Every finding on record at Sevierville Health and Rehabilitation Center

Based on facility policy reviews, medical record reviews, observations and interviews, the facility failed to follow appropriate infection practices to prevent the potential spread of infection for 8 residents (Residents #57, #54, #81, #9, #71, #30, #59, and #72) of 85 residents observed for infection control.The findings include:Review of the facility's undated policy titled, Wound Management, revealed .protocols for wound care are established .using current guidelines .for wound management .infection control practices are maintained to decrease and prevent the transmission of infection during wound care and/or dressing changes .Review of the facility's undated policy titled, Enhanced Barrier Precautions [EBP], revealed EBP are an infection control intervention designed to reduce transmission of MDRO's [Multi-Drug Resistant Organisms] in nursing homes. EBP expands upon Standard Precautions by requiring the use of gowns and gloves during specific high contact resident care activities .examples of high contact resident care activities requiring gown and glove use for residents on EBP include .wound care: any skin opening requiring a dressing .pressure ulcers .Review of the facility's undated policy titled, Infection Control Plan, revealed . The goals of the infection control program are .decrease the risk of infection of residents and staff .Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Heart Failure, and Pressure Ulcer of Sacral Region Stage 3.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #57 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. During an observation on 3/4/2026 at 9:40 AM, Licensed Practical Nurse (LPN) A entered Resident #57's room to provide wound care. There was a sign on Resident #57's door for EBP, including gown and gloves for high-contact activity. LPN A sanitized hands, donned gloves, gathered wound care items and placed them on a barrier at bedside. LPN A did not don a gown. LPN A assisted the resident to position on her left side, then discarded gloves and donned new gloves without performing hand hygiene. LPN A used normal saline soaked gauze and cleaned the wound using several strokes from proximal area (nearest to the head) to distal area (nearest to the toes) and back and did not use a circular pattern from innermost area of wound to the outside skin area. LPN A removed gloves and donned a new pair of gloves without performing hand hygiene. Using a gloved hand, LPN A placed the ordered medication into the wound bed and applied the ordered dressing. Continued observation revealed the wound did not exhibit any signs or symptoms of infection.During an interview on 3/4/2026 at 2:15 PM, the Director of Nursing (DON) confirmed the cleaning of a wound was to be performed in a circular motion from the inside to the outside, to help prevent the spread of bacteria into the wound. The DON confirmed EBP was to be used with high-contact resident care, including wound care, and hand hygiene should be performed every time gloves were discarded.Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including Dementia, History of a Stroke, and Generalized Muscle Weakness.Review of a quarterly MDS assessment dated [DATE], revealed Resident #54 scored a 9 on the BIMS assessment, which indicated the resident had moderate cognitive impairment. Further review revealed Resident #57 was always incontinent of bowel and bladder and was dependent on staff for toileting and toileting hygiene.During observations on 3/2/2026 at 11:15 AM, 3/3/2026 at 10:30 AM, and 3/4/2026 at 9:28 AM, revealed Resident #54's bathroom contained a metal grab bar behind the toilet, with a bedpan placed between the bar and the wall. There was no barrier around the bedpan. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Adult Failure to Thrive, and Generalized Muscle Weakness.Review of a quarterly MDS assessment dated [DATE] revealed Resident #81 was unable to participate in a BIMS assessment and had long and short-term memory impairment. Further review revealed Resident #81 was dependent on staff for transfers and oral hygiene.Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Dementia, Peripheral Vascular Disease, and Muscle Weakness. Review of an annual MDS assessment dated [DATE], revealed Resident #9 scored a 9 on the BIMS assessment, which indicated the resident had moderate cognitive impairment. Further review revealed Resident #9 required supervision for transfers, and set-up or clean-up assistance with oral hygiene.During observations on 3/2/2026 at 11:17 AM and 3/3/2026 at 10:32 AM, the shared bathroom of Residents #81 and #9 revealed a toothbrush on the back of the toilet, a toothbrush on the sink nearest to the toilet, and both were unlabeled and uncovered. Further observation on 3/4/2026 at 9:20 AM, revealed both unlabeled and uncovered toothbrushes were lying on the sink side by side.Review of the medical record revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Heart Failure, and Generalized Muscle Weakness.Review of the admission MDS assessment dated [DATE], revealed Resident #71 scored an 8 on the BIMS assessment, which indicated the resident had moderate cognitive impairment. Further review revealed Resident #71 had broken or loosely fitting full or partial denture, and required partial/moderate assistance with transfers and oral hygiene.During an interview on 3/2/2026 at 11:19 AM, Resident #71 stated she did not have dentures at this time and had an appointment in the next 2 weeks for new dentures to be made.Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including Dementia, Type 2 Diabetes Mellitus, and Generalized Muscle Weakness.Review of an admission MDS assessment dated [DATE], revealed Resident #30 did not have dentures.Review of a quarterly MDS assessment dated [DATE], revealed Resident #30 was unable to participate in BIMS assessment and had long and short-term memory impairment. Further review revealed Resident #30 was dependent on staff for transfers and oral hygiene.During observations on 3/2/2026 at 11:25 AM, 3/3/2026 at 9:23 AM, and 3/4/2026 at 9:37 AM, the shared bathroom of Residents #71 and #30 revealed a basket positioned between the sink and the wall, which contained unlabeled and uncovered denture brushes.Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including Subdural Hemorrhage, Mellitus, and Weakness.Review of an admission MDS assessment dated [DATE], revealed Resident #59 scored a 9 on the BIMS assessment, which indicated the resident had moderate cognitive impairment. Further review revealed Resident #59 was frequently incontinent of bowel and bladder, required substantial/maximal assistance with transfers, and did not use the toilet in the bathroom.Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Dementia, Hypothyroidism, and Generalized Muscle Weakness.Review of a quarterly MDS assessment dated [DATE], revealed Resident #72 was unable to participate in BIMS assessment and had long and short-term memory impairment. Further review revealed Resident #72 was always incontinent of bowel and bladder, was dependent on staff for transfers and toileting hygiene, and did not use the toilet in the bathroom.During observations on 3/2/2026 at 11:15 AM, 3/3/2026 at 10:30 AM, and 3/4/2026 at 9:28 AM, the shared bathroom of Residents #59 and #72 revealed a metal grab bar next to the toilet, with a bedpan in a clear bag hanging on the bar. The bedpan was unlabeled. During an interview on 3/4/2026 at 9:49 AM, Certified Nursing Assistant (CNA) A stated, .bedpans are stored in bags .they should have the resident's name on the bedpan .the name should be on the toothbrushes and there are containers for them .During an interview on 3/4/2026 at 1:40 PM, CNA B stated, .we are supposed to put the resident name on bedpans and toothbrushes so we know who they are used for .things like bedpans and toothbrushes should be in containers or bags .During observations and interview on 3/4/2026 at 2:15 PM, the Assistant Director of Nursing (ADON) confirmed the bedpan in the bathroom of Resident #54 was not labeled or stored in a bag, the shared bathroom of Residents #81 and #9 contained 2 toothbrushes lying side by side that were unlabeled and uncovered, the shared bathroom of Residents #71 and #30 contained unlabeled and uncovered denture brushes, and the shared bathroom of Residents #59 and #72 contained an unlabeled bedpan. During an interview on 3/4/2026 at 3:00 PM, the Director of Nursing (DON) confirmed unlabeled bedpans being stored without coverings or barriers and toothbrushes or dental brushed not properly stored or labeled did not follow the appropriate infection control practices.

Based on facility policy review, observation, and interview, the facility failed to ensure food items were labeled and stored properly in 1 of 2 freezers in the kitchen and failed to ensure a clean and sanitary milk cooler which had the potential to affect all 80 residents in the facility. The findings include: Review of the facility's undated policy titled, Sanitization, showed The food service area shall be maintained in a clean and sanitary manner .All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary .Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime .The Food Services Manager will be responsible for scheduling staff for regular cleaning of the kitchen and dining areas . Review of the facility's undated policy titled, Food Receiving and Storage, showed .Foods shall be received and stored in a manner that complies with safe food handling practices .All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . During an observation and interview on 11/6/2023 at 9:07 AM, of the walk-in freezer, with the Certified Dietary Manager (CDM), showed one 1/2 full opened and undated clear plastic bag of potato slices. The CDM confirmed the bag of potato slices had been opened, undated, and available for resident use. The CDM stated it was his expectation that items in the freezer were labeled with the date they were opened and discarded within 5 days. During an observation and interview on 11/6/2023 at 9:22 AM, of the milk cooler, with the CDM, revealed a foul odor when the milk cooler was opened. The bottom of the milk cooler was covered in milk. The CDM confirmed the foul odor and spilled milk in the bottom of the milk cooler. The CDM stated the milk was spilled by the milk delivery person on .Saturday (2 days ago) . The CDM stated it was his expectation that the kitchen was clean and sanitary and the milk should have been cleaned up at the time it was spilled.

Based on facility policy review, observation, and interview, the facility failed to ensure medical information was not visible for 1 resident (Resident #325) of 80 observed. The findings include: Review of the facility's policy titled, Resident Rights, with a revised date of 12/2016, showed .Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .a dignified existence .be treated with respect, kindness, and dignity .privacy and confidentiality . Resident #325 was admitted to the facility on [DATE] with diagnoses including Fracture of the Left Femur, Encounter for Orthopedic Aftercare, Fall, Muscle Weakness, and Anemia. During an observation and interview on 11/6/2023 at 10:53 am, in Resident #325's room, there was a sign above the resident's bed that read, NO BLOOD PRESSURES OR BLOOD DRAWS IN THE LEFT ARM The sign was visible to anyone who entered the room. Resident #325 stated the sign had been posted by someone from the facility and the resident had not requested for the sign to be posted. During an observation on 11/7/2023 at 7:53 am, there was a sign above Resident #325's bed that read, NO BLOOD PRESSURES OR BLOOD DRAWS IN THE LEFT ARM The sign was visible to anyone who entered the room. During an interview on 11/7/2023 at 1:51 PM, the Director of Nursing (DON) stated it was the facility's expectation that resident needs were communicated to staff through the care guide (kardex) and the care plan. The DON confirmed signs were not to be posted in resident's rooms unless requested by the resident or family. During an observation and interview on 11/7/2023 at 1:56 PM, with the DON, in Resident #325's room, there was a sign above the resident's bed that read, NO BLOOD PRESSURES OR BLOOD DRAWS IN THE LEFT ARM The DON confirmed the sign was visible to anyone that entered the room. The DON was unaware who posted the sign and stated the sign .basically says that [the resident] has had a mastectomy . The DON stated .absolutely . when this surveyor asked if the sign was a dignity concern.

Based on medical record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) assessment for 1 resident (Resident #60) of 18 residents reviewed for MDS assessments. The findings include: Resident #60 was admitted to the facility on [DATE] with diagnoses including Intracapsular Fracture of Left Femur, Malignant Neoplasm of Unspecified Bronchus of Lung, and Malignant Neoplasm of Brain. Review of the Physician's Orders dated 7/25/2023, showed Resident #60 had been ordered hospice care. Review of the comprehensive care plan dated 7/25/2023, showed Resident #60 received hospice services for end-of-life care. Review of the MDS assessment dated [DATE], showed hospice care had not been captured or documented on the MDS for Resident #60. During an interview on 11/7/2023 at 2:00 PM, Chief Clinical Officer confirmed the facility failed to capture hospice on the MDS assessment. During an interview on 11/8/2023 at 10:20AM, the MDS Coordinator confirmed she failed to complete a significant change MDS to include hospice services.

Based on medical record review and interview, the facility failed to resubmit a Pre-Admission Screening and Resident Review (PASARR) after a new mental health diagnosis for 1 resident (Resident #61) of 7 residents reviewed for PASARR. The findings include: Resident #61 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Depression, and Anxiety. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], showed Resident #61 had an active diagnosis of .Major Depressive Disorder .Depression .Anxiety . and received antipsychotic, antidepressant medications. Review of the Level I Pre-Admission Screening and Resident Review dated 9/22/2023, showed .Check any or all of the following mental health conditions that are diagnosed or suspected for the individual now or in the past .Anxiety Disorder .Depression .Should there be an exacerbation related to mental illness or a discrepancy in the reported information, a status change should be submitted [to the PASARR assessment authority] .for further evaluation . Review of the medical record showed Resident #61 received a diagnosis of Unspecified Psychosis on 9/28/2023. During an interview on 11/8/2023 at 7:44 AM, the Chief Clinical Officer confirmed a new PASARR had not been resubmitted when a new diagnosis of Psychosis had been added for Resident #61.

Based on medical record review and interview, the facility failed to follow a physician's order for 1 resident (Resident #326) of 3 residents reviewed for pressure ulcers. The findings include: Resident #326 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Sepsis, Adult Failure to Thrive, and Protein-Calorie Malnutrition. Review of Resident #326's admission skin assessment dated [DATE], showed .Redness [with] open area to Left Buttock . Review of Resident #326's baseline care plan dated 10/27/2023, showed .impaired skin integrity .open area to [left buttock] .Treatments as ordered by Physician . Review of Resident #326's physician telephone orders dated 10/27/2023, showed .[barrier cream] to bilateral buttocks BID [twice daily] . Review of the WOUND CARE PROGRESS NOTE dated 10/30/2023, showed . Wound #4: Left buttock stage 2 measuring 2 x 1 x less than 0.1 with erythema and maceration. No induration, exudate, tunneling, undermining .or odor. Treatment .apply [barrier cream] . Review of Resident #326's physician telephone orders dated 10/31/2023, showed .[barrier cream] to L [left] Buttock TID [three times daily] . Review of the Treatment Administration Record (TAR) for 11/2023, showed .[BARRIER CREAM] TO LEFT BUTTOCK THREE TIMES A DAY .Start Date: 11/01/23 [2023] . The TAR showed the medication was scheduled for 6:30 AM and 6:30 PM. The treatment was administered twice daily from 11/1/2023 - 11/7/2023. The physician had ordered treatment for three times daily. Review of the WOUND CARE PROGRESS NOTE dated 11/6/2023, showed .Wound #4: Left buttock stage 2 .resolved .It does have MASD [moisture associated skin damage] with trace erythema .Treatment: Apply [barrier cream] t.i.d. [three times daily] . During an observation and interview on 11/6/2023 at 2:19 PM, Resident #326 was seated in the chair beside his bed. There was an air mattress on the resident's bed. Resident #326 stated .I have a sore on my bottom from the hospital . and the facility was treating it with .salve [an ointment used to promote healing of skin or as protection] . During an interview on 11/8/2023 at 9:36 AM, the Chief Clinical Officer stated Resident #326 was admitted to the facility with a Stage 2 pressure ulcer of the left buttock. The resident had an order dated 10/27/2023 for (Barrier Cream) twice daily. The order for (Barrier Cream) was changed to three times daily on 10/31/2023, to be started on 11/1/2023. The Chief Clinical Officer confirmed there was a transcription error when the new order was entered into the facility's computer system and the medication was not changed to a three times daily schedule. The Chief Clinical Officer confirmed the barrier cream was administered twice daily instead of three times daily as ordered by the physician from 11/1/2023 - 11/7/2023. The Chief Clinical Officer confirmed it was the facility's expectation that treatments and medications were administered according to the physician's order. Resident #326's wound resolved on 11/6/2023. During a telephone interview on 11/8/2023 at 10:36 AM, the Wound Care Nurse Practitioner stated Resident #326 was admitted to the facility with a Stage 2 pressure ulcer of the left buttock that was treated with barrier cream. The Wound Care Nurse Practitioner confirmed the facility's failure to follow the order for the barrier cream] three times daily as ordered did not harm the resident and stated .the wound healed pretty fast .

Based on medical record review and interview, the facility failed to maintain accurate and complete medical records for 1 resident (Resident #21) of 24 residents reviewed for medical records. The findings include: Resident #21 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, Obsessive-Compulsive Disorder (OCD), Anxiety, Bipolar Disorder, and Depression. Review of Resident #21's Psychotropic Medication-Informed Consent form dated 2/25/2020, showed .Medication name .Depakote .why medication was prescribed: [blank] . Review of Resident #21's Psychotropic Medication-Informed Consent form dated 4/22/2022, showed .Medication name .Seroquel .Therapeutic classification: Anti-depressant .Reason why medication was prescribed: Depression . Review of Resident #21's Psychotropic Medication-Informed Consent form dated 3/28/2023, showed .Medication name .Lexapro .Therapeutic classification: [blank] .Reason why medication was prescribed: [blank] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #21 scored 9 on the Brief Interview for Mental Status (BIMS) assessment indicating the resident was moderately cognitively impaired and received antipsychotics and antidepressant medications. Review of Resident #21's Medication Administration Record (MAR) dated 11/2023, showed Lexapro (anti-depressant medication) for Depression, Seroquel (anti-psychotic medication) for Bipolar Disorder, and Divalproex (anti-convulsant) for OCD. During an interview on 11/8/2023 at 10:00 AM, the Chief Clinical Officer (CCO) stated Resident #21 had been ordered Lexapro for Depression, Depakote (Divalaproex) for OCD, and Seroquel for Bipolar Disorder. The CCO further stated the Seroquel is classified as an anti-psychotic medication not an anti-depressant. The CCO confirmed the medical record (Psychotropic Medication-Informed Consent forms) was inaccurate and incomplete.

Based on facility policy review, observation, and interview the facility failed to ensure medications were stored in a locked medication cart on 2 resident hallways (100 Back Hall and 200 Odd Hall) of 4 resident hallways observed. The findings include: Review of facility policy Medication Cart Use revised 6/1/2016 showed .Security The medication cart and its storage bins are kept locked until the specific time of medication administration . Observation on 3/15/2021 at 10:35 AM, on the 100 Hall outside of room [ROOM NUMBER] showed the 100 Back Hall medication cart with the medication drawers closed, unlocked, and unattended. During an interview on 3/15/2021 at 10:35 AM, the Registered Nurse (RN) House Supervisor confirmed the 100 Back Hall medication cart was left unlocked and unattended. Observation on 3/15/2021 at 4:20 PM, on the 200 Hall outside of room [ROOM NUMBER] showed License Practical Nurse (LPN) #1 unlocked the 200 Odd Hall medication cart then walk away from the cart leaving the cart with the medication drawers closed, unlocked, and out of line of site. During an interview on 3/15/2021 at 4:20 PM, the RN House Supervisor confirmed LPN #1 left the 200 Hall medication cart unlocked and out of line of site. The RN House Supervisor confirmed the facility failed to ensure medications were stored in a locked medication cart for 2 of 5 medication carts.

Based on facility policy review, review of manufacturer's guidelines, medical record review, observation, and interview, the facility failed to follow infection control practices during resident care for 2 residents (Resident #6 and Resident #8) of 7 residents reviewed and failed to follow the manufacturer's guidelines for sanitizing a glucometer after use for 1 glucometer (200 Hallway glucometer) of 19 glucometers observed. The findings include: Review of the facility policy titled Center for Clinical Standards and Quality/Quality, Safety & Oversite Group dated 12/17/2020 showed .All new admissions should be quarantined on admission for 14 days . Review of the facility policy titled Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, last revised 5/20/2020, showed .While in the building, personnel are required to strictly adhere to established infection prevention and control policies, including .Appropriate use of PPE .Standard, Contact, and Droplet Precautions .isolation gown .are implemented .Signage on the use of specific PPE (for staff) is posted in appropriate locations .outside of residents room . Review of the facility policy titled Glucometer-Maintenance, Cleaning and Disinfecting dated 10/2017 showed .To ensure that correct cleaning and disinfecting of the glucometer (blood glucose monitor) is followed to prevent the potential transmission of infectious organisms .to be completed by using an EPA (Environmental Protection Agency)-registered disinfectant .and follow product label instructions to disinfect the meter . Review of the facility policy titled COVID-19 Prevention, Monitoring, and Management for Long-Term Care Facilities dated 8/28/2020 showed .PPE Considerations .Hand hygiene should be performed before and after manipulating PPE . Review of the manufacturer guidelines titled Sani-Cloth Bleach Germicidal Disposable Wipe, undated, showed .GENERAL GUIDELINES FOR USE .4. Treated surface must remain visibly wet for a full four (4) minutes. Use additional wipe(s) if needed to assure continuous 4 minute wet contact time . Medical record review showed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to the quarantine unit for the 14-day monitoring period to monitor for signs and symptoms of COVID-19. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #6 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was moderately cognitively impaired. The MDS showed Resident #6 required 1 to 2 persons assistance with Activities of Daily Living (ADL's). Review of the care plan for Resident #6 dated 3/5/2021 showed .Resident will be monitored for 14 days on designated unit for s/s (signs/symptoms) of infection as recommended per CDC (Centers for Disease Control) . Observation of the 100 Hall quarantine unit on 3/15/21 at 10:30 AM showed Resident #6's room did not have an isolation sign on the outside of the door. Further observation showed Certified Nurse Assistant (CNA) #1 entered the resident's room without donning an isolation gown. During an interview on 3/15/21 at 10:32 AM, CNA #1 stated Resident #6 was not in quarantine any longer, so they didn't have to have an isolation sign on the door. The CNA confirmed she did not don an isolation gown at any time while she was in the room. During an interview on 3/15/2021 at 10:35 AM, the Infection Control Registered Nurse (RN) stated Resident #6 was on a 10 day quarantine and 3/15/2021 was the tenth day. The Infection Control RN confirmed isolation signage should have been on the outside of the door and CNA #1 should have donned an isolation gown. Review of the facility's new admissions quarantine policy revealed the quarantine period was 14 days. Observation and interview on 3/15/21 at 11:00 AM, on the 200 hall showed License Practical Nurse (LPN) #1 standing at a medication cart sanitizing a glucometer using a sani-cloth bleach germicidal disposable wipe. LPN #1 wiped the glucometer with one wipe for 30 seconds then placed it on top of the medication cart to dry. LPN #1 confirmed the glucometer was not in contact with the disinfectant for 4 minutes per the manufacturer's guidelines. Medical record review showed Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] showed Resident #8 scored an 8 on the BIMS assessment, which indicated the resident was moderately cognitively impaired. The MDS showed Resident #8 required 1 to 2 persons assistance with ADL's. Review of the care plan dated 2/17/2021 for Resident #8 showed .Resident is at risk for complications related to [DIAGNOSES REDACTED].(glucometer checks) .as ordered . Observation outside Resident #8's room on 3/15/21 at 4:15 PM showed LPN #1 touched her face mask with her hands, then picked up the glucometer from the top of a medication cart, and without sanitizing her hands walked into Resident #8's room. During an interview on 3/15/2021 at 4:16 PM, the Infection Control RN confirmed LPN #1 should have sanitized her hands after touching her face mask and prior to picking up the glucometer.

Based on medical record review, observation, and interview, the facility failed to ensure reasonable accommodation of needs for 1 of 1 resident (Resident #33) reviewed for call light accessibility. This failure had the potential to prevent Resident #33 from calling for assistance as desired and potentially prevent Resident #33's needs from being met. Findings include: Review of the Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 12/6/2019, indicated Resident #33 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] from an acute care hospital. Resident #33's [DIAGNOSES REDACTED]. Resident #33 had cognitive impairments, as evidenced by a Brief Interview for Mental Status Score (BIMS) score of 3 out of 15. Resident #33 required total assist from one to two staff members with all Activities of Daily Living (ADLs). Resident #33 had functional limitations in Range of Motion (ROM) and impairment on one side in the upper and lower extremities According to Resident #33's care plan, dated 5/29/2019, Resident #33 was dependent on staff assistance for ADL's related to Weakness, Left-sided [MEDICAL CONDITIONS], and Mild Cognitive Impairment. The care plan included an undated, handwritten intervention that read, Touch pad (touchpad) call light within reach at all times while in bed. On 1/13/2020 at 10:01 AM, Resident #33 was in his room lying in bed with the touchpad call light positioned on Resident #33's right shoulder. There was a note taped to the wall which read, nurse call (call light touchpad) on resident's right side. Resident #33 had contractures noted in both arms and hands. Both arms were flexed upward towards Resident #33's chest. His right hand was flexed inward at the wrist with his fingers in a straight, fixed position. Resident #33's left hand flexed at the wrist, with his fingers bent outward at the knuckles and in a fixed position. When asked, Resident #33 was unable to reach his touchpad call light. On 1/13/2020 at 3:30 PM, an interview with Resident #33's family member, in Resident #33's room, revealed there were previous issues with Resident #33's call light not being in place. Resident #33's family member said the note was posted on the wall to remind staff where to place the call light so Resident #33 could reach it. On 1/14/2020 at 9:45 AM, Resident #33 was observed in his room, lying in bed. The touchpad call light was on the floor behind the head of the bed. Resident #33 said, this happens all the time. On 1/15/2020 at 8:46 AM, Resident #33 was observed in his room, in bed sleeping. The touchpad call light was out of reach, positioned upon Resident #33's right shoulder. On 1/15/2020 at 10:33 AM, Resident #33 was observed in his room, lying in bed. The touchpad call light was up near Resident #33's right shoulder. When asked if he could reach the touchpad call light, Resident #33 attempted to reach for the touchpad call light but was unsuccessful. Resident #33 said he lost a lot of his dexterity and was unable to reach the touchpad call light. On 1/15/2020 at 10:39 AM, in the presence of Licensed Practical Nurse (LPN) #17, Resident #33 was observed in his room, lying in bed with the touchpad call light on Resident #33's right shoulder. LPN #17 said the call light was placed too high, asked Resident #33 where a good spot would be, and repositioned the call light. On 1/15/2020 at 11:20 AM, Certified Nursing Assistant (CNA) #12 was interviewed at the nursing station on Unit 200. The interview revealed Resident #33's touchpad call light should be on his chest. If not, Resident #33 was unable to reach the touchpad call light. CNA #12 indicated the touchpad call light was sometimes on Resident #33's right shoulder and at other times on Resident #33's chest. Staff made sure Resident #33 could reach his touchpad call light, which she reported doing that morning during breakfast. CNA #12 indicated staff used the resident's Activities of Daily Living (ADL) Assistance Legend to know what was going on with the resident. CNA #12 reviewed the ADL Assistance Legend and said the ADL assistance Legend did not provide direction regarding placement of Resident #33's touchpad call light, but said that information was in Resident #33's care plan, which staff should follow. On 1/15/2020 at 11:29 AM, Registered Nurse (RN) #21 was interviewed in the activity room on Unit 100. RN #21 said resident call lights should be in place to allow residents to call for assistance. RN #21 said she would expect staff to follow Resident #33's care plan. On 1/15/2020 at 12:04 PM, during a second interview with RN #21 in the nourishment room on Unit 200, RN #21 said on 12/9/19, staff changed out the call light for a soft-touch call light (touchpad call light). Review of the care plan with RN #21 revealed the touchpad call light should be within Resident #33's reach at all times when in bed. On 1/15/2020 at 12:20 PM, Nursing MDS #5 was interviewed in the conference room adjacent to Nursing MDS #5's office. The interview revealed that Resident #33 had returned to the facility from the hospital with increased contractures, and an inability to use his hands. Within a few days of Resident #33's return to the facility, staff determined Resident #33 could no longer use a regular call light and switched the call light out for a touchpad call light. Nursing MDS #5 said she went into Resident #33's room today (1/15/20) and asked Resident #33 to use the touchpad call light, and he was unable to. Since the placement of the touchpad call light, Nursing MDS #5 acknowledged she had not reassessed whether Resident #33 was capable of using the touchpad call light since it was changed. Nursing MDS #5 said LPN #17 reported to her that Resident #33 could use the touchpad call light sometimes, but not today. Nursing MDS #5 said the touchpad call light should be within Resident #33's reach. On 1/16/2020 at 2:00 PM, Quality Assurance Infection Prevention (QA/IP) Nurse #10 was interviewed a second time, in the presence of the Director of Nursing (DON), in the conference room adjacent to the MDS Coordinators office. The interview revealed Resident #33 was recently hospitalized and returned to the facility. Resident #33 had been slowly declining, and the staff initiated a touchpad call light since Resident #33 was unable to use a regular call light. QA/IP Nurse #10 indicated she had seen Resident #33 use the touchpad call light and the CNAs checked to make sure the call light was in place daily. Review of the care plan with QA/IP Nurse #10 showed the touchpad call light should be within Resident #33's reach at all times when in bed.

Based on facility policy review, review of facility Admission packet, medical record review, and interviews, the facility failed to issue bed hold notices within 24 hours after transfer to the hospital for 2 of 27 sampled residents (Resident #27 and Resident #1). Findings include: Review of the facility policy titled, Attachment F-Bed Hold Policy, last revised (MONTH) (YEAR), revealed, At the time the Resident is to leave the Center for a temporary stay in a hospital or for therapeutic leave, (or within 24 hours in care of an emergency transfer) the Resident/Resident Representative will be given a written copy of the Bed Hold Policy which specifies the duration of the bed-hold and may elect to hold open the Resident's room and bed until the Resident returns. At this time, the Resident/Resident Representative will indicate in writing whether the Resident desires or declines the bed hold. Review of the facility's Admission packet revealed the initial notice of the bed hold policy was provided to residents upon admission. This bed hold policy specified, At the time the resident is to leave the center for a temporary stay in a hospital or for therapeutic leave (or within 24 hours of an emergency transfer), the resident/resident representative will be given a written copy of the bed hold policy which specifies the duration of the bed-hold and may elect to hold open the resident's room and bed until the resident returns. At this time, the resident/resident representative will indicate in writing whether the resident desires or declines the bed hold. Resident #27 was admitted to the facility on [DATE]. Review of his clinical record revealed [DIAGNOSES REDACTED]. He had two unplanned transfers to the hospital on [DATE] returning 10/18/2019, and on 11/14/2019 readmitting on 11/18/2019. The Business Office Manager (BOM) was interviewed on 1/15/2020 at 2:09 PM in the conference room. She said she was responsible for completing the second bed hold notifications to the family members when the resident transferred to the hospital. The BOM said when a resident was transferred to the hospital, she usually found out about it the following day, and would contact the family via phone and ask if they wanted to hold the bed for the resident. She said she did not provide written notification to the family members. The BOM said there was no one else who sent bed hold notices to the residents or their representatives, and no one responsible for completing this task in her absence. The BOM said she had 3 days to send a bed hold notice to the resident or resident representatives. Review of the bed hold's policy notification binder, provided by the BOM, revealed Resident #27's representative (Family Member #1) was contacted by phone on 10/17/2019 and declined to hold the bed for the resident. The binder revealed there was no bed hold notice given (either written or via telephone) to Family Member #1 related to the 11/14/2019 emergent transfer to the hospital. Family Member #1 was interviewed on 1/16/2020 at 10:30 AM by telephone. Family Member #1 said she was not familiar with what a bed-hold notice was, and that the BOM never calls me. The Director of Nursing (DON) was interviewed on 1/16/2020 at 1:50 PM in the conference room. The DON said the BOM was responsible for contacting residents and resident representatives to provide the second bed hold notice. The DON said she did not think there was anyone assigned to provide bed hold notification to the resident or resident representatives in the BOM's absence. She said the bed hold notifications should be sent within 24 hours according to the regulations and facility policy. Resident #1 was admitted to the facility on [DATE] and was sent to the hospital on [DATE] for chest pain. Review of the clinical record revealed there was no documentation the resident was provided a bed hold notice upon transfer or within 24 hours of the transfer. During an interview on 1/15/2020 at 2:08 PM, the BOM stated when a Medicare resident was sent to the hospital, the resident had a 3 day leave of absence and after the third midnight, during the hospital admission, a bed hold notice was provided to the resident and/or the family. She further stated the bed hold notice for Resident #1 was not issued until 12/20/2019. During an interview on 1/15/2020 at 2:45 PM, with Resident #1 and Family Member #1, they stated they did not receive a bed hold notice when he was sent out on 12/17/2019.

Based on medical record review, interviews, and review of the Hospice Cooperative Agreement, the facility failed to implement a Bowel Movement (BM) protocol and failed to ensure effective coordination of hospice care for one resident (Resident #11) out of 15 sampled residents. These failures placed Resident #11 at risk for complications related to constipation and potential fecal impaction (a large mass of dry, hard stool that can develop in the rectum due to chronic constipation). Findings include: Review of the Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/31/2019, indicated Resident #11 was receiving hospice services and had moderate cognitive impairment, as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 out of 15. Review of the facility's Physician's Routine Orders for constipation, signed by the Medical Director on 1/1/2019, specified, If no BM (bowel movement) in three (3) days: Milk of Magnesia (or generic equivalent) 30 cc (cubic centimeter) by mouth every day PRN (as needed) constipation (notify MD (medical doctor) if [MEDICAL TREATMENT] resident). [MEDICATION NAME] (or generic equivalent) 5 mg (milligram) tabs (tablets) 1 (one) tab by mouth every day PRN constipation. [MEDICATION NAME] (or generic equivalent) 10 mg suppository 1 (one) PR (per rectum) PRN constipation. (Fleets) enema PR PRN if constipation not relieved with any two (2) of the above and notify the physician. Review of the BM Detail option 2 Roster dated 9/1/2019 through 1/16/2020 indicated Resident #11 did not have a documented BM for more than 3 consecutive days on 4 separate occasions as follows: 1. 9/19/2019 through 9/24/2019, 6 days without a documented BM: Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) dated (MONTH) 2019, showed the Physician's Routine Orders for constipation signed by the physician on 1/1/2019 were not on the MARs or TARs. The MARs and TARS did not indicate staff initiated the BM protocol on 9/22/2019 (after 3 days with no BM), 9/23/2019, or 9/24/2019. Review of the Department Notes dated 9/19/2019 through 9/24/2019 did not indicate Resident #11 had a BM or that staff initiated the facility's BM protocol. 2. 9/26/2019 through 10/3/2019, 8 days without a documented BM: Review of the MARs and TARS dated (MONTH) 2019, indicated the staff did not initiate the BM protocol on 9/29/2019, after 3 days with no BM. On 9/30/2019, 5 days after the last documented BM, staff received an order to administer Mirilax 17 gm PRN and Senna 8.6 mg daily. The [MEDICATION NAME] and Senna were not administered to Resident #11 on 9/30/2019. Review of the Department Note dated 9/30/2019, 5 days after Resident #11's last documented BM, indicated Resident #11 was ON NO BM LIST, PRUNE JUICE GIVEN, NEW ORDERS RECEIVED FOR [MEDICATION NAME] PRN AND SENNA DAILY. The nursing note did not indicate why the nurse gave prune juice instead of MOM, as outlined in the facility's BM protocol. Review of the Department Note dated 10/4/2019, 8 days after Resident #11's last documented BM, indicated Resident #11 was ON NO BM LIST, PRUNE JUICE WAS GIVE. WILL MONITOR FOR RESULTS. The nursing note did not indicate why the nurse gave prune juice instead of MOM as outlined in the facility's BM protocol. Review of the MARS and TARS dated (MONTH) 2019, indicated staff started administering Senna, ordered 9/30/2019, on 10/1/2019. The staff did not initiate the facility's BM protocol on 10/1/2019. On 10/3/2019, 8 days after Resident #11's last documented BM, staff received and initiated new orders for Senna Plus 8.6-50 mg tablets BID (twice daily). 3. 10/18/2019 through 10/23/2019, 5 days without a documented BM: Review of the MARS and TARS dated (MONTH) 2019, indicated Resident #11 received scheduled Senna 8.6 mg once a day from 10/1/2019 through 10/3/2019. On 10/3/2019 through 10/23/2019, Resident #11 received scheduled Senna Plus 8.6-50mg BID, except on 10/3/19 at 8:00 PM when the resident refused. The staff did not initiate the facility's BM protocol on 10/21/19 (after 3 days with no BM), 10/22/19, or 10/23/19. Review of the Department Notes dated 10/18/2019 through 10/23/2019, did not indicate Resident #11 had a BM or that staff initiated the facility's BM protocol. 4. 11/12/2019 through 11/15/2019, 4 days without a documented BM: Review of the MARs and TARs for (MONTH) 2019, indicated Resident #11 received scheduled Senna Plus 8.6 mg-50 mg BID from 11/1/2019 through 11/15/2019. Resident #11 refused one dose of Senna Plus on 11/11/2019 at 8:00 AM. The staff did not initiate the facility's BM protocol and did not administer PRN Mirilax or MOM on 11/15/19, after 3 days with no BM. On 1/13/2020 at 11:48 AM, Resident #11 was interviewed in her room. The interview revealed Resident #11 reported only having a BM once a week and had issues with constipation. Resident #11 said that her last BM was last night (1/12/2020); the staff had to give her MOM and an enema. On 1/15/2020 at 1:09 PM, Licensed Practical Nurse (LPN) #17 was interviewed at the nurses' station on Unit 200. The interview revealed the nurses run a No BM List each morning. If a resident was on the No BM List, nurses confirmed no BM with the resident. If the resident had not had a BM in 3 days, nurses administered MOM. If the resident was still on the No BM List, nurses administered a [MEDICATION NAME] suppository. LPN #17 said Resident #11 had issues with constipation; however, MOM or a suppository would usually work. LPN #17 reported initiating the facility's BM protocol on several occasions, which she reported to Hospice. LPN #17 added, sometimes, Resident #11 refused her medications and did not always eat a lot, which may contribute to her decreased BMs. On 1/15/2020 at 1:35 PM, the Assistant Director of Nursing (ADON) was interviewed in the conference room adjacent to the MDS office. The ADON said that if a resident did not have a BM in 3 days, the staff should initiate the facility's BM protocol. On 1/16/2020 at 11:06 AM, the Director of Nursing (DON) was interviewed in the main conference room across from the Administrator's office. The DON acknowledged the staff did not initiate the BM protocol when the resident did not have a documented BM within 3 days. The DON said the expectation was for staff to follow the facility BM protocol. Failure to follow the bowel protocol could potentially lead to an obstruction. Review of the Home Health and Hospice Nursing Home Cooperative Agreement, dated 8/15/2013, revealed the facility was responsible for coordinating services with the hospice provider to meet the patient's daily personal, medical, and emotional needs through utilization of the combined care plans of the facility and hospice provider. The hospice provider was responsible for communicating changes in the hospice patient's condition and/or death. The hospice provider was to provide the facility with a pink divider to be placed in the patient's medical record at the facility for hospice documentation. The Hospice guidelines in the nursing home and multidisciplinary progress notes for hospice staff was filed in this section. Review of the hospice Election of Medicare Hospice Benefit form, dated 10/23/2019, revealed Resident #11 elected hospice services effective 10/23/2019. Review of the care plan dated 11/11/2019 indicated Resident #11 chose to receive hospice services with a designated hospice provider. The care plan interventions directed staff to coordinate care with the hospice team. Review of the facility's BM Detail option 2 Roster dated 9/1/2019 through 1/16/2019 indicated Resident #11 did not have a BM on 10/27/2019, 11/4/2019, 11/8/2019, 11/25/2019, 11/29/2019, 12/9/2019, 12/13/2019, 12/19/2019, 12/30/2019, 1/3/2020, and 1/6/2020. Review of Resident #11's clinical record revealed the facility only had Hospice Aide Visit Notes from 12/16/2019 through 1/6/2020. The clinical record did not contain the Hospice Aide Visit Notes from 10/23/2019 through 12/13/2019. On 1/15/2020, the facility contacted the hospice provider and requested copies of the Hospice Aide Visit Notes from the start of hospice services on 10/23/2019. On 1/16/2020, the hospice provider faxed copies of the hospice Aide Visit Notes dated 10/28/2019 through 12/13/2019. Review of the Hospice Aide Visit Notes dated 10/28/2019 through 12/13/2019, (received from the Hospice provider on 1/16/20) revealed Resident #11 had a BM on 10/27/2019, 11/4/2019, 11/8/2019, 11/25/2019, 11/29/2019, 12/9/2019, and 12/13/2019, which did not correlate with the facility's BM Detail option 2 Report. Review of the Hospice Aide Visit Notes dated 12/16/2019 through 1/6/2020, revealed Resident #11 had a BM on 12/13/2019, 12/19/2019, 12/30/2019, 1/3/2020 and 1/6/2020, which did not correlate with the facility's BM Detail option 2 Report. On 1/16/2020 at 12:30 PM, Registered Nurse #21 was interviewed at the nursing station on Unit 200. RN #21 said the hospice provider should have a communication binder for Resident #11 at the facility. RN #21 said when Hospice came in to see the resident, they would come up to the nursing station and verbally communicate the care and services provided, any concerns, and whether the resident had a BM, which facility staff should document in the Electronic Health Record (EHR). On 1/16/2020 at 11:49 AM, LPN #22 was interviewed on Unit 200. LPN #22 said facility staff took care of the resident and provided the overall care, and Hospice was an add-on (offers additional services). Before the hospice aide or nurse left, they would advise staff of any concerns and if the resident had a BM. If hospice staff reported a resident had a BM, LPN #22 would chart the BM in the EHR and let the CNA know. LPN #22 said the facility started hospice binders with all the hospice providers, but she was unsure why Resident #11's hospice provider did not have a binder. On 1/16/2020 at 11:55 AM, CNA #12 was interviewed at the nursing station on Unit 200. CNA #12 said Hospice provided bed baths and made sure Resident #11 had the supplies she needed. CNA #12 said Hospice came in once a week (nurse and CNA) and they would communicate specifics about the resident that staff needed to know, such as BMs, which facility staff was responsible for documenting in the EHR. CNA #12 denied any concerns with hospice staff not providing information regarding the resident. On 1/16/2020 at 12:01 PM, LPN #17 was interviewed at the nursing station on Unit 200. LPN #17 said the hospice aides came in once or twice a week, bathe the resident, provided necessary supplies, and supervised all her medications. LPN #17 said the hospice nurse came in several times a week. The hospice aides and hospice nurse would verbally communicate concerns and the care provided. If the hospice aides or nurse notified her the resident had a BM, LPN #17 notified the resident's CNA, and the CNA was responsible for charting the BM in the EHR. On 1/16/2020 at 12:11 PM, CNA #11 was interviewed at the nursing station on Unit 200. CNA #11 said the Hospice aides came in three times a week, and the nurse may come in once a week. The Hospice aides verbally communicated the care provided and whether the resident had a BM, which she would document in the EHR. CNA #11 denied any concerns with Hospice communicating information on the care provided or when the resident had a BM. On 1/16/2020 at 1:06 PM, the DON was interviewed in the DON's office. The DON said the facility required Hospice to give the facility a binder that included their care plan, signed hospice documents, agreements, signed consents, and all Hospice related documents. The hospice staff verbally communicated any change in the resident, concerns, bathing, and BMs. The DON said the facility staff was responsible for documenting information related to the care and services provided in the EHR. The DON said there was a breakdown in communication and she reached out to Hospice on 1/6/20 to advise them they needed to provide all related documents to the facility. On 1/16/2020 at 3:12 PM, Hospice Director (HD) #20 was interviewed via the phone. She said Hospice provided all new orders and information to the facility. She attended the first care conference last week, which was when she first learned that the facility was requesting Hospice to send information to the facility. HD #20 was not sure whether the hospice notes entered into their Hospice system was sent to the facility. She said there was a hospice tab in the clinical record where the Hospice nurse documented concerns. On 1/16/2020 at 3:34 PM, the Hospice Registered Nurse (RN) #15 was interviewed via the phone. Hospice RN #15 said Hospice did not provide a written note in the clinical record. If there were new orders, Hospice faxed the order over to the facility, and the facility was responsible for transcribing and initiating the orders. She said Hospice provided the facility staff with verbal communication regarding care and services provided, and the facility was responsible for documenting this information in the EHR.

Based on medical record review and interview, the facility failed to provide 2 of 3 residents (Resident #20 and Resident #33) with the Advanced Beneficiary Notice, Center for Medicare and Medicaid Services (CMS)- when they ended therapy services and remained in the facility for long-term care services. This failure left residents without information related to the cost of therapy services if they desired to continue them in the facility and did not allow for them to have informed choice. Findings include: Resident #20 was admitted on [DATE] for a Medicare A stay. He had [DIAGNOSES REDACTED]. He received physical therapy, occupational therapy, and speech language therapy. The Social Service Director (SSD) issued the Notice of Medicare Non-Coverage (CMS- ) on 10/2/2019 informing him therapy services would end on 10/7/2019. The SSD did not issue the CMS- Advance Beneficiary Notice to the resident. The resident remained in the facility for long-term care and had Medicare benefit days remaining. Resident #33 was re-admitted on [DATE] after a hospital stay. His admitting [DIAGNOSES REDACTED].#33 received speech language therapy upon returning to the facility. The SSD issued the CMS- informing him that therapy would be ending on 12/20/2019. The CMS- was not issued to the resident or Family Member #33 indicating why the Medicare therapy services would no longer be covered and the cost of the therapy services, and the resident and representative were not provided with the choice to continue the services, pay privately for the services, or to stop the services. Interview with the SSD on 1/14/2020 at 12:01 PM revealed she was responsible for issuing all beneficiary notices. She stated she did not issue the CMS- to any residents remaining in the facility that had Medicare days remaining. She further stated the interdisciplinary team reviewed all Medicare residents and determined as a team that the individual no longer met Medicare requirements. She stated she was unaware that residents coming off Medicare and remaining in the facility as long-term care with benefit days remaining were supposed to receive the CMS- . Interview with Family Member #33 on 1/14/2020 at 12:35 PM revealed that they were not provided the CMS- . Interview with Resident #20 on 1/15/2020 at 3:11 PM revealed he had not been issued the CMS- detailing why his Medicare therapy was ending or the cost of the services.

Based on the facility policy review, medical record review, review of facility investigation, and interview, the facility failed to ensure all allegations of abuse or neglect were reported immediately to the Administrator and the State Survey Agency within 2 hours for 1 resident (#1) of 3 residents reviewed for abuse or neglect on 3 of 3 nursing units sampled. The findings included: Review of facility policy Abuse Prevention Policy and Procedure, last revised 2/26/18, revealed .1 .All alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately to the Administrator and Director of Nursing . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored a 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of a facility investigation dated 10/4/18 revealed Resident #1 told Registered Nurse (RN) #2 on 10/1/18 that RN #1 did not give her all her medications. Continued review revealed RN #2 reported the allegation to the Assistant Director of Nursing (ADON) on 10/1/18, but the allegation was not reported to the Administrator or the Director of Nursing (DON). Further review revealed the incident was reported to the DON by the resident's daughter on 10/4/18. Interview with the Administrator and the DON on 10/29/18 at 2:00 PM, in the Conference Room, confirmed no one reported the allegation to them until 10/4/18 (3 days later). Telephone interview with the Administrator on 10/30/18 at 8:35 AM confirmed the ADON failed to report the allegation to the DON or the Administrator. In summary, the allegation of neglect was not reported to the DON, the Administrator, or State Survey Agency until 10/4/18 (3 days later) and the facility failed to follow facility policy.

Based on facility policy review, observation, and interview, the facility failed to obtain and record temperatures in the ice cream freezer, milk cooler, and the reach-in cooler and failed to maintain dietary equipment in a sanitary manner, in 1 of 3 kitchen observations made, affecting 75 of 75 residents in the facility. The findings included: Review of the facility policy, Record of Refrigeration Temperatures, revised 7/2014, revealed .A daily temperature record is to be kept of refrigerated items .Record temperatures from the internal thermometers . Review of the facility policy, Dietary Department Guidelines, not dated, revealed .The dietary department will be maintained in a clean and sanitary manner to prevent foodborne illness .Refrigerator temperatures will be monitored regularly, and logs will be maintained of all temperatures . Review of the facility policy, Cleaning Schedules, revised 3/2014, revealed .The Dietary staff shall maintain the sanitation of the Dietary Department . Review of the facility policy, Can Opener, revised 9/2011, revealed .Sanitation of equipment .after each meal; more frequently if needed .Scrub the shank, paying special attention to blade . Observation and interview with the CDM on 11/28/17 at 10:15 AM, in the kitchen, revealed no documentation temperatures had been obtained or recorded for the ice cream freezer, milk cooler, or reach-in cooler. Interview with the CDM confirmed the facility failed to obtain and record temperatures for the ice cream freezer, milk cooler and reach-in cooler, and the temperature logs were not maintained. Observation with the CDM on 11/29/17 at 9:30 AM, in the kitchen, revealed a can opener with dried thick debris on the blade. Further observation revealed the convection oven had dried burnt debris on the interior bottom and on the interior doors of the oven. Interview with the CDM on 11/29/17 at 9:35 AM, in the kitchen, confirmed the facility failed to maintain dietary equipment in a clean and sanitary manner.

Based on facility policy review, medical record review, observation, and interview, the facility failed to assess 1 resident (#4) of 7 residents reviewed for self-administration of medications. The findings included: Review of facility policy Medication Administration dated 3/16/15 revealed .prepare medications immediately prior to administration .observe that the resident swallows oral drugs .do not leave medications with the resident to self-administer unless the resident is approved for self-administration of the medication . Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #4's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Observation and interview with Licensed Practical Nurse (LPN) #1 on 11/28/17 at 8:39 AM, in the resident's private room, revealed Resident #4 was alone in her room and a medication cup containing 8 pills was sitting on the resident's bedside table. Interview with LPN #1 revealed the medication cup contained the following medications: [REDACTED] *two 500 microgram (mcg) [MEDICATION NAME] tablets (medication to treat vitamin B-12 deficiency) *one 80 milligram (mg) [MEDICATION NAME] tablet (medication to treat fluid retention, [MEDICAL CONDITION], and swelling) *two 2,000 unit Vitamin D3 tablets (supplement to improve overall health or for treating [MEDICAL CONDITION]) *one 1,000 unit Vitamin D3 tablet *one 5 mg [MEDICATION NAME] capsule (Vitamin B supplement) *one 800 mg [MEDICATION NAME] tablet (medication to control phosphorus levels in people with [MEDICAL CONDITION]) Continued Interview with LPN #1 confirmed no assessment for self-administration of medications had been completed. Interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 11/30/17 at 9:15 AM, in the Nursing Office, confirmed Resident #4 was assessed for self-administration of medications and the facility failed to follow facility policy.

Based on facility policy review, medical record review, review of the facility investigation, and interview the facility failed to suspend an employee after an allegation of abuse for 1 resident (#1) of 4 residents reviewed. The findings included: Facility Policy review of the Abuse Prevention Policy and Procedure, revised 8/2016, revealed .report all allegations of abuse immediately to the Director of Nursing and Administrator .all employees are required to immediately notify the administrative or nursing supervisory staff that is on duty .so the resident's needs can be attended to immediately and investigation can be undertaken promptly .the charge nurse .will examine the resident .document findings in the clinical records .immediately initiate the Investigation protocol .any employee suspected of abuse, neglect, or mistreatment must be suspended as soon as the incident is reported pending outcome of the investigation .Do not wait . Medical record review revealed Resident #1 was a [AGE] year-old woman admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Continued review revealed the patient was discharged from the facility on 6/8/17. Medical record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact, required extensive assistance of 2 person with transferring, dressing, toileting, and personal hygiene, required extensive assistance of 1 person with walking in room and locomotion on unit, and supervision with eating. Medical record review of a Nursing Note dated 5/23/17 at 4:53 AM revealed .resident rang out for assistance to the restroom .both CNAs (certified nursing assistant) responded to help .resident was very inappropriate towards CNAs by cussing them out and threatening to get them fired .resident accused one CNA of pushing her in the wheelchair .CNA was only guiding .towards the chair .not the first time resident has cussed out these CNAs . Facility investigation review dated 5/23/17 revealed the incident occurred on 5/23/17 at 4:30 AM and at 6:40 AM Licensed Practical Nurse (LPN) #1 (days shift nurse) received the complaint and notified the Director of Nursing (DON) at 6:55 AM. Further review the DON interviewed the resident at 8:30 AM and revealed .stated .she put her light on at about 5:00 or 5:30 am this morning .two nurses came into the room .told them she had .to the bathroom .they (CNAs) wanted her to use the bedpan .she was supposed to be using the toilet .felt this made them mad .one (CNA) was in front of her .one behind the wheelchair .one behind the wheelchair pushed her down into the wheelchair causing her left leg to hurt .she told them nurse behind her .she was going to get her fired .going to tell her son .he would get a lawyer . Review at 10:00 AM the Social Worker interviewed the resident who stated 2 Registered Nurses (RN) came to her room to get her in her wheelchair and assist her to the bathroom .1 RN that was older with dark hair pushed her by her neck . Interview with LPN #1 on 6/13/17 at 11:53 AM in the conference room revealed .work dayshift .when I came in I got report .she (nightshift nurse) only told me the resident was all the time threatening staff with her attorney's .nothing was said about the resident making an allegation of abuse .the two CNAs on dayshift went to do the resident's blood pressure and the resident told them she had 2 CNAs last night and the older one .was helping her into her wheelchair from the bed .the CNA pushed her .said it hurt her and she felt she had been injured all over again .I reported it . Interview with RN #1 on 6/13/17 at 12:08 PM in the conference room revealed .I was assigned to her (resident) .(CNA #3) and (CNA #4) came out and informed me they were getting patient in wheelchair to go to restroom .(CNA #4) was going to assist her .because she was going to miss the wheelchair .I was new .I didn't know (to call supervisor) .(CNA #4) didn't go in room any more that night .I didn't assess her .I didn't know I was suppose to afterward . Interview with the Nurse Practitioner (NP) on 6/13/17 at 1:25 PM in the conference room revealed .she constantly complained .she did not want to be here .she was assessed and there were no signs of abuse .we did order some x-rays and they were negative . Interview with CNA #1 on 6/13/17 at 1:40 PM in the conference room revealed .me and (CNA #2) .had gone in to do her vital signs .said she had been abused .said .that girl last night .tall one .pushed her in her chair .we went and told (LPN #1) . Interview with CNA #2 on 6/13/17 at 2:50 PM in the conference room revealed .me and (CNA #1) .went in to her room cause her light was on .stated she came here for therapy not to be abused .said the CNA had pushed her down and hurt her leg .she didn't name the person .we told the (LPN #1) . Interview with CNA #3 on 6/14/17 at 6:00 AM in the conference room revealed .we had to help her to her wheelchair .I stood in front of her .(CNA #4) stood behind her .when she was fixing to sit she was going to miss the wheelchair .(CNA #4) put her hands on her hips to help assist her into the wheelchair so she would not miss it and fall .she said (CNA #4) pushed her .she was going to get her fired .we assisted her to the bathroom and back to bed .we told (RN #1) about what happened . Interview with CNA #4 on 6/14/17 at 6:15 AM in the conference room revealed .she was cussing .we got her up on the side of the bed .she got up .she was going to miss the wheelchair .I gently helped ease her over into the wheelchair so she would not fall and hurt herself .said you quit shoving me around .she was going to get someone fired .we assisted her to the restroom and back to bed .we mentioned it to the nurse I didn't take it serious .I finished working out the shift . Interview with the Administrator on 6/14/15 at 7:00 AM in the conference room revealed .we did discipline (RN #1) since she did not report the incident immediately and did not send (CNA #4) home . Interview with the Administrator and the DON on 6/15/17 at 9:25 AM in the Administrator's office confirmed the facility failed to report an allegation of abuse immediately to the DON and the Administrator and failed to suspend CNA #4 pending the investigation results per facility policy.

Based on facility policy review, observation, and interview, the facility failed to provide sanitary conditions in the kitchen for 2 of 5 employees observed. The findings included: Review of the facility policy Personal Hygiene, undated, revealed .Wear a clean hat or other hair restraint. Hair must be appropriately restrained or completely covered . Observation of the kitchen with the Dietary Manager (DM) on 12/7/15 at 11:50 AM, at the tray line, revealed Employee #1 with a brown hair net on. Observation revealed visible hair on the back of the head extended out past the hair net. Continued observation revealed Employee #1 was standing over an open ice cooler containing milk cartons. The DM instructed Employee #1 to cover the hair. Continued observation of the kitchen with the DM on 12/7/15 at 12:05 PM, at the tray line, revealed Employee #1 placing milk and ice cream on the trays. Employee #1's hair was not completely covered by the brown hair net. Observation of the kitchen with the DM on 12/7/15 at 12:15 PM, at the food prep sink, revealed Employee #2 with a cotton cap on the head, with visible hair extending past the cap. Observation on 12/9/15 at 8:05 AM, at the food prep sink, revealed Employee #1's hair extended from the back of the hair net. Interview with DM on 12/7/15 at 12:19 PM, at the tray line, confirmed both employees' hair was not completely covered by a hair net or cotton cap.

Based on facility policy review, observation, and interview, the facility failed to utilize proper hand washing during lunch service between resident rooms for 4 residents (#59, #61, #117, and #119) of 20 residents served on 1 hallway of 3 hallways observed. The findings included: Review of the facility policy Hand-hygiene technique, undated, revealed .The purpose of this procedure is to provide guidelines to employees for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of the transmission of infections .Before and after eating or handling food . Observation on 12/7/15 from 12:39 PM to 12:45 PM, on the skilled wing hallway, revealed Certified Nursing Assistant (CNA) #1 entered Resident #59's room with the lunch tray, moved the over bed table with the hands, placed the resident's tray on the over bed table, touched the uncovered plate, and exited the room. CNA #1 retrieved another tray from the cart, entered Resident #61's room, placed the tray on the resident's over bed table, touched the uncovered plate with the hands, opened the milk carton, and exited the room. CNA #1 retrieved another tray from the cart, entered Resident #117's room, placed the tray on the over bed table, touched the uncovered plate with the hands, and exited the room. CNA #1 retrieved another tray from the cart, walked into the Resident #119's room, moved the resident's over bed table, and touched the uncovered plate without disinfecting the hands. Interview with CNA #1 on 12/7/15 at 12:45 PM on the skilled wing hallway, confirmed, I did not wash my hands before or after entering the rooms to pass those trays. I have hand sanitizer in my pocket but I did not use it.

Based on observation, interview, and policy review, the facility failed to secure medications in two of four medication carts, and failed to safely store medications in two of two medication rooms. The findings included: Observation on October 13, 2014, at 8:05 a.m., in the skilled front hallway, revealed Licensed Practical Nurse (LPN) #1 went to a resident's room to administer medications, and the medication cart was left unlocked and was not in the LPN's view. Interview with LPN #1 on October 13, 2014, at 8:05 a.m., in the skilled front hallway, confirmed anyone could access the residents non-narcotic medications stored in the medication cart, and the narcotics were not double locked. Observation on October 13, 2014, at 8:30 a.m., in the West hallway near the shower room, revealed an unattended and unlocked medication cart. Continued observation revealed a resident opening the shower door approximately 15 feet from the unsecured medication cart. Interview with LPN #2 on October 13, 2014, at 8:33 a.m., in front of the medication cart, confirmed the cart was unlocked and medications were not secured. Review of the facility's Storage of Medication policy dated August 2010, revealed, "...In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts...are locked or attended by persons with authorized access..." Interview with the Assistant Director Nursing on October 14, 2014, at 1:30 p.m., in the nursing office, confirmed the medication carts were not secure. Observation on October 14, 2014, at 10:55 a.m., in the Skilled Wing Medication Room, revealed a tray containing the following items stored on a shelf where medications were stored: one quart bottle of Virex Solution (used for disinfecting), one quart bottle labeled Topical Mist, one 9.7 oz (ounce) bottle of Pledge (used to clean), and one quart bottle labeled HBV (Hepatitis B Virus) disinfectant. Interview with LPN #1 on October 14, 2014, at 11:00 a.m., in the Skilled Wing Medication Room, confirmed the quart bottle of Virex, the quart bottle of Topical Mist, the Pledge bottle, and the quart bottle of disinfectant were stored in the medication room on a shelf where medications were stored. Observation on October 14, 2014, at 11:20 a.m., in the West Wing Medication Room, revealed a cabinet underneath the sink, with a hole in the floor of the cabinet and wood debris observed on the entire floor of the cabinet. Further observation revealed a tray containing the following items stored in the cabinet: one bottle with 13 tablets of Nuedexta (medication used to treat irregular heart rhythms), one opened tooth brush, and one 12 ml (milliliter) bottle of hand sanitizer. Further observation revealed a tray containing supplies for starting IV (intravenous) access and one 9.7 oz bottle of Hot Shot (used to kill bugs) stored underneath the sink. Interview with LPN #1 on October 14, 2014, at 11:25 a.m., in the West Wing Medication Room, confirmed the medication and supplies were stored underneath the sink in the medication room. Interview on October 14, 2014, at 11:30 a.m., in the West Wing Medication Room, with the West Wing Unit Manager, confirmed the floor of the cabinet underneath the sink had a hole, had wood debris on the floor of the cabinet, and the supplies were stored underneath the sink. Further interview revealed "...we had a water leak back some time ago and we did not fix it..."

Based on medical record review, observation, policy review, and interview, the facility failed to notify the physician of a pressure ulcer for one resident (#145) of eight residents reviewed for pressure ulcers, which caused harm to resident #145. The findings included: Resident #145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Nursing Resident-Data Collection form dated June 14, 2013, revealed no pressure areas on the skin assessment. Review of the Norton Plus Pressure Ulcer Scale (instrument for assessing risk of developing a pressure ulcer) dated June 14, 2013, revealed the resident scored "9", with a score of 10 or less indicating a "High Risk" for developing a pressure ulcer. Review of a nurse's note dated June 20, 2013, at 1:30 p.m., revealed, "Lt (left) heel with weeping blister, 4X4 (gauze dressing) to cover and heel protectors on..." Review of a nurse's note dated July 4, 2013, at 7:30 a.m., revealed, "...ruptured blister area to left inner heel with tx (treatment) in progress..." Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #145 had one Stage 2 pressure ulcer. Review of treatment orders revealed no treatments were ordered for the pressure ulcer located on the left heel until June 29, 2013. Review of the physician's orders [REDACTED]. Review of the Treatment Records revealed no documentation of treatments to the resident's left heel pressure ulcer from June 20 to June 28, 2013. The first treatment documented on the Treatment Record was on June 29, 2013. Review of the medical record revealed the resident was transferred and admitted to a local hospital on July 8, 2013, with [DIAGNOSES REDACTED]." Review of the medical record revealed the resident was readmitted to the facility on [DATE]. The Entry MDS dated [DATE], documented the resident had one Stage 4 Pressure Ulcer. Review of the facility's policy titled "Pressure Ulcer, Care and Prevention of" revealed, "...when a pressure ulcer is found, nursing is to notify the MD (physician) within 24 hours for a treatment order. The treatment order is then placed on the TAR (Treatment Record)." Interview with the facility's Medical Director and Director of Nursing (DON) in the DON's office, on September 26, 2013, at 3:00 p.m., confirmed the facility applied heel protectors and guaze dressing per facility protocol, but the physician was not notified of the resident's pressure ulcer and orders were not obtained from the physician to treat the pressure ulcer until June 29, 2013.

Based on record review, observation, policy review, and interview, the facility failed to develop a comprehensive care plan for two residents (#145 and #207) of forty-four residents reviewed which caused harm to resident #145. The findings included: Resident #145 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission Nursing Resident-Data Collection form dated June 14, 2013, revealed no documentation of any pressure areas on the skin assessment. Review of the Norton Plus Pressure Ulcer Scale (instrument for assessing risk of developing a pressure ulcer) dated June 14, 2013, revealed the resident scored "9", with a score of 10 or less indicating a "High Risk" for developing a pressure ulcer. Review of the Interim Care Plan dated June 14, 2013, revealed no interventions planned to prevent pressure ulcers with the interventions "Preventive Care" and "Pressure Ulcer" unchecked/not chosen. Review of a nurse's note dated June 20, 2013, at 1:30 p.m., revealed, "Lt (left) heel with weeping blister, 4X4 (gauze dressing) to cover and heel protectors on..." Review of a nurse's note dated July 4, 2013, at 7:30 a.m., revealed, "...ruptured blister area to left inner heel with tx (treatment) in progress..." Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #145 had one Stage 2 pressure ulcer. Further review revealed no comprehensive care plan documented. Review of the medical record revealed the resident was transferred and admitted to a hospital on July 8, 2013, with [DIAGNOSES REDACTED]." Review of the medical record revealed the resident was readmitted to the facility on [DATE]. The Entry MDS dated [DATE], documented the resident had one Stage 4 Pressure Ulcer. Review of the medical record revealed, on September 24, 2013 (during the survey), there was no comprehensive care plan for Resident #145 and no interventions care planned for pressure areas. Observations on September 25, 2013, at 2:00 p.m, revealed Resident #145 had a healing stage 4 pressure ulcer, round shaped, and measuring approximately 2 centimeters long by 2 centimeters wide. Review of the facility's policy titled Resident Comprehensive Assessment and Care Plan revealed, "The results of the comprehensive assessment are used to develop, review and revise resident's comprehensive care plan." Interview with the Administrator and the Director of Nursing on September 24, 2013, at 4:45 p.m., in the Administrator's office, confirmed a comprehensive care plan had not been completed for Resident #145. Further interview with the Administrator confirmed the care plan was to have been completed after the care plan meetings and this was not done. Resident #207 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was rarely/never understood; rarely/never understands others; had severely impaired cognition and never/rarely made decisions; required extensive assistance with bed mobility; and was total dependence for transfers, eating, personal hygiene, and bathing. Medical record review of a History and Physical dated March 25, 2013, revealed "...has been bedridden for approximately 2 yrs. Is typically non responsive and nonverbal." Medical record review of a nurse's note dated March 24, 2013, at 4:30 revealed "...nurse was called to the resident's room. Resident was found on the floor face down on top of bedside table...Resident placed back into bed. 3 cm (centimeter) gash above L (left) eyebrow. L (left) eye bruised. Small abrasion on L (left) cheek. Small abrasion on R (right) lower lip. Indentation from bedside table on L (left) thigh. Bruise on L (left) shin. Laceration on forehead was bleeding. Pressure applied until bleeding stopped. Wound cleaned with wound cleanser and steri strips applied." The family and Nurse Practitioner was notified. Review of the radiology report dated March 25, 2013, revealed acute displaced [MEDICAL CONDITION] femur. Medical record review of the care plan last updated February 23, 2013, revealed no intervention for the head injury or the left femur fracture. Interview with the Assistant Director of Nursing on September 26, 2013, at 12:30 p.m., in the Director of Nursing office, confirmed the care plan had not been updated to reflect the fall on March 24, 2013, or the resident's left femur fracture. C/O .

Based on medical record review, observation, policy review, and interview, the facility failed to provide necessary treatment and services to prevent and treat pressure ulcers for one resident (#145) of eight residents reviewed for pressure ulcers, which caused harm to resident #145. The findings included: Resident #145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Nursing Resident-Data Collection form dated June 14, 2013, revealed no pressure areas on the skin assessment. Review of the Norton Plus Pressure Ulcer Scale (instrument for assessing risk of developing a pressure ulcer) dated June 14, 2013, revealed the resident scored "9", with a score of 10 or less indicating a "High Risk" for developing a pressure ulcer. Review of the Interim Care Plan dated June 14, 2013, revealed no interventions planned to prevent pressure ulcers with the interventions "Preventive Care" and "Pressure Ulcer" unchecked/not chosen. Review of a nurse's note dated June 20, 2013, at 1:30 p.m., revealed, "Lt (left) heel with weeping blister, 4X4 (gauze dressing) to cover and heel protectors on..." Review of a nurse's note dated July 4, 2013, at 7:30 a.m., revealed, "...ruptured blister area to left inner heel with tx (treatment) in progress..." Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #145 had one Stage 2 pressure ulcer. Review of treatment orders revealed no treatments were ordered for the pressure ulcer located on the left heel until June 29, 2013. Review of the physician's orders [REDACTED]." Review of the Treatment Records revealed no documentation of treatments to the resident's left heel pressure ulcer from June 20 to June 28, 2013. The first treatment documented on the Treatment Record was on June 29, 2013. Review of the medical record revealed the resident was transferred and admitted to a local hospital on July 8, 2013, with [DIAGNOSES REDACTED]." Review of the medical record revealed the resident was readmitted to the facility on [DATE]. The Entry MDS dated [DATE], documented the resident had one Stage 4 Pressure Ulcer. Review of the facility's policy titled Pressure Ulcer, Care and Prevention revealed, "...when a pressure ulcer is found, nursing is to notify the MD (physician) within 24 hours for a treatment order. The treatment order is then placed on the TAR (Treatment Record)." Interview with the facility's Medical Director and Director of Nursing (DON) in the DON's office, on September 26, 2013, at 3:00 p.m., confirmed there were no treatments documented on Resident #145's Treatment Record from the onset of the pressure ulcer on June 20, 2013 to June 28, 2013. Further interview revealed staff began treatment of [REDACTED].

Based on medical record review, facility policy review, and interview, the facility failed to prevent an accident which caused harm for one resident (#207) and failed to provide neurological checks for one resident (#206) of forty-four residents reviewed; and failed to ensure hand rails were free of decorations. The findings included: Resident #207 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the CAA (Care Area Assessment) summary dated February 23, 2013, revealed the resident had impaired communication abilities and the resident was unable to convey needs. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was rarely/neverunderstood; rarely/never understands others; had severely impaired cognition and never/rarely made decisions; required extensive assist with bed mobility; and was total dependence for eating; personal hygiene, and bathing. Medical record review of a History and Physical dated March 25, 2013, revealed "...has been bedridden for approximately 2 yrs. Is typically non responsive and nonverbal..." Medical record review of the nurses' notes revealed: March 24, 2013, at 4:30 a.m., "This nurse was called to resident's room. Resident was found on floor face down on top of bedside table...Resident placed back into bed. 3 cm (centimeter) gash above L (left) eyebrow. L eye bruised. Small abrasion on L cheek. Small abrasion on R (right) lower lip. Indentation from bedside table on L thigh. Bruise on L shin. Laceration on forehead was bleeding. Pressure applied until bleeding stopped. Wound cleaned with wound cleanser and steri strips applied. Family notified and @ (at) bedside NP (nurse practitioner) called. Awaiting call back." March 24, 2013, at 9:30 a.m.," Doctor notified of resident's fall. Family at bedside. Will continue to monitor." March 24, 2013, at 1:00 p.m., "suctioned times 2 with zero return per family's request. Resident alert-eyes open, zero bleeding from laceration, ice pack placed on face 6:30 a.m., and all day ice pack to face. Bed remains in low position with side rails up times 2. Zero pain noted. Routine pain meds given, zero distress noted, will monitor." March 24, 2013, at 5 p.m.," BP (blood pressure) 117/77, P. (pulse) 72, T. (temperature) 98; resting quietly, zero distress noted, R thigh edematous from fall. Family at bedside. All needs met via staff q (every) 2 hours. Will continue to monitor. N.O. (new order) for low bed." March 24, 2013, 11:00 p.m., "resting quietly. Zero s/s (signs/symptoms) of pain or discomfort. Bed in lowest position with side rails up times 2. Will continue to monitor." March 25, 2013, 10:30 a.m. (30 hours after fall) "resident presents with swelling to LLE (lower left extremity) specifically to lt. (left) thigh et (and) knee. Resident grimace with movement of LLE, notified NP, new orders at bedside. Resident sister at bedside." March 25, 2013, at 10:50 a.m., "notified mobile-x (mobile units used to take x-rays) of need of x-ray. Mobile was in bldg. (building) et conducted x-ray." March 25, 2013, 11:30 a.m." N. P. (nurse practitioner) here for visit. New orders rec'd (received)." March 25, 2013, 3:30 p.m., "rec'd x-ray results, notified N.P. Per N.P d/t (due to) resident's fragile state, potential for skin break down, ortho (physician to correct or straighten bone) not recommend at this time. Placed call to resident's son, advised of x-ray results, N.P. recommendations, son agrees." March 25, 2013, 5:00 p.m.," alert looking around room. No sign or symptoms of distress noted. Pain patch for pain will continued to monitor. Bed in low position with mats at bedside." March 25, 2013, 7:00 p.m.," resident in bed awake. HOB (head of bed) 30 degrees, no s/s of pain at this time, steri strips to Lt orbital area intact lg (large) bruise to Lt knee. Will continue to monitor." March 25, 2013, 9:15 p.m., "CNA (certified nursing aide) providing care called this nurse to room, upon removing bed covers a ? cm (centimeter) opening was noted with a hard object protruding from Lt (left) knee. Sm (small) amount of blood draining from area. Contacted physician to notify of status. Physician stated contact the family and ask if want resident sent to ER (emergency room ) to be evaluated." March 25, 2013, 9:25 p.m.," family P.O.A. (power of attorney) notified, physician felt the need to send to ER, family in agreement, gave verbal permission to transport to hospital." March 25, 2013, 9:51 p.m., "transported to the local hospital." March 26, 2013, 12:05 a.m.," Resident admitted to the hospital, [DIAGNOSES REDACTED]. Review of the facility's policy neurological checks revealed "to evaluate a residents neurological status usually after a fall with head injury. 1. The neurological assessment flowsheet will be initiated when an incident occurs with a possible head injury...3. Unless otherwise ordered by the physician, neurological checks shall be performed: every 15 minutes for 1 hours; every 30 minutes for 3 hours; every hour for four hours; every 2 hours for 8 hours; every 4 hours for 8 hours; every 8 hours for 24 hours. 4. The nurse shall document all assessments on neurological assessment flow sheet..." Interview with the Director of Nursing (DON) on September 25, 2013, at 1:40 p.m., in the DON's office, confirmed the facility had not completed neurological checks. Continued interview revealed the facility had completed an investigation of the fall and was not able to determine the cause. Continued interview revealed the family had requested for the resident to be on comfort measures on March 19, 2013. Interview with Certified Nursing Aide (CNA) #4 on September 25, 2013, at 10:15 a.m., via telephone, revealed the CNA was working the morning of March 24, 2013. Continued interview revealed the CNA was making rounds with a team mate, and entered the resident's room around 4:30 a.m., on March 24, 2013. Continued interview revealed the resident was found face down on the floor, with legs lying on the rail of the over bed table. Continued interview revealed both side rails were up on the bed. Continued interview revealed the CNA didn't know how the resident got out of bed, "had never seen the resident move." Interview with the N.P. on September 25, 2013, at 9:10 a.m., in the nurse practitioner's office, confirmed was notified of the resident's fall on March 24, 2013. Continued interview revealed saw the resident on March 25, 2013, lower left leg had increased edema, and increased pain was observed. Continued interview revealed the resident was on a comfort management treatment plan; the family was at bedside and an x-ray was requested of the lower left extremity. Continued interview revealed the x-ray revealed a fracture of the left femur. Continued interview revealed the family/POA (Power of Attorney) was informed of the fracture, and family requested no aggressive treatment due to the resident's multiple comorbidities and decreased quality of life. Continued interview with the N.P. revealed the N.P. had increased the pain patch and increased liquid pain medication. Review of the radiology report dated March 25, 2013, revealed an acute displaced fracture of the distal left femur. Interview with the Physician on September 25, 2013, at 12:55 p.m., in the DON's office, revealed the physician did not know how the resident got out of bed. Continued interview revealed the Physician would expect the facility to perform neurological checks after a fall with a head injury. Further interview revealed the Physician was notified of the resident's fracture. Continued interview revealed a fracture was usually immobilized until able to have a cast placed. Review of the facility's documentation of the fall investigation revealed no known cause of how the resident fell out of the bed. Continued review of the facility's documentation revealed no investigation of the origin of the cause of the compound fracture. Interview with the Assistant Director of Nursing (ADON) on September 26, 2013, at 12:30 p.m., in the DON's office, confirmed the facility had no policy on injury of unknown origin and the facility investigated all incidents. Continued interview confirmed no investigation was completed after the resident's bone came through the skin. Interview with the DON on September 26, 2013, at 12:35 p.m., in the DON's office, revealed the DON would expect any fracture to be placed in an immobilizer, but the resident's family did not want one placed due to the resident's skin condition. Continued interview revealed the facility had not provided inservices to the nurses or the CNAs on how to care for immobilizing the resident's leg. C/O # TN Resident #206 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the History and Physical dated September 7, 2013, revealed "...presented to the emergency room today from home...family reports increased confusion, decreased appetite, and coughing with p.o.(oral) intake..." Review of the Interim Care Plan dated September 10, 2013, revealed the resident required assistance of two persons for transfers, and was mobile with assistance in a wheelchair. Continued review of the Interim Care Plan revealed the resident was incontinent of bowel and bladder. Review of the Fall Risk assessment dated [DATE], revealed the resident was a high risk for falls. Review of the Nurse's Note dated September 16, 2013, 12:43 a.m., revealed, "...personal alarm on and working, SR (siderail) ? (indicating half rails) raised x (times) 2 (indicating both upper rails)." Review of a Nurse's Note dated September 18, 2013, at 7:00 a.m., revealed, "...Resident noted to be in floor lying on...back with top part of body underneath over-bed-table...laceration noted upper lip with active bleeding noted...7:50 a.m...transported to...ER (emergency room ) per MD (medical doctor) order...12:40 p.m...returned to facility...sutures noted to R (right) upper lip...Fx (fracture) R cheekbone with contusion noted..." Review of the facility's policy, Neurological Checks, revealed, "...To evaluate a residents neurological status usually after a fall with head injury...1. The Neurological Assessment Flowsheet shall be initiated when an incident occurs with a possible head injury...2. The physician and family will be notified per facility incident policy. 3. Unless otherwise ordered by the physician, Neurological checks shall be performed: every 15 minutes for 1 hour; every 30 minutes for 3 hours; every hour for 4 hours; every 2 hours for 8 hours; every 4 hours for 8 hours; and every 8 hours for 24 hours. 4. The nurse shall document all assessments on Neurological Assessment Flowsheet. 5. The nurse shall document and report any pertinent changes in the resident's neurological status to the physician." Interview with the Medical Director on September 25, 2013, at 1:20 p.m., in the Director of Nurse's (DON) office, confirmed, "...after any fall with a head injury, would expect neuro (neurological) checks to be completed ..." Interview with the Assistant Director of Nurses (ADON) on September 25, 2013, at 1:20 p.m., in the DON's office, confirmed neuro checks had not been performed on the resident after the fall with facial injuries. Observation on September 23, 2013, at 8:20 a.m., during the initial tour of the facility, revealed artificial leaf decorations wrapped around the hand rails at the East, West and Skilled Nursing Stations. Interview with the Housekeeping Director on September 24, 2013, at 9:36 a.m., in the East nursing station, confirmed the decorations were an accident hazard by camouflaging the handrails and should not be wrapped around the handrails.