Every finding on record at Palmetto Care Center and Rehab

Based on observations, interviews and record reviews facility failed to keep residents' information confidential on the South Wing as evidenced by facility's staff failed to close a computer screen on the south medication cart #2 during medication administration which left residents' information visible and staff member administering medications to Resident #89 in the hallway. There were 86 residents residing in the facility at the time of the survey. The findings included. Observation on 02/23/2026 at 9:28 AM revealed Staff D, Registered Nurse (RN) leaving the computer screen open (photo evidence) on the South Wing Cart 2 medication cart during medication pass. Interview on 02/23/2026 at 10:00 AM Staff D, RN stated: I understand that Health Insurance Portability and Accountability Act (HIPAA) involve protecting patient information and maintaining privacy, including using privacy curtains during patient care. Examples of HIPAA compliance include locking the computer screen and medication cart before walking away to prevent unauthorized access to patient information. Computer screens should not be left open and unattended. On 02/24/2026 at 2:12 PM an observation revealed Staff I, Registered Nurse (RN) administering medications to Resident # 89 in unit the South hallway. On 02/24/2026 at 2:17 PM Staff I, RN was interviewed about the facility's protocol for providing privacy during medication administration and stated, The protocol is to administer medications inside residents' room. I did not do this because the resident is going to an appointment and asked for pain medication. Interview on 02/25/2026 at 11:53 AM, the Director of Nursing (DON) stated: The nurses should maintain HIPAA compliance and protect patient confidentiality by ensuring that medical records are always kept covered and not discussed out loud in public or common areas. Staff are reminded to avoid sharing sensitive information where others could overhear, reinforcing the importance of maintaining privacy. The nurses also take precautions to safeguard both electronic and written records. Computers should never be left open or unattended, and medication carts and computer screens are kept locked whenever the nurse is not physically present. Staff receive HIPAA and confidentiality training through an online platform, which is completed annually to ensure compliance with current best practices. Record review of the facility's policy titled, Confidentiality of Information and Personal Privacy dated February 2021 revealed Policy Statement: Our facility will protect and safeguard resident confidentiality and personal privacy.

Based on record review and interviews the facility failed to provide quality of care according to professional standards for one (Resident #97) out of one resident sampled who was in respiratory distress as evidenced by record review revealed an antidepressant was given while Resident #97 was in respiratory distress. This medication had the potential to worsen Resident #97's condition. There were 86 residents residing in the facility at the time of survey. The findings include:Record review of Resident # 97's clinical records revealed the resident was admitted to the facility on [DATE] with diagnosis that included: Heart Failure and discharged on 7/3/25 due to respiratory distress. Record review of a Quarterly Minimum Data Set reference dated 7/3/25 revealed Resident # 97 had a Brief Interview of Mental Status score of 15, indicated no cognitive impairment and received oxygen therapy. Record review of a care plan initiated on 4/11/24 revealed Resident # 97 had self-care deficit with interventions included to observe for medication side effects. Record review of a physician's order sheet for Resident #97 revealed orders dated 7/3/25 for Trazodone Hydrochloride (HCl) Oral Tablet 50 milligram (mg). Give 0.5 tablet by mouth two times a day related to Major Depressive Disorder. Record review of a Nursing notes dated 7/3/2024 timestamped 1:00 PM indicated Resident # 97 was in bed awake drowsy, vital were taken, and oxygen was applied at 2 Liters per minute.Record review of an order note dated 7/3/2024 timestamped 1:05 PM revealed Resident # 97 was administered Trazodone Hydrochloride (HCl) Oral Tablet 50 MG, 0.5 tablet.Review of nursing notes dated 7/3/2025 revealed at 1:45 PM Resident # 97 continued with shortness of breath (SOB), very lethargic, and 911 was called.Record review of Resident # 97's July 2025 Medication Administration Record (MAR) revealed a signature on 7/3/2025 at 2:00 PM that indicated Trazodone Hydrochloride (HCl) Oral Tablet 50 milligrams (mg), half tablet was administered to Resident # 97.Interview on 02/26/2026 at 10:51 AM; the Director of Nursing stated: On 7/3/25 at 8:00 AM [Resident # 97] reported not feeling well and the nurse measured vitals and informed the medical doctor. Around 1:00 PM, the Oxygen saturation was 89% and [Resident # 97] was drowsy and the nurse administered Trazodone. In this situation the trazodone should not be given because [Resident # 97] was drowsy and side effects of Trazodone includes sedation.Record review of the facility's policy titled, Compliance Risks - Resident Quality of Care and Quality of Life dated January 2025 indicated. Policy Statement:Compliance with the Medicare and Medicaid Requirements of Participation for resident quality of care and resident quality of life is consistent with the goals of the overall compliance and ethics program. The facility does not submit claims for reimbursement that do not meet professional standards of quality.

Based on observation, record review and interview, the facility failed to provide an environment that is free from potential accidents and hazards on one (medication cart #1) out of four medication carts, one out of two Soiled utility rooms as evidenced by: Observation of lancets on top of the South Wing medication cart #1, unattended. Observation of an unlocked Soiled Utility Room door that contained Biohazard materials. A container of disinfectant wipes Resident #89's nightstand. Box of razors left unattended in the North Wing. There were 86 residents residing in the facility at the time of survey. The findings include:1) On [DATE] at 6:05 AM an observation was made of lancets left unattended on top of the South Wing medication cart #1(photo).On [DATE] at 6:07 AM, Staff H, Registered Nurse (RN) was notified and revealed lancets are to be keep locked in the carts. 2) On [DATE] at 6:21 AM an observation was made of The Soiled Utility room door left unlocked.On [DATE] at 6:30 AM Staff H, RN was notified and stated, The door is to be locked.During an interview on [DATE] at 6:58 AM, the Director of Nursing (DON) stated: The Soiled Utility room to be kept locked for infection control and the safety of residents. Also revealed the room contains Biohazard materials. 3) On [DATE] at 6:50 AM a container labeled Disinfectant wipes was observed at Resident # 89's bedside.On [DATE] at 6:52 AM, the DON was made aware and removed the container. The DON revealed the wipes are to be kept in the drawer.Record review of a demographic sheet revealed Resident # 89 was admitted to the facility on [DATE] with diagnosis that included but not limited to: Orthopedic aftercare. Record review of an admission Minimum Data Set reference dated [DATE] revealed Resident # 89 had a Brief Interview for Mental Status score of 15 indicated no cognitive impairment, required set up clean up assistance for eating and substantial/ maximal assistance for toileting and was dependent for transfers.Record review of a care plan initiated on [DATE] revealed Resident # 89 displayed deceased safety awareness related to generalized weakness after surgery with interventions that included: Self-care management training.Record review of a February 2026 physician orders sheet for Resident # 89 revealed order dated [DATE] for Mobility: Activities as tolerated. 4) Observation on [DATE] at 10:10 AM, on the North Wing revealed a box containing razors and an open box containing A&D ointments on an unattended wheeled platform utility cart. On [DATE] at 10:15 AM, the central supply staff notified of the identified concern revealed the razors should not be left unattended for the safety of residents.Record review of facility's policy titled Hazardous Areas, Devices and Equipment undated revealed Policy Statement: All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety

Based on observations, interviews and record review the facility failed to ensure staffing information on the North Wing and South Wing were readily available in a readable format to residents and visitors at any given time. The findings included: Record review of the Posting Direct Care Daily Staffing Numbers Policy and Procedure (no written date available) documented: Policy Statement: Our facility will post on a daily basis for each shit nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents; Policy Interpretation and Implementation: 1) Within two hours of the beginning of each shift, the number of licensed nurses (Registered Nurses-RN, Licensed Practical Nurses-LPN) and the number of unlicensed nursing personnel (Certified Nursing Assistants-CNA, Nursing Assistants-NA) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format and 2) Directly responsible for resident care means that individuals are responsible for residents' total care or some aspect of the residents' care. Shift staffing information is recorded on a form for each shift. The information recorded on the form shall include the following: b) The current date (the date for which the information is posted); c) The resident census at the beginning of the shift for which the information is posted; e) The shift for which the information is posted; f) Type (RN, LPN or CNA) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility (including contract staff); g) The actual time worked during that shift for each category and type of nursing staff and h) Total number of licensed and non-licensed nursing staff working for the posted shift. 1) Observation of the South Wing Nursing Assignments board on 2/23/26 at 6:05 AM revealed information documented was for the oncoming 7:00 AM to 3:30 PM shift. Photographic evidence. 2) Observation of the North Wing Nursing assignments board on 2/23/26 at 6:07 AM revealed the board had staffing information documented assignments for the 7:00 AM to 3:00 PM shift for 2/23/26. It did not have staffing assignments documented for the 11:00 PM to 7:00 AM shift for 2/22/26. Photographic evidence submitted. Interview with Staff E, Registered Nurse (RN) on 2/23/26 at 6:49 AM. She revealed the staffing board is to be changed one hour before the next shift starts. She confirmed that the staffing board documented the 7:00 AM to 3:00 PM shift for 2/23/26 and not the 11:00 PM to 7:00 AM shift for 2/22/26. Interview with the Director of Nursing (DON) on 2/23/26 at 6:55 AM. She stated, The present shift changes the nursing board for the next shift. The DON confirmed that the staffing board should reflect the current nursing staff working. Interview with the Staffing coordinator on 02/24/2026 at 3:25 PM revealed the assignment boards are to be posted within two hours of the beginning of the current shift. I think the overnight staff were attempting to be proactive by posting the assignment early so the oncoming staff can know where to go.

Based on observations, record review and interviews, the facility failed to provide safe and secure storage of medications and biologicals on for two out of two medication carts failed to ensure no medications, biologicals, treatments ointments etc. are left at residents' bedsides. As evidence by 1) unattended medications observed on South Wing Cart #1. 2) wound cleanser at Residents #32's bedside. 3) bottle of topical medicated powder at Resident #95's bedside. 4) medication cup marked Zinc Oxide observed at Resident #34's bedside and bottle with discontinued morphine solution noted in North Wing Cart #2. The findings included. Observation on [DATE] at 6:05 AM revealed unattended crushed medication, lancets, alcohol pads and an uncovered water bottle on medication cart #1on the South wing nursing unit (photo). On [DATE] at 6:07 AM, Staff H, Registered Nurse (RN) was notified of the identified concerns and stated, Medications, lancets, alcohol pads and ointments are to be kept locked in the carts. On [DATE] at 6:33 AM, an observation was made of Resident#32 in bed with no apparent distress and a bottle marked [brand] Wound Cleanser was on the nightstand next to bed (photo). On [DATE] at 6:35 AM Resident #95 was observed in bed and a bottle marked [brand] topical powder was on the nightstand (photo). On [DATE] at 6:36 AM Staff H, RN was notified of the identified items at the residents' bedsides On [DATE] at 6:58 AM, the Director of Nursing stated: No medications, ointments or lancets are to be left unattended. All are to be stored in a locked cart. Record review of the facility's policy titled Medication Labeling and Storage dated February 2023 revealed Policy heading the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. On [DATE] at 07:17 AM, Resident #34 was observed in bed with eyes closed. A medication container labeled Zinc Oxide Ointment was noted on the night table. On [DATE] at 7:18 AM Staff E Registered Nurse (RN) revealed the medication jar was empty and ready to be discarded but had not yet been removed. Interview with Director of Nursing on [DATE] 12:15 PM, revealed the facility's protocol prohibits keeping any medications, including over the counter products, in residents' rooms. Residents are educated that if family members bring any over the counter medications, these must be given directly to the nursing staff to ensure proper handling and compliance with safety procedures. Observation on [DATE] at 12:13 PM with Staff C, Registered Nurse (RN) during a narcotic count on North Wing Cart 2, it was revealed that a resident who expired on [DATE] at 18:29 Morphine Sulfate Oral Solution narcotic still remained in the cart as of [DATE] at 2:02 PM. Additionally, the Morphine Sulfate Oral Solution 100 mg/5 mL bottle shows 16 mL remaining, while the last documented administration was 12.5 mL on [DATE] at 01:03. Interview on [DATE] at 1:41 PM the Director of Nursing (DON) stated: Medications and narcotics are expected to be removed from the medication cart following a resident's discharge. however, in this instance the resident expired over the weekend, and removal had not yet occurred. Narcotics are discarded according to facility protocol either with the pharmacy, the Assistant Director of Nursing (ADON), or another authorized nurse administering the waste process. Interview on [DATE] at 2:18 PM with Pharmacist Consultant stated: Once a resident is discharged or expires, narcotics should be removed from the medication cart and secured for destruction, although the exact timeframe may depend on the facility's policy.' Record review of the facility's policy titled Controlled substances [DATE] stated 22. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in an area with restricted access until destroyed.23. Accountability records for discontinued controlled substances are kept with the unused supply until it is destroyed or disposed of as required by applicable law or regulation.24. The consultant pharmacist or designee routinely monitors controlled substance storage records. Record review of the facility's policy titled Medication Labeling and Storage February 2023 stated 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observations, interviews and record review the facility failed to store food under sanitary condition as evidenced by resident's food items were not dated and labeled in the South Wing Pantry refrigerator. This has the potential to affect seven-nine out of eighty-six residents who eat orally residing in the facility at the time of the survey.The findings included: Record review of the Foods Brought by Family/Visitors Policy and Procedure (no written date); Policy Statement-Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents; Policy Interpretation and Implementation: 7) Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food; b) Containers will be labeled with the resident's name, the item and the use by date and 8) The nursing staff will discard perishable foods on or before the use by date.Observation of the South Wing Pantry refrigerator used to store resident's foods on 02/23/26 at 07:03 AM revealed the refrigerator contained a bag with one container of yogurt and one container of cottage cheese. The bag was not labeled or dated. Photographic evidence submitted.Observation and interview with the DON on 02/23/26 at 07:33 AM. She stated, Since there is no name or date on this bag, I am throwing it away in the garbage. She confirmed that food items in the refrigerator should be labeled and dated.

Based on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F583 Personal Privacy/Confidentiality of Records related to the facility's staff failed to close a computer screen on the South medication cart # 2 during medication administration which left resident's information visible and it was observed a staff member administering medications to Resident # 89 in the hallways and F880 Infection Prevention and Control failed to ensure infection control standards were followed on the South Wing Soiled Utility Room and for one (Resident # 96) out of one sample resident receiving oxygen as evidenced by 1)Observation of facility's staff placing a dirty nasal cannula into Resident # 96's nostrils. 2) Observation of facility's staff exiting the Soiled Utility room without performing hand hygiene. This deficient practice had the potential to affect 86 residents residing in the facility at the time of survey. The findings included.The findings included:Record review of the facility's survey history revealed, during a recertification survey with exit dated February 27, 2025. F583 Personal Privacy/Confidentially of Records facility failed to safeguard and ensure privacy of resident's confidential Electronic Health Records (EHR); as evidenced by one out of four of the facility's medication carts' computer screen was left unlocked and unattended revealing resident's information. F880 Infection Prevention and Control, facility failed to follow infection prevention and control procedures for Resident # 183, as evidenced by Resident # 183's Spirometer was observed at Resident # 183's bedside with no protective covering. Interview with the Administrator on 02/26/2026 at 2:20 PM. She stated that the QAPI (Quality Assurance and Performance Improvement) meeting is held on the last Thursday of every month. She stated QAPI Committee included the Administrator, Director of Nursing, Medical Director, Social Services Director, Dietary Director, Infection Preventions, Medical Records Director, Nurse supervisors, the Maintenance Director, Environmental Director, MDS Coordinator and a Certified Nursing Assistant is invited. She stated they have a meeting every morning; staff revealed the issues from the prior day. She stated is the issue is high risk for residents; it is addressed immediately. She stated last month's meetings were discussed and working to prevent falls and it worked; the residents' fall incidents decreased in comparison to last year. She stated the facility reported that it is working to improve and maintain its systems by continuing to conduct audits of customer services, program advocacy processes, and quarterly resident sample interviews based on the critical pathway. The quality manager also interviews residents, family members, and staff involved with the same resident to support ongoing quality monitoring and service enhancement.Review of the Policy and Procedures for Quality Assurance and Performance Improvement (QAPI) Program not dated revealed Policy Statement: This facility shall develop, implement, and maintain an ongoing, facility-wide date-driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents. Policy Interpretation and Implementation: The objectives of the QAPI Program are to 1-Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2- Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3-Reinforce and build upon effective systems and processes related to the delivery of quality of care and services. 4-Establish systems through which to monitor and evaluate corrective actions.

Based on observations, interviews and record review the facility failed to ensure infection control standards were followed for one (Resident #96) out of one sampled resident receiving oxygen and the South Wing Soiled Utility Room as evidenced by: 1) Observation of facility's staff placing a dirty nasal cannula into Resident # 96's nostrils. 2) observation of facility's staff exiting the Soiled Utility room without performing hand hygiene. There were 86 residents residing in the facility at the time of survey. The findings include:Observation on 02/23/2026 at 6:39 AM in Resident # 96's room revealed the resident seated in a wheelchair; a nasal cannula was on the floor at the opposite side of the bed connected to the oxygen concentrator (photo).On 02/23/2026 at 6:40 AM Staff H, Registered Nurse (RN) was notified about the identified concern and stated, [Resident #96] requires continuous oxygen. Staff H, RN and surveyor entered the room and Staff H, RN picked up the nasal cannula from floor and placed into Resident # 96's nostrils. The Surveyor asked if this was within infection control protocol for oxygen supplies and Staff H, RN stated, The cannula was on the floor, and I should have used a new cannula. During an interview on 02/23/2026 at 6:58 AM, the Director of Nursing (DON) revealed oxygen tubing is to be stored in a dated bag with the room number and placed in the drawer. If a resident's nasal cannula comes out and is on the floor the nurse is to use the pulse oximeter and measure oxygen level then change the tubing and date it.Record review of a demographic sheet revealed Resident # 96 was admitted on [DATE] with Diagnosis that included but not limited to: Chronic Obstructive Pulmonary Disease (COPD) and Acute Pulmonary edema.Record review of a baseline care plan initiated on 2/2/2026 revealed Resident # 96 had the potential for complications of respiratory distress and the interventions included: Administer supplemental oxygen as ordered and perform lung sounds/respiratory assessment as needed.Record review of a physician order sheet revealed Resident#96 had an order dated:2/19/26 for Oxygen at 2 Liters per minute via Nasal Cannula as needed for Shortness of breath. 2) On 02/24/2026 at 12:01 PM, Staff J, Certified Nursing Assistant (CNA) was observed entering The Soiled Utility Room with a plastic bag of trash and exiting without performing hand hygiene.On 02/24/2026 at 12:07 PM the Assistant Director of Nursing/Infection Preventionist revealed staff are to perform hand hygiene before leaving the Soiled Utility Room. Interview on 02/24/2026 at 12:12 PM with Staff J, CNA (translated by other surveyor) Staff J, CNA revealed I did not wash my hands before exiting the Soiled Utility Room because I did not touch anything while in the room. Record review of facility's policy titled Infection Prevention and Control Program dated December 2025 revealed Policy Statement: An infection prevention and control (IPC) program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on observations record review an interview, the facility failed to safeguard and ensure privacy of residents' confidential Electronic Health Records (EHR); as evidenced by one out of four of the facility's medication carts' computer screen was left unlocked and unattended revealing residents' information. There were 88 residents residing in the facility at the time of the survey. The findings include: Observational tour of the facility on 02/25/25 at 07:21 AM revealed, the computer screen on unattended Medication Cart Two located on the South station was left unlocked with residents' Electronic Medication Administration Records (EMAR) visible. There were no nurses or other staff attending to the cart at the time. Interview on 02/25/25 at 08:20 AM, Registered Nurse (Staff B) stated: I know my EMAR screen on the South Medication Cart is supposed to be locked, I was rushing to go help a resident and forgot to lock the cart. Interview on 02/26/25 at 09:45 AM, the Director of Nursing was informed of the privacy and Health Insurance Portability and Accountability Act (HIPAA) concerns identified.

Based on observation, record review and interview, the facility failed to obtain orders for use of a Spirometer for Resident #183; as evidenced by Resident #183 was observed with a Spirometer and reported the equipment is used occasionally. The findings included: On 02/24/25 at 07:52 AM Resident #183 was observed in bed asleep, there was a Spirometer with no protective covering on the overbed table. Observation on 02/24/25 at 10:09 AM, the Spirometer was on the bedside table in Resident #183's room. On 02/25/25 at 09:00 AM, Resident #183 was observed in her room sitting in wheelchair; the Spirometer was on the bedside table. Resident #183 was asked about the Spirometer with Spanish translation conducted by a member of the survey team; Resident # 183 revealed she used the Spirometer occasionally. Interview on 02/25/25 at 09:13 AM, Licensed Practical Nurse (LPN), (Staff A) revealed she is assigned to Resident #183, and there was no order for use of the Spirometer, but sometimes when residents came from the hospital they may need to use it for a few days, and she will check with the supervisor if the resident is supposed to be using the Spirometer. Review of Resident #183's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to: Chronic Obstructive Pulmonary Disease. Review of the Physician's Order Sheet for February 2025 revealed Resident #183 had no prescribed orders documented for the use of the Spirometer. Review of Resident #183's Admission Minimum Data Set (MDS) assessment dated [DATE] Brief Interview for Mental Status (BIMS) documented a score of 15, on a 0-15 scale indicating the resident is cognitively intact. Record review of Resident #183 's Care Plans reference dated 02/17/2025 revealed: Resident has a potential for complications of respiratory distress related to diagnosis of cough. Interventions include Nebulizer treatments as ordered-observe for effectiveness, oxygen (02) saturation as ordered. Administer O2 as ordered. Vital signs as ordered and as needed. Perform lung sounds / respiratory assessment as needed. Encourage resident to take rest breaks with activity to minimize shortness of breath as needed. Observe for signs and symptoms of respiratory distress; update physician if noted. During an interview on 02/26/2025 at 09:47 AM, the Director of Nursing (DON) stated: I checked the Electronic Medication Administration Records (EMAR), and I do not see any orders for the use of the equipment. The assigned nurse contacted the resident's Physician (MD) on 2/25/2025 about the use of the Spirometer; apparently she came from the hospital with the Spirometer, or the family brought it into the facility. The MD stated the Spirometer is not necessary. Review of the facility's policy and procedure titled Use of Incentive Spirometer revision date 01/10/2025 indicate: The purpose of this policy is to ensure the appropriate and safe use of the incentive Spirometer to improve lung function, prevent respiratory complications, and promote optimal respiratory health in residents of the nursing home. Frequency and Duration: The residents should use the incentive Spirometer as ordered by the healthcare provider.

Based on observation, interview and record review the facility failed to follow pharmaceutical procedures for privacy, as evidence by failure to close the door and privacy curtains during medication administration for Residents #13 and Resident #36. There were 88 residents residing in the facility at the time of the survey. The findings included: On 02/25/25 at 08:00 AM during medication administration observation, Staff C, Registered Nurse (RN) no privacy was provided for Residents #13 and Resident #36, during medication administration; the residents' door and the privacy curtains were left open. Interview on 02/25/25 at 08:00 AM, Staff C, RN stated: I was so nervous, and I forgot to close the curtains and door to provide privacy for the two residents during medication administration. Interview on 02/26/25 at 09:45 AM, the Director of Nursing was informed of the privacy concerns identified during medication administration. Review of the facility's policy and procedure titled Administering Medications revision dated April 2019 documented: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Based on observation, record review and interview the facility failed to follow infection prevention and control procedures for Resident #183. As evidenced by Resident #183's Spirometer was observed at Resident #183's bedside with no protective covering. The findings included: On 02/24/25 at 07:52 AM, Resident #183 was observed in bed asleep, there was a Spirometer with no protective covering on the overbed table. Observation in Resident #183's room on 02/24/25 at 10:09 AM, the uncovered Spirometer was on the bedside table. Observation on 02/25/25 at 09:00 AM, Resident #183 was in her room sitting in wheelchair; the Spirometer on the bedside table was not in a protective covering. Resident #183 revealed she used the Spirometer occasionally. Interview on 02/25/25 at 09:13 AM, Licensed Practical Nurse (LPN), (Staff A) revealed she is assigned to Resident #183, and the Spirometer should be stored in a dated zippered bag when not in use for infection control reasons/issues. Review of Resident #183's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Chronic Obstructive Pulmonary Disease. Interview on 02/26/25 at 09:47 AM, the Director of Nursing (DON) revealed; when a resident's equipment is not being used, it is supposed to be stored in a [brand zippered bag] with the date it is replaced for infection control purposes and to protect the resident. Review of the facility policy and procedure titled Infection Prevention and Control, Revision date December 2023 states: The facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation: All personnel are trained on infection prevention and control policies and procedures upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.

Based on observations, record review and interviews, the facility failed to promote one (resident #18) out of 21 sampled residents dignity during dining. As evidenced by observations of staff standing over resident #18 while assisting to eating. This has the potential to affect the 43 residents residing in the facility who require assistance with feeding at the time of survey. The findings included: Observation on 09/25/23 at 8:23 AM in room [ROOM NUMBER] Staff C, a Certified Nursing Assistant (C N A) was observed standing while assisting resident #18 with breakfast. Observation on 09/27/23 at 1:00 PM in room [ROOM NUMBER] Staff A, a Registered Nurse (RN) was observed standing while assisting resident #18 with lunch. Record review of the Demographic face sheet revealed, resident #18 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included Dementia, Gastro-esophageal reflux disease, and Type 2 Diabetes. Record review of the quarterly Minimum Data Set (MDS) dated [DATE], Section C for cognitive patterns revealed a Brief Interview Mental Status score of 6, indicating resident #18 was severely cognitively impaired. Section G for functional status revealed resident #18 required extensive assistance by one person for all Activities of Daily Living (ADL). Section K for Weight Loss revealed resident #18 had no weight loss of 5% or more in the last month or 10% or more in last 6 months. Record review of the Care Plan dated 09/12/2023 revealed, Problem: Self-care deficit as evidenced by the need of assistance secondary to: Impaired mobility related to diagnosis of Dementia, Cerebrovascular Accident, left hemiplegia, Altered Mental Status, Hypertension. Interventions: Assist with Activities of Daily Living (ADLS) every shift and allow enough time for participation in care. Provide privacy and always maintain dignity. Staff to anticipate resident's needs with ADL's. Announce and introduce self while providing care and medications as ordered; observe for side effects and effectiveness. Breakdown tasks into subtasks and provide periods of rest as needed. Do frequent rounds. Encourage/remind resident to ask for assistance as needed. Explain procedures prior to beginning tasks or physical contact. Gather and set up supplies for care. Keep call light within reach and answer promptly. Observe for decline in ADL function; report to the physician as indicated. Praise her for all efforts. Provide assistance for transfer as indicated. Provide Range of Motion (ROM) during care. Physical therapy/ occupational therapy/ speech therapy screen prn. Interview on 09/25/2023 at 08:25 AM, Staff C stated, sometimes she stands and sometimes she sits. Staff C reported, she is aware that she should be sitting while assisting residents to eat. Interview on 09/25/2023 at 12:55 PM, Staff A stated, she is aware it is a dignity issue to stand over residents while assisting with meals. Staff A reported, moving forward she will sit while assisting any resident to eat. Review of the facility's policy and procedure entitled, Assistance with Meals (revised March 2022) revealed, the Policy statement: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy Interpretation and Implementation: Residents requiring full assistance: 2. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. not standing over residents while assisting them with meals.

Based on observation, interview, and record review, the facility failed to ensure the safety of a one vulnerable resident (#335) out of one (1) resident's reviewed for smoking. As evidenced by Resident #335 smoking in the facility's patio area without a smoking assessment or care plan and having cigarettes and a cigarette lighter in their personal belongings. There were 87 residents residing in the facility at the time of survey. The findings included: On 09/25/23 at 09:35AM, resident #335 was observed smoking on the smoking patio, with staff and family members in attendance. On 09/26/23 at 10:48 AM, resident #335 was observed in a wheelchair in the hallway returning from rehabilitation therapy, and stated she will not be smoking today because she has visitors. On 09/27/23 at 10:30 AM, resident #335 was observed in therapy exercising and stated, on admission she did not smoke because she did not feel like smoking, but recently she has been anxious and have been smoking 2-3 cigarettes a day. On 09/27/23 at 11:10 AM, observation of the smoking area revealed, 1 self-closing ashtray, 1 red self-closing metal bin, 1 fire blanket, and 1 fire extinguisher observed. The resident was not observed to be smoking at the time. On 9/28/23 at 12:20 PM, resident#335 was observed in a wheel chair on the patio smoking with a family member. A self closing astray was on table in front of the resident, and facility staff were in attendance on the patio. Interview on 09/25/23 at 01:11 PM via translator (Another surveyor on the team) the resident stated, she only smokes in the morning sometimes, she usually goes out to smoke after therapy, she keeps all of her smoking items with her. Resident #335 showed the surveyor her cigarettes in a small wallet case, and stated she also kept her cigarette lighter with her, but this morning on 9/25/23 after she came back from smoking, the social worker took her lighter away and told her the lighter will be kept at the nurses' station. The resident was very upset that the social worker took away her lighter today. Resident #335 reported, that they told her she has to pick her lighter up at the nurse's station. The resident refused to continue to be interviewed. Interview on 09/27/23 at 09:32 AM, with the Minimum Data Set (MDS) coordinator revealed, when asked about the Tobacco use coded-No in section J of the resident's MDS, it was reported, at the time of the resident's admission there was a smoking assessment completed on 8/29/23 on which the resident stated that she was not a smoker, and the MDS assessment was completed on 8/31/23 based on the information received from the smoking assessment on which the resident stated that she was not a smoker. On 9/25/23 another smoking assessment was completed for the resident and a smoking care plan was created. Interview on 09/27/23 at 09:43 AM, with the Social Services Director(SSD) revealed, when asked if Resident #335 is a smoker, it was reported, on admission, the assessment was completed and the resident stated that she did not smoke. The SSD stated when I was on the patio supervising another smoker on Monday (9/25/23), the resident came to the patio and stated she was there to smoke. I explained, to the resident information about our smoking policy. I went back to her later and explained to the resident in detail about the policy, the resident then gave me the lighter she had in her possession, I placed the lighter in the nurse's station with the resident's name. When the resident wants to smoke, she has to get her lighter and cigarettes from the nurse's station. We have designated smoking times and staff that goes out to supervise the residents. We established a smoking schedule with this resident for 1:00pm after lunch and after dinner and if she wanted to smoke at any other time, she would have to approach one of the staff and ask to go smoke. The Assistant Director of Nursing (ADON) completed another smoking assessment for the resident and a smoking care plan was implemented on 9/25/23. Since admission I have never had any reports from staff that this resident goes out to the patio to smoke. The first time I saw this resident was on Monday on the smoking patio, stating that she was there to smoke. Prior to this, I did several in-services with the nurses to let them know when they do their assessments on admission, ask the residents if they are a smoker, if they are, complete a smoking assessment and let me know if the resident is a smoker. We communicate with the staff to let them know what residents are smokers and there is a smoking binder on each nursing station that has a lists of the residents who smoke. As we receive new admissions and discharges, we update the smoking list in the binders at the nursing stations as needed. On 9/25/23, the resident had a room change because she requested a private room. Interview on 09/27/23 at 10:05 AM with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed, none of the staff including myself has never seen this resident smoking, on Monday 9/25/23 is the first time anyone has ever seen this resident smoking and we implemented a smoking assessment and a care plan for this resident immediately. This resident upon admission was not a smoker and she stayed in her room most of the time, when the DON was informed, by the surveyor that this resident had a pouch with a lighter and cigarette, the DON stated, the lighter and cigarettes' are now stored at the nursing station and the resident has to go to the nurses' station to retrieve her smoking materials to smoke with a staff member for supervision. Interview on 09/27/23 at 10:30 AM with the resident #335 while in therapy exercising it was stated via another surveyor translating, on admission, she did not smoke when she first came to the facility because she did not feel like smoking, but recently she has been anxious and has been smoking 2-3 cigarettes a day. Interview on 09/27/23 at 11:40 AM with the resident in her room with her son, via translation with another surveyor revealed, when asked how long she has been smoking at the facility, the resident reported, she started about 2 weeks ago, and the resident's son stated his mom has smoked her whole life. Interview on 09/28/23 at 07:55 AM, the Registered Nurse, from the South Unit (Staff A) via translator reported, she has never seen this resident smoking. Interview on 09/28/23 at 07:56 AM, the Registered Nurse, from the South Unit (Staff B) via translator reported, yesterday was the first day I was assigned to this resident, I saw her smoking yesterday, and her smoking supplies are stored at the nursing station. On 09/28/23 at 10:47 AM, the MDS Coordinator brought a signed statement of an interview with the resident that documented, the resident stated upon admission she forgot that she was a smoker and she never smoked until she got anxious a few days ago. Record review of Resident #335's Smoking Assessment documented-Resident was admitted on [DATE], smoking assessment completed on 8/29/23 documented no tobacco use, smoking assessment completed 9/25/23 documented- Resident uses Tobacco, Has the cognitive ability to smoke safely, Has the visual ability to smoke safely, Has physical dexterity and physical ability to smoke safely, Resident may smoke independently or with set up, Resident requires use of cigarette holder, and Security-All lighters, matches, lighting materials are kept in a secure location. Review of the medical records for Resident #335 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Displaced subtrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, Depression and Anxiety Disorder. Review of the Physician's Orders Sheet for September 2023 revealed, Resident #335 had orders that included but were not limited to: Amitriptyline Oral Tablet 50 milligram (MG)-Give 1 tablet by mouth two times a day related to Depression. Clonazepam Oral Tablet 1 Milligram (MG)-Give 1 tablet by mouth two times a day related to Anxiety Disorder. Record review of Resident # 335's Admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview of Mental Status Score 14, on a 0-15 scale indicating the resident is cognitively intact. Section E for behaviors documented rejection of care occurred 1-3 days. Section G for Functional Status documented Extensive assistance for Activities of daily living with one person assistance, except for eating, requiring setup only. Section H for Bowel and Bladder documented occasionally incontinent of bladder, always incontinent of bowel. Section J for Health Conditions documented no tobacco use. Section N for Medications documented resident received anticoagulants, antianxiety, antidepressant, diuretic in the last 7 days. Section O for Special Treatments, Procedures, and Programs documented resident received Occupational, Physical, and Psychological Therapy in the last 7 days, and Section P for restraints documented no physical restraints or elopement alarms used. Record review of Resident # 335 's Care Plans dated 9/25/23 revealed: Resident has desire to smoke. Resident will comply with smoking policy and rules through next review date. Resident will remain safe and free from injury during smoking episode through next review date. Interventions include- Smoking assessment, Smoking material should be kept at the nurse's station, supervise when smoking at all times, explain smoking policy and rules as needed, explain smoking policy to resident and family as needed, redirect resident to smoking area as needed, and smoking as per smoking schedule. Review of the facility's policy and procedure titled Smoking Policy-Residents effective date 09/15/2022 states: The center will establish and maintain a safe designated smoking area and safe smoking practices for the residents. Smoking is only allowed in the designated smoking areas of the facility and during designated smoking times. Smoking is not allowed during inclement weather. Oxygen is not permitted within 50 feet from the designated smoking areas. The center will have safety equipment available in designated smoking areas including fire blanket, smoking aprons, fire extinguisher, and non combustible self-closing ashtrays. Procedures: Residents that wish to smoke will have an initial smoking assessment, quarterly, with a change in condition, and as needed to determine if assistance and /or supervision is required for smoking. The center will retain and store all smoking materials, including matches, lighters, cigarettes, cigars, and any other smoking implement for all residents who wish to smoke.

Based on observation, interview, and record review, the facility failed to follow physician's orders for oxygen therapy administration for one out of four sampled residents (Resident #34) reviewed for oxygen therapy. The findings included: Observation on 09/25/2023 at 08:13 AM, revealed Resident #34 had her breakfast set up on the bedside table, and the resident was sleeping. Further observation revealed, the oxygen level was infusing at 3.5 liters per minute via nasal cannula. Observation on 09/26/2023 at 08:43 AM, revealed Resident #34 in bed awake. Observed the resident's oxygen level was at 3.5 liters per minute via nasal cannula. Observation on 09/27/2023 at 08:10 AM, revealed Resident #34 in her bed with the bedside table in front of her. Observed the resident's oxygen level was between 3 - 3.5 liters per minute infusing via nasal cannula. Observation on 09/28/2023 09:13 AM, revealed, resident #34 was sleeping, and the oxygen level was at 3.5 liters per minute infusing via nasal cannula. Review of the Resident #34's physician's orders revealed an order dated 07/21/2022 for oxygen (O2) at 2 liters per minute via nasal canula every shift for Shortness of breath for respiratory distress related to chronic obstructive pulmonary disease (unspecified). Review of Resident #34's medical diagnoses revealed, acute respiratory failure with hypoxia, history of right hip fracture and fall, Chronic obstructive pulmonary disease, hypertension, anemia, Alzheimer, hyperlipidemia. Review of Resident #34's care plan dated 07/18/2023 revealed, the resident has a potential for complications of respiratory distress. The facility's interventions included, Change oxygen tubing weekly and PRN (as needed) every night shift and Sunday; administer medications as ordered; O2 sats (saturated) as ordered; administer O2 as ordered. On 09/28/2023 at 10:05 AM, Staff C (Licensed Practical Nurse) stated, I think the oxygen level is supposed to be 2 liters, but I'm not sure. I will look at the computer. He then stated, I don't see it. I can't find the order. On 09/28/23 at 10:09 AM, observed the facility's staff educator came and helped Staff C to look for the physicians order. On 09/28/23 at 10:12 AM, the facility's staff educator stated, The order is in there. It's 2 liters per minute for shortness of breath. Review of the facility's policy and procedures relating to Oxygen Administration, dated October 2010 revealed: Purpose - The purpose of this procedure is to provide guidelines for oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess any special needs of the resident. 3. Assemble the equipment and supplies as needed. Steps in the procedure: 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. 9. Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter). 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. 13. Observed the resident upon setup and periodically thereafter to be sure oxygen is being tolerated (see assessment).

Based on observations, interview, and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level II for serious mental illness (SMI) or intellectual disability (ID) was requested at the time of admission for one resident (Resident # 23) out of three residents reviewed. There were 84 residents residing in the facility at the time of the survey. The findings included: On 09/19/2022 at 09:24 AM, Resident #23 was observed lying in her bed, awake. No distress noted. Observation of Resident #23 on 09/20/2022 at 08:23 AM revealed the resident was receiving hospice care. Observation of resident on 09/22/2022 at 09:01 AM. Resident was lying on her bed, sleeping. Record review of Admission Record revealed the resident was admitted to the facility on [DATE]. Medical diagnoses included, but were not limited to, [CONDITION(S)] Disease of Nervous System, Unspecified and [CONDITION(S)] Disorder, Unspecified. Record review of Resident # 23's PASRR Level I dated 07/13/2022 revealed identification of a serious mental diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Section 2, revealed for question number 1- Is there an indication the resident had or may have a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's developmental stage? Response documented was Yes. Question number 2B for concentration, persistence, and pace: The individual has serious difficulty in sustaining focused attention for a long enough period to permit the completion of tasks, manifests difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent error, or requires assistance in the completion of these tasks, documented response indicated Yes. Section 3 was not completed. Section 4 revealed the individual had no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Level II PASRR evaluation not required. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 tablet by mouth two times a day related to [CONDITION(S)] Disorder, Unspecified. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 tablet by mouth two times a day related to [CONDITION(S)] Disorder. The resident was monitored for Medication Management: Diagnosis [CONDITION(S)] disorder every shift, resident had restlessness throughout the days. Record review of Admission Minimum Data Set (MDS) Section A (A1500) for Preadmission Screening and Resident Review (PASRR), dated 07/20/2022 revealed: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? No was the response documented. Review of the Admission MDS Section C for Cognitive Patterns, dated 07/20/2022 revealed the Brief Interview for Mental Status (BIMS) Summary Score was left blank. Review of the Admission MDS Section D for Mood, dated 07/20/2022 revealed the interview could not be conducted because the resident was rarely and never understood. Review of the Admission MDS Section I for Active Diagnoses documented the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission MDS Section N for Medications, dated 07/20/2022 revealed the resident was receiving antipsychotics seven (7) days in a week. Review of Resident #23's Care Plans initiated on 07/14/2022 with next review date of 10/12/2022 revealed the resident was at risk for exhibiting behavioral problems. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Per Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Goal: The resident will not exhibit any behavior symptoms through the next review date. Interventions: Approach with kindness. Assess her when exhibiting behavior problems. Encourage family for frequent visitation. Medicate as ordered by physician. Praise all efforts. Provide emotional support. Psychiatrist/Psychologist consult as needed. Review of Psychiatrist consultation revealed the resident was seen on 08/23/2022. The resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident unable to be in a less restrictive environment. Physician recommended to continue with the same medications. Interview with Staff A, Licensed Practical Nurse (LPN) on 09/22/22 at 11:17 AM. Staff A revealed the resident was well, when the resident was admitted , did not eat well, but now the resident eats very well. The resident was not aggressive or combative with the staff. The only medication that the resident had was [MEDICATION(S)] 25 milligrams twice a day. The resident's condition improved since she was admitted . Staff made frequent rounds to checked on the resident because the resident was not able to call the light for assistance. The resident cooperated when the care was provided, hospice staff comes to provide care. Interview with Staff B, a Certified Nursing Assistant (CNA) on 09/22/2022 at 11:41 AM. Staff B reported that the resident was not aggressive when the care is provided. The resident sometimes refused to be assisted, but she waited for a while and then the resident permitted to be assisted. Interview with the Social Services Director on 09/22/2022 at 12:03 PM. The Social Services Director stated that she was not in charge to make decisions to request Level II PASRR for a resident. The Interdisciplinary Team (IDT) had meetings to discuss the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing (DON) was in charge of requesting a Level II PASRR. Interview with the Director of Nursing on 09/22/22 at 12:47 PM, revealed the resident was admitted on [DATE]. The Level I PASRR was done by the hospice care company. She stated the PASRR was reviewed by the IDT. We did not realize that the resident had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility Policies and Procedures for Preadmission Screening Resident Review (PASRR) revised 11/01/2011. Purpose: Preadmission Screening and Resident review (PASRR) is a Federal requirement which is designed to prevent inappropriate placements of individuals in Skilled Nursing Facilities (SNFs). Regardless of payor source, all individuals seeking admission to a Medicaid certified SNF must be screened for possible Serious Mental Illness (MI) and /or Mental [CONDITION(S)] (MR) or related condition, prior to admission. Procedure: 2- If the PASRR indicates MI and/or MR or a related condition appears to exist, the individual must be referred to the appropriate state agency by the acute care hospital staff for further evaluation (Level II Evaluation and Determination) before the individual is admitted unless specific exclusionary criteria stated on the PASRR is met. If the SNF allows the admission prior to the completion of the Level II Evaluation and Determination, then the SNF will notify the appropriate state agency.

Based on interview and record review, the facility failed to respond to grievances for 2 ( R#28 and R#62) out of 2 residents sampled for grievances .1) Resident #28 sampled for choices, 2) Resident #62 sampled for personal property. This had the potential to affect 82 residents who were present in the facility at the time of this survey The Findings Included: Record review of the facility's policy and procedures titled, Grievance Policy and Procedure, undated, revealed, The resident/resident representative has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without the fear of discrimination or reprisal. The resident/resident representative has the right to and the facility must make prompt efforts to resolve grievances the resident/resident representative may have. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their Long Term Care stay. These may be expressed at any time, both verbally and in writing. Staff have been trained on the policy and instructed on how to assist residents and resident representatives to write or complete a Grievance Form. A grievance may be presented anonymously if so chosen by the resident/resident representative. Residents or representatives are encouraged to report grievances as a positive step in arriving at a satisfactory resolution and outcome. Resident #28 Review of the Face Sheet for resident # 28 revealed the resident first admitted to the facility on [DATE] and readmitted on [DATE]. Clinical [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) for resident #28 dated 11/25/20 revealed a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated that the resident was able to verbalize his needs and was not cognitively impaired. Further review of the MDS revealed that the resident had no behaviors, he had adequate hearing, speech was clear, and he had the ability to understand others and express ideas and wants. On 02/03/2020 at 9:23 AM resident # 28 reported he had missing personal items. The items lost included shoes and clothes that he wore when he was admitted to the facility. It had been about two months since the Certified Nursing Assistant (CNA) picked up his clothes, took them to the wash and did not bring them back to his room. He had asked staff for the missing items. None of his CNAs found his clothes or offered to resolve the issue. Review of the grievance log revealed no grievances or concerns filed that addressed missing personal items for resident #28. Review of the Social Services Notes for resident # 28 revealed notes dated 1/13/20, 1/9/20, 12/31/19, 12/6/19 12/5/19 and 11/21/19 - none of the notes addressed the resident's concerns with staff or missing personal items. One note dated 1/13/2020 addressed unacceptable behavior On 2/04/20 at 03:43 PM , the Social Services Director (SSD) reported not being aware that resident #28 had any concerns with missing items or staff attitude. On 02/05/20 at 10:07 AM, Staff B a CNA reported she cared for resident #28 for about three weeks. The resident showed some aggressive behavior when he first moved to the unit. She learned from the resident that his clothes went missing about four days ago The CNA reported she understood the grievance process included communicating such concerns to the SSD. She did not communicate the missing items concern to Social Services. The CNA explained that the resident items went missing in a unit separate from the unit where she cared for him. It was the other CNAs responsibility to communicate to Social Worker. I did not notify Social Services because he was in the south wing, when he was transferred to the north he arrived without clothes. On 2/5/2020 at 11:11 AM the SSD revealed, she educated the staff on the grievance policy and procedure during orientation. Staff also completed said education periodically online. All concerns with staff attitude and or missing items should be address documented. The SSD explained, she just learned about the missing items for resident #28 and was addressing the grievance at the time of this interview. R#62 On 02/03/2020 at 11:29 am, via translation by the Life Safety Surveyor, resident #62 stated that she had no choice over when she received her showers. She received showers every day, but it was not at the times she wanted.; it was either too early, or too late; like around the same time as lunch. Also, it was never the same Certified Nursing Assistant (CNA) that would bathe her, it was someone different. Resident #62 stated that she wanted to receive her showers at 9:00 am, with the CNAs of her choice. The resident reported that she spoke to the Social Services Director, which was the person that she is supposed to speak to when she had a complaint. Resident #62 told the Social Worker about the shower situation, and that she wanted the same CNA to bathe her but she was still getting different CNAs. Review of the Grievance Log revealed a grievance for resident #62 dated 01/13/2020 indicating that the resident had a concern regarding nursing staff not being affectionate during her care; however, further review of the grievance log revealed no documented concerns related her choice of showers or CNAs. Review of the Social Services Notes for the months of (MONTH) 2019 to (MONTH) 2020 revealed no documentation of resident #62 having concerns about receiving showers at her time of choice, or having a preference for CNAs. The Certified Nursing Assistant (Staff B) on 02/05/2020 at 11:24 am revealed that she worked with resident #62. She assisted the resident with bathing; she took the resident to the shower room every day. When she worked with the resident, as soon as the resident finished her breakfast, she gave her a shower, which was around 9:00 am. Staff B reported that the resident told her about other staff being late with giving her showers. She explained to resident #62 that on the days that she did not work, other staff would not be able to assist her with the showers at the time that she wanted because other residents that needed to go to appointments or [MEDICAL TREATMENT] had more priority over her. Staff B stated that she reported it to a nurse, but could not remember which nurse it was. She also stated that she explained to the other CNAs that the resident had a preference as to what time she wanted to receive her showers, and that they should coordinate with her and be on time when providing her showers. However, Staff B did not report it to anyone else. She reported that if a resident had a concern or grievance she would tell the nurse on the floor, and if nothing happened then she would tell the Director of Nursing. If the resident still had a concern, then she would go to the nurse on the floor and try to figure out how they could resolve it. The Director of Social Services on 02/05/2020 at 11:52 am revealed that yesterday the Activities Director informed that during the resident council meeting with the State, resident #62 voiced a concern about the times she received her showers and the CNAs were not affectionate when telling the resident that they were going to come back. The Director of Social Services stated that right now she was in the process of resolving the grievance. However, before yesterday the resident did not say anything to Social Services about having a grievance related to her showers and care. No one told her that the resident had a concern about not receiving her showers at the times of her choice and staff should have informed Social Services.

Based on interviews, observations, and records reviewed, the facility failed to provide proper treatment and adequate care for two (Resident #75 and Resident #45 )out of 25 residents sampled. Resident #75 was reviewed for concerns with oral care and Resident # 45 was incorrectly assessed for skin conditions. This facility practice has the potential to have an adverse effect on the quality of care and treatment for [REDACTED]. There were 82 residents residing in the facility at the time of the survey. The Findings Included: Review of the face sheet for resident #75 revealed, the resident admitted to the facility on [DATE] and readmitted on [DATE]. Clinical [DIAGNOSES REDACTED]. Record review of the Minimum Data Set (MDS) for Resident # 75 revealed a comprehensive assessment dated [DATE]. Sections for Functional Status and personal hygiene indicated that the resident #75 required extensive assistance of one-person to physically assist for maintaining personal hygiene, including mouth care. Further review of the MDS revealed that Resident # 75's BIMS (Brief Interview for Mental Status) score was six out of fifteen, which indicated that the resident was cognitively impaired. Review of the Care Plans for Resident # 75 revealed, the care plan initiated on 12/06/19 addressed the problem; Resident #75 has self-care deficit as evidenced by the need of assistance secondary to heart Failure, [MEDICAL CONDITION], Dementia, Dysphagia . The Goal was that the resident would have clean, neat appearance daily through the next review Approaches included; Assist with Activities of Daily Living (ADL) tasks every shift and allow enough time for participation in care . Staff to anticipate resident's needs with ADL Dining observation on 02/03/20 at 11:11 AM revealed, Resident #75 was in bed. A white discoloration appeared to cover the resident's tongue. The discoloration was visible as the resident coughed and asked for water. The floor nurse responded to the resident's call. On 02/05/20 at 09:13 AM Certified Nursing Assistant (CNA) Staff C revealed, she cared for Resident #75 for about a month. The resident required total care and had a feeding tube. The aid explained that resident #75 always asked for water but was NPO (Nothing by mouth). Instead staff moisturized the resident's lips. When asked, The CNA reported that the white tongue discoloration was just dryness. The aid explained Every day I clean her tongue and the dryness goes away. Observation during the above mentioned interview on 02/05/20 at 09:21 AM revealed, the white discoloration remained and covered most her tongue. The CNA (Staff C) reported she would proceed to clean the resident's mouth. On 02/05/2020 at 4:08 PM Staff D Registered Nurse (RN) revealed, she was familiar with resident #75 for more than three months. The RN (Staff D) explained it would not be normal to see white discoloration on the resident's tongue and explained the resident suffered from dry mouth, and indicated she was not aware that the resident had white discoloration on her tongue. The RN agreed to observe Resident #75. On 02/05/20 at 04:38 PM, during observation and interview with Staff D, Resident #75 remained in her bed and white discoloration remained on the resident's tongue. Staff D reported she would communicate said observations to the physician. On 2/6/2020 at 12:48 PM, Staff G RN reported, that Resident #75 was seen by the physician yesterday. The physician prescribed [MEDICATION NAME], for [DIAGNOSES REDACTED]. The RN explained he was waiting for the medication. During the above-mentioned interview, the RN reported that Resident #75 received oral care every day. Normally the nurses notice, but also the CNAs. Once the nurse knows; we assess, write the note and call the doctor. During the interview, the RN reviewed Resident #75's clinical record and agreed only one note addressed the resident's mentioned condition; Nurses notes dated 2/5/2019 at 16:44 Staff R, noted, Observed with white patch on tongue . During the interview, Staff G agreed, that residents' tongue should be cleaned every day, white discolorations should be addressed. Resident #47 Record review of the medical Face Sheet revealed that resident # 47 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 02/03/20 at 9:37 , Resident#47 was observed in her room. Multiple red discolorations were noted on both arms and legs. There was also a red patch discoloration concentrated on her left leg. The resident was under the impression that the discoloration was a reaction to something that staff placed on her bed. On 02/05/20 at 08:53 AM revealed, Resident # 47 was in her room, sitting on her chair and eating breakfast, the red discolorations remained visible on arms and legs. On 02/03/2020 at 12:27 PM, the Social Services Director reported she met with Resident #47 on 1/28/2019. The SSD learned the Resident #47 was under the impression that someone was putting something on her feet. The SSD explained that she noticed the skin discolorations at the time. The resident told the SSD that she was applying a cream herself. On 02/05/20 at 09:48 AM Staff C, Certified Nursing Assistant ( CNA) reported she cared for Resident #47 at times. Resident #47 was able to do a lot on her own and required mostly supervision. The CNA explained that she noticed Resident #47 at times got rashes that appeared when she was anxious. The resident mentioned concerns that someone placed something on her bed that made her itch. The CNA stated that she reported all the resident's concerns to the floor nurse. Review of progress notes dated 1/28 /20 at 16:40 - documented by Social Services - addressed resident's concern that someone throws water while she was in bed. It noted, Called to the attention of the resident nurse to check the lower extremities of the resident since there is redness. (Other concerns addressed by psych) Review of skin assessments for Resident #47 revealed assessments dated 02/01/20, 01/25/20, 01/10/20 . none of the assessments addressed the resident's skin discolorations. Each assessment indicated that resident's skin was intact. Review of the nurses notes for Resident #47 revealed two notes that addressed resident's skin condition the last two months; progress note dated 1/31/20 :Nursing -1/31/2020 at 18:23 Dr. { } was called Resident c/o(complained of) generalized itching and is asking for allergy pill . Dr { } gave new orders, carried out orders. Progress notes dated 2/3/20 - 12:38 noted Resident noticed scratching by herself arms and legs, with skin redness in this- areas, anxious and hallucinating, talking about hot water in bed call placed to Doctor { } and said he will come to the facility . Also, Psychiatry Doctor { }notified. Weekly Skin Assessments dated 1/10/20 and 1/25/20 - No rash or redness. During observation and interview on 02/06/20 at 08:57 AM , Resident # 47 observed in her room, red discoloration remained. The resident stated, they started to cure me now. On 02/06/20 at 10:06 AM Staff X, Licensed Practical Nurse ( LPN) reported she was familiar with resident #47. Staff X reported that residents' assessments were completed every day and as needed. If I notice a problem in the patient I would document, we have to document on the shift. We notify doctor and follow orders. We also have weekly skin assessments. Review of the nurses notes during the above mentioned interview revealed, one note on 11/29/19 that addressed resident #47's skin discoloration : Resident had redness on both arms and received the [MEDICATION NAME] on both arms. The LPN (Staff X) explained; it was only redness, we thought it probably happened because of the agitation, it went away quickly, it was not routine. The nurse reported; assessments for her was completed on 2/1/20 - Long term assessment completed by the nurse in the evening; it shows skin warm and dry, skin color within normal limits, turgor normal. The one for the 25th (01/25/20) also shows the resident skin (intact). Upon Review of the skin assessment for 1/10/20, Staff X agreed that none of the of the assessments showed the resident's skin discoloration. The nurse explained that the skin assessments should reflect the redness, indicating that the assessments were incorrect. The nurse further explained that the resident received daily treatment to [MEDICAL CONDITION] on both legs. The orders included [MEDICATION NAME] Cream 1-0.05% ([MEDICATION NAME]-[MEDICATION NAME]) apply to bilateral legs [MEDICAL CONDITION] topically two times a day for [MEDICAL CONDITION]. Review of the Medication Administration Records (MAR) for (MONTH) and (MONTH) 2020 indicated that the resident received daily treatments for the leg [MEDICAL CONDITION]. Interview with the Director of Nursing (DON) on 02/06/20 at 11:17 AM, revealed resident's skin assessments were done weekly. If new rash, ulcer, skin tear . should be documented on the weekly skin assessment. The protocol included calling the physician, following physician's orders [REDACTED]. During the interview, the DON agreed to review skin assessments for Resident #47. Upon review of assessments the DON agreed they incorrectly indicated that Resident #47's skin was intact and the assessments should show the redness.

Based on record reviews, observations and interviews , the facility failed to ensure safe transfer practices for one resident (Resident #13) out of 20 sampled residents reviewed for concerns with safety. Improper transfer practices can cause an accident hazard with the potential to result in injury. This facility practice has the potential to affect the quality of care and safety for 34 residents in the facility identified to require two-person assistance with transfers at the time of the survey. The Findings included: Review of the facility policy Lifting Machine, Using a Mechanical Revised (MONTH) (YEAR): General Guidelines: Item 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. Review of the face-sheet revealed, Resident #13 was admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. On 02/03/20 11:41 AM, Resident #13 was observed in bed alone in her room. She was cognitively unable to respond to an interview. A lift was noted in the resident's room next to the resident's bed. Staff B, a Certified Nursing Assistant ( CNA) walked into the resident's room to continue providing care to the resident. No other staff was noted around the resident's room. Observation 02/04/20 at 11:47 AM revealed that Resident #13 was in bed accompanied by staff B. It appeared that staff B finished dressing the resident and was about to transfer the resident to the recliner that was noted across from the resident's bed. The lift was also noted in the room; next to the resident's bed. Resident #13 was observed in bed, resting on the on top of the fabric (Geri-pad) that is used with the lift. No other staff noted around to assist with transfer. Observation on 02/04/20 at 11:54 AM revealed, Staff B continued to use the lift and transfer resident #13 from the bed to the recliner, without the assistance of another staff. Resident #13 was observed on the lift as the CNA used a remote control to lower the resident into the recliner. When asked if she usually transferred the resident without assistance the CNA responded, I usually get help but now, the other aid is busy with dining. On 02/05/20 at 10:22 AM Staff B, CNA explained; my process is to make sure that the resident is balanced in the Geri pad then I call someone to supervise the transfer . They are there for safety. The CNA (Staff B) expressed understanding about safety risks posed to the resident that required two-person assist with transfers. She indicated her practice was appropriate because she had experience; The risk is always there, it's appropriate because I have experience, but I am aware that I should not have. Interview on 02/05/20 at 11:35 AM with Staff F RN and Minimum Data Set (MDS) coordinator revealed, Resident # 13's last MDS was a quarterly assessment completed on 10/28/2019. The resident's Brief Interview of Mental Status ( BIMS )score was two, which indicated the resident was severely impaired. The RN explained, that Resident # 13 required the mechanical lift for transfers. Staff F stated, she is total . lift is required and two persons, it has to be two people for safety needs. The Nurse explained that the CNAs notice on the Kardex indicated that resident # 13 required two people for transfer. Interview with the Director of Nursing (DON) on 02/06/20 at 11:13 AM revealed, both, Assistant Director of Nursing (ADON) and DON are both in charge of the education and making sure staff was aware of proper transfer techniques. It should always be two people to transfer a resident (with a lift), if other staff is not around, they know they can check with the nurse, with me, therapy, ADON . They have options and they are aware.

Based on record review and interview, the facility failed to develop an individualized risk of elopement care plan for one (resident #1) out of three sampled residents who displayed exit-seeking behavior and eloped from the facility. There were a total of two residents who were at risk for elopement at the time of this survey. The Findings included: Record review of the facility's policy and procedures titled, Wandering, Unsafe Resident, dated 2001, revised 08/2014, revealed, The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. The staff will identify residents who are risk for harm because of unsafe wandering (including elopement). The staff will assess at risk individuals for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. Record review of the medical facesheet for resident #1 revealed that the resident was originally admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE], with [DIAGNOSES REDACTED]. Record review of the comprehensive nursing evaluation dated 05/01/2019 revealed that resident #1 was assessed for the risk of elopement at the time of admission. It was noted that the resident did not wander, had never eloped, and was content with placement. The resident had a score of 2 indicating that he was not at risk for elopement. Record review of the narrative notes for resident #1 dated 05/14/2019, it was indicated that the resident was walking around looking for exits. Resident #1 was redirected and educated that he could not go out by himself unless he was with a responsible party; he was placed in front of the nursing station and monitored. Further review of the narrative notes revealed that on 05/23/2019 resident #1 was again restless and stated that he wanted to go home. Record review of the order administration note dated 05/25/2019 revealed that resident #1 received 1 milligram (mg) of [MEDICATION NAME], an anti-anxiety medication, and was noted as wandering and trying to get out of the facility; he stated that he was going home. Record review of the electronic medical record for resident #1 did not reveal a reassessment for the risk of elopement, and any other new interventions. Record review of the behavioral and mood problems care plan dated 05/03/2019, revised 05/31/2019, revealed that resident #1 was care planned for being anxious and trying to get out of bed, and walking around looking for exit on 05/14/2019. The goal included that the resident would not exhibit any mood state evidenced by socializing with peers at least twice a week through next review date of 07/31/2019. Interventions included, but not limited to, encourage family for frequent visitations, encourage to verbalize feelings, providing emotional support, and psychiatrist and psychologist consult as needed. None of the interventions specifically addressed resident #1's risk of elopement and precautions to prevent him from eloping. Record review of the narrative nurses' notes revealed that resident #1 was discharged to an assisted living facility (ALF) on 05/29/2019, and then readmitted back to the facility on [DATE]. Record review of the comprehensive nursing evaluation dated 07/26/2019 revealed that resident #1 was indicated as not wandering and had never eloped, and discontent but agreeable to facility placement. The resident's risk score entered on the form was a 10; indicating that he was at risk for elopement. However, resident #1 was coded as not at risk for elopement and no interventions were needed at the time. Record review of the narrative nurse's note dated 09/09/2019 revealed that resident #1 left the facility around 4:00 pm with authorization. He was found by a police officer and brought back to the facility. When he was assessed, he was noted to have a temperature of 104.5, disoriented with redness in his face, and sent to the hospital. Record review of the electronic medical record for resident #1 did not reveal a specific care plan addressing the resident's high score for elopement risk after readmission. However, further review revealed a falls care plan dated 08/01/2019, revised 09/13/2019, that indicated resident #1 was at risk for fall related injuries and the resident had left the facility without authorization and was brought back and discharged to the hospital, with a goal date of 10/25/2019. Interview with the Activities Director and Social Services Director (SSD) on 09/27/2019 at 12:31 pm revealed that for elopement, activities staff was made aware of the resident's risk for elopement and they would make sure that they encouraged the resident to participate in activities. In addition, activities staff made sure that if the resident was not in activities then they were being supervised by nursing staff; the resident was never left alone. The SSD stated that when they know a resident was at risk for elopement, nursing was advised and fell out a form, the comprehensive nursing evaluation, and she would develop a care plan. They would print a picture of the resident and place it in a binder at the nursing station. Nursing needed to make sure that they knew the whereabouts of the resident. If a resident was a wanderer, the nursing staff needed to take the resident to activities, or keep them close to the nursing station for supervision. The elopement assessments, or comprehensive nursing evaluations, were completed at the time of admission, readmission, or if the resident displayed exit-seeking behaviors during the course of their stay in the facility. After the resident was re-evaluated for exit-seeking behaviors, they would monitor the resident, contact the physician, and make changes to the care plan. The facility did not use the Wander guard system, and they did not why; however, it would be a good idea. During resident #1's first admission in (MONTH) 2019, and readmission in (MONTH) 2019, they were not aware of the resident having a history of elopement or exit-seeking behaviors. After the resident had eloped from the facility on 09/09/2019, the daughter told the SSD that the resident had previously eloped from the ALF and hospital. Both staff members reported that resident #1 should have been re-evaluated for the risk of elopement in (MONTH) 2019, and that an elopement care plan should have been developed for the resident in (MONTH) 2019 when he was readmitted . Interview with the Director of Nursing (DON), Administrator, and SSD on 09/27/2019 at 1:36 pm revealed that after resident #1 eloped on 09/09/2019 his daughter stated that he had eloped from the hospital and multiple times from an ALF. When asked why she had not told them before, she stated that she did not feel the need because he was in a wheelchair and was not able to walk. They told her once the resident was discharged from the hospital he would be reassessed, and they would have to do one to one supervision because they did not have a Wander-guard system in place. The DON stated that if she had known in (MONTH) 2019 that resident #1 had episodes of exit-seeking behavior then the resident would have been re-evaluated. In (MONTH) 2019, when the resident was readmitted he would have not had a care plan developed because his elopement assessment did not show that he had a high risk for elopement because his score was not added correctly.

Based on observation, record review and interview, the facility failed to ensure residents are free from neglect by failing to provide adequate assistance during bathing for 1 (Resident #207) of 3 residents reviewed for accidents. This has the potential to affect 35 residents that need assistance of 1 or 2 staff for bathing and transfers. The findings included: Observed Resident #207 on 10/24/17 at 3:55 P.M., in the activity room seated in her high back wheelchair listening to music with other residents and staff. A pillow was observed on each side of the resident. Resident #207 had a white dressing on her forehead dated 10/24/17, the bridge of her nose was noted with a yellowish discoloration and there was dark red discoloration under both eyes. Resident #207 was oriented to name only. Observed Resident #207 on 10/25/17 at 4:14 P.M. seated in her high back wheelchair with a pillow on each side by the nurses station. Resident #207 had a white dressing on her forehead dated 10/25/17 and the same dark discolorations under her eyes. At 4:17 P.M. the Social Worker approached the resident and told her that her Certified Nursing Assistant (CNA) was going to take her to bed. Resident #207 said she did not want to do that. The Social Worker asked Resident #207 if she wanted to go to the dining room and she said yes. The Social worker took Resident #207 to the dining room in the unit. During an observation on 10/26/17 at 11:46 A.M., Resident #207 was quietly seated in her high back wheelchair by the nurses station, with a pillow on each side. Resident #207 continued to have a white dressing on her forehead dated 10/26/17, and the same dark discolorations under her eyes. Record review of Resident #207's clinical record revealed admission to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of nurses notes documented: -10/21/17 CNA assigned to Resident #207 reported the resident fell down while she was in the shower with her. CNA stated she was trying to get the towel that was at the side to dry thighs area, resident slipped from the shower chair to the floor and hit her head with the wheelchair that was placed next to shower chair to transfer resident back to wheelchair. The Nurse assigned to resident did complete assessment and administered first aid. Resident #207's physician was notified and ordered to transfer resident to nearby acute hospital for further evaluation and treatment due to left [MEDICAL CONDITION]. Will continue to follow up closely.-(Note created by charge nurse) -10/21/17 12:46. CNA reported resident fell down while she was taking a shower. Complete assessment done head to toe. Resident awake, alert, confused, able to answer simple questions, pupils equal, round, reactive to light and accommodation (PERRLA), respiration unlabored, complained of pain at this time on her left forehead. Complete range of motion to all extremities. Resident observed with a laceration on left forehead, small amount of bleeding noted, cleaned with normal saline solution (NSS), pat dry, covered with gauze and wrapped with Kerlix. Doctor was notified by supervisor and new order given to transfer resident to nearby acute care hospital. All safety and comfort measures maintained. Will continue to monitor closely.-(Note created by resident's assigned nurse.) -10/21/17 12:56 Ambulance company at facility. Resident will be transferred to acute care hospital as ordered by physician. -10/21/17 Resident returned from hospital. Review of Resident #207's Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) 10/16/17 revealed resident's functional status documented as extensive assistance with two (2) person physical assist for transfers. Total dependence with two (2) persons physical assist for bathing. Resident #207 had care plans in place, not limited to: -10/10/17. Resident requires total assistance times two (2) for functional transfers due to muscle weakness. Interventions not limited to, provide set up and assistance as needed for transfers; instruct in safety precautions and use of adaptive equipment for transfers. Care plan reviewed and revised on 10/23/17 to resident requires extensive assistance times two (2). -10/10/17 resident requires total assistance times two (2) persons for self care tasks due to muscle weakness. Interventions not limited to provide assistance as needed. Interventions updated on 10/11/17. Right side support; high back reclining wheelchair. Care plan reviewed and revised 10/23/17 to resident requires extensive assistance times two (2). -10/09/17 resident requires total assistance times two (2) for bed mobility due to decline in function related to muscle weakness, rigid. Interventions not limited to provide set up and assistance as needed for bed mobility; instruct in safety precautions and use of assistance equipment for bed mobility. Review of Incident Report provided by the Director of Nursing (DON) on 10/25/17 at 3:23 P.M. revealed date of incident 10/21/17 12:00 P.M., location: south shower room, type of incident: observed fall. Observed by CNA. Description: CNA assigned to Resident #207 reported resident fell down while was in the shower room with her. CNA stated she was trying to get the towel that was at the side to dry her thighs and resident slipped from the shower chair to the floor and hit her head with wheelchair that was placed next to shower chair to transfer resident back to wheelchair. Nurse assigned to resident performed assessment and found range of motion present times four, PERRLA and laceration on her left forehead. First aid administered by nurse. Resident complained of left forehead pain. Physician was notified and ordered to transfer resident to nearby acute care hospital for further evaluation and treatment. Responsible party was called. At 1:00 P.M. resident sent to nearby acute care hospital. The incident reported was completed by charge nurse on 10/21/17 and signed by the DON. Review of Witness Statement For Incidents record attached to incident documented statement from CNA/Staff K. The statement was written in Spanish and it read: (Resident #207's name) was taking a shower in the shower chair and when I went to get the towel that was next to the knee and I turned to dry her thighs the resident slid to the floor and hit her head/forehead with the wheels of the wheelchair that was next to her to transfer her. Review of Occupation Therapy (OT) Progress Note dated 10/11/17, Resident #207 had been provided with right side support to aide with proper trunk support alignment while in wheelchair. A reclining wheelchair had been provided with a high back and a left shaped leg pad, all to improve sitting tolerance in wheelchair and proper body alignment. OT Progress Note dated 10/23/17 revealed Resident #207 was screened by OT as per nurse's request due to a fall incident on 10/21/17 at 12:00 P.M. According to nurse's notes, CNA assigned to the resident reported resident fell down while in the shower room with her. CNA stated she was trying to get the towel that was at the side to dry thigh area and resident slipped from the shower chair to the floor and hit her head with the wheelchair that was placed next to shower chair to transfer resident back to wheelchair/. Recommendation: 1-nursing staff (CNA) must secure resident prior and during activity 2-nursing staff (CNA) must have all needed items within reach 3-nursing staff (CNA) must request Assistance as needed During an interview on 10/25/17 at 4:22 P.M., Resident #207's 3:00 P.M.-11:00 P.M. assigned CNA/Staff M reported CNAs rotate. She worked with the resident yesterday and today. She has worked with her before. CNA/Staff M said she was going to put Resident #207 in bed now. CNA/Staff M explained she does the transfer by herself because the resident can help. CNA/Staff M was observed to proceed to wheel Resident #207 from the South Unit activity/dining room to her room. She closed the door and pulled the curtain. Resident #207 asked what was going on. CNA/Staff M told Resident #207 she was going to put her in bed. Resident #207 refused twice. CNA/Staff M said she would bring the resident back to the activity/dining room because she cannot stay alone on the room because she had a fall in the shower, but she does not know the details. CNA/Staff M explained for showers there are supposed to be two CNAs: one to remove the resident's clothes and the other one to make sure the resident does not fall. For transfers, only one CNA because she can manage the resident fine by herself. CNA/Staff M proceeded to wheel Resident #207 out of the room. During an interview on 10/25/17 at approximately 4:30 P.M., Resident #207's assigned 3:00 P.M.-11:00 P.M. Licensed Practical Nurse (LPN)/Staff L, who was observed in the hallway by her cart, revealed she has worked with the resident since she was admitted to the facility. LPN/ Staff L said Resident #207 needs one person physical assist with transfers and even showers because she is contracted but skinny. Resident #207 was not aggressive, not combative and she was able to follow commands. Resident #207 cannot stand. LPN/Staff L said she is usually in the room when the CNA transfers her to bed. During an interview on 10/26/17 at 11:57 A.M., CNA/Staff K, assigned to Resident #207 on 10/21/17 3:00 P.M.-11:00 P.M. shift revealed she went to the resident's room and sat her in the chair and noticed resident was leaning towards her left side and she had to help her reposition. Resident #207 was unable to hold her balance while sitting. She transferred the resident by herself from bed to her wheelchair and wheeled her to the shower room. In the shower room she transferred the resident by herself from wheelchair to the shower chair. They were alone in the shower room, there was nobody else. She proceeded to shower the resident and wash her hair. She dried resident's hair with a towel, she then got another towel and started drying her body. When she went to reach for another towel to continue drying the resident, the resident fell forward and to the side from the shower chair. Resident #207 hit her forehead with the wheel of the wheelchair. Everything happened so fast. She had the wheelchair right next to the shower chair in order to transfer the resident, by herself, back to it once she was done with the shower. The towels were on the wheelchair which was next to the shower chair. CNA/Staff K stated this was the first time she worked with Resident #207. During an interview on 10/26/17 at 1:40 P.M., the Assistant Director of Nursing (ADON) and DON revealed the CNAs communicate with the nurses and CNAs from prior shift about residents level of assistance needed. They communicate with the nurse and therapy staff. Interview with Rehabilitation (Rehab) Director on 10/26/17 at 1:43 P.M., revealed per OT evaluation dated 10/10/17 Resident #207 is excessive to total assist. Per most recent OT progress report dated 10/16/17, before the fall, resident was totally dependent with two staff and 75% cuing; for hygiene and grooming she was total dependence. Rehab Director reviewed Resident #207's Activities of Daily Living care plan and before the fall the resident was total assistance of two staff. No (brand name) lift needed because resident had some attempts to initiate. He said the OT 10/10/17 evaluation documented sitting balance was poor and she required maximum assist to maintain balance and physical support from staff or positioning devices. This means while sitting on the bed or on the chair she would need physical support from the staff. This is a patient that would not be safe to sit without support . Rehab Director stated he was aware Resident #207 had a fall in the shower room. After the fall the Occupational Therapist screened the resident and the note was given to the DON to talk to the staff about the recommendations. Interview with the DON on 10/26/17 at 2:02 P.M., revealed she talked to the CNA involved in the incident. She counseled her about what happened. Interview on 10/26/17 at 3:52 P.M. with the Unit Manager/Staff J revealed on 10/23/17 Resident #207's assigned nurse told her the CNA assigned to the resident (CNA/Staff K) had reported resident had a fall in the shower room. She called Resident #207's physician and notified her of the fall. The physician gave order to transfer resident to the hospital due to laceration on left forehead. Resident 207's daughter was notified. Unit Manager/Staff J talked to the CNA and asked her to write a statement on what happened. The CNA told her while she was trying to reach the towel to dry the resident, the resident slid from the shower chair and hit her forehead with the wheelchair that was next to it. Unit Manager/Staff J explained the CNAs communicate with the nurses and therapy when they need to know the level of assistance each resident need. Interview with DON/Risk Manager on 10/26/17 at 5:08 P.M. revealed Unit Manager/Staff J filled out incident report on 10/21/17. The DON went over the incident description. The DON received the incident report on 10/23/17 and started her investigation. She reviewed the documents from the hospital, spoke with the CNA involved and she described to her what happened. She spoke with Resident #207's daughter. After this, they have decided not to give the resident showers in the chair but to do bed baths. The resident does not need a (brand name) lift to be transferred; she is transferred with just one CNA. They concluded the resident cannot sit on a shower chair. She has talked to the CNAs and told them if they realize a resident cannot stay in the shower chair for long periods of times they need to stop the shower and communicate to the nurse or get assistance from another staff. Regarding the incident she said, they have not determined this to be an adverse incident yet, they are leaning more towards a no because the resident has had showers before and this is the first time this happened. She is not sure yet. The DON was presented with Resident #207's admission MDS with ARD date 10/16/17. After reviewing the Functional Status section, the DON said for transfers the resident was extensive assistance with two (2) staff assist and for bathing she was total dependence with two (2) staff assist. The DON agreed this was an avoidable fall.

Based on observation, record review and interview, the facility failed to follow a resident's care plan for Activities of Daily Living (ADLs) to ensure residents receive adequate assistance to prevent accidents during bathing for 1 (Resident #207) of 3 residents reviewed for accidents. This has the potential to affect 36 residents that need assistance of 1 to 2 staff for bathing and transfers. The findings included: During an observation on 10/24/17 at 3:55 P.M., Resident #207 was in the activity room seated in her high back wheelchair listening to music with other residents and staff. A pillow was observed on each side of the resident. Resident #207 had a white dressing on her forehead dated 10/24/17, the bridge of her nose was noted with a yellowish discoloration and there was dark red discoloration under both eyes. Resident was oriented to name only. Observed Resident #207 on 10/25/17 at 4:14 P.M. seated in her high back wheelchair by the nurses station. A pillow was observed on each side of the resident. Resident #207 had a white dressing on forehead dated 10/25/17 and the same dark discolorations under the eyes. At 4:17 P.M. the Social Worker approached the resident and told her that her Certified Nursing Assistant (CNA) was going to take her to bed. Resident #207 said she did not want to do that. The Social Worker asked Resident #207 if she wanted to go to the dining room and resident said yes. The Social Worker took Resident #207 to the dining room in the unit. Observed Resident #207 on 10/26/17 at 11:46 A.M. quietly seated in her high back wheelchair with a pillow on each side by the nurses station. There continued to be a white dressing on her forehead dated 10/26/17, and she had the same dark discolorations under her eyes. Record review of Resident #207's clinical record revealed admission to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of nurses notes documented: -10/21/17 CNA assigned to Resident #207 reported Resident #207 fell down while she was in the shower with her. The CNA stated she was trying to get the towel that was at the side to dry thighs area, resident slipped from the shower chair to the floor and hit her head with the wheelchair that was placed next to shower chair to transfer resident back to wheelchair. The Nurse assigned to Resident #207 did a complete assessment and administered first aid. Resident #207's physician was notified and ordered to transfer her to nearby acute hospital for further evaluation and treatment due to left [MEDICAL CONDITION]. Will continue to follow up closely.-(Note created by Charge Nurse/ Staff J) -10/21/17 12:46. CNA reported Resident #207 fell down while she was taking a shower. Complete assessment done head to toe. Resident awake, alert, confused, able to answer simple questions, pupils equal, round, reactive to light and accommodation (PERRLA), respiration unlabored, complained of pain at this time on her left forehead. Complete range of motion to all extremities. Resident observed with a laceration on left forehead, small amount of bleeding noted, cleaned with normal saline solution (NSS), pat dry, covered with gauze and wrapped with Kerlix. Doctor was notified by supervisor and new order given to transfer resident to nearby acute care hospital. All safety and comfort measures maintained. Will continue to monitor closely.-(Note created by Resident #207's assigned nurse.) -10/21/17 12:56 Ambulance company at facility. Resident will be transferred to acute care hospital as ordered by physician. -10/21/17 Resident returned from hospital. Review of Resident #207's Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) 10/16/17 revealed a Brief Interview for Mental Status (BIMS) summary score of 4 (severe cognitive impact). Resident #207's functional status was documented as extensive assistance with two (2) person physical assist for transfers including to or from bed, chair, wheelchair. Total dependence with two (2) person physical assist for bathing. For balance during transitions the resident was encoded as Not steady, only able to stabilize with staff assistance. The resident was encoded for functional limitation in range of motion as evidenced by upper extremity impairment on both sides. Resident #207 had care plans in place, not limited to: -10/10/17 resident requires total assistance times two (2) for functional transfers due to muscle weakness. Interventions not limited to, provide set up and assistance as needed for transfers; instruct in safety precautions and use of adaptive equipment for transfers. Care plan reviewed and revised on 10/23/17 to resident requires extensive assistance times two (2). -10/10/17 resident requires total assistance times two persons for self care tasks due to muscle weakness. Interventions not limited to provide assistance as needed. Interventions updated on 10/11/17. Right side support; high back reclining wheelchair. Care plan reviewed and revised 10/23/17 to resident requires extensive assistance times two (2). -10/09/17 resident requires total assistance times two (2) for bed mobility due to decline in function related to muscle weakness, rigid. Interventions not limited to provide set up and assistance as needed for bed mobility; instruct in safety precautions and use of assistance equipment for bed mobility. Review of Occupation Therapy (OT) Progress Note dated 10/11/17 Resident #207 had been provided with a right side support to aide with proper trunk support alignment while in wheelchair. A reclining wheelchair has been provided with a high back and a left shaped leg pad, all to improve sitting tolerance in wheelchair and proper body alignment. OT Progress Note dated 10/23/17 revealed Resident #207 was screened by OT as per nurse's request due to a fall incident on 10/21/17 at 12:00 P.M. According to nurse's notes, CNA assigned to the resident reported resident fell down while in the shower room with her. The CNA stated she was trying to get the towel that was at the side to dry thigh area and resident slipped from the shower chair to the floor and hit her head with the wheelchair that was placed next to shower chair to transfer resident back to wheelchair/. Recommendation: 1-nursing staff (CNA) must secure resident prior and during activity 2-nursing staff (CNA) must have all needed items within reach 3-nursing staff (CNA) must request assistance as needed Record review of nearby acute hospital Discharge Summary documentation dated 10/21/17 documented Resident #207 was treated for [REDACTED]. Interview with Resident #207's 3:00 P.M.-11:00 P.M. assigned CNA/Staff M, on 10/25/17 at 4:22 P.M. reported CNAs rotate. She worked with Resident #207 yesterday and today. She has worked with her before . CNA/Staff M said she was going to put Resident #207 in bed now. CNA/Staff M explained she does the transfer by herself because the resident can help. CNA/Staff M proceeded to wheel the resident from the South unit activity/dining room to her room. She closed the door and pulled the curtain. Resident #207 asked what was going on. CNA/Staff M told resident she was going to put her in bed. Resident #207 refused twice. CNA/Staff M said she will bring the resident back to the activity/dining room because she cannot stay alone on the room because Resident #207 had a fall in the shower but she does not know the details. CNA/Staff M explained for showers there are supposed to be two CNAs: one to remove resident's clothes and the other one to make sure the resident does not fall. For transfers, only one (CNA) because she can manage the resident fine by herself. CNA/Staff M proceeded to wheel resident out of the room. During an interview on 10/25/17, at approximately 4:30 P.M. Resident #207's assigned 3:00 P.M.-11:00 P.M. nurse/Staff L, who was observed in the hallway by her cart, revealed she had worked with the resident since she was admitted to the facility. Resident #207 needs one person physical assist with transfers and even showers because she is contracted but skinny. Resident #207 is not aggressive, not combative and she was able to follow commands. Resident #207 cannot stand. Resident #207's assigned 3:00 P.M.-11:00 P.M. nurse/Staff L said she is usually in the room when the CNA transfers the resident to bed. Interview on 10/26/17 at 11:57 A.M. Resident #207's assigned 3:00 P.M.-11:00 P.M. nurse/Staff K revealed she went to the resident's room and sat her in the chair and noticed resident was leaning towards her left side and she had to help her reposition. Resident #207 was unable to hold her balance while sitting. She transferred the resident by herself from bed to her wheelchair and wheeled her to the shower room. In the shower room she transferred the resident by herself from wheelchair to the shower chair. They were alone in the shower room, there was nobody else. She proceeded to shower the resident and wash her hair. She dried Resident #207's hair with a towel, she then got another towel and started drying her body. When she went to reach another towel to continue drying the resident the resident fell forward and to the side from the shower chair. Resident #207 hit her forehead with the wheel of the wheelchair. Everything happened so fast. She had the wheelchair right next to the shower chair in order to transfer the resident, by herself, back to it once she was done with the shower. The towels were on the wheelchair which was next to the shower chair. CNA/Staff K stated this was the first time she worked with Resident #207. Interview on 10/26/17 at 1:43 P.M., Rehabilitation (Rehab) Director revealed per OT evaluation dated 10/10/17 Resident#207 is excessive to total assist. Per most recent OT progress report dated 10/16/17, before the fall, resident was totally dependent with two staff and 75% cuing; for hygiene and grooming she was total dependence. Rehab Director reviewed Resident#207's Activities of Daily Living care plan and said before the fall Resident #207 was total assistance of two staff. No (band name) lift needed because resident had some attempts to initiate. He said the OT 10/10/17 evaluation documented sitting balance was poor and she required maximum assist to maintain balance and physical support from staff or positioning devices. This means while sitting on the bed or on the chair she would need physical support from the staff. This is a patient that would not be safe to sit without support. The Rehab Director stated he was aware Resident #207 had a fall in the shower room. After the fall the occupational therapist screened the resident and the note was given to the Director of Nursing (DON) to talk to the staff about the recommendations. During an interview on 10/26/17 at 3:52 P.M., the Unit Manager/Staff J revealed on 10/23/17 Resident #207's assigned nurse told her the CNA assigned to the resident (CNA/Staff K) had reported resident had a fall in the shower room. She called Resident #207's physician and notified her of the fall. The physician gave order to transfer resident to the hospital due to laceration on left forehead. Resident #207's daughter was notified. She talked to the CNA and asked her to write a statement on what happened. The CNA told her while she was trying to reach the towel to dry the resident, the resident slid from the shower chair and hit her forehead with the wheelchair that was next to it. Unit Manager/Staff J explained the CNAs communicate with the nurses and therapy when they need to know the level of assistance each resident need. The DON was presented with Resident #207's admission MDS with ARD date 10/16/17. After reviewing the Functional Status section the DON said for transfers the resident was extensive assistance with two (2) staff assist and for bathing she was total dependence with two (2) staff assist. The DON agreed this was an avoidable fall.

Based on observation, record review and interview, the facility failed to ensure residents receive adequate assistance to prevent accidents during bathing for 1 (Resident #207) of 3 residents reviewed for accidents. This has the potential to affect 35 residents that need assistance of 1 to 2 staff for bathing and transfers. The findings included: Observed Resident #207 on 10/24/17 at 3:55 P.M., in the activity room seated in her high back wheelchair listening to music with other residents and staff. A pillow was observed on each side of the resident. Resident #207 had a white dressing on her forehead dated 10/24/17, the bridge of her nose was noted with a yellowish discoloration and there was dark red discoloration under both eyes. Resident #207 was oriented to name only. Observed Resident #207 on 10/25/17 at 4:14 P.M. seated in her high back wheelchair with a pillow on each side by the nurses station. Resident #207 had a white dressing on her forehead dated 10/25/17 and the same dark discolorations under her eyes. At 4:17 P.M. the Social Worker approached the resident and told her that her Certified Nursing Assistant (CNA) was going to take her to bed. Resident #207 said she did not want to do that. The Social Worker asked Resident #207 if she wanted to go to the dining room and she said yes. The Social worker took Resident #207 to the dining room in the unit. During an observation on 10/26/17 at 11:46 A.M., Resident #207 was quietly seated in her high back wheelchair by the nurses station, with a pillow on each side. Resident #207 continued to have a white dressing on her forehead dated 10/26/17, and the same dark discolorations under her eyes. Record review of Resident #207's clinical record revealed admission to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of nurses notes documented: -10/21/17 CNA assigned to Resident #207 reported the resident fell down while she was in the shower with her. CNA stated she was trying to get the towel that was at the side to dry thighs area, resident slipped from the shower chair to the floor and hit her head with the wheelchair that was placed next to shower chair to transfer resident back to wheelchair. The Nurse assigned to resident did complete assessment and administered first aid. Resident #207's physician was notified and ordered to transfer resident to nearby acute hospital for further evaluation and treatment due to left forehead laceration. Will continue to follow up closely.-(Note created by charge nurse) -10/21/17 12:46. CNA reported resident fell down while she was taking a shower. Complete assessment done head to toe. Resident awake, alert, confused, able to answer simple questions, pupils equal, round, reactive to light and accommodation (PERRLA), respiration unlabored, complained of pain at this time on her left forehead. Complete range of motion to all extremities. Resident observed with a laceration on left forehead, small amount of bleeding noted, cleaned with normal saline solution (NSS), pat dry, covered with gauze and wrapped with Kerlix. Doctor was notified by supervisor and new order given to transfer resident to nearby acute care hospital. All safety and comfort measures maintained. Will continue to monitor closely.-(Note created by resident's assigned nurse.) -10/21/17 12:56 Ambulance company at facility. Resident will be transferred to acute care hospital as ordered by physician. -10/21/17 Resident returned from hospital. Review of Resident #207's Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) 10/16/17 revealed a Brief Interview for Mental Status (BIMS) summary score of 4 (severe cognitive impact). Resident #207's functional status was documented as extensive assistance with two (2) person physical assist for transfers including to or from bed, chair, wheelchair. Total dependence with two (2) person physical assist for bathing. For balance during transitions the resident was encoded as Not steady, only ale to stabilize with staff assistance. The resident was encoded for functional limitation in range of motion as evidenced by upper extremity impairment on both sides. Resident #207 had care plans in place, not limited to: -10/10/17. Resident requires total assistance times two (2) for functional transfers due to muscle weakness. Interventions not limited to, provide set up and assistance as needed for transfers; instruct in safety precautions and use of adaptive equipment for transfers. Care plan reviewed and revised on 10/23/17 to resident requires extensive assistance times two (2). -10/10/17 resident requires total assistance times two (2) persons for self care tasks due to muscle weakness. Interventions not limited to provide assistance as needed. Interventions updated on 10/11/17. Right side support; high back reclining wheelchair. Care plan reviewed and revised 10/23/17 to resident requires extensive assistance times two (2). -10/09/17 resident requires total assistance times two (2) for bed mobility due to decline in function related to muscle weakness, rigid. Interventions not limited to provide set up and assistance as needed for bed mobility; instruct in safety precautions and use of assistance equipment for bed mobility. Review of Incident Report provided by the Director of Nursing (DON) on 10/25/17 at 3:23 P.M. revealed date of incident 10/21/17 12:00 P.M., location: south shower room, type of incident: observed fall. Observed by CNA. Description: CNA assigned to Resident #207 reported resident fell down while was in the shower room with her. CNA stated she was trying to get the towel that was at the side to dry her thighs and resident slipped from the shower chair to the floor and hit her head with wheelchair that was placed next to shower chair to transfer resident back to wheelchair. Nurse assigned to resident performed assessment and found range of motion present times four, PERRLA and laceration on her left forehead. First aid administered by nurse. Resident complained of left forehead pain. Physician was notified and ordered to transfer resident to nearby acute care hospital for further evaluation and treatment. Responsible party was called. At 1:00 P.M. resident sent to nearby acute care hospital. The incident reported was completed by charge nurse on 10/21/17 and signed by the DON. Review of Witness Statement For Incidents record attached to incident documented statement from CNA/Staff K. The statement was written in Spanish and it read: (Resident #207's name) was taking a shower in the shower chair and when I went to get the towel that was next to the knee and I turned to dry her thighs the resident slid to the floor and hit her head/forehead with the wheels of the wheelchair that was next to her to transfer her. Review of Occupation Therapy (OT) Progress Note dated 10/11/17, Resident #207 had been provided with right side support to aide with proper trunk support alignment while in wheelchair. A reclining wheelchair had been provided with a high back and a left shaped leg pad, all to improve sitting tolerance in wheelchair and proper body alignment. OT Progress Note dated 10/23/17 revealed Resident #207 was screened by OT as per nurse's request due to a fall incident on 10/21/17 at 12:00 P.M. According to nurse's notes, CNA assigned to the resident reported resident fell down while in the shower room with her. CNA stated she was trying to get the towel that was at the side to dry thigh area and resident slipped from the shower chair to the floor and hit her head with the wheelchair that was placed next to shower chair to transfer resident back to wheelchair/. Recommendation: 1-nursing staff (CNA) must secure resident prior and during activity 2-nursing staff (CNA) must have all needed items within reach 3-nursing staff (CNA) must request Assistance as needed Record review of nearby acute hospital Discharge Summary documentation dated 10/21/17 documented Resident #207 was treated for [REDACTED]. During an interview on 10/25/17 at 4:22 P.M., Resident #207's 3:00 P.M.-11:00 P.M. assigned CNA/Staff M reported CNAs rotate. She worked with the resident yesterday and today. She has worked with her before. CNA/Staff M said she was going to put Resident #207 in bed now. CNA/Staff M explained she does the transfer by herself because the resident can help. CNA/Staff M was observed to proceed to wheel Resident #207 from the South Unit activity/dining room to her room. She closed the door and pulled the curtain. Resident #207 asked what was going on. CNA/Staff M told Resident #207 she was going to put her in bed. Resident #207 refused twice. CNA/Staff M said she would bring the resident back to the activity/dining room because she cannot stay alone on the room because she had a fall in the shower, but she does not know the details. CNA/Staff M explained for showers there are supposed to be two CNAs: one to remove the resident's clothes and the other one to make sure the resident does not fall. For transfers, only one CNA because she can manage the resident fine by herself. CNA/Staff M proceeded to wheel Resident #207 out of the room. During an interview on 10/25/17 at approximately 4:30 P.M., Resident #207's assigned 3:00 P.M.-11:00 P.M. Licensed Practical Nurse (LPN)/Staff L, who was observed in the hallway by her cart, revealed she has worked with the resident since she was admitted to the facility. LPN/ Staff L said Resident #207 needs one person physical assist with transfers and even showers because she is contracted but skinny. Resident #207 was not aggressive, not combative and she was able to follow commands. Resident #207 cannot stand. LPN/Staff L said she is usually in the room when the CNA transfers her to bed. During an interview on 10/26/17 at 11:57 A.M., CNA/Staff K, assigned to Resident #207 on 10/21/17 3:00 P.M.-11:00 P.M. shift revealed she went to the resident's room and sat her in the chair and noticed resident was leaning towards her left side and she had to help her reposition. Resident #207 was unable to hold her balance while sitting. She transferred the resident by herself from bed to her wheelchair and wheeled her to the shower room. In the shower room she transferred the resident by herself from wheelchair to the shower chair. They were alone in the shower room, there was nobody else. She proceeded to shower the resident and wash her hair. She dried resident's hair with a towel, she then got another towel and started drying her body. When she went to reach for another towel to continue drying the resident, the resident fell forward and to the side from the shower chair. Resident #207 hit her forehead with the wheel of the wheelchair. Everything happened so fast. She had the wheelchair right next to the shower chair in order to transfer the resident, by herself, back to it once she was done with the shower. The towels were on the wheelchair which was next to the shower chair. CNA/Staff K stated this was the first time she worked with Resident #207. During an interview on 10/26/17 at 1:40 P.M., the Assistant Director of Nursing (ADON) and DON revealed the CNAs communicate with the nurses and CNAs from prior shift about residents level of assistance needed. They communicate with the nurse and therapy staff. Interview with Rehabilitation (Rehab) Director on 10/26/17 at 1:43 P.M., revealed per OT evaluation dated 10/10/17 Resident #207 is excessive to total assist. Per most recent OT progress report dated 10/16/17, before the fall, resident was totally dependent with two staff and 75% cuing; for hygiene and grooming she was total dependence. Rehab Director reviewed Resident #207's Activities of Daily Living care plan and before the fall the resident was total assistance of two staff. No (brand name) lift needed because resident had some attempts to initiate. He said the OT 10/10/17 evaluation documented sitting balance was poor and she required maximum assist to maintain balance and physical support from staff or positioning devices. This means while sitting on the bed or on the chair she would need physical support from the staff. This is a patient that would not be safe to sit without support . Rehab Director stated he was aware Resident #207 had a fall in the shower room. After the fall the Occupational Therapist screened the resident and the note was given to the DON to talk to the staff about the recommendations. Interview with the DON on 10/26/17 at 2:02 P.M., revealed she talked to the CNA involved in the incident. She counseled her about what happened. Interview on 10/26/17 at 3:52 P.M. with the Unit Manager/Staff J revealed on 10/23/17 Resident #207's assigned nurse told her the CNA assigned to the resident (CNA/Staff K) had reported resident had a fall in the shower room. She called Resident #207's physician and notified her of the fall. The physician gave order to transfer resident to the hospital due to laceration on left forehead. Resident 207's daughter was notified. Unit Manager/Staff J talked to the CNA and asked her to write a statement on what happened. The CNA told her while she was trying to reach the towel to dry the resident, the resident slid from the shower chair and hit her forehead with the wheelchair that was next to it. Unit Manager/Staff J explained the CNAs communicate with the nurses and therapy when they need to know the level of assistance each resident need. Interview with DON/Risk Manager on 10/26/17 at 5:08 P.M. revealed Unit Manager/Staff J filled out incident report on 10/21/17. The DON went over the incident description. The DON received the incident report on 10/23/17 and started her investigation. She reviewed the documents from the hospital, spoke with the CNA involved and she described to her what happened. She spoke with Resident #207's daughter. After this, they have decided not to give the resident showers in the chair but to do bed baths. The resident does not need a (brand name) lift to be transferred; she is transferred with just one CNA. They concluded the resident cannot sit on a shower chair. She has talked to the CNAs and told them if they realize a resident cannot stay in the shower chair for long periods of times they need to stop the shower and communicate to the nurse or get assistance from another staff. Regarding the incident she said, they have not determined this to be an adverse incident yet, they are leaning more towards a no because the resident has had showers before and this is the first time this happened. She is not sure yet. The DON was presented with Resident #207's admission MDS with ARD date 10/16/17. After reviewing the Functional Status section, the DON said for transfers the resident was extensive assistance with two (2) staff assist and for bathing she was total dependence with two (2) staff assist. The DON agreed this was an avoidable fall.