #55's December 2023 EMAR revealed that Resident #55 received Morphine 20 mg/ml 0.25 ml dose on 12/2/23 for 4 out of 10 pain and on 12/17/23 for 7 out of 10 pain. Review on 12/29/23 of Resident #55's Brief Interview for Mental Status (BIMS), dated 11/6/23, revealed a score of 2 which indicated severe cognitive impairment. Interview on 12/29/23 at approximately 10:45 a.m. with Staff G (Director of Nursing) confirmed the above findings. 38218 Resident #51 Review on 12/27/23 of Resident #51's December 2023 Medication Administration Record revealed the following physician's order: Weigh one time a day for CHF [Congestive Heart Failure] Notify provider if there's a 4 pound weight gain in one day or 8 pounds in a week, Start Date 5/27/23. Review on 12/27/23 of Resident #51's weights revealed the following weight gain: 12/22/23 weight 150.0 12/23/23 weight 156.0 (6 pound gain) Interview on 12/29/23 at approximately 10:45 a.m. with Staff G confirmed the above findings and confirmed that the physician was not notified of the weight gain. Resident #94 Observation on 12/27/23 at approximately 10:00 a.m. of Resident #94's bilateral feet and ankles revealed that both were edematous. Interview on 12/27/23 at approximately 10:00 a.m. with Resident #94 revealed that he/she was unaware of any compression stockings being ordered for him/her. I wouldn't be able to put them on and no one has put them on me since I have been here. Observation on 12/28/23 at approximately 12:00 p.m. of Resident #94's bilateral feet and ankles revealed that both were edematous. Review on 12/28/23 of Resident #94's December 2023 Treatment Administration Record revealed the following: Apply TEDS [Thrombo Embolism Deterrent] to BLE [Bilateral Lower Extremities] as tolerated in the morning, in the morning for Edema, Start Date 1/23/23. Interview on 12/28/23 at approximately 12:00 p.m. with Staff F (Licensed Nursing Assistant (LNA)) revealed that he/she was unaware of Resident #94 ever wearing TEDS. Night shift gets [pronoun omitted] out of bed in the morning. Resident #95 Interview on 12/28/29 at approximately 11:45 a.m. with Resident #95 revealed that he/she had been telling staff since being admitted to the facility that his/her Lymphedema requires his/her legs to be wrapped daily. They get so swollen and no one listens to me that I need them wrapped. Review on 12/28/23 of Resident #95's diagnosis list revealed a diagnosis of Lymphedema in 8/2023. Review on 12/28/29 of Resident #95's Medication and Treatment Administration Records revealed there were instructions for the application of TEDS stockings. Interview on 12/28/23 at approximately 1:00 p.m. with Staff G revealed that Resident #95 did have a physician's order for wraps that never made it into the Treatment Administration Record. Review on 12/28/23 of the physician's order revealed: Circaid Compression Stockings BLE OD [Daily], Order Date 8/30/23.

Based on observation, interview, and record review, it was determined that the facility failed to provide equipment to a resident with limited range of motion for 1 of 1 resident reviewed for position/mobility in a final sample of 26 residents (Resident Identifier is #87). Findings include: Interview on 12/27/23 at approximately 10:30 a.m. with Resident #87 revealed that he/she had no movement to his/her left hand since having a stroke about a year ago. Further interview revealed that Resident #87 had been waiting for a splint/brace device from therapy for months. Interview on 12/28/23 at approximately 1:15 p.m. with Staff E (Occupational Therapist) revealed that therapy had placed an order for a splint from their supplier for Resident #87 prior to the resident being discharged from therapy and never followed up to see if the resident received the splint. Review on 12/28/23 of Resident #87's last therapy visit dated 7/5/23 thru 8/3/23 revealed: .Objective Progress/Short Term Goals Patient will maintain functional hand position with use of resting hand splint for LUE [Left Upper Extremity] to prevent hypermobility, promote skin integrity, and quality of life. (Target 8/3/23) .Objective Progress/Long Term Goals Patient will maintain functional hand position with use of resting hand splint for LUE to prevent hypermobility, promote skin integrity, and quality of life. (Target 7/25/23)

Based on observation, interview, and record review, it was determined that the facility failed to ensure that medications were secured on 1 of 3 units observed, and the facility also failed to ensure that medications were labeled after preparation and labeled with an opened or expiration date on 2 of 3 medication carts observed. ([NAME] unit, [NAME] Unit, and Tuck Unit) (Resident Identifiers are #1, #8, #16, #48, #99, and #104). Findings include: West Unit Observation on [DATE] at approximately 8:45 a.m. of the [NAME] Unit Medication Cart revealed the following medications left on top of the medication cart unattended: Resident #8 Lamictal 25 milligrams (mg) - 1 pill Pantoprazole 20 mg - 4 pills Resident #16 Pantoprazole 40 mg - 4 pills Lamotrigine 100 mg - 2 pills Furosemide 20 mg - 4 pills Interview on [DATE] at approximately 8:45 a.m. with Staff A (Medication Nursing Assistant (MNA)) confirmed the above findings. Tuck Unit Observation on [DATE] at approximately 8:55 a.m. of the Tuck Unit Medication Cart revealed the following: Resident #1 Humulin ,d+[DATE] insulin pen, opened without an opened date or expiration date. Resident #48 Lispro insulin pen, opened without an opened date or expiration date. Interview on [DATE] at approximately 8:55 a.m. with Staff B (Registered Nurse (RN)) confirmed the above findings. Review on [DATE] of the facility policy titled, 5.3 Storage and Expiration Dating of Medications, Biologicals, revision date [DATE] revealed: .4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines .5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened Review on [DATE] of the manufacturer's instructions for Lispro Insulin, dated 2023 revealed: .Throw away all insulin Lispro in use after 28 days, even if there is insulin left. Review on [DATE] of the manufacturer's instructions for Humulin ,d+[DATE] Qwikpen, dated 2023 revealed: .Throw away all opened vials after 31 days in use, even if there is still insulin left in the vial . Francouer Unit Observation on [DATE] at approximately 8:35 a.m. of the Francouer Medication Cart with Staff C (Registered Nurse (RN)) revealed that Resident #104's medications were in a medication cup in the medication cart crushed in applesauce. There was no resident identifying information on the medication cup. Resident #99's medications were in a medication cup in the medication cart. Interview on [DATE] at approximately 8:35 a.m. with Staff C confirmed the above findings. Review on [DATE] of the facility policy titled, 6.0 General Dose Preparation and Medication Administration, Revision Date [DATE] revealed: .3.2 Facility staff should only prepare medications for one resident at a time.

Based on observation, interview, and policy review it was determined that the facility failed to store food in accordance to professional standards in the main kitchen. Findings include: Observation on 12/27/23 at approximately 8:45 a.m. with Staff K (Dietary Director) of the walk-in refrigerator revealed the following: One box contained 30 lemons that were wilted, soft, and each with multiple brown spots. One container of celery stocks that were wilted with yellow/brown discolored wilted leaves. One container containing half an onion, half a cucumber, and 2 wilted tomato wedges with an expiration/use-by date of 12/25/23. Interview on 12/27/23 at approximately 8:45 a.m. with Staff K confirmed the above findings. Review on 12/29/23 of the Food and Drug Administration [FDA] Food Code, dated 2017, retrieved from: https://www.fda.gov/media/110822/download, revealed . Products which are damaged, spoiled, or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods . Review on 12/29/23 of the facility's policy titled, Receiving, dated 2/2023, revealed: .Safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all items .All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation .

Based on interview and record reviews revealed that a fall that occurred at the facility and was not recorded in the medical record for 1 of 4 residents reviewed for accidents in a final sample of 26 (Resident Identifier is #19). Findings include: Review on 12/27/23 of the facility matrix revealed that Resident #19 had a fall in the last 120 days. Review on 12/28/23 of Resident #19's medical record revealed no documentation of the fall. Interview on 12/28/23 at approximately 1:45 p.m. with Staff G (Director of Nursing) confirmed that Resident #19 had an unwitnessed fall at the facility on 10/26/23. Further interview confirmed that there was no documentation of the fall in Resident #19's medical record. Review on 12/28/23 of the facility policy titled, 4.25 Health Information Record and Chart Order, Revision Date 5/1/22 revealed: . The health information record will include: Sufficient information to identify the patient; A record of the patient's assessments; The comprehensive plan of care and services provided; . Purpose To ensure complete health information records are maintained in the service location . Review on 12/29/23 of the facility policy titled, NSG 215 Falls Management, Revision Date 8/7/23 revealed: . 5.3 Any patient who sustains an injury to the head from a fall and/or has an unwitnessed fall will be observed for neurological abnormalities by performing neurological check, per policy.

Based on interview and record review, it was determined that the facility failed to ensure that a resident recieved treatment and care in accordance with physcian orders for 1 out of 2 residents reviewed for intravenous (IV) fluid management (Resident identifier is #1). Findings include: Review on 5/25/23 of Resident #1's current physician's orders revealed the following order dated, 4/24/23: 2 gm (grams) Sodium 2g diet, Regular texture with 1500 ml (milliliters) fluid restriction and consistent carbohydrates. Review on 5/25/23 of Resident #1's medical record revealed that there was no documentation or monitoring of Resident #1's fluid intake. Interview on 5/25/23 at approximately 10:45 a.m. with Staff A (Director of Nursing) confirmed the above finding. Review on 5/25/23 of the facility policy titled, NSG Nutrition/Hydration Care and Services, revision date 2/1/23 revealed: 9.4 When a physician/APP (Advanced Practice Provider) orders a fluid restriction due to specific clinical condition: .9.4.3 Dietary will calculate the amount of fluids to be provided on the meal trays; 9.4.4 Nursing will calculate the remaining amounts of fluids allotted for each shift; .9.5 Monitor intake and output: . Review on 5/25/23 of Resident #1's May 2023's MAR (Medication Administration Record) revealed the following physician's order: Weight q (every) Monday, Wednesday, Friday for CHF (Congestive Heart Failure) one time a day every Monday, Wednesday, Friday, Start Date 4/28/23. Further review of Resident #1's MAR revealed that from 5/1/23 through 5/10/23, 1 weight was documented as obtained on 5/3/23. Interview on 5/25/23 at approximately 10:45 a.m. with Staff A confirmed that there should have been 5 weights obtained between 5/1/23 through 5/10/23. Review on 5/25/23 of Resident #1's physician's progress note dated 5/15/23 (Monday) revealed the following: I was asked to the patient today urgently at the request of nursing for abnormal labs and patient complaining of just not feeling right. [pronoun omitted] potassium was 5.8 on Friday. No indication that on-call provider was notified therefore [pronoun omitted] was not treated for [pronoun omitted] hyperkalemia. Interview on 5/25/23 at approximately 10:45 a.m. with Staff A confirmed that there was no documentation of the provider being informed of Resident #1's abnormal labs. Review on 5/25/23 of the facility policy titled, NSG115 Physician/Advanced Practice Provider (APP) Notification, revision date 12/1/21 revealed: .Upon identification of a patient who has a change in condition, abnormal laboratory values, . Report to physician/advanced practice provider (APP). If unable to to contact attending physician/APP, the medical director will be contacted. Review on 5/25/23 of Resident #1's Brief Interview for Mental Status (BIMS) revealed that resident scored a 14 on 4/26/23 which indicated that Resident #1 was cognitively intact. Interview on 5/25/23 at approximately 12:44 p.m. with Staff A confirmed that Resident #1 was his/her own person to make medical decisions. Review on 5/25/23 of Resident #1's nursing notes, revealed the following note dated, 5/16/23 8:39 a.m. revealed: Resident complaining of SOB [Shortness of Breath], RR [respirations] 28. ABD [abdominal] muscles being used.Staff reported [pronoun omitted] was yelling out throughout the night. Drowsiness and weakness noted. Complaining of pain all over .[The resident stated] There is something wrong with me. I want to go to the hospital. Interview on 5/25/23 at approximately 9:30 a.m. with Staff E (Licensed Practical Nurse (LPN)) revealed that he/she received report on the morning of 5/16/23 that Resident #1 was yelling out all night and wanted to be sent to the hospital. Staff E revealed that upon his/her assessment of Resident #1 the on call provider was notified that Resident #1 needed to be sent to the hospital for evaluation. Staff E did not know why Resident #1 was not sent to the hospital when he/she initially began asking during the night to be sent. Interview on 5/25/23 at approximately 1:15 p.m. with Staff A revealed that Resident #1 should have been sent to the hospital when he/she initially requested to be sent.

Based on record review and interview, it was determined that the facility failed to ensure that licensed nurses have specific intravenous (IV) certificate/competencies necessary to care for residents' needs for 2 out of 6 Licensed Practical Nurses (LPNs) reviewed and 1 of 1 Medication Nursing Assistant (MNA) reviewed. Findings include: Review on 5/25/23 of Resident #1's May 2023's Medication Administration Record (MAR) revealed the following orders: Sodium Chloride Solution 0.9% (percent) Inject 70 ml/hr (milliliters per hour) subcutaneously every shift for dehydration for 1 day x (times) 1 liter, start date 5/15/23. Further review of the MAR revealed the following staff were assigned to Resident #1 and documented in the MAR as administering the Sodium Chloride Solution: 5/15/23 Evening Shift - Staff B (LPN) 5/15/23 Night Shift - Staff C (MNA) Review on 5/25/23 of the daily staffing sheet for the [NAME] Unit (where Resident #1 resides), dated 5/15/23 revealed: West Unit, Night Shift was staffed with Staff C. Further review revealed Staff D (LPN) was assigned to the East Unit. Interview on 5/25/23 at approximately 12:30 p.m. with Staff A revealed that Staff C was being supervised by Staff D and that Staff D would be responsible for monitoring the infusion. Staff A (Director of Nursing) confirmed that Staff D was assigned to the East Unit and that there was no nurse physically assigned to the [NAME] Unit. Further interview with Staff A revealed that neither Staff D nor Staff B had competencies in subcutaneous administration of fluid and did not have any documented infusion therapy certification. Review on 5/25/23 of the facility policy titled, 6.3 Hypodermoclysis, Revision Date 6/1/21 revealed: To Be Performed By: Licensed nurses according to state law and facility policy. The nurse shall be competent in the safe delivery of infusion therapy within her or his scope of practice. The nurse shall be accountable for attaining and maintaining competence with infusion therapy within her or his scope of practice.

Based on interview and record review, it was determined that the facility failed to ensure that a resident with pressure ulcers had documentation of weekly assessments that contained measurements and description of the pressure ulcer for 1 of 1 residents reviewed for pressure ulcers out of a final sample of 24 residents. (Resident identifier #100.) Findings include: Interview on 11/29/22 at approximately 2:14 p.m. with Resident #100 revealed that they have pressure ulcers to left foot and to sacrum. Review on 11/30/22 at approximately 1:33 p.m. of Resident #100's admission Minimum Data Set (MDS) assessment, reference date 11/7/22, revealed the following coded information for Section M: M0210 Does this resident have one or more unhealed pressure ulcers/injuries? Coded YES; M0300B1 Number of stage 2 pressure ulcers. Coded 2; M300B2 Number of these stage 2 pressure ulcers that were present upon admission/entry or reentry. Coded 1; M300F1 Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar. Coded 1; M300F2 Number of these unstageable pressure ulcers that were present upon admission/entry or reentry. Coded 1. Review on 11/30/22 at approximately 1:33 p.m. of Resident #100's weekly skin checks revealed the following pressure areas identified: 11/7/22- Left outer ankle and sacrum; 11/14/22- sacrum, left ankle and left lateral foot. 11/29/22-sacrum, left ankle and left lateral foot. Review on 11/30/22 at approximately 1:35 p.m. of admission nursing documentation dated 11/5/22 under 3. Additional details about note revealed .Also has red area on sacrum, patch applied for protection. area on L [left] outer ankle pressure . Review on 11/30/22 at approximately 1:40 p.m. of Resident #100's medical record revealed no weekly wound documentation with description of wound or measurements for either of the stage 2 pressure ulcers on Resident 100's left foot/ankle. Further review of Resident #100's medial record revealed the following physican's orders: Pressure ulcer wound to left ankle: NSC [normal saline cleanser], pat dry. Apply hydrogel, cover with DSD [dry sterile dressing]. Change daily and PRN [as needed], with a start date of 11/9/22; Pressure wound to left lateral foot: NCS normal saline cleanser], pat dry. Apply hydrogel, cover with DSD [dry sterile dressing]. Change daily and PRN [as needed], with a start date of 11/12/22. Interview on 11/30/22 at approximately 1:50 p.m. with Staff A (Wound Consultant Nurse) stated they are only tracking the sacrum wound for Resident #100 and were unaware of any other pressure ulcers for Resident #100. Interview on 11/30/22 at approximately 1:50 p.m. with Staff B (Director of Nursing) confirmed that there was no documented description or measurements for either of Resident #100's pressure ulcers to their left foot/ankle since admission on 11/5/22. Review on 12/1/22 of facility policy titled Skin Integrity and Wound Management, revised on 9/1/22, revealed .6.5 Complete wound evaluations upon admission/readmission, new in-house acquired, weekly and with unanticipated decline in wounds .

Based upon record reviews, a confidential resident interview, staff interviews, review of the facility policy and procedure for elopement, review of facility investigations and Elopement Risk Book the facility failed to ensure that it ' s residents remained free from neglect as follows: Failed to provide timely Activity of Daily Living (ADL) assistance for 3 of 20 residents in a standard survey sample (Resident identifiers are #3, #5 and #6.) Failed to prevent 1 of 20 residents in a standard survey sample from eloping off the locked unit 2 times and failed to prevent this same resident from eloping out of the facility 3 times (Resident identifier is #10.) Failed to accurately identify the elopement risk status for 2 of 20 residents in a standard survey sample (Resident identifiers are #4 and #12) and two out of sample residents (Resident identifiers are #29 and #30.) Failed to allow 1 of 20 residents in a standard survey sample to exercise one of their rights (Resident identifier is #13.) Findings include: Resident #5 On 1/9/11 at approximately 6:00 a.m., according to a Resident/Patient Incident Report of 1/9/11 and a facility complaint investigation, Resident #5 was heard by Staff N LNA(Licensed Nursing Assistant) yelling for help. Staff N's LNA written statement of 1/9/11 noted finding Resident #5 drenched in urine no sheets on the bed or any blankets on the bed. Staff N LNA continued by stating Resident #5's"pants were down around their ankles. Staff N LNA also noted that Resident #5's bed was found in its most upright position. Resident #5, according to the facility complaint investigation, stated to Staff O LPN (Licensed Practical Nurse) on 1/9/11 after being cleaned up by Staff N LNA that I want something done and I should not be treated like that. The facility complaint investigation determined that Staff P LNA was responsible for Resident #5's care during the third shift on the evening of 1/8/11. Staff P LNA, according to the facility complaint investigation, did not respond to repeated facility requests to come in to address this incident and was terminated without providing a statement for the facility investigation. Confidential Resident interview A Confidential Resident interview on 1/19/11 revealed that this resident requires assistance in being toileted. This resident stated that staff because of a shortage of available help routinely fails to timely answer the call bell resulting in them having to go to the bathroom in their diaper. The resident stated that this was upsetting and felt humiliated when this occurred. Resident #10 Resident #10 eloped from the unit as evidenced by nursing notes documenting those events as follows: - 8/14/10 "Has been exit seeking all shift. Was only able to redirect times 3 and the other times ...(resident) got just outside door and was very hard to get back in...." - 8/21/10, 7-3, "Resident exit seeking all shift exited unit times one without letting staff know (sic.) able to convince resident back into unit after 15 minutes stated 'I want to go home back to ...(town)' ... (sic. security bracelet) intact and functioning, resident watching doors when staff puts code in then attempts to leave/exit. Resident encouraged to stay in common area with staff..." - 9/11/10, 1446 "Alerted by alarm to the door going off the unit, resident had gotten out through the employee entrance door and was standing in parking lot approximately 20 feet from the door." - 9/11/10, 1530 "At 3 p.m. resident had gotten out again and was walking towards the assisted living building, (Resident #10) was redirected back to unit. - 1/7/11, facility report -witness statement by Staff L (LNA/Assisted Living employee) stated that on 1/6/11 at about 9:00 p.m. "...(Staff L) drove into the parking lot and saw a man (suspected to be an unidentified resident) with a walker and no jacket crossing the street and began walking along the side walk. A (motorist) ... stopped and helped (Staff L) ...direct ...(this same unidentified resident) to the lobby of ...(Assisted Living). Then ...(Staff L) ran over to ...(nursing home) to get a nurse to identify ...(the resident as Resident #10) ... ." The Facility (Corporate) Policy 1.36 Elopement of Resident (effective date of 6/1/96 with a revision date of 11/1/09) was identified on 1/24/11 by Staff I (Corporate Consultant) as the policy that was in effect 6/1/96 through September, 2010. Review of this policy reads "Patients of ...(facility) will be provided a secure environment." Under Process is listed the following: - 1. All residents will be screened for potential elopement risk ... . .... - 3. For residents identified as at risk, an interdisciplinary elopement prevention care plan will be developed with family and resident participation, 3.1 Individual risk factors and patterns will be identified and addressed within the care plan. 3.2 Obtain current photograph of resident. ... - 6. Staff will be trained on the Center's door security system and required response to a sounding alarm. 6.1 Whenever an alarm sounds, an accounting of all residents will be conducted..... - 9. Staff witnessing a confused resident or an identified elopement risk resident attempting to leave the Center will intervene as appropriate to redirect to a safe area and prevent elopement. 9.1 If the resident can not be redirected, alert other staff members and stay with the resident until he/she is safely returned to the Center. .... - 14. The Safety Committee will: 14.1 Review all incidents of elopement, 14.2 Conduct a root cause analysis, 14.3 Correct systems to prevent further incidents, and 14.4 Forward information to the Quality Improvement Committee for further discussion. Review of the current care plan in effect during survey (1/19/11-1/24/11) for Resident #10 reveals a care plan for the problem identifying this resident as "at risk for elopement related to dementia". This care plan problem was initiated on 4/29/10 and includes some interventions which include the following; - If unable to redirect (resident) ... stay with resident and provide support and supervision until able to redirect. - Redirect (resident) ... when security system sounds and/or resident attempts to leave the building. - When (resident)... has increased agitation and/or exit seeking encourage to stay in supervised area. - In the event of elopement follow search and reporting protocols. A review of the care plan problem for elopement, which was effective on 4/29/10-12/29/10, reveals it contains an intervention which reads "Utilize and monitor security bracelet per protocol." During an interview with Staff C (Unit Manager Francouer Unit) on 1/20/11 it was confirmed that Resident #10 had a secure care alarm bracelet on until 12/29/10 when it was discontinued by physician order. Staff I was asked to provide facility incident reports and investigations on the 8/14/10, 8/21/10 incidents and the two incidents occurring on 9/11/10. On 1/20/11 Staff I provided the following: - 8/21/10 Facility "Resident/Patient Incident Report" and "Incident/Accident Investigation" - 9/11/10 Facility "Resident/Patient Incident Report" (which had both 9/11/10 incidents recorded on one form). During an interview with Staff I on 1/20/11, Staff I stated the facility did not have an incident report or investigation report for the elopement of Resident #10 on 8/14/10 and did not have investigation reports for the two elopements by Resident #10 occurring on 9/11/10. Staff I also stated the incident, which occurred at 3 p.m. on 9/11/10 (when Resident #10 eloped out of the building), was not reported to the State as required. During an interview with Staff B (Administrator), Staff M (Assistant Administrator), Staff I and two surveyors on 1/20/11 in the afternoon, multiple incidents including the 8/14/10, 8/21/10 and the two incidents on 9/11/10 of exit seeking/elopement for Resident #10 were reviewed. Staff B confirmed the following were not done according to the policy and procedure: - The incident report and investigation for the 8/14/10 incident were not completed. - Only one incident report was filled out for the two elopements occurring on 9/11/10 and no investigation report was completed for either incident on 9/11/10. - The 3 p.m. 9/11/10 unwitnessed elopement incidents were not reported to the State as required. During the same interview with Staff B, Staff M, Staff I and two surveyors on 1/20/11, Staff B was asked about whether a resident head count was done according to the policy and procedure by staff on the occasions that Resident #10 left the unit and building. Staff B stated that when Resident #10 eloped from the Francouer Unit on 8/21/10 and 9/11/10 staff did not initiate a resident head count. Staff B was also asked what care plan or process changes, based on a root cause analysis, the facility made after Resident #10 eloped off the Francouer unit and out of the building on 9/11/10. Staff B stated "No changes were made after that incident". The Facility (Corporate) Policy 1.36 Elopement of Resident (effective date of 6/1/96 with a revision date of 10/1/10) was identified on 1/24/11 by Staff I (Corporate Consultant) as the policy that was effective from 10/1/10 through the health recertification survey ending 1/24/11. Review of this policy reads "Patients of ...(facility) will be provided a secure environment." Under Process is listed the following: - 1. Patients will be evaluated for potential elopement risk during the nursing assessment process. - 2. For patients identified as at risk, an interdisciplinary elopement prevention care plan will be developed with family and patient participation....2.2 Obtain current photograph of patient. 2.3 Maintain a list of patients at risk of elopement along with current photographs at receptionist desk. .... - 9. In the event of an un-witnessed patient elopement or the report of a missing patient, staff will search: 9.1 Room to room and all areas of the Center..., 9.2 Outside building perimeter and grounds. - 10. The Administrator/designee will notify the following: ... 10.3 State Department of Public Health and other state agencies per state regulations. .... - 13. The Safety Committee will: 13.1 Review all incidents of elopement, 13.2 Conduct a root cause analysis, 13.3 Correct systems to prevent further incidents and 13.4 Forward information to the Quality Improvement Committee for further discussion. Review of the initial facility report dated 1/7/11 and the facility investigation sent to the State on 1/11/11 regarding an unwitnessed elopement by Resident #10 on 1/6/11 revealed the following: - Staff J (LNA) in a witness statement said that on 1/6/11 from 8:15 p.m. - 8:20 p.m. "saw (Resident #10) at entrance doors ...heard door alarms beeping." Staff J also revealed "At 8:30 p.m. ...(Staff J) was sitting in the living/dining room with some of the residents (not Resident #10). ...(Staff J) did not see or know that ...(Resident #10) had left the unit. Before ..(Staff J) went to sit with some of the residents, ...(Staff J) had last seen ...(Resident #10) in the front area of the unit near the couches." (Observations during survey reveal a sitting area, with lounge chairs and couch, is located directly adjacent to the alarmed entrance/exit doors to the Francouer Unit where this incident was alleged to have occurred.) - Staff L (LNA/Assisted Living employee) in a witness statement stated that on 1/6/11 at about 9:00 p.m. "...(Staff L) drove into the parking lot and saw a man (suspected to be an unidentified resident) with a walker and no jacket crossing the street and began walking along the side walk. A (motorist) ... stopped and helped (Staff L) ...direct ...(this same unidentified resident) to the lobby of ...(Assisted Living). Then ...(Staff L) ran over to ...(nursing home) to get a nurse to identify ...(the resident as Resident #10) ... ." During an interview with Staff B (Administrator), Staff M (Assistant Administrator), Staff I (Corporate Consultant) and two surveyors on 1/20/11 in the afternoon, the facility generated report and facility investigation sent to the State regarding an unwitnessed elopement by Resident #10 who was found at 9 p.m. on 1/6/11 and who had been outside for an unknown amount of time were reviewed. Staff B stated the following (when asked by surveyors): - No resident head count check, in accordance with the policy and procedure, was initiated by facility staff working on the Francouer Unit on 1/6/11 at 8:15 p.m. to 8:20 p.m. to safeguard against an unwitnessed elopement even though the exit/entrance doors to the Francouer Unit were sounding and required staff to input a code to deactivate the alarm. - On the 1/6/11 elopement, Resident #10 went out the ambulance exit/entrance of the building, crossed the employee parking lot, ambulated along the side of the facility toward Lafayette Road (also called Route 1) and at the intersection of the facility driveway with Lafayette Road turned right and ambulated with walker along the side walk which runs in front of the Partridge House Assisted Living Home when this resident was observed by an employee of Partridge House and a motorist who both stopped their vehicles and assisted the resident into the main entrance of the Partridge House Assisted Living Home which is located in front of the nursing home and directly on Lafayette Road/Route 1. - The bracelet alarm system used on the Francouer Unit was deactivated and discontinued in September 2010 and replaced with a keypad/code system. - With either the bracelet alarm system or the keypad/code system alarms a resident could push on the doors and after 15 seconds the doors would release and open. - When either the bracelet alarm system or the keypad/code system alarms sounded, facility staff needed to enter a code to stop the alarm. Per Staff B, the facility staff finding the door alarms sounding did not initiate a head count of residents on the unit to account for anyone who may have been an unwitnessed elopement. Staff would key a code into the keypad to deactivate the alarm as Staff B said "The alarm went off all the time." During this same interview with Staff B, Staff M, Staff I and two surveyors on 1/20/11 in the afternoon, Staff B identified interventions taken after Resident #10's 1/6/11 elopement incident as follows: - Staff were educated regarding the different sounds made by the keypad/code alarm doors when pushed on and when opened. Per Staff B, when initially pushed on the door alarm would be a high pitched sound. After 15 seconds, the doors would release and would open and once closed the alarm would continue to emit an alarm of a lower pitch. - A wall mirror was installed allowing staff to view the exit/entrance doors to the Francouer Unit from the long hallway. - An individual hand held communication device was added so that staff could talk to one another on the unit. - The ambulance entrance located in close proximity to the Francouer Unit exit/entrance doors was alarmed with the alarm operating from 8 p.m. to the morning when staff entered for the day shift. Facility "Elopement Risk Book" Review of the facility "Elopement Risk Book" and copies found at each of the nursing stations and at the receptionist desk on 1/20/11 in the morning revealed eight residents (including Resident #10) had been identified by the facility as elopement risks. Four residents resided on Francouer Unit, two residents resided on Tuck Unit, one resident resided on West Unit and one resident resided on East Unit. During an interview with Staff B, Staff M, Staff I and two surveyors on 1/20/11 in the afternoon, Staff B was asked about the four residents identified in the facility "Elopement Risk Book" as at risk who did not reside on the Francouer Unit. It was observed during the initial tour of the facility on 1/19/10 in the morning and confirmed by Staff B during this same interview that the Tuck Unit, the East Unit and the West Unit did not have locked entrance/exit doors leading to the units. Staff B stated the receptionist located by the main facility entrance had a copy of the "Elopement Risk Book" which contained resident pictures and would intervene if any of those residents at risk attempted to leave the building. On 1/20/11 it was observed during the noon hour that Staff Q (receptionist) was at lunch and Staff R (Admissions) was covering the main reception desk. Staff R was asked where the "Elopement Risk Book" could be found but Staff R did not know where the book was and did not know the residents who were identified as at risk. It was also observed that no staff or receptionist was at the main reception desk at 1:15 p.m. and a sign with a clock was posted saying "I will return at (clock face indicated) 1:25 p.m." Resident #12, #29 and #30. Per Staff I during an interview on 1/21/11, the facility reassessed all residents for elopement risk on the evening of 1/20/11 and identified three more residents (Resident #12, #29 and #30) as elopement risks. The "Elopement Risk Book" at each of the nurses stations and at the main reception desk were updated with information and photos of these three additional residents for a total of eleven residents who were assessed as at risk for elopement. Resident #12 and #30 reside on the Francouer Unit and Resident #29 reside on the East Wing. Resident #4 Review on 1/20/11 of Resident #4's "Elopement Risk Assessment" dated 4/15/10 revealed that Resident #4 was not considered to be at risk for elopement. Review of Resident #4's care plans revealed that Resident #4 had an active care plan for wandering behavior in place. Review of Resident #4's "Elopement Risk Assessment" dated 1/20/11 revealed that Resident #4 was not considered to be at risk for elopement. Review of "Elopement Risk Book" revealed that Resident #4 was included in this book prior to 1/21/11 and continued to be in the book after 1/21/11. The "Elopement Risk Book" is a binder that is used by the facility to identify which residents are at risk for elopement which is kept at the front desk and at the nurses' stations. In the event that an elopement were to occur the "Elopement Risk Book" contains identifying information about the residents to assist staff and the police in finding them. Interview on 1/24/11 in the morning with Staff A (Licensed Practical Nurse), Staff A described Resident #4 as having wandering behavior around the unit, but that Resident #4 was not an elopement risk. Staff A stated that in Staff A's opinion, Resident #4 should not have been or be in the "Elopement Risk Book" since Resident #4 was not an elopement risk. Resident #12 Review on 1/20/11 of Resident #12's "Elopement Risk Assessment" dated 4/15/10 revealed that Resident #12 was considered to be at risk for elopement. Review of Resident #12's care plans revealed that Resident #12 had a care plan for elopement which had been reviewed on 12/31/10 and remained in effect. Review of Resident #12's "Elopement Risk Assessment" dated 1/20/11 revealed that Resident #12 was not considered to be at risk for elopement. Review of "Elopement Risk Book" revealed that Resident #12 was not included in this book prior to 1/21/11, but was added to the book on 1/21/11. Interview on 1/24/11 in the morning with Staff A (Registered Nurse), Staff C (Registered Nurse) described Resident #12 as having wandering behavior around the unit, as having an active care plan in place for elopement and was at risk for elopement. Staff C stated that in Staff C's opinion, Resident #12 should have been and should be in the "Elopement Risk Book" since Resident #12 was at risk for elopement. Resident #3 Review of Resident #3's medical record on 1/19/11 reveals that Resident #3 has an ADL(Activities of Daily Living) care plan initiated on 7/28/09 and revised on 8/6/09. The care plan indicates that Resident#3 requires the assistance for ADL care in bathing, dressing, transfer, locomotion and toileting due to weakness and some loss of ROM (range of motion) in shoulders. Under Interventions the care plan indicates that Resident#3 requires one person assist with dressing, grooming, bathing, and toileting needs. Review of the social service notes dated 11/11/10 reveals "This writer met with Resident#3, (resident name omitted) today to follow up on the incident that occurred on 10/27/10". The social service notes indicated that Resident#3 reported that some days were ok and other days the resident would think about it a little. Resident #3 stated "I am glad that when I called someone came". Review of the facility's "Resident/Patient Incident Report" dated 11/5/10 indicated That Resident #3 was left alone in the whirlpool tub for 40 minutes after the staff LNA left the facility due to an emergency. The Resident/Patient Incident Report also indicates that (Resident #3) was spoken to after the incident and the resident was not angry, enjoyed sitting in the tub for a few extra minutes and soaking. Review of the facility's investigatory staff interviews on 11/9/10 reveals that on 10/30/10 ...Resident#3's family member approached the nurse on duty and reported that Resident#3 had not been the same since Resident#3 had been left in the tub alone. Resident#3's family member explained the incident to the staff nurse on duty after the staff nurse had indicated that this incident had not been reported during change of shift report. The nurse on duty reported the incident to the shift supervisor and also reported that no documentation was found on Resident#3 being left in the whirlpool tub alone. Review of the facility's written investigatory interviews conducted on 11/8/10 with Staff U, LNA reveals that Staff U, LNA was on duty on 10/27/10. Staff U indicated that Staff U found Resident#3 alone in the whirlpool tub. Staff U also indicated Resident#3 was turned around saying "please help me" and that Resident#3 was panicking. Staff U, got Resident#3 out of the tub and reported the incident to Staff X, LPN on duty at which time Staff X replied that Staff X had forgotten and was busy and forgot to tell the LNA's that Resident#3 was in the tub alone. Interview with Staff D, Director of Nurses on 1/20/2011 confirmed that Resident#3 was found alone in the whirlpool tub and that the staff member responsible for caring for Resident#3 did receive an emergency phone call, reported to Staff X,LPN that they had to leave and also reported that Resident#3 was in the tub alone. Staff D, also indicated that Staff X, LPN saw the staff member walk down the hallway towards the whirlpool tub room and assumed that the staff member was going to take the resident out of the tub, but the staff member was going to retrieve their belongings and left the building leaving the resident unattended. Staff D also indicated that this incident was not reported to Staff B, Administrator or Staff D, DON until 11/5/10. Resident #6 Review of Resident#6's Fall Risk assessment dated [DATE] reveals a score of 13. The falls risk form indicates that a total score of 10 or above represents High Risk. Review of the 14 day MDS (Minimum Data Set) Version 3.0 assessment, dated 11/10/10 reveals under section G0110. Activities of Daily Living, letter I. Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; the MDS is coded a 3 for extensive assist - resident involved in activity, staff provide weight-bearing support, and under the Support column the MDS is coded a 2 for one person physical assist. Review of Resident#6's nurses notes indicates the following; 11/25/10, 10:59 AM, Change in Condition, Resident#6 had a change in condition-medical. Facial color is pale, Level of consciousness is lethargic, a change from previous state. Orientation: person, place. Skin is cool. Gastrointestinal: nausea, decreased fluid intake, decreased urine output. 11/26/10, 10:00 PM, Change in Condition Follow-up Note on 11/25/10 Status of condition: no change. Data: Pt not eating food and minimal fluid intake. Pt on IV (intravenous) D5,1/2 NS (normal saline) 1L (liter) @ 60ml/hr. Pt is weak, tired and complains of general malaise. 11/27/10, at 1:00 AM, reveals Change in Condition Follow-up Note This is a follow-up note from the change in condition medical that occurred on 11/25/10. Data: Continues on IV for hydration. No s/s (signs or symptoms) on IV site. [MEDICATION NAME] (2 tabs) for leg pain. No other complaints. 11/27/10, at 8:49 AM, General Transferred out to (name omitted) Emergency Department per Nurse practitioner. Unable to rehydrate. DPOA (Durable Power Of Attorney) notified and requested transport ... Report given to ED(Emergency Department) nurse. 11/27/10, at 1:45 PM, Resident#6 returned from ED via stretcher. Treatment plan discussed with Staff H, Nurse Practitioner, DPOA arrived with resident. Discussed making resident CMO, (comfort measures only). DPOA in agreement and requesting hospice services. 11/27/10 3:04 PM, New order Resident #6 is now to be comfort measures only. May consult Hospice for evaluation and treatment. D/C (Discharge)IV fluids and D/C saline lock. Start [MEDICATION NAME] 4mg 1-2 tabs Q (every) 6H (hours) PRN (as needed) nausea. 11/28/10, 6:35 AM, Care and comfort maintained this shift no s/sx (signs or symptoms) of pain or discomfort. Incontinent of urine a small amount this shift. Took approximately 100 cc of water. Will continue to monitor. 11/28/10, 11:31 PM, at 3:15 PM resident found on floor by staff. Hematoma noted on right frontal area of head and bilateral abrasions to both knees. Review of the facility "Resident/Patient Incident Report" dated 11/28/10 at 3:15 PM Reveals that Resident #6 had an unwitnessed fall in the bathroom resulting in a large ecchymotic area on the right forehead and abrasions on both knees. The incident report also indicates that Resident #6 was alert and oriented prior to the fall and required an assist of 1 person. The"Patient Fall Investigation Form"dated 11/28/10 at 3:15 PM indicates under the Post Fall Evaluation section, that Resident#6 was in the bathroom alone, has protective stockings on for footwear and was given the call bell. Under the Contributing Factors/Issues section, it indicates that Resident#6 is alert and oriented and has poor safety awareness and was unassisted. The form also indicates that Resident#6 has experienced a recent change in gait/mobility, has pain, abnormal lab values and balance problems. Under the Patient Interview section, it was written "Client too ill to remember,doesn't want to talk about it." The Post Fall Evaluation form also indicates under the Conclusion and Summary of the investigation Resident #6 "will be upgraded to assist with ADL/amb (activities of daily living/ambulation). Addition of alarms and resident re-educated, Neuros (neurological assessment) checked, mechanical lift off floor after assessment". The fall investigation also reveals a statement written by Staff AA, LNA which indicates that Staff AA put Resident#6 on the toilet and then was informed by a nurse from another wing that Staff AA was needed for assistance on that other wing and left Resident#6 alone briefly. Resident #13 Review of facility generated investigation report reveals that Resident #13 requested to use the telephone during the early morning hours of 12/12/10 and was denied the assistance required by resident to use the phone to call daughter. Resident did have a telephone at the bedside but required assistance of staff to reach and dial telephone. Staff LL (RN) answered resident #13's call bell at approximately 7 am on 12/12/10. Resident #13 told Staff LL (RN) that (pronoun omitted) wanted to contact the daughter. Staff member asked if Resident #13 was aware of what time it was. Resident #13 started to cry and asked "Why won't (pronoun omitted) let me call my daughter?". Staff member indicated (pronoun omitted) didn't know if the resident knew what time it was. Staff LL (RN) assisted Resident #13 in contacting daughter. Interview on 1/22/11 at 11:30 a.m. of Staff D (DON) confirmed Resident #13 was delayed in contacting the daughter. Staff D told surveyor that all nursing staff had been re-educated on resident rights.

Based on record review, review of the facility policy and procedures of facility incident reports and facility Elopement Risk Book and staff interview the facility: Failed to ensure the safety of residents on 1 of 4 units by preventing an elopement which rose to the level of Immediate Jeopardy for 1 resident in a standard survey sample of 20 residents (Resident identifier is #10.) Failed to ensure the facility environment remained free of accident hazards and that each resident received adequate supervision and assistance devices to prevent avoidable incidents for 2 residents in a standard survey sample of 20 residents (Resident identifiers are #3, #6.) Failed to provide the provision of care in a safe manner for 1 resident in a standard survey sample of 20 and one out of sample resident (Resident identifiers are #11 and #31.) Failed to accurately identify residents at risk for elopement for 2 of 20 residents in the standard survey sample and two out of sample residents (Resident identifiers are #4, #12, #29 and #30.) Findings include: Resident #10 Resident #10 eloped from the unit as evidenced by nursing notes documenting those events as follows: - 8/14/10 "Has been exit seeking all shift. Was only able to redirect times 3 and the other times ...(resident) got just outside door and was very hard to get back in...." - 8/21/10, 7-3, "Resident exit seeking all shift exited unit times one without letting staff know (sic.) able to convince resident back into unit after 15 minutes stated 'I want to go home back to ...(town)' ... (sic. security bracelet) intact and functioning, resident watching doors when staff puts code in then attempts to leave/exit. Resident encouraged to stay in common area with staff..." - 9/11/10, 1446 "Alerted by alarm to the door going off the unit, resident had gotten out through the employee entrance door and was standing in parking lot approximately 20 feet from the door." - 9/11/10, 1530 "At 3 p.m. resident had gotten out again and was walking towards the assisted living building, (Resident #10) was redirected back to unit. - 1/7/11, facility report -witness statement by Staff L (LNA/Assisted Living employee) stated that on 1/6/11 at about 9:00 p.m. "...(Staff L) drove into the parking lot and saw a man (suspected to be an unidentified resident) with a walker and no jacket crossing the street and began walking along the side walk. A (motorist) ... stopped and helped (Staff L) ...direct ...(this same unidentified resident) to the lobby of ...(Assisted Living). Then ...(Staff L) ran over to ...(nursing home) to get a nurse to identify ...(the resident as Resident #10) ... ." The Facility (Corporate) Policy 1.36 Elopement of Resident (effective date of 6/1/96 with a revision date of 11/1/09) was identified on 1/24/11 by Staff I (Corporate Consultant) as the policy that was in effect 6/1/96 through September, 2010. Review of this policy reads "Patients of ...(facility) will be provided a secure environment." Under Process is listed the following: - 1. All residents will be screened for potential elopement risk ... . .... - 3. For residents identified as at risk, an interdisciplinary elopement prevention care plan will be developed with family and resident participation, 3.1 Individual risk factors and patterns will be identified and addressed within the care plan. 3.2 Obtain current photograph of resident. ... - 6. Staff will be trained on the Center's door security system and required response to a sounding alarm. 6.1 Whenever an alarm sounds, an accounting of all residents will be conducted..... - 9. Staff witnessing a confused resident or an identified elopement risk resident attempting to leave the Center will intervene as appropriate to redirect to a safe area and prevent elopement. 9.1 If the resident can not be redirected, alert other staff members and stay with the resident until he/she is safely returned to the Center. .... - 14. The Safety Committee will: 14.1 Review all incidents of elopement, 14.2 Conduct a root cause analysis, 14.3 Correct systems to prevent further incidents, and 14.4 Forward information to the Quality Improvement Committee for further discussion. Review of the current care plan in effect during survey (1/19/11-1/24/11) for Resident #10 reveals a care plan for the problem identifying this resident as "at risk for elopement related to dementia". This care plan problem was initiated on 4/29/10 and includes some interventions which include the following; - If unable to redirect (resident) ... stay with resident and provide support and supervision until able to redirect. - Redirect (resident) ... when security system sounds and/or resident attempts to leave the building. - When (resident)... has increased agitation and/or exit seeking encourage to stay in supervised area. - In the event of elopement follow search and reporting protocols. A review of the care plan problem for elopement, which was effective on 4/29/10-12/29/10, reveals it contains an intervention which reads "Utilize and monitor security bracelet per protocol." During an interview with Staff C (Unit Manager Francouer Unit) on 1/20/11 it was confirmed that Resident #10 had a secure care alarm bracelet on until 12/29/10 when it was discontinued by physician order. Staff I was asked to provide facility incident reports and investigations on the 8/14/10, 8/21/10 incidents and the two incidents occurring on 9/11/10. On 1/20/11 Staff I provided the following: - 8/21/10 Facility "Resident/Patient Incident Report" and "Incident/Accident Investigation" - 9/11/10 Facility "Resident/Patient Incident Report" (which had both 9/11/10 incidents recorded on one form). During an interview with Staff I on 1/20/11, Staff I stated the facility did not have an incident report or investigation report for the elopement of Resident #10 on 8/14/10 and did not have investigation reports for the two elopements by Resident #10 occurring on 9/11/10. Staff I also stated the incident, which occurred at 3 p.m. on 9/11/10 (when Resident #10 eloped out of the building), was not reported to the State as required. During an interview with Staff B (Administrator), Staff M (Assistant Administrator), Staff I and two surveyors on 1/20/11 in the afternoon, multiple incidents including the 8/14/10, 8/21/10 and the two incidents on 9/11/10 of exit seeking/elopement for Resident #10 were reviewed. Staff B confirmed the following were not done according to the policy and procedure: - The incident report and investigation for the 8/14/10 incident were not completed. - Only one incident report was filled out for the two elopements occurring on 9/11/10 and no investigation report was completed for either incident on 9/11/10. - The 3 p.m. 9/11/10 unwitnessed elopement incidents were not reported to the State as required. During the same interview with Staff B, Staff M, Staff I and two surveyors on 1/20/11, Staff B was asked about whether a resident head count was done according to the policy and procedure by staff on the occasions that Resident #10 left the unit and building. Staff B stated that when Resident #10 eloped from the Francouer Unit on 8/21/10 and 9/11/10 staff did not initiate a resident head count. Staff B was also asked what care plan or process changes, based on a root cause analysis, the facility made after Resident #10 eloped off the Francouer unit and out of the building on 9/11/10. Staff B stated "No changes were made after that incident". The Facility (Corporate) Policy 1.36 Elopement of Resident (effective date of 6/1/96 with a revision date of 10/1/10) was identified on 1/24/11 by Staff I (Corporate Consultant) as the policy that was effective from 10/1/10 through the health recertification survey ending 1/24/11. Review of this policy reads "Patients of ...(facility) will be provided a secure environment." Under Process is listed the following: - 1. Patients will be evaluated for potential elopement risk during the nursing assessment process. - 2. For patients identified as at risk, an interdisciplinary elopement prevention care plan will be developed with family and patient participation....2.2 Obtain current photograph of patient. 2.3 Maintain a list of patients at risk of elopement along with current photographs at receptionist desk. .... - 9. In the event of an un-witnessed patient elopement or the report of a missing patient, staff will search: 9.1 Room to room and all areas of the Center..., 9.2 Outside building perimeter and grounds. - 10. The Administrator/designee will notify the following: ... 10.3 State Department of Public Health and other state agencies per state regulations. .... - 13. The Safety Committee will: 13.1 Review all incidents of elopement, 13.2 Conduct a root cause analysis, 13.3 Correct systems to prevent further incidents and 13.4 Forward information to the Quality Improvement Committee for further discussion. Review of the initial facility report dated 1/7/11 and the facility investigation sent to the State on 1/11/11 regarding an unwitnessed elopement by Resident #10 on 1/6/11 revealed the following: - Staff J (LNA) in a witness statement said that on 1/6/11 from 8:15 p.m. - 8:20 p.m. "saw (Resident #10) at entrance doors ...heard door alarms beeping." Staff J also revealed "At 8:30 p.m. ...(Staff J) was sitting in the living/dining room with some of the residents (not Resident #10). ...(Staff J) did not see or know that ...(Resident #10) had left the unit. Before ..(Staff J) went to sit with some of the residents, ...(Staff J) had last seen ...(Resident #10) in the front area of the unit near the couches." (Observations during survey reveal a sitting area, with lounge chairs and couch, is located directly adjacent to the alarmed entrance/exit doors to the Francouer Unit where this incident was alleged to have occurred.) - Staff L (LNA/Assisted Living employee) in a witness statement stated that on 1/6/11 at about 9:00 p.m. "...(Staff L) drove into the parking lot and saw a man (suspected to be an unidentified resident) with a walker and no jacket crossing the street and began walking along the side walk. A (motorist) ... stopped and helped (Staff L) ...direct ...(this same unidentified resident) to the lobby of ...(Assisted Living). Then ...(Staff L) ran over to ...(nursing home) to get a nurse to identify ...(the resident as Resident #10) ... ." During an interview with Staff B (Administrator), Staff M (Assistant Administrator), Staff I (Corporate Consultant) and two surveyors on 1/20/11 in the afternoon, the facility generated report and facility investigation sent to the State regarding an unwitnessed elopement by Resident #10 who was found at 9 p.m. on 1/6/11 and who had been outside for an unknown amount of time were reviewed. Staff B stated the following (when asked by surveyors): - No resident head count check, in accordance with the policy and procedure, was initiated by facility staff working on the Francouer Unit on 1/6/11 at 8:15 p.m. to 8:20 p.m. to safeguard against an unwitnessed elopement even though the exit/entrance doors to the Francouer Unit were sounding and required staff to input a code to deactivate the alarm. - On the 1/6/11 elopement, Resident #10 went out the ambulance exit/entrance of the building, crossed the employee parking lot, ambulated along the side of the facility toward Lafayette Road (also called Route 1) and at the intersection of the facility driveway with Lafayette Road turned right and ambulated with walker along the side walk which runs in front of the Partridge House Assisted Living Home when this resident was observed by an employee of Partridge House and a motorist who both stopped their vehicles and assisted the resident into the main entrance of the Partridge House Assisted Living Home which is located in front of the nursing home and directly on Lafayette Road/Route 1. - The bracelet alarm system used on the Francouer Unit was deactivated and discontinued in September 2010 and replaced with a keypad/code system. - With either the bracelet alarm system or the keypad/code system alarms a resident could push on the doors and after 15 seconds the doors would release and open. - When either the bracelet alarm system or the keypad/code system alarms sounded, facility staff needed to enter a code to stop the alarm. Per Staff B, the facility staff finding the door alarms sounding did not initiate a head count of residents on the unit to account for anyone who may have been an unwitnessed elopement. Staff would key a code into the keypad to deactivate the alarm as Staff B said "The alarm went off all the time." During this same interview with Staff B, Staff M, Staff I and two surveyors on 1/20/11 in the afternoon, Staff B identified interventions taken after Resident #10's 1/6/11 elopement incident as follows: - Staff were educated regarding the different sounds made by the keypad/code alarm doors when pushed on and when opened. Per Staff B, when initially pushed on the door alarm would be a high pitched sound. After 15 seconds, the doors would release and would open and once closed the alarm would continue to emit an alarm of a lower pitch. - A wall mirror was installed allowing staff to view the exit/entrance doors to the Francouer Unit from the long hallway. - An individual hand held communication device was added so that staff could talk to one another on the unit. - The ambulance entrance located in close proximity to the Francouer Unit exit/entrance doors was alarmed with the alarm operating from 8 p.m. to the morning when staff entered for the day shift. Facility "Elopement Risk Book" Review of the facility "Elopement Risk Book" and copies found at each of the nursing stations and at the receptionist desk on 1/20/11 in the morning revealed eight residents (including Resident #10) had been identified by the facility as elopement risks. Four residents resided on Francouer Unit, two residents resided on Tuck Unit, one resident resided on West Unit and one resident resided on East Unit. During an interview with Staff B, Staff M, Staff I and two surveyors on 1/20/11 in the afternoon, Staff B was asked about the four residents identified in the facility "Elopement Risk Book" as at risk who did not reside on the Francouer Unit. It was observed during the initial tour of the facility on 1/19/10 in the morning and confirmed by Staff B during this same interview that the Tuck Unit, the East Unit and the West Unit did not have locked entrance/exit doors leading to the units. Staff B stated the receptionist located by the main facility entrance had a copy of the "Elopement Risk Book" which contained resident pictures and would intervene if any of those residents at risk attempted to leave the building. On 1/20/11 it was observed during the noon hour that Staff Q (receptionist) was at lunch and Staff R (Admissions) was covering the main reception desk. Staff R was asked where the "Elopement Risk Book" could be found but Staff R did not know where the book was and did not know the residents who were identified as at risk. It was also observed that no staff or receptionist was at the main reception desk at 1:15 p.m. and a sign with a clock was posted saying "I will return at (clock face indicated) 1:25 p.m." Resident #12, #29 and #30. Per Staff I during an interview on 1/21/11, the facility reassessed all residents for elopement risk on the evening of 1/20/11 and identified three more residents (Resident #12, #29 and #30) as elopement risks. The "Elopement Risk Book" at each of the nurses stations and at the main reception desk were updated with information and photos of these three additional residents for a total of eleven residents who were assessed as at risk for elopement. Resident #12 and #30 reside on the Francouer Unit and Resident #29 reside on the East Wing. Resident #4 Review on 1/20/11 of Resident #4's "Elopement Risk Assessment" dated 4/15/10 revealed that Resident #4 was not considered to be at risk for elopement. Review of Resident #4's care plans revealed that Resident #4 had an active care plan for wandering behavior in place. Review of Resident #4's "Elopement Risk Assessment" dated 1/20/11 revealed that Resident #4 was not considered to be at risk for elopement. Review of "Elopement Risk Book" revealed that Resident #4 was included in this book prior to 1/21/11 and continued to be in the book after 1/21/11. The "Elopement Risk Book" is a binder that is used by the facility to identify which residents are at risk for elopement which is kept at the front desk and at the nurses' stations. In the event that an elopement were to occur the "Elopement Risk Book" contains identifying information about the residents to assist staff and the police in finding them. Interview on 1/24/11 in the morning with Staff A (Licensed Practical Nurse), Staff A described Resident #4 as having wandering behavior around the unit, but that Resident #4 was not an elopement risk. Staff A stated that in Staff A's opinion, Resident #4 should not have been or be in the "Elopement Risk Book" since Resident #4 was not an elopement risk. Resident #12 Review on 1/20/11 of Resident #12's "Elopement Risk Assessment" dated 4/15/10 revealed that Resident #12 was considered to be at risk for elopement. Review of Resident #12's care plans revealed that Resident #12 had a care plan for elopement which had been reviewed on 12/31/10 and remained in effect. Review of Resident #12's "Elopement Risk Assessment" dated 1/20/11 revealed that Resident #12 was not considered to be at risk for elopement. Review of "Elopement Risk Book" revealed that Resident #12 was not included in this book prior to 1/21/11, but was added to the book on 1/21/11. Interview on 1/24/11 in the morning with Staff A (Registered Nurse), Staff C (Registered Nurse) described Resident #12 as having wandering behavior around the unit, as having an active care plan in place for elopement and was at risk for elopement. Staff C stated that in Staff C's opinion, Resident #12 should have been and should be in the "Elopement Risk Book" since Resident #12 was at risk for elopement. Resident #11, #31 Review of the facility's " Report of Abuse " investigation dated 10/24/10 indicates that on the 3-11 shift Staff S, RN noted that Staff T, LNA was swearing under their breath, acting annoyed with residents that needed Staff T ' s assistance and appeared very irritable. Staff S, RN also indicated that Staff T, LNA seemed to become increasingly angry, and was being very harsh in tone and demeanor. The investigation report also indicated that Staff V, LNA who was also assigned to the unit on the evening of 10/24/10 indicated that Staff T was angry the entire evening and while Staff V was completing their documentation Staff V saw Resident #31 who was seated in their wheelchair "come flying through the day room " and did not stop until the resident was almost at the fireplace. Staff W, LNA who was also assigned to the unit on 10/24/10 indicated in their statement that Staff W observed Staff T push Resident #31's wheelchair hard. Staff W, LNA also indicated that Staff T was observed to pull a resident by the left arm in an abrupt and angry manner when the resident needed to be changed. Staff, W LNA also reported that Staff T, LNA forced Resident #11 out of their room when Resident #11 requested to go to bed. Staff T, was reported to have wheeled Resident #11 out of their room and gave Resident #11 a push resulting in the Resident while seated in the wheelchair went wheeling unattended for approximately 5 feet. Review of the investigation report also indicates that at 9:45 p.m. Staff T, LNA reported to Staff S, RN that Resident #11 had a skin tear on the right arm. Review of the Resident/Patient Incident Report completed on 10/24/10 by Staff S, RN indicates that Resident #11 sustained a skin tear to the right lateral forearm, inferior to the elbow, it was bleeding moderate amounts of bright red blood. The wound was cleansed and noted there area to be beefy red with what appeared to be a deep wound through the skin and fat layer into the muscle, approximately 3 inches in length by 2 inches in width. The facility was unable to determine the root cause of Resident #11 ' s skin tear. Resident #3 Review of Resident #3's medical record on 1/19/11 reveals that Resident #3 has an ADL(Activities of Daily Living) care plan initiated on 7/28/09 and revised on 8/6/09. The care plan indicates that Resident #3 requires the assistance for ADL care in bathing, dressing, transfer, locomotion and toileting due to weakness and some loss of ROM (range of motion) in shoulders. Under Interventions the care plan indicates that Resident #3 requires one person assist with dressing, grooming, bathing, and toileting needs. Review of the social service notes dated 11/11/10 reveals "This writer met with Resident#3, (resident name omitted) today to follow up on the incident that occurred on 10/27/10". The social service notes indicated that Resident #3 reported that some days were ok and other days the resident would think about it a little. Resident #3 stated "I am glad that when I called someone came". Review of the facility's "Resident/Patient Incident Report" dated 11/5/10 indicated That Resident #3 was left alone in the whirlpool tub for 40 minutes after the staff LNA left the facility due to an emergency. The Resident/Patient Incident Report also indicates that (Resident #3) was spoken to after the incident and the resident was not angry, enjoyed sitting in the tub for a few extra minutes and soaking. Review of the facility's investigatory staff interviews on 11/9/10 reveals that on 10/30/10 ...Resident #3's family member approached the nurse on duty and reported that Resident #3 had not been the same since Resident #3 had been left in the tub alone. Resident#3's family member explained the incident to the staff nurse on duty after the staff nurse had indicated that this incident had not been reported during change of shift report. The nurse on duty reported the incident to the shift supervisor and also reported that no documentation was found on Resident #3 being left in the whirlpool tub alone. Review of the facility's written investigatory interviews conducted on 11/8/10 with Staff U, LNA reveals that Staff U, LNA was on duty on 10/27/10. Staff U indicated that Staff U found Resident #3 alone in the whirlpool tub. Staff U also indicated Resident#3 was turned around saying "please help me" and that Resident #3 was panicking. Staff U, got Resident#3 out of the tub and reported the incident to Staff X, LPN on duty at which time Staff X replied that Staff X had forgotten and was busy and forgot to tell the LNA's that Resident#3 was in the tub alone. Interview with Staff D, Director of Nurses on 1/20/2011 confirmed that Resident#3 was found alone in the whirlpool tub and that the staff member responsible for caring for Resident #3 did receive an emergency phone call, reported to Staff X, LPN that they had to leave and also reported that Resident #3 was in the tub alone. Staff D, also indicated that Staff X, LPN saw the staff member walk down the hallway towards the whirlpool tub room and assumed that the staff member was going to take the resident out of the tub, but the staff member was going to retrieve their belongings and left the building leaving the resident unattended. Staff D also indicated that this incident was not reported to Staff B, Administrator or Staff D, DON until 11/5/10. Resident #6 Review of Resident #6's Fall Risk assessment dated [DATE] reveals a score of 13. The falls risk form indicates that a total score of 10 or above represents High Risk. Review of the 14 day MDS (Minimum Data Set) Version 3.0 assessment, dated 11/10/10 reveals under section G0110. Activities of Daily Living, letter I. Toilet use - how resident uses the toilet room, commode, bed pan, or urinal; transfers on/off toilet; the MDS is coded a 3 for extensive assist - resident involved in activity, staff provide weight-bearing support, and under the Support column the MDS is coded a 2 for one person physical assist. Review of Resident # 6's nurses notes indicates the following; 11/25/10, 10:59 AM, Change in Condition, Resident #6 had a change in condition-medical. Facial color is pale, Level of consciousness is lethargic, a change from previous state. Orientation: person, place. Skin is cool. Gastrointestinal: nausea, decreased fluid intake, decreased urine output. 11/26/10, 10:00 PM, Change in Condition Follow-up Note on 11/25/10 Status of condition: no change. Data: Pt not eating food and minimal fluid intake. Pt on IV (intravenous) D5,1/2 NS (normal saline) 1L (liter) @ 60ml/hr. Pt is weak, tired and complains of general malaise. 11/27/10, at 1:00 AM, reveals Change in Condition Follow-up Note This is a follow-up note from the change in condition medical that occurred on 11/25/10. Data: Continues on IV for hydration. No s/s (signs or symptoms) on IV site. Vicodin (2 tabs) for leg pain. No other complaints. 11/27/10, at 8:49 AM, General Transferred out to (name omitted) Emergency Department per Nurse practitioner. Unable to rehydrate. DPOA (Durable Power Of Attorney) notified and requested transport ... Report given to ED(Emergency Department) nurse. 11/27/10, at 1:45 PM, Resident#6 returned from ED via stretcher. Treatment plan discussed with Staff H, Nurse Practitioner, DPOA arrived with resident. Discussed making resident CMO, (comfort measures only). DPOA in agreement and requesting hospice services. 11/27/10 3:04 PM, New order Resident #6 is now to be comfort measures only. May consult Hospice for evaluation and treatment. D/C (Discharge)IV fluids and D/C saline lock. Start Zofran 4mg 1-2 tabs Q (every) 6H (hours) PRN (as needed) nausea. 11/28/10, 6:35 AM, Care and comfort maintained this shift no s/sx (signs or symptoms) of pain or discomfort. Incontinent of urine a small amount this shift. Took approximately 100 cc of water. Will continue to monitor. 11/28/10, 11:31 PM, at 3:15 PM resident found on floor by staff. Hematoma noted on right frontal area of head and bilateral abrasions to both knees. Review of the facility "Resident/Patient Incident Report" dated 11/28/10 at 3:15 PM Reveals that Resident #6 had an unwitnessed fall in the bathroom resulting in a large ecchymotic area on the right forehead and abrasions on both knees. The incident report also indicates that Resident #6 was alert and oriented prior to the fall and required an assist of 1 person. The"Patient Fall Investigation Form"dated 11/28/10 at 3:15 PM indicates under the Post Fall Evaluation section, that Resident #6 was in the bathroom alone, has protective stockings on for footwear and was given the call bell. Under the Contributing Factors/Issues section, it indicates that Resident #6 is alert and oriented and has poor safety awareness and was unassisted. The form also indicates that Resident #6 has experienced a recent change in gait/mobility, has pain, abnormal lab values and balance problems. Under the Patient Interview section, What is the patient's explanation of how the fall occurred? it was written "Client too ill to remember,doesn't want to talk about it." The Post Fall Evaluation form also indicates under the Conclusion and Summary of the investigation Resident #6 "will be upgraded to assist with ADL/amb (activities of daily living/ambulation). Addition of alarms and resident re-educated, Neuros (neurological assessment) checked, mechanical lift off floor after assessment". The fall investigation also reveals a statement written by Staff AA, LNA which indicates that Staff AA put Resident #6 on the toilet and then was informed by a nurse from another wing that Staff AA was needed for assistance on that other wing and left Resident #6 alone briefly.

Based on interview, records review and review of facility policy and procedure 1.0 NH (Nursing Home) Abuse Prohibition, it was determined the facility failed to implement facility abuse and neglect policies and procedures, in the following areas: Failed to prevent abuse and neglect and misappropriation of funds for 7 out of 20 sampled residents, (Resident identifiers are #3, #5, #6, #10, #11 #13, and #20), and 2 out of sample residents. (Resident identifier includes 1 confidential resident interview, and #31.) Failed to protect residents once an alleged incident occurs for 1 out of 20 sampled residents. (Resident identifier is #11.) Failed to implement reporting procedures both initial (24 hrs) and completed investigation for 6 out of 20 sampled residents, (Resident identifiers are #3, #6, #10, #11,#13, #20), and 2 out of sample residents. (Resident identifiers are #24 and #31.) Failed to investigate allegations of abuse and neglect and misappropriation and injuries of unknown origin, for 4 out of 20 sampled residents, (Resident identifiers are #5, #10, #11, #13), and 1 out of sample resident. (Resident identifier is #24.) Failed to implement training for Abuse and Neglect Policies for 1 out of 5 employee staff files reviewed, Staff identifier is staff DD Findings include: Facility Policy and Procedure entitled " 1.0 NH Abuse Prohibition " Policy, current revision is dated 8/3/09. 5.0 Staff will identify events-such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse- and determine the direction of the investigation. This also includes resident-to-resident abuse. 5.1 Anyone who witnesses an incident of suspected abuse, neglect, exploitation, involuntary seclusion, injuries of unknown origin, or misappropriation of resident property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately ... 6. Upon receiving information concerning a report of suspected or alleged abuse, the administrator or designee will: 6.1 immediately make an oral report, by telephone or otherwise (telephone number omitted), followed by a written report to the department of Health and Human Services (fax number omitted) ... 6.1.1.7 Description of incident including time of occurrence, location and date if know; ... 6.1.1.15 Action taken to date by the facility, such as any personnel action regarding the alleged perpetrator (if there is one) , initial changes to the resident ' s Plan of Care, etc. 6.2 Conduct an immediate and thorough investigation that focuses on: ... 6.4 The investigation will be thoroughly documented on the Center ' s investigation form and log. Ensure that documentation of witnessed interviews is included. ... 8. The Administrator or designee will report findings of all completed investigations to the Department of Health and Human Services within 5 working days of the incident and take all necessary, corrective actions depending on the results of the investigation. Resident #24 Record review during the Abuse Prohibition survey protocol on 1/21/11 revealed a facility report entitled "Record of Customer and Family Concerns" dated 9/2/10 indicates that Resident #24 reported an allegation of missing money on 9/2/10. During interview with Staff CC (Social Worker) and Staff B (Administrator) on 1/24/11 at 10:40 a.m., Staff B confirmed that Resident #24's incident on 9/2/10 was not reported to other officials in accordance with State law through established procedures, including to the State Survey and Certification Agency. The report also revealed no documented evidence of an investigation being conducted by the facility in accordance with facility ' s policies and procedures. Facility policy and procedure review on 1/19/11 reveals the facility policy entitled, " 1.0-NH Abuse Prohibition " policy, current revision is dated 8/3/09, documents under section 3 3. Training will be provided to all employees, through orientation and ongoing sessions, and will include: 3.1 The (facility) Abuse Prohibition Policy; 3.2 appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; 3.3 how staff should report their knowledge related to allegations without fear of reprisals; 3.4 how to recognize signs of burnout, frustration, and stress, that may lead to abuse; and 3.5 what constitutes abuse, neglect, exploitation, and misappropriation resident property. ... Record review during the Abuse Prohibition survey protocol of new employee files, revealed Staff DD, Licensed Nursing Assistant (LMA), was hired by the facility on 9/7/10. Staff DD's employment, Orientation and medical education file revealed no written verification of Staff DD attending or completing " Patient & Resident Abuse Prohibition " training, during the 3 day orientation program provided for new employees by the facility. Interview on 1/24/11 at 9:45 a.m. with Staff EAE (Human Resource Manager) confirmed no written documentation verifying attendance or completion of abuse prohibition training during orientation. Staff EAE also confirmed there was no written verification of Staff DD attending/completing any facility offered abuse and neglect education. On 1/9/11 at approximately 6:00 a.m., according to a Resident/Patient Incident Report and an untitled facility complaint investigation of 1/13/11, Resident #5 was heard by Staff N LMA (Licensed Nursing Assistant) "yelling for help." Staff N's LMA written statement of 1/9/11 noted finding Resident #5 "drenched in urine no sheets on" the bed "or any blankets" on the bed. Staff N LMA continued by stating Resident #5's "pants were down around" their "ankles." Staff N LNA also noted that Resident #5's bed was found in its most upright position. Resident #5, according to the facility complaint investigation, stated to Staff O LPN (Licensed Practical Nurse) on 1/9/11 after being cleaned up by Staff N LNA that "I want something done" and "I should not be treated like that." The facility complaint investigation determined that Staff P LNA (Licensed Nursing Assistant) was responsible for Resident #5's care during the third shift on the evening of 1/8/11. Staff P LNA, according to the facility complaint investigation, did not respond to repeated facility requests to come in to address this incident and was terminated without providing a statement for the facility investigation. The facility failed to protect this resident from being neglected. Residents #11 & 31. On 10/24/10 during the 3-11 shift on the Francouer Unit Staff S RN (Registered Nurse, Charge Nurse), according to a "Report of Abuse" facility complaint investigation of 10/28/10, noted after being introduced to the other staff that Staff T LNA (Licensed Nursing Assistant) was "swearing under" their "breath" and "acting annoyed with any resident which needed" their "assistance, as well as" with "staff." Also Staff S's RN written statement of 10/26/10 indicated that Staff T LNA appeared "very irritable and was snapping orders at the other" LNA's. Staff S RN wrote that Staff T LNA "seemed increasingly angry, irritable and was being very harsh in tone and demeanor." Staff S RN asked Staff T LNA "what was wrong" and Staff T LNA replied that they'd "worked a double" shift "and didn't sleep at all today and now I'm back here." Staff S RN told Staff T LNA to "take a break have a cigarette but relax with the residents take it easy." Staff S's RN statement for the facility complaint investigation continued by indicating that "later when people were being put to bed one of the LNA's came to me and said" Staff T LNA is "flipping people in bed like nothing." Staff S RN asked this unidentified LNA what they meant. The unidentified LNA replied by stating to Staff S RN that Staff T LNA "grabbed" an unidentified resident's feet "and threw them over into the bed." Staff S RN stated that they "found" Staff T LNA and "told" them "to not be so rough" with residents. Staff S RN said Staff T LNA then stated "don't tell me how to do my job." Staff S RN, as the evening progressed, failed to report these incidents or to protect the residents of the Francouer Unit from being physically and verbally abused. Staff S RN reported that at approximately 9:45 p.m. Staff T LNA called Staff S RN to Resident #11's room. Staff T LNA said that while changing Resident #11 Staff T LNA noticed Resident #11 had a skin tear. Staff S RN, according to their statement, "assessed the wound, consulted with" Resident #11's Durable Power of Attorney and Staff H PA (Physician Assistant). Staff H PA ordered that "a pressure dressing" be applied to the wound. The facility Resident/Patient Incident Report of 10/24/10 indicates that this "area to be beefy red with what appeared to be a deep wound through the skin and fat layer into the muscle" about "3 inches long by 2 inches wide." The facility investigation, according to an 1/27/11 interview with Staff B(Administrator), could not determine what caused Resident #11's wound. The facility Incident/Accident Investigation form listing "Possible Causes for Incident(consider all contributing factors carefully):" listed "Pt. scratching self, Transfer" and "Repositioning" as possible causal factors of this injury of unknown origin but did not assess the possibility of physical abuse causing this injury. The facility 1.0-NH Abuse Prohibition policy specifies that "Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected." There was no documentation that the facility made this determination regarding Resident #11's wound discovered on 10/24/10 at 9:45 p.m. that evening. Staff V LNA (Licensed Nursing Assistance) was also working the 3-11 shift on the Francouer Unit and noted in their written statement that Staff T LNA "was angry the entire evening." Staff V LNA also wrote that "while doing my charts I saw Resident #31 come flying through the day room." Staff V LNA continued by stating that "The agency" Staff W LNA (Licensed Nursing Assistance) "said" Staff T LNA "pushed" Resident #31's "wheelchair hard." Staff V LNA concluded their statement by noting "I didn't observe that but" Resident #31's "wheelchair didn't stop until" they were "almost at the fireplace." Staff V LNA failed to immediately report these incidents. Staff W LNA stated in their written statement that they "observed" on 10/24/10 during the 3-11 shift an unidentified "resident being pulled by" their left "arm to be changed angry and abruptly" by Staff T LNA. Also Staff W LNA wrote that Staff T LNA "forced" Resident #11 "out of" their room and was wheeled out pushed through and the wheelchair and" Resident #11 "was released and free wheeling through the community room about 5 feet or longer without an attendant." Staff W LNA stated that Resident #11 "was very mad and all" Resident #11 "wanted to do is go to bed." Staff W LNA concluded their statement by noting that "I witnessed verbal abuse to residents and myself by" Staff T LNA and Staff Y LNA (Licensed Nursing Assistance). Staff W LNA failed to intervene to stop these incidents and didn't immediately report them to their supervisor as required by facility policy. Staff Y LNA, who worked this shift as well on 10/24/10 from 3-11 according to the facility complaint investigation, made a statement concerning just Resident #11's "skin tear." Staff Y LNA stated that they stayed with Resident #11 while Staff T LNA "went and got the nurse" at 9:45 p.m. to see the area. A 1/27/11 interview with Staff B (Administrator) revealed that during the facility investigation of this complaint Staff Y LNA wasn't asked to respond to what other staff members reported including that Staff Y LNA was verbally abusive toward Staff W LNA and other incidents which occurred on the Francouer Unit on the evening of 10/24/10. Resident #20 On 1/13/11 the facility, according to an investigation report, received a complaint from a visitor that a resident had been subjected to physical abuse by Staff Z(Housekeeper) who allegedly took a cloth with feces on it and rubbed Resident #20's face with this contaminated cloth. Staff B (Administrator) failed as per facility policy to "Immediately make an oral report" to State officials including to the State survey agency of this allegation of physical and verbal abuse. Staff B (Administrator) confirmed that the facility had failed to report this complaint as required during a 1/21/11 interview. A Confidential Resident interview on 1/19/11 revealed that this resident requires assistance in being toileted. This resident stated that staff because of a shortage of available help routinely fails to timely answer the call bell resulting in them having to go to the bathroom in their diaper. The resident stated that they were upset and felt humiliated when this occurred. Resident #10 Record review conducted 1/19/11 - 1/24/11 revealed this resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #10 resides on the Francouer Unit which is a locked unit. Resident #10 eloped from the unit as evidenced by nursing notes documenting those events as follows: - 8/14/10 "Has been exit seeking all shift. Was only able to redirect times 3 and the other times ...(resident) got just outside door and was very hard to get back in...." - 8/21/10, 7-3, "Resident exit seeking all shift exited unit times one without letting staff know able to convince resident back into unit after 15 minutes stated 'I want to go home back to ...(town)' ... (sic. security bracelet) intact and functioning, resident watching doors when staff puts code in then attempts to leave/exit. Resident encouraged to stay in common area with staff..." - 9/11/10, 1446 "Alerted by alarm to the door going off the unit, resident had gotten out through the employee entrance door and was standing in parking lot approximately 20 feet from the door." - 9/11/10, 1530 "At 3 p.m. resident had gotten out again and was walking towards the assisted living building, (Resident #10) was redirected back to unit. The Facility (Corporate) Policy 1.36 Elopement of Resident (effective date of 6/1/96 with a revision date of 11/1/09) was identified on 1/24/11 by Staff I (Corporate Consultant) as the policy that was in effect 6/1/96 through September, 2010. Review of this policy reads "Patients of ...(facility) will be provided a secure environment." Under Process is listed the following: - 1. All residents will be screened for potential elopement risk ... . .... - 3. For residents identified as at risk, an interdisciplinary elopement prevention care plan will be developed with family and resident participation, 3.1 Individual risk factors and patterns will be identified and addressed within the care plan. 3.2 Obtain current photograph of resident. ... - 6. Staff will be trained on the Center's door security system and required response to a sounding alarm. 6.1 Whenever an alarm sounds, an accounting of all residents will be conducted..... - 9. Staff witnessing a confused resident or an identified elopement risk resident attempting to leave the Center will intervene as appropriate to redirect to a safe area and prevent elopement. 9.1 If the resident can not be redirected, alert other staff members and stay with the resident until he/she is safely returned to the Center. .... - 14. The Safety Committee will: 14.1 Review all incidents of elopement, 14.2 Conduct a root cause analysis, 14.3 Correct systems to prevent further incidents, and 14.4 Forward information to the Quality Improvement Committee for further discussion. Review of the current care plan in effect during survey (1/19/11-1/24/11) for Resident #10 reveals a care plan for the problem identifying this resident as "at risk for elopement related to dementia". Staff I (Corporate Consultant) was asked to provide facility incident reports and investigations on the above incidents. On 1/20/11 Staff I provided the following: - 8/21/10 Facility "Resident/Patient Incident Report" and "Incident/Accident Investigation" - 9/11/10 Facility "Resident/Patient Incident Report" (which had both 9/11/10 incidents recorded on one form). During an interview with Staff I on 1/20/11, Staff I stated the facility did not have an incident report or investigation report for the elopement of Resident #10 on 8/14/10 and did not have investigation reports for the two elopements by Resident #10 occurring on 9/11/10. Staff I also stated the 3 p.m. incident, which occurred on 9/11/10 (when Resident #10 eloped out of the building), was not reported to the State as required. During an interview with Staff B (Administrator), Staff M (Assistant Administrator), Staff I (Corporate Consultant) and two surveyors on 1/20/11 in the afternoon, multiple incidents including 8/14/10, 8/21/10 and the two incidents on 9/11/10 of exit seeking/elopement for Resident #10 were reviewed. Staff B confirmed the following were not done according to the policy and procedure: - The incident report and investigation for the 8/14/10 incident were not completed. - Only one incident report was filled out for the two elopements occurring on 9/11/10 and no investigation report was completed for either incident on 9/11/10. - The 3 p.m. 9/11/10 unwitnessed elopement incidents were not reported to the State. During the same interview with Staff B, Staff M, Staff I and two surveyors on 1/20/11, Staff B was asked about whether a resident head count was done according to the policy and procedure by staff on the occasions that Resident #10 left the unit and building. Staff B stated that when Resident #10 eloped from the Francouer Unit on 8/21/10 and 9/11/10 staff did not initiate a resident head count. Staff B was also asked what care plan or process changes, based on a root cause analysis, the facility made after Resident #10 eloped off the Francouer Unit and went out of the building on 9/11/10. Staff B stated "No changes were made after that incident." Resident #13 Review of facility generated investigation report dated 12/13/10 and interview reveals Resident #13 called her daughter on 12/12/10 at approximately 7 a.m. and was very upset. Daughter of Resident #13 reported that Resident #13 had requested pain medication during the night shift and a staff member had told her "You know you're not the only one in the house that needs pain meds.". Review of Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. on 12/12/10. Review of nurses notes dated 12/12/10 revealed Resident #13 's pain medication was effective as resident was sleeping. Interview with Staff D (DON) on 1/22/11 at 11:30 a.m. confirmed that Resident #13's daughter had expressed concern that a staff member would speak to Resident #13 in that manner. Staff D indicated the LNA responsible was suspended during investigation and re-educated on resident's rights. The investigation followup report was submitted to State survey and certification agency on 12/24/10 which is five working days late. Resident #3 Review of Resident #3's medical record and the facility's Resident/Patient Incident Report reveals that on 10/27/10 Resident #3 was left unattended in the whirlpool tub for 40 minutes. Review of the social service notes dated 11/11/10 reveals "This writer met with Resident#3, (resident name omitted) today to follow up on the incident that occurred on 10/27/10". The social service notes indicated that Resident#3 reported that some days were ok and other days the resident would think about it a little. Resident #3 stated "I am glad that when I called someone came". Review of the facility's "Resident/Patient Incident Report" dated 11/5/10 indicated That Resident #3 was left alone in the whirlpool tub for 40 minutes after the staff LNA left the facility due to an emergency. This incident was not immediately reported to the facility's Administrator or the Director of Nursing. The Administrator and Director of Nursing were notified of the incident on November 5, 2010, 9 days after the incident occurred and as a result the incident was not reported to the State Survey and Certification Agency in a timely manner as required. Resident #6 Review of Resident #6, reveals that Resident #6 had an emergency room visit on 11/27/10 with a decline in medical status. Resident #6 returned to the facility the same day and was put on comfort measures only. The resident was assisted to the bathroom and left unattended resulting in a fall to the floor. The fall caused a hematoma to Resident #6's right forehead and abrasions to both knees. The facility's investigation confirmed that Staff AA, LNA who was responsible for the care of Resident #6 assisted Resident #6 on the toilet and then was informed by a nurse from another wing that Staff AA was needed for assistance on that other wing and left Resident #6 alone in the bathroom. Review of Resident#6's Fall Risk assessment dated [DATE] reveals a score of 13. The falls risk form indicates that a total score of 10 or above represents High Risk. Review of the 14 day MDS (Minimum Data Set) Version 3.0 assessment, dated 11/10/10 reveals under section G0110. Activities of Daily Living, letter I. Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; the MDS is coded a 3 for extensive assist - resident involved in activity, staff provide weight-bearing support, and under the Support column the MDS is coded a 2 for one person physical assist. There was no documented evidence showing that this allegation of neglect resulting in a fall was reported to the State Survey and Certification Agency in a timely manner as required. Cross Reference F225

Based upon a review of a facility report and a confidential interview the facility failed to care for a resident in a manner which promoted their dignity. (Resident identifier is #5) Findings include: Resident #5 Review of the Resident/Patient Incident Report of 1/9/11 reveals at approximately 6:00 a.m., according to the facility investigation, Resident #5 was heard by Staff N LNA(Licensed Nursing Assistant) yelling for help. Staff N's LNA written statement of 1/9/11 noted finding Resident #5 drenched in urine no sheets on the bed or any blankets on the bed. Staff N LNA continued by stating Resident #5's pants were down around their ankles. Staff N LNA also noted that Resident #5's bed was found in its most upright position. Resident #5, according to the facility's investigation, and stated to Staff O LPN on 1/9/11 after being cleaned up by Staff N LNA that I want something done and I should not be treated like that. The facility investigation determined that Staff P LNA was responsible for Resident #5's care during the third shift on the evening of 1/8/11. Staff P LNA, according to the facility complaint investigation, did not respond to repeated facility requests to come in to address this incident and was terminated without providing a statement for the facility investigation. A Confidential Resident interview on 1/19/11 revealed that this resident requires assistance in being toileted. This resident stated that staff, because of a shortage of available help, routinely fails to timely answer the call bells resulting in them having to go to the bathroom in their diaper. The resident stated that this was upsetting and felt humiliated when this occurred.

Based upon interview with the resident council and review of facility reports the facility failed to provide sufficient staff to meet the needs of the residents.(Resident identifiers include #5, #6 and #13). Findings include: Resident #5 Review of a facility Incident Report dated 1/17/11 reveals that on 1/9/11 at approximately 6:00 a.m, Staff N, LNA heard Resident #5 "yelling for help ". Staff N, LNA ' s written statement indicated that Resident #5 was found by Staff N with their bed in the most upright position with no blankets or sheets on the bed. Staff N, LNA also indicated that Resident #5 was found "drenched in urine with their pants down around their ankles". The facility report also indicated that Resident #5 stated to Staff O, LPN (Licensed Practical Nurse) on 1/9/11 after being cleaned up by Staff N, LNA that "I want something done" and "I should not be treated like that." The facility's investigation determined that Staff P, LNA (Licensed Nursing Assistant) was responsible for the care of Resident #5 during the third shift on the evening of 1/8/11. Staff P LNA, according to the facility ' s investigation, did not respond to repeated facility requests to come in to address this incident and was terminated without providing a statement for the facility investigation. Confidential interview on 1/19/11 reveals that because of a shortage of staff the call bells are not answered in a timely manner and if a resident needs assistance to go to the bathroom the resident may not be able to wait until the staff answers the call bell which causes the resident to have to go to the bathroom in their disposable briefs. This leaves the resident feeling upset and humiliated when this happens. Resident Council meeting conducted on 1/20/11 at 1:30 p.m. was attended by approximately 12 residents. Several residents identified staffing levels being inadequate at times, especially noted during 3-11 shifts, causing delay in answering call lights and toileting delays of over 10 minutes. During a confidential staff interview on 1/19/11 at approximately 11:00 a.m. revealed concern about not having adequate staffing available on the units during mealtimes. The interviewed staff member stated there is 1 LNA available on each wing to pass meal trays and answer call lights during mealtimes, resulting in staff being unable to meet resident care needs. Resident #13 Review of facility generated investigation report dated 12/13/10 revealed a statement dated 12/15/10 from Staff P (LNA) "On said night I was working solo on a 26 resident unit. 10 of which need assistance with toileting, 9 are incontinent and 4 have foley catheters. In addition to performing my rounds and answering call bells, I am required to rise, bath and dress 5 residents by 7 a.m. This particular morning I had a few time consuming unexpected issues, which I explained to the 7 am staff. The residents health and safety were never at risk and was always my priority.... With some assistance from the nurse or a co-worker this situation would have be avoided." Staffing sheets reviewed for 12/11/10 revealed 1 nurse and 1 LNA scheduled for the unit. Interview on 1/22/11 at 2 p.m. with Staff D (DON) confirmed that the unit was staffed with an agency nurse and an LNA on the 11-7 shift 12/11/10. Resident #6 Review of Resident#6's Fall Risk assessment dated [DATE] reveals a score of 13. The falls risk form indicates that a total score of 10 or above represents High Risk. Review of the facility " Resident/Patient Incident Report "dated 11/28/10 at 3:15 PM reveals that Resident #6 had an unwitnessed fall in the bathroom resulting in a large ecchymotic area on the right forehead and abrasions on both knees. The incident report also indicates that Resident #6 was alert and oriented prior to the fall and required an assist of 1 person. Under the "Patient Fall Investigation Form", dated 11/28/10 at 3:15 PM reveals, under Post Fall Evaluation section, that Resident #6 was in the bathroom alone, has protective stockings on for footwear and was given the call bell. Under the Contributing Factors/Issues section, it indicates that Resident #6 is alert and oriented and has poor safety awareness and was unassisted. The form also indicates that Resident #6 has experienced a recent change in gait/mobility, has pain, abnormal lab values and balance problems. Under the Interviews section of the form, it was written "Client too ill to remember, doesn't want to talk about it." The Post Fall Evaluation form also indicates under the Conclusion and Summary of the investigation Resident #6 "will be upgraded to assist with ADL/amb (activities of daily living/ambulation). Addition of alarms and resident re-educated, Neuros (neurological assessment) checked, mechanical lift off floor after assessment". The fall investigation also reveals a statement written by Staff AA, LNA which indicates that Staff AA put Resident #6 on the toilet and then was informed by a nurse from another wing that Staff AA was needed for assistance on that other wing and left Resident #6 alone.