Every finding on record at Plymouth Harbor Incorporated

Based on record review, review of facility's policies and procedures and staff interviews, the facility failed to protect the resident's right to be free from physical abuse by staff for 1 (Resident #1) of 3 residents reviewed.The findings included:Review of the facility's Abuse Prevention Policy effective 8/18/10, last revised December 2022 revealed Policy: 1. Plymouth Harbor will exercise all possible efforts to reduce the risk to residents from harm or mistreatment and to prevent incidents of Abuse, Neglect, Sexual Misconduct or Exploitation. 2. All allegations of abuse, neglect, sexual misconduct or exploitation of a resident will be thoroughly investigated and the resident protected during the course of the investigation. Purpose: To ensure residents are free from verbal, sexual, physical, and mental abuse, corporal punishment and/or involuntary seclusion. Procedures/Responsibilities: The definitions used in this document are based on federal regulations and guidelines as well as state law. A. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Physical Abuse includes hitting, punching, kicking, slapping, pinching, etc. It also includes controlling behavior through corporal punishment.Review of the clinical record for Resident #1 revealed an admission date of 11/21/25. Diagnoses included neurocognitive disorder with Lewy bodies (progressive brain disease causing fluctuating cognition, Parkinson's like movement issues).Review of the admission Minimum Data Set (MDS) assessment with an assessment reference date of 11/24/25 revealed Resident #1 scored 07 on the Brief Interview for Mental Status, indicating severe cognitive impairment, significant problems with memory, orientation and recall.The care plan initiated on 11/27/25 revealed the resident had impaired cognitive function or impaired thought processes related to the diagnosis of Lewy Body disease with rapid deterioration in cognitive status, and diagnosis of Parkinsonism. The interventions included to cue, reorient and supervise the resident as needed. Review of the facility provided incident investigations revealed on 12/8/25 the facility initiated a staff to resident physical abuse investigation for Resident #1.The allegation noted on 12/8/25 the Director of Nursing (DON) received an anonymous text message alleging that Licensed Practical Nurse (LPN) Staff A struck Resident #1.The details of the investigation noted the Administrator and the DON reviewed the facility's camera footage from the alleged incident. Resident #1 was seen attempting to bite LPN Staff A on the wrist. During the incident, two security officers assisted LPN Staff to put Resident #1 back in his wheelchair. The facility's investigation noted, The cameras showed no altercation involving abuse.On 12/9/25 the Administrator concluded the investigation and noted the allegation of physical abuse was not verified. The detailed description of the conclusion of the investigation noted, The camera footage review showed that the allegation of abuse is not verified. [Resident #1] attempted to get out of his wheelchair and he was assisted by the Nurse and two security guards back into his wheelchair. He was then wheeled back to his room by another staff member. The nurse nor the security guards struck the resident during this incident. The Administrator documented, Due to the investigation being unsubstantiated, there is no corrective action needed at this time.Review of the witness statements provided by the facility as part of the investigation revealed:On 12/8/25 LPN Staff A emailed a statement that on 12/7/25 at 10:30 p.m., Resident #1 was observed with increased agitation and restlessness. Resident #1 became verbally aggressive and combative, escalating to biting nursing staff during care interaction. Staff attempted verbal redirection and reassurance, but resident was not receptive. For safety, the nurse removed herself from the immediate area and notified additional staff for support. Resident continued to display exit seeking behavior and attempted to leave the premises. Resident eventually calmed with intervention of reapproach.On 12/8/25 Certified Nursing Assistant (CNA) Staff B wrote in a witness statement that she saw Resident #1 at the entry door trying to get out. Multiple staff tried to move him away from the door. He was just getting more agitated after multiple staff tried to redirect him. LPN Staff A came by and saw what was going on. She tried to help. Resident #1 tried to bite her on the arm. Multiple staff intervened.On 12/7/25 CNA Staff C wrote in a witness statement she witnessed Resident #1 beating the door with his wheelchair screaming to get out. LPN Staff A came, moved the resident and shut the alarms off. Resident #1 then went back to the doors. This time, the alarms did not lock the door so Resident #1 was able to get out. He was heading to the elevator. The resident's nurse was sitting at the nurse's station charting. LPN Staff A ran and grabbed the resident and placed him back in the wheelchair. Security then stepped in and peeled his hands off LPN Staff A.On 12/7/25 Security Guard Staff D wrote in a witness statement that he was called to the building because a resident was banging on the door and trying to leave the facility. Another nurse arrived to try to move him but when she tried to move him, the resident tried to bite the nurse. There was a bit of a struggle.On 12/7/25 Security Guard Staff E wrote in a witness statement that when he arrived at the facility Resident #1 was holding onto the door handle and refused to let go. At around 10:30 p.m., a nurse came by and attempted to remove his hand off the handle. The resident then went to bite her which is when she pushed the resident's head away with an open hand.On 12/11/25 at 1:46 p.m., in an interview Security Guard Staff D said on 12/7/25 he was called to the facility to help with a resident who was trying to leave through the front door. He said they were trying to redirect the resident when the resident bit the nurse.Security Guard Staff D said the nurse hit the resident in the face.On 12/11/25 at 3:45 p.m., in an interview, LPN Staff A said that on 12/7/25 around 10:30 p.m., Resident #1 was at the doors to the facility. She said the doors were locked because of his security bracelet that prevents him from eloping. She said she tried to get between him and the door so that staff could get in. She said he leaned over to bite her and he did not break the skin. She said as a reaction she guided his head back. She said she used her other hand to push more forcefully, then security came to help. She said after she pushed his head away, he thought she punched him, so he started yelling, Call the police, I want her picture taken. She said in hindsight, she probably shouldn't have approached him to block him from exit in that way. She probably should have tried talking to him more.On 12/11/25 at 4:25 p.m., in an interview, the DON said the expectations for handling a resident with dementia vary based on the resident. She said staff must be able to identify the sensory issues at hand and be able to pick up on cues. She said if Resident #1 was sitting at the door calmly, we would want to keep eyes on him. She said Resident #1 started becoming more agitated Friday afternoon (12/5/25). She said one to one supervision was not provided on Saturday (12/6/25) or Sunday (12/7/25).On 12/11/25 at 5:10 p.m., in an interview, Security Guard Staff E said that basically everything he wrote in his witness statement was true. He said that Staff A went over to the resident to try to get his hands off the door handles. He said the resident tried to bite her. Security Guard Staff E said he saw Staff A's hand hit Resident #1's face. He thought her hand was open.Review of the surveillance video of 12/7/25 from 10:25 p.m., through 10:30 p.m., provided by the facility as part of the investigation revealed:Resident #1 was sitting in a wheelchair facing a double door with glass panes. The resident's left hand was on the door handle. An unidentified person was seen speaking with the resident through the glass panes. Two security guards were observed walking towards the resident. They spoke with him and walked back to the nurse's desk about seven feet from the resident. At 10:27 p.m., a nurse wearing pink scrubs was observed approaching Resident #1rapidly from behind. The Administrator identified the nurse as LPN Staff A. The nurse was observed grabbing the resident's left arm to forcibly remove his hand from the door handle. Resident #1 appeared to resist and stood up from the wheelchair. LPN Staff A was observed striking the resident's face with her right hand. She held onto the resident's left arm and bent it at the elbow while a security guard was observed grabbing the resident's right arm. The other security guard was observed holding onto the resident's right arm while they placed him back in the wheelchair. They moved the resident's wheelchair away from the door. LPN Staff A opened the double doors and let an unidentified staff member in. Resident #1 attempted to stand up. A security guard wrapped his arm around the resident's torso and sat him back in the wheelchair. An unknown staff member was seen repositioning the resident from behind in the wheelchair. Resident #1 wheeled himself to the door, opened the door, stood up and attempted to go through the double doors. A security guard and LPN Staff A were observed holding onto the resident and place him back in the wheelchair.

Based on observation, record review and staff interview, the facility failed to provide care and services in accordance with professional standards of practice by failing to administer medications in accordance with the physician's orders for 1 (Resident #22) of 4 residents reviewed for compliance with physician's orders. The findings included: On 3/26/25 at 8:34 a.m., Licensed Practical Nurse (LPN) Staff A was observed preparing to administer medications to Resident #22, including Vitamin D3. LPN Staff A said she needed to clarify the order for the Vitamin D3 before administering it to the resident. Review of the Medication Administration Record (MAR) for March 2025 revealed the nurses signed off they administered one capsule of Vitamin D3 1000 International Units (IU) daily to Resident #22 as per the physician's orders. On 3/26/25 at 8:34 a.m., observation of Resident #22's medications revealed two blister cards of 30 tablets of Vitamin D3 of 2000 IU. One blister card was filled on 2/20/25. 29 tablets had been removed from the card. One blister card was filled on 3/24/25. None of the tablets were removed. On 3/26/25 at 11:57 a.m., in an interview LPN Staff A said the physician's order in the electronic clinical record for the Vitamin D3 was to administer 1000 IU. The Vitamin D3 2000 IU that she had available and that was being given was different from the physician's orders. She said she gave the incorrect dose of Vitamin D3 to the resident on 3/3/25, 3/4/25, 3/5/25, 3/6/25, 3/10/25, 3/17/25, 3/18/25, and 3/24/25. On 3/26/25 at 5:35 p.m., in an interview LPN Staff C said on 3/21/25 she was the nurse assigned to Resident #22 and administered the Vitamin D3 2000 IU that was in the medication cart to the resident. She said she never altered the medication, and the resident took the tablet of Vitamin D3 2000 IU whole. She did not crush or cut the tablet of Vitamin D3 2000 IU. On 3/27/25 at 12:30 p.m., in an interview the Director of Nursing (DON), she said she was made aware the incorrect dose of Vitamin D3 has been administered to Resident #22. She said she expects the nurses to follow the physician's orders.

Based on observation, record review, and interviews, the facility failed to implement care plan interventions to prevent falls and fall related injuries for 1 (Resident #12) with multiple falls of 2 residents reviewed for fall prevention. The findings included: Review of the clinical record for Resident #12 revealed an admitted [DATE]. Diagnoses included Dementia and Pelvic fracture due to multiple falls. Review of the Admission Minimum Data Set (MDS) assessment with a target date of 1/24/25 revealed Resident #12's cognition was severely impaired with a Brief Interview for Mental Status score of 7. The assessment noted the resident was dependent on staff for toileting (Helper does all the effort). Toilet transfer was not attempted due to safety concerns. Review of the care plan for Activities of Daily Living (ADL) initiated on 1/17/25 revealed the resident was totally dependent on two staff for toilet use. On 3/26/25 at 12:55 p.m., Certified Nursing Assistant (CNA) Staff B was observed assisting Resident #12 with toileting in the bathroom. The resident was standing in front of the toilet, and the CNA was standing next to the resident. There was no other staff assisting CNA Staff B with the toileting. On 3/26/25 at 12:58 p.m., in an interview CNA Staff B said she works for an agency and has been working at the facility for six months. She said she was not familiar with the Kardex (provides instructions for safe care) and the assignment sheet did not say the resident required the assistance of 2 for toileting. She said Resident #12 had multiple falls and was usually in the activity room due to the falls. On 3/26/25 at 1:26 p.m., CNA Staff B said she was not trained in using the Kardex to get resident information. She stated, Maybe you get trained when you are staff here, but no one ever really sat down and trained me on the Kardex. On 3/27/25 at 9:21 a.m., in an interview Registered Nurse (RN) MDS Coordinator Staff A said two staff for toileting was added to prevent accidents, including falls. The resident's ability fluctuates and there should have been two. On 3/27/25 at 11:48 a.m., the Assistant Director of Nursing (ADON) said Staff B should have had a second CNA on 3/26/25 when she was toileting the resident to prevent a possible accident/fall. She said she found out on 3/26/25 that Staff B did not know how to access the Kardex. Review of the care plan revealed Resident #12 sustained multiple falls at the facility as follows: 2/12/25: Fall with no injury. 2/16/25: Fall with minor injury. 2/24/25: Fall with no injury 3/1/25: Fall with minor injury 3/11/25: Fall with minor injury. Resident #12 was sent to the emergency room and returned to the facility. Fall #1: Review of the progress note dated 2/12/25 revealed Resident #12 was observed on the floor near the bed facing the bathroom at 3:30 a.m. The resident said she forgot she had a urinary catheter and was trying to go to the bathroom. On 2/12/25 the facility updated the care plan for frequent checks. Fall #2: The nursing progress notes did not include the circumstances of Resident #12's fall on 2/16/25. On 2/18/25 the facility updated the care plan to Place sign to remind the resident to call for assistance. On 2/19/25, the practitioner entered a progress note indicating the resident had a fall and will monitor closely, fall precautions. The practitioner added, dementia is stable, pleasantly confused, can speak and answer but not always accurate, obtained collateral information from family present. On 2/20/25 the facility added the following diagnoses to the resident's clinical record: muscle weakness, abnormality of gait and mobility, history of falling, and need for assistance with personal care. Fall #3 On 2/24/25 at 12:31p.m. the facility entered a fall progress note. The resident was on the floor at the foot of the bed. The resident told the staff at the time, I don't know what I was trying to do. I just wanted to go to the bathroom. On 3/24/25 at 3:22 p.m., Resident #12 was observed sitting in a wheelchair in the activity room. When asked about the care at the facility and the multiple falls, she said she gives them pluses. The resident could not explain what she meant and said we should call her daughter. Fall #4 On 3/1/25 at 3:15 a.m., an incident note documented the nurse heard a loud scream and walked into the resident's room. She found the resident on the bathroom floor. The resident stated she needed to use the bathroom. The resident had a skin tear to the left hand that reopened. Review of the progress note dated 3/2/25 revealed the facility placed falls mats on each side of the bed at the request of the resident's daughter and responsible party. The care plans did not identify the use of the fall mats use to prevent fall injury. On 3/27/25 at 9:21 a.m., in an interview Registered Nurse (RN) MDS Coordinator Staff A confirmed the fall mats were not on the care plan. She said if staff used them, they should be on the care plan. On 3/3/25 the facility updated the care plan with an intervention for bowel and bladder training. The clinical record lacked documentation of a bowel and bladder training program. On 3/26/25 at 2:02 p.m., in an interview the Assistant Director of Nursing (ADON) said the bowel and bladder training was added to the care plan on 3/3/25 but not implemented. She said it involves a bowel and bladder assessment by the nurse and then checking the resident every hour. On 3/27/25 at 9:21 a.m., in an interview the MDS coordinator said bowel and bladder training should have been implemented because the resident was falling when she tried to get to the bathroom without assistance. Fall #5 On 3/11/25 at 4:50 p.m., the alert progress note indicated an unwitnessed fall after for the resident after toileting herself and falling. The resident could not remember if she hit her head. 911 was called and the resident was transported to the hospital. The facility updated the fall care plan on 3/17/25 to include a medication review. On 3/24/25 at 11:03 a.m., in a telephone interview, Resident #12's daughter and responsible party said her mother had multiple falls at the facility in a short time and the facility's efforts have not prevented them. She said she was worried the resident will fall and sustain another fracture or worse. She said the resident has dementia and periods of confusion. On 3/27/25 at 9:21 a.m., in an interview Registered Nurse (RN) Minimum Data Set Assessment Coordinator (MDS) Staff A said all falls are reviewed with the Interdisciplinary team IDT and the team decides which new interventions are added to the care plan. She verified fall mats did not get added to the care plan. She said fall mats do not prevent falls and are not appropriate for all residents and can contribute to falls because of tripping. She said providing assistance of 2 staff for toileting was added to prevent accidents including falls. She said the resident's ability fluctuates from day to day. She said there should have been 2 CNAs toileting Resident #12, if not used to support the resident, to be there for assistance if the resident should lose balance and begin to fall. The MDS coordinator said the bowel and bladder training intervention was added because the resident fell multiple times while trying to get to the bathroom. The IDT team decided on the intervention, and it should have been implemented by the IDT, which included the ADON.

Based on clinical record review, resident representative and staff interviews, the facility failed to ensure the clinical record accurately reflected the residents' advance directives for 2 (Residents #5 and #8) of 2 residents reviewed for advance directives. The findings included: Review of the facility's Advance Directive Policy (revised [DATE]) revealed prior to or upon admission of a resident, the Social Services Director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. Upon admission the interdisciplinary team assesses the resident's decision-making capacity and identifies the primary decision-maker if the resident is determined not to have decision-making capacity. 1. Review of the clinical record for Resident #5 revealed an admitted [DATE]. Diagnoses included but were not limited to, cerebral infarction (stroke) and dementia. Review of the Minimum Data Set (MDS) Assessment with a target date of [DATE] revealed Resident #5 scored a six (6) on the Brief Interview for Mental Status (BIMS), indicating severe impaired cognition. Review of the physician's order dated [DATE] revealed Resident #5 had a full code status, meaning cardiopulmonary resuscitation (CPR) would be initiated if the resident had no pulse or respirations. Review of the Resident #5's care plan initiated on [DATE] revealed an Advance Directive Care Plan which noted Resident #5 had a full code status. Review of the incapacity statement signed by the attending physician and dated [DATE] showed Resident #5 was unable to make informed health care decisions or provide informed consent. Review of the progress note written on [DATE] by Registered Nurse (RN) MDS Coordinator revealed a plan of care meeting was conducted for Resident #5. The legal representative's preference for code status was DNR, do not resuscitate. On [DATE] at 10:10 a.m., in a telephone interview the legal representative said he told the nurse at the plan of care meeting Resident #5's code status was Do Not Resuscitate (DNR) meaning CPR would not be initiated if the resident had no pulse or respirations. On [DATE] at 5:28 p.m., in an interview the MDS coordinator said that Resident #5's medical record was incorrect and the code status should be DNR. She said she did not correct the code status when she wrote the note on [DATE]. On [DATE] at 5:47 p.m., in an interview the Director of Nursing (DON) said if the resident is incapacitated the legal representative is asked for code status preference and the record checked for accuracy. On [DATE] at 6:12 p.m., the Nursing Home Administrator (NHA) reviewed the entire medical record including the paper chart. The NHA said there was no Florida DNR order in the record, which is required for DNR status. She said after the facility was aware the representative wanted DNR status, the facility should have obtained the required document and changed the medical record to DNR. On [DATE] at 7:18 a.m., in an interview the Assistant Director of Nursing (ADON) said she contacted Resident #5's legal representative, and the preference is DNR. She said the facility had the incorrect code status in the medical record. 2. Review of the clinical record for Resident #8 revealed an admitted [DATE]. Diagnoses included pelvic fracture, acute pain and history of falling. Review of the Minimum Data Set (MDS) Assessment with a target date of [DATE] revealed Resident #8 scored a 13 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the physician's order dated [DATE] revealed Resident #8 had a full code status. Review of the care plan revealed no care plan for Advance Directives. Review of the clinical record including electronic and paper records revealed Resident #8 was full code status and CPR would be performed. Review of the hospital record dated [DATE] for Resident #8 revealed wishes to defer code status decision to the son. On [DATE] at 3:04 p.m., in a telephone interview the resident's son and power of attorney said Resident #8 does not comprehend informed health care decisions consistently and is often confused. He said the code status should be DNR. He said the resident signed a Florida DNR yellow form last year on [DATE] when the resident went to the same facility for rehabilitation. He said he thought it would carry over. He said the facility staff did not ask him about code preference. He assumed Resident #8 was DNR. On [DATE] 5:05 p.m., during an interview with Resident #8 and the son at the facility, the son said Resident #8 is a DNR. Resident #8 said she did not want CPR. On ,d+[DATE] 25 at 5:48 p.m., during an interview with Resident #8 in the bedroom, the resident told the DON she wanted DNR status in the facility. On [DATE] 6:29 p.m., the DON said she did not know the resident was undecided on code status when she was admitted , or she would have included the son in the decision. She obtained the old chart from the medical records file cabinet, which contained the DNR order dated [DATE]. On [DATE] 7:40 a.m., in an interview the Assistant Director of Nursing (ADON) said she did not consult the son with Resident #8's code status at any time during this admission. On [DATE] at 10:16 p.m. in a telephone interview Licensed Practical Nurse (LPN) Staff C said she admitted Resident #8 on [DATE]. She said the resident was undecided on code status and wanted to ask her son. The resident did not have a yellow DNR form, so she documented the resident would be full code. She said she did not write a progress note about the discussion. She thought someone else would follow up. In an interview with the DON on [DATE] at 12:23 p.m., she said she was not aware the resident was undecided on the code status because there was no documentation about it, and no one told her. The DON confirmed they had the hospital note indicating the resident deferred to her son for code status. The DON obtained the Florida DNR order the resident signed on [DATE] from the previous admission.

Based on observation, interview and record review, the facility failed to develop, implement and revise the care plan to meet the needs and preferences of 3 (Residents #5, #8 and #12) of 3 reviewed for care plans. The findings included: 1. Review of Resident #5's clinical record revealed an admitted [DATE]. Diagnoses included cerebral infarction and dementia. Review of the Minimum Data Set (MDS) Assessment with a target date of [DATE] revealed Resident #5's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) score of 06. Review of the incapacity statement signed by the attending physician and dated [DATE] showed Resident #5 was unable to make informed health care decisions or provide informed consent. On [DATE] at 12:37 p.m., Certified Nursing Assistant (CNA) Staff D was observed assisting Resident #5 with her lunch. In an interview during the observation, CNA Staff D said Resident #5 did not speak. Resident #5 stared straight ahead and did not respond to several attempts to interview. On [DATE] at 10:10 a.m., in a telephone interview the resident's Power of Attorney (POA) for health care said he was one of the resident's sons and made all health care decisions because Resident #5 was unable. He said he discussed the code status with the nurse. Resident #5's code status was DNR (Do not resuscitate) and the facility should not perform CPR (cardiopulmonary resuscitation). Review of nursing progress notes revealed on [DATE] MDS coordinator Registered Nurse (RN) Staff A documented the resident's healthcare representative decided Resident #5 would be Do Not Resuscitate (DNR). Review of the care plan for Advance Directives initiated on [DATE] and reviewed on [DATE] revealed Resident #5's code status was full code meaning cardiopulmonary resuscitation (CPR) would be initiated if the resident's heart or breathing would stop. Record review of the electronic and paper clinical record revealed no Florida DNR on file. On /,d+[DATE] at 9:20 a.m., in an interview the MDS coordinator RN Staff A said she wrote the progress note on [DATE] that Resident #5 should be DNR status. She said she was responsible to update the care plan but she did not change the code status on the care plan. She said the Social Services Director should have caught and correct the mistake. On [DATE] at 5:46 p.m., in an interview the Director of Nursing (DON) verified Resident #5's care plan was not accurate and did not reflect the resident's representative wishes for code status. On [DATE] at 92:0 a.m., in an interview the MDS coordinator said the resident's code status was not updated during the quarterly review in [DATE]. 2. Review of the clinical record for Resident # 8 revealed admitted on [DATE]. Diagnoses included but were not limited to pelvis stress fracture, acute pain, and history of falling. Review of the MDS Assessment with a target date of [DATE] revealed Resident #8 scored a 13 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. On [DATE] at 2:47 p.m., in a telephone interview the resident's son said Resident #8 does not consistently comprehend informed health care decisions and is often confused. He attended one care conference this admission and no one asked him about the resident's code status. He said He said the resident is a DNR and CPR should not be performed. On [DATE] at 5:05 p.m., in an interview Resident #8 said she did not want CPR and defers to her son for decisions regarding her code status. Resident #8's son was present during the interview and said the resident code status was DNR. He said Resident #8 signed a DNR form last year and he thought the DNR from the [DATE] admission would have carried over to this admission. He said no one spoke with him about the code status. Review of the baseline care plan for admission [DATE] revealed a code status for full code. Review of the physician's order summary revealed an active order dated [DATE] for full code status. Review of the comprehensive care plans on [DATE] at 3:19 p.m. revealed no comprehensive care plan for code status. Review of the record including progress notes and social services assessment dated [DATE] failed to reveal documentation the resident's son was included in the development of the resident's care plan for advance directives. 3. Review of the clinical record for Resident #12 revealed an admitted [DATE]. Diagnoses included Dementia and Pelvic fracture due to multiple falls. Review of the Admission Minimum Data Set (MDS) assessment with a target date of [DATE] revealed the resident's cognition was moderately impaired with a BIMS score of 07. The assessment noted the resident was totally dependent on staff for toileting (with the helper doing all the effort). Toilet transfer was not attempted due to safety concerns. Review of the care plan for Activities of Daily Living (ADLs) initiated on [DATE] revealed the resident was dependent on 2 staff for toilet use. Review of the ADL Toilet Record for Support Provided revealed each day from [DATE] through [DATE] the facility used only 1 staff for toileting Resident #12. Review of the progress note dated [DATE] revealed the facility initiated falls mats on each side of the bed at the request of the resident's daughter and responsible party. The care plan did not contain the use of fall mats to minimize fall related injury. On [DATE] the facility added a care plan intervention for bowel and bladder training. The care plan did not include instructions on the bowel and bladder training. On [DATE] at 12:55 p.m., Certified Nursing Assistant (CNA) Staff B was observed assisting Resident #12 with toileting in the bathroom. The resident was standing in front of the toilet, and the CNA was standing next to the resident. There was no other staff assisting CNA Staff B with the toileting. On [DATE] at 12:58 p.m., in an interview CNA Staff B said she works for an agency and has been working at the facility for six months. She said she was not familiar with the Kardex (provides instructions for safe care) and the assignment sheet did not say the resident required the assistance of 2 for toileting. She said Resident #12 had multiple falls and was usually in the activity room due to the falls. On [DATE] at 1:26 p.m., CNA Staff B said she was not trained in using the Kardex to get resident information. She stated, Maybe you get trained when you are staff here, but no one ever really sat down and trained me on the Kardex. On [DATE] at 2:02 p.m., in an interview the Assistant Director of Nursing (ADON) said the bowel and bladder training was added to the care plan on [DATE] but not implemented. She said it involves a bowel and bladder assessment by the nurse and then checking the resident every hour. On [DATE] at 9:21 a.m., in an interview Registered Nurse (RN) MDS Coordinator Staff A confirmed the fall mats were not on the care plan. She said if staff used them, they should be on the care plan. She said two staff for toileting was added to prevent accidents, including falls. The resident's ability fluctuates and there should have been two. The MDS coordinator said bowel and bladder training should have been implemented because the resident was falling when she tried to get to the bathroom without assistance. On [DATE] at 11:48 a.m., the ADON said Staff B should have had a second CNA on [DATE] when she was toileting the resident to prevent a possible accident/fall. She said she found out on [DATE] that Staff B did not know how to access the Kardex.

Based on record review and staff interview the facility failed to send a copy of the notice of facility-initiated transfer/discharge to the Office of the State Long Term Care Ombudsman for 9 (Resident #28, #200, #201, #202, #203, #204, #205, #206, and #207 ) of 9 residents sampled for facility-initiated transfers/discharges from the facility since (MONTH) 2019. The findings included: On 11/7/19 review of the facility discharged resident list beginning in (MONTH) 2019 showed the resident transfer/discharges were not reported to the Ombudsman's office for the following residents: Resident #28 was discharged to the hospital 9/24/19 Resident #200 was discharged to the hospital 2/6/19 Resident #201 was discharged to the hospital 4/8/19 Resident #202 was discharged to the hospital 5/1/19 Resident #203 was discharged to the hospital 7/25/19 Resident #204 was discharged to the hospital 8/28/19 and 9/2/19 Resident #205 was discharged to the hospital 9/29/19 Resident #206 was discharged to the hospital 10/4/19 Resident #207 was discharged to the hospital 10/26/19 In an interview on 11/7/19 at 9:07 a.m., the Director of Nursing (DON) confirmed they had been faxing notifications to the wrong number. The DON could not find documentation of where the notices had been faxed to. On 11/7/19 at 9:26 a.m., on a phone interview, the Ombudsman Supervisor said she had not received any notification of transfer/discharges from the facility for the last year.

Based on observation, review of facility's policies and procedures and staff interview, the facility failed to handle clean laundry in a sanitary manner. The facility failed to clean and disinfect resident care equipment for 1 (Resident #76) of 1 resident reviewed for use of a [MEDICAL CONDITION] (non-invasive device for patients suffering from sleep apnea) machine. The facility failed serve food in a sanitary manner for 1 (Resident #6) of 35 residents observed during meal delivery. The findings included: Review of the facility's policy and procedure SCC Resident Personal Linen (March 2019) specified .it is important to assure the proper handling of both clean and soiled resident clothing within the facility to reduce the risk of cross contamination. Observation on 11/5/19 at 9:30 a.m., a small laundry room which Laundry Aide Staff A used to wash, dry and fold residents' clothes. A glass of water with unknown floating leaves, and a can of Lysol spray were on a table which Staff A said was used to fold the residents' clean clothes. Staff A said the concoction of water and leaves belonged to her. She said she kept it on the folding table as she worked. Staff A said she always placed her personal items on the folding table while at work. Observations on 11/5/19 at 9:45 a.m., during a tour of the main laundry room on the first floor included Housekeeper Staff B was folding clean towels on her chest against her uniform. Staff B reached under the folding table, retrieved her purse and placed it on the table as she continued to fold the towels. On 11/5/19 at 9:45 a.m., the observation of Staff B was shared with the Laundry Room Supervisor who said, She shouldn't be doing that. I tell them all the time. In an interview on 11/5/19 at 10:05 a.m., the Director of Nursing (DON) verified the observation of Laundry Aide Staff A having personal items on the folding table in the small laundry room. The DON instructed Staff A to remove her water and the can of Lysol from the folding table. Observation on 11/5/19 at 11:40 a.m., Certified Nursing Assistant (CNA) Staff C was retrieving a lunch tray from the food cart. A bag of chips fell to the floor. Staff C picked it up and placed it back on the tray and served it to Resident #6. Upon surveyor intervention, Staff C removed the bag of chips from the tray and said, They're just chips. I'll get him another one. Staff C served the meal to Resident #6. Review of the policy and procedure Cleaning of Resident Equipment (revised 5/19) specified All Nebulizers, [MEDICAL CONDITIONS] and concentrators will be cleaned at least weekly. The night shift is responsible for changing out the tubing and providing fresh water to the machine as directed by the manufacturer . After completing use of the device, rinse out with sterile water and allow to dry. On 11/5/19 at 2:00 p.m., Resident #76's [MEDICAL CONDITION] machine was observed with the DON. A large deposit and dust was in the water reservoir. During this observation, Resident #76 said he uses the machine every night. He said he usually cleans it himself at home. Resident #76 said he had not been able to clean it at the facility. He said no one had cleaned the water reservoir since his admission to the facility on [DATE]. (photographic evidence obtained) Review of the clinical record for Resident #76 revealed a physician's orders [REDACTED]. In an interview on 11/5/19 at 2:10 p.m., the DON said, It's just protocol to clean the machine but nurses were not required to document the cleaning of the machine. In an interview on 11/6/19 at 8:30 a.m., the DON said she didn't know why the machine wasn't cleaned.

Based on observation, record review and staff interview, the facility failed to ensure 4 (Residents #14 #21, #23, and 76) of 12 residents reviewed for accidents failed to ensure appropriate alternatives were attempted prior to use of bedrails. This has the potential to have bed rails installed when alternatives with less chance of negative consequences could be utilized. The findings included: Review of the facility's policy and procedure for Side rails (Dec (YEAR)) specified under the Policy section: 2. Upon admission, the resident/family/POA (power of attorney) will be asked if they would like to have their upper half side rails up or down. 3. If the resident/family/POA chooses to not use them, the discussion is done. 4. If the resident/family/POA chooses to utilize the upper siderails only as assistive mobility devices or security, an informed consent explaining the risks and benefits of using the side rails will be attained. This informed consent will then be faxed to MD (physician) for signature. 5. The nurse will then conduct an assessment with the resident. 6. Both forms will be placed into the chart under the tab of Authorizations. 7. The siderails may now be utilized by the resident. The facility policy and procedure for side rails does not address the use of alternatives prior to use of side rails. 1. Observation on 11/4/19 at 1:36 p.m., 1/4 rails were noted in the up position on the bed of Resident #21. On 11/6/19, record review revealed no documented evidence appropriate alternatives were attempted prior to the installation of bedrails on the bed of Resident #21. 2. Observation on 11/4/19 at 2:08 p.m., 1/4 rails were noted in the up position on the bed of Resident #14. On 11/6/19, record review revealed no documented evidence appropriate alternatives were attempted prior to the installation of bedrails on the bed of Resident #14. In an interview on 11/6/19 at 11:13 a.m., the Director of Nursing (DON) reviewed the bedrail evaluation for Resident #14 #21, #23, and #76, and confirmed there was no documentation of alternatives to side rails were offered or attempted before the use of bedrails. 3. Observation on 11/4/19 at 9:56 a.m., Resident #76 was in bed with 1/2 siderails elevated bilaterally at the head of the bed. In an interview on 11/6/19 at 10:10 a.m., Resident #76 said he arrived at the facility around 8:30 p.m., and no one explained or offered alternatives to the side rails, they just put them on the bed. Review of the clinical record revealed Resident #76 was admitted to the facility on [DATE]. A Bedrail Risk assessment dated [DATE] at 9:47 p.m. specified alternatives to the use of side rails had not been considered. The nurse documented a decision was made to use the siderails. Review of the Functional Status evaluation completed on 10/30/19, the Physical Therapist and Occupational Therapist checked a box on the evaluation form indicating Side Rail Usage Approved. The form did not list any alternatives attempted prior to initiate the use of the bedrails. In an interview on 11/06/19 at 10:43 a.m., the DON verified the lack of documentation the facility attempted the use of appropriate alternatives for Resident #76 prior to using the siderails. She said she realized the facility policy did not address the use of alternatives prior to the installation of the rails. She said, It's not in the policy, but it's part of the process. The DON said she would add the use of alternatives to the policy. 4. Observation on 11/4/19 at 10:24 a.m., Resident #23 was lying in bed fully dressed, bedrails in place in the up position. In an interview on 11/4/19 at 10:24 a.m., Resident #23 said she was not sure if anyone discussed the risk and benefits for usage of the side rails and was not sure if she signed any consent. Review of the Bedrail Risk Assessment effective 8/19/19 indicated no alternatives to side rails had been considered, no decision had been made to use side rails, and no date the decision was made for usage of the side rails. During an interview on 11/07/19 at 10:46 a.m., the DON confirmed the bedrail assessment form documented no alternatives to bedrails were considered at the time of the assessment, and no alternatives were offered prior to the bed rails being used. The DON said, I cannot offer an explanation for that.

Based on observation, record review, resident, staff and family interviews, the facility failed to ensure 13 (Resident's #6, #7, #11, #17, #19, #21, #24, #26, #27, #28, #29, #86, and #87) of 13 residents reviewed for accident hazards were assessed for risk of entrapment, alternative interventions were attempted, and informed consent obtained prior to the use of bed rails. The facility failed to have ongoing routine maintenance of the bed rails in accordance with manufacturer's recommendations. The facility identified 34 out of the 35 residents residing in the facility were using bed rails. Failure to ensure bed rails were appropriate and safe put residents using bed rails at potential risk. The findings included: The facility's Policy and Procedure for Side Rails (undated) indicated bed rails and/or side rails can be used as assistive mobility devices. A Registered Nurse or Therapist is responsible for the assessment and review of bed rails. Bed rails should only be used if the benefit of using them is assessed as outweighing the potential risk to the patient. 1. On 12/6/18 at 11:02 a.m., Resident #26 was observed sitting up in his wheelchair in his room. Bed rails were observed in the raised position on both sides of the resident's bed. The bed was also equipped with rails on both sides of the bottom portion of the bed that were not raised. The resident said the rails had been there the whole time, the upper rails were always up and the bottom rails were raised when he was in bed. Resident #26 said staff did talk to him about the rails when he first came in but did not recall signing an informed consent. Review of Resident #26's clinical record revealed admission physician orders [REDACTED]. A Side Rail Rationale Form (Enabler Utilization Assessment) for the side rails was completed on 12/1/18 and was signed by Resident #26's family member. There was no evidence of an assessment for the safe use of the rails, other interventions attempted, or informed consent obtained prior to the use of side rails. 2. On 12/3/18 at 9:08 a.m., Resident #28 was observed sitting in a chair in his room. Bed rails were observed in the raised position on both sides in the upper portion of the bed. The bed was also equipped with rails on both sides of the bottom portion of the bed that were not raised. On 12/3/18 at 10:26 a.m., Resident #28 said the rails were on the bed when he arrived, and were so he did not fall out of bed. He did not use them other to operate the bed controls. Resident #28 said staff did not offer any alternatives to the bed rails and he signed a consent for all four of the rails, but only the upper ones were raised. Review of Resident #28's clinical record revealed admission physician orders [REDACTED]. A Side Rail Rationale Form (Enabler Utilization Assessment) for the side rails was completed on 12/1/18 and was signed by the resident. There was no evidence of an assessment for the safe use of the rails, other interventions attempted, or informed consent obtained prior to the use of side rails. 3. On 12/3/18 at 11:50 a.m., Licensed Practical Nurse (LPN) Staff C said the side rail consent form was the one in the chart dated 12/1/18 and did not actually go over the risk versus benefits of side rail use. On 12/5/18 at 12:00 p.m., the Assistant Director of Nursing (ADON) confirmed the facility had standard orders which included bilateral half side rail and were implemented upon admission to the facility. On 12/5/18 at 12:26 p.m., the Director of Nursing (DON) confirmed the upper bed rails were in use on all beds with the exception of one resident who refused them. She said all the beds were equipped with lower rails but these were never used. The DON acknowledged the concern of no evidence of an assessment for the bed rails, evidence of alterative interventions, or informed consent prior to the use of bed rails. 4. On 12/3/18 at 9:30 a.m., observed Resident #24's bed with 2 half side rails up at the top half of her bed. The rail on each side was approximately 36 inches long and 12 inches high. The side rail had various openings on the top half of each that were approximately 4 inches high. Record review revealed no assessment for risk of entrapment, other interventions attempted, and no informed consent was obtained from the resident representative prior to the use of the bed rails. Resident #24 was admitted to the facility with a [DIAGNOSES REDACTED]. Resident #24 was non-interviewable due to dementia. The Medical Director (MD) history and physical recorded Resident #24 was bedbound with no independent movement of bilateral upper or lower extremities noted and unable to self-position. Resident #24's current care plan for falls recorded the resident had a [DIAGNOSES REDACTED]. Resident was determined to lack capacity on 5/3/18 in a document signed a doctor. On 12/3/18 at 10:25 a.m., the DON said that she did do the side rail rationale form on Resident #24 on 12/1/18. She confirmed that it was her signature on the form. She also said the little line at the bottom of the page was the resident's line. The DON recorded on the form the resident had demonstrated poor bed mobility or difficulty moving to a sitting position or to side of bed. She marked the resident was currently using the side rail for positioning or support. She marked the top rails were indicated and served as an enabler to promote independence. The DON said the side rail rationale form was the only form the facility used for the side rails and it was done every 90 days. The DON said the risks of side rails were not explained to each resident. On 12/3/18 at 10:47 a.m., the Resident Assessment Coordinator said that when she had her care plan meeting they did talk about each care plan and what was being done as interventions. She said she did not go over side rails risks with the resident or the family. She reported she had never seen a form with risks and benefits and she was unaware of the need for the informed consent. She said the only form they had for the side rails was the form that was in the chart now that was the rational form to why the resident was using the side rails. On 12/6/18 at 5:00 p.m., Certified Nursing Assistant (CNA) Staff M who worked the 3-11 shift said Resident #24 was total care and she couldn't move her arms or her legs. He said she did not use the side rails at all but they were on the bed and they kept them up. He said the resident does not try to get out of bed and has never fallen because she cannot move on her own. On 12/6/18 at 5:12 p.m., Licensed Practical Nurse (LPN) Staff L said Resident #24 was unable to use her arms or legs and was unable to use the side rails at all. She said they just had side rails an all the beds. 5. On 12/5/18 at 10:04 a.m., Resident #29 was observed in her bed with both upper side rails raised. From the door of the room it was hard to see the resident in the bed because the side rail was so high. The side rails were approximately 36 inches long and 12 inches high. The resident may be unable to see past the side rail while in the bed, because the bottom of the rail was solid and the top of the rail had an opening of about 4 inches high. Resident #29 appeared to be sleeping at this time. Resident #29's record review revealed the resident was non-interviewable due to end stage dementia. On 12/6/18 at 12:25 p.m., Registered Nurse Staff N said that Resident #29 was in an advanced stage of dementia, and she really did not use the side rails, the staff got her up and into the chair. 6. On 12/4/18 at 10:15 a.m., during resident council meeting observation, Residents #17, #19 #22, #30, and resident council president Resident #18 said they had never been told about the risk of having side rails on their beds. When said they had not been informed or asked to sign a risk/benefit consent for the side rails on their beds. On 12/4/18 at 10:25 a.m., during resident council meeting, Resident #17 said that the side rails are a help and a hazard. She said that when she wants to get up she has to scoot herself down the bed so she can get around the side rail so she can get up. She then said that when she wants to get back into bed she has to get in around the side rail and then pull herself up in the bed so she can get to the top of the bed. This maneuvering causes her a lot of pain in her left arm that gives her problems. 7. On 12/3/18 and 12/4/18 observed Resident #27 in her bed with both upper side rails in the up position. Review of Resident #27's medical records revealed the plan of care for fall risk dated 10/24/18, noted as one of the approaches, to use upper side rails. A Side Rail Rational Form (Enabler Utilization Assessment) form was dated 12/1/18 and signed by the Director of Nursing (DON). On 12/4/18 at 2:00 p.m., in an interview with CNA Staff O, she said she has been working at the facility for several weeks and was a new employee. She said they did not get formal education during their orientation week but was told all residents were to have their upper side rails raised when they were in bed. She said both upper side rails were raised when Resident #27 was in her bed for her safety. On 12/4/18 at 2:24 p.m., in an interview with the Assistant Director of Nursing (ADON), she said she was in charge of staff education. She said they did not have a formal education related to side rails. Staff were required to follow each resident's plan of care as related for when to use the resident's side rails. On 12/4/18 at 2:44 p.m., the DON confirmed all residents side rails were raised when they were in bed unless they requested not to have them raised when they were in bed. She said they started to raise Resident #27's side rails when she was admitted on [DATE]. She said there was no documentation the facility attempted alternative interventions prior to the use of the side rails. She also said there was no documentation they had informed Resident #27 family/representative of the risk versus benefits of the use of side rails. She further said they did not obtain an informed consent prior to the use of side rails from Resident #27's representative as required. 8. On 12/3/18, observed Resident #7's upper side rails in the up position while he was in his bed. On 12/6/18 at 1:10 p.m., in an interview with Resident #7's wife, she said her husband was admitted to the facility late (MONTH) (YEAR) after he had a stroke. When he was admitted staff told her they would raise his upper side rails to keep him safe and assist with his turning in bed. She said she was not told prior to the use of the upper side rails of the risk versus benefits and did not sign an informed consent to use the side rails. On 12/6/18 at 2:44 p.m., the DON confirmed Resident #7 was admitted to the facility on [DATE] and they were raising both upper side rails when Resident #7 was in his bed since his admission. She said there was no documentation in Resident #7's medical record showing the facility attempted an alternative intervention prior to the use of the side rails. She further said there was no documentation the facility informed Resident #7 or his wife of the risk versus benefits of side rails and did not obtain an informed consent prior to the installation or use of the side rails. 9. On 12/3/18 at 9:08 a.m., Resident #17 said she was admitted to the facility in (MONTH) (YEAR) after a fall. The facility told her she had to have both her side rails up when she was in bed for her safety and to assist her in repositioning herself in bed. The facility did not tell her of any alternatives prior to the use of the side rails and she was never told the risks versus benefits prior to the use of the side rails. She said she did not sign an informed consent prior to the use of the side rails. On 12/4/18, a review of Resident #17's medical records revealed she was admitted to the facility 9/29/18. A Side Rails Informed Consent and Release form was signed and dated 12/3/18. On 12/4/18 at 4:00 p.m., in an interview with Resident #17, she said yesterday (12/3/18) the nurse told her she had to sign a Side Rail Informed Consent and Release form. This was the first time she was told about the risk and benefits of the use of side rails since being admitted to the facility. On 12/5/18 at 3:30 p.m., the DON said Resident #17's side rails were started when she was admitted to the facility on [DATE]. She said there was no documentation the facility attempted any alternatives prior to the use of the side rails. The DON also said there was no documentation the facility had explained to Resident #17 the risks versus benefits prior to the use of the side rails and obtain an informed consent prior to the use of the side rails as required. 10. Multiple observations on 12/3/18; 12/4/18; 12/5/18 and 12/6/18 revealed Residents #6, #11, and #21's beds with half rails raised bilaterally at the head of the bed. On 12/5/18, record review revealed no documented evidence of a consent for use of bed rails was signed by Resident #6, #11, and #21. 11. On 12/5/18 at 11:11 a.m., observed Resident #19's bed with a side rail that was held in place by the pressure of the mattress by sliding the device made of metal tube bent to slide between the mattress and the springs and form an upright loop for a hand hold. The rail had a large opening, approximately 20 inches wide and 14 inches high, made by a single loop of tube. The rail was not affixed to the bed with bolts. This was an accident hazard and entrapment concern. There was no documentation of assessment of the resident for side rails and no documentation of risk and benefit of side rails reviewed with the resident. In an interview on 12/6/18 at 11:08 a.m., the DON said the resident requested the specific side rail and the use of the side rail was added to the resident's plan of care. The DON acknowledged the unsecured bed rail was not safe and the large opening was a potential entrapment hazard. The DON said there was no discussion with the resident of the risk associated with using the bed rail. 12. During observation and interview on 12/3/18 at 9:00 a.m., Resident #86 was observed in bed with two side rails in the up position at the head of the bed. The resident said she was not informed of the risk of side rail use. The resident said the rails were put up by the nurse aides when she was bed. She said there had been no discussion about the use of side rails. A review of the resident record finds there was no entrapment assessment of Resident #86 for use of side rails. A consent form for side rails was not signed until after the start of the recertification survey on 12/3/18. 13. During observation and interview on 12/4/18 at 10:29 a.m., Resident #87, who was a new admission and interviewable was found to have two side rails at the head of the bed in the up position. Resident #87 said he was not informed of the entrapment risk of side rail use. Review of the resident's record finds there was no risk assessment and no documentation the risks versus benefits of bed rails was reviewed with the resident. A consent was signed on 12/4/18. The resident was care planned for fall risk. 14. During an environmental tour of the facility on 12/6/18 at 11:08 a.m., the Administrator (ADM) and DON acknowledged resident assessments for side rail use were not completed and no discussion held with residents regarding the benefit and risk of side rails before the side rails at the head of the bed were engaged. The DON confirmed there were physician standing orders for side rails that were implemented before assessment of the residents and before alternatives were attempted and risk to the resident of using side rails was discussed with the resident. The ADM said he did not have a log of bed check and preventive maintenance. The ADM said they had no documentation the recommendations were being followed. In an interview on 12/6/18 at 5:35 p.m., the ADM said the facility management had discussions with the provider of the beds about contracted repair maintenance and periodic preventive maintenance. They also discussed periodic maintenance only. The ADM said the facility board considered training in-house staff as certified technician for repair and preventive maintenance of the beds. He said the discussions ended without a decision, consequently, no maintenance program was implemented. There were no safety checks of the beds. **Pictures on File**

Based on observation, staff interview, and policy and procedure review, the facility failed to properly store, clean, and disinfect shared equipment between each use of the residents. The facility also failed to follow appropriate transmission-based precautions in the handling and processing of resident laundry increasing the potential risk for cross-contamination and to properly store a night-time urinary drainage bag and connector for 1 (Resident #6) of 1 resident reviewed for catheters. The findings included: Review of facilities Policy and Procedure for Infection Control Management of Resident Linens 12/2018; purpose: to reduce the risk of cross-contamination resident clothing will be considered contaminated and is managed according to Standard Universal Precautions. Prior to the removal of soiled resident clothing, the attendant shall don the proper Personal Protective Equipment (PPE) then remove resident clothing from the bag; clean PPE shall be donned when removing soiled resident clothing from the washer to the dryer; clean PPE shall be worn when folding or hanging the resident clothing. The World Health Organization Standard Precautions in Health Care; http://www.who.int/patientsafety/information_centre/ghhad_ ; Health-care facility recommendations for standard precautions for the use of PPE for handling of dirty laundry avoids transfer of pathogens to other patients and or the environment. Gowns are worn to protect soiling of clothing and to remove gown as soon as possible. 1. On 12/3/18 at 8:45 a.m., Laundry Aid Staff E was observed wearing an apron walking in and out of the laundry room without sleeves covering her upper body clothes. No Personal Protective Equipment (PPE) worn as required by facility policy. On 12/3/18 at 10:03 a.m., Staff F said she keeps the same apron on all day then takes it off to wash at the end of the day. On 12/6/18 at 10:58 a.m., review of Laundry Aid Staff E's most current education on Infection Control revealed it was completed on 12/5/18 through an on-line education course. On 12/5/18 at 2:15 p.m., the Administrator (ADM)/risk manager said training modules for infection control are done in each quarter. Staff E did these modules as well as the laundry technicians. The ADM confirmed laundry technicians should be wearing the yellow gowns to cover their clothing and changing between working with dirty and clean laundry. 2. On 12/3/18 at 8:04 a.m., observed Resident #6's bathroom with uncovered urinary drainage bag 1/3 full of urine with the tubing tip connector uncapped hanging on shower grab bar. According to Cleveland Clinic https://myclevelandclinic.org/health/articles/ -urine-drainage-bag-and-leg-bag-care it is important to put a cap on the end of the drainage bag tubing so it does not become contaminated. Physicians orders starting on 6/4/18 to change leg bag and night urinary drainage bag every 14 days during the night time every 2nd, 16th, of Jan, Feb, March, April, May, June, July, August, September, October, November, December. On 12/5/18 at 2:50 pm; interview with Registered Nurse (RN) Staff F said Resident #6 leg bag is emptied every day, at night it is changed to a Foley bag. She confirmed during the day the Foley catheter bag is stored in the bathroom in a plastic bag. On 12/5/18 at 2:55 p.m., observed urinary drainage bag and tubing hanging on the shower grab bar with urine in the tubing not in a protective bag. On 12/5/18 at 3:10 p.m., interview with Assistant Director of Nursing (ADON) who said during the day the leg bag is put back onto the suprapubic catheter then the Foley catheter is to be put into a bag and stored in the bathroom with an end cap on the connector site. 3. During initial observations of residents on 12/3/18, three mechanical assist to stand lifts (Sara lift) were found to be dirty with grimy debris and residue on the foot pads, knee pad and frame. Certified Nursing Assistants (CNA's) Staff A and Staff B were observed taking dirty Sara lifts from resident room to resident room. The lifts came out of the room in the same dirty condition as when they were taken into the room. The CNA's then parked the lifts against the wall in the corridor without cleaning the equipment. On 12/3/18 at 11:37 a.m., a Sara lift was observed stored in a resident's bathroom. The lift was dirty with debris and grime on the frame and foot pad. An environmental tour of the facility was conducted on 12/6/18 at 11:08 a.m. with the ADM and the Director of Nursing. Two of three Sara lifts were examined and found to be dirty with grimy debris and residue on the foot pads, knee pad and frame. The ADM acknowledged the Sara lifts were not clean. He said he was sure there was a schedule for cleaning. He also concurred the lifts should be cleaned between uses. The ADM produced a copy of the Mechanical Lift Cleaning Log. The Log was completely blank. No dates initialed for completed cleaning. The ADM said the person responsible for monitoring the task was promoted out of the position and the task got dropped. The ADM confirmed there was no indication the lifts are being cleaned regularly. **Pictures on File**

Based on observation, record review, resident and staff interview, the facility failed to ensure the mattresses and bed rails fit properly for 3 (Residents #87, #19 and #26) of 18 resident beds reviewed for safety. The facility failed to implement a regular maintenance program for bed safety. This had the potential for harm to residents by entrapment and accidents. The findings included: 1. During observation of Resident #19 on 12/5/18 at 11:11 a.m., observed the resident's bed with a side rail that was held in place by the pressure of the mattress by sliding the device made of metal tube bent to slide between the mattress and the springs and form an upright loop for a hand hold. The rail had a large opening, approximately 20 inches wide and 14 inches high, made by a single loop of tube. The rail was not affixed to the bed with bolts. This was an accident hazard and entrapment concern. There was no documentation of assessment of the resident for side rails and no documentation of risk versus benefit of side rails reviewed with the resident. In an interview on 12/5/18 at 12:30 p.m., Resident #19 said she ambulated with and without an assistive device such as a walker. The resident said she got out of bed on her own to go to the toilet. She said she needed the side rail to help her stand while getting out of the bed. In an interview on 12/6/18 at 11:08 a.m., the Director of Nursing (DON) said the resident requested the specific side rail and the use of the side rail was added to the resident's plan of care. The DON acknowledged the unsecured bed rail was not safe and the large opening was a potential entrapment hazard. The DON said there was no discussion with the resident of the risk associated with using the bed rail. 2. Resident #87 was observed lying in bed on 12/4/18 at 10:29 a.m. Two side rails were in place at the head of bed in the up position. The mattress on the bed did not fit properly. There was a 5 inch gap between the top of the mattress and the headboard. The 4gap at the bottom of the mattress and the foot board was filled with a square bolster. However, the square bolster did not fit the full width of the mattress. In an interview during an environmental tour of the facility on 12/6/18 at 11:08 a.m., the Administrator (ADM) and DON confirmed the mattress for Resident #87 was not properly fitted to the bed. 3. In an interview on 12/6/18 at 5:35 p.m., the ADM said he did not have a log of bed checks and preventive maintenance. The ADM provided a copy of the manufacturer's manual with recommendations for hazard and safety checks. The ADM said they had no documentation the recommendations were being followed. The ADM said the facility management had discussions with the provider of the beds about contracted repair maintenance and periodic preventive maintenance. They also discussed periodic maintenance only. The ADM said the facility board considered training in-house staff as certified technician for repair and preventive maintenance of the beds. He said the discussions ended without a decision, consequently, no maintenance program was implemented. There were no safety checks of the beds. 4. On 12/6/18 at 11:02 a.m., Resident #26's bed was observed to have a 5 and 1/2 inch gap between the headboard and mattress creating a potential entrapment zone. On 12/6/18 at 11:17 a.m., the ADM confirmed this finding. **Pictures on File**

Based on record review and staff interview, the facility failed to ensure as needed (PRN) [MEDICAL CONDITION] (medications that affect a person's mental state) medications were not extended beyond 14 days without being reordered and documenting the rationale and determined duration for 2 (Residents #12 and 21) of 7 residents whose medications were reviewed. This had the potential to lead to administration of unnecessary medication. The findings included: 1. A review of the Medication Administration Record [REDACTED]. The order was dated 11/7/18 and there was no evidence of an order to extend the medication after 14 days nor documentation of rationale and determined duration. The Pharmacist review dated 11/8/18 did not address the PRN [MEDICATION NAME] lacking an end date or review date at 14 days. The pharmacist review was completed one day after Resident #12's admission. At 30 days post admission the PRN [MEDICATION NAME] had not been addressed. In an interview on 12/6/18 at 2:06 p.m., Licensed Practical Nurse Staff F said there was no end date for the PRN [MEDICATION NAME] and confirmed there was no documented rationale for extending the duration. 2. Resident #21's clinical record revealed a physician's orders [REDACTED]. There was no specified duration for the PRN [MEDICAL CONDITION] medication or documentation as to the rationale for the extended use past the 14 days. The MAR indicated [REDACTED].

Based on staff interview and record review, the facility failed to ensure 4 (Staff J, K, H and I) of 10 staff reviewed had the required education and training in abuse, neglect and exploitation. Failure to provide staff with abuse, neglect and exploitation training prior to working with facility residents could lead to staff not knowing how to prevent and report abuse, neglect and exploitation. The findings included: On 12/6/18, review of Certified Nursing Assistant (CNA) Staff J's employee record revealed her start date was 10/30/18. Review of her employee training records revealed she did not receive education or training in abuse, neglect and exploitation prior to working with the facility residents. On 12/6/18, review of Licensed Practical Nurse (LPN) Staff K's employee record revealed her start date was 11/13/18. Review of her employee training records revealed she did not receive education or training in abuse, neglect and exploitation prior to working with the facility residents. On 12/6/18, review of LPN Staff H's employee record revealed her start date was 11/14/18. Review of her employee training records revealed she did not receive education or training in abuse, neglect and exploitation prior to working with the facility residents. On 12/6/18, review of Staff I's, a dining room server, employee revealed his start date was 5/16/18. Review of his employee training records revealed he did not receive education or training in abuse, neglect and exploitation prior to working with the facility residents. On 12/6/18, review of the facility's Abuse/Neglect Prevention policy and procedures dated (MONTH) (YEAR) revealed all employees would receive facility abuse prevention policy and procedures training during the orientation period as well as annually. The purpose of this training was to ensure all employees were trained to recognize signs and/or symptoms of possible abuse and know the appropriate action to take. On 12/6/18 at 4:20 p.m., in an interview with the Assistant Director of Nursing, she confirmed Staff J, K, H and I were current employees and had resident contact. She said she thought she had 30 days after the employees were hired to train them in abuse, neglect and exploitation. She confirmed Staff J's, K's, H's and I's hire dates and said as of 12/6/18 they had not had the required training in abuse and neglect as outlined in their Abuse/Neglect Prevention policy and procedures.

Based on record/policy review and interview the facility failed to provide care and services for 1 ( Resident #3) of 6 sampled residents to meet the needs for their highest practicable well being. The facility failed to contact a physician for a resident possibly experiencing an allergic reaction. The findings included: On 6/20/16 a review of Resident #3's medical record revealed he was admitted for respite care on 5/4/16 and discharged on [DATE]. A review of his hospice certification documented he did not have any allergies [REDACTED].>On 6/20/16 a nursing progress note dated 5/8/16 and entered on 5/10/16 documented Licensed Practical Nurse (LPN) Staff D asked LPN Charge Nurse Staff I to look at Resident #3's right eye that looks different. Staff I noted the puffiness to his right eye. Staff I notified Registered Nurse Supervisor Staff J who assessed Resident #3's right eye and noticed only puffiness of upper eyelid and no evidence of trauma. Staff J advised the medication nurse to apply warm a compress to area per nursing intervention. On 6/20/16 a nursing progress note for date 5/9/16 documented LPN Staff A was informed by Staff J of Resident #3's right eye swelling and resident said it was from the flowers for Mother's Day. The eye lid remained swollen. On 6/20/16 a nursing progress note for date 5/9/16 and entered on 5/12/16 by Certified Nursing Assistant Staff K documented Resident #3 left with his right eye lid slightly swollen with little to no color variance. On 6/20/16 a review of Resident #3's electronic Medication Administration Record [REDACTED]. On 6/20/16 at 2:00 p.m., the Social Services Director and the Director of Nursing (DON) said the facility should have contacted the family and didn't do it. On 6/20/16 at 4:00 p.m., the DON stated the facility can't diagnose. She said the facility should have contacted the doctor after realizing this may be an allergic reaction to the flowers and there was no telling where it could have potentially lead to. The Administrator was present and said he understood her statement. On 6/20/16 a review of the facility policy for Resident's Rights documented have your physician and if known, your legal representative immediately informed when there is a significant change in your physical status and there is a need to alter your treatment.

Based on interviews and observations, the facility failed to have policies and procedures in place for federal staff posting requirements; failed to ensure the postings were in a clear and readable format; and failed to ensure the total number and actual hours worked by the categories of nursing staff directly responsible for resident care were posted. The findings included: On 10/22/15 at 2:10 p.m., the Director of Nurses (DON), said she did not have a policy or procedure related to the federal requirements for posting the nurse staffing data. Between 10/19/15 through 10/22/15 observations were made throughout the survey . The staff posting was observed hanging on the wall by the nurse's station. The posting was not able to be read by residents who were seated in wheelchairs. Observations of the postings for each shift throughout the survey did not list the total number and actual hours worked by the Registered Nurses, Licensed Practical Nurses and Certified Nursing Assistants. On 10/22/15 at 2:15 p.m., in a second interview with the DON who agreed the postings did not list the total number and actual hours worked by the nursing staff and they did not keep 18 months' worth of the staff postings as required.

Based on observations, staff interview and resident interview the facility failed to maintain a clean and sanitary environment. Resident rooms, care equipment and furniture was not properly cleaned. The findings include: On 10/19/15 at 9:20 a.m., during resident observations the mechanical assist to stand lifts (Sara Lifts) were observed to be dirty with debris on the foot platform and sticky residue on the knee pad yoke. The knee pads were cracked. The Velcro straps were coated with hair and other debris. The hand grip padding was stained and dirty with grimy residue and in need of washing. On 10/22/15 at 10:00 a.m., during an environmental tour of the facility the administrator acknowledged the stand lifts were dirty with debris, liquid residue and stains. The administrator said the lifts should be wiped down after each use and on a regular cleaning schedule. On 10/19/15 at 1:53 p.m., during observations of residents in room 39 the over bed table base was dirty with liquid residue. The floors at the margins and in the corners had debris, grimy residue and cobwebs. In room 37 dirt and debris was observed under the furniture, behind the doors and around the edges of the room. In room 37 the bases of the over bed tables were dusty. On 10/22/15 at 10:00 a.m., during an environmental tour of the facility the administrator acknowledged the floors were dirty around the edges of the rooms and behind the doors and the over bed tables were not clean. During the tour Resident #41 pointed out to the administrator the floor in the closet was not being cleaned and the floor under the chair by the window was not cleaned. The administrator said the rooms need better care and the cleaning of all rooms will be improved.

Based on record review and interviews, the facility failed to develop a careplan to address a resident's physical and verbally abusive behaviors, for 1 (Resident #64) of 16 sampled residents. These behaviors have the potential to cause injury to himself or others and required the use of an antipsychotic medication. The findings include: Resident #64's clinical record contained a mood and behavior incident based report that indicated on 11/11/14 the resident had become resistive to therapy and became argumentative and combative with the Physical Therapist. On 11/28/14 the resident was reported as having verbal and physical aggression. The resident's clinical record contained a physician's orders [REDACTED]. On 1/8/15 the resident's physician identified the [DIAGNOSES REDACTED]. A Minimum Data Set Care Area Assessment was completed on 9/12/15. Behavioral symptoms and [MEDICAL CONDITION] drug use triggered as potential problems and indicated a careplan would be developed to address these areas. The residents current careplan was reviewed and did not identify the resident was on an antipsychotic medication, could be physically combative when approached for care, or have interventions for staff to use when the resident exhibited these behaviors. On 10/21/15 at 9:14 a.m., Certified Nursing Assistant (CNA) Staff D said some mornings the resident was in a good mood and other mornings he hits and kicks when she attempted to get him up and dressed. Staff D said she would stop what she was doing and tell him to let her know when he was ready for her to continue. She would stay in room but let him calm down and tried to re-approach him. Staff D said she used to give the resident his shower in the evenings and he sometimes would be combative then. Staff D said she tried to keep a quiet environment when working with him, does not turn on TV and always explained to him what she was going to do. Staff D said she did need the assistance of a second CNA to get him up but only has one person giving instructions and lets other person go as soon as possible. She said having the one on one made him feel less like they were ganging up on him. Staff D said she did not rush him either and goes slow in general. Staff D said it was important how you approach someone. She said the last person who worked with the resident would put the TV on and have side conversations with the other CNA in the room and that seemed to agitate him. On 10/21/15 at 11:54 a.m., interviewed Social Worker Staff F who confirmed the current careplan did not address the residents antipsychotic medication use and potentially combative behavior when approached for care.

Based on record reviews and interviews, the facility failed to have evidence of behavioral interventions trialed before recommending an antipsychotic medication for 1 (Resident #64) of 5 sampled residents reviewed for unnecessary medications. The facility also failed to have medical justification by the resident's physician for the continued use of antipsychotic medications for 2 (Resident #64 and #58) of 5 sampled residents as to why there was no attempt to reduce the dosage and/or eliminate the use of these antipsychotic medications. The findings include; 1. Resident #64 was admitted to the facility on [DATE]. An admission Minimum Data Set assessment dated [DATE] under section E0200, did not indicate any behaviors had occurred. A mood and behavior incident based report indicated on 11/11/14 the Physical Therapist reported the resident had become resistive to therapy and became argumentative and combative with her. On 11/28/14 the resident was reported as having verbal and physical aggression. The resident's clinical record contained a physician's orders [REDACTED]. There was no documentation found of the interventions trialed to manage the resident's agitated behavior prior to the use of the antipsychotic medication. On 1/8/15 the resident's physician identified the [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. (The medication [MEDICATION NAME] contains a manufacturers' black box warning of not being approved for elderly patients with dementia related [MEDICAL CONDITION]). There was no documentation found of any attempt to reduce the dosage of the medication or to discontinue it's use since the medication was initially ordered on [DATE]. There was also no documentation by the resident's physician as to why a gradual dose reduction (GDR) was clinically contraindicated for the resident. On 10/21/15 at 9:14 a.m., Certified Nursing Assistant (CNA), Staff D said some mornings the resident was in a good mood and other mornings he hits and kicks when she attempted to get him up and dressed. Staff D said she would stop what she was doing and tell him to let her know when he was ready for her to continue. She would stay in room but let him calm down and tried to re-approach him. Staff D said she used to give the resident his shower in the evenings and he sometimes would be combative then. Staff D said she tried to keep a quiet environment when working with him, did not turn on TV and always explained to him what she was going to do. Staff D said she did need the assistance of a second CNA to get him up but only has one person giving instructions and let that other person go as soon as possible. She said having the one on one made him feel less like they were ganging up on him. Staff D said she did not rush him either and goes slow in general. Staff D said it was important how you approach someone. She said the last person that worked with the resident would put the TV on and have side conversations with the other CNA in the room and that seemed to agitate him. The residents current careplan was reviewed and did not identify the resident was on an antipsychotic medication, could be physically combative when approached for care, or have interventions for staff to use when the resident exhibited these behaviors. On 10/21/15 at 11:54 a.m., the Social Worker Staff F said the facility's medication management committee had sent a request to Resident #64's Neurologist on 12/4/14 for the medication [MEDICATION NAME] 25 mg to be ordered. Staff F acknowledged there had been no request for a GDR made to the resident's physician in an attempt to reduce and/or eliminate the antipsychotic medication since the medication was started on 12/5/14. Staff F confirmed the current careplan did not address the residents antipsychotic medication use and potentially combative behavior when approached for care. Staff F could not provide evidence of the interventions trialed prior to the use of the antipsychotic medication but said she was still researching the careplan issue. On 10/22/15 at 10:04 a.m., Licensed Practical Nurse Staff A said when the resident was first admitted he was resistive to care and verbally abusive. She said the resident was doing great now. Staff A said they just had a careplan meeting and she told the resident's family member she had not heard of any issues with his behavior and he had been more cooperative. Staff A said there had been no documentation of any behaviors and can not recall any specific behavioral interventions being used for the resident other than stop the care and re-approach him later. Staff A said she would expect it to be on his careplan which was available to all staff. 2. Review of Resident #58's medication regimen revealed a physician order [REDACTED]. The [MEDICATION NAME] 12.5 mg was initially ordered on [DATE]. The [MEDICATION NAME] was increased on 3/9/14 to 25 mg. On 7/31/14 it was increased to 37.5 mg and on 8/28/14 the [MEDICATION NAME] was increased to 50 mg. Review of Resident #58's pharmacy monthly recommendations noted on 10/1/15 a recommendation to decrease the [MEDICATION NAME] to 25 mg. There was no documentation in the medical records the attending physician had addressed the pharmacist recommendation to decrease the [MEDICATION NAME] to 25 mg. On 10/21/15 at around 10:00 a.m., the Pharmacy Consultant confirmed Resident #58 was currently on [MEDICATION NAME] 50 mg for dementia with psychotic behaviors. He reviewed every resident's medication regimen in the facility prior to the third Thursday every month. On every third Thursday of the month there was a medication management meeting where we discuss all the resident's medications they were currently receiving. There were several people in the meeting including the Social Service Director (SSD), the Unit Managers, the Minimum Data Set Coordinator (MDSC) and others except the Director of Nursing who doesn't attend the meetings. Since I do not know the residents like the facility staff all pharmacy recommendations were determined by the team. If the medication team decided a medication was working as intended the team would write no recommendation for medication change for that month. He said by law all residents on a antipsychotic medications should have a GDR of those medications for 2 separate quarters for the first year and at least 1 attempt of a GDR every following year. He confirmed Resident #58 was ordered [MEDICATION NAME] 50 mg on 8/28/14 and the first request for a GDR for the [MEDICATION NAME] was made on 10/1/15. On 10/21/15 at around 12:30 p.m., the Director of Nursing (DON) said she did not attend the monthly medication management meetings but did know the meetings were attended by the Consultant Pharmacist and facility staff. She said she didn't know why the [MEDICATION NAME] GDR was not done for Resident #58's but would call the physician's office and see if they had documentation related to Resident #58's medication in their medical records. On 10/21/15 at 2:10 p.m., the MDSC and DON said the physician's office had just faxed the sequence of events related to Resident #58's medications. On 10/2/15 they had received the request for the facility for a GDR of the [MEDICATION NAME] from 50 mg to 25 mg via fax. They had faxed back to the facility on [DATE] to reduce the [MEDICATION NAME] to 25 mg every day. On 10/7/15 the physician's office faxed to the facility not to reduce the [MEDICATION NAME] 25 mg but to keep the [MEDICATION NAME] at 50 mg until they talked with the wife after their next nursing home visit. The DON said they had not received either fax from the physician on 10/2/15 or 10/7/15 and the [MEDICATION NAME] was not reduced on 10/2/15 as ordered by the physician. She further said the physician did not write a medical justification on 10/7/15 for them not to do a GDR for the [MEDICATION NAME] even though Resident #58's behaviors had greatly improved. The MDSC said the Consultant Pharmacist had reviewed Resident #58's medications on 9/15/15 but did not make a recommendation to do a GDR for the [MEDICATION NAME]. The recommendation came from the medication team meeting which was held on 10/1/15, 16 days after his review. The team decided since Resident #58's behavior had greatly improved to recommend the GDR of the [MEDICATION NAME] to the physician. The DON said she was not aware until today their request for a GDR was not addressed timely as required. On 10/21/15 at 2:56 p.m., the SSD confirmed on 10/1/15 a medication team meeting was held to review all facility residents medication regime. When they reviewed Resident #58's medication they determined since his behaviors had greatly improved a GDR for the [MEDICATION NAME] was indicated. They had faxed their request for the GDR to the physician's office but never heard back from them so she called the physician's office on 10/20/15. The office told her they had recommended a dose reduce on 10/2/15 but the wife told them she did not want a GDR of the [MEDICATION NAME] so they had rescinded the GDR on 10/7/15. The SSD confirmed the dose reduction ordered by the physician on 10/2/15 was not completed as ordered and there was no documentation from the physician on 10/7/15 in the medical records explaining the medical justification for not attempting a GDR for the [MEDICATION NAME] 50 mg. She also said the pharmacist was part of the medication management team but the team determined if a recommendation was sent to the physician including all GDR recommendations. She further confirmed the DON does not attend the medication management team meetings.

Based on record reviews and interviews, the facility's consultant pharmacist failed to report to the physician and Director of Nursing, the continued use of antipsychotic medications without an attempt to reduce the dosage or to possibly eliminate the use of the medication for 2 (Resident #64 and #58) of 5 sampled residents reviewed for unnecessary medications. The findings include: 1. Resident #64's clinical record contained a physician's orders [REDACTED]. On 1/8/15 the resident's physician identified the [DIAGNOSES REDACTED]. A [DIAGNOSES REDACTED]. (The medication Seroquel contains a manufacturers' black box warning of not being approved for elderly patients with dementia related psychosis). There was no documentation found of any attempt to reduce the dosage of the medication or to discontinue it's use since the medication was initially ordered on [DATE]. There was also no documentation by the resident's physician as to why a gradual dose reduction (GDR) was clinically contraindicated for the resident. On 10/20/15 at 3:04 p.m., the consultant pharmacist said he reviewed the residents medication regimen and would take his report to the monthly medication management committee meeting. The pharmacist said he would recommend a GDR be attempted but if the committee did not agree the prescribing physician was never notified of his recommendation. The pharmacist confirmed he had not made any recommendation to Resident #64's physician to attempt a GDR for the antipsychotic medication. 2. Review of Resident #58's medication regimen revealed a physician order [REDACTED]. The Seroquel 12.5 mg was initially ordered on [DATE]. The Seroquel was increased on 3/9/14 to 25 mg. On 7/31/14 it was increased to 37.5 mg and on 8/28/14 the Seroquel was increased to 50 mg. Review of Resident #58's pharmacy monthly recommendations noted on 10/1/15 a recommendation to decrease the Seroquel to 25 mg. There was no documentation in the medical records the attending physician had addressed the pharmacist recommendation to decrease the Seroquel to 25 mg. On 10/21/15 at around 10:00 a.m., the Pharmacy Consultant confirmed Resident #58 was currently on Seroquel 50 mg for dementia with psychotic behaviors. He reviewed every resident's medication regimen in the facility prior to the third Thursday every month. On every third Thursday of the month there was a medication management meeting where we discuss all the resident's medications they were currently receiving. There were several people in the meeting including the Social Service Director (SSD), the Unit Managers, the Minimum Data Set Coordinator (MDSC) and others except the Director of Nursing (DON) who doesn't attend the meetings. Since I do not know the residents like the facility staff all pharmacy recommendations were determined by the team. If the medication team decided a medication was working as intended the team would write no recommendation for medication change for that month. He said by law all residents on a antipsychotic medications should have a GDR of those medications for 2 separate quarters for the first year and at least 1 attempt of a GDR every following year. He confirmed Resident #58 was ordered Seroquel 50 mg on 8/28/14 and the first request for a GDR for the Seroquel was made on 10/1/15. On 10/21/15 at around 12:30 p.m., the DON said she did not attend the monthly medication management meetings but did know the meetings were attended by the Consultant Pharmacist and facility staff. She said she didn't know why the Seroquel GDR was not done for Resident #58's but would call the physician's office and see if they had documentation related to Resident #58's medication in their medical records. On 10/21/15 at 2:10 p.m., an interview was conducted with the MDSC and DON. The DON said the physician's office had just faxed to her the sequence of events related to Resident #58's medications. On 10/2/15 they had received the request for the facility for a GDR of the Seroquel from 50 mg to 25 mg via fax. They had faxed back to the facility on [DATE] to reduce the Seroquel to 25 mg every day. On 10/7/15 the physician's office faxed to the facility not to reduce the Seroquel 25 mg but to keep the Seroquel at 50 mg until they talked with the wife after their next nursing home visit. The DON said they had not received either fax from the physician on 10/2/15 or 10/7/15 and the Seroquel was not reduced on 10/2/15 as ordered by the physician. She further said the physician did not write a medical justification on 10/7/15 for them not to do a GDR for the Seroquel even though Resident #58's behaviors had greatly improved. The MDSC said the Consultant Pharmacist had reviewed Resident #58's medications on 9/15/15 but did not make a recommendation to do a GDR for the Seroquel. The recommendation came from the medication team meeting which was held on 10/1/15, 16 days after his review. The team decided since Resident #58's behavior had greatly improved to recommend the GDR of the Seroquel to the physician. She was not aware until today their request for a GDR was not addressed timely as required. On 10/21/15 at 2:56 p.m., an interview was conducted with the SSD. She confirmed on 10/1/15 a medication team meeting was held to review all facility residents medication regime. When they reviewed Resident #58's medication they determined since his behaviors had greatly improved a GDR for the Seroquel was indicated. They had faxed their request for the GDR to the physician's office but never heard back from them so she called the physician's office on 10/20/15. The office told her they had recommended a dose reduce on 10/2/15 but the wife told them she did not want a GDR of the Seroquel so they had rescinded the GDR on 10/7/15. She confirmed the dose reduction ordered by the physician on 10/2/15 was not completed as ordered and there was no documentation from the physician on 10/7/15 in the medical records explaining the medical justification for not attempting a GDR for the Seroquel 50 mg. She also said the pharmacist was part of the medication management team but the team determined if a recommendation was sent to the physician including all GDR recommendations. She further confirmed the DON does not attend the medication management team meetings.

Based on interview and record review, the facility failed to ensure the care plan for 1 (Resident #11) of 7 residents' care plans reviewed was updated and revised to reflect the latest/current plan of care. The findings include. Review of Resident #11's medical records on 9/4/14 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Sheet (MDS) assessment noted the resident was incontinent 7 or fewer times in a week period upon admission. Another MDS assessment completed on 8/2/14 noted Resident #11 had an increase of urinary incontinence 7 or more times in a week. Resident #11 had an increase in urinary incontinence since his admission. A review of the plan of care noted a care plan for urinary incontinence for retention, urinary infection and incontinence. Approaches were to toilet the resident every 2 hours while awake, may use urinal, monitor for sign of infection, monitor labs and offer toileting every 2 hours and as needed. A social service note written 8/28/14 indicated the Psychiatrist shared his concerns about the resident's bed alarm at night. On 9/4/14 at around 4:00 p.m., interview with Resident #11 found he has an incontinence problem, but it happens mostly at night. Every night the night shift puts the bed alarm on and tells him not to get out of his bed without them. He doesn't want to upset the staff or cause the alarm to go off so he stays in his bed causing him to be incontinent at times. On 9/4/14 at around 4:25 p.m., interview with the Director of Nursing (DON), Charge Nurse (CN) and the Social Service Director (SSD) found Resident #11 has multiple medical issues which is causing him to be more incontinent since his admission. They said they are aware of Resident #11 concerns about his incontinence partly due to the bed alarm being too loud and not wanting the staff getting upset if he was to get out of his bed to use the bathroom. They said all residents admitted to the facility have a bed alarm turned on; they have to opt-out if they do not want the bed alarm turned on. They had moved Resident #11 on 8/29/14 so he could have a private room and care planned the bed alarm sound to be set on low. SSD confirmed she had written a progress note on 8/28/14 stating the Psychiatrist was concerned the bed alarm was scaring Resident #11 and keeping him in his bed at night. The DON then stated they had moved Resident #11 to another room and informed the staff the bed alarm sound is to be kept on the low setting to address the psychiatrist concerns. They then reviewed the plan of care for Resident #11 and noted the bed alarm/sensor which is listed under the falls care plan does not include the alarm sound should be set on low. On 9/4/14 at around 4:45 p.m., Resident #11's room was observed with the DON. The DON turned on the bed alarm and noted the sound was not set on the lowest setting. On 9/5/14 at around 9:15 a.m., interview with Resident #11's Nurse Staff K confirmed all residents admitted to the facility have the bed alarm turned on with the alarm set at the highest sound setting. He said he was unaware of why Resident #11 had changed rooms and did not know the bed alarm sound was to be set on the lowest sound setting. On 9/5/14 at around 9:30 a.m., interview with Resident #11's Nursing Assistant Staff M confirmed all residents admitted to the facility have the bed alarm turn on. She stated all bed alarms are set to the highest sound level so the staff could hear it when it goes off. She stated she was unaware Resident #11's plan of care was to have his bed alarm sound set on low. She showed the certified nursing assistance plan of care for Resident #11. It did not say the alarm sound is to be set to the lowest setting. On 9/5/14 at around 10:00 a.m., in an interview the Medical Records Director said all care plans are updated daily and Resident #11's care plan was not updated to direct his bed alarm sound to be set at the lowest level. She also confirmed the care plan was not updated until after surveyor intervention.