Every finding on record at Onyx Care of Jena

Based on interview and record review the facility failed to ensure the Medical Director participated in the Quality Assessment and Assurance Process Quarterly meetings. Total sample size 41. Findings:Review of the Monthly and Quarterly Quality Assessment and Assurance Process revealed no documented evidence of the Medical Director attending any Quality Assessment and Assurance program meetings from 12/2025 through May 2026.During an interview on 06/03/2026 at 3:10 p.m., S1 Administrator confirmed the previous Medical Director had not attended any Quality Assessment and Assurance program meetings from 12/2025 through 05/2026, but should have.During a telephone interview on 06/03/2026 at 3:26 p.m., with previous Medical Director confirmed she had not attended any Quarterly Quality Assessment and Assurance meetings for 12/2025 to 05/2026.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to practice Enhanced Barrier Precautions for 5 (Resident #7, Resident #17, Resident #31, Resident #34, and Resident #73) of 41 sampled residents. Findings: Review of the facility's policy titled, Enhanced Barrier Precautions with a review date of 03/01/2026, revealed in part, Enhanced Barrier Precautions applies to all residents with any of the following: indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator); When a resident is placed on Enhanced Barrier Precautions, gown and gloves will be used during high-contact resident care activities. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: a. Dressing; b. Bathing/Showering; c. Transferring; d. Providing hygiene; e. Changing linens; f. Changing briefs or assisting with toileting; g. Device care or use of a device: central line, urinary catheter, feeding tube, tracheostomy; and, h. Wound care. Resident #7 Review of Resident #7's EHR revealed in part, an admission date of 08/08/2025 with diagnoses of Acute Respiratory Failure, Unspecified Whether with Hypoxia or Hypercapnia; and Encounter for Attention to Tracheostomy. Review of Resident #7's 06/2026 physician's orders revealed in part.Enhanced Barrier Precautions dated 05/01/2026. Observation on 06/02/2026 at 3:30 p.m., revealed S7 RT suctioning Resident #7 without wearing any PPE. EBP signage was observed on Resident #7's bedroom door upon entrance into their room. PPE for staff was available in a plastic bin in the hallway or on the back of the resident's door. Resident #34 Review of Resident #34's EHR revealed in part an initial admission date of 05/18/2026 with diagnoses of Acute Respiratory Failure, Unspecified Whether with Hypoxia or Hypercapnia; and Encounter for Attention to Tracheostomy. Review of Resident #34's 06/2026 physician's orders revealed in part.Enhanced Barrier Precautions dated 05/29/2026. Observation on 06/01/2026 at 10:12 a.m., revealed S7 RT suctioning Resident #34 without wearing any PPE. EBP signage was observed on Resident #34's bedroom door upon entrance into their room. PPE for staff was available in a plastic bin in the hallway or on the back of the resident's door. Resident #73 Review of Resident #73's Electronic Health Record (EHR) revealed in part an admission date of 05/29/2026 with a diagnosis of Acute Respiratory Failure, Unspecified Whether with Hypoxia or Hypercapnia. Review of Resident #73's 06/2026 physician's orders revealed in part.Enhanced Barrier Precautions dated 05/29/2026. Observation on 06/01/2026 at 10:00 a.m. revealed S7 RT suctioning Resident #73 without wearing any Personal Protection Equipment (PPE). EBP signage was observed on Resident #73's bedroom door upon entrance into their room. PPE for staff was available in a plastic bin in the hallway or on the back of the resident's door. Interview on 06/02/2026 at 3:40 p.m. with S7 RT confirmed that he did not implement EBP practices while suctioning Resident #7, Resident #34, and Resident #73, but should have. Interview on 06/02/2026 at 3:45 p.m. with S2 DON confirmed S7 RT should have worn a gown and gloves for Resident #7, Resident #34, and Resident #73 that required EBP. Resident #17 Review of Resident #17's medical record revealed an admission date of 04/20/2023 with diagnoses, which included Iron Deficiency Anemia; Hypotension; Diffuse Traumatic Brain Injury with loss of Consciousness; and Major Depressive Disorder. Review of Resident #17's Quarterly MDS with an ARD of 03/03/2026 revealed a Brief Interview Mental Status (BIMS) score of 09, which indicated moderate cognitive impairment. Review of Resident #17's current care plan revealed the following in part . (Date Initiated: 11/04/2024) Focus: Requires enhanced barrier precautions per CDC (Center for Disease Control) regulations related to presence of peg tube, etc. Interventions: Continue EBP for duration of stay or until reason for EBP to be resolved. Review of Resident #17's current physician's orders revealed the following in part . -Flush feeding tube with 30 milliliters of water before and after meds/feedings; -Bolus 237 milliliter of Fibersource PPT (per peg tube) every 4 hours; and -Initiate Enhanced Barrier Precautions due to presence of Peg/Cath to remain in effect until devices removed. Observation on 06/01/2026 at 11:59 a.m. revealed S8 LPN administered Resident #17's peg tube feeding without using PPE (gown and gloves). In an interview on 06/02/2026 at 10:24 a.m., S2 DON confirmed all staff who provided direct care for residents with EBP should wear PPE (gown and gloves). S2 DON acknowledged S8 LPN should have worn PPE while administering a bolus peg feeding for Resident #17. In an interview and observation on 06/01/2026 at 12:00 p.m., S8 LPN revealed she did not know what EBP meant. S8 LPN stated she was unaware she needed to wear PPE (gown and gloves) when administering a bolus feeding via peg tube for Resident #17. Resident #31 Review of Resident #31's medical record revealed an admission date of 04/20/2023 with diagnoses, which included Seizures; Major Depressive Disorder; Insomnia; and Diffuse Traumatic Brain Injury with loss of Consciousness. Review on 06/03/2026 at 2:36 p.m. of Resident #31's Annual MDS with an ARD of 05/05/2026 revealed a Brief Interview Mental Status (BIMS) was unable to be performed because Resident #31 was rarely/never understood. Further review of the MDS revealed Resident #31 had a peg tube. Review of Resident #31's current care plan revealed the following in part . (Date Initiated: 11/18/2024) Focus: Requires enhanced barrier precautions per CDC (Center for Disease Control) regulations related to presence of peg tube, etc. Interventions: Continue EBP for duration of stay or until reason for EBP to be resolved. In an interview on 06/02/2026 at 10:32 a.m., S9 CNA revealed she and S10 CNA gave Resident #31 a complete bed bath this morning. S9 CNA revealed EBP meant enhanced barrier precautions, which required them to wear gloves and gowns during direct care for residents who had a peg tubes. S9 CNA revealed she did not wear EBP PPE (gown and gloves) when she performed the bed bath for Resident #31 this morning. In an interview on 06/02/2026 at 10:39 a.m., S10 CNA revealed she and S9 CNA gave Resident #31 a complete bed bath this morning without wearing PPE (gown and gloves). In an interview on 06/02/2026 at 10:24 a.m., S2 DON confirmed all staff who provided direct care for residents with EBP should wear PPE (gown and gloves). S2 DON acknowledged S9 CNA and S10 CNA should have worn PPE while performing direct care/bed bath for Resident #31.

Based on interview and record review the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, by failing to honor 1(Resident #10) of 1 sampled resident's choices. Findings: Review of a Facility Policy titled Resident Rights-Exercise of Rights with a review date of 01/17/2024, revealed in part .Intent: All residents have rights guaranteed to them under Federal and State laws and Regulations. All activities and interactions with residents by any staff, temporary agency staff or volunteers must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's goals, preferences, and choices. Procedure: The facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.The facility will protect and promote the rights of the resident. Review of Resident #10's medical record revealed an admit date of 12/24/2024, with diagnoses which included in part. Hemiparesis following Cerebral Infarction affecting left non-dominant side, Type 2 Diabetes Mellitus, Bipolar Disorder, Unspecified Dementia, Post Traumatic Stress Disorder, General Anxiety, and Schizophrenia. Review of Resident #10's Quarterly MDS with an ARD of 04/28/2026, revealed a BIMS score of 15 indicating intact cognition. The MDS revealed Resident #10 had no behaviors and required set-up assistance with eating, personal hygiene, and oral hygiene, and required substantial/maximal assistance with toileting hygiene, dressing and bathing.Review of Resident #27's medical record revealed an admit date of 01/20/2023, with Diagnoses that included in part.Alzheimer's Disease with Late Onset, Major Depressive Disorder, Recurrent, sever with Psychotic Symptoms, Restlessness and Agitation. During an interview on 06/01/2026 at 9:48 a.m., Resident #10 revealed Resident # 27 who resided across the hall, had been coming in his room. Resident #10 stated he had complained about it to staff (didn't know the names of the staff), but nothing had been done about it. Resident #10 stated when he complained to staff they would say Oh, he's old and confused, or He has Dementia and is confused. During the interview with Resident #10, Resident #27 came inside the doorway of Resident #10's room. During an interview on 06/02/2026 at 8:51 a.m. S14 LPN revealed Resident #27 had a history of wandering in other residents' rooms. During an interview on 06/02/2026 at 8:55 a.m., S15 Housekeeper revealed he had seen Resident #27 in Resident #10's room several times, and had also seen him in several other residents' rooms. During an interview on 06/02/2026 at 9:00 a.m., S10 CNA stated Resident #27 did wander into Resident #10's room. S10CNA stated she had seen Resident #27 in Resident #10's room the previous day. During an interview on 06/02/2026 at 10:47 a.m., S1 Administrator revealed she was aware that Resident #27 propelled himself throughout the facility and was confused. S1 Administrator confirmed if staff were aware of Resident #27 wandering into Resident #10's room, they should have reported it. S1 Administrator confirmed Resident #27 should not have been wandering into Resident #10's room.

Based on interview and record review, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care that met professional standards of quality care for 1 (Resident #78) of 1 sampled residents.Findings: Review of Resident #78's medical record revealed an admission date of 05/29/2026 with diagnoses including, in part.Schizoaffective Disorder, Unspecified; Asymptomatic Human Immunodeficiency Virus, Bipolar Disorder, and Insomnia Review of Resident #78's medical record revealed Resident #78 did not have a baseline care plan. Interview on 06/01/2026 at 10:39 a.m., Resident #78 stated he was new to the facility and was recently admitted on [DATE]. Interview on 06/02/2026 at 12:52 p.m., S3 Unit Manager stated she was responsible for completing the baseline care plans and a floor nurse would complete it if a resident was admitted on the weekend or late at night. S3 Unit Manager stated she was responsible for following up on the completion of the baseline care plans to ensure they were developed and completed within the required 48-hour timeframe. S3 Unit Manager stated if a baseline care plan was not developed or completed it would flash in red on her computer's dashboard. S3 Unit Manager reviewed Resident #78's medical record and confirmed Resident #78's baseline care plan was not developed or completed within 48-hours, but should have been.

Based on observations, record review, and interviews the facility failed to ensure the Comprehensive Resident Centered Plan of Care was revised to include behaviors for 1 (Resident #31) of 41 sampled residents. Findings:Review of the facility's policy with a review date of 01/08/2026 titled Comprehensive Care Plans read in part.Policy Statement: To meet the resident's physical, psychosocial and functional needs, the facility will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and target goals. Procedure: Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. Review of Resident #31's medical record revealed an admission date of 04/20/2023 with diagnoses, which included Other Seizures; Essential Hypertension; Major Depressive Disorder; Insomnia; and Constipation. Review of Resident #31's Annual MDS with an ARD date of 05/05/2026 revealed a BIMS was unable to be performed. Further review of the MDS revealed Resident #31 was short tempered and easily annoyed. Observation of Resident #31 on 06/01/2026 at 2:35 p.m. revealed he was seated in the day room in his Geri chair hitting the side of chair constantly. In an interview on 06/02/2026 at 10:32 a.m., S10 CNA revealed she had worked at the facility for about a year. S10 CNA stated Resident #31's does have a lot of behaviors such as hitting, punching, and kicking at staff while performing direct care. S10 CNA stated Resident #31 had thrown feces all over the room last week twice. S10 CNA stated she has reported Resident 31's behaviors to S1 Adm and S2 DON. Review on 06/02/2026 at 11:25 a.m. of Resident #31's care plan with a target date of 08/06/2026 revealed there was no plan of care for behaviors. Review of May EMARs (electronic medication administration records) revealed on May 4, 9, 23, 28, and 29 nurses had documented Resident #31 had behaviors. Review of May 2026 Nurses notes revealed Resident #31 had documented behaviors on 04/18/2026, 04/22/2026, 04/26/2026, and 05/29/2026. In an interview on 06/02/2026 at 4:17 p.m. with S13 MDS Nurse revealed Resident #31's care plan had not been updated to reflect his behaviors and should have been. In an interview on 06/02/2026 at 2:42 p.m., S2 DON confirmed the plan of care had not been revised with Resident #31's behaviors and should have been. Observation and interview with S13 MDS on 06/03/2026 at 3:30 p.m. of the plan of care for Resident #31 revealed it was updated on 06/02/2026 to reflect his behaviors.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 (Resident #8 and Resident #26) sampled residents. The facility failed to: provide nail care for Resident #8; andprovide hair care for Resident #26. Findings: Review of the facility policy titled, Supporting Activities of Daily Living (ADL) with a reviewed date of 01/26/2026 revealed in part, Residents will be provided with care, treatment, and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care). 5. Functional decline or improvement will be evaluated in reference to the ARD and the following MDS definitions: Total Dependence-Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. 1. Resident #8 Review of Resident #8's clinical record revealed an admit date of 02/10/2026 with diagnoses that included in part: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side; Pressure Ulcer of Right Ankle, Unstageable; Dementia, Unspecified; and Anxiety. Review of Resident #8's Quarterly MDS with an ARD of 05/21/2026 revealed a BIMS Score of 03, which indicated severe cognitive impairment. Resident #8 was dependent for all ADLs. Review of Resident #8's Care Plan with a next review date of 08/21/2026 revealed in part.focus: the resident requires assistance with ADLs. Interventions: Bathing/Showering: check nail length and trim and clean on bath day and as necessary, with an initiated date of 02/27/2026. Review of Resident #8's facility task log revealed he required a daily bed bath on the day shift. The last documented bed bath was completed on 06/01/2026. Observation on 06/01/2026 at 11:48 a.m. revealed Resident #8 lying in bed asleep with untrimmed, jagged nails, and a black unknown substance underneath his fingernails. Observation on 06/02/2026 at 8:51 a.m., revealed Resident #8 lying in bed awake and alert to his self only. Observed Resident #8 with untrimmed, jagged nails, and a black unknown substance underneath his fingernails. Observation on 06/02/2026 at 11:43 a.m., revealed Resident #8 lying in bed awake and alert to his self only. Observed Resident #8 with untrimmed, jagged nails, and a black unknown substance underneath his fingernails. Observation on 06/03/2026 at 8:56 a.m., revealed Resident #8 lying in bed awake and alert to his self only. Observed Resident #8 with untrimmed, jagged nails, and a black unknown substance underneath his fingernails. Interview on 06/03/2026 at 9:09 a.m., S6 CNA revealed Resident #8 required total care assistance with all ADLs. S6 CNA stated Resident #8 required a daily bed bath and rarely refused care. She stated the daily bed bath consisted of cleaning Resident #8's fingernails. During observation at this time, accompanied by S6 CNA, of Resident #8's fingernails S6 CNA stated she gave him a bath on 06/01/2026 and there was no reason his fingernails should have looked like this. S6 CNA confirmed Resident #8's fingernails were untrimmed, jagged, and had a black unknown substance underneath. Interview on 06/03/2026 at 9:58 a.m., S3 Unit Manager accompanied surveyor to Resident #8's bedroom and stated Resident #8 required a daily bed bath. S3 Unit Manager confirmed that Resident #8's fingernails were untrimmed, jagged, and had a black unknown substance underneath his fingernails, but should not have been. 2. Resident #26 Review of Resident #26's medical record revealed an admission date of 02/06/2023 with diagnoses that included in part. Osteomyelitis, Anxiety Disorder, Major Depressive Disorder, Pain Unspecified, Unspecified Dementia, and Rash and other nonspecific skin eruptions. Review of Resident #26's Quarterly MDS with an ARD of 04/21/2026 revealed Resident #26 had a BIMS score of 99 which indicated resident was unable to complete interview. The MDS revealed Resident #26 was dependent for oral hygiene, toileting hygiene, shower/bathe, and personal hygiene. Resident #26 required set-up or clean-up assistance with eating. Review of Resident #26's care plan revealed in part.Resident #26 required assist with ADL's with interventions that included in part.Bathing/Showering-The resident require 1 person assist with daily bed bath; personal hygiene/oral hygiene-The resident require 1 person assist an ADL self-care. Review of Resident #26's bath roster for 05/2026 and 06/2026 read in part. Bed bath daily on day shift. No documented evidence of when Resident #26's hair was washed. During an observation on 06/01/2026 at 9:33 a.m. revealed Resident #26 in bed. Resident #26's hair was dirty, dry/flaky, and matted to her head. Resident #26 was unable to say when her hair had been washed. During an interview on 06/01/2026 at 12:19 a.m. with Resident #26's sister revealed she visited Resident #26 daily at the facility. Resident #26's sister stated My sister's hair is not being washed regularly. Resident #26's sister stated she had complained numerous times to staff (didn't know the staff's names) about Resident #26's hair being extremely dry/flaky and dirty, but the complaints had been ignored. During an observation on 06/02/2026 at 10:53 a.m. S12 LPN revealed Resident was bed bound and received hospice for palliative care. During observation of Resident #26's hair at that time, S12 LPN confirmed Resident #26's hair was dirty and needed to be washed. During an observation and interview on 06/02/2026 at 10:59 a.m., S14 LPN confirmed Resident #26's hair was dry/flaky, dirty, and needed to be washed. During a telephone interview on 06/02/2026 at 11:03 a.m., S17 Hospice Nurse revealed she had been providing care for Resident #26 for 2 to 3 months and her hair had been dry and flaky the whole time. During an observation and interview with S2 DON on 06/02/2026 at 2:20 p.m., S2 DON stated her hair (Resident #26) should not be looking like this, ideally it should be clean. S2 DON confirmed Resident #26's hair was not clean and it should be. S2 DON confirmed Resident #26's bath roster did not indicate when Resident #26's hair had been washed.

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #17) of 1 resident reviewed for respiratory care in a total sample of 41 residents. The facility failed to ensure respiratory equipment was properly changed, labeled, and stored. Findings:Review of the facility policy with a review date of 03/06/2026 titled Care and Cleaning of Respiratory Equipment revealed in part .Purpose: To maintain equipment in proper working order and to reduce the risk of nosocomial infection. XII. Additional Equipment. Respiratory tubing, catheters, masks, and cleaning kits will be secured or placed in a container, original package or bag. Review of Resident #17's medical record revealed an admission date of 04/20/2023 with diagnoses, which included Iron Deficiency Anemia; Morbid Obesity; Diffuse Traumatic Brain Injury with loss of Consciousness; and Unspecified Convulsions. Observation on 06/01/2026 at 12:44 p.m. revealed an undated Aerosol mask attached to a Nebulizer machine on Resident #17's nightstand, open to air. Review of Resident #17's May 2026 EMAR (electronic medication administration record) on 06/01/2026 at 3:35 p.m. revealed Resident #17 had a medication order of Ipratropium-Albuterol Solution-1 vial inhale orally four times a day for wheezing, cough for 5 days with a start date of 05/28/2026. Observation on 06/02/2026 at 8:49 a.m. revealed the undated Aerosol mask attached to a Nebulizer machine remained on Resident #17's nightstand, open to air. In an interview on 06/02/2026 at 10:03 a.m., S8 LPN confirmed the Aerosol mask attached to the Nebulizer machine on Resident #17's nightstand was open to air and not labeled or stored properly. In an interview on 06/02/2026 at 10:24 a.m., S2 DON confirmed Resident #17's Aerosol mask and tubing had not been dated or stored properly but should have been.

Based on record review and interviews, the facility failed to provide pharmaceutical services that ensure accurate acquiring, receiving, dispensing and administration of medications to meet the needs of each resident. The facility failed to provide medications and/or biologicals to meet the needs of residents for 1 (Resident #59) of 1 resident reviewed for pharmaceutical services in a total sample of 41 residents.Findings:Review of the facility's policy with a review date of 03/01/2026 titled, Medication Administration revealed in part .Intent: All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. 24. If medication is ordered but not present check to see if it was misplaced and then call the pharmacy to obtain the medication.Review of Resident #59's medical record revealed an admission date of 07/27/2025 with diagnoses, which included ESRD (End Stage Renal Disease); Type 2 Diabetes Mellitus with unspecified complications; Depression; Anxiety; Bipolar Disorder; and Parkinsonism. Review of Resident #59's Annual MDS with an ARD date of 04/28/2026 revealed a BIMS score of 15, which indicated intact cognition.Review on 06/03/2026 at 3:16 p.m. of Resident #59's April 2026 EMAR (electronic medication administration record) revealed Resident #59 had an order for Sevelamer Carbonate (Renvela) 800mg-1 tablet by mouth before meals for Other Disorders of Phosphorus Metabolism with a start date of 04/17/2026. Further review of the EMAR revealed Resident #59 had not received the above medication from 04/18/2026 to 04/30/2026.Review on 06/03/2026 at 3:16 p.m. of Resident #59's May 2026 EMAR(electronic medication administration record) revealed Resident #59 had a medication order of Renvela 800mg-1 tablet by mouth before meals for Other Disorders of Phosphorus Metabolism with a start date of 04/17/2026 and a hold date from 05/01/2026 to 05/04/2026; a hold date from 05/05/2026 to 05/19/2026; and another hold date from 05/22/2026 to 06/01/2026. Further review of EMAR revealed Resident #59 did not receive any doses of the above medication for the month of May 2026.Review on 06/03/2026 at 3:16 p.m. of Resident #59's June 2026 EMAR(electronic medication administration record) revealed Resident #59 had a medication order of Renvela 800mg-1 tablet by mouth before meals for Other Disorders of Phosphorus Metabolism. Further review of EMAR revealed Resident #59's had not received the above medication from 06/01/2026 to current. The EMAR revealed H in the boxes from the dates of 06/01/2026 to 06/12/2026 indicating the medication had been put on hold.In a telephone interview on 06/03/2026 at 10:52 a.m., S11 RD revealed she was the Registered Dietitian at the dialysis center for Resident #59. S11 RD stated Resident #59 is on a 1200 milliliter fluid restriction with monitoring of urine outputs. S11 RD also stated Resident #59 is on Sevelamer Carbonate 800mg- 2 tabs with meals and 1 with snacks because of his abnormal lab of an elevated phosphorus in 04/2026. S11 RD stated dialysis and herself communicate via communication forms and faxing over orders to the facility. Further interview with S11 RD revealed the dialysis center orders the Sevelamer Carbonate and sends it with the resident back to the facility. S11 RD stated the above medication was filled last on 03/27/2026 and 04/20/2026 and Resident #59 should not have been out of his medication. S11 RD stated the facility knows that they need to call dialysis for Sevelamer Carbonate refills. On 06/03/2026 at 3:16 p.m., a review of the dialysis communication sheets from April 2026 to June 2026 (current) revealed no new orders. In an interview on 06/03/2026 at 3:22 p.m. S12 LPN revealed she called the facility's pharmacy about getting the medication refilled and they told her they normally don't fill the Sevelamer Carbonate because dialysis refills it, but they could fill it if needed.In an interview on 06/03/2026 at 3:23 p.m., S2 DON stated she did not know Resident #59 had did not have any Sevelamer Carbonate doses from 04/18/2026 to 06/03/2026. S2 DON also stated she was under the impression the above medication could only be refilled through dialysis but confirmed they should have ordered it using the facility's pharmacy when they could not get it from dialysis. S2 DON confirmed the facility did not have the Sevelamer Carbonate for Resident #59 readily available, but should have.

Based on interviews and record review, the facility failed to ensure the physician was notified of a change in condition for 1 (#3) of 4 sampled residents when Resident #3 experienced severe pain but no pain medication was available to administer. This deficient practice resulted in an actual harm on 04/02/2026 at 6:23 p.m. when Resident #3 was admitted with a diagnosis of ORIF to both Left Femur and Right Wrist on 03/25/2026. admission orders included Hydrocodone 10/325mg by mouth every 6 hours as needed for pain. At that time Resident #3 complained of leg pain at a level of 6 out of 10, indicating severe pain per facility parameters, and was unable to receive any pain medication because the facility had not acquired her pain medication from the pharmacy. The nurse caring for Resident #3 failed to notify the physician that pain medication was unavailable for Resident #3.Findings:Review of a facility policy titled Notification of a Change in A Resident's Status dated 11/07, revealed in part:Policy: The attending physician/physicians extender (Nurse Practitioner) and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations. Responsibility: All Licensed Nursing PersonnelProcedure:1. Guideline for notification of physician/responsible party (not all inclusive):j. Abnormal complaints of pain, ineffective relief of pain from current regimen Review of Resident #3's medical record revealed an admit date of 04/02/2026 with diagnoses that included in part.Pain, Generalized Anxiety Disorder, Fracture of lower end of Left Femur and Fracture of Right Wrist S/P ORIF on 03/25/2026, Hypertension, Morbid obesity.Review of Resident #3's 5 day MDS with an ARD of 04/09/2026 revealed Resident #3 had a BIMS score of 15 ( which indicated intact cognition) and was coded as requiring set up or clean-up assistance with eating, dependent for toileting, substantial/maximal assistance with shower/bath, and turning/repositioning. Further review revealed Resident #3 had lower extremity impairment on one side. Further review, Resident #3 had the presence of pain, pain intensity rating scale of 10,worst pain you can imagine, at the time of assessment and received PRN pain medications.Review of Resident #3's Care Plan with a target date of 07/19/2026 revealed the resident has a Potential for Alteration in Comfort related to Femur fracture, Coronary Artery Disease, Hypertension, Hyperlipidemia, Obesity, Anxiety, Hypokalemia, and a history of Edema, with interventions that included: Anticipate the resident's need for pain relief, Medications as ordered, Notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain, reposition PRN for comfort.Review of Resident #3's 04/2026 Physician's Orders revealed in part.Hydrocodone-Acetaminophen Oral Tablet 10-325 Milligram-Give 1 tablet by mouth every 6 hours as needed for pain (start date 04/02/2026), Tylenol Oral Capsule 325 MG Give 2 tablets by mouth every 6 hours as need for Pain unspecified (start date 04/03/2026).Review of a Nursing Progress note dated 04/02/2026 at 6:23 p.m. read in part.Resident arrived to facility via ambulance service via stretcher in stable condition from hospital with diagnoses: S/P ORIF (Open Reduction and Internal Fixation-a surgical procedure) to both Left Femur and Right Wrist on 03/25/2026. Resident notes to have pain 6/10.During an interview on 05/05/2026 at 10:44 a.m. Resident #3 revealed she arrived at the facility via ambulance on 04/02/2026 between 6:00-6:30 p.m. and was hurting pretty bad. Resident #3 revealed she had surgery to her wrist and leg and had pain daily and received pain medication every six hours as needed. Resident #3 revealed upon admission into the facility she went a whole day without receiving her pain medication. Resident #3 revealed when she asked S3 LPN for pain medication, she was informed it had not arrived. Resident #3 revealed she had been hurting so badly the night of admission that she cried. Resident #3 stated her pain was 10 out of 10. Resident #3 revealed she was not offered any other pain medication such as Tylenol and was unable to recall if she had asked.During an interview on 05/06/2026 at 2:04 p.m. with S3 LPN revealed Resident #3 arrived to the facility by ambulance from the hospital on [DATE] between 6:00-6:30 p.m. S3 LPN revealed Resident #3 had a fractured Left Femur and Right Wrist which required surgical intervention. S3 LPN revealed Resident #3 had pain 6/10 on a pain scale of 1-10 upon arrival to the facility. S3 LPN further revealed Resident #3 continued to complain of pain to left leg and she provided comfort measures of repositioning and pillows, which did not relieve Resident #3's pain. S3 LPN confirmed she did not call Resident #3's physician to report Resident #3 had pain, but should have.During a telephone interview on 05/07/2026 at 10:27 a.m. S9 NP revealed he had not been notified of Resident #3's pain. S9 NP stated if had been notified, he would have ordered pain medication such as Tylenol to be administered until pain medications were available.During an interview on 05/11/2026 at 8:24 a.m. S1 Administrator, S2 Corporate Nurse and S4 DON confirmed the physician was not notified of Resident #3's pain but should have been.

Based on interviews and record review, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, and the comprehensive person-centered care plan, for 1 (Resident #3) of 4 residents reviewed for pain.This deficient practice resulted in an actual harm for Resident #3 on 04/02/2026 at 6:23 p.m., when the resident was admitted with an order for Hydrocodone 10/325 MG every 6 hours as needed for pain, and did not receive any pain medication. Resident #3 had diagnoses of status post ORIF to Left Femur fracture on 03/25/2026 and, ORIF of Right Wrist fracture on 03/25/2026 and pain. Resident #3 who complained of leg pain that hurt so bad it caused her to cry, stated the facility had not acquired her pain medication from the pharmacy, and her pain level was 10 out of 10 on a pain scale, indicating very severe pain, during that time. Findings:Review of a facility policy titled Pain Management with a review date of 12/17/2023 revealed in part:Policy: The facility shall provide adequate management of pain to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being .1. Evaluate the resident for pain upon admission and with change in condition or status .2. Behavioral signs and symptoms that may suggest the presence of pain include but are not limited to .K. Sighing, groaning, crying, and breathing heavily .4. If the resident's pain is not controlled by the current treatment regimen, the practitioner should be notified.Review of Resident #3's medical record revealed an admit date of 04/02/2026 with diagnoses that included in part.Pain, Generalized Anxiety Disorder, Fracture of lower end of Left Femur and Fracture of Right Wrist both requiring surgical intervention on 03/25/2026, Hypertension, and Morbid Obesity. Review of Resident #3's 5 day MDS with an ARD of 04/09/2026 revealed Resident #3 had a BIMS score of 15 (which indicated intact cognition), and the resident understands and has the ability to understand others. The MDS revealed Resident #3 was coded as requiring set up or clean-up assistance with eating, dependent for toileting, substantial/maximal assistance with shower/bath, and turning/repositioning. The MDS revealed Resident #3 had lower extremity impairment on one side. The MDS revealed Resident #3 had the presence of pain, pain intensity rating scale =10, worst pain you can imagine, at the time of assessment and received PRN pain medications.Review of Resident #3's Care Plan with a target date of 07/19/2026 revealed the resident has a Potential for Alteration in Comfort related to Femur fracture, Coronary Artery Disease, Hypertension, Hyperlipidemia, Obesity, Anxiety, Hypokalemia, and a history of Edema, with interventions that included: Anticipate the resident's need for pain relief, Medications as ordered, Notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain, reposition PRN for comfort.Review of a Nursing Progress note dated 04/02/2026 at 6:23 p.m. read in part.Resident arrived to facility via ambulance service via stretcher in stable condition from hospital with diagnoses: S/P ORIF (Open Reduction and Internal Fixation-a surgical procedure) to both Left Femur and Right Wrist on 03/25/2026. Resident notes to have pain 6/10. Resident had a fall on 03/23/2026 (before admission into the facility). Resident is non-weight bearing. Resident #3 requested to be transferred to the hospital because of pain medication having not arrived from pharmacy, called ambulance services for transportation, resident made aware, also called after hours pharmacy and canceled request for medications to be filled.During an interview on 05/05/2026 at 10:44 a.m. Resident #3 revealed when she arrived at the facility via ambulance on 04/02/2026 between 6:00-6:30 p.m. she was hurting pretty bad. Resident stated she had a fall in late March 2026 and fractured her Right Wrist and Left Femur. Resident #3 revealed she had surgery to her wrist and leg and was non-weight bearing. Resident #3 revealed upon admission into the facility she went a whole day without her pain medication. Resident #3 revealed when she asked S3 LPN for pain medication, she was informed it had not arrived. Resident #3 revealed she had been hurting so badly she cried on her first night at the facility and asked to be sent to the hospital to receive pain medication. Resident #3 stated her pain was a 10 out of 10, during the night of 04/02/2026. Resident #3 revealed she was not offered nor administered any medications to manage her pain on the night of 04/02/2026. Review of Resident #3's 04/2026 Physician's Orders revealed in part.Hydrocodone-Acetaminophen Oral Tablet 10-325 Milligram-Give 1 tablet by mouth every 6 hours as needed for pain (start date 04/02/2026). Review of Resident #3's Medication Administration Record revealed in part.04/03/2026 at 1:27 p.m. Hydrocodone-Acetaminophen Oral Tablet 10-325 Milligram-Give 1 tablet by mouth every 6 hours as needed for pain. Pain level 8, very severe pain. Medication initialed as administered by S5 LPN. During an interview on 05/05/2026 at 10:50 a.m. S4 DON revealed Resident #3 had admitted to the facility with diagnoses of Left Femur Fracture and Right Wrist Fracture. S4 DON revealed Resident #3 was non-weight bearing and had staples to the Left Femur Fracture. S4 DON revealed while making rounds on 04/03/2026 between 6:00-6:30 a.m. Resident #3 had complained of Pain to her Wrist (unable to recall pain level). S4 DON revealed she had inquired with nursing staff regarding Resident #3's pain medication, but had not notified the physician of Resident #3's pain. During an interview on 05/06/2026 at 2:04 p.m. S3 LPN revealed Resident #3 arrived to the facility by ambulance from the hospital on [DATE] between 6:00-6:30 p.m. S3 LPN revealed Resident #3 had a fractured Left Femur and Right Wrist which required surgical interventions. S3 LPN revealed upon arrival Resident #3 had pain 6/10 on a pain scale of 1-10. S3 LPN stated Resident #3's pain medication had already been ordered from the pharmacy. S3 LPN revealed Resident #3 continued to complain of pain to left leg and she provided comfort measures of repositioning and pillows. S3 LPN revealed on 04/03/2026 at approximately 2:00 a.m. Resident #3 and her family requested to send her to the ER for pain medication. S3 LPN revealed she notified the ambulance to transport Resident #3 to the hospital. S3 LPN revealed when the ambulance arrived Resident #3 refused to go. S3 LPN confirmed she did not call Resident #3's physician to report Resident #3 had increased pain and had requested to go to the hospital for pain management, but should have.Telephone interview on 05/07/2026 at 9:47 a.m. with S6 CNA revealed she provided care for Resident #3 on 04/02/2026-04/03/2026 on the 7:00 p.m.-7:00 a.m. shift. S6 CNA stated when she arrived to work on 04/02/2026 at 7:00 p.m. and made rounds, Resident #3 was complaining of everything, but mainly of her leg hurting. S6 CNA revealed she observed S3 LPN attempting to make Resident #3 comfortable by repositioning and pillows, but she continued to complain of pain. S6 CNA revealed Resident #3 didn't want to be moved because she was hurting and had cried all night.Telephone interview on 05/07/2026 at 10:30 a.m. with S7 CNA revealed she provided care for Resident #3 on 04/03/2026 on the 7:00 a.m.-7:00 p.m. shift. S7 CNA revealed Resident #3 stated she was in a lot of pain, and she had staples in her leg. S7 CNA revealed Resident #3 had complained of not receiving her pain medication during the night. During an interview on 05/07/2026 at 2:45 p.m. S5 LPN revealed she provided care for Resident #3 on 04/03/2026 on the 7:00 a.m. to 7:00 p.m. shift. S5 LPN revealed she had received report on Resident #3 from the night nurse S3 LPN. S5 LPN revealed she was made aware of Resident #3's pain. Telephone interview on 05/07/2026 at 10:27 a.m. with S9 NP revealed he had not been notified of Resident #3's increased pain. S9 NP stated if he had been notified, he would have ordered pain medication such as Tylenol to be administered until her pain medications were available.During an interview on 05/11/2026 at 8:24 a.m. S1 Administrator, S2 Corporate Nurse and S4 DON confirmed the physician should have been notified of Resident #3's increased pain and he had not been. S2 Corporate Nurse confirmed Resident #3 had not been administered anything for pain since 04/02/2026 at 1:50 p.m. when she left the hospital until 04/03/2026 when S5 LPN administered Tylenol at 1:15 p.m.

Based on interview and record review the facility failed to make a prompt effort to resolve grievances filed by a resident's representative, for 1 (Resident #3) of 4 sampled residents. Findings:Review of the facility's policy titled Grievances/Missing Property, with a review date of 08/2017, revealed in part.Policy: Residents and resident representatives have the right to voice concerns or grievances, which affect their lives at this facility, without fear or discrimination or reprisal.Purpose: To provide an opportunity for residents, resident representatives, and/or family to present concerns or grievances of the proper authorities at the facility and to receive responses to the issues raised.Responsibility: All staff, monitored by Department Heads, Executive Director and Grievance Official.Section 504 Grievance Procedure:1. A grievance is to be in writing on the Grievance Form, contain the name and address of the person filing it, and briefly describe the action alleged to be prohibited by the regulations.3. The Coordinator, or his/her designee, shall conduct such investigation of a grievance as may be appropriate to determine its validity. The investigation shall afford all interested persons and their representatives, if any, an opportunity to submit evidence related to the grievance.Review of Resident #3's medical record revealed an admit date of 04/02/2026 with diagnoses that included in part.Pain, Generalized Anxiety Disorder, Fracture of lower end of Left Femur, Hypertension, Morbid obesity, and Fracture of Right Wrist.Review of Resident #3's 5 day MDS with an ARD of 04/09/2025 revealed Resident #3 had a BIMS score of 15 ( which indicated intact cognition), and the resident understands and has the ability to understand others. The MDS revealed Resident #3 was coded as requiring set up or clean-up assistance with eating, dependent for toileting, substantial/maximal assistance with shower/bath, and turning/repositioning. The MDS revealed Resident #3 had lower extremity impairment on one side. The MDS revealed Resident #3 had the presence of pain, pain intensity rating scale =10 at the time of assessment and received PRN pain medications.Interview with Resident #3 on 05/05/2026 at 10:48 a.m. revealed when she admitted to the facility on [DATE], she didn't have any pain medications available for almost 24 hours, had been served raw chicken and had been spoken to rudely by S5 LPN. Resident #3 stated she had told her daughter about these issues.Telephone interview on 05/05/2026 at 3:29 p.m. with Resident #3's daughter stated the following: Her mother had been admitted to the facility on [DATE] with a broken leg and wrist and did not receive pain medication until the afternoon of 04/03/2026; Resident #3 had been served raw chicken; S5 LPN had spoken rudely to Resident #3; and Resident #3's hair was not being washed. Resident #3's daughter stated she had complained to S4 DON a few days after Resident #3 was admitted (couldn't recall exact date) about the above issues and again on 04/17/2026 related to S5 LPN speaking rudely to Resident #3, and about Resident #3's hair not being washed. Resident #3's daughter stated S4 DON told her to be patient.Interview on 05/11/2026 at 8:20 a.m. with S4 DON revealed she had spoken to Resident #3's daughter on 2 separate occasions on the phone. S4 DON stated Resident #3's daughter had concerns related to Resident #3 wanted her hair washed more frequently, undercooked chicken, S5 LPN speaking to Resident #3 rudely, and Resident #3's pain medications not being available upon admission. S4 DON revealed she did speak to Resident #3's daughter a second time over the phone on 04/17/2026 but couldn't understand what she was saying because of the poor phone connection.Interview on 05/11/2026 at 8:24 a.m. with S1 Administrator, S2 Corporate Nurse, and S4 DON revealed S1 Administrator was the Grievance Official. S1 Administrator revealed the above mentioned complaints from Resident #3's daughter were not brought to her attention. S4 DON confirmed she did not do a grievance on the above mentioned complaints from Resident #3's daughter because she thought she had taken care of the issues. S4 DON confirmed Resident #3's daughter had complained a second time on 04/17/2026 and she had not followed up with Resident #3's daughter, but should have. S1 Administrator confirmed a grievance should have been completed on the above mentioned complaints and had not been.

Based on record review and interview, the facility failed to ensure a copy of the written notice of discharge was sent to the Office of the State Long-Term Care Ombudsman for Resident 1 (#1) of 1 residents reviewed for facility-initiated discharge.Findings:Record review of the facility's undated policy regarding Subject: Discharge and Transfer Policy read in part.Procedure: 2. Documentation will be entered into the resident's medical records regarding the transfer/discharge reason(s) and the appropriate transfer/discharge information will be communicated to the receiving healthcare center, provider, resident and/or Resident Representative.a. Documentation includes: 14. Prior to resident being transferred or discharged , the facility must provide a written notice (B.3 (a) or State Required Form) to the resident, and if known, a family member or legal representative of the resident and the LTC ombudsman. This must be issued at least 30 days before the resident is transferred to discharge or as soon as practicable for immediate transfer or the resident has not resided in the facility for 30 days.Review of Resident #1's medical record revealed she was admitted on [DATE] with primary admission diagnosis of Acute and Chronic Respiratory Failure with hypoxia. Review of Resident #1's discharge summary indicated the resident was discharged on 03/23/2026.Review of Ombudsman Notification log for March 2026 failed to reveal that the Ombudsman was notified that Resident #1 was discharged from the facility. During an interview on 05/06/2026 10:46 a.m. with S10 LPN she stated, I have not done it at all, I have not reported discharges to the Ombudsman since August 2025. S10 LPN confirmed she was responsible for submitting the Notification log to the Ombudsman for the facility.In an interview on 05/06/2026 at 4:25 p.m., S1 Administrator confirmed, We don't provide 30-day notices to the Ombudsman. S1 Administrator acknowledged the facility had not provided documentation that the resident's discharge was reported to the Office of the State Long-Term Care Ombudsman as required.

Based on observation, interview and record review, the facility failed to provide care and services that met professional standards of quality by failing to ensure medications were accurately documented on the TAR (Treatment Administration Record) for 1 (Resident #4) of 7 sampled residents. The facility had a total census of 73 residents according to the Resident List Report provided by the facility.Findings:Review of the facility's policy and procedure titled Medication Administration with a review date of 03/01/2026 read in part.Guideline: 14. Document as each medication is prepared on the MAR (Medication Administration Record). 18. If medication is not given as ordered, document the reason on the MAR.Review of Resident #4's medical record revealed an admission date of 04/08/2024 with a re-entry date of 09/24/2024 with diagnoses that included in part, Depression, Pressure Ulcer of Sacral Region, Stage 4, Paraplegia, Presence of Urogenital Implants, and Neuromuscular Dysfunction of Bladder.Review of Resident #4's Quarterly MDS with an ARD of 02/17/2026 revealed a BIMs summary score of 15, indicating intact cognition. Resident #4 had an indwelling urinary catheter.Review of Resident #4's 01/2026 Physician Orders revealed in part.Clindamycin Phosphate External Solution 1% Topical: Apply to penial erosion site topically two times a day for Infection for 14 days (start date: 01/26/2026, completion date: 02/09/2026).Review Resident #4's Nurse Practitioner's (NP) Progress note revealed in part.01/24/2026 Nursing staff reports patient with wound to penis. Start Clindamycin 1% ointment to affected site twice daily x 14 days. Signed by S5 NP.Review of Resident #4's January 2026-February 2026 TAR revealed missed documentation of the 6:00 p.m. dose of Clindamycin Phosphate External Solution 1% Topical: Apply to penial erosion site topically two times a day for Infection for 14 days on the following dates: 01/27/2026, 01/28/2026, 01/29/2026, 01/30/2026, 01/31/2026, 02/01/2026, 02/03/2026, 02/05/2026, 02/06/2026, 02/07/2026, and 02/08/2026.In an interview on 03/17/2026 at 10:52 a.m., S3 DON reviewed Resident #4's 01/2026 and 02/2026 and acknowledged that there was no documentation on the dates listed above. S3 DON confirmed that the nurses should have documented on the TAR after administering Clindamycin 1% topical ointment to Resident #4 but did not. In a telephone interview on 03/17/2026 at 11:05 a.m., S8 LPN stated she remembered Resident #4's order of Clindamycin 1% topical ointment. S8 LPN confirmed that she didn't document on Resident #4's TAR after administering the topical ointment, but should have.

Based on interviews and record reviews, the facility failed to notify the Nurse Practitioner (NP) of a resident's change in condition of an elevated heart rate for 1 (Resident #5) of 7 sampled residents. The facility census was 73.Findings: Review of the facility's policy on 03/18/2026 at 1:44 p.m. titled Notification of a Change in a Resident's Status with a history date of 11/2017, revealed in part.Policy: The attending physician extender (NP) and the resident representative will be notified of a change in a resident's condition, per standards of practice and Federal and/or State regulations. Procedure: 1. Guideline for notification of physician/responsible party: a. significant change in/or unstable vital signs (Pulse). Review of Resident #5's medical record revealed an admission date of 12/15/2025 with diagnoses that included in part, Acute Respiratory Failure, Depression, Urinary Tract Infection, Pressure Ulcer of Left Buttock, Stage 3, and Infection of the Skin and Subcutaneous Tissue. Review of Resident #5's Quarterly MDS with an ARD of 03/15/2026 revealed a BIMs summary score of 8, which indicated moderate intact cognition. In an interview on 03/18/2026 at 12:20 p.m., S7 LPN revealed during her morning medication pass Resident #5's heart rate was elevated between 130-137 beats per minute. S7 LPN stated this was a new change in condition for Resident #5. S7 LPN stated Resident #5's heart rate remained elevated throughout her shift. S7 LPN stated she asked Resident #5 and her husband if they would like to go to the hospital, but they both declined. S7 LPN stated even if a resident refuses to be sent to the hospital, she is still required to notify the physician or NP of the change in condition. S7 LPN confirmed she did not notify the NP of the change in Resident #5's heart rate, but should have. In a telephone interview on 03/18/2026 at 2:49 p.m., S5 NP revealed that he expects to be notified by nursing home staff anytime there is a change from baseline in a resident's condition. S5 NP revealed he had no notification regarding Resident #5's elevated heart rate from the facility nursing staff. S5 NP confirmed that S7 LPN should have notified him of Resident #5's elevated heart rate. In an interview on 03/18/2026 at 2:24 p.m., S3 DON revealed a change in condition is any change in vital signs such as increased heart rate. S3 DON confirmed if there is a change in condition for any resident and they refuse treatment, the physician or NP still must be notified and made aware. S3 DON confirmed S7 LPN should have notified the NP of Resident #5's elevated heart rate.

Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) registry verification was obtained prior to re-hire for 1 (S9 CNA) of 2 (S9 CNA and S10 CNA) personnel records reviewed.Findings: Review of S9 CNA's personnel record revealed, in part, S9 CNA had an initial hire date of 10/22/2012, a termination date of 04/19/2018, and a re-hire date of 10/10/2018. Further review revealed a CNA registry verification with a date of 10/22/2012. There was no documented evidence, and the facility did not present any documented evidence, a CNA registry verification was obtained prior to re-hire for S9 CNA. In an interview on 03/18/2026 at 11:50 a.m., S1Admin confirmed the facility did not have documented evidence a CNA registry verification was obtained prior to re-hire for S9 CNA as required.

Observation on 03/18/2026 at 8:45 a.m. revealed a form for Daily Nursing Staff Posting dated 03/18/2026 was posted on a bulletin board in the middle of the facility. The resident census at start of shift, daily staffing hours required, or the actual hours worked were not posted on the form.Observation on 03/18/2026 at 8:45 a.m. also revealed a form for Daily Nursing Staff Posting dated 03/17/2026 that did not have resident census at start of shift, daily staffing hours required, or the actual hours worked documented on the forms or updated from the previous day.In an interview on 03/18/2026 at 9:20 a.m. with S4 SDC RN to review 03/17/2026 and 03/18/2026 Daily Nursing Staff Posting forms, S4 SDC RN confirmed the facility did not post the resident census, daily nursing hours required, or the actual nursing hours provided.S4 SDC RN confirmed that she had always posted the forms without the required information but should not have.

Review of the facility's policy titled Enhanced Barrier Precautions with a review date of 03/01/2026 revealed in part, Enhanced Barrier Precautions (EBP) is an approach of gown and glove use during high contact resident care activities.Examples of high contact resident care activities.wound care.Review of Resident #2's record revealed in part an admit date of 09/03/2025, a primary diagnosis of Acute Respiratory Failure with Hypoxia, an order dated 09/19/2025 for Enhanced Barrier Precautions, and a Care Plan item dated 09/15/2025 for enhanced barrier precautions.Observation on 03/16/20026 at 2:25 p.m. of Resident #2's wound care by S6 TXRN revealed that S6 TXRN failed to follow EBP protocol. S6 TXRN did not wear a gown and change her gloves between cleaning and applying ointments and powder to the wounds for Resident #2.Review of Resident #3's record revealed in part an admit date of 07/02/2024, a primary diagnosis of Restless Legs Syndrome, an order dated 11/19/2024 for Enhanced Barrier Precautions, and a Care Plan item dated 03/05/2025 for enhanced barrier precautions.Observation on 03/16/2026 at 2:45 p.m. of Resident #3's wound care by S6 TXRN revealed that S6 TXRN failed to follow EBP protocol. S6 TXRN did not wear a gown and change her gloves between cleaning and redressing the wound for Resident #3.Interview on 3/16/2026 at 3:15 a.m. with S2 CorpRN revealed that:EBP procedures require direct care staff to wear a gown and gloves during wound care.S2 CorpRN also confirmed that:S6 TXRN should have worn a gown and changed her gloves after cleaning a wound and before applying clean dressings or ointments to that wound per facility policy.

Based on interviews and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 (Resident #2 and Resident #3) of 3 sampled residents.Findings: Resident #2 Review of the facility's Incident Report revealed Resident #2 had Unwitnessed Fall Incidents on 11/14/2025 and 11/25/2025. Review of Resident #2's EMR revealed an admission date of 08/04/2025 with diagnoses including Seizures, Personal History of Traumatic Brain Injury, Dementia with Behavioral Disturbance, and Delirium. Review of Resident #2's Medicare 5 day MDS with ARD of 11/29/2025 revealed Resident #2 did not have a fall any time in the last month. Review of Resident #2's Discharge - Return Anticipated MDS with ARD of 11/18/2025 revealed the resident did not have any falls since the prior assessment. Resident #2 was not receiving antipsychotic medication. Review of Resident #2's Quarterly MDS with ARD of 11/11/2025 revealed Resident #2 was not receiving antipsychotic medication. Review of Resident #2's Physician's Orders revealed the following, in part. Rexulti 2mg po Q day for Dementia with Behavioral Disturbance, ordered 10/22/2025, and discontinued on 11/12/2025; and Rexulti 1mg po Q day for Dementia with Behavioral Disturbance, ordered 11/13/2025, and discontinued 11/18/2025. Resident #3 Review of Resident #3's EMR revealed an admission date of 06/14/2024 with diagnoses including Parkinson's Disease with Dyskinesia. Review of Resident #3's Quarterly MDS with ARD of 09/30/2025 revealed a BIMS score of 3, indicating severely impaired cognition. Resident #3 required supervision/touching assistance with transfers and was occasionally incontinent. Resident #3 had one fall without injury since the prior assessment, an Annual MDS with ARD of 07/01/2025. Review of Resident #3's care plan revealed the following, in part.Resident #3 had a fall with injury on 07/07/2025, and a fall without injury on 09/29/2025. Interview with S11MDS on 12/10/2025 at 1:26 p.m. confirmed Resident #2's MDS Assessments with ARDs of 11/29/2025, 11/18/2025, and 11/11/2025 did not accurately reflect the resident's status, but should have. S11MDS confirmed Resident #3's Quarterly MDS with ARD of 09/30/2025 did not accurately reflect the resident's status, but should have.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident #1) of 3 sampled residents. Findings: Review of Resident #1's EMR revealed an admission date of 03/19/2024 with diagnoses including Anoxic Brain Damage, Cardiac Arrest due to Other Underlying Condition, and Personal History of Other Venous Thrombosis and Embolism. Review of Resident #1's Quarterly MDS with an ARD of 09/16/2025 revealed a BIMS score of 15, indicating intact cognition. Review of Resident #1's Physician's Orders revealed the following, in part.Apixiban 5mg po BID for History of Deep Vein Thrombosis, dated 10/17/2025. Review of Resident #1's Care Plan revealed Resident #1 was not care planned for anticoagulant therapy. Interview with S7LPN on 12/10/2025 at 10:10 a.m. revealed a resident receiving anticoagulant therapy should have been care planned for anticoagulant therapy. Interview with S11MDS on 12/10/2025 at 1:26 p.m. confirmed Resident #1 should have been care planned for anticoagulant therapy, but was not.

Based on observations, record review, and interviews the facility failed to develop and implement a person-centered care plan for each resident to maintain the resident's highest practicable physical, mental, and psychosical well-being. The facility failed to: 1. Ensure staff placed, connected, and ensured proper functioning of Resident #122's bed alarm, as ordered; 2. Develop a comprehensive person-centered care plan for Resident #19; and Resident #30 There were 29 sampled residents. Findings: Resident #122 Review of Resident #122's medical record revealed an admit date of 05/22/2025 with diagnoses including Quadriplegia, Seizures, Generalized Anxiety Disorder, and Attention to Gastrostomy (PEG tube.) Observation and interview with Resident #122 on 06/02/2025 at 09:40 a.m. found resident's bed against the wall with the fall mat on the open side. Bed observed in low position. Detached bed alarm control box was noted hanging on bed frame. There were no wires observed connected to the bed alarm box. Geri chair noted at bedside reclined with bed alarm mat in seat of chair. Resident #122 did have a call light but stated she didn't know where it was and just calls out for assistance. Resident #122 stated she had previously fallen, but could not recall when. In an observation on 06/03/2025 at 08:30 a.m. Resident #122 was asleep in bed. Fall matt is on the open side of the bed with the other side of the bed against the wall. Bed alarm box was still hanging on bed frame with no wires connected. Bed alarm mat remains in Geri chair, not in resident's bed. In an observation on 06/03/2025 at 9:47a.m., Resident #122's bed alarm remained disconnected. Facility staff were observed removing bed alarm mat from Geri chair and leaving alarm box connected to bed frame with no wires connected to bed alarm control box. On 06/04/2025 at 08:45 a.m., Resident #122's bed alarm was observed with S13 CNA. S13 CNA confirmed bed alarm pad was not on the bed. S13 CNA could not find bed alarm mat and went to supplies to get another mat and alarm for resident's bed. Review of Current Physician Orders for Resident #122 revealed the following order: 06/02/2025 at 7:00 p.m.: Bed alarm to bed. Monitor for proper placement and batteries every shift, every day and night shift for fall risk. In an interview on 06/04/2025 at 10:05 a.m., S2 DON confirmed that Resident #122 should have had a functioning bed alarm in place as ordered. Resident #30 Review of a facility policy titled Smoking, with a revised date of 05/22 revealed the following in part, Policy: No smoking or use of smoking materials will be allowed inside the building or in facility vehicles. This includes all e-cigarette devices. Smoking is to occur only in designated areas and in accordance with each smoking resident's individualized plan of care based on the Smoking Evaluation Tool. Review of Resident #30's medical record revealed an admit date of 07/02/2024 with diagnoses that included in part: Metabolic Encephalopathy, Insomnia, Alcohol Abuse, and Cytomegaloviral Disease. Review of Resident #30's Quarterly MDS with an ARD of 07/09/2025 revealed a BIMS score of 15, which indicated intact cognition. On 06/03/2025 at 10:34 a.m., review of Resident #30's Smoking Evaluation Tool dated 03/04/2025 revealed Resident #30 smoked cigarettes. On 06/03/2025 at 10:42 a.m., review of Resident #30's care plan with a target date of 07/03/2025 revealed Resident #30 was not care planned for smoking. On 06/03/2025 at 11:07 a.m. Resident #30's care plan was reviewed together with S4 MDS LPN who stated she is responsible for the development and implementation of resident care plans. S4 MDS revealed that all smokers should be care planned for smoking. S4 MDS LPN confirmed she should have developed and implemented a care plan for Resident #30 being a smoker but had not. Resident #19 A review of facility policy titled, Comprehensive Centered Care Plans with a revision date of 01/2025 revealed in part . Policy: Each resident will have a person- centered care plan to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Responsibility: All members of the Interdisciplinary Team monitored by the Executive Director . Procedure: The Comprehensive Person- Centered Care Plan shall be fully developed within 7 days after completion of the admission MDS Assessment . A review of Resident # 19's medical record revealed an admission date of 04/30/2025 with diagnoses that included Schizophrenia, Anxiety Disorder, Alcoholic Hepatic Failure without come, Alcohol induced Acute Pancreatitis without necrosis or infection, Alcoholic Cirrhosis of liver without ascites, Depression, Chronic Obstructive Pulmonary Disease, Esophageal Varices with bleeding, and Anemia in other chronic diseases classified elsewhere. Review of Resident #19's Annual Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 05/07/2025, revealed Resident #19 had a BIMS score of 15, which indicated intact cognition. On 06/02/2025 at 11:30 a.m. review of Resident #19's care plan revealed only one care plan area with generalized interventions. Resident #19's entire care plan revealed one care area of general disease management with interventions that included: Resident #19 will be up to date on all immunizations, administer necessary immunizations unless contraindicated or allergic per provider order, alert provider of any condition alerts identified during resident evaluations, if resident is determined to be at risk, initiate plan to minimize risk, obtain immunization history, perform clinical admission evaluation, perform risk evaluations, perform scheduled clinical evaluations per facility's protocol. On 06/03/2025 at 09:50 a.m. Resident #19's care plan was reviewed with S4 MDS LPN. S4 MDS LPN confirmed the facility did not develop and implement a comprehensive person-centered care plan for Resident #19 in a timely manner and should have.

Based on interview and record review the facility failed to ensure a resident's right to be free from resident to resident physical abuse, for 1 (Resident #5) of 7 (Resident #1, Resident #2, Resident #3 Resident #4, Resident #5, Resident #6, and Resident #7) sampled residents. This deficient practice resulted in an Actual Harm for Resident #5 on 02/05/2024 at 2:20 p.m., when Resident #6 hit Resident #5 in the left eye two times with a closed fist. Resident #5 received first-aid treatment in the facility for multiple abrasions and bruising to the face. Resident #5 was sent to a local emergency department where he received treatment for a left periorbital/facial contusion. Findings: Review of the facility policy titled Abuse Prevention revealed in part . The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, friends, visitors, or any other individual. Abuse defined: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse may be resident to resident, staff to resident, family to resident, or visitor to resident. Physical Abuse: This includes but is not limited to hitting, slapping, pinching, and kicking. Resident #5 Review of the clinical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses that included in part .Hemiplegia following Cerebral Infarction affecting left non-dominant side, Depressive Episodes, Human Immunodeficiency Virus, Mental Disorder, Chronic Viral Hepatitis C, and Pain Unspecified. Review of Resident #5's Quarterly MDS with an ARD of 01/05/2024, revealed Resident #5 had a BIMS of 14, indicating no cognitive impairment. The MDS revealed Resident #5 required assistance for dressing; and was independent with eating, toileting, hygiene, shower/bath, and toilet transfer. The MDS revealed Resident #5 had impairment in functional range of motion to the upper and lower extremities on one side, and utilized a manual wheelchair for mobility. Review of Resident #5's care plan read in part .Socially inappropriate behavior-Resident calling another resident inappropriate names, attention seeking behavior and paranoia about diseases and disease process, with approaches that included: Re-direct inappropriate behaviors, Notify MD if behavior worsens or escalates, monitor for inappropriate behaviors and address promptly. Review of Resident #5's 24 hour progress note dated 02/06/2024 read in part .Bruise purple/red in color under left eye on cheek bone. Scratch noted to left temple extending to bruise on left cheek bone under eye. Review of an Emergency Department record dated 02/05/2024 at 3:20 p.m., revealed in part .Chief complaint: Left Periorbital/Facial Contusion. Patient with complaints of left periorbital facial swelling and pain. He was punched with a fist by another nursing home resident. Location: face. Review of a Radiology report dated 02/05/2024 read in part . Exam: CT Facial Bones History: Trauma over left eye/altercation and abrasions of face. Impression: Old incompletely united impacted nasal bone fracture. No definite acute facial bone fractures are identified. Review of Resident #5's February 2024 Treatment Record revealed a treatment to cleanse abrasion under left eye with normal saline, pat dry. Apply triple antibiotic ointment and leave open to air daily until healed. Monitor abrasion under left eye for signs and symptoms of infection daily until healed. Resident #6 Review of Resident #6's clinical record revealed an admitted [DATE], with diagnoses that included in part .Unspecified Dementia unspecified severity with other behavioral disturbance, Schizoaffective Disorder, Anxiety Disorder, and Schizoid Personality Disorder. Review of Resident #6's Quarterly MDS with an ARD of 01/11/2024, revealed Resident #6 had a BIMS score of 7, indicating severe cognitive impairment. The MDS revealed Resident #6 required supervision with oral hygiene and bathing; and was independent with eating, personal hygiene, dressing of upper/lower body, and chair/bed-to-chair transfer. Resident #6 had no range of motion limitations to the upper and lower extremities, and utilized a manual wheelchair for mobility. Review of Resident #6's care plan with a target date of 05/04/2024, revealed in part . Resident is a hoarder and has behaviors. Attention seeking behaviors, tells false stories on peers and will lash out on staff/residents with interventions that included: Monitor for inappropriate behaviors and address promptly and re-direct inappropriate behaviors. Review of a facility incident report documented by S2 DON, and dated 02/05/2024, revealed in part . on 02/05/2024 at 2:20 p.m. while out on the smoking deck, Resident #5 and Resident #6 were involved in a resident to resident altercation. Review of the facility's investigation, documented by S1 Administrator, revealed in part . on 02/05/2024 at 2:12 p.m., Resident #5 reported that Resident #6 stood up from his wheelchair and hit Resident #5 on the side of his face. Resident #5 then grabbed Resident #6's face to fend him off. S4 COTA was walking by the door to the smoking deck, and saw Resident #6 and Resident #5 making physical contact with each other. Observation on 02/07/2024 at 11:15 a.m. with Resident #5 revealed he had a left black eye, with periorbital bruising and swelling. Interview on 02/07/2024 at 12:12 p.m. with S1 Administrator, revealed on 02/05/2024 at 2:20 p.m., while on the smoker's deck, Resident #6 stood up from his wheelchair and hit Resident #5 in the face, causing a left black eye. S1 Administrator stated Resident #5 was sent to the emergency room after the resident to resident altercation. Interview with Resident #5 on 02/08/2024 at 8:31 a.m., revealed on 02/05/2024, he was outside on the smoker's patio when Resident #6 kept asking him for a cigarette, but he (Resident #5) didn't have any to give him. Resident #5 stated Resident #6 stood up from his wheelchair and punched him in the eye two times with his fist. Resident #5 stated his eye still hurt. Observation on 02/08/2024 at 8:39 a.m. with Resident #6 revealed he had several superficial scratches to his face. Interview with Resident #6 revealed he did not remember having a fight with another resident a few days ago. Interview on 02/08/2024 at 1:17 P.M. with S4 COTA, revealed on 02/05/2024, he witnessed Resident #6 stand up from his wheelchair and punch Resident #5 two times in the face with his fist. S4 COTA stated he immediately intervened. Interview on 12/12/204 at 1:23 p.m. with S1 Administrator confirmed Resident #5 was a victim of resident to resident physical abuse by Resident #6 on 02/05/2024.

Based on observation, interview and record review, the facility failed to ensure a resident received adequate supervision to prevent accidents for 1(#10) resident reviewed for accidents out of a total of 34 sampled residents. This failed practice resulted in an actual harm situation for resident #10 on 01/11/2022 at approximately 1:50 p.m. when Resident #10, a cognitively impaired resident who resided on the Memory Unit, and required supervision when ambulating, fell when S4CNA and S5TempCNA turned away after standing Resident #10 up from her wheelchair. Resident #10 sustained a laceration above the left eyebrow area with active bleeding. Resident #10 was sent to the emergency room and diagnosed with a left Subdural Hematoma, and received eight sutures to the left forehead. Findings: Observation of Resident #10 on 03/21/2022 from 9:47 a.m. to 11:30 a.m. revealed the resident was seated in a wheelchair, appropriately groomed, and wearing a self-releasing seat belt. Resident #10 was noted to be non-verbal and not attempting to rise from her wheelchair. A healed suture line was noted to the left side of Resident #10's head. Review of Resident #10's clinical record revealed an admitted [DATE], with diagnoses that included: Unspecified Dementia with Behavioral disturbance, Major Depressive Disorder, [CONDITION(S)], [CONDITION(S)], Vitamin Deficiency, Essential Hypertension, Shortness of Breath, Abnormal Weight loss, Generalized Anxiety Disorder, [CONDITION(S)], and Urinary Tract Infection, site not specified. Review of Resident #10's Annual MDS assessment dated [DATE] revealed Resident #10 BIMS Summary Score was not coded. The MDS revealed the following Functional Abilities: bed mobility, transfers, dressing, toileting, personal hygiene, eating, walk in room and in corridor (self-performance and walk support provided) she was coded as not assessed. The MDS further revealed Resident #10 was not steady and only able to stabilize with staff when moving from seated to standing position, walking with assistive devices, and turning around while walking. Review of Resident #10's Quarterly MDS Assessment with an ARD of 12/30/2021 revealed the BIMS Summary Score was left blank, and there was documentation that the resident was rarely/never understood. The MDS revealed the following Functional Abilities: bed mobility, transfers, dressing, toileting, personal hygiene, eating, walk in room and in corridor (self-performance and walk support provided) - coded as not assessed. Further review revealed the following activities did not occur: moving from seated to standing position, walking with assistive devices, and turning around while walking. Review of the Resident #10's Comprehensive Care Plan with a target date of 03/19/2021 revealed a problem of Potential for falls related to wandering and poor safety awareness. The following falls with interventions were implemented: 04/24/2021 - monitor resident when ambulating on unit and room. 08/02/2021 - rolled off the couch onto the floor, encourage resident to sleep in room in bed. 08/03/2021 - stood up from sofa, took a few steps, and lost her balance, falling onto right side, constant visual throughout shift. 01/08/2022 - stood up from wheelchair, lost balance and fell and sustained abrasion above right ear, neuro checks initiated. 01/11/2022 - fall to floor, ensure appropriate footwear, day area free of clutter. 01/20/2022 - self releasing seatbelt to wheelchair, every two hours peri- care and prn. Observe resident for adverse side effects/toxicity of medications in current drug regime. Contact physician with abnormal findings. If receiving behavior-altering drugs, review for possible dosage reduction at least yearly and document findings. Self-releasing seat belt for safety. Self-releasing seat belt was discontinued on 03/21/2022. 03/24/2022 - unsafe ambulation/gait self-releasing seatbelt reapplied. Review of Resident #10's Physical Therapy Plan of Care (Evaluation Only) dated 11/03/2021 revealed Resident #10 was referred for PT assessment to address the current status of being in a wheelchair with restraint present. The PT Evaluation revealed the following: Resident #10 does not require PT intervention at this time due to no significant change from prior level of function. Resident #10 remains ambulatory without assistive device and only requires redirection and close monitoring for safety. Resident #10 has decrease in ability to follow through with task and reduced ability to retain patient education. Further review revealed rehab potential was poor due to Resident #10 remains at a level where Resident #10 is ambulatory without assistive device, PT communicated with staff and nursing regarding PT recommendations for safety without use of multiple restraints, like a pommel cushion with a lap tray. Review of Resident #10's Daily Care Pocket Guide dated 03/23/2022 revealed in part .ambulates AD LIB, ensure appropriate footwear or rubber sole shoes, Fall Risk-ensure clear pathways, resident attempts self- transfers without assistance. Resident to be up in wheelchair, observe for trunk control stability. Further review did not reveal the level of assistance required for Resident #10 during ambulation. Review of Resident #10's Departmental Notes revealed that Resident #10 fell on [DATE] at 7:55 p.m. when she stood up from a wheelchair, lost balance and fell and sustained abrasion above right ear, neuro checks initiated, DON and RP notified. Further review of the Departmental Notes documented by S6 LPN revealed Resident #10 fell again on 01/11/2022 at approximately 1:50 p.m. The note revealed the following: S6LPN was sitting at the desk and heard a noise of verbal excitement. Upon looking up, S6LPN noted CNA was looking downward towards the floor, at which time S6LPN noted Resident #10 was laying left supine on floor. Upon assessment, noted Resident #10 appeared to have fallen, as small puddle of blood had started to form around head area. Noted Resident #10 was attempting to plant her hands on floor and push herself up. Upon closer inspection, noted Resident #10 had a gash above her left eyebrow, bruising and swelling noted to left eye, and small abrasion noted to upper left arm. Slight pressure applied to left eye gash and pressure bandage applied. Resident #10 assisted up and onto sofa. Noted Resident #10 with active range of motion times four as Resident #10 proceeded to try to stand up and attempting to push staff away. No change in level of consciousness noted. Ambulance notified and arrived at 2:18 p.m. Resident #10 out of facility at 2:20 p.m. Responsible party and medical doctor notified. Review of Resident #10's Skin and Wound Evaluation Form dated 01/11/2022 by S6 LPN revealed Laceration above left eyebrow - approximately 0.9 cm by 3.5 cm by 0.4 cm in size. Small abrasion to left upper arm-approximately 0.5 cm by 1.5 cm by 0.2 cm in size. Review of a Radiology Interpretation of CT scan of brain dated 01/11/2022 revealed an Acute Left Subdural Hematoma. Review of a follow-up Radiology Interpretation of CT scan of brain dated 02/08/2022, revealed chronic-appearing Subdural Hematoma with severe brain atrophy, with no interventions needed at this time. Review of the facility's investigation revealed on 01/11/2022 at approximately 2:00 p.m., Resident #10 was seated in her wheelchair on the memory unit in the day area when she stood up and was noticed by S4CNA and S5TempCNA, who were seated approximately three feet away. S4CNA and S5TempCNA decided at that time to encourage Resident #10 to be allowed to be escorted to her room to assess if peri-care was needed. S5TempCNA was to encourage Resident #10 to be escorted to her room while S4CNA remained in the day area, when another resident in the area gained their attention causing S4CNA and S5TempCNA to turn and address that resident. While their backs were turned Resident #10 fell to the floor. Resident #10's fall was not witnessed as S4CNA and S5TempCNA had turned to address another resident and the LPN was seated at the nurses' desk. S6LPN, who was at the nurses' station heard when the resident struck the floor and immediately proceeded to evaluate and administer first aid. Resident #10 had a laceration above the left eye brow area with active bleeding, and an abrasion to the right lateral forearm. Resident #10 was sent out to the hospital for further evaluation per MD order. While at the hospital, Resident #10 received several CT scans of the brain which confirmed a Left Subdural Hematoma, and received eight sutures to the left forehead area. Resident #10 remained in stable condition and was transferred back to the facility on [DATE], with instructions for follow up to include suture removal time frame, and an order for a repeat CT scan of the brain in an outpatient setting. Staff interviews with S6LPN, S4CNA, and S5TempCNA revealed Resident #10 did wander the day area of the memory unit throughout the day with frequent episodes of sitting for a while, then taking short walks and returning to a seated position near her husband, who also resided on the memory unit, with no episode of an unsteady gait. The facility determined that the staff was not negligent in the delivery of care to Resident #10. Review of Resident #10's Departmental Notes dated 02/09/2022 revealed IDT Fall/Safety committee meeting to include therapy, unit managers, and MDS met and discussed Resident #10's fall with head injury and reviewed the safety interventions in place being appropriate interventions to assist with fall prevention and reduction of injury. Resident #10 remains on the memory unit and able to ambulate ad lib with staff monitoring whereabouts for safety. Resident #10 had a repeat CT scan of the brain on 02/08/2022 with no further increase in subdural to warrant intervention. Review of a statement dated 01/11/2022 and written by S4CNA revealed, Resident #10 was up, and about to be walked down to her room to be changed. I, S4CNA, back was turned and I heard her hit the floor. I turned around and she was face down. Interview on 03/21/2022 at 9:50 a.m. with S6LPN revealed Resident #10 fell on [DATE] and fractured her nose, and sustained a small brain bleed. S6LPN stated the physician was monitoring the bleed. Interview on 03/23/2022 at 8:41 a.m. with S8CNA revealed Resident #10 had fallen a couple of times, and was a one person assist changing and turning, and sometimes due to her trembling she required two person assist. S8CNA stated Resident #10 was able to walk, but one person had to hold her hand and be present to prevent falls. S8CNA stated she had been working at the facility for nine months, and during that time, Resident #10 always required someone to guide her during ambulation. S8CNA stated Resident #10 had an unsteady gait. S8CNA stated that the information is in the pocket care guide on what type of assistance is needed for each resident. S8CNA stated she always kept the guide on her. Interview on 03/23/2022 at 8:48 a.m. with S15AgencyRN revealed she usually worked the memory care unit on the night shift. S15AgencyRN stated Resident # 10 was ambulating freely before she sustained a fall in 01/2022 which resulted in a bleed on her brain. S15Agency RN stated when Resident #10 returned from the hospital after the fall she was not walking, and was using a wheelchair with a lap belt. S15AgencyRN stated she just recently noticed that Resident #10 was starting to walk again. She stated when asked about the level of assistance needed for Resident #10, that the information was found in the pocket care guide at the nurses' station. Review of the pocket care guide at this time with S15AgencyRN confirmed it did not indicate the level of assistance required for Resident #10 when she ambulated. S15AgencyRN stated they must not have updated the guide, but she felt Resident #10 should have two people assisting her when ambulating. Interview on 03/23/2022 at 9:31 a.m. with S10TempCNA revealed Resident #10 was a two- person assist with almost everything, but changing while in the bed. S10TempCNA stated that the CNAs were informed during orientation to the memory care unit, of the level of assistance required for Resident #10 and the other residents on the unit. S10TempCNA stated that before Resident #10's fall in 02/2022, whenever Resident #10 got out of her chair, two people were required to escort her during ambulation. S10TempCNA stated the nurses working the memory care unit instructed the CNAs on the level of assistance required for each resident. She confirmed the pocket daily care guide did not indicate that, but she knew what CNAs were required to do for residents from orientation to the unit. Interview on 03/23/22 at 10:04 AM with S2DON revealed every morning the medical records personnel printed out each halls daily pocket care guide for each nurse's station. He stated on Fridays they printed the guide out for the weekend. S2DON stated he and the MDS nurse discussed any care plan updates that needed to be added to the guide each day. S2DON reviewed Resident #10's pocket care guide and agreed it did not provide any guide for assisting her during ambulation. Interview on 03/23/2022 at 10:10 a.m. with S18UnitLPN revealed that before her fall in 01/2022 and currently, Resident #10 required the assistance of two persons when ambulating. S18UnitLPN stated she and all unit managers, and the DON had the capability and responsibility for updating the care plan guides as needed. She stated during the Heart Team meetings the S2DON provided updates and discussions about any changes are occurrences in the last 24 hours. S18UnitLPN stated the updating of the care plans occur during those daily heart meetings. S18UnitLPN stated that the floor nurses have access to change the pocket care guides as needed, but was not sure if they do it or not, but they could also write changes on the hard copy. Interview on 03/23/2022 at 10:36 a.m. with S4CNA revealed she worked on 01/11/2022, and was getting ready to leave for a doctor's appointment. S4CNA stated Resident #10 was sitting in her wheel chair and needed her incontinent brief changed. S4CNA stated it was S5TempCNA's first day on the memory care unit, and she told S5TempCNA they had to walk Resident #10 to her room to change her brief. S4CNA stated she and S5TempCNA stood Resident #10 up from her chair, and S5TempCNA was going to walk Resident #10 to her room. S4CNA stated she had her back to them, looking in her bag, when she heard something that sounded like a fall or someone being hit. S4CNA stated when she turned around she noted Resident #10 had fallen face forward to the floor. S4CNA stated the CNAs were required to have their hands on Resident #10 when guiding her during ambulation. S4CNA stated she always held on to Resident #10's arm by locking her arms through Resident #10's arm, and was told that staff should be physically guiding Resident #10 when ambulating. S4CNA stated the pocket care guide gave instruction of level of care needed for each resident. When S4 CNA was informed that the pocket care guide did not indicate the level of care the CNAs provided for Resident #10 while ambulating, S4CNA stated she was told that staff should be physically guiding Resident #10 when ambulating. During an interview on 03/23/2022 at 11:53 a.m. with S6LPN, she stated she was sitting at the Desk on 01/11/2022 when Resident #10 sustained a fall. S6LPN stated it was S5TempCNA's first day on the memory care unit, and S4CNA and S5TempCNA were making rounds getting Resident #10 ready for incontinent care. S6LPN stated S5TempCNA and S4CNA got Resident # 10 up take her to her room, they both turned their backs to Resident #10 and she fell . S6LPN stated when Resident #10 ambulated, staff was required to hold one of her arms, but depending on Resident #10's balance at the particular time, the assistance may require one staff or two staff. S6LPN stated she and S4CNA had to provide guidance to S5TempCNA on what care was required for Resident #10 and the other residents on the memory care unit. Interview on 03/23/2022 at 12:10 p.m. with S5TempCNA revealed 01/11/2022 was her first day on the memory care unit, and she was being trained by S4CNA. S5TempCNA stated she and S4CNA were getting Resident #10 up for incontinent care when two residents asking to go smoke distracted her (S5TempCNA), and caused her to turn her back on Resident #10. S5TempCNA stated S4CNA also had her back turned from Resident #10 when they heard her fall to the floor. S5TempCNA stated S4CNA was completing her shift, and in the process of determining who was going to continue S5TempCNA's training when the incident occurred. S5TempCNA stated initially she was going to roll Resident #10 in her wheelchair to her room, but S6LPN told her Resident #10 was able to ambulate to her room with assistance. S5TempCNA stated she had only turned her head for a split second when Resident #10 fell . S5TempCNA stated she was very confused about what happened because Resident #10 never took a step before she fell . Interview on 03/23/2022 at 12:35 p.m. with S2DON revealed a Temp CNA was the same as a CNA, but was under guidance of unit manager, charge nurse, or a certified CNA. S2DON stated Resident #10 could stand without assistance and the 11/18/2021 MDS indicated Resident #10 needed assistance with ambulation. S2DON stated staff was to provide Resident #10 with standby assistance, because she had a history of jerking away from staff when they touched her. S2DON stated when Resident #10 fell on [DATE], S4CNA was getting something off the table, and S5TempCNA was speaking to other residents when the fall occurred. Interview on 03/23/2022 at 1:27 p.m. with S2DON revealed Resident #10 sustained a left Subdural Hematoma from the fall on 01/11/2022. S2DON stated that the CNAs caring for Resident #10 should have their eyes on her at all times, while she was ambulating. Interview on 03/24/22 at 9:25 a.m. with S29PT revealed she did not keep copies of any resident physical therapy screenings, but sent them to the DON to place in the resident records. S29 PT stated she was only aware of Resident #10 sustaining one other fall before 01/11/2022. S29 PT stated there were no PT screenings for Resident #10 after her 01/11/2022 fall. Interview on 03/24/2022 at 10:55 a.m. with S8TempCNA and S10TempCNA revealed that since they both started working at the facility around six months ago, Resident #10 seldom tried to ambulate on her own, but had always required staff to have their hands and eyes on her doing ambulation. S8TempCNA and S10TempCNA stated the nurse on the memory unit provided guidance on the assistance needed for ADL care for Resident #10 and the other residents on the memory unit.

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistive devices to prevent accidents for 1 (#46) of 16 residents reviewed for accidents; and failed to ensure the environment remained as free of accident hazards as possible for 13 sampled residents (#8, #14, #15, #31, #42, #43, #56, #59, #60, #76, #69, #47 and #36) and 1 random sampled resident (#R1). The facility failed to: 1. Ensure that a resident (#46), who was diagnosed with [REDACTED]. On 4/2/18 the resident drank hot tomato soup from a sippy cup with a snap-on lid, that had been heated in a microwave. The lid to the sippy cup came partially off causing the hot liquid to spill onto the resident's left breast and left abdomen, resulting in 2nd [MEDICAL CONDITION] the areas. The resident was evaluated and treated at the ER. This failed practice caused or is likely to cause serious injury, harm or impairment to a resident. The Immediate Jeopardy began on 4/2/18 at 6:15 p.m. when resident was given a sippy cup and spilled her hot tomato soup on herself, and was removed at 8:00 p.m. when she was transported to the E.R. The facility implemented corrective actions which were completed prior to the resident's return to the facility on [DATE], and prior to the State Agency's investigation, thus it was determined to be a past Noncompliance. The S1 Administrator was notified of the Past Noncompliance IJ on 4/10/18 at 3:20 p.m. 2. Ensure hot water temperatures did not exceed 120 degrees (F) for 3 of 4 halls in the facility. This failed practice resulted in and Immediate Jeopardy which began on 4/9/18 at 11:30 a.m. when water temperatures on the Alzheimer's Unit were discovered to be 138 degrees (F) in one of the Units two hall bathrooms/showers, and 130 degrees (F) in the second hall bathroom/shower. There were 8 (#8, #14, #56, #15, #60, #42, #43 and #76) residents on the unit determined by the facility to be cognitively impaired, identified as able to enter the bathrooms independently without staff present, and not able to regulate water temperatures The S1 Administrator was notified of the Immediate Jeopardy on 4/9/18 at 5:10 p.m. The Immediate Jeopardy was removed on 4/9/18 at 5:50 p.m. when the facility provided a Plan of Removal which included: a. All staff will be immediately notified to not use water on A Hall, B Hall and C Hall until further notice. b. A-Hall hot water heater was drained and allowed to refill. B-Hall and C-Hall hot water heater will be drained immediately. c. Professional has been called in to assess the cause of problem and make any repairs necessary to correct the issue. d. Water temperatures will be monitored every 30 minutes until the temperature remains no more than 120 degrees consistently x 2 hours then every 1 hour x 4 hours. The ED and Maintenance personnel will monitor throughout the night. e. Maintenance personnel will be educated on monitoring hot water and acceptable parameters of no more than 120 degrees. Findings: Resident #46 Review of the resident #46's Face Sheet revealed an admitted [DATE] and [DIAGNOSES REDACTED]. Review of the resident's Admission/Readmission form dated 5/31/17 revealed the resident fed herself with staff to assist with set up. Review of the resident's Quarterly MDS with an ARD of 2/21/18 revealed the following: The resident was coded to have a BIMS of 12. Review of the resident's Functional Status revealed the following: Eating - resident coded as 1 for supervision and coded as 1 for set up help only. Review of the resident's Comprehensive Plan of Care revealed a problem of Requires Extensive Assist with ADLs due to Contractures of Hands with a goal date of 6/6/18. Approaches included to assist with feedings. Review of the resident's (MONTH) (YEAR) Nurses Notes revealed the following: 7/20/17 at 1:26 p.m. - Summoned to resident's room at approximately. 8:30 a.m. per respiratory therapy, resident noted to have tomato soup on chest/gown/bed/side. Assessment revealed 4 burn areas with fluid filled blisters located to following areas: #1 - 6.3 x 4.5 center of chest; #2 - 2 x 6 right chest; #3 - 2.5 x 6 right, and #4 - 3 x 18.5 right rib cage to hip. Resident communicated to staff while eating her soup she lost grip of cup and it spilled on her. The note further revealed the resident's MD was notified and [MEDICATION NAME] was ordered. Interview on 4/9/18 at 12:55 p.m. with S2 DON revealed the resident's doctor assessed the resident on 7/24/17 and documented 1st & 2nd [MEDICAL CONDITION] the right side of her body. S2 DON stated after the 7/20/17 incident the resident's bowl of soup was changed to a sippy cup with snap on lid, and the resident & the resident's dad were both encouraged to let staff assist with the soup or monitor her during the soup intake. S2 DON stated they both refused and wanted her to have her independence. Further interview of S2 DON on the above date and time revealed other interventions were implemented after the 1st burn incident and included: -No reheating of soup. -Dietary to heat soup in microwave and place in sippy cup. -Staff to assist resident, but resident refused and the resident's dad also stated to continue letting the resident keep her independence as much as possible. Further interview on 4/9/18 at 1:00 p.m. with S2 DON revealed the resident had no further spills [MEDICAL CONDITION] hot liquid until a 2nd incident of spilling tomato soup to the left side of her body occurred on 4/2/18, which caused 2nd [MEDICAL CONDITION] the resident's left breast and left abdomen when the sippy cup lid that snapped on became loose. S2 DON also verified the facility had no documented temps of the resident's soup until 4/3/18 (after the resident's 2nd incident with spilled soup). Review of the facility's investigation report dated 4/2/18 revealed resident #46 was found in bed per CNAs with soup spilled on her chest and found to have blisters beginning to form. The resident was sent to the emergency room for evaluation and treatment. Review of the resident's ER Record dated 4/2/18 revealed the resident was transported per ambulance to the hospital for evaluation and treatment of [REDACTED]. The resident was assessed at the ER at 8:19 p.m. and diagnosed with [REDACTED]. The resident was treated with [MEDICATION NAME] and returned back to the nursing home on 4/3/18 at 7:10 a.m. Review of the resident's Telephone orders revealed: 4/9/18 (No time indicated) - Resident soup is not to be over 100 degrees. Review of the resident's (MONTH) & (MONTH) (YEAR) Nurses Notes revealed: 4/9/18 4:33 p.m. - Nursing reported new diet order per MD - all liquids to be served at 100 degrees. 4/3/18 7:10 a.m. - Resident RTF with [DIAGNOSES REDACTED]. 4/2/18 7:18 p.m. Resident found to be very lethargic with tomato juice spilled on her, NP & RP notified. Resident transported to hospital for evaluation. Interview on 4/9/18 at 1:30 p.m. with S1 Administrator revealed she was working in the kitchen on 4/2/18 (day of the resident's 2nd burn incident) where the resident's soup was being heated and after 2 ½ minutes she stopped the microwave containing the resident's tomato soup and estimated the temp of the tomato soup to be approximately 120 to 123 degrees Fahrenheit. Interview on 4/9/18 at 3:05 p.m. with S14 RT revealed around 6:00 p.m. on 4/2/18 she was checking on the resident and noticed tomato soup had spilled on her comforter. She stated the resident did not report any complaints of pain to her at that time. S14 RT stated she informed S15 CNA and S16 CNA, who were on duty. Interview on 4/9/18 at 3:15 p.m. with S15 CNA and S16 CNA revealed they were informed at the same time by S14 RT on 4/2/18 between 6:00 p.m. and 6:15 p.m. that the resident had spilled her soup on her comforter. They both went to change the resident's linens and her gown, but they noticed the resident had red splotches to her left breast and left side with one blister to the resident's left nipple, and one blister to the resident's left abdomen. S15 CNA stated the resident complained of no pain, was in no distress, and was not aware that she had redness to her skin. S15 CNA stated she notified nurse S5 LPN immediately, provided the resident with new linens/gown, and shortly after that the resident went to the hospital per ambulance. Interview on 4/10/18 at 9:20 a.m. with S5 LPN revealed around 7:19 p.m. S15 CNA informed her that while placing the resident in dry clothes due to spilled soup the resident was found with redness and blisters. S5 LPN stated she and the evening nurse, S17 LPN, both assessed the resident and found her to have 2 small blisters to her left breast and 2 blisters above her peg tube area to her left abdomen. S5 LPN stated the MD and the resident's RP were informed and received orders to transfer the resident to the ER. Telephone interview on 4/10/18 at 9:40 a.m. with S13 ER nurse revealed the resident arrived at theER on [DATE] between 8:00 p.m. & 8:30 p.m. per ambulance. She stated the doctor assessed the resident, diagnosed her with 2nd degree burns, treated her with [MEDICATION NAME], and sent the resident back to the facility after a few hours. Observation on 4/9/18 at 11:37 a.m. revealed the resident awake/alert lying in her bed in her room with a tracheotomy opening receiving continuous oxygen [MEDICAL CONDITIONS] and contractures noted to both hands. Interview with the resident revealed she was only able to mouth her words and unable to verbalize her comments. The resident stated she had an accident last week while she was drinking tomato soup from her sippy cup around supper time due to the sippy cup lid coming partially off. She stated that almost all of her tomato soup spilled on her comforter. The resident stated she later found out per staff that the soup had also spilled onto the left side of her body causing burn areas. The resident stated 2 CNAs came in and changed her sheets and gown after being informed by the RT of the spill, and the 2 CNAs noticed that she had red areas to her left breast and left side, and they notified the nurse. The resident stated she was transported to the hospital per ambulance after the nurse looked at her burns. The resident stated a similar incident happened last year when she was drinking her tomato soup from a bowl and it spilled on the right side of her body [MEDICAL CONDITION] she received treatment. The resident stated she never felt any pain from [MEDICAL CONDITION] either incident. The resident stated she had no feeling from her breasts down, and was able to and wanted to hold her bowl of soup or sippy cup of soup. The resident stated after the 1st incident staff made her start using a sippy cup with a lid instead of the bowl. The resident stated after the 2nd incident staff made her start using a sippy cup with a lid that screwed on and staff now had to stay with her 3 x a day while she drank her sippy cup of tomato soup (only kind of soup she wants) which takes her about 30 minutes to finish. The resident stated she did not like staff watching her drink her soup and she stated the temp of her soup is lukewarm and not at all hot like she would like it to be. The resident stated she had a peg tube, but she refused staff to give her tube feedings because it causes her to have diarrhea and she preferred only tomato soup, milk, water, and coke as her liquids. Interview on 4/10/18 at 1:30 p.m. with S1 Administrator that the following interventions were put into place after the resident's 2nd burn incident: 1. Sippy cup with screw top. 2. Resident's tomato soup now heated in double insulated metal steam tray pan on top of stove to temp of 140 degrees F and cooled to temp of 130 to 135 F per kitchen staff before giving to CNA to serve. 3. Order changed on 4/9/18 for hot liquids not to exceed 100 degrees. 4. Assigned CNA will go to the kitchen to pick up the soup that has already been poured into a sippy cup with handles, and CNA remains with and monitors the resident until all of the soup is gone 3 times a day. 5. OT tried the tomato soup in a bowl with spoon again per staff and resident refused. 6. RP informed again of the risks and RP stated to let the resident have her independence. 7. Protective covers are to be placed on the resident's chest/abdomen before giving her the soup. The facility has implemented the following actions to correct the deficient practice: Review of the Actions Taken to Prevent Re-Occurrence [MEDICAL CONDITION] the resident after the resident's burn incident occurring on 4/2/18 which were put into effect 4/3/18 after her return to the facility included: 1. In-service prepared and immediately started for dietary staff to heat resident's soup to 140 degrees and allow to cool to 130-135 degrees prior to serving. The soup is to be placed in a cup with a lid and handles prior to CNA picking it up from the kitchen and then delivering the cup to the resident. Dietary staff to take the temperatures of the soup to ensure safe temperature and log it every meal on the production sheets. All dietary staff will have competency on calibrating and use of the thermometer and have on going in-service until all dietary staff are educated. Any new staff will be educated during their orientation. 2. The DM will monitor daily for compliance and the RD and/or ED will monitor the dietary staff and food temperature log at least twice weekly to ensure compliance. 3. CNA and Nursing staff immediately in-serviced to pick the soup up from the kitchen and deliver it to the resident and ensure the soup is in a cup with a lid and handles. Staff to remain with resident the entire time she is eating her soup. Ongoing in-service will continue until all CNA and Nursing staff are educated and new staff will be educated during orientation. 4. The Unit Managers will monitor CNA and Nursing staff at least one meal daily to ensure compliance. The DON and/or ADON will do random audits at least 3 times a week to ensure compliance. 5. Protective clothing garments were ordered on [DATE] and an apron or towel will be used until the protective clothing garments arrive to provide the resident an added protection in the event the resident spills on herself. 6. OT will reevaluate for safe use of a cup with lid and handles to consume hot soup. 7. CNA and Nursing staff will be in serviced on proper and safe heating temperatures of food in the microwave in the event other resident's request food heated up and log in the temperatures. 8. The RP was contacted to schedule a Care Plan conference to discuss resident safety and resident refusal to allow staff to assist her with her meals. 9. Care Plan and Pocket Guide has been updated to reflect the new interventions. Review of a corrective action update dated 4/5/18 revealed: 1. Care conference was held with the resident and family on 4/4/18 at 11:38 a. m. and the risk of injury was reviewed and the resident and family have agreed to have soup served in a bowl and staff will assist. Interview on 4/11/18 at 10:50 a.m. with S2 DON revealed staff attempted again to feed the resident her soup from a bowl, but the resident refused staff to feed her and requested soup be placed in sippy cup again. 2. Staff was in-serviced on the new process. Review of the resident's (MONTH) (YEAR) Daily Care Guide updated on 4/3/18 & 4/9/18 revealed the following instructions: 1. CNAs to remain with and assist resident with eating soup. 2. Hot Water Temperatures Observations of water temperatures on the Alzheimer's Unit on 4/9/18 at 11:25 a.m. revealed water temperatures were 138 degrees (F) in one of the halls two bathrooms/showers, and 130 degrees (F) in the second hall bathroom/shower. There were 9 residents on the unit (#8, #14, #15, #42, #43, #56, #59, #60, and #76) who were identified as able to enter the bathrooms independently and not able to regulate water temperatures. Observations on 4/9/18 at 2:05 p.m. of water temperatures on a B-Hall bathroom revealed a temperature of 130 degrees (F). There were 4 residents on B-hall who were identified as able to enter the bathrooms independently and not able to regulate water temperatures (#36, #47, #69 and #R1). Observation on 4/9/18 at 2:20 p.m. of water temperature in on a C-Hall residents (#31) room revealed a temperature of 129 degrees (F), and the resident was identified as not able to regulate water temperatures safely. Interview with S1 Administrator and S12 Corporate RN on 4/9/18 at 5:50 p.m. revealed that there was still hot water available for use on D Hall. They stated that water temperatures throughout the building would be monitored throughout the night and until a Professional plumber could assess and correct the problem. Recheck of the water temperatures revealed they were below 120 degrees F. Observation on the Alzheimer's/Memory unit on 4/9/18 at 11:25 a.m. revealed that there were 2 bathroom/shower areas used by the residents who resided on the unit. There was a total of 18 residents residing on the unit. Further observation on 4/9/18 at 11:30 a.m. revealed that the hot water temperature in bathroom near room (f) measured 130 degrees F. Observation of the bathroom near room (c) revealed the temperature measured 138 degrees F. The hot water temperature was observed to drop to 94 degrees F after 15 seconds, then spike back up to 128 degrees F. Random observations on the unit on 4/9/18 revealed resident #43 who had a BIMS of 9 (moderately severe) was observed going in and out of the hall bathroom in his wheelchair numerous times without staff present. Resident #42 who had a BIMS of 10 (moderately impaired), was observed going into the hall bathrooms alone on 3 different occasions. Both residents were identified as not able to self-regulate water temperatures safely. Interview with S6 Maintenance Supervisor on 4/9/18 at 11:35 a.m. confirmed that the water temperatures were high and further confirmed that the temperatures were not stable and fluctuated greatly between hot and cold. Interview with S4 LPN and S7 LPN on 4/9/18 at 11:48 a.m. revealed that of the 18 residents residing on the unit, 9 residents were identified as cognitively impaired, and able to randomly wander into the bathrooms without assistance. S4 LPN and S7 LPN stated that there had been no formal assessments of residents to determine if they were able to regulate hot water independently and safely. During an interview with S1 Administrator and S2 DON on 4/9/18 at 11:50 a.m., they were informed that water temperatures were high and maintenance was working on lowering the temperature of the hot water. S2 DON confirmed that there had been no formal assessments of residents to determine if they were able to regulate hot water independently and safely. Interview with S4 LPN / MDS Nurse on 4/9/18 at 1:35 p.m. confirmed that none of the facility's residents had been assessed to determine if they could self regulate hot water. Observation on C-hall on 4/9/18 at 2:56 p.m. revealed that the hot water temperature in resident #31's bathroom was 129 degrees F. Review of the resident's record revealed he had a BIMS score of 11, and [DIAGNOSES REDACTED]. The record also revealed that the resident had frequent episodes of forgetfulness and was an elopement risk secondary to his [DIAGNOSES REDACTED]. Observation of the resident revealed that he propelled himself in the hallway and in his room. He was able to wheel himself into the bathroom without supervision. Interview with S11 LPN on 4/10/18 at 2:15 p.m. confirmed that the resident frequently went to the bathroom in his wheelchair and had the potential to turn the hot water on and burn himself. Observation on 4/9/18 at 3:00 p.m. with S6 Maintenance Supervisor revealed he had been working on lowering the water temperatures. He stated that it may be a problem with the hot water mixing valves and he was checking the water temperatures frequently to ensure that they stayed below 120 degrees in the areas where hot water was being used. Review of the documentation on the hot water temperature log with S6 Maintenance Supervisor revealed documented water temperatures were below 120 degrees F. The last documented water temperature, prior to 4/9/18 was 3/27/18. Interview with S6 Maintenance Supervisor on 4/9/18 at 3:00 p.m. stated he normally took the water temperatures in the facility weekly and always between 8:00 a.m. and 9:00 a.m.

Based on interview and record review the facility failed to ensure staff adequately supervised and monitored 1 (#6) of 5 (#5, #6, #13, #14 & #16) residents at risk for elopement wearing a Wanderguard Bracelet and resided on the facility's Memory Unit, and 4 residents with wanderguard bracelets who did not reside on the Memory Unit (#10, #11, #12, & #15). The facility failed to: 1. ensure staff adequately respond to the activation of the alarm system in place to prevent elopement of a resident who resided on the Memory Unit and wore a Wanderguard bracelet; 2. increase supervision for resident #6 after a previous elopement attempt on 9/12/16, and immediately after the resident was returned to the facility after eloping on 9/20/16. This failed practice resulted in an Immediate Jeopardy situation for resident #6. The Immediate Jeopardy began on 9/20/16 at 9:17 a.m. when a housekeeper who was on the Memory Unit opened the locked door of the Memory Unit using the key pad to allow a vendor to enter the unit, then turned and walked away. The alarm system was activated and the unit sounded. As the vendor entered the unit, resident #6 exited the unit unnoticed and left the building. The facility became aware of the resident's elopement when they were contacted by the Sheriff's department. The resident was found by the Sheriff's department walking along a busy highway and was returned to the facility on [DATE] at 9:32 a.m. Additionally, according to interview and record review, the resident had a previous elopement attempt on 9/12/16, and was found attempting to elope out of another resident's window. The S1 Executive Director was informed of the Immediate Jeopardy on 9/21/16 at 5:10 p.m. The Immediate Jeopardy was removed on 09/21/16, when the S1 Executive Director presented the surveyor with an acceptable plan of removal and the plan was being implemented. The plan of removal included the following.: 1. Immediately, the resident was assessed for injuries and none were noted. The resident's wander guard was checked upon her return and was found to be working properly. The facility's video cameras were reviewed to determine how the resident eloped. 2. On 9/20/16, an inservice was started on responding to the alarms when they are triggered and performing a complete head count for all residents throughout the facility and what entrance/exits could be accessed. All residents with wander guards were checked to ensure they were in working order. 3. On 9/21/16, the facility posted a sign on the entrance of the Memory Unit (A-Hall), door alarm codes were changed until all staff were re-inserviced on the Wandering/Elopement Policy. The windows on the unit were secured (screwed the resident's window screen closed) to prevent an access that would allow elopement attempts. Resident #6 was placed on every 15 minute visual checks on 9/21/16. 4. The QA committee met on 9/21/16 to review resident #6's incident - Elopement Evaluation. Wander guards will be checked daily on every shift per MAR. In-service on 9/21/16 was conducted to all staff for the safety and security of the residents: all staff must respond to door alarms. If a resident is located at the door, please remove the resident before re-setting the alarm. If staff approach a door and the alarm is sounding but a resident is not present the employee must alert a nursing supervisor to begin a head count of all residents. The employee will then proceed out of the door where the alarm is sounding and walk the premises of the facility to ensure that a resident has not exited. 5. The ED and/or Supervisor will make random observational rounds daily X 7 days X 4 weeks to ensure that door alarms are being responded to timely by staff and wandering/elopement policy is being followed. Results of audits will be forwarded to QA Committee. QA committee will determine the frequency of audits based upon results achieved. This deficient practice continued at a potential for more than minimal harm for resident #6 and the remaining 8 residents who wore Wanderguard bracelets (#5, 10, 11, 12, 13, 14, 15 and 16). According to the Resident Census and Condition of Residents form, the facility had a total census of 83. Findings: Review of the resident's [DIAGNOSES REDACTED]. Review of the resident's Quarterly MDS assessment dated [DATE] revealed a BIMS of 99. Review of the resident's Risk of Elopement Evaluation dated 6/7/16 revealed the resident was at risk for elopement, resident monitoring bracelet applied, and placed on locked unit. The Risk of Elopement Evaluation form was dated as reviewed on 8/4/16, 8/20/16 and 9/20/16. Review of the resident's Care Plan with a goal date of 11/23/16 revealed the resident was care planned for being at risk for elopement with approaches that included to observe behavior and attempt to determine pattern frequency and intensity, review for recent changes such as bed moves, room changes, medication change, or change in cognitive function, observe resident's whereabouts, wander guard bracelet in place and keep daily routines as normal as possible. Interview with S1 ED at 9:20 a.m. on 9/21/16 revealed there had been an elopement on 9/20/16 when an A/C company vendor came to the front of the building and was trying to get in using the key pad, but could not get in. She stated S3 Housekeeper went to the door and unlocked the door using the key pad. She stated the S3 Housekeeper turned around to go back to her cart and the A/C vendor came through the door, and as it was closing the resident just slipped out the front door. She stated the alarm from resident's wander guard bracelet activated the system causing the alarm to sound; however, no one noticed the resident had gotten out. The alarm system was reset by S2 DON without checking to see if a resident had exited the building, and without doing a head count of the residents. She stated that it wasn't until they received a phone call from the Police Department asking if resident #6 was their resident and that she had been found wandering along highway 459 (hwy in front of facility), did they realize she was not in the facility. She stated that they determined how she exited the facility by watching the replay of the camera system. She stated from the time the resident left the building to the time she was returned was approximately 15 minutes. She confirmed the housekeeper that unlocked the door for the vendor was S3 Housekeeper. Interview with S3 Housekeeper on 9/21/16 at 9:25 a.m. revealed she did unlock the door for the A/C vendor on 9/20/16 from the front entrance. She stated she put the code in and as the A/C vendor was coming in she turned back around and headed back to her cart. She stated she did not hear the alarm going off and she did not see the resident exit the facility. She also stated she did not see the resident sitting near the front door entrance. Observation of the resident on 9/21/16 at 9:30 a.m. revealed she was sitting in a recliner with O2 at 2 L/NC in progress and her eyes were closed. Further observation revealed S5 CNA sitting with the resident. Interview with S4 CNA on 9/21/16 at 9:32 a.m. revealed that if the alarm system goes off she would step outside and see if she saw a resident, and then she would reset the alarm system and do a head count. She stated she worked on the Memory Unit some days and other days she just worked off the Memory Unit. Interview with S5 CNA on 9/21/16 at 9:35 a.m. revealed, if the alarm system was alarming, she would look outside and see if she saw a resident and then she would reset the alarm. She confirmed that she was on every 15 min. checks for resident #6. She stated she worked both on and off the Memory Unit; and she worked where she was assigned. She stated she did not hear the alarm going off on 9/20/16 when the resident eloped. Interview with S6 LPN on 9/21/16 at 9:40 a.m. revealed she would check outside to see if she saw a resident if she heard the alarm going off. Then, she would do a head count and disengage the alarm. Interview with S2 DON on 9/21/16 at 10:00 a.m. revealed the resident had attempted an elopement about a week prior. She stated she was found in another resident's room attempting to go out the window. The resident had one leg in the building and one leg out. She confirmed the resident had her wander guard bracelet on, but the alarm doesn't work on the windows. She confirmed the window have no alarms. S2 DON confirmed they did not increase monitoring on the resident after she attempted to elope out the window. She stated the only interventions that were put in place were that they screwed the resident's window screen closed and added an extra CNA staff person to the day shift, and the extra CNA was not added to specifically monitor resident #6. Further interview with the S2 DON revealed that after the elopement on 9/20/16, they did not increase monitoring of resident #6 until 6:00 a.m. on 9/21/16, because the resident was ambulatory and went to the bathroom on her own. She stated when the resident eloped on 9/20/16, she (DON) was in the administrator's office and heard the alarm going off. She stated it kept alarming so long that she got up and went to reset it herself. She stated she even commented to S7 LPN, I don't know why nobody has reset the alarm. She confirmed she did not look outside to see if a resident was outside before resetting the alarm, and she did not do a head count to ensure all residents were accounted for. Interview with S8 CNA on 9/21/16 at 11:05 a.m. who was assigned to the unit on the day the resident eloped, revealed she was not present on the unit when the resident eloped. She stated she was out back taking another resident to smoke. Interview with S2 DON on 9/21/16 at 11:10 a.m. revealed the resident had gotten 182 feet down the highway from the point of exit from the facility. She stated she used her I phone's step calculator to count off the feet. Interview with S9 Housekeeping Supervisor on 9/21/16 at 11:20 a.m. revealed she worked on 9/20/16 and heard the alarm going off. She stated S2 DON was at the door trying to reset it but couldn't, so she walked over and reset it for her. Interview with the RP on 9/21/16 at 11:30 a.m. revealed the following. The RP (who is employed by the facility) approached the surveyor at the facility and stated she needed to talk. She stated that the resident eloped yesterday (9/20/16) and was picked up by the police, and the facility did not notify her of the incident which occurred at 9:30 a.m., until 11:15 a.m. when she came to pick the resident up for an outing. She stated someone from the community called her daughter at home and told her about the incident before the facility notified her. She confirmed this was not the resident's first attempt at elopement. She stated that a week prior she almost made it out another resident's window. Interview with S2 DON and S1 ED on 9/21/16 at 11:39 a.m. revealed the video of the incident was time stamped 2 hours behind, because of a delay in video. Both stated that the time stamp on the video began at 9:15 a.m. Observation of the facility's video system revealed on 9/20/16 at 11:40 a.m., revealed that at approximately 9:15 a.m. the resident walked into the front Dayroom/Dining Room on the Memory Unit with her purse. She sat down in a chair (2nd chair to door) not looking at the door. S7 LPN could be observed standing at her cart with two other residents at her cart. Observation revealed S3 Housekeeper walked towards the door, used the key pad to unlock the door, and turned around and walked away. The vendor walked in through the door, and as the door was closing, the resident got out of the chair and walked out the front door. There was no audio on the video system, so the alarm was not heard. After 2 minutes passed on the video, S2 DON was observed to walk to the front door and attempt to reset the alarm. The S9 Housekeeping Supervisor walked over and assisted her. S2 DON and S9 Housekeeping Supervisor did not look outside to see if a resident had left the building, or performed a head count after resetting the alarm. Interview with S1 ED and S2 DON on 9/21/16 at 11:50 a.m. confirmed the facility did not have a Policy or Procedure for the alarm system. She stated there was no specific policy on how the staff was to respond to the alarm going off. She stated that there was a verbal policy that they followed, first to man the doors until secured, check outside to see if they see a resident, reset the system and do a head count. Both confirmed the verbal policy was not followed. Further interview with S2 DON at 12:00 p.m. revealed there was no increase in supervision of resident #6 after the elopement attempt on 9/12/16. She confirmed they did place an extra CNA on the unit, but not specifically to monitor resident #6. Interview with S1 ED on 9/21/16 at 1:30 p.m. confirmed there was no Policy or Procedure for what staff was to do when the alarm system goes off (alarms). She stated it had not been included in the staff orientation and there had not been any in-services given. She confirmed there was no training regarding the alarm system. She also confirmed that the Missing Resident/Elopement Policy and Procedure that the facility had did not address the use of the alarm system. Interview with S7 LPN on 9/22/16 at 10:50 a.m. revealed that the day resident #6 eloped she was in the front dayroom area, but was busy with medication administration and did not see the resident exit the building. She stated she saw the S3 Housekeeper go and unlock the door for the A/C man.

Based on record review and interview the Administrator failed to administrate the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (#6) of 9 (#5, #6, #13, #14 & #16) residents at risk for elopement wearing Wanderguard Bracelets in the facility. The facility failed to have a policy and procedure in place that specified how staff were to respond to a door alarm sounding in the facility. This failed practice resulted in an Immediate Jeopardy situation for resident #6. The Immediate Jeopardy began on 9/20/16 at 9:17 a.m. when a housekeeper who was on the Memory Unit opened the locked door of the Memory Unit using the key pad to allow a vendor to enter the unit, then turned and walked away. The alarm system was activated and the unit sounded. As the vendor entered the unit, resident #6 exited the unit unnoticed and left the building. The facility became aware of the resident's elopement when they were contacted by the Sheriff's department. The resident was found by the Sheriff's department walking along a busy highway and was returned to the facility on [DATE] at 9:32 a.m. Additionally, according to interview and record review, the resident had a previous elopement attempt on 9/12/16, and was found attempting to elope out of another resident's window. The S1 Executive Director was informed of the Immediate Jeopardy on 9/21/16 at 5:10 p.m. The Immediate Jeopardy was removed on 09/21/16, when the S1 Executive Director presented the surveyor with an acceptable plan of removal and the plan was being implemented. The plan of removal included the following.: 1. Immediately, the resident was assessed for injuries and none were noted. The resident's wander guard was checked upon her return and was found to be working properly. The facility's video cameras were reviewed to determine how the resident eloped. 2. On 9/20/16, an inservice was started on responding to the alarms when they are triggered and performing a complete head count for all residents throughout the facility and what entrance/exits could be accessed. All residents with wander guards were checked to ensure they were in working order. 3. On 9/21/16, the facility posted a sign on the entrance of the Memory Unit (A-Hall), door alarm codes were changed until all staff were re-inserviced on the Wandering/Elopement Policy. The windows on the unit were secured to prevent an access that would allow elopement attempts. Resident #6 was placed on every 15 minute visual checks on 9/21/16. 4. The QA committee met on 9/21/16 to review resident #6's incident - Elopement Evaluation. Wander guards will be checked daily on every shift per MAR. In-service on 9/21/16 was conducted to all staff for the safety and security of the residents: all staff must respond to door alarms. If a resident is located at the door, please remove the resident before re-setting the alarm. If staff approach a door and the alarm is sounding but a resident is not present the employee must alert a nursing supervisor to begin a head count of all residents. The employee will then proceed out of the door where the alarm is sounding and walk the premises of the facility to ensure that a resident has not exited. 5. The Adm. and/or Supervisor will make random observational rounds daily X 7 days X 4 weeks to ensure that door alarms are being responded to timely by staff and wandering/elopement policy is being followed. Results of audits will be forwarded to QA Committee. QA committee will determine the frequency of audits based upon results achieved. This deficient practice continued at a potential for more than minimal harm for resident #6 and the remaining 8 residents who wore Wanderguard bracelets (# 5, 10, 11 12, 13, 14, 15 and 16). According to the Resident Census and Condition of Residents form, the facility had a total census of 83. Findings: Cross refer to findings at tag F323. Interview with S1 ED and S2 DON on 9/21/16 at 11:50 a.m. confirmed the facility did not have a Policy or Procedure for the alarm system. She stated there was no specific policy on how the staff were to respond to the alarm going off. She stated that there was a verbal policy that they followed, first to man the doors until secured, check outside to see if they see a resident, reset the system and do a head count. Both confirmed the verbal policy was not followed. Interview with S1 ED on 9/21/16 at 1:30 p.m. confirmed there was no Policy or Procedure for what staff were to do when the alarm system goes off (alarms). She stated it had not been included in the staff orientation and there had not been any in-services given. She confirmed there was not training. She also confirmed that the Missing Resident/Elopement Policy and Procedure did not address the use of the alarm system.

Based on interview and record review the facility failed to ensure an accurate assessment of the residents' ROM was performed for 2 (#2 and #3) of 5 (#1, #4, #5) sampled residents at risk for ROM limitation. The facility failed to: 1- ensure an accurate assessment was conducted for resident #3's ROM limitations on 3/19/12 and 5/21/12, 2- ensure an accurate assessment was documented for resident #2's ROM limitation on 6/18/12 and 9/12. As a result of the facility failure to obtain an accurate assessment the facility failed to ensure services were provided to prevent a decline in resident #3's ROM. According to an Initial MDS Assessment, resident #3 was admitted to the nursing facility on 02/23/12 with no ROM limitations. Further review of the MDS Assessments for 3/19/12 and 5/21/12 reflected no ROM limitation. Review of an ER assessment dated [DATE] revealed the resident had developed contractures in the bilateral lower extremties. Findings: 1. Review of resident #3's nursing facility Face Sheet reflected he was admitted to the nursing facility on 02/23/12. [DIAGNOSES REDACTED]. Review of the Admission MDS assessment with an observation end date of 03/07/12 reflected the resident was totally dependent upon staff for bathing, dressing, transfer, eating and personal hygiene. Further review of the above dated MDS reflected the resident was coded as having no ROM impairments for his upper and lower extremities. Review of the MDS Assessment reflected the resident was discharged to an acute care hospital on [DATE] to 04/03/12. Review of the ER assessment dated [DATE] at 9:50 p.m. reflected the resident was paraplegic and had contractures of the bilateral lower extremities. Review of the Discharge/Return Anticipated MDS Assessment with an observation end date of 03/19/12, reflected the resident was totally dependent upon staff for bed mobility, transfer, dressing, eating, toilet use, personal hygiene and bathing. Further review of the above dated MDS reflected the resident was coded as having no ROM impairments for his upper and lower extremities. Further review of the resident's clinical record reflected he was readmitted to an acute care hospital on [DATE] to 04/17/12. Review of the Quarterly MDS/Re-entry Assessment from the acute hospital with an observation end date of 05/21/12, reflected the resident was totally dependent upon staff for locomotion on and off unit, dressing, eating, toilet use, personal hygiene and bathing. The above dated MDS assessment further reflected the resident was coded as having no ROM impairments of his upper and lower extremities. Review of Respiratory Therapy Departmental Notes dated 04/17/12 documented by S8 RT, reflected resident #3's legs were contracted. Interview of S8 RT on 10/17/12 at 11:05 a.m. confirmed she documented the above dated notes, and confirmed the resident had contractures of the lower extremities. Additionally, review of the MDS assessment dated [DATE] reflected the resident had no ROM impairments of his upper and lower extremities. Interview of S4 LPN/MDS Nurse on 10/17/12 at 1:07 p.m. reflected she had found documentation in the medical record that the resident had developed contractures, and confirmed the MDS assessment dated [DATE] regarding ROM limitations was incorrect. Interview of the S2 DON on 10/17/12 at 3:30 p.m. confirmed the ER documentation dated 03/18/12 reflected the resident had contractures of the lower extremities, and confirmed the MDS assessment regarding ROM limitation for 03/19/12 and 05/21/12 were inaccurate. 2. Observation of resident #2 on 10/15/12 at 11:35 a.m. revealed the resident lying in his bed. The resident was non-responsive to verbal stimuli and did not open his eyes. The resident was observed to have contractures of his bilateral hands/arms and legs. Hand rolls and pillows were observed in place. Review of the the resident's Initial MDS assessment dated [DATE] reflected the resident was coded as having no ROM impairment of his upper and lower extremities Review of an OT Review Form dated 06/12/12 reflected OT screened the resident as a result of the resident being newly admitted to the nursing facility. The form reflected the resident had no contractures, had a feeding tube and was dependent upon staff for all ADLs. The form reflected OT was not recommended. Review of an OT Review Form dated 06/19/12 reflected OT screened the resident again due to the resident having "increased response" per nursing referral. Documentation on the nursing referral did not reflect the nature of the increased response. The Review Form reflected the resident had no contractures, had a feeding tube, was non-verbal and was dependent upon staff for all ADLs. The Review Form reflected OT was not recommended. Review of the Quarterly MDS dated [DATE] reflected the resident was coded as having ROM impairments bilaterally for upper and lower extremities Review of the resident's clinical record reflected there was no documented evidence that reflected when the resident developed the contractures to his upper and lower extremities. Interview of S4 LPN/MDS Nurse on 10/16/12 at 1:20 p.m. confirmed resident #2 had contractures to his upper and lower extremities. Further interview of S4 LPN/MDS Nurse on 10/16/12 at 2:30 p.m. and 3:05 p.m., confirmed there was no documentation to reflect when the resident developed the contractures between the 06/18/12 MDS and the 09/11/12 MDS. She stated the above dated MDS was conducted by a previous MDS Nurse who was terminated. Interview of S2 DON on 10/16/12 at 12:30 p.m. confirmed the resident was not admitted with contractures according to his MDS dated [DATE]; however, the 09/11/12 MDS reflected contractures.

Based on observation, interview and record review the facility failed to follow the written plan of care by failing to ensure physician orders were followed timely for OT and PT for evaluation and treatment of [REDACTED].#5) for 2 (#3, #5) of 5 (#1, #2, #4) sampled residents. According to an Initial MDS Assessment, resident #3 was admitted to the nursing facility on 02/23/12 with no ROM limitations. OT and PT interventions were not implemented timely as ordered. As a result, documentation of the resident having contractures was reflected on an ER note dated 03/18/12. According to interview with the S2 DON on 10/15/12 the facility had a resident census of 69. The facility failed to: 1- obtain an OT evaluation as ordered by physician on 3/7/12 until 3/14/12 (#3); 2- have a process in place to ensure OT and PT evaluations were conducted within two days of written physician orders as specified by facility policy and procedure (#3); 3- ensure physician orders received on 3/7/12 were followed timely for OT and PT evaluation and treatment (#3); 4- obtain an evaluation for OT until 3/14/12 after an Interdisciplinary Review Referral for OT was made on 2/28/12 (#3); 5- obtain an evaluation for PT until 4/24/12 after a written physician's order for PT was received on 3/7/12 (#3). 6- turn and reposition a resident, and apply heel protectors according to the plan of care (#5). As a result of the facility failure to obtain OT/PT evaluation and treatment timely as ordered the facility failed to prevent a decline in resident #3's ROM. According to an Initial MDS Assessment, resident #3 was admitted to the nursing facility on 02/23/12 with no ROM limitations. Documentation in an ER note dated 03/18/12 reflected the resident had developed contractures in the bilateral lower extremities. Findings: Resident #3 1. Review of resident #3's nursing facility Face Sheet reflected he was admitted to the nursing facility on 02/23/12. [DIAGNOSES REDACTED]. Review of an Interdisciplinary Review Form dated 02/28/12 reflected Occupational Therapy was recommended for the resident. Further review of the form revealed it was signed by the nursing facility's therapy department's COTA on 2/28/12. Review of physician's orders dated 03/07/12 reflected an order for [REDACTED]. Review of the OT Plan of Treatment notes reflected resident #3 was not evaluated for therapy until 03/14/12. The Plan of Treatment further reflected the resident was referred to therapy to address symptoms consistent with L Spastic [MEDICAL CONDITION] and bilateral upper extremity joint stiffness in order to increase the functional mobility and independence with ADL tasks. Interview of S3 LOTR on 10/16/12 at 2:10 p.m. confirmed the Interdisciplinary Review Form reflected the nursing facility had referred the resident for evaluation for OT 02/28/12; however, the S3 LOTR reflected the resident was not evaluated by OT until 03/14/12. Interview of S2 DON on 10/16/12 at 2:15 p.m. confirmed the Interdisciplinary Form dated 02/28/12 reflected OT was recommended for the resident. The S2 DON stated the resident should have been evaluated by therapy within 2 working days of the referral, and confirmed the form had been signed by the COTA on 2/28/12. Additionally review of the Initial PT Plan of Treatment reflected the resident was not evaluated for physical therapy until 04/24/12. Further review reflected the resident screened positive for therapy due to decreased flexibility of multiple joints that resulted in limited ROM. Review of the facility policy for Physical Therapy provided by the S2 DON reflected the evaluation should be initiated within 2 work days of the referral. Interview of S2 DON on 10/17/12 at 11:56 a.m. confirmed the physician's order dated 03/07/12 for PT and OT to evaluate and treat. Further interview of the S2 DON on the above date and time confirmed the initial evaluation for PT was not done until 04/24/12, and the initial evaluation for OT was not done until 03/14/12. The DON further stated she had reviewed the findings with the therapy department director to confirm the evaluation dates, and the dates were confirmed by the director. Additionally, the S2 DON confirmed the facility's policy reflected a resident should be evaluated by therapy within 2 work days of the referral. Further review of the S2 DON on 10/17/12 at 12:17 p.m. revealed the Unit Managers should have followed up on the resident's physician orders to ensure interventions were in place as ordered. Resident #5 2. Review of resident #5's clinical record reflected she was admitted to the nursing facility on 07/06/12. [DIAGNOSES REDACTED]. Review of Department Notes dated 09/19/12 reflected 2 stage II pressure areas were noted to the resident's left ischium. Review of physician orders dated 09/26/12 revealed an order to discontinue treatment to wounds #16, #2 and to the left ischium: areas healed. Review of the resident's comprehensive plan of care with a goal date of 01/01/13, reflected a problem of "altered skin integrity related to pressure ulcer". The plan of care was not specific as to where the ulcer was located, or the stage of the ulcer. Approaches included: Incontinent care following incontinent episodes; measure wounds weekly; treatments as ordered; labs; pressure reducing devices as needed; and turn and reposition as needed. The plan of care further reflected a problem of "requires assistance with bed mobility". Approaches included: turn and position every 2 hours and pressure reduction mattress. Observation of resident #5 on 10/15/12 at 11:15 a.m. revealed the resident in bed lying on her back after receiving a bath. The resident did not have on heel protectors. Observation of resident #5 on 10/15/12 at 1:05 p.m. revealed the resident asleep in bed. The resident remained on her back. The resident did not have on heel protectors. Observation of the resident on 10/15/12 at 2:00 p.m. revealed her lying in bed. Again, the resident was observed lying on her back. Observation further revealed the resident did not have heel protectors in place. Interview of S5 CNA on 10/15/12 at 11:10 a.m. revealed she was the resident's CNA on the 6:00 a.m. to 2:00 p.m. shift. She stated the resident had no pressure ulcers; however, the resident's buttocks stayed red. She further stated the resident was on a pressure relieving mattress. Review of physician orders for 10/10 reflected A and D Ointment to bilateral heels every day and prn, apply Allevyn heel protectors to bilateral heels every 3 days and prn for protective measures, and Boudreaux Butt Paste to excoriated areas. Interview of S1 LPN on 10/15/12 at 2:00 p.m. confirmed the resident did not have on heel protectors, and stated the resident should have heel protectors in place. Additionally, she confirmed resident #5 had not been turned since her bath at 11:30 a.m. on 10/15/12. The S1 LPN stated the resident was not capable of turning herself. The S1 LPN further stated S6 CNA and a nurse were currently turning the resident. Interview of S2 DON on 10/15/12 at 2:05 p.m. revealed the resident should have Allevyn heel protectors on . She stated the heel protectors were applied by the Treatment Nurse, and may have been removed before bath and not reapplied. The S2 DON confirmed the heel protectors should have been reapplied after her bath.

Based on observation, interview and record review the facility failed to prevent a decline in the ROM for a resident that entered the facility without ROM limitations for 2 (#2 and #3) of 5 sampled residents (#1, #4, #5) at risk for ROM decline. According to interview with S2 DON on 10/15/12, there was a total of 69 residents residing at the facility. The facility failed to: 1- ensure an accurate MDS assessment of resident #3's ROM in bilateral extremities was performed and documented on 3/7/12, 3/19/12, and 5/21/12; 2- obtain an OT evaluation as ordered by physician on 3/7/12 until 3/14/12 (#3); 3- have a process in place to ensure OT and PT evaluations were conducted within two days of written physician orders (#3) as specified by facility policy and procedure; 4- ensure physician orders received on 3/7/12 were followed timely for OT and PT evaluation and treatment (#3); 5- obtain an evaluation for OT until 3/14/12 after an Interdisciplinary Review Referral for OT was made on 2/28/12 (#3); 6- obtain an evaluation for PT until 4/24/12 after a written physician's order for PT was received on 3/7/12 (#3); 7- ensure a resident who was coded as having no ROM limitations received PROM as documented in the resident's comprehensive plan of care (#2); 8- follow facility policy and procedure to obtain OT and PT evaluations within 2 working days of date of referral for a resident identified on admission as being at risk for developing contractures (#3). As a result of the facility failure to obtain OT/PT evaluation and treatment timely as ordered the facility failed to prevent a decline in resident #3's ROM. According to an Initial MDS Assessment, resident #3 was admitted to the nursing facility on 02/23/12 with no ROM limitations. Documentation in an ER note dated 03/18/12 reflected the resident had developed contractures in the bilateral lower extremities. Findings: Resident #3 1. Review of the hospital discharge summary for resident #3 reflected the resident was hospitalized from [DATE] to 02/23/12 prior to nursing facility admission. Further review reflected the resident had suffered a gunshot wound to the left forehead and had required surgery. Review of resident #3's nursing facility Face Sheet reflected he was admitted to the nursing facility on 02/23/12. [DIAGNOSES REDACTED]. Review of an Interdisciplinary Review Form dated 02/28/12 reflected Occupational Therapy was recommended for the resident. Further review of the form revealed it was signed by the nursing facility's therapy department's COTA on 2/28/12. Review of physician's orders dated 03/07/12 reflected an order for [REDACTED]. Review of the OT Plan of Treatment notes reflected resident #3 was not evaluated for therapy until 03/14/12. The Plan of Treatment further reflected the resident was referred to therapy to address symptoms consistent with L Spastic [MEDICAL CONDITION] and bilateral upper extremity joint stiffness in order to increase the functional mobility and independence with ADL tasks. Interview of S3 LOTR on 10/16/12 at 2:10 p.m. confirmed the Interdisciplinary Review Form reflected the nursing facility had referred the resident for evaluation for OT 02/28/12; however, the S3 LOTR reflected the resident was not evaluated by OT until 03/14/12. Interview of S2 DON on 10/16/12 at 2:15 p.m. confirmed the Interdisciplinary Form dated 02/28/12 reflected OT was recommended for the resident. The S2 DON stated the resident should have been evaluated by therapy within 2 working days of the referral, and confirmed the form had been signed by the COTA on 2/28/12. Additionally review of the Initial PT Plan of Treatment reflected the resident was not evaluated for physical therapy until 04/24/12. Further review reflected the resident screened positive for therapy due to decreased flexibility of multiple joints that resulted in limited ROM. Review of the facility policy for Physical Therapy provided by the S2 DON reflected the evaluation should be initiated within 2 work days of the referral. Review of the Admission MDS assessment with an observation end date of 03/07/12 reflected the resident was totally dependent upon staff for bathing, dressing, transfer, eating and personal hygiene. Further review of the above dated MDS reflected the resident was coded as having no ROM impairments for his upper and lower extremities. Review of the current comprehensive care plan reflected a problem dated 2/23/12 of "extensive to total assist with all ADLs and potential risk for contractures related to impaired mobility due to gunshot wound to head". Approaches included passive ROM exercises with a.m. routine care, screen by therapy per MD orders, monitor and document an increase in contractures, and notify the MD as indicated. Review of MDS Assessment reflected the resident was discharged to an acute care hospital on [DATE] to 04/03/12. An ER assessment dated [DATE] at 9:50 p.m. reflected the resident was paraplegic and had contractures of the bilateral lower extremities. Review of the Discharge/Return Anticipated MDS Assessment with an observation end date of 03/19/12, reflected the resident was totally dependent upon staff for bed mobility, transfer, dressing, eating, toilet use, personal hygiene and bathing. Further review of the above dated MDS reflected the resident was coded as having no ROM impairments for his upper and lower extremities. Further review of the resident's clinical record reflected he was readmitted to an acute care hospital on [DATE] to 04/17/12. Review of the Quarterly MDS/Re-entry Assessment from the acute hospital with an observation end date of 05/21/12, reflected the resident was totally dependent upon staff for locomotion on and off unit, dressing, eating, toilet use, personal hygiene and bathing. The above dated MDS assessment further reflected the resident was coded as having no ROM impairments of his upper and lower extremities. Review of Respiratory Therapy Departmental Notes dated 0 4/17/12 documented by S8 RT, reflected resident #3's legs were contracted. Interview of S8 RT on 10/17/12 at 11:05 a.m. confirmed she documented the above dated notes, and confirmed the resident had contractures of the lower extremities. Additionally, review of the MDS assessment dated [DATE] reflected the resident had no ROM impairments of his upper and lower extremities. Interview of S4 LPN/MDS Nurse on 10/17/12 at 1:07 p.m. reflected she had found documentation in the medical record that the resident had developed contractures, and confirmed the MDS assessments dated 05/21/12 regarding ROM limitations was incorrect. Interview of S2 DON on 10/17/12 at 11:56 a.m. confirmed the physician's order dated 03/07/12 for PT and OT to evaluate and treat. Further interview of the S2 DON on the above date and time confirmed the initial evaluation for PT was not done until 04/24/12, and the initial evaluation for OT was not done until 03/14/12. The DON further stated she had reviewed the findings with the therapy department director to confirm the evaluation dates, and the dates were confirmed by the director. Additionally, the S2 DON confirmed the facility's policy reflected a resident should be evaluated by therapy within 2 work days of the referral. Interview of the S2 DON on 10/17/12 at 12:17 p.m. revealed the Unit Managers should have followed up on the resident's physician orders to ensure interventions were in place as ordered. Interview of the S2 DON on 10/17/12 at 3:30 p.m. confirmed the ER documentation dated 03/18/12 reflected the resident had contractures of the lower extremities, and confirmed the MDS assessment regarding ROM limitation for 03/19/12 and 05/21/12 were inaccurate. Resident #2 2. Observation of resident #2 on 10/15/12 at 11:35 a.m. revealed the resident lying in his bed. The resident was non-responsive to verbal stimuli and did not open his eyes. The resident was observed to have contractures of his bilateral hands/arms and legs. Hand rolls and pillows were observed in place. Interviewed of S12 CNA on the above date and time revealed she was assigned to care for the resident on the 6:00 a.m. to 2:00 p.m. shift. She stated she moved the resident's arms and his legs through ROM during morning care. Review of the resident's Initial MDS assessment dated [DATE] reflected the resident was coded as having no ROM impairment of his upper and lower extremities Review of an OT Review Form dated 06/12/12 reflected OT screened the resident as a result of the resident being newly admitted to the nursing facility. The form reflected the resident had no contractures, had a feeding tube and was dependent upon staff for all ADLs. The form reflected OT was not recommended. Review of an OT Review Form dated 06/19/12 reflected OT screened the resident again due to the resident having "increased response" per nursing referral. Documentation on the nursing referral did not reflect the nature of the increased response. The Review Form reflected the resident had no contractures, had a feeding tube, was non-verbal and was dependent upon staff for all ADLs. The Review Form reflected OT was not recommended. Review of the Quarterly MDS dated [DATE] reflected the resident was coded as having ROM impairments bilaterally for upper and lower extremities Review of the current comprehensive plan of care reflected a problem of "decreased mobility and potential for contractures" with an onset date of 07/18/12. The care plan was not updated to reflect the resident's current/actual contractures. Interventions in the care plan reflected PROM would be provided with a.m. care, and staff would report to the nurse any possible onset of contracture noted during routine care. Review of ADL Flow Sheets from June through October, 2012 did not reflect documented evidence that PROM was provided to the resident during this time period. Review of the resident's clinical record reflected there was no documented evidence that reflected when the resident developed the contractures to his upper and lower extremities. Additionally, there was documented evidence in the clinical record to reflect interventions to prevent the resident from developing contractures to his upper and lower extremities after his admission to the facility. Interview of S4 LPN/MDS Nurse on 10/16/12 at 1:20 p.m. revealed the facility had a Restorative Nursing Program, but it was not in place from 09/13/12 to 09/24/12 due to a need for additional CNA training. She confirmed resident #2 had contractures to his upper and lower extremities, and currently had not been evaluated for the Restorative Nursing Program. Further interview of S4 LPN/MDS Nurse on 10/16/12 at 2:30 p.m. and 3:05 p.m., confirmed there was no documentation to reflect when the resident developed the contractures between the 06/18/12 MDS and the 09/11/12 MDS. She stated the above dated MDS was conducted by a previous MDS Nurse who was terminated. Interview of S2 DON on 10/16/12 at 12:30 p.m. confirmed the resident was not admitted with contractures according to his MDS dated [DATE]; however, the 09/11/12 MDS reflected contractures. She confirmed there was no documentation to reflect facility interventions to prevent the resident from developing contractures, and confirmed CNA's and nurses did not document passive ROM.

Based on observation, interview and record review the facility failed to consult with the resident's physician timely when the resident began to exhibit increased confusion, foul smelling urine and complaints of burning upon urination and when the resident was noted to have diminished lung sounds with crackles to the left side, and an O2 sat of 81% on room air for 1 of 3 residents investigated for hospitalization in a total sample of 30 Stage II residents (#61). The facility's total census was 76 according to the Resident Census and Conditions of Residents form. Resident #61 began to show signs of UTI on 1/11/11 at 6:00 p.m. with increased confusion, foul smelling urine and complaints of burning upon urination. The facility did not notify the physician of the resident's complaints until she was sent to the emergency room by ambulance at 10:10 p.m. per standing orders. The resident was admitted to the hospital with [REDACTED]. The resident returned to the facility on [DATE]. On 2/1/11 the resident was noted with diminished lung sounds with crackles to the left side, and an O2 sat of 81% on room air. The facility notified the physician via a fax to his office at 8:50 p.m., although it was after office hours. The resident was readmitted to the hospital on [DATE] at 1:00 a.m. with [DIAGNOSES REDACTED]. Findings: Observation on 3/21/11 at 12:15 p.m. revealed resident #61 was seated at a table in the dining room. The resident was being fed by the CNA when her son entered the dining room and began to feed her. Review of the resident's Accumulative [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Review of the nurse's note dated 1/11/11 at 9:04 p.m. reflected the note was a late entry for 6:00 p.m. when the resident began to show signs of UTI. The note reflected the resident had increased confusion, foul smelling urine and burning upon urination. The resident's daughter was notified and requested the staff give the resident cranberry juice. The resident's daughter also stated she wanted to think about sending the resident to the doctor. Review of the nurse's note dated 1/12/11 at 12:15 a.m. reflected the resident was assisted to the bedside commode on 1/11/11 at 9:00 p.m. The resident was complaining of burning and lower abdominal pain with urination. The resident's urine was dark yellow with foul odor and a small amount of blood. The resident also had increased confusion. The resident's daughter was called again and requested the resident be encouraged to drink water and cranberry juice. She stated she would come to the facility, and she did not want the resident sent to the hospital. The note reflected the resident was offered honey thickened water but the resident refused. Review of the nurse's note dated 1/11/11 at 9:45 p.m. reflected the daughter arrived to the facility and wanted the resident sent to the emergency room . The resident was sent to the hospital at 10:10 p.m. per ambulance by physician's standing order. There was no documentation in the nurses' notes to reflect the resident's physician was notified of the resident's increased confusion, signs of UTI or refusal of water. Review of the nurse's note dated 1/12/11 at 1:59 a.m. reflected the resident was admitted to the hospital with [REDACTED]. Interview on 3/25/11 at 10:00 a.m. with S2 DON confirmed the resident's physician was never contacted regarding the change in her condition on 1/11/11. Review of the nurse's note dated 2/2/11 at 1:37 a.m. reflected the CNA reported on 2/1/11 at 8:50 p.m. that the resident was on the floor mat next to the bed. The resident was noted to have diminished lung sounds with crackles to the left side, and an O2 sat of 81% on room air. O2 per nasal cannula was applied and the physician was notified via FYI sheet faxed to his office. The resident's vital signs were: T - 98.3, P - 95, R - 20 and B/P - 160/36. At 10:40 p.m., the resident was found on the floor mat again. The resident was assessed with [REDACTED]. O2 sat was 90% with O2 @ 2L. There was no documentation to reflect any further attempts to notify the physician of the resident's condition other than the fax sent to the office at 8:50 p.m. There was also no documentation to reflect verification was made that the physician's office was open at that time, or the fax was received. Further review of the nurses' notes dated 2/2/11 at 1:37 a.m. reflected on 2/1/11 at 11:30 p.m. the resident was asleep with an O2 sat of 92% with O2 per NC. At 1:00 a.m., the resident was awake, lethargic and the lung sounds were diminished with crackles to the left lung. The resident was having labored breathing. An order was obtained at that time to send the resident to the hospital for evaluation and treatment.

Based on observation, interview and record review the facility failed to conduct a comprehensive and complete assessment of a resident's risk for dehydration and UTI (#61) for 1 of 3 residents investigated for hospitalization and a resident's risk for falls (#30) for 1 of 3 residents investigated for accidents in a total sample of 30 Stage II residents. The facility's total census was 76 according to the Resident Census and Conditions of Residents form. The facility failed to: 1. ensure a resident hospitalized for [REDACTED]. The resident was hospitalized again 5 days later for Dehydration and UTI. The resident was not assessed upon return from the hospital for increased risk of UTI and was diagnosed with [REDACTED]. 2. ensure a resident's quarterly fall risk assessment was completed, and the resident was re-assessed after a fall (#30). Resident #61 was admitted to the facility on [DATE]. The resident was hospitalized from [DATE] until 1/28/11 with [DIAGNOSES REDACTED]. There were no assessments of the resident upon her return from the hospital identifying her as being at risk for Dehydration or UTI, nor was the resident's care plan updated to include interventions for the prevention of Dehydration or UTI. The resident was readmitted to the hospital from 2/2/11 until 2/17/11 with [DIAGNOSES REDACTED]. The resident was again not assessed following her second recent hospitalization with [DIAGNOSES REDACTED]. On 3/2/11, the resident was diagnosed with [REDACTED]. Findings: 1. Observation on 3/21/11 at 12:15 p.m. revealed resident #61 was seated at a table in the dining room. The resident was being fed by the CNA when her son entered the dining room and began to feed her. Review of the resident's Accumulative [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Review of the resident's current MDS dated [DATE] reflected the resident was totally dependent for eating and drinking with one staff assistance. Review of the Assessment of Dehydration Risk form dated 12/17/10 reflected the resident was coded as "6". The form reflected a resident was at low risk with a score of 00-08 and high risk with a score of 09-20. The form also reflected a resident might be at risk with abnormal lab values in spite of other scores. Review of the resident's record reflected there were no lab values in the record to aid in determining the resident's dehydration risk. Review of the Nutritional Assessment form dated 12/28/10 reflected the RD assessed the resident's estimated nutritional needs as requiring a daily fluid intake of 1400 - 1792 cc. The RD documented there were no lab results available at the time of the assessment. Review of the Bladder Continence assessment dated [DATE] reflected the resident's fluid intake was fair (1000-2000 cc daily). However, there was no documentation to reflect the resident's actual fluid intake was being monitored. Review of the nurse's note dated 1/7/11 at 7:07 p.m. reflected a new order had been received for [MEDICATION NAME] Sodium (stool softener) 200 mg po every day after the resident had received multiple doses of prn MOM (laxative) for constipation, and the family had requested a stool softener for constipation. There were no assessments for possible factors contributing to the resident's on-going problems with constipation. Review of the nurse's note dated 1/12/11 at 1:59 a.m. reflected the resident was admitted to the hospital with [REDACTED]. Review of the facility's Readmission assessment dated [DATE] reflected the resident's admitting [DIAGNOSES REDACTED]. Review of the Dehydration Risk Assessment reflected there was no reassessment of the resident's dehydration risks following the hospital return on 1/28/11. Interview on 3/25/11 at 10:00 a.m. with S2 DON reflected risk assessments were done quarterly. S2 stated the facility had recently implemented a plan to update the risk assessments upon return from the hospital. S2 confirmed the plan was not in place when the resident returned from the hospital on [DATE], and the dehydration risk assessment had not been updated. Review of the nurse's note dated 2/2/11 at 1:00 a.m. reflected the resident was sent to the hospital for evaluation and treatment. Review of the hospital's History and Physical reflected the resident was admitted on [DATE]. The impression included Pneumonia, recurrent, Dehydration, Pyuria, rule out UTI and Dementia. The plan included to admit for IV antibiotics and IV fluids for correction of Dehydration. Review of the hospital's Discharge Summary dated 2/17/11 reflected the resident was admitted for treatment of [REDACTED]. The final [DIAGNOSES REDACTED]. Review of the facility's Readmission assessment dated [DATE] reflected the admitting [DIAGNOSES REDACTED]. 2. Observation of resident #30 on 3/24/11 at 9:50 a.m. revealed she was disoriented to time, person and place. Review of nurses' notes dated 3/1/11 at 9:12 a.m. revealed the resident was found in her room on the floor by the LPN. The resident's wheelchair was unlocked and the resident was unable to say what happened. The resident sustained [REDACTED]. Review of the last MDS assessment reference dated 1/17/11 revealed the resident's active [DIAGNOSES REDACTED]. Review of the resident's quarterly risk assessment for falls dated 1/17/11 revealed it had not been completed to include the resident's pre-disposing conditions as noted on the form. Review of the RAI revealed it had triggered the need for a fall assessment. Further review revealed there was also no record of a re-assessment after the resident's fall on 3/1/11. Interview with S7 MDS Assessment nurse on 3/25/11 at 10:00 a.m. confirmed the quarterly fall risk assessment dated on 1/17/11 was only partially completed.

Based on observation, interview and record review the facility failed to review and revise the plan of care for 6 of 30 Stage II sampled residents (#61, #30, #13, #3, #10 and #33) . The facility's total census was 76 according to the Resident Census and Conditions of Residents form. The facility failed to: 1. care plan for a resident's risk for Dehydration and UTI, including their estimated fluid needs (#61); 2. care plan for a resident's fall (#30); 3. care plan for a resident's hand splints (#13); 4. care plan for a resident's hospice services (#3); 5. care plan for residents' ROM (#10 and #33); and 6. care plan for a resident' urinary catheter (#10). Resident #61 was admitted to the facility on [DATE]. The RD assessed the resident on 12/28/10 and recommended a daily fluid intake of 1400 - 1792 cc. The resident's plan of care failed to include interventions for meeting or monitoring the recommended fluid needs. The resident was hospitalized from [DATE] until 1/28/11 with [DIAGNOSES REDACTED]. The resident's care plan was not updated to include interventions for the prevention of Dehydration or UTI after the resident's hospitalization . The resident was hospitalized again from 2/2/11 until 2/17/11 with [DIAGNOSES REDACTED]. The care plan was not updated to include interventions to prevent or monitor for signs of Dehydration or UTI upon return from the hospital. On 3/1/11, the physician ordered a U/A and urine C&S due to a report of the resident's urine having a foul odor. A new order was obtained on 3/2/11 for an antibiotic due to UTI. The facility failed to update the care plan with any new measures for the new [DIAGNOSES REDACTED]. Findings: 1. Observation on 3/21/11 at 12:15 p.m. revealed resident #61 was seated at a table in the dining room. The resident was being fed by the CNA when her son entered the dining room and began to feed her. Review of the resident's Accumulative [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Review of the resident's current MDS dated [DATE] reflected the resident was totally dependent for eating and drinking with one staff assistance. Review of the Assessment of Dehydration Risk form dated 12/17/10 reflected the resident was coded as "6". The form reflected a resident was at low risk with a score of 00-08 and high risk with a score of 09-20. The form also reflected a resident might be at risk with abnormal lab values in spite of other scores. Review of the resident's record reflected there were no lab values in the record to aid in determining the resident's dehydration risk. Review of the Nutritional Assessment form dated 12/28/10 reflected the RD assessed the resident's estimated nutritional needs as requiring a daily fluid intake of 1400 - 1792 cc. The RD documented there were no lab results available at the time of the assessment. Review of the resident's care plan, goal date of 3/28/11, reflected it did not include any interventions for the resident meeting the fluid recommendations, nor for monitoring if the resident received the recommended fluids. Interview on 3/25/11 at 10:00 a.m. with S2 DON confirmed the resident was never placed on intake and output or any other type of monitoring system to ensure she received the estimated fluid needs identified by the RD. Review of the nurse's note dated 1/12/11 at 1:59 a.m. reflected the resident was admitted to the hospital with [REDACTED]. Review of the facility's Readmission assessment dated [DATE] reflected the resident's admitting [DIAGNOSES REDACTED]. Review of the resident's care plan reflected it was not updated following the hospital stay to include approaches to prevent or monitor for Dehydration or UTI. Review of the nurse's note dated 2/2/11 at 1:00 a.m. revealed the resident was sent to the hospital for evaluation and treatment. Review of the hospital's History and Physical reflected the resident was admitted on [DATE]. The impression included Pneumonia, recurrent, Dehydration, Pyuria, rule out UTI and Dementia. The plan included to admit for IV antibiotics and IV fluids for correction of Dehydration. Review of the hospital's Discharge Summary dated 2/17/11 reflected the resident was admitted for treatment of [REDACTED]. The final [DIAGNOSES REDACTED]. Review of the facility's Readmission assessment dated [DATE] reflected the admitting [DIAGNOSES REDACTED]. The thickened liquids had been discontinued. Review of the Assessment of Dehydration Risk dated 2/17/11 reflected the resident was identified as high risk with a score of "9" upon return from the hospital. Review of the Bladder Continence assessment dated [DATE] reflected the resident's fluid intake was poor (500 - 1000 cc daily). Review of the Instant Care Plan dated 2/17/11, following the resident's hospitalization for Dehydration and UTI, reflected an intervention was checked to encourage fluid intake. However, there was no documentation how often the resident was offered fluids, or if she accepted the fluids when offered. Also, there were no measures put in place to monitor the resident for signs of Dehydration or UTI after her hospital stay, and after she was assessed as being at high risk for dehydration and having poor fluid intake. Interview on 3/25/11 at 10:00 a.m. with S2 DON reflected risk assessments were done quarterly. S2 stated the facility had recently implemented a plan to update the risk assessments upon return from the hospital. S2 confirmed the plan was not in place when the resident returned from the hospital on [DATE], and the dehydration risk assessment had not been updated. S2 DON also confirmed a resident identified as being at high risk on an assessment should have the care plan updated with goals and interventions for the identified problem. S2 confirmed the Assessment for Dehydration Risk completed on 2/17/11 identified the resident at high risk for dehydration. Review of the nurse's note dated 3/1/11 at 3:00 p.m. reflected the CNA reported the resident's urine had a foul odor. A new order was obtained for a U/A and urine C&S. Review of the nurse's note dated 3/2/11 at 4:40 p.m. reflected the U/A results had been received and faxed to the physician. A new order was received for Bactrim DS (an antibiotic) 1 po bid x 10 days, dx: UTI. Review of the care plan reflected there were no interventions put into place due to the resident's [DIAGNOSES REDACTED]. 2. Observation of resident #30 on 3/24/11 at 9:50 a.m. revealed she was disoriented to time, person and place. Review of the nurses' notes dated on 3/1/11 at 9:12 a.m. revealed the resident was found in her room on the floor by the LPN. It also revealed the wheelchair was unlocked and the resident was unable to tell what had happened. The resident sustained [REDACTED]. Review of resident #30's care plan revealed a problem with Trauma, Potential for Falls related to external factors and had goals that the resident would remain free from falls through nursing intervention and prevention as evidenced by no falls through 4/16/11. Review of the resident's care plan revealed the resident's 3/1/11 fall incident had not been reflected on the care plan. There was also no documentation to reflect revisions or new approaches added to the resident's care plan to prevent further falls. Interview with the S10 LPN Unit Manager on 3/24/11 at 2:00 p.m. revealed their process was that falls were reported during their daily staff meetings to the Unit Manager, who then reviewed the fall incident and revised the care plan usually the next day. However, she indicated another Unit Manager had the resident at the time of the fall and the Unit Manager had been transferred to work on the floor. She confirmed the care plan had not been reviewed and revised to address the resident's fall on 3/1/11. Interview with S9 LPN on 3/25/11 at 9:35 a.m. revealed she was unable to follow through on the resident's 3/1/11 fall incident and had turned over those incidents to S10 LPN because she had been transferred back to work as a floor nurse on 3/2/11 and was no longer working as a Unit Manager. Interview with S2 DON on 3/25/11 at 9:54 a.m. confirmed the resident's care plan was not reviewed and revised to address the 3/1/11 fall because of the change in Unit Managers. 3. Observations of resident #13 on 3/21/2011 at 10:30 a.m., 3/22/2011 at 8:00 a.m., and 3/23/2011 at 11:00 a.m. and 11:35 a.m. revealed the resident was lying in her bed. The resident was observed to have bilateral hand contractures, and there were no hand splints in place. Review of the Annual MDS assessment dated [DATE] reflected the resident had functional limitations in range of motion impairment of both hands Review of the care plan, goal date of 5/6/11, reflected a problem for multiple contractures and at risk for further contractures. Review of the approaches for the problem did not reflect any interventions for contractures. Interview on 3/24/2011 at 1:35 p.m. with S7 LPN/ MDS confirmed the resident's care plan did not include interventions to prevent further contractures. 4. Review of resident #3's physician's telephone orders reflected an order dated 7/15/10 to admit the resident to hospice with a [DIAGNOSES REDACTED]. Interview on 3/23/11 at 11:05 a.m. with S11 LPN confirmed the resident received hospice services, including nurse and CNA visits. Review of the care plan with a goal date of 5/26/11 reflected no problems or approaches for hospice. Interview on 3/23/11 at 2:00 p.m. with S2 DON confirmed the resident's care plan did not include hospice services. She also confirmed the care plan should have included hospice services with approaches and interventions specific to the services that were to be provided. 5. Review of resident #10's care plan dated 7/1/10 revealed a problem of ROM. Further review of the care plan revealed the problem had been discontinued on 10/1/10. Interview on 3/23/11 at 2:30 p.m. with S8 LPN revealed the CNAs were performing ROM exercises for the resident daily during ADL care. Interview on 3/24/11 at 1:45 a.m. with S7 MDS/LPN confirmed the care plan dated 7/1/10 for ROM had been discontinued on 10/1/10 due to unrealistic approaches for the resident. S7 confirmed the resident's care plan had not been updated with realistic approaches for ROM needs. Further interview on 3/24/11 at 11:20 a.m. with S2 DON revealed resident #10 had an indwelling urinary catheter. S2 DON revealed the resident had returned to the facility with the catheter on 1/28/11 after a hospitalization . Further review of resident #10's care plan dated 7/1/10 did not reflect a problem or interventions for the resident's indwelling urinary catheter. Interview on 3/24/11 at 1:45 a.m. with S7 MDS/LPN confirmed the resident's current care plan did not reflect a problem, goal, or approaches for the resident's urinary catheter. 6. Review of resident #33's current care plan reflected a problem for range of motion which had been discontinued on 10/11/10. Interview on 3/23/11 at 2:30 p.m. with S8 LPN revealed the CNAs were currently performing ROM exercises for the resident during ADL care each day. Interview on 3/24/11 at 1:45 a.m. with S7 MDS/LPN confirmed the care plan dated 10/11/10 for ROM with a target date of 1/11/11 had been discontinued because the goals were unrealistic. There was no date when the care plan for ROM had been discontinued. Further interview with S7 MDS/LPN confirmed the resident's care plan had not been updated with realistic approaches for ROM.

Based on observation, interview and record review the facility failed to provide services by qualified persons in accordance with each resident's written plan of care by failing to ensure the RD's recommendations for a resident's estimated fluid needs were followed (#61) and a nurse trimmed a diabetic resident's nails (#3) for 2 of 30 Stage II sampled residents. The facility's total census was 76 according to the Resident Census and Conditions of Residents form. The facility failed to: 1. ensure RD recommendations for fluid intake were followed (#61) and 2. ensure a nurse trimmed a diabetic resident's nails (#3). Resident #61 was admitted to the facility on [DATE]. The RD assessed the resident on 12/28/10 and recommended a daily fluid intake of 1400 - 1792 cc. There was no evidence the physician was notified of the recommended fluid needs, nor was there evidence the resident was receiving the recommended fluids. The resident's plan of care failed to include interventions for meeting or monitoring the recommended fluid needs. The resident began to show s/s of UTI on 1/11/11 at 6:00 p.m. with increased confusion, foul smelling urine and complaints of burning upon urination. The resident was hospitalized from [DATE] until 1/28/11 with [DIAGNOSES REDACTED]. Upon return from the hospital, the facility did not put any measures in place to ensure the resident was meeting the recommended fluid needs and she was hospitalized again from 2/2/11 until 2/17/11 with [DIAGNOSES REDACTED]. Upon return from the hospital, the facility still did not follow up on the RD's fluid recommendations and the resident was diagnosed with [REDACTED]. Findings: 1. Observation on 3/21/11 at 12:15 p.m. revealed resident #61 was seated at a table in the dining room. The resident was being fed by the CNA when her son entered the dining room and began to feed her. Review of the resident's Accumulative [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Review of the resident's current MDS dated [DATE] reflected the resident was totally dependent for eating and drinking with one staff assistance. Review of the Assessment of Dehydration Risk form dated 12/17/10 reflected the resident was coded as "6". The form reflected a resident was at low risk with a score of 00-08 and high risk with a score of 09-20. The form also reflected a resident might be at risk with abnormal lab values in spite of other scores. Review of the resident's record reflected there were no lab values in the record to aid in determining the resident's dehydration risk. Review of the Nutritional Assessment form dated 12/28/10 reflected the RD assessed the resident's estimated nutritional needs as requiring a daily fluid intake of 1400 - 1792 cc. The RD documented there were no lab results available at the time of the assessment. Review of the record reflected there was no documentation the resident's physician was notified of the RD recommendations. Further review reflected the care plan, goal date of 3/28/11, did not include any interventions for the resident meeting the fluid recommendations, nor for monitoring if the resident received the recommended fluids. Interview on 3/25/11 at 10:00 a.m. with S2 DON confirmed the RD recommendations dated 12/28/10 included estimated fluid needs of 1400 - 1792 cc for the resident. S2 stated the RD would leave specific recommendations for a resident and the Unit Manager would fax those recommendations to the physician. S2 stated the information left by the RD to fax to the physician did not include fluid recommendations. S2 confirmed the physician was never notified of the estimated fluid needs documented by the RD. S2 also confirmed the resident was never placed on intake and output or any other type of monitoring system to ensure she received the estimated fluid needs identified by the RD. Review of the Bladder Continence assessment dated [DATE] reflected the resident's fluid intake was fair (1000-2000 cc daily). However, there was no documentation to reflect the resident's actual fluid intake was being monitored. Review of the nurse's note dated 1/12/11 at 1:59 a.m. reflected the resident was admitted to the hospital with [REDACTED]. Review of the facility's Readmission assessment dated [DATE] reflected the resident's admitting [DIAGNOSES REDACTED]. Review of the nurse's note dated 2/2/11 at 1:00 a.m. reflected the resident was sent to the hospital for evaluation and treatment. Review of the hospital's History and Physical reflected the resident was admitted on [DATE]. The impression included Pneumonia, recurrent, Dehydration, Pyuria, rule out UTI and Dementia. The plan included to admit for IV antibiotics and IV fluids for correction of Dehydration. Review of the hospital's Discharge Summary dated 2/17/11 reflected the resident was admitted for treatment of [REDACTED]. The final [DIAGNOSES REDACTED]. Review of the facility's Readmission assessment dated [DATE] reflected the admitting [DIAGNOSES REDACTED]. The thickened liquids had been discontinued. Review of the Assessment of Dehydration Risk dated 2/17/11 reflected the resident was identified as high risk with a score of "9" upon return from the hospital. Review of the Bladder Continence assessment dated [DATE] reflected the resident's fluid intake was poor (500 - 1000 cc daily). Review of the Instant Care Plan dated 2/17/11, following the resident's hospitalization for Dehydration and UTI, reflected an intervention was checked to encourage fluid intake. However, there was no documentation how often the resident was offered fluids, or if she accepted the fluids when offered. Review of the nurse's note dated 3/1/11 at 3:00 p.m. reflected the CNA reported the resident's urine had a foul odor. A new order was obtained for a U/A and urine C&S. Review of the nurse's note dated 3/2/11 at 4:40 p.m. reflected the U/A results had been received and faxed to the physician. A new order was received for Bactrim DS (an antibiotic) 1 po bid x 10 days, dx: UTI. The nurses' notes did reflect that fluids were encouraged for the resident but there was no documentation if the resident accepted the fluids. Review of the RD note dated 3/11/11 at 3:37 p.m. reflected the RD had again assessed the resident's estimated fluid needs as 1400-1792 cc of water daily. She also recommended adding [MEDICATION NAME] supplement 1 cup q day for additional calories. There was no documentation the physician was notified of the recommendations until 3/16/11 at 11:59 a.m. when a fax was sent to the physician's office regarding the resident's weight loss and the RD recommendations to add [MEDICATION NAME]. The physician was not notified of the RD recommendations for fluid intake. Review of the Meal Intake form provided by S2 DON reflected the resident's fluid intake was monitored during meal times. However, the form did not reflect if the resident was offered any other fluids, or if she received any other fluids throughout the day. Interview with S2 DON on 3/25/11 at 10:15 a.m. confirmed the form was not used for monitoring the resident's daily fluid intake as recommended by the RD. 2. Observation on 3/23/11 at 10:46 a.m. revealed S12 CNA was trimming resident #3's fingernails in her room. Further observation revealed S13 CNA was present in the room. Review of the resident's Accumulative [DIAGNOSES REDACTED]. Review of the March 2011 physician's orders [REDACTED]. Review of the care plan with a goal date of 5/26/11 reflected a history of DM. The approaches reflected the nurse was to trim the resident's fingernails and toenails per NH routine. Interview on 3/23/11 at 2:00 p.m. with S2 DON confirmed diabetic residents' nails should be trimmed by a nurse. Interview on 3/23/11 at 2:15 p.m. with S13 CNA confirmed S12 CNA had trimmed the resident's fingernails that morning. S12 also confirmed the resident was diabetic, and her nails should be trimmed by a nurse.

Based on observation, interview and record review the facility failed to provide the necessary care and services to ensure a resident maintained the highest practicable physical, mental and psychosocial well-being for 1 of 3 residents investigated for hospitalization in a total of 30 Stage II sampled residents (#61). The facility's total census was 76 according to the Resident Census and Conditions of Residents form. The facility failed to: 1. ensure RD recommendations for fluid intake were followed; 2. ensure a resident hospitalized for [REDACTED]. The resident was hospitalized again 5 days later for Dehydration and UTI. The resident was not assessed upon return from the hospital for increased risk of UTI and was diagnosed with [REDACTED]. 3. review and revise the resident's comprehensive care plan to include specific interventions to prevent the recurrence of Dehydration and UTI; and 4. notify the resident's physician timely of changes in the resident's condition. Resident #61 was admitted to the facility on [DATE]. The RD assessed the resident on 12/28/10 and recommended a daily fluid intake of 1400 - 1792 cc. There was no evidence the physician was notified of the recommended fluid needs, nor was there evidence the resident was receiving the recommended fluids. The resident's plan of care failed to include interventions for meeting or monitoring the recommended fluid needs. The resident began to show s/s of UTI on 1/11/11 at 6:00 p.m. with increased confusion, foul smelling urine and complaints of burning upon urination. The facility did not notify the physician of the resident's complaints until she was sent to the emergency room by ambulance at 10:10 p.m. per standing orders. The resident was admitted to the hospital with [REDACTED]. The resident returned to the facility on [DATE]. There were no assessments of the resident upon return from the hospital identifying her as being at risk for Dehydration or UTI, nor was the resident's care plan updated to include interventions for the prevention of Dehydration or UTI. On 2/1/11 the resident was noted with diminished lung sounds with crackles to the left side, and an O2 sat of 81% on room air. The facility notified the physician via a fax to his office at 8:50 p.m., although it was after office hours. The resident was readmitted to the hospital on [DATE] at 1:00 a.m. with [DIAGNOSES REDACTED]. The resident returned to the facility on [DATE]. The resident was assessed as being at high risk for Dehydration at that time but the care plan was not updated to include interventions to prevent or monitor for signs of Dehydration. There was no evidence the facility put any measures in place to prevent Dehydration or UTI. On 3/1/11, the physician ordered a U/A and urine C&S due to a report of the resident's urine having a foul odor. A new order was obtained on 3/2/11 for an antibiotic due to UTI. The facility failed to put any new measures in place with the new [DIAGNOSES REDACTED]. Findings: Observation on 3/21/11 at 12:15 p.m. revealed resident #61 was seated at a table in the dining room. The resident was being fed by the CNA when her son entered the dining room and began to feed her. Review of the resident's Accumulative [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Review of the resident's current MDS dated [DATE] reflected the resident was totally dependent for eating and drinking with one staff assistance. Review of the Assessment of Dehydration Risk form dated 12/17/10 reflected the resident was coded as "6". The form reflected a resident was at low risk with a score of 00-08 and high risk with a score of 09-20. The form also reflected a resident might be at risk with abnormal lab values in spite of other scores. Review of the resident's record reflected there were no lab values in the record to aid in determining the resident's dehydration risk. Review of the Nutritional Assessment form dated 12/28/10 reflected the RD assessed the resident's estimated nutritional needs as requiring a daily fluid intake of 1400 - 1792 cc. The RD documented there were no lab results available at the time of the assessment. Review of the record reflected there was no documentation the resident's physician was notified of the RD recommendations. Further review reflected the care plan, goal date of 3/28/11, did not include any interventions for the resident meeting the fluid recommendations, nor for monitoring if the resident received the recommended fluids. Interview on 3/25/11 at 10:00 a.m. with S2 DON confirmed the RD recommendations dated 12/28/10 included estimated fluid needs of 1400 - 1792 cc for the resident. S2 stated the RD would leave specific recommendations for a resident and the Unit Manager would fax those recommendations to the physician. S2 stated the information left by the RD to fax to the physician did not include fluid recommendations. S2 confirmed the physician was never notified of the estimated fluid needs documented by the RD. S2 also confirmed the resident was never placed on intake and output or any other type of monitoring system to ensure she received the estimated fluid needs identified by the RD Review of the Bladder Continence assessment dated [DATE] reflected the resident's fluid intake was fair (1000-2000 cc daily). However, there was no documentation to reflect the resident's actual fluid intake was being monitored. Review of the nurse's note dated 12/17/10 at 7:08 p.m. reflected a new order was obtained to change the resident's diet to pureed with honey thickened liquids. Review of the nurse's note dated 1/7/11 at 7:07 p.m. reflected a new order had been received for [MEDICATION NAME] Sodium (stool softener) 200 mg po every day after the resident had received multiple doses of prn MOM (laxative) for constipation, and the family had requested a stool softener for constipation. There were no assessments for possible factors contributing to the resident's on-going problems with constipation. Review of the nurse's note dated 1/11/11 at 9:04 p.m. reflected the note was a late entry for 6:00 p.m. when the resident began to show signs of UTI. The note reflected the resident had increased confusion, foul smelling urine and burning upon urination. The resident's daughter was notified and requested the staff give the resident cranberry juice. The resident's daughter also stated she wanted to think about sending the resident to the doctor. Review of the nurse's note dated 1/12/11 at 12:15 a.m. reflected the resident was assisted to the bedside commode on 1/11/11 at 9:00 p.m. The resident was complaining of burning and lower abdominal pain with urination. The resident's urine was dark yellow with foul odor and a small amount of blood. The resident also had increased confusion. The resident's daughter was called again and requested the resident be encouraged to drink water and cranberry juice. She stated she would come to the facility, and she did not want the resident sent to the hospital. The note reflected the resident was offered honey thickened water but the resident refused. Review of the nurse's note dated 1/11/11 at 9:45 p.m. reflected the daughter arrived to the facility and wanted the resident sent to the emergency room . The resident was sent to the hospital at 10:10 p.m. per ambulance by physician's standing order. There was no documentation in the nurses' notes to reflect the resident's physician was notified of the resident's increased confusion, signs of UTI or refusal of water. Review of the hospital's lab results, which were faxed to the facility during the survey on 3/25/11, reflected the chemistry results dated 1/11/11 at 2315 (11:15 p.m.) indicated a BUN of 27H. The normal range was 5 -20 mg/dL. The U/A results reflected the following abnormal results with the corresponding normals: Clarity - slightly cloudy (clear) Bilirubin - small (negative) [MEDICATION NAME] - trace (negative) Blood - large (negative) Protein - 100 (negative) Leukocytes - moderate (negative) WBC - TNTC (negative) RBC - 20-30 (negative) Mucus - Moderate (negative) Bacteria - 2+ (negative). Review of the nurse's note dated 1/12/11 at 1:59 a.m. reflected the resident was admitted to the hospital with [REDACTED]. Interview on 3/25/11 at 10:00 a.m. with S2 DON confirmed the resident's physician was never contacted regarding the change in her condition on 1/11/11. Review of the Readmission assessment dated [DATE] reflected the resident's admitting [DIAGNOSES REDACTED]. Review of the Dehydration Risk Assessment reflected there was no reassessment of the resident's dehydration risks following the hospital return on 1/28/11. Review of the care plan reflected it was not updated following the hospital stay to include approaches to prevent or monitor for Dehydration or UTI. Review of the nurse's note dated 2/2/11 at 1:37 a.m. reflected the CNA reported on 2/1/11 at 8:50 p.m. that the resident was on the floor mat next to the bed. The resident was noted to have diminished lung sounds with crackles to the left side, and an O2 sat of 81% on room air. O2 per nasal cannula was applied and the physician was notified via FYI sheet faxed to his office. The resident's vital signs were: T - 98.3, P - 95, R - 20 and B/P - 160/36. At 10:40 p.m., the resident was found on the floor mat again. The resident was assessed with [REDACTED]. O2 sat was 90% with O2 @ 2L. There was no documentation to reflect any further attempts to notify the physician of the resident's condition other than the fax sent to the office at 8:50 p.m. There was also no documentation to reflect verification was made that the physician's office was open at that time, or the fax was received. Further review of the nurses' notes dated 2/2/11 at 1:37 a.m. reflected on 2/1/11 at 11:30 p.m. the resident was asleep with an O2 sat of 92% with O2 per NC. At 1:00 a.m., the resident was awake, lethargic and the lung sounds were diminished with crackles to the left lung. The resident was having labored breathing. An order was obtained to send the resident to the hospital for evaluation and treatment. Review of the hospital's lab results, which were faxed to the facility during the survey on 3/25/11, reflected the Hematology results dated 2/2/11 at 0326 (3:26 a.m.) included the following abnormal results with the corresponding normals: WBC - 14.2H (4.5 - 11.0 K/uL), Review of the Chemistry results dated 2/2/11 at 0354 (3:54 am.) indicated the following abnormal results with the corresponding normals: BUN - 44H (5 - 20 mg/dL) Cr - 1.9H ( 0.5 - 1.4 mg/dL) Potassium - 5.3H (3.4 - 4.7 mmol/L), and the U/A reflected the following abnormal results with the corresponding normals: [MEDICATION NAME] - trace (negative) Blood - small (negative) Protein - 100 (negative) Leukocytes - trace (negative) WBC - 20-25 (negative) RBC - 1-3 (negative) Mucus - Much (negative) Bacteria - 3+ (negative). Review of the hospital's History and Physical reflected the resident was admitted on [DATE]. The impression included Pneumonia, recurrent, Dehydration, Pyuria, rule out UTI and Dementia. The plan included to admit for IV antibiotics and IV fluids for correction of Dehydration. Review of the hospital's Discharge Summary dated 2/17/11 reflected the resident was admitted for treatment of [REDACTED]. The final [DIAGNOSES REDACTED]. Review of the facility's Readmission assessment dated [DATE] reflected the admitting [DIAGNOSES REDACTED]. The thickened liquids had been discontinued. Review of the Assessment of Dehydration Risk dated 2/17/11 reflected the resident was identified as high risk with a score of "9" upon return from the hospital. Review of the Bladder Continence assessment dated [DATE] reflected the resident's fluid intake was poor (500 - 1000 cc daily). Review of the Instant Care Plan dated 2/17/11, following the resident's hospitalization for Dehydration and UTI, reflected an intervention was checked to encourage fluid intake. However, there was no documentation how often the resident was offered fluids, or if she accepted the fluids when offered. Also, there were no measures put in place to monitor the resident for signs of Dehydration or UTI after her hospital stay, and after she was assessed as being at high risk for dehydration and having poor fluid intake. Interview on 3/25/11 at 10:00 a.m. with S2 DON reflected risk assessments were done quarterly. S2 stated the facility had recently implemented a plan to update the risk assessments upon return from the hospital. S2 confirmed the plan was not in place when the resident returned from the hospital on [DATE], and the dehydration risk assessment had not been updated. S2 DON also confirmed a resident identified as being at high risk on an assessment should have the care plan updated with goals and interventions for the identified problem. S2 confirmed the Assessment for Dehydration Risk completed on 2/17/11 identified the resident at high risk for dehydration. Review of the nurse's note dated 3/1/11 at 3:00 p.m. reflected the CNA reported the resident's urine had a foul odor. A new order was obtained for a U/A and urine C&S. Review of the nurse's note dated 3/1/11 at 8:39 p.m. reflected the nurse had been unable to collect the urine specimen due to the resident was up in the geri chair in the lobby and did not want to go to bed. There was no documentation to reflect when the urine specimen was collected. Review of the U/A results dated 3/2/11 reflected the following abnormal results with the corresponding normals: Bilirubin - small (negative) [MEDICATION NAME] - trace (negative) Blood - small (negative) Protein - 100 (negative) Leukocytes - small (negative) WBC - 8-12 (negative) RBC - 12-14 (negative) Bacteria - 4+ (negative). Review of the nurse's note dated 3/2/11 at 4:40 p.m. reflected the U/A results had been received and faxed to the physician. A new order was received for Bactrim DS (an antibiotic) 1 po bid x 10 days, dx: UTI. The nurses' notes did reflect that fluids were encouraged for the resident but there was no documentation if the resident accepted the fluids. There was no documentation to reflect any interventions were put into place due to the resident's [DIAGNOSES REDACTED]. Review of the RD note dated 3/11/11 at 3:37 p.m. reflected the RD had again assessed the resident's estimated fluid needs as 1400-1792 cc of water daily. She also recommended adding [MEDICATION NAME] supplement 1 cup q day for additional calories. There was no documentation the physician was notified of the recommendations until 3/16/11 at 11:59 a.m. when a fax was sent to the physician's office regarding the resident's weight loss and the RD recommendations to add [MEDICATION NAME]. The physician was not notified of the RD recommendations for fluid intake. Further interview on 3/25/11 at 10:00 a.m. with S2 DON revealed the resident had been receiving thickened liquids until the hospital return on 2/17/11. She stated the resident would frequently refuse the thickened liquids prior to being hospitalized so the order was discontinued during the hospital stay. There was no documentation to reflect the physician was notified of the resident's refusal to drink thickened liquids. Review of the Meal Intake form provided by S2 DON reflected the resident's fluid intake was monitored during meal times. However, the form did not reflect if the resident was offered any other fluids, or if she received any other fluids throughout the day. Interview with S2 DON on 3/25/11 at 10:15 a.m. confirmed the form was not used for monitoring the resident's daily fluid intake.