Every finding on record at South Campus Care Center and Rehab

Based on interview and record review the facility failed to inform the resident representative of discharge for one (Resident #2) of 3 residents reviewed for discharge. Findings include: Review of Resident #2's census data showed Resident #2 was admitted to the facility on [DATE] with the payor source hospice respite private. Review of Resident #2's Discharge Return not Anticipated minimum data assessment, dated 3/21/2026, showed Resident #2's cognitive summary score to be 7 [severe problems with memory and thinking]. Review of Resident #2's admission record showed his spouse was listed as emergency contact #1 and diagnoses that included vascular dementia with agitation. Review of Resident #2's progress note, dated 3/19/2026, read Patient admitted for a 5-day respite stay through [Name of Hospice Provider] with a diagnosis of cerebral atherosclerosis. Resident is A&Ox2 [alert and oriented times 2]. Review of the facility grievances showed Resident #2's spouse filed a grievance with the facility on 3/21/2026 that alleged Resident #2 had been discharged from the facility with his daughter and Resident #2's spouse (emergency contact #1) had not been notified of the discharge by the facility. The grievance file documented education had been given to the nursing staff on 3/23/2026 to refer to a patient's face sheet before completing a discharge. The education titled Discharge Process read All discharges require doctor's order, family or POA [Power of Attorney] notification, agreement and documentation of who the resident leaves with, no exceptions. Before discharge a resident, nurse must notify and obtain agreement from responsible party to ensure safe pickup, and document the process. During interview on 4/23/2026 beginning at 9:24 AM, the Administrator reported Resident #2's daughter had come to the facility and signed him out. She stated she did not believe Resident #2's daughter was his Power of Attorney. She reported Resident #2's daughter had taken him out of the facility and had not told Resident #2's spouse. The Administrator reported the incident had not yet been reviewed by the quality assurance performance improvement committee. Stated she did not know if anyone from the facility had notified Resident #2's spouse (emergency contact #1) that his daughter was removing him from the facility. During interview on 4/23/2026 beginning at 9:28 AM, the Director of Nursing stated there was no designated Power of Attorney in Resident #2's file but Resident #2's spouse was listed as his emergency contact #1. During interview on 4/23/2026 at 12:32 PM, Staff A, Licensed Practical Nurse, stated I was working the cart and all I know is there was a couple that came in and said the mom wanted him home. He was already in bed. It was about 8 o'clock. They were on the phone with somebody and kept saying the mom wants him home tonight. They kept insisting so I went and got the supervisor and she took over. I knew it was the daughter because she said she was the daughter. I only work 2 days a week. That's why I got the supervisor. They were on the phone the whole time and it appeared to be his wife. He did not object to leaving. He had no problem going with them. Wasn't objecting. I heard him talking to them. During interview on 4/23/2026 at 1:40 PM, Staff B, Registered Nurse, stated I don't remember any kind of time frame of that night. Daughter came to visit him and said mother wanted him home. Not that I'm aware of did anyone call the wife. Review of Resident #2's progress notes failed to reveal documentation the facility had attempted to contact Resident #2's emergency contact #1 to verify the identity of the person removing Resident #2 from the facility and to verify Resident #2's emergency contact was aware of and approved of Resident #2's removal from the facility.

Based on observations and interviews, the facility failed to maintain a homelike physical environment when access to the pull cords for the lighting fixtures behind the resident's beds were unavailable for residents for one of three hallways.Findings include: During an interview on 1/5/2026 at 9:40 AM, Resident #128 stated, Since I have been here, I cannot turn on my over-the-bed light because there is no string to pull. It has been like this since I was admitted . I have told nursing. During an observation on 1/5/26 at 9:40 AM, the light was off behind Resident #128's bed and there was no cord attached to the pull chain that would enable the resident to turn the light on himself. During an interview on 1/5/26 at 10:45 AM, Resident #125 stated, 'The environment needs repair. I cannot access the light cord behind the bed.During an observation on 1/5/26 at 10:45 AM, the light cord for light behind Resident #125's bed was not long enough for her to control the light.During an interview on 1/6/26 at 8:30 AM, Resident #45 stated, I cannot turn on the light behind my bed because there is no string. I have told them and it has been like that since I arrived.During an observation on 1/6/2025 at 8:30 AM, Resident #45 was in bed sitting up with head of bed elevated. There was no chord attached to the pull chain to the light fixture on the wall behind his bed. Resident does not have independent control to turn on and off the light behind his bed. During an interview on 1/7/2025 at 5:30 PM, the Administrator stated, We have guardian angels (Department leaders) assigned to make daily rounds with all of the residents and if they identify that there are environmental issues or repairs needs, they enter a work order into [name of maintenance software]. The guardian angels utilize a checklist that includes the environment observation regarding cleanliness etc. I will provide you the check list tomorrow morning.During an interview on 1/7/2025 at 5:40 PM, the maintenance director stated, It is an easy fix to attach a cord to the light chain. During an interview on 1/8/2026 at 8:30 AM, the provided the surveyor with an updated checklist that includes checking to be sure that light cord is within reach and he stated, we will be checking all of the lights today. During an observation on 1/8/2026 at 9:30 AM, the following 8 rooms did not have a light cord attached or long enough for the resident to use while in bed to turn on the over bed light: room [ROOM NUMBER] B, room [ROOM NUMBER] B, room [ROOM NUMBER] B, room [ROOM NUMBER] B, room [ROOM NUMBER] A, room [ROOM NUMBER] B, room [ROOM NUMBER] A and room [ROOM NUMBER] B.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (Resident # 0) of 8 residents reviewed. Findings include:During an interview on 1/5/2025 at 11:08 AM, Resident #50 stated, The port was when I was getting chemotherapy.During an observation on 1/5/2026 at 11:08 AM, Resident #50 had a venous access port (a small, implanted device placed under the skin to provide long term access to a vein for medications, fluids, and blood draws) near her left shoulder with a dressing covering it. The dressing is dated 12/5/2025. Photographic evidence obtained on 1/5/2025 at 11:08 AM. During record review of Resident #50's resident centered plan of care, there is no care plan for Resident #50's venous access port.During interview on 1/7/2026 at 10:10 AM, [NAME] Unit Manager, Licensed Practical Nurse (LPN) stated, I do not see a care plan for the resident for her access port. There should have been a plan of care for her venous access port.Record review of facility policy titled, Comprehensive Assessments and Care Plans, with last review date of 4/1/2022, reads, Standard: It will be the standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS (Center for Medicare & Medicaid Services). The assessment will include at least the following: (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Date Set (MDS).

Based on observation, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living, receive the necessary services to maintain good grooming and clean clothing for 1 of 7 residents (Resident #33) reviewed for activities of daily living.Findings include:On 1/5/26 at 11:04 AM, Resident #33 was observed in a visibly soiled jacket and pants, facial hair unkept in appearance and had a sour body odor. Resident was pleasantly confused, standing at the doorway to his room.On 1/6/26 at 9:58 AM, Resident #33 was observed in the same visibly soiled jacket and pants, partially fallen due to missing belt loops, facial hair unkept in appearance, and a foul/sour body odor. Resident is observed standing in the hallway next to the door of his room.On 1/7/26 at 8:52 AM, Resident #33 was observed in the same visibly soiled jacket and pants, partially fallen due to missing belt loops, facial hair unkept in appearance, and a foul/sour body odor. Resident #33 is observed walking the hallway in the unit.Review of Resident #33's admission record documented an admission date of 11/2/23 with a diagnosis that include metabolic encephalopathy, vascular dementia, and muscle weakness. Review of Resident #33's person centered care plan, revised 12/2/25, documented, [Resident #33's Name] has a self-care deficit with dressing, grooming, bathing r/t [related to]: generalized weakness, visual limitations. Interventions included provide hands on assistance with dressing, grooming, bathing as needed.Review of Resident #33's person centered care plan, revised 12/22/23, documented, [Resident #33's Name] needs assistance with ADL's r/t muscle weakness. Interventions include assist/provide ADL care and support as needed.Review of Resident #33's person centered care plan did not document shower refusals or behavior concerns with ADL care.Review of Resident #33's progress notes found no documentation of refusal of showers.During an interview on 1/6/26 at 9:58 AM , Resident #33 was asked if he had another jacket and pants to change. Resident #33 stated, this is my jacket, I got it on. Resident #33 was unable to understand question regarding changing his clothing, Resident #33 was observed to remove glasses and started talking about his wife.During an interview on 1/7/26 at 12:22 PM, Staff A, Licensed Practical Nurse (LPN), stated, [Resident #33's Name] did not get a shower last night, it is documented as resident was not available. I know that [Resident #33's Name] can refuse showers and be difficult.During an interview on 1/7/26 at 12:26 PM, Staff B, Certified Nursing Assistance (CNA), stated, [Resident #33's Name] dresses himself, always pick out the same outfit each day. We will help [Resident #33's Name] get ready for the day or change and then [Resident #33's Name] goes right back to picking out the same clothes.An observation of Resident #33's closet was observed with CNA and the resident does have other jackets, shirts and pants in closet.During an interview on 1/7/26 at approximately 2:20 PM, Director of Nursing (DON), stated, If a resident refuses an shower, the CNA responsibility is to let the nurse know so the resident can be approached another time. Then document that the resident refused to be able to address possibly on the next shift.During an interview on 1/8/26 at 9:20 AM, Administrator stated, the shower was provided last night, the documentation was in error. [Resident #33's Name] clothing has a peculiar odor from re-wearing the same clothing items. Review of the facility policy titled, Showers/Bathing, issued 4/1/2022. Read, Policy: It will be the policy to assure that showers/bathing are offered at least two times weekly or per resident/resident representative preference , unless specifically ordered otherwise by the physician or care planned otherwise. Procedure 4. Refusals for shower/bathing should be reported to nursing staff via placement on the 24 hour report, verbally comment via denotation of refusal In the electronic health record POC [point of care] system or in any other acceptable means to ensure the nurse is aware of the refusal.

Based on observation, interview and record review, the facility failed to adhere to professional standards of practice for the care and maintenance of a venous access catheter port for 1 (Resident #50) of 2 residents reviewed.Findings include:Review of the medical record for Resident #50, documented tunneled venous access catheter was in place for the administration of chemotherapy for cancer. During an interview on 1/5/2026 at 11:05 AM, Resident #50, stated I had the port placed for chemotherapy. They are not using it now. During an observation on 1/5/2026 at 11:05 AM, Resident #50 has a venous access port (implanted device to provide long term access for medications) near her left shoulder with a dressing covering it. The dressing is dated 12/5/2025. (Photographic evidence obtained) During an interview on 1/7/2026 at 10:10 AM, the [NAME] Unit Manager/Licensed Practical Nurse (UMLPN) stated, Our policy is an access port needs to have weekly changes of the Huber needle and dressing. The dressing should have been changed.Review of the facility policy and procedures titled, Implanted Venous Port with a last review date of 2/2019, read, Purpose: To provide the guidance for the care of the venous port, to access the venous septum to administer medication, and proper procedure to de-access the non-coring port needle from the port.14. A folded 2 inch by 2 inch sterile gauze may be placed under the wings of the non-coring needle if it does not obscure the insertion site. This would be done if needle is not at same level as the port to stabilize it, or for protection of the skin. This is not considered to be a gauze dressing and can stay in place for 7 days. 15. Cover needle with transparent sterile dressing, making sure that edges of the dressing are firm against the skin. Use skin protecting agent (e.g., Skin Prep) on skin first, if necessary, and let dry before placing dressing on skin. 16. Label dressing with date, time, and initials of person who is performing procedure.

Based on observation, interview, and record review the facility failed to maintain complete and accurate medical records for 1 (Resident #117) of 3 residents reviewed for advance directives and respiratory services.Findings include:Review of the admission record for Resident #117 documented an initial admission date of 12/2/25 and a re-admission date of 1/3/26.On 1/5/25 at 10:50 AM, Resident #117 was observed wearing oxygen (O2) via nasal cannula on 2 liters with the oxygen concentrator.During an interview on 1/5/26 at 10:50 AM, Resident #117's significant other, who was at resident's bedside, stated [Resident #117's Name] was hospitalized for Respiratory Syncytial Virus (RSV) and was brought back to facility on Saturday after the hospital said she was stable to return. The cough has been persistent since diagnosis of RSV and has improved. [Resident #117's Name] being on oxygen is new and never [had] been on oxygen prior to this episode. On 1/6/26 at 3:24 PM, Resident #117 was observed in bed wearing O2 on 2 liters with the oxygen concentrator, resident is being repositioned by significant other and facility staff.On 1/7/26 at 11:20 AM, Resident #117 was observed in bed wearing O2 on 2 liters with the oxygen concentrator.Review of the Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated 1/3/26 documented in Section V: Treatment Devices the resident was transferred on 2 liters of continuous oxygen.Review of physician orders for Resident #117 for the period of 1/3/2026 through 1/7/2026 documented no physician orders for Oxygen therapy.Review of the clinical record for Resident #117 showed a yellow document titled Do Not Resuscitate (DNR) signed and dated 9/8/25.Review of Progress notes dated 12/4/25 read, Resident admitted for Long Term Care diagnosis hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant aphasia. Resident spouse is Durable Power of Attorney (DPOA) and is currently a DNR.Review of physician orders for Resident #117 dated 1/3/25 read, Advanced Directive: Full Code.During an interview on 1/5/26 at 1:20 PM, the Administrator stated, The code status should have been checked on admission by nursing.During an interview on 1/7/26 at 11:39 AM, the Director of Nursing stated, The expectation is for the nurse to review the incoming orders and transcribe into [Name of clinical record software]. The weekend nursing supervisor should go through the admission packet to verify all orders are transcribed correctly. Review of the facility policy titled, Admissions Policy, issued 4/1/2022, reads, Policy: It will be the policy of this facility to provide appropriate admission guidelines when admitting residents to the facility in accordance with federal guidelines. The facility will evaluate/ assess and document the resident condition upon admission, confirm orders with the physician and obtain appropriate demographic and contact information. Procedure: 7. At the time each resident is admitted , the facility must have physician's orders for the resident immediate care. In the event the resident arrives to the facility without specific instructions the nursing staff should reach out to the medical director or physician assigned to a newly admitted resident to receive orders for care and services. 9. The newly admitted resident should have diet/type of nourishment, medications and treatments and advanced directives verified by the physician, communicated to the pharmacy for delivery and transcribed to the MAR/ TAR or entered into the electronic health record.

Based on observations and interviews, the facility failed to provide a clean homelike environment for 2 of 9 residents, Residents #1 and #7, reviewed for environment. Findings include: 1) During an observation on 4/29/2025 at 10:39 AM of Resident #1's room and bathroom there were tiles noted to be missing along the wall of the sink and toilet, these were located along the baseboard of the wall. The bathtub does have a rust colored discoloration near the faucet and brown staining on the tile along the wall. (Photographic evidence obtained) During an interview on 4/29/2025 at 3:20 PM the Regional Plan Operator stated, The condition of the tiles and bathtub were not acceptable and needed to be fixed. During an interview on 4/29/2025 at 3:40 PM the EVS (Environmental Services) Manager stated, The bathtub discoloration is not to his expectations for cleanliness. 46523 2) During an observation on 4/29/2025 at 9:15 AM of Resident #7's room there was a loose baseboard with dry wall debris that spans the length of Resident #7's bed. (Photographic evidence obtained) During an interview on 4/29/2025 at 9:15 AM Resident #7 stated, I do not know what happened to the wall. I think it was water damage. It [the wall baseboard] has been that way for some time now. During an interview on 4/29/2025 at 3:26 PM the Regional Plan Operator stated, [Resident #7's name] room shows up in our report on 4/7/2025 . The floor is given a critical category and would need to be corrected in four hours. Baseboard damage should be repaired right away. [Resident #7's name] baseboard should have been repaired right away. During an interview on 4/29/2025 at 4:13 PM the Director of Nursing stated, A critical entry in the maintenance log is right way and a medium entry should be repaired by the end of the day. Review of the facility policy and procedure titled Environment of Care with an issued date of 4/1/2022 read, Policy: It will be the policy of this facility to provide the residents with a safe, comfortable and homelike environment.

Based on record reviews and interviews the facility failed to document blood glucose levels and administration of insulin for one of 3 residents, Resident #1, reviewed for medication administration, and 1 of 3 residents, Resident #1, reviewed for wound care. Findings include: 1) Review of Resident #1's medical record documented a medical diagnosis of diabetes mellitus (DM) type 2. Review of the physician order dated 2/20/2025 for Resident #1 read, Insulin Lispro subcutaneous solution pen 100 unit/ml (milliliter), inject 4 units subcutaneously before meals for DM and Insulin Glargine Solostar Subcutaneous Solution Pen-Injector 100 unit/ml, inject 15 units subcutaneously at bedtime for DM. Review of the physician order dated 2/21/2025 for Resident #1 read, Glucose monitoring before meals and at bedtime for DM. Review of the medication administration record for April 2025 for Resident #1 did not provide documentation of the administration for Insulin Lispro for April 27th at 4:30 PM, Insulin Glargine for April 27th at 9:00 PM, and did not provide documentation of Resident #1's blood glucose levels for April 27th at 4:30 PM and 9:00 PM. During an interview on 4/29/2025 at 3:17 PM Staff A, License Practical Nurse (LPN) stated, I worked a double shift that day and I forgot to document the blood glucose levels and the administration of the insulin. During an interview of 4/29/2025 at 5:25 PM the Director of Nursing (DON) stated, My expectations are that the nurses document glucose serum levels and medication administration accurately in real time. 46523 2) During an observation on 4/29/2025 at 12:00 PM with the DON Resident #1 had a wound dressing on his left leg dated 4/26. Review of Resident #1's physician order dated 3/26/2025 read, Wound care to left lateral malleolus: cleanse w/NS [with normal saline], apply Iodosorb & [and] cover w/border gauze. Review of Resident #1's Wound Assessment Report dated 4/16/2025 documented the left lateral malleolus wound had a resolved status. Review of Resident #1's Treatment Record Administration for the month of April 2025 for wound care to the left lateral malleolus wound documented blank entries on 4/10/2025, 4/13/2025, 4/15/2025, 4/17/2025, 4/18/2025, 4/21/2025, 4/22/2025, and 4/27/2025. Review of Resident #1's Treatment Record Administration for the month of April 2025 for the left lateral malleolus wound care documented on 4/28/2025 wound care was provided. During an interview on 4/29/2025 at 1:45 PM the DON stated, [Resident #1's name] wound had resolved since April 16. The nurse should have discontinued the order. The staff should be checking off when the wound care is completed and not checking off the treatment record if treatment is not being done, only signing off if the treatment is completed. The treatment record is to be filled out accurately to represent the care provided. During an interview on 4/29/2025 at 2:53 PM Staff B, Registered Nurse/Wound Care Nurse stated, [Resident #1's name] wound was healed about a week ago, it was healed. I should have discontinued the order and put in a progress note regarding the wound being resolved. If the staff are doing the wound care nurses should check it off in the treatment record, if they are not doing the wound care, it should not be checked off. If they have any questions, they can let me know or reach out to the provider. During an interview on 4/29/2025 at 5:51 PM Staff C, LPN stated, I didn't do wound care for Resident #1 on 4/28/2025. I checked off doing the treatment by mistake. Review of the facility policy and procedure titled Wound Care with an issued date of 4/1/2022 read, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. Procedure: 10. Document in the clinical record when treatments are performed. Review of the facility policy and procedure title Charting and Documentation with an issued date of 4/1/2022 read, Policy: It is the policy of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. Procedure: Observations, medication administration, services performed, etc., should be documented in the resident's clinical records.

Based on observations, interviews, and policy review, the facility failed to ensure food was stored, covered, labeled, or discarded in the kitchen walk-in coolers and dry storage areas and maintained standards of practice for cleaning and sanitary conditions in the dietary department. Findings included: An initial walk-through of the kitchen was conducted on 7/21/24 at 9:00 AM with the Dietary Manager (DM). An observation was made at 9:08 AM of two large full containers of cottage cheese with an expiration date of 7/14/24. An observation was made in the walk-in cooler of a large metal bowl of a fruit type mixture with no identifying label or date. An observation was made in the kitchen of a dirty cloth and a dirty metal scrubby left on the sink and not in a Santi-container or solution. An observation was made in the dish room of 3 large 5-gallon containers of chemicals for the dish machine stored on the floor. (photographic evidence obtained) An interview was conducted with the Dietary Manager (DM) at 9:15 AM. The DM confirmed he observed the two large cottage cheese containers with an expiration date of 7/14/24. The DM stated the containers should have been used before the expiration date or discarded. The DM confirmed he observed the large bowl of a fruit type mix and that the bowl did not have an identifying label or date and there should have been a label and date on the container. The DM confirmed the 5-gallon containers were not on a shelf or roller [NAME] and stated the 5-gallon containers of chemicals should not have been stored on the floor. The DM confirmed the dirty rag and scrubby left on the 3-compartment sink counter should have been put in the clean sanitizing container. A follow up walk through was conducted on 07/22/24 at 06:38 AM with the DM. An observation was made of a large buildup of dirt, grime, and debris on the walls, ceiling, and metal-type conduit pipes running up beside the food steam table and around throughout the kitchen. An observation was made in the kitchen of 5 partial packages of hamburger and hot dog buns, sliced wheat and white bread with no open date on each of the 5 packages. (photographic evidence obtained) A second interview was conducted with the DM on 7/22/24 at 7:08 AM related to the buildup of dirt and debris on the walls, ceiling and conduit pipes. The DM confirmed the buildup of dirt, grime and debris was visible around and close to the food steam table area and throughout the kitchen and should have been cleaned to prevent a buildup. The DM confirmed that the cleaning policy included non-food contact surfaces. Review of the policy titled Refrigerated Storage dated 10/01/23 and with a revision date 11/29/23 read, Policy: Refrigerated items should be properly stored, labeled and maintained by dietary staff. 4. Dietary staff will label, date, and monitor refrigerated food, including but not limited to leftovers to ensure use-by-dates, or frozen are discarded. Review of the policy titled Kitchen Sanitation dated 10/01/23 and with a revision date 11/29/23 read, Policy: It will be the policy of the facility that the food service area and equipment shall be maintained in a clean and sanitary manner. 13. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime.

Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflect the resident's status for 1 (Resident #109) of 3 residents reviewed for range of motion and 1 (Resident #20) of 2 residents reviewed for gastrostomies. Findings include: 1. During an observation on 7/21/2024 at 10:05 AM, Resident #109 was lying in bed guarding his right arm with his left hand. During an interview on 7/21/2024 at 10:05 AM, Resident #109 was asked if he was able to move both arms without limitations, he nodded No and touched his right hand. When asked if he was able to move both lower extremities without limitation he nodded No. Review of Resident #109's admission record documented resident was admitted on [DATE] with diagnosis including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and muscle weakness. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE], documented in Section GG titled Functional Abilities and Goals that Resident #109 had no impairment in his upper or lower extremities. Review of Resident #109's physiatry [medical specialty that focuses on function, independence and quality of life for people with disabilities] progress note, dated 7/16/2024 read, Transition of Care: Mobility and ADL (activity of daily living) deficits secondary to intraparenchymal hemorrhage. His condition is complicated by muscle weakness, difficulty walking and aphasia. Chief complaint: Mobility and ADL deficits secondary to intraparenchymal hemorrhage. His condition is complicated by muscle weakness, difficulty walking and aphasia. History of present illness: Patient is a 53 y/o (year old) Male with PMH (past medical history) significant for abdominal wall abscess, acute hypoxic respiratory failure, acute renal failure requiring dialysis, anemia, aphasia, cerebral vascular accident with right-sided body involvement, constipation, dysphagia, heart disease, hypertension, metabolic encephalopathy, neurogenic bladder, paroxysmal atrial fibrillation, and deep vein thrombosis prophylaxis, who was admitted to South Campus Rehabilitation and Nursing for skilled nursing and rehabilitation secondary to deficits in mobility and ADL's . Musculoskeletal Exam: Tone: Patient with decreased tone to bilateral upper and lower extremities. Stability: Joints are stable with no joint laxity or subluxation. Palpation: No tenderness to palpation of b/l UE and LE (bilateral upper extremities and lower extremities). Range of Motion: Functional range of motion to left upper and left lower extremity. Decreased range of motion to right upper extremity and right lower extremity . During an interview on 7/23/2024 at 9:02 AM, Staff D, Certified Nursing Assistant (CNA), stated [Resident #109 name] has impairment on his right leg; he will not do anything with that leg. He is a Hoyer lift [resident is transferred using a mechanical lift]. I would say he has impairment on lower extremities and somewhat of impairment on one side of upper extremities. During an interview on 7/23/2024 at 12:23 PM, Staff E, Physical Therapist (PT), stated I took care of resident [Resident #109]. He has right side impairment due to his cardiovascular accident. During an interview on 7/23/2024 at 1:10 PM, Staff F, Physical Therapist Assistant (PTA), stated Resident is moderate to maximum assist. Resident has impairment on one side of his body; the side of his stroke. During an interview on 7/23/2024 at 1:12 PM, Staff G, Certified Occupational Therapist Assistant (COTA), stated, Resident has right sided weakness; he is able to use his left side. 2. During an observation on 7/23/2024 at 12:30 PM Resident #20 was lying in bed, gastric tube noted on left side of abdomen with clean dressing dated 7/23/2024. Nursing staff administering medication via gastric tube. Review of Resident #20's physician's order dated 4/11/2024 read, Nepro 80 ml (milliliters)/hour via g-tube (gastric tube) on at 1800 [6:00 PM] and off at 400 [4:00 AM] two times a day for supplement on at 1800 and off at 0400. Review of Resident #20's physician's order dated 7/02/2024 read, Enteral Feed order every shift Nepro continuous @ (at) 90ml/hr x 10 hours (90 milliliters per hour times 10 hours) (ON @ 1800; OFF @ 0400). Review of the MDS Quarterly assessment dated [DATE], documented in Section K titled Swallowing /Nutritional Status that Resident #20 had no feeding tube while a resident of the facility. During an interview on 7/23/2024 at 1:21 PM, Staff H, MDS Coordinator stated [Resident 109's name] does have upper and lower extremity impairments; the MDS was coded incorrectly. [Resident #20's name] does have a gastric tube and receives feedings and medication via gastric tube. Her MDS was coded incorrectly. Review of the facility policy and procedure titled, MDS Assessments with a last review date of 11/29/2023, read, Policy: It will be the policy of this facility to complete MDS assessments in accordance with the RAI (Resident Assessment Instrument) manual guidelines.

Based on observation, interview and record review, the facility failed to ensure residents who needed assistance to perform activities of daily living (ADLs) received assistance for 1 of 3 residents reviewed for ADL care, Resident #367. Findings include: Review of Resident #367's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including acute respiratory failure with hypoxia, morbid (severe) obesity due to excess calories, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, difficulty in walking, need for assistance with personal care, other abnormalities of gait and mobility, muscle weakness, hyperlipidemia, constipation, essential (primary) hypertension, low back pain, gout, opioid dependence, personal history of malignant neoplasm of prostate, gastrointestinal hemorrhage, headache, obstructive sleep apnea, hypo-osmolality and hyponatremia, chronic diastolic (congestive) heart failure, chronic kidney disease, and anemia. During an observation on 7/21/2024 at 10:16 AM, Resident #367 had long and untrimmed fingernails with dark substance under nail beds. During an interview on 7/21/2024 at 10:16 AM, Resident #367 stated, I like my fingernails to be cut. Last time they were cut at home. During an observation on 7/22/2024 at 8:13 AM, Resident #367 had long and untrimmed fingernails with dark substance under nail beds. During an observation with Staff D, Certified Nursing Assistant (CNA), on 7/23/2024 at 8:25 AM, Resident #367 had long and untrimmed fingernails with dark substance under nail beds. During an interview on 7/23/2024 at 8:25 AM, Staff D, CNA, confirmed that the Resident #367's fingernails were long and untrimmed with dark substance underneath, and they needed to be cut. Review of Resident #367's care plan dated 7/11/2024 showed it read, Focus: Resident needs assist with ADLs . Interventions . Assist/provide ADL care and support as needed. During an interview on 7/23/2024 at 8:56 AM, the Director of Nursing (DON) stated, They [residents] get nail care on shower days and as needed. Review of the facility policy and procedure titled ADL Care and Assistance issued on 4/1/2022 and last reviewed on 11/29/2023 showed the policy read, Policy: IT will be the policy of this facility to provide the resident with Activities of Daily Living (ADL) care and assistance while attempting to maintain the highest practicable level of function for the resident.

Based on interview and record review, the facility failed to ensure the residents received medication per physician orders for 1 (Resident #37) of 7 residents reviewed for medication administration. Findings include: Review of Resident #37's physician's order, dated 1/14/2024, read Acetaminophen Tablet 325mg (milligrams) give 2 tablets by mouth every 4 hours as needed for mild pain, level 1-3, related to pain, unspecified (R52) not to exceed 3gm (grams)/3000mg per 24 hours . Review of Resident #37's Medication Administration Record (MAR) for June 2024 documented the resident received Acetaminophen Tablet 325mg on June 2 at 0429 [4:29 AM] for a pain level of 4, June 3 at 0500 [5:00 AM] for a pain level of 5, June 6 at 0929 [9:29 AM] for a pain level of 7, June 7 at 0053 [12:53 AM] for a pain level of 7, June 13 at 1423 [2:23 PM] for a pain level of 4, June 14 at 0447 [4:47 AM] for a pain level of 4, June 15 at 1907 [7:07 PM] for a pain level of 10, June 16 at 0500 [5:00 AM] for a pain level of 5, June 26 at 0101 [1:01 AM] for a pain level of 7, June 27 at 0050 [12:50 AM] for a pain level of 7 and at 2352 [11:52 PM] for a pain level of 8. Review of Resident #37's Medication Administration Record (MAR) for July 2024 documented the resident received Acetaminophen Tablet 325mg on July 10 at 0453 [4:53 AM] for a pain level of 4, July 11 at 0610 [6:10 AM] for a pain level of 7, July 13 at 2118 [9:18 PM] for a pain level of 4, July 21 at 1610 [4:10 PM] for a pain level of 7 and on July 23 at 0508 [5:08 AM] for a pain level of 4. During an interview on 7/23/2024 at 11:20 AM, the Director of Nursing (DON) stated I did see where the nurses gave the medication when [Resident 37's name] pain level exceeded the ordered parameters. The nursing staff are expected to follow the parameters when they are in place and if any questions should get clarification from the medical doctor. Review of the facility policy and procedure titled Medication Administration' with a last review date of 11/29/2023 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability or medication or refusals of medications by the resident.

Based on observation, record review, and interview, the facility failed to ensure residents received oxygen according to physician order for 1 of 3 residents sampled for respiratory care, Resident #366. Findings include: Review of Resident #366's admission record showed the resident was admitted on [DATE] with the diagnoses including diabetes mellitus due to underlying condition, chronic obstructive pulmonary disease, overreactive bladder, nondisplaced fracture of lateral malleolus of right fibula, chronic systolic (congestive) heart failure, depression, dementia, obstructive sleep apnea, atherosclerotic heart disease, repeated falls, muscle weakness, essential (primary) hypertension, morbid (severe) obesity due to excess calories, and anxiety disorder. During an observation on 7/21/2024 at 9:50 AM, Resident #366 was in bed, receiving oxygen through nasal cannula at 3.5 liters per minute (LPM). During an interview on 7/21/2024 at 9:51 AM, Resident #366 stated, I need oxygen at 2 liters 24/7. During an observation on 7/22/2024 at 8:15 AM, Resident #366 was in bed, receiving oxygen through nasal cannula at 4 LPM. During an observation on 7/22/2024 at 2:20 PM with Staff I, Registered Nurse (RN), Unit Manager, Resident #366 was in bed receiving oxygen via nasal cannula at 4 LPM. During an interview on 7/22/2024 at 2:20 PM, Staff I, RN, Unit Manager, confirmed that the resident was receiving oxygen at 4 LPM and stated that it needed to be 2 LPM. During an interview on 7/22/2024 at 2:27 PM, the Director of Nursing (DON), stated, The nurses have to check that, and we have to follow the physician orders. Review of Resident #366's physician order dated 7/16/2024 read, Oxygen concentrator 2 liters via nc [nasal cannula] every shift for prophylaxis. Review of Resident #366's care plan dated 7/16/2024 read, Focus: Resident needs oxygen constantly or intermittently to aide in breathing. Intervention: O2 [oxygen] at 2 liters per minute . Resident needs O2 constantly or as needed. Review of the facility policy and procedure titled Respiratory Care issued on 4/1/2022 and last reviewed on 11/29/2023 read, It is the policy of this facility to provide respiratory care and safe oxygen administration to meet the needs of the residents. Procedure: 1. Verify that there is a physician's order for respiratory procedures or oxygen use. Review the physician's order for oxygen administration.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for unattended medications in 1 unit of 3 units. Findings Include: During an observation on 7/21/2024 at 9:25 AM in Resident #109's room, there was one unopened packet of zinc oxide formula barrier cream on top of the room drawer. [photographic evidence obtained] Review of Resident #109's physician's orders on 7/21/2024 did not document orders for medication self-administration. During an observation on 7/21/2024 at 9:37 AM of Resident #38's room, there was one unopened packet of zinc oxide formula barrier cream on top of resident's bedside table. [photographic evidence obtained] Review of Resident #38's physician's orders on 7/21/2024 did not document orders for medication self-administration. During an observation on 7/21/2024 at 9:38 AM of Resident #78's room, there were two packets of unopened oxide formula barrier cream on top of resident's television table. [photographic evidence obtained] Review of Resident #78's physician's orders on 7/21/2024 did not document orders for medication self-administration. During an observation on 7/21/2024 at 9:45 AM of Resident #51's room, there was two open packets halfway filled of oxide formula barrier cream on top of resident's drawer. [photographic evidence obtained] Review of Resident #51's physician's orders on 7/21/2024 did not document orders for medication self-administration. During an interview on 7/23/2024 at 1:25 PM, the Director of Nursing stated medications shouldn't be unsecured at resident's bedside. [Resident #38's name, Resident #51's name, Resident #78's name and Resident #109's name] are not able to self-administer medication. Review of the facility policy titled, Medication/Biological Storage with a last review date of 11/29/2023, read, Policy: It will be the policy of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene while providing dining services and failed to ensure staff used appropriate personal protective equipment while providing high contact direct care to residents on enhanced barrier precautions to prevent the possible spread of infection and communicable diseases. Findings include: 1. During an observation on 7/22/2024 at 12:00 PM, Staff A, Certified Nursing Assistant (CNA), entered Resident #105's room and delivered a meal tray. Staff A exited the room and returned with a drink. Staff A exited the room and did not perform hand hygiene. Staff A walked down the hall and entered another resident's room and quickly exited the room. Staff A entered Resident #12's room and without performing hand hygiene started to assist the resident with lunch meal. Staff A stood at the room doorway and went back into the room. Staff A lifted Resident #20's plate cover and asked if the resident was hungry and wanted to eat. Staff A, without performing hand hygiene, returned to Resident #12's side of the room and began to assist the resident with meal. Staff A stood next to the bed, walked to the trash can, and readjusted the trash can closer to the side of the wall. Staff A, without performing hand washing, returned to Resident #12's side and retrieved Resident #12's fork and continued to assist with feeding. During an interview on 7/22/2024 at 12:23 PM, Staff A, stated, I did not perform hand hygiene in between the residents. I should have performed hand hygiene when entering the room and after touching the trash can. During an observation on 7/22/2024 at 12:41 PM, Staff B, CNA, was assisting Resident #105 with the lunch meal. Staff B exited the room and placed meal tray back on the meal cart. Staff B walked down the hall and did not perform hand hygiene. Resident #27 was sitting in a wheelchair at the room doorway asking for a drink. Staff B retrieved her cup and placed it on top of the meal cart. Staff B removed a clear plastic cup, poured a drink for Resident #27 and handed the cup to the resident. During an interview on 7/22/2024 at 12:47 PM, Staff B, CNA, stated, I should have done hand hygiene in between the residents. [Resident #27's name] wanted iced tea. I did not do hand hygiene, and I should have. 2. During an observation on 7/23/2024 at 11:30 AM, Staff C, Registered Nurse (RN), entered Resident #266's room. Resident #266's room door had an enhanced barrier sign posted on the entrance door with a bin containing personal protective equipment outside of the room. Staff C donned gloves but did not don a gown. Staff C inspected Resident #266's midline and cleaned the needleless connector with an alcohol swab and flushed the midline with normal saline. Staff C removed her gloves and performed hand hygiene. Staff C exited the resident room and returned with a port protector. Staff C entered Resident #266's room and donned gloves but did not don a gown. Staff C placed the port protector on Resident #226's midline needleless connector. During an interview on 7/23/2024 at 11:44 AM, Staff C, RN, stated, [Resident #266's name] is on enhanced barrier precautions due to his midline. I should have donned a gown when administering the flush via the IV [intravenous] line. During an interview on 7/23/2024 at 1:50 PM, the Director of Nursing stated, Staff are expected to wear gloves and gown when providing direct care if a resident has enhanced barrier precautions and the staff should be performing hand hygiene in between residents when passing out meal trays or assisting with dinning. During an interview on 7/23/2024 at 3:09 PM, the Infection Preventionist stated, The staff should be donning gloves and gown when they are going to provide direct care to a resident who has enhanced barrier precautions. The staff should be performing hand hygiene between residents. If they are assisting with feeding a resident, the staff should perform hand hygiene, don gloves and not touch the resident's food or anything in the room while feeding the resident. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 11/29/2023, showed the policy read, Policy: It will be policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organism. Definitions: Enhanced barrier precautions refer to the use of gown and gloves for certain residents during specific high-contact resident acre activities that have been found to increase risk for transmission of multidrug-resistant organisms. Review of the facility policy and procedure titled Hand Hygiene with the last review date of 11/29/2023, showed the policy read, Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure . 5. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . b. Before and after direct contact with residents . p. Before and after assisting a resident with meals.

Based on observation, interview and record review, the facility failed to ensure nurse staffing information was posted on a daily basis. Findings include: During an observation on 7/21/2024 at 9:04 AM, the nurse staffing information posted at the entrance lobby was dated 7/19/2024. During an interview on 7/21/2024 at 9:04 AM, Staff J, Licensed Practical Nurse (LPN) Supervisor, confirmed that the staffing information posted at the entrance lobby was dated 7/19/2024 and it had not been updated. During an interview on 7/22/2024 at 3:02 PM, the Administrator stated, The Staffing Coordinator is responsible for preparing the weekend staffing information and the receptionist is responsible for displaying it. The information was prepared but not displayed. Review of the facility policy and procedure titled Staff Postings issued on 4/1/2022 and last reviewed on 11/29/2023, read, Policy: It will be the policy of this facility to display staff posting information for visitors, families, residents and staff to be able to see. Procedure: 1. Nurse Staffing Information: (1) Data requirements. The facility will post the following information on a daily basis.

Based on record review and interview, the facility failed to maintain accurate and complete medical records for 2 of 3 residents reviewed for documentation, Residents #1 and #10. Findings include: 1. Review of Resident #1's admission record revealed the resident was admitted to the facility with the diagnoses including unspecified right femur fracture, respiratory failure, type 2 diabetes mellitus, anemia, chronic pain, right knee, left knee right hand contracture, unspecified atrial fibrillation, adult failure to thrive, atherosclerosis of coronary artery bypass grafts without angina pectoris, unspecified heart failure, unspecified seizures, status post colostomy, presence of cardiac pacemaker, and essential hypertension. Review of Resident #1's physician order dated 9/21/2023 reads, Medihoney wound burn dressing external gel, apply to left inner ankle topically every day shift for stage two, cleanse with normal saline, pat dry, apply Medihoney to open area, cover with clean dry dressing. Review of Resident #1's Treatment Administration Record (TAR) for October 2023 showed no entries documented for administration of wound treatment to left inner ankle on 10/6/2023, 10/11/2023, 10/13/2023, 10/14/2023, 10/16/2023, and 10/20/2023. Review of Resident #1's physician order dated 9/21/2023 reads, Medihoney wound burn dressing external gel, apply to left outer ankle topically every day shift for stage two, cleanse with normal saline, pat dry, apply Medihoney to open area, cover with clean dry dressing. Review of Resident #1's TAR for October 2023 showed no entries documented for administration of wound treatment to left outer ankle on 10/5/2023, 10/11/2023, 10/13/2023, 10/14/2023, 10/16/2023, and 10/18/2023. Review of Resident #1's physician order dated 9/21/2023 reads, Xeroform oil emulsion gauze external pad apply to right knee topically every day shift for skin tear, cleanse with normal saline pat dry, apply Xeroform to open area, cover with clean dry dressing. Review of Resident #1's TAR for October 2023 showed no entries documented for administration of wound treatment to right knee on 10/5/2023, 10/11/2023, 10/13/2023, 10/14/2023, 10/16/2023, and 10/18/2023. Review of Resident #1's physician order dated 10/6/2023 reads, Wound care left lateral ankle, cleanse wound with normal saline, pat dry, apply Medihoney and cover with clean border gauze one time a day for wound care. Review of Resident #1's TAR for October 2023 showed no entries documented for administration of wound treatment to left lateral ankle on 10/11/2023, 10/13/2023, 10/14/2023, 10/16/2023, 10/18/2023 and 10/20/2023. Review of Resident #1's physician order dated 10/6/2023 reads, Wound care left medial ankle cleanse wound with normal saline, pat dry, apply Medihoney and cover with clean bordered gauze one time a day for wound care. Review of Resident #1's TAR showed no entries documented for administration of wound treatment to left medial ankle on 10/11/2023, 10/13/2023, 10/14/2023, 10/16/2023, 10/18/2023 and 10/20/2023. 2. Review of Resident #10's admission record revealed the resident was admitted to the facility with the diagnoses including unspecified dementia, acquired absence of right leg below the knee, polyneuropathy unspecified, presence of cardiac pacemaker, depression, unspecified anxiety disorder, unspecified anemia, and hyperlipidemia. Review of Resident #10's physician order dated 10/27/2023 reads, Wound care, apply betadine to left medial foot daily and leave open to air every day shift for DTI [Deep Tissue Injury]. Review of Resident #10's TAR for November 2023 showed no entries documented for administration of wound treatment to left medial foot on 11/4/2023 and 11/9/2023. During an interview on 11/15/2023 at 9:35 AM, the Director of Nursing stated, All treatments should be signed and documented as completed by the nurses. There are treatments that are not documented on [Resident #1 and Resident #10's names]. There should be complete documentation. Review of the policy and procedure titled Wound Care issued on 4/1/2022 reads, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment . 6. Care procedures and treatments shall be performed according to physician orders . 10. Document in the clinical record when treatments are performed.

Based on record review and interview, the facility failed to utilize the Quality Assessment and Process Improvement (QAPI) process to monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained for the concerns identified with documentation of wound care. Findings include: Review of the policy and procedure titled Quality Assurance and Performance Improvement (QAPI) Program issued on 4/1/2022 reads, Policy: It will be the policy of this facility, including a facility that is part of a multiunit chain, to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Procedure: 1. The facility shall maintain documentation and demonstrate evidence of its ongoing QAPI program. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities . 5. The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that the QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions and services provided to residents based on performance indicator data, and resident and staff input and other information, corrective actions address gaps in systems and are evaluated for effectiveness. Review of Resident #1's physician order dated 9/21/2023 reads, Medihoney wound burn dressing external gel, apply to left inner ankle topically every day shift for stage two, cleanse with normal saline, pat dry, apply Medihoney to open area, cover with clean dry dressing. Review of Resident #1's Treatment Administration Record (TAR) for October 2023 showed no entries documented for administration of wound treatment to left inner ankle on 10/6/2023, 10/11/2023, 10/13/2023, 10/14/2023, 10/16/2023, and 10/20/2023. Review of Resident #1's physician order dated 9/21/2023 reads, Medihoney wound burn dressing external gel, apply to left outer ankle topically every day shift for stage two, cleanse with normal saline, pat dry, apply Medihoney to open area, cover with clean dry dressing. Review of Resident #1's TAR for October 2023 showed no entries documented for administration of wound treatment to left outer ankle on 10/5/2023, 10/11/2023, 10/13/2023, 10/14/2023, 10/16/2023, and 10/18/2023. Review of Resident #1's physician order dated 9/21/2023 reads, Xeroform oil emulsion gauze external pad apply to right knee topically every day shift for skin tear, cleanse with normal saline pat dry, apply Xeroform to open area, cover with clean dry dressing. Review of Resident #1's TAR for October 2023 showed no entries documented for administration of wound treatment to right knee on 10/5/2023, 10/11/2023, 10/13/2023, 10/14/2023, 10/16/2023, and 10/18/2023. Review of Resident #1's physician order dated 10/6/2023 reads, Wound care left lateral ankle, cleanse wound with normal saline, pat dry, apply Medihoney and cover with clean border gauze one time a day for wound care. Review of Resident #1's TAR for October 2023 showed no entries documented for administration of wound treatment to left lateral ankle on 10/11/2023, 10/13/2023, 10/14/2023, 10/16/2023, 10/18/2023 and 10/20/2023. Review of Resident #1's physician order dated 10/6/2023 reads, Wound care left medial ankle cleanse wound with normal saline, pat dry, apply Medihoney and cover with clean bordered gauze one time a day for wound care. Review of Resident #1's TAR showed no entries documented for administration of wound treatment to left medial ankle on 10/11/2023, 10/13/2023, 10/14/2023, 10/16/2023, 10/18/2023 and 10/20/2023. During an interview on 11/14/2023 at 2:05 PM, the Director of Nursing (DON) stated, I was made aware that there were concerns from the EMS [Emergency Medical Services] staff. I did review the record and we did identify that after he [Resident #1] was readmitted in June. He [Resident #1] no longer had routine orders for suprapubic catheter care. There was no daily documentation of the suprapubic catheter care. There was no documentation that the staff assessed the insertion site for any problems or signs of infection. There was no documentation that the resident had his catheter bag changed and no orders to see the urologist to have the catheter changed based on the review of his medical record. We did do a PIP [Performance Improvement Plan] for this and educated staff. I have been auditing. Also, I did review the chart and that was when I found that he had no orders for care or to had his suprapubic changed. I did not realize that his wound care was not documented as completed. I suppose I should have found this when I reviewed his chart. I did not do a PIP related to documentation of wound care. I suppose I should have. I did not audit all wounds to see if wound care was being documented. Review of the policy and procedure titled Wound Care issued on 4/1/2022 reads, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment . 6. Care procedures and treatments shall be performed according to physician orders . 10. Document in the clinical record when treatments are performed.

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 3 of 6 residents reviewed for oxygen administration, Residents #84, #227, and #321, in a total sample of 52 residents. Findings include: 1. During an observation on 3/12/2023 at 1:01 PM, Resident #321 was lying in bed with oxygen running at 3.5 liters per minute via nasal cannula. During an observation on 3/13/2023 at 8:43 AM, Resident #321 was lying in bed with oxygen running at 4 liters per minute via nasal cannula. Review of Resident #321's admission records revealed the resident was admitted to the facility on [DATE] with the diagnoses including contracture on right knee, right hand, and left knee, other muscle spasm, atherosclerosis of coronary artery bypass graft(s) without angina pectoris, unspecified atrial fibrillation, adult failure to thrive, sick sinus syndrome, heart failure, peripheral vascular disease, unspecified convulsions, presence of cardiac pacemaker, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, shortness of breath, and essential (primary) hypertension. Review of the physician order dated 12/2/2020 for Resident #321 reads, Continuous O2 [oxygen] at 2 L/Min [liter/minute] via NC [Nasal Cannula] q [every] shift. During an interview on 3/14/2023 at 7:44 AM, Staff A, Licensed Practical Nurse (LPN), Unit Manager, stated, The O2 is set to 2.5 liters per minute and should be set to 2 liters per minute. This is the incorrect setting. During an interview on 3/15/2023 at 9:33 AM, the Director of Nursing (DON) stated, Nurses are to look at the physician order and verify O2 settings are correct when administering oxygen. 46523 2. During an observation on 3/12/2023 at 10:06 AM, Resident #84 was lying in bed with oxygen running at 3.5 liters per minute via nasal cannula. Oxygen machine had brown splatter stains. Passive Nebulizer treatment mask was lying on top of the right side night table. During an interview on 3/12/2023 at 10:07 AM, Resident #84 stated, The nurse will adjust my oxygen. I am not sure what the stains are. It was dirty since they gave it to me. During an observation on 3/13/2023 at 7:54 AM, Resident #84 was lying in bed resting with eyes closed. Oxygen was running at 4 liters per minute via nasal cannula. Oxygen machine had brown stains. Review of Resident #84's admission records revealed the resident was admitted to the facility on [DATE] with diagnoses including acute embolism and thrombosis of unspecified deep veins of left lower extremities, generalized anxiety disorder, psoriasis, allergic rhinitis due to pollen, anemia, morbid (severe) obesity due to excess calories, major depressive disorder, emphysema, and chronic obstructive pulmonary disease. Review of the physician order dated 1/4/2023 for Resident #84 reads, Continuous oxygen 2L [liter] via Nasal cannula every shift for prophylaxis related to chronic obstructive pulmonary disease. During an interview on 3/14/2023 at 11:00 AM, the (DON) confirmed Resident #84's oxygen was running at 3.5 liters per minute. 41334 3. During an observation on 3/12/2023 at 12:20 PM, Resident #227 was resting in bed with oxygen running at 4 liters via nasal cannula. Tubing was not labeled and dated. During an observation on 3/13/2023 at 8:34 AM, Resident #227 was resting in bed with oxygen running at 2 liters via nasal cannula. During an observation on 3/13/2023 at 1:04 PM, Resident #227 stated, I am not able to touch the oxygen. I can't reach it and am too weak to do it. During an interview on 3/13/2023 at 1:55 PM, Staff E, LPN stated, This oxygen is not at the right amount. It should be at 3 liters via nasal cannula. Review of Resident #227's admission records documented that the resident was admitted to the facility on [DATE] with the diagnoses including malignant neoplasm (cancer) of esophagus, malignant neoplasm of the bronchus or lung, secondary malignant neoplasm of the liver and intrahepatic bile duct, unspecified protein calorie malnutrition, dysphagia (difficulty swallowing), and adult failure to thrive. Review of the physician orders for Resident #227 dated 2/24/2023 reads, Continuous O2 at 3L via NC q shift. During an interview on 3/14/2023 at 2:05 PM, the Director of Nursing (DON) stated, All oxygen should be running at the ordered amount. Nurses should check daily to make sure it is. They should be following physician orders. Review of the facility policy and procedure titled Oxygen Administration issued on 2/1/2022 reads, Procedure . 4. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter as is ordered by the physician or required to provide for the needs of the resident.

Based on observation, interview, and record review, the facility failed to ensure accommodate resident needs were accommodated by failing to have functioning call light system for 1 of 3 residents reviewed for falls, Resident #102. Findings include: During an observation on 3/12/2023 at 9:57 AM, Resident #102 was in bed with a bell noted on top of the bedside table. During an interview on 3/13/2023 at 9:57 AM, Resident #102 stated, My call light has not been working for four months now. Maintenance came in and the part they brought did not work. That was months ago. The staff will not answer when I ring the bell. They never come. During an interview on 3/13/2023 at 9:58 AM, Resident #30 stated, I will turn my light on when he needs help. During an observation on 3/13/2023 at 10:00 AM, Resident #102 pressed the call light. The light did not turn on outside of the room. During an observation on 3/14/2023 at 10:35 AM, Resident #102 was ringing the bell. Staff I, Licensed Practical Nurse (LPN), was in the hallway. No assistance was provided to Resident #102. Observation ended at 10:40 AM. During an observation on 3/14/2023 at 12:51 PM, Resident #102 rang the bell. Staff I, LPN, was on floor. Staff I did not address the call ringing. Resident #102 rang the bell again at 12:53 PM. Staff J, Certified Nursing Assistant (CNA), was on the floor with food trays and Staff I, LPN, was passing medication. No staff member provided assistance to Resident #102. Observation ended at 1:01 PM. Review of Resident #102's admission records revealed the resident was admitted to the facility on [DATE] with the diagnoses including traumatic subdural hemorrhage without loss of consciousness, difficulty in walking, muscle weakness, cognitive communication deficit, repeated falls, history of falling, and adult failure to thrive. Review of Resident #102's care plan initiated on 9/27/2022 reads, [Resident #102's name] is at risk for falls and/or fall related injury r/t [related to]: impaired mobility, respiratory failure, cardiac conditions, DM [diabetes mellitus], weakness, shortness of breath upon exertion, impaired balance, unsteady gait, uses w/c [wheelchair] as a primary mode of locomotion, h/o [history of] frequent falls, UTI [Urinary Tract Infection] upon 1st admission, use of opioids and psychotropic medication . Interventions: 1/13/23: Educate resident to use call bell when assistance is needed. Review of Resident #30's Quarterly Minimum Data Set (MDS) dated [DATE], reads, Section C. Cognitive Patterns: C0500. BIMS Summary Score: 14. During an interview on 3/14/2023 at 1:36 PM, the Director of Maintenance stated that he was aware call light was not working. He stated, We have been having problems getting parts. It is an old system. The new part has been ordered. We have not received it. During an interview on 3/14/2023 at 2:13 PM, Staff A, License Practical Nurse (LPN), Unit Manager, stated, I was not aware [Resident #102's name] call light was not working. Normally a report would be placed in the computer system. Depending what the issue is, maintenance will come and look at the bulb outside to see if that is the reason it is not turning on. If that does not work, they will order parts. During an interview on 3/14/2023 at 2:29 PM, Staff J, CNA, stated, Yes, I was aware his call light is not working. Most of the time, he will have his roommate use his call light to call staff. I did not hear the bell ring. If I am close to the room, I might hear it but if I am away from the room, I am not able to hear the bell ring. During an interview on 3/14/2023 at 2:31 PM, Staff I, LPN, stated, I was not aware [Resident #102's name] call bell was not functioning. I have not noticed the bell he has on top of his bedside table. I did not hear the bell. I was doing other things. During an interview on 3/15/2023 at 8:08 AM, the Director of Nursing stated, I was not aware of [Resident #102's name] call light. I would have offered resident if he would like to move to another room. Review of the facility policy and procedure titled Call Lights last reviewed on 1/19/2023, reads, Procedure . 3. The call light should be plugged in at all times with the exception of occurrences when the system is under repair or malfunctioning, in which case an alternative system of Staff notification for need of assistance may be utilized.

Based on observation, interview and record review, the facility failed to accurately assess and code each resident for swallowing abilities; necessary supervision with dining; and weight loss for 1 of 3 sampled residents reviewed for weight loss. Resident #10 sustained a 13.1 % weight loss over a 6 month period and was at risk for choking due to swallowing problems. The facility failed to ensure the accuracy of coding a pressure sore for 1 of 1 random resident (resident #190) Findings: 1. An observation on 9/23/13 at 12:57 PM revealed resident #3 dining in her bed. The resident was served pureed food. The resident was observed to place a spoon full of food in her mouth and the food was observed to drop out of her opened mouth. The resident's mouth was observed to never close, but stayed wide open during dining. The food she had placed in her mouth was repeatedly observed to fall out of her mouth onto her chest. Approximately 6 ounces of food was observed on the resident's clothing protector. No staff were observed in her room during dining. An interview with resident #3's Certified Nursing Assistant (CNA) on 9/23/13 at 1:03PM, in the hallway, revealed the resident refuses help with dining, but that he checks on her every "now and again". A review of the clinical record revealed the resident was admitted to the facility 4/25/03. Further review of the clinical record, revealed the resident had Speech Therapy Services (ST) from 6/12/13 until 6/28/13 for communication and swallowing. The discharge summary dated 7/2/13 revealed a goal to "improve swallow abilities to Min/close supervision as evidenced by ability to safely and efficiently swallow least restrictive diet with minimal to absent s/s (signs/symptoms) of oral dysphasia coughing and/or wet vocal quality post swallows in order to meet primary nutrition/hydration needs." In addition, "Patient will safely swallow any/all solids/liquids using bolus size modifications and general swallow techniques/precautions with 80% of attempts and with occasional verbal cues in order to decrease s/s of oral and /orpharyngeal dysphagia." The discharge further stated "Pt (patient) and Caregiver Training: Skilled SLP educated PT and caregivers on use of adaptive feeding equipment, alternating solids with liquids and being upright in a chair as opposed to upright in bed. Pt. indicated agreement and understanding to therapy provided. Caregivers demonstrated variable levels of understanding and agreement to suggestions to assist PT with meals." The discharge summary also stated "Supervision for Oral Intake=Close Supervision". An interview with the Unit Manager on 9/23/13 at 1:05 PM revealed she was not aware the Speech Therapist indicated the resident needed close supervision during meals or that there was meal time instructions staff should follow. A review of the Nutritional review completed by the facility Certified Dietary Manager (CDM) dated 8/5/13 revealed a 11.5 % weight loss in 180 days. The nutritional review further stated the resident had " appropriate " ability to chew/swallow and the CDM would refer the resident to the Registered Dietician. The assessment by the CDM dated 8/5/13 failed to identify the resident had a swallowing problem. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident scored an 11 on cognitive abilities. The resident was coded as being able to eat independently with set up only and no staff oversight needed. Further review of the MDS revealed the resident was coded as having Peripheral Artery Disease, a Stoke, and [MEDICAL CONDITION]. The MDS coded the resident as having no swallowing problems and a 5% weight loss. The MDS also stated the resident did not receive Speech Therapy since the last assessment dated [DATE]. An interview with the MDS coordinator on 9/25/13 at 9:20 PM revealed she was not aware the resident had Speech Therapy; was having difficulty with swallowing; or that the resident could not eat independently. 2. Review of the admission evaluation and interim care plan form dated 8/10/2013 for resident #190 revealed that the resident was admitted with the following skin assessments: open area on left heel, redness on right heel, open area on left buttocks, redness on lateral side of right and left big toes, redness both knees, and abdominal left [MEDICAL CONDITION]. Admission Braden score is 10 which indicates high risk for predicting pressure ulcer development. Review of resident #190's Minimum Data Set (MDS) with an Assessment Reference date (ARD) date of 9/13/2013 under Section M0300 documented that there are 0 (Zero) current number of unhealed wounds. Review of Vohra Wound Care Specialist Evaluation Form dated 9/05/2013 revealed an Unstageable deep tissue injury on left lateral ankle measuring 1.5 x 1.3 with surface area of 1.95 cm (centimeters) with light serous exudates and an Unstageable deep tissue injury (DTI) of the right lateral ischium measuring 0.5 x 0.5 x 1.2 cm with surface area of 0.25 cm. Review of Vohra Wound Care Specialist Evaluation Form dated 9/12/2013 revealed an Unstageable deep tissue injury on left lateral ankle measuring 1.5 x 1.0 with surface area of 1.50 cm with light serous exudates and an Unstageable deep tissue injury (DTI) of the right medial ischium measuring 2.5 x 1.0 with surface area of 2.50 cm. Review of Vohra Wound Care Specialist Evaluation Form dated 9/19/2013 revealed an Unstageable deep tissue injury on left lateral ankle measuring 1.5 x 1.0 with surface area of 1.50 cm with light serous exudates and an Unstageable deep tissue injury (DTI) of the right medial ischium measuring 3.0 x 1.0 x 0.6 cm. with surface area of 3.00 cm. Interview with Staff I, Registered Nurse (RN) /Minimum Data Set (MDS) coordinator on 9/26/2013 at 2:35 PM revealed that Resident # 190's wounds have resolved. When asked about the unstageable deep tissue injury (DTI) of the right medial ischium documented by Dr. Vohras' Wound Care Specialist on 9/12/2013, the MDS Nurse replied that "DTI is not a pressure ulcer and I can not code DTI in the MDS". Interview with the Director of Nursing (DON) on 9/26/13 at approximately 2:40PM revealed that she had corrected her MDS Nurse and will educate her about pressure wounds. The DON stated that DTIs are unstageable and therefore should be coded as unstageable in the MDS. On 9/26/2013 at 3:05 PM, the DON provided a corrected copy of the MDS assessment for resident # 190 and stated that it has not been submitted. The MDS section M0300 was now coded as 1 for presence of unstageable pressure ulcer.

Based on observation, record review and interview, the facility failed to ensure staff provided care in accordance with the plan of care for 1 of 24 sampled residents (#3) related to the provision of close supervision with eating for a resident identified as having swallowing problems and accurate accounting of food intake without sufficient interventions to prevent weight loss which which resulted in the resident sustaining a 13.1% weight loss within 6 months. Findings: An observation on 9/23/13 at 12:57 PM revealed resident #3 dining in her bed. The resident was served pureed food. The resident was observed to place a spoon full of food in her mouth and the food was observed to drop out of her opened mouth. The resident's mouth was observed to never close, but stayed wide open during dining. The food she had placed in her mouth was repeatedly observed to fall out of her mouth onto her chest. Approximately 6 ounces of food was observed on the resident's clothing protector. No staff were observed in her room during dining. An interview with resident #3's Certified Nursing Assistant (CNA) on 9/23/13 at 1:03PM, in the hallway, revealed the resident refuses help with dining, but that he checks on her every "now and again". A review of the clinical record revealed the resident was admitted to the facility 4/25/03. Further review of the clinical record, revealed the resident had Speech Therapy Services (ST) from 6/12/13 until 6/28/13 for communication and swallowing. The discharge summary dated 7/2/13 revealed a goal to "improve swallow abilities to Min/close supervision as evidenced by ability to safely and efficiently swallow least restrictive diet with minimal to absent s/s (signs/symptoms) of oral dysphasia coughing and/or wet vocal quality post swallows in order to meet primary nutrition/hydration needs." In addition, "Patient will safely swallow any/all solids/liquids using bolus size modifications and general swallow techniques/precautions with 80% of attempts and with occasional verbal cues in order to decrease s/s of oral and /orpharyngeal dysphagia." The discharge further stated "Pt (patient) and Caregiver Training: Skilled SLP educated PT and caregivers on use of adaptive feeding equipment, alternating solids with liquids and being upright in a chair as opposed to upright in bed. Pt. indicated agreement and understanding to therapy provided. Caregivers demonstrated variable levels of understanding and agreement to suggestions to assist PT with meals." The discharge summary also stated "Supervision for Oral Intake=Close Supervision". An interview with the Unit Manager on 9/23/13 at 1:05 PM revealed she was not aware the Speech Therapist indicated the resident needed close supervision during meals or that there was meal time instructions staff should follow. A review of the Nutritional review completed by the facility Certified Dietary Manager (CDM) dated 8/5/13 revealed a 11.5 % weight loss in 180 days. The nutritional review further stated the resident had " appropriate " ability to chew/swallow and the CDM would refer the resident to the Registered Dietician (RD). The assessment by the CDM dated 8/5/13 failed to identify the resident had a swallowing problem. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident scored an 11 on cognitive abilities. The resident was coded as being able to eat independently with set up only and no staff oversight needed. Further review of the MDS revealed the resident was coded as having Peripheral Artery Disease, a Stoke, and [MEDICAL CONDITION]. The MDS coded the resident as having no swallowing problems and a 5% weight loss. The MDS also stated the resident did not receive Speech Therapy since the last assessment dated [DATE]. An interview with the MDS coordinator on 9/25/13 at 9:20 PM revealed she was not aware the resident had Speech Therapy; was having difficulty with swallowing; or that the resident could not eat independently. A review of the resident's care plan revised on 9/5/13 revealed short term memory problems and Dementia. The Care Plan for dysphagia dated 6/11/13 and reviewed 9/5/13 documented: allow extra time to eat; provide additional assistance; Head of Bed to be elevated 30-45 degrees during intake. Further review of the care plan with a revision dated 9/5/13 revealed: " can feed self with set up " and " should be fed but wants to feed self." Review of the nutritional care plan dated 6/11/13 and last reviewed 9/5/13 revealed the resident has nutritional risks due to " age, DX (diagnosis), labs, Meds (medications) " with the goal to increase her weight by 1-3 pounds through next month. The interventions include: Liquid consistency as ordered; Fluids as ordered; Diet as ordered; RD (Registered Dietician) consult and follow; Supplements as ordered;Offer substitutes if less than 50% of meal eaten; Med pass 4 oz (ounces) bid (twice a day) and Nursing to monitor consumption A Review of labs done on 8/7/13 revealed resident #3's [MEDICATION NAME] was low at 3.0 with a reference range of 3.5-5.2. CBC with Differential done 8/7/13 revealed Hemocrit was low at 35.7 with reference range of 37.0-47.0 and hemoglobin low at 11.1 with a reference range of 12.0-16.0. A review of the facility ' s weight book for resident #3 revealed the resident had the following weights: 3/1/13 ...121 pounds 6/4 13 ...110 pounds 8/6/13 ...110 pounds 9/2/13 ...107 pounds which was a 13.1 % loss. An interview with the RD 09/24/13 at 1:40 PM revealed she had not observed resident #3 during dining and was not aware the resident's food would fall out of her mouth during dining. She further stated that food falling out of a resident's mouth was not her concern but Speech Therapy. An observation on 9/25/13 at 8:52 AM, revealed the resident dining in her bed. The resident was observed to have her mouth open at all times and large quantities of food had fallen from her mouth to her clothing protector. A Certified Nursing Assistant (CNA) was observed in the resident's room observing the resident dining. An interview with the resident's CNA on 9/24/13 at 11:25 AM revealed when she was assigned to the resident and that she would record the amount of food consumed by the resident by determining how much food was left on the resident's plate. She further stated she did not take into account the amount of food that had fallen out of the resident ' s mouth and landed on her clothing protector. An observation on 9/25/13 at 8:52 AM revealed resident had her mouth open at all times and food had fallen from her mouth to her clothing protector. An interview with the assigned CNA for supervision of breakfast for resident #3 on 9/25/13 at 8:52 AM revealed she had not been trained in the strategies of safe swallowing techniques for this resident or placement of the bolus in the resident's mouth to facilitate swallowing or the use of adaptive equipment. She further stated she was just observing the resident. Interview with Director of Therapy on 9/25/13 at 9:42 AM revealed she had no evidence the CNAs were trained in eating for resident #3 or that Speech Therapy monitored resident #3 for dining or her CNAs after therapy was completed. Interview with the Director of Nursing (DON) on 9/25/13 at 9:42 AM revealed the facility was not aware of the Speech Therapist's report indicating the resident needing supervision at meal times, so it did not occur until dinner on 9/23/13 after it was brought to their attention by surveyor. She also stated the resident's weight was stable and was not aware the resident had lost 3 pounds in the last month. Interview with the Therapy Director on 9/25/13 at 12:45 PM revealed there should have been formal training of CNAs; and the resident should have been placed in restorative dining upon discharge from Therapy. The Therapy Director stated that they did train staff on how to work with resident #3 on 9/25/13. An interview with the Speech Therapist on 9/25/13 at 12:52 PM. revealed she did monitor the resident eating; however, she did not document it. She further stated she wrote an order in June 2013 that resident #3 needed assistance with all meals. She stated: "No one approached me after her sessions with me and informed me there was any problem. " Therefore, the speech therapist was under the assumption that once she entered her information in the computer system (care tracker) staff should have been informed of the resident's needed supports. A review of signed, printed physician's orders [REDACTED]." A review of signed, printed physician's orders [REDACTED]."

Based on observation, interview and record review, the facility failed to accurately assess each resident for swallowing abilities, need for supervision during meals, follow physician's orders [REDACTED]. Resident #3 experience a 13.1% weight loss within six months and is at risk for choking. Findings: An observation on 9/23/13 at 12:57 PM revealed resident #3 dining in her bed. The resident was served pureed food. The resident was observed to place a spoon full of food in her mouth and the food was observed to drop out of her opened mouth. The resident's mouth was observed to never close, but stayed wide open during dining. The food she had placed in her mouth was repeatedly observed to fall out of her mouth onto her chest. Approximately 6 ounces of food was observed on the resident's clothing protector. No staff were observed in her room during dining. An interview with resident #3's Certified Nursing Assistant (CNA) on 9/23/13 at 1:03PM, in the hallway, revealed the resident refuses help with dining, but that he checks on her every "now and again". A review of the clinical record revealed the resident was admitted to the facility 4/25/03. Further review of the clinical record, revealed the resident had Speech Therapy Services (ST) from 6/12/13 until 6/28/13 for communication and swallowing. The discharge summary dated 7/2/13 revealed a goal to "improve swallow abilities to Min/close supervision as evidenced by ability to safely and efficiently swallow least restrictive diet with minimal to absent s/s (signs/symptoms) of oral dysphasia coughing and/or wet vocal quality post swallows in order to meet primary nutrition/hydration needs." In addition, "Patient will safely swallow any/all solids/liquids using bolus size modifications and general swallow techniques/precautions with 80% of attempts and with occasional verbal cues in order to decrease s/s of oral and /orpharyngeal dysphagia." The discharge further stated "Pt (patient) and Caregiver Training: Skilled SLP educated PT and caregivers on use of adaptive feeding equipment, alternating solids with liquids and being upright in a chair as opposed to upright in bed. Pt. indicated agreement and understanding to therapy provided. Caregivers demonstrated variable levels of understanding and agreement to suggestions to assist PT with meals." The discharge summary also stated "Supervision for Oral Intake=Close Supervision". An interview with the Unit Manager on 9/23/13 at 1:05 PM revealed she was not aware the Speech Therapist indicated the resident needed close supervision during meals or that there was meal time instructions staff should follow. A review of the Nutritional review completed by the facility Certified Dietary Manager (CDM) dated 8/5/13 revealed a 11.5 % weight loss in 180 days. The nutritional review further stated the resident had " appropriate " ability to chew/swallow and the CDM would refer the resident to the Registered Dietician (RD). The assessment by the CDM dated 8/5/13 failed to identify the resident had a swallowing problem. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident scored an 11 on cognitive abilities. The resident was coded as being able to eat independently with set up only and no staff oversight needed. Further review of the MDS revealed the resident was coded as having Peripheral Artery Disease, a Stoke, and [MEDICAL CONDITION]. The MDS coded the resident as having no swallowing problems and a 5% weight loss. The MDS also stated the resident did not receive Speech Therapy since the last assessment dated [DATE]. An interview with the MDS coordinator on 9/25/13 at 9:20 PM revealed she was not aware the resident had Speech Therapy; was having difficulty with swallowing; or that the resident could not eat independently. A review of the resident's care plan revised on 9/5/13 revealed short term memory problems and Dementia. The Care Plan for dysphagia dated 6/11/13 and reviewed 9/5/13 documented: allow extra time to eat; provide additional assistance; Head of Bed to be elevated 30-45 degrees during intake. Further review of the care plan with a revision dated 9/5/13 revealed: " can feed self with set up " and " should be fed but wants to feed self." Review of the nutritional care plan dated 6/11/13 and last reviewed 9/5/13 revealed the resident has nutritional risks due to " age, DX (diagnosis), labs, Meds (medications) " with the goal to increase her weight by 1-3 pounds through next month. The interventions include: Liquid consistency as ordered; Fluids as ordered; Diet as ordered; RD (Registered Dietician) consult and follow; Supplements as ordered;Offer substitutes if less than 50% of meal eaten; Med pass 4 oz (ounces) bid (twice a day) and Nursing to monitor consumption A Review of labs done on 8/7/13 revealed resident #3's [MEDICATION NAME] was low at 3.0 with a reference range of 3.5-5.2. CBC with Differential done 8/7/13 revealed Hemocrit was low at 35.7 with reference range of 37.0-47.0 and hemoglobin low at 11.1 with a reference range of 12.0-16.0. A review of the facility ' s weight book for resident #3 revealed the resident had the following weights: 3/1/13 ...121 pounds 6/4 13 ...110 pounds 8/6/13 ...110 pounds 9/2/13 ...107 pounds which was a 13.1 % loss. An interview with the RD 09/24/13 at 1:40 PM revealed she had not observed resident #3 during dining and was not aware the resident's food would fall out of her mouth during dining. She further stated that food falling out of a resident's mouth was not her concern but Speech Therapy. An observation on 9/25/13 at 8:52 AM, revealed the resident dining in her bed. The resident was observed to have her mouth open at all times and large quantities of food had fallen from her mouth to her clothing protector. A Certified Nursing Assistant (CNA) was observed in the resident's room observing the resident dining. An interview with the resident's CNA on 9/24/13 at 11:25 AM revealed when she was assigned to the resident and that she would record the amount of food consumed by the resident by determining how much food was left on the resident's plate. She further stated she did not take into account the amount of food that had fallen out of the resident ' s mouth and landed on her clothing protector. An observation on 9/25/13 at 8:52 AM revealed resident had her mouth open at all times and food had fallen from her mouth to her clothing protector. An interview with the assigned CNA for supervision of breakfast for resident #3 on 9/25/13 at 8:52 AM revealed she had not been trained in the strategies of safe swallowing techniques for this resident or placement of the bolus in the resident's mouth to facilitate swallowing or the use of adaptive equipment. She further stated she was just observing the resident. Interview with Director of Therapy on 9/25/13 at 9:42 AM revealed she had no evidence the CNAs were trained in eating for resident #3 or that Speech Therapy monitored resident #3 for dining or her CNAs after therapy was completed. Interview with the Director of Nursing (DON) on 9/25/13 at 9:42 AM revealed the facility was not aware of the Speech Therapist's report indicating the resident needing supervision at meal times, so it did not occur until dinner on 9/23/13 after it was brought to their attention by surveyor. She also stated the resident's weight was stable and was not aware the resident had lost 3 pounds in the last month. Interview with the Therapy Director on 9/25/13 at 12:45 PM revealed there should have been formal training of CNAs; and the resident should have been placed in restorative dining upon discharge from Therapy. The Therapy Director stated that they did train staff on how to work with resident #3 on 9/25/13. An interview with the Speech Therapist on 9/25/13 at 12:52 PM. revealed she did monitor the resident eating; however, she did not document it. She further stated she wrote an order in June 2013 that resident #3 needed assistance with all meals. She stated: "No one approached me after her sessions with me and informed me there was any problem. " Therefore, the speech therapist was under the assumption that once she entered her information in the computer system (care tracker) staff should have been informed of the resident's needed supports. A review of signed, printed physician's orders [REDACTED]." A review of signed, printed physician's orders [REDACTED]."

Based on record review, observations, and interview, the facility failed to ensure that 1 (1#) of 3 sampled residents, who was identified as at risk for falls, was provided adequate supervision/assistance and/or assistive devices to prevent accidents. Resident #1 sustained a laceration with bruising to her forehead after a fall from her bed during the provision of care by facility staff. Finding: Review of resident #1's clinical record revealed that the resident was admitted to the facility on [DATE] and was assessed as a high risk for falls (with a score of 12). A side rail assessment was conducted on 6/01/10. It was recommended that the resident to use ? side rail to enable independence. Review of the 2/27/11 side rail assessment documents that the patient uses side rails as an enabler for turning and positioning. The resident was documented as having fluctuations in levels of consciousness due to dementia. Review of the fall risk assessment for 6/14/11 revealed that the resident was assessed as a high risk for falls (with a score of 13). The side rail assessment dated [DATE] documents that the resident uses side rails as an enabler. Review of the 9/7/11 side rail assessment documents that the resident uses side rails as an enabler. Review of the side rail evaluation dated 1/28/12 revealed that the resident has expressed a desire to have side rails raised while in bed for her own safety and comfort. Review of the side rail evaluation for 4/26/12 revealed that the resident uses the left and right half rails to promote independence. The side rails assist the resident to rise from a supine position to a sitting position. Review of the 7/30/12 fall risk assessment revealed that the resident had declined and now the score was 15. A side rail evaluation was also conducted on 7/30/12 and the recommendations were half rails on the left and right. It was documented that the side rails are indicated and serve as an enabler to promote independence. The side rails assist the resident to rise from a supine position to a sitting position. Review of the Physical Therapy Discharge Summary dated 07/23/2012, with dates of services indicated as 07/11/2012-07/20/2012, revealed that for bed mobility the resident requires maximum assistance. Review of nursing notes dated 10/08/2012 revealed that the resident requires 1-2 person assist for ADLs. Review of the ADL Flow record for October 2012 from October 1- October 17, 2012 indicates that for all 3 shifts (except for 3rd shift on 10/6 and 10/9) the resident's bed mobility is listed as 3 (Extensive assist), 2( One Person Assist). Review of the nurses notes dated 10/17/12 revealed that at 6:30AM the nurse was notified that resident #1 had fallen out of bed. Emergency Medical Services (EMS) was called and the resident was sent to the hospital. Review of the hospital admission documentation dated 10/17/12 revealed that the resident was admitted to the hospital with [REDACTED]. Continued review of the hospital documentation revealed that: "she (resident #1) was being cleaned on her bed by the nursing staff and when she was rolled over to the other side of the bed, she basically fell and hit her head." During the interview with the assigned certified nursing assistant (CNA) on 11/27/12 at 2:30 PM, in the presence of the Director of Nursing (DON) and consultant, the CNA stated that the resident assists the staff with her ADL's and will roll over in the bed to reposition herself. The CNA continued to say that the resident's bed did not have side rails. During the interview with the DON on 11/27/12 at 4:00 PM, she stated that it was the facility's practice to place residents who are at risk for falls in low beds with blue mats and no side rails. The DON was asked to produce the written policy related to this practice, but could not do so. She stated that it was an unwritten policy. Review of the Facility's "Restraints: Side Rail Use Policy" states that residents with functional needs will receive appropriate therapeutic measures, including assistive devices such as side rails, that treat specific medical symptoms and enable the resident to be at his/her highest functional ability. Observations with the DON on 11/27/12 at 4:05 PM revealed that residents #2 and #3 were in a low bed with blue mats and two ? side rails in the up position. During a second interview with the resident's assigned CNA on 11/27/12 at 3:15 PM, she stated that resident #1 continues to turn on her side and reposition herself in bed when she (the CNA) walks into the room to perform the resident's ADL's. During interview with the consultant and the DON on 11/27/12 at 3:30 PM, both stated that the low beds are raised higher when staff assist the residents with their activities of daily living and confirmed that resident #1 did not have side rails on her bed on 10/17/12 at the time of the incident. No information was provided to indicate that two staff persons were assisting the resident with her ADLs at the time of the incident.