Every finding on record at Parkhill North Nursing Home

Based on observation, record review, and interview, the facility failed to ensure routine inspection of a resident bed and side rails were conducted for 1 (#18) of 2 sampled residents reviewed for accident hazards.The DON identified six residents used side rails.Findings:On 12/09/25 at 12:06 p.m., Resident #18 was observed lying in their bed with their eyes closed. On each side of the bed, around the resident's shoulder and head, a quarter side rail was observed attached to the bed frame and in the up position.On 12/12/25 at 3:18 p.m., Resident #18 was observed lying in bed with their eyes closed. The bilateral quarter rails on the resident's bed located around the resident's shoulders and head were in the up position.On 12/16/25 at 10:37 a.m., Resident #18 was observed lying in their bed with their eyes open. The two bed rails attached to the resident's bed frame were in the up position.A MDS annual assessment, dated 11/07/25, showed in Section C Resident #18 had a BIMS score of 13 which indicated the resident's cognition was intact and suggested normal memory and thinking abilities. On 12/16/25 at 10:52 a.m., the facility maintenance supervisor was asked how long they had been in charge of facility maintenance. They stated they had been in that position for 1.5 years. They were asked to describe the maintenance program they had regarding bed frames and side rails. They stated when someone reported an issue with the beds or the rails they went and fixed them. They were asked if they had a program to routinely inspect the bed frames and bed rails. They stated they did not do that, but only made repairs when they got a report and put together new beds when they came into the facility.On 12/16/25 at 11:48 a.m., the DON was asked if residents' beds and bed rails were routinely inspected. They stated they believed they were inspected before a resident used them, but they did not have any documentation of bed frame or bed rail inspections. They were asked if they had a policy and procedure regarding bed frame and bed rails use. They stated they did not.

Based on record review and interview, the facility failed to ensure labs were obtained as ordered by the physician for 2 (#33 and #5) of 5 sampled residents whose labs were reviewed.The DON identified 37 residents had lab orders.Findings:1.A policy titled Lab and Diagnostic Test Results-Clinical Protocol, dated November 2018, read in part, 1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests.A physician order, dated 04/11/25, showed Resident #33 was to have a CBC and CMP every six months in April and October.A quarterly assessment, dated 10/31/25, showed Resident #33 had a BIMS score of 2, which indicated the resident was severely impaired in cognition for daily decision making, and did not have any pressure ulcers.A care plan, revised 10/31/25, showed the resident was at risk for pressure ulcers, did not currently have any pressure ulcers, and to monitor labs as ordered by the physician.Review of the clinical record did not show labs had been completed as ordered by the physician in April or October 2025.On 12/17/25 at 11:09 a.m., the DON stated the ordered labs for Resident #33 had not been completed. They stated they did not know why labs were not completed as ordered by the physician.2. A physician order, dated 03/12/24, showed Resident #5 was to receive a CBC, CMP, LFT, and Valproic Acid level every six months in April and October.An annual assessment, dated 10/09/25, showed a staff assessment that Resident #5 was severely impaired in cognition for daily decision making and had hypertension (high blood pressure).A care plan, revised 10/09/25, showed Resident #5 had hypertension and staff were to monitor labs as ordered.Review of the clinical record did not show the ordered labs had been completed in October 2025.On 12/17/25 at 11:09 a.m., the DON stated the CBC, CMP, LFT, and Valproic Acid labs had not been completed in October 2025. They stated they were supposed to monitor the lab reports monthly, but did not know why that was not being done.

Based on observation and interview, the facility failed to employ a full-time dietary manager and have competent kitchen staff assigned to perform the duties of cook and/or dietary aide. The DON identified 39 residents received meals prepared in the kitchen. Findings: On 12/09/25 at 10:50 a.m., there was no dietary manager observed in the kitchen.On 12/09/25 at 1:30 p.m., there was no dietary manager observed in the kitchen.On 12/10/25 at 10:30 a.m., there was no dietary manager observed in the kitchen. A hospice aide entered the kitchen without a hair net or hair cover and scooped ice from a cooler located in the center of the kitchen. [NAME] #1 and cook #2 were present, but neither corrected the hospice aide nor offered them a hair net. On 12/10/25 at 4:40 p.m., there was no dietary manager observed in the kitchen. Dietary Ade #1 stepped onto the top of an open box of russet potatoes located on the bottom shelf of the food preparation table in the center of the kitchen. The dietary aide tied their shoe before returning their foot/shoe to the floor. On 12/15/25 at 9:20 a.m., there was no dietary manager observed in the kitchen. [NAME] #1 pureed canned carrots. They slid a butter knife back and forth between the blender housing and the cover until the safety engaged and the blender started. On 12/15/25 at 11:50 a.m., there was no dietary manager observed in the kitchen. [NAME] #1 plated a pureed diet plate with pureed lasagna, carrots, and a whipped dessert. There was no bread served.On 12/15/25 at 5:55 p.m., there was no dietary manager observed in the kitchen. [NAME] #2 was observed touching multiple kitchen counter surfaces and the food preparation table with their bare hands. [NAME] #2 picked up a gallon size can of pears, pushed the metal lid down into the can, and placed the can in the refrigerator. Without washing their hands, cook #2 grabbed a small plate, covered the surface area where food would go with their palm and four fingers. [NAME] #2 placed the plate on the counter and immediately reached over with their other bare hand and picked up and placed a grilled cheese sandwich on the plate. [NAME] #2 exited the kitchen with the grilled cheese and delivered it to a resident's room. [NAME] #2 was in the room for a few seconds before exiting and returning to the kitchen which they entered without washing their hands. [NAME] #2 began storing leftovers and disposing of packaging in the trash can.On 12/15/25 at 6:20 p.m., there was no dietary manager observed in the kitchen. Dietary Aide #1 was in the kitchen. A 44-ounce Styrofoam cup with lid and straw was present on the top shelf above the counter top. There was a gallon sized can of pears in the refrigerator. Dietary aide #1 was shown the canned pears stored inside the refrigerator. Dietary Aide #1 moved the pears to a plastic storage container with lid and labeled the lid. An unidentified CNA requested a pureed tray and received a plate of mashed potatoes, apple sauce, and chicken broth. There were no noodles or meat in the broth. Another unidentified CNA requested a regular diet tray and received half of a grilled cheese sandwich, a ladle full of diced peaches, and a Styrofoam bowl of chicken noodle soup. There was a half a loaf of white bread in a package sitting on top of the toaster. On 12/10/25 at 10:40 a.m., cook #1 stated the facility did not have a dietary manager and were told they did not need a dietary manager since the registered dietician visited once a month. On 12/15/25 at 9:20 a.m., cook #1 stated the top cover to the commercial blender the staff used to make puree meals was broken and required a butter knife to engage the lock before the blender would work. [NAME] #1 stated they had a new top for the blender on order. [NAME] #1 stated they would not puree the bread sticks that were on the menu for residents. On 12/15/25 at 5:15 p.m., cook #2 was asked to provide a copy of the extended menus for the week. [NAME] #2 stated they did not know of an extended menu. The extended menu was described to cook #2 as the menu approved by the registered dietician, which detailed what each person received based on their ordered diet (For example: what was fixed for residents who received a pureed diet, or renal diet) and which gave the serving size for each menu item. [NAME] #2 stated they were never shown an extended menu. On 12/15/25 at 5:55 p.m., cook #2 stated they were the evening cook two days a week. [NAME] #2 stated they did not know the requirements for storing leftover foods. [NAME] #2 stated they were not taught how to properly cool leftover food and did not know what the temperature danger zone was for foods. When asked what the holding temperature for cold food and for food stored on the steam table, cook #2 only shrugged. When asked what did the staff do to reduce the risk of foodborne illness in residents, cook #2 initially shrugged and then stated they only received two days of training and never heard of a temperature danger zone for food, did not know what an extended menu was, and did not know what the proper holding temperatures for hot and cold foods were to be. [NAME] #2 stated they did not know what the dietary requirements were for residents who received a pureed diet and served what the daytime cook wrote for them to fix for the evening meal. On 12/15/25 at 6:20 p.m., dietary aide #1 stated they did not know about an extended menu, the temperature danger zone for foods, or the holding temperatures for hot/cold foods. Dietary Aide #2 stated they did not cook or plate food, but common sense would tell you not to touch the surface area of the plate where the food would lay or to touch the food with bare hands. With a smile on their face, dietary aide #1 stated the open drink in the kitchen was theirs. Dietary Aide #1 stated it was unsanitary to have personal drinks in the kitchen or to use the open top box of stored baking potatoes as a raised step to tie your shoes. Dietary Aide #1 stated cook #2 must have placed the gallon size can of pears in the refrigerator and this was not the way to store foods in the refrigerator. Dietary Aide #1 stated cook #2 said they ran out of bread and the activities director stated to cut the grilled cheese sandwiches in half and service half servings to the residents. Dietary Aide #1 stated they did not know why the cook served mashed potatoes and apple sauce for the pureed evening meal. Dietary Aide #1 stated the biggest problem they saw with the kitchen was a lack of management and training. On 12/15/25 at 6:35 p.m., the DON stated the facility did not have a dietary manager and cook #1 was like an interim dietary manager because they had been there the longest. On 12/18/25 at 4:30 p.m., cook #1 stated they were not filling in as the dietary manager. [NAME] #1 stated they did not puree the bread sticks because residents who received pureed diet would not eat pureed bread. [NAME] #1 stated the activities director was responsible for ordering the food and based the order off what was needed to prepare the scheduled meals from the menu. [NAME] #1 stated the facility did not require a food handler's permit to work in the kitchen and the registered dietician told them if anything needed to change. On 12/18/25 at 4:40 p.m., the DON stated the residents who received pureed meals should have received what was on the menu. The DON stated the activities director reviewed the menu and ordered the food, but if they ran out of something, they went to the local grocery store to purchase it. The DON stated they gave the kitchen staff a week or two of training with the main cook and the registered dietician in-serviced the kitchen staff. The DON was asked who was responsible to ensure the kitchen staff were competent/trained in their duties. The DON stated it was the activities director and cook #1 who monitored the kitchen duties and dietary staff. The DON stated cook #2 was untrainable. The DON stated it was hard to get someone to apply because the pay was so low for the dietary department, but they set them to train with kitchen staff who worked in the facility for a while.

Based on observation, record review, and interview, the facility failed to:a. ensure hair restraints were used by individuals entering the kitchen;b. ensure the integrity of the kitchen environment was free of breaks/holes; c. ensure leftover foods were stored according to standards of practice;d. ensure the kitchen staff followed infection control standards of practice;e. ensure the ice machine was kept clean; andf. ensure food was served according to standards of practice.The DON identified 39 residents ate meals prepared in the kitchen. Findings: On 12/09/25 at 10:50 a.m., the following observations were made in the kitchen: a. a metal pipe of a type used as an electrical conduit, exited the ceiling through a hole which was not sealed around the metal. There was also another quarter size hole in the ceiling six inches from the pipe. The hole had two white wires hanging through the quarter size hole. The hole was not sealed around the two wires,b. a partially painted over bell was hanging loosely from the ceiling. There was electrical wiring and a screw exposed between the base of the bell and the ceiling. There were two screw holes in the ceiling and another quarter sized hole which appeared to have wires coming through the hole and to the bell. None of the holes were sealed,c. the crown molding in the corner of the kitchen appeared separated from the ceiling and wall, andd. there was an unsealed dime sized hole in the ceiling, adjacent to the ceiling rack for pots/pans which hung from the ceiling over one end of the center food preparation table. On 12/09/25 at 1:30 p.m., the ice machine was observed with the maintenance supervisor. There was a black and brown mucous looking substance along the edges of the drip pan and a dark substance covering the inside and outside of the opaque tubing used to move water throughout the ice machine for the creation of ice. On 12/10/25 at 10:30 a.m., a hospice aide entered the kitchen without a hair net or hair cover and scooped ice from a cooler located in the center of the kitchen. [NAME] #1 and cook #2 were present, but neither corrected the hospice aide nor offered the aide a hair net. On 12/10/25 at 4:40 p.m., dietary aide #1 stepped onto the top of an open box of russet potatoes located on the bottom shelf of the food preparation table in the center of the kitchen. The dietary aide tied their shoe. On 12/15/25 at 5:55 p.m., cook #2 was observed touching multiple kitchen counter surfaces and the food preparation table with their bare hands. [NAME] #2 picked up a gallon size can of pears, pushed the metal lid down into the can, and placed the can in the refrigerator. Without washing their hands, cook #2 grabbed a small plate, covered the surface area where food would go with their palm and four fingers. [NAME] #2 placed the plate on the counter and immediately reached over with their other bare hand and picked up and placed a grilled cheese sandwich on the plate. [NAME] #2 exited the kitchen with the grilled cheese and delivered it to a resident's room located near the kitchen. [NAME] #2 was in the room only a few seconds before exiting and returning to the kitchen which they entered without washing their hands. [NAME] #2 began storing leftovers and disposing of packaging in the trash can. On 12/15/25 at 6:20 p.m., dietary aide #1 was in the kitchen. A 44-ounce Styrofoam cup with lid and straw was present on the top shelf above the corner countertop of the kitchen. There was an open gallon sized can of pears in the refrigerator. Dietary Aide #1 was shown the canned pears stored inside the refrigerator. Dietary Aide #1 transferred the pears to a plastic storage container with lid and labeled the lid. There was an unsealed plastic bag of white bread on top of the toaster. On 12/09/25 at 1:35 p.m., the maintenance supervisor stated they used to clean the ice machine one to two times a month, but the facility recently hired an outside company to clean the ice machine. The maintenance supervisor stated the ice machine needed to be cleaned and they would be in contact with the contracted company. On 12/10/25 at 10:40 a.m., cook #1 stated the facility did not have a dietary manager and were told they did not need a dietary manager since the registered dietician visited once a month. On 12/15/25 at 5:55 p.m., cook #2 stated they were the evening cook two days a week. [NAME] #2 stated they did not know the requirements for storing leftover foods. [NAME] #2 stated they were not taught how to properly cool leftover food and did not know what the temperature danger zone was for foods. When asked what the holding temperature for cold food and for food stored on the steam table, cook #2 only shrugged. When asked what did the staff do to reduce the risk of foodborne illness in residents, cook #2 initially shrugged and then stated they only received two days of training and never heard of a temperature danger zone for food, did not know what an extended menu was, and did not know what the proper holding temperatures for hot and cold foods were to be. [NAME] #2 stated they did not know what the dietary requirements were for residents who received a pureed diet and served what the daytime cook wrote for them to fix for the evening meal. On 12/15/25 at 6:20 p.m., dietary aide #1 stated they did not know about an extended menu, the temperature danger zone for foods, or the holding temperatures for hot/cold foods. Dietary Aide #1 stated they did not cook or plate food, but common sense would tell them not to touch the surface area of the plate where the food would lay or to touch the food with bare hands. With a smile on their face, dietary aide #1 stated the Styrofoam cup and straw was their open drink in the kitchen. Dietary Aide #1 stated it was unsanitary to have personal drinks in the kitchen or to use the open top box of stored baking potatoes as a raised step in which to tie their shoes. Dietary Aide #1 stated cook #2 must have placed the open gallon size can of pears in the refrigerator and this was not the way to store foods in the refrigerator. Dietary Aide #1 stated cook #2 said they ran out of bread and the activities director instructed them to cut the grilled cheese sandwiches they served for dinner in half and give half servings to the residents. Dietary Aide #1 stated they did not know why the cook served mashed potatoes and apple sauce for the pureed evening meal. Dietary Aide #1 stated the biggest problem they saw with the kitchen was a lack of management and training. On 12/15/25 at 6:35 p.m., the DON stated the facility did not have a dietary manager and cook #1 was like an interim dietary manager because they had been employed in the kitchen the longest. On 12/18/25 at 4:30 p.m., cook #1 stated they were not filling in as the dietary manager. The cook stated the activities director was responsible for ordering the food and based the order off what was needed to prepare the scheduled meals from the menu. [NAME] #1 stated the facility did not require a food handler's permit to work in the kitchen and the registered dietician told them if anything needed to change. On 12/18/25 at 4:40 p.m., the DON stated the activities director reviewed the menu and ordered the food but if they ran out of something, they went to the local grocery store to purchase it. The DON stated they gave the kitchen staff a week or two of training with the main cook and the registered dietician in-serviced the kitchen staff. The DON was asked who was responsible to ensure the kitchen staff were competent/trained in their duties. The DON stated some of the kitchen staff were not trainable. The DON stated it was hard to get someone to apply because the pay was so low for the dietary department, but they set new staff to train with kitchen staff who worked in the facility. The DON stated it was the activities director and cook #1 who monitored the kitchen duties and dietary staff. The DON stated kitchen was recently renovated and they were unaware of the holes in the kitchen.

Based on observation, record review, and interview, the facility failed to provide meals according to the menu approved by the registered dietician for two of two observed meal services. The DON identified 39 residents ate meals prepared in the kitchen and cook #1 identified six residents received pureed diets.Findings:On 12/15/25 at 9:20 a.m., cook #1 was observed pureeing canned carrots. [NAME] #1 slid a butter knife back and forth between the blender housing and the cover until the safety engaged and the blender started. On 12/15/25 at 11:10 a.m., cook #1 was observed pureeing prepared lasagna. [NAME] #1 slid a butter knife back and forth between the blender housing and the cover until the safety engaged and the blender started. On 12/15/25 at 11:50 a.m., cook #1 was observed plating a pureed diet plate with pureed lasagna, carrots, and a whipped dessert. There was no breadstick/bread served. On 12/15/25 at 6:20 p.m., there was a half a loaf of white bread observed in a package sitting on top of the toaster. Dietary Aide #1 was in the kitchen. An unidentified CNA requested a pureed tray and received a plate of mashed potatoes, apple sauce, and chicken broth. There were no noodles or meat in the broth. Another unidentified CNA requested a regular diet tray and received half of a grilled cheese sandwich, a ladle full of diced peaches, and a Styrofoam bowl of chicken noodle soup. The extended menu for the noon meal, dated for week three, day 16 (12/15/25), showed the pureed meal consisted of: a #6 scoop (6 ounces) of pureed lasagna, a #8 scoop (4 to 5 ounces) of pureed vegetable blend, a #16 scoop (2 to 2.25 ounces) of pureed garlic bread, and a #10 (3 to 4 ounces) scoop of pureed brownie. The extended menu for the evening meal, dated for week three, day 16 (12/15/25), showed the regular textured meal was to consist of: three quarters cup chicken noodle soup, 2 ounces of pimento cheese sandwich, half of a cup of cucumber onion salad, six saltine crackers, and half of a cup of emerald pears. The pureed textured meal was to consist of: #6 scoop of pureed chicken noodle soup, two #8 scoops of pureed pimento cheese sandwich, a #8 scoop of pureed vegetable blend, a #16 scoop of pureed bread, and a #12 scoop of pureed emerald pear. On 12/15/25 at 9:20 a.m., cook #1 stated they would not puree the bread sticks. [NAME] #1 stated they wrote their substitutions on a paper on the wall for the registered dietician to review. On 12/15/25 at 5:15 p.m., cook #2 was asked to provide a copy of the extended menus for the week. [NAME] #2 stated they did not know of an extended menu. The extended menu was described to cook #2 as the menu approved by the registered dietician, which detailed what each person received based on their ordered diet (i.e. what was fixed for residents who received a pureed diet, or renal diet, etc.) and what the serving size was for each menu item. [NAME] #2 stated they were never shown an extended menu and served what the daytime cook wrote on the board for the day. [NAME] #2 stated they did not know what the dietary requirements were for residents who received a pureed diet and served what the daytime cook wrote for them to fix for the evening meal. On 12/15/25 at 6:20 p.m., dietary aide #1 stated they did not know about an extended menu. Dietary Aide #1 stated cook #2 said they ran out of bread and the activities director stated to cut the grilled cheese sandwiches in half and serve half servings to the residents. Dietary Aide #1 stated they did not know why cook #2 served mashed potatoes and apple sauce instead of what was on the menu for the pureed evening meal. Dietary Aide #2 stated the biggest problem they saw with the kitchen was a lack of management and training. On 12/15/25 at 6:35 p.m., the DON stated the facility did not have a dietary manager and cook #1 was like an interim dietary manager because they had been there the longest. On 12/18/25 at 4:30 p.m., cook #1 stated the residents would not eat the pureed bread sticks so they quit pureeing the bread sticks. [NAME] #1 was asked why the dietary staff did not follow the menu or serving sizes, especially with the puree diets. [NAME] #1 repeated the residents just would not eat the pureed bread. [NAME] #1 stated it was the activities director who reviewed the menu and ordered the food. [NAME] #1 was asked about the training the facility provided to the dietary staff. [NAME] #1 stated the registered dietician told them if something changed. On 12/18/25 at 4:40 p.m., the DON was asked why the kitchen staff did not follow the menu. The DON stated the residents were supposed to get the missing menu items, but they have found the evening cook was not trainable. The DON stated the activities director was responsible for ordering food and if anything was missing, they went to the local grocery store to purchase the missing items. The DON stated the kitchen staff was provided a week or two of training with the main cook, the registered dietician performed in-services, and they were certain the facility required a food handler's permit to work in the kitchen.

Based on observation and interview, the facility failed to maintain a commercial blender in working order for the preparation of puree meals. [NAME] #1 identified six residents ate puree meals prepared in the kitchen. Findings: On 12/15/25 at 9:20 a.m., cook #1 was observed to pour canned carrots into the bowl of a blender, placed a broken cover onto the bowl, and used a butter knife to engage the safety and start the blender. [NAME] #1 was observed to blend the canned carrots and lasagna utilizing the bowl with broken cover and a butter knife to engage the safety and start the blender. The cover to the blender bowl was observed to be cracked in several places and the plastic portion which locked the blender bowl in place was missing and appeared to have broken off. On 12/15/25 at 9:19 a.m., cook #1 stated the top to the blender they used to puree foods was broken and they had to work the safety with a butter knife to get the blender to work. [NAME] #1 stated the office had ordered another top for the blender.

Based on record review and interview, the facility failed to ensure a resident did not receive an antipsychotic medication for the diagnosis of dementia for 1 (#10) of 5 sampled residents reviewed for unnecessary medications.The DON identified 11 residents received antipsychotic medications.Findings:A facility policy titled Monitoring of Anti-Psychotics, dated 2025, showed residents were only to be prescribed antipsychotic medications if one of the listed diagnoses in the policy were used. The list in the policy did not include any form of dementia.A physician's order, dated 11/19/25, showed Resident #10 was to be administer quetiapine (an antipsychotic medication) one tablet of 25 mg once every morning for the diagnosis of vascular dementia, unspecified severity, with agitation.A physician's order, dated 11/19/25, showed Resident #10 was to be administer quetiapine (an antipsychotic medication) one tablet of 50 mg once every bedtime for the diagnosis of vascular dementia, unspecified severity, with agitation.A medication administration record for Resident #43, dated December 2025, showed Resident #43 was administered both the morning and bedtime doses of quetiapine on dates of 12/01/25, 12/02/25, 12/03/25, 12/04/25, 12/05/25, 12/06/25, 12/07/25, 12/08/25, 12/09/25, 12/10/25, and 12/11/25.On 12/12/25 at 11:20 a.m., the DON provided a copy of the facility's policy on antipsychotic medications. They were asked if antipsychotic medications were approved for the treatment of dementia. They stated they were not.On 12/12/25 at 12:01 p.m., LPN #1 was asked why Resident 43 had been administered quetiapine. They stated the resident had been given that medication for their aggression toward other residents. They were asked if they knew if the medication was approved for the treatment of dementia with aggression. They stated they did not know.

Based on record review and interview, the facility failed to ensure assessments were accurate for 1 (#5) of 14 sampled residents whose assessments were reviewed.The DON identified 39 residents resided in the facility. Findings: A medication administration record, dated July 2025, showed Resident #5 was ordered lorazepam (an anxiolytic medication) 1mg every four hours as needed for anxiety from 07/02/25 through 07/16/25. The medication administration record, showed Resident #5 had received lorazepam 1mg on 07/15/25 at 9:26 p.m. The medication administration record showed Resident #5 was ordered and received divalproex (an anticonvulsant medication) 125mg daily from 07/01/25 through 07/16/25. A quarterly assessment, dated 07/15/25, showed a staff assessment for cognition revealed Resident #5 was severely impaired in cognition for daily decision making, had not received an antianxiety medication or an anticonvulsant medication during the seven-day look back period. An annual assessment, dated 10/09/25, showed a staff assessment for cognition revealed Resident #5 was severely impaired in cognition for daily decision making, and had not received an anticonvulsant medication during the seven-day lookback period. A medication administration record, dated October 2025, showed Resident #5 was ordered and received divalproex 125mg daily. The medication administration record showed Resident #5 had received divalproex during the seven-day look back period on 10/03/25, 10/04/25, 10/05/25, 10/07/25, and 10/08/25. On 12/16/25 at 11:39 a.m., MDS coordinator #1 stated they reviewed the medication administration records when completing assessments and did not know why they had not accurately coded the assessment dated [DATE] for the lorazepam. On 12/16/25 at 12:01 p.m., MDS coordinator #1 stated since Resident #5 had not had a diagnosis of seizures they did not code the divalproex as an anticonvulsant medication the resident had received during the seven-day lookback period on the assessment dated [DATE] or the assessment dated [DATE].

Based on record review and interview, the facility failed to ensure a baseline care plan was developed for 1 (#19) of 14 sampled residents whose care plans were reviewed. The DON identified 39 residents resided in the facility.Findings:The admission assessment, dated 06/20/25, showed Resident #19 had been admitted to the facility on [DATE] and had a BIMS score of 13, which indicated the resident was cognitively intact for daily decision making.Review of the clinical record did not show a baseline care plan had been completed for Resident #19. On 12/18/25 at 11:02 a.m., MDS coordinator #1 stated they or the ADON completed baseline care plans. They reviewed the electronic clinical record and the paper chart and stated the ADON may know where the baseline care plan was located for Resident #19. On 12/18/25 at 11:09 a.m., the ADON stated they completed baseline care plans for residents. The ADON reviewed the electronic clinical record and stated they had not completed a baseline care plan for Resident #19 within 48 hours of admission for Resident #19 because they had been off work on those days.

Based on record review and interview, the facility failed to ensure a resident assessed to be at risk for wandering and elopement had a problem, goals, and interventions in their care plan for wandering and elopement for 1 (#43) of 2 sampled residents reviewed for accident hazards.The DON identified two residents were at risk of wandering.Findings:An MDS admission assessment, dated 12/01/24, showed in Section C under staff assessment, Resident #43's cognition was moderately impaired. In Section E of the assessment, it showed the resident experienced delusions and wandered one to three days in the previous seven days.A quarterly wandering/elopement assessment, performed by LPN #4 on 09/02/25, showed the answers to the questions: Is the resident resistant to being placed in facility, does the resident have a history of wandering, is the resident confused and disoriented, and are there any indications of dementia, were answered yes. According to the instructions printed on the assessment, one yes answer to any of the questions required the resident be put on wandering / elopement precautions.An MDS admission assessment, dated 12/04/25, showed in Section C staff assessment, Resident #43's cognition was severely impaired. In Section E of the assessment, it showed the resident experienced delusions and wandered one to three days in the previous seven days.A care plan for Resident #43, revised 12/06/25, showed no problem, goals, or interventions for wandering or elopement risk.On 12/18/25 at 10:45 a.m., the ADON was asked who at the facility had the responsibility to create the resident care plans. They stated they did. They were asked to review Resident #43's care plan for entries regarding wandering or elopement. After reviewing the document, the ADON stated there was nothing care planned for wandering or elopement risk in the care plan. The ADON was asked what they knew about resident #43 should there be problems, goals, and interventions related to wandering and elopement risk. They stated since the resident did wander and had dementia the problems should have been included in the care plan.

Based on observation, record review, and interview, the facility failed to ensure a resident who had been assessed as an elopement risk was unable to exit the building and enter the facility parking lot unseen for 1 (#43) of 2 sampled residents reviewed for accident hazards.The DON identified two residents that wandered.Findings:On 12/09/25 at 10:00 a.m., Resident #43 was observed attempting to open the front door of the facility when they observed the surveyors waiting to enter. The resident repeatedly pushed on the door latch until a staff member intervened.A facility policy titled Elopement, dated 2008, read in part, Staff shall investigate and report all cases of missing residents,An MDS admission assessment, dated 12/01/24, showed in Section C staff assessment, Resident #43's cognition was moderately impaired. In Section E of the assessment, it showed the resident experienced delusions and wandered one to three days in the previous seven days.A quarterly wandering/elopement assessment, performed by LPN #4 on 09/02/25, showed the answers to the questions: Is the resident resistant to being placed in facility, does the resident have a history of wandering, is the resident confused and disoriented, and are there any indications of dementia, were answered yes. According to the instructions printed on the assessment one yes answer to any of the questions required the resident be put on wandering / elopement precautions.An MDS admission assessment, dated 12/04/25, showed in Section C staff assessment, Resident #43's cognition was severely impaired. In Section E of the assessment, it showed the resident experienced delusions and wandered one to three days in the previous seven days.On 12/17/25 at 2:56 p.m., LPN #3 was asked if Resident #43 had ever gotten out of the facility without anyone knowing. They stated the resident had done that once. They were asked when that occurred. LPN #3 stated they could not recall when it occurred. They were asked if they were on duty when it occurred. LPN #3 stated they had been on duty at the time but had not witnessed the resident leave the building. They stated the resident had been found outside the front door of the facility. On 12/17/25 at 2:59 p.m., LPN #1 was asked if they knew of an instance when Resident #43 had exited the building without anyone knowing. They stated it had happened once, but they could not recall when it occurred. On 12/17/25 at 3:27 p.m., LPN #3 was asked if they had informed anyone in administration about Resident #43 getting out of the building. They stated they did not since the resident had just walked around the building.On 12/18/25 at 8:32 a.m., LPN #4 was asked if they knew of an incident where Resident #43 had left the faciity on their own. They stated they were aware, but had not seen it. They stated they were at the facility and recalled nurse aides going toward the front door and returning with Resident #43. They were asked if they had reported the incident to anyone in administration. They stated they had not.On 12/18/25 at 8:36 a.m., CNA #3 was asked if they knew of an incident where Resident #43 had exited the facility without anyone knowing. They stated they could not recall exactly when it occurred, but thought it was on a Friday during the summer. They stated CNA #2, LPN #2, and certified medication aide #3 had been in the building when it occurred. They stated they had observed Resident #43 in the front parking lot and went outside to get them.On 12/18/25 at 9:23 a.m., the DON was asked when they had become aware Resident #43 had previously exited the facility. They stated when this surveyor had told them about what the other staff members had said on 12/17/25. They were asked if there was a system in place at the facility regarding the reporting of such incidents. They stated yes and the staff were supposed to report to them when that occurs.On 12/18/25 at 9:32 a.m., CNA #2 was asked if they knew of an instance when Resident #43 had left the building without staff knowing. They stated it had occurred once, but they could not recall when. They stated CNA #4 had said the resident was outside and that they went with CNA #4 to get the resident. On 12/18/25 at 9:41 a.m., CNA #4 was asked if they knew of a time when Resident #43 had been found outside the building without anyone knowing. They stated they did recall that had occurred but not when. They stated they were the first person to go out to get the resident.On 12/18/25 at 9:59 a.m., the DON made the statement that they believed what occurred with Resident #43 was not elopement as a staff member CNA #5 had never lost sight of the resident. The DON stated they were attempting to contact CNA #5 to get them to contact this surveyor. On 12/18/25 at 10:18 a.m., CNA #3 was asked who the first person was to reach Resident #43 on the date they went outside the building. They stated it was CNA #4. They were asked if CNA #5 had assisted during the incident. They stated CNA #5 was not there when it occurred.On 12/18/25 at 10:21 a.m., CNA #2 was asked who the first person was to reach Resident #43 on the date they went outside the building. They stated it was CNA #4. They were asked if CNA #5 had assisted during the incident.On 12/18/25 at 10:24 a.m., CNA #4 was asked if CNA #5 had been present when they had found Resident #43 outside the building. They stated no and the incident occurred during the day shift and CNA #5 worked the evening shift.

Based on observation, record review, and interview, the facility failed to ensure indwelling urinary catheters were changed when ordered by the physician for 1 (#19) of 1 sampled resident reviewed for indwelling urinary catheters.The DON identified four residents with indwelling urinary catheters.Findings: On 12/17/25 at 9:31 a.m., Resident #19 was observed in bed with an indwelling urinary catheter. A physician order, dated 06/10/25, showed the indwelling urinary catheter was to be changed every month on the 9th and as needed. A quarterly assessment, dated 12/04/25, showed Resident #19 had a BIMS score of 15, which indicated the resident was cognitively intact for daily decision making, had an indwelling urinary catheter, and had obstructive uropathy. A care plan, revised 12/04/25, showed Resident #19 had an indwelling urinary catheter. The care plan showed the indwelling urinary catheter was to be changed every month and as needed. The medication administration record, dated 12/01/25 through 12/17/25, showed the indwelling urinary catheter was to be changed on 12/09/25, but was not documented as completed. On 12/17/25 at 9:31 a.m., Resident #19 stated they had received catheter care as indicated but their catheter had not yet been changed in December 2025. On 12/17/25 3:11 p.m., LPN #3 stated they thought the hospice nurse had changed the catheter for Resident #19 on 12/09/25. On 12/18/25 at 10:39 a.m., the DON stated the hospice nurse had not changed the indwelling urinary catheter for Resident #19 on 12/09/25. The DON stated the charge nurse was responsible to complete indwelling urinary catheter changes. They stated they did not have monitoring in place to ensure indwelling urinary catheters were changed as ordered by the physician.

Based on observation, record review, and interview, the facility failed to ensure communication between the facility and a resident's dialysis provider was conducted routinely for 1 (#3) of 1 sampled resident reviewed for dialysis care.The DON identified one resident received dialysis care.Findings:On 12/17/25 at 10:08 a.m., LPN #1 was observed conducting a pre-dialysis assessment of Resident #3.A facility policy titled Dialysis-General Guidelines and Management, dated 01/2008, was reviewed. The policy did not address the continued communication between the dialysis center and the facility.A physician's order, dated 01/30/25, showed Resident #3 was to be sent to a contracted dialysis provided every Monday, Wednesday, and Friday.On 12/17/25 at 10:20 a.m., LPN #1 was asked if they had used the facility's dialysis communicating form to document Resident #3's assessment results. They stated they had not since they had been a nurse at the facility. They were asked how long they had been a nurse at the facility. They stated it had been two years. They were asked again if they had used the facility's dialysis communication form to document their pre and post dialysis assessments and had they sent the form with the pre-dialysis assessment results to the dialysis center. They stated they had not. They were asked if they had ever sent pre-dialysis assessment information to the personnel at the dialysis center. They stated they had not and that they believed the reason was that in the past the dialysis center would never fill out their section of the form or send the form back at all.On 12/17/25 at 10:45 a.m., DON was asked about the use of the facility's dialysis communication form. They stated they did have that form, but it had not been filled out and sent to the dialysis center in years. They were asked how they received information from a session of dialysis from the dialysis center. They stated they had not received routine communication back from the dialysis about Resident #3 during the time they had been going to the dialysis center for care. They stated the only exception was that the dialysis center nutritionist did send regular documentation about nutrition.

Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours a day, seven days a week. The administrator reported 36 residents resided in the facility. Findings: A nursing schedule for April 2024 documented the facility did not have RN coverage for eight consecutive hours on 04/05/24, 04/08/24, 04/09/24, and 04/10/24. On 06/05/24 at 1:01 p.m., the DON was requested to provide documentation that an RN had worked eight consecutive hours in the facility on 04/05/24, 04/08/24, 04/09/24, and 04/10/24. On 06/05/24 at 1:30 p.m., the DON reported they did not have RN coverage in the facility on 04/05/24, 04/08/24, 04/09/24, and 04/10/24.

Based on record review and interview, the facility failed to ensure all allegations of abuse were reported within two hours of the reported incident for one (# 1) of three residents sampled for abuse. The DON reported the census was 35. Findings: A facility policy, revised 01/18, titled Abuse - Reportable Events, read in part, .It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law .Abuse 2-hour limit .it includes verbal abuse, sexual abuse, physical abuse, and mental abuse . Resident #1 had diagnoses which included hypertension and generalized anxiety disorder. An annual assessment, dated 02/23/24, documented Resident #1 was cognitively intact for daily decision making and required partial assistance from staff with bathing. A review of the OSDH form 283 dated 03/27/24 contained a fax cover page indicating it was sent to the OSDH at 12:03 p.m. On 03/29/24 at 9:19 a.m., the DON reported that Resident #1's allegation was reported to them at approximately 3:15 p.m. on 03/26/24. They also stated they thought they had 24 hours to report and that it should have been reported within the required 2 hours.

Based on record review and interview, the facility failed to protect residents from potential abuse by allowing an employee named in an allegation of abuse to continue working for one (# 1) of three residents sampled for abuse. The DON reported the census was 35. Findings: A facility policy, revised 01/18, titled Abuse - Reportable Events documented that an employee named in an allegation of abuse will be suspended pending an investigation. Resident #1 had diagnoses which included hypertension and generalized anxiety disorder. An annual assessment, dated 02/23/24, documented Resident #1 was cognitively intact for daily decision making and required partial assistance from staff with bathing. On 03/28/24 at 3:02 p.m., LPN #1 stated they notified the DON of an allegation of abuse at approximately 3:15 p.m. on 03/26/24. The abuse allegation was made by Resident #1 and named CNA #1 as the alleged abuser. LPN #1 also stated CNA #1 was allowed to work their shift on 03/26/24 after the allegation had been reported to the DON. On 03/29/24 at 9:19 a.m., the DON reported that CNA #1 was suspended pending investigation on 03/27/24 but worked on 03/26/24 after the abuse allegation had been reported to the DON.

Based on interview and record review, the facility failed to ensure an RN (Registered Nurse) was on duty for eight hours a day on the weekends, a total of 38 days. This had the potenital of effecting all 38 residents residing in the facility A report titled Labor Analysis-Overtime Report, did not document an RN was on duty for the Saturdays and Sundays for the weeks of 10/1/22 through 04/24/23. On 04/21/23 at 2:12 p.m., ADON #1 was asked why there was no RN coverage on the weekends. They stated they didn't have RN coverage on the those weekends.

Based on observation, record review, and interview the facility failed to maintain a clean ice machine. The Resident Census and Conditions report, dated 04/14/23, documented 36 residents received ice from the ice machine. Findings: On 04/21/23 at 2:00 p.m., the ice machine was observed to have a black substance on the plastic components inside the machine. The ice came in contact with the black substance. A log titled Ice Machine Cleaning Schedule 2022, was reviewed. The ice machine was documented to have been cleaned once in November 2022 and December 18, 2022. There was no documentation of cleaning the ice machine in 2023. On 04/22/23 at 11:15 a.m., Cook #1 was asked to identify the black substance on the inside plastic components of the ice machine. They stated it was scum. They were asked if the black substance should be there. The cook stated no, they had tried to clean it in the past but it kept coming back. They were asked who was responsible for cleaning the ice machine. They stated the maintenance staff but they are new and may not know they are to clean it. Cook #1 was asked when the last time the ice machine was cleaned. They stated December 18, 2022. They were asked if it should have been cleaned since December. They stated yes. Maintenance employee #1 was asked who was responsible for cleaning the ice machine. They stated, I guess me but I have only been here for 3 weeks and no one has trained me on that yet. Maintenance employee #1 was asked to identify the black substance in the machine. They stated they didn't know what it was, it's probably mold. 04/22/23 at 11:54 a.m., they were asked if it should be there. They replied no.

Based on interview and record review, it was determined the facility failed to notify a resident's physician and/or responsible party when there was a change in the resident's condition for one (#1) of five sampled residents who were reviewed for changes in condition. The facility identified 41 residents resided at the facility. Findings: Resident #1 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual assessment, dated 03/19/21, documented the resident was moderately impaired with cognition for daily decision making, required extensive assistance with ADLs, and had a foley catheter. A nursing progress note, dated 04/15/21, documented, Resident complaining of needing to urinate so bad his stomach was hurting. Lower abdominal area was noted to be distended and very painful to the touch. Catheter bag was noted to be empty. Foley cath was removed and was very painful for resident. 18fr catheter was inserted using sterile technique with instant urine return of 2500 MLS of dark yellow urine with a moderate amount of sediment noted. He tolerated it well. There was no documentation the physician or resident's family/responsible party had been notified the resident had experienced pain, been unable to urinate, and his urinary catheter had been changed with a large amount of urine with sediment collected after the change of the catheter. A nursing progress note, dated 04/19/21, documented, Lab .drawn r/t [CONDITION(S)] .DR .notified, instruction's to add CHF DX continue [MEDICATION(S)] and potassium. There was no documentation the resident's family/responsible party had been notified the resident had a new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/09/21 at 11:00 a.m., the DON was asked when a resident's family/physician should be notified. She stated after a change in the resident's condition. She was asked where it would be documented if the physician or family was notified. She stated it should be in the progress notes on the electronic health record. She was informed of the resident's catheter change. She stated the physician and family should have been notified. She was informed of the new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation and interview, it was determined the facility failed to: ~ ensure staff wore appropriate PPE when conducting outbreak testing; ~ ensure staff wore masks appropriately; ~ ensure residents were monitored for all symptoms of COVID-19; and ~ ensure a disinfectant from the EPA's list N was utilized for floors. The facility identified 36 residents who resided in the facility. Findings: The Centers for Disease Control guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019, documented: .Collection of Diagnostic Respiratory Specimens .When collecting diagnostic respiratory specimens (e.g., nasopharyngeal or nasal swab) from a patient with possible [DIAGNOSES REDACTED]-CoV-2 infection, the following should occur: HCP in the room should wear an N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown . The Centers for Disease Control guidance titled, Using Personal Protective Equipment, documented: .Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap) .Facemask: Mask ties should be secured on crown of head (top tie) and base of neck (bottom tie) . The CDC guidance titled, Symptoms of Coronavirus, documented: .People with these symptoms may have COVID-19 .Fever or chills .Cough .Shortness of breath or difficulty breathing .Fatigue .Muscle or body aches .Headache .New loss of taste or smell .Sore throat .Congestion or runny nose .Nausea or vomiting .Diarrhea . The CDC guidance titled, Preparing for COVID-19 in Nursing Homes, documented: .Ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment . 1. On 11/24/20 at 10:00 a.m., LPN #1 was observed to conduct a COVID test for social services #1. She was observed to wear a KN95 face mask and don gloves. She was not observed to wear a gown or eye protection. At 10:31 a.m., LPN #1 was observed to conduct a COVID test for CMA #1. She was observed to wear a KN95 face mask and don gloves. She was not observed to wear a gown or eye protection. At 10:51 a.m., LPN #1 was observed to conduct a COVID test for housekeeper #1. She was observed to wear a KN95 face mask and don gloves. She was not observed to wear a gown or eye protection. At 3:03 p.m., LPN #1 was asked what PPE she utilized when conducting COVID testing for residents and staff. She stated if the resident was in quarantine or isolation she utilized full PPE. She was asked what PPE she utilized if a resident was not in isolation/quarantine. She stated she wore a mask and gloves for residents who were not isolated and staff. She was asked why she did not wear a gown and eye protection with the mask and gloves for all COVID testing. She stated she only focused on wearing a mask and gloves. At 3:07 p.m., the infection preventionist was asked what PPE staff were to utilize when conducting COVID testing. She stated they were to wear a mask and gloves for staff and residents who were not in isolation/quarantine. She stated if a resident was in isolation/quarantine they wore full PPE. She was asked why they did not utilize eye protection or gowns during COVID testing. She stated she did not know. At 3:25 p.m., the DON was asked what PPE staff were to utilize when conducting COVID testing. She stated a mask and gloves for staff and residents. She stated if a resident was isolated they utilized full PPE. She was asked why eye protection and a gown was not utilized during COVID testing. She stated, I guess we thought we didn't need to. 2. On 11/24/20 at 10:08 a.m., housekeeper #1 was observed in resident #1's room cleaning. The bottom strap of her N95 face mask was observed to hang below her chin. The DON reported resident #1 was in isolation because his roommate had tested positive for COVID-19. At 12:02 p.m., LPN #2 was observed to don PPE and conduct a FSBS for resident #5. She stated resident #5 received [MEDICAL TREATMENT] and was quarantined. She was observed to leave the bottom strap of the N95 mask hanging below her chin. At 12:30 p.m., cook #1 was observed to don PPE to deliver a meal to resident #1. She was observed to leave the bottom strap of the N95 mask hanging below her chin. At 2:54 p.m., LPN #2 was asked why she had not utilized the bottom strap of the N95 mask when performing the FSBS for resident #5. She stated she did not realize she had not utilized the bottom strap. At 3:07 p.m., the infection preventionist was asked who was responsible to monitor staff to ensure masks were worn properly. She stated everyone was responsible. She was asked why staff were not utilizing the bottom strap of the N95 masks. She stated, They are supposed to. At 3:19 p.m., cook #2 was observed to wear a surgical mask which had approximately one inch of the top portion of the mask cut off. Approximately two inches of the top portion of the mask which was molded against her nose was intact. She was asked why her mask had been altered. She stated she had to cut the top portion of the mask off because it irritated her eyes. At 3:25 p.m., the DON was asked how staff were monitored to ensure face masks were worn properly. She stated they monitored by making rounds. She was informed of the above observations and acknowledged the findings. 3. Review of the clinical records for resident #1, #2, #3, and #4 did not reveal the residents were monitored for all symptoms of COVID-19. Review of the monitoring form did not reveal the residents were monitored for runny nose, congestion, chills, or diarrhea. On 11/24/20 at 3:07 p.m., the infection preventionist was asked why residents were not monitored for all symptoms of COVID-19 as listed by the CDC. She stated she had thought when they updated the form they had included all of the symptoms. At 3:25 p.m., the DON was asked why residents were not monitored for all symptoms of COVID-19 as listed by the CDC. She stated she did not know. She stated they needed to update the form. 4. On 11/24/20 at 10:26 a.m., the housekeeper #3 was asked what disinfectant the facility was utilizing for their floors. She stated Dual Action Floor Cleaner. Review of the product's container did not reveal an EPA registration number. She was asked why a disinfectant from the EPA's List N was not utilized for the floors. She stated she would need to review the products information. At 10:47 a.m., housekeeper #3 stated an EPA registration number was not found on the product's information sheet. At 3:20 p.m., the infection preventionist was asked why a disinfectant from the EPA's list N was not utilized on the floors. She stated she did not know.

Based on observation, interview, and record review, it was determined the facility failed to be administered in a manner to enable residents to attain and/or maintain their highest levels of well-being for 2 (#7 and #10) of 53 residents who resided in the facility. The facility's administration failed to identify system failures related to ensuring residents did not develop a fecal impaction for resident #7 and #10. Findings: 1. The facility failed to assess, monitor, and intervene for resident #10 who had experienced constipation resulting in a fecal impaction, which resulted in pain and discomfort. The facility failed to intervene when the resident had only 4 bowel movements (BMs) in 19 days in February 2015 and only 3 BMs in 10 days in March 2015. The facility failed to follow their bowel protocol program to intervene when a resident went more than 3 days without a BM. 2. The facility failed to assess, monitor, and intervene for resident #7 who had experienced constipation resulting in a fecal impaction, which resulted in the resident being sent to the emergency room to remove the impaction. The facility failed to follow their bowel protocol program to intervene when a resident went more than 3 days without a BM. Please refer to F309.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents maintained their highest level of well-being for 2 (#7 and #10) of 12 sampled residents whose records were reviewed for well-being. a. The facility failed to assess, monitor, and intervene for resident #10 who had experienced constipation resulting in a fecal impaction, which resulted in pain and discomfort. The facility failed to intervene when the resident had only 4 bowel movements (BMs) in 19 days in February 2015 and only 3 BMs in 10 days in March 2015. The facility failed to follow their bowel protocol program to intervene when a resident went more than 3 days without a BM. b. The facility failed to assess, monitor, and intervene for resident #7 who had experienced constipation resulting in a fecal impaction, which resulted in the resident being sent to the emergency room to remove the impaction. The facility failed to follow their bowel protocol program to intervene when a resident went more than 3 days without a BM. The facility census and condition identified 53 residents resided in the facility. Findings: A facility Bowel Elimination policy, signed by the director of nursing (DON) on 08-28-08, documented, "...It is the policy of (facility name deleted) that every resident will have a bowel movement at least every three days...Residents not having a bowel movement at least every three days will be given medication for constipation according to their individual physician's orders [REDACTED]. 1. Resident #10 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A care plan, dated 02-09-15, documented, "...Altered comfort; Pain r/t [MEDICAL CONDITION] bowel movements daily..." An admission assessment, dated 02-22-15, documented the resident was cognitively intact, required total assistance of two staff members for toileting, was frequently incontinent of bowel and bladder, and had no constipation. A care plan, dated 02-22-15, documented, "...High risk for constipation r/t pain meds and poor mobility...Resident will demonstrate good bowel elimination as evidenced by passage of soft formed stool q (every) 2-3 days...Administer any meds as ordered...Administer any PRN (as needed) meds per order as needed...Monitor bowel movements daily..." A facility Vitals Report, dated February 2015, documented resident #10 had a small BM on 02-13-15, a medium BM on 02-22-15, a small BM on 02-23-15, and a large BM on 02-24-15. There were no other BMs documented in the month of February 2015. A facility Vitals Report, dated March 2015, documented resident #10 had two large BMs on 03-03-15 and a small BM on 03-05-15. There were no other BMs documented in the month of March 2015. The February/March Vitals Report documented resident #10 had gone 9 days without a BM from 02-13-15 to 02-22-15 and there were no interventions documented, had gone 7 days without a BM from 02-25-15 to 03-03-15 and there were no interventions documented, and 5 days without a BM from 03-05-15 to 05-10-15. A Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A MAR, dated March 2015, documented resident #10 had been administered a [MEDICATION NAME] suppository on 03-05-15 and 03-10-15. The MAR indicated [REDACTED]. On 03-10-15 at 4:55 p.m., resident #10 was observed in bed in his room. Resident #10 stated, "I have a stoppage in my intestine." He stated the staff had given him prune juice and that day the staff had given him a suppository. He stated he had not had a BM yet and that was the third time that had happened. Resident #10 stated, "My ass hurts like there is a freight train coming through." On 03-10-15 at 4:55 p.m., certified medication aide (CMA) #2 was asked who was responsible for documenting the residents' BMs. She stated the certified nursing assistants (CNAs) and CMAs were responsible for documenting BMs. CMA #2 was asked who monitored the residents' BMs to see if a resident had not had a BM. She stated registered nurse (RN) #1 checked the computer and if a resident had not had a BM in 3 days she informed the CMAs to give the resident a medication. On 03-10-15 at 5:07 p.m., CNA #6 was asked about resident #10's BMs. She stated the resident had a small BM that day. CNA #6 stated the resident did have problems at times with having a BM. She stated on 03-05-15 she had assisted him to the bathroom to have a BM. She stated he was unable to get it out so they put him back in bed and informed LPN #2. CNA #6 stated LPN #2 put on some gloves and using a lubricant she dug the BM out of resident #10. CNA #6 was asked if the resident complained of pain. She stated no. CNA #6 stated the resident was asked if he felt relief and he stated no. CNA #6 stated LPN #2 stated the resident still needed to finish having a BM and at that time LPN #2 helped resident #10 finish having a BM using her finger to remove the stool. CNA #6 stated the LPN was able to get a lot of BM out. On 03-10-15 at 5:40 p.m., LPN #2 was asked about resident #10's BMs. She stated the resident had been having trouble having a BM. She stated last week he had to have medication and a suppository. LPN #2 was asked if resident #10 had ever been impacted with stool. She stated yes. She stated the resident's niece was an LPN at the facility and she had helped remove an impaction from resident #10. LPN #2 was asked if she had ever removed an impaction from resident #10. She stated she had helped him one day last week or a couple of weeks ago. LPN #2 stated, "I remember I dug him out." She stated she removed a large amount of stool. She stated the resident had not complained of pain and had just said, "hurry, hurry." LPN #2 was asked if she had documented she removed stool from resident #10. She stated no, she had just passed the information on to the next shift. LPN #2 was asked who monitored resident's BMs. She stated the day shift monitored BMs and gave a list of the residents who have not had a BM in 3 days to the CMAs. She stated the CMAs then gave the resident a medication for constipation. On 03-10-15 at 6:15 p.m., LPN #3 was asked about resident #10's BMs. She stated the resident had problems with constipation. LPN #3 was asked if she had ever helped resident #10 have a BM by manually removing the stool. She stated yes, last month. LPN #3 stated resident #10 had been constipated so she got an order for [REDACTED]. LPN #3 was asked if she documented it. She stated she did not think she did. LPN #3 stated later in the shift while resident #10 was sitting on the commode she used a glove and KY jelly and tried to break up the stool. LPN #3 stated she helped the resident get the stool out. She stated the resident had stated, "That hurts." LPN #3 was asked what the facility bowel protocol was. She stated if a resident had not had a BM in 3 days they were given something for constipation. She stated she was not sure who was responsible for monitoring the BMs that flagged on the computer. 2. Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An admission assessment, dated 02-06-14, documented the resident was moderately impaired cognitively, had short and long term memory loss, required total assistance of two staff members for toileting, and had no constipation or dehydration during the look back period. A facility Vitals Report, dated June and July 2014, documented resident #7 had a small bowel movement (BM) on 06-25-14 and 07-02-14 (a total of 7 days between BMs). The report documented resident #7 had a small BM on 07-09-14 (again a total of 7 days between BMs). The report documented resident #7 had a small BM on 07-10-14, and 07-13-14, and a medium BM on 07-12-14. The Medication Administration Record, [REDACTED]. A hospital discharge instruction sheet, dated 07-14-14, documented resident #7 had been sent to the emergency department. The discharge sheet documented a [DIAGNOSES REDACTED]." A patient transfer form from (name deleted) medical center, dated 07-14-14, documented a [DIAGNOSES REDACTED]. The form documented a new order for [MEDICATION NAME] stool softener daily. A care plan, dated 07-14-14, documented, "...High risk for constipation...Resident will demonstrate good bowel elimination as evidenced by passage of soft formed stool q (every) 2-3 days...Monitor bowel movements daily..." An annual assessment, dated 02-07-15, documented the resident was cognitively intact, required total assistance of two staff members for toileting, and had no constipation or dehydration during the look back period. A care plan, dated 02-07-15, documented, "...High risk for constipation...Resident will demonstrate good bowel elimination as evidenced by passage of soft formed stool q 2-3 days...Administer any meds as ordered...Monitor bowel movements daily..." On 03-10-15 at 6:10 p.m., resident #7 was observed lying in bed awake. Resident #7 was asked if she had problems with constipation. She stated no, she took a medication for constipation. Resident #7 was asked if she had ever had problems with constipation where she had to have help to remove it. She stated yes, only once. She stated she had to go to the emergency room and the staff had "dug out" the impaction. On 03-10-15 at 6:28 p.m., the DON was asked about the facility's bowel elimination protocol. She stated the residents were monitored daily for a bowel movement. She stated if the resident had not had a BM in 3 days then the resident would be given a stool softner. The DON was asked who monitored the residents to see if they had gone longer than 3 days without a BM. She stated at that time the minimum data set (MDS) coordinator was monitoring the BMs. She stated the computer would flag the residents who had gone over 3 days without a BM and the MDS coordinator would then inform the nurse or certified medication aide (CMA) so they could administer a stool softner. On 03-10-15 at 7:07 p.m., MDS/LPN coordinator #5 was asked who was responsible for monitoring resident BMs. She stated she had been assigned that task about 4 weeks ago. She was asked why she was assigned to monitor resident BMs. She stated she believed it was because things were being missed. She stated she was supposed to look at the computer everyday to see if any residents had been flagged for not having a BM in 3 days. She stated the last two weeks she had not been able to check them due to being off.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents received adequate supervision to prevent accidents for 2 (#1 and #3) of 2 sampled residents whose records were reviewed for an injury incident. The facility failed to: a. provide supervision with toileting which resulted in a fall with head injury for resident #1. The director of nursing (DON) identified twelve residents who required assistance with ambulation. b. secure a personal alarm properly which resulted in the resident ambulating unsupervised in her room and falling for resident #1. The DON identified 21 residents resided in the facility who used a personal alarm. c. provide supervision with bathing which resulted in a fall which dislocated the resident's left elbow for resident #3. The charge nurse stated all of the facility residents required supervision with bathing. The administrator identified 54 residents resided in the facility. Findings: 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An annual assessment, dated 01-04-14, documented the the resident was moderately impaired cognitively, had disorganized thinking, had delusions, rejected care daily, required extensive assistance of one staff person for all ADLs, including ambulation and toileting, had functional limitation to the lower extremity on one side, was occasionally incontinent of bladder, had one fall with a major injury, and had received an antipsychotic medication and an antianxiety medication seven of the last seven days of the look back period. A fall care plan, dated 01-04-14, documented, "...Resident has history of falling R/T balance problem with dementia...Resident will remain free from injury...Assure floor is free of glare, liquids, foreign objects...Encourage resident to assume a standing position slowly...Keep call light in reach at all times...Keep personal items and frequently used items within reach...Leave night light on in room...Provide proper, well-maintained footwear...Provide resident an environment free of clutter..." A nurse's note, dated 02-10-14, documented, "...Personal alarm in use @ (at) this time..." A nurse's note, dated 02-17-14, documented, "...Res (resident) is in bed sleeping...Personal alarm is attached @ this time. Call light in reach. Will Continue to monitor..." A facility incident/accident report, dated 02-17-14, documented resident #1 had been found in her room in front of her dresser on her knees. The report documented there had been no injury to the resident. The report documented suggested safety precautions to prevent recurrence as, "...Always use call light for assistance..." A fall care plan update, dated 02-17-14, documented, "...High risk for repeat fall...Monitor for side effects from medication, Appetite as cause for falls...Have call light close (and) answer promptly...Monitor resident for steadiness (and) balance...encourage Resident to use call light..." The updated care plan documented a new intervention to monitor the resident for steadiness and balance and to encourage the resident to use the call light. A facility incident/accident report, dated 02-18-14 at 10:05 a.m., documented resident #1 had been heard hollering from her room by facility staff. The report documented the facility staff responded and found the resident lying on her back beside her bed on the floor. The report documented there were no obvious injuries and resident #1 had been sent to the emergency room for further evaluation. The report documented suggested safety precautions to prevent recurrence as, "...Always use call light for assistance..." A nurse's note, dated 02-18-14, documented, "...Cna (certified nurse assistant) States She had just done Resident Care 4-5 minutes prior to incident and pt (patient) Seemed her Normal Status..." A nurse's note, dated 02-18-14 at 2:20 p.m., documented resident #1 had returned to the facility with a [DIAGNOSES REDACTED]. A fall care plan update, dated 02-18-14, documented, "...Resident had another fall will continue fall care plan..." The updated care plan did not document any new interventions to prevent falls. A facility Inservice Education document, dated 02-25-14, documented, "...Call Light placement, personal alarms, braces its everyones responsibility to assure call lights are c (with) in reach, Personal Alarms are attached.." A physician's telephone order, dated 03-05-14, documented to hold resident #1's antipsychotic and antianxiety medications. A significant change assessment, dated 03-07-14, documented the resident was severely impaired cognitively, had short and long term memory loss, had inattention and disorganized thinking continuously, had an altered level of consciousness and psychomotor retardation that fluctuated, had delusions, required total assistance of two staff members with most ADLs, including toilet use, ambulation had not occurred seven of the seven days of the look back period, had no functional impairment of her extremities, was occasionally incontinent of bladder, had no falls, had received an antipsychotic medication two days of the seven day look back period, and had received an antianxiety medication three days of the seven day look back period. A fall care plan, dated 03-07-14, documented, "...Resident has history of falling R/T balance problem with dementia...Resident will remain free from injury...Apply personal alarm...Assure the floor is free of glare, liquids, foreign objects...Encourage resident to assume a standing position slowly...Keep call light in reach at all times...Keep personal items and frequently used items within reach...Provide proper, well-maintained footwear...Provide resident an environment free of clutter..." An ADL Functional / Rehabilitation Potential care plan, dated 03-07-14, documented, "...Resident's ability to transfer, walk in room, walk in corridor, dress, toilet, maintain personal hygiene has deteriorated R/T dementia...provide max (maximum) assist (assistance) with all ADL's as needed..." A facility incident/accident report, dated 03-08-14 at 7:25 a.m., documented resident #1 had been found lying on the floor of her room on her back with her personal alarm in her hand. The report documented resident #1's personal alarm had been attached to the resident's clothing and the personal alarm box had been laying beside the resident. The report documented resident #1 had been sitting in her recliner approximately 10 minutes before the incident. The report documented the resident had answered yes when asked if she had hit her head. The report documented no bumps, bruises, edema, redness or lacerations had been noted and the resident's neurological assessment had been within normal limits. A facility "After Surveillance Review" incident/accident report, dated 03-08-14, documented, "...after Video Was reviewed it Showed pt (patient) had fell (sic) back Wards and hit R (right) Side of neck and Shoulder against Foot board of Bed..." The report documented suggested safety precautions to prevent recurrence as, "...Always use call Light, Bed alarm, bedside sensor alarm, new Personal alarm to be ininated (sic)..." A radiology report, date 03-08-14, documented an x-ray had been obtained of resident #1's right shoulder. The report documented the right shoulder was negative for injury. A fall care plan update, dated 03-08-14, documented, "...At risk for complications from fall on 3-8-14...No repeat falls...Monitor for side effects from medication, Appetite as cause for falls...Have call light close (and) answer promptly...Monitor resident for steadiness (and) balance..." A physician's telephone order, dated 03-10-14, documented, "...May use hi (high) low bed c (with) bed @ (at) lowest position while in use..." A fall care plan, dated 03-12-14, documented, "...Resident has history of falling R/T non-compliant with turning on call light for assist with all transfers...Resident will remain free from injury...Assure the floor is free of glare, liquids, foreign objects...Encourage resident to assume a standing position slowly...Equip resident with device that monitors rising...Keep bed in lowest position with brakes locked...Keep call light in reach at all times...Keep personal items and frequently used items within reach...Provide proper, well-maintained footwear...Provide resident an environment free of clutter..." On 03-12-14 at 8:52 a.m., resident #1 was observed in bed with the head of the bed up feeding herself breakfast. A certified nursing assistant (CNA) was at the bedside assisting as needed. Resident #1 spoke using word random words when trying to converse with this surveyor. On 03-12-14 at 10:50 a.m., resident #1's daughter was interviewed. The daughter stated video surveillance of resident #1's fall on 02-18-14 showed the resident had been left alone in the bathroom by CNA #1. On 03-12-14 at 2:38 p.m., CNA #1 was asked how staff knew which residents required assistance with toileting. She stated the staff received a report from nursing daily and they also observed residents for their toileting ability. CNA #1 was asked how staff ensured cognitively impaired residents were safe with toileting and transfers if the resident required staff assistance. CNA #1 stated that type of resident would have a personal alarm. CNA #1 was asked if she ever left a resident alone in the bathroom. She stated only if the resident was independent. CNA #1 was asked how she determined if it was safe to leave a resident in the bathroom alone. She stated if a resident had a personal alarm they should not be left alone. On 03-13-14 at 10:00 a.m., resident #1 was observed sitting in her recliner with her feet elevated and her eyes closed. A call light was attached to her clothing as well as a personal alarm. The personal alarm box was lying on the table beside her chair. The alarm box was not secured to any surface. On 03-13-14 at 1:25 p.m., resident #1 was observed sitting in her recliner with her feet elevated and her eyes closed. A call light was attached to her clothing as well as a personal alarm. The personal alarm box was lying on the table beside her chair. The alarm box was not secured to any surface as noted above. Resident #1's daughter was in the room sitting on the resident's bed. This surveyor asked the daughter about the personal alarm box sitting on the table beside the resident. She stated the alarm box was laying on the table unsecured when she arrived. She further stated she found the alarm box unsecured frequently. On 03-13-14 at 1:30 p.m., resident #1's daughter showed this surveyor the video surveillance of the 02-18-14 fall incident. The video showed CNA #1 assisting resident #1 in the resident's room at 9:46 a.m. The video showed resident #1 ambulate into her bathroom while CNA #1 provided standby supervision. The video showed CNA #1 walking away after closing the bathroom door. At 9:51 a.m., six minutes later, the video showed resident #1 ambulating out of the bathroom alone. Resident #1 ambulated to the left side of her bed while holding onto the edges of the mattress. Resident #1 then looked through the drawers of her bedside chest before turning and ambulating to the right side of her bed. Resident #1 held onto the edge of the mattress while ambulating around the bed. Resident #1 stopped and held onto the side rail on the right side of the bed and then began to wobble. Resident #1's legs buckled and she fell backwards onto the floor. The video showed resident #1 lying motionless for a few seconds and then she began to move and start hollering. The video showed licensed practical nurse (LPN) #1 responding in less than a minute. On 03-13-14 at 3:00 p.m., CNA #1 was informed this surveyor had observed the video surveillance of resident #1's fall on 02-18-14. CNA #1 was asked if she left resident #1 in the bathroom by herself. CNA #1 stated she thought she had left the resident in her chair with her call light and personal alarm. CNA #1 was informed the video showed the resident had been left alone in the bathroom. CNA #1 was asked why she would have left resident #1 alone in the bathroom. She stated resident #1 had been gaining strength and she must have been more steady at that time or she would not have left her alone. CNA #1 was reminded about the interview conducted the day before when she stated if a resident had a personal alarm they were a high risk for falls and should not be left alone in the bathroom. CNA #1 stated it would depend on how the resident was at the time. She stated if the resident was more steady that day she would not consider them a high risk for falls. On 03-13-14 at 3:40 p.m., LPN #1 was asked about resident #1's fall on 02-18-14. She stated it was difficult to tell what happened but she thought the resident may have been coming out of the bathroom the way she was lying on the floor. LPN #1 stated she was not sure if the resident had hit her head so she had her transferred to the emergency room for an evaluation. LPN #1 stated later the family came in and showed her the video clip of the resident falling and it had showed the resident hitting her head. LPN #1 was asked if she had been aware the video showed CNA #1 had left the resident in the bathroom alone. She stated no, she had not seen that part of the video and no one had reported that to her. LPN #1 was asked who investigated the fall. She stated she had investigated the fall. She stated CNA #1 had told her she had provided care to resident #1 four to five minutes prior to the fall and the resident had been in her chair with her call light and personal alarm. On 03-13-14 at 3:45 p.m. resident #1's physician was asked about resident #1's recent decline cognitively and her frequent falls. The physician stated the residents cognitive changes had started after an event when the resident had fallen. He stated a brain image had been done and it showed the resident had a hemorrhagic stroke. The physician stated there was no way to know if the stroke had been connected with the fall event. He stated resident #1 had terrible vascular disease and would continue to deteriorate and be at risk for falls. On 03-13-14 at 4:00 p.m., registered nurse #1 was asked what the proper procedure was for securing a personal alarm. She stated the alarm box should be secured to something and the clip attached to the resident. On 03-13-14 at 5:00 p.m., resident #1's daughter was asked if she had reported to the facility staff that the resident had been left alone in the bathroom on 02-18-14. She stated she was not sure but thought she told LPN #1. She further stated she had not told the director of nursing. On 03-13-14 at 5:07 p.m., the facility administrator was asked if she was aware resident #1 had been left alone in the bathroom by CNA #1 prior to the fall sustained on 02-18-14. She stated no. The administrator was asked how a personal alarm should be secured. She stated if the resident was in bed the box should be attached to the side rail and if the resident was in a chair the box should be secured out of sight. On 03-13-14 at 5:30 p.m., resident #1's daughter came back to this surveyor and stated she had thought about it and remembered telling LPN #1 about the resident being left alone. 2. Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 11-27-13, documented the resident was cognitively intact, was independent with most activities of daily living, required supervision of one staff person with bathing, and was continent of bowel and bladder. A care plan, updated 11-27-13, documented, "...Resident is limited in ability to bathe self R/T (related to) intellectual disabilities...Resident will bathe self independently/with standby assistance..." A facility incident/accident report, dated 02-01-14 at 2:20 p.m., documented resident #3 had been found lying on her left side on the floor of the shower room with her left arm bent behind her. The report documented the resident had not been able to move her arm and was sent to the hospital for evaluation. The report documented resident #3 had been in the shower room getting ready to take a shower. The report documented resident #3 stated she had become dizzy and had fallen down. A nurse's note, dated 02-01-14 at 2:20 p.m., documented LPN #1 had heard resident #3 hollering while she was sitting at the nurse's station. The note documented LPN #1 had found the resident in the shower room on the floor. A nurse's note, dated 02-01-14 at 5:20 p.m., documented resident #3 had arrived back to the facility. The note documented resident #3's left elbow had been dislocated and she had her arm in a sling. The note documented resident #3 had been given general anesthesia and had a reduction performed on her left elbow. A hospital discharge instruction sheet, dated 02-01-14, documented, "...Dislocation of Elbow..." A significant change assessment, dated 02-15-14, documented the resident was cognitively intact, was independent with most activities of daily living, required supervision and set up by staff with bathing, and was continent of bowel and bladder. A care plan, dated 02-15-14, documented, "...Resident is limited in ability to bathe self R/T intellectual disabilities...Resident will bathe self independently/with standby assistance..." On 03-12-14 at 3:00 p.m., resident #3 was observed sitting on the side of her bed working a puzzle. She was alert and cheerful. Resident #3 was asked about her fall incident on 02-01-14. She stated she had been in the shower room alone when she fell . On 03-13-14 at 10:30 a.m., CNA #2 (shower aide) was asked about the fall incident with resident #3. She stated resident #3 usually took her shower by herself. CNA #2 was asked if she knew resident #3's care plan documented she should be supervised during bathing. CNA #2 stated, no. On 03-13-14 at 5:07 p.m., the administrator was asked if a resident's care plan documented standby supervision with bathing what would she expect to be done. She stated staff should gather the resident's personal care items and then stay with the resident while she showers.

Based on observation, interview, and record review, it was determined the facility failed to identify and prevent potential accident hazards related to hot water: a. for 1 (east) hall of 4 halls. b. for 1 (south) shower room of 2 shower rooms. Fourteen residents resided on east hall. The facility census and condition identified 54 residents resided in the facility. Findings: A facility maintenance policy, undated, documented, "...The following items shall be tested daily:...Water temperature-any elevation in temperature over 115 F (Fahrenheit) to be reported to administrator..." On 01-22-14 from 12:30 p.m. through 12:50 p.m., water temperatures were checked in resident rooms on the east hall and the south shower room. The water temperatures were as follows: 1. Room #1's bathroom sink water temperature was 124 degrees F. There were two residents who resided in the room. Both residents were alert and oriented. One resident was dependent on staff with all transfers and stated she did not use the bathroom sink. The other resident stated the water was not too hot, and she had never sustained a burn from the hot water in the bathroom sink. 2. Room #3's bathroom sink water temperature was 128 degrees F. There were two residents who resided in the room. One resident was alert and oriented and independent with most activities of daily living (ADL). This resident stated if the water would get too hot he would turn on the cold water. He stated he had never sustained a burn from the hot water in the bathroom sink. The other resident in the room was severely cognitively impaired, was independent for all ADLs, and did not use the bathroom sink. A south hall shower room water temperature was 125 degrees F. The shower room door was locked. At 12:55 p.m., the administrator was notified of the hot water. She immediately notified the maintenance supervisor. The maintenance supervisor adjusted the temperature on the hot water tank and ran water through the water pipes. The maintenance supervisor stated he regularly checked the water temperatures and they had all been within a safe range. At 1:11 p.m., the water temperatures were re-checked by the surveyor. The water temperature in room #1 was 102 degrees F., in room #3 it was 102 degrees F., and in the south hall shower room it was 104 degrees F. At 1:30 p.m., the facility incident reports were reviewed for the last year. There were no documented incidents of a resident being burned by hot water. Certified medication aide (CMA) #1 identified there were no residents who resided in the facility and wandered into other resident's rooms. At 4:30 p.m., the facility maintenance temperature log was reviewed. All temperatures documented were within a safe temperature range.

Based on observation, interview, and record review, it was determined the facility failed to provide adequate supervision to help prevent falls for 1 (#1) of 3 sampled residents who were observed for falls. The facility failed to position the resident's call light within her reach and failed to use the personal alarm after the resident had sustained two falls. The director of nursing (DON) identified eight residents resided in the facility who were a high risk for falls. Findings: Resident #1 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 10-06-13, documented the resident was moderately impaired cognitively, rejected care daily, was independent with transferring, ambulation, dressing, eating, and toileting. The assessment documented the resident required supervision with bathing, was continent of bowel and bladder, and had no falls. A fall risk assessment, dated 12-15-13, documented resident #1 scored a 10. The assessment documented a total score of 10 or above represented a high risk for falls. A facility incident/accident report, dated 12-21-13, documented resident #1 had been found lying on the floor of her room. The report documented the resident stated she fell and hit the back of her head. The report documented the resident had a knot on the back of her head. The report documented, "...SUGGESTED SAFETY PRECAUTIONS TO PREVENT RECURRENCE Always use call light for assist..." A pain management flowsheet, dated 12-21-13, documented resident #1 had been sent to the hospital for an evaluation following her fall. The note documented the resident returned to the facility the same afternoon. The note documented the resident's neurological checks had been within normal limits and the resident denied any pain or discomfort. The note documented the resident's call light was within reach and the resident had been encourage to use the call light for assistance. A care plan, dated 12-21-13, documented, "...High risk for repeat fall...Have call light close (and) answer promptly...Monitor resident for steadiness (and) balance..." A facility incident/accident report, dated 12-22-13 at 8:47 a.m., documented resident #1 had been found on the floor in her bathroom. The report documented the resident complained of right knee pain. The report documented, "...SUGGESTED SAFETY PRECAUTIONS TO PREVENT RECURRENCE Always use call light for assist..." A nurse's note, dated 12-22-13, documented resident #1 had been sent to the emergency room for complaint of right knee pain at 2:10 p.m. The note documented the resident returned to the facility at approximately 6:30 p.m. with a [DIAGNOSES REDACTED]. The note documented the resident had been assisted to bed, with bed in lowest position, and the call light within reach. The note documented resident #1 had been encouraged to use the call light for assist with all transfers and the resident had voiced understanding. A care plan update, dated 12-22-14, documented, "...Resident had another fall c (with) injury sent to ER (emergency room ) returned c brace on R (right) leg (no) Fx (fracture)..." An annual assessment, dated 01-04-14, documented the resident was moderately impaired cognitively, rejected care daily, required extensive assistance with all ADLs, including transfers, ambulation, and toileting, was independent with eating, was continent of bowel and occasionally incontinent of bladder, and had sustained one major fall with injury. On 01-16-14 at 8:35 a.m., resident #1 was observed sitting in a recliner in her room. She was feeding herself breakfast. Resident #1 had her feet elevated and a knee immobilizer on her right leg. She was dressed in clean pajamas, her face and hair was observed to be clean. A personal alarm was attached to the side rail on the far side of her bed and the call light was attached to the other side rail, out of the residents reach. Resident #1 stated she had not had any falls and did not know what happened to her right leg. She became a little agitated when questioned and told the surveyor, "Good by." On 01-16-14 at 2:25 p.m., resident #1 was observed ambulating in the hallway with a wheeled walker. She was dressed appropriately, clean, and well groomed. She was not wearing the knee immobilzer. Resident #1 was observed ambulating into the dining room and sitting at one of the dining room tables. This surveyor went to the resident's room and observed the knee immobilizer laying on the resident's overbed table. On 01-16-14 at 2:35 p.m., certified nursing assistant (CNA) #2 was asked about resident #1 ambulating in hallway without her knee immobilizer. CNA #2 asked resident #1 where her immobilizer was and the resident stated, "I don't know, go get it." CNA #2 went to the resident's room and took the immobilizer to resident #1 and assisted her to put it on. CNA #2 stated resident #1 could dress herself and remove the immobilizer. On 01-16-14 at 2:50 p.m., CNA #3 was asked who had assisted resident #1 to dress. She stated she had not assisted the resident but would ask the other CNAs if they had. After checking with the other staff no one had assisted resident #1 to dress. CNA #3 stated resident #1 would not always ask for assistance. She stated the resident would remove her personal alarm and hide it. She stated she found the alarm in the trash can one time. On 01-16-14 at 5:05 p.m., the DON was asked what interventions had been put in place for resident #1 to help keep her safe after she had fallen twice. She stated we council her about using assistance but she wanes and wanes on memory.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents received adequate supervision to prevent accidents for 2 (#1 and #3) of 2 sampled residents whose records were reviewed for an injury incident. The facility failed to: a. provide supervision with toileting which resulted in a fall with head injury for resident #1. The director of nursing (DON) identified twelve residents who required assistance with ambulation. b. secure a personal alarm properly which resulted in the resident ambulating unsupervised in her room and falling for resident #1. The DON identified 21 residents resided in the facility who used a personal alarm. c. provide supervision with bathing which resulted in a fall which dislocated the resident's left elbow for resident #3. The charge nurse stated all of the facility residents required supervision with bathing. The administrator identified 54 residents resided in the facility. Findings: 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An annual assessment, dated 01-04-14, documented the the resident was moderately impaired cognitively, had disorganized thinking, had delusions, rejected care daily, required extensive assistance of one staff person for all ADLs, including ambulation and toileting, had functional limitation to the lower extremity on one side, was occasionally incontinent of bladder, had one fall with a major injury, and had received an antipsychotic medication and an antianxiety medication seven of the last seven days of the look back period. A fall care plan, dated 01-04-14, documented, "...Resident has history of falling R/T balance problem with dementia...Resident will remain free from injury...Assure floor is free of glare, liquids, foreign objects...Encourage resident to assume a standing position slowly...Keep call light in reach at all times...Keep personal items and frequently used items within reach...Leave night light on in room...Provide proper, well-maintained footwear...Provide resident an environment free of clutter..." A nurse's note, dated 02-10-14, documented, "...Personal alarm in use @ (at) this time..." A nurse's note, dated 02-17-14, documented, "...Res (resident) is in bed sleeping...Personal alarm is attached @ this time. Call light in reach. Will Continue to monitor..." A facility incident/accident report, dated 02-17-14, documented resident #1 had been found in her room in front of her dresser on her knees. The report documented there had been no injury to the resident. The report documented suggested safety precautions to prevent recurrence as, "...Always use call light for assistance..." A fall care plan update, dated 02-17-14, documented, "...High risk for repeat fall...Monitor for side effects from medication, Appetite as cause for falls...Have call light close (and) answer promptly...Monitor resident for steadiness (and) balance...encourage Resident to use call light..." The updated care plan documented a new intervention to monitor the resident for steadiness and balance and to encourage the resident to use the call light. A facility incident/accident report, dated 02-18-14 at 10:05 a.m., documented resident #1 had been heard hollering from her room by facility staff. The report documented the facility staff responded and found the resident lying on her back beside her bed on the floor. The report documented there were no obvious injuries and resident #1 had been sent to the emergency room for further evaluation. The report documented suggested safety precautions to prevent recurrence as, "...Always use call light for assistance..." A nurse's note, dated 02-18-14, documented, "...Cna (certified nurse assistant) States She had just done Resident Care 4-5 minutes prior to incident and pt (patient) Seemed her Normal Status..." A nurse's note, dated 02-18-14 at 2:20 p.m., documented resident #1 had returned to the facility with a [DIAGNOSES REDACTED]. A fall care plan update, dated 02-18-14, documented, "...Resident had another fall will continue fall care plan..." The updated care plan did not document any new interventions to prevent falls. A facility Inservice Education document, dated 02-25-14, documented, "...Call Light placement, personal alarms, braces its everyones responsibility to assure call lights are c (with) in reach, Personal Alarms are attached.." A physician's telephone order, dated 03-05-14, documented to hold resident #1's antipsychotic and antianxiety medications. A significant change assessment, dated 03-07-14, documented the resident was severely impaired cognitively, had short and long term memory loss, had inattention and disorganized thinking continuously, had an altered level of consciousness and psychomotor retardation that fluctuated, had delusions, required total assistance of two staff members with most ADLs, including toilet use, ambulation had not occurred seven of the seven days of the look back period, had no functional impairment of her extremities, was occasionally incontinent of bladder, had no falls, had received an antipsychotic medication two days of the seven day look back period, and had received an antianxiety medication three days of the seven day look back period. A fall care plan, dated 03-07-14, documented, "...Resident has history of falling R/T balance problem with dementia...Resident will remain free from injury...Apply personal alarm...Assure the floor is free of glare, liquids, foreign objects...Encourage resident to assume a standing position slowly...Keep call light in reach at all times...Keep personal items and frequently used items within reach...Provide proper, well-maintained footwear...Provide resident an environment free of clutter..." An ADL Functional / Rehabilitation Potential care plan, dated 03-07-14, documented, "...Resident's ability to transfer, walk in room, walk in corridor, dress, toilet, maintain personal hygiene has deteriorated R/T dementia...provide max (maximum) assist (assistance) with all ADL's as needed..." A facility incident/accident report, dated 03-08-14 at 7:25 a.m., documented resident #1 had been found lying on the floor of her room on her back with her personal alarm in her hand. The report documented resident #1's personal alarm had been attached to the resident's clothing and the personal alarm box had been laying beside the resident. The report documented resident #1 had been sitting in her recliner approximately 10 minutes before the incident. The report documented the resident had answered yes when asked if she had hit her head. The report documented no bumps, bruises, edema, redness or lacerations had been noted and the resident's neurological assessment had been within normal limits. A facility "After Surveillance Review" incident/accident report, dated 03-08-14, documented, "...after Video Was reviewed it Showed pt (patient) had fell (sic) back Wards and hit R (right) Side of neck and Shoulder against Foot board of Bed..." The report documented suggested safety precautions to prevent recurrence as, "...Always use call Light, Bed alarm, bedside sensor alarm, new Personal alarm to be ininated (sic)..." A radiology report, date 03-08-14, documented an x-ray had been obtained of resident #1's right shoulder. The report documented the right shoulder was negative for injury. A fall care plan update, dated 03-08-14, documented, "...At risk for complications from fall on 3-8-14...No repeat falls...Monitor for side effects from medication, Appetite as cause for falls...Have call light close (and) answer promptly...Monitor resident for steadiness (and) balance..." A physician's telephone order, dated 03-10-14, documented, "...May use hi (high) low bed c (with) bed @ (at) lowest position while in use..." A fall care plan, dated 03-12-14, documented, "...Resident has history of falling R/T non-compliant with turning on call light for assist with all transfers...Resident will remain free from injury...Assure the floor is free of glare, liquids, foreign objects...Encourage resident to assume a standing position slowly...Equip resident with device that monitors rising...Keep bed in lowest position with brakes locked...Keep call light in reach at all times...Keep personal items and frequently used items within reach...Provide proper, well-maintained footwear...Provide resident an environment free of clutter..." On 03-12-14 at 8:52 a.m., resident #1 was observed in bed with the head of the bed up feeding herself breakfast. A certified nursing assistant (CNA) was at the bedside assisting as needed. Resident #1 spoke using word random words when trying to converse with this surveyor. On 03-12-14 at 10:50 a.m., resident #1's daughter was interviewed. The daughter stated video surveillance of resident #1's fall on 02-18-14 showed the resident had been left alone in the bathroom by CNA #1. On 03-12-14 at 2:38 p.m., CNA #1 was asked how staff knew which residents required assistance with toileting. She stated the staff received a report from nursing daily and they also observed residents for their toileting ability. CNA #1 was asked how staff ensured cognitively impaired residents were safe with toileting and transfers if the resident required staff assistance. CNA #1 stated that type of resident would have a personal alarm. CNA #1 was asked if she ever left a resident alone in the bathroom. She stated only if the resident was independent. CNA #1 was asked how she determined if it was safe to leave a resident in the bathroom alone. She stated if a resident had a personal alarm they should not be left alone. On 03-13-14 at 10:00 a.m., resident #1 was observed sitting in her recliner with her feet elevated and her eyes closed. A call light was attached to her clothing as well as a personal alarm. The personal alarm box was lying on the table beside her chair. The alarm box was not secured to any surface. On 03-13-14 at 1:25 p.m., resident #1 was observed sitting in her recliner with her feet elevated and her eyes closed. A call light was attached to her clothing as well as a personal alarm. The personal alarm box was lying on the table beside her chair. The alarm box was not secured to any surface as noted above. Resident #1's daughter was in the room sitting on the resident's bed. This surveyor asked the daughter about the personal alarm box sitting on the table beside the resident. She stated the alarm box was laying on the table unsecured when she arrived. She further stated she found the alarm box unsecured frequently. On 03-13-14 at 1:30 p.m., resident #1's daughter showed this surveyor the video surveillance of the 02-18-14 fall incident. The video showed CNA #1 assisting resident #1 in the resident's room at 9:46 a.m. The video showed resident #1 ambulate into her bathroom while CNA #1 provided standby supervision. The video showed CNA #1 walking away after closing the bathroom door. At 9:51 a.m., six minutes later, the video showed resident #1 ambulating out of the bathroom alone. Resident #1 ambulated to the left side of her bed while holding onto the edges of the mattress. Resident #1 then looked through the drawers of her bedside chest before turning and ambulating to the right side of her bed. Resident #1 held onto the edge of the mattress while ambulating around the bed. Resident #1 stopped and held onto the side rail on the right side of the bed and then began to wobble. Resident #1's legs buckled and she fell backwards onto the floor. The video showed resident #1 lying motionless for a few seconds and then she began to move and start hollering. The video showed licensed practical nurse (LPN) #1 responding in less than a minute. On 03-13-14 at 3:00 p.m., CNA #1 was informed this surveyor had observed the video surveillance of resident #1's fall on 02-18-14. CNA #1 was asked if she left resident #1 in the bathroom by herself. CNA #1 stated she thought she had left the resident in her chair with her call light and personal alarm. CNA #1 was informed the video showed the resident had been left alone in the bathroom. CNA #1 was asked why she would have left resident #1 alone in the bathroom. She stated resident #1 had been gaining strength and she must have been more steady at that time or she would not have left her alone. CNA #1 was reminded about the interview conducted the day before when she stated if a resident had a personal alarm they were a high risk for falls and should not be left alone in the bathroom. CNA #1 stated it would depend on how the resident was at the time. She stated if the resident was more steady that day she would not consider them a high risk for falls. On 03-13-14 at 3:40 p.m., LPN #1 was asked about resident #1's fall on 02-18-14. She stated it was difficult to tell what happened but she thought the resident may have been coming out of the bathroom the way she was lying on the floor. LPN #1 stated she was not sure if the resident had hit her head so she had her transferred to the emergency room for an evaluation. LPN #1 stated later the family came in and showed her the video clip of the resident falling and it had showed the resident hitting her head. LPN #1 was asked if she had been aware the video showed CNA #1 had left the resident in the bathroom alone. She stated no, she had not seen that part of the video and no one had reported that to her. LPN #1 was asked who investigated the fall. She stated she had investigated the fall. She stated CNA #1 had told her she had provided care to resident #1 four to five minutes prior to the fall and the resident had been in her chair with her call light and personal alarm. On 03-13-14 at 3:45 p.m. resident #1's physician was asked about resident #1's recent decline cognitively and her frequent falls. The physician stated the residents cognitive changes had started after an event when the resident had fallen. He stated a brain image had been done and it showed the resident had a hemorrhagic stroke. The physician stated there was no way to know if the stroke had been connected with the fall event. He stated resident #1 had terrible vascular disease and would continue to deteriorate and be at risk for falls. On 03-13-14 at 4:00 p.m., registered nurse #1 was asked what the proper procedure was for securing a personal alarm. She stated the alarm box should be secured to something and the clip attached to the resident. On 03-13-14 at 5:00 p.m., resident #1's daughter was asked if she had reported to the facility staff that the resident had been left alone in the bathroom on 02-18-14. She stated she was not sure but thought she told LPN #1. She further stated she had not told the director of nursing. On 03-13-14 at 5:07 p.m., the facility administrator was asked if she was aware resident #1 had been left alone in the bathroom by CNA #1 prior to the fall sustained on 02-18-14. She stated no. The administrator was asked how a personal alarm should be secured. She stated if the resident was in bed the box should be attached to the side rail and if the resident was in a chair the box should be secured out of sight. On 03-13-14 at 5:30 p.m., resident #1's daughter came back to this surveyor and stated she had thought about it and remembered telling LPN #1 about the resident being left alone. 2. Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 11-27-13, documented the resident was cognitively intact, was independent with most activities of daily living, required supervision of one staff person with bathing, and was continent of bowel and bladder. A care plan, updated 11-27-13, documented, "...Resident is limited in ability to bathe self R/T (related to) intellectual disabilities...Resident will bathe self independently/with standby assistance..." A facility incident/accident report, dated 02-01-14 at 2:20 p.m., documented resident #3 had been found lying on her left side on the floor of the shower room with her left arm bent behind her. The report documented the resident had not been able to move her arm and was sent to the hospital for evaluation. The report documented resident #3 had been in the shower room getting ready to take a shower. The report documented resident #3 stated she had become dizzy and had fallen down. A nurse's note, dated 02-01-14 at 2:20 p.m., documented LPN #1 had heard resident #3 hollering while she was sitting at the nurse's station. The note documented LPN #1 had found the resident in the shower room on the floor. A nurse's note, dated 02-01-14 at 5:20 p.m., documented resident #3 had arrived back to the facility. The note documented resident #3's left elbow had been dislocated and she had her arm in a sling. The note documented resident #3 had been given general anesthesia and had a reduction performed on her left elbow. A hospital discharge instruction sheet, dated 02-01-14, documented, "...Dislocation of Elbow..." A significant change assessment, dated 02-15-14, documented the resident was cognitively intact, was independent with most activities of daily living, required supervision and set up by staff with bathing, and was continent of bowel and bladder. A care plan, dated 02-15-14, documented, "...Resident is limited in ability to bathe self R/T intellectual disabilities...Resident will bathe self independently/with standby assistance..." On 03-12-14 at 3:00 p.m., resident #3 was observed sitting on the side of her bed working a puzzle. She was alert and cheerful. Resident #3 was asked about her fall incident on 02-01-14. She stated she had been in the shower room alone when she fell . On 03-13-14 at 10:30 a.m., CNA #2 (shower aide) was asked about the fall incident with resident #3. She stated resident #3 usually took her shower by herself. CNA #2 was asked if she knew resident #3's care plan documented she should be supervised during bathing. CNA #2 stated, no. On 03-13-14 at 5:07 p.m., the administrator was asked if a resident's care plan documented standby supervision with bathing what would she expect to be done. She stated staff should gather the resident's personal care items and then stay with the resident while she showers.