Every finding on record at Person Memorial Hospital

Based on record reviews, and staff and physician interviews, the facility failed to limit the duration of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) ordered on an as-needed (PRN) basis to 14 days and/or indicate the duration and rationale for extending the PRN order beyond 14 days. This occurred for 1 of 5 residents whose medications were reviewed (Resident #36). Findings Included:Resident #36 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder.On 5/9/25, the physician ordered one (1) milliliter (ml) of Lorazepam Intensol Oral Concentrate (Lorazepam) 2 milligrams/milliliter (mg/ml) to be administered via Percutaneous Endoscopic Gastrostomy (PEG) tube every 2 hours as needed (PRN) for anxiety. Lorazepam is a psychotropic and controlled substance medication.The resident's most recent Minimum Data Set (MDS), dated [DATE], indicated that Resident #36 was severely cognitively impaired with no behaviors or rejection of care. The Medication section of the MDS revealed that Resident #36 received an antianxiety medication during the 7-day look-back period. The resident was in hospice care.Resident #36's electronic medical record (EMR) indicated that the physician's PRN Lorazepam order (dated 5/9/25) remained active through the review date of 12/17/25. A review of Resident #36's Medication Administration Records (MARs) revealed that two to three doses of PRN Lorazepam were administered weekly from 5/9/25 through 12/17/25. The last documented dose was administered on 12/16/25.During an interview on 12/15/25 at 2:00 PM, Nurse #1 stated that Resident #36 experienced agitation and anxiety during care. The resident was diagnosed with colon cancer and was under hospice care. The nurse indicated that the resident received PRN Lorazepam at least two (2) to three (3) times per week.During a telephone interview on 12/17/25 at 12:58 PM, the hospice nurse stated that Resident #36 sometimes experienced agitation and anxiety during care. The hospice nurse explained that Resident #36's medications were reviewed every two weeks by the hospice interdisciplinary team, which included the hospice physician. The facility physician reviewed residents' medications and wrote all medication orders. The facility physician could accept or decline any recommendations from hospice. The hospice physician only performed medication reconciliation, while the facility physician managed the medications.During an interview on 12/17/25 at 12:02 PM, the interim DON stated that she had been in the position for one week. She stated that psychotropic medications could be ordered PRN but should include a stop date, and the resident had to be reevaluated if the medication needed to be continued.During an interview on 12/17/25 at 10:00 AM, Physician #1 stated that he served as the Medical Director during October and November 2025. He acknowledged that psychotropic medications should be reviewed, a rationale should be provided, and an end date for PRN medications should be indicated.During a telephone interview on 12/17/25 at 10:15 AM, the current Medical Director stated that he had accepted the position a few weeks earlier. He confirmed that residents who received PRN psychotropic medications needed to be evaluated by the provider within the regulatory timeframe. He further stated that, regardless of whether a resident was on hospice or not, all psychotropic medications should be reviewed by a physician, a rationale for continuation should be provided, and the duration of PRN medications should be specified.During an interview on 12/17/25 at 2:08 PM, the Administrator stated that she was serving as the interim contract Administrator and had been hired a few weeks earlier. The Administrator acknowledged that physicians should review resident medications and that all psychotropic medications should be evaluated per CMS regulations.

Based on record reviews and staff, consultant pharmacist, and physician interviews, the facility failed to act on recommendations made by the consultant pharmacist and failed to document a response to the pharmacist's findings and recommendations in the resident's medical record for 2 of 5 residents whose medications were reviewed (Resident #36, and Resident #4).Findings included:1. Resident #36 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder. On 5/9/25, the physician ordered one (1) milliliter (ml) of Lorazepam Intensol Oral Concentrate (Lorazepam) 2 milligrams/milliliter (mg/ml) to be administered via Percutaneous Endoscopic Gastrostomy (PEG) tube every 2 hours as needed (PRN) for anxiety. Lorazepam is a psychotropic medication and a controlled substance. Resident #36's Electronic Medical Record (EMR) indicated that the physician's PRN Lorazepam order (dated 5/9/25) remained active through the review date of 12/17/25. A review of Resident #36's Medication Administration Records (MARs) revealed that two (2) to three (3) doses of PRN Lorazepam were administered weekly from 5/9/25 through 12/17/25. The last documented dose was administered on 12/16/25. A review of the consultation reports dated 7/15/25, 8/13/25, 9/11/25, 10/13/25, 11/13/25, and 12/10/25 indicated that the pharmacist recommended the physician address the PRN Lorazepam order, which lacked a stop date. The consultation reports did not show that Resident #36's physician reviewed or responded to the pharmacist's recommendations. A telephone interview with the Consultant Pharmacist on 12/17/25 at 9:30 AM revealed that he completed monthly medication regimen reviews (MMRs) for all residents. He explained that if there were regulatory concerns related to medications, he emailed his recommendation reports to the facility's Director of Nursing (DON) and Administrator. The DON handled nursing recommendations and forwarded physician recommendations to the appropriate physician. The physician either approved or declined the recommendations, signed off on the report, and provided a rationale for any decline. The DON ensured that the physician reviewed the recommendations. The Consultant Pharmacist stated Resident #36 was on PRN psychotropic medication (Lorazepam). He explained that psychotropic PRN medications required a stop date, and the resident needed to be reviewed by the physician before the medication could be ordered again. The Physician had to provide a rationale for the extended time period and the duration of the PRN order. He indicated the reports were sent to the Administrator and DON. The Consultant Pharmacist stated that, for the past couple of months, turnover among DONs and Administrators disrupted the process. He indicated that when he did not receive a response to his recommendation reports, he notified the DON. However, before he could follow up, the DON left the facility, and he did not receive any response. During an interview on 12/17/25 at 12:02 PM, the interim DON stated that she had been in the position for one week and was unaware of the process as to how the pharmacy recommendation reports were handled. She indicated that the physician should review medication recommendations and either accept or decline them. During an interview on 12/17/25 at 10:00 AM, Physician #1 stated that he served as the Medical Director during October and November 2025. He indicated that he had not received any pharmacy recommendation reports for any residents. Physician #1 stated that if the pharmacist or floor nurses had questions regarding medication treatment, they could call him or any of the three other physicians listed in the system. Any of the physicians could approve or decline recommendations. Physician #1 confirmed that the consultation reports for Resident #36 were not reviewed or signed by a physician, and he was unsure who had reviewed the pharmacist's recommendations prior to his tenure. During a telephone interview on 12/17/25 at 10:15 AM, the current Medical Director stated that he had accepted the position a few weeks earlier and was not familiar with the detailed process or communication method for irregularities identified during medication regimen reviews. He stated that he was unaware of the issue related to the pharmacist's recommendation reports not being reviewed and signed by a physician. During an interview on 12/17/25 at 2:08 PM, the interim Administrator stated that she had been hired a few weeks earlier. She further stated that she began receiving pharmacy recommendation letters starting November 2025 and she indicated that she reviewed these reports. The Administrator acknowledged that pharmacy medication recommendation reports should be reviewed by the physician, accepted or rejected, and signed. She stated that previously these documents were provided to the DON and the previous Administrator; however, due to management turnover, there was a break in this process. 2. Resident #4 was admitted to the facility on [DATE]. Her cumulative diagnoses included major depression and anxiety disorder. On 10/14/25, the physician ordered one (1) milligram (mg) of Lorazepam to be given as one tablet by mouth every 8 hours as needed (PRN) for anxiety and agitation. Lorazepam is a psychotropic and controlled substance medication. Resident #4's EMR indicated that the physician's PRN Lorazepam order (dated 10/14/25) remained active through the review date of 12/17/25. A review of Resident #4's Medication Administration Records (MARs) revealed that one (1) to two (2) doses of PRN Lorazepam were administered weekly from 10/14/25 through 12/17/25. The last documented dose was administered on 12/14/25. A review of the consultation report dated 11/12/25 indicated that the pharmacist recommended the physician address the PRN Lorazepam order, which lacked a stop date. The consultation report did not show that Resident #4's physician reviewed or responded to the pharmacist's recommendation. Pharmacy medication regimen review note dated 12/10/25 revealed no noted irregularities and/or recommendation. A telephone interview with the consultant pharmacist on 12/17/25 at 9:30 AM revealed that he completed monthly medication regimen reviews (MMRs) for all residents. He explained that if there were regulatory concerns related to medications, he emailed his recommendation reports to the facility's Director of Nursing (DON) and Administrator. The DON handled nursing recommendations and forwarded physician recommendations to the appropriate physician. The physician either approved or declined the recommendations, signed off on the report, and provided a rationale for any decline. The DON ensured that the physician reviewed the recommendations. The Consultant Pharmacist stated Resident #4 was on PRN psychotropic medication (Lorazepam). He explained that psychotropic PRN medications required a stop date, and the resident needed to be reviewed by the physician before the medication could be ordered again. The Physician had to provide a rationale for the extended time period and the duration of the PRN order. He indicated the November report was sent to the Administrator and DON. The Consultant Pharmacist stated that, for the past couple of months, turnover among DONs and administrators disrupted the process. He indicated that when he did not receive a response to his recommendation reports, he notified the DON. However, before he could follow up, the DON left the facility, and he did not receive any response. During an interview on 12/17/25 at 12:02 PM, the interim DON stated that she had been in the position for one week and was unaware of the process as to how the pharmacy recommendation reports were handled. She indicated that the physician should review medication recommendations and either accept or decline them. During an interview on 12/17/25 at 10:00 AM, Physician #1 stated that he served as the Medical Director during October and November 2025. He indicated that he had not received any pharmacy recommendation reports for any residents. Physician #1 stated that if the pharmacist or floor nurses had questions regarding medication treatment, they could call him or any of the three other physicians listed in the system. Any of the physicians could approve or decline recommendations. Physician #1 confirmed that the consultation reports for Resident #4 were not reviewed or signed by a physician. During a telephone interview on 12/17/25 at 10:15 AM, the current Medical Director stated that he had accepted the position a few weeks earlier and was not familiar with the detailed process or communication method for medication regimen reviews. He stated that he was unaware of the issue related to the pharmacist's recommendation reports not being reviewed and signed by a physician. During an interview on 12/17/25 at 2:08 PM, the interim Administrator stated that she had been hired a few weeks earlier. She further stated that she began receiving pharmacy recommendation letters only in November 2025. She indicated that she reviewed both November and December reports. The Administrator acknowledged that pharmacy medication recommendation reports should be reviewed by the physician, accepted or rejected, and signed. She stated that previously these documents were provided to the DON and the previous Administrator; however, due to management turnover, there was a break in this process.

Based on observations and staff interviews, the facility failed to maintain 2 of 2 double-door ovens and 1 of 1 grill clean and free of grease. The facility also failed to label and date leftover food in 1 of 1 reach-in refrigerator and 1 of 1 walk-in refrigerator. These practices had the potential to affect food served to residents.Findings included:a. The initial kitchen tour was conducted with the Dietary Aide #1 on 12/14/25 from 9:25 AM to 9:50 AM. Observations of double-door oven #1 and double-door oven #2 on 12/14/25 at 9:35 AM revealed black burnt food stains inside the ovens. The oven floors had a black layer of crust that appeared to be burnt food. The oven doors had dark brown oil stains. b. Observation of the grill on 12/14/25 at 9:40 AM revealed the top grill plate had a thick black layer of burnt grease and food, along with some freshly cooked, yellow-colored leftover food.During an interview with the Dietary Aide#1 on 12/14/25 at 9:40 AM, he indicated the grill had been used earlier that morning and the thick burnt layer was due to cooking food that morning. He stated the Dietary [NAME] had cooked chicken on the grill that morning. He acknowledged that the double-door ovens needed to be cleaned.c. Observation of the reach-in refrigerator on 12/14/25 at 9:45 AM revealed a large aluminum pan with thick white creamy-textured food. The cling wrap covered only three-quarters of the pan. There was no label or date on the pan. A white plastic container with a green lid, half-filled with light yellowish food of smooth-to-chunky texture, was also observed. There was no label or date on the container.During an interview with the Dietary Aide#1 on 12/14/25 at 9:45 AM, he indicated the thick white creamy-textured food was gravy used for the morning breakfast. He was unsure why it was not completely covered. Dietary Aide #1 stated the food in the white container was applesauce but was unsure when it was placed in the reach-in refrigerator.d. Observation of the walk-in refrigerator on 12/14/25 at 9:50 AM revealed a small aluminum pan with creamy white coleslaw. There was no label or date on the pan.During an interview with the Dietary Aide #1 on 12/14/25 at 9:50 AM, he indicated the coleslaw was to be used for the afternoon lunch meal and therefore was not labeled or dated.During an interview with the Dietary Director on 12/16/25 at 1:20 PM, she indicated the Dietary Cooks should clean the double-door ovens and grill daily after cooking. She stated she was unsure why they were not cleaned. The Dietary Director acknowledged she was aware of food not being labeled in the refrigerator. She stated all Dietary staff were responsible for labeling and dating leftover food placed in the refrigerator. She indicated any leftover or opened food placed in the refrigerators should be labeled and dated.During an interview with the Administrator on 12/17/25 at 8:58 AM, she stated all leftover food should be covered and labeled, even if it was to be used in the upcoming meal. She emphasized that all kitchen equipment should be cleaned after each use and that dietary staff should maintain a cleaning schedule.

Based on observations, record reviews, and staff interviews, the facility failed to post an updated daily nurse staffing sheet for residents and visitors on 1 of the 4 days during the survey period (12/14/25). The facility failed to provide upon demand the posted daily nurse staffing sheets for 10 of the 45 daily nurse staffing sheets reviewed (11/8/25, 11/13/25, 11/16/25, 11/17/25, 11/18/25, 11/20/25, 12/2/25, 12/3/25, 12/12/25, and 12/13/25). In addition, of the 35 daily nurse staffing sheets reviewed the facility failed to complete 3 daily nurse staffing sheets with information related to Nursing Assistants (11/2/25, 11/9/25, and 11/29/25). Findings included:a. On 12/14/25 (Sunday), during the initial tour of the facility at 9:05 AM daily nurse staffing sheet posted near the facility elevator was dated 12/11/25 (Thursday). The daily nurse staffing sheet was not updated to reflect the current date, census, and staffing information. The daily nurse staffing sheet posted dated 12/11/25 remained during another observation at 11:00 AM on the same day.During an interview on 12/15/25 at 2:30 PM, Nurse #1 stated the Scheduler prepared the daily nurse staffing sheets and placed them in a folder on Fridays at the nurses' station for nurses to update and post on the weekends. The nurse indicated she worked on 12/13/25 (Saturday), 12/14/25 (Sunday), and the day of the interview (12/15/25), and had not noticed the daily nurse staffing sheet posted near the elevator had not been updated since 12/11/25.During an interview with the admission Coordinator on 12/17/25 at 2:30 PM, she stated the Scheduler completed and posted the daily nurse staffing sheets. She explained when the Scheduler was unavailable, she tried to complete and post the daily nurse staffing sheets. The facility nurses usually ensured the daily nurse staffing sheet was current and updated to reflect the actual staff working in the facility.The Scheduler was unavailable for interview during the survey.During an interview on 12/17/25 at 1:57 PM, the Administrator stated that it was the Scheduler's responsibility to complete the daily nurse staffing sheet. On weekdays the Scheduler posted the daily nurse staffing sheet near the elevator, and nurses were responsible for posting it on weekends. The Administrator indicated the daily nurse staffing sheet was not updated because the Scheduler was unavailable. The Administrator stated that going forward, the medical records staff would be responsible for posting and updating the daily nurse staffing sheet so that it would remain accurate and clearly visible to residents and visitors.b. The daily nurse staffing sheets for the period of 11/1/25 to 12/15/25, a 45-day period, were reviewed with the admission Coordinator on 12/16/25. The following daily nurse staffing postings were missing or unavailable for review: 11/8/25, 11/13/25, 11/16/25, 11/17/25, 11/18/25, 11/20/25, 12/2/25, 12/3/25, 12/12/25, and 12/13/25. A total of 10 daily nurse staffing postings were unavailable for review.During an interview with the admission Coordinator on 12/16/25 at 2:30 PM, she stated the Scheduler completed the daily nurse staffing sheets and was responsible for maintaining the daily nurse staffing sheets. The admission Coordinator indicated she was unable to locate the missing daily nurse staffing sheets.The Scheduler was unavailable for an interview during the survey.During an interview on 12/17/25 at 1:57 PM, the Administrator explained the Scheduler filled out the daily nurse staffing sheets and provided these documents to the Director of Nursing. However, due to significant management turnover, the facility was unable to locate the missing daily nurse staffing sheets.c. Daily nurse staffing sheets for the period of 11/1/25 to 12/15/25 were reviewed with the admission Coordinator on 12/16/25. On 11/2/25, 11/9/25, and 11/29/25, the daily nurse staffing sheets were incomplete. Information regarding Nursing Assistants (NAs) was missing. On 11/2/25 and 11/9/25, the evening shift (3:00 PM to 11:00 PM) NA information and NA hours were missing. On 11/29/25, the day shift (7:00 AM to 3:00 PM) NA information and NA hours were missing.During an interview with the admission Coordinator on 12/16/25 at 2:30 PM, she stated the Scheduler completed the daily nurse staffing sheets and was responsible for ensuring accuracy. The admission Coordinator indicated the Scheduler had been unavailable for the past couple of days, and she had started assisting with staff scheduling and daily nurse staffing sheets.The Scheduler was unavailable for an interview during the survey.During an interview on 12/17/25 at 1:57 PM, the Administrator indicated the Scheduler was responsible to complete the daily nurse staffing sheets accurately to reflect the daily census and the actual staff working on the floor.

Based on observations, record review, and staff, Family Member, and Physician Assistant interviews, the facility failed to provide care in a safe manner when a resident rolled off the raised bed while incontinence care was being provided. The resident had a history of stroke with residual left side weakness. Nurse Aide #1 turned the resident away from her onto her left side with the resident holding the upper side rail with her right hand. While care was being provided Resident #1 stated she could not hold on anymore and rolled out of the bed landing on her knees and immediately complained of pain in her knees, back and legs. Resident #1 was transferred to the local hospital by emergency medical services (EMS) for evaluation and a CT scan (computed tomography scan) confirmed distal right femur (thigh bone just above the knee joint) fracture. It was determined that the resident required a higher level of care and she was transferred to a local trauma center for further evaluation and treatment. CT scans of the lower extremities revealed an oblique fracture (broken at an angle) on the right and left distal femur and left lateral tibial fracture (break in the upper part of the shin bone that forms the lower part of the knee joint). Resident #1 had a surgical procedure used to repair severe fractures by realigning broken bones and securing them with metal hardware of bilateral femur fractures and the left tibial plateau fracture (flat top part of the shin bone). At discharge the resident required acetaminophen 975 milligrams (mg) three times a day, oxycodone (opioid analgesic) 7.5-10 mg every 4 hours as needed and gabapentin 300 mg at bedtime for pain relief. An interview with a Family Member revealed more than two months after the fall and surgical interventions Resident #1 remained in severe pain, her mobility had decreased with physical movements, and her cognition continued to decline. The occurred for 1 of 3 residents reviewed for accidents (Resident #1). Immediate jeopardy began on 7/28/25 when Resident #1 rolled out of the bed onto her knees while Nurse Aide #1 was providing care and resulted in severe fractures. Immediate jeopardy was removed on 11/15/25 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of a D which is no actual harm with potential for more than harm that is, not immediate jeopardy to ensure staff education and monitoring systems put in place are effective.Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses included right middle cerebral artery stroke with residual left side weakness, atrial fibrillation and diabetes.Resident #1's quarterly Minimum Data Set, dated [DATE] indicated moderately impaired cognition. She required extensive assistance with transfers and locomotion and one person assistance with activities of daily living and mechanical lift for transfer. Resident #1 was dependent upon staff for bed mobility. She did not have any falls in the past 6 months or since admission. She required as needed pain medication for frequent pain. Resident #1's weight was 135.Review of the Medication Administration Record (MAR) revealed ticagrelor (an antiplatelet medication used to prevent blood clots) 90 milligrams twice a day was started on 5/16/22 for cerebral vascular accident. A focused area of the care plan dated 4/25/25 revealed Resident #1 was at risk for falls related to cerebral vascular accident. The goal included Resident #1 would be free of falls. Interventions included the staff would anticipate and meet the resident needs, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Physical therapy would evaluate and treat as ordered or as needed. Resident #1 needed a safe environment with (even floors, free from spills, and/or clutter), the bed in lower position at night and items within reach. The resident had an activity of daily living self-care deficit related to cerebral vascular accident. The goal was resident would maintain current level of function in daily care needs. Intervention included the resident will have 1/4 side rails up as per physician orders for safety during care provision and to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition as necessary to avoid injury. The resident required staff assistance to turn and reposition. The resident required 1-2-person assistance with bathing/showering and the use of a mechanical lift for transfers.A written statement from Nurse Aide #1 dated 7/29/25 indicated nothing had been reported as change in condition regarding the resident to Nurse Aide #1. Resident #1 was her normal self, alert during resident care. Nurse Aide #1 described the incident as she was changing the resident and her sheets, standing on the right side of hospital type bed next to the window. She had the sheet rolled under resident and was placing brief, Resident #1 was holding onto top upper bed rail and said, I can't hold on. Resident #1 turned loose and rolled off bed onto her knees. Nurse Aide #1 said she helped move the residents' legs and laid her down, placed pillow under her head and went to get help. Nurse Aide #2 was across the hall and immediately responded to help. Nurse #1 was notified and responded. Care and comfort provided until emergency medical service arrived to transport resident to the emergency department. A telephone interview was conducted on 10/30/25 at 9:45 AM with Nurse Aide (NA) #1 who performed incontinence care and changed Resident #1's bed linens on 7/28/25. Nurse Aide #1 stated she had worked with Resident #1 numerous times, and she was a one-person assist for activities of daily living. She indicated the resident was able to hold onto the side rail most days without any problems with her right hand. She reported the two top rails were up and the two bottom rails were down. NA #1 indicated she was standing on the right side of the bed near the window in the center of the bed performing incontinence care and changing the bed linens as the resident was holding the top left side rail with her right hand. Resident #1 was facing away from NA #1. Resident #1 stated she could not hold on any longer and she let go of the rail and her feet hit the floor and the resident rolled and fell forward on her knees and ankles. NA #1 stated the bed was not at full height capacity, it was at her waist level when the resident fell. She reported the resident fell on her knees toward the foot of the bed and did not hit her head on the bed or the floor. NA #1 further stated when the resident fell on her knees and ankles the resident complained of pain in her knees, back and legs, so she repositioned the resident onto her back on the floor and placed a pillow under her head until she could get help. She reported she had called out for help, and another nurse aide came to help until she could get the nurse on the floor to come to the room. The assigned nurse was not available, so she got Nurse #1 to come assess the resident. NA #1 stated that the Administrator and another person asked her to perform a return demonstration of the events. NA #1 stated she demonstrated what she did and the position of the resident while she performed the care and where and how the resident fell. NA#1 did not indicate there was an issue with how she performed the care after the return demonstration with the Administrator.A written statement from Nurse Aide #2 dated 7/29/25 indicated Nurse Aide #1 called out for help and said she fell on her knees. When I came in the room Resident#1's feet were towards head of bed and head towards foot with pillow under her head. Resident #1 complained of pain and asked me to move her leg and that her foot was hurting. I explained I couldn't move her, but EMS was on the way. The response from EMS was about 15 minutes. Nurse #1 was in the room with Resident #1 until EMS arrived.Nurse Aide #2 was called on 10/29/25 at 2:24 PM and 10/30/25 at 11:13 AM and was not available for interview.A written statement from Nurse #1 dated 7/29/25 indicated Nurse #1 responded to the request for help in Resident #1's room. Nurse #1's assessment of Resident #1 revealed she was lying on floor with her right foot turned out complaining of foot and back pain. Resident#1 was not moved from the floor. The physician was notified and gave an order to send the resident to the emergency department for evaluation. Emergency Medical Services (EMS) was called and transported the resident to the emergency department (ED). Resident #1's spouse was notified of the incident and the resident being transported by EMS to local emergency department.An interview conducted on 10/30/25 at 9:15 AM with Nurse #1 revealed she responded to Resident #1's room on 7/28/25 at the request of the NA #1 who stated the resident rolled off the bed. Nurse #1 stated when she entered the room Resident #1 was lying on the floor at the foot of the bed and her right foot was rotated outward in a slightly twisted manner. The two top rails were up, and the bottom rails were down on both sides of the bed. Based on her observation of Resident #1's foot and leg position and the residents' report of pain on several parts of the body, she made the clinical decision to contact the physician for transfer for further evaluation. She asked the resident who was alert what happened, and the resident only said she fell out of bed. She stated NA #1 said she was providing incontinence care and changing the resident's bed linens when the resident rolled out of bed onto the floor hitting her knees. Nurse #1 stated she asked NA #1 to show her how Resident #1 fell out of bed and NA #1 stated she was behind the resident on the right side of the bed near the window toward the middle of the bed providing incontinence care and changing the sheets. Resident #1 was positioned on her left side on her hip and was holding onto the side rail when the resident stated she could not hold on and let go of the side and fell on her knees. NA #1 called for help and Nurse Aide #2 was in the room until she (Nurse #1) came to do her assessment. Resident #1 reported pain in her back, leg and ankle. Nurse #1 indicated she did not ask NA #1 how high she had the bed when providing care to Resident #1 and did not check the bed position at the time of the assessment since the resident was already on the floor. She stated the resident remained on the floor with staff present until EMS arrived. The physician and resident representative were notified immediately, and orders were given for transfer to emergency department for further evaluation.The facility incident report dated 7/28/25 at 2:30 PM completed by Nurse #1 revealed Nurse Aide #1 called Nurse #1 to the room and found Resident #1 on the floor on her back. Range of motion was performed and Resident#1's right foot was noted to be rotated outward. Resident #1 complained of pain to the right foot and lower back. The physician was made aware of the finding and gave an order for the resident to be transferred to the emergency department for evaluation. The resident representative was made aware of Resident #1's condition and transfer to the emergency department. Nurse Aide #1 stated she had Resident #1 turned on her side when she was changing her and she rolled out of bed. Resident #1 stated she was turned on her side when Nurse Aide #1 was changing her, and she rolled off bed.The Emergency Medical Service (EMS) report dated 7/28/25 revealed EMS responded at 2:43 PM, the chief complaint was Resident #1 had injuries/pain/fall, injury to knee, acute pain due to trauma. Upon arrival the providers were directed to the room where resident was found lying on the floor next to her hospital bed. Staff reported they were assisting resident to a standing position when she lost her balance, falling to her knee and then to the floor. Staff denied resident losing consciousness prior to fall. Resident was lifted to the stretcher, with pain in her right hip, thigh, knee and ankle area. Resident #1 denied losing consciousness or getting dizzy prior to or after fall. Resident was lifted with draw sheet stabilizing her hip area. Resident #1 was given 5.5 milligrams of morphine intramuscular (IM) for pain management. Nasal capnography (is a method of monitoring the concentration or partial pressure of carbon dioxide) placed for monitoring of Resident#1's breathing and respiratory status. The local Emergency Department (ED) that was connected to the skilled nursing facility provider note dated 7/28/25 read in part: Resident #1 was seen for right leg pain after falling from her bed. There was no report indicating Resident #1 hit her head or loss of consciousness. The physical exam revealed there was shortening of the right lower extremity concerning for a femur fracture. A CT scan of the lower extremity confirmed a distal right femur fracture. Resident #1 was placed in a knee immobilizer splint and was given morphine for pain. Resident #1 had an abnormally high number of white blood cells (leukocytosis) noted on blood work. The case was discussed with Resident #1 and admitting team of the trauma center. Resident #1 was transferred for further evaluation and higher level of care. An interview was conducted on 10/29/25 at 1:00 PM with the local emergency room Physician Assistant (PA) who initially saw resident in the local emergency room. He stated Resident #1 was alert enough to state that she had pain on the right side of her body to include the knee, hip and leg. The Physician Assistant further stated the resident did not report loss of consciousness or hitting her head and the fall occurred while staff were changing her. He reported that based on Resident #1's level of reported pain, several CT scans were done of the body, and a fracture of the right distal femur was found. He indicated the review of the CT scan documented soft tissue was unremarkable with an oblique fracture (bone is broken at an angle) of the medial aspect of the distal femur (inner aspect of the femur near the knee joint) involving the medial epicondyle (bony prominence located on the lower portion of the femur). There were no significant degenerative changes in the joints. The PA stated based on the presentation of the resident at the time of admission, the focus was on the identified pain, the fracture area and providing stabilization interventions until the resident could be transferred to the trauma hospital for further orthopedic evaluation and treatment. The PA indicated he was unable to provide a definitive cause of the fractures due to age related changes in bone density and weakening of the bones that could not be pinpointed therefore, further evaluation was necessary.The trauma center provider note dated 7/28/25 indicated Resident #1 was admitted from a local hospital following a fall from the bed with chief complaint of pain in her right hip, knee and ankle and leukocytosis. Primary diagnosis was a right distal femur fracture and left lateral tibial fracture after a mechanical fall. CT scan of the lower extremities revealed an oblique fracture (broken at an angle) on the right and left distal femur. On arrival at the trauma center Resident #1 was noted to be briefly hypotensive (low blood pressure) with an elevated white blood cell count (WBC) of 18.5 (the normal white blood cell count is 4 to 10). An elevated WBC can indicate an underlying health issue including infection.Operative note dated 7/29/25 revealed surgical procedures for Resident #1 who sustained bilateral distal femur fractures following a fall from bed. The left lower extremity distal femoral condyle (rounded end of the rounded part of the femur that forms the knee joint with the tibia and patella), right lower extremity of the medial distal fracture that extends anteriorly into (trochlea) the knee is the groove on the front of the thigh bone (femur) where the knee bends and strengthens. The fractures were indicated for operative fixation to prevent early degradation of joint surfaces leading to osteoarthritis as well as to improve limb length and alignment and to allow for earlier return to functional mobility. For this patient, who ambulates just for transfers, the facture (sic) is indicated for fixation to assist with pain control and healing. Discharge summary dated [DATE] from the trauma center revealed the admitting diagnoses were bilateral femur fractures and left lateral tibial fracture after mechanical fall. Resident #1 had a surgical procedure used to repair severe fractures by realigning broken bones and securing them with metal hardware of bilateral femur fractures and left tibial plateau fracture status post femur open reduction and internal fixation. Resident #1 was transferred from outside hospital for level 1 trauma after suffering a witnessed mechanical fall at her skilled nursing facility. Imaging showed multiple fractures in the lower extremities including left distal femur, lateral tibia plateau, and right medial femoral condylar. She was evaluated by orthopedic surgery, trauma surgery and palliative care. Family believed that surgery for pain management aligned with Resident #1's goals of care. She was taken for bilateral femur fixation. At discharge adequate pain control was achieved with Tylenol 975 milligrams three times a day, oxycodone (opioid analgesic) 7.5-10 milligrams every 4 hours as needed and gabapentin 300 milligrams hours of sleep. VTE (Venous thromboembolism) prophylaxis (strategies to prevent blood clots forming in the veins) with enoxaparin (heparin-like drug that prevents blood clots) 40 milligrams every day for 3 weeks.An interview was conducted on 10/29/25 at 2:33 PM with the Family Member who stated another family member received a call from the facility that Resident #1 fell out of bed while care was being provided and was transferred to the local hospital. The Family Member reported Resident #1 only had some mobility in her right arm and severe left side weakness due to a previous stroke. The Family Member reported that based on the facility report of the incident safety measures should have been in place to ensure residents do not roll out of bed during care. She indicated the facility was aware of Resident#1's left side weakness and the facility expected her to hold a position while care was being provided for an undetermined amount of time. She further stated different interventions should have been in place since Resident #1 had known left side weakness and would become weak at any point in time. She stated the family had not been provided with a full explanation of how high the bed really was or how far the resident was from the edge of the bed when the resident rolled out of the bed. She stated the situation could have been avoided if proper use of the side rails were in place while care was provided based on Resident #1's limited mobility. The Family Member stated that since the surgery Resident #1 remained in severe pain, her mobility had decreased with physical movements, and her cognition continued to decline since the incident. The Administrator did call and tell the family they would provide training on bed safety during care and there were no further details provided about the investigation.Summary of facility investigation completed by the former Administrator on 7/29/25 revealed Resident #1 was being provided care in her room by the nurse aide. The nurse aide stated that she had the resident on her side on the right of the bed changing the linen and preparing a brief to fit on the resident. The nurse aide stated the resident was holding on to the upper side rail and told her she could not hold her position and rolled further and slid off the bedside onto both her knees hitting the floor. Bed was positioned at height for the nurse aide to provide direct care. The nurse aide stated she went around the bed to the resident who voiced that her right leg hurt, and the nurse aide called out for help, then positioned the resident from her knees back to rest on her back, moving out the resident's legs and knees out from underneath the upper body. The nurse aide provided a pillow for the resident's head and then obtained assistance from the charge nurse and another nurse aide. The doctor was notified and provided an order for EMS to transfer to the acute hospital for further care. The family was notified by the charge nurse, and the acting DON was notified. The resident was transported by EMS to the local hospital emergency department. We performed an X-ray on Resident #1's right side of the body and it was noted that she had a fracture of the medial aspect of the distal femur. The resident was then transferred to trauma Hospital for further treatment. She is currently at the trauma Hospital in [NAME], NC for interventions on the fracture. The investigation concluded from the evidence gathered that this was an accidental occurrence. The facility will continue to manage the resident at trauma hospital. Care policies will be reviewed, and any education and training will be provided.A telephone interview was conducted on 10/30/25 at 8:33 AM, with the former Administrator who stated he received a report from nursing that Resident #1 had fallen out of bed 7/28/25. He stated upon receipt of the incident he and the interim Director of Nursing spoke with Nurse Aide #1 to get her statement and perform a return demonstration of the events of the fall. He stated the nurse aide demonstrated that she was on the right side of the bed closest to the window behind the resident performing incontinence care and changing linen, while the resident was holding onto the top left side rail. Resident #1 stated she could no longer hold onto the rail and rolled out of bed. He stated he was unable able to speak with the resident directly because the resident had already been transferred to the hospital. He indicated based on his investigation and interviews with the staff involved and the return demonstration by the Nurse Aide #1 the situation was an accident. He stated the events were reviewed, the facility management and legal team all agreed it was an accident. He further stated he did not suspend the staff since the fall was witnessed, however he did have a discussion with the Nurse Aide involved about resident safety during care, but no other in-service or training was conducted due to no staff development coordinator being available. An interview was conducted in conjunction with a record review on 10/29/25 at 11:00 AM with the current Administrator who stated the only available document for Resident #1's fall was the former Administrator summary of events. She was unable to locate any formal training provided to the Nurse Aide #1 or staff about resident safety, use of side rails during care or care policy updates to prevent accidents during care. She indicated the review of the file revealed the nurse aide continue to work her shift and the hospital management handled the remaining part of the investigation.An interview was conducted on 10/29/25 at 11:23 AM, with the Lead Nurse Chief Officer for the local hospital who was interim Director of Nursing at time of incident. She stated the assigned Nurse Aide #1, Nurse #1 and Nurse Aide #2 were interviewed in conjunction with the Administrator to gather details of the incident. She stated when she received the initial information it was reported that Nurse Aide #1 was providing Resident #1 incontinence care and changing the resident's linen when she fell out of the bed. Resident #1 who was a 1-person assist was holding onto the top left side rail when she rolled out bed after the resident released her hands from the rail and fell out of bed onto her knees. She further stated Nurse Aide #1 was asked to do a return demonstration of the events with the Administrator present. The DON stated she was not aware of the actual training done by the former Administrator following the incident.A return demonstration of events was done by the Interim Director of Nursing (DON) of her observation/investigation on 10/29/25 at 11:43 AM. She stated Nurse Aide #1 had shown her and the Administrator her position at bedside when the resident rolled forward out of bed. The Interim Director of Nursing demonstrated NA #1 was positioned at the top of the right side of bed behind the resident performing incontinence care and trying to change the soiled sheet at the same time and both top side rails were up. The two bottom side rails were down. Based on what the NA #1 reported the bed was waist high to the nurse aide. The DON stated she did not inquire about the full height of bed at the time of demonstration. NA #1 demonstrated she had rolled Resident #1 away from her onto her left side to hold onto the left side rail. NA #1 reported Resident #1 was on the left side of her body close to the edge of the bed when Resident #1 reported she could no longer hold the position, and the resident let go of the rail and rolled forward out of bed onto her legs/knees. The Interim Director of Nursing reported that NA #1 demonstrated that the resident fell on her knees which repositioned the resident's body resulting in the resident's legs facing the head of the bed and her head at the foot of the bed. NA #1 reported to her that the resident did not hit her head, but she had placed a pillow under the resident's head for support until she could get help. The resident did report pain in her legs and back per the aide. The Interim Director of Nursing did not indicate how Resident #1 was positioned in bed when NA #1 did the return demonstration.The Administrator was notified of Immediate Jeopardy on 11/10/25 at 9:46 AM. The facility provided the following credible allegation of immediate jeopardy removal:Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.On July 28, 2025, the resident cited rolled out of bed during incontinence care, resulting in a major injury. Staff failed to maintain appropriate positioning and supervision during care, including the use of side rails. The facility failed to provide care in a safe manner and placed resident at risk of falls and injuries.The fall incident was reviewed by the previous administrator and Interim director of nursing on 7/29/2025. Interviews were conducted with two certified nursing assistants and one registered nurse as responders to the incident. An assessment was completed with a look back period of 30 days prior to July 28, 2025. The results concluded that there were no other residents that were affected by the same deficient practice. An assessment was completed on 11/14/2025 by the Interim Director of nursing and the Interim Administrator. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete.Administration took the following actions to ensure other residents were not at risk or likely to suffer harm. On August 6, 2025, administration continued weekly quality oversight meetings discussing the needs of the unit including staffing needs, resources, education and training and quality issues. The new Interim Director of Nursing started on Extended Care Unit on August 11, 2025. An audit was completed by the Director of Nursing on August 13th, 2025, to review all 45 residents' mobility and transfer needs. Upon completion of the audit, it was determined that each resident had the correct amount of assistance on each care plan. The Interim Administrator of Extended Care Unit started on October 16th, 2025. By November 6th, 2025, all residents had an updated MDS completed, including functional abilities and goals. The Director of Nursing/ Nursing Designee provided targeted verbal and return demonstration education to licensed nursing and certified nursing assistants on proper positioning in bed including side rails and adjusting height of bed during care to ensure residents are safely aligned, supported, and protected from injury. Instruction reinforced correct techniques for turning, boosting, and positioning residents. Staff are expected to review the care plan and Kardex and to follow the specified staffing needs with transfers and mobility of the resident. On 11/10/2025 the Director of Nursing began education with all licensed nursing staff and certified nursing assistants. All staff were required to complete education prior to their next scheduled shift or be removed from the schedule until educated. The Director of Nursing was monitoring the list of everyone that was educated.On November 10, 2025, administration implemented a process change in baseline care plans. The responsibility for initiating the baseline care plan during the admission assessment has shifted from the MDS RN coordinator to the admitting licensed nurse. The baseline care plan includes interventions for safe positioning during care to prevent falls and injury. Administration updated the Extended Care Unit-specific new hire orientation process for certified nursing assistants and licensed nurses to include proper positioning in bed during care to ensure residents are safely aligned, supported, and protected from injury. Instruction will reinforce correct techniques for turning, boosting, and positioning residents. This education will be documented on the unit specific checklist and completed by the Director of Nursing/ Nursing Designee and implemented on 11/11/2025 for any new hires. The new hire orientation process was updated on 11/11/2025 by the administration team for certified nursing assistants and licensed nurses to include proper ergonomics, body mechanics, and safety precautions with lifting and moving residents. Education material was reviewed by the licensed physical therapist and education includes written materials. Administration implemented weekly risk meetings on 11/11/2025. These weekly meetings will involve detailed resident specific information that will be documented in the medical record as well as on paper. These meetings will include interdisciplinary team members who will discuss resident specific changes in condition, falls, weight loss, infections, and mobility needs. This new process will improve departmental communication and resident centered care. This action will include implementation of a weekly risk meeting form to be utilized by the notetaker. The immediate jeopardy removal date is November 15, 2025. An onsite validation of the immediate jeopardy removal plan was completed on 11/19/25. Interviews with nurses and nurse aides from different shifts revealed they were educated on proper body positioning and incontinent care by 11/13/25. Multiple nurses were interviewed, and the interviews revealed the nurses were educated about doing baseline care plans when a resident was admitted . The nurses revealed they had received the education regarding the baseline care plans by 11/13/25. Weekly risk meeting records, which started 11/11/25, were reviewed. Orientation materials to be used for nurses and nurse aides were reviewed and were found to include education related to proper positioning, repositioning, and body mechanics during care. There had been no new nurses or nurse aides trained through orientation since the implementation of the immediate jeopardy removal plan. Residents were observed positioned safely in bed. Resident repositioning was observed when two nurse aides were observed repositioning a resident in bed. The two nurse aides repositioned the resident utilizing safe technique and no risk to the resident was observed. The immediate jeopardy removal date of 11/15/25 was validated.

Based on record reviews and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 2 of the 33 days reviewed for staffing. The findings included: A review of the daily posted nursing staff forms, daily nursing staff assignment sheets, and staff clock-in sheets from 8/17/24 through 9/18/24 was conducted on 9/19/24. A. On 8/24/24 the daily staff posting indicated 1 RN working day shift (7 AM - 3PM). Daily posting also indicated 2 Licensed Practical Nurse (LPN) and 2 NA working night shift (11PM - 7 AM). Review of the nursing staff assignment sheet for 8/24/24 indicated the RN, Nurse #9, working from 7 AM - 7 PM. The RN, Nurse #9, was also assigned to work as a Nurse Aide from 11 PM to 7 AM. Review of the staff clock-in sheet revealed no RN working from 7 AM - 3 PM shift. Further review revealed there was no RN working for the period of 3 PM -11 PM. An RN, Nurse #9, had clocked in at 11:00 PM. There was only one NA clocked in at 11 PM. During an interview on 9/19/24 at 3:15 PM, Nurse #9 indicated she was a Registered Nurse and worked as an NA when needed. She indicated on 8/24/24 she had worked on the floor as an NA and not as an RN. She indicated her assignment was indicated in the assignment sheet. She stated she was not in the facility from 7 AM - 7 PM on 8/24/24. B. On 8/25/24 the daily staff posting indicated 1 RN working day shift (7 AM- 3 PM) and 2 LPNs working evening (3 PM - 11 PM) and night shift (11 PM- 7 AM). Review of the staff clock-in sheet revealed no RN working from 7 AM - 7 PM shift. Review of the nursing assignment sheet did not indicate an RN working the 7 AM -7 PM shift. During an interview on 9/19/24 at 3:44 PM, the scheduler indicated the facility did not have any agency Nurse aides. They however had contract with an agency for nurses. The scheduler stated on days when there was an NA call out and the slot was unable to be filled by another NA then a nurse was called into fill the slot. The scheduler indicated as there was a RN in the building, the regulations for RN for 8 hours a day was met, During an interview on 9/19/24 at 4:34 PM, the Administrator indicated the call out policy was for staff to call the management 2 hours prior to their shift. The scheduler ensures that the call out slots were filled by staff who were willing to work overtime or by another staff not on assignment that day. The Administrator further indicated the facility had no NAs who were from agency. They however had agency nurses working for them. The Administrator stated nurses (both Registered nurse and License Practical Nurse) were called to fill in assigned NA shifts when needed. These Nurses worked as NAs and helped with patient care. The Administrator further stated when there was only one RN in the building and was assigned NA duty, the RN was also responsible to complete her duties as both a Nurse and Nurse Aide. The Administrator stated the requirement for RN for 8 hours was met, when the RN was in the facility and was working a NA.

Based on observation and staff interviews, the facility failed to post the daily nurse staffing information for residents and visitors on 1 of the 4 days of the survey period. The facility also failed to update the daily staffing information to reflect actual staffing changes for 6 of 33 days reviewed for posted nurse staffing information. Finding included: 1. On 9/15/24 (Sunday) during the facility initial tour at 9:20 AM and for multiple observations throughout the day including 1:30 PM and 3 PM, the daily nurse staffing sheet posted near the facility elevator was dated 9/13/24 (Friday). The posting was not updated to reflect the current date, census, and staffing information. During an interview on 9/17/24 at 8:09 AM, the scheduler stated she was responsible for posting the daily staff posting during the weekdays. The scheduler stated she completed the staffing form for the weekend and left the posting sheet in a folder near the nurse's station. She explained the weekend nurses were responsible for posting and updating the daily staffing sheets on the weekend. During an interview on 9/17/24 at 9:49 AM, the Minimum Data Set (MDS) Nurse stated she was the nurse working on 9/15/24. She indicated all nurses over the weekend were responsible for ensuring the staff posting was updated near the elevator. The MDS Nurse stated she forgot to look at the posting and post an updated staff posting. During an interview on 9/17/24 at 1:59 PM, Nurse #3 stated she was hired 3 weeks ago and worked on 9/15/24. She added she was not aware that as a weekend nurse she was responsible for changing the staff posting over the weekend. During an interview on 9/19/24 at 1:14 PM, Nurse #1 stated she was the charge nurse over the weekend of 9/14/24 and 9/15/24. She added she was not aware she was responsible for changing the staff posting over the weekend. 2. Review of the daily nursing staff postings from 8/17/24 through 9/18/24 and staff clock in sheets for the same period was conducted on 9/19/24. The daily posted staffing indicated the facility did not update the posting to reflect staffing changes for the following: - On 8/24/24 the daily staff posting indicated 1 Registered Nurse (RN) and 3 Licensed practical Nurses (LPN) for day shift (7 AM-3 PM). Review of the staff clock in sheets revealed no RN and 2 LPNs were working for day shift. - On 8/25/24 the daily staff posting indicated 1 RN and 3 LPNs for day shift. Night shift (11 PM - 7 AM) indicated 4 Nurse Aides (NA). Review of the staff clock in sheets revealed no RN and 2 LPNs working for day shift. There were only 2 NAs working for the night shift. - On 8/30/24 the daily staff posting indicated 4 NAs working the evening shift (3PM - 11PM). Review of the staff clock in sheet revealed only 3 NAs working. - On 8/31/24 the staff posting indicated 2 RNs working the day shift. Review of the staff clock in sheet revealed only 1 RN working for the day shift. - On 9/1/24 the daily staff posting indicated 4 NAs for day shift, 5 NAs for evening shift and 3 NAs for night shift. Review of the staff clock in sheets revealed 3 NAs working for both day and evening shift. The night shift had only 2 NAs working. - On 9/14/24, the daily staff posting indicated 2 LPNs working the day shift. Review of the staff clock-in sheets revealed only 1 LPN working for the day shift. During an interview on 9/19/24 at 3:44 PM, the scheduler stated the staff schedule was made a month ahead. If any staff had a call out, then the staff posting needed to be updated. She indicated if she was in the facility, she would try to make the changes. During an interview on 9/19/24 at 5:00 PM, the Administrator stated posting should be checked by the charge nurse, scheduler or MDS clerk were responsible for oversight for posted during the weekday. The charge nurse was responsible over the weekend for ensuring that the daily nurse staffing sheet was accurately and was posted daily The Administrator stated the daily staffing sheet should be updated by the scheduler or the charge nurse to reflect the accurate staff working in the facility.

Based on record review, observations and staff interviews, the facility failed to remove an expired multi-dose vial of insulin for 1 of 3 medication administration carts, failed to date opened multi-dose vials of insulin medication for 2 of 3 medication administration carts, and discard loose pills in the medication cart drawer for 2 of 3 medication administration carts (rehabilitation hall, short and long halls). Findings Included: 1a. On 9/15/24 at 9:15 AM, an observation of the medication administration Rehabilitation Hall cart with Nurse #1 revealed one opened and undated multi-dose vial of Insulin Glargine. A review of the manufacturer's literature indicated to discard Glargine multi-dose vial 28 days after opening. 9/15/24 at 9:40 AM, during an interview, Nurse #1 indicated that the nurses, who worked on the medication carts, were responsible to discard expired multi-dose vials. The nurse stated that she had not checked the date of opening on insulin vials in her medication administration cart at the beginning of her shift. The nurse did not administer expired insulin this shift. b. 9/15/24 at 9:40 AM, an observation of the Long Hall medication administration cart with Nurse #2 revealed one, opened undated, half-empty multi-dose vial of Novolog insulin, one expired Basaglar Kwik Pen Insulin, opened on 8/15/24, one expired Humalog Pen (insulin), opened on 8/3/24, and one expired Insulin Aspart Flex pen, opened on 9/1/24. A review of the manufacturer's literature indicated to discard the insulin multi-dose vial 28 days after opening. On 9/15/24 at 9:40 AM, during an interview, Nurse #2 indicated that the nurses, who worked on the medication carts, were responsible to discard expired multi-dose vials. The nurse stated that she had not checked the date of opening on insulin vials in her medication administration cart at the beginning of her shift. The nurse did not administer expired insulin this shift. On 9/16/24 at 9:30 AM, during an interview, the Director of Nursing (DON) indicated that all the nurses were responsible for putting the date of opening on multi-dose medication containers, checking all the medications in medication administration carts for expiration date and remove expired medications every shift. He expected that no expired items or loose pills be left in the medication carts. 2a. On 9/15/24 at 9:15 AM, an observation of the medication administration Rehabilitation Hall cart with Nurse #1 revealed in the second draw of the medication cart there were noted two white loose capsules and one pink round shape loose pills. On 9/15/24 at 9:20 AM, during an interview, Nurse #1 indicated that she could not identify what each of the pills were but stated the nurses were responsible for checking and cleaning their medication administration carts each shift. Nurse #1 did not clean the cart before her shift. b. On 9/15/24 at 9:25 AM, an observation of the medication administration Short Hall cart with Nurse #3 revealed in the first draw of the medication cart there was one white and three pink round shape loose pills. On 9/15/24 at 9:25 AM during an interview, Nurse #3 indicated that she could not identify what each of the pills were but stated the nurses were responsible for checking and cleaning their medication administration carts each shift. Nurse #3 did not clean the cart before her shift. On 9/16/24 at 9:30 AM, during an interview, the Director of Nursing (DON) expected that no loose pills be left in the medication carts. On 9/16/24 at 10:50 AM, during an interview, the Administrator indicated that all the nurses were responsible for putting the date of opening on multi-dose medication containers, checking all the medications in medication administration carts for expiration date and remove expired medications every shift. He expected that no expired items or loose pills be left in the medication carts.

Based on observations, staff interview and record review, the facility failed to provide an on-going activity program that met the individual interest and needs for 3 of 3 cognitively impaired residents reviewed for activities(Resident #22, Resident #27 and Resident #28). The findings included: 1.Resident #22 was admitted to the facility on [DATE] . The diagnoses included cognitive impairment and dementia. Resident #14 was coded on the annual Minimum Data Set(MDS) dated 8/24/24 as having cognition impairment and she needed assistance with activities. The MDS also coded Resident 22 's activity interest as very important to participate in favorite activities to include music, religious service and outside events. The resident was coded for total assistance with transfers and locomotion. The annual activity assessment dated [DATE] revealed Resident #'22s preference with interest in listening to music, religious services, and outside events. A focus area on the care plan dated 8/25/24 revealed Resident #22 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. The goal included Resident #22 would maintain involvement in cognitive stimulation, social activities as desired. The interventions included to ensure the activities Resident #22 attended was compatible with physical and mental capabilities; compatible with known interests and preferences; adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), compatible with individual needs and abilities and age appropriate. Invite the resident to scheduled activities. Introduce the resident to other residents in similar activities. The facility developed a list on 8/20/24 of residents who needed assistance to be transported to activities and Resident #22 was identified as person who needed assistance to activities. Record review revealed there were no activity notes available after the assessment 8/24/24 for Resident #22.There were no documented notes of participation in activities for Resident #22 prior to 8/24/24. The activity calendar on 9/15/24 offered the following activities at 10:00 AM coffee time,10:30AM at 11:00 AM gospel hymns, 1:00 PM-2:00 PM, room visits movies and 2:00 PM-4:00 PM activities with Ladystany. Staff were observed passing by the resident's room and did not stop to offer the resident assistance to participate in the scheduled activity. An observation was conducted on 9/15/24 at 9:58 AM, there was an activity calendar posted on the resident's bulletin board where resident could see the events of the day. Resident #22 was observed in bed staring at the wall. Resident#22 reported she does like church/gospel events. She reported the activity person does ask but nursing staff does not usually ask. She indicated no one asked her this morning to go anywhere. The scheduled activity for 9/15/24 at 10:00 AM coffee time, 10:30AM at 11:00 AM gospel hymns, Resident #22 was not up or dressed to participate in any of the scheduled activity of her interest. The activity calendar on 9/16/24 offered the following activities at 10:00 AM devotion, 11:00 AM bowling 11:30 AM snack activity and 2:00 PM-4:00 PM tic-tac-toe. Observations was conducted on 9/16/24 at 10:00 AM, the scheduled activity was devotion and 10:30 AM, Resident #22 was lying in bed, staring at the wall. The television was not on, and the resident reported she had attended some activities in the past but was not able to get herself up and ready for the activity. She stated she depended on staff. She reported staff don't get most residents up on the weekend. She reported she would have liked to participate in the devotion. Staff were observed in other resident rooms providing care. An interview was conducted on 9/16/24 at 1:45 PM, with the Activity Director who stated she developed a list of residents who needed staff assistance and transport to activities on 8/20/24 and provided the information to the management team. She indicated several residents who benefited and enjoyed activities were not ready or transported to activities when scheduled activities on their interest was being conducted. The Activity Director stated she would go room by room asking residents to participate and attend activities, but they would not be ready or get to the activity until nearly the end or not at all. She reported the concern was discussed in the management meetings and the plan was for all staff to ask residents if they wanted to participate and attend activities. The nursing team was in-serviced in August to get the identified resident up for activities and transport them to activities. She further stated was unable to escort all the residents, resulting in the identified residents not participating in activities. She further stated she was unaware she needed to document resident participation in the resident record. The Activity Director stated she only kept resident attendance and primarily the same residents attend the activities. She confirmed after review of the record there had been no documented activities notes since 2022 of resident participation in activities. Observation on 9/16/24 at 2:00 PM, tic -tac-toe in progress: Observation and interview were conducted and revealed Resident #22 remained in bed watching television. Resident #22 stated she would like to participate in activities, but staff did not get her out of bed, and she would have loved to see what was going on. An interview was conducted on 9/17/24 at 4:42 PM, with the Administrator who stated the nurse aides were responsible for asking resident daily if they wanted to get up and participate in facility activities. He reported there was a list of residents identified based on the quality improvement of residents who needed assistance with transport to activities. The identified residents included the residents who would participate in activities either morning or the afternoon scheduled activities. The Nurse Aides and Nursing should be asking all residents and assisting residents to the desire activities. The Nurses would document in the record the resident refusal to participate in activities. An interview was conducted on 9/18/24 at 8:40 AM, with the Staff Development Coordinator who stated all staff were in-serviced on 8/8/24 regarding the quality improvement plan to ensure staff were getting the identified residents who needed assistance with transport to activities up for scheduled activities. Staff were informed to notify the nurse and activity director when a resident refused to get up for an activity and document in the resident record. An interview was conducted on 9/19/24 at 9:43 AM, with Nurse #1 who stated she worked the weekend and during the week stated and she did not receive a report from any of the aides that any resident on the activity list refused to participate in activities. She indicated the training consisted of aides reporting to nursing when a resident refused to get up or participate in activities and she would document in the record the resident refused activities. Staff were expected to assist and transport resident to activities. She indicated nursing would attempt to encourage the resident to participation. An interview was conducted on 9/18/24at 10:00 AM, the Nurse Aide#1 who was assigned to Resident #22 stated everyone was responsible for asking residents if they wanted to get up and participate in activities. She reported when she worked on 9/15/24 she did not report to nursing that any of the resident refused activities. An interview was conducted on 9/19/24 at 9:43 AM, the Director of Nursing stated the staff should be encouraging/offering and assisting residents to participate in their preferred activities of interest daily. The Nurse Aide should notify nursing and the Activity Director of any resident who refused activities.Nursing should be documenting in the resident chart when a resident refused participation in activities. An interview was conducted on 9/19/24 at 1:00 PM, with the Social Worker who stated the resident was identified in the quality improvement program as one of the residents who needed assistance to activities. Several meetings and discussions have been held with nursing and management staff about getting resident up and ready for activities and providing transport to the activities, however the nurses and aides continue to not assist residents. Nurse Aides and Nursing staff have received an in-service in August about assisting residents to activities and reporting directly to nurse when the residents on the identified list refused to get up for activities. Nursing would encourage residents to participate in activities and document in the resident record, however, there had been no consistent follow-up the quality improvement plan. 2. Resident #27 was admitted to the facility on [DATE] . The diagnoses included cognitive impairment and dementia. Resident #27 was coded on the Minimum Data Set(MDS) dated [DATE] as having cognition impairment and she needed assistance with activities. The MDS also coded Resident #27 's activity interest as very important to participate in favorite activities to include music and news and current events. The resident was coded for total assistance with transfers and locomotion. The annual activity assessment dated [DATE] revealed Resident #'27s preference with interest in listening to music, news, current events bingo, animals, religious events and outside activities. A focus area on the care plan dated revealed Resident #27 had little, or no activity involvement related to physical limitations and depression. The goal included Resident #27 would express satisfaction with type of activities and level of activity involvement when asked. The interventions included invite/encourage the resident's family members to attend activities with resident to support participation. The facility developed a list on 8/20/24 of residents who needed assistance to be transported to activities and Resident #27 was identified as person who needed assistance to activities. Record review revealed there were no activity notes available after the assessment 5/10/24 for Resident #27. There were no documented notes of participation in activities for Resident #27 prior to 5/10/24. The activity calendar on 9/15/24 offered the following activities at 10:00 AM coffee time, 10:30AM at 11:00 AM gospel hymns, 1:00 PM-2:00 PM, room visits movies and 2:00 PM-4 PM activities with Ladystany. Staff were observed passing by the resident's room and did not stop to offer the resident assistance to participate in the scheduled activity. An observation was conducted on the hall at 9:55 AM-10:00 AM at 9/15/24 of the Nurse Aide#1 assigned to Resident #27. The Nurse Aide #1 stated the Aides should offer the resident the opportunity to get up and go to the activities of the day and assist with transport to the activity. The Nurse Aide #1 stated if the nurse aides were providing care, they were unable to take residents to activities at the start of the activities and maybe only able to take the residents toward the end of the activity. The Nurse Aide#1 stated she would let the nurse know when a resident refused activities. Nurse Aide#1 did not state why she did not offer the resident assistance to get up for activities. An observation was conducted on 9/15/24 at 11:30 AM, Resident #27 was in bed she stated she does like to go to activities. She reported on Sunday afternoons her husband and son visits, so going in the morning was fine unless she did not feel well. She reported on the weekends, no one really asks, and she was no sure if activities were happening. She pointed to the calendar on the wall and stated she had not been asked to go to anything in the morning. The activity calendar on 9/16/24 offered the following activities at 10:00 AM devotion, 11:00 AM bowling 11:30 snack activity and 2:00 PM -4 PM tic-tac-toe. An observation was conducted on 9/16/24 at 10:30 AM the scheduled activity was devotion; Resident #27 was in her room and staff were observed passing by the resident's room and did not stop to offer the resident assistance to participate in the scheduled activity. Resident #27 was observed in bed humming some church songs in her room. She stated she really loved church services and music and food parties the facility had down in the activity room. She indicated no one came to and get her out of bed anymore for activities. She stated she could not take herself to activities without assistance so just ended up hanging out in bed. Resident #27 further stated she would have liked to go to the devotion activities, but no one asked her if she wanted to get up for activities. Nurse Aide #9 who was assigned to Resident #27 stated she was working with another resident and could not assist with taking resident to the activity. She indicated all residents should be asked if they wanted to participate in activities. She reported she was aware of the list of residents that needed assistance, however, due to care responsibilities she was unable to get residents up early enough prior to the activities. She does her best to get individuals to the remaining activities. An interview was conducted on 9/16/24 at 1:45 PM, with the Activity Director who stated she developed a list of residents who needed staff assistance and transport to activities on 8/20/24 and provided the information to the management team. She indicated several residents who benefited and enjoyed activities were not ready or transported to activities when scheduled activities on their interest was being conducted. The Activity Director stated she would go room by room asking residents to participate and attend activities, but they would not be ready or get to the activity until nearly the end or not at all. She reported the concern was discussed in the management meetings and the plan was for all staff to ask residents if they wanted to participate and attend activities. The nursing team was in-serviced in August to get the identified resident up for activities and transport them to activities. She further stated was unable to escort all the residents, resulting in the identified residents not participating in activities. She further stated she was unaware she needed to document resident participation in the resident record. The Activity Director stated she only kept resident attendance and primarily the same residents attend the activities. She confirmed after review of the record there had been no documented activities notes since 2022 of resident participation in activities. The activity calendar on 9/17/24 offered the following activities at 10:00 AM pet therapy, 10:30 AM perfection , 11:00AM coffee activity and 2:00 PM-4:00 PM bowling. An interview was conducted on 9/17/24 at 1:46 PM, the scheduled activity was bowling at 2:00 PM. Resident #27 reported staff did not come and ask her if she wanted to participate in activities. She reported she enjoyed the bingo, music. There was an overhead announcement but of the activity, but no staff came to the room to ask if she wanted to get up and go to the activity. 3. Resident #28 was admitted to the facility on [DATE] . The diagnoses included cognitive impairment and dementia. Resident # 28 was coded on the admission Minimum Data Set(MDS) dated [DATE] as having cognition impairment and she needed assistance with activities. The MDS also coded Resident#28 's activity interest as very important to participate in favorite activities to include music, pets group activities, religious services and outside events. The resident was coded for total assistance with transfers and locomotion. The activity assessment dated [DATE] revealed Resident #'28s preference with interest include music, pets group activities, religious services and outside events. The resident was coded for total assistance with transfers and locomotion. The facility developed a list on 8/20/24 of residents who needed assistance to be transported to activities and Resident #28 was identified as person who needed assistance to activities. A focus area on the care plan dated 6/25/24 revealed Resident #28 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. The goal included Resident #28 would maintain involvement in cognitive stimulation, social activities as desired. The intervention included invite the resident to scheduled activities. Staff would provide Resident #28 with an activities calendar. Notify resident of any changes to the calendar of activities. Resident #28 needs assistance/escort to activity functions. Record review revealed there were no activity notes available after the7/11/24 assessment for Resident #28. There were no documented notes or participation records for Resident #28 prior to the 7/11/24. The activity calendar on 9/15/24 offered the following activities at 10:00 AM coffee time, 10:30AM at 11:00 AM gospel hymns, 1:00 PM-2:00 PM, room visits movies and 2:00 PM-4:00 PM activities with Ladystany. Staff were observed passing by the resident's room and did not stop to offer the resident assistance to participate in the scheduled activity. The activity calendar on 9/16/24 offered the following activities at 10:00 AM devotion, 11:00 AM bowling 11:30 AM snack activity and 2:00 PM-4 PM tic-tac-toe. An observation was conducted on 9/15/24 at 9:55 AM, Resident #28 was in her resident sitting up in bed. There was no television on, and the resident continued to ask what was going on in the hall area. She reported she liked to go to activities but had to wait for people to come get and get her up and take her down to the room. She indicated no one asked if she wanted to go to the activities. Resident #28 reported she liked to get up every day, enjoyed church music, table activities, bingo and food stuff. The resident was not asked to participate in the scheduled 10:00 AM coffee activity. The assigned Nurse Aide #13 was in another room, all other aides were in other rooms. Observation was conducted on 9/15/24 at 1:59 PM, Resident #28 resident was not in any activity, she was resident was in her room. She stated was not asked to be taken to any of the activities for the day. Resident #28 stated she did not know what was going on and would have like to go to activities, but no one got her out of bed. An observation was conducted on 9/16/24 at 10:30 AM, Resident #28 was in her room yelling out to get out of bed, the assigned Nurse Aide #9 was in another room. resident was not taken to the activity room until 11:30 AM. Nurse Aide #9 stated she was working with other residents and had not been able to get the resident up any early. She further stated the nurse aides should offer the resident the opportunity to get up and go to the activities of the day. The nurse aide stated if the nurse aides were providing care, they were unable to take residents to activities at the start of the activities and maybe only able to take the residents toward the end of the activity. She indicated the weekends were very difficult to get all residents to activities due to limited staff. An interview was conducted on 9/16/24 at 1:45 PM, with the Activity Director who stated she developed a list of residents who needed staff assistance and transport to activities on 8/20/24 and provided the information to the management team. She indicated several residents who benefited and enjoyed activities were not ready or transported to activities when scheduled activities on their interest was being conducted. The Activity Director stated she would go room by room asking residents to participate and attend activities, but they would not be ready or get to the activity until nearly the end or not at all. She reported the concern was discussed in the management meetings and the plan was for all staff to ask residents if they wanted to participate and attend activities. The nursing team was in-serviced in August to get the identified resident up for activities and transport them to activities. She further stated was unable to escort all the residents, resulting in the identified residents not participating in activities. She further stated she was unaware she needed to document resident participation in the resident record. The Activity Director stated she only kept resident attendance and primarily the same residents attend the activities. She confirmed after review of the record there had been no documented activities notes since 2022 of resident participation in activities. An interview was conducted on 9/17/24 at 4:42 PM, with the Administrator who stated the nurse aides were responsible for asking the resident if they wanted to get up and participate in facility activities. He reported there was a list of residents identified based on the quality improvement of residents who needed assistance with transport to activities. The identified residents included the residents who would participate in activities either morning or the afternoon scheduled activities. The Nurse Aides and Nursing should be asking all residents and assisting residents to the desire activities. The Nurses would document in the record the resident refusal to participate in activities. An interview was conducted on 9/18/24 at 8:40 AM, with the Staff Development Coordinator who all staff were in-serviced on 8/8/24 regarding the quality improvement plan to ensure staff were getting the identified residents who needed assistance with transport to activities up for scheduled activities. Staff were informed to notify the nurse and activity director when a resident refused to get up for an activity and document in the resident record. An interview was conducted on 9/19/24 at 9:30 AM, Nurse Aide #13 stated she had been assigned to Resident #28 the weekend and was unable to transport resident to the activity due to assisting other residents. The Nurse Aide #13 stated staff should offer the resident the opportunity to get up and go to the activities of the day. The nurse aide stated if the nurse aides were providing care, they were unable to take residents to activities at the start of the activities and maybe only able to take the residents toward the end of the activity. Nurse [NAME] #13 stated she did not report any residents who refused activities on the weekend due to being busy providing care. An interview was conducted on 9/19/24 at 9:43 AM, the Director of Nursing stated the staff should be encouraging/offering and assisting residents to participate in their preferred activities of interest daily. The Nurse Aide should notify nursing and the Activity Director of any resident who refused activities. Nursing should be documenting in the resident chart when a resident refused participation in activities. An interview was conducted on 9/19/24 at 1:00 PM, with the Social Worker who stated the resident was identified in the quality improvement program as one of the residents who needed assistance to activities. Several meetings and discussions have been held with nursing and management staff about getting resident up and ready for activities and providing transport to the activities, however the nurses and aides continue to not assist residents. Nurse Aides and Nursing staff have received an in-service in August about assisting residents to activities and reporting directly to nurse when the residents on the identified list refused to get up for activities. Nursing would encourage residents to participate in activities and document in the resident record, however, there had been no consistent follow-up the quality improvement plan.

Based on observation, staff interview and record review, the facility failed to provide fingernails and toenails care for 2 of 2 residents, dependent on staff for activities of daily living (ADL) care. (Resident # 37 and Resident #24) Findings included: 1. Resident #37 was admitted to the facility on [DATE] with diagnoses that included Parkinson disease. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as moderately cognitively impaired. The assessment indicated that Resident #37 was dependent on staff for Activities of Daily Living (ADL) including personal hygiene, toileting and showers/ bathe self. Review of the care plan dated 6/27/24 indicated the resident was care planned for ADL self-care performance deficit due to impaired balance, activity intolerance, and confusion. Interventions for bathing and showering included checking nail length, trimming and cleaning on bath day and as necessary. The resident was totally dependent on staff to provide bed bath and/or shower. The Skin monitoring: comprehensive Certified Nurse Aide (CNA) shower review for 9/12/24 and 9/16/24 were reviewed. On the form the question does the resident need his/her fingernails/toenails cut? Was marked as NO. Review of the ADL Tracking Documentation for August and September 2024 revealed bathing activity was marked on every Monday and Thursday of the week during the 3 PM- 11 PM shift. The resident was noted to be totally dependent on staff and needed one-person physical assistance. The documentation did not indicate if the resident received a bed bath or shower. During an observation and interview on 9/15/24 at 10:20 AM, Resident #37's fingernails on both her hands were observed to be about 1 to 1 and one fourth inch long from the nail bed. There was some light black deposit under the fingernails. The resident stated she preferred her fingernails trimmed, however there was on one who could trim her nails. During an interview on 9/16/24 at 10:33 AM, Resident #37 indicated she had asked a Nurse Aide (NA) to trim her nails in the morning. The NA had reported to her that her nails would be cleaned and trimmed at 2 PM that day. Resident indicated she wanted her nails cleaned and trimmed so she asked the NA who was assisting her with care that morning. During an observation on 9/17/24 at 8:25 AM, Resident #37 was observed propped up in her bed and turned to her left side. Observation revealed the resident's fingernails were not trimmed. Resident indicated no staff had come back to trim her nails on 9/16/24. On 9/17/24 at 8:38 AM, Nurse #5 was interviewed. Nurse #5 observed Resident #37's fingernails and indicated the resident's nails should have been trimmed. Nurse #5 stated when residents were provided a bed bath or shower, the assigned NA completed a skin and nails check. The NA should indicate on the shower sheets if the nails needed to be trimmed and/or if the nails were trimmed. Nurse stated if the resident was not diabetic then the NAs could trim their nails. However, if the resident was diabetic then the NA needed to inform the assigned nurse. Resident #37 was not diagnosed with diabetes mellitus and the NA should have trimmed her nails. Nurse#5 stated the resident received a completed bed bath the day prior (9/16/24) and should had her nails checked and trimmed. During an interview on 9/19/24 at 10:12 AM, NA #1 indicated she was assigned to Resident #37 and had offered a bed bath on 9/16/24. NA #1 stated the resident did not request her to trim her nails on the 9/16/24. NA indicated skin and nails check were completed during bed bath and/or shower. Nails were trimmed if needed. NA indicated she had not noticed the resident's fingernails and hence had not trimmed them. During an interview on 9/17/24 at 8:44 PM, the Director of Nursing (DON) stated the NAs were responsible to trim residents' finger and toenails when the residents were not diabetic residents. The DON further stated the NAs had to complete a full body check when bed bath or shower was offered. The DON observed Resident #37's fingernails and stated the assigned NAs should have trimmed her nails when a complete bed bath was offered. 2. Resident #24 was admitted to the facility on [DATE] with diagnoses that included secondary malignant neoplasm of the bone. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was assessed as severely cognitively impaired. The assessment indicated that the resident was dependent on staff for Activities of Daily living. A revised care plan dated 8/9/24 indicated Resident #24 was care planned for ADL care due to diagnoses of cancer, dementia and depression. Interventions included providing a sponge bath when a full bath or shower was not tolerated. Resident was totally dependent on staff for showers and bed bath. NAs to provide skin inspection daily with care. On 9/15/24 at 10:06 AM, during an observation, Resident #24's toes nails on both feet were observed to be one and a half inches beyond the nail bed. The pinky toe nails on both feet had toenails growing into the toe next to it. On 9/17/24 at 1:25 PM, during the observation of incontinence care, Resident #24's toenails were observed clean and approximately one and a half inches long, with deformities. The resident did not have signs of discomfort. During an interview on 9/19/24 at 10:12 AM, NA #1 indicated she was assigned to Resident #24. NA stated the resident received bath and showers from both facility and hospice staff. NA indicated she did provide the resident a bed bath and had not looked at or noticed the resident's toenails. During an interview on 9/17/24 at 8:38 AM, Nurse #5 stated the resident was under hospice care. Both facility staff and hospice staff provided care for the resident. Nurse #5 stated the hospice staff were responsible for trimming resident's nails. During a telephone interview on 9/19/24 at 8:23 AM, the hospice nurse stated the hospice NAs do not trim the resident's finger or toenails. It was the responsibility of facility nursing staff to provide nail care. During an interview on 9/17/24 at 8:44 PM, the Director of Nursing (DON) indicated the NAs were responsible to trim residents' finger and toenails when the residents were not diabetic residents. The DON further stated the NAs had to complete a full body check when bed bath or shower was offered. The DON stated the nursing staff should be checking and providing nail care to all residents as needed.

Based on record review, family and staff interviews, the facility failed to provide a written grievance summary for 1 of 1 residents (Residents #24) reviewed for grievances. Finding included: Resident #24 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident #24 was assessed as severely cognitively impaired. Review of the Grievance /Concern Form dated 6/24/24 indicated a concern that was reported by Resident #24's responsible party (RP) regarding bruising of the resident's left arm, left hand and right forearm. Action indicated was the management was notified, abuse investigation sheet completed, law enforcement was notified and the staff member in question was taken off of the schedule. The form indicated the grievance was under investigation. This was signed by Administrator indicating the grievance was received. There was no indication on the form that indicated the complainant, resident, or family was contacted to inquire if the grievance was resolved to their satisfaction. The grievance was not signed off as resolved. During an interview on 9/16/24 at 11:50 AM, Resident #24's RP indicated she had reported her concerns about the bruising on resident's arms to the Administrator and to the hospital management. The RP stated both the nursing home administration, and the hospital administration were in the same building and under same management. Resident #24's RP stated she had not been made aware as to how her allegation was investigated nor how it was resolved. She explained no written summary of the grievance investigation or resolution was provided to her. During an interview on 9/16/24 at 3:37 PM, the Social Worker (SW) indicated she was the grievance coordinator. When any grievance was received from any resident or family member by any staff, it was directed to the appropriate department for investigation and resolution. Once the grievance was investigated and a resolution was reached, it would be discussed in the morning team meeting with all nursing staff. The SW further indicated that she would notify the family about the resolution and that the resolution was to the satisfaction of the family/ resident. The resolved Grievance was placed in a folder and entered in the log. The Social Worker stated she was not aware of the grievance written on 6/24/24 from Resident #24's RP and hence not documented in the Grievance log. The SW stated the resident's RP concern was investigated as abuse investigation. Due to being investigated as abuse, the investigation was conducted by the Administrator. During an interview on 9/19/24 at 2:20 PM, the Administrator, stated he had spoken with the resident's RP regarding the abuse allegation 1-2 days after the grievance was received. The Administrator further stated the resident's RP was made aware that the abuse allegation was been investigated. The NA involved was suspended and would not be returning to the facility. The NA was an agency staff, and the agency was made aware about it. The Administrator stated he had not documented the resolution as it was an abuse investigation, nor did he record any information regarding his conversation with the family in the grievance form. The investigation findings were sent to the state. He further stated the family was aware of the outcome of the investigation. The family was made aware the allegation was unsubstantiated. The Administrator stated he did not provide them with any written documentation regarding the resolution. He indicated it was an abuse investigation and no findings were discussed with the family. With regards to the grievance given to the Hospital Quality Director, he indicated it was a different entity and unsure of the outcome.

Based on observations, residents and staff interviews, the facility failed to post the notice of location and make accessible the facility survey results for residents in a wheelchair. This was observed on 4 of 5 days of the survey. The findings included: During initial tour on 9/15/24 at 9: 10 AM, an observation was made of the survey results located in a small hall area near the eye wash station. On a large bulletin board was a black caddy with the survey book, which was not wheelchair accessible. The caddy was in the center of the bulletin board out of reach of residents in wheelchairs. There was no signage posted throughout the facility regarding the availability and location of the recent survey results. Multiple observations were conducted from 9/15/24 to 9/18/24. Observations were made on 9/15/24 at 9:58 AM, on 9/16/24 10:30 AM, on 9/17/24 10:00 AM and on 9/18/24 at 11:02 AM. Observations revealed there was no notice posted in the facility regarding the availability and location of the recent survey results. The location of the survey remained unreachable for residents in wheelchairs. During the Resident Council Members meeting on 9/18/24 at 11:02 AM, the resident council members who attended the meeting (Resident #28, Resident #25; Resident #21; Resident #10; Resident #22; Resident #18; Resident #44; Resident #20; and Resident #3) stated they had no knowledge of the location of the survey result notebook. The members of the group further stated they were unaware of any signage posted indicating the location of the results. An interview was conducted on 9/18/24 at 11:45 AM, with the Social Worker and the Activity Director, who both confirmed there was no visible posting that informed residents and families where the survey results were located. They both staff stated the survey book was originally located under the bulletin board where the master activity calendar was posted with a sign informing residents/family and visitors. The facility administrator moved the book to the current location and did not post any information of where the book could be found. The Social Worker further stated all the public postings should be accessible to everyone and the previous location was visible upon entry to the facility, however things had been moved out of resident, visitor/family view by the administrator. An interview was conducted on 9/18/24 at 11:56 AM, with the facility Administrator who confirmed the current location of the survey book was not accessible to the residents/families or visitors. He also confirmed there was no visible posting to inform residents/families or visitors of the location of the survey book.

Based on observations, staff interviews, and record review the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following a recertification and complaint survey on [DATE] in order to achieve and sustain compliance. This was for a recited deficiency on a recertification survey on [DATE]. The deficiency was in the area of medication storage and kitchen sanitary condition. The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program. The findings included: The tag was cross referenced to: F761: Based on observations and staff interviews, the facility failed to remove expired multi-dose vial of insulin, stored in 1 of 3 medication administration carts (200 hall); failed to discard several loose pills that were identified in the medication cart's draw for 1 of 3 medication administration carts (200 hall). During the previous recertification surveys on [DATE], the facility failed to lock an unattended medication administration cart for 2 of 3 carts reviewed for medication storage (Rehabilitation Hall cart and Long Hall cart) and failed to lock the controlled substances storage drawer on 1 of 3 carts (Rehabilitation Hall cart). F812: Based on observations and staff interviews, the facility failed to keep food service equipment clean, free from debris, grease buildup, and/or dried spills during two kitchen observations. This practice had the potential to affect food served to all residents. During the previous recertification surveys on [DATE], the facility failed to ensure the following kitchen equipment was clean: the stove, the oven, two compartment hot box and two compartment cold box. The facility failed to clean the cooler and discard rotten vegetables, expired juice, and unlabeled produce from 1 cooler. The facility failed to remove dented cans from use. On [DATE] at 6:20 PM, the Administrator indicated that all the citations would be reviewed, and a plan of correction would be put in place. The Administrator continued that the Quality Assistance and Assurance (QAA) committee met monthly, identified areas of concern, conducted the root cause analysis, created the plan of correction, and discussed the outcome. The Interdisciplinary Team will continue monitoring until the deficient area concerns will be resolved.

Based on observations and staff interviews, the facility failed to keep food service equipment clean, free from debris, grease buildup, and/or dried spills during two kitchen observations. This practice had the potential to affect food served to all residents. The findings included: During a kitchen tour on 8/20/23 at 9:50 AM, the following observations were made with the Dietary Manager: a. The 8- stove burners had heavy grease build-up on the stove burners, walls behind the stove, and front of the stove. There were substantial amounts of burnt foods, dried, encrusted, liquid and splatters throughout the stove area. The inside and outside of the combination stove and oven doors had grease buildup, dried foods, and liquid spills. b. The 4-compartment ovens had a heavy grease buildup, dried food, and liquids on the inside and outside. The grease buildup was encrusted on doors/shelves where food was being cooked. There was a dried grease buildup observed on the fronts of the ovens and on the walls on the inner walls of the oven or on the walls behind the oven. c. The fryer had dried brown/yellow liquid matter encrusted on edges inside and outside. The fryer had heavy grease and food build-up inside and outside, and food products behind the fryer. An interview was conducted on 8/20/23 at 9:50 AM. The Dietary Manager (DM) presented a checklist of the kitchen cleaning schedule. She stated staff were required to wipe down ovens, stove, and fryer daily after each meal and deep cleaned weekly. The DM further stated she was responsible for ensuring the kitchen staff kept the equipment clean and orderly. She added the kitchen equipment should be wiped down daily and cleaned weekly in accordance with the kitchen cleaning checklist. The DM confirmed the identified kitchen equipment had not been cleaned. Follow-up observation on 8/22/23 at 11:33 AM, was made of the identified kitchen equipment. The equipment remained the same as the initial tour on 8/20/23. Some areas have been worked on but not yet complete. An interview was conducted on 8/22/23 at 11:34 AM, the Cook stated there was a cleaning checklist. All staff were required to clean equipment in accordance with the clean checklist daily. The identified equipment had not been consistently cleaned therefore, there would be a buildup of grease. All staff were responsible for wiping down equipment after each use. An interview was conducted at 11:40 AM on 8/22/23, The Chief Cook stated the kitchen staff were required to wipe down kitchen equipment after each meal and deep cleaned weekly in accordance with the kitchen cleaning checklist. The Chief Cook stated he was responsible for ensuring the kitchen staff kept the equipment clean and orderly and to ensure the tasks were completed. He presented the last completed individual area cleaning schedule dated 8/14/23, which did not include the ovens, fryers, and stoves.

Based on record review, observations and staff interviews, the facility failed to remove an expired multi-dose vial of insulin and discard loose pills in the medication cart drawer for 2 of 3 medication administration carts (200 short hall and 200 long hall). Findings Included: 1. On 8/20/23 at 9:10 AM, an observation of the long hall medication administration cart on 200 hall with Nurse #2 revealed in the second draw of the medication cart there were noted one white loose capsule and two blue round shape loose pills. On 8/20/23 at 9:20 AM, during an interview, Nurse #2 indicated that she could not identify what each of the pills were but stated the nurses were responsible for checking and cleaning their medication administration carts each shift. Nurse #2 did not clean the cart before her shift. On 8/24/21 at 11:10 AM, during an interview, the Director of Nursing (DON) indicated that all the nurses were responsible for checking all the medications in medication administration carts for expiration date and remove expired medications every shift. She expected that no expired items or loose pills be left in the medication carts. 2. On 8/20/23 at 9:30 AM, an observation of the short hall medication administration cart on 200 hall with Nurse #3 revealed one, half-empty multi-dose vial of Novolog insulin, opened on 7/2/23. A review of the manufacturer's literature indicated to discard the insulin multi-dose vial 28 days after opening (7/30/23). On 8/20/23 at 9:35 AM, during an interview, Nurse #3 indicated that the nurses, who worked on the medication carts, were responsible to discard expired multi-dose vials. The nurse stated that she had not checked the date of opening on insulin vials in her medication administration cart at the beginning of her shift. The nurse did not administer expired insulin this shift. On 8/24/21 at 11:10 AM, during an interview, the Director of Nursing (DON) indicated that all the nurses were responsible for checking all the medications in medication administration carts for expiration date and remove expired medications every shift. She expected that no expired items or loose pills be left in the medication carts.

Based on observations, staff interview and record review, the facility failed to provide an on-going activity program that met the individual interests and needs to enhance the quality of life for 1 of 2 residents reviewed for activities (Resident #45). The findings included: Resident #45 was admitted to the facility on [DATE]. The diagnoses included cognitive and communication deficits. The annual Minimum Data Set (MDS) dated [DATE] coded Resident #45's cognition as moderately impaired. The resident's activity preferences indicated the following were very important: religious services, going outside for fresh air, listening to music, keeping up with the news and being around animals. He was also coded for total assistance with transfers and locomotion. The activity assessment completed by the former Activity Director, Activity Director #2, dated 4/5/23 revealed Resident #45's preference in group activities with interest in religious devotion, music, sports, bingo, community outings, pet therapy outdoor activities, current events, movies, and social events. On 8/23/23 at 10:00 AM a phone interview was attempted with the former activity director, Activity Director #2, who completed Resident #45's most recent activity assessment. She was unable to be reached. The care plan related to activities for Resident #45 dated 4/5/23 revealed conflicting information with the activity assessment of the same date (4/5/23). The care plan identified the problem as Resident #45 has little or no activity involvement related to disinterest, resident wishes not to participate. The goal included the resident would express satisfaction with type of activities and level of activity involvement when asked. The interventions included staff would explain to Resident #45 the importance of social interaction, leisure activity time. Encourage the residents' participation by talking about the activities allocated for the day. Remind the resident he may leave activities at any time and is not required to stay for entire activity. The resident prefers the following radio stations: Oldies and Gospel. The resident prefers the following TV channels: Westerns. A review of Resident #45's record from 4/5/23 through 8/19/23 revealed no evidence of the resident attending any activities. Review of the activity calendar for Sunday 8/20/23 revealed the only activity noted was independent activities. On Sunday, 8/20/23, Resident #45 was observed in bed in his room watching television during the following times: 9:00 AM, 10:30 AM, 1:00 PM, and 2:30 PM. Review of the activity calendar on 8/21/23 indicated the following activities were listed: 10:00 AM coffee hour, 11:00 AM gospel hymns, and 2:00 PM activity of choice. Observation was conducted of Resident #45 on 8/21/23 at 11:00 AM, the time that the activity of gospel hymns was scheduled. Resident #45 was in his room and staff were observed passing by the resident's room and did not stop to offer the resident assistance to participate in the scheduled activity. During an interview and observation on 8/21/23 at 11:10 AM, Resident #45 was observed in bed humming some church songs in his room. He stated he really loved church services and music and food parties the facility had down in the activity room. He indicated no one came to and get him out of bed anymore for activities. He stated he could not take himself to activities without assistance so just ended up hanging out in bed. Resident #45 further stated he just hummed his favorite songs. A telephone interview was conducted on 8/21/23 at 1:57 PM with Resident #45's responsible person. The responsible person stated she would like for the resident to participate in more activities and had been told by staff (no name or date was identified) when she called to check on Resident #45 that he participated in activities in the past. She explained that she had not seen him out of bed much lately during her visits in the past two months. She stated he may or may not want to participate but was not certain how often he was even asked. She further stated he loved church and food related things/activities. He liked to socialize with other people. Observation and interview were conducted on 8/21/23 at 2:30PM and revealed Resident #45 remained in bed watching television. Resident #45 stated he would like to participate in activities but staff did not get him out of bed and he would have loved to see what was going on. He indicated staff had not asked if he wanted to attend any activities today. The activity calendar on 8/22/23 indicated the following activities were listed: 10:00 AM sittercise (sitting exercise), 10:30 AM bible trivia, 11:00 AM reminisce and 3:00 PM bingo. Observations on 8/22/23 of Resident #45 were conducted during the timeframes of each of the following activities: 10:00 AM sittercise, 10:30 AM bible trivia, 11:00 AM reminisce and 3:00 PM bingo. Resident #45 was observed in bed during each of the activities. Staff were observed walking past the resident's room. An interview was conducted on 8/22/23 at 1:22PM, Nurse Aide #3 who was assigned to Resident #45. She stated she did not get the resident up for any activities on 8/22/23 because she was busy with other responsibilities. She added Nurse Aides were responsible for asking the residents if they wanted to attend activities and get them ready. Nurse Aide#3 stated when she had a few minutes, the resident would be taken to the activity room. Nurse Aide #3 indicated she was aware Resident #45 liked to participate in activities. An interview was conducted with Nurse Aide #5 on 8/22/23 at 2:30 PM. Nurse Aide #5 stated the assigned nurse aide should offer their residents the opportunity to get up and go to the activities of the day. Nurse Aide #5 stated the independent activities were of the resident choice on the weekend. Nurse Aide #5 further stated when there were activities of choice, the residents do what they want. Nurse Aide #5 further stated Resident #45 does like to attend activities and she was not assigned to Resident #45 on 8/22/23 and did not offer to take the resident to any activities today. An observation was conducted on 8/22/23 at 3:00 PM of bingo progress as indicated on the activity schedule. Resident #45 was not observed in the activity. An interview was conducted with the current activity director, Activity Director #1 on 8/22/23 at 11:00 AM. She stated she previously was the activity director at the facility and had left for several months prior to returning to the position in June 2023. She revealed upon her return she discovered there were no activity notes completed, there were incomplete resident assessments for activity preferences and there were limited activities during the week and weekends. Activity Director #1 stated she had worked with Resident #45 in the past and knew Resident #45 enjoyed and participated in religious activities, food activities and social events. She stated because she conducted the activities herself, she could not bring everyone down to the activity room and leave the other residents unattended in the room. Activity Director #1 added the expectation was for the nurse aides to assist bring residents to the activities. Activity Director #1 confirmed when she returned to the position in June of 2023, Resident #45 did not have any documentation that he participated in group activities or received any 1:1 activities of his preference. She further stated she did not have any documentation of activities that were done February 2023 through May 2023 for Resident #45. She stated since she returned, the activity calendar included more activities during the week and on the weekends. An interview was conducted with the Director of Nursing (DON) on 8/22/23 at 2:40 PM. The Director of Nursing stated she had only been working in the facility two weeks. The Director of Nursing indicated she was not aware of an issue with residents being asked if they wanted to participate in activities. The Director of Nursing stated all residents should be offered 1:1 and group activities daily and nurse aides should assist residents to activity. The Director of Nursing reviewed Resident #45's activity assessment done on 4/5/23 with the resident's preferences and confirmed Resident #45 should have been offered to participate in the activities that were offered on the schedule available based on Resident #45's preferences. An interview was conducted on 8/22/23 at 4:30 PM, the Administrator stated he began working at the facility April 2023 and was aware the activity program was not fully operational. He explained there was a lack of programing for resident activities during the week and weekends, inconsistent completion of activity assessments/preferences and no quarterly documentation of resident participation in activities. He was currently in the process of revitalizing the entire program with the hiring of the recent activity director, Activity Director #1, in June 2023 and activity assistant will be hired in the near future to create a more effective program for all residents during the week and weekends. He indicated There was no start date identified for the activity assistant.

Based on resident and staff interviews and review of resident council minutes, the facility failed to provide regular resident council monthly meetings (February 2023, March 2023, April 2023, and May 2023) for 4 consecutive months. The findings included: Review of resident council meeting minutes revealed no evidence that resident council meetings were conducted from February through May 2023. The resident council meeting was held on 8/22/23 at 2:00 PM. There were 10 residents identified as alert and oriented who participated in the meeting. The members of the group reported they were regular attendees of the resident council meetings. The residents reported the facility did not have any activity staff for four months to hold resident council meetings (February through May 2023). An interview was conducted on 8/22/23 at 4:00 PM with the Activity Director. The Activity Director stated she started working in the activities department in June 2023. The Activity Director further stated there was no documentation resident council meetings were held from February 2023 through May 2023. During an interview conducted on 8/22/23 at 4:30 PM the Administrator confirmed there were no resident council meetings held for residents per record review from February 2023 through May 2023. The Administrator further stated he assumed the position April 2023 and had difficulty hiring the proper activity staff to ensure resident council meetings were being held. He stated he would be hiring an activity assistant and ensure resident council meetings were being held monthly. The Administrator was unaware of who was responsible for conducting the meetings before the Activity Director returned in June 2023.

Based on record review and staff interviews the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours (hrs.) a day for 1 of 30 days reviewed. (7/23/23). Findings included: Review of the facility daily staffing schedules from 7/20/23 through 8/20/22 revealed the following: On 7/23/23 the staffing sheets indicated the facility census was 54 and 0 (zero) RN on duty. During an interview on 8/22/23 at 11:00 PM, the staff scheduler stated on 7/23/23 there was no RN assigned to the building, however she was made aware that if there was no RN on the schedule then the hospital RN supervisor would be counted as the RN for the nursing home. During an interview on 8/22/23 at 4:00 PM, The Director of Nursing (DON) stated when she was hired, she was informed that the hospital RN supervisor could be counted as the RN for the facility when there was no RN on the schedule. On 8/23/23 at 12:25 PM, the DON gave the surveyor the Job description for Person House Supervisor RN (Hospital). In the document the following was highlighted and read as follows. Nursing care: Demonstrate necessary skill and knowledge to provide care for patients according to division/unit specific competencies. Provide personal patient care to provide comfort and wellbeing to patient, acknowledging physiological and psychological needs. The DON stated based on the Hospital RN supervisor job description, the Hospital RN supervisor was responsible for the nursing home when there was no RN scheduled for the nursing home. During an interview on 8/23/23 at 5:30 PM, the Administrator stated there was a RN supervisor in the hospital and her job description indicated she would overlook both Hospital and Nursing home when there was no RN scheduled.

Based on staff interviews, the facility failed to complete performance evaluations of nurse aides at least once every 12 months and provide in-service education based on the outcome of these reviews for 2 of 2 Nurse Aides (NA) (NA #3 and NA #5). The findings included: During an interview on 8/23/23 at 10:00 AM, NA #3 stated she was hired 4 years ago. NA #3 stated she does not recollect having any performance evaluation for a long time. During an interview on 8/23/23 at 10:30 AM, NA #5 stated she was hired 5 years ago. NA #5 indicated she does not recollect any performance reviews completed annually. During an interview on 8/23/23 at 11:02 AM the Human Resource Staff (HR) stated the staff performance reviews were conducted by the appropriate department. The HR department did not maintain these files. On 8/23/22 at 4:50 PM, the Director of Nursing (DON) and Unit Manager were interviewed. Both DON and Unit Manager indicated they were unsure how staff performance was reviewed or assessed annually. The DON stated she was unable to find any documentation related to annual performance review or any education based on the annual reviews. The DON stated she would be working with the hospital education department to ensure that annual performance reviews were completed for all staff and appropriate education was provided based on these reviews. During an interview on 8/23/23 at 5:30 PM, the Administrator stated he does not have any nursing degree and the performance review for NA's should be completed by the nursing department. Education and training should be based on these reviews.

Based on record review and staff interviews, the facility failed to complete Minimum Data Set (MDS) assessments within the regulated time frame for 2 of 8 reviewed for resident assessment (Resident # 63, and Resident # 210). Finding included: 1.Resident #63 was admitted to the facility on [DATE] with diagnoses that included heart failure and depression. A review of Resident #63's admission MDS assessment dated [DATE] revealed the MDS was incomplete and was still in progress as of 8/22/23. The admission MDS assessment was due on 8/16/23. Review of the discharge return not anticipated MDS revealed the Resident #63 was discharged on [DATE]. During an interview on 8/22/23 at 2:55 PM, the MDS Nurse stated she was hired on 8/14/23 and was in the process of completing all pending and incomplete MDS assessments. She indicated the assessments should be completed within 14 days from the admitted . During an interview on 8/23/23 at 6:06 PM, the Administrator stated the MDS assessments should be completed and transmitted within the time frame as indicated. The Administrator indicated the facility had hired agency staff to complete MDS assessments. He stated he was in the process of directly hiring a MDS Nurse for the facility. 2.Resident #210 was admitted to the facility on [DATE] with diagnoses that included chronic pulmonary edema and hypothyroidism. A review of Resident #210's admission MDS assessment dated [DATE] revealed the MDS was incomplete and was still in progress as of 8/22/23. The admission MDS assessment was due on 8/14/23. During an interview on 8/22/23 at 2:55 PM, the MDS Nurse stated she was hired on 8/14/23 and was in the process of completing all pending and incomplete MDS assessments. She indicated the assessments should be completed within 14 days from the admitted . During an interview on 8/23/23 at 6:06 PM, the Administrator stated the MDS assessments should be completed and transmitted within the time frame as indicated. The Administrator indicated the facility had hired agency staff to complete MDS assessments. He stated he was in the process of directly hiring a MDS Nurse for the facility.

Based on record review, observations and staff and family interview, the facility failed to have a fall mat in place for a resident who sustained a fall, which resulted in a laceration, hematoma, and suture repair for 1 of 3 residents reviewed for accidents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident had a care plan (initiated 8/1/19 and last revised 8/1/19) for behavior problems related to sliding out of the bed. An intervention revealed ensure that low bed and fall mat is in place at all times when in bed. Resident #1's admission Minimum (MDS) data set [DATE] revealed the resident was moderately cognitively impaired. The resident had no behaviors present but had moods of feeling tired or having little energy. The resident required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. The resident required total dependence with transfers and locomotion on and off the unit. The resident used a wheelchair and was always incontinent of bowel and of bladder. The resident had a fall in the last 2-6 months prior to admission. The resident was receiving an anticoagulating medication for the last 7 days. physician's orders [REDACTED]. An incident report dated 11/6/19 revealed staff were called to the resident's room by the nursing assistant (NA). The resident was observed lying face down on the floor beside of the bed. The resident had blood pooling under her. The resident complained of right arm, hand, and face pain. The resident stated I get up wash hands then the resident stated no, the bed. I was trying to put my feet in the floor and flipped off the bed onto the floor. The emergency medical services (EMS) was called, and the resident was assessed for bleeding. The resident was turned over and the resident's right lower leg was noted to be bleeding under the dressing on the resident's leg. Pressure was applied to the right shin and an open area was noted to the resident's right hip. A hematoma (bleeding into tissues) was noted to the left brow and an abrasion was noted to the left knee. Predisposing factors revealed the resident was ambulating without assistance and had a gait imbalance. The resident was taken to the hospital. A nursing note dated 11/6/19 written by Nurse #1 revealed at 6:10 PM, the writer was called to the room by the N[NAME] The resident was observed lying face down on floor beside the bed. The resident was alert and verbally responsive. The resident was noted to have blood under her. The resident was turned over and assessed for blood. The right shin dressing was saturated with blood. Pressure was applied to her right shin and 911 was called. Resident #1 complained of right hand, arm pain, and face pain. A hematoma was noted to the left brow. At 6:30 PM, 911 Emergency Medical Services (EMS) arrived. The resident was taken to the emergency room . At 6:40 PM, the resident exited the facility via EMS. A nursing note dated 11/6/19 written by Nurse #1 revealed at 6:10 PM, the resident stated, I wash my hands. when ask what the resident was trying to do. The resident stated, I was putting my feet on the floor and flipped out of the bed head first. The note stated, Pt bed in lowest position. Hospital records dated 11/6/19 revealed the resident was seen after a fall. The resident had a laceration to the right leg. The lacerating measured 4 centimeters. The note stated the laceration was deep and that 1 suture was placed. The resident was also started on an antibiotic due to the high risk of infection of the area due to [MEDICAL CONDITION]. No fracture was seen on X-RAY. The resident also sustained a contusion and facial hematoma. The note also revealed regarding the Computed [NAME]ography (CT) finding of the abnormal carotid as a non-emergent evaluation. The resident was discharged back to the facility. A doctor's note dated 11/7/19 revealed resident #1 had severe [MEDICAL CONDITION] arthritis, was bedridden with chronic [MEDICAL CONDITION], chronic [MEDICAL CONDITION] and was on chronic anticoagulation with Eliquis. The resident sustained [REDACTED]. She fell off the bed and struck her face against the floor and had a small laceration to the right leg. She denied any other complaint of [MEDICAL CONDITION] (dizziness), abdominal pain or chest pain. No fever or new complaints were noted. The head CT showed no acute intracranial pathology. The resident was resting comfortably in no acute distress. Dressing over the anterior shin on the right was clean, dry and intact. Some bruises were noted over both knees. The note stated to resume Eliquis and continue antibiotics. Resident #1 was observed on 11/25/19 at 3:20 PM. The resident had a light, black circle under both of her eyes and a discolored area above her left brow. Her fall mat was in place and bed was in the lowest position. Nursing Assistant #1 was interviewed on 11/26/19 at 2:02 PM. She stated she was not assigned Resident #1 that night (11/6/19). She stated she heard a weird, muffled noise and she went in the resident's room and saw her on the floor. She stated she got the nurse. The resident was lying face down. Her head was the same direction as the head of the bed. The bed was not in a high position. She stated she did not remember if the resident had a fall mat in place or not. She stated after she got the nurse, she let the nurses take over. She repeated that she did not recall anything about the fall mat. She added the resident was a fall risk. NA #3 was interviewed on 11/26/19 at 3:45 PM. She stated the resident was incontinent and usually stayed in bed on her shift. She stated when she passed by the resident's door, the resident was on the floor. She stated herself and another NA were passing by the resident's room at the same time. The resident was on the floor and was bleeding. The other NA got the nurse. The resident's bed was in the low position. She stated she could not remember if there was a fall mat in place or not. They had to call 911 and send the resident to the emergency room . The resident usually had a fall mat in place. She revealed she couldn't remember if the resident had the fall mat in place for that day. She would go to the cardex on the computer or would ask the nurse how to care for the resident if she was unsure. They tried to keep the resident's bed in the lowest position, check the resident a lot, and keep water close to the resident to keep her from falling. Nurse #1 was interviewed on 11/26/19 at 1:16 PM (who was assigned Resident #1 on 11/6/19). She stated when the resident fell it was towards the end of her shift. The Nursing Assistant (NA) got her and stated the resident was bleeding. She stated they put pressure on the resident's leg and called 911. She revealed she stayed with the resident and talked to the resident. The resident stated she was trying to wash her hands prior to the fall. The resident's bed was in the low position, but no fall mat was in place next to the resident's bed. She stated the resident did not have a fall mat at this time. This resident would try to get up when she was first admitted to the facility but then had stopped trying to get up, so this fall was surprising. The resident liked to sit on the side of the bed. She added the resident was lying face down with her face towards to wall (head of the bed) and her feet were towards the end of the bed. NA #2 was interviewed on 11/26/19 at 3:36 PM. He stated Resident #1 was confused and had been on contact precautions. The resident was at risk for falls. He stated he was working the day the resident had a fall (11/6/19). The resident was found face down. He stated the resident tried to get out of the bed and was found on the floor. He could not recall if the fall mat was in place. The resident's family was interviewed on 11/26/19 at 4:24 PM. She stated the resident had a fall and sustained a big bruise to her head, which caused her eye to swell up. The resident also required stiches to her leg; it was a deep wound. She stated she did not think the resident's fall mat was in place or the resident would not have sustained such a bad injury. The resident's doctor was interviewed on 11/25/19 at 3:43 PM. He stated the resident was alert and oriented to herself only. He stated the resident had a fall and went to the hospital. He saw the resident the next day after the fall. He revealed the resident's mental status was back to normal. He assessed her eye and the resident for bleeding as she was on Eliquis. He had not been notified about any concerns with the dressing changes to the resident's leg. The Director of Nursing (DON) was interviewed on 11/26/19 at 4:26 PM. She stated residents would have a fall risk assessment completed to see if they were at risk for falls. Therapy would also alert them if a resident was at risk for falls. The NAs have the Kardex to refer to, complete shift to shift hand offs, and have the nurses as a resource to ask if they are unsure how to care for a resident. She stated staff called her and let her know that Resident #1 had a fall (11/6/19). The resident was lying face down on the floor and the resident stated she was trying to wash her hands. She stated the resident already had a wound to her shin, but the wound had opened more after the fall. The resident had swelling to her eye. The resident had no major injuries but had a stitch to her leg. The resident did not have any long-term effects from the fall. She was made aware the resident's fall mat wasn't in place next to the resident's bed. The facility did a complete audit (on 11/15/19) of all the residents that were at risk for falls. She stated fall mats appeared as an order on the Treatment administration Record now. They also went through the rooms to make sure everything was in place for residents at risk for falls, including care plans and interventions. She stated, they didn't do an in-service on falls but mentioned it in the morning huddle to the inter-disciplinary team. She also added that the issue would be discussed in the next quality assurance meeting. The Administrator was interviewed on 11/26/19 at 4:58 PM (DON was present). He stated he would expect if the resident scored high on the risk assessment as being a fall risk then there should be interventions in place to reduce the risk for falls and to minimize the injury.

Based on observation, interviews with the staff, pharmacist, nurse practitioner, and Medical Director and record review, the facility neglected to answer call bells timely, provide assistance in a timely manner and provide functioning call bells in the bathrooms so if a resident needed to summon staff for assistance, they could get help and prevent an accident from occurring, follow up on lab specimens to determine the course of treatment for [REDACTED]. This affected 5 of 40 sampled residents (#10, #24, #66, #130 and #131). Immediate jeopardy began on 9/7/17 and is ongoing for Resident #66. This resident could not find staff to assist her to the toilet, she transferred independently onto the commode. She did not have a means to call for help after toileting and prior to transferring back into her wheelchair because the call bell was not functioning. She expressed anger and stated that it was dangerous. She had a high likelihood for falling and receiving a serious injury associated with her post-surgical knee [MEDICAL CONDITION], high blood sugar on that day and a continued need for occupational therapy for transferring, toileting and dressing the lower body. On 9/7/17, three hours passed before hand bells were distributed to the bathrooms that had non-functioning call bells. Examples number 2 - 5 are at no actual harm with potential for more than minimal harm that is not immediate jeopardy and the scope is a pattern (E). Findings included: 1. Resident #66 was admitted to the nursing home on 7/17/17. Her admission Minimum Data Assessment indicated she had [DIAGNOSES REDACTED]. Her Minimum Data Set (MDS) assessment dated [DATE] indicated she was moderately impaired in cognition (Brief Interview for Mental Status was 11), required extensive assistance from one person for transfer, dressing and toilet use. She was not steady with moving on and off the toilet and only able to stabilize with staff assistance. She had no fall history and she received both occupational and physical therapy during the assessment period. The Care Area Assessment indicated activity of daily living, urinary incontinence and falls would be addressed in the care plan to minimize risks and avoid complications. A care plan dated 8/1/17 indicated all problems were cancelled and resolved. A new care plan was initiated on 8/7/17. It only contained one problem for being on a therapeutic diet. A Fall Event report indicated Resident #66 had an assisted fall on Sunday, 8/27/17 at 10:00 AM. It said, The Certified Nurse Aide (CNA) was assisting resident with transfer from bed to wheelchair. CNA assisted resident to the floor. There was no harm and the Therapy Director provided education to the CNA on transfers. A corresponding physical therapy note dated 8/30/17 indicated Nurse Aide (NA) #10 was trained in regards to toilet transfer to support fall prevention during transfers. An attempt to interview NA#10, who worked on the weekends, was made at 11:56 AM on 9/12/17, but it was unsuccessful. Interview with the therapy director on 9/12/17 at 11:30 AM revealed Resident #66 had assisted fall over a weekend. She was in the bathroom and her leg buckled. The therapy director said she was working that day and showed NA#10 how to transfer her using the grip bars. According to the Occupational Therapy (OT) therapy notes dated 9/4/17, Resident #66 required substantial assistance with lower body dressing and had improved in toileting - transfers to being able to safely transfer to the toilet with supervision or touching -minimum assistance for toileting routine. Resident #66 was interviewed on 9/06/2017 at 9:20 AM. She said, sometimes she was treated with dignity and respect and added, When they don't come and they are short of help, you just have to wait until someone comes and helps you out. On 9/07/2017 at 10:08 AM, Resident #66 said, At home I used pull ups and used the toilet. Here, I use the ones that fasten on the side. The staff get me to the toilet two to three times a day. When I press the call bell they will come. I used the walker before I came. Therapy gives me exercises in my room sometime. Coming, when I call them, is a problem. Mostly on days sometimes on second shift. A Health Status Note dated 9/7/2017 at 2:39 PM read in part, alert and oriented times three with forgetfulness at times. Requires extensive assist with activities of daily Living (ADLs), set-up for oral care and meal tray. Blood sugar at 11:30 AM 236, receives insulin per sliding scale insulin order. On 9/07/2017 at 4:25 PM Resident #66 was observed in her private bathroom on her own. She was attempting to transfer back into her wheelchair. She appeared anxious and was tightly gripping the grab bar and struggling to back herself into her wheelchair. At approximately the same time NA #15 was passing by Resident #66's room. She said she had to take vital signs and blood sugars. She said Resident #66 goes to the bathroom on her own if she feels like it. At 4:30 PM Resident #66 came out of the bathroom and said in a loud and angry voice, I LIKE TO fell AND NEED MY BRITCHES UP. NA #15 went in the room to assist Resident #66. According to the blood sugar (BS) monitoring record and the Medication Administration Record [REDACTED]. Twelve units of insulin was administered by Nurse #4. On 9/08/2017 at 7:54 AM Resident #66 was asked if she had put on the call bell yesterday to let the aide know she needed help. She said the call bell was not working in the bathroom. The surveyor tested the call bell and it did not light outside the door or ring at the nurses' station. On 9/08/2017 at 7:58 AM the surveyor informed the Unit Secretary that the call bell in Resident #66's bathroom was not working. She said it was the first time she had heard about it. On 9/08/2017 at 11:15 AM Nurse #3 was interviewed about call bells. She said, I am aware of a call bell reported not working. I would get in contact with the Maintenance Director. I would call his pager or leave a message. When Nurse #3 was asked about other means for the resident to use to call for help, she said, We have bells and would have to find them. Immediately following the interview she was seen distributing hand bells to Resident #66 and to the other residents who did not have functioning call bells. On 9/08/2017 at 11:25 AM, the Director of Plant Operations was interviewed. He said, If we get a report about a problem, then we get a service call. We would not check other call bells. It is on an as needed basis. He confirmed that the call bell in Resident #66's bathroom room did not work. On 9/09/2017 at 11:01 AM a hand bell was observed in Resident #66's bathroom. On 9/08/2017 at 3:17 PM the Occupational Therapist was interviewed. She said she had worked with Resident #66 on functional transfers to toilet. She said, Initially she needed two person assistance. Now she needed minimum assist and cues for safety and hand placement. She needed contact guard assistance. We've done safety training with nurse aides in the room. She added, Typically, someone would be with her. She is good about calling if she needs help. I would not recommend her toileting by herself. She can self-propel in wheelchair. She is compliant. The safety awareness has already been an issue (i.e., hand placement). Safety is a huge thing. Resident #66 was interviewed again on 9/08/2017 at 4:20 PM. She said, I tried to get someone yesterday and couldn't find anyone. It was dangerous. On 9/09/2017 at 10:15 AM the Director of Nurses was interviewed. She confirmed that Resident #66 required assistance from one person and needed supervision with activities of daily living. She needed a nurse aide (NA) due to her [DIAGNOSES REDACTED]. Resident #66 had some episodes of confusion. She had tried to get up. She had one assisted fall with staff. She was trying to get out of wheelchair and she did not wait for assist. The Director of Rehab provided education to the CNA. On 9/8/17 at 12:30, the administrator was informed of the immediate jeopardy. 2. Resident #130 was admitted on [DATE]. Her admitting [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set assessment was dated 8/30/17. The resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 12. She required extensive assistance from one person for toileting and she was not steady moving on and off the toilet. She was always continent. Resident #130 had an activity of daily living (ADL) self-care performance deficit related to limited mobility, limited range of motion, musculoskeletal impairment and pain all due to fractures suffered in a fall at home. A nurse practitioner (NP) progress note dated 8/31/2017 at 12:34 PM stated in part, Her (family member) also relates patient complaint of painful urination this morning and she noted pink tinge to urine. Her temperature was taken and it was normal. - A thorough assessment was performed. The NP wrote, Will follow up on lab tests with appropriate orders to follow . On 8/31/2017 at 5:23 PM a Health Status Note was written and said, Resident was noted having white mucus discharge from vagina (NP) was notified. New order was given to obtain UA and complete blood count (CBC). Resident and family were notified. On 9/2/2017 at 2:50 AM a Health Status Note was written and said, .her family reports a white discharge from vaginal area, np is aware. Her vital signs are stable and she is afebrile . On 9/3/2017 at 8:24 PM a Health Status Note was written and said the physician was notified that urinalysis (u/a) was ordered on 8/31 had not yet be obtained. Family wished to speak and see him .Informed him of her most recent vital signs and again about the u/a. He ordered STAT (immediate) complete blood count (CBC), basal metabolic panel (BMP) and urinalysis and culture and sensitivity (u/a c&s), an antibiotic, [MEDICATION NAME], was started. The first attempt to obtain u/a was unsuccessful, noted white discharge noted in collection tube. Encouraged her to drink fluids and was able to obtain u/a sample on second attempt. STAT labs results pending. Denies any pain or discomfort. A telephone order was written on 9/3/17 for a Stat CBC, BMP, UA & C&S possible urinary tract infection [MEDICAL CONDITION] - [MEDICATION NAME] 750 milligrams (mg) per oral (PO) daily for 5 days. On 9/4/2017 at 9:16 AM a Health Status Note read, in part, .Lab results faxed in from lab, AM nurse aware. First dose of [MEDICATION NAME] 750 mg given at 9:00 PM for (urinary tract infection) UTI. No (signs or symptoms) s/s of adverse reaction noted. On 9/5/17, the C&S result was >100,000 Proteus mirabilis. On 9/7/2017 a physician's orders [REDACTED]. An NP progress note dated 9/7/2017 at 11:52 AM indicated intramuscular [MEDICATION NAME] had been started and the previous antibiotic was stopped. Organism was sensitive to both agents, however, clinically she was not improving. With the change she is showing improvement and is able to sit up in bedside chair today and more mentally clear. She has improved with [MEDICATION NAME] addition . Interview with the NP on 9/7/17 at 4:22 PM revealed he ordered the UA & C&S. on 8/31/17 I would have written a hard script for it. The Unit Secretary would take the order off and give it to the nurse. The family asked about results and wanted to see the MD. He ordered another UA C&S. He started her on [MEDICATION NAME]. She had no clinical improvement then put her on [MEDICATION NAME]. The NP was asked what impact not getting the results had on the resident. He said it would have been better if treated. Nurse #9, signed off on the order dated 8/31/17 to obtain a UA and C&S. The physician was interviewed on 9/07/2017 at 4:45 PM. The MD said the family spoke to him on 9/3/17. He ordered new labs and a UA C&S. He said he did not know why the sample was not collected. He said the family said there was pus in urine. No vital signs suggested a problem. He added, Fortunately the labs CBC & BMP were normal. The vital sign record indicated Resident #130's temperature range from 8/31/17 - 9/3/17 was 96.6 - 98.9 degrees F. On 9/08/2017at 7:59 AM an attempt was made to interview Resident #130 about her signs and symptoms of UTI. She said she was sleeping a lot and did not remember. She declined observation of care. Nurse #9 was interviewed on 9/09/2017 at 10:50 AM about her actions on 8/31/17. She said, I collected the urine and sent it to the lab. It was around lunch time. The NP gave me the order. I asked how to obtain the specimen and was told by in and out catheterization. A family member was in the room. I put a label on the specimen. I put on time and date. I put it in a biohazard bag. I saw the lady in the lab. I put it in the basket. I put label in the computer. I reported off to next shift nurse and sent to lab. I was off the next three days. I came back on 9/4/17 and the resident was on an antibiotic. On 9/09/2017 at 10:15 AM the Director of Nurses said Nurse #9 claims she collected the urine specimen and took it to the lab. She said, I am still in the process of trying to validate that the sample was obtained. I am still investigating. She said there should not be a delay. It goes back to process. I've had conversations with nurses about how we put lab orders in. On 9/9/17 at 11:00 AM interview with Resident #130's family member confirmed the specimen was collected on 8/31/17. 3. Resident #24 was admitted on [DATE] with the admission of malnutrition, diabetes mellitus and hypertension. The most recent minimum (MDS) data set [DATE] revealed Resident #24 was severely impaired cognition, and required limited assistance with dining and had no swallowing problems. Her most current weight on 08/02/17 was 73 pounds. A review of the most recent care plan dated 05/01/17 revealed Resident #24 had a nutritional problem related to severe malnutrition. The goal was to maintain adequate nutrition status as evidenced by maintaining weight within 10% of 100lbs with no sign or symptoms of malnutrition and consuming greater than 50% of at least 3 meals daily. The interventions were, in part, to provide and serve her diet as ordered. A review of the August and September 2017 medication administration records (MAR) revealed treatment for [REDACTED]. A review of a nursing note dated 09/01/17 revealed accepted medication with lots of encouragement to close mouth and swallow. A review of the nursing notes from 8/28/17 until 09/07/17 revealed no behaviors during meals. A review of the behavior summary report ending for the week of 09/10/17 revealed no behaviors. On 09/07/17 at 12:20 PM, a continuous observation was conducted with Aide #3 who was assigned to Resident #24. The trays were delivered to the room at 1:22PM and Resident #24 was lying in bed resting. Aide #3 went into the room at 1:27 PM. The aide woke up and fed Resident #23, the roommate. She completed the feeding at 1:50 PM and left the room and went into the break room across the hall. During an interview on 09/07/17 at 2:00 pm, Aide #3 indicated that she wasn't going to feed lunch to Resident #24. When asked why, Aide #3 stated Resident #24 wasn't going to eat ground chicken, carrots and mashed potatoes. Aide #3 indicated Resident #24 would just mash it up and play in it and stated that Resident #24 fought and spit during meals and wanted to feed herself and did better with finger foods. Aide #3 indicated that she would leave the tray for the next shift to feed her because she didn't want to upset Resident #24 because she was old and had woke up in a bad mood. On 09/07/17 at 2:31 PM, Nurse #2 indicated Aide #3 had not reported Resident #24 had not eaten her lunch. Nurse #2 indicated she knew Resident #24 was combative with activities of daily living (ADLs) care and should always be offered her meals. On 09/08/17 at 8:48 AM, Aide #2 was observed waking up Resident #24 for breakfast. Aide #2 repositioned her and attempted to feed her eggs. Resident #24 pushed the eggs out with her tongue. Aide #2 offered Resident #24 pancakes which she accepted but was very slow to eat. During the observation, Aide #2 indicated she had heard that Resident #24 would hit during ADL care. Aide #2 stated Resident #24 was a slow eater and required patience and time. On 09/08/17 at 10:24 AM, the Director of Nursing stated she expected Aides to attempt to feed all residents. If the resident refused, the aides were to re-approach later and feed. 4. Resident #131 was admitted to the facility on [DATE] upon discharge from a hospital. The resident's medical history included a fracture of her left hip with surgical repair. A review of the resident's hospital Discharge Summary dated 9/4/17 included special instructions which read, Patient should be on strict fall precautions she will need physical therapy and occupational therapy. A review of the facility's medical record for Resident #131 revealed her Admission Minimum Data Set (MDS) assessment and individualized care plan were not yet due for completion. A review of the facility's Admission Nursing Summary dated 9/4/17 at 3:15 PM revealed the resident was alert. Her short and long term memory were assessed to be intact and decisions were reported to be consistent and reasonable. The resident required extensive assistance for all of her Activities of Daily Living (ADLs), with the exception of requiring limited assistance of one with dressing and being independent with eating. Resident #131 was reported to be continent of bowel and bladder. A Fall Risk Assessment completed on 9/4/17 revealed Resident #131 was determined to be at a moderate risk for falls. She was noted to have a history of a fall at home with a left [MEDICAL CONDITION] and repair. The Fall Risk Assessment indicated the resident required, hands-on assistance to move from place to place. A review of Resident #131's Physical Therapy (PT) Plan of Care dated 9/5/17 included an assessment of the resident's current functional abilities. The Plan of Care indicated the resident required supervision or touching assistance for ambulation. This level of assistance was further defined as needing a helper to provide verbal cues or touching/steadying assistance as the resident ambulated, either throughout the activity or intermittently. A review of Resident #131's Occupational Therapy (OT) Plan of Care dated 9/5/17 also revealed an assessment of the resident ' s current functional abilities was conducted. The Plan of Care indicated the resident required supervision or touching assistance for toileting. The resident was also assessed as requiring supervision for transfer with toileting. She was determined to be at a moderate risk for balance and falls. A review of the resident's medical record included a Nursing Note dated 9/6/17 at 2:34 PM. The note indicated the resident was able to verbalize her needs. She ambulated with a walker with the assist of one. Review of a Nursing Note dated 9/7/17 at 8:59 AM also revealed Resident #131 ambulated with the help of a walker, but required assistance and was described as not very steady. Further review of Resident #131's medical record included a Nursing Note dated 9/9/17 at 12:58 AM. This note also indicated Resident #131 ambulated with a walker and the assistance of one. An observation was conducted on 9/9/17 at 7:40 AM. Upon entering the resident ' s hallway, Resident #131's call light was observed to be lit above the door to her room and the sound of an activated call bell was heard. The resident's door was closed and she could not be viewed from the hallway. At that time, a continuous observation was made of Resident #131 ' s door and the call light above her doorway. At 7:51 AM a Housekeeping staff member was observed as she passed by Resident #131's room. The Housekeeping staff member did not knock or look into the resident's room. The call light continued to be lit above the door to Resident #131's room. At 8:01 AM, Administrative Staff Member #1 was observed as she walked by the resident's room. The administrative staff member did not knock or look into the resident's room. The call light continued to be lit above the door to Resident #131's room. At 8:07 AM, Administrative Staff Member #2 was observed as she passed by the resident's room. The administrative staff member she did not knock or look into the resident's room. The call light continued to be lit above the door to Resident #131's room. At 8:08 AM, Administrative Staff Member #3 passed by Resident #131's room. The administrative staff member she did not knock or look into the resident's room. The call light continued to be lit above the door to the resident's room. At 8:13 AM, Resident #131's breakfast tray was delivered to her room. Within one minute of the tray delivery, the resident's call light was turned off. On 9/9/17 at 8:15 AM, Nursing Assistant (NA) #2 was observed as she came out of the resident's room and closed the door. An interview was conducted with NA #2 at that time. During the interview, the NA was asked why the resident had her call light on. The NA reported the resident needed assistance to get to the bathroom. An interview was conducted on 9/9/17 at 3:20 PM with Resident #131. Upon inquiry, the resident recalled putting on her call light in the morning before breakfast and stated she needed to use the bathroom. Resident #131 reported she was not supposed to go to the bathroom by herself and needed assistance to do so. She did not recall what time she put on the call light that morning, but reported, Sometimes it takes a half hour for them to come. Resident #131 stated she did not have a clock or watch to see exactly how much time had elapsed before staff came to assist her. The resident also described one night earlier in the week when she put on the call light to request bathroom assistance. Resident #131 reported she waited for what seemed to be quite a long time. The resident stated she couldn't wait any longer for staff to come because, I just knew I would wet myself all over if I waited anymore. Resident #131 reported she used the walker in her room to walk to the bathroom unassisted and then back to bed (also unassisted). Resident #131 stated she met the facility ' s Administrator a couple of days ago and told her, You need more help. A follow-up interview was conducted on 9/10/17 at 9:40 AM with Resident #131. During the interview, the resident recalled the night her call light was not answered by staff when she needed assistance to go to the bathroom. The resident stated she had actually used the call light twice that night and ended up getting to the bathroom and back to bed by herself unassisted because no one came to help her. The resident reported she knew she shouldn't walk unassisted but didn't feel she had a choice. She reported she just didn't feel strong enough to safely walk by herself and had been instructed by therapy and staff that she should not ambulate without assistance. An interview was conducted on 9/10/17 at 3:36 PM with the facility's Director of Nursing (DON). Upon inquiry as to who was responsible for responding to call lights, the DON responded, All staff .we have the no-passing zone. The DON reported ' the no-passing zone ' meant all staff from all departments, including housekeeping and dietary, should answer call lights. She reported if the particular staff member answering the call light could not meet the needs of the resident, he/she should let someone know who could take care of the resident's need. When asked what her expected response time would be for staff to answer a call light, the DON stated, Ideally, less than 5 minutes. An interview was conducted on 9/12/17 at 11:55 AM with Physical Therapist (PT) #1. PT #1 reported he had been working with Resident #131 since her admission to the facility a little over one week ago. Upon inquiry, the PT reported the resident continued to require assist of one for ambulation and toileting. The resident ' s report of ambulating to/from the bathroom on her own in the night were discussed with the PT. The PT stated he, would have wanted her to have help. 5. Resident #10 was admitted to the facility on [DATE]. The resident ' s cumulative [DIAGNOSES REDACTED]. A review of the resident's November 2016 Physician order [REDACTED]. --2 milligrams (mg) [MEDICATION NAME] (an antipsychotic medication) given as 1 tablet by mouth every night at bedtime related to [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] type; --0.5 mg [MEDICATION NAME] given as 1 tablet by mouth every night at bedtime related to [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] type; --20 mg [MEDICATION NAME] (an antidepressant) given as 1 tablet by mouth every day related to major [MEDICAL CONDITION], single episode; --30 mg duloxetine (an antidepressant) given as 1 capsule by mouth every day related to major [MEDICAL CONDITION], single episode; --40 mg Fetzima (an antidepressant) given as 1 tablet by mouth every day related to major [MEDICAL CONDITION], single episode; --20 mg [MEDICATION NAME] (an antidepressant) given as 1 tablet by mouth every day related to major [MEDICAL CONDITION], single episode; --5 mg [MEDICATION NAME] (an antianxiety medication) given as one tablet by mouth twice daily for [MEDICAL CONDITION] and anxiety. A review of the resident ' s medical record included a notation made by Resident #10's former physician (dated 11/15/16) written in response to a Consultation Report (dated 9/27/16) from the facility ' s consultant pharmacist. The Consultation Report reported Resident #10 received 4 antidepressants in addition to an antipsychotic and antianxiety medication. The pharmacist indicated the need for four antidepressant agents with the same (or similar) action represented a duplication of therapy and recommended the need for four antidepressant agents be re-evaluated. She suggested consideration be given to tapering and discontinuing use of one or more (perhaps [MEDICATION NAME] or [MEDICATION NAME]) to avoid the risk of side effects. The physician declined the pharmacist's recommendation on 11/15/16 with a notation that read: Recently - psych ([MEDICAL CONDITION]) meds reviewed by (Name of Medical Center) - no changes were made. A review of Resident #10's March 2017 Physician order [REDACTED]. The [MEDICAL CONDITION] medications included [MEDICATION NAME], duloxetine, Fetzima, [MEDICATION NAME], and [MEDICATION NAME]. Further review of the resident's medical record included a Consultation Report from the consultant pharmacist dated 3/14/17. The Consultation Report indicated Resident #10 received 4 antidepressants in addition to an antipsychotic and antianxiety medication. The pharmacist recommendation indicated the need for four antidepressant agents with the same (or similar) action represented a duplication of therapy and suggested the regimen be re-evaluated with consideration given to tapering the [MEDICATION NAME] dose at this time. The NP declined the recommendation on 4/15/17, noting Long standing h/o (history of) mental illness-meds eval (evaluated) by psych with no changes--no med change at this time. A review of Resident #10's medical record revealed the frequency of her [MEDICATION NAME] dosing was increased on 5/11/17 from 5 mg given twice daily to 5 mg [MEDICATION NAME] given three times a day. There was no documentation in the resident's paper or electronic medical record to indicate the resident's target behaviors/mood were being monitored and to support the rationale for the dose increase. A review of the resident's medical record included a Consultation Report from the consultant pharmacist dated 5/17/17. The Consultation Report indicated [MEDICATION NAME] was a long-acting medication and considered a high risk medication due to the increased risk of sedation, depression, confusion, addiction and falls in the elderly. The report acknowledged the recent dose increase of [MEDICATION NAME] and recommended consideration be given to tapering down the dose. The NP declined the pharmacist's recommendation on 7/17/17 with a notation that read: Recently assessed by psych-no changes were made to her long term psych meds including [MEDICATION NAME] ([MEDICATION NAME]). Further review of the resident's medical record included a Consultation Report from the consultant pharmacist dated 6/9/17. The Consultation Report indicated the resident received [MEDICATION NAME], which increased her risk for dry mouth, constipation, [MEDICAL CONDITION], blurred vision, and increased confusion/sedation. The pharmacist also noted the resident received 3 additional antidepressants, an antipsychotic and an antianxiety medication. The report recommended consideration be given to re-assessing the use of [MEDICATION NAME] due to the risk for side effects. The NP declined the pharmacist's recommendation on 7/17/17 with a notation that read: Recently assessed by psych-no changes were made to her long term psych meds including [MEDICATION NAME] ([MEDICATION NAME]). A review of the resident ' s medical record included a 7/17/17 Consultation Report (noted as a repeat recommendation from 5/17/17) from the consultant pharmacist. This report reiterated the recommendations made in the 5/17/17 Consultation Report. The NP declined the pharmacist's recommendation on 8/22/17 with a notation that read: Psych eval completed with med rec (medication reconciliation) done and no changes made - will continue current regimen. A review of Resident #10's August 2017 Physician order [REDACTED]. The [MEDICAL CONDITION] medications included [MEDICATION NAME], duloxetine, Fetzima, [MEDICATION NAME], and [MEDICATION NAME]. A review of Resident #10's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had intact cognitive skills for daily decision making. Section D of the MDS reported the resident had a mood severity score of zero (0); Section E indicated the resident exhibited no behaviors nor rejection of care. Section N of Resident #10's assessment revealed she received an antipsychotic, antidepressant, and antianxiety medication on 7 out of 7 days during the look back period. A review of the resident's care plan (not dated) included the following area of focus: The resident uses [MEDICAL CONDITION] medications related to depression, anxiety, and [MEDICAL CONDITION] (Initiated and Revised on 6/28/16). The planned interventions for this area of focus included: --Administer [MEDICAL CONDITION] medications as ordered by physician. Monitor for side effects and effectiveness Q-shift (every shift). --Monitor/document/report PRN (as needed) any adverse reactions of [MEDICAL CONDITION] medications: [REDACTED]

Based on record review, observations, physician, pharmacy, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey on 10/6/16. Four of the nine current immediate jeopardy citations during the recertification survey on 9/12/17, were also cited on the prior recertification survey including F279 (Comprehensive Care Plan), F353 (Staffing), F441 (Infection Control), and 520 (Quality Assurance). The continued failure of the facility during 2 federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance program. Findings included: 1. F279 Based on observation, staff interview and record review, the facility failed to develop comprehensive care plans to address the current needs of the residents and to form the basis for the delivery of care for 4 of 18 sampled residents (Resident #8, #56, #66 and #128). Immediate jeopardy began on 9/7/17 and is ongoing for Resident #66. This resident could not find staff to assist her to the toilet, she transferred independently onto the commode. She did not have a means to call for help after toileting and prior to transferring back into her wheelchair because the call bell was not functioning. The facility was also cited at F279 during the recertification survey on 10/6/16 when the facility failed to develop a comprehensive plan of care for a resident (Resident #38) for Urinary Incontinence and Indwelling Catheter; Falls; Dehydration/Fluid Maintenance; Pressure Ulcer; and, Pain. 2. F353 Based on resident interviews, staff interviews and review of the staffing records, the facility failed to provide staffing in sufficient numbers to meet the needs of residents for 4 of 40 sampled residents (#66, #103, #131, and #56). Immediate jeopardy began on 9/7/17 and is ongoing for Resident #66. This resident could not find staff to assist her to the toilet, she transferred independently onto the commode. She did not have a means to call for help after toileting and prior to transferring back into her wheelchair because the call bell was not functioning. She expressed anger and stated that it was dangerous. She had a high likelihood for falling and receiving a serious injury associated with her post-surgical knee [MEDICAL CONDITION], high blood sugar on that day and a continued need for occupational therapy for transferring, toileting and dressing the lower body. On 9/7/17, three hours passed before hand bells were distributed to the bathrooms that had non-functioning call bells. On 9/8/17 at 12:30, the administrator was informed of the immediate jeopardy. The facility was also cited at F353 during the recertification survey on 10/6/16 when the facility failed to ensure adequate staff to provide activities of daily living care for 2 of 6 dependent residents(Resident #59 and #19) and apply splints for 1 of 1 sampled resident with contractures(Resident #1). 3. F441 Based on observations and staff interviews, the facility staff: 1) Failed to disinfect a shared glucometer (device used to measure a resident's blood glucose or blood sugar level) between residents and failed to perform hand hygiene between residents for 1 of 3 residents observed to have their blood glucose checked (Resident #55). The facility staff also failed to wear gloves when completing a blood glucose check for 2 of 3 residents observed to have their blood glucose checked (Resident #55 and Resident #134); and, 2) Failed to perform hand hygiene after providing bowel incontinence care and before providing perineal care for 1 of 1 resident reviewed for infection control (Resident #10). Immediate jeopardy began on 9/8/17 and is ongoing. Neither the Nursing Assistant (NA) #10 observed to do blood glucose checks nor the hall nurse (Nurse #2) were adequately trained on how to disinfect a shared glucometer between residents. NA #10 did not perform hand hygiene between residents when doing the blood glucose checks and did not wear gloves on two separate occasions when doing the blood glucose checks. The facility was also cited at F441 during the recertification survey on 10/6/16 when the facility failed to wear gloves and gowns when entering a room with Contact Precautions for one of two residents (Resident # 31) reviewed for Contact Isolation Precautions. 4. F520 During the recertification survey on 10/6/16, the facility was cited at F520 when the facility Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place in December 2015. This was for one recited deficiencies which was originally cited on November 2015 on a recertification survey and on the current recertification survey. The deficiency was in the areas of splint application. The continued failure of the facility during two federal surveys of record show a pattern of the facilities inability to sustain an effective Quality Assurance Program. On 9/12/17 at 3:37 PM, the Administrator and Director of Nursing (DON) were interviewed. The Administrator indicated she oversaw the Quality Assurance (QA) meetings and the DON attended all QA meetings. When informed that four of the immediate jeopardy citations had been cited on the last recertification survey on 10/6/16, the Administrator stated, We are not as effective as we have needed to be. She indicated she had discussed staffing with the Chief Executive Officer and the Chief Financial Officer and had some incentives in place. Both the DON and the Administrator agreed they did not have enough staff, but were working on it and did have some new employees in place already. The Director of Nursing stated they had identified holes in documentation and had sought guidance from the state agency about a month ago. The DON indicated a comprehensive care plan was expected to capture the resident accurately and said, it boils down to patient-centered care.

Based on observation, staff interview and record review, the facility failed to develop comprehensive care plans to address the current needs of the residents and to form the basis for the delivery of care for 4 of 18 sampled residents (Resident #8, #56, #66 and #128). Immediate jeopardy began on 9/7/17 and is ongoing for Resident #66. This resident could not find staff to assist her to the toilet, she transferred independently onto the commode. She did not have a means to call for help after toileting and prior to transferring back into her wheelchair because the call bell was not functioning. She expressed anger and stated that it was dangerous. She had a high likelihood for falling and receiving a serious injury associated with her post-surgical knee amputation, high blood sugar on that day and a continued need for occupational therapy for transferring, toileting and dressing the lower body. Three hours passed before hand bells were distributed to the bathrooms that had non-functioning call bells. Examples number 2 - 4 are at no actual harm with potential for more than minimal harm that is not immediate jeopardy and the scope is isolated (D). Findings included: 1. Resident #66 was admitted to the nursing home on 7/17/17. Her admission Minimum Data Assessment indicated she had [DIAGNOSES REDACTED]. Her Minimum Data Set (MDS) admission assessment dated [DATE] indicated she was moderately impaired in cognition, required extensive assistance from one person for transfer, dressing and toilet use. She was not steady with moving on and off the toilet and only able to stabilize with staff assistance. She had no fall history and she received both occupational and physical therapy during the assessment period. The Care Area Assessment indicated activity of daily living, urinary incontinence and falls would be addressed in the care plan to minimize risks and avoid complications. The Care Area assessment dated [DATE] associated with MDS above indicated a care plan would be initiated to address cognitive loss/dementia, activity of daily living rehabilitation potential, urinary incontinence, falls, nutritional status, dehydration/fluid maintenance, pressure ulcer, [MEDICAL CONDITION] drug use and pain. The MDS section of the electronic medical record indicated Resident #66 was discharged with a return anticipated on 7/31/17. A care plan dated 8/1/17 indicated all problems were cancelled and resolved. The MDS section of the electronic medical record (EMR) indicated Resident #66 was readmitted to the nursing home on 8/2/17 A new care plan was initiated on 8/7/17. It only contained one problem for being on a therapeutic diet. A Kardex located under the care plan tab within the EMR included one instruction for transfer. * Use lifting device, draw sheet, etc. etcetera) to reduce friction. Monitor Vitals All (BP (Blood Pressure), P (Pulse), R (Respirations), T (Temperature)). A Current Care Record located under the care plan tab within the EMR contained a form for nurse aides to document care. In a hard copy format this form is called the Documentation Survey Report v2. In the left column it indicated an intervention/task. The next column included the shift and the subsequent columns included the days of the month. A key that explained the coding was located below each intervention/task section. The Documentation Survey Report v2 for the month of September was reviewed for Resident #66. The Intervention/Tasks included in part, Transferring, Toilet Use and Dressing. There were no individualized instructions. Documentation was reviewed for transfer from September 1 - 7, 2017. On 9/1 transfer occurred one time on second shift with total dependence from two staff. There was no entry made on Saturday, 9/2, Monday, 9/4 or Thursday 9/7. On Sunday, 9/3, night shift documented NA. This was the same for Tuesday, 9/5 and Wednesday 9/6. Documentation was reviewed for toilet use from September 1 - 7, 2017. On 9/1 toilet use occurred one time on second shift with total dependence from one staff. There was no entry made on Saturday, 9/2, Monday, 9/4 or Thursday 9/7. On Sunday, 9/3, night shift documented total dependence from one person. This was the same for Tuesday, 9/5 and Wednesday 9/6. Documentation was reviewed for dressing from September 1 - 7, 2017. On 9/1 dressing occurred one time on second shift with total dependence from one staff. There was no entry made on Saturday, 9/2, Monday, 9/4 or Thursday 9/7. On Sunday, 9/3, night shift documented NA. This was the same for Tuesday, 9/5 and Wednesday 9/6. On 9/07/2017 at 10:08 AM, Resident #66 said, At home I used pull ups and used the toilet. Here, I use the ones that fasten on the side. The staff get me to the toilet two to three times a day. When I press the call bell they will come. Nurse Aide (NA) #6 was interviewed on 9/07/2017 at 10:22 AM about how she knows what care to provide residents. She said, After a day or two, I get to know the routine. Sometimes, she (Resident #66) will pee in a diaper. Now, she likes to use the commode. She wears a diaper just in case. She will press call bell for help . Nurse #4 interview was interviewed on 9/07/2017 at 10:33 AM. She had been employed for a couple of weeks. She said for care needs she looks at the chart and gets report. She said nurse aides are given a verbal report. She said nurse aides document in the electronic medical record. She pulled up the care plan and said there was only one problem for a therapeutic diet. She said Resident #66 can tell you what she needs. A Health Status Note dated 9/7/2017 at 2:39 PM read in part, alert and oriented times three with forgetfulness at times. Requires extensive assist with activities of daily Living (ADLs), set-up for oral care and meal tray. On 9/07/2017 at 4:25 PM Resident #66 was observed in her private bathroom on her own. She was attempting to transfer back into her wheelchair. She appeared anxious and was tightly gripping the grab bar and struggling to back herself into her wheelchair. At approximately the same time NA #15 was passing by Resident #66's room. She said she had to take vital signs and blood sugars. She said Resident #66 goes to the bathroom on her own if she feels like it. At 4:30 PM Resident #66 came out of the bathroom and said in a loud and angry voice, I LIKE TO fell AND NEED MY BRITCHES UP. NA #15 went in the room to assist Resident #66. The MDS Nurse was interviewed on 9/08/2017at 3:34 PM. She said she had worked there a little less than a month and didn't know the residents. She confirmed that Resident #66 discharged on [DATE] and returned on 8/2/17. She said all care plan problems were discontinued on 8/1/17 and the previous care plan problems were not viewable to staff. She said the therapeutic diet problem was restarted. She said Resident #66 should have a whole lot of care plans. Interview with Nurse #3 on 9/08/2017 at 11:15 am revealed Resident #66 was alert and oriented. She needed assistance with transfer and she was still working with therapy. On 9/08/2017 at 3:17 PM the Occupational Therapist was interviewed. She said she had worked with Resident #66 on functional transfers to toilet. She said, Initially she needed two person assistance. Now she needed minimum assist and cues for safety and hand placement. She needed contact guard assistance. We've done safety training with nurse aides in the room. She added, Typically, someone would be with her. She is good about calling if she needs help. I would not recommend her toileting by herself. She can self-propel in wheelchair. She is compliant. The safety awareness has already been an issue (i.e., hand placement). Safety is a huge thing. Resident #66 was interviewed again on 9/08/2017 at 4:20 PM. She said, I tried to get someone yesterday and couldn't find anyone. It was dangerous. On 9/09/2017 at 10:15 AM the Director of Nurses was interviewed. She confirmed that Resident #66 required assistance from one person and needed supervision with activities of daily living. She needed a nurse aide (NA) due to her [DIAGNOSES REDACTED]. Resident #66 had some episodes of confusion. She had tried to get up. She had one assisted fall with staff. She was trying to get out of wheelchair and she did not wait for assist. The Director of Rehab provided education to the CNA. On 09/09/2017 at 3:03 PM NA #2 was interviewed. She was a new employee. She said she found out how to provide care for a resident by shift report from another nurse aide and sometimes from the nurse. She said she had never used any written document to provide care. She added, I've tried the Kardex, but it kicks me out. On 9/9/17 at 4:30 PM, the Chief Executive Officer was informed of the immediate jeopardy for this problem. The Physical Therapy director was interviewed on 9/12/2017 at 11:41 AM. She described an assisted fall the resident have over a weekend and how she provided training to NA #11. She said one thing I thought was important was when a resident comes in new, they should have a care guide in the closet so the aides would know what to do. She said this was brought up to the Administrator. She added that in the EMR, there is a care guide, but does not know who is entering the information onto it. She said we are working on getting the individualization onto the care record. On 9/12/2017 at 12:50 PM, the Administrator was interviewed regarding the Kardex system. She said we knew it was not in place and were working with corporate to figure out whether we have all of the components to the EMR. 2. Resident #128 was admitted on [DATE]. Her admitting [DIAGNOSES REDACTED]. A physician order [REDACTED]. The admission Minimum Data Set with an assessment reference date of 8/23/17. She was assessed as cognitively intact. For dressing, toilet use and personal hygiene she required supervision by one person. Her balance was not steady. She had functional limitation on one side for range of motion. She was totally dependent on staff for bathing from one person. She was always continent and received both occupational and physical therapy. Her Care Area assessment dated [DATE] indicated a care plan would be initiated to address activity of daily living rehabilitation potential, psychosocial well-being, falls, nutritional status, dental, pressure ulcer, and pain. The care plan dated 8/17/17 had two problems. One was for falls and the other for being on a therapeutic Diet. The only instruction on the Kardex was ensure that the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair and follow facility fall protocol. The Documentation Survey Report v2 did not include any individualized instructions for how to bathe the resident. The intervention/task was bathing. On Sunday, August20th, it indicated a bath was given that required total assistance from one person. A Look Back Report was provided for September. On Sunday, August 27, 2017 the bathing entry was blank and on Sunday, September 3, 2017, an entry at 2:39 AM indicated not applicable. The resident was interviewed on 9/06/2017at 10:59 AM about her care. She said she cleaned her own teeth. She said it would be after 3:00 PM before she got dressed unless the therapist did it. She said she could bathe from her waist down, but not waist up. She said, It was like pulling teeth. Three times I did not get a bath. Every Sunday it was after 3:00 PM. She added that she had a bad skin disease and it has an odor. She said she was conscious of the odor when church friends would see her. The resident was packed up and ready to be discharged following the interview, therefore an observation of care had not been made. NA #6 was interviewed on 9/08/2017 at 11:23 AM. She said she needed help with bathing and that she always gave her a bed bath. The MDS Nurse was interviewed on 9/10/2017 at 10:37 AM about the care plan and how to bathe the resident. She acknowledged the lack of a care plan for activities of daily living said I am behind on my care plans and confirmed the resident had been in the nursing home for twenty-two days. Nurse #3 was interviewed about the flow of care need on 9/10/2017at 11:02 AM. She said OT and PT would communicate needs with nursing and nurses would communicate with the nurse aides. 3. Resident #8 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of the care plan dated 05/03/17 for Resident #8 revealed there was no plan of care for her end stage [MEDICAL CONDITION] or her [MEDICAL TREATMENT] treatment. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #8 revealed she had a [DIAGNOSES REDACTED]. Record review of a discharge summary dated 08/16/17 revealed a left thigh fistula on 08/13/17 and a right femoral catheter and [MEDICAL TREATMENT] three times per week. On 09/07/2017 at 5:19 PM Aide #1 indicated Resident #8 was a [MEDICAL TREATMENT] patient. On 09/10/2017 at 3:51 PM, Nurse #9 indicated that she referred to the Medication Administration Record [REDACTED]. On 09/07/2017 at 5:21 PM Administrative Staff Member #3 indicated a care plan for [MEDICAL TREATMENT] should have been initiated on 5/9/17 and updated on 6/8/17. 4. Resident #56 was originally admitted to the facility on [DATE] and was discharged on [DATE]. Resident #56 was admitted to the facility again on 08/09/17 with [DIAGNOSES REDACTED]. Resident #56's current nursing care plan dated 08/09/2017 revealed there were 2 problems present as follows: constipation related to decreased mobility, use/side effects of medication usage and resident is on a therapeutic diet of diabetic, cardiac due to past medical history. The problem of constipation indicated it was initiated and last revised on 11/30/15, and the problem regarding the therapeutic diet was initiated on 12/01/15 and last revised on 08/16/17. There were no other problems addressed on the resident's current care plan. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had [DIAGNOSES REDACTED]. The same MDS indicated Resident #56 was cognitively intact, required extensive assistance with bed mobility, toileting and personal hygiene, and was totally dependent upon staff for bathing. Resident #56 was always incontinent of bowel. In addition, the same MDS indicated that Resident #56 had frequent pain which made it hard for him to sleep at night and limited his day-to-day activities. The pain intensity level assessed for the resident was 8 on a scale of 1 through 10, with 10 representing the most severe pain. The Care Area Assessment Summary signed on 08/23/17 revealed the following care areas triggered for care planning, and that each area would be care planned: ADL function, falls, nutritional status, pressure ulcers, pain, and return to the community. Further review of Resident #56's current care plan of 08/09/2017 revealed it did not address the areas of ADL function, falls, pressure ulcers, pain, and return to the community. In an interview with Resident #56 on 09/09/17 at 10:34 AM, he stated he received physical and occupational therapy to help him with is core strength and to help with his ability to perform his activities of daily living. He also explained he had frequent pain due to his arthritis and his recent surgery to amputate his foot, and at times he had to wait a long time to receive repositioning or pain medication to relieve his pain. He added he did not recall participating in a care plan meeting with the staff after his admission to the facility on [DATE]. Resident #56 further stated he had not been a resident in the facility since December of 2015 and he was going to be discharged from his current stay in the facility on 09/09/17. On 09/10/17 at 9:37 AM, an interview was conducted with the MDS Coordinator. She explained that she recently started working at the facility to fill the temporary position as the MDS nurse, and that she was working on a backlog of MDS assessments and care plans for the facility's residents. She explained that she was aware that the care plan for Resident #56 needed to be comprehensive and based upon his admission MDS assessment dated [DATE]. The MDS nurse reviewed Resident #56's care plan and stated it was inadequate. She added that the resident had a previous admission to the facility in 2015, and that the intervention for constipation last updated 11/30/15 may not be pertinent to his current needs. She stated she had not had time to develop his care plan, and that at the very least, the care plan should have included problems and interventions based upon the current triggered care areas, the physician orders, and Resident #56's diagnoses. She also stated that interventions to address his needs for surgical aftercare, activities of daily living, incontinence, pain, and his skin conditions should have been included in a comprehensive care plan. During an interview with the Director of Nursing (DON) on 09/10/17 at 4:09 PM, she stated that the facility was trying to provide MDS assessments and care plans based upon the comprehensive assessments. She indicated that a temporary MDS nurse was hired to help with completing all comprehensive MDS assessments so that care plans could be individualized to meet the residents' needs.

Based on observation, record, review and staff and resident interviews, the facility failed to provide: Resident #66 a functioning call bell in her bathroom so she could call for assistance when needed; Resident #56 incontinence care when requested; Resident #10 a bath and incontinence care in a manner to maintain the dignity; Resident #131 timely call bell response for toileting assistance. This affected 4 of 40 sample residents reviewed for dignity (Resident #10, #56, #66 and #131). Immediate jeopardy began on 9/7/17 and is ongoing for Resident #66. This resident could not find staff to assist her to the toilet, she transferred independently onto the commode. She did not have a means to call for help after toileting and prior to transferring back into her wheelchair because the call bell was not functioning. She expressed anger and stated that it was dangerous. Examples number 2 - 4 are at no actual harm with potential for more than minimal harm that is not immediate jeopardy and the scope is isolated (D). Findings included: 1. Resident #66 was admitted to the nursing home on 7/17/17. Her admission Minimum Data Assessment indicated she had [DIAGNOSES REDACTED]. Her Minimum Data Set (MDS) assessment dated [DATE] indicated she was moderately impaired in cognition, required extensive assistance from one person for transfer, dressing and toilet use. She was not steady with moving on and off the toilet and only able to stabilize with staff assistance. She had no fall history and she received both occupational and physical therapy during the assessment period. The Care Area Assessment indicated activity of daily living, urinary incontinence and falls would be addressed in the care plan to minimize risks and avoid complications. Resident #66 was interviewed on 9/06/2017 at 9:20 AM. She said, sometimes she was treated with dignity and respect and added, When they don't come and they are short of help, you just have to wait until someone comes and helps you out. On 9/07/2017 at 10:08 AM, Resident #66 said, At home I used pull ups and used the toilet. Here, I use the ones that fasten on the side. The staff get me to the toilet two to three times a day. When I press the call bell they will come. I used the walker before I came. Therapy gives me exercises in my room sometime. Coming, when I call them, is a problem. Mostly on days sometimes on second shift. Nurse Aide (NA) #6 was interviewed on 9/07/2017 at 10:22 AM about how she knows what care to provide residents. She said, After a day or two, I get to know the routine. Sometimes, she (Resident #66) will pee in a diaper. Now, she likes to use the commode. She wears a diaper just in case. She will press call bell for help . The nurse aide's Documentation Survey Report for September 7, 2017 had no activity of daily life entry for that day. It also did not include any individualized instruction for dressing, transferring or toileting. On 9/07/2017 at 4:25 PM Resident #66 was observed in her private bathroom on her own. She was attempting to transfer back into her wheelchair. She appeared anxious and was tightly gripping the grab bar and struggling to back herself into her wheelchair. At approximately the same time NA #15 was passing by Resident #66's room. She said she had to take vital signs and blood sugars. She said Resident #66 goes to the bathroom on her own if she feels like it. At 4:30 PM Resident #66 came out of the bathroom and said in a loud and angry voice, I LIKE TO fell AND NEED MY BRITCHES UP. NA #15 went in the room to assist Resident #66. On 9/08/2017 at 7:54 AM Resident #66 was asked if she had put on the call bell yesterday to let the aide know she needed help. She said the call bell was not working in the bathroom. The surveyor tested the call bell and it did not light outside the door or ring at the nurses' station. On 9/08/2017 at 7:58 AM the surveyor informed the Unit Secretary that the call bell in Resident #66's bathroom was not working. She said it was the first time she had heard about it. On 9/08/2017 at 11:15 AM Nurse #3 was interviewed about call bells. She said, I am aware of a call bell reported not working. I would get in contact with the Maintenance Director. I would call his pager or leave a message. When Nurse #3 was asked about other means for the resident to use to call for help, she said, We have bells and would have to find them. Immediately following the interview she was seen distributing hand bells to Resident #66 and to the other residents who did not have functioning call bells. On 9/09/2017 at 11:01 AM a hand bell was observed in Resident #66's bathroom. On 9/08/2017 at 3:17 PM the Occupational Therapist was interviewed. She said she had worked with Resident #66 on functional transfers to toilet. She said, Initially she needed two person assistance. Now she needed minimum assist and cues for safety and hand placement. She needed contact guard assistance. We've done safety training with nurse aides in the room. She added, Typically, someone would be with her. She is good about calling if she needs help. I would not recommend her toileting by herself. She can self-propel in wheelchair. She is compliant. The safety awareness has already been an issue (i.e., hand placement). Safety is a huge thing. Resident #66 was interviewed again on 9/08/2017 at 4:20 PM. She said, I tried to get someone yesterday and couldn't find anyone. It was dangerous. On 9/8/17 at 12:30 PM, the administrator was informed of the immediate jeopardy. 2. Resident #131 was admitted to the facility on [DATE] upon discharge from a hospital. The resident's medical history included a fracture of her left hip with surgical repair. A review of the resident ' s hospital Discharge Summary dated 9/4/17 included special instructions which read, Patient should be on strict fall precautions she will need physical therapy and occupational therapy. A review of the facility's medical record for Resident #131 revealed her Admission Minimum Data Set (MDS) assessment and individualized care plan were not yet due for completion. A review of the facility's Admission Nursing Summary dated 9/4/17 at 3:15 PM revealed the resident was alert. Her short and long term memory were assessed to be intact and decisions were reported to be consistent and reasonable. The resident required extensive assistance for all of her Activities of Daily Living (ADLs), with the exception of requiring limited assistance of one with dressing and being independent with eating. Resident #131 was reported to be continent of bowel and bladder. A Fall Risk Assessment completed on 9/4/17 revealed Resident #131 was determined to be at a moderate risk for falls. She was noted to have a history of a fall at home with a left [MEDICAL CONDITION] and repair. The Fall Risk Assessment indicated the resident required, hands-on assistance to move from place to place. A review of Resident #131's Physical Therapy (PT) Plan of Care dated 9/5/17 included an assessment of the resident's current functional abilities. The Plan of Care indicated the resident required supervision or touching assistance for ambulation. This level of assistance was further defined as needing a helper to provide verbal cues or touching/steadying assistance as the resident ambulated, either throughout the activity or intermittently. A review of Resident #131's Occupational Therapy (OT) Plan of Care dated 9/5/17 also revealed an assessment of the resident's current functional abilities was conducted. The Plan of Care indicated the resident required supervision or touching assistance for toileting. The resident was also assessed as requiring supervision for transfer with toileting. She was determined to be at a moderate risk for balance and falls. A review of the resident's medical record included a Nursing Note dated 9/6/17 at 2:34 PM. The note indicated the resident was able to verbalize her needs. She ambulated with a walker with assistance of one staff member. Review of a Nursing Note dated 9/7/17 at 8:59 AM also revealed Resident #131 ambulated with the help of a walker, but required assistance and was described as not very steady. Further review of Resident #131's medical record included a Nursing Note dated 9/9/17 at 12:58 AM. This note also indicated Resident #131 ambulated with a walker and the assistance of one. An observation was conducted on 9/9/17 at 7:40 AM. Upon entering the resident ' s hallway, Resident #131's call light was observed to be lit above the door to her room and the sound of an activated call bell was heard. The resident ' s door was closed and she could not be viewed from the hallway. At that time, a continuous observation was made of Resident #131's door and the call light above her doorway. At 7:51 AM a Housekeeping staff member was observed as she passed by Resident #131's room. The Housekeeping staff member did not knock or look into the resident's room. The call light continued to be lit above the door to Resident #131's room. At 8:01 AM, Administrative Staff Member #1 was observed as she walked by the resident's room. The administrative staff member did not knock or look into the resident's room. The call light continued to be lit above the door to Resident #131's room. At 8:07 AM, Administrative Staff Member #2 was observed as she passed by the resident's room. The administrative staff member she did not knock or look into the resident's room. The call light continued to be lit above the door to Resident #131's room. At 8:08 AM, Administrative Staff Member #3 passed by Resident #131's room. The administrative staff member she did not knock or look into the resident's room. The call light continued to be lit above the door to the resident ' s room. At 8:13 AM, Resident #131's breakfast tray was delivered to her room. Within one minute of the tray delivery, the resident's call light was turned off. On 9/9/17 at 8:15 AM, Nursing Assistant (NA) #2 was observed as she came out of the resident's room and closed the door. An interview was conducted with NA #2 at that time. During the interview, the NA was asked why the resident had her call light on. The NA reported the resident needed assistance to get to the bathroom. An interview was conducted on 9/9/17 at 3:20 PM with Resident #131. Upon inquiry, the resident recalled putting on her call light in the morning before breakfast and stated she needed to use the bathroom. Resident #131 reported she was not supposed to go to the bathroom by herself and needed assistance to do so. She did not recall what time she put on the call light that morning, but reported, Sometimes it takes a half hour for them to come. Resident #131 stated she did not have a clock or watch to see exactly how much time had elapsed before staff came to assist her. The resident also described one night earlier in the week when she put on the call light to request bathroom assistance. Resident #131 reported she waited for what seemed to be quite a long time. The resident stated she couldn't wait any longer for staff to come because, I just knew I would wet myself all over if I waited anymore. Resident #131 reported she used the walker in her room to walk to the bathroom unassisted and then back to bed (also unassisted). A follow-up interview was conducted on 9/10/17 at 9:40 AM with Resident #131. During the interview, the resident recalled the night her call light was not answered by staff when she needed assistance to go to the bathroom. The resident stated she had actually used the call light twice that night and ended up getting to the bathroom and back to bed by herself unassisted because no one came to help her. The resident reported she knew she shouldn't walk unassisted but didn't feel she had a choice. When asked how this made her feel, the resident stated, I felt bad. She reported she just didn't feel strong enough to safely walk by herself and had been instructed by therapy and staff that she should not ambulate without assistance. An interview was conducted on 9/10/17 at 3:36 PM with the facility's Director of Nursing (DON). Upon inquiry as to who was responsible for responding to call lights, the DON responded, All staff .we have the no-passing zone. The DON reported 'the no-passing zone' meant all staff from all departments, including housekeeping and dietary, should answer call lights. She reported if the particular staff member answering the call light could not meet the needs of the resident, he/she should let someone know who could take care of the resident's need. When asked what her expected response time would be for staff to answer a call light, the DON stated, Ideally, less than 5 minutes. An interview was conducted on 9/12/17 at 11:55 AM with Physical Therapist (PT) #1. PT #1 reported he had been working with Resident #131 since her admission to the facility a little over one week ago. Upon inquiry, the PT reported the resident continued to require assist of one for ambulation and toileting. The resident's report of ambulating to/from the bathroom on her own in the night were discussed with the PT. The PT stated he, would have wanted her to have help. 3. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact, was incontinent of her bladder and bowel, and that she was totally dependent upon staff for toilet use and bathing. The resident required extensive assistance of one staff member for personal hygiene. An observation of a bath and incontinence care provided for Resident #10 was made on 09/09/17 at 11:19 AM. Nursing assistant (NA) # 7 and NA # 13 provided the bath using a washcloth, soap, and warm water. While Resident #10 lay on her back, NA #7 provided perineal care using a washcloth with soap and warm water, wiping front to back 3 times, folding the washcloth with each wipe. Some light brown color was noted on the washcloth at that time. The resident was turned to her side, and then NA #7 noted there was a large bowel movement on the buttocks. NA #7 used disposable wipes to clean most of the bowel movement, and then she continued cleaning the buttocks with the washcloth with soap and water. NA #7 dried the buttocks, drew a fresh basin of water, then continued bathing Resident #10's upper and lower back and the back of her thighs using the same washcloth and wearing the same gloves she wore while cleaning the bowel movement. When the bath was completed, NA #7 applied a zinc paste to the buttocks, and then to the front perineal area as she still wore the same pair of gloves used to clean the bowel movement. NA #7 applied a clean pillowcase to Resident #10's pillow, placed it under her head, and then picked up her clean shirt and assisted the resident with pulling the shirt over her head. A clean top sheet was placed over the resident. All this care was provided while NA #7 was wearing the same pair of gloves. NA #7 did not wash her hands or change gloves throughout the entire procedure. In an interview with NA #7 on 09/09/17 at 11:46 AM, she stated she had not been educated to wash hands or change gloves after cleaning a bowel movement and before continuing the remainder of the bath or applying a zinc paste to the perineal area. She added she had not been instructed to wash hands or change gloves after providing bowel incontinence care and before applying clean sheets to the bed. NA #7 also stated she had not thought about this being a dignity issue for the resident. During an interview with the Director of Nursing (DON) on 09/09/17 at 4:09 PM, she stated she would expect for the nursing assistant to wash hands and change gloves after providing bowel incontinence care and before continuing the bath and applying perineal paste. The DON continued that hand hygiene she be performed after bowel incontinence care and before clothing, sheets or pillowcase should be applied. She confirmed this was a dignity issue. Resident #10 was interviewed on 09/12/17 at 11:45 AM. She stated that after she received the remainder of her bath with the same washcloth used to clean her bowel movement on 09/09/17, she did not feel clean and she would not want other people to see her or smell odors from her. She stated she felt as though staff didn't really care about her basic cleanliness. 4. Resident #56 was admitted to the facility from the hospital as a short-term resident with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was cognitively intact, required extensive assistance with toileting and personal hygiene, and was totally dependent upon staff for bathing. Resident #56 was always incontinent of bowel. During an interview with Resident #56 on 09/09/17 at 10:34 AM, he stated he had used his call light during the week (09/03/17 through 09/09/17) to summon help after he had soiled himself with a bowel movement, and no one responded until 2 hours later. He stated he could not remember exactly what time he called for help, but it was at least 2 hours he waited before staff arrived. He added he even called his wife at home to see if she could get to the facility to help him after no one responded for so long. He explained he felt that the staff did not care about him and did not respect his need for help. He added that he did not like sitting in his own mess. Upon request, there was no nursing assistant (NA) documentation provided to indicate whether toileting or incontinence care was provided for Resident #56 during the month of September 2017. In an interview with NA #2 on 09/09/17 at 4:25 PM, she stated she worked with Resident #56 during the week of 09/03/17 but did not recall providing incontinence care for him on any specific date. During an interview with the Director of Nursing on 9/10/17 at 4:09 PM, she agreed that lack of bowel incontinence care was a dignity issue and that nursing assistants were expected to provide incontinent care as soon as possible to their assigned residents. On 09/12/17 at 2:16 PM an interview was conducted with Nurse #4 on 9/12/17. She stated that she always worked on the rehabilitation hall. She stated it would be her expectation that anyone who needed incontinence care should receive the care within 5 to 15 minutes, depending on how busy the staff were at that time. She added that no one should have to sit in soiled clothing and sheets for any long period. During an interview with NA #6 on 09/12/17 at 2:40 PM, she stated she worked with Resident #56 on during the week of 09/03/17, and she did not specifically remember providing bowel incontinence care on any specific date, but was aware of his incontinence issue. NA #6 stated that a resident might have to wait for incontinence care when she had 15 to 20 residents assigned to her as she often did. She explained she would have to prioritize who needed care the most and finish up with one resident before she could move to the next. She further explained that she tried to get to each one as soon as possible and she agreed that a resident would not want to wait a few hours to receive bowel incontinence care. In an interview with the on-call physician on 9/12/17 at 3:18 PM he stated that bowel incontinence care should be provided as soon as possible and that he would not want his family member to lie in feces waiting for care for 2 hours or even 20 minutes.

Based on observation, resident interview, staff interview and record review, the facility failed to provide functioning call bells in resident bathrooms so that if a resident needed to summon staff for assistance, they could get help and prevent an accident from occurring. The call bell was not working in the bathroom for 2 of 2 sampled residents who used the private bath in their rooms (Resident #66 & Resident #38). The facility also failed to supervise and prevent the elopement of a cognitively impaired resident (Resident #103), known to have wandering behavior. This affected 1 of 3 sampled residents reviewed for supervision to prevent accidents. Immediate jeopardy began on 4/16/17 for Resident #103, unsupervised by staff, took the elevator to the first floor, exited the building and was found in the facility parking lot. Resident #103 was located by staff after an undetermined amount of time outside of the facility and had no injuries. Immediate jeopardy began on 9/7/17 and is ongoing for Resident #66. This resident could not find staff to assist her to the toilet, she transferred independently onto the commode. She did not have a means to call for help after toileting and prior to transferring back into her wheelchair because the call bell was not functioning. She expressed anger and stated that it was dangerous. She had a high likelihood for falling and receiving a serious injury associated with her post-surgical knee amputation, high blood sugar on that day and a continued need for occupational therapy for transferring, toileting and dressing the lower body. Three hours passed before hand bells were distributed to the bathrooms that had non-functioning call bells. Immediate jeopardy began on 9/8/17 and is ongoing for Resident #38 who toilets independently and had a call bell that did not work. Findings included: 1. Resident #66 was admitted to the nursing home on 7/17/17. Her admission Minimum Data Assessment indicated she had [DIAGNOSES REDACTED]. Her Minimum Data Set (MDS) assessment dated [DATE] indicated she was moderately impaired in cognition, required extensive assistance from one person for transfer, dressing and toilet use. She was not steady with moving on and off the toilet and only able to stabilize with staff assistance. She had no fall history and she received both occupational and physical therapy during the assessment period. The Care Area Assessment indicated activity of daily living, urinary incontinence and falls would be addressed in the care plan to minimize risks and avoid complications. A care plan dated 8/1/17 indicated all problems were cancelled and resolved. A new care plan was initiated on 8/7/17. It only contained one problem for being on a therapeutic diet. According to occupational therapy (OT) notes, Resident #66 began working with occupational therapy on 8/3/17. Goals were set for lower body dressing, toileting hygiene and toileting transfer. She was assessed as needing substantial/maximal assistance in lower body dressing and toileting hygiene. On 8/16/17 another MDS indicated her brief interview for mental status score improved from 11 to 12. A Fall Event report indicated Resident #66 had an assisted fall on Sunday, 8/27/17 at 10:00 AM. It said, The Certified Nurse Aide (CNA) was assisting resident with transfer from bed to wheelchair. CNA assisted resident to the floor. There was no harm and the Therapy Director provided education to the CNA on transfers. A corresponding physical therapy note dated 8/30/17 indicated Nurse Aide #10 was trained in regards to toilet transfer to support fall prevention during transfers. An attempt to interview NA #10, who worked on the weekends, was made at 11:56 AM on 9/12/17. Interview with the therapy director on 9/12/17 at 11:30 AM revealed Resident #66 had assisted fall over a weekend. She was in the bathroom and her leg buckled. The therapy director said she was working that day and showed NA#10 how to transfer her using the grip bars. On 8/27/17 a Fall Risk Assessment was done. She was determined to need assistance with elimination and was unable to come to a standing position and a recent fall. An aide's care record for September had entries for toilet use every shift on 9/1, 9/3, 9/5 & 9/6. According to the Occupational Therapy (OT) therapy notes dated 9/4/17, Resident #66 required substantial assistance with lower body dressing and had improved in toileting - transfers to being able to safely transfer to the toilet with supervision or touching -minimum assistance for toileting routine. Resident #66 was interviewed on 9/06/2017 at 9:20 AM. She said, sometimes she was treated with dignity and respect and added, When they don't come and they are short of help, you just have to wait until someone comes and helps you out. On 9/07/2017 at 10:08 AM, Resident #66 said, At home I used pull ups and used the toilet. Here, I use the ones that fasten on the side. The staff get me to the toilet two to three times a day. When I press the call bell they will come. I used the walker before I came. Therapy gives me exercises in my room sometime. Coming, when I call them, is a problem. Mostly on days sometimes on second shift. Nurse Aide (NA) #6 was interviewed on 9/07/2017 at 10:22 AM about how she knows what care to provide residents. She said, After a day or two, I get to know the routine. Sometimes, she (Resident #66) will pee in a diaper. Now, she likes to use the commode. She wears a diaper just in case. She will press call bell for help . The nurse aide's Documentation Survey Report for September 7, 2017 had no activity of daily life entry for that day. It also did not include any individualized instruction for dressing, transferring or toileting. A Health Status Note dated 9/7/2017 at 2:39 PM read in part, alert and oriented times three with forgetfulness at times. Requires extensive assist with activities of daily Living (ADLs), set-up for oral care and meal tray. Blood sugar at 11:30 AM 236, receives insulin per sliding scale insulin order. On 9/07/2017 at 4:25 PM Resident #66 was observed in her private bathroom on her own. She was attempting to transfer back into her wheelchair. She appeared anxious and was tightly gripping the grab bar and struggling to back herself into her wheelchair. At approximately the same time NA #15 was passing by Resident #66's room. She said she had to take vital signs and blood sugars. She said Resident #66 goes to the bathroom on her own if she feels like it. At 4:30 PM Resident #66 came out of the bathroom and said in a loud and angry voice, I LIKE TO fell AND NEED MY BRITCHES UP. NA #15 went in the room to assist Resident #66. According to the blood sugar (BS) monitoring record and the medication administration record (MAR), the Resident #66's BS was documented as 499 at 5:23 PM on 9/7/17. Twelve units of insulin was administered by Nurse #4. Interview with Nurse #3 on 9/08/2017 at 11:15 am revealed Resident #66 was alert and oriented. She needed assistance with transfer and she was still working with therapy. On 9/08/2017 at 7:54 AM Resident #66 was asked if she had put on the call bell yesterday to let the aide know she needed help. She said the call bell was not working in the bathroom. The surveyor tested the call bell and it did not light outside the door or ring at the nurses' station. On 9/08/2017 at 7:58 AM the surveyor informed the Unit Secretary that the call bell in Resident #66's bathroom was not working. She said it was the first time she had heard about it. On 9/08/2017 at 8:13 AM Contract Maintenance Person #1 and #2 arrived. One said, It's hooked up, but not working. There were two call bells in the bathroom - one about waist height on one side of the commode and another about knee height on the other side of the commode and neither worked. The Contract Maintenance Person #1 said, I've tried both and neither works. Surveyors initiated call bell checks on 9/08/2017 at 10:00 AM. Four more calls in bathrooms were not working. These were in rooms 201, 265, 270 and shared bathroom 240 and 241. On 9/08/2017 at 10:58 AM, the Administrator said she calls maintenance when there is a call bell in the bathroom that doesn't work. On 9/08/2017 at 11:15 AM Nurse #3 was interviewed about call bells. She said, I am aware of a call bell reported not working. I would get in contact with the Maintenance Director. I would call his pager or leave a message. When Nurse #3 was asked about other means for the resident to use to call for help, she said, We have bells and would have to find them. Immediately following the interview she was seen distributing hand bells to Resident #66 and to the other residents who did not have functioning call bells. On 9/08/2017 at 11:25 AM, the Director of Plant Operations was interviewed. He said, If we get a report about a problem, then we get a service call. We would not check other call bells. It is on an as needed basis. He confirmed that the call bell in Resident #66's bathroom room did not work. On 9/09/2017 at 11:01 AM a hand bell was observed in Resident #66's bathroom. On 9/08/2017 at 3:17 PM the Occupational Therapist was interviewed. She said she had worked with Resident #66 on functional transfers to toilet. She said, Initially she needed two person assistance. Now she needed minimum assist and cues for safety and hand placement. She needed contact guard assistance. We've done safety training with nurse aides in the room. She added, Typically, someone would be with her. She is good about calling if she needs help. I would not recommend her toileting by herself. She can self-propel in wheelchair. She is compliant. The safety awareness has already been an issue (i.e., hand placement). Safety is a huge thing. Resident #66 was interviewed again on 9/08/2017 at 4:20 PM. She said, I tried to get someone yesterday and couldn't find anyone. It was dangerous. On 9/09/2017 at 10:15 AM the Director of Nurses was interviewed. She confirmed that Resident #66 required assistance from one person and needed supervision with activities of daily living. She needed a nurse aide (NA) due to her [DIAGNOSES REDACTED]. Resident #66 had some episodes of confusion. She had tried to get up. She had one assisted fall with staff. She was trying to get out of wheelchair and she did not wait for assist. The Director of Rehab provided education to the CNA. On 9/8/17 at 12:30, the administrator was informed of the immediate jeopardy. 2. Resident #38's bathroom call bell was tested on [DATE] during rounds at 10:00 AM. The resident said she used the bathroom. Her quarterly Minimum Data Set had an assessment reference date of 7/11/17 indicated her cognition was severely impaired. Her dressing, transfer and toileting ability was independent. A care plan with a review start date of 10//17 included approaches for problems with ADLs and for falls indicated, Encourage the resident to use bell to call for assistance and The resident needs a safe environment with floors free from spills and/or clutter; adequate light; a working and reachable call light and personal items within reach. Her care plan dated 7/20/2017 indicated she was able to toilet independently. Surveyors initiated call bell checks on 9/08/2017 at 10:00 AM. The call bell in Resident #38's bathroom did not work when tested . On 9/08/2017 at 10:58 AM, the Administrator said she calls maintenance when there is a call bell in the bathroom that doesn't work. On 9/08/2017 at 11:15 AM Nurse #3 was interviewed about call bells. She said she would contact the Maintenance Director if a call bell problem was noted. I would call his pager or leave a message. When Nurse #3 was asked about other means for the resident to use to call for help, she said, We have bells and would have to find them. Immediately following the interview she was seen distributing hand bells to Resident #38 and to the other residents who did not have functioning call bells. On 9/08/2017 at 11:25 AM, the Director of Plant Operations was interviewed. He said, If we get a report about a problem, then we get a service call. We would not check other call bells. It is on an as needed basis. He confirmed that the call bell in Resident #38's bathroom room did not work. On 9/09/2017 at 11:05 AM a hand bell was observed in Resident #38's bathroom. On 9/08/2017 at 11:25 AM, the Director of Plant Operations was interviewed. He said, If we get a report about a problem, then we get a service call. We would not check other call bells. It is on an as needed basis. Interview with NA#8 on 9/12/17 at 11:52 AM revealed Resident #38 was very independent with activities of daily living and used the bathroom on her own. 3. Resident #103 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident was discharged to the community on 4/22/17. The attending physician's admission note dated 4/10/17, had early onset, advanced dementia. There was no written, initial plan of care in Resident #103's clinical record. A Nurse's Note, written by Nurse #10, dated 4/14/17 at 7:52 AM stated, redirected several times on PM (evening) shift ambulation in hallway attempting to go in other patients room without knocking. Combative with incontinent care on pm shift. Hitting and kicking staff as care was being provided. Refused pain med (medication). Night shift redirected X2(twice) ambulating in hallway. Observed sleeping in bed A several times. A Nurse's Note, written by Nurse #10, dated 4/15/17 at 8:31 AM, revealed the resident had become combative and a one-time intramuscular dose of Haldol 5 milligrams (mg) was administered at 6:16 AM for agitation. Haldol is an antipsychotic drug used to treat acute psychosis. The facility was unable to provide a Wander Risk Assessment for Resident #103 or documentation about when a wander guard was placed on Resident #103. The admission comprehensive Minimum Data Set (MDS) was in progress but had not yet been completed. The Nurse's Notes written by Nurse #2 dated 4/16/17 at 3:30 PM read, Pt (Patient) eloped from facility. Pt located sitting on curbing in front of ER (emergency room which was in the same building as the nursing facility). Pt ambulated back to floor. Skin intact. Denies pain. The note also stated the Director of Nursing (DON), physician, House Supervisor and the Resident Representative had been notified and that the resident was wearing a wander guard alarm bracelet on her right ankle at the time of the elopement. A Safety/Security Event form dated 4/16/17, specified the resident had wandered outside of the facility and was found sitting on a curb in front of the ER. It also stated a wander guard was on her right ankle and that it did not trigger the door alarm to lock. On the form, the Section for Witnesses/Parties Involved stated Not Specified The Follow-up Actions on the Safety/Security Event form was dated 4/27/17 by the DON and indicated that Maintenance and the wander guard company had been contacted. The facility provided email correspondence dated 4/17/17, in which the DON asked the Plant Operations Director to review the camera in an effort to establish a timeline for the elopement. The response was, The resident came off the elevator on the first floor at 2:38. She was found outside the ER by CNA's (Nursing Assistants) at 3:03. When asked for an investigation of the incident, the facility provided a note, handwritten by Nurse #2 that was dated 4/20/17 (no time). It simply stated which staff persons had tried to locate Resident #103 and where each person had searched. It also stated the resident had been found sitting on the curb in front of the ER. The paragraph was signed by the nurse. Nurse #1, who had participated in the search was interviewed on 9/12/17 at 2:28 PM. Nurse #1 said, I think (Nurse #2) is the one who had her. (Resident #103) was a wanderer and went into other people's rooms and she could ambulate pretty well. The wander guard helped by alarming when she passed certain zones. Nurse #1 did not know if the wander guard had malfunctioned or if it had been tested . The Admissions Coordinator, who had assisted in the search for Resident #103 was interviewed on 9/12/17 at 2:38 PM. The Admissions Coordinator stated, Resident #103 was known to wander in other resident rooms and in the halls. She stated the resident was wearing a wander guard ankle bracelet, but when the resident left via the second floor elevator, it had not locked in place. The Admissions Coordinator did not know which NA was assigned to Resident #103 but said, We looked for 5 or 10 minutes. By the time we were looking, if I remember, it was the ER (staff who) brought her back up. The Admissions Coordinator specified the ER staff had been made aware of the missing resident due to a Code Pink that was paged overhead in the building that described the resident and what she was wearing. NA #9, who had participated in the search was interviewed on 9/12/17 at 2:46 PM. NA #9 said, They are in and it's hard to keep up on resident names. NA #9 was unable to remember Resident #103 or the incident. Nurse #2, who was assigned to the Resident #103 on day of elopement, could not be reached by phone for an interview. The facility was unable to identify which nursing assistant was assigned to the resident on the day of the elopement. The Plant Operations Director was interviewed on 9/12/17 at 4:54 PM. The Plant Operations Director stated he had only worked at the facility for a few weeks at the time of the elopement. He said that prior to the elopement, there was an alarm that was near the elevator that would sound if the resident was near the elevator. The Plant Operations Director was not aware at the time of the elopement, that the wander guard system did not include locking the elevator door when a resident wearing a wander guarded entered the elevator. The Plant Operations Director indicated after Resident #103 was found outside in the parking lot, he was asked by administration to check the cameras to see how the resident got out of the building. He said, She took the elevator to first floor and then went out the door by the ER. He also said, I immediately brought folks in who knew the system, both the elevator and the company for the wander guard system. We found that it had an outdated transponder. To make a long story short, we purchased an updated transponder and brought in the state elevator folks to approve it. We did our due diligence and now it locks and will not move if a person with a wander guard enters the elevator. He did not know if the ankle bracelet itself was tested to see if it was working at the time of the elopement. The Administrator and DON were interviewed on 9/12/17 at 4:16 PM. The Administrator stated Resident #103 was wearing a wander guard ankle bracelet at the time of the elopement which was effective in sounding an alarm and locking all exit doors, but that the resident had left the second floor of the facility by using the elevator. The Administrator stated that prior to the elopement in April, she had made a request for something that would prevent the elevator from working with a resident with a wander guard who attempted to get on. She also stated that since the elopement, the elevator had been fixed and residents could no longer get out of the facility that way.

Based on resident interviews, staff interviews and review of the staffing records, the facility failed to provide staffing in sufficient numbers to meet the needs of residents for 4 of 40 sampled residents (#66, #103, #131, and #56). Examples 1 and 2 were at the immediate jeopardy level. Examples 3 - 5 were at no actual harm with potential for more than minimal harm that is not immediate jeopardy and the scope is a pattern (E). Findings included: 1. Resident #66 was admitted to the nursing home on 7/17/17. Her admission Minimum Data Assessment indicated she had [DIAGNOSES REDACTED]. Her Minimum Data Set (MDS) assessment dated [DATE] indicated she was moderately impaired in cognition (Brief Interview for Mental Status was 11), required extensive assistance from one person for transfer, dressing and toilet use. She was not steady with moving on and off the toilet and only able to stabilize with staff assistance. She had no fall history and she received both occupational and physical therapy during the assessment period. The Care Area Assessment indicated activity of daily living, urinary incontinence and falls would be addressed in the care plan to minimize risks and avoid complications. According to the Occupational Therapy (OT) therapy notes dated 9/4/17, Resident #66 required substantial assistance with lower body dressing and had improved in toileting - transfers to being able to safely transfer to the toilet with supervision or touching -minimum assistance for toileting routine. Resident #66 was interviewed on 9/06/2017 at 9:20 AM. She said, sometimes she was treated with dignity and respect and added, When they don't come and they are short of help, you just have to wait until someone comes and helps you out. On 9/07/2017 at 10:08 AM, Resident #66 said, At home I used pull ups and used the toilet. Here, I use the ones that fasten on the side. The staff get me to the toilet two to three times a day. When I press the call bell they will come. I used the walker before I came. Therapy gives me exercises in my room sometime. Coming, when I call them, is a problem. Mostly on days sometimes on second shift. A Health Status Note dated 9/7/2017 at 2:39 PM read in part, alert and oriented times three with forgetfulness at times. Requires extensive assist with activities of daily Living (ADLs), set-up for oral care and meal tray. Blood sugar at 11:30 AM 236, receives insulin per sliding scale insulin order. On 9/07/2017 at 4:25 PM Resident #66 was observed in her private bathroom on her own. She was attempting to transfer back into her wheelchair. She appeared anxious and was tightly gripping the grab bar and struggling to back herself into her wheelchair. At approximately the same time NA #15 was passing by Resident #66's room. She said she had to take vital signs and blood sugars. She said Resident #66 goes to the bathroom on her own if she feels like it. At 4:30 PM Resident #66 came out of the bathroom and said in a loud and angry voice, I LIKE TO fell AND NEED MY BRITCHES UP. NA #15 went in the room to assist Resident #66. On 9/08/2017 at 7:54 AM Resident #66 was asked if she had put on the call bell yesterday to let the aide know she needed help. She said the call bell was not working in the bathroom. On 9/08/2017 at 3:17 PM the Occupational Therapist was interviewed. She said she had worked with Resident #66 on functional transfers to toilet. She said, Initially she needed two person assistance. Now she needed minimum assist and cues for safety and hand placement. She needed contact guard assistance. We've done safety training with nurse aides in the room. She added, Typically, someone would be with her. She is good about calling if she needs help. I would not recommend her toileting by herself. She can self-propel in wheelchair. She is compliant. The safety awareness has already been an issue (i.e., hand placement). Safety is a huge thing. Resident #66 was interviewed again on 9/08/2017 at 4:20 PM. She said, I tried to get someone yesterday and couldn't find anyone. It was dangerous. On 9/09/2017 at 10:15 AM the Director of Nurses was interviewed. She confirmed that Resident #66 required assistance from one person and needed supervision with activities of daily living. She needed a nurse aide (NA) due to her [DIAGNOSES REDACTED]. Resident #66 had some episodes of confusion. She had tried to get up. She had one assisted fall with staff. She was trying to get out of wheelchair and she did not wait for assist. The Director of Rehab provided education to the CNA. Immediate jeopardy began on 9/7/17 and is ongoing for Resident #66. This resident could not find staff to assist her to the toilet, she transferred independently onto the commode. She did not have a means to call for help after toileting and prior to transferring back into her wheelchair because the call bell was not functioning. She expressed anger and stated that it was dangerous. She had a high likelihood for falling and receiving a serious injury associated with her post-surgical knee [MEDICAL CONDITION], high blood sugar on that day and a continued need for occupational therapy for transferring, toileting and dressing the lower body. On 9/7/17, three hours passed before hand bells were distributed to the bathrooms that had non-functioning call bells. On 9/8/17 at 12:30, the administrator was informed of the immediate jeopardy. 2. Resident #103 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident was discharged to the community on 4/22/17. The attending physician's admission note dated 4/10/17, had early onset, advanced dementia. There was no written, initial plan of care in Resident #103's clinical record. A Nurse's Note, written by Nurse #10, dated 4/14/17 at 7:52 AM stated, redirected several times on PM (evening) shift ambulation in hallway attempting to go in other patient's room without knocking. Combative with incontinent care on pm shift. Hitting and kicking staff as care was being provided. Refused pain med (medication). Night shift redirected X2(twice) ambulating in hallway. Observed sleeping in bed A several times. A Nurse's Note, written by Nurse #10, dated 4/15/17 at 8:31 AM, revealed the resident had become combative and a one-time intramuscular dose of [MEDICATION NAME] 5 milligrams (mg) was administered at 6:16 AM for agitation. [MEDICATION NAME] is an antipsychotic drug used to treat acute [MEDICAL CONDITION]. The facility was unable to provide a Wander Risk Assessment for Resident #103 or documentation about when a wander guard was placed on Resident #103. The admission comprehensive Minimum Data Set (MDS) was in progress but had not yet been completed. The Nurse's Notes written by Nurse #2 dated 4/16/17 at 3:30 PM read, Pt (Patient) eloped from facility. Pt located sitting on curbing in front of ER (emergency room which was in the same building as the nursing facility). Pt ambulated back to floor. Skin intact. Denies pain. The note also stated the Director of Nursing (DON), physician, House Supervisor and the Resident Representative had been notified and that the resident was wearing a wander guard alarm bracelet on her right ankle at the time of the elopement. A Safety/Security Event form dated 4/16/17, specified the resident had wandered outside of the facility and was found sitting on a curb in front of the ER. It also stated a wander guard was on her right ankle and that it did not trigger the door alarm to lock. On the form, the Section for Witnesses/Parties Involved stated Not Specified The Follow-up Actions on the Safety/Security Event form was dated 4/27/17 by the DON and indicated that Maintenance and the wander guard company had been contacted. The facility provided email correspondence dated 4/17/17, in which the DON asked the Plant Operations Director to review the camera in an effort to establish a timeline for the elopement. The response was, The resident came off the elevator on the first floor at 2:38. She was found outside the ER by CNA's (Nursing Assistants) at 3:03. When asked for an investigation of the incident, the facility provided a note, handwritten by Nurse #2 that was dated 4/20/17 (no time). It simply stated which staff persons had tried to locate Resident #103 and where each person had searched. It also stated the resident had been found sitting on the curb in front of the ER. The paragraph was signed by the nurse. Nurse #1, who had participated in the search was interviewed on 9/12/17 at 2:28 PM. Nurse #1 said, I think (Nurse #2) is the one who had her. (Resident #103) was a wanderer and went into other people's rooms and she could ambulate pretty well. The wander guard helped by alarming when she passed certain zones. Nurse #1 did not know if the wander guard had malfunctioned or if it had been tested . The Admissions Coordinator, who had assisted in the search for Resident #103 was interviewed on 9/12/17 at 2:38 PM. The Admissions Coordinator stated, Resident #103 was known to wander in other resident rooms and in the halls. She stated the resident was wearing a wander guard ankle bracelet, but when the resident left via the second floor elevator, it had not locked in place. The Admissions Coordinator did not know which NA was assigned to Resident #103 but said, We looked for 5 or 10 minutes. By the time we were looking, if I remember, it was the ER (staff who) brought her back up. The Admissions Coordinator specified the ER staff had been made aware of the missing resident due to a Code Pink that was paged overhead in the building that described the resident and what she was wearing. NA #9, who had participated in the search was interviewed on 9/12/17 at 2:46 PM. NA #9 said, They are in and it's hard to keep up on resident names. NA #9 was unable to remember Resident #103 or the incident. Nurse #2, who was assigned to the Resident #103 on day of elopement, could not be reached by phone for an interview. The facility was unable to identify which nursing assistant was assigned to the resident on the day of the elopement. The Plant Operations Director was interviewed on 9/12/17 at 4:54 PM. The Plant Operations Director stated he had only worked at the facility for a few weeks at the time of the elopement. He said that prior to the elopement, there was an alarm that was near the elevator that would sound if the resident was near the elevator. The Plant Operations Director was not aware at the time of the elopement, that the wander guard system did not include locking the elevator door when a resident wearing a wander guarded entered the elevator. The Plant Operations Director indicated after Resident #103 was found outside in the parking lot, he was asked by administration to check the cameras to see how the resident got out of the building. He said, She took the elevator to first floor and then went out the door by the ER. He also said, I immediately brought folks in who knew the system, both the elevator and the company for the wander guard system. We found that it had an outdated transponder. To make a long story short, we purchased an updated transponder and brought in the state elevator folks to approve it. We did our due diligence and now it locks and will not move if a person with a wander guard enters the elevator. He did not know if the ankle bracelet itself was tested to see if it was working at the time of the elopement. The Administrator and DON were interviewed on 9/12/17 at 4:16 PM. The Administrator stated Resident #103 was wearing a wander guard ankle bracelet at the time of the elopement which was effective in sounding an alarm and locking all exit doors, but that the resident had left the second floor of the facility by using the elevator. The Administrator stated that prior to the elopement in April, she had made a request for something that would prevent the elevator from working with a resident with a wander guard who attempted to get on. She also stated that since the elopement, the elevator had been fixed and residents could no longer get out of the facility that way. Immediate jeopardy began on 4/16/17 for Resident #103, unsupervised by staff, took the elevator to the first floor, exited the building and was found in the facility parking lot. Resident #103 was located by staff after an undetermined amount of time outside of the facility and had no injuries. 3. Resident #131 was admitted to the facility on [DATE] upon discharge from a hospital. The resident's medical history included a fracture of her left hip with surgical repair. A review of the resident's hospital Discharge Summary dated 9/4/17 included special instructions which read, Patient should be on strict fall precautions she will need physical therapy and occupational therapy. A review of the facility's medical record for Resident #131 revealed her Admission Minimum Data Set (MDS) assessment and individualized care plan were not yet due for completion. A review of the facility's Admission Nursing Summary dated 9/4/17 at 3:15 PM revealed the resident was alert. Her short and long term memory were assessed to be intact and decisions were reported to be consistent and reasonable. The resident required extensive assistance for all of her Activities of Daily Living (ADLs), with the exception of requiring limited assistance of one with dressing and being independent with eating. Resident #131 was reported to be continent of bowel and bladder. A Fall Risk Assessment completed on 9/4/17 revealed Resident #131 was determined to be at a moderate risk for falls. She was noted to have a history of a fall at home with a left [MEDICAL CONDITION] and repair. The Fall Risk Assessment indicated the resident required, hands-on assistance to move from place to place. A review of Resident #131's Physical Therapy (PT) Plan of Care dated 9/5/17 included an assessment of the resident's current functional abilities. The Plan of Care indicated the resident required supervision or touching assistance for ambulation. This level of assistance was further defined as needing a helper to provide verbal cues or touching/steadying assistance as the resident ambulated, either throughout the activity or intermittently. A review of Resident #131's Occupational Therapy (OT) Plan of Care dated 9/5/17 also revealed an assessment of the resident ' s current functional abilities was conducted. The Plan of Care indicated the resident required supervision or touching assistance for toileting. The resident was also assessed as requiring supervision for transfer with toileting. She was determined to be at a moderate risk for balance and falls. A review of the resident's medical record included a Nursing Note dated 9/6/17 at 2:34 PM. The note indicated the resident was able to verbalize her needs. She ambulated with a walker with the assist of one. Review of a Nursing Note dated 9/7/17 at 8:59 AM also revealed Resident #131 ambulated with the help of a walker, but required assistance and was described as not very steady. Further review of Resident #131's medical record included a Nursing Note dated 9/9/17 at 12:58 AM. This note also indicated Resident #131 ambulated with a walker and the assistance of one. An observation was conducted on 9/9/17 at 7:40 AM. Upon entering the resident ' s hallway, Resident #131's call light was observed to be lit above the door to her room and the sound of an activated call bell was heard. The resident's door was closed and she could not be viewed from the hallway. At that time, a continuous observation was made of Resident #131's door and the call light above her doorway. At 7:51 AM a Housekeeping staff member was observed as she passed by Resident #131's room. The Housekeeping staff member did not knock or look into the resident's room. The call light continued to be lit above the door to Resident #131's room. At 8:01 AM, Administrative Staff Member #1 was observed as she walked by the resident's room. The administrative staff member did not knock or look into the resident's room. The call light continued to be lit above the door to Resident #131's room. At 8:07 AM, Administrative Staff Member #2 was observed as she passed by the resident's room. The administrative staff member she did not knock or look into the resident's room. The call light continued to be lit above the door to Resident #131's room. At 8:08 AM, Administrative Staff Member #3 passed by Resident #131's room. The administrative staff member she did not knock or look into the resident's room. The call light continued to be lit above the door to the resident's room. At 8:13 AM, Resident #131's breakfast tray was delivered to her room. Within one minute of the tray delivery, the resident's call light was turned off. On 9/9/17 at 8:15 AM, Nursing Assistant (NA) #2 was observed as she came out of the resident's room and closed the door. An interview was conducted with NA #2 at that time. During the interview, the NA was asked why the resident had her call light on. The NA reported the resident needed assistance to get to the bathroom. An interview was conducted on 9/9/17 at 3:20 PM with Resident #131. Upon inquiry, the resident recalled putting on her call light in the morning before breakfast and stated she needed to use the bathroom. Resident #131 reported she was not supposed to go to the bathroom by herself and needed assistance to do so. She did not recall what time she put on the call light that morning, but reported, Sometimes it takes a half hour for them to come. Resident #131 stated she did not have a clock or watch to see exactly how much time had elapsed before staff came to assist her. The resident also described one night earlier in the week when she put on the call light to request bathroom assistance. Resident #131 reported she waited for what seemed to be quite a long time. The resident stated she couldn't wait any longer for staff to come because, I just knew I would wet myself all over if I waited anymore. Resident #131 reported she used the walker in her room to walk to the bathroom unassisted and then back to bed (also unassisted). Resident #131 stated she met the facility's Administrator a couple of days ago and told her, You need more help. A follow-up interview was conducted on 9/10/17 at 9:40 AM with Resident #131. During the interview, the resident recalled the night her call light was not answered by staff when she needed assistance to go to the bathroom. The resident stated she had actually used the call light twice that night and ended up getting to the bathroom and back to bed by herself unassisted because no one came to help her. The resident reported she knew she shouldn't walk unassisted but didn't feel she had a choice. She reported she just didn't feel strong enough to safely walk by herself and had been instructed by therapy and staff that she should not ambulate without assistance. An interview was conducted on 9/10/17 at 3:36 PM with the facility's Director of Nursing (DON). Upon inquiry as to who was responsible for responding to call lights, the DON responded, All staff .we have the no-passing zone. The DON reported 'the no-passing zone' meant all staff from all departments, including housekeeping and dietary, should answer call lights. She reported if the particular staff member answering the call light could not meet the needs of the resident, he/she should let someone know who could take care of the resident's need. When asked what her expected response time would be for staff to answer a call light, the DON stated, Ideally, less than 5 minutes. An interview was conducted on 9/12/17 at 11:55 AM with Physical Therapist (PT) #1. PT #1 reported he had been working with Resident #131 since her admission to the facility a little over one week ago. Upon inquiry, the PT reported the resident continued to require assist of one for ambulation and toileting. The resident's report of ambulating to/from the bathroom on her own in the night were discussed with the PT. The PT stated he, would have wanted her to have help. 4.a. Resident #56 was admitted to the facility from the hospital as a short-term resident with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was cognitively intact, required extensive assistance with toileting and personal hygiene, and was totally dependent upon staff for bathing. Resident #56 was always incontinent of bowel. During an interview with Resident #56 on 09/09/17 at 10:34 AM, he stated he had used his call light during the week (09/03/17 through 09/09/17) to summon help after he had soiled himself with a bowel movement, and no one responded until 2 hours later. He stated he could not remember exactly what time he called for help, but it was at least 2 hours he waited before staff arrived. He added he even called his wife at home to see if she could get to the facility to help him after no one responded for so long. He explained he felt that the staff did not care about him and did not respect his need for help. He added that he did not like sitting in his own mess. Upon request, there was no nursing assistant (NA) documentation provided to indicate whether toileting or incontinence care was provided for Resident #56 during the month of September 2017. In an interview with NA #2 on 09/09/17 at 4:25 PM, she stated she worked with Resident #56 during the week of 09/03/17 but did not recall providing incontinence care for him on any specific date. During an interview with the Director of Nursing on 9/10/17 at 4:09 PM, she agreed that lack of bowel incontinence care was a dignity issue and that nursing assistants were expected to provide incontinent care as soon as possible to their assigned residents. On 09/12/17 at 2:16 PM an interview was conducted with Nurse #4 on 9/12/17. She stated that she always worked on the rehabilitation hall. She stated it would be her expectation that anyone who needed incontinence care should receive the care within 5 to 15 minutes, depending on how busy the staff were at that time. She added that no one should have to sit in soiled clothing and sheets for any long period. During an interview with NA #6 on 09/12/17 at 2:40 PM, she stated she worked with Resident #56 on during the week of 09/03/17, and she did not specifically remember providing bowel incontinence care on any specific date, but was aware of his incontinence issue. NA #6 stated that a resident might have to wait for incontinence care when she had 15 to 20 residents assigned to her as she often did. She explained she would have to prioritize who needed care the most and finish up with one resident before she could move to the next. She further explained that she tried to get to each one as soon as possible and she agreed that a resident would not want to wait a few hours to receive bowel incontinence care. In an interview with the on-call physician on 9/12/17 at 3:18 PM he stated that bowel incontinence care should be provided as soon as possible and that he would not want his family member to lie in feces waiting for care for 2 hours or even 20 minutes. 4.b. Resident #56 was admitted to the facility on [DATE] from the hospital as a short-term resident with multiple [DIAGNOSES REDACTED]. A review of Resident #56's current nursing care plan dated 08/09/2017 revealed there were no problems, goals, or interventions for pain management or aftercare from surgery. There were two physician's orders [REDACTED].#56 as follows: 08/09/17 - [MEDICATION NAME] Tablet 2 MG give 1 milligram (mg) by mouth every 4 hours as needed for pain. 08/10/17 - [MEDICATION NAME] Patch 5 %. Apply to painful area topically one time a day for pain. Apply patch to most painful area up to 12 hours and remove per schedule. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had [DIAGNOSES REDACTED]. The same MDS indicated Resident #56 was cognitively intact and had frequent pain which made it hard for him to sleep at night and limited his day-to-day activities. The pain intensity level recorded on the assessment was 8 on a scale of 1 through 10, with 10 representing the most severe pain. In an interview with Resident #56 on 09/09/17 at 10:34 AM, he stated he had used his call light the previous Friday (09/01/2017) and that it took at least an hour for someone to respond to provide him with pain medication. He was unable to remember exactly what time he called for pain medication, but he knew it was a little over an hour. Resident #56 explained that he had pain from his recent foot surgery as well as pain in his back due to arthritis. He added that sometimes repositioning helped his back pain, but both his back pain and surgical pain sometimes were strong enough that he needed the [MEDICATION NAME] or his oral pain medication, [MEDICATION NAME]. He further stated that his pain in his back was at pain level 7 on a scale of 1 through 10 that Friday, but by the time he was given pain medication, his pain level was at 8. Resident #56 stated this was not the only time he had to wait a long time to receive pain medication. He explained it took a very long time for anyone to answer his call light for any of his pain issues or other needs, so staff never knew he needed pain medication until they finally answered the call light. Review of the August 2017 Medication Administration Record [REDACTED]. A review of the September 2017 MAR indicated [REDACTED]. An interview was conducted on 09/09/17 at 4:15 PM with the Nurse #9 who was on duty on 09/01/17 when Resident #56 reported having pain at level 7. She stated if a resident had pain issues, then she would typically refer to the care plan for pain management interventions and would check to see if pain medications were ordered. Nurse #9 explained Resident #56 had a scheduled [MEDICATION NAME] to be given once daily, and [MEDICATION NAME] ordered as needed every 4 hours to address his pain. She did not specifically recall Resident #56 complaining of pain on 09/01/17 or how long it took to respond to his call, but added that she would want to have pain medication provided in a timely way, especially if the pain level was at 7 or 8. Nurse #4, who had worked with Resident #56 regularly, was interviewed on 9/12/17 at 2:16 pm. She stated that the resident did not ask for pain medication very often, but when he did, she would expect for pain medication to be given within 5 to 10 minutes. In an interview with nursing assistant (NA) #6 on 09/12/17 at 2:50 PM, she stated she did recall the Resident #56 had asked for pain medication at times, but did not specifically remember answering his call light on 09/01/17 for his pain medication request. She stated that anytime a resident reported to her he had pain, she reported it to the nurse. During an interview with NA #2 on 09/12/17 at 4:25 PM, she stated if a resident reported to her that he/she needed pain medication she would report it to the nurse as soon as she could. She explained she had been working in the facility a very short time and that she was not very familiar with the residents and which ones had pain problems. She did not remember answering Resident #56's call light when he requested pain medication on 09/01/2017. During an interview with the on-call physician on 09/12/17 at 3:18 PM, he stated his expectation was to provide pain medication as soon as possible after the resident called for pain relief and that there is no reason for a resident to be in pain. 5. A record review of the Resident Council (RC) minutes revealed from August 2017, I lay in bed and the nursing assistants (NAs) are not getting me up. The resident also stated that a third shift NA told him to get the NA on the next shift to help him since she was getting ready to leave. Another resident stated They don't help with getting me dressed and my roommate will help me sometimes but sometimes they leave you wet. In July 2017, RC minutes revealed residents stated they were not getting up on time on Sunday to go to Bible Study. In June of 2017, RC minutes revealed ongoing concerns from residents about getting water in a timely manner. The aides tell residents let me get your aide when we need help to go to the bathroom. The resident stated we need more help so we can get to our appointments on time. The May 2017 RC minutes revealed the DON informed the residents that attended the meeting that 2 NAs would be starting today and agency nurses would stay for 3 months and some nurses will be leaving. The residents stated We need good NAs and nurses. There were also staffing concerns noted in April, 2017 RC minutes as well as March, 2017. An interview with NA #6 on 9/7/17 at 10:22 am revealed today she had 14 residents but she has had up to 18 residents on her assignment. An interview was conducted with (NA) #1 at 3:15 pm on 9/8/17. NA #1 reported she had 9 residents on this day and that it was a manageable assignment. NA #1 stated she worked the 3:00 pm to 11:00 pm shift and reported there were usually 3 to 4 on this shift. NA #1 reported she did what she could and tried to do her best to get all the care done. NA #1 reported they need more help in order to get the care done without rushing. An interview was conducted with Nurse #1 at 3:30 pm on 9/8/17. Nurse #1 revealed she was here with just two nurses more often than not. Nurse #1 stated she worked the 7:00 am to 7:00 pm shift and most times had 25 to 30 residents. She stated it was battle trying to meet the resident's needs and she felt overworked and burnt out. Nurse #1 continued to add that the medication pass was nonstop and it was difficult to assist with the residents and the aides. Nurse #1 reported the residents know we do the best we can, but they knew there was not enough help. Nurse #1 reported she did not feel there was enough staff in the facility and stated everyone has addressed it and had been addressing it. Nurse #1 stated we reported it to the Administrator, the Director of Nursing (DON), and even had a meeting with the CEO (Chief Executive Officer) in August, 2017 to address the staffing issues, but nothing seems to get done. An interview was conducted with Nurse #2 at 3:45 pm on 9/8/17. Nurse #2 reported typically we have 30 residents for each of the two nurses. Sometimes we will have an extra nurse and then we will get about 20 residents, but most often it was only 2 nurses scheduled. Nurse #2 stated when we have 30 residents, it can be very difficult to manage and meet the needs of the residents, and too many things have to get passed on to the next shift. Nurse #2 stated we do not have a wound treatment nurse so we have to do all our own treatments and this can be very time consuming if there were a lot of treatments. Nurse #2 added that sometimes there was enough staff but most times there was not. Nurse #2 reported that the hospital staff very rarely came to help us. An interview was conducted with the Dietician on 9/8/17 at 3:55 pm. The Dietician stated they don't have enough staff and it was a struggle to follow the resident's weights because the weights and heights were not always done. The Dietician stated she had reported this concern to the DON. An interview was conducted with Nurse #3 on 9/8/17 at 4:00 pm. Nurse #3 revealed the goal was to have 3 nurses

Based on observations and staff interviews, the facility staff: 1) Failed to disinfect a shared glucometer (device used to measure a resident's blood glucose or blood sugar level) between residents and failed to perform hand hygiene between residents for 1 of 3 residents observed to have their blood glucose checked (Resident #55). The facility staff also failed to wear gloves when completing a blood glucose check for 2 of 3 residents observed to have their blood glucose checked (Resident #55 and Resident #134); and, 2) Failed to perform hand hygiene after providing bowel incontinence care and before providing perineal care for 1 of 1 resident reviewed for infection control (Resident #10). Immediate jeopardy began on 9/8/17 and is ongoing. Neither the Nursing Assistant (NA) #10 observed to do blood glucose checks nor the hall nurse (Nurse #2) were trained on how to disinfect a shared glucometer between residents in accordance with the manufacturer's directions for the disinfectant. NA #10 did not perform hand hygiene between residents when doing the blood glucose checks and did not wear gloves on two separate occasions when doing the blood glucose checks. One of these occasions occurred after the nursing assistant had been instructed by the hall nurse to use gloves. Example number 2 is at no actual harm with potential for more than minimal harm that is not immediate jeopardy and the scope is isolated (D). The findings included: 1. A review of the facility policy entitled Blood Glucose Monitoring/Treatment (Originated June 2015) read, in part: Clean the (Brand name of a glucometer) with approved facility disinfectant wipes after each resident use. A review of the facility's policy entitled Hand Hygiene (Revised July 2017) read, in part: A. Indications for Use: .2. Use an alcohol-based hand rub in all other recommended situations below, unless hands are visibly soiled. The situations on the list included: Before and after direct patient contact and contact with the patient's environment; and, after contact with potentially infectious materials and/or bodily fluids, specimens, etc. A portion of the facility's policy on Hand Hygiene (Revised July 2017) also addressed Other Aspects of Hand Care and Protection. This section identified situations when the use of gloves was indicated and read, in part: Gloves should be used when: 1. Touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin . 4. Handling potentially contaminated items 5. It is likely that hands will come in contact with blood, body fluids, or other potentially infectious material . An interview was conducted on 9/8/17 at 11:05 AM with the Infection Control nurse shared by the hospital. The Infection Control nurse reported her duties included the tracking and trending of infections for the facility. The nurse also reported she provided education to staff on several infection control topics, including hand washing. A continuous observation was conducted on 9/8/17 at 4:52 PM of Nursing Assistant (NA) #10 as she did a finger stick on Resident #85 to obtain blood for a blood glucose (BG) check. NA #10 was not wearing gloves when she used the lancet to do a finger stick and completed the BG check. The NA was observed as she placed the glucometer in a plastic case (which also contained single-use lancets, individually wrapped alcohol wipes, and BG test strips) and exited the room. On 9/8/17 at 4:54 PM, NA #10 was observed as she entered Resident #55's room with the glucometer and BG supplies in the plastic case. The NA did not disinfect the glucometer between residents. She did not wash her hands, use a hand sanitizer, or put on gloves. NA #10 put a test strip into the glucometer and turned towards Resident #55 to perform a finger stick on the resident. At that time, the NA was asked to stop the procedure and step out into the hallway. An interview was conducted on 9/8/17 at 4:55 PM with NA #10. During the interview, the NA was asked as to how she was supposed to disinfect a shared glucometer between residents. The NA hesitated before stating she needed to use a wipe. When asked which wipes she would use, the NA stated she did not know. At that time, the NA was asked who she would go to if she had any questions regarding disinfection of the glucometer. She stated she would go to the hall nurse. The NA was observed as she approached the Nurse #2 on 9/8/17 at 4:58 PM. Nurse #2 was the hall nurse assigned to care for Resident #55. When NA #10 inquired what wipes she needed to use to disinfect a shared glucometer, Nurse #2 instructed her to use an alcohol wipe. The NA began to go back into Resident #55's room to use an alcohol wipe to disinfect the shared glucometer. At that time, a request was made for the NA to exit the resident ' s room. Nurse #2 was asked who she would go to if she had any questions regarding the disinfection of a shared glucometer. The nurse stated she would go to the facility ' s Director of Nursing (DON). On 9/8/17 at 4:59 PM, Nurse #2 was accompanied as she went to the DON's office and inquired which wipes needed to be used for glucometer disinfection. The DON instructed the nurse to use the wipes with the purple top (an approved germicidal wipe). Nurse #2 then told NA #10 she would need to get the wipes with the purple top and use those to disinfect the glucometer. While NA #10 was retrieving the germicidal wipes, the nurse was asked if gloves needed to be used when a BG check was done. Nurse #2 responded, Of course, it's blood. Upon the NA's return with the germicidal wipes, the nurse reminded her to use gloves when doing a BG check. After NA #10 opened the new container of germicidal wipes, the NA was asked if she had been told how to use these wipes. The NA stated she had not. The NA was directed to the manufacturer directions on the label of the germicidal wipes and encouraged to ask the hall nurse or DON for further instructions, as needed. NA #10 read the directions for disinfection and was observed as she used the germicidal wipes in accordance with the manufacturer instructions to disinfect the glucometer. A follow-up interview was conducted with NA #10 on 9/8/17 at 5:05 PM. During the interview, the NA was asked why she did not wash her hands between residents and use gloves when performing a blood glucose check. The NA stated she knew she should and did not verbalize a reason as to why she did not. A separate observation was made on 9/8/17 at 5:18 PM of a blood glucose check being done on a second hallway of the facility. At that time, NA #10 was observed from the hallway as she did a finger stick to complete a BG check on Resident #134. The NA was not wearing gloves. When the surveyor entered the room, NA #10 pulled out a pair of gloves she had in her pocket and put them on. She told the resident she needed to stick him again because she did not get an adequate blood supply the first time. The NA was again observed as she used a lancet to do a second finger stick on Resident #134. When the BG check was completed, NA #10 exited the room and went to the nursing station where the container of germicidal wipes had been placed. She then used the germicidal wipes to disinfect the glucometer. An interview was conducted on 9/8/17 at 5:35 PM with the facility's DON. During the interview, the infection control concerns observed during the BG checks were discussed. The DON reported she would expect staff to wash their hands between residents, use gloves when doing a BG check, and disinfect the blood glucometer appropriately after each use. On 9/15/17 at 1:07 PM, the facility's Director of Nursing was informed of the Immediate Jeopardy by telephone. The facility's Administrator was not available. 2. Review of the facility's Infection Control, Hand Hygiene Policy, last revised on 07/2017 revealed the following on pages 1, 2, and 3: A.1. Indications for Use (Hand Hygiene) Use plain lotion soap and water, or antimicrobial soap and water if hands are visibly soiled (important to physically remove the material) 2. Use an alcohol-based hand rub in all other recommended use below, unless hands are visibly soiled when moving from a contaminated body site to a clean body site during patient care. Under Other Aspects of Hand Care and Protection the following was written: C. e) Perform hand hygiene after removing gloves. Gloves do not replace hand hygiene. An observation of a bath and incontinence care provided for Resident #10 was made on 09/09/17 at 11:19 AM. Nursing assistant (NA) # 7 and NA # 12 washed their hands and donned gloves and provided the bath using a washcloth, soap, and warm water. While Resident #10 lay on her back, NA #7 provided perineal care using a washcloth with soap and warm water, wiping front to back 3 times, folding the washcloth with each wipe. Some light brown color was noted on the washcloth after the second wipe. After NA #7 completed the perineal care, she rinsed the washcloth in the basin of water. The resident was turned to her side, and NA #7 noted there was a large bowel movement present. NA #7 used disposable wipes to clean most of the bowel movement, and then she continued cleaning the buttocks with the same washcloth she used for the perineal care. NA #7 dried the buttocks, drew a fresh basin of water, then continued the bath with the same washcloth that had the brown residue present and wearing the same gloves. NA # 7 did not remove her gloves or perform hand hygiene at that time. NA #7 applied a zinc paste to the buttocks. When the resident was turned to her back, perineal care was provided again to ensure all the bowel movement had been removed. NA #7 continued to wear the same gloves and use the same washcloth to provide the perineal care. After the perineal area was dried, NA #7 applied zinc paste to the front perineal area as she continued to wear the same pair of gloves worn to clean the bowel movement. NA #7 did not wash her hands, use an alcohol based hand rub, or change gloves throughout the entire bathing, incontinence, or perineal care procedure. In an interview with NA #7 on 09/09/17 at 11:46 AM, she stated she had not been educated to wash hands or change gloves after cleaning a bowel movement and before continuing the remainder of the bath, cleansing the perineum, or applying a zinc paste to the perineal area. She added she had not been instructed to use a clean washcloth after cleaning the rectal area and before cleansing the perineum, and she did not know that using bowel contaminated washcloths or gloves during perineal care could put the resident at risk for UTIs. NA #7 stated she had only been trained do hand hygiene and wear gloves only before providing care for a resident and after care was completed before leaving the room. On 09/09/17 at 12:04 PM an interview was conducted with NA #12. She stated it had been a year or two since she was assigned to Resident #10, and that usually she worked in activities. She stated she remembered having a hand hygiene in-service in recent months and that she was taught to do hand hygiene only when entering a resident's room and before leaving the room. She stated she was not taught to complete hand hygiene or change gloves when moving from a contaminated body site to a clean body site. During an interview with the Director of Nursing (DON) on 09/10/17 at 4:09 PM, she stated she would expect for the nursing assistant to wash hands and change gloves after providing bowel incontinence care and before continuing the bath or providing perineal care. She also stated she would expect the NAs to follow the infection control and perineal care policies. The DON added that zinc paste should not have been applied to the perineum using the same gloves used to clean the bowel movement and acknowledged the procedure that was used could lead to a UTI. An interview was conducted with the Infection Preventionist (IP) on 09/12/17 at 11:29 AM. The IP stated that she educated the employees on infection control upon orientation and through small sessions throughout the year. She explained there was a hand hygiene day several months earlier (May 2017) to educate the employees. The IP also stated she was not a nurse, so she did not specifically provide hand hygiene education regarding nursing procedures for patient care, such as perineal care. She added that she would probably need to collaborate with the DON to provide education regarding hand hygiene and glove use during bathing, incontinence, and perineal care for infection control.

Based on observation, resident interview, family interview, staff interview and record review, the facility failed to provide functioning call bells that had a light working outside of the room and an audible component at the nurses' station in the bathrooms to allow residents to call for assistance. The call bell was not working in the bathrooms for 5 of 18 bathrooms checked (Private bathrooms 201, 262, 265, 270 and shared bathroom for room 240 and 241). Immediate jeopardy began on 9/7/17 and is ongoing. Resident #66 could not find staff to assist her to the toilet, she transferred independently onto the commode. She did not have a means to call for help after toileting and prior to transferring back into her wheel chair because the call bell was not functioning. She expressed anger and stated that it was dangerous. She had a high likelihood for falling and receiving a serious injury associated with her post-surgical knee amputation and continued need for occupational therapy for transferring, toileting and dressing the lower body. Three hours passed before hand bells were distributed to the bathrooms that had non-functioning call bells. Immediate jeopardy began on 9/8/17 and is ongoing for Resident #38 who toilets independently and had a call bell that did not work. Findings included: 1. Resident #66 was admitted to the nursing home on 7/17/17. Her admission Minimum Data Assessment indicated she had [DIAGNOSES REDACTED]. Her Minimum Data Set (MDS) assessment dated [DATE] indicated she was moderately impaired in cognition, required extensive assistance from one person for transfer, dressing and toilet use. She was not steady with moving on and off the toilet and only able to stabilize with staff assistance. She had no fall history and she received both occupational and physical therapy during the assessment period. A Fall Event report indicated Resident #66 had an assisted fall on Sunday, 8/27/17 at 10:00 AM. Interview with the therapy director on 9/12/17 at 11:30 AM revealed Resident #66 had assisted fall over a weekend. She was in the bathroom and her leg buckled. The therapy director said she was working that day and showed NA#10 how to transfer her using the grip bars. On 8/27/17 a Fall Risk Assessment was done. She was determined to need assistance with elimination and was unable to come to a standing position and a recent fall. An aide's care record for September had entries for toilet use every shift on 9/1, 9/3, 9/5 & 9/6. According to the Occupational Therapy (OT) therapy notes dated 9/4/17, Resident #66 required substantial assistance with lower body dressing and had improved in toileting - transfers to being able to safely transfer to the toilet with supervision or touching -minimum assistance for toileting routine. Nurse Aide (NA) #6 was interviewed on 9/07/2017 at 10:22 AM about how she knows what care to provide residents. She said, After a day or two, I get to know the routine. Sometimes, she (Resident #66) will pee in a diaper. Now, she likes to use the commode. She wears a diaper just in case. She will press call bell for help . On 9/07/2017 at 4:25 PM Resident #66 was observed in her private bathroom on her own. She was attempting to transfer back into her wheelchair. She appeared anxious and was tightly gripping the grab bar and struggling to back herself into her wheelchair. At approximately the same time NA #15 was passing by Resident #66's room. She said she had to take vital signs and blood sugars. She said Resident #66 goes to the bathroom on her own if she feels like it. At 4:30 PM Resident #66 came out of the bathroom and said in a loud and angry voice, I LIKE TO fell AND NEED MY BRITCHES UP. NA #15 went in the room to assist Resident #66. On 9/08/2017 at 7:54 AM Resident #66 was asked if she had put on the call bell yesterday to let the aide know she needed help. She said the call bell was not working in the bathroom. The surveyor tested the call bell and it did not light outside the door or ring at the nurses' station. On 9/08/2017 at 7:58 AM the surveyor informed the Unit Secretary that the call bell in Resident #66's bathroom was not working. She said it was the first time she had heard about it. On 9/08/2017 at 8:13 AM Contract Maintenance Person #1 and #2 arrived. One said, It's hooked up, but not working. There were two call bells in the bathroom - one about waist height on one side of the commode and another about knee height on the other side of the commode and neither worked. The Contract Maintenance Person #1 said, I've tried both and neither works. Surveyors initiated call bell checks on 9/08/2017 at 10:00 AM. Four more calls in bathrooms were not working. These were in rooms 201, 265, 270 and shared bathroom 240 and 241. On 9/08/2017 at 10:58 AM, the Administrator said she calls maintenance when there is a call bell in the bathroom that doesn't work. On 9/08/2017 at 11:15 AM Nurse #3 was interviewed about call bells. She said, I am aware of a call bell reported not working. I would get in contact with the Maintenance Director. I would call his pager or leave a message. When Nurse #3 was asked about other means for the resident to use to call for help, she said, We have bells and would have to find them. Immediately following the interview she was seen distributing hand bells to Resident #66 and to the other residents who did not have functioning call bells. On 9/08/2017 at 11:25 AM, the Director of Plant Operations was interviewed. He said, If we get a report about a problem, then we get a service call. We would not check other call bells. It is on an as needed basis. He confirmed that the call bell in Resident #66's bathroom room did not work. On 9/09/2017 at 11:01 AM a hand bell was observed in Resident #66's bathroom. On 9/08/2017 at 3:17 PM the Occupational Therapist was interviewed. She said she had worked with Resident #66 on functional transfers to toilet. She said, Initially she needed two person assistance. Now she needed minimum assist and cues for safety and hand placement. She needed contact guard assistance. We've done safety training with nurse aides in the room. She added, Typically, someone would be with her. She is good about calling if she needs help. I would not recommend her toileting by herself. She can self-propel in wheelchair. She is compliant. The safety awareness has already been an issue (i.e., hand placement). Safety is a huge thing. Resident #66 was interviewed again on 9/08/2017 at 4:20 PM. She said, I tried to get someone yesterday and couldn't find anyone. It was dangerous. On 9/09/2017 at 10:15 AM the Director of Nurses was interviewed. She confirmed that Resident #66 required assistance from one person and needed supervision with activities of daily living. She needed a nurse aide (NA) due to her [DIAGNOSES REDACTED]. Resident #66 had some episodes of confusion. She had tried to get up. She had one assisted fall with staff. She was trying to get out of wheelchair and she did not wait for assist. The Director of Rehab provided education to the CNA. On 9/8/17 at 12:30, the administrator was informed of the immediate jeopardy. 2. Resident #38's bathroom call bell was tested on [DATE] during rounds at 10:00 AM. The resident said she used the bathroom. Her quarterly Minimum Data Set had an assessment reference date of 7/11/17 indicated her cognition was severely impaired. Her dressing, transfer and toileting ability was independent. A care plan with a review start date of 10//17 included approaches for problems with ADLs and for falls indicated, Encourage the resident to use bell to call for assistance and The resident needs a safe environment with floors free from spills and/or clutter; adequate light; a working and reachable call light and personal items within reach. Her care plan dated 7/20/2017 indicated she was able to toilet independently. Surveyors initiated call bell checks on 9/08/2017 at 10:00 AM. The call bell in Resident #38's bathroom did not work when tested . On 9/08/2017 at 10:58 AM, the Administrator said she calls maintenance when there is a call bell in the bathroom that doesn't work. On 9/08/2017 at 11:15 AM Nurse #3 was interviewed about call bells. She said she would contact the Maintenance Director if a call bell problem was noted. I would call his pager or leave a message. When Nurse #3 was asked about other means for the resident to use to call for help, she said, We have bells and would have to find them. Immediately following the interview she was seen distributing hand bells to Resident #38 and to the other residents who did not have functioning call bells. On 9/08/2017 at 11:25 AM, the Director of Plant Operations was interviewed. He said, If we get a report about a problem, then we get a service call. We would not check other call bells. It is on an as needed basis. He confirmed that the call bell in Resident #38's bathroom room did not work. On 9/09/2017 at 11:05 AM a hand bell was observed in Resident #38's bathroom. On 9/08/2017 at 11:25 AM, the Director of Plant Operations was interviewed. He said, If we get a report about a problem, then we get a service call. We would not check other call bells. It is on an as needed basis. Interview with NA#8 on 9/12/17 at 11:52 AM revealed Resident #38 was very independent with activities of daily living and used the bathroom on her own. 3. A three month history of all work orders for the Extended Care Unit was reviewed. On 7/19/17 a work order was entered. The description was 271 call light does not show on door light and 271 bathroom light rings for 261. The work order was completed on 7/19/17. On 9/08/2017 at 11:25 AM, the Director of Plant Operations was interviewed. He said, If we get a report about a problem, then we get a service call. We would not check other call bells. It is on an as needed basis. Surveyors initiated call bell checks on 9/08/2017 at 10:00 AM. Four more calls bells in bathrooms were not working. These were in rooms 201, 265, 270 and shared bathroom 240 and 241. The resident in 201 said she used the toilet. The resident in room 265 said the call ball isn't worth five cents here. A family member in room 270 said the light is out, but will ring at desk. On 9/08/2017 at 10:58 AM, the Administrator said she calls maintenance when there is a call bell in the bathroom that doesn't work. On 9/08/2017 at 11:15 AM Nurse #3 was interviewed about call bells. She said, I am aware of a call bell reported not working. I would get in contact with the Maintenance Director. I would call his pager or leave a message. When Nurse #3 was asked about other means for the resident to use to call for help, she said, We have bells and would have to find them. Immediately following the interview she was seen distributing hand bells to Resident #66 and to the other residents who did not have functioning call bells. On 9/08/2017 at 11:25 AM, the Director of Plant Operations was interviewed. He said, If we get a report about a problem, then we get a service call. We would not check other call bells. It is on an as needed basis. He confirmed, by observation with the surveyor that bathroom call bells in rooms 201, 265, and 270 and 240/241, in addition to room 262 did not work. The family member of the resident in room 270 said the light did not work. The Director of Plant Operations said two of the five bathrooms only had the visual component not working. A signal was sent to the nurses' station for room 270 and 240/241. On 9/09/2017 at 11:01 AM a hand bell was observed in each of the identified bathrooms. On 9/08/2017 at 4:10 PM, the Director of Plant Operations said the call bell in room 201 was repaired. A service request form was provided. It indicated the vendor was onsite from 9/08/2017 at 2:54 PM until 4:55 PM. It said, Room 201 repaired. Room 240, 270 working. Rooms 262 & 265 has bad bath master and part on order. On 9/09/2017 at 10:14 AM the DON confirmed the residents in 240 & 241 do not use bathroom. Observations on 9/9/17 beginning at 11:01 AM revealed Room 265 & 262 still had manual call bells in the bathroom and the call bell in room 101 worked. On 9/09/2017 at 10:15 AM, the Director of Nurses said she had not had any concerns with call bells not working. On 9/8/17 at 12:30, the administrator was informed of the immediate jeopardy.

Based on record review, observation and resident, staff, Pharmacy Consultant, Nurse Practitioner and Medical Director interview, the facility administration failed to provide the leadership and management necessary to ensure residents' needs were met. Immediate jeopardy began on 4/16/17 when Resident #103, unsupervised by staff, took the elevator to the first floor, exited the building and was found in the facility parking lot. Resident #103 was located by staff after an undetermined amount of time outside of the facility and had no injuries. Resident #103 was discharged to the community on 4/22/17. Immediate jeopardy began on 9/8/17 and is ongoing for Resident #38 who toilets independently and had a call bell that did not work. Findings included: This tag is cross-referred to: F224 J Based on observation, interviews with the staff, pharmacist, nurse practitioner, and Medical Director and record review, the facility neglected to answer call bells timely, provide assistance in a timely manner and provide functioning call bells in the bathrooms so if a resident needed to summon staff for assistance, they could get help and prevent an accident from occurring, follow up on lab specimens to determine the course of treatment for [REDACTED]. This affected 5 of 40 sampled residents (#10, #24, #66, #130 and #131). Immediate jeopardy began on 9/7/17 and is ongoing for Resident #66. This resident could not find staff to assist her to the toilet, she transferred independently onto the commode. She did not have a means to call for help after toileting and prior to transferring back into her wheelchair because the call bell was not functioning. She expressed anger and stated that it was dangerous. She had a high likelihood for falling and receiving a serious injury associated with her post-surgical knee [MEDICAL CONDITION], high blood sugar on that day and a continued need for occupational therapy for transferring, toileting and dressing the lower body. On 9/7/17, three hours passed before hand bells were distributed to the bathrooms that had non-functioning call bells. F241 J Based on observation, record, review and staff and resident interviews, the facility failed to provide: Resident #66 a functioning call bell in her bathroom so she could call for assistance when needed; Resident #56 incontinence care when requested; Resident #10 a bath and incontinence care in a manner to maintain the dignity; Resident #131 timely call bell response for toileting assistance. This affected 4 of 40 sample residents reviewed for dignity (Resident #10, #56, #66 and #131). Immediate jeopardy began on 9/7/17 and is ongoing for Resident #66. This resident could not find staff to assist her to the toilet, she transferred independently onto the commode. She did not have a means to call for help after toileting and prior to transferring back into her wheelchair because the call bell was not functioning. She expressed anger and stated that it was dangerous. F279 J Based on observation, staff interview and record review, the facility failed to develop comprehensive care plans to address the current needs of the residents and to form the basis for the delivery of care for 4 of 18 sampled residents (Resident #8, #56, #66 and #128). Immediate jeopardy began on 9/7/17 and is ongoing for Resident #66. This resident could not find staff to assist her to the toilet, she transferred independently onto the commode. She did not have a means to call for help after toileting and prior to transferring back into her wheelchair because the call bell was not functioning. She expressed anger and stated that it was dangerous. She had a high likelihood for falling and receiving a serious injury associated with her post-surgical knee amputation, high blood sugar on that day and a continued need for occupational therapy for transferring, toileting and dressing the lower body. Three hours passed before hand bells were distributed to the bathrooms that had non-functioning call bells. F323 J Based on observation, resident interview, staff interview and record review, the facility failed to provide functioning call bells in resident bathrooms so that if a resident needed to summon staff for assistance, they could get help and prevent an accident from occurring. The call bell was not working in the bathroom for 2 of 2 sampled residents who used the private bath in their rooms (Resident #66 & Resident #38). The facility also failed to supervise and prevent the elopement of a cognitively impaired resident, known to have wandering behavior. This affected 1 of 2 sampled residents reviewed for supervision to prevent accidents. Immediate jeopardy began on 4/16/17 for Resident #103, unsupervised by staff, took the elevator to the first floor, exited the building and was found in the facility parking lot. Resident #103 was located by staff after an undetermined amount of time outside of the facility and had no injuries. Immediate jeopardy began on 9/7/17 and is ongoing for Resident #66. This resident could not find staff to assist her to the toilet, she transferred independently onto the commode. She did not have a means to call for help after toileting and prior to transferring back into her wheelchair because the call bell was not functioning. She expressed anger and stated that it was dangerous. She had a high likelihood for falling and receiving a serious injury associated with her post-surgical knee amputation, high blood sugar on that day and a continued need for occupational therapy for transferring, toileting and dressing the lower body. Three hours passed before hand bells were distributed to the bathrooms that had non-functioning call bells. Immediate jeopardy began on 9/8/17 and is ongoing for Resident #38 who toilets independently and had a call bell that did not work. F353 J Based on resident interviews, staff interviews and review of the staffing records, the facility failed to provide staffing in sufficient numbers to meet the needs of residents for x of x sampled residents (#66, #103, #131, and #56). Examples 1 and 2 were at the immediate jeopardy level. Examples 3 - 5 were at no actual harm with potential for more than minimal harm that is not immediate jeopardy and the scope is a pattern (E). Immediate jeopardy began on 4/16/17 for Resident #103, unsupervised by staff, took the elevator to the first floor, exited the building and was found in the facility parking lot. Resident #103 was located by staff after an undetermined amount of time outside of the facility and had no injuries. Immediate jeopardy began on 9/7/17 and is ongoing for Resident #66. This resident could not find staff to assist her to the toilet, she transferred independently onto the commode. She did not have a means to call for help after toileting and prior to transferring back into her wheelchair because the call bell was not functioning. She expressed anger and stated that it was dangerous. She had a high likelihood for falling and receiving a serious injury associated with her post-surgical knee amputation, high blood sugar on that day and a continued need for occupational therapy for transferring, toileting and dressing the lower body. Three hours passed before hand bells were distributed to the bathrooms that had non-functioning call bells. F441 J Based on observations and staff interviews, the facility staff: 1) Failed to disinfect a shared glucometer (device used to measure a resident's blood glucose or blood sugar level) between residents and failed to perform hand hygiene between residents for 1 of 3 residents observed to have their blood glucose checked (Resident #55). The facility staff also failed to wear gloves when completing a blood glucose check for 2 of 3 residents observed to have their blood glucose checked (Resident #55 and Resident #134); and, 2) Failed to perform hand hygiene after providing bowel incontinence care and before providing perineal care for 1 of 1 resident reviewed for infection control (Resident #10). Immediate jeopardy began on 9/8/17 and is ongoing. Neither the Nursing Assistant (NA) #10 observed to do blood glucose checks nor the hall nurse (Nurse #2) were trained on how to disinfect a shared glucometer between residents in accordance with the manufacturer's directions for the disinfectant. NA #10 did not perform hand hygiene between residents when doing the blood glucose checks and did not wear gloves on two separate occasions when doing the blood glucose checks. One of these occasions occurred after the nursing assistant had been instructed by the hall nurse to use gloves. F520 J Based on record review, observations, physician, pharmacy, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey on 10/6/16. Four of the nine current immediate jeopardy citations during the recertification survey on 9/12/17, were also cited on the prior recertification survey including F279 (Comprehensive Care Plan), F353 (Staffing), F441 (Infection Control), and 520 (Quality Assurance). The continued failure of the facility during 2 or more federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance program. Immediate jeopardy began on 4/16/17 for Resident #103, unsupervised by staff, took the elevator to the first floor, exited the building and was found in the facility parking lot. Resident #103 was located by staff after an undetermined amount of time outside of the facility and had no injuries. Immediate jeopardy began on 9/7/17 and is ongoing for Resident #66. This resident could not find staff to assist her to the toilet, she transferred independently onto the commode. She did not have a means to call for help after toileting and prior to transferring back into her wheelchair because the call bell was not functioning. She expressed anger and stated that it was dangerous. She had a high likelihood for falling and receiving a serious injury associated with her post-surgical knee amputation, high blood sugar on that day and a continued need for occupational therapy for transferring, toileting and dressing the lower body. Three hours passed before hand bells were distributed to the bathrooms that had non-functioning call bells. On 9/12/17 at 3:37 PM, the Administrator and Director of Nursing (DON) were interviewed regarding the administration of resources to meet the needs of residents. Both the Administrator and the DON expressed concern about neglect and call bell response. The DON stated some education had been done with the nursing assistants (NAs) but indicated there had to be a better understanding of the definition for neglect. The Administrator stated she wanted to talk with NAs to find out if they were failing to report when a resident was not being fed a meal. The DON stated she felt that resident assessment and care planning, as well as communication with the nursing assistants were issues to be addressed by the facility. The Administrator specified that environmental rounds were being done, but call bells were not included in the rounds. The Administrator said, We are not as effective as we have needed to be.