Every finding on record at Pelican Valley Health Center

Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented in accordance with Centers for Disease Control (CDC) guidelines for 1 of 3 (R8) residents who were reviewed for enhanced barrier precautions.CDC guidelines dated 8/12/22, identified EBP are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. CDC guidelines updated 6/28/24 identified examples of indwelling medical devices include, but are not limited to, central vascular catheters (including hemodialysis catheters, peripherally inserted central catheters (PICCs)), indwelling urinary catheters, feeding tubes, and tracheostomy tubes. R8's Significant Change Minimal Data Set (MDS) dated [DATE], identified R8 had mild cognitive impairment. R8 had a diagnosis that included heart failure, end-stage renal disease, and diabetes. R8 required maximuml assistance with personal hygiene and dressing, and needed touching assistance with toilet transfers. R8's Care Area Assessment (CAA) dated 2/20/26, identified R8 required staff assistance with toileting needs. Staff assists with toileting every two hours as needed. R8's care plan revised on 2/9/26, directed staff to use EBP due to venous access site for dialysis. R8 needs hemodialysis related to renal failure. Monitor dialysis access site daily. Resident had an IJ tunnel catheter (IJC) placed. Dialysis center to change dressing. R8 required assistance of one staff for personal hygiene and dressing. R8 received dialysis. R8's ADL report sheet, not dated, revealed R8 needed assistance to transfer to the toilet and was on EBP. During an observation/ interview on 3/23/26 at 10:24 a.m., R8 reported having dialysis stopped the previous week as her dialysis port was not working. R8 had a large, tan, non-transparent renal dressing on the upper right chest; the external limbs of the catheter were not showing. During an observation on 3/24/26 at 9:43 a.m., nursing assistant (NA)-A, went into R8's room and transferred R8 onto the toilet. R8's room did not have an EBP sign on the door, and no gowns were located outside the door or in R8's room. During an observation and interview on 3/24/26 at 9:45 a.m., NA-A knocked on R8's door and asked if R8 was done on the toilet. NA-A transferred R8 from the toilet to the wheelchair. NA-A verified she did not wear a gown when R8 was toileted as there were no signs on the door or gowns to identify R8 was on EBP. NA-A indicated there were gowns next to the door and a sign on the door indicating R8 was on EBP when R8 was receiving dialysis, but the sign and gowns were removed when R8 dialysis was put on hold, and a dressing covered the dialysis site. During an interview on 3/23/26 at 5:02 p.m., registered nurse (RN)-A indicated R8 had an internal jugular catheter (IJC) for hemodialysis, and the port was occluded (blockage) and was not receiving dialysis at this time. During an interview on 3/25/26 at 8:30 a.m., infection preventionist (IP) indicated R8's IJC is covered by a dressing applied by the dialysis unit, and staff were not to change the dressing unless the dressing comes off. Dialysis was stopped the previous week. The plan was to monitor labs and remove the IJC the following week. IP indicated a staff member removed the EPB sign and gowns last week when the IJC was covered, and dialysis was stopped. IP verified R8 should have been on the EBP, as R8 continued to have the IJC. IP verified R8 did not have a sign on the door or gowns by the room on 3/23/26 and 3/24/26. IP verified staff should have been wearing gowns when toileting resident, and during all high contact care. IP verified the EPB sign and gowns were replaced on 3/24/26 after becoming aware of being removed. IP indicated EPB were important to protect staff and residents from multidrug resistant organisms (MDROs). During an interview on 3/25/26 at 9:08 a.m., director of nursing (DON) verified staff should have used EBP when performing high contact activities, such as toileting, as R8 had an IJC. EBP precautions were important to protect staff and residents from MDROs. Review of facilty policy titled enhanced barrier precaution policy dated 4/11/24, revealed Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in conjunction with contact precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multidrug-resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. Gloves and a gown are applied prior to performing the high-contact resident care activity (as opposed to before entering the room). Personal protective equipment (PPE) is changed before caring for another resident. Face protection may be used if there is also a risk of splash or spray. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and, wound care (any skin opening requiring a dressing). In general, gowns and gloves would not be recommended when performing transfers in common areas such as dining or activity rooms, where contact is anticipated to be shorter in duration. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid(R)) or similar dressing. Examples of chronic wounds include, but are not limited to: pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, venous stasis ulcers. Indwelling medical device examples include: central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP. Staff are trained prior to caring for residents on EBPs. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. PPE will be available outside of the resident rooms, and alcohol-based hand rub is readily accessible to staff. Residents, families and visitors are notified of the implementation of EBPs throughout the facility.

Based on observation, interview, and document review, the facility failed to maintain the ice machines located in the kitchen and on the 300 wing in a sanitary manner to prevent potential illness. This deficient practice had the potential to affect all 32 residents who received water from the ice machines. Findings include: During an observation on 1/6/25 at 10:13 a.m., the ice machine in the dining room had a thick white hard powder substance approximately one-fourth of an inch in height around the entire inside and outside of the ice spout. During an observation on 1/6/25 at 11:33 a.m., the ice machine on the 300 wing had a thick white hard powder substance approximately one-fourth of an inch in height around the entire inside and outside of the ice spout. The drip pan drain below the ice and water spouts had a thick white hard powder substance. During an observation on 1/7/25 at 4:15 p.m., the ice machine on 300 wing continued to have the white hard powder substance around the ice spout and drain. The ice machine in the dining room appears to have been cleaned and no longer had a thick white hard powder build-up. During an observation on 1/8/25 at 7:20 a.m., the ice machine on the 300 wing continued to have the white hard powder substance around the ice spout and drain. During an interview on 1/6/25 at 11:47 a.m., the dining director confirmed the build-up on the ice machine in the dining room had a thick hard white powered substance buildup. The dining director indicated the kitchen staff were not responsible for the cleaning of the ice machines. During an interview on 1/6/25 at 4:41 p.m., the environmental services director (ESD) verified a thick, white, hard, powder substance was present on the outside and inside of the ice machine in the dining room. The ESD verified there was a thick, white, hard, powder substance present on the outside and inside of the ice machine on the 300 wing. The ESD indicated the ice machine on the 300 wing had a continuous water drip. The ESD stated the water spouts were removed and cleaned monthly. The ESD indicated the water spouts would still have build-up even after being cleaned. The ESD printed out an ice machine cleaning log identifying the spouts that were cleaned monthly and the entire ice machines that were cleaned inside and out every three months. ESD verified keeping the waterspouts clean was important since residents drank the water that came out of the machines. During an interview on 1/8/25 at 12:11 p.m., the infection preventionist (IP) indicated he expected staff to clean the ice machines more frequently when needed. IP verified maintenance was responsible for the cleaning of the ice machines. Keeping the ice machines clean was important as it is was the source of drinking water for the residents. IP indicated a resident could become ill if there was a build-up as it could cause food-borne illness. During an interview on 1/8/25 at 12:11 p.m., the director of nursing (DON) indicated housekeeping was responsible for cleaning the ice machines. DON indicated her expectation was the ice machines would have been kept clean and sanitary, as that was where the residents obtained their drinking water from. DON indicated a resident could become ill if there was a build-up present as it could be a source for food-borne illness. Review of the ice machines cleaning and service spreadsheet titled 2024 ice machine cleaning and service, recorded the ice machines had been fully cleaned every three months. The exterior of the ice machines had been cleaned monthly along with the shower head and faucets. Review of the ice machine manual titled Scotsman ice systems installation and user's manual for meridian ice maker dispenser's models HID312, HID625, and HID 540 dated 2015, revealed steps to clean the ice machine, along with time to clean was when the clean light was on when unit had not been cleaned for at least six months. Water drips from spout may be normal, a few drops per minute is normal. Maintenance and cleaning wash out the drip tray and dispense chutes. Use ice machine scale remover if needed to dissolve scale.

Based on observation, interview and document review, the facility failed to maintain sanitary conditions for mechanical lifts for four (R2, R25, R7, R15) out of five residents observed who used a mechanical lift. Finding include: During an observation on 1/6/25 at 6:59 p.m., nursing assistant (NA)-A assisted R7 into bed with a mechanical lift. NA-A placed the mechanical lift away in the nook without sanitizing the mechanical lift. No sanitizing wipes were in the nook where the lifts were stored. During an observation on 1/7/25 at 8:48 a.m., NA-B took the mechanical lift out of R2's room and placed the mechanical lift in the nook without sanitizing the machine. During an observation on 1/7/25 at 9:15 a.m., NA-C took the mechanical lift out of R25's room, placed it in the corner of the living room, and did not sanitize the mechanical lift. During an observation on 1/7/25 at 9:31 a.m., NA-D took the mechanical lift without sanitizing it before bringing it into R7's room. NA-D and NA-C hooked R7's lift pad to the lift and lifted R7 out of the wheelchair. R7's arms came into contact with the mechanical lift during the transfer. NA-D took the mechanical lift out of the room along with a bag of garbage. The garbage bag touched the mechanical lift as NA-D pushed the mechanical lift to the corner of the living room. NA-D did not sanitize the mechanical lift. During an observation on 1/7/25 at 10:00 a.m., NA-D took the mechanical lift to R25's room. NA-D hooked R25 up to the mechanical lift and lifted R25 out of the wheelchair. R25 grabbed onto the mechanical lift. NA-D laid R25 into bed. NA-D placed the mechanical lift in the living room corner, without sanitizing the mechanical lift. During an observation on 1/7/25 at 3:55 p.m., licensed practical nurse (LPN)-A took the mechanical lift into R15's room. At 4:02 p.m., LPN-A took the mechanical lift out of R15's room and placed it in the nook without sanitizing the lift. After continuous observations at 4:20 p.m., NA-A brought the lift into room R2's room without being sanitized. During an observation on 1/8/25 at 8:10 a.m., LPN-B brought a mechanical lift into R25's room without sanitizing the lift first. At 8:14 a.m., LPN-B brought the mechanical lift to the living room corner and walked away without sanitizing the mechanical lift. During an observation on 1/8/25 at 8:36 a.m., NA-E took the mechanical lift into R7's room without sanitizing the lift. At 8:45 a.m., NA-E brought the mechanical lift out of R7's room and placed the lift in the corner of the living room without sanitizing the lift. During an interview on 1/6/25 at 7:39 p.m., NA-A verified the mechanical lift was not sanitized after use. NA-A's normal practice was not to sanitize mechanical lifts. NA-A believed night shift sanitized and cleaned the mechanical lifts. During an interview on 1/7/25 at 10:16 a.m., NA-B verified the mechanical lift was not sanitized after use in R2's room. NA-B did not sanitize the lift after using it as there were not any sanitizing wipes nearby. During an interview on 1/7/25 at 10:35 a.m., NA-D verified the mechanical lift was not sanitized after being in R25's and R7's rooms. NA-D was not certain when a mechanical lift should have been sanitized. During an interview on 1/7/25 at 4:26 p.m., LPN-A verified the mechanical lift had not been sanitized after being used in R15's room. LPN-A verified mechanical lifts were to be sanitized between each resident. During an interview on 1/8/25 at 11:33 a.m., LPN-B verified she did not sanitize the mechanical lift before or after use in R25's room. LPN-B verified lifts were to be sanitized between residents. During an interview on 1/8/25 at 11:37 a.m., NA-E indicated her normal process was to sanitize the mechanical lifts before use and not after use to ensure the lifts were clean. During an interview on 1/7/25 at 12:20 p.m., infection preventionist (IP) indicated his expectation would be for staff to sanitize mechanical lifts between residents to prevent cross-contamination between residents. During an interview on 1/8/25 at 12:11 p.m., director of nursing (DON) verified mechanical lifts were to be sanitized between residents. The DON's expectation was that sanitizing wipes were to be kept in the cubby next to the lifts. DON verified sanitizing lifts was important to prevent cross contamination. Review of policy titled Cleaning and disinfecting mechanical lifts policy dated 10/27/23, revealed it was the policy of the facility to clean and disinfect mechanical lifts that were shared between residents. Indirect contact transmission- Mechanical lifts may transmit pathogens if devices contaminated with blood or body fluids were shared between residents without cleaning and disinfecting between residents. If a mechanical lift had been used for one resident and must be reused for another resident, the device must be cleaned and disinfected before it can be used for another resident.

Based on interview and document review, the facility failed to develop and implement a comprehensive infection control program to include ongoing process and outcome surveillance, and routine analysis of the collected data to ensure infections were not spreading within the facility to other residents and/or employees. This deficient practice had potential to affect all 29 residents in the facility. Findings include: During review of the facility's infection prevention program on 11/6/23 at 3:00 p.m., with the Infection Preventionist (IP), IP stated he received information on resident illnesses when the nurses on the floor completed a resident infection form. The nurses completed the form when a resident was displaying symptoms of illness such as cough or fever, the form was provided to the IP and he then filed the form in his office. Since IP did not have access to the facility's computer tracking system, the director of nursing (DON) entered resident illnesses into the system. IP stated when staff called in ill, whoever took the call completed an absence report and provided it to the staff scheduler. The scheduler tracked staff illnesses and notified IP or the DON if there were more than one similar staff illness at a time. During an interview on 11/6/23 at 3:20 p.m., the staff scheduler (SS) stated she received staff absence reports and reviewed them to assist her in replacing the shifts. After SS worked on replacing the ill staff member's shift, the reports were then filed. SS did not track or trend staff illness, as she was not a nurse and only referred to them for scheduling purposes. SS filed the reports until the first of every month and then returned the reports back to the floor nurses. SS could not recall any staff member asking to review the absence reports and was not sure what was done with the reports after she returned them every month. During an interview on 11/6/23 at 7:30 p.m., the DON stated when a resident displayed symptoms of illness or infection, the floor nurse opened a symptom tracker on their computer system. The system directed the nurses to chart on the resident for three days. At the end of the three days, the nurses would determine if further follow up was needed. DON stated the facility did have an infection control tracking system in their computer program, however the last entry made had been in May 2023, by the previous IP and had not currently been in use. DON confirmed the facility had not been tracking or trending resident or staff illnesses at the time and there was no overall facility wide monitoring in place. DON stated IP was having difficulty accessing the infection control computer programs and was unsure why. DON stated it was important to track and trend all illnesses in the facility to be able to look at the bigger picture for any potential spread of infections. Review of the facility policy Infection Prevention and Control amended 6/7/22, identified the infection prevention and control program would attempt to meet federal and state regulations for infection control where applicable. A system of identifying, reporting, investigating, and controlling infections and communicable diseases for ill residents, all employees, volunteers, visitors, and other individuals providing services under a contractual arrangement would be tracked where possible on a infection control tracking record and reviewed by the infection preventionist and Quality Assurance and Performance Improvement (QAPI) committee who would keep record of corrective action taken.

Based on interview and document review, the facility failed to develop an antibiotic stewardship program which included the development of protocols and a system to monitor antibiotic use for 3 of 3 residents (R2, R135, R28) reviewed for antibiotic stewardship. This deficient practice had the potential to affect all 29 residents who resided in the facility. Findings include: On 11/6/23 at 7:30 p.m., the facility's infection control program was reviewed with the director of nursing (DON). The infection control program lacked protocols for a facility-wide system to monitor the use of antibiotics which included appropriate prescribing of antibiotics, and periodic review of antibiotic use by physicians. In addition, the program lacked protocols for review of labs, determination of appropriate antibiotic use and reporting of any patterns identified. Review of R2's progress notes dated 9/19/23, identified an order to start antibiotic treatment for cellulitis. and progress note 10/12/23, identified an order to start antibiotic treatment for a urinary tract infection. Review of R135's undated physician order sheet identified an order had been received to start antibiotic treatment for ten days on 11/2/23. Review of R28's undated physician order sheet identified an ongoing antibiotic treatment had been initiated on 8/16/23, for blood infection. The facility's monthly Infection Surveillance Report indicated the last resident illness entered for antibiotic use was on 5/11/23, for an ear infection in which R13 had received antibiotic treatment. The report lacked any documentation of antibiotic use for R2, R135, R28 or any other residents since 5/11/23. During an interveiw on 11/7/23 at 1:45 p.m., the DON confirmed the facility had not established an antibiotic stewardship program that tracked and trended antibiotic use. The facility's computer system automatically entered in a resident's name and antibiotic when staff entered the information into the resident's medication list. The data just included the resident's name and the name of the antibiotic ordered. DON stated the data was not individualized and confirmed the last time anyone had reviewed the antibiotic program was in May 2023, when R13's ear infection had been entered. The facility's infection preventionist had left the facility shortly after that. DON indicated the facility had recently hired a new infection preventionist nurse however he had not been fully trained yet on how to access the system. The facility policy Antibiotic Stewardship Program with revision date 12/1/22, identified the purpose was to maintain an antibiotic stewardship program with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. The facility would incorporate seven core elements outlined by the Centers of Disease Control (CDC) of leadership commitment, accountability, drug expertise, action, tracking, reporting and education. A key objective for 2023 was to establish an antibiotic stewardship program and a system to track antibiotic use.

Based on interview and document review, the facility failed to provide pneumococcal conjugate vaccine 20 variant (PVC20) education as directed by the Centers for Disease Control (CDC) for 3 of 5 residents (R5, R10, R134) reviewed for immunizations. Findings include: R5 R5's quarterly Minimum Data Set (MDS) dated [DATE], identified diagnoses of diabetes, heart and kidney disease. R5's undated immunization record, identified R5 received the pneumococcal conjugate vaccine 13 variant (PCV13) on 2/6/19. R5's medical record lacked documentation the PCV20 (pneumonia immunization) was offered and/or education was provided in conjunction with the provider to R5/R5's representative. R10 R10's quarterly MDS dated [DATE], identified diagnoses of chronic obstructive pulmonary disease (COPD), diabetes, obesity and heart failure. R10's undated immunization record, identified R10 received PPSV23 on 5/30/02, and the PCV13 on 10/29/18. R10's medical record lacked documentation the PCV20 was offered and/or education was provided in conjunction with the provider to R10/R10's representative. R134 R134's admission MDS dated [DATE], identified a diagnosis of encephalopathy. R134's undated immunization record, identified R134 received the PCV13 on 4/7/15. R134's medical record lacked documentation the PCV20 was offered and/or education was provided in conjunction with the provider to R134/R134's representative. During an interview on 11/6/23 at 3:20 p.m., with the director of nursing (DON) the DON confirmed the facility had not been currently offering the PCV20 to their residents. They had just completed resident's yearly influenza vaccination review and planned to review PCV20 requirements for the residents in the future. A vaccination policy was requested, however none was provided.

Based on observation, interview and document review, the facility failed to provide assistance with personal hygiene for 1 of 2 residents( R22) reviewed for activities of daily living (ADL)'s. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had intact cognition and had diagnosis which included leukemia, hypertension (elevated blood pressure), (HTN) and coronary artery disease (plaque buildup in the arteries). Identified R22 required extensive assistance with activities of daily living (ADL's) which included bed mobility, toileting, transfers, and personal hygiene. R22's current care plan last revised 10/10/23, indicated R22 had deficits with ADL's related to Chronic Lymphocytic Leukemia. R22 required staff participation with set up for personal hygiene. R22's comprehensive Care Area assessment dated [DATE], identified R22 required extensive assistance with ADL's. Indicated R22 had weakness and HTN. During an observation on 11/6/23 at 2:20 p.m., R22 was seated in the hallway in her wheelchair and had 1/4 inch long gray facial hairs on her chin. During an interview on 11/6/23 at 2:30 p.m., R22 stated she required staff assistance to shave her chin hairs and that she had wished they would assist her to shave more often. During an observation on 11/7/23 at 8:30 a.m., R 22 was seated in her wheelchair in the dining room and continued to have 1/4 inch long gray facial hairs present on her chin. During an interview on 11/7/23 at 8:45 a.m., nursing assistant (NA)-A stated R22 required staff assistance to shave facial hair. NA-A stated she had not assisted R22 with shaving recently and was unsure of the last time R22 had been shaved. During an interview on 11/7/23 at 8:50 a.m., registered nurse (RN)-A stated R22 required staff assistance to shave facial hair. RN-A verified R22 had several long facial hairs and was unsure the last time R22 had been shaved. RN-A stated her expectation was R22 would have been shaved when facial hair was present. During an interview on 11/7/23 at 11:03 a.m., director of nursing (DON) indicated R22 required staff assistance with shaving. DON stated her expectation was R22 would have been shaved weekly or when facial hair was present. Facility policy titled Activities of Daily Living (ADLs) Policy amended 4/8/22, indicated residents would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Further indicated residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview and document review, the facility failed to test staff for COVID-19 according to Centers for Medicare and Medicaid (CMS) guidance for outbreak testing requirements for 4 of 5 staff reviewed for COVID-19 testing. This deficient practice had the potential to affect all 26 residents residing in the facility, all staff, and any visitors to the facility. Findings include: The CMS QSO-20-38-NH memo revised 9/23/22, directed, upon identification of a single new case of COVID-19 infection in any staff or residents, outbreak testing should begin immediately. Furthermore, the memo directed testing should follow the Centers for Disease Control (CDC) guidelines and be repeated every 3-7 days until no new cases were identified for 14 days. A facility form titled Positive Resident's past three months undated, indicated R5 had tested positive for COVID-19 on 1/26/23, with no further outbreaks noted since this date. Review of Facility hand written form titled R5 positive contact tracing form dated 1/26/23, indicated R26 tested positive and R5 had not been out of her room in the last 24 hours. Contact tracing of staff included nursing assistant (NA)-A, NA-B, NA-C, registered nurse (RN)-A and RN-B for the 1/24/23, 1/25/23 and 1/26/23. Review of the COVID-19 Testing Staff Consent Forms (TSCF) for staff in the facility's plastic COVID-19 testing binder from 1/1/23, to 2/22/23, revealed the following: NA-C's TSCF identified the last time COVID-19 testing had been completed was 9/27/22 and lacked evidence of any further testing. RN-B's TSCF identified the last time COVID-19 testing had been completed was on 1/25/23, 1/30/23, 2/8/23, 2/12/23, and 2/20/23, with negative results of COVID-19 and lacked evidence of any further testing. The binder lacked evidence of testing for NA-A, NA-B and RN-A. NA-A, NA-B and RN-A TSCF forms in the binder indicating no testing had been completed for COVID-19. During an interview on 2/22/23, at 2:43 p.m. NA-C indicated she was up to date on her COVID-19 vaccinations and was not required to test on a regular basis. NA-C indicated she would test if she had any symptoms of COVID-19 and stated she had tested last week due to allergy symptoms, then tested again three days later and was negative for COVID-19. NA-C confirmed she had not completed any testing after being exposed to a resident who had a positive case of COVID-19 and was not directed to test. During an interview on 2/22/23, at 11:57 a.m. RN-B indicated she was currently not vaccinated for COVID-19 and was required to test on a weekly basis. RN-B confirmed the weekly testings were the only times she had been tested . RN-B stated there was a testing station in the director of nursing (DON)'s office along with a book staff were expected to sign and enter the results of their COVID-19 tests into. During an interview on 2/22/23, at 2:21 p.m. DON confirmed the above findings and indicated she was responsible for overseeing the COVID-19 testing and contact tracing for staff. DON indicated staff were responsible to record their own results and had not been consistently recording them. The DON stated her expectations were for staff to be tested on day one, day three and day five after being exposed or when an outbreak had occurred. DON indicated staff were expected to record their test results so she could verify the testing had occurred as required. Review of the facility policy titled, Health Care Worker COVID-19 Testing and Returning to Work updated on 10/13/22, indicated when a health care worker or resident has tested positive, outbreak testing will begin, either by method of contact tracing/targeted testing or broad-based testing. Contact tracing must be completed within 24 hours, if this was not feasible, broad-based testing will be conducted.

Based on interview and document review, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) level one assessment had been completed for 1 of 4 residents (R25) reviewed for PASARR. Findings include: R25's quarterly Minimum Data Set (MDS) dated [DATE], identified R25 had diagnoses which included: anxiety, depression, and post traumatic stress disorder (PTSD). R25's MDS indicated R25 required supervision with dressing, walking in corridor, locomotion, and was independent with other areas of activities of daily living (ADL). R25's care plan revised 11/11/22, identified R25 had impaired cognitive function and/or impaired thought processes related to cognitive communication deficit. The care plan indicated R25 had a need for social service intervention related to borderline intellectual functioning. R25's care plan identified R25 had an ADL self care performance deficit related to weakness and impaired cognition and required limited assistance of one staff with bathing. Review of R25's medical record (MR) lacked a level one PASARR screening had been completed to consider a referral for further evaluation and determination of need for specialized services. During an interview on 2/21/23, at 3:34 p.m. administrator confirmed the above findings. During an interview on 2/22/23, at 9:17 a.m. social service designee (SSD)-A indicated she was responsible for the completion of PASARR screenings and confirmed R25 did not have a PASARR screening in her medical record. SSD-A stated the facility did did not have a process to assure the PASARR screenings were received prior to resident admissions. SSD-A indicated the PASARR was important to assure the residents received specialized services and referrals when needed. The facility policy titled Preadmission Screening Level II (PASARR) dated 8/5/2017, identified prior to admission all residents would have a PASARR completed and if the level I screening identified the need for a PASARR level II then it would be completed prior to the resident being admitted to the facility. The policy identified the level I and level II screening would be kept on file in the resident's chart and the recommendations from the level II screening would be followed by the facility.

Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect an accurate cognitive pattern and mood status for 1 of 1 residents (R25) reviewed for Pre-Admission Screening and Resident Review (PASARR). Findings Include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2019, Section C: Cognitive Patterns, identified the intent of this section was to determine the resident's attention, orientation and ability to register and recall new information and these items were crucial factors in many care-planning decisions. The RAI manual indicated Section D: Mood, the intent of this section was to address mood distress, a serious condition that was under diagnosed and under treated in the nursing home and was associated with significant morbidity. The RAI manual continued to identify section D as particularly important to identify signs and symptoms of mood distress among nursing home residents as these signs and symptoms were treatable. R25's quarterly MDS dated [DATE], identified section C-Cognitive pattern, included CO100: Should Brief Interview for Mental Status be conducted?, identified yes with a check mark. The rest of section C-cognitive pattern of the MDS had not been completed. R25's MDS section D-Mood, included D0100: Should Resident Mood Interview Be Conducted?, identified yes with a check mark. The rest of section D had not been completed. R25's quarterly MDS dated [DATE], identified section C-Cognitive pattern, included CO100: Should Brief Interview for Mental Status be conducted?, identified yes with a check mark. The rest of section C-cognitive pattern of the MDS had not been completed. R25's MDS section D-Mood, included D0100: Should Resident Mood Interview Be Conducted?, identified yes with a check mark. The rest of section D-mood, of the MDS had not been completed. R25's care plan revised 11/11/22, identified R25 had impaired cognitive function and/or impaired thought processes related to cognitive communication deficit and had a need for social service intervention related to borderline intellectual functioning. R25's care plan indicated R25 had an activities of daily living (ADL) self care performance deficit related to weakness and impaired cognition. Required limited assistance of one staff with bathing and instructed staff to report any changes in ADL abilities to the charge nurse. During an interview on 2/22/23, at 1:49 p.m. director of nursing (DON) reviewed R25's MDS's and confirmed the above findings. DON indicated she would expect all sections of the MDS be completed as required. DON stated Section D was important to determine a resident's potential depression symptoms and indicated she was unaware section C or D had not been completed for R25. DON stated MDS coordinator (MDSC)-A typically informed the staff if areas of the MDS were not completed. In addition, MDSC-A sent out a MDS schedule to assure MDS assessments were completed timely. During a telephone interview on 2/22/23, at 3:03 p.m. MDSC-A indicated she was responsible for completing the MDS assessments in the facility. MDSC-A stated she monitored the resident's MDS schedules and sent reminders to facility staff via e-mail. MDSC-A confirmed the above findings and indicated she had been aware section C and D had not been completed for R25's MDS assessments. MDSC-A stated she had informed the facility staff and the social service designee (SSD)-A of the incomplete MDS. In addition, MDSC-A indicated she had repeatedly reported the R25's MDS's had not been completed at the facility's monthly Quality Assurance and Performance Improvement (QAPI) meetings since November, 2022. During an interview on 2/22/23, at 3:08 p.m. SSD-A confirmed the above findings. SSD-A stated she remembered she did not have time to document her assessment findings in R25's MDS's. SSD-A indicated section D of the MDS assessment was important to assist in identifying depressive feelings, anxiety or thoughts of harm to self. Additionally, SSD-A stated section C was important to assess since it identified if there was a decline in cognition which could be an indicator of an underlying medical condition. During an interview on 2/22/23, at 5:10 p.m. the administrator confirmed the above findings. The administrator stated the problem of incomplete MDS's had been identified and discussed at their monthly QAPI meetings. Administrator indicated the facility audited residents' MDS completion rates in the past and initially noted improvement however it had regressed. The facility policy titled MDS 3.0 (Minimum Data Set) Policy amended 6/17/22, identified the resident assessment process was completed by the interdisciplinary team (IDT) within the federally mandated timeline to provide a baseline of the resident's functional status on admission with scheduled assessments to determine ongoing functional status and changes. The policy indicated the MDS coordinator determined the MDS schedule and routed it to all IDT members. The policy identified the MDS coordinator oversaw the MDS completion process and all department managers were expected to be knowledgeable for ensuring accurate documentation of the MDS for each resident.

Based on observation, interview and document review the facility failed to provide timely incontinence care for 1 of 3 residents (R17) who were dependent upon staff for activities of daily living. Findings include: R17's quarterly Minimum Data Set (MDS), dated [DATE], identified R17 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R17 required extensive assistance of one staff for bed mobility, transfers, personal hygiene, dressing and toileting. Further, the MDS identified R17 was occasionally incontinent of bowel and frequently incontinent of bladder, and was not on a bowel or bladder toileting program. R17's care area assessment (CAA) dated 8/11/20, indicated R17 was frequently incontinent of urine, had diarrhea and required extensive assistance from staff. The CAA also indicated R17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R17's current care plan dated 4/8/21, identified R17 had potential/actual impairment to skin integrity related to incontinence of bowl and bladder. The care plan listed various interventions which directed staff to toilet R17 every two hours. Review of nursing aid Additional Information sheet undated, indicated R17 had a walking program for staff to encourage R17 to get up and walk to the bathroom every two hours. During observations on 4/21/21, at 7:11 a.m. R17 layed in bed sleeping. Nursing assistant (NA)-A indicated R17 was known to be a late sleeper and routinely did not get out of bed until around 11:00 a.m. NA-A stated R17 was able to reposition herself in bed. - at 7:48 a.m. R17 continued to be in bed sleeping. - at 8:00 a.m. R17 continued to be in bed sleeping. - at 8:35 a.m. R17 continued to be in bed sleeping. -at 10:57 a.m. R17 layed in her bed on her right side with a blanket covering her when trained medication aid (TMA)-A knocked and entered R17's room. TMA-A informed R17 she was there to do a dressing change to her buttocks area. TMA-A applied gloves to her hands and informed R17 she was going to change her incontinent cares. TMA-A unhooked the incontinent product, tucked it under R17 and proceeded to use wipes to cleanse R17's peri area and buttocks. TMA-A removed the soiled incontinent product which was saturated with urine and continued to wipe R17's buttocks. TMA-A placed a clean incontinent product under R17 while she laid on her right side. TMA-A removed the dressing from R17's buttocks dated 4/19/21,which was also saturated with urine. R17's buttocks area was noted to be red in color and two blanchable open areas were noted on her right upper and lower buttocks. TMA-A asked R17 to roll to her back, fastened her incontinent product in place and informed her she was going to ask the director of nursing (DON) to assess her buttocks. TMA-A removed her gloves, covered up R17 with a blanket, washed her hands and left the room. R17 had not been toileted or checked/changed for a total of 3 hours and 46 minutes even though she was dependent upon staff for incontinence care and was at risk for skin breakdown. On 4/21/21, at 11:12 a.m. NA-B indicated R17 was incontinent of bowel and bladder and she did not know the last time R17 had been toileted or checked/changed. NA-B stated R17 was to be checked/changed every 2 hours and indicated the night shift usually completed rounds around 5:00 a.m. NA-B indicated she arrived to work at 6:00 a.m. and she had not checked or changed R17 and indicated they were running behind in completing their duties. On 4/21/21, at 2:17 p.m. NA-A stated R17 was incontinent of bowel and bladder and she had not been into R17's room to see if she needed to be toileted, checked/changed every 2 hours. On 4/22/21, at 2:30 p.m. register nurse (RN)-A verified R17 needed staff assistance with being toileted and checked/changed every two hours and indicated staff were expected to follow the care plan. On 4/22/21, at 2:27 p.m. the DON confirmed the findings and indicated R17 required staff assistance to be toileted or checked/changed every two hours. The DON indicated she would expect staff to follow the care plan. Review of facility policy titled, Activities of Daily Living amended on 1/19, indicated residents would be provided the care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living.

Based on interview and document review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours to address the individualized needs for 1 of 1 residents (R27) who was recently admitted . Additionally, the facility failed to provide a summary of the baseline care plan to the resident or resident representative for 1 of 1 residents (R27) recently admitted . Findings include: R27's admission Minimum Data Set (MDS) dated [DATE], indicated R27 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R27 required limited assistance of one staff for bed mobility, transfers, dressing, toileting and personal hygiene. R27 was admitted to the facility on [DATE], R27's medical record included a baseline care plan which had been completed and signed on 2/25/21. The medical record lacked any documentation that R27 or R27's representative had received a copy of his baseline care plan. On 4/20/21, at 3:30 p.m. the director of nursing (DON) confirmed the above finding and indicated she could not find anything in R27's medical record indicating R27 or his representative had received a copy of his baseline care plan. The DON indicated she expected staff to develop the baseline care plan within 48 hours and to review it with the resident or representative. Review of facility policy titled, Baseline Care Plan Policy dated 10/2018, indicated this care plan was required for each resident that included the instructions needed to provide effective and person centered care for the resident that met professional standards of quality care. The baseline care plan must be developed within 48 hours of the residents admission.

Based on interview and document review, the facility failed to notify the ombudsman of facility initiated discharges for 1 of 1 residents (R27) who were discharged to the hospital. Findings include: R27's admission Minimum Data Set (MDS) dated [DATE], indicated R27 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R27 required limited assistance of one staff for bed mobility, transfers, dressing, toileting and personal hygiene. Review of R27's Progress Notes from 2/18/21, to 3/9/21, revealed the following: - on 3/8/21, at 3:00 p.m. R27 was seen by primary doctor in clinic and transferred to hospital via ambulance for elevated while blood cell count. Social services contacted R27's family with an update and discussed bed hold. R27 was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 04/22/21, at 9:18 a.m. the director of nursing (DON) verified the above finding and indicated the ombudsmen had not been notified of R27's transfer to the hospital. The DON indicated their social worker no longer worked there and it had been missed. The DON indicated she expected staff to fill out the transfer form, sign it and send it to the ombudsmen. On 4/22/21, at 9:47 a.m. social services designee (SS)-D) confirmed R27 was transferred to the hospital and admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/22/21, a policy was requested regarding notifying the ombudsmen of transfer/discharge and one was not provided.

Based on interview and document review, the facility failed to ensure minimum required information was provided to a receiving healthcare facility for 1 of 1 residents (R27) who was transferred to the hospital and was subsequently admitted to the hospital. Findings include: R27's admission Minimum Data Set (MDS) dated [DATE], indicated R27 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R27 required limited assistance of one staff for bed mobility, transfers, dressing, toileting and personal hygiene. Review of R27's Progress Notes from 2/18/21, to 3/9/21, revealed the following: - on 3/8/21, at 3:00 p.m. R27 was seen by primary doctor in clinic and transferred to hospital via ambulance for elevated while blood cell count. Social services contacted R27's family with an update and discussed bed hold. R27 was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R27's medical record lacked any documentation the required transfer information was sent to the receiving hospital. On 4/22/21, at 9:18 a.m. the director of nursing (DON) confirmed the above findings and indicated she could not find any documentation in R27's medical record that the receiving facility had received the required paper work for R27's being hospitalized . The DON indicated she would expect staff to fill out the facility transfer form with R27's information on it, his face sheet, med list, Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/22/21, at 9:47 a.m. social service designee (SSD) confirmed R27 was transferred to the hospital and admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled, Transfer or Discharge Documentation dated 10/23/17, indicated when a resident was transferred or discharged , details of the transfer or discharge would be documented in the medical record and appropriate information would be communicated to the receiving health care facility or provider.

Based on interview and document review, the facility failed to ensure an alleged violation of Misappropriations of property was reported no later than twenty four hours to the State Agency (SA) for 1 of 3 residents (R120) reviewed for allegations of abuse. Findings include: R120's significant change Minimum Data Set (MDS) assessment dated [DATE], identified R120 was cognitively intact and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also indicated R120 required one to two staff assistance with most activities of daily living (ADL's) which included bed mobility, transfers, dressing, toileting, personal hygiene, eating and bathing. Review of the Nursing Home Incident Report (NHIR) submitted to the SA on 2/7/20, at 11:41 p.m. indicated R120 had reported he was missing one hundred and twenty dollars to the life enrichment coordinator (LEC)-A. LEC-A asked R120 where the money had been and R120 pointed to a metal storage container on top of his night stand. LEC-A looked in the container and identified there was one dollar bill and some loose change of an unknown amount. LEC-A reported the loss of money to the SW-A and a room search had been conducted with no success of locating the missing money. SW-A indicated she contacted R120's power of attorneys (POA) and POA-A and POA-B and both believed he had twenty dollars. On 2/7/20, SW-A received a phone call from POA-B who recalled after their initial conversation R120 had some money in his tin can next to his bed. POA-B indicated she was confident R120 had under fifty dollars and indicated he had 2-3 ten dollar bills, some five dollar bills and some one dollar bills roughly about 2 weeks ago. The NHIR identified the incident occurred on 2/5/2020, at 11:30 a.m. and was reported to the SA on 2/7/2020, at 11:41 p.m. over sixty hours after the incident occurred. On 4/22/21, at 4:07 p.m. the administrator confirmed the above findings and indicated he would expect staff to report all allegations of misappropriation of property immediately to the charge nurse, SW, director of nursing and him. The administrator indicated he would expect staff to report any allegation of abuse to the SA within 2 hours and within 24 hours for all other allegations. The administrator indicated the allegation should have been reported within 24 hours. Review of facility policy titled, [NAME] Valley Senior Living Abuse Prevention Plan dated 1/2020, indicated the intent of this policy was to ensure that all residents of the facility would enjoy a safe living environment and to provide guidelines for investigating and reporting suspected maltreatment/mistreatment. The policy defined maltreatment or mistreatment as verbal, sexual, physical and mental abuse, corporal punishment, neglect, involuntary seclusion, financial exploitation and misappropriation of property. The policy indicated instances of serious bodily injury must be reported to law enforcement as soon as possible and no later than two hours. this included, but was mot limited to, injury with extreme pain, substantial risk of death, loss/impairment of a body part, organ or mental faculty, required medical interventions. All other cases that cause reasonable suspicion a crime was committed (but don't result in serious bodily injury) should be reported no later than 24 hours after forming the suspicion.

Based on observation, interview, and document review, the facility failed to ensure insulin pens were accurately dated when opened for 3 of 3 residents (R4, R7, R9) who received insulin injections. Findings include: R4's signed Order Summary Report dated 4/7/21, indicated R4 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's signed Order Summary Report dated 4/5/21, indicated R7 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's signed Order Summary Report dated 4/9/21, indicated R9 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/20/21, at 9:03 a.m. during observation of the station two medication cart with trained medication aid (TMA)-A two insulin pens of [MEDICATION(S)] were located in the top drawer of the medication cart. The insulin pens were properly labeled but had no open date located on them. TMA-A verified the findings and indicated she did not know when the insulin pens had been opened. TMA-A verified R4 and R9 were currently receiving their [MEDICATION(S)] insulin every evening and indicated once the insulin pens were opened they were good for 28 days. On 4/20/21, at 9:27 a.m. during observation of the station one medication cart with registered nurse (RN)-A one insulin pen of [MEDICATION(S)] was located in the top drawer of the medication cart. The insulin pen was properly labeled and had no open date located on it. RN-A indicated she did not know when the insulin pen had been opened and verified R4, R7 and R9 were currently receiving their [MEDICATION(S)] insulin every evening at bedtime. RN-A verified the above findings and stated staff were expected to use the orange label to write the open and expiration dates on the insulin pens when they were opened. RN-A indicated she would expect staff to follow the facility policy and to make sure the insulin pens were dated when opened. On 4/20/21, at 10:30 the director of nursing verified the above finding and confirmed staff were expected to be dating the insulin pens when opened. A policy on medication storage and labeling was requested, but one was not received. The [MEDICATION(S)] insulin package insert from Sanofi-Aventis dated 7/2020, directed pre-filled pens in use or carried as a spare may be stored for a maximum of 4 weeks not above 30 Celsius and away form direct heat and direct light.

Based on observation, interview and document review the facility failed to ensure appropriate hand hygiene was implemented during assistance of personal cares to prevent the spread of infection for 1 of 3 (R21) observed during personal cares. Findings include: R21's significant change Minimum Data Set (MDS), dated [DATE], indicated R21 had moderate cognitive impairment and [DIAGNOSES REDACTED]. The MDS further indicated R21 required extensive assistance of one staff with bed mobility, dressing, grooming and bathing and required set-up assistance with eating. The MDS documented R21 required assistance of two staff with transfers and toileting. R21's care Area Assessment (CAA) for urinary incontinence dated 12/29/18, indicated R21 was at risk for developing urinary tract infections. The CAA indicated staff would provide assistance to R21 with toileting tasks and perineal cares. R21's care plan, last revised on 1/3/19, indicated R21 was incontinent of bladder and required observation for signs and symptoms of urinary tract infections. Additionally, the care plan instructed staff to clean perineal area with each incontinence episode and as needed. On 2/13/19, at 7:46 a.m. nursing assistant (NA)-D applied gloves and maneuvered R21 to a standing position from R21's wheelchair utilizing the standing lift. NA-D removed R21's incontinence brief, which was wet with urine, and lowered R21 to the commode. NA-D removed gloves and filled R21's wash basin with water, then applied new gloves. At 7:49 a.m. NA-D proceeded to complete morning cares that consisted of washing R21's face, back and chest and removed gloves. At 7:53 a.m. NA-D assisted R21 with dressing by applying bra and blouse. At 7:57 a.m. NA-D applied new gloves and guided R21 to a standing position from the commode with the standing lift. NA-D provided perineal cares to R 21 and removed gloves while R21 stood with assistance from the standing lift. NA-D guided R21 with the use of the standing lift to R21's wheelchair. NA-D gathered soiled washcloth and towel and placed on R21's bed. At 8:02 a.m. NA-D picked up the soiled linen on R21's bed with bare hands and moved the soiled linen to another area of R21's bed. At 8:04 a.m. NA-D wheeled R21 into R21's bathroom and applied gloves. NA-D then proceeded to apply toothpaste to R21's toothbrush, handed it to R21 and subsequently removed gloves. R21 handed toothbrush back to NA-D when task had been completed. NA-D failed to complete hand hygiene at any time during cares. At 8:09 a.m. NA-D wheeled R21 to the dayroom, returned to R21's room and completed hand hygiene at that time. On 2/13/19, at 8:27 a.m. NA-D confirmed she had not performed hand hygiene at any time while she completed cares for R21. NA-D stated it was usual practice to complete hand hygiene after removing soiled gloves to prevent the spread of infection. NA-D further stated it was usual practice to handle soiled linen with gloved hands due to the risk of contamination. On 2/14/19, at 9:39 a.m. registered nurse manager (RNM) confirmed the expectation would have been to complete hand hygiene after providing cares. RNM further confirmed the expectation would have been to utilize personal protective equipment (PPE) when handling soiled linens. RNM stated those expectations were in place to prevent the spread of infection to residents and staff. On 2/14/19, at 10:42 a.m. director of nursing (DON) confirmed the expectation was for staff to complete hand hygiene after removing gloves. DON further confirmed the expectation was for staff to wear appropriate PPE when handling soiled linens. DON stated staff have received training upon hire and annually regarding infection control practices. Review of facility policy titled Hand Hygiene Policy created 10/2018, indicated hand hygiene was the primary means to prevent the transmission for infections. The policy instructed staff to complete hand hygiene before and after having direct contact with residents, after contact with blood and body fluids, after contact with resident's intact skin, before and after providing personal cares for a resident, after removing gloves and between the use of gloves and after touching any item or surface that may have been contaminated (measuring graduate, commode, etc.). Review of facility policy titled Infection Control- Resident Care Equipment reviewed 11/2009, indicated infection control procedures were followed to prevent the transmission of infection. The policy instructed staff to handle soiled linens as potentially contaminated.

Based on observation, interview and document review the facility failed to routinely provide range of motion (ROM)restorative exercises to maintain or improve range of motion for 2 of 3 residents (R4, R19) who were reviewed with limited ROM. Findings include: R4's quarterly Minimum Data Set ((MDS) dated [DATE], identified R4 had long and short term memory impairment, and had [DIAGNOSES REDACTED]. The MDS further identified R4 required extensive assistance with bed mobility, and total assistance for all other areas of daily living (ADL). The MDS indicated R4 had a functional limitation of bilateral upper and lower extremities. The Care Area Assessment (CAA) dated 1/24/19, lacked documentation or summary of R4's limited ROM or restorative nursing program. Review of R4's care plan, revised 2/1/18, identified a focus of impaired physical mobility related to impaired cognition, impaired balance, physical function due to [DIAGNOSES REDACTED], [MEDICAL CONDITION] disease and dementia. The care plan's goal for R4 was R4 will remain free of complications related to immobility including contractures, by maintaining current level of mobility by extending bilateral elbow joints and straighten lower extremities fully in bed. R4's care plan listed various interventions which included: nursing restorative: passive ROM to upper and lower extremities 5 repetitions and stretch and hold position of tight joints for 1 minute times 1. Perform every day to two times a day 3 to 7 times a week, focus on wrists and fingers. Review of the facility form titled P[NAME] (point of care) Response History, from 1/16/19 through 2/13/19, directed Task: Restorative: Passive ROM to upper extremities (UE) and lower extremities (LE) two times a day (BID) with cares as tolerates: 5 repetitions each motion and stretch/ hold position of tight joints for 1 minute, times 1. Focus on wrists and fingers. To prevent contractures. Bilateral. Palm Protectors at night and as needed. The form identified the program had been provided for R4 on 1/16/18, for 5 minutes, 1/26/19, for 5 minutes, 1/31/19, resident refused, 2/5/19, for 15 minutes, 2/12/19, for 5 minutes, 2/13/19, for 10 minutes, and all other days were documented not applicable. On 2/12/19, at 3:04 p.m. R4 lay in bed on his back, with blankets covering the lower half of his body. R4's arms lay at his sides on the bed. R4 had sheep skin covered hand splints on both hands which were secured in place with straps extending around the back of R4's hands near the knuckles. On 2/13/19, at 7:41 a.m. NA-B provided the ROM services as R4 lay on his bed after a bath with legs and arms extended on the bed. NA-B dried and applied lotion to R4's upper and lower extremities while gently speaking to R4 and moving his arms. NA-B extended R4's ankles, wrists, and fingers one at a time to dry, apply lotion and file nails. On 2/14/19, at 9:37 a.m. NA-B identified restorative nursing services including exercises and ROM services were routinely provided to residents by a NA scheduled for that position, however; because NA- B had provided R4's bath on 2/13/19, she had performed R4's ROM services. NA-B indicated documentation of the ROM services was documented in the electronic record when completed, if not completed, a refusal was documented, or the column not applicable used which indicated the services were not completed for other reasons besides refusal. NA-B was unaware of the reason not applicable would be documented. On 2/14/19, at 11:20 a.m. NA-E indicated a sixth nursing assistant was scheduled to provide all of the exercises and ROM services. NA-E indicated when this position was not scheduled the NAs try to provide these services, if there was time, when getting the resident up for the day. NA-E indicated most services are scheduled for 3 to 4 days a week so they do not need to be provided daily. NA-E explained staff documented when services were provided and if the resident refused. NA-E was unaware what the documentation of not applicable indicated on R4's P[NAME] Response History form. On 2/14/19, at 11:38 a.m. the MDS coordinator (MDSC) verified R4 had limited ROM due to a disease process and required the use of hand splints and ROM services. With review of R4's restorative documentation MDSC verified the program was documented as completed 5 times in 30 days, with 1 refusal and the remaining 54 opportunities R4 had to receive ROM services were either left blank or marked as not applicable. MDSC indicated the facility practice did not include routine review of the restorative programs. MDSC identified she and another MDS coordinator entered resident restorative programs in to the computer for staff to provide, and reviewed them quarterly with the MDS assessments or when a problem was brought to their attention, for example a resident decline in ability. Review of R4's progress notes from 1/16/19, to 2/13/19, revealed a late entry dated effective 1/24/19, R4 was at risk for potential decline in mobility due to disease process and had a restorative nursing program for passive ROM to upper and lower extremities to prevent contractures. On 2/14/19, at 12:03 p.m. the director of nursing (DON) verified R4's ROM program had not been provided as directed while the two restorative NAs had been on leave from the facility. The DON identified while the two restorative NAs were on leave the NAs which provided resident care were expected to provide the ROM services to prevent contractures or limiting of the residents abilities. R19 R19's annual Minimum Data Set ((MDS) dated [DATE], identified R19 was cognitively intact and had [DIAGNOSES REDACTED]. R19's MDS further identified he required extensive assistance with bed mobility, dressing, personal hygiene and toileting. R19's MDS failed to identify any days R19 received restorative programs. R19's Care Area Assessment (CAA) dated 12/20/18, identified R19 had two nursing restorative programs to help keep his upper extremities strong and his lower extremities contracture free to be able to assist/participate in activities of daily living (ADL) and cares. R19's care plan, revised 12/26/18, identified R19 had an ADL self-care performance deficit and limited physical mobility related to impaired balance, limited mobility, and musculoskeletal impairment due to [MEDICAL CONDITION]. R19's care plan listed various interventions which included: nursing rehab/restorative: bed mobility Program: UE (upper extremities) exercises every day to twice a day five to seven days a week, in bed or wheelchair 15 to 20 reps each. R19's care plan listed exercises which included shoulder flexion and extension, shoulder abduction and elbow flexion, Passive range of motion (PROM) program once or twice a day, five to seven days a week which included ten reps times (x) two sets each for ankles, knees and hips. R19's care plan listed additional exercises which included ankle pumps, heel slide, hip abduction, straight leg rises, internal and external hip rotation, ankle circles and sit-up/curl ups in bed reaching from waist to above head in an arch motion. R19's ADL interventions included transfers with a full body lift and two staff to move between surfaces. On 2/11/19, at 12:59 p.m. R19 indicated he had not been receiving his restorative nursing program for six weeks. R19 indicated the usual staff who completed his exercises was on leave. On 2/13/19, at 8:10 a.m. R19 was dressed and in his wheelchair in the dining room at a table with other residents. R19 indicated he had received his exercises yesterday, but R19 indicated he had not had the exercises for awhile. R19 stated he felt he was still in good shape, and had not lost his strength. On 2/13/19, at 1:57 p.m. restorative aide (RA)-A entered R19's room and informed him she was there to do his exercises. R19 was alert, dressed and lying in his bed. RA-A asked R19 if he wanted to use bands or weights for his UE exercises, and R19 chose weights. R19 began his UE exercises independently while RA-A completed PROM exercises to his lower extremities. RA-A began with R19's right leg and completed hip flexion and extension movements, knee flexion, ankle flexion and rotation exercises. RA-A asked R19 if he wanted to do 10 or 20 repetitions on his right side. R19 requested only 10 on his right side, and indicated he had some pain. RA-A completed the same PROM exercises on R19's left side, and completed 10 repetitions, stopped, then did 10 more of all exercises on his left side. RA-A removed a form titled Restorative Resident Listing from her pocket, reviewed the exercises listed for R19, then indicated she had completed them all. RA-A indicated she felt R19 had not had a decline in his ROM or ability to perform his exercises. The untitled facility nursing assistant care sheet, undated, directed staff to see restore plans for R19. R19's progress notes identified on 3/20/17, OT (occupational therapy) recommended a restorative nursing program for transfers to prevent dependency as needed upon admission such as with full body lift. R19 would maintain his strength and ability to use bilateral grab bars to assist to lean forward and place self on slide board with assist for transfers. R19 to perform with supervision UE exercises every day to twice a day 3 to 7 days per week in bed or wheelchair 15 to 20 reps with exercises listed which included shoulder flexion and extension, shoulder abduction, elbow flexion and arm curls. PT (physical therapy) recommendation to maintain mobility and prevent contracture would initiate a PROM restorative nursing for bilateral LE (lower extremity) in bed. PROM to be done every day to twice a day 5-7 days per week. Exercises listed included ten reps x two, for ankles, knees and hips to include ankle pumps, heel slide, hip abduction, straight leg rises, internal and external rotation, ankle circles and sit-up/curl ups in bed reaching from waist to above head in an arch motion. No other therapy notes were provided. The untitled facility form, referred to by facility staff as Restorative Resident Listing, undated, listed R19's PROM exercises and UE exercises. The form identified his rehab plan was to be completed every day to twice a day 5-7 days per week. Review of R19's form titled P[NAME] (point of care) Response History, provided from facility, from 1/16/19, to 2/14/19, which listed task: restorative; Bed Mobility UE exercises every day to twice a day 5-7 times a week, identified the following: -week of 1/16/19, to 1/19/19: one day documented as R19 refused, all other entries documented as not applicable. R19 received zero of possible seven days of restorative program. -week of 1/20/19, to 1/26/19: not applicable documented for all entries documented. R19 received zero of possible seven days of restorative program. -week of 1/27/19, to 2/2/19: four days documented as R19 refused, all other entries documented as not applicable. R19 received zero of possible seven days of restorative program. -week of 2/3/19, to 2/9/19: one day 15 repetitions of exercise documented on 2/9/19, two entries documented as refused, all other entries documented as not applicable. R19 received one time of possible seven days of restorative program. -week of 2/10/19, to 2/14/19: one day 15 repetitions of exercise documented on 2/12/19, and 20 repetitions of exercise documented on 2/13/19, all other entries documented as not applicable. R19 received two of possible seven days of restorative program so far that week. Review of R19's form titled P[NAME] Response History, provided from facility, from 2/1/19, to 2/14/19, which listed task: restorative PROM bilateral lower extremity in bed 10 reps times two sets each, identified the following: -week of 2/1/19, to 2/2/19, one entry documented as R19 refused, all other entry documented as not applicable. R19 received zero of possible two days of restorative program. -week of 2/3/19, to 2/9/19, one day 10 minutes of PROM provided 2/9/19, two days documented as R19 refused, and all other entries documented as not applicable. R19 received one time of possible seven days of restorative program. -week of 2/10/19, to 2/14/19, on 2/12/19, and 2/13/19, 15 minutes of PROM provided, and all other entries marked as not applicable. R19 received two of possible seven days of restorative program so far that week. Review of R19's progress notes from 1/16/19, to 2/14/19, lacked any documention or summary of R19's restorative nursing program. On 2/13/19, at 11:05 a.m. nursing assistant (NA)-E indicated R19 was on a restorative program. NA-E indicated the facility usually had a sixth NA who worked as a restorative aide usually around four times a week. NA-E indicated the facility had two staff who generally provided the restorative program, but one had been on vacation for awhile. NA-E indicated if a restorative aide was not scheduled, the NA staff would pick up what they could on the restorative program for the residents. NA-E indicated R19 had two restorative nursing programs scheduled for day and evening shift which would show up on their computer to be completed. On 2/13/19, at 1:13 p.m. RA-A indicated she worked as the restorative aide, but had not worked in that role hardly at all lately as she had been working on the floor as a NA lately. RA-A indicated when she worked on the floor walking programs got done for residents, but usually not full ROM exercises or the NuStep exercise equipment. RA-A indicated the other RA had been gone about a month and RA-A indicated she had not been scheduled the last two schedules, as a resident aide either. RA-A indicated R19 could complete his UE exercises independently, but needed cuing to complete them. On 2/14/19, at 9:02 a.m. registered nurse (RN)-A confirmed she was responsible for the restorative nursing program. RN-A indicated recommendations were provided by therapy department to maintain resident's function and prevent decline. RN-A indicated the program was monitored quarterly with assessments and if needed. RN-A indicated the RAs would also inform her if there were any concerns. RN-A indicated when the restorative exercises were documented not applicable, it was not done or the staff did not have time to do it. RN-A indicated she did not complete the schedule, but was aware one of the RAs were out on an extended leave. RN-A reviewed R19's electronic record and confirmed R19 had not been receiving restorative nursing program as scheduled. On 2/14/19, at 10:26 a.m. director of nursing (DON) indicated resident restorative programs were typically completed 3-7 days per week. DON indicated if the programs were not completed, the residents were at risk for contractures, decreased mobility and a decrease in their ADL abilities. DON indicated she expected the restorative programs to be completed as scheduled and if a resident was in an activity or out, she would expect the staff to re-approach and offer the restorative program later. DON confirmed one of the usual RAs was on a leave of absence, but all the nursing assistants had training and written instructions to follow. DON indicated either the RA role was marked on each two week schedule, or it would be added into their communication binder. DON indicated RN-A monitored resident restorative programs quarterly or as needed if concerns were reported. DON reviewed R19's restorative program documentation and confirmed R19 had not received the restorative program as scheduled. The facility policy titled Restorative Nursing Program revised 5/2011, identified the program was to protect each residents' ability to adapt to attain his or her maximum functional potential. To promote each resident's highest practicable level of physical, mental and psychosocial functioning. The procedures listed included: each resident who participates in the restorative nursing program will have an individual program with individual goals. Documentation of the resident's restorative progress toward goal response to treatment will be summarized weekly on the appropriate documentation tool. Restorative nursing staff will document the activity and the number of minutes provided each time an activity is completed on a designated documentation tool. The interdisciplinary team, under the direction of the RN, will do a quarterly review of the restorative nursing program.

Based on interview and document review, the facility failed to provide the required notices when residents discharged from a Medicare Part A stay for 1 of 1 residents (R21) reviewed who remained in the facility and 2 of 2 residents (R200, R201) who discharged from the facility. Findings include: R21 R21's Centers for Medicare and Medicaid Services (CMS)- form, Medicare Part A listed services started 11/28/18, and the last covered day of Part A service was 12/14/18. The form indicated the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. R21 remained in the facility after 12/14/18. R21's record review revealed the facility provided a form titled CMS- , Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN), which explained the services provided would no longer be covered under Medicare beginning 12/14/18. R21's record indicated a CMS- was provided as indicated, however the required Notice of Medicare Non-Coverage (NOMNC) CMS- had not been provided to R21. R200 R200's CMS- form, Medicare Part A listed services started 9/4/18, and the last covered day of Part A service was 10/24/18. The form indicated the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. R200 discharged from the facility after 10/24/18. R200's record review revealed the facility provided a form titled CMS- ,SNFABN, which explained that the services provided would no longer be covered under Medicare beginning 10/24/18. R200's record indicated a CMS form SNFABN was provided and not the required Notice of Medicare Non-Coverage (NOMNC) CMS- . R201 R201's CMS- form, Medicare Part A listed services started 7/17/18, and the last covered day of Part A service was 8/24/18. The form indicated the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. R201 discharged from the facility after 8/24/18. R201's record review revealed the facility provided a form titled CMS- ,SNFABN, which explained the services provided would no longer be covered under Medicare beginning 8/24/18. R201's record indicated a CMS form was provided and not the required Notice of Medicare Non-Coverage (NOMNC) CMS- . On 2/13/19, at 1:56 p.m. the licensed social worker verified although being aware of the required 48 hour notice to residents being discharged from Medicare skilled coverage, she was unaware of the required CMS- form. On 2/13/19, at 1:59 p.m. the administrator verified being unaware of the specific needed forms for resident liability notices. The requested facility policy was not provided.

Based on interview and document review, the facility failed to establish a water management program for the prevention of Legionella (a bacterium) in the facility water system to prevent cases and outbreaks of Legionnaires' disease (a serious type of pneumonia). This deficient practice had the potential to affect all 25 residents who resided in the facility. Findings include: A Center for Disease Control (CDC) document, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 6/5/17, indicated Legionnaire's disease was a serious type of pneumonia caused by bacteria, called Legionella that live in water. Legionella can make people sick when they inhale contaminated water from building water systems that are not adequately maintained. Implementing a water management program can reduce a building's risk for growing and spreading Legionella. On 1/4/18, at 2:10 p.m. environmental services director (ESD) verified he was responsible for the Legionella water management program at the facility. ESD stated the facility's management company provided him with an educational handout titled What is Legionnaires' disease? Get the facts in under 30 seconds, and had sent in consultants that completed a facility assessment about six weeks ago. ESD indicated the facility had not yet heard the results of the assessment or put a plan in place for water testing. ESD verified the Legionella management program was not complete. On 1/4/18, at 2:43 p.m. the administrator indicated the facility has had a Legionella policy in place for months and that they had started to work with the city on a plan so that the facility would be the quarterly testing site for Legionella for the entire city. She stated the facilities management company had them stop their plan with the city and to utilize a contracted company that the management company had vetted. She confirmed the facility assessment was completed, however had not received a water testing plan from the contracted company. The adminstrator stated she would expect the Legionella management program to already be in place. A facility policy titled Legionella/Water Control Policy effective 8/29/17, indicated the purpose of the water management program was to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building water systems.

Based on observation, interview and document review, the facility failed to comprehensively assess residents for risk of falls and effectively implement the application of personal safety alarms resulting in an immediate jeopardy situation for 2 of 4 residents (R40, R34) reviewed at risk for falls. Both R40, R34 sustained actual harm when they sustained fractures following a fall. In addition to the residents in immediate jeopardy, the facility failed to appropriately implement personal safety alarms, which resulted in the potential for harm that was not immediate jeopardy for 2 of 2 residents (R31, R39) with a history of falls The immediate jeopardy began on October 23, 2013, due to the systemic failure of the facility to appropriately implement personal safety alarms to prevent falls. The administrator and the director of nursing (DON) were notified on 10/23/2013, at 5:25 p.m. of the immediate jeopardy for R40 and R34. The IJ was removed on 10/25/2013, at 10:24 a.m., however, non-compliance remained at a scope and severity level of G, which indicated actual harm for R40 and R34 due to fractures sustained following falls. Findings include: R40 was assessed by the facility as a high risk for falls related to cognition impairment, impairment of gait and transferring, history of falls, forgets limitations and has unpredictable behaviors. Interventions identified by the facility included the use of a personal safety clip alarm to be used while R40 was in bed or in a chair. However, during observations of R40, the battery operated alarm was not securely attached to an affixed object nor was the clip attached to R40's clothing that would allow the peg to detach to sound the alarm to alert staff. In addition, the facility failed to comprehensively assess R40's risk factors related to falls which would include possible causal factors related to attempts at unsafe independent transfers. R40 had [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE], identified R40 was severely cognitively impaired, required extensive assist of two with transfers, toilet use and bed mobility, and utilized a wheel chair for locomotion on and off the unit. The MDS also indicated R40 had one fall that resulted in a major injury, a pelvic fracture, during the assessment period. The Care Area Assessment (CAA) dated 8/29/13, identified R40 was at high risk for falls related to balance problems during transition, history of falls, use of anti-anxiety medications, anti-depressant medications, and also has unpredictable activity and behaviors. The assessment also revealed a decline in activities of daily living which identified R40 to require more assistance with cares. The CAA also indicated that R40 had a [DIAGNOSES REDACTED]. R40 also had a [DIAGNOSES REDACTED]. The care plan, revised 10/19/13, identified R40 had potential for injury (falls) related to impaired cognition and mobility due to cerebrovascular accident, multi infarct dementia with unpredictable activity/ behaviors, and history of falls. The care plan listed various interventions which included: clip alarm on in bed, and clip alarm while in chair, to alert staff of needs. The quarterly fall risk assessment dated [DATE], indicated R40 continued to be at risk for factors noted on comprehensive assessment. The fall risk assessment indicated R40 was being managed for behaviors and cognition conditions due to cerebrovascular accident and was tolerating medications well with no adverse effects noted. Mood and cognition was identified as stable. However the fall assessment indicated R40 had knee discomfort which affected her gait at times, but also identified R40 was steady and would use handrails in the hallways. Will continue plan of care. The quarterly functional safety assessment dated [DATE], identified R40 continued to be independent with supervision for bed mobility, transfers, and ambulation. R40's facility undated nursing assistant (NA) care sheet directed staff to use a clip alarm when R40 was in her wheelchair and in bed at night. A facility incident report dated 8/14/13, at 9:00 a.m. revealed R40 had experienced an unwitnessed fall in the dining room. According to the report, R40 had stood up and attempted to sit down and fell on the floor missing the chair. The report indicated R40 had no injuries, that staff had implemented a toileting plan after a 3 day bowel and bladder collection, and that the resident was to utilize a wheel chair as needed. The report also revealed R40 had risk factors of dementia and macular degeneration, as well as underlying conditions of impaired mobility, impaired vision, depression, change in mood, behavioral issues, and impaired cognition. The post fall plan of action was to assess and observe the resident's normal toileting schedule for the next 3 days and then to implement a specific toileting plan based on the data collected. A facility incident report dated 8/15/13, at 1:00 p.m. revealed R40 was in the dining room attempting to ambulate, knees bent and R40 fell to the ground. The report indicated R40 had sustained a bruise to the inside of the wrist from the Watchmate (a Wanderguard bracelet), and had complaints of pain in her shoulder and left leg. Staff implemented a clip alarm to be attached to R40's chair and clipped to the resident to alert staff of R40's attempts to self transfer or ambulate. The report also revealed R40 had risk factors of dementia, knee pain, macular degeneration, impaired mobility, impaired vision, depression, change in mood, behaviors, and impaired cognition. The post fall plan of action indicated a clip chair alarm was placed on R40's wheel chair to help alert staff when the resident attempts to transfer or ambulate by herself. The annual fall risk assessment dated [DATE], indicated R40 was at high risk for falls related to a history of falls, secondary diagnosis, impaired gait/transferring, and forgets limitations. The assessment indicated R40 had experienced two recent falls, 8/14/13 and 8/15/13, and that R40 had sustained a pelvic fracture from the fall on 8/15/13. The annual functional assessment dated [DATE], indicated R40 was not steady, and was only able to stabilize with human assistance when moving from a seated to standing position, moving on and off toilet, and during surface to surface transfers. R40 had functional limitation in range of motion to lower extremity with impairment on one side due to left pelvic fracture. The assessment identified R40 required extensive assist of two persons to physically assist with her activities of daily living. Furthermore, R40's safety interventions indicated she was to have a clip alarm in the chair and a motion alarm in bed. A facility incident report dated 10/19/13, at 5:30 a.m. revealed R40 was found sitting on the floor next to her bed clutching her right upper arm. The report indicated R40 stated to staff that she had fallen out of bed and landed on her right arm. The report indicated R40 had sustained a 1 inch skin tear on the right elbow and had swelling of the right upper arm. R40 was sent to the clinic and was diagnosed with [REDACTED]. The report also revealed R40 had risk factors of impaired cognition and judgement, impaired safety awareness, as well as underlying condition of knee pain, environmental factors of bed not in low position, impaired mobility, and balance. The post fall plan of action was to keep R40's bed in the low position when R40 was in bed to prevent falls. Interdisciplinary progress notes reviewed from 7/29/13 to 10/21/13 revealed: On 7/29/13, R40 received limited assistance with bed mobility and transfers and she ambulates independently in her room and hall. R40 will utilize a wheel chair during day due to knee pain. On 8/16/13, R40 having severe pain today with any movement, R40 unable to stand or sit on toilet and screamed in pain which seemed to be in both legs, hips and knees. On 8/17/13, R40 continued to have severe pain to her left hip, and having difficulty with transfers and any weight bearing. R40 required two assist with all transfers. R40 sent to clinic to be assessed and possible x-ray. Results from x-ray revealed left superior and inferior pelvic fracture. On 8/29/13, R40 has been more dependent with cares and more incontinent due to decline in health and strength. Has severe pain upon any movements of lower extremities. At present time resident is not ambulating due to a fractured pelvis. On 9/29/13, R40 had clip alarm attached to night clothing to alert staff of independently transferring to and from bathroom. Staff to standby to assure safety. R40 will attempt to ambulate in her room, and in the hall independently but staff are alerted by alarm and will assist her depending on her level of pain due to pelvic fracture. At times makes efforts to get up without any assistance, alarm is connected to resident to keep her safe. On 10/19/13, R40 was found sitting on floor next to her bed clutching her right upper arm/shoulder, and was sent to Sanford clinic for x-ray. X-ray results revealed a fracture of the right humeral head. During observation on 10/23/13, at 8:45 a.m., R40 was alone in her room, lying in bed, yelling out loudly, with her bed in a low position, her left leg was hanging over the side of the bed onto the floor. R40 wore a black fabric sling on her right arm and her left hand was clutching her right arm while she was rocking her torso back and forth in bed, attempting to get of of bed. A metal clip was attached to R40's left shoulder of her gown and the cord of the clip was laying over the top of the pillow. R40 continued to attempt to get out of bed, with her leg hanging out of bed and continued to rock back and forth until 8:49 a.m. when the surveyor notified staff. Nursing assistant (NA)-B came to R40's room to assist R40. No alarms were sounding during the entire observation. On 10/23/13, at 12:15 p.m., NA-B confirmed R40 was to have a clip alarm on when she is in bed or in a chair. NA-B stated R40 does try to get out of bed and does try to transfer herself daily. NA-B confirmed that the clip is to be hooked to R40's clothing towards her shoulder area and that she would either hook the alarm box to the wheelchair or lay it on the bed on the far side of the pillow. NA-B confirmed that R40's clip alarm was not sounding when she was attempting to self transfer on 10/23/13 at 8:45 a.m. During continuous observation on 10/23/13, from 10:14 a.m. to 10:24 a.m., NA-A assisted R40 to transfer into a recliner in the lounge at 10:14 a.m. NA-A attached the metal clip of the alarm to R40's left shoulder and placed the alarm box on the left arm of the recliner and immediately walked out of the lounge. The personal safety alarm box was not affixed to a stationary surface. On 10/23/13 at 10:20 a.m., NA- A confirmed that R40 was to have a clip alarm on while in the chair or recliner, and confirmed she had rested the alarm box on the arm of the recliner. NA-A stated, "We don't have anything to hook it to." At 10:24 a.m., NA-A reentered the lounge and moved the personal safety alarm from the left arm of the recliner to the back of R40's wheelchair and secured the alarm box with a large metal clip. Then NA-A proceeded to hook the small metal clip of the alarm to R40's right shoulder. NA-A then exited the area. Prior to this, R40's personal safety alarm was not attached securely to an affixed object for ten minutes while R40 sat in the recliner unsupervised. During continuous observation on 10/23/13, from 11:12 a.m. to 11:26 a.m., R40 was seated in a recliner in the lounge area, with her wheelchair sitting next to the recliner and the alarm box attached to the back of the wheelchair with a large metal clip. The small metal clip at the end of the string, from the box was observed laying in the seat of the wheelchair, not attached to the resident. At 11:26 a.m. on 10/23/13, the clip alarm continued to be observed on the seat of R40's wheelchair next to the recliner, not clipped to R40's shirt. During interview with NA-B at that time, NA-B confirmed the clip alarm was not attached to R40. NA-B proceeded to hook the clip of the alarm to the back of R40's right shoulder, while the alarm box remained attached to the back of R40's wheelchair. R40's clip alarm had not been appropriately attached to her shirt for fourteen minutes while she sat in recliner unsupervised. On 10/23/13, at 11:30 a.m., registered nurse (RN)-A confirmed R40's current care plan directed staff to have a clip alarm on R40 while in bed or in a chair. RN-A confirmed R40 self transferred at times, and was confused. RN-A confirmed R40 sustained fractures after her falls on 8/15/13 and 10/19/13. RN-A stated the usual practice was to attach the clip to R40's clothing towards her shoulder area and alarm box to be attached to the wheelchair or it rested on the bed above the pillow. RN-A stated, "Alarm is not securely attached to anything." On 10/23/13, at 1:53 p.m., NA-C confirmed R40's care plan directed staff to use a clip alarm when she is in bed or in a chair. NA-C stated R40 did attempt to self transfer from her wheelchair to the recliner routinely. On 10/23/13, at 2:08 p.m., NA-D confirmed R40 was to have a clip alarm on when she was in bed and in a chair. NA-B stated R40 did try to get out of bed and also did transfer herself. NA-B confirmed the clip was to be hooked to R40's clothing towards her shoulder area and the alarm box was attached to the wheelchair and when in bed the box lays on the bed. NA-D stated, "I don't think it is securely attached." On 10/23/13, at 2:24 p.m., licensed practical nurse (LPN)-A confirmed R40 was to have a clip alarm on while in bed or in a chair because she has fallen in the past. She stated R40 did try to transfer herself occasionally. LPN-A confirmed the clip was to be hooked to R40's clothing and the alarm box either hooked to the wheelchair or when in bed the box is placed on the bed under her pillow. On 10/23/13, at 2:35 p.m., NA-E confirmed R40 was to have a clip alarm on when she is in bed and in a chair. NA-E also confirmed R40 did try to get out of bed herself and did try to transfer herself at least twice a week. On 10/23/13, at 11:16 a.m., the assistant director of nursing (ADON) confirmed it would be expected the personal safety alarms would be attached to R40's clothing and the alarm box would be affixed to a secure surface while R40 was in any chair or her bed. The ADON further indicated attaching the alarm box to a secure surface would allow the clip alarm to detach, and trigger the sound of the alarm to alert staff of R40's movements. Review of the facility policy titled Fall Prevention, dated October 2007, included: The facility would provide a safe, comfortable and secure environment for residents, and provide an ongoing system for monitoring residents. Furthermore, the facility would analyze incidents of falls in order to determine causal factors and implement the appropriate interventions. Review of manufacturer's guidelines undated, for the Alert-Mate Alarm model #SAM-1 alarm, also known as a "clip alarm," identified techniques to attach the alarm by using Velcro and to affix the alarm to the bed, chair, wheelchair or night stand out of reach of the resident. The guidelines further indicated a Mate holder could also be used, to insert alarm into holder and attach to bed, chair, wheelchair or nightstand, out of reach of the resident. R34 had been assessed by the facility as high risk for falls, and had a history of [REDACTED]. However, during observations of R34, the battery pack was not securely affixed to a surface to allow detachment of the magnetized end from the battery pack alarm box to allow the alarm to sound. In addition, the facility failed to comprehensively assess R34's risk factors related to falls which would include possible causal factors related to attempts at unsafe independent transfers. R34 had [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE], identified R34 was severely cognitively impaired, required the extensive assistance for all activities of daily living, and utilized a wheel chair for locomotion. The fall risk assessment dated [DATE], revealed R34 was at high risk for falls related to cognitive impairment, lack of awareness of limitations and impaired gait and transferring. The care plan, revised 10/4/2013, identified R34 was at risk for falls related to impaired mobility, pain, dementia, arthritis and would forget limitations. R34's care plan directed facility staff to assist with transfers, and toileting. The care plan further directed R34 was to have a "clip alarm" in place when in bed and in the chair. R34's facility undated nursing assistant care sheet directed staff to utilize a clip alarm when R34 was in the chair as the resident did not ambulate, and to utilize a clip alarm when R34 was in bed. R34's annual MDS, dated [DATE], revealed a brief interview for mental status was not performed as R34 was rarely understood. The MDS further revealed R34 made poor decisions, required supervision, extensive assistance for all ADL's, and required staff to stabilize her balance during movements from seated to standing, moving on and off the toilet and transferring between bed and a chair. Review of R34's CAA dated 12/13/2012, for activities of daily living, revealed a decline in her general medical condition related to multiple [DIAGNOSES REDACTED]. The CAA further identified R34 was at high risk for falls related to balance problems, a recent fall and the utilization of anti-anxiety and antidepressant medication. R34's facility fall risk assessment dated [DATE], revealed R34 had a fall 10/25/12, while attempting to get up to the bathroom. The fall assessment dated [DATE], identified R34 was at high risk for falls and interventions were to continue with a bowel and bladder plan, assess and manage pain, discontinue use of the remote sensor alarm and utilize a clip alarm when R34 was in bed and when in a chair. The facility incident report, dated 3/8/2013, revealed R34 was found at 8:15 p.m., on the floor by her bathroom door. R34 stated she was looking to go to the bathroom. The report revealed R34 received a 5 centimeter (cm) scratch to her mid back. The intervention initiated was to offer toileting after supper and to anticipate toileting needs. The root cause analysis of the fall identified the following: R34 had impaired mobility related to rheumatoid arthritis and was not oriented to her own abilities. She was impulsive and unaware of safety. She needed extensive assist of one for toileting and had a clip alarm to alert staff to independent transfers. The facility incident report, dated 3/30/13, revealed R34 was found resting on the floor in her room on her side with hands tucked under her head. R34 had no apparent injuries. The root cause analysis of the fall identified the following: R34 had dementia that prevented insight into her physical limitations. R34 had arthritis with limited mobility and poor physical strength. The report indicated the clip alarm had been utilized, and a new intervention was to place a foam "noodle" to pad the outer edge of the bed to give the clip alarm "an added chance to catch movement." The facility incident report dated 4/20/13, revealed R34 was found on the floor at 10:30 a.m., in the facility dining room with another resident witness who stated R34 got up and walked to another dining table to help another resident with a tray, turned to go back to the chair, and fell on the floor. The report revealed R34 had severe right hip pain and stated it hurt to touch. Ice was applied to the right hip and Morphine given with scant relief. R34 was subsequently admitted to the local hospital with severe right hip pain and a [DIAGNOSES REDACTED]. The new intervention was to keep R34 under observation when up. The root cause analysis of the fall identified the following: R34 had dementia with extremely poor short term memory, impaired cognition, and had judgement/safety awareness deficit. R34 appeared to forget that she was too weak and it was too painful for her to walk. The fall risk assessment dated [DATE], revealed R34 returned from the hospital on [DATE] and was at continued high risk for falls, was cognitively impaired and resistive to cares and redirection at times. The assessment identified R34 did not ambulate, transferred with the assist of one to two, and had chronic pain from rheumatoid arthritis. The plan for fall prevention was to continue with previous measures. The facility incident report dated 5/2/13, revealed R34 was found on the floor in her room at 2:10 a.m. There were no injuries noted. The root cause analysis revealed the following: R34 had impaired mobility and pain due to fracture of the right hip on 4/20/13. Her cognition was impaired due to a [DIAGNOSES REDACTED]. The intervention initiated was to change R34's bed to one lower to the floor and place a fall mat next to the bed made to absorb impact in the event of another fall, and keep the clip alarm on in bed and chair. The facility incident report dated 9/13/13, revealed R34 fell from a recliner lift chair when another resident attempted to assist her out of the recliner chair. R34 received 2 scratches on her mid back and left buttock and on the left buttock there was a 4 cm pink area. The root cause analysis of the fall revealed the following: R34 had an underlying [DIAGNOSES REDACTED]. R34 had impaired mobility and balance. R34 had a history of [REDACTED]. The report identified the intervention was to turn up the volume on the chair clip alarm, replace if needed, reinforce toileting and check on R34 when in the recliner. The facility incident report dated 9/18/13, revealed R34 was up in the wheel chair in the TV (television) room in front of the nurses' station when the chair alarm went off and R34 was found kneeling in front of her wheel chair. R34 had no apparent injuries. The root cause analysis of the fall revealed the following: R34 had a [DIAGNOSES REDACTED]. R34's rheumatoid arthritis affected her mobility and balance and put her at risk for falls. The plan of action was to reinforce with R34 the need to stay sitting upright, avoid leaning too far forward as she could fall out of her wheelchair/chair. Review of interdisciplinary team progress notes from 1/2013 to 10/2013, revealed the following: 1/3/13- R34 had a decline in general health with low energy level 2/6/13- R34 did not communicate needs. 3/8/13- R34 was found sitting on the floor in her room R34 stated she was looking for the bathroom. A scratch 5 cm long on mid back. 3/30/13- R34 was found on floor in room lying on her side and stated she was trying to get out of bed. 4/13/13- R34 was routinely checked during scheduled every two hour rounds and had a clip alarm attached to her night clothes to alert staff of attempt to independently transfer. The progress note further identified R34 would remove the alarm at times. 6/12/13- R34 was unable to verbalize needs, was acting out with anger and aggression and had been irritable. Orders were obtained for an increase in pain medication and to evaluate for improvement in pain and restlessness. 7/17/13- The previous night R34 was found sitting up and removing clip safety alarm. R34 required extensive assistance to ambulate in the bathroom. R34 was never using the call system and staff was required to anticipate needs and provide them due to dementia. A safety alarm was clipped to her nightgown, the bed was in lowest position, and a safety mat was kept on floor next to bed "for her history of restless episodes, climbing out of bed and falling. Will remove the clip alarm and hide it under her pillow. Since it will take her time, staff have been able to assist her as soon as alarm has sounded." 8/13/13- Required extensive assist for all repositioning. Bed was kept in lowest position, a safety mat was placed on the floor and a clip alarm was attached to her nightgown. R34 continued to have a history of sitting up and attempting to transfer self, and a prior history of falls. 9/13/13- R34 had a fall while attempting to get out of the recliner. Scratches to her skin and back and left buttocks with a pink raised area 4 cm around. No other injuries apparent. 9/15/13- On nights when R34 had poor sleep she was restless, digging in drawers, attempting to get out of bed, transfer to a standing position, angry at staff. R34 had a personal safety clip alarm to alert staff when she was restless. During observation on 10/22/13, at 1:17 p.m., R34 was observed seated in a brown overstuffed recliner lift chair in the facility TV lounge. The chair was fully reclined and R34's feet were on the foot rest. A metal clip on a cord was attached to the back of R34's sweater, however, the white alarm box with UMP lettering was loosely placed above R34's head on the top edge of the back of the recliner and was not affixed to the fabric of the recliner and could move freely from the chair. During continuous observation from 1:17 p.m. to 4:01 p.m. on 10/22/13, R34 was seated in the TV room in the recliner chair with the alarm box loosely resting on the top edge of the chair above her head. At 1:50 p.m., R34 repositioned herself to the right to see the TV, the alarm box continued in the same position, loosely resting, and not affixed to the chair. The alarm did not sound. At 2:38 p.m., R34 was resting in the chair, the alarm box remained resting on top of the recliner headrest, not affixed to the chair. At 2:56 p.m. NA-C briefly approached R34 and then proceeded to walk out of the lounge area. NA-C did not check the alarm box which remained resting on top of the recliner headrest, not affixed to the chair. At 4:01 p.m., LPN-B and the surveyor examined R34's clip alarm box and LPN-B confirmed that the box was not affixed to R34's chair. LPN-B further confirmed that usual practice would be to clip the alarm box to a surface which would allow the magnetic clip to detach if R34 attempted to transfer independently. On 10/23/13, during continuous observation from 7:03 a.m. to 8:50 a.m., R34 was lying in her room in bed on her left side. R34's personal safety alarm was clipped to the back of her nightgown, however, the alarm box was loosely resting on the mattress above the pillow, and was not affixed to any surface to allow the magnetic tab to detach and trigger the personal safety alarm if R34 attempted to transfer independently: At 7:07 a.m., RN-A approached R34 with a morning medication. RN-A raised the head of the bed for R34 to take the medication and the alarm box slid down the head of the bed. RN-A then placed the alarm box under R34's pillow, however the alarm box was not affixed to any surface. At 7:18 a.m., NA-H stated R34 did frequently attempt to get out of bed independently and the personal safety clip alarm was utilized to alert facility staff if R34 was attempting to get out of bed or the chair independently. At 7:03 a.m. until 8:50 a.m., R34 remained in bed, with the personal safety alarm resting loosely on the mattress not affixed to any surface. At 9:00 a.m., R34 was seated in the dining room in her wheel chair, there was no personal safety alarm affixed to the wheel chair or to R34's clothing. At 9:04 a.m., R34 was seated in the wheel chair at a dining table, however, the safety alarm was not present, not attached to R34's clothing or wheelchair. The ADON was present in the dining room, getting food items from the steam table. At 9:04 a.m. during interview, the ADON indicated she was not aware R34's safety alarm was not in place. She confirmed R34 was to have a personal safety alarm attached at all times when in the chair or in bed. The ADON immediately left the dining room and returned with R34's safety alarm box and proceeded to attach the clip to R34's clothing and the alarm box to the back of the wheel chair. On 10/23/13, at 9:59 a.m., NA-D stated R34 frequently attempted to get out of bed or get up out of the wheel chair independently. NA-D stated the usual placement of the alarm box for R34's personal safety alarm while in bed was to place the box loosely on the mattress behind R34. NA-D further stated the usual way to place the alarm box when in the recliner chair was to tuck it under a cover on the recliner or clip it to the wheel chair. On 10/23/13, at 10:06 a.m., NA-B stated R34 frequently attempted to get up from the recliner chair by swinging legs over the edge of the chair. NA-B stated the last time R34 attempted to get out of the chair was approximately 2 weeks prior. NA-B stated R34 also frequently attempted to get out of bed independently, the last time was two days ago. NA-B stated the usual placement of the personal safety alarm box when R34 was in bed was to lay it on the mattress behind R34's head. NA-B indicated the alarm box was not attached to a surface but loosely placed on the mattress. On 10/23/13, at 10:30 a.m., NA-A stated R34 frequently attempts to lean forward in the chair and indicated R34 had an alarm on the wheel chair to alert staff of any attempts to transfer independently. On 10/23/13 at 10:36 a.m., RN-A confirmed R34 was frequently restless at night and made attempts to get out of bed independently. RN-A further indicated R34's attempts to self transfer were the reason for the low bed, floor mat and safety alarm. On 10/23/2013 at 11:16 a.m., during review of R34's fall reports and fall assessments, the ADON confirmed the current care plan for R34 and verified that R34 was to have a personal safety clip alarm attached when in bed or a chair. The ADON further confirmed R34 was at high risk for falls and had fallen and sustained a fracture in the past. The ADON also confirmed it would be expected that the personal safety alarms would be attached to R34's clothing and the alarm box would be affixed to a secure surface while R34 was in any chair or her bed. The ADON indicated this would allow the magnetic tab to detach, and trigger the sound of the alarm to alert staff of R34's movements. On 10/23/13 at 3:55 p.m., the director of nursing (DON) provided installation and instructions for the personal safety alarms. DON confirmed the instructions gave direction to secure the alarm boxes to a stationary surface. Review of manufacturer's guideline instructions for the UMP Standard monitor identified techniques to attach the alarm to a non movable surface, with use of a chair strap and a mounting bracket for the bed. In a post survey telephone response from the manufacturer's representative on 11/5/13 at 4:15 p.m., a representative of the Universal Medical Products company stated the alarm box was to be firmly affixed to a chair or bed to allow the magnetic seal to be broken between the monitor and the magnet. Review of the facility policy titled Fall Prevention, dated October 2007, revealed the facility would conduct ongoing assessments, and provide an ongoing system for monitoring and analyzing incidents of falls in order to determine causal factors and implement appropriate interventions. The immediate jeopardy that began on 10/23/13, at 5:25 p.m., was removed on 10/25/13, at 10:24 a.m., after verification of staff education, training of staff, and reasse