Every finding on record at Riverside Lifelong Health & Rehabilitation Sanders

Based on observation, staff interview, and facility policy review, the facility staff failed to properly store, label and date food items, and clean the floors within the facility's main kitchen. This failure had the potential to affect all 51 residents who consumed food prepared from the facility's kitchen. The findings included: 1. Facility staff failed to cover stored food and discard expired milk located in walk-in Refrigerator #4. On [DATE] at approximately 10:45 AM, observations during the initial tour of the kitchen revealed 2 clear plastic tubs which held approximately 4 dozen ears of shucked corn on the cob located in walk-in Refrigerator #4. The tubs were labeled and dated, however there was no lid or covering to protect the exposed corn from any potential contaminants. There was also an unopened gallon of milk with an expiration date of [DATE] sitting on the shelf with other gallons of milk that were not expired. On [DATE] at approximately 11:00 AM, an interview and kitchen tour was conducted with the facility's Dietary Director (DD) who confirmed he was in charge of the kitchen, kitchen staff, and food procurement. The DD observed the tubs of corn and stated, Those tubs should be covered with something, plastic wrap, I will take of this. The DD observed the expired gallon of milk and stated, This milk should not be sitting here available for use, it should have been discarded, it is out of date. The DD removed the expired milk from the shelf. 2. Facility staff failed to label and date food items located in the walk-in freezer. On [DATE] at approximately 11:00 AM, an interview and kitchen tour was conducted with the DD. There were several bags of different food items, located within the walk-in freezer, that had been previously opened, however the bags were not labeled or dated. The food items included a partial bag of crinkle-cut french fries, a partial bag of breaded onion rings, and a partial bag of breaded nuggeted food pieces. The DD stated, These bags should be labeled and dated, those nuggets look like chicken nuggets but I cannot be sure of that, I will dispose of these things right now. The DD also stated, Labels are needed to identify food items so that potential food allergens can be identified before serving it to people and dating food lets us know when it may no longer be safe to serve. On [DATE] at approximately 10:30 AM, an additional observation was made of the kitchen freezer with the DD and revealed 2 frozen cake items which appeared to be angel food cake, however there was no label and no date. These items were not observed on inspection the previous day. The DD stated, Some items were taken out of their original boxes last night when we were organizing the freezer but I see there is no label or date on the cakes and there should be, this was an oversight. 3. Facility staff failed to ensure the floor behind and around the icemaker, located within the facility kitchen, was free from dirt and debris. On [DATE] at approximately 11:00 AM, an interview and kitchen tour was conducted with the DD. Observations of the icemaker located in the kitchen revealed dirt and debris, including an overturned plastic cup, had collected behind the icemaker which stood approximately ,d+[DATE] inches away from the kitchen wall. The DD stated, It looks like this area is being missed, it is filthy back there, I be sure that it gets cleaned up. On [DATE] at approximately 10:30 AM, an additional observation was made of the kitchen floor behind the icemaker with the DD. The dirt and debris remained the same as the day before. The DD confirmed the observation and had no further statement. On [DATE] at approximately 11:15, the Facility Administrator was informed of the initial findings. A facility policy was requested and received. The facility policy titled, Food and Nutrition Services Infection Control, Food Safety, and Sanitation Policy, revised [DATE], subtitle, Food Storage, Service, and Holding Temperatures, item G, read, All Time/Temperature Controlled for Safety (TCS) foods prepared on-site or opened must be stored in clean containers or wrappings and labeled (as to content) and dated . On [DATE] at approximately 11:00 AM, the Facility Administrator was updated on the additional findings on the second kitchen walk-through. At approximately 11:30, the Facility Administrator reported that the kitchen floor around the icemaker had been swept, mopped, and sanitized which was confirmed by observation at 11:45 AM. No additional information was provided.

Based on observation, interview, record review, and review of the Recreational Therapy Director's job description, the facility failed to consistently provide a program of meaningful activities in accordance with the resident's preferences as identified in the resident assessment for two (Residents (R)39 and R27) of four residents reviewed for activities in a total sample of 20. This failure placed the residents at risk of a diminished quality of life. Findings include: Review of an undated Recreational Therapy Director job description, provided by the Administrator, revealed, .Implements, and evaluates activity programs which provide leisure opportunities that will meet the interests and needs of the resident, adapted to his/her medical limitations .Contributing to and/or directing/delegating the contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident . 1. Review of a significant change Minimum Data Set (MDS) assessment, located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 06/15/23 revealed R27 had a Brief Interview of Mental Status (BIMS) score of two out of 15 which indicated she was severely impaired in cognition for daily decision-making. In addition, the assessment showed that staff had assessed R27 for her activity preferences, which included: group activities, pets, books, music and going outside. Review of the 06/17/22 Activity Care Plan located in the Care Plan tab of the EMR, revealed R27 was at risk for activity deficit due to her move and new surroundings. Interventions included: will provide a monthly activity calendar; Staff will assist her to activities; Staff will assist with activities when needed; and cue her through the activity (06/17/23) and Staff will encourage outdoor activities when weather allows (07/04/23). Review of the July 2023 Activity Calendar located on the bulletin board across from the household two's dining room, revealed on 07/18/23 the activity would be: 9:30 AM Beauty Parlor, and 2:00 PM Happy Hour. During an observation on 07/18/23 at 10:14 AM, R27 was dressed and alert, however, was only able to answer simple questions. R27 was observed sitting in her wheelchair at the dining table. There was no activity occurring at this time. Further observation revealed the resident did not attend any activities from 07/18/23 to 07/20/23. 2. Review of the quarterly MDS assessment located in the MDS tab of the EMR with an ARD of 06/13/23 revealed R39 had a BIMS score of nine out of 15 which indicated she was moderately impaired in cognition for daily decision-making. During an observation on 07/18/23 at 12:00 PM, R39 was sitting in her wheelchair at the dining table. She was very drowsy and did not awaken to questions. According to R39's Activity Care Plan located in the Care Plan tab of the EMR dated 07/19/23 revealed R39 was at risk for activity deficit due to her poor hearing and cognitive decline. Interventions included: music, family visits, playing cards, bingo, talking with others, and entertainment. Staff were to invite R39 to activities daily and assist as needed. During an interview on 07/19/23 at 9:40 AM, Family Member (FM) 1 was asked about activities. FM 1 stated, I do feel they could do a better job (with activities). Yesterday there was supposed to be Happy Hour, but they did not have it. I stayed and played cards with the ladies until 5:00 PM as there was nothing else for them to do. FM 1 further stated, I do feel the calendar is often wrong and the activities don't happen. Many days, especially Saturday, nothing happens. Review of the Activity Documentation, provided by the facility revealed R39 had one visit documented for the past 30 days. No other activities were listed for R39. During an interview on 07/20/23 at 8:51 AM, the Recreational Therapy Director (RTD) was asked about the activities program. The RTD stated, Since I was made the Director, and I lost my assistant in May, things have been kind of thin. The RTD was asked what happens when you cannot do an activity. She stated, Sometimes, if I have a volunteer and they can't come, then I have to improvise with something else. I do hate it when that happens, but it does happen. The RTD was asked about weekend activities. She stated, I agree there is not much on the weekend. I usually will do a movie and popcorn one evening and I am trying to get volunteers back in the facility to church, but it's been hard. During an interview on 07/20/23 at 11:30 AM, the Director of Nursing (DON) was told about the current findings regarding the lack of activities. The DON confirmed that the activity program had been something that Administration was working on to improve.

Based on observation, interview, record review, and review of facility policy, the facility failed to develop a comprehensive plan of care directing measurable goals and interventions related to pain for one (Resident (R) 6) of two sampled residents reviewed for pain in a total sample of 20. This failure placed the resident at risk of unmet care needs and a diminished quality of life. Findings include: Review of the facility policy titled, Comprehensive Care Planning, dated 07/01/23 revealed, .The facility must work with the resident and their representative, if applicable, to understand and meet the resident's preferences, choices, and goals while they are at the facility. The facility must establish, document, and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicability quality of life. The facility must develop care plans that describe the resident's medical, nursing, physical, mental, and psychosocial needs and preferences and how the facility will assist in meeting these needs and preferences. Care plans must include person-specific, measurable objectives and timeframes in order to evaluate the resident's progress toward their goals . Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 02/09/23 revealed, R6 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated R6 was cognitively intact for daily decision-making. In addition, she was not administered pain medication, however, had almost constant pain in which she rated her pain level at a five out of 10 but did not limit her day-to-day activity or keep her awake at night. Review of the Care Area Assessment (CAA) revealed that pain was a triggered care area, as determined by the admission MDS and a Pain Care Plan would be developed. Review of the Comprehensive Care Plan, dated 02/14/23, did not show a Pain Care Plan had been developed. During an interview on 07/18/23 at 10:02 AM, R6 stated, I have had pain a long time, it's mostly in my back. I have had bad posture most of my life. They only give me Tylenol, but it doesn't help. During an interview on 07/19/23 at 2:34 PM, the Director of Nursing (DON) was asked if a Pain Care Plan had been developed for R6's complaints of pain. The DON confirmed and verified that a Pain Care Plan had not been developed despite the CAA summary indicating that a Pain Care Plan would be developed.

Based on observation, and staff interview, the facility staff failed to provide required postings, including a list of names, addresses, and telephone numbers for State Agencies and advocacy groups which are accessible and understandable for the resident population for one of three buildings ([NAME] 2). The findings included: During this surveyor's initial tour of the facility on 3-1-22 observations included all resident rooms and common areas of one of three all inclusive neighborhood buildings. No posting which listed the required names, addresses, and telephone numbers for State Agencies and advocacy groups which are accessible and understandable for the resident's could be found. LPN B (Licensed Practical Nurse) was asked where the posting could be found, and she stated it had fallen off of the wall and broken, and it had not as yet been replaced. When asked how long ago that happened, she stated she could not remember, and further stated it was awhile ago. On 3-2-22 the LPN unit Manager was asked about the posting, and she stated they were going to replace it immediately. On 3-3-22 at the time of survey exit, the posting had still not been replaced. The Administration was made aware of the findings and had nothing further to add.

Based on Observation, staff interview, clinical record review, and facility document review, the facility staff failed to perform handwashing, and gloving during medication pour and pass observations to prevent the spread of infection, for two Residents (Resident #31, and #19) in a survey sample of 15 residents observed receiving medications. The findings included: 1) LPN B filled a syringe and administered oral liquid [MEDICATION(S)] pain medication without applying gloves. 2) LPN B did not wash her hands for a sufficient amout of time to prevent the spread of infection, 3) turned off the water faucet of the sink with ungloved bare hands which had been turned on with soiled hands. 4) LPN B then handled the now recontaminated oral syringe with bare hands placing it back in the medication cart and continued to prepare medications for the next resident. Resident #31's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #19's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #31 was observed on 3-1-22 at 11:30 AM. laying on an alternating pressure air bed, resting with eyes closed, and easily aroused. The Resident stated in a soft voice that he was experiencing pain. During observations of Medication pour and pass administration on 3-1-22 at 11:30 a.m., LPN B prepared and administered [MEDICATION(S)] oral liquid pain medication to Resident #31 with bare hands. After administration of the medication, Licensed Practical Nurse LPN B went to the sink in the Resident's room and turned on the water faucet with her bare hands holding the contaminated oral syringe. LPN B washed the oral syringe in water only, with her ungloved bare hands in the room sink of Resident #31 for appoximately 3-5 seconds. LPN B dried her hands with a paper towel, threw the paper towel in the trash can by the sink and turned the water handle off, (while holding the syringe the entire time), with her ungloved bare hands. LPN B then returned the syringe to a drawer in the medication cart with her ungloved bare hands. LPN B then proceeded to Resident #19's room and prepared Tylenol medication for Resident #19 with ungloved bare hands and did not further sanitize her hands. On 3-1-22 at 5:00 PM, LPN B, and the LPN (C) Unit Manager, was informed of LPN B's failure to maintain a safe and sanitary environment to prevent the spread of infections such as Covid-19 by not washing hands long enough, nor using soap after handing an oral syringe with bare hands which had been in the mouth of Resident #31, and not using gloves when coming into contact with the [MEDICATION(S)] membranes of Resident #31, and prior to administering Resident #19's oral medication. The unit Manager LPN C was asked what infection control reference and guidlines were used in the facility, and she responded CDC (Centers for Disease Control). CDC Guidelines instruct the following excerpts; Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Hands should be washed with soap and water for at least 20 seconds when visibly soiled, before eating, and after using the restroom. On 3-2-22 at 5:00 PM, the facility administrator and Director of Nursing were informed of the findings at the end of day debrief. At that time it was re-iterated by the Administration that CDC guidelines were the infection control reference used for the facility.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to continue skilled care services following the issuance of a SNF ABN (skilled nursing facility advance beneficiary notice), when the Resident's representative selected to continue services and they would pay for them, for one Resident (Resident #15) in a sample of 3 Residents selected for review of ABN notices. The findings included: Resident #15, was admitted to the facility on [DATE], for skilled care services following hospitalization . On 12/15/21, Resident #15's responsible party (RP) was issued an ABN notice to notify them that skilled care services, to include physical therapy (PT) and occupational therapy (OT), would be ending. This notice also informed Resident #15 that as of 12/18/21, the Resident would no longer qualify for skilled care. The RP for Resident #15 selected [MEDICATION(S)] on the ABN. This option read, I want the care listed above. I understand that I may be billed now because I am responsible for payment of care. I cannot appeal because Medicare won't be billed. Review of the clinical record revealed that PT and OT services ended, despite the RP for Resident #15 indicating they wanted the Resident to continue to receive services [PT and OT] and agreeing to pay for such services. PT ended 12/17/21, and OT ended 12/17/21. On 3/2/22 at 3:26 PM, an interview was conducted with Employee F, the discharge planner. Employee F said that her supervisor had trained her last month, in February because she had been doing the ABN forms wrong. Employee F said she thought they were indicating they wanted the custodial care and not that they wanted to continue with the skilled services. Employee F went on to say, It makes sense now, I was doing it wrong. On 3/2/22 at 4:41 PM, an interview was conducted with Employee G, the Regional Therapy Director. Employee G was asked about what it meant if someone selected [MEDICATION(S)] on an ABN. Employee G said, We would bill them privately for that therapy. If that happens, we do education with the patient and family on why Medicare denied and why we don't see that it is clinically appropriate and discuss restorative nursing and other things that may be more appropriate. Employee G said if this conversation is held, it would be charted. Employee G was given Resident #15's name and asked if she saw any such documentation and if the family changed their mind. Employee G agreed to review the chart and let Surveyor F know if she found such documentation. Employee G didn't follow-up with any additional information before the conclusion of the survey. On 3/3/22, the facility Administrator provided Surveyor F with documents of training they received with regards to ABNs. This information gave the following explanation that read, [MEDICATION(S)]: I want to stay and I don't want to appeal. The facility policy titled, - Notification of Non-Coverage: Medicare Part A Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) was reviewed. This policy read, .The SNF Advanced Beneficiary Notice (SNFABN) will continue to be issued on two occasions: .2. Discharge: All residents who are discharged from Medicare Part A without utilizing their 100 day benefit and remain in the building must be issued an SNFABN. This may be issued to the resident or resident representative (RR) and must have a signature with date completed on or before the date of discharge. This includes SNF to hospice . The facility policy regarding the SNFABN, gave no direction to the facility on how to respond in the instance that a Resident selected [MEDICATION(S)], other than directing the staff to reference the CMS (Centers for Medicare and Medicaid Services) website. A review of the CMS website was conducted. CMS provided the following guidance: The SNFABN provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare Part A) . Regarding the options Residents have to choose from, CMS defines [MEDICATION(S)] as, .[MEDICATION(S)]. This option allows the beneficiary to receive the non-covered items and/or services and pay for them out of pocket. No claim will be filed and Medicare will not be billed. Thus, there are no appeal rights associated with this option . Accessed online at: https://www.cms.gov/Medicare/Medicare-General-Information/BNI Additional information from CMS stated, [MEDICATION(S)]: You want the items or services that may not be paid for by Medicare, but you don't want your provider or supplier to bill Medicare. You may be asked to pay for the items or services now, but because you ask your provider or supplier to not submit a claim to Medicare, you can't file an appeal. This information was accessed online 3/3/22, at https://www.medicare.gov/claims-appeals/your-medicare-rights/advance-beneficiary-notice-of-noncoverage The Administrator was informed on 3/2/22 and 3/3/22, during end of day meetings of the concern regarding Resident #15. No further information was provided.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to prevent Resident #19 from abusing one resident (Resident #148) in a sample of 21 residents. This is harm. The Findings included: For Resident #148, the facility staff failed to protect him from abuse. Resident #148 was assaulted by Resident #19 resulting in a [MEDICAL CONDITION]. Resident #148 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #148's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of [DATE] was reviewed. Resident #148 had a Brief Interview of Mental Status Score of 00, indicating severe cognitive impairment. On [DATE], a review of Resident #148's clinical record was conducted, revealing nurses notes. According to the notes, Resident #148 was pushed by Resident #19 and he sustained a fall. Resident #148 was sent to the hospital on [DATE] at 6:30 P.M., where he was diagnosed with [REDACTED].M. with new orders for pain medication. Resident #19 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #19's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of [DATE] coded Resident # 19 as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. On [DATE] a review was conducted of facility documentation, revealing a Facility Reported Incident follow-up report dated [DATE]. In summary, on [DATE] at approximately 4:00 P.M., Resident #19 went into the dining room and noticed another resident (Resident #148) sitting at the dining table in the location that Resident #19 preferred to sit in. Resident #19 demanded that Resident #148 move away from the table, when Resident #148 stood up from his wheelchair, and used the table to brace himself, Resident #19 pushed on Resident #148's knees, causing him to fall and sustain a [MEDICAL CONDITION]. Resident #148 was hospitalized , then returned to the facility, where he expired on [DATE]. A Certified Nursing Assistant (CNA K) was present and witnessed the incident. An excerpt from CNA K's written statement dated [DATE] read, I saw (Resident #19) leave his usual spot in the dining room. Quickly after (Resident #148) approached his spot. (Resident #19) returned and was agitated that (Resident #148) was there, he asked him to move but (Resident #148) was hard of hearing. (Resident #19) grabbed onto his knees and pushed backward as (Resident #148) was holding onto the table trying not to be pushed and he fell on to the floor. Before I could get up to interfere (Resident #148) was already on the floor. On [DATE] at 11:30 [NAME]M. an interview was conducted with Resident #19 in the dining room. He denied pushing Resident #148, and stated, That guy didn't belong here. I learned to defend myself when I was young. I know how to fight. On [DATE] a review was conducted to Resident #19's clinical record, revealing his care plan, and nursing notes. Prior to the incident on [DATE], there was no documentation of previous incidents of physical or verbal aggression toward others. On [DATE] at 12:34 P.M., an interview was conducted with the MDS Coordinator (RN B), who was responsible for writing Resident #19's care plan. When asked what types of interventions should have been included in Resident #19's care plan that was created on [DATE], she stated, Psych. consults, counseling by a psychiatric nurse practitioner, or psychiatrist, we should have looked for triggers and the medical team should have done an investigation. No further information was received.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for four residents (Resident #97, Resident #27, Resident #31, Resident #297) in a sample size of 21 residents. The findings included: 1. For Resident #97, there was an active physician's order for Do not Resuscitate but the code status was listed as Full Code on the baseline care plan and on the Patient Summary page in the electronic health record. Resident #97, an [AGE] year old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #97's admission Minimum Data Set was in progress. On [DATE] at approximately 09:30 AM, Resident #97's clinical record was reviewed. A physician's order dated [DATE] documented, Do Not Attempt Resuscitation. Ensure DNR (do not resuscitate) on file. A Durable Do Not Resuscitate Order form dated [DATE] and signed by physician and Resident Representative was in the hard chart. The baseline care plan in the electronic health record listed the code status as Full code. On [DATE] at 4:48 PM, Certified Nursing Assistant A (CNA A) was asked how she determined a resident's code status. CNA A stated she looks on her 'Patient Summary' page in the electronic health record. This surveyor and CNA A observed the Patient Summary page for Resident #97 on the electronic health record and CNA A stated, (Resident #97) is a full code. Licensed Practical Nurse A (LPN A) was asked how the information gets populated to the Patient Summary page and LPN A stated the nurse should update this from the orders. When asked about the importance of having the correct code status on the CNA Patient Summary page, LPN A stated, So everyone can be on same page and know what's going with (Resident #97's) code status. On [DATE] at approximately 5:15 PM, the DON was notified of findings and stated she expects the code status information to match throughout the clinical record. On [DATE] at approximately 4:30 PM, the administrator and DON had no further information or documentation to offer. 2. For Resident #27 the facility staff failed to maintain an accurate medical record to indicate the CPR/code status. Resident #27 was admitted to the facility on [DATE] with a recent readmission date of [DATE]. Review of Resident #27's careplan revealed an Advance Directive status of Do Not Resuscitate with an effective date of [DATE]. On [DATE] at 9:43am review of Resident #27's clinical chart revealed a signed DNR (do not resuscitate) signed on [DATE] by both of Resident #27's daughters, who are Medical Power of Attorney. The physician had not signed the form. A progress note from the Psychiatric Nurse Practitioner dated [DATE] indicated Resident #27 is now a DNR. However a review of Resident #27's physician orders for April, May, (MONTH) and (MONTH) reveal a Full Code status (meaning CPR would be performed in the event of cardio-pulmonary arrest). On [DATE] at 12:39 an interview was conducted with LPN C regarding Resident #27's CPR/Code status. LPN C stated she is a full code. LPN C looked in the computer at Resident #27's electronic medical record and noted that it read Full Code. LPN C went to Resident #27's room and agreed that the purple dot on her name tag indicated she was a DNR and stated, oh, I don't know who put that there. LPN C went to Resident #27's chart and on the spine there was now a purple dot. LPN C looked in the chart and saw the signed DNR form. LPN C stated, the physician never signed it, so it's not valid. I know she is a full code I guess it is my fault for not looking at the stickers. I am very upset by this. This is a copy. When LPN C was asked if a copy is valid, LPN C stated, no. LPN C was asked if Resident #27 was to go into [MEDICAL CONDITION] would she perform CPR, LPN C was unable to answer. Review of the facility policy titled, Color-Coded Wristbands with an effective date of [DATE] read, To adopt the following risk reduction strategies: color-coded circles on identification cards clarifying the intent. Page 2 of this document under definitions the policy read, purple- Do Not Resuscitate. No further information was provided. 3. For Resident #31 the facility failed to maintain an accurate clinical record regarding the use of and refusal of a bi-pap machine. Resident #31 was admitted to the facility on [DATE]. Resident #31's [DIAGNOSES REDACTED]. Observations on [DATE], [DATE] and [DATE] of Resident #31's private room revealed an oxygen concentrator at bedside and a bi-pap machine, which was on the bedside table. Review of Resident #31's physician orders for (MONTH) and (MONTH) 2019 revealed an order, which had an origination date of [DATE], and read: Apply Bi-Pap with 2L O2 at 21:00 every day. Review of Resident #31's Treatment Administration Record (TAR) for (MONTH) 2019, revealed an entry that read, Apply Bi-pap with 2L O2 (2 liters of oxygen) at 2100 every day. There was only one note, which was dated [DATE] and indicated not administered due to refusal. Review of Resident #31's TAR for (MONTH) 2019 indicated the bi-pap had been discontinued [DATE] and there was no record of it being applied as ordered by the physician or refused by the Resident for the entire month of July. On [DATE] at 5:20pm an interview was conducted with LPN D. LPN D accompanied the surveyor to Resident #31's room and LPN D was questioned regarding the bi-pap machine located at the bedside. LPN D did indicated yes when asked if they have an order to use it. LPN D stated, she refuses it all the time. When asked if they put it on Resident #31, LPN D stated, yes but she may keep it on 5 minutes and remove the mask. No further information was provided. 4. For Resident #297, the facility staff failed to document the self administration of [MEDICATION NAME]. Resident #297, an [AGE] year old male, was admitted to the facility on [DATE]. On [DATE] at approximately 12:35 PM, during the course of an interview, an [MEDICATION NAME] inhaler with a spacer was observed in Resident #297's dresser drawer. Resident #297 stated, my wife brought that up here to me yesterday from home for me to start using and further stated, the nurse saw it out on my bed yesterday when my wife brought it up here and told me just to stick it in my dresser drawer, I only use it if I feel like I need to, I used it once or twice yesterday and once so far today. Clinical record review on [DATE] at approximately 3:00 PM. There was no documentation of the ,[DATE] self-administered doses of [MEDICATION NAME] previously taken by Resident #297 located within the clinical record.

Based on observation, resident interview, staff interview, and clinical record review the facility staff failed to provide a qualified activities director for one of three units. The findings included: 1. For Facility Unit #1, the facility staff failed to provide a qualified activities director and develop an activities program. On 07/11/2019 at approximately 9:35 AM, an interview with Employee K was conducted. When asked about her role, Employee K stated she was a social worker but also planned activities for residents living in Facility Unit #1. On 07/11/19 at 01:07 PM, Employee K verified her credentials as social worker and also stated she has not received any training in activities. A copy of the Activities Department policy was requested and the DON verified there was no Activities policy. On 07/11/2019 at approximately 4:30 PM, the administrator and DON had no further information or documentation to offer.

Based on staff interview and facility documentation review, the facility staff failed to have quarterly QAA/QAPI (Quality Assessment and Assurance/ Quality Assurance/Performance Improvement) meetings for 3 of a possible 4 quarters The findings include: On 07/11/19 at 12:06 PM, a review of the facility's QAA/QAPI program was conducted. When asked for the attendance logs of QAPI meetings since the last survey, the administrator presented two attendance records. One document was dated 05/30/2019 and the other was dated 06/26/2019. The administrator verified he did not have attendance logs or meeting minutes as evidence QAA/QAPI meetings were held quarterly. Also, the attendance log dated 05/30/2019 did not have the Medical Director in attendance. The facility provided a copy of their policy entitled, Quality Management Systems. In Section III, Part (a), under the header, Facility on page 5, it was documented, Conduct quarterly facility-specific Quality and Performance Improvement meetings. On 07/11/2019 at approximately 4:30 PM, the administrator and the DON had no further documentation or information to offer.

Based on observation, staff interview, and clinical record review, the facility staff failed to maintain dignity for one resident (Resident #97) in a sample size of 21 residents. The findings included: For Resident #97, a facility staff member was standing over him in the dining room while coaching him to eat his breakfast on 07/10/2019. Resident #97, an [AGE] year old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set was in progress. On 07/10/19 at 08:07 AM, Resident #97 was observed sitting in his wheelchair in the dining room receiving assistance to eat breakfast. Employee C, a speech therapist, was standing to the left of Resident #97 and coaching him throughout the mealtime. On 07/10/19 at 08:22 AM, an interview with Employee C was conducted. When asked if it was her routine process to stand next to residents when assisting them through mealtimes, she stated. Sometimes. Employee C stated she didn't know it was a dignity issue to stand over him while giving assistance at mealtime. On 07/10/19 at 10:47 AM, the DON was notified of findings and stated that staff should sit when assisting residents with meals to maintain resident dignity. A policy on assisting residents with meals was requested. On 07/10/19 at 04:14 PM, Employee [NAME] from Quality Assurance stated the facility did not have a policy regarding assisting residents with meals. On 07/11/2019 at approximately 4:30 PM, the administrator and DON had no further information or documentation to offer.

Based on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure safety and clinical appropriateness for self-administration of medication for 1 resident (Resident #297) in a survey sample of 21. The findings included: For Resident #297, the facility staff failed to properly determine the safety and clinical appropriateness for self-administration of an [MEDICATION NAME] inhaler. Resident #297, an [AGE] year old male, was admitted to the facility on [DATE]. On 07/09/19 at approximately 12:35 PM, during the course of an interview, an [MEDICATION NAME] inhaler with a spacer was observed in Resident #297's dresser drawer. Resident #297 stated, my wife brought that up here to me yesterday from home for me to start using and further stated, the nurse saw it out on my bed yesterday when my wife brought it up here and told me just to stick it in my dresser drawer, I only use it if I feel like I need to. On 07/09/19 at approximately 1:05 PM, the Director of Nursing (Employee B) stated, that Resident #297 is not approved for self-administration, we were getting ready to do that, it was brought to my attention this morning and when asked if she expected the inhaler to be stored in the Resident's dresser drawer, she stated, no, it shouldn't be there. LPN B approached the nursing station during this interview and stated that she had assessed Resident #297 for self-administration of his inhaler and she had approved it. On 07/09/19, review of the clinical record revealed an Assessment for Self Administration of Medications form completed by LPN B at 10:46 AM. Documentation of that assessment indicates that Resident #297 correctly verbalizes medication purpose--able with cueing, correctly documents administration of medication--unable, and can demonstrate correct ability to store medications in room--able with cueing. On 07/10/19, review of the facility's policy entitled Resident Care: Self-Administration of Medications (last review date 2/2019), the purpose states, If a resident requests to self-administer medications, it is the responsibility of the interdisciplinary team to determine that it is safe for the resident to self-administer the medications, before the resident may exercise that right The attending physician must approve a recommendation from the interdisciplinary team prior to the resident being permitted to self-administer medications. The physician's orders [REDACTED]. At approximately 5:20 PM, the DON (Employee B) was interviewed and stated, the IDT (interdisciplinary team) is made up of leadership in different departments and I represent clinical nursing, IDT has not met since he (Resident #297) has been admitted , I am not familiar with the facility policy (regarding self-administration of medication), can you give me an education?.

Based on staff interview, facility documentation review and clinical record review the facility staff failed to uphold a Resident's desire to formulate an Advance directive for one Resident (Resident #27) in a survey sample of 21 Residents. The findings include: For Resident #27 the facility staff failed to notify the physician of the Resident's desire to execute a Do Not Resuscitate (DNR) and indicate in the Resident's record, this wish. Resident #27 was admitted to the facility on [DATE] with a recent readmission date of [DATE]. On [DATE] at 9:43am review of Resident #27's clinical chart revealed a signed DNR (do not resuscitate) signed on [DATE] by both of Resident #27's daughters, who are Medical Power of Attorney. The physician had not signed the form. On [DATE] at 9:43am, it was observed that on the spine of Resident #27's chart there were colored dots, yellow and red. During a staff interview to explain the dots the staff indicated that a purple dot indicates the person is a DNR (which was not present), yellow means a fall risk and red indicates allergies [REDACTED].>Review of Resident #27's physician orders for April, May, (MONTH) and (MONTH) reveal a Full Code status (meaning CPR would be performed in the event of cardio-pulmonary arrest). On [DATE] 01:10 PM outside of Resident #27's room, the name plate was observed to have a purple dot, indicating Resident #27 has a DNR. On [DATE] at 12:39 an interview was conducted with LPN C regarding Resident #27's CPR/Code status. LPN C stated she is a full code. LPN C looked in the computer at Resident #27's electronic medical record and noted that it read Full Code. LPN C went to Resident #27's room and agreed that the purple dot on her name tag indicated she was a DNR and stated, oh, I don't know who put that there. LPN C went to Resident #27's chart and on the spine there was now a purple dot. LPN C looked in the chart and saw the signed DNR form. LPN C stated, the physician never signed it, so it's not valid. I know she is a full code I guess it is my fault for not looking at the stickers. I am very upset by this. This is a copy. When LPN C was asked if a copy is valid, LPN C stated, no. LPN C was asked if Resident #27 was to go into [MEDICAL CONDITION] would she perform CPR, LPN C was unable to answer. Review of the facility policy titled, Color-Coded Wristbands with an effective date of [DATE] read, To adopt the following risk reduction strategies: color-coded circles on identification cards clarifying the intent. Page 2 of this document under definitions the policy read, purple- Do Not Resuscitate. No further information was provided.

Based on staff interviews and clinical record review, the facility staff failed to notify the Resident and Resident's representative of the reason for and location of transfer, and failed to notify the ombudsman for one Resident (Resident #14) in a survey sample of 21 Residents. The findings included: For Resident #14 the facility staff failed to provide written notification of transfer/discharge to the Resident and/or Resident Representative; and failed to notify the ombudsman of the discharge. Resident #14 was admitted to the facility on [DATE] with a readmission date of [DATE]. On 7/11/19 a review of Resident #14's clinical record revealed that Resident #14 was sent to the hospital on [DATE]. Review of the entire clinical record revealed no indication that the Resident or Resident Representative had been provided a notice of transfer in writing. There was no indication that the ombudsman being notified of the transfer. On 7/11/19 at 12:34PM an interview was conducted with LPN C. When asked about transferring a resident to the hospital she indicated that the Resident and Resident representative is told of the transfer but no written information is provided to either party other than the bed hold information. When LPN C was asked who notifies the ombudsman of transfers and discharges, LPN C was unaware of who an ombudsman is. On 7/11/19 at 12:55pm an interview was conducted with the Director of Nursing (DON). When asked what is done when a Resident is transferred and/or discharged to the hospital she indicated that only the bed hold information was provided to Resident #14's family. On 7/11/19 at 2:01pm the DON provided a Transfer/Discharge Notice dated 4/22/19, which had been partially filled out, date of discharge was blank. The DON stated, the day (Resident #14) discharged , they didn't do the process. The nurse filled this out but she didn't know what to do with it. The DON also stated, when we send residents to the hospital we do not notify the Ombudsman, we classify this as a leave of absence because we plan for them to come back. We need to be educated on this for our plan of correction. Review of the facility policy titled Nursing Home Discharge/Transfer Policy with a date of origin: 4/8/19 with a revision date of 6/5/19 read on page 2: The resident/representative will be provided with all applicable state and federal notices at the time of discharge to include: discharge notice. A copy of this notice will also be forwarded to the State Ombudsman. No further information was provided.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to develop a comprehensive care plan for one Resident (Resident #19) in a sample size of 21 residents. The findings included: For Resident # 19, the facility staff failed to develop a comprehensive Behavioral Care Plan to include mental health and psychosocial services after Resident #19 assaulted another resident, resulting in a [MEDICAL CONDITION]. Resident #19 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #19's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 11/28/18 coded Resident # 19 as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. On 7/9/19 a review was conducted of facility documentation, revealing a Facility Reported Incident follow-up report dated 2/25/19. In summary, on 2/17/19 at approximately 4:00 P.M., Resident #19 went into the dining room and noticed another resident (Resident #148) sitting at the dining table in the location that Resident #19 preferred to sit in. Resident #19 demanded that Resident #148 move away from the table, when Resident #148 stood up from his wheelchair, and used the table to brace himself, Resident #19 pushed on Resident #148's knees, causing him to fall and sustain a [MEDICAL CONDITION]. On 7/9/19 a review was conducted of Resident #19's clinical record, revealing his care plan initiated 2/27/19. It read, Behavioral symptoms. Physical and verbal symptoms directed at others. The care plan did not contain any mental health and psychosocial interventions. The identified interventions were limited to nursing staff giving him medication, reminding him after the fact that his behavior is inappropriate and removing him from the situation. On 7/9/19 at 11:30 [NAME]M. an interview was conducted with Resident #19 in the dining room. He denied pushing Resident #148, and stated, That guy didn't belong here. I learned to defend myself when I was young. I know how to fight. On 7/11/19 at 12:34 P.M. an interview was conducted with the MDS Coordinator (RN B), who was responsible for writing Resident #19's care plan. When asked what types of interventions should have been included in Resident #19's care plan that was created on 7/2/19, she stated, Psych consults, counseling by a psychiatric nurse practitioner, or psychiatrist, we should have looked for triggers and the medical team should have done an investigation. No further information was received.

Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to follow professional practice standards for medication and treatment administration for three Residents (Residents #16 #97, and #297) in a survey sample of 21 Residents. The staff stated their professional standard for nursing was Mosby. The findings included: 1. For Resident #16, the facility staff failed to ensure medications and treatments were not left at bedside unattended. Resident #16, was initially admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #16's most recent MDS (minimum data set) with an ARD (assessment reference date) of 5-14-19 was coded as an annual full assessment. Resident #16 was coded as having severe cognitive impairment, and was not able to make her own daily life decisions. The Resident was coded as requiring extensive to total assistance of one to two staff members to perform all activities of daily living. During initial tour of the facility alone on 7-9-19, at 11:15 a.m., it was noted on the overbed table in Resident #16's room, 2 clear 30 milliliter medication cups, each having a different color of medicated cream in them. One was white with a silvery sheen, and the other was a yellow matte color. Resident #16's room was returned to by surveyors 3 times and after the final and third time, at 1:00 p.m., the nurse for that room was sought by surveyors. The Nurse manager was taken to the room and asked what the medication cups contained, and she responded she would have to get the nurse to explain. The surveyor followed the unit manager to find the nurse. LPN C was found in the supply room and the nurse stated that the medicated creams were [MEDICATION NAME], for under the Resident's breasts, and a house barrier cream for incontinence. She was asked why the creams were left at bedside, and she replied the Resident was at lunch, and so she was waiting for her to finish to apply the medicated ointments. She was asked if it was a facility standard to leave medicated ointments at the bedside, and she replied no. The nurse manager also replied no medications or treatments should be left at bedside. Review of Resident #16's clinical record revealed a physician's order for the following medication/treatment: [MEDICATION NAME] cream ordered 3-30-18 under breast as needed for redness. The house Barrier cream according to the unit manager needs no order and is used for all residents with incontinence to protect their skin from moisture contact. When interviewed, the DON (director of nursing) stated the staff should never leave medication and treatments at the bedside unattended. Guidance for nursing standards for the administration of medication is provided by Fundamentals of Nursing, 7th Edition, Mosby's: Professional standards, such as the American Nurses Association's Nursing : Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation The documents also described the act of patient self administration of medication, and instruct that medications are never left unattended. The administrator, DON and corporate consultant were informed on 7-10-19 at 5:00 p.m. of the failure of the staff to ensure medications were not left unattended at bedside for Resident #16. 2. For Resident #97, the facility staff failed to complete neuro checks after a fall on 07/06/2019. Resident #97, an [AGE] year old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #97's admission Minimum Data Set was in progress. On 07/10/19 at approximately 09:30 AM, Resident #97's clinical record was reviewed. The baseline care plan dated 07/02/2019 had an entry under the header Safety that selected Risk for Falls. Under the sub-header, Interventions, it documented, call bell in reach at all times, bed in lowest position, personal items in reach. An undated entry below that documented, (Resident #97) has had an actual fall 7/6/19 and he is at risk for future falls secondary to weakness. Our goal is no major injuries from a fall for (Resident #97) by next review. We will provide skilled therapy for strengthening. Perform frequent rounding. Keep his call light within reach and remind him to use call light. A clinical note dated 7/7/2019 at 3:05 p.m. documented, Night nurse reported resident found on the floor bending down on his knees in front of his bed on last night (sic) Spoke to resident about this. Resident said he think (sic) he had a fall by trying to get up out of bed unassisted. Assessment completed on resident (sic) with no findings of bruises or active bleeding observed. Nothing out of the norms. Resident denies having any pain. Resident is able to move all extremities without any difficulty. Right side is weaker than the left from primary dx (diagnosis) of having a stroke. this (sic) weakness is normal. V/s/ (sic) (vital signs) BP (blood pressure) 96/57 temp (temperature) 98.5 pulse-96 - resp/18 (respirations 18) o2 sats 99% r/a (on room air). BP has been running low notified the physicians (sic) Resident denies h/a (headache) or blurry vision. Notified the RR (resident representative) in reference to this. Notified the provider. Resident is without any complaints. Call bell and personal belongings are within reach. Staff continue to monitor, educate and remind resident to ring the call bell for assistance. He is easily redirected. Resident acknowledge (sic) verbal understanding to this and has been ringing his call bell for assistance. Neuro checks are in place. On 07/11/2019 at approximately 10:30 AM, a copy of the neuro checks and their policy on fall protocols were requested. On 07/11/2019 at 12:55 PM, the DON provided a copy of a flowsheet entitled, Post Fall Assessment. the neuro check documented post-fall. The column for frequency indicated neuro checks were to be done every 30 minutes x 4, then every hour x 4, then every 2 hours x 4, then every 4 hours x 4, then every 8 hours x 6. The neuro checks were completed beginning 07/06/2019 at 9:50 PM through 07/08/2019 at 7:00 PM. The final 8 opportunities (every 4 hours x 2 and every 8 hours x 6) were not completed. When asked about expectations for performing neuro checks as indicated following a fall, the DON stated that they should've been completed. The facility provided a copy of their policy entitled, Falls Prevention and Management. In Section C entitled, Fall Documentation Standards, in part (2), item (c), it was documented, Neuro Assessment for all unwitnessed fall or witnessed falls involving the head. The policy did not address frequency of neuro checks following a fall. According to the Code of Ethics for Nurses with Interpretive Statements by the American Nurses Association (2015), Provision 4 documented, The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care. On 07/11/2019 at approximately 4:30 PM, the administrator and DON had no further information or documentation to offer. 3. Resident #297 was told by a nurse to keep his [MEDICATION NAME] in his drawer. In addition, LPN B did not enter a complete order. Resident #297, an [AGE] year old male, was admitted to the facility on [DATE]. On 07/09/19 at approximately 12:35 PM, during the course of an interview, an [MEDICATION NAME] inhaler with a spacer was observed in Resident #297's dresser drawer. Resident #297 stated, my wife brought that up here to me yesterday from home for me to start using and further stated, the nurse saw it out on my bed yesterday when my wife brought it up here and told me just to stick it in my dresser drawer, I only use it if I feel like I need to, I used it once or twice yesterday and once so far today. On 07/09/19 at approximately 1:05 PM, LPN B stated that she would be putting in an order for [REDACTED]. The clinical record review also revealed a verbal order entered by LPN B at 1:48 PM that read: Write In .Resident may self-administer Inhaler and notify nurse to access when he uses it .Ordering Prescriber: (attending physician name redacted) .Order Date 7/9/2019. There was no physician's order specifically authorizing the medication, [MEDICATION NAME], including strength, dosage, frequency, route or indication for use. Guidance for nursing standards for the administration of medication is provided by Fundamentals of Nursing, 7th Edition, Mosby's: Professional standards, such as the American Nurses Association's Nursing : Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation The documents also described the act of patient self administration of medication, and instruct that medications are never left unattended.

Based on observation, staff interview and clinical record review, the facility staff failed to provide an activity program for two Residents (Resident #27, Resident #97) in a survey sample of 21 Residents. The findings included: 1. For Resident #27 the facility staff failed to provide a program to support the Resident's interests. Resident #27 was admitted to the facility 8/28/15. On 7/9/19 at 11:50am Resident #27 was observed in her room, in bed, with no stimulation being provided such as a radio or television on. No supplies for independent activities was observed in the room of Resident #27. On 07/09/19 at 03:18 PM Resident #27 was observed in her room, in bed with no stimulation provided. No supplies for independent activities was observed. On 7/10/19 during multiple observations throughout the day, from 9am-5pm, Resident #27 was observed in her room, in bed looking up at the ceiling. No form of stimulation was provided, such as a radio, television or any supplies for independent activities was observed. On 7/10/19 a request was made to receive copies of activity attendance for Resident #27 for the past year. No documents were provided by the facility staff. On 7/11/19 at 9:15am another request was made to receive copies of Resident #27's activity attendance. Upon exit of the survey team on 7/11/19 at 5pm no documents were received. On 07/11/19 at 09:24 AM an interview was conducted with Employee G, the certified activity director. When the activity director was asked where activity attendance is recorded, the activity director stated, I just came up with a form to start doing that. When asked if attendance has been recorded, the activity director stated, I started here the end of (MONTH) and there has been no logging of who attends activities since I have been here. On 7/11/19 a request was made to the activities director, employee G, for the activity calendars for the past year. Group activity calendars were provided for March, April, May, (MONTH) and (MONTH) 2019. When the activity director was asked for activity calendars/programing prior to March, the activity director stated, I don't have any. Review of Resident #27's careplan revealed, (Resident #27) is at risk for social/diversional activity deficit related to [MEDICAL CONDITION] Disorder Mood/behavioral disturbance and loss of interest in socialization/diversion. Interventions included: invite to/engage resident in activities of known interest. Past/current interests include, but are not limited to: gardening, painting. Review of the March, April, May, (MONTH) and (MONTH) 2019 activity calendar revealed one scheduled gardening activity and one painting activity for the entire 5 month period. A request was made for activity related policies and the activity director and corporate staff stated there were no activity related policies. No further information was provided . 2. For Resident #97, the facility staff failed to assess, develop, and plan an individualized activities program. Resident #97, an [AGE] year old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #97's Minimum Data Set was in progress. On 07/09/2019 at approximately 1:15 PM, Resident #97 was observed in his room, fully dressed, awake, lying on his bed. On 07/10/19 at 08:07 AM, Resident #97 was observed eating his breakfast in the dining room. 07/11/19 at 08:33 AM, Resident #97 was observed self-propelling himself back to his room after breakfast. Resident #97 positioned his wheelchair next to bathroom with his back to his room door. There was a TV in the room but it was off. When asked if he liked to watch TV, Resident #97 stated, Not really but added that sometimes he likes to watch cowboy movies. When asked what other things he liked to do, Resident #97 stated, I don't know. When asked if he liked to paint, Resident #97 shook his head no. When asked if he liked working with tools, Resident #97 nodded and stated he likes building things and putting things together. On 07/11/2019 at approximately 9:20 AM, an interview with Employee G, the Activities Director, was conducted. When asked about Resident #97's activity preferences, Employee G stated that Resident #97 lives in the other building (Facility Unit #1). She went on to say that she oversees activities for only for (Facility Unit #2). On 07/11/2019 at approximately 9:35 AM, an interview with Employee K was conducted. When asked about her role, Employee K stated she was a social worker but also planned activities for residents living in (Facility Unit #1). When asked about activity preferences for Resident #97, Employee K stated that (Resident #97) likes to read. When asked what other activities Resident #97 preferred, Employee K stated she would need to look at her notes. This surveyor and Employee K went to retrieve her notebook. Employee K looked through her notes and stated she didn't have notes about Resident #97 and his activity preferences. When asked about her process for setting up an activities program for each resident, Employee K stated she learns about new admissions in the morning meetings and she will then schedule a time to meet with the resident and/or the family. Employee K stated she attempts to meet with residents as soon as possible. When asked if she met with Resident #97, she stated yes but did not meet with his family. When asked about the documentation for Resident #97's activities assessment and activities plan, Employee K stated there was no assessment documentation, no activity plan, no activity log, and no activity schedule for Resident #97. When asked for Facility Unit #1 Activities Calendar, Employee K stated there was no Activity Calendar for Facility Unit #1. On 07/11/19 at 01:04 PM, Resident #97 was observed in his room sitting in his wheelchair. When asked if he liked to read, Resident #97 stated, Depends on the topic. When asked about what he likes to read, Resident #97 stated, I don't know, I can't think. On 07/11/19 at 01:07 PM, Employee K verified her credentials as social worker and also stated she has not received any training in activities. On 07/11/2019 at 2:50 PM, the DON was notified of findings and asked about her expectations. The DON stated she expects there should be an activities calendar, an activities assessment for each resident, activities plan, activities schedule, and for all of it to be documented in the clinical record. A copy of the Activities Department policy was requested and the DON verified there was no Activities policy. On 07/11/2019 at approximately 4:30 PM, the administrator and DON had no further information or documentation to offer.

Based on observation, resident interview, and staff interview, the facility staff failed to mitigate an accident hazard for 1 (Resident #297) of 21 sampled residents. The findings include: For Resident #297, the facility staff failed to properly repair the handles on 3 dresser drawers that are located in his room and being accessed by him for storage of personal belongings. Resident #297, an [AGE] year old male was admitted to the facility on [DATE]. On 07/09/19 at approximately 12:35 PM, during initial tour of the facility, Resident #297 shared concerns regarding sharp objects in his dresser drawers and stated, I am afraid my hand may catch on the screw that is sticking out and scratch me, I have asked numerous times for them to come look at it and fix it. Three drawers in his dresser revealed the heads of screws protruding approximately 2 centimeters on the inside of the drawer. Sharp edges existed around the circumference of the screw heads. The screws were holding the outside dresser drawer handles in place. The Maintenance Director (Employee F) was interviewed and confirmed that maintenance had been performed on Resident #297's dresser recently with an open work order waiting for parts to help the drawers slide easier.

Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to provide appropriate treatment and services for 1 resident (Resident #39) with a clinically-justified indwelling urinary catheter in a survey sample of 21 residents. The findings included: For Resident #39, the facility staff failed to secure the tubing of the indwelling urinary catheter in a manner that would reduce the risk for a traumatic dislodgement from the Resident's bladder. Resident #39, a [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/10/19 at approximately 1:20pm, RN C was observed changing an incontinence brief for Resident #39 who has a clinically-justified indwelling urinary catheter which was unsecured. RN C responded, it (urinary catheter tubing) should be secured to her leg, otherwise it can catch on stuff and be pulled out accidentally, that can cause trauma to her urethra. Review of the facility's policy entitled Resident Care: Urinary Catheterization, under subheading C. Care Practices Related to Catheterization, revealed item 1e: Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter (for female, on anterior thigh .).

Based on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to develop a careplan to include the respiratory [DIAGNOSES REDACTED].#31) in a survey sample of 21 Residents. The findings included: 1. For Resident #31 the facility staff failed to revise the careplan to include the [DIAGNOSES REDACTED]. The care plan status was marked completed. Resident #31 was admitted to the facility on [DATE]. Resident #31's [DIAGNOSES REDACTED]. Observations on 7/9/19 and 7/10/19 revealed the following: On 07/09/19 at 12:39 PM Resident #31's bi-pap was on the bedside table and an oxygen concentrator was at the bedside. On 07/09/19 at 04:33 PM the bi-pap was on the bedside table and an oxygen concentrator was at the bedside. On 07/10/19 at 09:23 AM the bi-pap was on the bedside table and an oxygen concentrator was at the bedside. On 07/10/19 at 01:13 PM the bi-pap was on the bedside table and an oxygen concentrator was at the bedside. Review of Resident #31's physician orders [REDACTED]. Review of Resident #31's careplan revealed a careplan created 2/21/17 which included the [DIAGNOSES REDACTED]. The entire careplan, including problem statement, goals and interventions related to respiratory was discontinued on 1/15/19 Review of Resident #31's careplan revealed a new careplan developed 1/15/19 which stated, (Resident #31's name) is at risk for ineffective lower airway gas exchange/difficulty in breathing r/t (related to) her dx (diagnosis) of asthma, [MEDICAL CONDITION]. The use of oxygen and the [MEDICAL CONDITION] were not listed on the careplan. On 7/10/19 at 5:28pm the DON (Director of Nursing) was asked if she would expect the use of oxygen or a bi-pap to be care planned, the DON said, yes. No further information was provided.

Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff performed an improper transfer that resulted in harm for 1 resident ( Resident #3) in the survey sample of 14 residents. Resident #3 sustained 3 fractures in her right lower leg when a staff member performed a one person transfer instead of a two person transfer, per the residents plan of care. The Findings included: Resident #3 was an [AGE] year old who was admitted to the facility on [DATE], and readmitted after hospitalization on [DATE]. Resident #3's [DIAGNOSES REDACTED]. Resident #3's most recent Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 2/29/16, coded Resident #3 as being able to understand and be understood by others. In addition she was coded as requiring the assistance of 2 staff members for transfers, and as requiring 2 staff members for assistance for toileting. On 3/29/16 at 3:30 P.M. an observation was made of Resident #3 in her room sitting in a wheelchair with her legs elevated in a protective cradle. On 3/29/16 a review was conducted of Resident #3's clinical record, revealing a hospital report. It read: 9/8/15. Impression: 1. Comminuted fracture proximal fibular shaft. 2. Comminuted fracture distal tibia shaft with will 1/2 shaft with lateral displacement of the distal fragment. 3. Comminuted fracture distal fibula. 4. Ankle mortise is intact. Debridement and irrigation of the right open distal tib/fib (tibia/fibula) fracture with provisional closed reduction and splinting. Intramedullary rodding of right comminuted distal third open tib/fib fractures with 10 mm (millimeter) titanium nail. A nursing note dated 9/8/15 read, Resident was being toileted. Resident grabbed bars and stood up. CNA (Certified Nurse Assistant) stated resident took one step back when she lost control and started to fall. CNA tried to prevent fall but was unsuccessful. Resident fell causing RLE (Right Lower Extremity) fracture. MD (Medical Doctor) and RP (Responsible Party) aware. Sent to ER (emergency room ) for treatment. The facility performed an investigation of the incident on 9/8/15. On 9/8/15 the CNA B submitted the following written statement, Around 3:30 P.M. today I was helping (Resident #3) back into her wheelchair. Her chair was locked, she had her shoes on and I had my arm under her arm. She stood up and grabbed the bars and stood up. She took one step back when she lost control and began to go down to the floor. I tried to keep her up but I couldn't do it. I call for help and a staff member came running in the room. I told her that (Resident #3) was on the floor and for her to get the nurse. The facility's investigation stated the following: Outcome. Resident will be a two person transfer with gait belt. On 8/29/15 a Fall Risk Evaluation was conducted. Resident #3 was given a score of 10, indicating that she was at high risk for falls. On 3/30/16 an interview was conducted with RN B. she stated, On 9/9/15 I spoke with (CNA B) about the use of the gait belt. I educated (CNA B) that a gait belt should be used at all times when transferring a resident that requires any type of hands on assistance. (CNA B) expressed understanding of the use of gait belt with a two person assist. If (CNA B) has any questions regarding a resident's transfer she will talk with the nurse on duty prior to transferring a resident. CNA B was not available for an interview because she no longer worked at the facility. Prior to Resident #3's fall on 9/8/15, the Minimum Data Set, which was a 5-Day Assessment with an Assessment Reference Date of 9/5/15 was completed. Resident #3 had a Brief Interview of Mental Status Score of 7, indicating moderate impairment in making daily life decisions. In addition, she was coded as requiring the extensive assistance of 2 staff persons for toileting. Resident #3's care plan read, 7/9/15. Resident chooses to be incontinent. She is aware but will not call for assistance when need to void. 2 person assist - encourage toileting more frequently - often refused. On 9/28/15 Resident #3 was readmitted to the facility from the hospital. On 8/29/15 a Transfer/Mobility Status Criteria assessment was completed. It read, Resident is able to bear weight for short periods of time. Has functional upper body strength with shoulders and arms. Must be able to hold on with both hands. Staff verbally cue. Needs two or more persons for assistance in bed mobility or use of device. Resident refuses to use Hoyer lift. Prior to the fall on 9/8/15, Resident #3 had 3 falls the previous year. 1. 4/18/14 Unwitnessed fall sliding out of wheelchair after falling asleep. No injury. 2. 7/7/14 fell during transfer from wheelchair to commode. Did not call for staff assistance with toileting. No injury. 3. 10/16/14 fell after getting up from toilet with the assistance of 1 CNA. Bruise on right side of forehead, skin tear to front center scalp, bruise to right cheek, bruise to right hip, skin teal to right knee. After the fall a new intervention was put into place, requiring 2 staff persons to assist with toileting. On 3/30/16 at 3:15 P.M. an interview was conducted with the MDS Coordinator (RN A). The MDS Coordinator stated that prior to the fall, Resident #3 required the extensive assistance of 2 staff persons for toileting transfers. She further stated that Resident #3 refused to use a Hoyer Lift for transfers. On 3/30/16 at 4:11 P.M. an interview was conducted with CNA A, who was Resident #3's current CNA. She stated that she had been working with Resident #3 since December of 2015. She stated that she always used the assistance of another staff person when transferring Resident #3. She further stated, There's always another staff to help provide assistance. On 3/30/16 at 3:30 P.M. an interview was conducted with the Rehabilitation Manager (Other A). The Rehabilitation Manager stated that Resident #3 had received Physical Therapy services from 8/23/15 until her fall on 9/8/15. The Rehabilitation Manager stated that prior to the fall, Resident #3 required the assistance of 2 to 3 persons for toileting transfers. She stated that Resident #3 had received safety training regarding toileting transfers. Upon Resident #3's readmission to the facility from the hospital on [DATE], a Falls Management / Initial Plan of Care was completed. It read; To prevent the occurrence of a fall. Transfer; 2 persons. Bed in lowest position, Increased help with Activities of Daily Living. Resident #3 was currently receiving Physical Therapy since 3/14/16. She received Therapeutic Exercise, Gait Training, Wheelchair management, and Neuromuscular Re-education. On 3/3/16 an interview was conducted with the Director of Nursing (Administration B), and the Administrator (Administration A). They both stated that the facility had identified the concern and put a Plan of Correction into place prior to the survey. The Plan of Correction was as follows: 1. (Resident #3) fell during a transfer to the bathroom on 9/8/15 and sustained a fracture to right lower extremity. Resident was transferred without the use of gait belt and 2 person assist. (CNA B ) was educated by nurse mentor on 9/9/15 regarding the use of gait belts for all residents requiring assistance during transfer. (Resident #3's) fall / transfer was discussed with the Interdisciplinary team on 9/9/15 in morning huddle. 2. All residents requiring assistance during transfers with gait belts are at risk for falls. Education for nurses and CNA's was conducted on 9/10/15. This education addressed the use of gait belts and transfers. Falls are discussed daily in the morning huddle with the Interdisciplinary team and individualized resident interventions addressed for each resident fall. 3. Education for nurses and CNAs was conducted on September 10, 2015. This education addressed the use of gait belts for transfers Use of gait belts and modes of transfers with assist are discussed with team members during household huddles to ensure safe transfers for all residents. Fall trends / patterns and falls with major injury are reviewed monthly with Interdisciplinary Team during Clinical Operations report. Risks are identified and system processes are reviewed to ensure compliance. A mobility transfer list is maintained in a book on each household to ensure communication of mobility / transfer needs. This list is updated by nurse mentor or designee as needed. Use of gait belt with return demonstration is conducted on all new nursing team members during orientation. 4. Monitoring. All falls are entered into the Care Incident Tracking System for trending and tracking. Falls are investigated at the time of the fall and recorded in the Care Tracking System with the nurse mentor reviewing for any additions or updates. the DON (Director of Nursing) closes out the incident with subsequent follow up if needed. Fall trends / patterns are reviewed and discussed as part of the monthly clinical operation report which in an extension of the facility Quality Assurance Improvement Program. 5. Date of Compliance (AOC) September 21, 2015. All staff training documentation was submitted and reviewed. Fall tracking documentation was reviewed. The facility did not have any further transfer related fall incidents after the 9/21/15. Also, during the survey 11 current resident reviews were conducted. There were no additional concerns identified regarding transfers. During the survey, none of the residents were observed to be transferred inappropriately in accordance with their care plans or physician orders. In addition, there were no incidents involving transfers. Lastly, there weren ' t any transfer - related concerns expressed by residents, or family members.