Every finding on record at Signature Healthcare at Summerfield Rehab & Wellne

Based on interviews, record review, and review of the facility's policies, it was determined the facility failed to ensure each resident or the resident's representative received adequate notice before transfer or discharge for four out of five residents (Resident (R) 3, R4, R13, and R14). The facility initiated a transfer/discharge based on the facility's inability to meet the resident's needs. However, upon complaint investigation, it was determined by interview and record review that the transfer/discharge was due to the facility needing to move the residents out of their rooms to make space for a new rehabilitation unit. Residents 3, R4, and R13 were selected based on their least likely to have a connection with the community. The residents were provided a notice of transfer/discharge on 07/26/2024. On 07/30/2024, four days after the notice was issued, the facility transferred and discharged the residents to other healthcare facilities, moving them further away from their families and friends. This was completed without providing a 30-day notification period and without obtaining the approval of the residents' State Guardian. On 07/31/2024, the residents' State Guardian was unaware the residents had already been transferred to other healthcare facilities. Review of an email the State Guardian sent to the facility revealed she requested them to hold off on transferring the residents. This resulted in psychosocial harm with R3 experiencing difficulty with adjusting to her new environment, crying, and stating, What did I do wrong? Additionally, the facility transferred R14 to the Emergency Psychiatric Services (EPS) on the evening of 08/15/2024 due to her challenging behaviors. On 08/16/2024, the facility initiated a discharge for R14 and refused to accept the resident upon return from the 08/15/2024 emergency room visit. The Emergency Psychiatric Services (EPS) explained to the facility that the resident's behaviors were related to the progression of the resident's disease process for dementia. Further, the EPS advised that the resident's medications be reviewed for the successful management of the resident's disease. The facility, however, failed to follow the recommendations of the EPS. Instead, on 08/16/2024, the facility left the resident at the hospital, refusing to accept the resident. This complicated the ability of the resident's State Guardian to place the resident within another facility. The resident remained at the hospital until, 09/12/2024, when the resident's State Guardian was finally able to place the resident in a long-term care facility. The facility's failure to have an effective system in place to ensure each resident's State Guardian was notified of the intent to transfer and discharge residents within the required 30 days so that approval would be granted for a safe and orderly discharge to other healthcare facilities has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/13/2024 and was determined to exist on 07/30/2024 in the area of 42 CFR 483.15, F623 Transfer and Discharge Requirements at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on 09/13/2024. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 09/20/2024, alleging removal of the IJ on 09/20/2024. The State Survey Agency (SSA) determined the facility removed the IJ as alleged before exit on 09/20/2024. The facility implemented the following: 1. a. On 07/26/2024, Social Service spoke with Resident #3's appointed State Guardian and discussed the transfer of Resident #3 to a sister facility. On 07/26/2024 Social Services talked to the Ombudsman and informed them of the transfer. On 07/30/2024, four days later, the facility transferred Resident #3 to the sister facility. Resident #3 is no longer a resident of the facility. 1. b. On 07/26/2024, Social Service spoke with Resident #4's appointed State Guardian and discussed the transfer of Resident #4 to a sister facility. On 07/26/2024 Social Services talked to the Ombudsman and informed them of the transfer. On 07/30/2024, four days later, the facility transferred Resident #4 to a sister facility. Resident #4 is no longer a resident of the facility. 1. c. On 07/26/2024, Social Services spoke with R13's appointed State Guardian and discussed the transfer of R13 to a sister facility. On 07/26/2024, Social Services talked to the Ombudsman and informed them of the transfer. On 07/30/2024, four days later, the facility transferred R13 to a sister facility. R13 is no longer a resident of the facility. 2. a. All residents have the potential to be affected. 2. b. On 09/15/2024, the facility Administrator reviewed 98 residents currently in-house for facility-initiated transfer/discharge. No facility-initiated transfer/discharge notices were in effect on the 98 residents. (Facility-initiated transfer or discharge: A transfer or discharge which the resident objects to, did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences). This does not include emergency transfers. 3.a. On 09/19/2024, the Corporate Independent Risk Manager (IRM) spoke with the State Guardian for the current residents. The Guardian educated the Corporate Independent Risk Manager on the process the State Guardian office must complete before approving a Facility-Initiated Transfer/Discharge of a resident. 3.b. On 09/19/2024, the Corporate Independent Risk Manager (IRM) educated in a small group setting the [NAME] President of Clinical Operations (VPCO), Signature Care Consultant (SCC), Regional Social Services, the Administrator, Interim Director of Nursing, Business Office Manager, and Social Services on the process the State Guardian office must complete for a Facility-Initiated Transfer/Discharge of a resident. The Corporate Independent Risk Manager (IRM) created two resource binders to be kept in each Social Service Office. The resource binders would include the steps needed for the state Guardian Office concerning transferring or discharging a resident with an appointed state guardian. If a new Social Service, Business Office Manager, Director of Nursing, or Administrator is hired, they will be trained in orientation by Signature Care Consultant or Corporate Independent Risk Manager on the process the State Guardian office must complete for a Facility Initiated Transfer/Discharge of a resident. 3.c. On 09/19/2024, the Senior [NAME] President of Quality requested the local Ombudsman to be a member of the newly created Facility-Initiated Transfer or Discharge Subcommittee. The local ombudsman agreed to be a team member on the Facility-Initiated Transfer or Discharge Subcommittee on 09/19/2024. This subcommittee was created on 09/15/2024. 3.d. On 09/15/2024, the facility implemented a new procedure concerning Facility initiated transfers or discharges, utilizing a subcommittee of members (Vice President of Operations (VPO), [NAME] President of Clinical Operations (VPCO), Independent Risk Manager, Signature Care Consultant, Social Services, a nurse or C.N.A. familiar with the resident, the Medical Director, and the Ombudsman. As of 09/19/2024, there has not been a meeting scheduled for the subcommittee as there has not been an identified need for a Facility-Initiated Transfer or Discharge in the facility. 4.a. An Ad Hoc Quality Assurance meeting was held on 09/15/2024 with the Medical Director, the Facility Administrator, the Interim Director of Nursing, and the Care Consultant at that time on 09/15/2024. The Facility Administrator presented the plan and information at the QAPI meeting on 09/15/2024. The Medical director attended via phone on 09/15/2024 and was notified of the implementation of the facility's improvement plan. The Medical Director reviewed the entirety of the plan and made no further suggestions. The Medical Director stated the plan was appropriate. Starting on 09/15/2024, the Facility Administrator will hold a Quality Assurance meeting daily until immediacy is removed. Then, it will decrease to monthly for recommendations and further follow-up regarding the above-stated plan. Moving forward, the Facility Administrator will continue to be the person who presents the information and audits at the QAPI Meetings, and the following members are expected to be present unless unable to attend: Facility Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Plant Ops Director, Social Services Director, Activity Director, Therapy Director, and MDS Coordinator. The QAPI Committee will determine at what frequency any ongoing audits must continue. The Administrator is responsible for implementing this plan. During a telephone interview with the District Ombudsman on 09/20/2024 at 3:05 PM, she stated the facility requested that the Ombudsman sit on the Facility-Initiated Transfer or Discharge Subcommittee. The Ombudsman joining the committee was to ensure the facility did not transfer/discharge a resident without following the appropriate guidelines and collaborating with the entire team as required. The findings include: Review of the facility's policy titled, Transfer/Discharge Notice, revised 03/25/2024, revealed the appropriate notice will be provided to the resident and/or resident representatives along with other required organizations if it is necessary to transfer or discharge a resident from a facility. Additionally, the facility will issue a notification at least 30 days before the date of transfer/discharge. 1. Review of R3's Face Sheet found in the resident's electronic medical record (EMR) revealed the facility admitted the resident on 10/06/2023 with diagnoses to include unspecified dementia, mood disturbance, and anxiety. Review of R3's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/30/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13 of 15, which indicated the resident was cognitively intact. Review of R3's Notice of Transfer or Discharge letter, dated 07/26/2024, and addressed to R3's State Guardian, revealed it was delivered in person to the resident and sent by overnight mail to the family member/legal representative with a Return Receipt Requested. According to the letter, the facility stated that the transfer was necessary for the welfare of the resident, as the facility could not meet R3's needs. The effective discharge date was 07/30/2024, four days after the notice was issued to the resident. Review of R3's EMR revealed a Resident Progress Note, dated 07/26/2024 at 4:52 PM, revealed the Social Service Director (SSD) spoke with the resident's State Guardian and informed her the resident would be transferred to a sister facility (the facilities share the same parent company). Review of R3's EMR revealed a Resident Progress Note, dated 07/26/2024 at 5:02 PM, revealed the Social Service Director (SSD) spoke with the State Long Term Care (LTC) Ombudsman and informed her the resident would be transferred to a sister facility. During an interview with Family (F) 3 on 09/11/2024 at 12:59 PM, she stated she learned the facility transferred R3 to another facility by accident from the resident's State Guardian. Family (F) 3 stated the State Guardian called her to inform her of the requested transfer and to discuss any concerns F3 would have regarding having R3 further away from the family. During the conversation on 07/30/2024 with the State Guardian, she stated the facility had requested R3 to be transferred to a sister facility. Family 3 stated she told the State Guardian that it would burden the family significantly and potentially mean they could not visit as frequently as they do. Family 3 stated the State Guardian never stated that R3 had been transferred already, only that she was scheduled to be transferred. Per the interview, F3 stated that within her discussion with the resident's State Guardian, she was informed that placement closer to the resident's family would be requested. F3 stated the facility never asked if transferring the resident would burden the family, and they never told her why the resident was transferred. Furthermore, F3 stated when she hung up the phone after speaking with the resident's State Guardian, she immediately received a call from the sister facility. According to F3, the sister facility's nurse called her to inform her the facility had admitted R3. In a continued interview with F3, on 09/11/2024 at 12:59 PM, she stated the new facility was 80 miles away from the resident's family. Further, she stated this made it difficult and even physically challenging for the family, many in their eighties, to visit R3. Previously, F3 was only 14 miles from the facility, making visiting more accessible for all the family. Additionally, due to R3's dementia, F3 stated visits can only last for 15 to 20 minutes, and sometimes R3 was not receptive to visits at all. She stated it would be an extreme burden for the family to drive 160 miles round trip to be denied a visit by R3. Additionally, F3 was upset about R3's transfer, primarily due to the facility needing approval from the State Guardian. Family 3 stated the State Guardian was still looking for a facility closer to the family. She stated she was concerned about how the facility handled the entire process and said it was all done in a [NAME] and [NAME] manner. During a telephone interview with Social Service Director (SSD), at the accepting facility, on 09/11/2024 at 3:49 PM, she stated R3 had difficulty adjusting to the transfer to her new home. Upon arrival, R3 was crying and expressed confusion as to why she was sent away from her home and would often ask, What did I do wrong? She stated R3 repeatedly requested to speak with her State Guardian about her transfer. The SSD stated R3 was slowly adjusting to her new environment over the past several weeks and was getting along well with her roommate. The State Survey Agency (SSA) surveyor requested to speak with the resident; however, the SSD stated the resident was engaged in an outside activity and was having a good day. Per the interview, the SSD stated that discussing the resident's transfer with her might upset her. 2. Review of R4's Face Sheet found in the resident's EMR revealed the facility admitted the resident on 10/29/2022 with diagnoses to include cerebral infarction, generalized anxiety disorder, and mild cognitive impairment. Review of the R4's quarterly MDS, with an ARD of 07/30/2024, revealed the facility assessed the resident to have a BIMS score of 10 of 15, which indicated the resident was moderately impaired. Review of R4's Notice of Transfer or Discharge letter, dated 07/26/2024, and addressed to R3's State Guardian, revealed it was delivered in person to the resident and the State Guardian, and sent by overnight mail to the family member/legal representative with a Return Receipt Requested. According to the letter, the facility stated the transfer was necessary for the welfare of the resident, as the facility could not meet R3's needs. The effective date of discharge was 07/30/2024, four days after the notice of transfer or discharge was issued to the resident. Review of R4's EMR revealed a Resident Progress Note, dated 07/26/2024 at 4:57 PM, revealed the Social Service Director (SSD) spoke with the resident's State Guardian and informed her the resident would be transferred to a sister facility. Per the note, the Ombudsman was also made aware of the transfer. During a telephone interview with the SSD at the accepting facility on 09/11/2024 at 3:49 PM, she stated R4 was adjusting well to his transfer and has had no complaints. The SSD stated the facility accepted the resident on 07/30/2024. According to the interview, the SSD stated R4 has not exhibited any behaviors since his arrival. Per the SSD, R4 was unavailable for an interview. During an interview with the SSD on 09/05/2024 at 4:15 PM, she stated she spoke with R3 and R4's State Guardian on 07/26/2024 regarding both of their discharges. She stated the State Guardian agreed with the transfer/discharge. During a telephone interview with R3 and R4's State Guardian on 09/05/2024 at 11:15 AM, she stated the facility failed to provide a 30-day notice before the resident's discharge on 07/30/2024. The State Guardian stated she made the SSD aware through e-mails and telephone conversations discussing the possible transfer/discharge that the State Guardian's office has a process that she must follow to ensure the residents were not inappropriately discharged . The State Guardian stated she needed to obtain supervisory approval for the transfer/discharges. She also stated she informed the SSD that she would need to make a site visit to each facility before approving the transfer/discharge. She stated the facility knew the process because she had informed the administration, more than once, of the need to notify her before any transfer or discharge. 3. Review of R13's Face Sheet found in the resident's EMR revealed the facility admitted the resident on 11/29/2023 with a primary diagnosis of hemiplegia related to cerebral vascular accident (CVA), reduced mobility, psychiatric disorder, cognitive communication deficit, anxiety, unspecified psychosis, dementia, and failure to thrive. Review of R13's Notice of Transfer or Discharge letter, dated 07/26/2024, and addressed to R13's State Guardian, revealed it was delivered in person to the resident and the State Guardian. According to the letter, the facility stated the transfer was necessary for the welfare of the resident, as the facility could not meet the resident's needs. The effective date of discharge was 07/30/2024 with the resident's transfer being more than 150 miles away to the sister facility. Review of R13's EMR revealed a Resident Progress Note, dated 07/26/2024 at 4:56 PM, revealed the SSD spoke with the resident's State Guardian and informed her the resident would be transferred to a sister facility. Per the note, the Ombudsman was also made aware of the transfer. Record review of R13's MDS, dated [DATE], revealed the facility assessed the resident at discharge to have a BIMS score of 9 out of 15, which indicated the resident had moderate cognitive impairment. Review of the SSD email, dated 07/30/2024, revealed she emailed R13's State Guardian and requested a reply to her email, informing her the resident would be transferred/discharged . The resident's State Guardian replied by requesting the facility to hold off on discharging the resident. She replied, I am waiting for my supervisor's approval on this. Further review of the SSD's email, dated 07/31/2024 at 8:30 AM, revealed the resident's State Guardian emailed, Please, do not send the residents to other facilities until I get approval. This email was sent after the resident had been admitted to the sister facility. During an interview on 09/06/2024 at 10:15 AM with the Regional Nurse Consultant, she stated the residents with the least connection to the community were chosen to transfer to sister facilities. She stated the purpose of the residents' transfers was to open their rooms up for a different type of skilled services. During an interview on 09/09/2024 at 10:48 AM, the SSD stated that she and the Chief Nursing Officer (CNO) called the residents' State Guardian, and she was 100% (percent) in agreement with transferring the residents to sister facilities. Per the interview, she stated she had emails to validate the State Guardian's agreement. However, a review of the emails between the SSD and the State Guardian revealed the State Guardian requested for the transfer/discharge to be held until she could obtain approval from her supervisor. 4. Review of R14's Face Sheet, found in the electronic medical record (EMR), revealed the facility admitted the resident on 02/21/2024 with diagnoses to include unspecified dementia with behavioral disturbance and major depressive disorder. Review of R14's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/21/2024 revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS), score of three out of 15, which indicated severe cognitive impairment. Review of the Psychiatry Progress Note dated 04/12/2024, at 11:46 AM, revealed the resident was referred to psych services due to her history of depression, dementia, and sleep problems. Further review of the note revealed nursing staff had reported no changes in R14's mood or cognition. Further review of the progress note revealed the resident's chart was reviewed for any medication changes, labs, behaviors, with no significant findings. Review of R14's emergency room Discharge Orders, found in the resident's EMR, dated 07/11/2024, revealed R14 was transferred from the facility to the local hospital's Emergency Psychiatric Services (EPS) for a psychiatric evaluation relating to endorsing actual harm. The resident denies this and no sign of agitation or other symptoms was noted. Continued review revealed R14 did not meet the criteria for admission. Further review revealed the resident had progressed dementia. Review of R14's Discharge MDS, dated [DATE] revealed the resident was discharged to an independent psychiatric facility. There was no BIMS score listed in this MDS. Further review of the MDS revealed the resident had a change in her baseline cognition. Further review of the MDS, under Section E, revealed the resident had no behaviors noted, at discharge. A review of a local hospital's Psychiatry Transfer Form, found in R14's EMR, revealed that R14 was admitted to the local hospital on 07/24/2024 with diagnoses to include recurrent, severe major depressive disorder with psychotic features, suicidal ideation, moderate, unspecified dementia with other behavioral disturbances. Review of R14's Psychiatry Notes found in the resident's EMR, dated 08/15/2024 at 6:48 PM, indicated the resident was transferred from the facility to the local hospital's Emergency Psychiatry Service (EPS) for a psychiatric evaluation due to the resident experiencing combative behavior with staff at the facility. Further review of the note revealed the resident had a diagnosis of dementia, and this was a normal progression of her disease. The note revealed the resident did not meet the criteria for admission to a psychiatric facility. Additionally, an addendum was added which listed a diagnosis of dementia with behavioral disturbances and the resident's medications should be considered and other recommendations for a more successful management of her disease. Continued review of the note revealed the facility was working on locating new placement for the resident, a locked facility. The note revealed the hospital would keep the resident overnight to allow the facility time to plan for the resident. The Director of Nursing (DON) had promised to call the physician by 9:00 AM with a plan and R14 would be discharged at that time. That call never happened and the resident was subsequently returned to the facility on the evening of 08/16/2024. The facility declined to accept this resident and she was returned to the hospital EPS and was admitted to the Behavioral Health Unit until her discharge to a Long Term Care facilty on 09/12/2024. Review of a Social Service Progress Note, found in R14's EMR, dated 08/15/2024 at 11:07 PM revealed the SSD spoke with the EPS attending physician to advise him that the facility was not the appropriate place for R14 due to her escalating behaviors, being a danger to herself and others. She documented in the progress note that R14 had recent mental decompensation, resulting in three visits to the hospital. The progress note documented that the attending physician at EPS explained that R14 was not appropriate for an acute psychiatric stay and revealed that R14 was not exhibiting the same behaviors at the hospital. Further review of the note revealed the physician explained to the SSD he assessed R14 as having a progression of dementia, which an acute psychiatric stay would not fix, nor was it appropriate at this time. According to the note, the EPS physician recommended a dementia unit due to the progression of the resident's diagnosis. During an interview on 09/09/2024 at 3:15 PM, with an Emergency Psychiatry Services (EPS), MD he stated on 08/15/2024 he spoke with the (former) Director of Nursing, and she stated if he could keep the resident overnight, she would call EPS first thing in the morning with a plan for placement. He stated the former DON never returned his call. On 08/16/2024, he stated the resident was discharged and transferred to the facility, but was turned away by staff. The EPS MD stated he could not recall the nurse's name, but when he spoke with the facility's nurse, on the night of 08/16/2024, she stated she was not going to accept the resident and would be sending her back to the hospital. With no placement, he stated the resident was subsequently admitted to the medical floor until placement could be found. During a telephone interview with Registered Nurse,(RN)2, on 09/04/2024 at 3:16 PM, she stated that when R14 returned to the facility from the hospital on 08/16/2024, she declined to accept the resident at the door. She stated the (former) DON instructed her not to accept the resident. During an interview on 09/09/2024 at 3:56 PM with the Chief Nursing Officer (CNO) for the facility, regarding R14 who was sent to EPS and not allowed to return to the facility, she stated she had been on the phone with the resident's guardian six (6) or seven (7) times about various things. She stated R14 had been in and out of the facility for behaviors. Further, she stated the facility did not have, in writing, the reason for the resident's discharge, a notice that was sent to the Ombudsman, or notification to the resident's State Guardian, that was at least 30 days before the resident was discharged from the facility. During an interview with the Nurse Practitioner, on 09/09/2024 at 3:20 PM, she stated she was unaware of any recommendations from the EPS, which suggested the resident's medications would be reviewed with other recommendations for the management of the resident's disease. During an interview with the Medical Director, on 09/10/2024 at 4:05 PM, he stated he was not familiar with any recommendations from the Hospitalist regarding medication adjustments for the resident. Further, he stated the resident should have been referred to Psychiatric Services for any changes. During an interview on 09/09/2024 at 1:10 PM with the State Guardian, she stated that the old team seemed to understand the process but since the change in management, she has repeatedly tried to educate the facility on the process, but assistance was declined. She stated the standard process was to schedule a meeting with the resident and staff to discuss with the guardian what the need might be. Then the guardian would go to his or her next-line supervisor and provide information on the intended facility. At that time, she stated the intended or selected facility would be reviewed and approved by her team. She stated the approval would be relayed to the Interdisciplinary team (IDT) for further action. The State Guardian stated she asked the facility to look for a facility for R14 before discharging her. Per the interview, she stated she was unable to secure placement for the resident until September. During an interview on 09/10/2024 at 2:10 PM with the Medical Director, he stated he was aware of the plan to change some of the long-term beds to skilled beds and that there were residents who would be transferred to sister facilities. Further, he stated he was not responsible for the residents' transfer/discharge. During an interview on 09/09/2024 at 3:56 PM with the CNO, she stated that she was on the call with the SSD and the State Guardian during a conversation regarding the transfer of residents to sister facilities. She stated the reason she was on this call was to make sure things went smoothly. She stated there were emails to prove that the State Guardian was aware of the plan for transfer/discharge of the residents to sister facilities, to open rooms for a new type of service. The CNO revealed the facility had not provided the residents with a 30-day notice before transfer/discharge. She stated this was a learning experience for the facility. 50192

Based on observation, interview, record review, and facility policy review it was determined, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one for 30 sampled residents, Resident (R) 1. R1 sustained a fall between 04/16/2024 and 04/18/2024. Interviews and record review revealed staff failed to follow the resident's care plan which instructed staff to utilize the mechanical lift when transferring the resident from her bed to wheelchair. An unknown staff member transferred the resident without utilizing the resident's mechanical lift and the resident fell on her knees, resulting in a fracture of the distal right femur (broken thigh bone near the knee). The findings include: Review of the facility's policy titled Falls, with a revision date of 09/15/2023, revealed the intent of the policy was to ensure the environment was as free from accidents and hazards as possible to prevent avoidable falls. Per review, the guidelines included fall risk assessments to be performed upon admission, readmission, quarterly, annually and with a significant change of condition to identify fall risks. Continued review revealed a comprehensive care plan (CCP) was to be implemented based upon the resident's risk of falls and goals with interventions placed to reduce the risk of avoidable falls. Continued review of the facility's policy revealed the CCP should be reviewed following each fall with revisions of goals and interventions. Additional review of the facility's policy revealed the Interdisciplinary Team (IDT), and the Quality Assurance/Performance Improvement Committee (QAPI) were to perform reviews of residents' falls. Review of the facility's policy titled, Resident Rights, undated, revealed residents had the right to a safe environment. The State Survey Agency (SSA) surveyor requested a copy of a mechanical lift policy. However, the facility does not have a policy and followed the manufacturer's recommendations for mechanical lift use. Review of the facility's mechanical lift user manual titled, Maxi Move Floor Lift User Manual, undated, revealed while the lift was designed for safe usage with one caregiver, there are circumstances, such as contractures, of the individual that may dictate the need for two-person transfers. Further, it stated it is the responsibility of each facility to determine if one or two person transfers is more appropriate based on the task, the resident load, the environment, and capability and skill level of the staff member. Review of R1's Face Sheet found in the resident's electronic medical record (EMR) revealed the facility admitted the resident on 04/29/2016 with diagnoses to include quadriplegia following a motor vehicle accident in 2015, contracture of both knees, and Alzheimer's disease. Review of R1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/02/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Continued review of the MDS Section GG - Functional Abilities and Goals revealed R1 did not attempt a sit to stand due to her medical conditions. Additionally, R1 was totally dependent (resident does none of the effort to complete the activity or the assistance of two or more helpers was required for the resident to complete the activity) on staff to transfer her from the bed to her wheelchair. Review of the R1's quarterly MDS, with an ARD of 07/31/2024, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Continued review of the MDS Section GG - Functional Abilities and Goals revealed R1 did not attempt a sit to stand due to her medical conditions. Additionally, R1 was totally dependent (resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) on staff to transfer her from the bed to her wheelchair. Review of R1's Comprehensive Care Plan (CCP), dated 03/22/2023, revealed R1 was identified as a fall risk on 03/19/2020 related to impaired balance, use of psychotropic medications, dependent (with transfers, pain, muscle weakness, and contractures). Interventions placed on 08/11/2021 were to use a mechanical lift with transfers. It did not specify how many staff were to assist with the mechanical lift for transfers. There were no revisions noted. Continued review of the CCP revealed the resident was identified as having a self-care deficit due to a decline in activities of daily living (ADL) with interventions to include, two staff assist required for bed mobility, initiated on 07/24/2024. Review of R1's PT Evaluation & Plan of Treatment, dated 04/11/2024, revealed that PT assessed R1 as being dependent at baseline on safely transferring from lying to sitting on the side of the bed with no back support. Further review revealed the resident had non-weight bearing status in bilateral lower extremities (BLE). Further review revealed the resident was dependent on staff for chair/bed-to-chair transfers, and due to R1's diagnosis of quadriplegia, sit-to-stand was non-applicable. Review of R1's Physical Therapy Treatment Encounter Note, dated 04/18/2024, revealed the physical therapist (PT) noticed increased swelling in R1's right lower extremity and informed the nurse on duty. According to the note, R1 had tenderness in the area but no severe pain with movement. Review of R1's, Change In Condition (CIC), dated 04/18/2024 at 2:47 PM, revealed the former Director of Nursing (DON) assessed R1 for a CIC related to her right knee. According to the CIC report, the former DON found non-pitting edema with redness and warmth in R1's right knee. The former DON did not conduct any additional review of systems. The nurse practitioner (NP) and R1's responsible party were notified. Review of R1's Nurse Progress Notes, dated 04/18/2024 at 3:58 PM, revealed R1 presented with swelling, redness, and warmth in the right knee. Resident 1 denied any pain. According to the progress note, R1 stated that she did not fall or hit her leg on anything. The nurse notified the NP, who ordered a stat (immediate) radiograph (x-ray) of the right knee. Review of the Facility Reported Incident (FRI), undated, revealed on 04/18/2024 at approximately 2:30 PM, R1 was assessed by PT as having edema to her right knee. According to the FRI, R1 stated she did not have any pain, nor did she know why her knee was swollen. R1 denied having fallen or injuring her knee. The resident was again questioned on 04/19/2024 and stated during an incorrect transfer, she hurt her knee. Further review revealed no staff had any knowledge of a fall or incorrect transfer. Review of R1's, Fall Event Report, dated 04/19/2024 at 10:55 AM, revealed the resident had a witnessed fall with injury out of her bed. According to the report, R1 denied any complaint of pain and reported that she fell a few nights ago, but was unable to recall the date/time of the fall. Review of R1's Fall Risk Score Total, dated 04/19/2024 at 10:55 AM, revealed a fall score of 14, indicating a high risk for falls. The evaluation revealed R1 required staff assistance for mobility and transfer. Review of R1's, Nursing Progress Note, dated 04/19/2024 at 10:58 AM, revealed the resident stated that a few days ago the aide was helping transfer her from bed to her wheelchair. During the transfer, the resident fell . The resident states that she currently has no pain. Review of R1's, Nursing Progress Note, dated 04/19/2024 at 11:00 AM, revealed the radiology report was faxed to the triage nurse for the nurse practitioner to review. Review of R1's, Nursing Progress Note, dated 04/19/2024 at 11:04 AM, revealed R1 was transferred to a local hospital related to a right knee fracture. The State Survey Agency (SSA) surveyor requested a copy of R1's x-ray report from the Care Consultant on 09/09/2024 at 5:00 PM, however, the facility did not provide the document. Review of R1's Emergency Department (ED) Note, dated 04/19/2024 at 5:54 PM, revealed R1 presented to the ED following a fall and was assessed with symptoms of pain, swelling, and loss of mobility in the right lower extremity. According to the ED notes, R1 stated during a transfer from the bed to her wheelchair, one aide tried to do the transfer alone but was unable to and dropped R1 on the floor. Per the note, an x-ray was performed at 2:49 PM on 04/19/2024, and the findings showed an acute, comminuted (broken into multiple fragments) and impacted (high-impact forces or sudden, severe compression) fracture of the distal right femur. Further review of the ED notes revealed R1 rated her pain as four (meaning moderate pain) on a universal pain scale of one to 10, with 10 indicating worst pain possible. At 1:32 PM, R1 received morphine (an opiate pain reliever) 4 milligrams intravenously (IV) for pain. During observation and interview with R1 on 09/04/2024 at 12:30 PM, she stated she had fallen and broken her femur in April 2024 while being transferred from her bed to the wheelchair. The resident stated she required a mechanical lift for all transfers because she was quadriplegic. She stated she explained this to the Certified Nursing Assistant (CNA) who came to assist her with transferring her from her bed to the wheelchair. R1 stated the aide insisted she could transfer the resident without the mechanical lift and asked the resident to stand up, despite informing the aide she could not use her legs. The resident stated that while sitting in her bed the CNA assisted her to the side of the bed and tried to lift her. The resident stated she then fell . R1 stated that after the fall, EMS transferred her to the hospital where she underwent surgery. The resident stated she was unable to identify the CNA and never saw the CNA again. Further interview with R1, on 09/04/2024 at 12:30 PM, she stated that after the fall, other staff members helped her back into bed. She stated the nurses did not assess her after the fall, despite the obvious deformity of her leg, which she believed indicated a fracture. R1 stated that she had informed the staff about her pain for several days, but no action was taken until she arrived at the Emergency Department (ED). She stated she did not receive pain medication after her injury. The State Survey Agency (SSA) Surveyor asked the resident to rate her pain utilizing the Pain Scale of 1 to 10, with 10 being the most severe pain. R1 stated her pain was about a 7 out of 10, which indicated severe pain. The resident stated her pain was finally relieved by intravenous (IV) pain medication upon arrival at the hospital. During an interview with Family (F) 6, on 09/12/2024 at 11:20 AM he stated that the facility notified him in April 2024 that R1 had fallen. He stated the facility did not provide details on how the fall occurred. However, when he spoke to R1, she explained that a CNA had come in to her room to transfer her into a wheelchair, but did not have a mechanical lift in the room. He stated R1 told the CNA three times that she could not stand and needed the mechanical lift, but the CNA insisted on transferring her without it. As a result, F6 stated R1 fell on to her knee during the transfer. Family 6 stated R1 told him that several staff members entered the room and placed her back into bed after the fall, but he is unsure if a nurse assessed R1 for injuries at that time. He stated R1 informed him that she had expressed concerns related to pain and something in her leg not feeling right to the staff for several days after the fall, but her concerns were ignored. Family 6 stated during a conversation with R1's orthopedic surgeon, the physician noted that R1's injury would have caused excruciating pain for someone without a spinal cord injury. However, due to R1's injury, her pain was dulled. During an interview with the Paramedic on 09/12/2024 at 2:13 PM, he stated on 04/19/2024 around 12:00 PM, when he arrived at the facility to transfer R1 to the local hospital, he was informed by LPN5 that R1 had a fractured femur. He stated he reviewed paperwork which included x-rays dated 04/19/2024 at 5:18 PM. He stated he was concerned the facility was negligent in responding to the resident's needs after her fall and their failure to transport the resident to the hospital earlier. Per the interview, he stated LPN5 mentioned that they were unsure when R1 fell , but an x-ray was taken on 04/18/2024. LPN5 described the incident as an unwitnessed fall and stated that staff found R1 on the floor, but no one took responsibility for the fall, and the exact cause remained unknown. He stated he assessed R1 and noted that she was alert and oriented to person, place, time, and situation. The Paramedic stated that R1 informed him that during a transfer to her wheelchair, They dropped me and expressed frustration, stating, I told them for two days something wasn't right, but they ignored me and did nothing. The paramedic observed tenderness and R1 complained of pain in her right knee and leg. Upon assessment, he stated R1 had swelling of her knee and distal aspect of the right thigh, as well as external rotation of the right foot. During an interview with CNA4 on 09/06/2024 at 10:35 AM, she stated residents transferred by a mechanical lift usually require the assistance of two persons. She stated she has received training on how to use the mechanical lift and the proper reporting protocol for falls. CNA4 stated she was not aware of the specific mechanical lift policy. Additionally, she stated that although a care plan may require a mechanical lift, if she is able to do it alone, she would transfer the resident without the aid of the lift and stated further, I just go and do it. During an interview with CNA2 on 09/06/2024 at 1:15 PM, she stated that it always takes two people to use a mechanical lift. She stated that a resident deemed to require a mechanical lift cannot be lifted by just one person. During an interview with Licensed Practical Nurse (LPN) 6 on 09/09/2024 at 4:42 PM, she stated that R1 was not bedbound and does get out of bed once or twice a week. LPN6 stated R1 was dependent upon staff due to her diagnosis of quadriplegia and was care planned to use a mechanical lift for chair/bed-to-chair transfers. LPN6 stated further that on 04/18/2024, the PT informed her that R1 had redness and swelling in her knee. She stated she assessed R1 who complained of a sore knee. LPN6 noted that the PT was with her during the assessment. LPN6 stated R1's right leg was red and swollen but with no bruising. In a continued interview, on 09/09/2024 at 4:42 PM, LPN6 stated she assessed R1 and called the on-call Advance Practice Nurse Practitioner (APRN), who ordered a stat x-ray. She stated she believed the x-ray provider performed the procedure that same afternoon, but she did not recall the time. She stated the results were not back when her shift ended; however, LPN6 stated she reported to RN2 to look for R1's x-ray results. She stated that when she returned to work, she could not believe that R1 had a fractured leg because she did not believe the resident fell on her shift and the resident did not complain of pain. During an interview with Registered Nurse (RN) 2 on 09/10/2024 at 2:05 PM, she stated she cared for R1 during night shift on 04/18/2024. She stated she remembered knowing about the resident's fall but did not recall receiving R1's x-ray results report while on duty. She stated that the contracted x-ray service company would usually call the nurse on duty when an abnormal result, such as a fracture, occurred. During an interview with RN4 on 09/20/2024 at 2:38 PM, she stated she was unaware of a mechanical lift policy; however, staff were to follow the manufacturer's guidelines for mechanical lift use. Further, she stated she had not read the guidelines nor knew where to find the manufacturer's guidelines for the lift. RN4 stated that current nursing standards were to use two persons during a mechanical lift unless told otherwise. She stated she was unaware of any incident when staff transferred R1 without using a mechanical lift. During an interview with RN5 on 09/20/2024 at 2:38 PM, she stated staff should document the use of a mechanical lift as an intervention in the resident's care plan. RN5 stated that staff can provide one-person assistance during a mechanical lift transfer based on the resident's needs, but she stated current nursing standards require the use of a two-person assist during a mechanical lift transfer for the safety of the resident. RN5 stated she was unsure of where to find the manufacturer ' s guidelines and had not read them. During a telephone interview with Unit Manager (UM) 1 on 09/11/2024 at 3:58 PM, she stated she was unfamiliar with R1, although she resides on UM1's unit. She stated it was her expectation for staff to follow the care plan for mechanical lifts. She stated if a resident was care planned for a mechanical lift, she expected the staff to use a mechanical lift for transfers. Additionally, UM1 stated it was important to follow the care plan so that staff would not compromise residents' safety by attempting to move them without a mechanical lift. During an interview with the PT on 09/10/2024 at 10:27 AM, she stated the therapy department had been regularly attending to R1, since admission. According to the PT, R1 has incomplete quadriplegia and experiences occasional pain and limited mobility. The therapist had been working with R1 on bed mobility and observed no swelling or pain in R1's knee the day before. However, on 04/18/2024, the PT noticed swelling, redness, and warmth in R1's lower femur and knee. The therapist informed LPN6 about the issue, and LPN6 said she would address it. During the assessment, R1 appeared alert and oriented and did not complain of pain. The PT also noted that R1 did not know what caused her knee to swell. During an interview with the APRN on 09/10/2024 at 10:12 AM and 3:20 PM, the APRN stated that she was not on duty at the time of the incident and could not recall specific concerns regarding R1's fall and femur fracture. She noted that the nurse calls the on-call APRN when a resident falls and she expected staff to inform her of any falls and report any delays in care, such as a delayed x-ray. She stated if a bone was deformed or the resident needed emergent care, she would send the resident to the ED. She stated it was important that all care plans were followed. Further, the APRN stated the facility's policies and procedures should be followed to ensure the safety and well-being of the residents. She further stated that resident-centered care was important to maintain the resident's quality of life. During a telephone interview with the former DON on 09/12/2024 at 11:15 AM, she stated she was the DON from April 2024 to July 2024. She stated that R1 fell , but the cause could not be identified. She indicated that she conducted most of the investigation with the Care Consultant. Further, she stated she did not have additional information to add related to the resident's fall. During an interview with the Care Consultant on 09/10/2024 at 12:24 PM, she stated she and the former Director of Nursing (DON) investigated R1's injury. She said the investigation involved reviewing R1's medical record and conducting staff interviews. Per the interview, the Care Consultant stated the resident's recollection of the event changed and she could not identify the staff member involved. She stated staff interviews did not reveal any specific event or incident that led to the resident's injury. Further interview on 09/10/2024 at 12:24 PM, the Care Consultant stated a one- or two-person assist may be required to use the mechanical lift depending on the situation. She stated that there was no specific mechanical lift policy; however, it was her expectation staff adhered to the mechanical lift manufacturer's instructions. In addition, the Care Consultant stated it was her expectation that staff would follow the resident's care plans and provide timely updates for any change in condition. During an interview with the Interim Director of Nursing (IDON) on 09/20/2024 at 11:48 AM, she stated she has been at the facility since 09/03/2024 to train the ADON and has since taken on the role of IDON. The IDON revealed that staff members were trained in using the mechanical lift, and she stressed the importance of training to prevent any potential safety risks for the residents. The IDON stated CNAs could access resident care plans in the EMR, and they carried paper care plans for quick reference. She stated that following the care plan was crucial for providing resident-centered care. During an interview with the Administrator on 09/17/2024 at 2:32 PM, he stated it was his expectation staff followed all the facility's policies to keep residents safe.

Based on observation, interview, review of the Centers for Disease Control and Prevention's (CDC) document, review of medication package inserts, and review of the facility's policy, the facility failed to ensure appropriate environmental controls were used to preserve their integrity in one of two medication refrigerators. Additionally, the facility failed to ensure drugs and biologicals were stored per currently accepted professional principles for six of 96 residents (Residents (R) 7, R8, R9, R10, R27, and R28). Observation on 09/04/2024, revealed one opened and undated vial of purified protein derivative (PPD), (used in a tuberculin skin test for tuberculosis) was found in the [NAME] Unit medication refrigerator. On 09/04/2024, during an observation of the medication cart on the 700 Hall, it was noted that multiple eye drops and insulin vials were not dated when opened. All the insulin pens were found to be opened and undated. Additionally, four insulin pens were not stored in separate plastic bags. One insulin pen lacked the original pharmacy label and had the resident's name written on it with a dark marker. The writing was barely legible due to the pen being dark blue. An antibiotic ointment was stored in the same drawer as insulin and eye drops. The findings include: Review of the facility's policy titled, Medication Storage, dated 01/2023, revealed the purpose of the policy was to ensure medications and biologicals were stored properly following manufacturer's recommendations to maintain their integrity. Per the policy, the pharmacy dispensed medication and containers that met state and federal labelling requirements. The medications were to remain in these containers. Internally administered medications were to be stored separately from ointments. Further review of the policy revealed medication storage conditions were monitored on a regular basis as a random quality assurance (QA) check. Review of the facility's policy titled, Medication Administration, revised 06/24/2024, revealed the purpose of the policy was to ensure medications and biologicals were administered in accordance with the manufacturer's recommendations to maintain their integrity. Per the policy, licensed staff should check the expiration date on the package/container. Review of the package insert/product label revealed PPD was used as an aid in the detection of infection with mycobacterium. Further review revealed a multi-dose vial of PPD, which had been opened and used, should be discarded after 30 days. 1. Observation of the [NAME] Unit's medication room refrigerator on 09/04/2024 at 10:10 AM, revealed one opened vial of PPD, not stored in its original packaging, with no opened date listed on the vial. The original packaging was on the shelf next to the vial, but it did not have an open date. During an interview with Licensed Practical Nurse (LPN) 1 on 09/04/2024 at 10:13 AM, she stated the nursing staff monitored refrigerators routinely to check for outdated or expired medications and vaccines. She stated when a medication was expired it should be sent back to pharmacy or discarded. LPN1 stated she did not know why the PPD vial was not dated. However, she stated it was important to date and store medication according to the manufacturer's instruction and the facility's policy to ensure the safety of the residents. 2. Observation of the 700 Hall medication cart on 09/04/2024 at 11:18 AM, revealed R7's insulin lispro was opened and not dated; R8's insulin lispro, insulin glargine, Lantus, latanoprost 0.005%, Betimol 0.5% eye drops, and Novolog pen were opened and not dated. R8's Novolog pen had no original pharmacy label, but the resident's name was written on the dark blue pen in barely visible black ink; R9's insulin lispro, insulin glargine, and Ketorolac 0.5% eye drops were open and not dated; R10's insulin lispro was opened and not dated; R27's Betimol 0.5% eye drops and Dorzolamide HCL 2% eye drops were opened and not dated; and R28's Bacitracin ointment was open, not dated, and stored with insulin pens and vials, and with eye drops. The tube was not in its original package and had no identifying resident label. During an interview with LPN1 on 09/04/2024 at 11:18 AM, she stated she was the nurse in charge of the 700 Hall medication cart. LPN1 stated that according to the facility's policy, nursing staff should date all vials, pens, and ointments when opened. She stated she was unsure if anyone in the facility conducted routine medication audits on any of the medication carts. The LPN stated nursing staff should discard all expired medicines. LPN1 further stated all opened eye drops, and insulin should be discarded 30 days after opening. During an interview with LPN7/Unit Manager (UM) on 09/10/2024 at 9:57 AM, she stated the nurse taking the cart was responsible to check for undated or expired medications. LPN7/UM stated as the Unit Manager she did not do formal audits of the medication carts and was unaware the 700 Hall medication cart had multiple opened and undated medications. She stated it was her expectation that nurses and Kentucky Medication Aides (KMA) label the medication vial, bottle, or insulin pen with the date it was opened. She stated further it was her expectation nurses and KMAs ensure medications were not expired prior to administering any medication. During an interview with the Infection Preventionist/Staff Development Coordinator (IP/SDC) on 09/06/2024 at 1:35 PM, she stated nurses working the medication carts were responsible for checking the medication carts and refrigerators for expired medications. She stated nursing leadership did not conduct formal audits of the medication carts and refrigerators. She stated that nurses were educated on policies and procedures related to medication administration and as nurses should follow nursing standards to label and date medication when opened. She stated it was her expectation that nurses and KMAs monitor the medication carts and the medication refrigerator to ensure the integrity of medications administered to residents. She stated it was important for the safety of the residents. During an interview with the Assistant Director of Nursing (ADON) on 09/20/2024 at 11:27 AM, she stated it was her expectation staff followed all the facility's medication administration policies and procedures. The ADON stated nurses and KMAs must date all multiuse medications when opened. The ADON stated it was important that nurses date all medications upon opening them to maintain the efficacy of the medication and for the safety of the residents. The ADON stated further that the nurse or KMA assigned to the cart was responsible to ensure that all medications were dated and labeled. She stated she did not require nurses to check every medication on the medication cart for expiration dates. The ADON stated nurses should ensure medications were not expired prior to administering any medication. During an interview with the Interim Director of Nursing (IDON) on 09/20/2024 at 11:48 AM, she stated it was her expectation that medications in the medication cart and refrigerator were stored according to the facility's policy and manufacturer's guidelines. She stated multi-dose vials should be dated when opened and discarded according to labeling instructions, and medication should not be stored in the refrigerator door. She further stated it was important to discard all expired medications to ensure their efficacy. The IDON stated she did not know why the bottle of PPD was not dated when opened. She stated it was important to date medication when opened and store all refrigerated medication properly to ensure the safety of the residents and safeguard the efficacy of the medication. During an interview with the Care Consultant (CC) on 09/20/2024 at 10:15 AM, she stated there was no scheduled medication cart audits by nurse leadership. The CC stated it was her expectation nurses and KMAs date medications when opened according to facility's policy. She stated if a nurse observed that a medication was opened and not dated, she should check the delivery date of the medication and if it was greater than the recommended shelf-life or was expired, it should be disposed of appropriately. She stated it was important to monitor the medication carts and the medication refrigerator to ensure the integrity of medications administered to residents. She stated it was important for the safety of the residents. During an interview with the Administrator on 09/17/2024 at 2:32 PM, he stated it was his expectation staff followed all of the facility's policies to keep residents safe. During a telephone interview with the Medical Director on 09/10/2024 at 4:05 PM, he stated it was his expectation staff followed all of the facility's policies and procedures related to all resident care. He stated it was important for the safety and well-being of the residents.

Based on observation, interview, record review, and review of the facility's policies and review of the contracted company's policies and documents it was determined the facility failed to store food in the residents' refrigerator in a safe and sanitary manner. This affected 25 of 96 current residents. Observation of [NAME] Unit's resident food freezer on [DATE] revealed there was no thermometer in the freezer. An unfrozen ice gel pack was observed in the freezer. Additionally, multiple frozen food boxes were stored inside grocery bags, and were unlabeled and undated. The boxes of food were not frozen solid. The freezer compartment floor was dirty with melted liquid, packaging debris, dirt, food particles, and hair. The findings include: Review of the Federal Food and Drug Administration's (FDA) document titled, Safe Food Handling, current as of [DATE], revealed the freezer operating temperature should be zero degrees Fahrenheit (F). Frozen food should be frozen solid. Staff should reject if fluids or water stains appeared in the bottom of the freezer or on packaging; or if there was ice crystals or frozen liquids on the food or the packaging. Review of the Dietary Service Agreement, between the facility and the contracted service provider (CSP), dated [DATE], revealed the Registered Dietitian (RD) shall inspect all areas of the dietary department. Additionally, the RD was responsible to provide guidance and training to the Dietary Manager and dietary staff as required. Review of the CSP's Job Description titled, Dining Services Director/Account Manager, not dated, revealed the Dining Services Director was responsible for food safety and would ensure that established sanitation and safety standards were maintained. Review of the [NAME] Unit's nourishment refrigerator and freezer temperature logs on [DATE] at 11:37 AM, revealed the freezer temperature was recorded as four degrees Fahrenheit (F) on [DATE]. Staff previously logged temperatures of two degrees F on [DATE], six degrees F on [DATE], and three degrees F on [DATE]. On [DATE] at 11:45 AM, [DATE] at 9:57 AM, [DATE] at 1:56 PM, and [DATE] at 10:15 AM, State Survey Agency (SSA) surveyor requested documentation for ,d+[DATE], ,d+[DATE], and ,d+[DATE] of the nourishment refrigerator/freezer temperature logs. The facility did not provide the requested documentation. On [DATE] at 9:57 AM, [DATE] at 1:56 PM, and [DATE] at 10:15 AM, the SSA surveyor requested a Resident Food/Nourishment Storage policy. The facility did not provide the requested documentation. Observation of the [NAME] Unit's resident nourishment freezer on [DATE] at 11:37 AM, revealed the freezer unit felt warm and it was noted that there was no thermometer in the freezer. The recorded temperature on the facility's Temperature Log, dated [DATE] was four degrees F. Staff previously logged temperatures of two degrees F on [DATE], six degrees F on [DATE], and three degrees F on [DATE]. An unfrozen ice gel pack was observed in the freezer. Additionally, multiple frozen food boxes stored inside grocery bags were unlabeled and undated. The freezer compartment floor was noted to have melted liquid, packaging debris, dirt, food particles, and hair. During an interview with the Interim Director of Nursing (IDON) on [DATE] at 12:01 PM, she stated the night shift nurses monitored the nourishment refrigerator/freezer and documented the temperature on the posted Temperature Log. She stated everyone was responsible to ensure that the refrigerator and freezer were kept clean and sanitary and ensured food was stored according to policy. She stated the nourishment refrigerator/freezer was used for residents only and no staff food should be stored with resident food. Additionally, the IDON stated that all residents' food should be labeled and dated. During an interview with LPN7/Unit Manager (UM) on [DATE] at 9:57 AM, she stated that the refrigerator and freezer temperatures were taken daily on the night shift. She stated the freezer should be at zero degrees F or below. During an interview with Licensed Practical Nurse (LPN) 11 on [DATE] at 3:12 PM, she stated it was everyone's responsibility to check expiration dates, log refrigerator and freezer temperatures, and keep the nourishment refrigerator clean. LPN11 stated there was no set cleaning schedule, but the night shift clinical staff, the UM, and the dietary staff cleaned it weekly. The LPN stated the freezer should be at 32 degrees F. During an interview with Registered Nurse (RN) 3 on [DATE] at 3:12 PM, she stated it was everyone's responsibility to check expiration dates, log refrigerator and freezer temperatures, and keep the nourishment refrigerator clean. RN3 stated there was no set cleaning schedule, but the night shift clinical staff, the UM, and the dietary staff cleaned it weekly. RN3 stated the freezer should be at 32 degrees F. During an interview with the Dining Services Director (DSD) on [DATE] at 2:20 PM, he stated dietary staff stocked the nourishment refrigerator daily with snacks and ordered supplements. He stated stock was rotated. He stated that if staff saw that the nourishment refrigerator was not working properly, it would be his expectation that they notified the UM or himself. During a continued interview with the DSD on [DATE] at 3:55 PM, he stated that it was everyone's responsibility to ensure the cleanliness of the nourishment refrigerator, check the temperature of both the refrigerator and freezer, and monitor food expiration dates. He stated that the nursing staff was in charge of recording temperatures on the daily temperature log and that he followed the CDC's food storage guidelines. The DSD also stated the residents' nourishment freezer should be maintained below 32 degrees F. The DSD stated storing residents' food according to food safety guidelines was important for the safety of the residents and to prevent food-borne illness. During a telephone interview with the RD on [DATE] at 11:52 AM, she stated she was currently covering for someone on leave. The RD stated the CSP provided dietary services, including RD clinical services. She stated the CSP followed a policy and procedure manual, but there were occasions when there were policies not included in their manual. In such cases, the RD stated she referred to the facility's specific policy. She stated the dietary staff was responsible for stocking the refrigerators to ensure there were nutritional supplements for the residents. She stated the dietary staff was also responsible for disposing of anything not related to residents, such as staff items. During continued interview the RD on [DATE] at 11:52 AM, she stated, I believe it's the nursing staff that is responsible for keeping the refrigerators cold. The RD stated it was a team effort. She stated that whoever was going in to stock the refrigerator and clean it should be responsible for checking to ensure the temperature was within acceptable parameters. The RD stated it was her expectation that everything in the residents' nourishment refrigerator and freezer should be labeled. She stated for proper storage the freezer temperature should remain at zero degrees F or colder for the safety of the residents and to prevent any food-borne illness. During an interview with the Interim Director of Nursing on [DATE] at 11:48 AM, she stated it was everyone's responsibility to check the refrigerator freezer. She stated the ambassadors continually check their areas in the facility, including the residents' nourishment refrigerator freezer. She stated that everyone was responsible for ensuring the residents' food was dated and not expired. Additionally, she stated that it was everyone's responsibility to ensure that it was clean and that the daily temperatures were logged. The DON state the freezer should be 32 degrees F or below. During a telephone interview with the Chief Executive Officer (CEO) on [DATE] at 2:32 PM, he stated it was his expectation that all staff follow the facility's policy and procedures to ensure the safety of both residents and staff. During a telephone interview with the Medical Director on [DATE] at 4:05 PM, he stated it was his expectation staff followed all the facility's policies and procedures related to all resident care. He stated it was important for the safety and well-being of the residents.

Based on observation, interview, record review, and review of the facility's policies, the Centers for Medicare and Medicaid Services (CMS), and the Centers for Disease Control and Prevention (CDC) guidelines, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases affecting five of 96 Residents (Resident 5 (R5), R17, R18, R21, R23). Observation on 09/04/2024 revealed the doors to two droplet precaution isolation rooms, rooms [ROOM NUMBERS], remained open. The trash can inside R17 and R18's room, was overflowing with contaminated personal protective equipment (PPE). An opened bag of hand sanitizer gel was found on top of two boxes of opened gloves on the PPE cart located outside of R23's room, Observation on 09/06/2024 revealed Licensed Practical Nurse (LPN) 2 failed to clean shared vital sign equipment after use on R19's and failed to don (put on) appropriate PPE when entering R30's room, an enhanced-barrier precaution (EBP) room. Observation on 09/06/2024 revealed CNA5 and Unit Manager (UM) 1 failed to don (put on) appropriate PPE when entering R21's room, an EBP room, and failed to properly handle contaminated linen. Observation on 09/09/2024 revealed Registered Nurse (RN) 1 failed to perform hand hygiene after removing contaminated gloves, and before donning a clean pair of gloves. The findings include: Review of the CDC's Guidelines Clinical Safety: Hand Hygiene for Healthcare Workers, dated 02/27/2024, revealed hand hygiene should be used immediately before touching a patient, after touching a patient or patient's surroundings, and immediately after glove removal. Review of the CDC's signage titled, Special Droplet/Contact Precautions, revised 03/09/2020, revealed the door to the isolation room must remain closed. Review of the facility's policy, Infection Control, dated 01/23/2024, revealed the policy's purpose was to maintain a safe, sanitary, and comfortable environment and help prevent and manage transmission of diseases and infections. According to the policy, staff would prevent infections and implement isolation precautions, including standard and transmission-based precautions and provide for the safe cleaning and reprocessing of resident care equipment. Review of the facility's policy, Transmission-Based Precautions (TBP), dated 09/15/2023, revealed TBPs were initiated when a resident developed signs and symptoms of a transmissible infection. Transmission-based precautions may include contact precautions, droplet precautions, or airborne precautions. According to the policy, TBPs signage informs the staff of the CDC precautions and the instructions for use of PPE. PPE (i.e., gloves, gowns, and masks) were maintained outside the resident's room so that anyone entering the room could apply the appropriate equipment. Review of the facility's policy, Enhanced-Barrier Precautions, dated 09/15/2023, revealed the policy's purpose was to maintain a safe, sanitary, and comfortable environment and help prevent and manage transmission of diseases and infections. Signage was placed at the room entrance to inform staff of the need for and the type of precaution(s) Additionally, the signage informed the staff of instructions for use of PPE. Review of the facility's policy, Infection Control Disinfection of Non-Critical Patient Care Equipment, dated 01/23/2024, revealed the purpose of the policy was to maintain a safe sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. According to the policy noninvasive, non-critical portable clinical items shared among residents were part of the patient's immediate surroundings and may pose a threat of pathogen transmission. Routine cleaning disinfection should occur for non-critical patient care devices at a minimum when visibly soiled and on a regular basis between patients with an Environmental Protection Agency (EPA) registered hospital disinfectant. The facility did not provide a Hand Hygiene Policy. 1) Observation of the Blue Unit on 09/04/2024 at 8:55 AM, revealed an empty PPE cart outside R17's and R18's room. There were two boxes of opened gloves on top of the cart, with a computer and its cord also placed on top of the gloves. Additionally, the door to the room, which was a droplet isolation room, was open. The trash can inside the room was overflowing with contaminated PPE. Further observation revealed two opened boxes of gloves on top of the PPE cart outside of R23's room. Additional observation of R23's room revealed an open hand sanitizer bag on top of the gloves. Continued observation revealed that the door to R5's room, a droplet isolation room, was open. During an interview with CNA4 on 09/06/2024 at 10:35 AM, she stated she received training upon hire and throughout the year on infection control. CNA4 stated signs on the door indicated the type of PPE required to enter the room. She stated the doors to droplet/contact precaution rooms must remain closed. She could not say why the doors were left open. In addition, CNA4 stated staff were responsible for emptying the trash when it was full and taking it to the soiled utility room. Continued interview revealed staff should store PPE inside individual PPE carts located outside of each TBP room. She stated following infection control policies and keeping trash emptied and doors closed were important to prevent the spread of disease between residents and staff. During an interview with CNA3 on 09/06/2024 at 11:22 AM, she stated she received infection control training, including types of TBPs and using PPE. She stated that signs on the door indicated the type of isolation and the PPE required to enter the room. She stated the doors to droplet/contact precaution rooms should be kept closed if the resident was in the room. Continued interview revealed staff were responsible for emptying trash and bagging contaminated linen before leaving the room. She stated staff take linen and trash to the soil utility room. In addition, CNA3 stated PPE should be stored inside the PPE carts located outside rooms under TBP. She stated following facility policy, and ensuring doors to TBP rooms were closed was important to prevent cross-contamination and the spread of infection to residents. During an interview with CNA2 on 09/06/2024 at 1:15 AM, she stated doors to droplet isolation rooms must remain closed and that staff must put on PPE according to the signage before entering a TBP room. CNA2 stated before exiting the room staff should remove and dispose of the PPE in the trash. CNA2 stated PPE should be stored inside the PPE carts located outside of each TBP room. She stated following facility policy was important to prevent infections. 2) Observation of the Blue Unit on the 400 Hall on 09/06/2024 at 8:55 AM, revealed CNA6 exited R17's and R18's room, a droplet precaution isolation room, and did not doff her N95 respirator mask. During an interview with CNA6 on 09/06/2024 at 8:55 AM, she stated another staff member, whose name she could not recall, informed her that she was required to wear a N-95 respirator while in a droplet precaution room. However, she stated she was unaware she needed to remove the respirator after leaving the room. CNA6 stated she received infection control training, including information on types of TBPs and proper use of PPE when she was hired. CNA6 emphasized the importance of disposing contaminated PPE before leaving a room to prevent the spread of infection. 3) On 09/06/2024 at 9:05 AM, during an observation of the Blue Unit on the 200 Hall, LPN2 was observed performing a vital sign assessment and administering medications to R19. LPN2 brought the portable vital sign machine from room [ROOM NUMBER] across the hall to plug it into an electrical outlet. After using the machine LPN2 did not clean and disinfect it. Continued observation revealed LPN2 then entered R30's room, an EBP room, without donning PPE and used a portable wrist blood pressure (BP) cuff to take a blood pressure on R30. LPN2 placed the cuff on the medication cart without cleaning and disinfecting it. During an interview with LPN2 on 09/06/2024 at 9:17 AM, he stated he should have worn PPE in the EBP room. He did not provide an explanation for not following the facility's policy. LPN2 stated he received infection control training, including information on types of TBPs and proper use of PPE, when he was hired. Additionally, LPN2 stated signs were posted on the doors to EBP and TBP rooms to guide the staff and indicate the type of isolation and the PPE required to enter the room. LPN2 stated it was important to follow the signs posted on the door and follow the facility's policy to clean and disinfect shared equipment before and after use to prevent cross contamination and this spread of disease. 4) On 09/06/2024 at 9:20 AM, during an observation of the Blue Unit on the 200 Hall, CNA5 and Unit Manager (UM) 1 were observed providing direct care to R21, who was under EBPs. Both UM1 and CNA5 were wearing gloves, but they did not wear all of the appropriate PPE when repositioning R21 and changing his bed linens. Continued observation revealed R21's television remote fell on the floor. CNA5 picked up the remote but did not clean and disinfect it before putting it back on the bed. Additionally, CNA5 threw soiled linen on the floor. Neither the UM nor CNA bagged the contaminated linen before leaving the room. During an interview with CNA5 on 09/06/2024 at 9:28 AM, she stated this was her first day on the floor, and she was still getting used to the workflow. CNA5 stated she received infection control training, including information on types of TBPs and proper use of PPE when she was hired. She also noted that signs on the door indicated the type of isolation and the PPE required to enter the room. CNA5 stated she forgot to take the linen out of the room. She stated it was important to follow infection control policy, so residents 'do not catch diseases. During an interview with UM1 on 09/06/2024 at 9:28 AM, she stated she only needed a gown in an EBP room if she provided direct care to the resident. She stated full PPE was only required when staff provided direct care to a resident. UM1 stated that staff must wear a gown and gloves during high-contact resident care, such as bathing, device care, and wound care. Additionally, UM1 stated she did not stop to educate CNA5 about throwing contaminated linen on the floor because she did not want to do it in front of the SSA surveyor. She stated it was important to place contaminated linen in a plastic bag and not throw it on the floor to prevent the spread of infection. 5) During an observation of the Blue Unit on the 400 Hall on 09/09/2024 at 11:15 AM, Registered Nurse (RN) 1 was observed in the hallway removing her gloves. RN1 did not perform hand hygiene after doffing the gloves. The RN then took a new pair of gloves from the medication cart located in the hallway and did not perform hand hygiene before donning the new gloves. During an interview with RN1 on 09/09/2024 at 11:15 AM, she stated she should not have worn gloves in the hall. Furthermore, she stated she should have performed hand hygiene after removing her gloves and before donning a new pair. Per the interview, RN1 stated hand hygiene should be immediately before touching a patient, after touching a patient or patient's surroundings, and immediately after glove removal. She stated she received infection control training, including information on hand hygiene, types of TBPs, and the proper use of PPE when she was hired. She stated further it was important to follow infection control guidelines to prevent the spread of infection and keep residents safe. During an interview with the Infection Prevention/Staff Development Coordinator (IP/SDC) on 09/06/2024 at 1:35 PM, she emphasized the importance of following infection prevention and control procedures (IPCP). The IP/SDC stated it was important to keep room doors closed if the resident was on droplet precautions to prevent the spread of infectious droplets outside the room. She stated it was the responsibility of staff to empty trash when full. She stated staff know to doff PPE inside the resident's room. The IP/SDC stated it was never appropriate to doff PPE in the hallway. Per the interview, staff were to bag contaminated PPE and linen and place it in hampers in the dirty utility room. She stated that in an EBP room, staff do not need PPE if they do not anticipate contact with the resident or their belongings; however, staff must don PPE for direct care or if they touch the resident's belongings. Furthermore, the IP/SDC stated she expected staff to perform hand hygiene with alcohol-based hand rub (ABHR), or soap and water, before and after each resident's care. She stated that all staff were to use gel when going in and out of rooms. According to the IP/SDC, staff must hand sanitize before and after donning and doffing of all PPE. In addition, all shared medical equipment, such as the rolling vital sign machine and BP cuffs, should be sanitized between each resident use with Clorox Bleach Wipes. She stated it was important to prevent contamination of clean supplies and stop the spread of infection. During continued interview, the IP/SDC stated the facility followed its policies and CDC guidelines and that it was essential to adhere to policies and procedures to prevent the spread of infection, especially to residents at risk of infection or rehospitalization . The IP/SDC stated nurse leadership, including the DON, ADON, and the Unit Managers (UM), were well-trained in infection prevention and control practices. She stated they usually do monthly in-service with ongoing education related to hand hygiene, CDC guidelines, and personal protective equipment. She stated they do not formally audit staff, but if she saw a breach in infection control, she stopped and educated staff on the spot. The IP/SDC stated it was her expectation that staff knew what type of isolation precaution the resident was in and keep up with daily changes. During interview with the Interim Director of Nursing (IDON) on 09/20/2024 at 9:15 AM, she stated staff received training on infection control upon hire. She stated the IP/SDC and nursing leadership monitored staff for infection control compliance. Further interview revealed the purpose of cleaning and sanitizing shared equipment, proper hand hygiene, and correct use of PPE was to decrease the risk of transmission of infection. The IDON stated it was her expectation all staff followed the facility's policy and procedures related to ICP. During an interview with the Administrator on 09/17/2024 at 2:32 PM, he stated it was his expectation staff followed all the facility's policies to keep residents safe. During a telephone interview with the Medical Director on 09/10/2024 at 4:05 PM, he stated it was his expectation staff followed all the facility's policies and procedures related to all resident care. He stated it was important for the safety and well-being of the residents.

Based on observation, interview, record review, review of the facility's fact sheet Preventing the Spread of Bloodborne Pathogens, review of the facility's online education course outline, Bloodborne Pathogens and the Use of Standard Precautions, review of Assure Platinum Blood Glucose Monitoring System Cleaning and Disinfecting QA/QC Reference Manual, Microdot (brand) bleach wipes manufacturer's instructions, Cleaning and Disinfecting Recommendations,'; review of the facility's internal resource Common Infections, PPE & Isolation Guidelines,; review of the CDC's Enhanced Barrier Precaution (EBP) door signage, and review of the facility's policies, it was determined the facility failed to implement recommended interventions for the cleaning and disinfecting of a shared glucometer (glucose monitoring device), according to manufacturer's instructions. This affected two (2) of seventy-one (71) sampled residents (Residents #325 and #327). The facility had twenty-six (26) residents that required glucose monitoring. Observation on 01/22/2024 of Licensed Practical Nurse (LPN) #1, performing a blood glucose fingerstick using a shared glucometer between Residents #325 and #327 revealed the LPN failed to clean and disinfect the glucometer per the manufacturers' instructions between resident use. In addition, LPN #1 failed to perform hand hygiene between the residents. Further observation on 01/25/2024 of LPN #4 cleaning and disinfecting the glucometer after use on Resident #332 revealed LPN #4 did not use barriers for the machine, failed to disinfect it correctly, and failed to place it in its disinfection case for storage. The facility's failure to have an effective system in place to ensure residents had blood glucose fingersticks performed using a clean and disinfected glucometer has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/24/2024 and was determined to exist on 01/22/2024 in the area of 42 CFR 483.80 Infection Control at a Scope and Severity (S/S) of a J. The facility was notified of the Immediate Jeopardy (IJ) on 01/24/2024. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 01/26/2024 alleging removal of the IJ on 01/27/2024. The State Survey Agency (SSA) determined the removal of the IJ as alleged before exit on 01/28/2024, which lowered the S/S to an E while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Furthermore, the facility failed to follow its infection prevention and control policies and procedures regarding the handling of linens to prevent the spread of infection, and failed to disinfect a shared lift. The findings include: Review of the facility's policy titled, Infection Control, revised 10/2018, revealed the facility established guidelines for implementing isolation precautions, including standard and transmission-based precautions, and to provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment. Continued review of the policy revealed that all personnel would be trained on infection control policies and practices upon hire and periodically thereafter. Per the policy, the quality assurance and performance improvement (QAPI) committee and the infection control committee were responsible to review and revise the facility's Infection Prevention and Control Program (IPCP) and to assist department heads and managers to ensure that infection control policies and practices were implemented and followed. Review of the facility's policy titled, Glucometer Cleaning and Disinfecting, revised 01/24/2024, revealed the purpose of cleaning glucometers was to minimize the risk of transmitting bloodborne pathogens. The review revealed cleaning and disinfection procedures should be performed to clean dirt, blood, and other bodily fluids off the exterior of the glucometer before performing the disinfectant procedure. Furthermore, the policy stated all licensed staff would follow the manufacturer's guidelines and recommendations for cleaning and disinfecting of the glucometer. Review of the Assure Platinum Blood Glucose Monitoring System Cleaning and Disinfecting QA/QC Reference Manual, revised 12/2014, revealed the blood glucose meters needed to be cleaned and disinfected after each use. The manual stated cleaning and disinfecting was accomplished according to the manufacturer's guidelines with an Environmental Protection Agency (EPA) registered disinfectant or germicide that was approved for a health care setting. Per the manual, Microdot (brand) bleach wipes were approved for use with the Assure Platinum (brand) glucometer. Review of the Microdot bleach wipes instructions, Cleaning and Disinfecting Recommendations, no date, revealed to thoroughly clean the glucometer surface; wrap the glucometer with a bleach wipe, covering all surfaces of the glucometer; and place the wrapped glucometer face down inside the disinfection case. The instructions continued, with the lid closed, activate a timer for three (3) minutes to allow the glucometer to remain in contact with the bleach wipes. Review of the facility's policy titled, Transmission Based Precautions, dated 09/15/2023, revealed transmission-based precautions (TBP) included contact precautions, droplet precautions, and airborne precautions. The policy stated TBP were initiated when a resident developed signs and symptoms of a transmissible infection or had a laboratory confirmed infection and was at risk for transmitting the infection to other residents. 1. Review of the facility's Glucose Monitoring list, dated 01/23/2024, revealed the list contained twenty-four (24) residents, including Residents #325 and #327. Review of the facility's Glucose Monitoring list, dated 01/24/2024, revealed the list contained twenty-six (26) residents, including Resident #325 and #327. Continuous observation, on 01/22/2024 at 6:22 PM, of Licensed Practical Nurse (LPN) #1, while performing a pre-meal blood glucose test revealed LPN #1 entered Resident #325's room holding a blue plastic basket with Resident #325's insulin pen, a bottle of glucose testing strips, unwrapped gauze, unused lancets, alcohol wipes, and band aids. The LPN performed a blood sugar finger stick on Resident #325. LPN #1 exited the room without performing hand hygiene (HH). She was carrying the shared glucometer inside the basket on top of the other supplies. LPN #1 failed to clean the glucometer used on Resident #325. LPN #1 then walked into Resident #327's room with the basket of supplies and the contaminated glucometer and performed a blood sugar finger stick on the resident. She did not perform HH prior to entering the room. LPN #1 then exited the room with the glucometer inside the basket. She did not clean the glucometer prior to exiting Resident #327's room nor did she perform HH upon exit. In an interview with LPN #1 on 01/22/2024 at 6:30 PM, she stated she cleaned the glucometer after each use. She stated she had just used a bleach wipe which was located on her medication cart. The State Survey Agency (SSA) Surveyor asked LPN #1 to demonstrate how she cleaned the glucometer. LPN #1 placed the contaminated glucometer in the top drawer of the medication cart without a barrier. LPN #1 stated, I used these. She then opened the bottom drawer of the medication cart and took out a container of Microdot bleach wipes. LPN #1 stated she tried to pull a wipe out of the container but realized the container had never been opened and was still factory sealed. The LPN then stated, I didn't clean it [the glucometer] between sticks. I'm not going to lie to you. When asked about the cleaning process of the glucometer, LPN #1 stated it should be cleaned after every use and left wet for five (5) minutes. In continued interview with LPN #1 on 01/22/2024 at 6:30 PM, she stated the shared glucometer should be stored in a plastic container after cleaning. Although she pointed to a blue plastic lid, she was unable to find the bottom part of the container. Observation, at the time of the interview, revealed there was a blue lid on the medication cart, but no disinfection container was available. Furthermore, when interviewed about placing the contaminated glucometer and Resident #325's insulin pen on top of unused clean lancets and the blood glucose monitoring strips, she stated that was how she carried her supplies from room to room. LPN #1 stated she did not consider placing contaminated equipment on clean supplies was an infection control breach. The LPN stated, Nothing touched a resident. She stated she received IPCP training upon hire and annually. When interviewed related to the significance of cleaning and disinfecting multi-use equipment and performing HH before and after direct resident care, LPN #1 explained that those actions helped to prevent the spread of infection. In an interview with Registered Nurse (RN) #1 on 01/23/2024 at 10:02 AM, she stated her practice for cleaning shared glucometers was to wipe them down with an alcohol wipe after each use. She further stated she cleaned the glucometer at the beginning of her shift with a bleach wipe. Per the interview, the facility trained her to clean the glucometers but did not specify which wipe to use. In an interview with the Director of Nursing/Infection Preventionist (DON/IP) and the Minimum Data Set/Infection Preventionist (MDS/IP) Nurse on 01/23/2024 at 1:27 PM, they stated all staff members were trained on IPCP. The DON/IP stated the facility followed state and federal guidelines to prevent the spread of infection. The DON/IP stated the facility did not have a specific policy addressing shared equipment, and clinical staff members were trained to clean multiuse or shared equipment, including vital sign equipment, glucometers, and Hoyer lifts (brand of mechanical lift) after each use. The DON/IP stated, Everyone who is clinical receives this on hire. She stated it was her expectation for staff using shared and multi-use equipment to clean and disinfect the equipment after each use with a bleach wipe and to wait for the appropriate time. The DON/IP further stated clinical staff members were aware of kill times, and they were posted on the bleach wipe container. During the interview the DON/IP stated, We use an alcohol swab to clean bleach residue off the glucometer and use a bleach wipe first for proper kill time. I'd have to refer to the container for kill time, but I believe it's two (2) or three (3) minutes. The DON/IP stated that she and the unit managers continually perform visual audits and on the spot education. However, she stated, We don't keep paper records of those audits. Both the DON/IP and the MDS/IP Nurse stated following IPCP guidelines were important to prevent the spread of infectious material. Observation with the DON, on 01/24/2024 at 8:55 AM, revealed there were currently twelve (12) shared glucometers being used throughout the facility, and all should be kept on the medication carts. Further observation revealed seven (7) of the eight (8) medication carts had glucometers, with two (2) on the 100 Hall; one (1) on the 200 Hall; one (1) on the 400 Hall; one (1) on the 500 Hall; two (2) on the 600 Hall; two (2) on the 700 Hall; and one (2) on the 800 Hall. One (1) glucometer was found on the 300 Hall treatment cart. The 300 Hall glucometer was stored in a blue plastic tray with unwrapped gauze, band aids, lancets, alcohol wipes, and packaged needles. In additional interview with the DON/IP on 01/24/2024 at 9:15 AM, she stated to prevent cross contamination, shared glucometers should not be stored inside the plastic basket along with other supplies on the medication cart. She stated they should be placed in a container with a lid after cleaning and disinfecting per manufacturer's instructions. When asked who was responsible for ensuring IPCP compliance and addressing breakdowns related to infection control, the DON stated that unit managers and nurse leadership perform weekly audits of the medication carts and daily visual rounds of clinical staff performing direct care to ensure compliance with IPCP. The DON/IP stated of the residents who received glucose monitoring, one (1) resident had a bloodborne pathogen. She stated Resident #329 had a diagnosis of HIV. Additionally, she stated Resident #329 had a diagnosis of diabetes and received insulin and blood glucose monitoring before meals. Review of Resident #329's Face Sheet revealed the facility admitted the resident on 01/17/2024 with diagnoses to include human immunodeficiency virus (HIV) disease, type 2 diabetes mellitus, and history of urinary tract infections. Resident #329 was on the Glucose Monitoring list. Review of Resident #331's Face Sheet revealed the facility admitted the resident on 01/12/2024 with diagnoses to include type 2 diabetes mellitus and acute and chronic hepatitis B (HBV). Resident #331 was on the Glucose Monitoring list. Observation on 01/25/2024 at 3:45 PM during quality monitoring, by a Regional Care Consultant Nurse, of Licensed Practical Nurse (LPN) #4 performing a blood glucose fingerstick on Resident #332, revealed LPN #4 retrieved the glucometer from the top drawer of the medication cart. The glucometer was resting on top of an open roll of bandage tape along with a pair of bandage scissors. It was in close contact with various items in the drawer. LPN #4 placed the glucometer on the medication cart without using a barrier sheet, and then collected the necessary supplies in a plastic cup. LPN #4 proceeded to the resident's bedside and put the supplies on the bedside table. The blood glucose fingerstick was performed, and immediately after the procedure, the LPN placed the contaminated glucometer, with the test strip still engaged on top of the resident's bedside table without using a barrier. LPN #4 then moved to the resident's sink and placed the glucometer on a barrier. The LPN removed the Microdot bleach wipe container from the cart and placed it on the resident's sink without using a barrier. The LPN gloved and cleaned the glucometer. The glucometer was then wrapped with bleach wipes; however, LPN #4 did not cover all four (4) sides, and it was placed on top of the medication cart using a barrier instead of being put in the disinfectant case as per manufacturer's instructions. In an interview with LPN #4 on 01/25/2024 at 3:45 PM, he stated that all clinical staff had received training to include written instruction and a test regarding how to clean and disinfect glucometers. However, he stated he did not receive a live demonstration and was not asked to demonstrate proper technique back. 2. Observation on 01/23/2024 at 3:10 PM, revealed a dirty towel on the floor in the 400 Hall outside of room [ROOM NUMBER]. The towel remained on the floor for five (5) minutes while multiple staff members walked past it. When the DON noticed the towel, she picked up the towel and placed it in a plastic bag, which she then put in the soiled utility room. Observation, on 01/23/2024 at 5:30 PM, revealed a dirty sheet lying in the entrance of room [ROOM NUMBER], which extended to the hallway of the 700 Hall. In an interview with the Director of Housekeeping on 01/24/2024 at 5:00 PM, the Director stated linen should never be thrown on the floor or other surfaces in the room or in the hallway. The Director stated linen should be bagged and taken to the dirty utility promptly. Observation on 01/25/2024 at 8:30 AM, revealed Certified Nursing Assistant (CNA) #14 walking down the 800 Hall holding clean linens against her uniform. In an interview with CNA #14 she stated she had been trained on IPCP policies. She stated linen should be held away from the body to prevent the spread of germs. In an interview with the MDS/IP Nurse on 01/24/2024 at 8:35 AM, she stated staff should not hold linen up against their clothing. She stated linen should be held away from the body to prevent cross contamination. She stated when she saw staff members failing to follow IPCP policies she would stop and educate them on the spot. 3. Observations on 01/22/2024 at 3:38 PM and on 01/23/2024 at 3:27 PM revealed the sit-to-stand lift in the 400 Hall was visibly soiled with a brown substance streaked on the foot pad and bottom bar of the lift. In an interview on 01/23/2024 at 3:27 PM, the Director of Nursing (DON) stated the lifts should be cleaned after every use and when visibly soiled. She further stated she would clean the lift and re-educate staff. In an interview with the Regional Care Consultant (RCC) Nurse on 01/28/2024 at 5:32 PM, she stated that all staff should follow IPCP to prevent the spread of infection in the facility. In an interview with the Director of Regulatory on 01/28/2024 at 2:45 PM, she stated the role of the Director of Regulatory was to assist the facility and train the nursing leadership and staff. Additionally, she stated regional nurses were assigned to help the DON by providing resources. The Director of Regulatory emphasized that all staff members should follow the facility's IPCP. She also mentioned that the facility followed state and federal guidelines, and if CMS required something to be followed, the facility should comply with the requirements. She stated it was important to prevent the spread of infection. During an interview with the Administrator on 01/28/2024 at 5:05 PM, the Administrator stated it was her expectation for the staff to follow the facility's IPCP, which included current standards, policies, and procedures based on state and federal regulations. She stated the QAPI committee reviewed policies annually. When asked if following current guidelines was important to provide a safe environment and to help prevent the spread of infections, she stated, Yes. She reported nurse leadership ensured quality assurance and compliance with IPCP through a triple check system that included daily visual rounds at the bedside and of clinical staff performing direct care. She added that although daily rounding by nurse leadership was not documented, issues were resolved through a root cause analysis of the failure. According to the Administrator, the root cause of the staff's failure to clean the glucometers was that staff did not understand the education. She further emphasized that the facility followed state and federal regulations, including the state health department recommendation. She stated all staff should follow IPCP to prevent the spread of infection in the facility. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 01/26/2024, alleging removal of the IJ on 01/27/2024. Review of the IJ Removal Plan revealed the facility implemented the following: 1. Residents #325 and #327 were assessed by a licensed nurse on 01/24/2024 using a Risk for Infection Assessment, in which each resident was assessed for any signs and symptoms of infections. A full set of vital signs was included in the assessment. Residents #325 and #327's physician and responsible parties were notified of the potential for bloodborne pathogen exposure on 01/24/2024 by a licensed nurse. Glucometer Cleaning and Disinfecting Policy was revised on 01/24/2024 by the Governing Body, which included the [NAME] President (VP) of Regulatory, VP of Clinical Operations, VP of Operations, and the VP of Clinical Reimbursement. LPN #1 was educated by the Chief Nursing Officer (CNO) on 01/24/2024 on Preventing the Spread of Bloodborne Pathogens. 2. On 01/24/2024 all twenty-six (26) residents receiving accu-checks (blood glucose monitoring) were assessed by a licensed nurse to ensure there were no signs and symptoms related to bloodborne pathogen exposure. In addition, on 01/24/2024, all residents receiving accu-checks and/or the residents' representatives and physicians were notified of the potential bloodborne pathogen exposure. Each was offered lab testing related to the potential bloodborne pathogen exposure. This was completed by licensed nurses. On 01/24/2024, physician's orders were obtained for twenty-five (25) of the twenty-six (26) residents and/or resident representatives who requested lab testing completed. A hepatitis (HEP) and human immunodeficiency virus (HIV) exposure panel was obtained on 01/26/2024 for twenty-three (23) of the twenty-six (26) residents. One (1) resident refused labs, one (1) resident was transferred to the hospital on 01/25/2024, and one (1) resident was discharged home on 01/25/2024 prior to the lab being drawn. An at Risk for Infection care plan was implemented and completed on 01/24/2024 for each of the twenty-six (26) residents. Testing was offered and he/she is expected to return to the facility. Resident #325 refused and then was admitted to the hospital. Resident #325 was offered and refused, wishing to have it done at his/her PCP. 3. Education by the Regional Care Consultant (RCC) Nurse, Director of Regulatory, and the Vice-President (VP) of Clinical Operations on the Glucometer Cleaning and Disinfecting process per the manufacturers' guidelines and on bloodborne pathogens was provided to the Director of Nursing (DON), Minimum Data Set (MDS) Nurses, and licensed nurses on 01/24/2024. A posttest was given requiring a minimum score of one hundred percent (100%). Those who did not receive a score of one hundred percent (100%) were reeducated and tested again, until a score of one hundred percent (100%) was achieved. Any nurse not receiving education by 01/24/2024 would be provided with the education prior to working their next shift. Due to a breach in infection control practices observed on 01/24/2024 during observation of an accu-check being performed, all licensed nursing staff were immediately reeducated. The RCC Nurse, Director of Regulatory, and the VP of Clinical Operations revised the education to include the required steps of completing an accu-check per the manufacturers' guidelines and on the cleaning and disinfection process of the glucometer per manufacturers' guidelines. The revised reeducation was done on 01/25/2024 and required a competency review with a return demonstration. This was repeated until each licensed nurse on the day and evening shifts passed the competency return demonstration with one hundred percent (100%) accuracy. The RCC Nurse arrived at the facility prior to the day shift on 01/26/2024 so that any licensed nurses that had not been educated and were scheduled to work were reeducated prior to working their shift. Any licensed nurse not receiving reeducation by 01/26/2024 would not work until they had completed reeducation and passed the competency return demonstration. All new licensed nurses or agency nurses would be educated by a member of nursing management during orientation prior to providing resident care. Starting 01/25/2024, the DON, Assistant DON, Unit Managers, MDS Nurse, or Regional Nurses would observe ten (10) accu-checks weekly for four (4) weeks, being performed with the cleaning and disinfecting process after the accu-check had been performed. 4. An ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held on 01/24/2024 with the Medical Director and the QAPI Team Members, which included the DON, Administrator, and the Administrator in Training. The QAPI Committee would meet daily for seven (7) consecutive days, starting on 01/25/2024, then weekly for four (4) weeks, then monthly thereafter for recommendations and further follow up regarding the plan of correction. Audit documentation would be submitted to the QAPI Committee for review and to ensure compliance. The Administrator was responsible for the oversight of the removal plan to ensure ongoing compliance. The State Survey Agency validated implementation of the facility's IJ Removal Plan as follows: 1. Review of the Risk for Infection Assessments dated 01/24/2024 confirmed Residents #325 and #327 were assessed by the DON and each resident was assessed for any signs and symptoms of infections. A full set of vital signs was included in the assessment. Review of the Risk for Infection Assessments dated 01/24/2024 confirmed Residents #325 and #327's physician and responsible parties were notified by the Director of Nursing (DON) of the potential for bloodborne pathogen exposure on 01/24/2024. Review of the revised Glucometer Cleaning and Disinfecting Policy, dated 01/24/2024, revealed it included the addition of 1) licensed staff would follow the manufacturer's guidelines and recommendations for the cleaning and disinfecting of the glucose monitors; and 2) the staff would receive education on cleaning and disinfecting the glucose monitors per the manufacturer's guidelines upon hire and as needed. Review of signed documentation related to LPN #1's reeducation by the Chief Nursing Officer (CNO), dated 01/24/2024, indicated LPN #1 was educated on the Glucometer Cleaning and Disinfecting Policy, the Infection Control Policy, and Preventing the Spread of Bloodborne Pathogens education module by the American Red Cross. 2. Review of the Risk for Infection Assessment sheets, dated 01/24/2024, revealed the DON, the RCC Nurse, and the Director of Regulatory (also a nurse) performed a risk assessment on all twenty-six (26) residents receiving accu-checks (glucose monitoring). Review of the Risk for Infection Assessment sheets, dated 01/24/2024, revealed the DON, the RCC Nurse, and the Director of Regulatory notified all residents and/or the residents' representatives and physician of the potential bloodborne pathogen exposure. Review of lab orders dated 01/24/2024 for twenty-five (25) of the twenty-six (26) residents receiving accu-checks, revealed a HEP and HIV Exposure Panel was ordered by the physician for residents and/or resident representatives who requested lab testing. One (1) resident was discharged on [DATE]. Review of the completed lab orders revealed a HEP and HIV Exposure Panel lab draw was completed on 01/26/2024 for twenty-three (23) of the twenty-six (26) residents. One (1) resident refused labs, one (1) resident was transferred to the hospital on 01/25/2024, and one (1) resident was discharged home on 01/25/2024 prior to the lab being drawn. Review of Care Plans revealed a Risk for Infection care plan was implemented on 01/24/2024 for each of the twenty-six (26) residents to include the resident was at risk for potential adverse effects related to potential bloodborne pathogen exposure. Interventions included to notify the provider of the potential exposure, perform a nurse assessment for signs and symptoms of adverse effects, obtain labs as ordered by the provider, and notify the resident and/or responsible party of the potential exposure. 3. Review of education, posttests with a score of one hundred percent (100%) achieved, and sign-in sheets, dated 01/24/2024, revealed thirty-one (31) nursing staff members were educated on the Glucometer Cleaning and Disinfecting process per the manufacturers' guidelines and on bloodborne pathogens, and it was provided by Nursing Leadership. Review of the revised reeducation, completed on 01/25/2024 to 01/26/2024, revealed training and education to include Glucometer Cleaning and Disinfecting and Blood Glucose Testing, with return demonstration competency tests, signed by the staff and educator, showing one hundred percent (100%) accuracy achieved for thirty (30) nursing staff. Review of the quality assurance (QA) audits revealed the Regional Nurses observed three (3) accu-checks being performed with the cleaning and disinfecting process after the accu-check had been performed on 01/26/2024 and 01/27/2024. Observation on 01/28/2024 at 11:30 AM of Licensed Practical Nurse (LPN) #4 performing a blood glucose fingerstick on Resident #330, revealed LPN #4 performed the procedure and cleaned and disinfected the glucometer correctly, per manufacturers' instructions. Observation on 01/28/2024 at 11:45 AM of RN #7 (Agency) performing a blood glucose fingerstick on Resident #90, revealed RN #7 performed the procedure and cleaned and disinfected the glucometer correctly, per manufacturers' instructions. Observation on 01/28/2024 at 12:01 PM of LPN #10 performing a blood glucose fingerstick on Resident #97, revealed LPN #10 performed the procedure and cleaned and disinfected the glucometer correctly, per manufacturers' instructions. Observation on 01/28/2024 at 12:15 PM of RN #2 performing a blood glucose fingerstick on Resident #20, revealed RN #2 performed the procedure and cleaned and disinfected the glucometer correctly, per manufacturers' instructions. In interviews with Licensed Practical Nurse (LPN) #4 on 01/28/2024 at 11:30 AM; RN #7 on 01/28/2024 at 11:45 AM; LPN #10 on 01/28/2024 at 12:01 PM; and RN #2 on 01/28/2024 at 12:15 PM, all stated the RCC Nurse conducted one-on-one (1:1) training for all nurses on how to properly clean and disinfect glucometers. All stated the nurse trainer provided live demonstrations and had the nurses perform a return demonstration to ensure proper understanding. All stated infection control training was important in preventing the spread of disease. All stated they had received a live demonstration and education to include written instruction and a test regarding how to perform blood glucose monitoring and how to clean and disinfect glucometers per the manufacturer's instructions. They further stated they had to pass the written test with one hundred (100%) accuracy, and they were required to perform a return demonstration. In an interview with the RCC Nurse on 01/28/2024 at 5:32 PM, she stated she was responsible for providing education to all nurses working in the facility on how to clean and disinfect glucometers. She stated that she had provided training to all nurses before the start of their shift, which involved both instruction and live demonstration. After that, she stated each nurse was required to provide a return demonstration to ensure compliance. She stated the education was based on the manufacturer's instructions for the glucometer and Microdot bleach wipes. In an interview with the Director of Regulatory on 01/28/2024 at 2:45 PM, she stated nursing staff received education on cleaning and disinfecting glucometers from the RCC Nurse. She stated the training was followed by a return demonstration to ensure the staff understood it. The Director of Regulatory reported the education was based on manufacturers' instructions for the glucometer and Microdot bleach wipes. 4. Review of the QAPI sign-in sheet dated 01/24/2024 revealed the QAPI Committee, which included the Medical Director, Administrator, DON, Risk Manager, VP of Clinical Operations, VP Regulatory, VP Operations, and Administrator in Training, had a meeting. Review of the QAPI sign-in sheet dated 01/25/2024 revealed the QAPI Committee, which included the Medical Director, Administrator, DON, MDS Nurse, and the Social Services Director, had a meeting. Review of the QAPI sign-in sheet dated 01/26/2024 revealed that the QAPI Committee, consisting of the Medical Director, Administrator, DON, MDS Nurse, and Social Services Director, had a meeting. During an interview with the VP of Clinical Operations on 01/26/2024 at 3:43 PM, he stated the QAPI Committee had convened to address the IJ findings. He stated the committee discussed the education and re-education of staff, as well as the progress of staff education and competency training. He stated the Medical Director, Administrator, DON, and other nursing leadership members met daily on 01/24/2024, 01/25/2024, and 01/26/2024 as part of the IJ removal plan. 46710

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs for nine (9) of seventy-one (71) sampled residents (Residents #1, #4, #11, #39, #41, #48, #59, #325, and #381). Resident #59's care plan had interventions to provide incontinence care, which staff failed to implement causing emotional distress. Resident #41's care plan had interventions for falls. However, observations revealed these interventions were not implemented. Resident #381 was identified as a fall risk with an intervention placed in the care plan but not implemented. Resident #39's and #48's care plans were not developed to address the resident's hydration needs to decrease the likelihood of dehydration through adequate fluid intake. Resident #325's care plan was developed for pain management; however, the facility failed to implement these interventions. Resident #1's care plan stated the facility would provide a communication device; however, the facility failed to implement this intervention. Resident #11's care plan was not developed for management of supplemental oxygen therapy. Resident #4's care plan did not specify the resident's preferences for getting out of bed in the morning, though the resident had expressed his/her wishes repeatedly. The findings include: Review of the facility's Comprehensive Care Plan policy, last revised 09/15/2023, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident. A licensed nurse and/or the Interdisciplinary Team (IDT) was to develop and maintain a comprehensive care plan that identified the highest level of functioning the resident might be expected to maintain. Per the policy, care plan interventions were implemented after consideration of the resident's problem areas and their causes. Interventions were to address the underlying source(s) of the problem area(s) rather than addressing only symptoms and triggers. The facility's policy noted the comprehensive care plan was to be developed within seven (7) days of the completion of the resident's comprehensive assessment. The policy stated the care plan should reflect the current status of the resident. Review of the facility's policy, Resident Rights, dated 09/15/2023, revealed all residents were to be treated in a manner and in an environment that promoted maintenance or enhancement of quality of life. 1. Review of Resident #59's Face Sheet revealed the facility admitted the resident on 01/25/2023 with diagnoses including unspecified dementia, need for assistance with personal care, and overactive bladder. Review of Resident #59's Annual Minimum Data Set (MDS) Assessment, dated 12/06/2023, revealed the facility assessed the resident using a Brief Interview for Mental Status (BIMS) with a score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as dependent on staff for toileting hygiene. Review of Resident #59's Care Plan, dated 12/21/2023, revealed the facility assessed the resident as incontinent of urine and needing staff assistance for incontinence care. Further review revealed the interventions for incontinence care included providing incontinence care after each incontinence episode. Continued review revealed the facility assessed the resident as at risk for skin breakdown related to incontinence and impaired mobility and included the intervention, Keep clean and dry as possible. Minimize skin exposure to moisture. Observation on 01/23/2024 at 9:51 AM revealed Resident #59's call light was on, and the resident was lying in bed, fidgeting with his/her blanket, and looking toward the hallway with an anxious look on his/her face. Further observation revealed Resident #59 reported to Registered Nurse (RN) #1 that he/she had soiled his/her briefs and needed incontinence care. Resident #59 further stated he/she had last been changed around 5:00 AM. Further observation revealed RN #1 failed to provide the resident with incontinence care and informed the resident that Certified Nursing Assistant (CNA) #1 was busy but would come change the resident's brief soon. In continued observation, Resident #59 became increasingly agitated and stated, I can't be going through this every day. It didn't used to be like this, but now it takes them so long to come change me! Further observation at 10:32 AM revealed CNA #4 provided incontinence care to Resident #59. Observation revealed Resident #59's brief was saturated with urine, as well as the absorbent pad, draw sheet, and fitted sheet over the resident's mattress. While CNA #4 changed Resident #59's brief, the resident began crying and stated, I can't be going through this every day! and What did I ever do to them? I try to be nice, and it never pays off! It never used to be like this, but I need to be cleaned up! In an interview on 01/22/2024 at 4:42 PM, Resident #59 stated aides changed his/her brief once in the morning and once in the afternoon, and the sheets were often soaked before the aides provided incontinence care. Resident #59 further stated there were not enough aides to assist all the residents, and he/she felt frustrated when waiting for incontinence care. In an interview on 01/23/2024 at 3:40 PM, Certified Nursing Assistant (CNA) #1 stated she could not provide care to all the residents as needed when she was the only aide assigned to the hall. Per interview, CNA #1 did not know how to access the care plan in the computerized charting system. 2. Review of Resident #41's Face Sheet revealed the facility admitted the resident on 07/20/2018 with diagnoses including hemiplegia affecting left non-dominant side, epilepsy, and unspecified dementia. Review of Resident #41's Annual Minimum Data Set (MDS) Assessment, dated 10/29/2023, revealed the facility assessed the resident using a Brief Interview for Mental Status (BIMS) with a score of two (2) of fifteen (15), indicating the resident was severely cognitively impaired. Further review revealed the facility failed to fill out the assessment for the resident's functional status (Section GG). Review of Resident #41's Care Plan, dated 01/23/2024, revealed the facility identified Resident #41 as at risk for falls and included interventions such as keeping the bed in low position, fall mats to the left side of bed, and keeping the resident's wheelchair within reach. Observation on 01/23/2024 at 8:58 AM revealed Resident #41's bed was elevated high off the floor while the resident was in bed asleep. Further observation on 01/28/2024 at 9:52 AM revealed Resident #41's bed was elevated high off the floor while the resident was asleep. In an interview on 01/23/2024 at 2:47 PM, Certified Nursing Assistant (CNA) #7 stated she did not know how to find out what care the residents needed as this was her first day working on the floor, though she received three (3) days of orientation the week before. CNA #7 stated she did not know if Resident #41 was at risk for falls, nor did she know if Resident #41's bed should have been lowered from its current elevated level. In an interview on 01/23/2024 at 2:55 PM, CNA #21 explained she worked on the odd number rooms on the 300 Hall, and she was not familiar with the residents in the even number rooms. While standing at Resident #41's room, CNA #21 observed Resident #41's bed up in a higher than normal bed position. In continued interview, CNA #21 was unable to say if the resident's bed was supposed to be in a low position. Per interview, CNA #21 stated she did not know how to find out what care the residents required other than what she was told during report from the previous shift. In an interview on 01/28/2024 at 11:55 AM, Registered Nurse (RN) #2 stated that Resident #41 was at risk for falls, and his/her bed should be kept in the lowest position. Per interview, RN #2 stated Resident #41 would sometimes raise his/her own bed but that staff members should lower it when they saw it elevated. In an interview on 01/28/2024 at 2:03 PM, the Director of Nursing (DON) stated Resident #41 liked to use his/her bed controls to raise the bed sometimes, but she expected staff to lower it back down when they noticed it was elevated. In an interview on 01/28/2024 at 5:05 PM, the Administrator stated she expected each care planned fall prevention measure to be followed by staff. Per interview, the Administrator stated Resident #41 might raise his/her bed but that staff should lower it during routine safety rounds. 3. Review of Resident #381's Face Sheet revealed the facility admitted the resident on 12/14/2023 with diagnoses to include displaced fracture of cervical vertebra with routine healing, difficulty in walking, lack of coordination, and long term use of anticoagulants (blood thinners). Review of the Brief Interview for Mental Status (BIMS), dated 01/09/2024, revealed the facility assessed Resident #381 as being cognitively intact, scoring thirteen (13) of fifteen (15). Review of Resident #381's Comprehensive Care Plan, dated 01/27/2024, revealed the facility assessed the resident as a fall risk with a goal to minimize potential for fall related to injury with a target date of 04/02/2024. Interventions included Dycem (a material applied to prevent slippage or provide a better grip) to the wheelchair was placed on the care plan with an approach date of 01/19/2024. Observation on 01/27/2024 at 8:00 AM revealed Resident #381 in bed, and the wheelchair in his/her room without Dycem to the cushion of the wheelchair. During an interview with Certified Nursing Assistant (CNA) # 9 on 01/25/2024 at 11:30 AM, she stated she was caring for Resident #381 and knew the resident was a fall risk, so she kept his/her bed in low position. She stated she did not look at the Care Plan, and the facility had not offered training on that task. CNA #9 stated, when asked if Dycem was in Resident #381's wheelchair, that she did not know what that was. During an interview on 01/26/2024 at 10:30 AM with Licensed Practical Nurse (LPN) #3, she stated she was caring for Resident #381 and knew he/she was a fall risk. She stated the resident fell last night, and no additional supervision was being provided to Resident #381. During an interview on 01/27/2024 at 1:50 PM with LPN #9, she stated she was agency and had been working at the facility off and on for about six (6) months; and the last time was about three (3) weeks ago. She stated she was taking care of Resident #381, but had not viewed Resident #381's care plan and was just going by what night shift had reported to her. She stated she had taken care of Resident #381 in the past, at least three (3) weeks ago. LPN #9 stated she was unsure if Resident #381 had been a fall risk but was now since his/her fall last night. She stated if Resident #381 had Dycem ordered to his/her wheelchair, it should be placed so the resident could sit on it and not slip off. She stated the only fall intervention, she thought, was a bedside commode in the room. During an interview on 01/28/2024 at 4:00 PM with the Director of Nursing (DON), she stated the nurse should place an intervention on the care plan immediately after a fall, and the care plan should be followed. 43694 4. Review of Resident #48's Face Sheet revealed the facility initially admitted the resident on 10/26/2020 with diagnoses of kidney disease, respiratory failure, epilepsy, and type 2 diabetes. Review of Resident #48's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed the resident with a Brief Interview of Mental Status (BIMS) score of ten (10) of fifteen (15) signifying the resident was moderately cognitively impaired. The MDS revealed the resident was set-up only for eating. Review of Resident #48's person-centered Comprehensive Care Plan (CCP) established on 09/19/2023, revealed the resident used an indwelling catheter and staff were to encourage adequate fluid intake as recommended by dietary (09/19/2023). Continued review revealed the facility care planned the resident for dehydration and fluid maintenance on 03/31/2023 with the intervention to assess the resident for signs and symptoms of dehydration as needed. Staff were to assist the resident with fluid intake as needed (03/21/2023). Staff were also to encourage fluids to help prevent constipation (03/21/2023), monitor risk of dehydration and nutritional needs, monitor intake of food and liquids (03/12/2021) and observe for signs and symptoms of dehydration (03/21/2021). The CCP revealed the resident required set up assistance with his/her meals (11/06/2020). Review of Resident #48's Nutrition Evaluation completed by Registered Dietitian #2 on 08/16/2023, revealed she assessed the resident required 1950 milliliters of fluid intake per day. Review of Resident #48's Nutrition Evaluation dated 10/03/2023, revealed RD #2 evaluated the resident and assessed him/her to require 2030 ml of fluids per day. Review of Resident #48's daily fluid intake log, revealed in October, November, December 2023 and January 2024, the facility failed to provide documented evidence the resident took in and or was monitored for his/her daily fluid intake as outlined in the CCP. 5. Review of Resident #39's Face Sheet revealed the facility admitted the resident on 11/29/2023 with diagnoses of cerebral infraction, malnutrition, and psychosis. Review of Resident #39's Nutrition Evaluation Therapy form dated 12/07/2023 revealed the Registered Dietitian (RD) assessed the resident with a daily fluid intake need of 1420 to 1660 milliliters (ml). Review of Resident #39's Admission Minimum Data Set (MDS) Assessment, dated 12/05/2023, revealed the facility assessed the resident with a Brief Interview of Mental Status (BIMS) score of two (2) of fifteen (15) signifying a severe cognitive impairment. The facility assessed the resident as needing supervision, cueing, touching, and steadying while eating. The resident had a contracture to the right hand and wrist. Review of Resident #39's Comprehensive Care Plan (CCP), initiated 12/04/2023, revealed staff was to encourage the resident's oral food and fluid intake, monitor the resident for swallowing concerns (12/07/2023), encourage the resident to eat in the common area to increase intake (12/19/2023), refer to Restorative Dining (12/19/2023), and observe for side effects of antipsychotic medication such as dry mouth and urinary retention (12/20/2023). Resident #39's hydration needs were not added to the care plan until 01/23/2024, noting staff was to offer the resident fluids within limits, and limits were not noted on the care plan. Continued review of Resident #39's CCP, revealed a problem area for dehydration/fluid maintenance was created on 01/23/2024; the facility listed that date as the date the problem started but also as the edited date. Interventions were created on 01/23/2024 for dehydration/fluid maintenance as being at risk for fluid volume deficit related to impaired cognition and risk of malnutrition, both diagnoses present upon admission. Staff was to offer the resident fluids of his/her choice within limits (01/23/2024). The care plan revealed ADL problem was developed on 01/23/2024 related to functional ability deficits secondary to impaired mobility, impaired cognition, seizures and stroke, all diagnoses which were also present upon admission. Interventions were to set the resident up with meals and provide support as needed for consumption and help with incontinent care every shift (01/23/2024). 44001 6. Review of Resident #325's Facesheet revealed he/she was admitted on [DATE] with diagnoses to include pain in left ankle and joints of the left foot, type 2 diabetes, and chronic obstructive pulmonary disease (COPD). Review of Resident #325's Provider Progress Note, dated 01/10/2024, revealed the resident was admitted with left ankle pain due to tenosynovitis. Further review revealed the resident complained of ongoing right ankle pain, which increased with movement and improved with pain medication. Review of Resident #325's Discharge Summary from an acute care hospital, dated 01/08/2024, revealed the resident had a discharge diagnosis of left ankle pain due to tenosynovitis. Further review revealed the resident's pain had not resolved, and he/she remained in quite a bit of pain with tenderness in the left foot. Review of Resident #325's Admission Minimum Data Set (MDS) Assessment, dated 01/14/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. Review of Resident #325's person-centered Comprehensive Care Plan (CCP), revised 01/23/2024, revealed the facility care planned the resident at risk for pain related to left ankle tenosynovitis (inflammation of the tendon sheath where muscle connects to bone) and diabetic neuropathy. Nursing staff was to administer pain medications as ordered and to monitor and record the effectiveness of the medications. Nursing staff was to assess the effects of pain on the resident and to notify the physician if the resident did not demonstrate relief or reduction of pain with current treatment regimen. Further intervention included that nursing staff was to observe and record any complaints of pain, to include the location, duration, quantity, quality, and alleviating factors or aggravating factors. Nursing staff was also to observe and record any nonverbal signs of pain including guarding, moaning, restlessness, grimacing, and diaphoresis. Review of Resident #325's Physician's Orders, dated 01/09/2024, revealed a medication order for acetaminophen (analgesic to treat minor aches and pain) 325 mg (milligrams), two (2) tablets by mouth every four (4) hours and oxycodone-acetaminophen (opioid pain reliever to treat moderate to severe pain) 7.5-325 mg one (1) tablet by mouth every six (6) hours as needed for pain. Review of Resident #325's Medication Administration Record (MAR), dated 01/2024, revealed the resident received two (2) acetaminophen 325 mg tablets on 01/21/2024 at 6:40 AM. It was charted as being effective with no time given for follow up assessment of pain. During an interview with Resident #325 on 01/22/2024 at 5:30 PM, the resident stated that in the early morning, on 01/21/2024, he/she woke up with severe pain radiating down his/her left ankle and foot. The resident stated that he/she first rang the call light at 3:33 AM to request pain medication. The resident stated at 6:38 AM the nurse gave the resident two (2) acetaminophen tablets, after he/she requested oxycodone-acetaminophen. Review of Nurse Progress Notes revealed there was no nursing note recorded on 01/21/2024 which documented nursing observations to include the location, duration, quantity, quality, and alleviating factors or aggravating factors related to Resident #325's complaint of pain. 49267 7. Review of Resident #1's Face Sheet revealed the facility admitted the resident on 06/24/2021 with diagnoses of bilateral sensorineural hearing loss, chronic obstructive pulmonary disease (COPD), and type 2 diabetes. Review of Resident #1's care plan, dated 12/10/2023, revealed an identified problem of hearing loss and an intervention in place that provided adaptations as needed for hearing loss. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 12/02/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) of fifteen (15), which indicated no impaired cognition. Observation on 01/22/2024 at 3:21 PM revealed a caption phone on Resident #1's bedside table. The phone was on and connected to power. Additional observation revealed no visible captions on the telephone when the resident attempted an outside call. During an interview with Resident #1 on 01/24/2024 at 8:53 AM, the resident stated his/her phone had not worked in a long time. The resident stated it worked when he/she first came to the facility in 2021. The resident further stated he/she notified staff multiple times, but it was never fixed. Resident #1 stated he/she thought it just needed an internet connection. In an interview on 01/28/2024 at 2:02 PM with the Director of Nursing (DON), she stated she was not aware of Resident #1's caption phone and did not know the care plan was not followed. She further stated a hearing impairment with interventions for communication should be addressed on a care plan and staff should follow it. 8. Review of Resident #11's Face Sheet revealed the facility admitted the resident on 06/26/2018 with diagnoses including congestive heart failure, acute respiratory failure, and chronic obstructive pulmonary disease (COPD). Review of Resident #11's Quarterly Minimum Data Set (MDS) Assessment, dated 11/08/2023, revealed the facility assessed the resident using a Brief Interview for Mental Status (BIMS) with a score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. Further review revealed the facility did not indicate on the MDS assessment that Resident #11 received supplemental oxygen therapy during the look-back period. Observation on 01/23/2024 at 9:51 AM, on 01/24/2024 at 3:25 PM, on 01/25/2024 at 11:06 AM, and on 01/26/2024 at 6:22 PM revealed Resident #11 was wearing a nasal cannula, attached to an oxygen concentrator, set to deliver two (2) liters of oxygen per minute. Review of Resident #11's care plan, dated 12/22/2023, revealed the facility failed to include supplemental oxygen therapy management in Resident #11's care plan. In an interview on 01/27/2024 at 4:21 PM, Registered Nurse (RN) #5 stated parameters for oxygen therapy management should have been located on Resident #11's care plan, but she had not looked to see if interventions were included on Resident #11's care plan. In an interview on 01/28/2024 at 2:03 PM, the Director of Nursing (DON) stated her expectations were for oxygen therapy to be included in the resident's care plan. She further stated she was unable to pinpoint how the process failed with Resident #11's orders and care plan not being developed. In an interview on 01/28/2024 at 5:05 PM, the Administrator stated the process for care plan development was for the Interdisciplinary Team (IDT), which included the DON and MDS Coordinator, to review the discharge information from the acute care facility and talk with the resident to ensure relevant care areas were included in the resident's care plan. She further stated the facility was in the process of conducting a root cause analysis as to why the oxygen therapy was not added to Resident #11's care plan. 9. Review of Resident #4's Face Sheet revealed the facility admitted the resident on 12/20/2024 with diagnoses including polyneuropathy, generalized muscle weakness, and anxiety disorder. Review of Resident #4's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident's preferences for his/her daily schedule. Further review revealed the resident indicated choosing his/her bedtime, choosing what to wear, and doing his/her favorite activities were all very important to him/her. Review of Resident #4's Quarterly Minimum Data Set (MDS) Assessment, dated 11/30/2023, revealed the facility assessed the resident using a Brief Interview for Mental Status (BIMS) with a score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. Continued review revealed the facility assessed the resident as dependent for sit-to-stand and bed-to-chair transfers. Review of Resident #4's care plan revealed the facility identified Resident #4 required extensive assist from one (1) staff member for dressing and was dependent on two (2) staff members and a Hoyer lift for transfers. Further review revealed the facility did not specify when Resident #4 preferred to get up in the morning or go to bed at night. Review of the CNA Care Guide, not dated, revealed no documentation of Resident #4's preference for a time to be dressed for the day. In an interview on 01/22/2024 at 3:24 PM, Resident #4 stated staff did not get him/her out of bed until between 10:00 AM and 11:00 AM, or sometimes later. Resident #4 stated he/she had told multiple staff members he/she wanted to get up by 9:30 AM, but staff did not honor his/her request. Observation on 01/23/2024 at 11:08 AM revealed Resident #4 was in bed, wearing a hospital gown, wanting to get up for the day. Additional observation on 01/24/2024 at 10:16 AM, on 01/25/2024 at 10:22 AM, and on 01/27/2024 at 10:02 AM revealed Resident #4 in bed, wearing a hospital gown, with unbrushed hair. In an interview on 01/23/2024 at 11:08 AM, Resident #4 stated he/she was sick of this place never getting him/her ready for the day before lunch time. In additional interview on 01/23/2024 at 2:40 PM, Resident #4 stated staff assisted him/her in getting dressed and up into the wheelchair after lunch. In an interview on 01/23/2024 at 3:40 PM, CNA #1 stated she knew Resident #4 preferred to get dressed and out of bed by 10:00 AM, but she was not able to honor that request because there were too many dependent residents in her assignment that she needed to take care of first. In an interview on 01/28/2024 at 2:03 PM, the Director of Nursing (DON) stated she was not aware of Resident #4's preference to get out of bed earlier in the morning. She further stated when a resident expressed a preference regarding their care, it was her expectation for staff to update the CNA care guide, and the nurse should update the care plan. In an interview with Registered Nurse (RN) #2 on 01/28/2024 at 4:32 PM, she explained it was important for staff to follow the resident's care plan to ensure the resident received the correct care and treatment and prevent him/her from getting hurt. She explained care plans should be current and up-to-date with new interventions as needed. She stated floor nurses could update the care plan in urgent situations, but they were usually updated in the morning meeting by the clinical team. During an interview with Minimum Data Set (MDS) Nurse #1 on 01/28/2024 at 10:38 AM, she stated she completed assessments, reviewed hospital records, interviewed residents and family, and looked at any special treatment the resident received to help with development of the comprehensive care plan upon admission. She stated the clinical team met every morning Monday through Friday to review care plans. MDS Nurse #1 said it was up to the floor nurse to determine if something was missing from a resident's care plan and follow up with the physician. She stated there was a form the admitting nurse completed and provided to the MDS nurse. She stated the department heads were responsible for ensuring the accuracy of the care plan as it related to new orders. MDS Nurse #1 stated nurses updated care plans when there was a resident change and informed aides of the change. She further stated any changes and new intervention(s) were reviewed the next day in the clinical meeting. She stated if new interventions were added on a weekend, those interventions were reviewed the following Monday. MDS Nurse #1 stated all floor staff, nurses, aides, and agency staff were responsible for reviewing care plans prior to providing resident care. MDS Nurse #1 stated new orders should be added to the care plan immediately with a new intervention and that could be done by the floor nurse. She stated nurses should update the care plan when an event happened. She stated after the care plan was updated the nurse should inform the aides of the changes. MDS #1 explained all floor staff, nurses, aides, and agency staff should review the care plan before they provided care for a resident. She stated aides had a care guide which was on each unit in a binder. She also called it the ADL (Activities of Daily Living) Book. The MDS Nurse stated it was up to the clinical team to keep those books up-to-date, between the Director of Nursing (DON) and the Unit Managers. MDS Nurse #1 stated she could not identify where a breakdown occurred in not developing or implementing interventions in care plans. In an interview with the Minimum Data Set (MDS) Coordinator on 01/28/2024 at 10:45 AM, she said her expectation for all staff was to view residents' care plans, adding the CNAs had an ADL binder they referred to as well for care to be provided to residents. She stated a resident's care plan should be revised quarterly, change of condition, and with any orders. She stated the process for developing a comprehensive care plan was to review discharge information from the acute care facility and speak with the resident and his/her family to determine what care the resident required. She further stated care plans were updated in the clinical meeting on each weekday, based on new orders or incidents noted for each resident. In further interview, the MDS Coordinator stated, I'm not going to tell you we are caught up with the care planning process and ensuring that each resident's care plan was up-to-date with his/her current treatments. During an interview with the Director of Nursing (DON) on 01/28/2024 at 4:00 PM, she stated it was her expectation for staff to view and follow care plans, adding the care should be reflected in the care plan. In an interview on 01/28/2024 at 5:05 PM, the Administrator stated she expected all residents to be treated with dignity and respect. She further stated that included honoring the resident's preferences for when to get up because residents deserved to make decisions in their home. In further interview, the Administrator stated resident care needs and preferences should be recorded in the CNA Care Guide. The Administrator stated her expectations were for the care plan to be resident-specific and for staff to implement care planned interventions. During additional interview with the Administrator on 1/28/2024 at 6:10 PM, she stated the facility ensured that daily reviews of resident assessments were performed by the DON, Unit Managers, and clinical leaders, with care plans created to ensure assessments were current. She stated she made sure care plans were followed through clinical meeting reviews, policy and procedures, and communication with the DON and MDS Coordinator.

Based on observation, interview, record review, review of the facility's job descriptions, and review of the facility's policy, it was determined the facility failed to provide necessary services to a resident who was incapable of carrying out activities of daily living to maintain personal hygiene for one (1) of seventy-one (71) sampled residents (Resident #59). Resident #59 was dependent on staff to perform toileting hygiene; staff failed to change Resident #59's briefs timely resulting in the resident experiencing emotional distress, crying because he/she was left laying in a bed soaked with urine. The findings include: Review of the facility's policy, Activities of Daily Living, dated 09/15/2023, revealed the facility was to provide needed assistance for residents who were unable to perform activities of daily living, including toileting. Review of the facility's Certified Nursing Assistant (CNA) job description, dated 03/2021, revealed CNAs were responsible for promptly answering residents' call lights and assisting with residents' needs. Review of the facility's Charge Nurse job description, dated 03/2021, revealed the nurse was responsible for promptly answering residents' call lights and assisting with residents' needs. Further review revealed the Charge Nurse was responsible for confirming that CNAs were aware of residents' care plans and confirming that appropriate care was rendered. Review of Resident #59's face sheet revealed the facility admitted the resident on 01/25/2023 with diagnoses that included unspecified dementia, need for assistance with personal care, and overactive bladder. Review of Resident #59's Annual Minimum Data Set (MDS) Assessment, dated 12/06/2023, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), which indicated the resident was cognitively intact. Further review revealed the facility assessed the resident as dependent on staff for toileting hygiene. Review of Resident #59's care plan, dated 12/21/2023, revealed the facility assessed the resident as incontinent of urine and needing staff assistance for incontinence care. Further review revealed the interventions for incontinence care included providing incontinence care after each incontinence episode. Continued review revealed the facility assessed the resident as at risk for skin breakdown related to incontinence and impaired mobility and included the intervention, Keep clean and dry as possible. Minimize skin exposure to moisture. Observation on 01/23/2024 at 9:51 AM revealed Resident #59's call light was on, the resident was lying in bed, fidgeting with his/her blanket, and looking toward the hallway with an anxious look on his/her face. Further observation revealed Resident #59 reported to Registered Nurse (RN) #1 that he/she had soiled his/her brief and needed incontinence care. Resident #59 further stated he/she had last been changed around 5:00 AM. Further observation revealed RN #1 failed to provide the resident with incontinence care and informed the resident that Certified Nursing Assistant (CNA) #1 was busy, but would come change the resident's brief soon. In continued observation, Resident #59 became increasingly agitated and stated, I can't be going through this every day. It didn't used to be like this, but now it takes them so long to come change me! Continued observation at 10:32 AM, revealed CNA #4 provided incontinence care for the resident, and Resident #59's brief was saturated with urine, as well as the absorbent pad, draw sheet, and fitted sheet over the resident's mattress. While CNA #4 changed Resident #59's brief, the resident began crying and stated, I can't be going through this every day! and What did I ever do to them? I try to be nice, and it never pays off! It never used to be like this, but I need to be cleaned up! In an interview on 01/22/2024 at 4:42 PM, Resident #59 stated aides changed his/her brief once in the morning and once in the afternoon, and the sheets were often soaked before the aides provided incontinence care. Resident #59 further stated there were not enough aides to assist all the residents, and he/she believed they were doing their best but he/she felt frustrated when waiting for incontinence care. In additional interview with Resident #59 on 01/23/2024 at 10:17 AM, he/she stated aides had last provided incontinence care at 5:00 AM. Per interview, Resident #59 told several staff members that he/she needed to be changed before breakfast, but he/she did not recall their names. Resident #59 stated staff members told him/her to wait until after breakfast. Resident #59 stated he/she called the service desk if staff did not answer the call light timely. In an interview on 01/23/2024 at 3:40 PM, Certified Nursing Assistant (CNA) #1 stated she was assigned to twenty-two (22) residents that morning and helped each resident as quickly as she could. The CNA stated it was too hard to provide care to that many residents for just one (1) person. She stated when she had that many residents, which happened frequently, she knew residents had to lay wet for longer than they should. Per interview, CNA #1 felt sad for residents who had to wait for incontinence care, but she was doing the best she could with a heavy assignment. In an interview on 01/23/2024 at 5:48 PM, Registered Nurse (RN) #1 stated she did not address Resident #59's incontinence needs because she had a lot of medicine to administer, dressings to change, and other nursing responsibilities. She stated she did not have time to help the aide too. In an interview on 01/28/2024 at 2:03 PM with the Director of Nursing (DON), she stated it was her expectation for any nurse or aide to provide incontinence care to a dependent resident every two (2) hours and upon the resident's report of an incontinence episode. The DON stated it was inappropriate for a nurse to tell a resident to wait for the aide to provide incontinence care. In an interview on 01/28/2024 at 5:05 PM, the Administrator stated it was her expectation for all licensed staff to provide incontinence care immediately when a resident reported he/she had soiled briefs.

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to store and prepare food under sanitary conditions. Observation on [DATE] on the initial kitchen tour revealed ingredient containers not dated; and scoops, a set of solid stainless steel bowls, and a strainer stored sitting up. Continued observation during the supper meal service revealed no hand washing between glove changes, and a staff member patted the surface of the plate into the plate holder using a bare hand. The findings include: Review of the facility's policy titled, Receiving, dated ,d+[DATE], revealed all food items would be appropriately labeled, dated, and stored properly to ensure appropriate and timely utilization based on the principle of first in-first out (FIFO). Review of the facility's policy titled, Staff Attire, dated ,d+[DATE], revealed fingernails would be kept clean, trimmed, filed, and maintained. Use of nail polish, acrylic and gel nails was not permitted unless wearing intact gloves, in good repair, when handling food. Observation on [DATE] at 3:43 PM, during the initial kitchen tour, revealed three (3) large round clear containers of one (1) labeled thickener, one (1) labeled breadcrumbs and one (1) labeled salt that did not have a use by date. Continued observation revealed scoops turned up in the dish tray, a nested set of solid stainless steel bowls, and a colander turned up and not turned over on the shelf. Observation on [DATE] at 5:31 PM during supper service tray line, revealed a Dietary Aide touching the middle of the plate, put the plate into the base, and patted the plate into the base with bare hands that had long painted nails. Further observation revealed the cook and an aide did not wash their hands between glove changes. In an interview with Cook #1 on [DATE] at 9:45 AM, she stated food should be labeled with the use by date and then thrown out when it had expired. She stated, if not dated, food could spoil and old food could be used. She stated staff must wash their hands when changing gloves, touching their face, leaving the kitchen and re-entering, and when changing stations to prevent cross contamination. She stated to move plates, suction cups should be used to prevent touching them on the surface to prevent cross contamination. In an interview with Cook/Diet Aide #2 on [DATE] at 10:10 AM, Cook/Aide #2 stated food should be dated with an opened date and last date to be used. She stated food products should be labeled for identification so the wrong food ingredient would not be used because some food ingredients looked the same. Cook/Diet Aide #2 stated hands should be washed upon entering the kitchen, changing gloves, and changing tasks. She stated staff should handle the plate with four (4) fingers underneath the plate and the thumb on the rim not to touch the middle of the plate. Cook/Diet Aide #2 stated touching the plate surface could cause cross contamination. She stated dishware should be turned over to remain clean. In an interview with Dietary Aide #3 on [DATE] at 10:13 AM, he stated staff labeled food with the date opened and the use by date. He stated staff should wash their hands after every event between glove changing. He stated dishware should be stored so water could drain and nothing could fall into the dishware. He stated plates should be touched from the bottom to avoid getting germs from the hands on the surface of the plate. In an interview with the Dietary Manager (DM) on [DATE] at 3:33 PM and on [DATE] at 10:22 AM, he stated food should be labeled and dated to identify the food item and to see that it was not expired. He stated staff should wash their hands between change of gloves and on return to the kitchen to prevent cross contamination. He stated dishware should be turned upside down to dry and to prevent them from being contaminated by other food or debris falling into the dishware. The DM stated plates should be handled by the bottoms of the plates because physical cross contamination from touching the surface with bare or gloved hands would be a concern. He stated fingernails should be short, and staff should wear gloves if nails were long with polish. In an interview with the Director of Nursing on [DATE] at 2:26 PM, she stated her expectations were for food to be labeled and dated, staff to use appropriate hand hygiene with glove changing, and safe dishware storage to prevent cross contamination. In an interview with the Administrator on [DATE] at 11:25 AM, she stated her expectation was for staff to follow safe food handling protocols.

Based on observation, interview, record review and review of the facility's assessment, it was determined the facility failed to ensure the Facility Assessment was clear on evaluating its resident population; identifying the resources needed; and the level of staffing for each unit, to provide the necessary care and services to match the acuity level of the community. The findings include: Review of the document titled, Facility Assessment, [NAME] 2023 Facility Assessment, Resident Population Profile 08/05/2022-08/04/2023, revealed three (3) columns were assigned for: Admissions/Stays, % of Admissions/Stays, and Frequency Relative to Benchmark. The first two (2) columns had quantitative data where the last column was assigned (High-Low), with no quantitative data. The assessment utilized the Barthel Index which measured the degree of assistance required by an individual on ten (10) mobility and self-care Activities of Daily Living (ADL) items. Low ADL function score < 30 indicated total dependence, moderate ADL function score 31-59 indicated severe dependency, and high ADL function score >60 indicated slight dependency. The Facility Assessment failed to determine the amount of staff to match the level of care involved for each resident. Further review revealed no evidence the Facility Assessment determined the amount of staff needed to provide quality of care to the residents based on resident acuity. In the section titled, Staffing, Training, Services and Personnel, all ADLs for overall staffing, staff training/Competencies, and Services were scored as sufficient, instead of quantitative data. Another section titled, Acuity-Diseases, Conditions, and Treatments indicated either sufficient or not applicable for staffing requirements. During an interview with Social Services Director (SSD), on 01/24/2024 at 10:34 AM, she stated she was familiar with the facility's assessment. However, she was not involved in the process of determining its composition. During an interview with the Director of Nursing (DON), on 01/28/2024 at 2:05 PM, she stated, she did not have anything to do with the Facility Assessment as that was handled by the Administrator. During an interview with Administrator, on 01/28/2024 at 6:17 PM and 01/28/2024 at 7:14 PM, she stated she was the person responsible for completing the Facility Assessment. She stated she could explain the facility's assessment by admissions, percent of admissions, and frequency rates related to benchmarks. She stated, for example, Activities of Daily Living (ADLs) had three hundred and ninety-five (395) residents which equated to 66.3 percent of the residents. The frequency relative to benchmark indicated low. She further stated she could not give a value for what low indicated, or any of the other values. She stated the Facility Assessment document was used across the company, but it was hard to understand. She stated the Facility Assessment did not clearly indicate the discipline and amount of staff needed to provide quality of care to the residents based on the residents' acuity.

Based on observation, interview and review of facility policy it was determined the facility failed to provide a safe, clean, comfortable and homelike environment for five (5) of seventy-one (71) sampled residents, (Residents #44, #55, #60, #65, and #88). Observations during the survey revealed a continuous odor of urine on the 100 Unit. During interview with Resident #44, he/she stated that he/she kept the door closed to cut down on the odor; however, he/she could smell the odor when the door opened. During interview with Resident #55, he/she stated he/she moved quickly down the hallway to avoid the odor. Observation revealed Resident #60 had excessive accumulation of dead skin under the books and puzzles pieces on the bedside table and excessive dead skin under the foot of the bed. Observation revealed soiled/stained linens on Residents #65's and #88's beds. Neither resident was able to recall the last time their bed linens had been changed. The findings include: Review of the facility's policy, Resident Rights, dated 09/2023, revealed all residents had the right to be treated with respect and dignity. Further review revealed all residents were to be treated in a manner and in an environment that promoted maintenance or enhancement of quality of life. 1a. Observation on 01/23/2024 and 01/24/2024 revealed a strong odor of urine occurring on the 100 Unit in the hallway 8:30 AM and 1:30 PM daily. Continued observation revealed urine odors on the 100 Unit on 01/25/2024 at 2:05 PM and on 01/26/2024 at 8:15 AM. On 01/26/2024 at 4:40 PM there was a light odor of urine on the 100 unit. Review of the Face Sheet revealed the facility admitted Resident #44 on 09/18/2023 with diagnoses including Allergic Rhinitis, Asthma, and Anxiety. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 12/13/2023 revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15), which indicated the resident was cognitively intact. During interview with Resident #44 on 01/27/2024 at 4:43 PM he/she stated that he/she kept the door closed due to sensitivity to light and sound. The resident stated he/she could smell the odor entering the room after the door was opened. Resident #44 stated the strong odor of urine from the hallway was offensive. 1b. Review of the Face Sheet revealed the facility admitted Resident #55 on 07/27/2023 with diagnoses including major depression, and obesity. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 11/19/2023 revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15) which indicated the resident was cognitive intact. During interview with Resident #55 on 01/27/2024 at 4:45 PM he/she stated there was always a strong odor in the hall and he/she moved quickly through the hall because of the bad odor. Resident #55 stated the odor was stronger in other different places in the halls. Resident #55 stated he/she thought the odor was coming from other residents that were not clean. During interview with Housekeeper #1 on 01/23/2024 at 2:56 PM she stated she was assigned to clean the 100 Unit and half of the 200 Unit. She stated in residents' rooms she mopped the floors daily, cleaned the bathroom sink, toilet and replaced toilet paper. She further stated she thought the regular housekeeper assigned to the 100 Unit did not clean very well. During interview with the District Manager for Housekeeping, on 01/25/2024 at 11:36 AM, he stated his expectation was for staff to empty all trash, spot clean daily, stock supplies, clean bathroom, clean vertical surfaces and all high touch areas in residents' rooms. He stated he expected his staff to sweep, mop, and clean the bathroom in each resident's room daily including spraying the trash can and/or sink to keep odor under control daily. 2. Review of Resident #60 Quarterly MDS, dated [DATE] revealed the facility admitted Resident #60 on 06/09/2018 with diagnoses that included anemia, hypertension and dementia. Review of the MDS, dated [DATE] revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (13) out of fifteen (15) which indicated the resident was cognitively intact. Observation in Resident #60's room on 01/22/2024 at 6:42 PM revealed an excessive amount of dead skin present on Resident #60's bedside tray table. There were two (2) black books sitting on top of puzzle pieces with dead skin around and under the puzzle pieces. The floor under the foot of Resident #60's bed was covered with dead skin. The pillowcase at the head of the bed was stained with dried blood. Resident #60's polo style shirt, he/she was wearing in bed contained dried blood stains on it. The resident's Khaki pants lying over the foot of the bed had dried blood and other stains on them. Continued observation revealed Resident #60 used white tissue to blot the blood oozing from the left side of the resident's neck. The resident then discarding the tissue to the right side of the bed hitting a full trash receptacle and falling onto the floor. Observation in Resident #60 room on 01/23/2024 at 11:03 AM revealed it still contained dead skin at the foot of the bed and on the bedside table. Observation of Resident #60's physical appearance revealed Resident #60 had excessive dermatitis on both arms, head, and neck. Resident #60 also had opened wounds on his/her neck and hands that he/she refused to let staff treat or cover the bleeding wounds. The pillowcase was stained with dried blood. Continued observation revealed the trash receptacle was full and overflowed. The sheets on the bed were disheveled and stained. The bedside table was covered with two (2) black books, puzzle pieces, and dead skin under the puzzle pieces. During interview with Resident #60 on 01/23/2024 at 11:03 AM, he/she stated, You just do not get it. They never come in here to clean. I must go and get my own sheets and towels. Many times, I grab extra off the cart and put them in my dresser. Resident #60 stated I have to take out my own garbage. They do not do anything around here. This place is a 'shit hole'. During interview with Housekeeper #3, who was assigned to the 300 Hall, on 01/23/2024 at 10:31 AM, she stated that was her first day to work on that hall. She stated she noted Resident #60's room needed to be cleaned badly. During interview with Registered Nurse (RN) #2 on 01/24/2024 at 10:15 AM she stated Resident #60 could be very difficult to deal with at times. He/she could be verbally abusive, and she had heard him/her become aggressive. RN #2 stated, I bring (him/her) (his/her) pills and check on (him/her). She stated she knew Resident #60's room was filthy, but it was not easy dealing with his/her outbursts. Observation of Resident #60's room on 01/24/2024 at 2:19 PM revealed the bedside table had remnants of dead skin next to the drink cup. During interview with the District Manager of Housekeeping, on 01/25/2024 at 11:35 AM he stated he expected staff to complete the assignments. He stated there was a process to follow when a resident refused to have their room cleaned. He stated his staff should inform him and he would contact the Social Services Director. The District Manager of Housekeeping stated he was familiar with Resident #60, who could sometimes be difficult to deal with and some staff refused to go into Resident #60's room until he/she asked them to come in. He stated he was aware Resident #60's floor and bedside table were dirty and had not been cleaned, but he was not aware of the build-up of dirt under the resident's bed on 01/22/2024 and 01/23/2024. Observation of Resident #60's room on 01/26/2024 at 1:59 PM revealed there continued to be dead skin on the bedside table and floor. 3. Review of Resident #65's face sheet revealed the facility admitted the resident on 10/29/2022 with diagnoses of osteomyelitis and reduced mobility. Review of Resident #65's Quarterly MDS, dated [DATE], revealed a BIMS' score of fourteen (14) out of fifteen (15) which indicated intact cognition. Observation on 01/23/2024 at 1:23 PM revealed visible dried stains to Resident #65's bed linens. Observation revealed multiple small oval and round stains to the pillowcases that were light brown and light red in color. Continued observation revealed specks of scattered light brown stains and overall dingy gray color to the white sheets. During interview with Resident #65, on 01/23/2024 at 4:21 PM, he/she stated he/she was not sure the last time the linens had been changed. He/she further stated, he/she thought they were last changed three (3) or four (4) days ago but he/she could not say for sure. 4. Review of Resident #88's face sheet revealed the facility admitted the resident on 05/28/2022 with diagnoses of chronic obstructive pulmonary disorder (COPD), chronic nausea, and dysphagia oropharyngeal phase. Review of Resident #88's Quarterly MDS, dated [DATE], revealed a BIMS' score of twelve (12) out of fifteen (15) which indicated moderate impaired cognition. Observation on 01/23/2024 at 9:13 AM revealed visible stains to Resident #88's bed linens. Observation revealed three (3) round dried stains that were approximately twelve inches in diameter and light brown in color in the middle of the bed. During interview with Resident #88, on 01/23/2024 at 9:13 AM, he/she stated he/she could not remember the last time the sheets on his/her bed had been changed. During interview with CNA #19, on 01/28/2024 at 10:01 AM, he stated he did not usually work at this facility, but he changed bed linens routinely and as needed wherever he worked. During interview with the Director of Nursing (DON), on 01/27/2024 at 2:22 PM, and on 01/28/2024 at 2:02 PM and 01/28/2024 at 4:40 PM, she stated she expected dirty briefs to be disposed of and taken outside as soon as possible. The DON stated she expected each resident's room to be cleaned daily. In continued interview with the DON, she stated Resident #60 could be quite difficult, but that was no excuse for him/her to have a dirty room. In further interview with the DON, she stated she expected all staff responsible for changing bed linen to observe daily to see if the linen was visibly soiled and needed changing. During an interview with the Administrator, on 01/28/2024 at 11:25 AM, on 01/28/2024 at 6:17 PM, and on 01/28/2024 at 6:19 PM, she stated her expectations were for the facility to be free from any odors. The Administrator stated housekeeping staff were expected to perform their assigned duties for all residents' rooms and other areas of the facility. She stated they will usually have one side of a hall and the hall adjacent to that. She stated he expectation was for all rooms to be cleaned (moped, trash removed, and bathrooms cleaned daily). The Administrator stated they have residents who refuse the services. She explained that the process was to get the Social Services Director, along with the Housekeeping Director together to work with residents to clean dirty areas. She stated Resident #60 went to visit another resident daily, so they would try to clean when he/she was out of the room. She stated it was her expectation that resident rooms, including bed linens were always clean. She further stated the facility did not have a policy for changing linens and that it was based on need. 49050 49267

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for five (5) of seventy-one (71) sampled residents (Residents #1, #8, #11, #324, and #381). Resident #11 received oxygen (O2) without a Physician's Order. Additionally, Residents #1, #8, #11, and #381 had O2 tubing that was not labeled nor dated. Furthermore, Resident #324's nebulizer machine was not stored in a plastic bag when not in use. The findings include: Review of the facility's policy titled, Oxygen Administration, revised 07/25/2022, revealed oxygen therapy was supposed to be administered as ordered by a physician. Further review revealed staff were to check the resident's medical record to confirm the presence of a complete and appropriate physician's order. Continued review revealed staff were to change the oxygen tubing weekly. 1a) Review of Resident #11's Face Sheet revealed the facility admitted the resident on 06/26/2018 with diagnoses including congestive heart failure, acute respiratory failure, and chronic obstructive pulmonary disease (COPD). Review of Resident #11's Care Plan, dated 12/22/2023, revealed the facility failed to include supplemental oxygen therapy management in Resident #11's care plan. Review of Resident #11's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) with a score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Further review revealed the facility did not indicate on the MDS that Resident #11 received supplemental oxygen therapy during the look-back period. Review of Resident #11's Physician Orders, updated on 01/13/2024, revealed the facility failed to have an order for the oxygen. There was no order to describe the parameters for supplemental O2 therapy, including flow rate, associated monitoring, and frequency of tubing change. Observations on 01/23/2024 at 9:51 AM, on 01/24/2024 at 3:25 PM, on 01/25/2024 at 11:06 AM, and on 01/26/2024 at 6:22 PM, revealed Resident #11 was wearing a nasal cannula, attached to an O2 concentrator, set to deliver two (2) liters of O2 per minute. In an interview with Registered Nurse (RN) #5, on 01/27/2024 at 4:21 PM, she stated supplemental O2 should not be administered without a Physician's Order. She further stated she was aware Resident #11 was wearing a nasal cannula, but could not find the order for O2 therapy in the electronic medical record (EMR). Per interview, RN #5 stated she would call the physician to find out what O2 flow rate Resident #11 required. In an interview with the Director of Nursing (DON), on 01/27/2024 at 4:32 PM, she stated her expectations for supplemental O2 therapy were for nurses to follow Physician's Orders to initiate or adjust a resident's O2 therapy. She further stated she could not find Physician's Orders for Resident #11's O2 therapy, but needed to investigate further to determine the cause of this system failure. In an interview with the Medical Director, on 01/28/2024 at 2:43 PM, he stated when a resident was admitted or returned from the hospital, the facility's process was for the nurse to take verbal orders over the telephone for O2 as needed. He further stated the process was subject to human error if a nurse failed to enter an order. In an interview with the Administrator, on 01/28/2024 at 5:05 PM, she stated her expectations were for orders to be in place for a resident's supplemental O2 therapy. 1b) Observations on 01/23/2024 at 9:51 AM, and on 01/24/2024 at 3:25 PM, revealed that Resident #11's O2 tubing was not dated. In an interview with Registered Nurse (RN) #5, on 01/27/2024 at 4:21 PM, she stated O2 tubing should be labeled with the date it was changed. She further stated the facility's process was to follow physician's orders to change O2 tubing, which was usually ordered for once per week on night shift. In further interview, RN #5 could not locate orders for tubing changes for Resident #11. In an interview with the DON, on 01/27/2024 at 4:32 PM, she stated O2 tubing should be changed once per week. In an interview with the Administrator, on 01/28/2024 at 5:05 PM, she stated her expectations were for clinical staff to follow physician's orders and the facility's policies and procedures in regards to O2 tubing changes. 49267 2) Review of Resident #1's Face Sheet revealed the facility admitted the resident on 06/24/2021 with diagnoses of bilateral sensorineural hearing loss, chronic obstructive pulmonary disease (COPD), and Type 2 diabetes. Review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of fourteen (14) out of (15), indicating cognition intact. Review of Resident #1's Care Plan, dated 06/28/2021, revealed the resident was assessed for impaired O2 exchange with supplemental O2 as ordered. Review of Resident #1's Physician Orders, dated 07/05/2021, revealed an open-ended order for O2 therapy. Further review revealed an updated open-ended order for O2 therapy was entered on 01/26/2024. Further review of Resident #1's Physician Orders, dated 06/28/2023, revealed an open-ended order to change O2 tubing weekly. Further review revealed an updated open-ended order for O2 tubing was entered on 01/27/2024. Observations on 01/26/2024 at 4:12 PM, and on 01/27/2024 at 3:21 PM, revealed O2 tubing for Resident #1 was not labeled and dated. In an interview with the DON, on 01/27/2024 at 4:32 PM, she stated O2 tubing should be changed once per week. In additional interview with the DON, on 01/28/2024 at 2:02 PM, she stated nurse leaders were responsible for changing O2 tubing and it was changed weekly. She further stated if unlabeled tubing was identified or tubing was observed to be on the floor, it should be replaced immediately and labeled and dated correctly. In an interview with the Administrator, on 01/28/2024 at 5:05 PM, she stated her expectations were for clinical staff to follow physician's orders and the facility's policies and procedures regarding changing O2 tubing. 3) Review of Resident #381's Face Sheet revealed the facility admitted the resident on 12/14/2023 with diagnoses to include emphysema, supraventricular tachycardia, atrial fibrillation, and chronic obstructive pulmonary disease (COPD). Review of Resident #381's BIMS, dated 12/14/2023, revealed the facility assessed the resident with a score of thirteen (13) out of fifteen (15), indicating cognition intact. Review of Resident #381's Care Plan, dated 12/20/2023, revealed health related complications and impaired O2 gas exchange due to COPD and pulmonary nodule. The goal stated staff would minimize potential for complications through the next review. Continued review revealed no interventions for O2 therapy. Review of Resident #381's Physician Orders, dated 12/14/2023 through 01/28/2024, revealed orders dated 12/21/2023 for continuous O2 at two (2) liters. Review of Resident #381's Medication Administration Record (MAR), dated 01/01/2024 through 01/28/2024, revealed entries for continuous O2 at two (2) liters with entries as being performed, but no columns for O2 tubing changes. Observations on 01/22/2024 at 5:45 PM, and on 01/26/2024 at 8:58 AM, revealed Resident #381's O2 tubing on the concentrator was not dated. An attempt was made by the State Survey Agency (SSA) Surveyor to call the facility's Director of Respiratory by telephone, on 01/26/2024 at 3:07 PM, however, there was no answer and a call was never returned after leaving a message. In and interview with LPN#3, on 01/26/2024 at 10:30 AM, when asked about Resident #381's O2 tubing not being dated, she stated she thought there was an order to change the tubing. In an interview with the DON, on 01/27/2024 at 3:00 PM, she stated the reason the O2 tubing should be changed was to decrease the growth of bacteria in the tubing, and the tubing should be changed every seven (7) days. In continued interview with the DON, on 01/28/2024 at 4:00 PM, she stated new staff were trained on how often to change O2 tubing, adding she had not seen any O2 tubing not dated. She further stated there was not a document to keep track of the O2 tubing changes. 44000 4) Review of Resident #8's Face Sheet, revealed the facility admitted the resident on 08/24/2018 with the diagnoses of chronic obstructive pulmonary disease (COPD), personal history of pulmonary embolism, and shortness of breath. Review of Resident #8's Care Plan, initiated 03/26/2020, revealed the resident had the potential for altered respiratory status and exacerbation of respiratory symptoms, related to diagnoses of COPD. The goal stated the resident would not exhibit signs of respiratory distress, and the interventions directed staff to administer O2 as ordered and observe O2 precautions. Review of Resident #8's Physician Orders, dated 04/14/2023, revealed an order for nursing to change O2 tubing every week, on Sunday. Observations on 01/22/2024 at 4:16 PM and on 01/24/2024 at 1:15 PM, revealed Resident #8's O2 tubing on the concentrator was dated 12/01/2023. Further observation revealed the resident was sitting in a wheelchair, and the O2 tubing he/she was wearing was not dated. In an interview with LPN #6, on 01/27/2024 at 3:22 PM, she stated residents who had an order for O2 also had an order to change the O2 tubing every week. She stated she was notified by an alert on the computer when the O2 tubing needed to be changed. In an interview with LPN #4, on 01/27/2024 at 4:04 PM, he stated he knew when to change the O2 tube by looking at the date on the tube and changing it every week. In an interview with the DON, on 01/27/2024 at 2:59 PM, she stated she was not aware of who supplied the O2 to the facility. She stated the nurses date the O2 tubing once a week, and the nurse must look at the date on the tube and change it prior to the expiration date. She further stated that she, the medical records person, unit managers, and regional nurses check to assure the tubing was changed prior to the expiration date. She was not aware of who was accountable to make sure the tubing was changed prior to the expiration date, and there was a schedule on the white board in the conference room. She further stated she expected staff to change the tubing as ordered and if soiled, and bacteria could grow in the tube if it was not changed when needed. In an interview with the Administrator, on 01/26/2024 at 10:25 AM, she stated the facility did not utilize in house respiratory therapists and therefore did not have a respiratory services agreement. She further stated staff should follow the facility's policy and change the O2 tubing as ordered. 44001 5) Review of the facility's policy titled, Oxygen Administration, revised 07/25/2022, revealed staff were to change the oxygen tubing weekly. Review of Resident #324's Face Sheet revealed the facility admitted the resident on 01/03/2024 with diagnoses to include pneumonia, acute pulmonary edema, acute respiratory failure with hypoxia, personal history of congenital malformations of the heart and circulatory system, atrial fibrillation, and congestive heart failure. Review of Resident #324's Admission MDS, dated [DATE], revealed the facility assessed the resident with a BIMS' score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Further review revealed the facility's assessment indicated that Resident #324 received supplemental O2 therapy. Review of Resident #324's Physician's Orders, with a start date of care on 01/04/2024, revealed the physician ordered O2 therapy via nasal cannula at two (2) liters per minute continuous. Review of Resident #324's MAR, dated 01/01/2024 to 01/24/2024, revealed entries for O2 at two (2) liters per minute continuous, with entries as being performed, but no columns for O2 tubing changes. Review of Resident #324's Care Plan, revised 01/23/2024, revealed the facility care planned the resident to include supplemental O2 therapy management. Observation of room [ROOM NUMBER] on 01/22/2024 at 4:30 PM, revealed the nebulizer machine tubing was not dated. The nebulizer machine and tubing were sitting on top of the resident's bedside commode, and it was not inside a protective plastic bag. In an interview with Resident #324, on 01/25/2024 at 10:40 AM, the resident stated the last date the O2 had been changed was 01/17/2024, adding that was the first time the O2 tubing had been changed since his/her admission on 01/03/2024. Resident #324 stated the tubing often hit the floor during transfers and the staff did not clean or replace the dirty tubing. In an interview with the DON, on 01/27/2024 at 3:00 PM, she stated the reason O2 tubing should be changed was to decrease the growth of bacteria in the tubing, and the tubing should be changed every seven (7) days. In continued interview with the DON, on 01/28/2024 at 2:02 PM, she stated nurse leaders were responsible for changing O2 tubing weekly and as needed (PRN). She further stated if unlabeled tubing was identified or tubing was observed to be on the floor, it should be replaced immediately and labeled and dated correctly. She stated new staff were trained on how often to change O2 tubing, adding she had not seen any O2 tubing not dated. Furthermore, she stated O2 supplies, including nebulizer machines, should be placed inside a protective plastic bag when not in use. When asked if there was a document to keep track of the oxygen tubing changes, she stated there was not. In an interview with the Administrator, on 01/28/2024 at 5:05 PM, she stated her expectations were for clinical staff to follow physician's orders and facility's policies and procedures regarding changing O2 tubing.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure that medications were stored in proper temperatures and other appropriate environmental controls to preserve their integrity for two (2) of two (2) refrigerators. Additionally, it was determined the facility failed to ensure opened and in-use vials of tuberculin skin test (TST) solution, eye drops, and inhalers were not expired, on three (3) of five (5) medication carts. The findings include: 1. Review of the facility policy titled, Medication Storage, revised [DATE], revealed medications requiring refrigeration or temperatures between thirty-six (36) degrees Fahrenheit (F) and forty-six (46) degrees F, were to be kept in a refrigerator with a thermometer to allow for temperature monitoring. A temperature log or tracking mechanism would be maintained to verify that the temperature was within accepted limits. Observation of the medication refrigerator on the Blue Unit, on [DATE] at 4:07 PM, revealed the temperature was thirty-two (32) degrees F. The thermometer was located on the middle shelf, in the middle of the shelf, approximately six (6) inches from the front of the shelf, and there were vials of insulin and insulin pens in the refrigerator. Review of the temperature log, located on the left side of the medication refrigerator on the Blue Unit, revealed Temperature of refrigerator must be between 36 - 41 degrees F. Freezer must be at or below freezing. If not contact maintenance immediately! Further review of the temperature log revealed the following documentation: a. Documentation on [DATE] revealed the temperature was thirty-four (34) degrees F; however, it was not documented that maintenance was notified. b. Documentation on [DATE] revealed the temperature was thirty-two (32) degrees F; however, it was not documented that maintenance was notified. c. Documentation on [DATE] revealed the temperature was thirty-four (34) degrees F; however, it was not documented that maintenance was notified. d. Documentation on [DATE] revealed the temperature was thirty-five (35) degrees F; however, it was not documented that maintenance was notified. Observation of the medication refrigerator on the Green Unit, on [DATE] at 4:37 PM, revealed the temperature was thirty-three (33) degrees F. The thermometer was located on the middle shelf, in the middle of the shelf, approximately six (6) inches from the front of the shelf. Continued observation revealed there were five (5) bottles of insulin, eleven (11) insulin pens, an emergency kit, a pneumonia vaccine, and a hepatitis B vaccine in the refrigerator. During an interview with Licensed Practical Nurse (LPN) #8, at the time of the observation, she stated, I need to turn it up. When asked why she needed to turn it up, she stated if the temperature was too low the medication may not be effective and could possibly cause an adverse reaction, and medical complications. Further observation of the medication refrigerator on the Green Unit, on [DATE] at 10:16 AM, revealed the temperature was fifty-two (52) degrees F. The thermometer was located on the middle shelf, in the middle of the shelf, approximately six (6) inches from the front of the shelf. During an interview with the Director of Nursing (DON) at the time of the observation, she stated she expected staff to keep the temperature between thirty-six (36) degrees F to forty-one (41) degrees F. She stated the medications may not be effective if not at the correct temperature, and this could cause an adverse effect on a resident. She further stated all refrigerated medications would be wasted. Further observation of the medication refrigerator on the Blue Unit, on [DATE] at 10:40 AM, revealed the temperature was twenty-eight (28) degrees F. The thermometer was located on the middle shelf, in the middle of the shelf, approximately six (6) inches from the front of the shelf. Continued observation revealed the original temperature flow sheet had been replaced with a new one, beginning on [DATE]. During further interview with the DON at the time of the observation, she stated an adverse reaction could be possible if medications were not stored at the correct temperature. During an interview with the Pharmacist, on [DATE] at 3:08 PM, he stated there could potentially be harm to a resident if a medication was not stored at the correct temperature. During an interview with the Administrator, on [DATE] at 10:25 AM, she stated she expected staff to follow the policy on storage of medications. She stated she was not aware of any issues with medications not stored at the correct temperature, and she would expect staff to let her know if there were any issues with medication storage. Three (3) requests were made for a copy of the temperature logs for the last three (3) months, however, they were not provided. 2. Review of the facility's policy titles, Medication Administration - General Guidelines, revised [DATE], revealed the nurse shall place a 'date opened' sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened. Further review revealed multi-use eye drops and ointments should be disposed of twenty-eight (28) days after initial use and multidose vials shall be labeled to assure product integrity, considering the manufacturers' specifications. Continued review revealed nursing staff should document the date opened on multi-dose vials on the attached auxiliary label. Observation of the Blue Unit 100 Hall medication cart, on [DATE] at 6:25 PM, revealed three (3) bottles of eye drops that were opened and not dated. During an interview with the Certified Nursing Assistant/Kentucky Medical Assistant (CNA/KMA) #3 at the time of the observation, she stated she was not aware the medications were not dated. She stated she knew the facility's policy required medications to be dated after opening and to remove the medications after twenty-eight (28) days. Observation of the 400 Hall medication cart, on [DATE] at 4:25 PM, revealed there was an opened albuterol inhaler not dated. During an interview with Registered Nurse (RN) #1, at the time of the observation, she stated medications should be dated when opened. She further stated medications may not be effective if out of date and could also potentially harm a resident. Observation of the 100 Hall medication cart, on [DATE] at 10:01 AM, revealed there was an opened, undated, bottle of TST solution. During an interview with LPN #4 at the time of the observation, she stated she could not verify when the bottle was opened, and the solution may not be effective if out of date. She stated this could lead to an inaccurate test result and potentially harm the resident and other residents. Observation of the Blue Unit 200 Hall medication cart, on [DATE] at 4:35 PM, revealed an opened, undated, bottle of eye drops. During an interview with LPN #3, at the time of the observation, she stated she did not know why the eye drops were undated. She stated there could be harm to a resident if the eye drops were outdated. Observation of the medication refrigerator on the Green Unit, on [DATE] at 4:37 PM, revealed there was an opened, undated, bottle of TST solution. During an interview with the DON, on [DATE] at 2:59 PM, she stated that she and the unit managers monitored the medication carts to assure the medications were dated when opened, and not expired. She stated she did not know why there were medications on the cart that were opened and undated. The DON stated she expected staff to follow the policy. During an interview with the Administrator, on [DATE] at 10:25 AM, she stated she expected staff to follow the policy on the storage of medications. She was not aware of any issues with medications being undated after opening, and she would expect staff to let her know if there were any issues with medication storage. 50192

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to treat each resident with dignity, and care in a manner and environment that promotes maintenance or enhancement of his or her quality of life for three (3) of seventy-one (71) sampled residents (Residents #1, #11, and # 324). Resident #324 stated he/she was not incontinent, but staff told the resident to use a brief, causing Resident #324 to sit in his/her own feces and urine until assisted. Resident #1 had a severe hearing impairment. He/she had a caption phone in his/her room that had not been functional for an unknown amount of time. The facility was made aware by the resident, but failed to ensure the resident had an effective means of communication. Certified Nursing Assistant (CNA) #11 left Resident #11 lying naked in bed while obtaining supplies during a bed bath. The findings include: Review of the facility's policy titled Resident Rights, revised 09/13/2023, revealed the facility would protect each resident's right to be treated with dignity. 1) Review of Resident #324's Face Sheet revealed the facility admitted the resident on 01/03/2024 with diagnoses that included pneumonia, gastroesophageal reflux disease, muscle weakness, difficulty walking, type 2 diabetes mellitus, Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuritis, hypertension, atrial fibrillation, and congestive heart failure. Resident #324 currently had a stage III pressure ulcer. Review of Resident #324's Admission Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) which indicated the resident was cognitively intact. Further review revealed the facility assessed the resident as dependent on staff for toileting, bathing, and lower body dressing. Continued review revealed the facility assessed the resident as frequently incontinent of bowel and bladder. Review of Resident's #324's Baseline Care Plan, dated 01/04/2024, revealed the resident's bowel and bladder elimination was within normal limits. The Care Plan goal was to maintain present patterns without adverse side effects. Review of the Care Plan, revised on 01/23/2024, revealed the resident was not care planned for incontinence of bowel and bladder. The resident was care planned for activities of daily living (ADL) with a long term goal to maintain functional ability with no significant decline through the next review. An intervention stated staff would provide incontinence care needs and toileting needs every shift. Review of a Progress Note, dated 01/04/2024 at 2:25 PM, revealed when Resident #324 arrived at the facility, he/she was alert and oriented to person, place, and time. It was noted that the resident was continent of bowel and bladder. Observation and interview with Resident #324, on 01/22/2024 at 4:10 PM, revealed he/she was very upset over the treatment he/she had received at the facility. He/she stated on the first night at the facility he/she was told by a CNA that he/she would have to wear briefs. Resident #324 stated, The aide said that if I soiled the bed, I could just lie in it till they got around to cleaning me up. Resident #324 could not remember the CNA's name. The resident stated, I felt coerced to wear diapers although I am fully continent. It's undignified and I am embarrassed. During the observation and interview, on 01/22/2024 at 4:10 PM it was noted that there was a bedside commode in the room and a bedpan in the bathroom. The resident stated that he/she had never used the bedside commode while in the facility because it required staff assistance to place him/her on it. Resident #234 stated that there was never enough staff available to help him/her when needed. Additionally, Resident #324 stated that he/she suffers from constipation, and when laxatives were given, it became very difficult to control his/her bowel movements. The resident stated those were the only times when he/she has had incontinent episodes. The resident stated that he/she was forced to wet and soil his/her brief because staff would take so long to provide assistance. Resident #324 further stated that if staff came when he/she rang the bell, he/she was fully capable of using the bedpan. In an interview with Licensed Practical Nurse (LPN) #4, on 01/23/2024 at 4:15 PM, she stated Resident #324 was alert and oriented and capable of expressing his/her preferences. The LPN stated the resident was continent of bowel and bladder and would call for assistance with the bedpan. LPN #4 stated the resident did have some incontinent diarrhea stools while on antibiotic therapy. In an interview with the Administrator, on 01/28/2024 at 5:05 PM, she stated it was her expectation that each resident be treated with dignity. She stated that it was one hundred percent the resident's right to make choices. She stated it was important because the facility was the resident's home and they had the right to make their own decisions. She further stated it was her expectation that all staff were to assist residents and answer lights. 49267 2) Review of Resident #1's Face Sheet revealed the facility admitted the resident on 06/24/2021 with diagnoses of bilateral sensorineural hearing loss, chronic obstructive pulmonary disease (COPD), and Type II diabetes. Review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS' score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Review of Resident #1's Care Plan, dated 12/10/2023, revealed an intervention to provide adaptations as needed for hearing loss. Observation on 01/22/2024 at 3:21 PM revealed Resident #1 was able to effectively read lips when his/her roommate was directly in his/her view. Additional observations revealed the caption phone on the resident's bedside table was on and connected to power. In an interview on 01/24/2024 at 8:53 AM, Resident #1 stated his/her phone had not worked in a long time. The resident stated it worked when he/she first came to the facility in 2021. He/She further stated he/she notified staff multiple times, but it was never repaired. Resident #1 stated he/she thought it just needed to be connected to the Internet. In an interview on 01/24/2024 at 9:02 AM with Resident #79 (Resident #1's roommate), he/she stated he/she helped Resident #1 communicate with staff. A phone interview was attempted with Resident #1's daughter on 01/24/2024 at 2:57 PM. A message was received that calls were not accepted and there was no capability of leaving a voicemail message. There were no alternate numbers listed for the resident's daughter, and Resident #1 was unable to provide an alternate telephone number. A phone interview was attempted with Resident #1's son on 01/24/2024 at 3:01 PM. A voicemail message was left and Resident #1's son replied via text message and stated he would call later in the evening after work. The State Survey Agency (SSA) Surveyor never received a phone call. A phone interview was attempted twice more with Resident #1's son on 01/23/2024 at 11:01 AM and 12:52 PM, and a return call was never received. In an interview CNA #5, on 01/25/2024 at 10:22 AM, she stated Resident #1 read lips well. She further stated she knew Resident #1 had a phone that did not work. CNA #5 stated at some point the facility had some type of trouble with phones and a phone company, so maybe that had something to do with the problem, but she did not really know. In an interview with the Plant Director, on 01/26/2024 at 12:14 PM, he stated he did not know much about Resident #1's phone other than he heard at some point it needed Internet. He further stated the phone was an issue he was responsible for and it would be addressed. In an interview with the DON, on 01/26/2024 at 4:20 PM, she stated she was not aware of an issue with Resident #1's phone. She was then notified by the SSA Surveyor that Resident #1 had a caption phone that allowed him/her to talk to people outside of the facility, and the phone was not functional. In an interview with the Medical Records Registered Nurse (RN) on 01/27/2024 at 2:39 PM, he stated he looked at the phone a short time ago and it was connected to Wi-Fi. He further stated he used his phone to call Resident #1's phone and captions appeared. He stated the problem was with the number she had called, he explained the issue to the resident, and she verbalized understanding. He stated he obtained alternate contact numbers of family members for Resident #1. In further interview with the DON, on 01/28/2024 at 2:02 PM, she stated the facility used white boards or other written means to communicate with hearing impaired residents. The DON was not able to address outside communication for hearing impaired residents. The DON stated she was not aware of Resident #1's caption phone and did not know the care plan was not followed. She further stated a hearing impairment with interventions for communication should be addressed on a care plan. In an interview with the Administrator, on 01/28/2024 at 6:19 PM, she stated she made sure care plans were followed through clinical meeting reviews, policy and procedures, and communication with the DON and MDS coordinator. The Administrator stated it was her expectation that all channels of communication, both inside and outside the facility, were available for hearing impaired residents. 46710 3) Review of Resident #11's Face Sheet revealed the facility admitted the resident on 06/26/2018 with diagnoses including congestive heart failure, acute respiratory failure, and chronic obstructive pulmonary disease (COPD). Review of Resident #11's Quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS' score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as dependent on staff for upper and lower body dressing, bathing, and personal hygiene. Observation on 01/25/2024 at 11:06 AM revealed CNA #11 providing Resident #11 with a partial bed bath and incontinence care. Resident #11 was completely naked, and the curtain was open when the SSA Surveyor entered the room. Resident #11's roommate (Resident #59) was also present in the room, within view of Resident #11's naked body. Further observation revealed CNA #11 closed the curtain, but the resident remained naked with no sheet or towel covering him/her from 11:08 AM to 11:12 AM while CNA #11 left the room to obtain additional linens. In an interview on 01/25/2024 at 4:22 PM, CNA #11 stated her process to provide a resident with privacy while changing his/her briefs or clothes was to close the door and the curtain. Per interview, CNA #11 would cover the resident with a towel or a sheet if she had to leave the room to get supplies. CNA #11 further stated keeping the resident covered was important for resident dignity and privacy. In continued interview, CNA #11 stated she forgot to cover Resident #11 when she left the resident's room to obtain additional linens. In an interview on 01/28/2024 at 2:03 PM, the DON stated it was her expectation that staff cover a resident if they had to leave to obtain additional supplies during a bed bath. In an interview on 01/28/2024 at 5:05 PM, the Administrator stated it was her expectation that each resident be treated with dignity because the facility was the resident's home. She further stated it was important in promoting resident dignity for staff to cover a resident if they needed to leave the room during a bed bath.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to honor the resident's right to self-determination as related to choosing his/her daily schedule for one (1) of seventy-one (71) sampled residents (Resident #4). The facility failed to get Resident #4 out of bed timely in the morning according to his/her preferences. The findings include: Review of the facility's policy titled, Resident Rights, revised 09/13/2023, revealed the facility was to respect the resident's individuality and value their input by providing them a dignified existence through self-determination related to provision of care and services. Review of Resident #4's Face Sheet revealed the facility admitted the resident on 12/20/2014, with diagnoses that included polyneuropathy, generalized muscle weakness, and anxiety disorder. Review of Resident #4's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status Score (BIMS) score of fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact. Continued review revealed the facility assessed Resident #4's preferences for his/her daily schedule which included choosing his/her bedtime, choosing what to wear, and doing his/her favorite activities, which were all very important to him/her. Review of Resident #4's Quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS' score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Continued review revealed the facility assessed Resident #4 to need moderate assistance with lower body dressing. Further review revealed the facility additionally assessed the resident as dependent for sit-to-stand and bed-to-chair transfers. Review of Resident #4's care plan revealed the facility identified Resident #4 required extensive assist from one (1) staff member for dressing and was dependent on two (2) staff members and a mechanical lift for transfers. Further review revealed the facility had not specified on the care plan when Resident #4 preferred to get up in the morning or go to bed at night. Review of the Certified Nursing Assistant (CNA) Care Guide, undated, revealed no documented evidence of Resident #4's preference for a time to be dressed for the day. In an interview on 01/22/2024 at 3:24 PM, Resident #4 stated staff did not get him/her out of bed until between 10:00 AM and 11:00 AM, or sometimes later. Resident #4 stated he/she preferred to get up before 10:00 AM; however, there was usually only one (1) aide assigned to the hall, so it took them a long time to get to his/her room. In further interview, Resident #4 stated he/she had told multiple staff members he/she wanted to get up by 9:30 AM, but staff did not honor his/her request. Observation on 01/23/2024 at 11:08 AM revealed Resident #4 was lying on his/her bed, with unbrushed hair, wearing a hospital gown, scowling, and speaking with a raised voice about wanting to get up for the day. In an interview on 01/23/2024 at 11:08 AM, Resident #4 stated he/she was sick of this place never getting him/her ready for the day before lunch time. In additional interview on 01/23/2024 at 2:40 PM, Resident #4 stated staff assisted him/her in getting dressed and up into his/her wheelchair after lunch. The resident stated CNA #1 was slow and lectured residents about not being able to assist them according to their preferred schedule because there were so many residents needing assistance. Additional observations on 01/24/2024 at 10:16 AM, on 01/25/2024 at 10:22 AM, and on 01/27/2024 at 10:02 AM revealed Resident #4 still lying on his/her bed, wearing a hospital gown, and with unbrushed hair. In an interview on 01/23/2024 at 3:40 PM, CNA #1 stated she knew Resident #4 preferred to get dressed and out of bed by 10:00 AM. However, she was not able to honor that request because she had twenty-two (22) residents in her assignment that morning and several of them were totally dependent on staff for care and unable to voice their needs. The CNA stated she felt bad about not being able to get Resident #4 up earlier in the day, but she felt the residents who were unable to speak up for themselves needed attention first. In further interview, CNA #1 stated she tried to explain why she got other residents up before Resident #4, but the resident did not accept her explanation. In an interview on 01/28/2024 at 2:03 PM, the Director of Nursing (DON) stated she knew Resident #4 but she believed the resident had not made his/her preferences known regarding getting up in the morning. She stated when a resident expressed a preference regarding their care, it was her expectation for staff to update the CNA care guide, and the nurse should update the care plan, and honor the resident's preference. In further interview, the DON stated residents were to express their preferences, and the process was if the resident expressed a preference, it should be put in the care plan and the CNA care guide. In an interview on 01/28/2024 at 5:05 PM, the Administrator stated she expected all residents to be treated with dignity and respect. She further stated her expectations included honoring the resident's preferences for when to get up for the day, because residents deserved to make decisions in their home. In further interview, the Administrator indicated it was up to residents to make their preferences known.

Based on interview and record review, it was determined the facility failed to notify the Power of Attorney (POA) of a fall and transfer to the hospital for one (1) of seventy-one (71) sampled residents (Resident #326). The findings include: Review of Resident #326's Face Sheet revealed the facility admitted the resident on 09/29/2023 with diagnoses to include metabolic encephalopathy, urine retention, cognitive communication deficit, generalized muscle weakness, history of falling, type 2 diabetes mellitus, and generalized anxiety disorder. Resident #326 was admitted to the facility with an indwelling catheter. Review of Resident #326's Admission Minimum Data Set (MDS) for resident assessment and care screening, dated 10/06/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15), indicating moderate cognitive impairment. Review of Resident #326's Discharge Summary, dated 09/29/2023, revealed the resident was admitted to the hospital with urinary retention, and was then discharged on [DATE] from the hospital with an indwelling Foley (brand name) catheter. Review of Resident #326's Change in Condition (CIC) Note, dated 10/06/2023 at 9:30 PM and recorded on 10/07/2023 at 2:07 AM, revealed the event note did not provide details of when and how Resident #326's son was notified regarding the CIC. Review of the Nurse's Progress Note, dated 10/06/2023 at 9:30 PM (recorded as a late entry on 10/07/2023 at 2:17 AM), documented Resident #326's fall and transfer to the hospital. Per the Progress Note, the RN #10 stated Nurse observed resident in the floor laying on his/her left side. Resident observed to have increased confusion and was unable to give details of what exactly (he/she) was trying to do. Resident c/o [complaints of] left hip pain and a small laceration bleeding from the back of the resident[s] head. Full head to toe assessment was completed. On call notified with orders to send to ED [emergency department] for eval [evaluation] and treat. Family and DON [Director of Nursing] notified. EMS [emergency medical services] transported to hospital. LPN #10 did not provided identifying information in the progress not about the family member with whom they spoke. In an interview with Resident #326's son and POA, on 01/27/2024 at 12:11 PM, he stated the facility failed to contact him about Resident #326's fall with injury and subsequent transfer to the hospital. The son stated the resident was admitted to the facility on [DATE]. He further stated his parent showed signs and symptoms of a urinary tract infection (UTI) on the day of admission from the hospital, and he had requested for the nurse (who he did not remember the name of) to ask the provider to obtain a urinalysis (UA). However, the son stated the urinalysis was never obtained. On 10/01/2023, when the son visited his parent, he was told that Resident #326 had a rough weekend and had pulled out his catheter. The son requested a UA again, but it was not done. On 10/02/2023, the son asked once again if the UA was done, but it was not. Per the son, he was familiar with the signs and symptoms his parent exhibited when they had a UTI. During the interview, the son mentioned that he went out of town for two (2) days and visited his parent when he returned on 10/04/2023. He asked the nurse (whose name he did not remember) for an update, but she told him there were no updates. The son stated he did not find out about Resident #326's transfer to the hospital until later in the day on 10/07/2023. He stated his stepsister called him after she had gone to the facility to visit Resident #326 and was told the resident was not there. The son stated, My stepsister asked if I knew that [parent] had been taken to the hospital. The son stated he was not notified about this incident. The son further stated he answers his phone twenty-four (24) hours a day, seven (7) days a week and when he looked back through his call log and messages, there were no calls or voicemail messages from the facility on 10/06/2023 or 10/07/2023. He further stated, I understand that the facility has a lot to do, and they are under a tremendous burden, but I need to be notified if [my parent] deteriorates, falls, or gets transferred to a hospital. The State Survey Agency (SSA) Surveyor attempted to contact LPN #10 on 01/27/2024 at 9:29 AM. The phone was disconnected. During an interview with the DON, on 01/27/2024 at 2:34 PM, she stated the nurses were educated to chart a CIC and notifications to family in a progress note and under an event note. If not able to reach the family, they try to recontact family. Nurses were also expected to notify family and the DON if there was a fall with injury. She stated she was notified regarding Resident #326's fall and transfer and stated staff called the resident's son with the CIC. During an interview with the Administrator, on 01/28/2023 at 5:05 PM, she stated it was her expectation for the staff to follow the facility's policy related to notifying family regarding fall with injury and transfer to another facility. It was important that the resident representative was informed to make any required decisions.

Based on observation, interview, record review, and facility policy review it was determined, the facility failed to ensure the residents' environment remained as free of accident hazards as possible, and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two (2) of seventy-one (71) sampled residents (Residents #41 and #381). 1. Resident #381 sustained a fall on 01/18/2024; however, the facility failed to develop and implement new interventions to address the resident's safety and prevention of further falls. Resident #381's Comprehensive Care Plan was revised after the fall on 01/18/2024 to place Dycem (a nonslip material used to help stabilize/hold objects firmly in place in a resident's wheelchair); however, this intervention was not implemented by facility staff. 2. Resident #41 fell out off his/her bed on 01/14/2024, and observation during the State Agency Survey revealed the resident's bed was in an elevated position. The findings include: Review of the facility policy titled, Falls dated 06/01/2015 with a revision date of 09/15/2023, revealed the intent of the policy was to ensure the environment was as free from accidents and hazards as possible to prevent avoidable falls. Per review, the guidelines included fall risk assessments to be performed upon admission, readmission, quarterly, annually and with a significant change of condition to identify fall risks. Continued review revealed a comprehensive care plan (CCP) was to be implemented based upon the resident's risk of falls and goals with interventions placed to reduce the risk of avoidable falls. Continued review of the facility's policy revealed the CCP should be reviewed following each fall with revisions of goals and interventions. Additional review of the facility's policy revealed the Interdisciplinary Team (IDT) and the Quality Assurance/Performance Improvement committee (QAPI) was to perform reviews of residents' falls. 1. Review of Resident #381's face sheet revealed the facility admitted the resident on 12/14/2023, with diagnoses to include displaced fracture of the cervical vertebra with routine healing, difficulty in walking, long term use of anticoagulants (blood thinners), and lack of coordination. Review of the Entry Tracking Minimum Data Set (MDS) assessment dated [DATE], revealed no documented entries for Section GG regarding mobility and assistive devices. Review of the MDS assessment dated [DATE], revealed the facility assessed Resident #381 to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15), indicating he/she was cognitively intact. Review of the facility's event report dated 01/18/2024 at 12:38 PM, revealed Resident #381 had fallen out of his/her wheelchair while attempting to pick up a straw. Per review, Resident #381 did not sustain any injuries. Review of the facility's Interdisciplinary Team (IDT) meeting notes dated 01/19/2024 at 8:56 AM, revealed the root cause analysis (RCA) concluded Resident #381 had slid out of the wheelchair. Further review revealed an intervention was placed for Dycem to Resident #381's wheelchair. Review of the facility's Fall Risk Assessment tool revealed the facility assessed Resident #381 to have a risk score of sixteen (16), which determined the resident was at high risk for falls. Review of the event report dated 01/27/2024, revealed a nurse found Resident #381 lying on his/her back on the floor between the air conditioning unit and bed. Continued review revealed when Resident #381 was asked what had happened, the resident stated, I was trying to get up to bathroom. Review of the IDT meeting notes dated 01/27/2024 at 8:47 AM, revealed the RCA concluded Resident #381 had been attempting to self- ambulate to the bathroom. An intervention was placed for a low air loss (LAL) bolstered mattress which was ordered. Review of the Fall Risk Assessment tool dated 01/27/2024 revealed the facility assessed Resident #381 to be a high risk for falls with a score of twenty-seven (27). Review of Resident #381's CCP with a creation date of 01/22/2024, revealed the facility care planned the resident for falls as a Problem category. Continued review revealed an intervention for Dycem to the resident's wheelchair. During observation on 01/26/2024 at 8:58 AM, Dycem was observed underneath a padded cushion on Resident #381's wheelchair. Observation on 01/27/2024 at 8:00 AM, revealed Resident #381 lying on his/her bed, with his/her wheelchair in his/her room and no Dycem observed on the wheelchair. Review of the Physician's Orders dated 12/14/2023 through 01/28/2024, revealed an order dated 12/15/2023, for a pressure relieving redistributing mattress. Review of the Activities of Daily Living (ADL) binder for the 700 Hall revealed a document titled, Assignment 700, last updated 11/29/2023, revealed columns which included: the room number; resident's name; incontinent supply; shower schedule; thickened fluid/fluid restriction; oxygen; fluid restriction; lift sling size; transfer assist; mobility bar; toileting; additional skin interventions; and safety interventions. Further review revealed additional columns listing toileting/urine and transfer/assist. Review further revealed however, Resident #381's name was not listed on the Hall 700 documentation. During an interview with Certified Nursing Assistant (CNA) #9 on 01/25/2024 at 11:30 AM, she stated she was caring for Resident #381 that day and knew the resident was a fall risk and kept his/her bed in low position. In continued interview CNA #9 stated she did not look at the residents' Care Plan and also stated the facility had not offered training on that task. CNA #9 stated she had not worked any of the times Resident #381 sustained falls; however, she tried to offer increased supervision by constantly walking the hall. She further stated when asked if Dycem was to be in Resident #381's wheelchair, she stated she did not know what that was. During an interview with CNA #10 on 01/27/2024 at 10:20, she stated she was taking care of Resident #381 that day. CNA #10 stated she had not gotten report on Resident #381 that day. When the State Survey Agency (SSA) Surveyor asked CNA #10 about the fall Resident #381 sustained last night, the CNA said she had not been told anything about that. When the SSA Surveyor asked the CNA how she knew what care to provide Resident #381 if she had not received report, she stated she looked in the ADL book. She further stated the ADL book was located in the nurses' station and it had schedules in it and told the CNA's what they needed to know about how the resident got up and down and what their needs were. During an interview with the Physical Therapy Rehabilitation Director (PTRD) on 01/25/2024 at 12:05 PM, she stated Resident #381 had started therapy after he/she sustained a cervical fracture following a fall. She stated Resident #381 was a fall risk and should have Dycem to his/her wheelchair. The PTRD stated Resident #381 was getting stronger and felt like moving about more and do things on his/her own. In an additional interview with the PTRD on 01/26/2024 at 9:00 AM, she stated Dycem was to be in contact with the person sitting in chair/wheelchair. During an interview on 01/26/2024 at 10:30 AM, Licensed Practical Nurse (LPN) #3 she stated she was caring for Resident #381 that day and knew the resident was a fall risk. The LPN further stated the resident had sustained a fall last night, and said no additional supervision was being provided to Resident #381. During an interview on 01/27/2024 at 1:50 PM, with LPN #9 she stated she was an agency nurse and had been staffing at the facility off and on for about six (6) months, with the last time being about three (3) weeks ago. She stated she was taking care of Resident #381 that day. However, she had not viewed the resident's CCP and was providing care just going by what night shift had reported to her. The LPN stated she had taken care of Resident #381 in the past. When the SSA Surveyor asked if Resident #381 was a fall risk, during the time she had worked for the facility, she said she was unsure, but knew the resident was one now since his/her fall. In continued interview she said if Resident #381 had Dycem ordered to his/her wheelchair it should have been placed there so the resident could sit on it and not slide out of the chair. LPN #9 further stated she was unsure if any other interventions had been placed, other than she thought a bedside commode was in the resident's room. 2. Review of Resident #41's face sheet revealed the facility admitted the resident on 07/20/2018, with diagnoses including hemiplegia (paralysis of one side of the body) affecting his/her left non-dominant side, epilepsy, and unspecified dementia. Review of Resident #41's Annual MDS assessment dated [DATE], revealed the facility assessed the resident with a BIMS' score of two (2) out of fifteen (15), indicating the resident was severely cognitively impaired. Further review revealed the facility had not completed the assessment for the resident's functional status (Section GG). Review of Resident #41's care plan, dated 01/23/2024, revealed the facility identified Resident #41 as at risk for falls and developed interventions such as keeping the bed in low position (added 07/30/2021), fall mats to the left side of his/her bed, and keeping the resident's wheelchair within reach. Review of the facility's document titled, Event Report, dated 01/14/2024, revealed staff found Resident #41 lying on the floor after he/she attempted to self-transfer from the wheelchair to the bed. Further review revealed the facility assessed the resident as at high risk for falls due to cognitive limitations and unsteady gait. Observation on 01/23/2024 at 8:58 AM, revealed Resident #41's bed was elevated high off the floor while the resident was lying on the bed with his/her eyes closed. Further observation on 01/23/2024 at 8:58 AM and on 01/28/2024 at 9:52 AM, revealed Resident #41's bed remained elevated high off the floor while the resident was lying on the bed with his/her eyes closed. In an interview on 01/23/2024 at 4:53 PM, Resident #41 stated he/she fell out of bed last month. In an interview on 01/23/2024 at 2:47 PM, Certified Nursing Assistant (CNA) #7 stated she did not know how to find out what care residents needed, as this was her first day working on the floor. In further interview, CNA #7 stated she did not know if Resident #41 was at risk for falls, nor did she know if the resident's bed should have been lowered from its current elevated level. CNA #7 did not lower Resident #41's bed at that time. In an interview on 01/23/2024 at 2:55 PM, CNA #21 explained she worked on the odd number rooms on the 300 Hall, and she was not familiar with the residents in the even numbered rooms, where Resident #41 resided. While standing at Resident #41's room, CNA #21 observed Resident #41's bed up in a higher than normal bed position; however, she did not go and lower the resident's bed. CNA #21 stated she was unable to say if the resident's bed was supposed to be in a low position or not. Per interview, CNA #21 further stated she did not know how to find out what care the residents required, other than what she was told during report from the previous shift. In an interview on 01/28/2024 at 11:55 AM, Registered Nurse (RN) #2 stated Resident #41 was at risk for falls and his/her bed should have been kept in the lowest position. Per interview, RN #2 stated Resident #41 would sometimes raise his/her own bed, but staff should lower the bed when they saw it elevated. In an interview on 01/28/2024 at 2:03 PM, the Director of Nursing (DON) stated Resident #41 liked to use his/her bed controls to raise the bed sometimes; however, she expected staff to lower it back down when they noticed it was elevated. Per interview, the DON further stated she expected resident-centered care plan interventions to be followed by all staff. In an interview on 01/28/2024 at 5:05 PM, the Administrator stated she expected each care planned fall prevention measure to be followed by staff. Per interview, the Administrator stated Resident #41 might raise his/her bed, but staff should lower it during their routine safety rounds. In an interview with the Minimum Data Set (MDS) Coordinator on 01/28/2024 at 10:45 AM, she stated it was her expectation for all staff to review all resident CCPs, adding the CNAs had an ADL binder they referred to as well for care to be provided to residents. She stated the ADL binder was to be updated, she thought by the Director of Nursing (DON), Assistant Director of Nursing (ADON) or Unit Managers. In an interview with the DON on 01/28/2024 at 4:00 PM, she stated she had held the title for about six (6) months and her job duties included oversight of the clinical component of the facility, which included nurses and nurse aides. She stated her oversight included providing education; assuring tasks were being performed; and directing staff tasks. The DON stated her expectation of staff was for them to follow residents' CCP and the facility's CCP process. When the SSA Surveyor asked her about falls, she stated the process was when a fall occurred an event was to be opened, and the nurse should place intervention(s) immediately, and notify her (DON) by phone when it occurred. The DON further stated the Interdisciplinary Team (IDT) then reviewed the event and the interventions put in place. In an interview with the Administrator on 01/28/2024 at 6:10 PM, she stated she had held her title for about five (5) months at the facility. The Administrator stated it was her expectation of staff to follow the Care Plan for each resident. When the SSA Surveyor asked her about falls at facility, she stated a pattern had not been identified and there were no concerns related to falls, adding a fall risk assessment was to be performed to assure the safety of the resident. 46710

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide the necessary hydration needs for two (2) of seventy-one (71) sampled residents, (Resident #48 and Resident #39). Review of Resident #48's Nutrition Therapy Evaluation completed by the Registered Dietitian (RD) on [DATE] revealed the facility assessed the resident to require 1950 milliliters (ml) daily for his/her fluid intake. The Nutrition Evaluation completed by the RD on [DATE] revealed the facility assessed Resident #48 to require 2030 ml/daily for fluid intake. However, review of Resident #48's fluid intake log for October, November, and [DATE] and [DATE], revealed those daily needs were not met. The facility failed to document any refusals by Resident #48 to account for a reason the need was not met. Review of Resident #39's Nutrition Therapy Evaluation completed on [DATE], revealed Resident #39 required the daily intake of 1420 to 1660 ml of fluid. However, review of the resident's daily fluid intake log revealed those needs were not met for fifteen (15) days out of twenty-four (24) in [DATE] and twenty-eight (28) days out of thirty-one (31) days in [DATE]. The findings include: Review of the facility's Hydration Policy, dated [DATE], revealed residents would be provided sufficient amounts of fluid to maintain proper hydration to the extent possible. Per the policy, facility staff would offer fluids to residents throughout all shifts. The policy stated fluids were to be available to the residents at mealtimes, between meals, and at the bedside, as needed and as requested. Per the policy, the dietitian would assess each resident for the daily hydration needs quarterly and as needed, and any changes in the resident's hydration status would be reported to a licensed nurse and an assessment would be completed. 1. Observation on [DATE] at 3:25 PM, revealed Resident #48 was sleeping, almost flat on his/her back, had oxygen on, was in a hospital gown, and had a low air flow mattress. There was no water at the bedside. Observation on [DATE] at 8:45 AM, revealed Resident #48's breakfast tray was sitting on the tray table over the bed, the resident was sleeping, and had not touched any of his/her food. Observation on [DATE] at 1:30 PM, revealed Resident #48 was sleeping, and no water was in the room for the resident to drink. Observation on [DATE] at 10:00 AM, revealed Resident #48 was sleeping, and no water was in the room for the resident to drink. Observation on [DATE] at 8:37 AM, revealed Resident #48 was leaned all the way over to the left in the bed, and the resident did not have the ability to lift himself/herself back up. The resident was awake and tried to feed himself/herself; however, the resident could not reach the food. Per the observation, the resident reached the milk and attempted to drink it but began to choke. The State Survey Agency (SSA) Surveyor got staff to assist. The SSA Surveyor talked to the resident while waiting for staff to come. The resident had the look of panic on his/her face. Registered Nurse (RN) #2 arrived and attended to the resident. Review of Resident #48's Face Sheet revealed the facility initially admitted the resident on [DATE] with diagnoses of kidney disease, respiratory failure, epilepsy, and type 2 diabetes. Review of Resident #48's Hospital Discharge Summary, dated [DATE], revealed on [DATE], the resident was found hard to arouse, was very pale in color, and had a weak hand grip. The summary stated the resident had a blood pressure of ,d+[DATE], pulse of 54, and oxygen saturation of 92 percent with two (2) liters of oxygen. The resident was sent to the Emergency Department (ED) and was admitted for treatment for acute hypoxic respiratory failure, urinary tract infection (UTI), and toxic metabolic encephalopathy. Review of Resident #48's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident with a Brief Interview of Mental Status (BIMS) score of ten (10) of fifteen (15), which indicated the resident was moderately cognitively impaired. The MDS assessment revealed the resident was dependent on staff for bed mobility and transfers; set-up only for eating; and, the resident had a catheter in place. Review of Resident #48's Comprehensive Care Plan revealed staff was to encourage adequate fluid intake as determined by dietary as of [DATE]. Per the care plan, staff was to assist the resident with fluids as needed to prevent dehydration as of [DATE]. Review of Resident #48's Nutrition Therapy Evaluation completed by Registered Dietitian (RD) #2 on [DATE], revealed she assessed the resident for 1950 milliliters of fluid intake per day. The facility documented the following fluid intake for Resident #48 for [DATE] after the assessment: on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] the facility did not document any fluid intake for the resident. Further review for the resident's fluid intake revealed the following: on [DATE], 760 ml; [DATE], 720 ml; [DATE], 660 ml; [DATE], 600 ml; and [DATE], 480 ml. Review of Resident #48's census revealed he/she was present in the facility [DATE] through [DATE]. Review of Resident #48's Nutrition Therapy Evaluation, dated [DATE], revealed RD #2 evaluated the resident and assessed him/her for 2030 ml of fluids per day. The facility documented Resident #48's fluid intake for [DATE] as [DATE], 660 ml; [DATE], 240 ml; [DATE], 480 ml; [DATE], 780 ml; [DATE], 240 ml; [DATE], 920 ml; [DATE], 720 ml; [DATE], 720 ml; and [DATE], 340 ml. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] through [DATE] there was no documented evidence of fluid intake for Resident #48. Review of Resident #48's daily fluid intake log for [DATE], revealed the facility documented the following intake: on [DATE], 780 ml; [DATE], 480 ml; [DATE], 650 ml; [DATE], 120 ml; [DATE], 600 ml; [DATE], 620 ml; [DATE], 480 ml; and [DATE], 480 ml. There was no documented evidence of fluid intake monitoring for Resident #48 on [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] through [DATE]. Review of Resident #48's census, revealed the resident was present in the facility for the entire month of [DATE]. Review of Resident #48's census, revealed the resident was in the hospital [DATE] through [DATE]. Review of Resident #48's daily fluid intake log for [DATE], revealed [DATE], 660 ml; [DATE], 240 ml; [DATE], 620 ml; [DATE], 240 ml; [DATE], 480 ml; [DATE], 480 ml; [DATE], 480 ml; [DATE], 480 ml; [DATE], 240 ml; [DATE], 225 ml; and [DATE], 240 ml. The log also revealed the facility failed to provide documented evidence of any fluid intake for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE] and [DATE]. 2. Observation on [DATE] at 9:00 AM of Resident #39, revealed the resident was sleeping, with the television tray next to the bed. However, the resident did not have any drinking water present at his/her bedside. Observation on [DATE] at 1:40 PM of Resident #39, revealed the resident was in his/her bed watching television, and the resident did not have drinking water available. Observation on [DATE] at 8:40 AM of Resident #39, revealed breakfast trays had not yet been served, and the resident did not have drinking water available at his/her bedside. Observation on [DATE] at 10:00 AM, revealed Resident #39's bed was in a low position, the resident had placed his/her cup on the fall mat next to the bed on the floor. The resident was able to reach down, pick up his/her cup, and lift it to his/her mouth. The cup had a straw in it, and the resident attempted to take a drink, but the cup had very little fluid in it, and a slurp could be heard. The resident laughed and shrugged his/her shoulders. Per the observation, Resident #39 was able to communicate well, when asked yes and no questions. Also, the resident was able to say he/she was in the Navy but could not remember what he/she did in the Navy. The observation revealed the resident had the ability to make some needs known. Review of Resident #39's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses of cerebral infraction, malnutrition, and psychosis. Review of Resident #39's Nutrition Evaluation Therapy form, dated [DATE], revealed the Registered Dietitian (RD) assessed the resident with a daily fluid intake need of 1420 to 1660 milliliters (ml). Review of Resident #39's census revealed he/she was present in the facility for the entire month of [DATE]. Review of Resident #39's daily fluid intake log for [DATE], revealed the facility did not provide documented evidence the resident received 1420 ml of fluid per day starting [DATE]. The resident's medical record revealed also on [DATE] the resident took in 480 ml of fluid; [DATE], 960 ml; [DATE], 720 ml; [DATE], 0 ml; [DATE], 480 ml; [DATE], 1090 ml; [DATE], 240 ml; [DATE], 480 ml; [DATE], 480 ml; [DATE], 850 ml; [DATE], 480 ml; [DATE], 240 ml; [DATE], 720 ml; [DATE], 600 ml; and [DATE], 480 ml. Review of Resident #39's daily fluid intake log for [DATE], revealed the facility failed to provide documented evidence of daily fluid intake for [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Additionally, the intake log revealed the resident's daily fluid intake was [DATE], 960 ml; [DATE], 1080 ml; [DATE], 480 ml; [DATE], 1200 ml; [DATE], 480 ml; [DATE], 480 ml; [DATE], 480 ml; [DATE], 240 ml; [DATE], 480 ml; [DATE], 640 ml; [DATE], 1120 ml; [DATE], 1280 ml; [DATE], 1120 ml; [DATE], 960 ml; [DATE], 760 ml; [DATE], 1320 ml; [DATE], 600 ml; [DATE], 1280 ml; [DATE], 720 ml; [DATE], 1120 ml; [DATE], 480 ml; and [DATE], 640 ml. Review of Resident #39's Admission Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of two (2) of fifteen (15), signifying a severe cognitive impairment. The facility assessed the resident as needing supervision, cueing, touching, and steadying while eating. The resident had a contracture to the right hand and wrist. Review of Resident #39's Comprehensive Care Plan (CCP) initiated [DATE] revealed staff was to encourage the resident's oral food and fluid intake, monitor the resident for swallowing concerns ([DATE]), encourage the resident to eat in the common area to increase intake ([DATE]), refer to Restorative Dining ([DATE]), and observe for side effects of antipsychotic medication such as dry mouth and urinary retention ([DATE]). Resident #39's hydration needs were not added to the care plan until [DATE], noting staff was to offer the resident fluids within limits, and limits were not noted on the care plan. In an interview with the Activities Director on [DATE] at 11:21 AM, she stated she helped serve drinking water and ice to the residents. She explained it was important for the residents who were able to drink fluids to have the needed fluid intake daily. The Activities Director stated a resident could become sick if he/she did not take in fluids daily. She stated she talked with the residents and encouraged them to drink throughout the day. In an interview with Certified Nursing Assistant (CNA) #19 on [DATE] at 10:05 AM, he stated he counted residents' fluid intake when he picked up trays and throughout the day when he checked on the residents. He stated there was staff who brought around water and ice. CNA #19 stated he charted fluid intake right after he saw the resident with a drink. He stated it was important to keep track of a resident's fluid intake, and if there was a change, he informed the nurse so the nurse could assess the resident. CNA #19 explained for the residents who were unable to drink on their own, he offered them sips throughout the day. He stated, for residents' health and safety, it was important to monitor the residents' intake and output. In an interview with Certified Nursing Assistant (CNA) #23 on [DATE] at 4:10 PM, she explained she wrote down each resident's fluid intake after meals. She stated she tried to encourage residents to drink the necessary fluids throughout the day. The CNA also stated there were some residents that needed physical assistance to be able to drink, and in that case those residents were offered a few sips at a time. CNA #23 stated if she noticed a resident did not take in enough fluids for the day, she would notify the nurse. She explained if the resident did not get enough fluids, it could have a negative impact on how much the resident used the bathroom and that could be a concern. CNA #23 said Resident #39 had the ability to drink water on his/her own and did better with the use of a straw. In an interview with Registered Nurse (RN) #2 on [DATE] at 4:32 PM, she stated she encouraged residents to take fluids when she administered medication. She stated if an aide reported to her a resident had not taken in the daily needed fluid, she would go and assess the resident. She explained the meal tickets had the required daily fluid intake for each resident, and aides were expected to document the intake for each meal and throughout the day. RN #2 stated if a resident was not able bodied , she would help and encourage the resident to drink the water. She stated she would try to find out if there was a reason the resident did not want to drink the water. RN #2 stated concerns for residents who did not take in the necessary fluids could be dehydration which could lead to a urinary tract infection (UTI) and weight loss. She stated she would contact the Medical Director to determine what course of action was needed. RN #2 stated Resident #48 was able to eat and drink on his/her own until recently with a decline in health. RN #2 stated Resident #39 had the ability to drink on his/her own but required constant reminders to do so. In an interview with the Director of Nursing (DON) on [DATE] at 2:17 PM, she was unable to determine why Resident #48's and Resident #39's missing documentation of daily fluid intake was not caught and addressed in the clinical whiteboard meeting which was held Monday through Friday in the morning. She stated a report of fluid intake was printed each day and reviewed for concerns. The DON stated items of concern were addressed in real time in those daily meetings. She stated she was unable to explain why Resident #48 and Resident #39 had so many undocumented days of fluid intake and why a plan was not established to ensure their daily needs were met. The DON stated in nursing if something was not documented, it meant it did not happen. She explained there would be many concerns for a resident who did not get his/her daily needed fluid intake,such as dehydration and/or a urinary tract infection (UTI). The DON stated the facility had a Hydration program two (2) times a week throughout the facility in which additional fluids were provided. In an interview with the Administrator on [DATE] at 6:10 PM, she stated she expected all residents to be provided the necessary daily fluids to meet their intake needs. She explained if a resident was not taking in the necessary fluids daily it would need to be addressed as it could cause serious health concerns for the resident. She also could not explain why concerns for these two (2) residents were not identified and addressed in the morning meeting. The Administrator stated she expected all staff members to follow the policies of the facility, and any concerns were to be reported to the nurse and followed up by the DON.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure pain management was provided to residents who required such services. The facility failed to ensure pain medication was administered as needed and as ordered to the resident per the Physician's Orders, the Comprehensive Care Plan, and the goals and preferences for one (1) of seventy-one (71) sampled residents (Resident #325). The findings include: Review of the facility's policy titled, Pain Management, revised 09/01/2023, revealed the facility would ensure that pain management was provided, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Review of the facility's policy titled, Medication Administration General Guidelines, dated 09/2018, revealed when necessary medications were administered the complaints or symptoms for which the medication was given should be documented. Review of Resident #325's Face Sheet revealed the facility admitted the resident on 01/08/2024 with diagnoses to include pain in the left ankle and joints of the left foot, type 2 diabetes, and chronic obstructive pulmonary disease (COPD). Review of Resident #325's Discharge Summary from the hospital, dated 01/08/2024, revealed the resident had a discharge diagnosis of left ankle pain due to tenosynovitis (inflammation of the protective sheath that surrounds tendons). Further review revealed the resident's pain had not been resolved and he/she remained in quite a bit of pain with tenderness in the left foot. Review of Resident #325's Admission Minimum Data Set (MDS) Assessment, dated 01/14/2024, revealed in the Pain Assessment Interview, the resident self-reported not having constant pain within the last five (5) days, and no further assessment was completed. Further review revealed the resident had a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15)which indicated the resident was cognitively intact. Review of Resident #325's Baseline Care Plan (BCP), dated 01/09/2024, revealed the resident was assessed as verbalizing or exhibiting signs of pain or at risk for pain. Review of Resident #325's Person-Centered Comprehensive Care Plan (CCP), revised 01/23/2024, revealed the resident was care planned for being at risk for pain related to left ankle tenosynovitis and diabetic neuropathy, updated 01/21/2024. Nursing staff were to administer pain medications as ordered and to monitor and record the effectiveness of the medications, updated 01/21/2024. Nursing staff were to assess the effects of pain on the resident, and notify the physician if the resident did not demonstrate relief or reduction of pain with the current treatment regimen, updated 01/21/2024. Further review revealed interventions that included: nursing staff were to observe and record any complaints of pain, to include the location, duration, quantity, quality, and alleviating factors or aggravating factors, updated 01/21/2024. Nursing staff were also to observe and record any nonverbal signs of pain including guarding, moaning, restlessness, grimacing, and diaphoresis, updated 01/21/2024. Review of Resident #325's Physician Orders, dated 01/09/2024, revealed a medication order for acetaminophen (analgesic to treat minor aches and pain) 325 mg (milligrams), two (2) tablets by mouth every four (4) hours and oxycodone-acetaminophen (opioid pain reliever to treat moderate to severe pain) 7.5-325 mg one (1) tablet by mouth every six (6) hours as needed (PRN) for pain. Review of Resident #325's Medication Administration Record (MAR), dated 01/2024, revealed the resident was receiving acetaminophen tablet 325 mg (milligrams), two (2) tablets by mouth every four (4) hours PRN for pain. Additionally, the resident was receiving oxycodone-acetaminophen; 7.5-325 mg one (1) tablet by mouth every six (6) hours PRN for pain. The resident received two (2) acetaminophen 325 mg tablets at on 01/21/2024 at 6:40 AM. It was charted as being effective with no time given for follow up assessment of pain. Review of Resident #325's Provider Progress Note, dated 01/10/2024, revealed the resident was admitted with left ankle pain due to tenosynovitis. Further review revealed the resident complained of ongoing right ankle pain, which increased with movement and improved with pain medication. Review of Resident #325's Progress Notes, dated 01/10/2024, revealed no nursing progress notes were entered on 01/21/2024 related to observation of any complaints of pain, to include the location, duration, quantity, quality for Resident #325's complaint of pain, and request for medications. During an interview with Resident #325, on 01/22/2024 at 5:30 PM, the resident stated that in the early morning, on 01/21/2024, he/she woke up in severe pain radiating down his/her left ankle and foot. The resident stated his/her ankle and foot were swollen and felt warm to the touch. He/she stated that he/she rang the call light at 3:33 AM to request pain medication. At 3:43 AM, a Certified Nursing Assistant (CNA) answered the call light. The CNA came into the resident's room, turned off the call light, and stated she would tell Registered Nurse (RN) #9 about the resident's pain. The resident stated that RN #9 did not come to the room. The resident waited and rang the call light again at 5:00 AM. At 6:00 AM, the call light had not been answered. During continued interview Resident #325 stated, The staff was ignoring the call light for 2 hours and 54 minutes. He/she stated they were sure of the timing because he/she had set the timer on his/her phone to time the staff's response. The resident stated RN #9 peeked his head in the room at 6:15 AM and asked what he could do for the resident. Resident #325 stated he/she told the RN that he/she was experiencing pain and requested Oxycodone-acetaminophen pain medication. The resident stated RN #9 did not assess the pain or check the left ankle and foot. At 6:38 AM, RN #9 returned with two (2) acetaminophen tablets. The resident stated, I was not given the Oxycodone-acetaminophen I asked for. After waiting so long for the nurse, I needed the stronger pill to get relief. The Tylenol didn't touch the pain. The resident stated at 6:47 AM he/she placed a call to 911 to get help. Review of the Police Incident Report, dated 01/21/2024, revealed police were dispatched to the facility at 6:50 AM after the resident called 911 and stated the reason for the request was, Staff withholding pt [patient] meds [medications]. Review of the Police Run Report, dated 01/21/2024, revealed a Police Department Officer (Badge ID #7134) arrived at the facility at 6:50 AM and reported, Victim stated on 01/21/24 in the early morning hours that [he/she] was in very uncomfortable pain. Victim pressed the call button for the nurse and no one ever came into the room. Victim then again pressed the call button and began a timer. [He/she] stated it took 2 hours and 54 minutes before anyone came in and checked on [him/her]. No further interviews were taken by the Officer. In an interview, on 01/28/2024 at 2:03 PM, the Director of Nursing (DON) stated she expected that medications were administered timely and as per the Physician's Orders. She stated if the resident had pain medication ordered as needed the medication should be administered when the resident had pain She further stated it was her expectation that nursing staff follow physician orders and follow the care plan. In an interview, on 01/28/2024 at 5:05 PM, the Administrator stated her expectations were for the care plan to be resident-specific and for staff to implement care planned interventions. She stated she expected staff to provide timely assistance to residents, emphasizing that staff were expected to administer pain medicatons for residents in pain, as ordered.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for two (2) out of seventy-one (71) sampled residents (Residents #11 and #17). During medication pass observations, the facility failed to have magnesium 400 milligrams (mg) available for Resident #11. Furthermore, the facility failed to have polyethylene glycol 17 grams (Miralax) and a lidocaine 5% patch available for Resident #17. The findings include: Review of facility's policy titled, Medication Administration, dated 09/2018, revealed medications were to be administered as prescribed and in accordance with good nursing practices. 1) Review of Resident #11's Face Sheet revealed the facility admitted the resident on 06/26/2018 with diagnoses including congestive heart failure, acute respiratory failure, and chronic obstructive pulmonary disease (COPD). Review of Resident #11's Electronic Medication Administration Record (eMAR), dated 01/2024, revealed the physician ordered magnesium oxide four hundred (400) milligrams (mg) by mouth once per day. Further review revealed Registered Nurse (RN) #1 charted the medication as unavailable on 01/23/2024. Observation on 01/23/2024 at 9:51 AM revealed RN #1 prepared medications for Resident #11, but could not locate the magnesium oxide pills in the medication cart. Further observation revealed RN #1 marked the medication as not available and proceeded with medication administration. In an interview on 01/23/2024 at 9:51 AM, RN #1 stated her process for an unavailable medication was to notify pharmacy after she finished medication pass to get the medication delivered for the next day. 2) Review of Resident #17's Face Sheet revealed the facility admitted the resident on 10/06/2016 with diagnoses including diverticulitis (inflammation of the intestines), muscle weakness, and type 2 diabetes. Review of Resident #17's eMAR, dated 01/2024, revealed the physician ordered two (2) patches of lidocaine five percent (5%) to be applied to the resident's back every day for twelve (12) hours. Further review revealed staff marked the medication as unavailable on 01/15/2024, 01/19/2024, 01/22/2024, 01/24/2024, and 01/27/2024. Continued review revealed the physician ordered polyethylene glycol 17 grams (Miralax) to be administered once per day. Per record review, LPN #9 marked polyethylene glycol 17 grams (Miralax) as unavailable on 01/26/2024. Observation on 01/26/2024 at 8:33 AM revealed Licensed Practical Nurse (LPN) #9 found Resident #17's lidocaine 5% patch was not available. Further observation revealed LPN #9 reordered the medication from the eMAR system, and a message displayed that LPN #9 had previously reordered the medication on 01/24/2024. In an interview on 01/26/2024 at 8:33 AM, LPN #9 stated she ordered Resident #17's lidocaine patch on 01/24/2024 and showed that date in the electronic Medication Administration Record system. In further interview, she stated she had not worked since 01/24/2024 and did not realize the medication had not been delivered. Per interview, LPN #9 stated pharmacy made multiple deliveries to the facility each day and the lidocaine patch should have been on one of the deliveries. A phone interview was attempted with the pharmacy representative, on 01/28/2024 at 4:17 PM, however, the State Survey Agency (SSA) Surveyor was left on hold and never received an answer. In an interview on 01/28/2024 at 2:03 PM, the Director of Nursing (DON) stated the process for ensuring medications were available to be administered timely was for staff to reorder any medication that was low, whether that was on the reminder sticker on the card or when they noticed a multi-dose bottle, such as polyethylene glycol (Miralax), was low. She further stated she had not been notified of an issue with medication delivery, but she would investigate if she became aware of medications being missed or administered late. In an interview on 01/28/2024 at 5:05 PM, the Administrator stated the facility's process for ensuring medications were available to be administered timely was for the nurse to reorder any medication that was running low. She further stated the pharmacy typically sent a thirty (30) day supply of medications, but she did not know if a resident's maintenance medications were refilled automatically.

Based on interview, record review, review of facility policies and video surveillance, it was determined the facility failed to have an effective system to ensure implementation of a comprehensive care plan for one (1) of three (3) sampled residents (Resident #1). On 05/24/19 at approximately 9:56 AM, Resident #1 exited the facility without staff knowledge. Staff observed Resident #1 in a grassy area of the adjoining property where the resident fell at approximately 10:10 AM. The facility care planned the resident to include an intervention of an audible alarm to alert staff when the resident displayed exit-seeking behaviors. Review of the facility's video revealed the resident propelled his/her wheelchair out of the facility as the Hairdresser entered the facility. Staff was seen in the video in the same area when the resident exited the facility; however, there were no attempts by staff to prevent Resident #1 from exiting and an alarm did not sound. Staff assessed the resident without injury and returned the resident to the facility. The facility's failure to have an effective system in place to implement comprehensive care plans has caused, or is likely to cause, serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 07/19/19, and was determined to exist on 05/24/19. The facility was notified of the Immediate Jeopardy on 07/19/19. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 07/22/19, alleging the removal of Immediate Jeopardy on 06/06/19. The State Survey Agency verified Immediate Jeopardy was removed on 06/06/19 as alleged, prior to initiation of this investigation, on 07/16/19; therefore, it was determined to be past Immediate Jeopardy. The findings include: Review of facility policy Department: Clinical Elopement/Wandering, revised 05/30/18, revealed the facility maintained resident safety by identifying residents at risk for wandering/elopement behavior. Review of facility policy Department: Clinical Comprehensive Care Plans, revised 07/19/18, revealed a person-centered comprehensive care plan included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs, and was developed for each resident. The care plan included how the facility would assist the resident to meet their needs, goals and preferences. Additionally, item #8 revealed the facility implemented care plan interventions after consideration of a resident's problem areas and causes, and addressed the underlying source(s) of the problem area(s). Further review revealed the nurse/Interdisciplinary team were responsible for the review and update of care plans. Review of the medical record for Resident #1 revealed the facility admitted the resident on 04/01/16 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed the resident scored a twelve (12) on the Brief Interview for Mental Status (BIMS) exam and the facility determined the resident was interviewable. Review of Section G revealed the facility assessed the resident with a one (1) for walking in room and locomotion on unit, indicating supervision with oversight, encouragement or cueing. Additionally, the facility assessed the resident with a zero (0) for locomotion off unit, indicating independent. Review of Section J revealed the facility assessed the resident with a two (2) indicating falls with no injury since reentry or prior assessment. Review of Section P revealed the facility assessed the resident as using wander/elopement alarms daily. Review of the Comprehensive Care Plan for Resident #1 revealed the Problem, Elopement Risk Exit Seeking, dated 04/10/19. For this problem the facility listed interventions including the use of an audible monitoring system to alert staff of exit seeking behaviors, dated 01/23/19; to observe tailgating when visitor in the building, dated 04/22/19; and, to use diversion activities when exit seeking behavior is occurring, dated 04/22/19. Review of the physician's orders [REDACTED]. Further review revealed the order dated 01/17/19 to check function of wander guard daily. Review of the Medication Administration Record [REDACTED]. Review of the facility's investigation into the event revealed a facility resident observed Resident #1 outside the facility on the adjoining property and alerted social services who responded outside and observed Resident #1 lying on the grass. Social Services returned into the building and alerted nursing staff. Nursing staff immediately responded and found Resident #1 standing in the grassy area where nursing staff then assessed Resident #1 with no injury and assisted Resident #1 back into the facility. Further review revealed the facility discovered the wander guard for Resident #1 was not in place when the resident was discovered outside. Interview with Registered Nurse (RN) #2, on 07/18/19 at 2:42 PM, revealed she was present the day Resident #1 eloped. RN #2 stated she had previously observed Resident #1 in her wheel chair near the front desk and door. RN #2 stated if Resident #1 found a way to remove the wander guard, the resident would remove the wander guard. She stated the plan of care directed staff in the care needs of the resident. She stated if not followed the resident would not be taken care of properly. Interview with RN #1, on 07/18/19 at 3:22 PM, revealed she was present and assessed the resident with no injuries. RN #1 stated the resident was not wearing a wander guard when staff discovered the resident outside. RN #1 stated, on the day of the elopement, she did not remember if she visualized Resident #1's wander guard in place, prior to his/her elopement; however, she did document on the MAR indicated [REDACTED]. Interview with the Minimum Data Set (MDS) Coordinator, on 07/19/19 at 2:11 PM, revealed the comprehensive care plan focused the staff on the care needs of the resident. The MDS stated care plans also alerted staff to risks for each resident. The MDS stated if staff failed to follow a comprehensive care plan then the facility had not taken care of the resident, which could lead to negative effects, complications, or adverse actions. Interview with the Director of Nursing (DON), on 07/19/19 at 2:47 PM, revealed a comprehensive care plan gave staff a picture of how to care for a resident, and not following a resident's comprehensive care plan could lead to resident injury. Interview with the Administrator, on 07/19/19 at 4:50 PM, revealed the facility followed State and Federal regulations and listed a goal to provide the best care and safety of the residents. The Administrator stated the facility determined the absent wander-guard care plan intervention for Resident #1, allowed the resident to elope from the facility.

Based on interview, record review, and review of the facility's policies and video surveillance, it was determined the facility failed to have an effective system to ensure residents assessed at risk for elopement received adequate supervision to ensure their safety for one (1) of three (3) sampled residents (Resident #1). Record review revealed the facility assessed Resident #1 at risk for elopement and the resident used a wander/elopement alarm daily. Review of the facility's video revealed on 05/24/19 at approximately 9:56 AM, revealed Resident #1 propelled his/her wheelchair out of the facility without staff knowledge and was returned to the facility approximately ten (10) minutes later after another resident alerted staff the resident was outside. Review of the facility's investigation, not dated, revealed Resident #1 had exited the facility via the front doors and had fallen on the ground in a grassy area of the church property next door. Staff assessed the resident without injury and determined the resident did not have a wander guard bracelet in place. The facility's failure to have an effective system in place to ensure staff provided adequate supervision of residents has caused, or is likely to cause, serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 07/19/19, and was determined to exist on 05/24/19. The facility was notified of the Immediate Jeopardy on 07/19/19. The facility provided an acceptable Allegation of Compliance (A[NAME]) on 07/22/19, alleging the removal of Immediate Jeopardy on 06/06/19. The State Survey Agency verified Immediate Jeopardy was removed on 06/06/19 as alleged, prior to exit on 07/24/19; therefore, it was determined to be past Immediate Jeopardy. The findings include: Review of the facility's policy Department: Clinical Elopement/Wandering, revised 05/30/18, revealed the facility maintained resident safety by identifying residents at risk for wandering/elopement behavior. The facility completed an elopement/wandering assessment upon admission, and quarterly thereafter. Review of the facility's policy Secure (Wandering) System on Door, revised (MONTH) 2005, revealed all exterior doors would alarm when opened with the proper steps followed to insure the safety of residents and staff members. Record review revealed the facility admitted Resident #1 on 04/01/16 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed the resident scored a twelve (12) on the Brief Interview for Mental Status (BIMS) exam and the facility determined the resident was interviewable. Review of Section G revealed the facility assessed the resident to need supervision while walking in his/her room and during locomotion on the unit. Review of Section P revealed the facility assessed the resident as using wander/elopement alarms daily. Review of the Comprehensive Care Plan for Resident #1 revealed the Problem, Elopement Risk Exit Seeking, dated 04/10/19. For this problem the facility listed interventions including the use of an audible monitoring system to alert staff of exit seeking behaviors, dated 01/23/19; to observe tailgating when visitor in the building, dated 04/22/19; and, to use diversion activities when exit seeking behavior is occurring, dated 04/22/19. Review of the Progress notes revealed an entry dated 05/24/19, recorded at 8:57 PM that stated the SSA notified Registered Nurse #1 Resident #1 had fallen outside the building. The progress note revealed RN #1 and the Nurse Practitioner found the resident at the church next door. The progress note further revealed staff assessed the resident with no injuries. Review of the facility's investigation, not dated, revealed Resident #1 exited the facility's front doors at approximately 9:56 AM, and staff found the resident around 10:10 AM outside the facility on the adjoining property laying on the grass. Staff assessed the resident with no injuries and assisted back into the building. The resident reported to the staff he/she was going home. Further review revealed the facility determined the wander guard for Resident #1 was not in place when facility staff discovered the resident outside. Observation of the facility's video, dated 05/24/19, revealed at approximately 9:56 AM, Resident #1 was seated in wheelchair as he/she self-propelled through the facility's two sets of front doors. At the same time, the facility's Hairdresser entered the building, while other staff walked in the path of the front doors without acknowledging Resident #1 exiting. Continued review revealed another resident in a wheelchair entered the facility from outside and stopped the Social Services Assistant (SSA) that was exiting, and then pointed outside to the right of the facility. The SSA went outside looked around, then came back in the building, and appeared to search for assistance in a hurry. The SSA then returned with other staff and proceeded outside. Approximately ten minutes later staff re-entered the building with Resident #1 in his/her wheelchair. Interview with the Hairdresser, on 07/19/19 at 9:41 AM, revealed she did not know Resident #1 was an elopement risk and the facility had not trained her on the Elopement Policy. Interview with Social Services Assistant (SSA), on 07/19/18 at 9:04 AM, revealed a resident alerted her Resident #1 was outside the facility. The SSA stated she went outside and observed Resident #1 lying on the grass; then went back into the facility to obtain assistance and returned to Resident #1 with Registered Nurse (RN) #1, and the Nurse Practitioner (NP). The SSA stated staff determined Resident #1 was not wearing a wander guard as ordered. Interview with Registered Nurse (RN) #1, on 07/18/19 at 3:22 PM, revealed she was present and assessed the resident with no injuries. RN #1 stated the resident was not wearing a wander guard when staff discovered the resident outside. Interview with the NP, on 07/19/19 at 11:06 AM, revealed she responded with facility staff after she learned Resident #1 had fallen outside the facility. The NP stated she assisted with a brief assessment of the resident outside and found no concerns, and conducted a more thorough assessment upon returning the resident into the facility. The NP stated she did not remember if there was a wander guard on the resident's ankle. Interview with the Social Services Director (SSD), on 07/19/19 at 9:57 AM, revealed she was aware Resident #1 was at risk for elopement. The SSD stated she observed Resident #1 sitting by the front door on the day the resident eloped but could not recall if the resident was wearing a wander guard. The SSD stated a resident who eloped was at risk for falling, getting hit by traffic, or could experience heat related concerns. Further review of Resident #1's medical record revealed physician's orders [REDACTED]. Further review revealed the order dated 01/17/19 to check function of wander guard daily. Review of the Medication Administration Record [REDACTED]. Interview with Certified Nursing Assistant #1 (CNA), on 07/18/19 at 2:15 PM, revealed she was in a time crunch the morning of 05/24/19 and did not do a visual to check to see if Resident #1 had on the wander guard bracelet during morning care. She stated a resident could get hurt if the wander guard bracelet was not in place. Interview with Registered Nurse (RN) #1, on 07/18/19 at 3:22 PM, revealed she had documented the bracelet was in place on the MAR but could not actually remember visualizing the alarms that morning. She stated she believed the resident was capable of taking the bracelet off. Interview with the Director of Nursing (DON), on 07/19/19 at 2:47 PM, revealed she was not sure what system process broke down to allow the resident to elope without staff knowledge. She stated the facility's front doors were normally unlocked during the daytime hours and then locked at night with access through a push button code. In addition, the DON stated the front doors had a wander guard alarm that would alert staff if a resident with a wander guard bracelet in place got near the door. She stated on 05/24/19 staff found Resident #1 outside by the church sign on the property next door and the wander guard system had not alarmed to notify staff of the elopement. The DON stated the facility determined Resident #1's elopement was due to the unlocked front doors and the resident's wander guard was not in place. She further stated if staff did not ensure the resident had the wander guard bracelet in place, the resident could experience an injury. Interview with the Administrator, on 07/19/19 at 4:50 PM, revealed the facility's goal was to provide the best care and ensure resident safety. The Administrator stated she did not think there was a breakdown in the facility's system to protect residents assessed at risk for Elopement nor had the Secure Wandering System played a role in the resident's elopement. The Administrator stated Resident #1 eloping without staff knowledge was a random situation. She stated the facility determined the resident's absent wander guard allowed Resident #1 to elope from the facility without staff supervision. The facility implemented the following actions to remove Immediate Jeopardy as follows: 1. On 05/24/19 at approximately 10:15 AM, the Staff Development Coordinator (SDC) brought Resident #1 back into the facility without incident. The Nurse Practitioner, who was in the facility at the time of the incident, examined Resident #1 with no injuries noted and ordered one-to-one (1:1) supervision for Resident #1. The Scheduler provided 1:1 supervision of Resident #1 until 3:00 PM. At 3:00 PM Nurse Practitioner discharged 1:1 supervision and implemented every fifteen (15) minute observation checks until 05/28/19. 2. On 05/24/19, facility staff conducted a resident head count determining all 133 residents were accounted for. There was 129 residents in the building and four (4) residents off-site at physician appointments. 3. On 05/24/19, the Administrator and Director of Nursing (DON) notified the resident's Medical Director (physician) and Power of Attorney (POA). The Medical Director ordered a Urinary Analysis, which returned with no noted concerns. 4. On 05/24/19, the DON, Unit Manager (UM) #1, and Social Services Director (SSD) reviewed and updated Resident #1's care plan and elopement risk assessment. 5. On 05/24/19, the Maintenance Director checked all twelve of the facility's exit doors confirming they prevented residents with Wander Guard devices from exiting the facility. Three (3) of the twelve (12) doors had a wander guard systems installed. 6. On 05/24/19, Unit Managers (UMs) checked fourteen (14) residents' Wander Guard monitors and noted placement and functioning was correct. 7. On 05/24/19, the Interdisciplinary Team (Administrator, SDC, DON, Assistant Director of Nursing (ADON), and UMs met and determined the root cause for Resident #1 exiting the facility was that no wander guard was found on his/her person. The DON interviewed nursing staff who worked prior shifts with Resident #1 and it was noted his/her wander guard was in place throughout the night on 05/23/19-05/24/2019. 8. On 5/24/19, the UM #1 applied a replacement bracelet to Resident #1's left ankle and an additional wander guard device to the back of the resident's wheelchair. 9. On 05/24/19, the Administrator and SSD reviewed Elopement Binders confirming the Elopement Binders contained a current listing of residents at risk for elopement. 10. On 05/24/19, the ADON, UMs, and Medical Records conducted a physical body check of all current residents who were care planned for Wander Guard placement, to ensure Wander Guard devices were in place and functional. 11. On 05/24/19, an Ad Hoc Quality Assurance (QA) meeting was held. The attendees included the Medical Director by telephone, Administrator, DON, ADON, UMs, Assistant Administrator, SDC, and the Regional Nurse Consultant. During the QA meeting, the Elopement Policy and Procedures (which include care planning), Policies for Charting and Documenting Wander Guard placement and functioning, and details related to Resident #1's incident were discussed. The Ad Hoc QA committee recommended staff only access in and out of the facility's main entrance doors by code entry/exit until additional safety measures were initiated. The QA meeting also reviewed and approved staff educational training materials and post-test related to Elopement Policy and Procedures. The Regional Vice President of Operations and/or Regional Nurse Consultant reviewed and signed QA Meeting Minutes. 12. On 05/24/19, the Administrator changed access in and out of the facility's main entrance to be only accessible by staff utilizing door entry/exit codes. The Administrator directed staff to post instructions on doors to inform residents, visitors, and staff that they could only acquire access in and/or out of the facility through the main entrance doors until further notice. 13. On 05/25/19, the Quality of Life/Activities Director held an Ad Hoc Resident Council Meeting to communicate the door system changes for representatives of the resident population. 14. On 05/29/19, Psychiatric Services evaluated Resident #1 with no new orders initiated and decreased the resident's supervision to every hour (1) observation checks. 15. On 05/30/19, the Nurse Practitioner decreased Resident #1's supervision to every thirty (30)-minute observation checks, which included placement visualization and functioning of the Wander Guard devices. 16. On 5/24/19-5/28/19, the DON, ADON, UM #1, and UM #2 completed Elopement Risk Evaluations on all current residents and identified sixteen (16) residents at risk for elopement. The Administrator, DON, ADON, UM #1, and UM #2, and SSD updated the identified elopement risk residents' care plans and physician orders. 17. From 05/24/19-05/29/19 stakeholders received education, which included a post-test from the SDC, UM #1, UM #2, DON, and Quality of Life/Activities Director. The education was comprised of the Elopement/Wandering Policies and Procedures (which include care planning), Safety and Supervision of Residents, Wander Guard Charting and Documentation, and the new process for door security. All educated stakeholders scored 100% on post-tests, prior to working in the facility. 18. On 05/24/19-06/03/19, the Receptionist, UM #1 and UM #2 initiated daily Door Observation audits to ensure staff were letting residents, vendors, and visitors in and out of the facility's main entrance door utilizing entry codes. 19. On 05/29/19, the Maintenance Director installed a convex mirror to the facility's main entrance area to ensure the receptionist could view the main entrance/exit doors and determine who was accessing the doors before allowing them entrance into the facility. The Maintenance Director and Administrator ordered the mirror on 05/24/19. 20. On 5/25/19, UM #1, UM #2, ADON, and DON initiated Observation Audits on residents care planned for Wander Guard placement. The observations included checking visualization placement and functioning of wander guards. The audits were conducted seven (7) days a week for a total of two (2) weeks, then decreased to five (5) days a week and have continued to date. 21. On 05/28/19, UM #1, UM #2 , ADON, and DON initiated clinical documentation reviews for any potential changes for residents at risk for elopement. The reviews were conducted five (5) times each week and have continued to date. 22. On 05/29/19, a contracted company installed a button release (located at the receptionist desk area) to the facility's main entrance/exit doors, which allowed staff to open the doors at the reception desk after visualizing who they were permitting in/out of the facility, prior to allowing them facility entry and/or exit. 23. On 06/03/19, the Nurse Practitioner discontinued Resident #1's 1-hour observation checks because the resident had not displayed any further exit seeing behaviors, had not removed or attempted to remove the Wander Guards, and had continued normal activities of daily living. 24. The facility conducted Code Green Drills three (3) times a week for one (1) week. Then weekly for four (4) weeks. The facility continued Code Green Drills on a month basis. 25. On 05/31/19-07/05/19, the Regional Vice President of Operations and/or Regional Nurse Consultant reviewed and signed the facility's QA Meeting Minutes. The State Agency validated the removal of Immediate Jeopardy as follows: 1. Review of the Nurse Practitioner's evaluation of Resident #1, dated 05/24/19, revealed nursing requested an evaluation of Resident #1 after a non-injurious fall. The patient was resting in bed without any complaint of pain. The evaluation further revealed the Nurse Practitioner ordered a Urinary Analysis, Basic Metabolic Panel (BMP tests that gave important information about a person's metabolism, including health of the kidneys, blood glucose level, and electrolyte and acid/base balance), a Complete Blood Count (CBC a test used to evaluate overall health and detect disorders that may include [MEDICAL CONDITION], infection and [MEDICAL CONDITION]), and Physical Therapy and Occupational Therapy evaluations. Review of Resident #1's Telephone Order, dated 05/24/19, revealed the Medical Director order staff to apply Wander Guard devices to the resident's person and place the resident on 1:1 supervision until 3:00 PM, due to exit seeking behaviors. Review of Resident #1's Observation Checks documented on Nurse's Notes, dated 05/24/19-05/28/19, revealed staff initiated observation check by documenting time, initials, and resident's status every fifteen minutes beginning on 05/24/19 at 3:00 PM. Interview with SDC, on 07/17/19 at 2:26 PM, revealed Social Services Director notified her that Resident #1 was outside on the ground. She stated when she went out to assist the resident back inside the building, after the Nurse Practitioner completed her initial assessment. According to the SDC, she escorted Resident #1 inside the building, via wheelchair. Interview with the Scheduler, on 07/24/19 at 10:47 AM, revealed after SDC brought resident back inside the building she provided 1:1 supervision with the resident on 05/24/19 until 3:00 PM. She stated the Nurse Practitioner came to Resident #1's room and completed an assessment. Interview with the Nurse Practitioner, on 07/24/19 at 11:40 AM, revealed she was in another resident's room when staff requested she go outside and evaluated Resident #1 for injuries because the resident had exited the facility and fallen. The Nurse Practitioner stated when she went outside she observed several staff members outside standing round Resident #1 who had mud on his/her pants. According to the Nurse Practitioner, she completed a quick assessment outside, then conducted a full assessment of the resident after staff brought him/her to his/her room. She further stated she approved the resident's 1:1 supervision, per facility protocol. 2. Record Review of the facility's Census Board, dated 05/24/19, revealed the facility's census totaled 133 residents and staff determined 129 residents were in the building at the time of the incident related to Resident #1 because four (4) residents were attending off-site physician appointments. Interview with the Administrator, DON, ADON, UM #1, UM #2, LPN #1, LPN #2, LPN #4, CNA #1, CNA #2, CNA #3, Receptionist, Social Services Director, Physical Therapist, Ouality of Life/Activities Director, and the Scheduler, from 07/16/19 through 07/24/19, revealed they participated with determining all 133 residents were accounted for on 05/24/19 by locating the status of each resident and documenting their location. 3. Record Review of the facility's documented incident related to Resident #1 exiting the building, dated 05/24/19, revealed the Administrator and DON notified the resident's physician (Medical Director) and Power of Attorney (POA) the resident exited the facility and fell . Record Review of Resident #1's Progress Note, dated late entry 05/24/19 at 3:30 PM, revealed the DON documented that the Administrator and herself spoke to the resident's POA regarding the resident's fall and event. The note also revealed the POA voiced understanding without concern. Interview with the DON, on 07/24/19 at 3:40 PM, revealed she contacted the Administrator about Resident #1's incident and after the Administrator arrived at the facility they notified the Medical Director and Resident #1's POA. She stated she documented date and time of the notifications in the resident's clinical record. Interview with the Administrator, on 07/24/19 at 4:23 PM, revealed her and the DON notified the Resident #1's POA and the Medical Director regarding the resident exiting the facility and falling. 4. Review of Resident #1's Elopement Risk Evaluation, dated 05/24/19, revealed the evaluation assessment determined the resident was at risk for elopement. Review of Resident #1's Comprehensive Care Plan which addressed Elopement Risk /Exit Seeking behaviors, revised on 05/24/19, revealed the resident exited the facility self-propelling in his/her wheelchair. Interventions included Resident #1 was placed on 1:1 supervision for exit seeking behaviors from 10:00 AM-3:00 PM; Wander Guard devices were replaced and added to wheelchair; and fifteen minute checks were implemented at 3:00 PM. In addition, staff updated the care plan on 05/28/19 decreasing supervision to every thirty (30) minute checks and then on 05/29/19 decreased supervision to every one (1) hour checks. Interview with UM #1, on 07/24/19 at 3:16 PM, revealed after she assisted with bringing Resident #1 back inside the facility, she completed an Elopement Risk Assessment on the resident and made updates on the resident's care plan. Interview with SSD, on 07/24/19 at 2:17 PM, revealed she reviewed several residents' care plans and Elopement Risk Assessments including Resident #1's and made updates as needed. She stated the DON and UM #1 also assisted with the reviews that were conducted on 05/24/19. Interview with DON, on 07/24/19 at 3:40 PM, revealed she directed and assisted the Social Services Director and UM #1 with completing an Elopement Risk Assessment and revised Resident #1's Comprehensive Care Plan. 5. Observation of twelve (12) entry/exit doors during rounds with the Maintenance Director, on 07/24/19 at 12:00 PM, revealed three (3) doors contained functioning Wander Guard alarm systems (Front Entrance Door, Therapy Entrance Door at the end of Hall 700, and a Dining Room Door). Observations also revealed the remaining nine (9) doors contained code entry panels. Review of the TELS Logbook Documentation, dated 05/24/19 at 11:45 AM, revealed the Maintenance Director documented he inspected the functioning of twelve (12) doors and they passed his inspection. Interview with the Maintenance Director, on 07/24/19 at 12:00 PM, revealed the Administrator directed him to inspect all facility doors for functioning, which included the three doors with Wander Guard alarms. He stated he checked the doors and they all passed inspection. Interview with the Administrator, on 07/24/19 at 4:23 PM, revealed she completed rounds with the Maintenance Director on 05/24/19, ensuring all facility doors were secured. 6. Review of the Wander Guard Physical Body Checks, dated 05/24/19 at 1:52 PM, revealed the ADON, Unit Manager (UM) #1, and UM #2 physically observed and checked functioning of fourteen (14) other residents' Wander Guards. They documented the Wander Guards' location on the residents with no concerns noted. Interview with the ADON, UM #1, UM #2, on 07/24/19 at 3:16 PM, revealed after the completed elopement risk assessments the facility identified four (4) additional residents who were at risk for elopement, which included new admissions. They physically observed and checked the Wander Guard functioning of the fourteen (14) residents with no concerns noted. 7. Record review of the facility's Telephone Interview with the RN #1 assigned to Resident #1 at the time of the incident, dated 05/24/19 at 11:25 AM, revealed when the DON interviewed RN #1, she could not remember physically seeing the residents Wander Guard on his/her person or wheelchair. Record review of Telephone Interview with the LPN #1 assigned to Resident #1 during the previous shift, dated 05/24/19 at 11:25 AM, revealed when the DON interviewed the LPN she remembered physically seeing the residents Wander Guard on his/her person during 3rd Shift and documented accordingly. Review of Certified Nurse Aide (CNA) #3's signed written statement, dated 05/28/19, revealed on 05/23/19, he was assigned to Resident #1 and he recalled checking on the resident several times throughout the night. CNA #3 wrote when he pulled Resident #1's socks off he saw the Wander Guard on the resident's person. Attempted telephone interview with RN #1, on 07/24/19 at 11:31 AM, revealed surveyor left voice mail requesting RN to return call. However, she never responded to surveyor's voice mail message. Interview with the SDC, on 07/24/19 at 2:33 PM, revealed she attended IDT meetings every weekday morning and they re-congregated on 05/24/19, after Resident #1 exited the building because they were attending the IDT meeting when they were notified the resident was outside on the ground. The SDC stated they determined Resident #1 did not have on a Wander Guard device and that was how he/she left the building without staff knowledge. According to the SDC, the DON interviewed all nursing staff who were assigned to the resident within a 24-48 hour period. In addition, they searched the entire building looking for Resident #1's Wander Guard, but they could not locate it. Interview with the ADON, UM #1, and UM #2, on 07/24/19 at 3:16 PM, revealed another resident watched Resident #1 leave the facility through the front entrance doors and alerted staff. They stated they reviewed video footage and determined the Wander Guard device did not sound the door alarm. When they completed a full body assessment for Resident #1, they discovered it was not on his/her person. Interview with the DON, on 07/24/19 at 3:40 PM, revealed she interviewed LPN #1, the nurse assigned to Resident #1 during the previous shift; RN #1, the nurse assigned to the resident on 05/24/19; and CNA #3, who was assigned to the resident the previous shift. The DON stated the interviews determined the resident had the Wander Guard on during third shift on 05/23/19. RN #1 had not yet checked or documented checking Resident #1's Wander Guard placement or functioning before he/she left the building because she was passing medications. Interview with the Administrator, on 07/24/19 at 4:23 PM, revealed she met with the IDT to determine how Resident #1 left the building without staff knowledge. She stated after they determined all doors and Wander Guard alarm systems were functioning properly, they viewed the video footage, and found Resident #1's Wander Guard device was missing, they discovered the root cause was the resident did not have the device on when he/she left the facility. 8. Observation of Resident #1 on 05/23/19 at 2:30 PM and on 05/24/19 at 10:00 AM, revealed the resident had a Wander Guard device applied to the left ankle and wheelchair. Interview with UM #1, on 07/24/19 at 3:16 PM, revealed immediately after she assisted Resident #1 back inside the facility, she replaced the resident's ankle Wander Guard and placed an additional Wander Guard to his/her wheelchair. 9. Observations and review of the facility's Elopement Binders during initial tour, on 07/23/19 at 1:43 PM, revealed the binders contained a list of sixteen (16) residents who were at risk for elopement. Each resident had information listed in the binders identifying them by picture, room number, Elopement Risk Evaluations, Location of Wander Guard placement on residents, Elopement-Care Plans and facility Elopement policies and procedures including implementation of Code Green. The binders contained an accurate and current listing of residents for elopement. Interview with SSD, on 07/24/19 at 2:17 PM, revealed on 05/24/19 she reviewed the Elopement Binders to determine if the were accurate and current. She stated she took ownership of ensuring the binders remained updated when any revision was made regarding residents who were determined to be at risk for elopement. She further stated the binders contained a list of the residents, an updated picture of the resident, the location of the Wander Guard device, elopement policies and procedures, and the Code Green Drill policy, instructions and procedures. In addition, the SSD stated she ensured the binders contained Elopement Risk Assessments and Elopement care plans for residents listed. Interview with the Administrator, on 07/24/19 at 4:23 PM, revealed she reviewed the Elopement Binders at the nursing stations and front desk areas after they were updated. She stated she decided to place additional binders in the Dietary and Therapy Departments. 10. Review of the Wander Guard Physical Body Checks, dated 05/24/19 at 1:52 PM, revealed the ADON, UM #1, and UM #2 reviewed care plans on all residents who had a physician's orders [REDACTED]. They documented they physically observed and checked functioning of the residents' Wander Guards. They documented the Wander Guard location on the residents with no concerns noted. Interview with the ADON, UM #1, UM #2, on 07/24/19 at 3:16 PM, revealed on 05/24/19 they reviewed care plans for residents who had a physician's orders [REDACTED]. 11. Review of an Ad Hoc-QA Meeting Minutes and Sign-In Sheet, dated 05/24/19, revealed the Medical Director by telephone, Administrator, DON, ADON, UM #1, UM #2, SDC, SSD, and the previous Assistant Administrator attended the meeting. According to the QA Meeting Minutes, the purpose of the meeting was to address elopement/wandering program policies, procedures, and process. The QA Meeting discussed Resident #1's elopement and identified opportunities for quality improvement. Interview with SDC, on 07/17/19 at 2:26 PM, revealed she was in attendance at the Ad Hoc-QA Meeting held on 05/24/19 and they discussed Elopement policies and procedures for a long period of time. The meeting resulted in implementing new ways to prevent residents from leaving the building without staff's knowledge. Interview with the ADON, UM #1, UM #2, on 07/24/19 at 3:16 PM, revealed on 05/24/19 the Administrator called an Ad Hoc-QA Meeting and they determined how to proceed with educating staff on the Elopement/Wandering policies and procedure that included implementing Code Green Drills. They also discussed additional security measures and identifying all residents who were at risk for elopement. Interview with the DON, on 07/24/19 at 3:40 PM, revealed during the Ad Hoc-QA Meeting they determined the need to conduct an elopement risk assessment on every resident and to check Wander Guard placement and functioning on residents at risk for elopement. The DON stated they reviewed physician's orders [REDACTED]. She also stated they review the Elopement Binders for accuracy and discussed placing additional security measures to prevent future occurrences from happening. Interview with the Administrator, on 07/24/19 at 4:23 PM, revealed on 05/24/19 she directed the Maintenance Director to check all facility doors, place

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to implement resident care plan interventions for two (2) of sixteen (16) sampled residents, Resident #1 and #2. Resident #1's Certified Nursing Assistant plan of care directed staff to place pillows under the calves in order to float heels off the bed. Observations on 08/23/17 at 7:30 AM, 8:32 AM and 3:14 PM, revealed no pillows under Resident #1's calves. A skin assessment of Resident #1's right lateral foot, on 08/24/17 at 3:10 PM, revealed four (4) unidentified pressure areas. Observation of Resident #2, on 08/23/17 at 8:17 AM, revealed the resident's fractured left upper arm was not placed in the physician ordered sling. Continued observation revealed staff completed a two (2) person assisted transfer, placing their arms under Resident #2's armpits, and the resident moaned in pain when raised from the wheelchair and placed in the bed. The findings include: Review of the facility's policy, Comprehensive Care Plans, not dated, revealed care plan interventions were implemented after consideration of the resident's problem areas and their causes. Interventions address the underlying sources of the problem areas, rather than addressing only symptoms or triggers. The care plan aided in the prevention or reduction of resident decline in functional status and/or levels. 1. Observations, on 08/23/17 at 7:30 AM, 8:32 AM and 3:14 PM, revealed Resident #1 was in bed without pillows under the calves, in order to float the heels off the bed. Observations, on 08/24/17 at 7:00 AM, 8:02 AM, and 3:10 PM, revealed Resident #1 did not have pillows under calves while in bed. Observation of Resident #1 while in bed, on 08/25/17 at 8:15 AM, revealed no pillows under the resident's calves. Review of Resident #1's clinical record revealed the facility admitted the resident on 04/11/17, with the [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident was at risk for developing pressure ulcers, needed extensive assistance of two (2) persons for bed mobility and was not interviewable. Review of the Treatment Administration Record, for 08/01/17 through 08/31/17, revealed nursing was to apply a gauze pad between the right second toe, and if there were any noted issues, to follow up with wound care. Continued review for this treatment revealed nursing only documented the application of the gauze on nine (9) days out of the twenty-two (22) opportunities for application. No Resident refusals were documented, the areas were blank. Review of Resident #1's Care Plan, dated 12/08/16, revealed the resident was at risk for developing skin breakdown related to bed mobility and bowel/bladder incontinence. The goal stated the resident would have intact skin, free of redness, blisters or discoloration over bony prominence. The interventions directed staff to assist the resident as necessary to reposition or shift weight to relieve pressure, minimize pressure over bony prominences, and to notify nursing immediately of any new areas of skin breakdown, redness, blisters, bruises, or discoloration noted during daily care. Review of Certified Nursing Assistant (CNA) Care Sheet, undated, revealed nursing staff were to ensure pillows were under Resident #1's calves and heels off the bed. Review of Resident #1's Weekly Skin Assessment, dated 08/18/17 at 1:39 AM, revealed no documented wounds, pressure areas, or skin breakdown on the feet. Observation of Resident #1's skin assessment, performed by Licensed Practical Nurse (LPN) #3, on 08/24/17 at 3:10 PM, revealed LPN #3 removed the resident's covers to find no pillows were under the resident's calves and both feet were touching the bed sheets. Observation of the resident's feet revealed two (2) unidentified facility acquired pressure areas located on the side of the resident's right foot. In addition, both second toes on the right and left foot had a dark brown to black scabbed round areas noted on the knuckles of the toe, below the toenail. Interview with LPN #3, on 08/24/17 at 3:10 PM, revealed prior to the skin assessment, she had no knowledge of skin breakdown to Resident #1's right foot or the second toes on both feet. LPN #3 stated she had a treatment order to place a gauze pad on the right toe, as a pressure prevention measure, which she had not completed as if yet. She stated she had no treatment ordered for the second toe on the left foot. LPN #3 stated the nursing assistants had not reported to her any noted skin breakdown to the resident's feet. She stated the two (2) areas to the right side of the foot were pressure related injuries. LPN #3 described the first wound on the right foot closer to the pinky toe as round, dark brown in the middle to black around the edges, and scabbed in appearance with an approximated size of one (1) inch in diameter. The second wound, closer to the right ankle, was pink in the middle with dark brown edges with an approximated size of one and half (1 1/2) inches in diameter. The LPN stated the resident also had dark brown-scabbed wounds on both second toes on the right and left. She described the second toe, on the left foot, to have a pink center with dark brown edges. She stated she was not aware Resident #1 had a care plan intervention to place pillows under the calves in order to float the heels off the bed. She stated the CNAs were responsible for implementing the intervention and she was responsible for monitoring. LPN #3 stated if she did not know about the intervention how could she monitor for its implementation. She stated resident care plans were located in an office near the entrance to the facility and she would have to refer to physician orders, medication administration orders, or treatment orders for care plan interventions. She stated placing pillows under calves would be a nursing intervention and would not necessarily be in the electronic medical record for reference. She stated nursing staff were responsible for implementing care plan interventions to ensure the residents at risk for skin breakdown did not develop skin breakdown. She stated resident harm could occur if staff did not implement resident care plan interventions related to skin breakdown. Observation of the MDS Office, on 08/25/17 at 1:25 PM, revealed a cart with binders containing resident care plans from both nursing units was in the back of the room. Interview with MDS Coordinator #1, on 08/25/17 at 1:25 PM, revealed the care plan binders were kept in the office in order for the care plans to be updated after the morning meeting, which occurred around 8:30 AM. She stated the binders would remain in the office until they left at 8:00 PM, while they worked on the care plans. She stated after they left, staff would have to retrieve a master key at the reception desk which was closed in the evening to get into the MDS office. Interview with CNA #10, on 08/25/17 at 1:55 PM, revealed she did not obtain a copy of the CNA Care Sheet prior to beginning her work on the unit. She stated she did not know much about Resident #1 or that pillows were required under the calves and heels were to be off the bed. CNA #10 stated she had not removed the resident's socks during the time she cared for Resident #1 to inspect the feet for skin breakdown because she was very busy during her shift. She stated placing pillows under the calves helped to keep pressure off the resident's feet while in the bed. CNA #10 stated it was very important to follow care plan interventions to protect residents from skin breakdown. CNA #10 stated harm could occur to residents if staff did not implement care plan interventions. Interview with CNA #12, on 08/23/17 at 11:55 AM, revealed she referred to the CNA Care sheet to remind her of the care plan interventions needed for her assigned residents. CNA #12 stated she did not know if Resident #1 had skin breakdown to the feet and had not received report from nursing staff that the resident had skin breakdown to the feet. She stated according to the CNA Care Sheet, Resident #1 should have pillows under his/her calves. CNA #12 stated the intervention was to prevent skin breakdown to the feet. However, she got busy and did not determine if the pillows were actually in place. She stated harm could occur to the resident if staff did not implement care plan interventions. Interview with CNA #5, on 08/24/17 at 4:20 PM, revealed she was not aware of skin breakdown on Resident #1's feet. She stated she did not perform foot care on the resident today; however, she did place another pair of socks over the pair the resident already had in place. She stated it was important to perform foot care in order to assess the feet. She stated the CNA Care Sheet instructed her to place pillows under the calves to prevent skin breakdown. She stated she had placed pillows under the resident's legs after lunch and was not sure why they were not under them now. She stated pressure areas could develop if the resident's feet rested too long on the bed in one place. Interview with the Director of Nursing (DON), on 08/25/17 at 2:45 PM, revealed it was her expectation that staff follow care plan interventions related to pressure ulcer prevention. She stated she had not conducted audits to determine if staff were implementing those care plan interventions. She stated she depended on her licensed nurses to monitor for the implementation of care plan interventions and report to her if issues occurred. She stated she had not received reports from licensed nurses regarding CNAs not following care plan interventions. The DON stated the facility identified Resident #1 was at risk for the development of pressure ulcers. However, it had not been reported to her, prior to 08/22/17, that Resident #1 had unidentified pressure areas to the feet. She stated she believed the resident had previous identified areas to the feet, but that they had resolved. She stated if staff did not follow care plan interventions, resident harm could occur, such as skin breakdown. Interview with the Administrator, on 08/25/17 at 2:45 PM, revealed he expected staff to implement resident care plan interventions. He stated he had not received reports from his management staff regarding direct care staff failing to implement care plan interventions related to pressure or skin breakdown. He stated if staff did not implement care plan interventions, harm such as wounds, could develop and that would be a bad outcome for the resident. 2. Review of Resident #2's clinical record revealed the facility admitted the resident on 06/11/1,2 with the [DIAGNOSES REDACTED]. Review of the quarterly MDS, dated [DATE], revealed the facility assessed the resident required extensive assistance of two (2) persons with transfer and was not interviewable. Review of Resident #2's Radiology Report, dated 08/22/17, revealed the resident had a fracture to the distal Humerus (upper bone in the arm closer to the elbow) with displacement and associated joint effusion (increased swelling in the joint). Review of Resident #2's Physician Order, dated 08/22/17, revealed staff was to ensure Resident #2's left arm was in a sling at all times to immobilize the left arm due to a fracture. The order also directed staff to make the resident an appointment with an orthopedic specialist. Review of Resident #2's Care Plan, dated 08/23/17, revealed the resident had pain related to a fractured left elbow. The goal stated the resident would not experience a decline in overall function related to pain through the next review. The interventions directed staff to observe and report to the nurse signs and symptoms of pain or worsening pain and for the resident to have a sling on the left elbow/arm at all times. Observation of Resident #2, on 08/23/17 at 7:17 AM, revealed the resident sitting in the dayroom in a wheelchair, without a sling on the left arm. A Certified Mediation Technician (CMT) transported Resident #2 to the dining room at 7:29 AM, with no sling on the left arm. Interview with the CMT, on 08/24/17 at 11:15 AM, revealed when she transported Resident #2's to the dining room on 08/23/17, she did not know his/her left arm was fractured or the arm should have been in a sling. Continued observation, on 08/23/17 at 7:34 AM, revealed Resident #2 was in the dining room seated at a table with no sling on the left arm. Observation at 8:12 AM, revealed the Administrator transported Resident #2 to the 400 Hall on the Blue Unit then the Administrator walked back towards the front of the facility. There was no sling on the Resident's arm. Continued observation revealed Resident #10 pushed Resident #2 to the doorway of his/her room. Further observation, on 08/23/17 at 8:17 AM, revealed CNA #12, came out of Resident #2's room and noticed Resident #2 had wet pants. CNA #12 proceeded to push Resident #2 into his/her room then left to find the resident's assigned CNA #7. Together they transferred Resident #2 into bed by putting their arms under the armpits of Resident #2's, then lifted, pivoted, and placed the resident in the bed. The resident moaned aloud in pain during the transfer. Resident #2 moaned again as the CNAs removed the resident's pants and brief by turning and repositioning the resident, at times touching the resident's left arm. Interview with CNA #7, on 08/23/17 at 3:34 PM, revealed she arrived to work at 7:00 AM and started getting residents up for breakfast. She stated night shift had gotten Resident #2 up and she had not laid eyes on the resident until CNA #12 came and told her the resident was wet and needed changing. She stated she received a brief report from the off going nursing assistant that her assigned residents were all okay. She stated she did not receive a report from the nurse regarding her assigned residents. Continued interview with CNA #7, on 08/24/17 at 11:30 AM, revealed sometime after lunch she made a round to see if Resident #2 needed changing and at that time, the resident again complained of pain and she noticed the resident's left arm was red and swollen. She stated she informed LPN #1 and that was when she found out the resident had a broken left arm. She stated the LPN also told her the resident needed a sling, but they could not locate one in the facility. She stated another nurse went out to the store to purchase one, came back and put it on, which occurred sometime after 5:00 PM on 08/23/17. She stated not knowing about the fractured arm and transferring the resident without the sling on was probably the reason the resident moaned in pain when they transferred and repositioned the resident during care on the morning of 08/23/17. She stated a sling was an intervention to immobilize a fracture or an injured arm. She stated if staff did not follow care plan interventions, residents harm could occur, just as it had to Resident #2. Interview with LPN #1, on 08/24/17 at 11:18 AM, revealed he/she was notified on 08/23/17 that Resident #2 needed a sling for a fractured arm. However, they were unable to locate one. LPN #1 stated he/she was extremely busy the morning of 08/23/17, and failed to notify CNA #7 about the resident's fractured arm. LPN #1 stated he/she had not assessed the resident prior to CNA #7 informing him/her the resident had complained of pain and CNA #7's observation of the swollen arm. He stated not having a sling in place could worsen the fracture and/or cause the resident undue pain or discomfort. Interview with the Interim Unit Manager of the Blue Unit, on 08/25/17 at 3:40 PM, revealed the facility received an order for [REDACTED]. She stated the resident's care plan was revised to reflect the need for a sling at all times and for nursing to evaluate for complaints of pain. The Unit Manager stated she reported in the morning management meeting, Resident #2 needed a sling. She stated she also reported to LPN #1, on the morning of 08/23/17, that Resident #1's left arm was broken . She stated a sling still could not be located and she finally went out to a drug store late that evening and purchased one for the resident. She stated following care plan interventions such as applying a sling and assessing for pain was important for the care of the resident. She stated the resident could experience undo harm if interventions were not followed. Interview with the DON, on 08/25/17 at 2:45 PM, revealed an X-Ray taken late on 08/22/17, determined Resident #2's left arm was broken. She stated she expected staff to communicate with each other regarding the needed care and services the resident required. She stated after a change in condition, nursing staff should update the plan of care and put interventions in place. The DON stated staff did not inform her that a sling could not be located within the facility until the afternoon of 08/23/17. She stated the Unit Manager should have followed through with the plan of care to ensure the sling was in place. She stated the Unit Manager made the Administrator aware of the need for a sling sometime on 08/23/17. She stated the facility implemented the plan of care to the best of their ability. She stated if care plan interventions were not implemented, the resident would not receive the needed care and services. In addition, the resident could experience a decline. Interview with Administrator, on 08/25/17 at 4:25 PM, revealed he was not aware until later in the day on 08/23/17, that the facility did not have a sling for Resident #1's arm. The Administrator stated a staff member obtained the sling from an outside source and placed it on the resident, sometime during the evening hours on 08/23/17. The Administrator stated not having a sling in place could cause the resident pain or further injury to the arm.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to implement physician orders [REDACTED].#2. Staff received a physician order [REDACTED].#2 into bed by putting their arms under the armpits of Resident #2, then lifted, pivoted, and placed the resident in the bed. The resident moaned aloud in pain during the transfer. Interviews revealed no one informed CNA #7 about Resident #2's fractured left arm prior to her transferring the resident and was probably why the resident moaned in pain. The findings include: Review of the facility's policy, Physician Orders, not dated, revealed the procedure established uniform guidelines for receiving, recording, and implementing orders for treatment. Nursing staff should record and follow orders to include specifying treatment, location, frequency, and duration of treatment. Review of Resident #2's clinical record revealed the facility admitted the resident on 06/11/12, with [DIAGNOSES REDACTED]. Review of Resident #2's quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident required extensive assistance of two (2) persons with transfers and was not interviewable. Review of a Radiology Report, dated 08/22/17, revealed Resident #2 had a fracture to the distal Humerus (upper bone in the arm) with displacement and associated joint effusion (increased swelling in the joint). Review of a Physician Order, dated 08/22/17, revealed staff was to ensure Resident #2's left arm was in a sling at all times to immobilize the left arm due to a fracture. Review of Resident #2's Care Plan, dated 08/23/17, revealed the resident had pain related to a fractured left elbow. The goal stated the resident would not experience a decline in overall function related to pain. The interventions included staff to observe and report to the nurse signs and symptoms of pain or worsening pain and for the resident to have a sling on the left elbow/arm at all times. Observation, on 08/23/17 at 8:17 AM, revealed CNA #12 noticed Resident #2 had wet pants and pushed Resident #2, in his/her wheelchair, into his/her room then left to find the resident's assigned CNA, CNA #7. Together they transferred Resident #2 into bed by putting their arms under the armpits of Resident #2's then lifted, pivoted, and placed the resident in the bed. The resident moaned aloud in pain during the transfer. Resident #2 moaned again as the CNAs then removed the resident's pants and brief by turning and repositioning the resident, at times touching the resident's left arm. Interview with CNA #7, on 08/24/17 at 11:30 AM, revealed sometime after lunch she made a round to see if Resident #2 needed changing and at that time, the resident complained of pain and she noticed the resident's left arm was red and swollen. She stated she informed Licensed Practical Nurse (LPN) #1 and that was when she (CNA #7) found out the resident had a broken left arm. She stated the LPN also told her the resident needed a sling but could not locate one in the facility. She stated another nurse went out to the store to purchase one, came back and put it on, which she stated occurred sometime after 5:00 PM on 08/23/17. She stated the physician ordered the sling to immobilize the resident's fractured arm. She stated staff had to follow physician orders [REDACTED].#2. Interview with LPN #1, on 08/24/17 at 11:18 AM, revealed Resident #2's physician ordered a sling for his/her fractured arm on 08/22/17; however, the night shift staff was unable to locate one in the facility. LPN #1 stated he was extremely busy the morning of 08/23/17, and believed the management staff worked on getting a sling for the resident. He stated he was so busy he failed to notify CNA #7 about the resident's fractured arm so she could be cautious when providing care. LPN #1 stated not having a sling in place could worsen the fracture and/or cause the resident undue pain or discomfort, especially during care such as transfers. According to LPN #1, following physician orders [REDACTED]. Interview with the Interim Unit Manager of the Blue Unit, on 08/25/17 at 3:40 PM, revealed the facility received an order on 08/22/17, for Resident #2 to have a sling placed on the left arm and a search of the facility revealed no sling was available. She stated it was not an issue, even though the order stated the sling was to be in place at all times, because the resident would be resting in the bed. The Unit Manager stated she reported in the morning management meeting the need for the sling. She stated after she searched the facility and could not locate a sling, she went out to the store late that evening and purchased a sling for the resident. The Unit Manager stated it was the responsibility of nursing staff to follow physician orders [REDACTED]. She stated the resident could experience a decline or undo harm if staff did not implement physician orders. Interview with the Director of Nursing (DON), on 08/25/17 at 2:45 PM, revealed she expected staff to implement and follow physician orders [REDACTED]. The DON stated she expected the Unit Manager to follow up on the order and obtain the sling. She revealed the Unit Manager did make the Administrator aware of the need for a sling at some point on 08/23/17. According to the DON, not implementing physician orders [REDACTED]. Interview with the Administrator, on 08/25/17 at 4:25 PM, revealed he was not aware the facility did not have a sling for Resident #2's fractured arm until the afternoon of 08/23/17. He stated following physician orders [REDACTED]. The Administrator revealed he expected staff to inform him earlier rather than later about the need for patient care items, such as a sling. He stated not following physician orders, related to the application of a sling, could cause a resident to decline or experience increased pain.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to meet residents' activities of daily living needs necessary to maintain personal hygiene for two (2) of sixteen (16) sampled residents, Resident's #1 and #2. Observations of Resident #1 revealed the resident did not eat independently and did not received needed assistance to eat. Review of the clinical record revealed Resident #1 had a significant weight loss. Additionally, review of Resident #1's showers, from 07/02/17 to 08/23/17, revealed the resident was scheduled to receive fourteen (14) showers; however, only received two (2). In addition, observation, on 08/23/17 at 7:17 AM, revealed Resident #2 sitting in a wheelchair wearing sweat pants with a large wet area in the front and staff did not address incontinent care needs until 8:25 AM. Record review revealed Resident #2's received three (3) of fifteen (15) scheduled showers from 07/02/17 to 08/23/17. The findings include: Review of the facility's policy, Increasing Resident Independence, not dated, revealed direct care staff would assist, support, and encourage the resident to maintain good standards of personal hygiene and grooming which included bathing, oral care, hair care, nail care, elimination, and reduction of body odor. Activities of daily living would be performed by healthcare providers for those residents unable to perform the activities themselves. Review of the facility's policy, Resident Rights, not dated, revealed the facility would make every effort to assist each resident in exercising his/her rights to assure the resident was always treated with respect, kindness, and dignity. Review of the facility's policy, Comprehensive Care Plans, not dated, revealed care plan interventions were implemented after consideration of the resident's problem areas and their causes. Interventions addressed the underlying sources of the problem areas, rather than addressing only symptoms or triggers. The care plan aided in the prevention or reduction of resident decline in functional status and/or levels. 1. Review of Resident #1's clinical record revealed the facility admitted the resident on 04/11/17, with the [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) for Resident #1, dated 07/30/17, revealed the facility assessed the resident was at risk for developing pressure ulcers, required extensive assistance of two (2) persons for bed mobility, and was not interviewable. In addition, the facility assessed Resident #1 was always incontinent of bowel and bladder and required extensive assistance of one (1) person with bathing/hygiene. The facility assessed the resident to need a therapeutic and mechanically altered diet and required extensive assistance of one (1) person with eating meals. The MDS stated the resident had a weight loss of 5% or more in the last month or loss of 10% or more in the last six (6) months. The MDS stated the resident's weight at the time of assessment was 152 pounds. Review of Resident #1's Care Plan, dated 02/24/17, revealed Resident #1 was at risk for potential complications associated with incontinence of bowel and bladder. The goal stated staff would keep the resident clean, dry, and comfortable daily and the resident would not develop any complications associated with incontinence. The interventions included staff to maintain privacy and dignity when checking resident for incontinent episodes, monitor and report any changes in bladder status such as foul smelling urine, frequency, or urgency, and report any changes to peri-area/skin to the physician. Further review of Resident #1's Care Plan, dated 12/08/16, revealed the resident was at risk for developing skin breakdown related to impaired bed mobility and bowel/bladder incontinence. The goal stated the resident would have intact skin, free of redness, blisters, or discoloration over bony prominence. The interventions included staff to assist the resident as necessary to reposition or shift weight to relieve pressure, minimize pressure over bony prominences, and notify nursing immediately of any new areas of skin breakdown, redness, blisters, bruises, or discoloration during daily care. In addition to providing incontinence care after incontinent episodes, apply barrier cream as needed. The resident was at nutritional risk related to a mechanical altered therapeutic diet. The goal stated the resident would not have further significant weight loss. Staff was to monitor intake and offer substitutes if the resident did not consume 50 % or more of his/her food. Continued review of the plan of care and the Certified Nursing Assistant (CNA) Care Sheet revealed neither directed staff to provide Resident #1 the extensive assistance of one (1) when eating meals, as per the MDS assessed required need. Review of the Shower Schedule for Resident #1, not dated, revealed the resident was to receive a shower every Monday and Thursday. Review of Resident #1's showers, documented in the CNA Kiosk computer, revealed from 07/02/17 to 08/23/17, the resident should have received fourteen (14) showers. The CNA's documentation revealed Resident #1 received two (2) showers, on 07/10/17 and 08/20/17. The CNA's documented on ten (10) other scheduled shower days the resident received partial bed baths. The documentation stated the resident received full bed baths on 08/10/17 and 08/21/17. Continued review revealed staff did not document the resident had refused or was ill on any scheduled shower day. Review of Resident #1's Weekly Skin Assessment sheet, dated 08/18/17, revealed the resident had a seven (7) centimeter by seven (7) centimeter excoriation to the right buttock and an unmeasured excoriation to the left buttock. The upper left thigh had a ten (10) centimeter by five (5) centimeter excoriation area. Review of Resident #1's Wound Care Notes, dated 08/22/17, revealed the resident had moisture associated skin damage to the sacral, left buttock, and thigh areas. The open sacral wound measured 1.0 centimeters (cm) x 0.8 cm and the left buttock area measured 1.5 cm by 2.5 cm. The areas were described as partial thickness with 76-100% granulation. The skin was noted as friable with serosanguineous (mixture of blood and serum) drainage. Review of Resident #1's Nursing Notes, dated 08/22/17 at 2:30 PM, revealed the Advanced Practice Registered Nurse (APRN) was in to perform a follow/up assessment regarding Resident #1's moisture associated skin damage to the buttocks and sacrum. Nursing noted the resident complained of pain during cleansing of the wound sites. Observation of Resident #1, on 08/22/17 at 1:17 PM, revealed the resident sitting in a wheelchair in his/her room wearing tan pants and a white shirt with tan/gold colored dots. Observation of Resident #1, on 08/22/17 at 1:45 PM, revealed the resident was sitting in his/her wheelchair in his/her room. At 2:05 PM, Resident #1 had his/her head down and eyes closed while sitting in the wheelchair. Continued observation of Resident #1, on 08/22/17 at 2:22 PM, revealed staff used a mechanical lift to transfer the resident back to bed. Observation of Resident #1's Skin Assessment, performed by LPN #3, on 08/24/17 at 3:10 PM, revealed the resident's inner thighs were red and pink in color and excoriated. The resident's sacral and left buttock had open areas surrounded by pink excoriated skin. Interview with CNA #3, on 08/22/17 at 1:45 PM and 2:22 PM, revealed staff had gotten Resident #1 out of bed at 10:30 AM on 08/22/17, using the mechanical lift. The CNA stated the resident was dependent on staff for transfers and incontinent care. She stated she had not checked or changed the resident since 10:30 AM because she was busy completing other tasks. She stated nursing staff had requested she put Resident #1 back to bed at 2:22 PM because the Wound Care Nurse Practitioner was there to re-evaluate the skin breakdown on Resident #1's buttocks and inner thighs. She stated it was important to keep the resident's skin clean and dry to prevent further skin breakdown. Observation, on 08/23/17 at 8:32 AM, revealed Resident #1 sitting up in bed with a breakfast tray on the over bed table across the lap. The resident's tray contained a chopped up banana, eggs, toast with jelly on it, cereal in a bowl with milk, an opened carton of milk, and a glass of juice. The resident had on the same clothes as 08/22/17; however, the shirt had a pink stain in the middle. The resident's lips were dry and cracked and the corners of the mouth had an unknown dried brown substance. The resident's hands were dry and the fingernails had an unknown brown substance under them. The resident's eyes had a yellow substance in the eyelashes. Interview with Resident #1, on 08/23/17 at 8:32 AM, revealed the resident was hungry but needed help eating. Observation, on 08/23/17 at 8:53 AM, revealed Resident #1 sitting up in the bed with his/her eyes closed with an untouched plate of food in front of the resident. The resident was wearing the same shirt, lips still dry, corners of mouth with an unknown dried brown substance, eyelashes still had unknown substance, and nails dirty. The Administrator, Director of Nursing (DON), Licensed Practical Nurse (LPN) #1 and CNA #10, passed by Resident #1's room several times as they tended to other residents or passed breakfast trays. Interview with CNA #7, on 08/23/17 at 9:00 AM, revealed she was assigned to the 400 Hall and was answering call lights and assisting a resident with toileting when the DON came to her and requested she go to Resident #1's room and assist the resident with the breakfast meal because the surveyor was watching the care provided on the hall. She stated now her residents would be waiting for her to return to tend to their needs while she assisted Resident #1. She stated the breakfast cart came to the unit at 7:30 AM, and she did not know who served Resident #1 the breakfast tray. She stated the resident was able to feed himself/herself several weeks ago but now she thought the resident needed more help. She stated she did not have a CNA Care Sheet for the 200 Hall and could not say how much assistance Resident #1 required when eating. CNA #7 stated she was not sure if there was a requirement to notify the nurse if the resident ate a certain amount of the meal. Observation of CNA #7 revealed she picked up the resident's fork and began to feed the resident the eggs and bananas. Observation, on 08/23/17 at 11:30 AM, revealed Resident #1 sitting in a wheelchair in his/her room and clothing had been changed. Observation at 12:30 PM, revealed the resident in the main dining room with staff assisting with the meal. Continued observation of Resident #1's skin assessment, on 08/24/17 at 3:10 PM, revealed Resident #1's legs had dry flaky skin. Interview with CNA #5, on 08/24/17 at 4:20 PM, revealed she had not performed morning hygiene care for Resident #1 because she did not have time. She stated after lunch, she put Resident #1 back to bed and placed another pair of socks over top a pair the resident already had in place. CNA #5 stated she did not provide foot care or apply lotion to the resident's leg during the time she provided care to the resident. She stated it was important to keep residents clean to protect their skin from skin breakdown. Interview with CNA #10, on 08/23/17 at 4:20 PM, revealed Resident #1 was dependent on staff for incontinent care and should be checked for incontinence at least every two (2) hours. She stated she got Resident #1 out of bed at 9:30 AM, and changed him/her at that time. She stated she put the resident back to bed using a lift around 1:30 PM. CNA #10 stated she had only changed the resident (2) two times, once at 9:30 AM and again around 2:30 PM, and both times the resident was wet. She stated five (5) hours between checks and changes was too long and skin breakdown could occur. CNA #10 stated the resident had skin breakdown presently and it could get worse sitting in wet briefs. She revealed her workload was very heavy with (15) fifteen residents, and her numerous tasks prevented her from making timely rounds on all her residents. Interview with the APRN, on 08/22/17 at 2:25 PM and 08/25/17 at 10:00 AM, revealed Resident #1 was a heavy wetter, which contributed to the residents moisture associated skin damage on the buttocks. She stated sitting in urine would contribute to the resident's skin breakdown and the development of yeast infections that the resident had a history of [REDACTED].#1 sat in wet briefs for extended periods. The APRN stated she expected staff to check and change Resident #1 at least every two (2) hours. However, since the resident was a heavy wetter, checking the resident every hour for incontinence would be more beneficial for prevention measures. Interview with the DON, on 08/25/17 at 2:45 PM, revealed it was her expectation staff provided residents incontinent care and performed showers per the shower schedule. She stated she was not aware staff was not able to complete their assigned tasks. She stated if staff did not provide the assessed care needs related to incontinence, residents could experience skin breakdown. Interview with the Administrator, on 08/25/17 at 4:25 PM, revealed it was his expectation staff provided the assessed care needs as it related to incontinence and provided scheduled showers. He stated no one had brought it to his attention that there was a problem with staff not completing their assigned tasks, such as providing resident showers. He stated residents could have a decline if the facility did not meet their needs. 2. Observation of the facility, on 08/22/17 at 12:20 PM, revealed a strong odor of urine throughout the hallways of the Blue Unit. Observation of the facility, on 08/23/17 at 7:09 AM, revealed the Blue Unit had a strong odor of urine. Observation of the facility, on 08/24/17 at 7:05 AM, revealed the Blue Unit had a strong odor of urine and feces. Review of Resident #2's clinical record revealed the facility admitted the resident on 06/11/12, with the [DIAGNOSES REDACTED]. Review of the quarterly MDS for Resident #2, dated 07/30/17, revealed the facility assessed the resident required extensive assistance of two (2) persons with transfers and was incontinent of bowel and bladder. The facility assessed the resident required extensive assistance of one (1) person with bathing and hygiene. In addition, the facility assessed the resident as not interviewable. Review of Resident #2's Care Plan, dated 08/01/17, revealed the resident had potential for complications associated with incontinence of bowel and bladder. The goal stated staff would keep the resident clean, dry, and comfortable. The interventions included staff to monitor and report changes in bladder status, and maintain privacy and dignity when checking the resident for incontinent episodes. Review of the Shower Schedule for Resident #2, not dated, revealed the resident was to receive a shower every Wednesday and Saturday. Review of Resident #2's showers, documented in the CNA Kiosk computer, revealed from 07/02/17 to 08/23/17, the resident should have received fifteen (15) showers. The CNA's documentation revealed Resident #2 received three (3) showers, on 07/05/17, 08/12/17, and 08/16/17. The CNAs documented on eight (8) other scheduled shower days the resident received partial bed baths. Continued review revealed staff did not document the resident had refused or was ill on any scheduled shower day. Interview with CNA #12, on 08/23/17 at 11:55 AM, revealed she had thirteen (13) residents to care for on 08/23/17. CNA #12 stated she had four (4) resident showers to give along with her other tasks. She stated a shower meant taking the resident to the shower room and bathing the resident in the shower. CNA #12 stated a partial bed bath meant washing the face, armpits, and private parts in the residents' room. The CNA stated due to their many tasks and the assignment of (3) three to (5) showers a day, it was impossible to give all residents their scheduled showers. She stated if staff did not provide routine scheduled showers, then the resident's hygiene and skin condition could decline. Interview with CNA #4, on 08/23/17 at 12:50 PM, revealed she was assigned to give (5) five showers to residents on her assigned hall on 08/21/17. She stated she was not able to give all the assigned showers and she reported it to nursing, but they just told her to do the best she could. She stated resident's skin condition could break down if not kept clean. Observation of the Dayroom on the Blue Unit, at 7:09 AM on 08/23/17, revealed nine (9) residents sitting in wheelchairs and the room had a strong odor of urine. The nurses' station had nursing staff seated at the desk within a few feet of the dayroom and additional staff passed by the dayroom completing tasks. Observation of the Blue Unit Dayroom, on 08/23/17 at 7:17 AM, revealed Resident #2 sitting in a wheelchair wearing sweat pants with a large wet area in the front that proceed down to the middle of the thighs and Resident #2 had a strong odor of urine. The DON, along with a Restorative Nursing Assistant, entered the Dayroom at 7:17 AM. The DON moved Resident #2 out of the way in order to transport another resident to the main dining room. The Restorative Nursing Assistant passed by Resident #2 to retrieve another resident to transport to the main dining room. Neither the DON nor the Restorative Nursing Assistant addressed Resident #2's wet pants. Observation of CNA #12 revealed she entered the Blue Unit Dayroom, at 7:25 AM on 08/23/17, and moved Resident #2 from one area to another area to obtain another resident to transport to the main dining room. Interview with CNA #12, at 7:25 AM on 08/23/17, revealed she did not know who was assigned to care for Resident #2. Continued observation, on 08/23/17 at 7:29 AM, revealed CNA #12 left the Dayroom without addressing Resident #2's wet pants to transport another resident to the main dining room for breakfast. Observation, on 08/23/17 at 7:29 AM, revealed the Certified Medication Technician (CMT) transported Resident #2 to the main dining room without addressing the resident's wet pants. Continued observation revealed Resident #2 was in the main dining room in front of a table at 7:34 AM, with wet pants visible and a light brown ring had developed around the edges of the wet spot. Observation of Resident #2, in the main dining room, on 08/23/17 at 7:35 AM, revealed LPN #2 assisted the resident with repositioning both feet back onto the wheelchair pedals and did not address Resident #2's wet pants. LPN #2 then placed a clothing protector on the resident and pushed the resident up closer to the table. Observation, on 08/23/17 at 7:40 AM, revealed the Social Worker provided Resident #2 a cup of hot chocolate and did not address the wet spot on the resident's pants. Observation, on 08/23/17 at 8:12 AM, revealed the Administrator transported Resident #2 back to the Blue Unit and left the resident in the 400 hallway. Further observation at 8:17 AM, revealed Resident #10 transported the resident to his/her doorway on the 400 Hall and then left. Continued observation revealed CNA #12 exited Resident #2's room and noticed the resident's wet pants and pulled the resident into his/her room, then walked across the hall to get Resident #2's assigned CNA, CNA #7. Further observation revealed CNA #7 and #12 transferred the resident into bed, removed the wet clothing and wet brief, and provided incontinent care. Interview with CNA #7, on 08/23/17 at 8:25 PM, revealed Resident #2 was confused and dependent on staff for incontinent care. She stated she could smell a strong odor of urine coming from Resident #2. CNA #7 stated the resident's pants were saturated with urine and the light brown ring meant the urine had started to dry. She stated the resident had been wet for quite some time. CNA #7 stated she started her shift at 7:00 AM and it was the responsibility of night shift to get Resident #2 up for breakfast. She stated the resident probably had been up since 6:00 AM. The CNA revealed she had not laid eyes on Resident #2 since she arrived. She stated the brief report she received from the off going CNA regarding her residents was that they all were okay. She stated she had thirty (30) minutes to get the rest of her assigned resident's up, cleaned, toileted, and changed and to the dining room by 7:30 AM. She revealed she did the best she could but did not have time to check on Resident #2. She stated Resident #2 could experience skin breakdown from being left wet for long periods. Interview with the CMT, on 08/24/17 at 7:45 AM, revealed she did not observe Resident #2's wet pants as she transported the resident to the main dining room on 08/23/17. She stated she was in a hurry to get as many residents to the dining room as possible so she could help pass trays. The CMT stated if she had witnessed the wet pants, she would have changed the resident. She stated the resident could experience skin breakdown if left in urine for a long period. Interview with LPN #2, on 08/23/17 at 10:00 AM, revealed he did not notice Resident #2's wet pants when he reposition the residents legs and feet in the dining room. He stated if he had, he would have taken the resident back to the unit and changed the brief and clothing. He stated the resident could experience skin breakdown if left in urine for a long period. Interview with the Interim Unit Manager (UM), on 08/25/17 at 3:40 PM, revealed she was an agency Unit Manager and just returned to the facility on [DATE]. She stated she relied on the licensed nursing staff to supervise the CNAs. She stated she was new and the regular staff was not used to bringing concerns to her attention yet. The UM stated staff had not told her they were unable to perform showers or other tasks; however, she had identified residents were not as clean as they should be. She stated she was responsible for ensuring staff provided the necessary care and services to meet the residents' needs. Interview with the DON, on 08/25/17 at 2:45 PM, revealed she had not noticed Resident #2 had wet pants when she had moved the resident around in the Blue Unit Dayroom. The DON stated she walked the halls routinely and helped in the dining room daily; however, she had not identified any concerns with staff not providing showers or incontinent care to residents. She stated she depended on nursing staff to keep her updated on the care and services provided or not provided. She stated the UM had not informed her of any concerns. She stated staff should address resident shower and incontinent care needs because skin breakdown could occur, if left wet for long periods or not showered. Interview with Administrator, on 08/25/17 at 4:25 PM, revealed it was his expectation that staff provide timely incontinent care to residents dependent on staff. He stated staff should not leave residents wet or smelling of urine. He stated to his knowledge, the facility did not have a problem ensuring resident hygiene needs were met. The Administrator stated he had not directed the management staff to audit for these issues or determine if staff was indeed meeting resident needs as it related to incontinent care or showering. He stated that if staff did not meet resident care needs, the residents could decline or not have quality of life.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents at risk for pressure ulcers did not develop pressure areas for one (1) of sixteen (16) sampled residents, Resident #1. Resident #1's Certified Nursing Assistant plan of care directed staff to place pillows under the calves in order to float heels off the bed; however observations on 08/23/17 at 7:30 AM, 8:32 AM, and 3:14 PM, revealed no pillows under Resident #1's calves. A skin assessment of Resident #1's feet, on 08/24/17 at 3:10 PM, revealed four (4) unidentified pressure areas. The findings include: Review of the facility's policy, Pressure Ulcer Treatment, not dated, revealed the facility should redistribute pressure, implement pressure relieving devices in accordance with resident's assessed needs. Staff would evaluate until redness was no longer present. When eschar (a dry scab or slough formed on the skin) was present, a pressure ulcer could not be accurately staged until the eschar was removed. Review of Resident #1's clinical record revealed the facility admitted the resident on 04/11/17 with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident was at risk for developing pressure ulcers, needed extensive assistance of two (2) persons for bed mobility and was not interviewable. In addition, the facility assessed Resident #1 was always incontinent of bowel and bladder and required extensive assistance of one (1) person for bathing/hygiene. Further review of Resident #1's Care Plan, dated 12/08/16, revealed the resident was at risk for developing skin breakdown related to bed mobility and bowel/bladder incontinence. The goal stated the resident would have intact skin, free of redness, blisters, or discoloration over bony prominence. The interventions included staff to assist the resident as necessary to reposition or shift weight to relieve pressure, minimize pressure over bony prominences and to notify nursing immediately of any new areas of skin breakdown, redness, blisters, bruises, or discoloration noted during daily care. In addition, interventions included to provide incontinence care after incontinent episodes and apply barrier cream as needed. Review of Certified Nursing Assistant (CNA) Care Sheet, undated, revealed nursing staff were to ensure pillows were under Resident #1's calves and heels off the bed to relieve and minimize pressure. Observations, on 08/23/17 at 7:30 AM, 8:32 AM, and 3:14 PM, revealed Resident #1 was in bed on his/her her back without pillows under the calves in order to float the heels off the bed. Observations of Resident #1, on 08/24/17 at 7:00 AM, 8:02 AM, and 3:10 PM, revealed the resident in bed on his/her back, without pillows under calves. Observation, on 08/25/17 at 8:15 AM, of Resident #1 while in bed, revealed no pillows under the resident's calves. Observation during Resident #1's Skin Assessment performed by Licensed Practical Nurse (LPN) #3, on 08/24/17 at 3:10 PM, revealed the resident had two (2) unidentified pressure wounds to the lateral left foot. In addition, the resident had a wound on the second toe of the left and right foot. Continued observation revealed the resident's skin on the legs and feet was dry and flaky. Review of Resident #1's Weekly Skin Assessment sheet, dated 08/18/17, revealed nursing documented no skin breakdown or wounds to the feet or toes. Review of the Wound Care Notes, dated 08/22/17, revealed no documentation of wounds to Resident #1's feet or toes. Review of Nursing Note documentation, dated 08/22/17 at 2:30 PM, revealed the Advanced Practice Registered Nurse (APRN) was in to perform a follow/up assessment regarding Resident #1's moisture associated skin damage to the buttocks and sacrum. However, there was no documentation of an assessment of Resident #1's wounds located on both feet. Interview with CNA #10, on 08/25/17 at 1:55 PM, revealed she did not obtain a copy of the CNA Care Sheet prior to beginning her work on the unit. She stated she did not know much about Resident #1 or that pillows were required under the calves and heels were to be off the bed. CNA #10 stated she had not removed the resident's socks during the time she cared for Resident #1, in order to inspect the feet for skin breakdown. She stated she was very busy during her shift trying to complete her numerous assigned tasks. She stated placing pillows under the calves helped to keep pressure off the resident's feet while in the bed. CNA #10 stated pressure ulcers and/or skin breakdown could occur if pressure relief was not provided. Interview, on 08/23/17 at 11:55 AM, with CNA #12, revealed she referred to the CNA Care Sheet to remind her of the care plan interventions needed for her assigned residents. CNA #12 stated she did not know if Resident #1 had skin breakdown to the feet and had not received report from nursing staff that the resident had skin breakdown to the feet. She stated according to the CNA Care Sheet, Resident #1 should have pillows under his/her calves. CNA #12 stated the intervention was to prevent skin breakdown to the feet; however, she got busy and did not determine if the pillows were actually in place. She stated since the resident was dependent on staff for bed mobility, harm could occur to the resident if staff did not keep pressure off the feet. Interview with CNA #5, on 08/24/17 at 4:20 PM, revealed she was not aware of skin breakdown on Resident #1's feet. She stated she did not perform foot care on the resident today; however, she did place another pair of socks over the pair the resident already had in place. She stated it was important to perform foot care in order to assess the feet. She stated the CNA Care Sheet instructed her to place pillows under the calves to prevent skin breakdown. She stated she had placed pillows under the resident's legs after lunch and was not sure why the pillows were not under the resident's legs now. She stated pressure areas could develop if the resident's feet rested too long on the bed in one place. Interview with LPN #1, on 08/22/17 at 1:22 PM, revealed he did not believe Resident #1 had wounds to the toes or feet. He stated nursing performed weekly skin assessments and documented findings in the medical record. LPN #1 stated if nursing had identified Resident #1 had pressure areas, it would be on the 24 hour report sheet located at the desk; however, he did not routinely refer to the report sheet due to a lack of time. He stated if he did not get a verbal report from another nurse, he would not know if the resident had developed pressure wounds. LPN #1 stated he believed there was an order to put a 2 by 2 gauze on the left toe to prevent pressure. LPN #1 stated as far as he knew, that was the only treatment the resident received regarding the feet. Review of Resident #1's Treatment Administration Record, for 08/01/17 through 08/31/17, revealed an order for [REDACTED]. No Resident refusals were documented, the areas were left blank. Interview with LPN #3, on 08/24/17 at 3:10 PM, revealed prior to Resident #1's skin assessment, she had no knowledge of skin breakdown to the resident's right foot or the second toes on both feet. LPN #3 stated she had a treatment order to place a gauze pad on the right toe, as a pressure prevention measure, which she had not completed as of yet. She stated she had no treatment ordered for the second toe on the left foot. LPN #3 stated the nursing assistants had not reported skin breakdown to the resident's feet. She stated the two (2) areas to the right side of the foot were pressure related injuries. LPN #3 described the first wound on the right foot, closer to the pinky toe, as round, dark brown in the middle to black around the edges, and scabbed in appearance with approximated size of one (1) inch in diameter. The second wound, closer to the right ankle, was pink in the middle with dark brown edges with an approximated size of one and half (1 ½) inches in diameter. The LPN stated the resident also had dark brown-scabbed wounds on both second toes on the right and left feet. She described the second toe on the left foot had a pink center with dark brown edges. She stated the wounds on the toes were probably pressure related. She stated she was not aware Resident #1 had a nursing intervention to place pillows under the calves in order to float the heels off the bed. She stated the CNAs were responsible for implementing the intervention and she was responsible for monitoring. LPN #3 stated if she did not know about the intervention, how could she monitor for its implementation. She stated resident harm could occur if staff did not implement resident care plan interventions related to pressure relief and skin breakdown. Interview with the APRN, on 08/22/17 at 2:25 PM and 08/25/17 at 10:00 AM, revealed she performed a follow up assessment of Resident #1's wounds to the buttocks, sacrum, and thighs on 08/22/17. However, nursing staff did not mention the resident had wounds on the feet nor did they request her to assess the feet. She stated she would put it on her list to do at her next visit. She stated the resident was dependent on staff for bed mobility and if staff did not elevate the resident's feet off the bed, the resident would develop avoidable pressure areas to the feet. Interview with the Director of Nursing (DON), on 08/25/17 at 2:45 PM, revealed she was not aware Resident #1 had unidentified pressure areas on both feet until the surveyor observed the skin assessment with LPN #3. The DON stated she expected staff to make her aware of any significant skin care changes. She stated she had not conducted audits to determine if staff was implementing pressure-reducing interventions. She stated she depended on licensed nurses to supervise the CNAs to ensure pressure-relieving interventions, such as pillow use, were implemented. She stated pressure ulcers could develop if staff did not monitor residents at risk and implement interventions to prevent. Interview with the Administrator, on 08/25/17 at 4:25 PM, revealed it was his expectation that staff make him aware of issues or concerns with resident care. He stated he expected staff to implement nursing measures to prevent skin breakdown. He stated if staff did not implement pressure ulcer prevention interventions, then harm, such as wounds, could develop and that would be a bad outcome for the resident.

Based on observation, interview, record review and review of the facility policy it was determined the facility failed to ensure residents at risk for weight loss received extensive assistance with eating, as assessed, for one (1) of sixteen (16) sampled residents, Resident #1. Interview with the Registered Dietitian (RD) revealed Resident #1 experienced a 5.5% weight loss in thirty (30) days, 8.6% weight loss in ninety (90) days, and a 17% weight loss in six (6) months. In addition, the facility failed to ensure staff obtained daily weights for the resident. The findings include: Review of the facility's policy, Weight Monitoring, not dated, revealed the facility would identify residents at nutritional risk. The resident's weight would be monitored weekly upon admission/readmission for four (4) weeks and monthly thereafter, or as indicated by the resident's condition or physician's order. Recommendations and interventions would be implemented as appropriated by the Physician, Therapy, and/or Dietary recommendations. Weights would be monitored weekly for four (4) weeks or until stable, as determined by the Registered Dietitian or resident wishes through the Advance Directives or resident's responsible party. Parameters for evaluating Significant Weight Loss: 5% weight loss/gain in one (1) month, 7.5% weight loss/gain in three (3) months, 10% weight loss/gain in six (6) months, and any unintentional weight change. If significant weight change were identified, the nurse would document and notify the physician and the responsible party. The Registered Dietitian would be notified for any recommendations. Residents would be weighed weekly for four (4) weeks and reviewed until the resident's weight had stabilized or the issue was resolved through other parameters. Observation, on 08/24/17 at 12:25 PM, revealed Resident #1 in the dining room being fed by the Certified Medication Technician (CMT). The resident had a carton of milk, a glass of tea, a slice of pie, a roll, ground beef, and mashed potatoes. The resident ate a few bites of pie, ground beef, and mashed potatoes, and then was pushed away from the table. The staff did not offer the resident a substitute prior to pushing the resident out into the hallway. Interview with Certified Nursing Assistant (CNA) #7, on 08/24/17 at 12:35 PM, revealed she calculated the resident ate 25% of the meal and drank 240 cubic centimeters (cc) of the fluids. She stated she did not know it was part of the resident's plan of care to offer the resident a substitute meal or food item if the resident ate 50% or less of the meal, or that she needed to report to the resident's nurse how much the resident consumed. She stated offering the resident a substitute would help entice the resident to eat more food of their choosing. She stated she did not know if Resident #1 had a recent weight loss. Review of Resident #1's clinical record revealed the facility admitted the resident on 04/11/17, with the [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to need a therapeutic and mechanically altered diet and required extensive assistance of one (1) person with eating meals. The MDS stated the resident had a weight loss of 5% or more in the last month or loss of 10% or more in the last six (6) months. The MDS stated the resident's weight at the time of assessment was 152 pounds. The MDS assessment also stated the resident was not interviewable. Further review of Resident #1's clinical record revealed the facility transferred the resident to the hospital for a change in mental status from a urinary tract infection on 07/21/17, and the resident returned on 07/27/17. Review of documented weights for Resident #1, revealed prior to the hospitalization , the resident weighed 153.8 and after readmission, he/she weighed 157.4. Continued review revealed the resident's documented weight was 144 pounds on 08/24/17. Resident #1 had a 13 pound weight loss from 07/27/17 to 08/24/17. Further review of the medical record revealed the facility did not weigh the resident on 08/20/17, 08/18/17, or 08/06/17. Review of Resident #1's Care Plan, dated 12/08/16, revealed the resident was at nutritional risk related to a mechanical altered therapeutic diet. The goal stated the resident would not have further significant weight loss. The care plan approaches directed staff to obtain daily weights as ordered, provide and monitor intake of fluids/diet, and to offer substitutes if the resident did not consume 50% or more of his/her food. The last revision to the plan of care, dated 08/08/17, directed staff to provide a mechanical soft diet with no salt packets. Continued review of the plan of care and the CNA plan of care sheet revealed neither directed staff to provide Resident #1 the extensive assistance of one (1) when eating meals, as per the MDS assessed required need. Review of the Meal Report for Resident #1 revealed on 08/24/17, the resident ate 25% of the breakfast meal with 360 cc of fluid. During the lunch meal, the resident ate 25% with 240 cc of fluid, at supper; staff recorded the resident consumed 50% of the meal with 360 cc of fluid. Staff did not document that a substitute was offered when the resident ate less than 50% of the meal. Continued review of the Meal Report for 08/23/17 revealed staff recorded the resident ate 75% of the breakfast meal and drank 240 cc of fluid. During the lunch meal, the resident ate 25% and drank 120 cc of fluid. On 08/23/17, there were no recorded amounts of food or liquids for the supper meal. Staff did not document if a substitute was offered to the resident after the resident ate less than 50% of the meal. Further review of the Meal Report for Resident #1 revealed staff did not document breakfast, lunch, or supper meal consumption on 07/29/17, 08/09/17, 08/11/17, 08/12/17, 08/13/17, 08/18/18, or 08/19/17. Continued review revealed there was no documentation of the amount of supper meal consumed on 08/02/17, 08/06/17, 08/10/17, 08/14/17, 08/17/17, 08/21/17, 08/22/17, or 08/23/17. Staff did not document that Resident #1 had refused the meal, was ill, or that a substitute was offered. Review of CNA documentation of the amount and type of care assistance provided to Resident #1 on 08/20/17 during 7:00 AM to 7:00 PM, revealed the CNAs provided Resident #1 meal set up only. The CNAs documented Resident #1 was independent and required no assistance with eating meals on 08/21/17. On 08/22/17, the resident was documented as independent requiring only tray set up and no assistance with eating meals provided. On 08/23/17, CNAs documented the resident required extensive assistance of one (1) during one (1) meal between 7:00 AM and 7:00 PM. No other meal assistance/service was documented on 08/23/17. Review of Resident #1's Physician Orders, dated 07/26/17, revealed staff should weigh the resident daily. Staff was to administer 150 milliliters (ml) of Med Plus (dietary supplement) and give a House Shake supplement three (3) times a day. In addition, provide 30 ml of PROMOD liquid protein supplement by mouth daily. Review of Resident #1's Medication Administration Record [REDACTED]. Continued review revealed nursing did not document the amount of PROMOD liquid and Med Plus supplement consumed on 08/01/17 through 08/31/17, as they did with the House Shake supplement. Review of the Registered Dietitian (RD) Note, dated 08/07/17, revealed Resident #1's weight was 153.6 pounds. The RD noted Resident #1 had a required caloric need of 2100 calories, which required the resident to consume 95% of his/her food to obtain. In addition, the resident needed 2100 ml of fluids to maintain hydration. Further review of the RD's notes revealed the resident had a 2.1 pound weight loss in the last thirty (30) days, a 5 pound weight loss in the last ninety (90) days, and an 11.2 pound weight in the last six (6) months. The resident ate 61% of his/her food during the last fourteen (14) meals documented. The RD documented no skin issues were noted. The RD recommended Resident #1 be provided a low sodium mechanical soft diet with no salt packets on the tray and increase house shakes to three (3) times a day. Interview with the RD, on 08/24/17 at 3:45 PM, revealed when she was at the facility, the facility staff provided her with a report of the residents with weight loss for her to assess. She stated she did not review every resident on the days she was in the building. However, she had assessed Resident #1 for weight loss on 08/07/17 and made recommendations. She stated as part of her review of the resident, she looked at skin issues, dietary intake, need for assistant, illness etc. in order to determine her recommendations. The RD stated she had not received further updates or requests to re-evaluate the resident since her assessment on 08/07/17. She stated she was not aware the resident had skin breakdown on the buttocks and feet or that the resident now weighed 144 pounds, as of 08/24/17. The RD stated she reviewed facility documentation of meal and supplement consumption during each visit; however, it was hard to determine recommendations or if they were effective when staff did not document resident intake of supplements or food. She stated staff should offer the resident substitutes if the resident did not eat at least 50% of his/her food because offering food preferences increased the resident's chances of eating more calories. The RD stated the resident had a recent hospitalization and was experiencing increased weakness. She stated the resident required increased assistance with eating and if staff was not assisting the resident, it could cause additional weight loss. She stated nursing staff administered the supplements; however, they failed to document how much of the supplements the resident consumed, which made it difficult for her to make additional recommendations. The RD stated if the staff did not provide extensive assistance with feeding, document food and supplement consumption amounts, or offer substitutes if the resident ate 50% or less of his/her food, she would consider Resident #1's weight loss avoidable. She stated Resident #1 experienced a 5.5% weight loss in thirty (30) days, 8.6% weight loss in ninety (90) days, and a 17% weight loss in six (6) months. Interview with CNA #14, on 08/24/17 at 6:37 AM, revealed she worked the night shift routinely and the night shift CNAs were responsible for weighing Resident #1. She stated she weighed the resident with the lift at 6:00 AM on 08/24/17, and the resident weighed 144.4 pounds. She stated she wrote it on the 24-hour report book and told the nurse. She stated she did not normally work the 200 Hall and could not say if Resident #1 had a weight loss or not. She stated there were times she was too busy getting residents up for breakfast and checking and changing them before she left at 7:00 AM, and she could not get all of the required residents weighed. She stated she did the best she could and would tell the oncoming CNAs that certain residents still needed to be weighed. She stated obtaining residents weights was important because staff needed to know if there was a weight change in order to address it with an intervention. Review of the Kitchen Tray Schedule, not dated, revealed the Breakfast Meal Cart was delivered to the units at 7:30 AM. Observation, on 08/23/17 at 7:40 AM, revealed the breakfast trays were not in the kitchen area and had been delivered to the units. Observation ,on 08/23/17 at 8:32 AM, revealed Resident #1 sitting up in bed with a breakfast tray on the over bed table across his/her lap. The resident's tray contained a chopped up banana, eggs, toast with jelly on it, cereal in a bowl with milk, an opened carton of milk, and a glass of juice. The resident's lips were dry and cracked and the corners of the mouth had an unknown dried brown substance. Interview with Resident #1, on 08/23/17 at 8:32 AM, revealed the resident was hungry but needed help eating. Observation, at 8:40 AM on 08/23/17, revealed the Administrator was serving breakfast trays on the 200 Hall. Further observation, on 08/23/17 at 8:53 AM, revealed Resident #1 sitting up in the bed with his/her eyes closed, with an untouched plate of food in front of the resident. Continued observation at 8:53 AM, revealed the Administrator, Director of Nursing (DON), Licensed Practical Nurse (LPN) #1 and CNA #10, passed by Resident #1's room several times as they tended to other residents or passed breakfast trays. Interview with CNA #7, on 08/23/17 at 9:00 AM, revealed she was assigned to the 400 Hall and was answering call lights and assisting a resident with toileting when the DON came to her and requested she go to Resident #1's room and assist the resident with the breakfast meal because the surveyor was watching the care provided on the hall. She stated now her residents would be waiting for her to return to tend to their needs while she assisted Resident #1. She stated the breakfast cart came to the unit at 7:30 AM, and she did not know who served Resident #1 the breakfast tray. She stated the resident was able to feed himself/herself several weeks ago but now she thought the resident needed more help. She stated she did not have a CNA Care Sheet for the 200 Hall and could not say how much assistance Resident #1 required when eating. CNA #7 stated she was not sure if there was a requirement to notify the nurse if the resident ate a certain amount of the meal. Observation of CNA #7 revealed she picked up the resident's fork and began to feed the resident the eggs and bananas. Interview with CNA #10, on 08/23/17 at 4:20 PM and 08/25/17 at 1:55 PM, revealed she was assigned to care for Resident #1. She stated when she arrived at work there were no CNA Care Sheets available for her to use as a reference to know what type or amount of care her residents needed. She stated she did not know Resident #1 needed extensive assistance of one (1) with eating or if he/she ate less than 50% of his/her food to report it to the nurse. She stated her morning assignment required her to pass trays in the dining room for the breakfast meal. She stated when she was off the floor; the staff that remained was responsible for the residents that remained on the unit. Interview with LPN #1, on 08/22/17 at 1:22 PM and 08/23/17 at 11:05 AM, revealed he believed Resident #1's health had stabilized since his/her return from the hospital in July. He stated as far as he knew, Resident #1 did not have weight loss. LPN #1 stated the CNAs were responsible for obtaining resident weights; however, he did not receive a report regarding the resident's weight from the CNAs or off going nursing staff, that Resident #1 had a weight loss or how much he/she weighed. He stated there was a 24-hour report book at the desk that might have additional information about Resident #1's weight; however, he had not looked at the report and routinely did not have the time to refer to it. He stated he did not have access to the resident's plan of care to determine if there were interventions for weight loss because the MDS Coordinators kept the binders in their office. He stated he would have to refer to physician orders and the medication and treatment records to see if the resident received care and services related to weight loss. LPN #1 also stated the CNAs had not reported to him the amount of meal consumption Resident #1 had during each meal. He stated the CNAs documented in the KIOSK (CNA computer documentation record) the residents' intake and output. He stated he was extremely busy and had not reviewed the documentation to assess the resident's amount of food intake. He stated he was not sure if Resident #1 required extensive assistance of one (1) with eating or not. He revealed having knowledge of resident weights and amount of intake and output was important in order to assess resident change in condition or need for additional interventions. Interview with the Interim Unit Manager (UM), on 08/25/17 at 3:20 PM, revealed she was an agency UM that floated between buildings and she was just assigned to come back to the facility on [DATE]. She stated since she was new to the facility staff were not used to reporting issues or concerns to her as of yet. The UM stated the facility had not updated the CNA care sheet to inform the CNAs or other nursing staff that Resident #1 needed extensive assistance of one (1) with eating meals until today. She stated she updated the CNA Care Sheets to inform the CNAs they needed to feed Resident #1 going forward. She stated she did not know what the resident weighed or if he/she had experienced a weight loss. She stated if the resident was not provided the required extensive assistance with eating, the resident could experience weight loss. Interview with the DON, 08/25/17 at 2:45 PM, revealed she was not aware of Resident #1's weight loss. She stated the RD would notify her of any weight loss issues. The DON stated she made rounds and ensured all residents had meal trays. She stated the facility had identified an issue with staff not documenting the care and services provided to the residents; however, the facility was still working on improving the identified issue. Interview with the Administrator, on 08/25/17 at 4:25 PM, revealed he had not directed the management staff to audit meal service or whether staff was providing the resident's with the required assistance with meals per the facility assessed need. He stated the only meal issues he was aware of came from Resident Council Meetings and none of which required an audit. He stated the facility had identified an issue with staff not documenting the care provided and the facility was still working on improving staff documentation. The Administrator stated he was not aware staff did not provide Resident #1 with the assessed extensive assistance of one (1) with eating or that the resident had a seventeen (17) pound weight loss over a six (6) month period of time. He stated he expected staff to provide the care the resident needed to maintain their maximum well-being.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide sufficient nursing staff to provide care and services for two (2) of sixteen (16) sampled residents, Resident #1 and #2. Record review revealed Resident #1 received two (2) of fourteen (14) scheduled showers from 07/02/17 to 08/23/17, experienced a significant weight loss, and developed pressure areas to the feet. Observation of Resident #1's care revealed staff did not implement the assessed care needs to prevent skin breakdown or weight loss. Observation of the Blue Unit Dayroom, on 08/23/17 at 7:17 AM, revealed Resident #2 sat in a wheelchair with a large wet area on the front of his/her pants that proceeded down to the middle of the thighs and had a strong odor of urine. Continued observation revealed staff did not address Resident #2's need for incontinent care until 8:25 AM. Record review revealed Resident #2's received three (3) of fifteen (15) scheduled showers from 07/02/17 to 08/23/17. The findings include: Review of the facility's policy, Nurse Staffing, not dated, revealed facility staff included Licensed Nursing Staff, which referred to registered nurses, licensed practical nurses, or licensed vocational nurses. Unlicensed nursing staff were certified nursing assistants. The facility staff were those that provided direct care to residents or supervised those who provided direct care to residents. Direct care included, but was not limited to, activities as assistance with activities of daily living, performing gastrointestinal feeds, giving medications, supervising the care provided by certified nursing assistants, and performing nursing assessments, admitting residents, or notifying physicians about a change in condition. Review of the facility's policy, Resident Rights, not dated, revealed the facility would make every effort to assist each resident in exercising his/her rights to assure the resident was always treated with respect, kindness, and dignity. Review of the facility's Resident Census and Condition of Residents form, dated 08/22/17, revealed the facility had a census of one-hundred and twelve residents (112). Fifty-eight (58) of those residents were totally dependent on staff for bathing. Nineteen (19) residents were totally dependent for toileting. Fourteen (14) residents were totally dependent on staff for eating and seventy-four (74) required the assistance of one (1) or two (2) staff for eating. The facility assessed ninety-three (93) residents as occasionally or frequently incontinent of urine and seventy (74) as incontinent of bowel. In addition, the facility had eleven (11) residents with stage 2 or greater pressure ulcers of which only three (3) were present on admission. Nine (9) residents were listed with unplanned weight loss/gain. Review of the facility's Staffing Schedules, dated 08/22/17, revealed the Certified Nursing Assistants (CNA) shift began at 7:00 AM and the licensed nursing staff at 6:15 AM. Review of the Kitchen Tray Schedule, not dated, revealed the facility served breakfast in the main dining room at 7:30 AM and delivered breakfast meal carts to the units at 7:30 AM. Lunch was served at 11:30 AM and Supper at 5:00 PM. Review of the facility Roster/Sample Matrix and Facility Census, provided on 08/22/17, revealed the facility had a census of eighty-two (82) on the Blue Unit and thirty (30) residents on the Green Unit. Review of the Daily Assignment Sheet for the Green Unit, for 08/23/17, revealed the facility staffed the Green Unit with two (2) LPNs and three (3) CNAs. The Green Unit total census was thirty (30) residents. The facility assigned one (1) LPN to take the 500 and 800 Halls, which had fifteen (15) residents, and the other LPN was assigned to take the 600 Hall, which had fifteen (15) residents. Review of the Daily Assignment Sheet for the Blue Unit, for 08/23/17, revealed the facility staffed the Blue unit with three (3) Licensed Practical Nurses (LPN), one (1) Certified Medication Technician (CMT), and six (6) CNAs for eight-two (82) residents. The CMT was assigned to the 200 Hall and the assignment sheet directed the licensed nursing staff on the 100 Hall to take seven (7) residents on the 200 Hall, for a total of twenty-four (24) residents. The 300 Hall nurse was to take eight (8) residents on the 200 Hall, for a total of thirty-one (31) residents. The 400 Hall nurse was to take seven (7) residents on the 200 Hall, for a total of twenty-six (26) residents. Review of the Blue Unit Assignment Sheet for CNAs, dated 08/24/17 for 7:00 AM to 7:00 PM, revealed the 100 Hall CNA had three (3) residents to get out of bed and dressed prior to the breakfast meal service, which began at 7:30 AM. That CNA's other daily duties included passing breakfast, lunch, and supper meal trays, feeding the residents on the hall during each meal, answering call lights, and taking out the trash before 10:00 AM. The CNA assigned to rooms 205-212 had nine (9) residents to get up out of bed prior to the breakfast meal service. That CNA's other duties included passing trays and feeding residents in the dining room, inputting meal consumption for residents, passing ice/water for resident pitchers, and taking out the trash before 10:00 AM. The CNA assigned to rooms 306-312 had eight (8) residents to get up prior to the breakfast meal service. That CNA's other duties included feeding residents on the unit, answering call lights, and taking out trash before 6:00 PM. The CNA assigned to rooms 405B-412, had seven (7) residents to get up prior to the breakfast meal. That CNA's other duties were to serve trays during all three (3) meal services, feed residents in the main dining room, input resident meal consumption, and take out trash before 6:00 PM. The CNA assigned to 101-102 and 301-305, had eight (8) residents to get up for breakfast. That CNA's other duties included passing trays and feeding residents on the unit, answering call lights, and cleaning the shower room. The CNA assigned to rooms 201-204 and 402-405A, had eight (8) residents to get out of bed for breakfast. That CNA's other duties included passing trays and feeding residents in the main dining room, inputting resident meal consumption, cleaning the Blue Unit Lounge, and empty the trash. Review of the Blue Unit Shower Schedule, not dated, revealed each Wednesday and Saturday, eighteen (18) residents were to receive showers. The CNA assigned to rooms 103-110 had four (4) showers to give along with their other assigned duties. The CNA assigned to rooms 205-212 had five (5) showers to complete along with his/her other assigned duties. The CNA assigned to rooms 306-312 had one (1) shower to give. The CNA assigned to rooms 405B-412, had three (3) resident showers to give. The CNA assigned to rooms 101-102 and 301-305 had four (4) showers to give. The CNA assigned to rooms 201-204 and 402-405A had one (1) shower to give. Review of the Daily Assignment Sheet for the Blue Unit, for 08/24/17, revealed the facility staffed the Blue unit with three (3) Licensed Practical Nurses (LPN), one (1) Certified Medication Technician (CMT) (Certified Medication Technician can only administer oral and topical medications under the supervision of a licensed nurse) and six (6) CNAs for eight-two (82) residents. The facility assigned the CMT to the 300 hall. Continued review of the assignment sheet revealed the facility assigned the licensed nursing staff additional residents from the CMT's 300 Hall. The 100 Hall LPN had seventeen (17) assigned residents and was required to take an additional seven (7) residents on the 300 Hall, for a total of twenty-four (24) residents. The 200 Hall nurse had twenty-three (23) assigned residents plus eight (8) residents on the 300 Hall, for a total of thirty-one (31) residents. The 400 Hall nurse had nineteen (19) assigned residents plus eight (8) on the 300 Hall, for a total of twenty-seven (27) residents. Review of the Blue Unit CNA Assignment Sheet, for 08/24/17, revealed there were six (6) CNAs scheduled and their room assignments were rooms 101-110, for a total of seventeen (17) residents. Rooms 205-212, for a total of fifteen (15) residents. Rooms 306-312, for a total of fourteen (14) residents. Rooms 405B-412 for a total of twelve (12) residents. Rooms 101-102 and rooms 301-305 for a total of twelve (12) residents. Rooms 201-204 and 402-405A for a total of fifteen (15) residents. Review of the Daily Assignment sheet for the Blue Unit, on 08/25/17 and observation of staff on the unit at 7:45 AM, revealed six (6) CNAs scheduled to work the unit; however, only five (5) were present. Interview with CNA #5, on 08/25/17 at 7:50 AM, revealed there were five (5) CNAs on the unit because one (1) CNA was a no show. She stated the schedule in the book had six (6) CNAs listed but that was not correct. She stated she was assigned to provide care to nineteen (19) residents on the 400 Hall, including rooms 201-204 and 304. She stated it was impossible for her to care for that many residents and provide quality care timely. The CNA stated she was already behind getting resident needs met. 1. Review of Resident #1's clinical record revealed the facility admitted the resident on 04/11/17, with the [DIAGNOSES REDACTED]. Review of Resident #1's quarterly MDS, dated [DATE], revealed the facility assessed the resident was at risk for developing pressure ulcers, needed the extensive assistance of two (2) persons for bed mobility, was always incontinent of bowel and bladder, required extensive assistance of one (1) person for bathing/hygiene, and required extensive assistance of one (1) person with eating meals. The MDS stated the resident had a weight loss of 5% or more in the last month or loss of 10% or more in the last six (6) months. Review of Resident #1's Care Plan, dated 02/24/17, revealed Resident #1 was at risk for potential complications associated with incontinence of bowel and bladder. The goal stated staff would keep the resident clean, dry, and comfortable daily and the resident would not develop any complications associated with incontinence through the next review date. The interventions included staff to maintain privacy and dignity when checking resident for incontinent episodes, monitor and report any changes in bladder status such as foul smelling urine, frequency, or urgency, and report any changes to peri-area/skin to the physician. Further review of Resident #1's Care Plan, dated 12/08/16, revealed the resident was at risk for developing skin breakdown related to bed mobility and bowel/bladder incontinence. The goal stated the resident would have intact skin, be free of redness, blisters, or discoloration over bony prominence through the next review date. The interventions included staff to assist the resident as necessary to reposition or shift weight to relieve pressure, minimize pressure over bony prominences, and to notify nursing immediately of any new areas of skin breakdown, redness, blisters, bruises, or discoloration noted during daily care. In addition to providing incontinence care after incontinent episodes, apply barrier cream as needed. The resident was also at nutritional risk related to a mechanical altered therapeutic diet. The goal stated the resident would not have further significant weight loss. Continued review of the plan of care and the CNA Care Sheet revealed neither directed staff to provide Resident #1 the extensive assistance of one (1) when eating meals, as per the MDS assessed required need. Review of Certified Nursing Assistant (CNA) Care Sheet, undated, revealed nursing staff were to ensure pillows were under Resident #1's calves and heels off the bed to relieve and minimize pressure. Observation of Resident #1, on 08/22/17 at 1:17 PM, revealed the resident sitting in a wheelchair in his/her room wearing tan pants and a white shirt with tan/gold colored dots. Observation of Resident #1, on 08/22/17 at 1:45 PM, revealed the resident sitting in his/her wheelchair in his/her room. At 2:05 PM, Resident #1 had his/her head down and eyes closed while sitting in the wheelchair. Continued observation of Resident #1, on 08/22/17 at 2:22 PM, revealed staff used a mechanical lift and transferred the resident back to bed. Interview with CNA #3, on 08/22/17 at 1:45 PM and 2:22 PM, revealed staff got Resident #1 out of bed at 10:30 AM on 08/22/17, using the mechanical lift. The CNA stated the resident was dependent on staff for transfers and incontinent care. She stated she had not checked or changed the resident since 10:30 AM because she was busy completing other tasks. She stated nursing staff had requested she put Resident #1 back to bed at 2:22 PM because the Wound Care Nurse Practitioner was there to re-evaluate the skin breakdown on Resident #1's buttocks and inner thighs. She stated it was important to keep resident's skin clean and dry to prevent further skin breakdown. Observations, on 08/23/17 at 7:30 AM, revealed Resident #1 was in bed on his/her her back without pillows under the calves in order to float the heels off the bed. Observation, on 08/23/17 at 8:32 AM, revealed Resident #1 sitting up in bed with a breakfast tray on the over bed table across the lap. The resident's tray contained a chopped up banana, eggs, toast with jelly on it, cereal in a bowl with milk, an opened carton of milk, and a glass of juice. The resident had on the same clothes as 08/22/17; however, the shirt had a pink stain in the middle. The resident's lips were dry and cracked and the corners of the mouth had an unknown dried brown substance. The resident's hands were dry and the fingernails had an unknown brown substance under them. The resident's eyes had a yellow substance in the eyelashes. The resident did not have pillows under the calves in order to float the heels off the bed. Interview with Resident #1, on 08/23/17 at 8:32 AM, revealed the resident was hungry but needed help eating. Observation, on 08/23/17 at 8:53 AM, revealed Resident #1 sitting up in the bed with his/her eyes closed with an untouched plate of food in front of the resident. The resident was wearing the same shirt, lips still dry, corners of mouth with an unknown dried brown substance, eyelashes still had unknown substance, and nails dirty. The Administrator, Director of Nursing (DON), Licensed Practical Nurse (LPN) #1 and CNA #10, passed by Resident #1's room several times as they tended to other residents or passed breakfast trays. Interview with CNA #7, on 08/23/17 at 9:00 AM, revealed she was assigned to the 400 Hall and was answering call lights and assisting a resident with toileting when the DON came to her and requested she go to Resident #1's room and assist the resident with the breakfast meal because the surveyor was watching the care provided on the hall. She stated now her residents would be waiting for her to return to tend to their needs while she assisted Resident #1. She stated the breakfast cart came to the unit at 7:30 AM, and she did not know who served Resident #1 the breakfast tray. She stated the resident was able to feed himself/herself several weeks ago but now she thought the resident needed more help. She stated she did not have a CNA Care Sheet for the 200 Hall and could not say how much assistance Resident #1 required when eating. CNA #7 stated she was not sure if there was a requirement to notify the nurse if the resident ate a certain amount of the meal. Observation of CNA #7 revealed she picked up the resident's fork and began to feed the resident the eggs and bananas. Observation, on 08/23/17 at 11:30 AM, revealed Resident #1 sitting in a wheelchair in his/her room and clothing had been changed. At 12:30 PM, the resident was in the main dining room with staff assisting with the meal. Observation, on 08/23/17 at 1:35 PM, revealed Resident #1 in bed with staff in the room tending to the resident's roommate. Observation at 2:30 PM and 3:14 PM, revealed Resident #1 in bed with eyes closed. Observations of Resident #1, on 08/24/17 at 7:00 AM, 8:02 AM, and 3:10 PM, revealed the resident in bed on his/her back, without pillows under calves. Observation, on 08/25/17 at 8:15 AM, of Resident #1 while in bed, revealed no pillows under the resident's calves. Interview with CNA #10, on 08/25/17 at 1:55 PM, revealed did not know much about Resident #1 or that pillows were required under the calves and heels were to be off the bed. CNA #10 stated she had not removed the resident's socks during the time she cared for Resident #1, in order to inspect the feet for skin breakdown. She stated she was very busy during her shift trying to complete her numerous assigned tasks. She stated placing pillows under the calves helped to keep pressure off the resident's feet while in the bed. CNA #10 stated pressure ulcers and/or skin breakdown could occur if pressure relief was not provided. Observation during Resident #1's Skin Assessment performed by Licensed Practical Nurse (LPN) #3, on 08/24/17 at 3:10 PM, revealed the resident had two (2) unidentified pressure wounds to the lateral left foot. In addition, the resident had a wound on the second toe of the left and right foot. The resident's inner thighs were red and pink in color and excoriated. The resident's sacral and left buttock had open areas surrounded by pink excoriated skin. Continued observation revealed the resident's skin on the legs and feet was dry and flaky. Review of Resident #1's Weekly Skin Assessment sheet, dated 08/18/17, revealed nursing documented no skin breakdown or wounds to the feet or toes. Review of the Wound Care Notes, dated 08/22/17, revealed no documentation of wounds to Resident #1's feet or toes. Review of Resident #1's Weekly Skin Assessment sheet, dated 08/18/17, revealed the resident had a 7 centimeter (cm) by 7 cm excoriation to the right buttock and an unmeasured excoriation to the left buttock. The upper left thigh had a 10 cm by 5 cm excoriated area. Review of Resident #1 Wound Care Notes, dated 08/22/17, revealed the resident had moisture associated skin damage to the sacral, left buttock, and thigh areas. The open sacral wound measured 1.0 cm by 0.8 cm and the left buttock area measured 1.5 cm by 2.5 cm. The areas were described as partial thickness with 76-100% granulation. The skin was noted as friable with serosanguineous (blood and serum mixture) drainage. Review of Resident #1's Nursing Note, dated 08/22/17 at 2:30 PM, revealed the Advanced Practice Registered Nurse (APRN) was in to perform a follow/up assessment regarding Resident #1's moisture associated skin damage to the buttocks and sacrum. Nursing noted the resident complained of pain during cleansing of the wound sites. Review of the Shower Schedule for Resident #1, not dated, revealed the resident was to receive a shower every Monday and Thursday. Review of Resident #1's shower documentation in the CNA Kiosk computer, revealed from 07/02/17 to 08/23/17, the resident should have received fourteen (14) showers; however, documentation revealed Resident #1 received two (2) showers, on 07/10/17 and 08/20/17. The CNAs documented on ten (10) other scheduled shower days the resident received partial bed baths. The documentation stated the resident received full bed baths on 08/10/17 and 08/21/17. Continued review revealed staff did not document the resident had refused or was ill on any scheduled shower day. Interview with CNA #5, on 08/24/17 at 4:20 PM, revealed she had not done morning hygiene care for Resident #1 because she did not have time. She stated after lunch, she put Resident #1 back to bed and placed another pair of socks over top a pair the resident already had in place. CNA #5 stated she did not provide foot care or apply lotion to the resident's leg when she provided care to the resident because she did not have time. Interview with CNA #10, at 4:20 PM on 08/23/17, revealed Resident #1 was dependent on staff for incontinent care and should be checked for incontinence at least every two (2) hours. She stated she got Resident #1 out of bed at 9:30 AM and changed him/her at that time. CNA #10 stated she put the resident back in bed around 1:30 PM. CNA #10 stated she had changed the resident (2) two times on 08/23/17, at 9:30 AM and again around 2:30 PM, and both times the resident was wet. She stated five (5) hours between checks and changes was too long and skin breakdown could occur. She stated the resident had skin breakdown presently and it could get worse sitting in wet briefs. CNA #10 revealed her workload was very heavy, with (15) fifteen residents, and her numerous tasks prevented her from making timely rounds on all her residents. Interview with the APRN, on 08/22/17 at 2:25 PM and 08/25/17 at 10:00 AM, revealed Resident #1 was a heavy wetter, which contributed to the residents moisture associated skin damage on the buttocks. She stated sitting in urine contributed to skin breakdown and the development of yeast infections, which the resident had a history of [REDACTED].#1 sat in wet briefs for extended periods. The APRN stated she expected staff to check and change Resident #1 at least every two (2) hours. However, she stated since the resident was a heavy wetter, checking the resident every hour for incontinence would be more beneficial for prevention measures. Interview with the Restorative Aide (RA), on 08/25/17 at 9:00 AM, revealed the facility assigned her to the back of the 400 Hall at 9:00 AM. She stated prior to that, she was doing her restorative aide assignments and later in the morning would be going out of the facility with a resident for a doctor's appointment. The RA stated the CNA assigned to the front of the 400 Hall had the entire hall until the facility told her (RA) that her assignment had changed. She stated she did not receive a report regarding her newly assigned residents. The RA stated the Blue Unit had worked with five (5) CNAs on the floor on several occasions, which made the workload very heavy. Interview with CNA #9, on 08/25/17 at 2:30 PM, revealed the facility called her into work from 11:00 AM to 3:00 PM, because the facility was short a CNA on the Blue Unit. She stated when she arrived she immediately began providing care and did not get a report from a CNA or nurse regarding the residents. She stated there were several residents that needed changing and morning care when she arrived. CNA #9 stated she had not completed all the assigned resident showers and would be leaving at 3:00 PM and was not sure who would be taking over after she left. Interview with LPN #4, on 08/25/17 at 9:15 AM, revealed a CNA did not show up and the decision was made to have the CNA assigned to the front of the 400 Hall take the rest of the residents on the 400 Hall. She stated administration made the assignment changes. LPN #4 stated the resident care on the hall was heavy and everyone was trying to do his or her best to help the CNA provide resident care. Interview with the Interim Unit Manager, on 08/25/17 at 3:50 PM, revealed there was a scheduling conflict and not enough CNAs were available on 08/25/17 for the Blue Unit. She stated the facility expected all staff to pitch in to help in order to meet all resident care needs. She stated staff did not make her aware resident needs had not met during the time they were down one (1) CNA. Interview with LPN #6, on 08/23/17 at 1:47 PM, revealed the facility assigned her to care for twenty (20) residents on the Green Unit. She stated her responsibilities included taking vital signs, passing medications, performing treatments, resident assessments, answering call lights, taking phone calls, taking physician orders, performing resident documentation, assisting the CNAs in direct resident care, passing meal trays, and feeding residents, just to name a few. She stated it was just too much for her to complete all the required tasks for twenty (20) residents timely. LPN #6 stated the facility was routinely short staffed and nursing could not provide quality care for their assigned number of residents. 2. Review of Resident #2's clinical record revealed the facility admitted the resident on 06/11/12, with the [DIAGNOSES REDACTED]. Review of Resident #2's quarterly MDS, dated [DATE], revealed the facility assessed the resident required extensive assistance of two (2) persons for transfers and was incontinent of bowel and bladder. The resident required extensive assistance of one (1) person for bathing and hygiene. In addition, the facility assessed the resident was not interviewable. Review of Resident #2's Care Plan, dated 08/01/17, revealed the resident had potential for complications associated with incontinence of bowel and bladder. The goal stated staff would keep the resident clean, dry, and comfortable through the next review. The interventions included staff to monitor and report changes in bladder status, and maintain privacy and dignity when checking resident for incontinent episodes. Review of the Shower Schedule for Resident #2, not dated, revealed the resident was to receive a shower every Wednesday and Saturday. Review of Resident #2's shower documentation in the CNA Kiosk computer, revealed from 07/02/17 to 08/23/17, the resident should have received fifteen (15) showers; however, documentation revealed Resident #2 received three (3) showers, on 07/05/17, 08/12/17, and 08/16/17. The CNA's documented on eight (8) other scheduled shower days the resident received partial bed baths. Continued review revealed staff did not document the resident had refused or was ill on any scheduled shower day. Interview with CNA #12, on 08/23/17 at 11:55 AM, revealed nursing assigned her to care for thirteen (13) residents on 08/23/17. CNA #12 stated she had four (4) resident showers to give along with completing her other tasks. She stated a shower meant taking the resident to the shower room and bathing the resident in the shower. She stated a partial bed bath meant washing the face, armpits, and private parts in the residents' room. The CNA stated due to the many tasks and assignment of (3) three to (5) showers a day, it was impossible to give all residents their scheduled showers. She stated if staff did not provide routine scheduled showers, the resident's hygiene and skin condition could decline. Interview with CNA #4, on 08/23/17 at 12:50 PM, revealed she was assigned to give (5) five showers to residents on her assigned hall on 08/21/17. She stated she was not able to give all the assigned showers and reported it to nursing, but they just told her to do the best she could. She stated if should could not give all required showers, she at least tried to make sure the resident had a partial bed bath, which meant washing of the face, hands, armpits, and private areas. Observation of the Blue Unit Dayroom, on 08/23/17 at 7:09 AM, revealed nine (9) residents sitting in wheelchairs and the room had a strong odor of urine. The nurses' station had nursing staff seated at the desk within a few feet of the dayroom, and additional staff passed by the dayroom completing tasks. Observation of the Blue Unit Dayroom, on 08/23/17 at 7:17 AM, revealed Resident #2 sitting in a wheelchair wearing sweat pants with a large wet spot in the front that proceed down to the middle of the thighs and a strong odor of urine. The DON, along with a Restorative Nursing Assistant, entered the dayroom at 7:17 AM. The DON moved Resident #2 out of the way in order to transport another resident to the main dining room. The Restorative Nursing Assistant passed by Resident #2 to retrieve another resident to transport to main dining room. Neither the DON nor the Restorative Nursing Assistant addressed Resident #2's wet pants. Observation of CNA #12 revealed she entered the Blue Unit Dayroom on 08/23/17 at 7:25 AM, and moved Resident #2 from one area to another area to obtain another resident to transport to the main dining room. Interview with CNA #12, on 08/23/17 at 7:25 AM, revealed she did not know who was assigned to care for Resident #2. Continued observation, on 08/23/17 at 7:29 AM, revealed CNA #12 left the dayroom without addressing Resident #2's wet pants to transport another resident to the main dining room for breakfast. The CMT then transported Resident #2 to the main dining room without addressing the resident's wet pants. Continued observation revealed Resident #2 was in the main dining room in front of table at 7:34 AM, with wet pants visible and now a light brown ring had developed around the edges of the wet spot. Observation of Resident #2 in the main dining room, on 08/23/17 at 7:35 AM, revealed LPN #2 assisted the resident with repositioning both feet back onto the wheelchair pedals without addressing Resident #2's wet pants. LPN #2 then placed a clothing protector on the resident and pushed the resident up closer to the table. Observation at 7:40 AM on 08/23/17, revealed the Social Worker provided Resident #2 a cup of hot chocolate and did not address the wet spot on the residents pants. Observation at 8:12 AM on 08/23/17, revealed the Administrator transported the resident back to the Blue Unit and left the resident in the 400 hallway. Further observation at 8:17 AM, revealed Resident #10 transported the resident to his/her doorway on the 400 Hall and then left. Continued observation revealed CNA #12 exited Resident #2's room and noticed the resident's wet pants and took the resident into his/her room, then walked across the hall to get Resident #2's assigned CNA, CNA #7. The two (2) CNAs transferred the resident into bed, removed the wet clothing and wet brief, and provided incontinent care. Interview with CNA #7, on 08/23/17 at 8:25 PM, revealed Resident #2 was confused and dependent on staff for incontinent care. She stated she could smell a strong odor of urine coming from Resident #2. CNA #7 stated the resident's pants were saturated with urine and the light brown ring meant the urine had started to dry and the resident had been wet for quite some time. CNA #7 stated she started her shift at 7:00 AM, and it was the responsibility of night shift to get Resident #2 up for breakfast and the resident probably had been up since 6:00 AM. The CNA stated she had not laid eyes on Resident #2 since she arrived and the brief report she received from the off going CNA was that all the residents were okay. She stated she had thirty (30) minutes to get the rest of her assigned resident's up, cleaned, toileted, changed, and to the dining room by 7:30 AM. She stated she did the best she could but did not have time to check on Resident #2. CNA #7 stated it was impossible for one person to complete all the assigned morning tasks timely. Interview with the CMT, on 08/24/17 at 7:45 AM, stated she was responsible for passing medications on the Blue Unit and required to pass trays, feed residents, and answer call lights. The CMT stated she did not observe Resident #2's wet pants as she transported the resident to the main dining room on 08/23/17. She stated she was in a hurry to get as many resident to the dining room as possible so she could help pass trays. The CMT stated between getting morning report, counting narcotics on her cart, passing morning medications, taking resident blood sugars before breakfast, answering call lights, and transporting residents to the main dining room, it was difficult to complete all assigned tasks timely with the amount of staff on duty. Interview with LPN #2, on 08/23/17 at 10:00 AM, revealed the facility recently cut staff and the Blue Unit did not routinely have a desk nurse or a secretary to help with the numerous non-direct care tasks such as answering phones, taking off physician orders, updating resident care sheets, or making resident appointments. He stated due to the CMT's scope of practice, they c(TRUNCATED)

Based on observation, interview, record review, review of the Resident Assessment Instrument (RAI) Manual, Incident Reports, Fall Investigations, and facility policy, it was determined the facility failed to revise the care plan with interventions to prevent further falls for one (1) of twenty-five (25) sampled residents (Resident #4). Resident #4 sustained a fall on 12/31/14 resulting in a bruised lump on the forehead, bruising of the left upper arm and a skin tear on the left forearm that required a transfer to the hospital emergency room for evaluation and treatment. Resident #4 fell again on 02/25/15 when the resident sustained [REDACTED]. The facility failed to revise the care plan after each fall with interventions to prevent additional falls. The findings include: Interview with the Administrator, on 03/19/15 at 2:20 PM, revealed the facility used the RAI Manual, Version 3.0, dated October/November 2012, as the facility's policy for revision of care plans. Review of the RAI Manual, Version 3.0, dated October/November 2012, page 4-8, revealed the care plan should be revised on an ongoing basis to reflect changes in the resident and the care the resident received. Review of the facility's policy regarding Falls Management, dated 01/01/10, revealed the purpose of the policy was to establish a program to identify residents with risk factors that might place them at risk for falls, and to manage those residents who experience a fall to minimize the risk of a fall from reoccurring or minimize the risk of injury related to a fall. Review of the current plan of care and if necessary revision of the interventions to reduce the likelihood that the fall would reoccur and/or minimize the risk of injury related to a fall. Review of the clinical record for Resident #4 revealed the facility admitted the resident on 10/12/12 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #4 and completed by the facility on 01/04/15, revealed the facility assessed the resident with the Brief Interview for Mental Status as a score of eight (8) which meant the resident had a moderate cognitive impairment and interviewable. The facility assessed the resident to require limited assistance of one for transfers, ambulation and dressing, and extensive assistance with hygiene and bathing. The facility determined the resident was frequently incontinent of bowel and bladder and received psychoactive medications. Review of the Comprehensive Care Plan for Resident #4, dated 01/04/15, revealed the resident was at risk for falls related to impaired mobility and the use of a psychoactive medication. Interventions included: self transfers and assist as needed; provide incontinent care as indicated; complete falls assessment per facility protocol; attempt to keep room/hall free from clutter, keep call light and personal items within reach; encourage use of rolling walker for ambulation; encourage resident to participate in range of motion and ambulation; may be up in recliner/lift chair; ensure the resident wears tennis shoes at all times; medications as ordered; medication adjustments as ordered; observe for signs of adverse reactions related to psychoactive medications; attempt a gradual drug reduction unless otherwise indicated; re-educate the resident to use walker at all times for ambulation; physical therapy referral related to a fall on 12/31/14; and, sensor alarm to bed and chair added on 01/29/15. There was no evidence the care plan for Resident #4 was reviewed or revised to ensure one staff member provided assistance to the resident when transferring and ambulating Review of the Incident Report and the Fall Investigation for 12/31/14, revealed the staff turned off the sensor alarm on the bed and left the room as the resident planned to get out of bed. Resident #4 removed his/her tennis shoes, got out of bed, and walked to the hallway without the use of the assistive device of a walker. The resident slipped and fell in the hallway at 4:15 PM. The resident had a bruise and a lump on the forehead, a raised bruise on the left upper arm and a skin tear on the left forearm. The cause of the fall was attributed to the resident transferring out of bed without assistance. The Fall Investigation did not contain evidence that referenced the staff allowed Resident #4 to get out of bed alone when the MDS assessment revealed the resident needed the limited assistance of one to transfer and ambulate. There was no evidence the facility reviewed or revised the care plan after the fall to ensure the resident was assisted by staff to ambulate. Interview with Certified Nursing Assistant (CNA) #5, on 03/18/15 at 10:41 AM, revealed the resident had a fall after the sensor alarm was turned off by staff. She indicated the resident planned to get out of bed so the alarm was turned off prior to the staff leaving the room. She stated the resident often ambulated without staff assistance, but did need the walker. Review of the Incident Report and the Fall Investigation for 02/25/15, revealed Resident #4 was assisted out of bed by staff. The resident was ambulated by staff for several feet when the staff left the resident's side and returned to obtain the resident's walker sitting by the bedside. Before the staff could get back to the resident, the resident was at the doorway and fell face first onto the floor. The cause of the fall was attributed to the resident ambulating without assistance. There was no evidence the facility reviewed or revised the care plan after the fall to ensure staff assisted the resident to ambulate. Interview with Certified Nursing Assistant (CNA) #5, on 03/18/15 at 10:41 AM, revealed she stated she had cared for Resident #4. She stated the facility policy was to check all residents every two (2) hours in order to provide care for incontinence, turning, and fluids. She stated Resident #4 had frequent falls and wandered around the facility without a walker or staff assistance frequently. She stated the resident had the right to be independent even if injured during a fall. She further stated the resident had sensor alarms on the chair and bed and she checked on the resident about every two (2) hours. Interview with Licensed Practical Nurse (LPN) #1, on 03/19/15 at 9:15 AM, revealed all incidents/accidents were documented by the nurse then reviewed by the Interdisciplinary Team in Morning Meeting. She stated the care plans were revised during the meeting and reviewed by the team to ensure the revision was appropriate for the problem. She stated the revisions were communicated to the staff. She stated she did not remember Resident #4's care plan being revised to ensure the resident was walked with the limited assistance of one person. She stated the resident walked alone and sometimes used a walker. She indicated the resident's care plan had not been revised to prevent further falls since the fall on 02/25/15. Interview with CNA #7, on 03/19/15 at 12:30 PM, revealed Resident #4 received care from her frequently. She stated she checked residents every two (2) hours for cleanliness and turning. She stated Resident #4 liked to be independent and walked all around the unit. She indicated the resident did not use the walker consistently and staff would attempt to redirect the resident if she wandered too far from the unit. She stated the staff would try to redirect the resident and sometimes the resident was not able to be redirected. She stated she was not aware the resident required the assistance of one with ambulation. She stated she had the Nurse Aide Care Plan for instructions; however, she saw the resident often walking alone. Interview with LPN #7, on 03/19/15 at 12:43 PM, revealed nursing staff supervised residents every two (2) hours and there was no policy she knew of to require supervision more frequently. She stated there were times the resident would not use the walker and became agitated when encouraged to do so. She indicated it was better to leave the resident alone and go back later. She stated the nurses were responsible for supervising the nurse aides; however, the resident often ambulated without staff assistance and staff were used to seeing it. She stated the resident's balance was poor and the resident could fall while walking without assistance. She stated the care plan should be changed to ensure the resident was assisted by one person while ambulating to prevent further falls and possible injuries. Interview with the Blue Unit Manager, on 03/19/15 at 12:57 PM, revealed she reviewed all incident reports and fall investigations for completeness. She stated there were no special interventions to supervise residents based on history of falls or behaviors that placed the resident at high risk of falls. She indicated that all staff checked residents every two (2) hours and had received training on fall prevention and investigation. She stated care plans were updated daily if there were changes in the resident's care. She stated she was unable to explain how Resident #4's care plan was missed after the falls. Interview with the Director of Nursing, on 03/19/15 at 2:09 PM, revealed the incident reports and fall investigations were reviewed daily by the nursing management and interventions were added to the care plan to prevent further falls. She stated the Morning Meeting was held Monday through Friday and care plans were revised as needed during the meeting. She stated she was not able to recall Resident #4's falls or review of the care plan. She stated the resident had sustained falls and injuries and needed the assistance of staff to ambulate. She stated the care plan should reflect the resident's actual need for assistance.

Based on observation, interview, record review and policy review, it was determined the facility failed to ensure staff followed the care plans for three (3) of twenty-five (25) sampled residents. (Residents #6, #9 and #19). The nursing staff failed to follow the care plan for Resident #6 when Certified Nursing Assistant (CNA) #11 failed to utilize a Maxi lift (mechincal lift) and use two (2) person assist while transferring Resident #6 from the wheelchair to the bed resulting in a fall. Resident #6 sustained a fracture to the Proximal Diaphysis of the right Fibula that resulted in a transfer to hospital emergency room for evaluation. In addition, the nursing staff failed to follow the care plan for Resident #9 for placement of [MEDICAL CONDITION] gloves, Geri sleeves and utilizing arm troughs resulting in [MEDICAL CONDITION] and bruising. The nursing staff failed to follow the care plan for Resident #19 when the splint for contractures was not placed in the resident's hand. The findings include: Interview with the Administrator, on 03/19/15 at 2:20 PM, revealed the facility utilized the Minimum Data Set (MDS) Manual, Version 3.0, Section 4, 4-6, Page 4-11, which stated the Interdisciplinary Team identified specific, individualized steps or approaches that would be taken to help the resident achieve his or her goals. These approaches serve as instructions for resident care and provide for the continuity of care by all staff. Precise and concise instructions help staff understand and implement interventions. 1. Review of Resident #6's clinical record, revealed the facility admitted the resident on 04/11/14, with [DIAGNOSES REDACTED]. Review of Resident #6's MDS Significant Change Assessment, dated 12/09/14, revealed the facility assessed Resident #6 with a Brief Interview for Mental Status (BIMS) score of three (3), which meant the resident was not interviewable. The facility determined Resident #6's ambulation status was an eight (8) of eight (8) which indicated the activity was not performed by the resident and did not occur during the entire observation period for that assessment. Review of Resident #6's Nursing Care Plan, dated 07/23/14, revealed the staff was to assist the resident with two (2) persons for all transfers and use a Maxi lift, as indicted. Review of Resident #6's CNA Sheet, dated 10/01/14, revealed the staff was to use a Maxi lift with two (2) persons assist. Review of Resident #6's Nursing Notes, dated 10/02/14 at 10:16 PM, revealed Licensed Practical Nurse (LPN) #12, documented she was alerted by CNA #11 that Resident #6 had reported right knee pain after Resident #6 was placed onto the bed. CNA #11 stated a pop sound was heard while transferring the resident by pivot from the wheelchair to the bed. Further review of the Nursing Note revealed LPN #12 documented she then completed an assessment of Resident #6 and the resident reported pain at that time. Interview with CNA #11, (who was an agency staff pulled from another unit) on 03/19/15 at 12:34 PM, revealed she received training from the facility and knew the CNA Care Sheets could be found at the Nurses' Station. However, CNA #11 stated she did not obtain a CNA Care Sheet when she came onto the Green Unit. She stated she remembered Resident #6 requested to go to bed multiple times so she asked CNA #12 to assist her with Resident #6's care. Further interview revealed CNA #12 told her that Resident #6 could be pivoted to the bed. CNA #1 stated she was not aware Resident #6 was not interviewable, (as she did not have a CNA Care Sheet) so she asked Resident #6 if he/she could stand and pivot and the resident answered "yes". CNA #11 stated as she got Resident #6 up from his/her wheelchair, she noticed Resident #6 could not turn his/her leg and when she went to turn the resident onto the bed she heard a pop sound. CNA #11 stated if she had looked at the CNA care sheet, Resident #6 would not have sustained an injury, because she would have used a Maxi lift on the resident with assistance. Interview with LPN #12, on 03/18/15 at 4:17 PM, revealed she remembered working with agency staff the night of the incident. LPN #12 stated when the CNA agency staff come onto the Unit they obtain their CNA Care Sheets and tour the unit with a staff member. LPN #12 stated she remembered at or around dinner time CNA #11 stated she had transferred Resident #6 without a lift, but she did not give an explanation as to why she did this. LPN #12 stated she assessed Resident #6's limb and there was no visible injury though the resident complained of pain. The LPN stated the care plans were in place so staff would know how to take care of the residents. LPN #12 stated she would expect the CNAs to inform her if they needed help with residents. Review of Resident #6's x-ray to the right knee, dated 10/05/14, revealed there was a minimally displaced [MEDICAL CONDITION] (situated nearer to the center of the body) Diaphysis (shaft of the long bone) of the right Fibula (calf bone in the leg located on the outer side of the tibia, the small bone). Observation of Resident #6, on 03/17/15 at 11:50 AM and 1:31 PM, revealed Resident #6 was lying on the bed. Observation of Resident #6, at 2:27 PM and 4:00 PM, revealed Resident #6 was sitting up in his/her wheelchair with his/her legs elevated. Interview with Resident #6, on 03/17/15 at 2:27 PM, revealed he/she remembered sustaining an injury to the right lower leg when a nurse fell on the leg a few months ago. Interview with the Unit Manager, on 03/19/15 at 1:38 PM, revealed she looked at the CNA Care Sheets everyday and updated the CNA care sheets when orders were changed. The Unit Manager stated she tried to monitor the staff to ensure they were following the care plans and her expectation was for the staff to follow the care plans. She stated if CNA #11 had utilized a Maxi lift as care planned, it would have prevented the fracture from occurring to Resident #6. Interview with the MDS Coordinator, on 03/19/15 at 5:02 PM, revealed care plans were in place to ensure each resident was cared for and given care on an individual need. The MDS Coordinator stated she expected the staff to follow the care plans. Interview with the Assistant Director of Nursing (ADON), on 03/19/15 at 2:34 PM, revealed she felt if CNA #11 had used the Maxi lift with two (2) assist, the injury in which Resident #6 had sustained could have been avoided. Interview with the Director of Nursing (DON), on 03/19/15 at 4:23 PM, revealed the Unit Managers were responsible to ensure the CNA Care Sheets were updated. The DON stated the incident occurred because CNA #11 did not follow the CNA care sheet. 2. Review of the clinical record for Resident #9 revealed the facility admitted the resident on 10/14/11 with [DIAGNOSES REDACTED]. Review of Resident #9's quarterly MDS assessment, completed on 02/07/15, revealed the facility assessed the resident as requiring extensive assistance from staff to toilet, transfer to wheelchair, for locomotion within the facility, and bathing. The facility conducted a Brief Interview for Mental Status (BIMS) exam in which the facility scored the resident as a fifteen (15), indicating the resident was interviewable. Review of Resident #9's care plan, updated 02/07/15, revealed the staff was to elevate both the resident's arms in a trough attached to the wheel chair daily for positioning. The nursing staff was to place a full arm length [MEDICAL CONDITION] glove on each of the resident's arms and Geri-sleeves on each of the resident's arms as the physician ordered. Review of the CNA Care Plan, not dated, revealed the CNAs were to place Geri-sleeves on both of the resident's arms and that the resident wore them at all times. The CNAs were also to place [MEDICAL CONDITION] gloves on the resident daily to prevent swelling. The CNA's could remove the [MEDICAL CONDITION] gloves at night. The CNA Care Plan stated CNAs were to place a trough on each of the resident's wheelchair arms daily for arm positioning. Review of the physician's orders [REDACTED]. The nursing staff was to apply a full arm length [MEDICAL CONDITION] glove daily to both of the resident's arms and could remove the [MEDICAL CONDITION] gloves at night and for personal care. The staff was to apply an elevating arm trough to Resident #9's wheelchair daily for positioning and to prevent [MEDICAL CONDITION]. Review of the Treatment Administration Record (TAR) for Resident #9, dated March 2015, revealed the nurse documented the resident refused to wear Geri-sleeves, [MEDICAL CONDITION] gloves, and refused to use the arm troughs on one (1) of the last nineteen (19) days. Review of the Nurses Skin Audit for Resident #9, dated March 2015, revealed the resident suffered [MEDICAL CONDITION] to his/her bilateral upper extremities at the time of the last skin check completed on 03/19/15. The skin check also revealed the resident had purple bruising to both arms. Observation of Resident #9, on 03/17/15 at 1:15 PM, revealed the resident did not have Geri-sleeves or [MEDICAL CONDITION] gloves on. The resident did not have both arms placed on troughs to rest his/her arms. At 2:00 PM, the resident did not have [MEDICAL CONDITION] gloves or Geri-sleeves on either arm, and did not have both arms placed on the troughs on the wheelchair at that time. At 4:00 PM, the resident was sitting in his/her room in a wheelchair. The resident was not wearing [MEDICAL CONDITION] gloves or Geri-sleeves. There was no arm troughs on the wheel chair. Observation of Resident #9, on 03/18/15 at 8:00 AM, revealed the resident was lying in his/her bed watching television. The resident was wearing a short sleeve shirt with no [MEDICAL CONDITION] gloves or Geri-sleeves. At 12:00 PM, the resident was up in his/her wheelchair. The resident was wearing a short sleeve shirt and did not have Geri-sleeves or [MEDICAL CONDITION] gloves on the resident's arms. There were no arm troughs on the resident's wheelchair. Interview with Resident #9, on 03/19/15 at 9:50 AM, revealed the resident was wearing the Geri-sleeves and resting his/her arms in the arm troughs attached to his/her wheelchair. Resident #9 stated he/she felt comfortable with the arm troughs. The resident stated he/she used to wear the Geri-sleeves all of the time when sitting in the wheelchair, but did not wear them often anymore. Resident #9 stated he/she wore the devices when staff offered them, but if the staff did not offer, he/she did not remind them. Interview with CNA #8, on 03/19/15 at 10:10 AM, revealed the CNAs read the CNA Card, also known as the CNA Care Plan, to find out what care to give each resident. The CNA stated she looked at the CNA Card daily at the start of her shift. The CNA also stated the nurses told the CNAs about any changes with any resident. CNA #8 stated, according to the CNA Care Plan, Resident #9 wore Geri-sleeves and had his/her arms resting on arm troughs attached to the resident's wheelchair. CNA #8 stated Resident #9 sometimes refused to wear the devices. When this happened, the CNA informed the nurse of the resident's choices. Interview with the Occupational Therapist (OT), on 03/19/15 at 11:00 AM, revealed OT started working with Resident #9 on 07/08/14. OT ordered the [MEDICAL CONDITION] gloves for the resident at that time to decrease swelling in the resident's arms. OT stated the resident's arms were more prone to injury due to the [MEDICAL CONDITION] and the [MEDICAL CONDITION] gloves may not have provided enough protection against possible skin tears. Nursing staff used the Geri-sleeves with the [MEDICAL CONDITION] gloves to protect the resident's arms from injury and [MEDICAL CONDITION]. OT further stated the Therapy Department fitted and placed arm troughs on each of the wheelchair arms for Resident #9. OT stated if the resident did not use the [MEDICAL CONDITION] gloves, Geri-sleeves, and arm troughs, the resident would be at risk for increased skin tears and bruising due to the [MEDICAL CONDITION]. Interview with the Assistant Unit Manager of the Green Unit, on 03/19/15 at 12:40 PM, revealed the CNAs used the CNA Care Plans to find out what equipment, devices, and care to give to each resident. CNAs obtained a copy of the CNA care plan each shift from a folder at the Nurse's station after the CNAs received their assignments for the shift. CNAs also asked the nurses on the hall for information on how to give care to the residents. If a CNA had any questions about care, they asked the Assistant Unit Coordinator or the Unit Manager. The Assistant Unit Coordinator revealed the CNAs were to place the [MEDICAL CONDITION] gloves and Geri-sleeves on Resident #9. CNAs were also to attach the arm troughs to the wheelchair arms for Resident #9. The Assistant Unit Coordinator stated the resident sometimes refused to wear this equipment; however, there were no nursing notes stating the resident refused this equipment on 03/17/15 or 03/18/15. The Assistant Unit Coordinator reviewed the TAR as well and stated nursing had no documentation that indicated the resident refused the devices. Interview with the Unit Manager of the Green Unit, on 03/19/15 at 1:35 PM, revealed she oversaw the nursing staff on the Green Unit. She stated she monitored the nursing staff by making rounds on the hallway. The Unit Manager admitted that she did not check all of the devices on each resident to ensure the residents each had all of their care equipment in place. The Unit Coordinator stated per the Care Plan, the nursing staff placed [MEDICAL CONDITION] gloves on the arms of Resident #9 to reduce [MEDICAL CONDITION]. The CNAs were to place Geri-sleeves on the resident to prevent skin tears, and CNAs placed arm troughs on Resident #9's wheelchair. The Unit Manager stated the resident had a history of [REDACTED]. The Unit Coordinator stated she provided education to the nursing staff about documenting, but did not check every nursing note or documentation to ensure the nurses documented refusals of care. The Unit Manager stated Resident #9 was at increased risk of [MEDICAL CONDITION] and skin tears without his/her devices in place. 3. Observation of Resident #19, on 03/18/15 at 3:30 PM, revealed the resident was laying on the bed with his/her eyes closed and covered. The resident did not have the carrot splint in the left hand. Observation of Resident #19, on 03/19/15 at 9:00 AM, revealed the resident was sitting up in a Geri-chair and had a carrot splint in his/her left hand. Review of the clinical record for Resident #19 revealed the facility admitted the resident on 02/24/14 with [DIAGNOSES REDACTED]. The resident used a Geri-chair when up out of the bed. Review of Resident #19's quarterly MDS assessment, completed on 12/31/14, revealed the facility assessed the resident as needing extensive assistance from staff to toilet, walk, and bathe. The facility conducted a Brief Interview for Mental Status (BIMS) exam during the assessment and scored the resident with a ninety-nine (99) indicating the resident was unable to complete the BIMS exam and was not interviewable. Review of an untitled document located in the clinical record, dated 06/11/14, revealed staff reported contractures were causing Resident #19's hand to close more and more each day and that the palm protector was no longer working. The form stated OT addressed this issue and applied a carrot splint to the resident's hand. Review of the Physicians Orders for Resident #19, dated 03/04/15, revealed the nursing staff was to place a carrot splint in Resident #19's left hand. The staff would place the splint in the resident's left hand every morning and would only remove the splint during range of motion (ROM) and cleansing of hand twice per day. Review of Resident #19's Care Plan for left hand contractures, dated 12/31/14, revealed nursing staff was to place the hand splint on Resident #19 as ordered on [DATE]. The care plan further stated staff was to use a green carrot splint on the resident's left palm for skin hygiene. Review of the Restorative Referral form, dated 03/18/14, for Resident #19 revealed the resident was at risk for progressive range of motion (ROM) loss, increased contractures, and skin breakdown in the resident's left hand. The Referral form stated the restorative goal was to prevent skin breakdown in the resident's left hand. Review of the CNA care plan, not dated, revealed the CNA was to place the splint on the resident's left hand every morning. Interview with the OT, on 03/19/15 at 10:00 AM, revealed Resident #19 was referred to therapy because he/she had contractures in his/her hands. OT started the resident with palm protectors. Restorative therapy and the palm protectors became too painful for the resident because the resident's hand was clamped too tightly with contractures. At that time, OT assessed and initiated the carrot splint. The OT stated the resident would develop skin breakdown without the carrot splint. OT also stated staff would have a difficult time treating any skin breakdown on the inside of the closed hand. OT stated Resident #19 was supposed to wear the carrot splint at all times. He stated that if the resident did not wear the splint for three (3) to four (4) hours, the resident was at risk for not being able to open the hand enough to put the splint back in. Interview with CNA #8, on 03/19/15 at 2:35 PM, revealed the care plan stated the CNA should place the splint on Resident #19 in the morning. CNA #8 admitted the care plan did not state when the resident should wear the splint. CNA #8 stated she interpreted the care plan to indicate the CNA should remove the carrot splint in the evening and at night. Interview with CNA #9, on 03/19/15 at 2:45 PM, revealed the CNA kept the carrot splint on Resident #19 during second shift, and then removed the splint at night. The CNA stated the carrot splint was also removed for hand hygiene during second shift and the CNA would leave the splint off of the resident for one (1) to one and a half (1 ½) hours before putting the splint back on the resident. Interview with Licensed Practical Nurse (LPN) #8, on 03/19/15 at 3:00 PM, revealed she looked at each resident at least every two (2) hours and visually ensured residents had the required equipment and that they had their needs met. LPN #8 stated the CNA's on her hall reported to her and that the CNA's would let the LPN know if any of the residents refused to use any adaptive equipment. LPN #8 stated she was in Resident #19's room, but did not notice if the resident had the carrot splint on at that time. The LPN stated the CNA might have taken the splint off when they put the resident to bed, or the resident may have dropped the splint. Interview with the Assistant Unit Manager of the Green Unit, on 03/19/15 at 12:40 PM, revealed the CNA care plan was reviewed by her and determined it was confusing and not clear on how the CNAs provided care to Resident #19 as it pertained to the carrot splint. The Assistant Unit Coordinator further stated the facility was not clear about how to apply the carrot splint for Resident #19 in the Nursing Care Plan. The Nursing Care Plan stated to apply the splint per the physician's orders [REDACTED]. Interview with the Unit Manager of the Green unit, on 03/19/15 at 1:35 PM, revealed the CNA Care Plan for Resident #19 was confusing. She stated the resident had a carrot brace for his/her hand due to contractures and used the brace to circulate air and keep the hand open. The Unit Manager stated without the brace, the resident's hand could get tighter and would be more difficult to clean. Interview with the Director of Nursing (DON), on 03/19/15 at 4:15 PM, revealed the DON oversees the Unit Managers. The DON stated the Unit Managers ensured the CNA assignment sheets were clear, understandable, and updated. The DON stated she looked at the CNA care plans and had last looked at them about two (2) weeks ago. The DON stated it was important for CNAs to follow the resident care plans and physician orders [REDACTED]. The DON stated she monitored CNAs and nurses by making rounds on the units and monitored the residents on a daily basis. The DON stated she looked at care devices and at the residents to see what they looked like. The DON stated the Unit Managers and Nurses made rounds on the units as well to ensure residents had all of their care devices in place. Post survey interview via telephone with the Green Unit Assistant Manager, on 04/01/15 at 8:45 AM, revealed the facility did not have a formal system in place to ensure staff providing care followed the care plan. However, she stated she made rounds through out the day talking to residents and staff. She further stated care plan changes were communicated to the nurses and CNA verbally and anyone could make a change to the care plan. She stated she was not sure of a specific policy regarding following care plans and would have to ask about the policy; however, she knew they had specific protocals to follow such as for falls. Post survey interview via telephone with the Green Unit Manager, on 04/01/15 at 9:10 AM, revealed she spent most of her time at the nurses station. She further stated she made rounds two (2) to three (3) times a shift, talking with families, looking at the environment to ensure residents had needed equipment. The Unit Manager stated she did not know if there was a specific policy regarding following the care plan as the care plan was based on the assessed needs of the resident and it was a nursing standard of care. The Unit Manager further stated she communicated with staff through unit meetings to discuss resident specific changes and reinforced the care plan interventions with the nurses. She further stated the CNAs received report specific to each resident when they began their shift and would get a copy of the CNA sheet to assist with the care. Post survey interview via telephone with the ADON, on 04/01/15 at 10:10 AM, revealed the facility's system to ensure staff followed the care plans involved updating CNA care sheets specific to the resident, provide the CNA with a report before starting work, and utilizing a 24 hour report sheet that would be reviewed in the morning meeting each day. The ADON further stated her role in supervision of care was a paper compliance issue; however, she did check that devices were used correctly. She further stated the CNA was required to have the resident care sheet on them at all times as part of their uniform, the staff was told this during orientation, and she would go out and ask staff if they had it on them. She stated this was not in policy, it was her requirement.

Based on observation, interview, record review, policy review and review of incident/accident reports and facility investigation, it was determined the facility failed to ensure residents received supervision to prevent accidents and utilized appropriate assistive devices to prevent injuries, for two (2) of twenty-five (25) sampled residents, (Resident #4 and #6). Certified Nursing Assistant (CNA) #11 transferred Resident #6 on 10/05/14 without the assessed assistive device and two person assist that resulted in a fracture of the Proximal Diaphysis of the right Fibula and required an evaluation at the hospital emergency room . In addition, Resident #4 sustained two falls, one on 12/31/14 resulting in a bruised lump on the forehead, bruising of the left upper arm and a skin tear on the left forearm and a transfer to the hospital emergency room for evaluation and treatment. A second fall on 02/25/15 occured when the resident sustained [REDACTED]. The findings include: Review of the Falls Management Policy, effective 01/01/10, revealed the facility would establish a program to identify residents with risk factors that may place them at risk for falls, and to manage those residents who experience a fall to minimize the risk of the fall reoccurring or minimize the risk of injury related to the fall. It was the policy of the facility to screen all residents to identify possible risk factors that may place a resident at risk for falls, to evaluate those risks, implement interventions to reduce those risks and monitor those interventions and modify when necessary. It was also the policy of the facility to investigate any resident falls to determine appropriate interventions to put in place to reduce the likelihood that a fall would reoccur and/or to minimize the risk of injury related to a fall. A fall was defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, was considered a fall. The facility was to manage the resident who experienced a fall by completing an incident report for Quality Assurance Reporting, document the incident in the nursing notes to include: date, time, place, what occurred, treatment required and notification of family and physician, and to complete a post fall investigation tool (this would be completed at the time of the fall) for Quality Assurance Reporting. 1. Review of Resident #6's record, revealed the facility admitted the resident on 04/11/14, with [DIAGNOSES REDACTED]. Review of Resident #6's Minimum Data Set (MDS), Significant Change Assessment, dated 12/09/14, revealed the facility assessed Resident #6 with a Brief Interview for Mental Status (BIMS) and scored the resident at a three (3), which meant the resident was not interviewable. Resident #6's ambulation status was an eight (8) of eight (8), which meant the activity was not performed by the resident and did not occur during the entire observation period for this assessment. Dressing was assessed as extensive assist of one person. Transferring was assessed as extensive assistance of two persons. Bathing was assessed as dependant on staff for completion. The facility further assessed the resident as always incontinent of bowel and bladder. Review of Resident #6's Physical Therapy Notes, dated 04/14/14, revealed Resident #6 presented with significant pain and stiffness to the left knee that impacted Resident #6's range of motion and left extremity use. Resident #6 had poor range of motion to the right knee due to a Total Knee Arthroplasty. Resident #6 had gross bilateral lower extremity weakness, debility due to primarily in bed or wheelchair. Resident #6 was non ambulatory, utilized a Maxi lift for transfers due to lack of progress with transfers. Resident #6 had impaired posture in bed and needed wheelchair set up for proper positioning, posture, and comfort when out of bed. Review of Physical Therapy Notes, dated 04/30/15, revealed Resident #6's transfer status would be total dependence with a Maxi lift. Review of Resident #6's Nursing Care Plan, dated 07/23/14, revealed the staff was to assist with all transfer using assist of two (2) persons and a Maxi lift as indicted. Review of Resident #6's Certified Nursing Assistant (C.N.A) sheet, dated 10/01/14, revealed the staff was to use a Maxi lift with two (2) person assist. Review of Resident #6's Nursing Notes, dated 10/02/14 at 10:16 PM, revealed Licensed Practical Nurse (LPN) #12, documented she was alerted by CNA #11, that Resident #6 was reporting right knee pain after Resident #6 was placed onto the bed. CNA #11, stated a pop sound was heard while transferring the resident by pivot from wheelchair to the bed. LPN #12 documented she then completed an assessment of Resident #6 and Resident #6 reported pain at that time. Further review of the Nursing Notes, revealed the Doctor was called with new orders for an X-Ray of the right knee and ice pack applied for twenty (20) minutes every two (2) hours as needed. The family was notified of the incident and the new orders. The family member voiced understanding. Review of Resident #6's X-Ray, to the right knee, on 10/02/14, revealed there were no fractures or dislocation. Review of the Incident Report completed by LPN #12, on 10/02/14 at 9:00 PM, revealed the incident occurred in Resident #6's room and Resident #6 complained of right knee pain. The nursing assessment was completed at 9:10 PM and Resident #6 was given Tylenol 325 mg. A transfer to the hospital did not occur. The Doctor was notified on 10/02/14 at 9:15 PM and the family was notified on 10/02/14 at 9:20 PM . The Post Fall Investigation Tool was not completed. The Post Injury Investigation Tool, revealed Resident #6 had sustained an injury by CNA #11. CNA #11 alerted LPN #12 of a possible knee injury on transfer of resident while being put to bed. The investigation revealed no further investigation was required and their was a reasonable explanation for how the injury occurred because of the unsafe transfer. LPN #12 documented she reported to the Director of Nursing (DON), the Agency Supervisor and educated CNA #11. Review of Resident #6's Nursing Notes, dated 10/03/15 at 2:15 PM, revealed the Doctor was informed the results of the X-Ray of the knee was negative and orders for pain medication was received. Review of Resident #6's X-Ray, to the right knee, on 10/05/14, revealed there was a minimally displaced fracture of the Proximal (situated nearer to the center of the body) Diaphysis (shaft of the long bone) of the right Fibula (calf bone in the leg located on the lateral side of the tibia, the small bone). Review of the Nurses Notes, dated 10/06/14 at 7:35 PM, revealed the Doctor was called related to Resident #6 had no relief from right knee pain with Tramadol (pain medication). New orders were obtained for Norco 5/325 mg every six (6) hours as needed for pain. A repeat X-Ray of the right knee was to be obtained immediately. The right knee X-Ray results showed a fracture and the family was notified. Resident #6 was sent to the hospital for evaluation and treatment. Interview with Resident #6, on 03/17/15 at 2:27 PM, revealed Resident #6 remembered sustaining an injury to the right lower leg when a nurse fell on the leg a few months ago. Review of CNA #11's statement, dated 10/02/14, revealed she transferred Resident #6 from the wheelchair to the bed and heard Resident #6's leg break. Resident #6 requested to see the nurse and so CNA #11 went and got the second shift supervisor and she informed CNA #11 that Resident #6 was a two (2) person assist and a Maxi lift. CNA #11 documented she took full responsibility for not consulting with the CNA Care Sheet to see how Resident #6 was to be transferred. Interview with CNA #11 (who worked for an agency), on 03/19/15 at 12:34 PM, revealed when she came into the facility on [DATE] she initially started on the Blue Unit. CNA #11 stated she obtained a CNA care sheet and began to pass ice on the hall. CNA #11 stated she was then pulled to the Green Unit by CNA #12 who informed CNA #11 of what residents needed assistance getting up and transferring, but she did not obtain a CNA care sheet. CNA #11 stated she remembered Resident #6 requested to go to bed multiple times and CNA #11 kept looking for CNA #12 to assist her with Resident #6's care. CNA #11 stated CNA #12 informed her Resident #6 could be pivoted to the bed. CNA #11 stated she asked Resident #6 if he/she could stand and pivot and Resident #6 responded with a yes answer. CNA #11 stated as she got Resident #6 up from his/her wheelchair, she noticed Resident #6 could not turn his/her leg and when she went to turn Resident #6 onto the bed she heard a pop sound. CNA #11 stated she informed Resident #6 she was sorry and would go get the nurse. LPN #12 assessed the resident and Resident #6 complained of pain. LPN #12 asked CNA #11 where was her CNA care sheet and CNA #11 answered she did not have one. CNA #11 stated she should have had her CNA care sheet and she felt bad because she had not caused harm to a resident before. CNA #11 stated she was not aware Resident #6 was not interviewable. CNA #11 stated if she had looked at the CNA care sheet, Resident #6 would not have sustained an injury, because she would have used a Maxi lift on the resident with assistance. CNA #11 stated she received training from the facility and knew to find the CNA care sheet at the nurses station. Interview with LPN #12, on 03/18/15 at 4:17 PM, revealed she remembered working with agency staff the night of the incident. LPN #12 stated when the CNA agency staff come onto the unit they obtain their CNA care sheets and tour the unit with a staff member. LPN #12 stated she remembered on or around dinner CNA #11 stated she transferred Resident #6 without a lift and did not give an explanation as to why she did this. LPN #12 stated she had CNA #11 write a statement. LPN #12 stated the Maxi lifts were functioning so their was no excuses as to why CNA #11 could not use the lift. LPN #12 stated Resident #6 was already in the bed when she was alerted to the incident. LPN #12 stated she assessed the Resident and his/her limb with no visible injury. LPN #12 called the Doctor whom ordered an X-Ray, pain management and ice. Interview with the Unit Manager on the Green Unit, on 03/19/15 at 1:38 PM, revealed she did not remember receiving a phone call on the night of the incident. The Unit Manager stated she remembered reviewing the incident report a couple of days later when there were complaints by Resident #6 of still having pain to the right leg. The Unit Manager stated the Nurse on the unit informed her of the swelling and increase pain Resident #6 was having, so the nurse obtained a new X-Ray and found the fracture and sent Resident #6 out to the Hospital. The Unit Manager stated she reviewed the incident reports in the morning meetings with the DON, but did not remember reviewing Resident #6's incident report. The Unit Manager stated she was not sure if the incident reports were reviewed in the fall meeting, since this occurrence was not a fall. The Unit Manager stated Resident #6 had always been total care. Resident #6 was pretty fragile and sometimes he/she did not like to get out of the bed. The Unit Manager stated if CNA #11 had utilized a Maxi lift it could have prevented the fracture from occurring; however, Resident #6 had a [DIAGNOSES REDACTED]. Interview with the Assistant Director of Nursing (ADON), on 03/19/15 at 2:34 PM, revealed the incident reports were reviewed in the morning meetings. The incidents were reviewed with the Unit Managers separately from the fall meeting. The ADON stated she sometimes attended the incident meetings and sometimes she did not. The ADON stated she had not talked to any of the staff involved in the incident with Resident #6 and it was not the facility's practice to document interviews. The ADON stated she looked over the incident report to ensure the report was documented thoroughly and try to find the root cause of an incident. The ADON stated she could not find a full investigation of the incident nor come up with an evaluation or analysis of the incident. The ADON stated the information she had was the verbal "stuff" that she had heard about the incident. The ADON stated CNA #11 was educated about the care plan because it was an isolated incident. The ADON stated she remembered walking around to ensure staff had their care plan, though the rounds were not documented. There was no auditing tool. The ADON stated she did not do an investigation to rule out neglect because she felt the CNA care sheet was the root cause and if CNA #11 would have used the Maxi lift with two (2) assist, the injury in which Resident #6 had sustained may have been avoided. Interview with the DON, on 03/19/15 at 10:09 AM, revealed she could not recall receiving a phone call the day of the incident. The DON stated she called the Agency in which CNA #11 worked and informed them what had happened and discussed CNA #11 not coming back to the facility because the CNA did not acknowledge or follow the care plan. The DON stated the only bit of evidence she had to ensure she had investigated the incident was the statement that she had received from CNA #11. The DON stated she did not obtain a statement from LPN #12. The DON stated no education was provided on following the care plan and the incident was not considered a fall, though it was a major injury. There was no formal investigation. Continued interview with the DON, on 03/19/15 at 4:23 PM, revealed Resident #6's incident would have been an acute issue and she felt the incident occurred because of a lack of not having a CNA care sheet to follow. The DON stated she expected the staff to follow the care plan. The DON stated if the CNA would have followed her assignment sheet there may have been a different outcome for Resident #6. Interview with the Administrator, on 03/19/15 at 2:54 PM, revealed he did not attend the incident meetings, but was aware of the incidents as they occurred. The Administrator stated he knew what CNA #11 had done and that Resident #6 was assessed. The Administrator stated from his end he knew the CNA had taken responsibility for the incident. The Administrator stated the incident did not trigger an abuse investigation and he believed the CNA was not neglectful. The Administrator stated neglect was something that was done on purpose and had a negative result. The Administrator stated he did make sure Resident #6 was taken care of and that CNA #11 no longer worked in the building. The Administrator stated he could not say yes or no to the fact that if CNA #11 had utilized a Maxi lift with Resident #6, it could have prevented an injury to Resident #6. Further interview with the DON, on 03/19/15 at 4:23 PM, revealed she had a small "pow wow" with the Unit Managers to see if anything had occurred like falls and accidents. The Fall Committee met weekly and then there was a daily meeting where she would talk about any acute issues. Continued interview with the Unit Manager on the Green Unit, on 03/19/15 at 1:38 PM, revealed they assisted the residents because it was the safest thing to do for the residents. The Unit Manager stated as part of her responsibilities, she was to review the incident report to ensure the family and Doctor were notified. The Unit Manager stated the Quality Assurance Director was also responsible for review of the incident Further interview with the Administrator, on 03/19/15 at 2:54 PM, revealed the facility did not have a call log or a way to document the notification of the Administrator and DON. The Administrator stated all incidents and accidents were tracked and trended and he trusted his staff to complete the investigations. The Administrator stated he just knew that the DON was doing Quality Assurance audits though he did not review any documentation. The Administrator stated the staff was to complete the investigation and complete the investigation tool. There was some fact gathering and if something triggered such as neglect the Administrator stated he would have formalized a process and would have required an investigation. The Administrator stated he was tracking and trending falls and there was a committee. The Administrator stated they logged the falls as a way to track them. 2. Review of the clinical record for Resident #4, revealed the facility admitted the resident on 10/20/12 with [DIAGNOSES REDACTED]. Review of the Falls Risk Assessment, on 10/14/14, revealed the facility assessed Resident #4 as a high risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #4 and completed by the facility on 01/04/15, revealed the facility assessed the resident with a Brief Interview for Mental Status and scored the resident with an eight (8) meaning moderate cognitive impairment and interviewable. The facility further assessed the resident as requiring limited assistance of one with transfers, ambulation and dressing, and extensive assistance with hygiene and bathing. The facility further assessed the resident as frequently incontinent of bowel and bladder and receiving psychoactive medications. Review of the Comprehensive Care Plan for Resident #4, revealed the facility had identified the resident as being a fall risk since 10/23/13. The facility did not add the fall of 12/31/14 to the care plan or the referral that was made for a physical therapy screen on 01/02/15. There was no evidence the facility evaluated the care plan for effectiveness or add interventions to prevent or minimize further injury from another fall. On 01/29/15, the facility added sensor alarms to bed and chair. Review of the Comprehensive Care Plan for Resident #4, dated 01/04/15, revealed the facility determined the resident had a risk of falls related to impaired mobility and use of psychoactive medications. Interventions included: self transfers and assist as needed; provide incontinent care as indicated; complete falls assessment per facility protocol; attempt to keep room/hall free from clutter, keep call light and personal items within reach; encourage use of rolling walker for ambulation; encourage resident to participate in range of motion and ambulation; may be up in recliner/lift chair; ensure resident wears tennis shoes at all times; medications as ordered; medication adjustments as ordered; observe for signs of adverse reactions noted from psychoactive medications; attempt gradual drug reduction unless otherwise indicated; re-educate resident to use walker at all times for ambulation; physical therapy referral related to a fall on 12/31/14; and, sensor alarm to bed and chair on 01/29/15. Review of the Fall Investigation for Resident #4, revealed the resident fell , on 12/31/14 at 4:15 PM. The report documented the resident removed both shoes, got out of bed and fell . The bed sensor alarm was turned off by staff prior to the fall since the resident expressed the wish to get out of bed. The staff then left the resident's room. There were no witnesses according to the report. The resident sustained [REDACTED]. The facility sent the resident to the emergency room later where a Urinary Tract Infection was diagnosed . The investigation determined Resident #4's fall and injuries were a result of the resident making a transfer without seeking assistance from staff. There was no evidence the facility identified environmental hazards or determined the resident's need for supervision in order to reduce the risk of an accident. There was no evidence of interviews with staff to determine how the resident fell . The Fall Investigation did not contain evidence that referenced the staff allowed Resident #4 to get out of bed alone. Interview with CNA #5, on 03/18/15 at 10:41 AM, revealed the resident did have a fall after the sensor alarm was turned off by staff in the room. She indicated the resident planned to get out of bed so the alarm was turned off. She revealed the resident often ambulated without staff assistance but did need the walker. Review of the Fall Investigation for Resident #4, revealed the resident fell , on 02/25/15 at 4:45 AM. The nursing staff found the resident awake and assisted the resident out of bed. The staff accompanied the resident toward the doorway then turned around to go back and retrieve the resident's walker. Before the staff reached the resident, the resident fell face first to the floor. The facility sent the resident to the emergency room where the resident was diagnosed with [REDACTED]. There was no evidence the facility reassessed environmental hazards or determined the resident's need for supervision. There was no evidence of interviews with staff who witnessed or provided care prior to the fall. There was no evidence the facility recognized the CNA left the resident's side while the resident was walking and the resident fell . On 02/25/15, the resident fell and sustained injuries. The was no evidence the facility evaluated the care plan for effectiveness or add interventions to prevent further falls and injuries. In addition, there was no evidence the facility implemented increased supervision for the resident to prevent further falls and injuries. Observation of Resident #4, on 03/17/15 at 11:17 AM, 11:32 AM, 1:56 PM, 2:21 PM and on 03/18/15 at 7:51 AM, 8:25 AM and 9:23 AM, revealed the resident was up and walking about in the room and hallway without assistance of staff or a walker. The resident was dressed and had on socks and tennis shoes. The resident's balance was poor and gait was unsteady. The resident was able to talk; however, most answers were unclear and difficult to understand. The resident's left cheek was a yellowish color down to the mouth and both eyes were purple with black areas. Review of the Facility In-Service Training, revealed training was provided on falls, investigation and care plans for the interdisciplinary care plan team on 10/30/14. Nursing staff received training on falls on 11/04/15. The facility did not provide specific information on the training content although this information was requested. Interview with CNA #5, on 03/18/15 at 10:41 AM, revealed she had received training on falls and prevention of falls by the facility. She stated she provided care for Resident #4 and checked all residents every two (2) hours for incontinence and to see if they needed fluids or turned. She stated the resident did have a fall after the sensor alarm was turned off by staff in the room. She indicated the resident planned to get out of bed so the alarm was turned off. She revealed the resident often ambulated without staff assistance but did need the walker. She indicated Resident #4 had frequent falls and wandered around the facility with a walker or with no assistive device frequently. She stated the resident had the right to be independent even if injured in falls. She stated the resident had sensor alarms on the chair and bed and she checked on the resident about every two (2) hours. She stated Resident #4 did not have any specific interventions for supervision. Interview with CNA #7, on 03/19/15 at 12:30 PM, revealed Resident #4 received care from her frequently. She stated all residents were checked every two (2) hours for cleanliness and turning. She stated the resident liked to be independent and walked all around the unit. She indicated the resident did not use the walker consistently and staff would attempt to redirect the resident. She stated the resident could be redirected; however, sometimes the resident was not able to be redirected. She stated she was not aware the resident required the assistance of one when ambulating. She stated she did have the Nurse Aide Care Plan for instructions; however, she saw the resident walking alone often. She stated there were no specific instructions for Resident #4 to be supervised on any schedule or specific time. Interview with LPN #7, on 03/19/15 at 12:43 PM, revealed nursing staff supervised residents every two (2) hours and there were no assessments she was aware of that required supervision more frequently. She stated Resident #4 did wander and was at risk for elopement. She stated there were times the resident would not use the walker and became agitated when coached to do so. She indicated it was better to leave the resident alone and go back later. She stated the nurses were responsible for supervising the nurse aides; however, the resident often ambulated without staff assistance and staff were used to seeing that. She stated she had received training on falls and determining the root cause of a fall. Interview with the Blue Unit Manager, on 03/19/15 at 12:57 PM, revealed she reviewed all incident reports and fall investigations for completeness. She stated there were no special interventions to supervise residents based on history of falls or behaviors that placed the resident at high risk of falls. She indicated that all staff had received training on fall prevention and investigation. Interview with the Director of Nursing, on 03/19/15 at 2:09 PM, revealed all staff had been trained on prevention of falls and investigation of falls. She stated the incident reports and fall investigations were reviewed daily by the nursing management and interventions were added to the care plan to prevent further falls. She stated she did not know what interventions were added as a result of fall investigations and she did not see any interventions to provide added supervision to prevent further falls. She stated there were no written minutes of the daily meetings to discuss falls or of the weekly Fall Committee meetings. She stated falls were not added to the care plans by direction of her corporate management. Further interview with the DON, on 03/19/15 at 4:23 PM, revealed she had a small "pow wow" with the Unit Managers to see if anything had occurred like falls and accidents. The Fall Committee met weekly and then there was a daily meeting where she would talk about any acute issues. Continued interview with the Unit Manager on the Green Unit, on 03/19/15 at 1:38 PM, revealed they assisted the residents because it was the safest thing to do for the residents. The Unit Manager stated as part of her responsibilities, she was to review the incident report to ensure the family and Doctor were notified. The Unit Manager stated the Quality Assurance Director was also responsible for review of the incident Further interview with the Administrator, on 03/19/15 at 2:54 PM, revealed the facility did not have a call log or a way to document the notification of the Administrator and DON. The Administrator stated all incidents and accidents were tracked and trended and he trusted his staff to complete the investigations. The Administrator stated he just knew that the DON was doing Quality Assurance audits though he did not review any documentation. The Administrator stated the staff was to complete the investigation and complete the investigation tool. There was some fact gathering and if something triggered such as neglect the Administrator stated he would have formalized a process and would have required an investigation. The Administrator stated he was tracking and trending falls and there was a committee. The Administrator stated they logged the falls as a way to track them.

Based on observation, interview, record review, and review of activities of daily living (ADL) reports, it was determined the facility failed to provide incontinent care for one (1) of twenty-six (26) sampled residents in a manner that would enhance the resident's dignity. The facility assessed Resident #6 as requiring total assistance for incontinent care every 2 hours or as needed. On 11/19/11, the facility failed to provide Resident #6 incontinent care for over four (4) hours. Facility staff found Resident #6 crying and very upset because the resident was left wet requiring a complete change of bed linens and clothing. Resident #6 was observed, on 11/30/11 at 6:25 PM, having visable signs of anger: i.e. stiffening of the body, vocal changes and speed changes in speech while explaining the incident of 11/19/11. Refer to F312. The findings include: The facility was unable to provide documented evidence of a specific policy to address dignity. The facility indicated they would follow standards of care. Interview with the Director of Nursing (DON), on 12/01/11 at 4:00 PM, revealed residents are checked for incontinence every two (2) hours when turned and repositioned. Review of the clinical record revealed Resident #6 had resided at the nursing facility since May 2003. Review of the most current [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, dated 09/19/11, revealed the facility assessed the resident as having no cognitive deficit, no behaviors, totally dependent on staff for bathing, dressing, grooming, toileting, bed mobility, and transfers and always incontinent of bowel and bladder requiring assistance from staff for incontinent care. Review of the care plan dated, 09/26/11, revealed the resident was at risk for pressure ulcer formation related to incontinence of bowel and bladder. The interventions detailed staff was to assist with turning and repositioning and would provide pericare routinely and as needed. Interview, on 12/01/11 at 6:20 PM, with the day shift CNA #3 revealed she had worked on 11/19/11 and left early. CNA #3 revealed she was assigned and responsible for Resident #6's care. She was in Resident #6's room several times; however, documentation in the ADL detail reports revealed she provided care for Resident #6 at 10:22 AM and no other time. Interview, on 11/29/11 at 3:15 PM and 11/30/11 at 6:25 PM, with Resident #6 revealed he/she was changed one time at 10:00 AM and the day shift CNA did not come back and change the resident again before she left for the day. The resident stated he/she was total care and dependent on staff because of the hand contractures. He/she revealed even though he/she used the call light to get assistance staff did not respond timely, he/she had an incontinent episode resulting in the resident having to lie in wet clothing and on wet bed linens. She stated she was very upset and this situation made her cry. Interview, on 11/30/11 at 6:05 PM, with the evening shift CNA #4 revealed she found Resident #6 wet on 11/19/11 when she responded to the resident's call light. She went to the resident's room around 2:30 PM to see what the resident needed and found Resident #6's bed linens and clothing urine soaked which required changing. The resident was crying and was upset. In addition, CNA #4 stated the resident's peri-area was red on observation and she stated according to the resident the peri-area was painful. CNA #4 further stated she provided care to other residents and did not document the care provided on the ADL detail report until 4:44 PM. Review of the ADL detail report for 11/19/11 revealed incontinent care was provided for Resident #6 at 10:22 AM and 4:44 PM. There was no documented evidence incontinent care was provided between those times. Interview, on 11/29/11 at 3:15 PM and 11/30/11 at 6:25 PM, with Resident #6 revealed he/she had concerns regarding being left wet and staff not providing incontinent care as requested. The Resident stated he/she was very upset when this occurred. The resident reported the incident to the Social Worker. Interview, on 12/01/11 at 4:00 PM, with a Social Worker who Resident #6 reported the 11/19/11 incident, revealed the resident was upset during their conversation. The Social Worker stated the resident reported he/she was left wet by the day shift CNA #3. The resident told her that he/she had activated the call light but the CNA had turned off the light and not provided care. The Social Worker indicated the resident gets upset whenever the routine is altered and it sounded to her like the staff missed the 2:00 PM round. Interview, on 11/29/11 at 4:00 PM, with the Director of Nursing (DON) revealed she became aware of the incident on 11/22/11. She stated the Social Worker reported she was in Resident #6's room speaking with the roommate when Resident #6 requested to speak with someone regarding his/her concerns. The resident had reported to the Social Worker he/she had been left wet on 11/19/11. The DON stated she went to speak with the resident on 11/22/11. The resident told the DON that CNA #3 (first shift aide assigned to Resident #6) left early and did not provide incontinent care. In addition, the DON revealed she had not reviewed the ADL detail to determine if facility staff had provided timley incontinent care to this resident. Observation, on 11/29/11 at 11:30 AM, revealed Resident #6 was lying in bed with a splint on his/her right hand and right leg due to contractures. Interview with the resident at this time revealed the resident was totally dependent on staff for all care needs. The resident stated he/she gets upset just talking about the 11/19/11 incident. The resident was observed visibly angry as evidenced by the resident's body stiffening in bed, having a change in the sharpness of the tone of his/her voice and his/her speech becoming rapid while detailing the incident.