Every finding on record at The Arboretum At The Woodlands

Based on facility policy, record review, observation, and interview, the facility failed to report an allegation of potential abuse/neglect to the abuse coordinator for hours after it was reported to a staff member for 1 of 1 resident (R)6, reviewed for abuse. Findings include: Review of the facility policy titled Abuse Prevention and Investigation reported under the policy, Neglect is the failure of the community, it's employees or service providers to provide goods and services necessary to avoid physical harm, mental anguish or emotional distress. Additionally the policy recorded, It is the policy of this Health Center to investigate different types of incidents and to identify the employees responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities. Each resident has the right to be from verbal, sexual, physical, physical and mental abuse .neglect . Identification; Licensed nursing home will identify events, such as .occurrence's, patterns and trends that may constitute abuse and determine the direction of the investigation. Reporting to the State Agency, and take all necessary corrective actions depending on the results of the investigation, the report of abuse should be reported no later than 2 hours after the allegation is made . Record review of education titled, Abuse dated 06/13/24, recorded a Staff In-Service. If you suspect any form of elder abuse, it is your duty to report it promptly. All suspected abuse and mistreatment of residents should be reported to the Abuse Coordinator immediately at, (phone number was recorded). There are no exceptions to this. Record review of R6's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to; gastro esophogeal reflux disease, ulcerative colitis, respiratory failure, and alzheimer's disease. Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 10/18/24 revealed his Brief Interview of Mental Status (BIMs) score was 10, indicating moderately impaired cognition. On 10/22/24 at 11:02 AM, R6 was observed in the hallway. He stated, I requested a urinal last night. I rang the bell for help, but she refused. Requested further clarification, so R6 went to his room. He then said,I asked for the urinal. She told me to urinate in my brief. I've never worked with her before, she was new. I told her to get the h*** out of here. She left and never came back. R6 stated this occurred on the night shift. He was able to describe her. R6 stated, I put my light on again, and waited and someone else came into my room. I asked for the urinal and they did get it. I did not tell the nurses, but I told that person about it. He was a male. On 10/22/24 at 11:15 AM, an interview with Certified Nurse Assistant (CNA)1 revealed, R6 told me about the CNA. She refused to give him the urinal last night. I reported it to the Registered Nurse Unit Manager (RN/UM), my nurse assistant manager, and Licensed Practical Nurse (LPN)1, his primary nurse. That was about 8:30 AM, he reported that to me. On 10/22/24 at 11:35 AM, an interview with LPN1 revealed, R6 said that he asked for his urinal and the lady would not give it to him. He said it was sometime last night, a new CNA whom he had not seen before. He likes to hang it on the bedrails, at night he likes it closer to reach it. During the day, he likes it kept in the bathroom. He is independent with it for the most part. We will help him use it when we are in there with him. I have not told my RN/UM or Director of Nurses (DON) yet, but I will tell them. On 10/22/24 at 11:37 AM, an interview with the RN/UM revealed, It was just reported to me that a CNA refused to give him his urinal last night. I'm getting ready to find out about it now. On 10/22/24 at 11:53 AM, an interview with CNA2 revealed, I am the scheduler and a med tech as well and work on the Assisted Living (AL) side. CNA1 did tell me about the urinal, about 30-40 minutes ago. I was in AL this am giving medicine. On 10/22/24 at 11:58 AM, an interview with LPN1 revealed, I told the DON and the UM found out at the same time, after I spoke to you. R6 told me himself about 9:30 AM. CNA1 never told me about it, until after the fact, I had already found out. We have an abuse coordinator number we call immediately. If the DON or UM was not here, we would call the abuse hotline immediately. The UM should have told somebody when he first found out. We just had an in-service on abuse about 2 weeks ago. Different scenarios, the different kinds of abuse. That was for all staff. On 10/22/24 at 12:29 PM, an interview with the Administrator revealed, If a staff member finds out about a reportable, they are expected to contact the Abuse Coordinator within 5 minutes. If it was an allegation of abuse, it should have been reported. Based on what R6 reported and what the staff told us, it is more of a customer service situation. On 10/22/24 at 12:38 PM, an interview with the DON revealed, I am conducting an investigation on R6. She stated the staff have 5 minutes after they hear or learn of an allegation to report any allegation to me. They are educated on this. On 10/22/24 at 12:48 PM, an interview with CNA3 revealed, I work as needed, (PRN), about once a month. I was R6's CNA last night. I had not ever worked with him before. R6 rang the call bell. He said he needed to be changed. He did not ask for a urinal. When I grabbed his brief, he went off on me and told me to get the h*** out of his room. Another CNA went in and answered the call light. It was 5 minutes later. I could hear him yelling from the room. He did ask for a urinal from the CNA. The CNA told me afterward, he uses a urinal. No-one gave me a report on him. I could have asked a nurse, but I didn't. He had pull ups and regular briefs. I didn't get him a urinal, I didn't pay attention. I didn't know he used one. I did not report this to the nurse. This was between 12-1:30 am. I spoke with my DON earlier, she called me. I'm not scheduled to work until I let them know I'd like to pick up a shift. On 10/22/24 at 4:26 PM, an interview with the DON and the Administrator revealed, the DON stated the investigation was still still on-going. I became aware at 11:57 AM. Based on the statements so far, based on what the majority of the statements by staff were they didn't feel it was enough to report. Any suspicion of abuse is reported to me within 5 minutes. They stated, We did report this to Department of Health and Environmental Control (DHEC) as an allegation of neglect.

Based on observation, and staff interview, the facility failed to ensure discontinued medications were removed from the treatment cart with pharmacy labels that were blacked out in marker. Additionally, open treatment items were not dated for 1 medication room and 1 of 2 treatment carts reviewed for medication storage. Findings include: Multiple requests were made at the time of the survey for a policy on medication storage, none was provided. On 10/22/24 at 08:09 AM, an observation of the Medication Room revealed SPS Suspension Kaexalate 60 milliliters (ml) was not open, but was in the cabinent. Most of the label has been removed and a partial piece on the left side remains. An observation of the treatment cart revealed a Skin Prep Pump with a label that was blacked out with ink, but a resident's name remained visable with lot #86740. Additionally, an open bottle of normal saline, 100 ml Lot #230035050, undated with an open date. A box of Tubi Grip with a resident's name blacked out on the pharmacy label, but with a marker that was written House stock. On 10/22/2024 at 8:35 AM, an interview with Registered Nurse Unit Manager (RN/UM) revealed, The labels should be intact. He stated, I don't know why the items remain in the cart of residents whom discharged and said he wasn't sure why house stock was written on it. All open items should be dated. The Director of Nurses (DON) came into the medication room. The DON agreed that the labels should have been intact and confirmed the resident names on the labels were blacked out with ink and continued to remain on the cart. She stated, They should have been sent back to pharmacy or given to the resident upon discharge.

Based on interviews, record reviews, document reviews, and facility policy review, the facility failed to ensure allegations of abuse were reported immediately, but not later than two hours after an allegation was made, for 2 (Resident (R)1 and R2) of 3 sampled residents reviewed for abuse prohibition and failed to report the results of an investigation for 1 (R2) of 3 sampled residents reviewed for abuse prohibition. Findings included: A review of the facility's policy titled, Abuse Prevention, Reporting and Investigation dated 01/31/2018, revealed, 9. Reporting a. Licensed Nursing Home Administrator or Designee will report all alleged violations and all substantiated incidents to the State Agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation; the report of abuse or serious bodily injury should be reported no later than 2 hours after the allegation is made and no later than 24 hours if the allegation does not involve abuse and does not result in serious harm. 1. A review of R1's Profile Face Sheet revealed the facility admitted the resident on 09/13/2023, with diagnoses that included Alzheimer's disease, vascular dementia, contusion of the right knee, mild protein-calorie malnutrition, muscle weakness, difficulty in walking, pain in the right knee, dysphagia, and cognitive communication deficit. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/2023, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Per the MDS, the resident was independent with eating, toileting hygiene, showering/bathing self, upper body dressing, lower body dressing, and personal hygiene. The MDS revealed R1 required setup or clean-up assistance with rolling left and right, and with a sitting to standing position. The MDS revealed R1 received an antiplatelet medication. A review of a facility Five-Day Follow-Up Report, dated 12/14/2023, indicated Resident #1 reported to Certified Nursing Assistant (CNA)5 that a staff member grabbed the resident's arm which caused the discolored area to the right forearm. During an interview on 02/02/2024 at 8:56 AM, CNA5 revealed on 12/10/2023 between 7:30 AM and 8:00 AM, she was helping R1 get dressed for breakfast. She indicated that the R1 was sitting on the toilet and held their arm out and said, look at that. CNA5 revealed she asked what happened and R1 said a woman grabbed the resident the previous night and told the resident to shut up. R1 said they did not know why the woman was so mad at the resident. CNA5 revealed R1 had a bruise on the top of their right forearm that was dark blue and purple. CNA5 stated she notified Licensed Practical Nurse (LPN)6 of the resident's allegation. A review of LPN6's facility statement dated 12/10/2023, revealed R1 held up their right arm and reported she hurt my arm last night, she grabbed me, and I don't know why. She was so angry, but I don't know why. The LPN asked how they hurt the resident's arm and the resident replied, that girl last night. The resident pointed to a staff member's scrubs and stated, she was wearing that color outfit and gave the female's race. According to the statement, LPN6 reported the incident to the Director of Nursing (DON). During an interview on 02/02/2024 at 4:54 AM, LPN6 revealed CNA5 called her to R1's room. CNA5 asked R1 to repeat what the resident told her, and R1 held up their right arm and stated a female hurt their arm last night. R1 said she grabbed me, and they did not know why. R1 could not remember who the staff member was and was initially unable to describe them but later stated the person wore red scrubs, had brown hair, and the race of the person. LPN6 revealed she asked CNA1 to look at bruise to see if she remembered it since she worked with R1 the day before. CNA1 indicated that she did not recall seeing any bruises on R1 the previous day. LPN6 revealed that she did a full body audit and reported the incident to the DON on 12/10/2023 between 8:30 AM and 9:00 AM. A review of an Initial Report dated 12/11/2023, indicated the state survey agency was notified of the abuse allegation on 12/11/2023 at 5:15 PM, more than 24 hours after R1 reported the allegation of abuse. During an interview on 02/01/2024 at 12:35 PM, the Administrator stated the DON was out of the country. During an interview on 02/01/2024 at 4:35 PM, the Administrator revealed the DON initially reported R1's bruise was an injury of unknown origin since R1 was on long term use of aspirin. During a follow-up interview on 02/02/2024 at 4:18 PM, the Administrator revealed it was his expectation that staff report any abuse allegation immediately, or within five minutes, to the facility's abuse hotline, which went straight to the DON's cell phone. The Administrator further revealed that he expected the SA to be notified within two hours. The Administrator revealed he reported the abuse allegation when he became aware of it on 12/11/2023. 2. A review of R2's Profile Face Sheet indicated the facility admitted the resident on 12/18/2023. A review of the resident's Patient History Report dated 01/23/2024 revealed the resident had diagnoses that included anxiety, acute lateral meniscus tear of the left knee; pathological fracture of the left ankle, left tibia, left fibula, and a toe of the left foot due to age-related osteoporosis; closed displaced fracture of the phalanx of the left great toe; left tibial plateau fracture; close fracture of the neck of the left fibula; bimalleolar fracture of the left ankle; and a closed fracture of the medal plateau of left tibia. A review of R2's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/24/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. According to the MDS, the resident was dependent on staff for toileting hygiene and required substantial/maximal assistance for rolling left and right. Further review of the MDS revealed R2 was always incontinent of urine and occasionally incontinent of bowel. The MDS revealed the resident had frequent pain that occasionally interfered with day-to-day activities. The resident rated the pain as severe. A review of the facility's Five-Day Follow-Up Report, dated 01/10/2024, revealed R2 reported that on 01/06/2024 at 12:00 AM, CNA11 entered their room in response to a call light and spoke to them in a manner that they perceived to be abusive. R2 reported they did not want CNA11 to roll them as part of a brief change because it would cause pain or discomfort. R2 reported that the staff member was angry and said she must change the brief the only way she knew how. R2 denied that CNA11 made any specific statements. R2 reported the CNA's tone was unacceptable and made them fearful. During an interview on 02/02/2024 at 2:21 PM, CNA10 revealed that on the night of the incident she went into R2's room and heard R2 talking with CNA11. CNA10 said she could tell R2 was getting upset. CNA10 stated she was assigned to provide care for R2 and CNA11 was helping since CNA10 was in another resident's room. CNA10 stated CNA11 was trying to assist R2 and the resident wanted the CNA to place two briefs on the resident. CNA10 stated she could not do that and was having issues getting the briefs from underneath R2 since the resident could not roll. CNA10 stated she changed R2's incontinence brief. CNA10 further stated R2 preferred to have a brief folded and placed between their legs to act as a pad inside a second brief. CNA10 stated R2 was crying and stated they were not double briefed. CNA10 stated R2 reported that CNA11 was not professional with the resident. CNA10 revealed R2 did not express that CNA11 was verbally abusive towards them or abusive otherwise. CNA10 further indicated that she did not witness CNA11 being verbally abusive or unprofessional toward R2. CNA10 stated she reported the incident to Licensed Practical Nurse (LPN)7. During an interview on 02/02/2024 at 4:45 PM, LPN7 stated she did not remember the date of the incident with R2. LPN7 stated CNA10 notified her that R2 was upset. LPN7 stated she spoke with R2, and the resident was upset because CNA11 would not double brief them. Per LPN7, R2 stated CNA11 was spiteful because the resident thought CNA11 took the water cup out of their room. LPN7 stated R2 informed her that they did not want CNA11 back in their room. LPN7 stated at that point she did not feel this was an allegation of abuse. However, later in the morning she called the Director of Nursing (DON) and notified her of R2's concern. A review of the facility Initial Report dated 01/08/2024, revealed no documentation to indicate the state agency (SA) was notified of the abuse allegation and no fax transmittal to support the time and date the alleged abuse allegation was reported to the SA. A review of an email dated 02/02/2024 at 11:22 AM, revealed the facility did not notify the SA of the allegation until 01/08/2024 at 5:55 PM, which was not submitted to the SA agency timely. A review of the Five-Day Follow-Up Report dated 01/10/2024 revealed no documented evidence the facility's required 5-day investigation report was submitted to the SA. According to an email dated 02/02/2024 at 11:22 AM, the SA did not receive the facility's five-day report. During an interview on 02/02/2024 at 4:18 PM, the Administrator stated he expected staff to report any abuse allegation immediately or within five minutes to the abuse hotline, which went straight to the DON's cell phone. The Administrator further stated he expected the DON to notify the SA, or he would notify the SA within two hours. The Administrator stated after a full investigation, the report should be submitted to the SA within five days. The Administrator stated he reported the abuse allegation when he became aware on 01/08/2024. The Administrator also stated the facility faxed the follow-up report on 01/10/2024; however, he did not have a fax transmittal to support it was sent.

Based on observation, interview, record review, and policy review the facility failed to properly store foods in the skilled nursing satellite kitchen in a manner minimizing the risk for the spread of foodborne illness. Specifically, -Foods were stored in excess of established time frames. -Foods stored in the refrigerator were not properly labeled. -The refrigerator temperature was not within a safe temperature range. These failures had the potential to affect all residents in the skilled nursing facility. Findings include: During the initial tour of the facility skilled nursing satellite kitchen on [DATE] starting at 10:00 a.m. the following concerns were observed: A tray of cooked sausage patties labeled [DATE] was observed in a non-refrigerated cabinet next to the serving area. During an interview at 10:01 a.m. the Cook stated she had just opened the sausage that morning and stated that she had labelled the meat tray with the wrong date. An opened jar of peanut butter, without an open date, was noted under the kitchen grill preparation table. Observation of the satellite kitchen refrigerator at 10:10 a.m. revealed a temperature of 48 degrees Fahrenheit. The refrigerator temperature log was noted to have no entries for [DATE], [DATE], [DATE], or [DATE], indicating a failure to adequately monitor for safe temperatures. Additional concerns observed within the refrigerator included: -Two (2) large and 14 small individual Styrofoam serving containers were labelled with dates of [DATE]; however, there was no label indicating what food was in the containers. Observation revealed that the containers contained salads. -One (1) large bulk container of cut-up cantaloupe dated [DATE]. -One (1) large bulk plastic container of peaches dated [DATE]. -One large unlabeled plastic container of what appeared to be canned fruit. -A plastic tub in the refrigerator with undated plastic individual serving souffle cups with clear plastic covers labeled BBQ. The plastic tub also contained similar plastic souffle cups that appeared to have BBQ sauce in them but there was no labelling indicating the date or contents. The plastic tub also contained multiple small plastic individual souffle cups dated ,[DATE] but no indication of the contents. -An opened bottle of cocktail sauce dated [DATE]. During an interview on [DATE] at 10:15 a.m., the Cook stated it was the policy and practice of the facility for all items to be labelled with date opened and contents, that opened foods should be discarded after five (5) days, and that the expired items should have been discarded. The Cook stated that the refrigerator temperature log should have been maintained with daily temperature recordings. During an interview at 10:20 a.m. on [DATE], the Registered Dietician (RD) stated that s/he oversaw the foods in the kitchen as part of his/her duties and stated that expired foods should be discarded. S/he stated that the Director of Dining Services (DD) was responsible for ensuring that the satellite kitchen was operated according to food safety regulations. During an interview at 10:45 a.m. on [DATE], the DD stated that all foods should be maintained according to food safety regulations and facility policy. The DD stated the refrigerator temperature of 48 degrees Fahrenheit was a concern, and that the temperature log should have been maintained. The DD stated the main kitchen of the facility prepared and distributed food to the satellite kitchen that served the skilled nursing facility residents. The DD stated that since the coronavirus (COVID)-19 pandemic began, the facility had moved to a neighborhood model that meant that personnel were assigned to specific areas in the facility and were not allowed to go to different areas. S/he stated the managers, including the DD, were not allowed to go to the satellite kitchen in the skilled nursing area and that there had been no oversight of the satellite kitchen operations. The DD stated that the satellite cook was experienced and expected to ensure that foods were stored according to food service regulations and facility policy about food storage. During an interview at 11:50 a.m. on [DATE] the Administrator stated the satellite kitchen was under the direct supervision of the DD and was expected to follow regulations and facility policies for food safety. The Administrator stated the DD was mistaken about the management not being allowed to oversee the satellite operations due to COVID restrictions. During an interview on [DATE] at 1:20 p.m. the DD stated the facility had policies and procedures in place for food storage and that the facility followed the South Carolina Department of Health and Environmental Control (SC DHEC) food service regulations. The DD provided copies of the policies and procedures as well as a copy of the SC DHEC ,[DATE] regulations. During a follow up observation on [DATE] at 3:00 p.m. all expired foods in the satellite kitchen had been removed and the refrigerator temperature was noted to be 39 degrees Fahrenheit. During a follow-up observation on 8//20/ 2020 at 11:00 a.m. the refrigerator temperature was noted to be 42 degrees Fahrenheit. The refrigerator temperature log reflected entries for [DATE] and [DATE] for 42 and 40 degrees Fahrenheit, respectively, that were not on the log when it was initially viewed on [DATE] at 10:10 a.m. Review of facility Dining Services Orientation Checklist (undated) Subject: Major cause of food borne illness reflected that foods were to be kept out of the danger zone from 41 degrees to 140 degrees. The Subject: Store foods and equipment properly section, reflected staff were to cover, label, and date foods in storage and check temperatures of refrigerators and freezers daily. Review of the SC DHEC Regulation ,[DATE] (updated [DATE]) included in pertinent part: -Section ,[DATE].12 Time/Temperature Control for Safety, reflected that the temperature shall be held: (A) Under refrigeration that maintains the food temperature at 41 degrees F (5 degrees C) or less. - Section ,[DATE].16 Time/Temperature Control for Safety Food, Hot and Cold Holding reflected that (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under ,[DATE].19, and except as specified under (B) and in (C) of this section, time/temperature control for safety food shall be maintained at 41 degrees F (5 degrees C) or less. - Section ,[DATE].17 Ready to Eat, Time/Temperature Control for Safety Food, Date Marking reflected that refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a retail food establishment for more than twenty-four (24) hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees F (5 degrees C) or less for a maximum of seven (7) days. The day of preparation shall be counted as Day One (1). -Section ,[DATE].11 Food Labels reflected that Food packaged in a retail food establishment shall be labeled as specified in law. Label information shall include the common name of the food or, absent a common name, an adequately descriptive identity statement; Census provided by the DON on [DATE] reflected 19 residents resided on the skilled nursing unit and all residents received their food from the satellite kitchen.

Based on interview and record review the facility failed to keep residents free from abuse for 1 of 3 residents reviewed for abuse. Certified Nursing Assistant (CNA) #1 verbally and physically abused Resident #1. The findings included: The facility reported an allegation of abuse to the State Agency for physical and verbal abuse of Resident #1 by CNA #1. Review of the facility's Five-Day Follow-Up Report dated 9/21/18 revealed the incident occurred on 9/19/18 between 5:31 AM and 6:00 AM. At approximately 6:11 AM Resident #1 reported to Licensed Practical Nurse (LPN) #1 that CNA #1 had slapped him/her and called him/her a name. Resident #1 was able to identify the CNA when given pictures of several staff members. Review of the facility's investigation revealed a statement by Resident #1 that indicated I got slapped. It was a (wo/man) and (s/he) slapped me in the left side of my face. (S/he) called me something it was not nice . Further review of the facility's investigation revealed a statement completed by the Director of Nursing (DON) on 9/20/18 related to witnessing Resident #1 provide a statement to the police related to the allegation of abuse. The statement indicated (Resident #1) was interviewed by two officers with this nurse present. (S/he) was presented with four pictures to which (s/he) stated No when pictures shown. Officers then brought in picture of accused and resident stated yes beyond a doubt. Resident stated that (CNA #1) called (him/her) a [***] and slapped (him/her) on the left side of my face. Review of the Incident/Accident Report dated 9/19/18 at 6:16 AM completed by LPN #1 revealed Resident #1 was at nursing station with this nurse when s/he stated (S/he) slapped me. After questioning s/he said that it was the girl/guy that got him/her dressed this morning. No injury/marks noted to face where resident showed staff where s/he was hit. Review of the Police Department Supplemental Report dated 9/19/18 revealed the officer was able to speak to Resident #1 and had him/her look at pictures of other females that cared for him/her. Resident #1 informed the officer that none of the pictures were of the person that assaulted him/her. The officer then showed Resident #1 a picture of CNA #1 and informed the resident that the person pictured also may not be the person that assaulted him/her. Resident #1 informed the officer that CNA #1 was the person that assaulted him/her. Interview with the DON on 1/15/19 at approximately 11:10 AM revealed Resident #1 still remembers the incident and talks about it. Resident #1 does not remember the CNA's name, but can still give the details of the incident. The DON stated there were no witnesses to the incident. The DON stated there are cameras in the common area but the videos are not maintained. They reviewed the footage at the time of the incident and noted CNA #1 entering and leaving the room within the same timeframe as when the resident stated the incident occurred. Interview with the DON and Unit Manager on 1/15/19 at approximately 11:20 AM revealed Resident #1 is usually alert and oriented with some confusion. Resident #1 will refuse care at times, it depends on his/her mood and is not a daily thing. Resident #1 is not combative, s/he will move a hand away or verbally decline. Resident #1 may use profanity at times. Staff is trained to walk away when the resident refuses care. CNA #1 was a night shift CNA and was normally assigned to Resident #1. Resident #1 reported the incident to the night nurse, LPN #1. LPN #1 reported the allegation to the DON and told CNA#1 to leave immediately. The DON stated s/he documented Resident #1's oral statement of the incident. They interviewed the resident twice and s/he told them the same thing twice as far as being slapped and called a name. Human Resources printed out pictures of staff who were at the facility at the time of the incident. The police got pictures of random different people to see if Resident #1 could identify the staff member who abused him/her. Resident #1 picked the same person both times. Resident #1 described the same events to the DON on initial interview and again with the police. On the video, you can see CNA #1 leave the resident's room and then Resident #1 come out immediately and go to the nurses' station. On 1/15/19 at approximately 12:25 PM the DON provided a written timeline that included what was observed on video footage at the time of the incident. CNA #1 entered Resident #1's room at 5:31 AM and closed the door. The CNA opened the door at 5:39 AM and got the resident up in the wheelchair at 5:55 AM. Brought resident out of room at 6:00 AM and the resident went to the nurses' station at 6:05 AM. Resident #1 spoke to LPN #1 at 6:11 AM. The DON stated CNA #1 left the door open during care and they could see the foot of the bed. That is how they know the time Resident #1 was up to the wheelchair. Resident #1 went to the nurses' station at 6:05 AM. Resident #1 reported the incident to LPN #1 when s/he came to the nurses' station. LPN #1 took CNA #1 to the therapy room to talk with him/her about the incident.

Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse. Certified Nursing Assistant (CNA) #1 verbally and physically abused Resident #1. One of three residents reviewed for abuse. The findings included: The facility reported an allegation of abuse to the State Agency for physical and verbal abuse of Resident #1 by CNA #1. Review of the facility's Five-Day Follow-Up Report dated 9/21/18 revealed the incident occurred on 9/19/18 between 5:31 AM and 6:00 AM. At approximately 6:11 AM Resident #1 reported to Licensed Practical Nurse (LPN) #1 that CNA #1 had slapped him/her and called him/her a name. Resident #1 was able to identify the CNA when given pictures of several staff members. Review of the facility's investigation revealed a statement by Resident #1 that indicated I got slapped. It was a (wo/man) and (s/he) slapped me in the left side of my face. (S/he) called me something it was not nice . Further review of the facility's investigation revealed a statement completed by the Director of Nursing (DON) on 9/20/18 related to witnessing Resident #1 provide a statement to the police related to the allegation of abuse. The statement indicated (Resident #1) was interviewed by two officers with this nurse present. (S/he) was presented with four pictures to which (s/he) stated No when pictures shown. Officers then brought in picture of accused and resident stated yes beyond a doubt. Resident stated that (CNA #1) called (him/her) a [***] and slapped (him/her) on the left side of my face. Interview with the DON and Unit Manager on 1/15/19 at approximately 11:20 AM revealed staff interviewed the resident twice and s/he told them the same thing twice as far as being slapped and called a name. Human Resources printed out pictures of staff who were at the facility at the time of the incident. The police got pictures of random different people to see if Resident #1 could identify the staff member who abused him/her. Resident #1 picked the same person both times. Resident #1 described the same events to the DON on initial interview and again with the police. On the video, you can see CNA #1 leave the resident's room and then Resident #1 come out immediately and go to the nurses' station. Review of the facility's Abuse Prevention, Reporting and Investigation policy revealed each resident has the right to be free from verbal and physical abuse.

Based on observation and record review, the facility failed to demonstrate knowledge of safe holding and reheating temperatures for foods in 1 of 1 unit kitchen. Cook #1 was unable to identify when a food item had been held at an improper temperature, did not know the safe holding temperature, and did not know the safe reheating temperatures. The findings included: Observation of food temping on 2/21/18 at approximately 11:26 AM revealed Cook #1 did not identify that Fried Okra--stored at 122 degrees Fahrenheit--was not at safe temperatures. Only after s/he stated the temping process was over--when asked again what the temperature of the okra was--did s/he realize it needed to be reheated. Interview with Cook #1 on 2/21/18 at approximately 11:30 AM revealed the Cook did not know safe holding and reheating temperatures for food. When asked what the okra should be reheated to, s/he gave a range of temperatures (145 - 165). When asked what the safe holding temperatures were for food, s/he gave a similar range in temperatures (145-165). Review of policy on 2/21/18 at approximately 12 AM revealed the Facility's holding temperature for foods was a minimum of 140 degrees Fahrenheit.

Based on observations, interviews and review of the facility's Standards & Guidelines for Linen, the facility failed to handle and process resident's personal laundry in a manner to control the spread of infections. Staff was observed handling residents soiled clothing without using gloves, gowns or proper hand washing prior to leaving laundry area. Resident clothing was observed in plastic hampers with lid with no plastic lining in resident's bathroom and there was nothing in place to sanitize or clean the plastic clothes hampers. One of one laundry area on the unit. The findings included: A laundry observation on 2/22/18 at approximately 9:20 AM with Certified Nursing Aide (CNA) #1 revealed CNA #1 getting a blue plastic bag out of the laundry room and then knocking door to resident's room to get the resident's soiled laundry out of a plastic hamper with a lid in resident's bathroom. The hamper did not have a plastic lining. The CNA put on disposable gloves to get the clothes out of the hamper to put the in the blue plastic bag. The CNA removed the disposable gloves and proceed to the laundry area. The CNA was asked if there was a process of wiping down the plastic hampers since they did not have a plastic lining for soiled linen and the CNA #1 stated he/she did not know. Upon entering the laundry room the CNA opened the door and placed the soiled resident's clothing in the washer with his/her bare hands. He/she then set the washer and proceeding to exit the laundry room. There was no hand washing observed during the process and the CNA did not use gloves and gown while handling the soiled clothing. CNA #1 confirmed the findings. An interview on 2/22/18 at approximately 9:35 AM with the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #1 revealed the 11 PM to 7 AM shift does resident laundry and that CNAs who did not work that shift are not aware of the laundry process. The DON stated he/she did not know the plastic hampers should have a plastic lining and he/she was not aware that the plastic hampers should be wiped down. The DON provided a laundry process policy dated 1/31/18 that indicated clothing should be transported in accordance with procedures consistent with universal precautions. There was no policy in place for handling residents' personal laundry that was done in the facility. An interview on 2/22/18 at approximately 10:20 AM, the DON stated he/she spoke with housekeeping and there was no system in place to clean inside of plastic hampers for storage of resident's soiled clothing that was kept in the resident's bathroom

Based on interviews and record review, the facility failed to provide Resident #23 with a shower per his/her preference and per the shower schedule, 1 of 1 sampled residents reviewed for Choices. The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. During an interview with Resident #23, with a family member present, on 2/20/2018 at 11:12 AM, Resident #23 stated he/she did not receive a shower as frequently as he/she would like. Resident #23 stated he/she wants a shower 3 times a week on Monday, Wednesday and Friday. Resident #23 stated he/she did not receive a shower yesterday (Monday-2/19/2018) on his/her scheduled day. When asked if he/she was notified by the facility that he/she would not be receiving a shower, or if he/she was notified the shower was being rescheduled, Resident #23 stated he/she was not. During an interview with Resident #23 on 2/20/2018 (Tuesday) at 3:47 PM (with the same family member present), Resident stated he/she had not receive a shower today. When asked if he/she was offered a shower today the resident stated he/she was not. During an interview with the Director of Nursing (DON) on 2/22/2018 at 9:57 AM, the DON confirmed Resident #23 was scheduled to receive a shower every Monday, Wednesday and Friday on the day shift (7am -3pm). Record review of the Certified Nursing Assistant (CNA) Daily Charting on 2/22/2018 at 10:35 AM revealed Resident #23 did not receive a shower on 2/19/2018. Review of the CNA assignments for 2/19/2018 on 2/22/2018 at 11:05 AM, revealed CNA #2 was assigned to Resident #23 that day. Review of the schedule and Staff Posting indicated the facility was fully staffed on 2/19/2018. During an interview with CNA #2 on 2/22/2018 at 10:50 AM, CNA #2 stated he/she did not give Resident #23 a shower on 2/19/2018. In addition, CNA #2 stated she/he thought the resident may have been out of the facility during the day shift that day. CNA #2 stated Resident #23 would have received a shower on the next shift if he/she was out of the facility on the day shift. During an interview with Licensed Practical Nurse (LPN) #1 on 2/22/2018 at 11:03 AM, LPN #1 confirmed CNA #2 was assigned to Resident #23 on 2/19/2018. In addition, LPN #1 confirmed the shower for 2/19/2018 was not documented as done. During an interview with the family member present with Resident #23 on all days of the survey on 2/22/2018 at 11:01 AM, the family member stated she/he visits the resident daily and spends most of the day with the resident. She/he stated Resident #23 was not out of the facility on 2/19/2018. The family member stated she/he comes to the facility in the morning at about Resident #23's shower time. On 2/19/2018, she/he stated Resident #23 did not appear to have had a shower and told her/him that he/she did not get a shower.

Based on record review and interview the facility failed to inform family of a scheduled medical procedure. Resident #8 had a scheduled ultrasound that the spouse was not notified of. The findings included: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with spouse of Resident #8 on 2/21/18 at approximately 11:12 AM revealed the spouse had not yet been notified of a scheduled ultrasound procedure. Review of 2/17/18 nursing note on 2/21/18 at approximately 11:20 AM revealed that the mobile xray company had been scheduled to perform an ultrasound on Resident #8 in 4 days. Review of orders on 2/21/18 at approximately 12:01 PM revealed a doppler had been scheduled for 2/21/18. Interview with Licensed [MEDICATION NAME] Nurse (LPN) #1 on 2/21/18 at approximately 12:30 revealed the nurse had spoken with Resident #8's son/daughter regarding the ultrasound appointment, but not his/her spouse. LPN #1 confirmed this had not been documented anywhere.

Based on record review and interview, the facility failed to develop a comprehensive care plan with specific interventions to prevent the development of Pressure Ulcers for Resident #46, 1 of 3 sampled residents reviewed for Pressure Ulcers. Resident #46 was admitted to the facility with mushy, boggy heels and developed a Pressure Ulcer to the Left Heel. The findings included: The facility admitted Resident #46 with [DIAGNOSES REDACTED]. Record review of the Nurse's Notes on 5/4/2017 at 12:35 PM revealed an admission note, dated 3/14/2017, that indicated the resident's heels are mushy. A note, dated 4/3/2017, read Quarter size open area where 'boggy' area was noted last week. Record review of a weekly skin audit, dated 3/28/2017, indicated the resident had a boggy left heel. Record review of the APRN (Advanced Practice Registered Nurse) progress notes on 5/4/2017 at 10:29 AM, revealed Resident #46 was seen on 4/3/2017 for an open area to the left heel. The APRN documented that the area was likely a pressure ulcer and unstageable. New treatment orders were written. Resident #46 was seen again by the APRN on 4/10/2017. The APRN documented that the pressure injury to the left heel was now a Stage 2 pressure ulcer and new treatment orders were written. Record review of the weekly pressure ulcer assessments on 5/4/2017 at 11:18 AM, revealed an assessment, dated 4/5/2017, that read Area noted on 3/30/2017, intact blister, pressure from shoes. on 4/2/2017 area opened as a stage 2 open blister to wound bed. Record review of the care plan on 5/4/2017 at 10:53 AM, revealed a problem area for the resident being at risk for skin breakdown/injury related to his/her skin being very fragile and tears easily (dated 3/27/2017). A note added to the care plan on 4/2/2017 indicated the resident had an open area to the left heel and the left heel was boggy on admission. The care plan did not reflect that the resident had been admitted with mushy heels. In addition the care plan was not reviewed or revised after it was noted on 3/28/2017 that the resident's left heel was boggy and on 3/30/2017 that the left heel had developed a blister. There were no interventions on the care plan to address the residents mushy, boggy or blistered area to the left heel prior to the resident developing a pressure ulcer to the left heel. Record review of the initial care plan, dated 3/14/2017, on 5/4/2017 at 11:30 AM, revealed no problem areas or interventions related to the resident's heels. During an interview with LPN (Licensed Practical Nurse) #4 on 5/4/2017 at 1:00 PM, LPN #4 stated she/he had updated the care plan on 4/2/2017 and wrote the note that the resident's heel was boggy on admission. LPN #4 was asked if any interventions were implemented for the resident's boggy heels to prevent skin breakdown prior to developing the pressure ulcer. LPN #4 stated that if there were no interventions listed on the comprehensive plan of care or the initial care plan then there were no specific preventative interventions in place to prevent skin breakdown to the resident's heels. LPN #4 confirmed that the resident's heels were not identified as a problem area when the care plan was developed and no specific interventions were implemented to protect the resident's heels. In addition, LPN #4 confirmed that specific interventions related to the resident's heels were not implemented until after the resident developed the pressure ulcer. During an interview with the APRN (with the DON present) on 5/4/2017 at 1:39 PM, the APRN stated that interventions to prevent skin breakdown should have been implemented due to the boggy and blistered left heel. The APRN stated that interventions such as floating the heels and applying skin prep should have been implemented for the resident. The APRN, also stated prior to the pressure injury, she/he had observed the resident using his/her heels to self propel in his/her wheelchair. The APRN stated the pressure injury to the heel had the appearance of a shearing wound, possibly caused by the resident sliding his feet on the floor or bed. The DON stated the resident had been very mobile in his/her wheelchair.

Based on observation, record review and interview, the facility failed to implement interventions to prevent Pressure Ulcers for Resident #46, 1 of 3 sampled residents reviewed for Pressure Ulcers. Resident #46 acquired a Pressure Ulcer after admission to the facility. The findings included: The facility admitted Resident #46 with [DIAGNOSES REDACTED]. Record review of the TO (Telephone orders) on 5/3/2017 at 8:51 AM, revealed a wound care order, dated 4/2/2017, for an open area to the resident's left heel. In addition, a TO, dated 4/3/2017, was written for a heel protector to the left foot at all times. Record review of the TAR (Treatment Administration Record) on 5/4/2017 at 10:42 AM, revealed that treatment was initiated to the left heel on 4/2/2017. The order for the heel protector to the left heel and an order to float heels while in bed were initiated on 4/4/2017. There were no orders written prior to 4/2/2017 for preventative care for the residents heels. Record review of the APRN (Advanced Practice Registered Nurse) progress notes on 5/4/2017 at 10:29 AM, revealed Resident #46 was seen on 4/3/2017 for an open area to the left heel. The APRN documented that the area was likely a pressure ulcer and unstageable. New treatment orders were written. Resident #46 was seen again by the APRN on 4/10/2017. The APRN documented that the pressure injury to the left heel was now a Stage 2 pressure ulcer and new treatment orders were written. Record review of the Nurse's Notes on 5/4/2017 at 12:35 PM revealed an admission note, dated 3/14/2017, that indicated the resident's heels are mushy. A note, dated 4/3/2017, read Quarter size open area where 'boggy' area was noted last week. Record review of a weekly skin audit, dated 3/28/2017, indicated the resident had a boggy left heel. Record review of the weekly pressure ulcer assessments on 5/4/2017 at 11:18 AM, revealed an assessment, dated 4/5/2017, that read Area noted on 3/30/2017, intact blister, pressure from shoes. on 4/2/2017 area opened as a stage 2 open blister to wound bed. Record review of the care plan on 5/4/2017 at 10:53 AM, revealed a problem area for the resident being at risk for skin breakdown/injury related to his/her skin being very fragile and tears easily (dated 3/27/2017). A note added to the care plan on 4/2/2017 indicated the resident had an open area to the left heel and the left heel was boggy on admission. There were no interventions on the care plan to address the residents mushy, boggy or blistered area to the left heel prior to the resident developing the pressure ulcer. Record review of the initial care plan, dated 3/14/2017, on 5/4/2017 at 11:30 AM, revealed no interventions to address the resident's heels. During an interview with LPN (Licensed Practical Nurse) #4 on 5/4/2017 at 1:00 PM, LPN #4 stated she/he had updated the care plan on 4/2/2017 and wrote the note that the resident's heel was boggy on admission. LPN #4 was asked if any interventions were implemented for the resident's boggy heels to prevent skin breakdown prior to developing the pressure ulcer. LPN #4 stated that if there were no interventions listed on the comprehensive plan of care or the initial care plan then there were no specific preventative interventions in place to prevent skin breakdown to the resident's heels. LPN #4 confirmed there were no interventions related to the resident heels on the care plan. During an interview with the DON (Director of Nursing) and LPN #3 on 5/4/2017 at 1:01 PM, LPN #3 stated she/he had documented that the left heel was boggy in the weekly skin assessments and nurse's notes. LPN #3 stated that boggy meant that the skin to the heel was soft and not firm. LPN #3 stated the way the heel looked, she/he did not think it was going to breakdown and open. LPN #3 stated she/he would have gotten an order for [REDACTED]. The DON stated she/he completed the pressure ulcer assessment on 4/5/2017. The DON stated she/he recalled the resident having a blister to the left heel on 3/30/2017. In addition, the DON stated she/he thought she/he had instructed one of the nurses to get an order for [REDACTED]. heel. During an interview with the APRN ( with the DON present) on 5/4/2017 at 1:39 PM, the APRN stated that interventions to prevent skin breakdown should have been implemented due to the boggy and blistered left heel. The APRN stated that interventions such as floating the heels and applying skin prep should have been implemented for the resident. The APRN, also stated prior to the pressure injury, she/he had observed the resident using his/her heels to self propel in his/her wheelchair. The APRN stated the pressure injury to the heel had the appearance of a shearing wound, possibly caused by the resident sliding his feet on the floor or bed. The DON stated the resident had been very mobile in his/her wheelchair. Wound care for Resident #46 was observed on 5/4/2017 with no concerns related to infection control or appearance of the wound. A copy of the facility's wound care protocol was requested, but not provided by the facility.

Based on observations, interviews and the facility's Kitchen Temperature Log, the facility failed to store, prepare and served foods in sanitary manner. The kitchen staff failed to wear the appropriate hair coverage while in the main and skilled unit kitchen where meals were prepared or served, unused bread stored in area where bread to be used was stored, 9 clear tea pitchers noted with brown stains, discolored linen in clear plastic bags stored in food storage area and staff not monitoring the correct temperature of foods being served. The findings included. During initial tour of the main kitchen on 5/02/17 at approximately 9:05 AM the Certified Dietary Manager (CDM) escorted the surveyor in the food preparation area without wearing a hairnet. An interview on 5/02/17 at appropriately 9:10 AM with the facility's Chef confirmed the findings. The Chef further stated staff was not to enter beyond the doors of the main kitchen without a hairnet. Further review of the main kitchen revealed multiple kinds of bread stored uncovered on rack under covered bread to be used for residents. The Chef stated the uncovered bread was being stored there to determine how much bread was being wasted. There were multiple clear plastic bags of disclosed linen being stored in food storage area. The were nine clear plastic serving pitchers noted with brown stains. The Chef stated the brown stains were due to tea being served out of the pitchers. The Chef further stated that only tea was served in the brown stained pitchers. Random observation of the main kitchen on 5/03/17 at approximately 9:15 AM revealed breads being stored uncovered on rack, multiple clear plastic bags of disclosed linen being stored in food storage area and multiple clear plastic serving pitchers noted with brown stains. Random observation of the skill kitchen on 5/03/17 at approximately 10:26 AM revealed a trash can at entrance door to kitchen noted with food particles on top of lid. There was no trash can under the hand washing sink and the trash can being using by staff under a larger sink did not have a lid. Random observation on 5/03/17 during food temperatures at approximately 11:25 AM in the skill unit kitchen revealed a female staff member with the front of his/her hair uncovered near food that was prepared for the resident and two male staff members with beards in the area were prepared food was being plated without hairnet coverage for their beards. An observation and interview on 5/03/17 at approximately 11:35 AM with Kitchen Staff #1 who did the food temps with the surveyor, performed the food temps without having beard covered while doing the food temps. During interview, Kitchen Staff #1 confirmed no hairnet for beard was worn and further stated a hairnet for beard was worn in the main kitchen but not in the skilled unit kitchen. Further review of the food temp observation revealed Kitchen Staff #1 not attempting to calibrate the thermometer due to having calibrated the thermometer in the main kitchen per staff. The thermometer was re-calibrated prior to observing the food temps. Kitchen Staff #1 was using a check list instead of recording actual temperature of foods to be served. The Kitchen Staff did a food temp for pork chop and attempted to put the thermometer in baked crab/flounder before being asked by surveyor, Do you clean your thermometer between foods?, the Kitchen Staff then cleaned the thermometer. An interview on 5/03/17 at approximately 11:45 AM with Kitchen Staff #2 confirmed a hairnet was not used to cover a beard while in the kitchen area were food was prepared to be plated An interview on 5/03/17 at approximately 11:50 AM with Kitchen Staff #3 confirmed he/she did not have the front of his/her hair covered while in the food preparation area where resident foods were being plated. An interview on 5/03/17 at approximately 12 PM with Chef revealed staff should wear hairnets in the main kitchen and in the skilled unit kitchen where food is being prepared and plated for the residents. Review of the food temp logs on 5/04/17 revealed kitchen staff just randomly placed checks in boxes on the Kitchen Temperature Log without ensuring the temperatures of the foods checked are correct. Review of the facility's food temp documentation dated 4/19/17 indicated biscuits and regular apples met serving temps of 135-160 degrees. Food temp documentation dated 4/21/17 indicated biscuits, cantaloupe and cream cheese cake met serving temps of 135-160 degrees. Food temp documentation dated 4/24/17 indicated oranges and old fashioned cake met serving temps of 135-160 degrees. Food temp documentation dated 4/25/17 indicated pineapples met serving temps of 135-160. Food temp documentation dated 4/26/17 indicated cantaloupe and strawberry napoleon met serving temps of 135-160 degrees. The food temp documentation dated 4/27/17 did not have any checks to indicate the food met serving temps. The food temp documentation dated 4/28/17 indicated pears met serving temps of 135-160 degrees. The food temp documentation dated 5/01/17 indicated biscuits, oranges and peanut butter bars met serving temps of 135-160 degrees. The food temp documentation log dated 5/02/17 indicated biscuits, pineapples and buttermilk pie met serving temps of 135-160 degrees and the 5/03/17 food temp log indicated cantaloupe met a serving temp of 135-160 degrees. An interview on 5/04/17 at approximately 12:45 PM with the Certified Dietary Manager (CDM) confirmed the documentation on the Kitchen Temperature Log and stated they were in error and that the fruit was checked off to indicated they were below 40 degrees. The facility's food check off temperature log did not address the temps of chilled foods.

Based on observations and interviews, the facility failed to ensure that all residents seated at the same table during the dining experience were served sequentially during 2 meal observations in 1 of 1 main dining room and in addition random observations of staff entering residents rooms without knocking. The findings included: During random observation on 5/02/17 at approximately 12:19 PM five (5) residents were observed seated at a table in back of the dining room near the hallway. A resident had his/her meal tray placed in front of him/her while a staff member was seated feeding a resident near the resident with the food tray who was not eating or being fed. There were also three other residents seated at the table that did not have a food tray placed in front of them, while the staff member was seated feeding a resident at the table. A staff member approached the resident with the food tray placed in front of him/her. The staff member cut the resident's meat and stood briefly while feeding the seated resident. At approximately 12:33 PM there were still residents seated at the table not being served or fed while other residents at the same table were served and eating or being fed by staff. At approximately 12:38 PM another resident with his/her food tray placed in front of him/her was observed with a staff member standing briefly while feeding a resident that was seated. Random observation on 5/02/17 at approximately 3:39 PM revealed Licensed Practical Nurse #1 entering and exiting residents rooms near room [ROOM NUMBER] without knocking. A random observation on 5/02/17 at approximately 4 PM revealed nursing aide staff entering resident rooms without knocking near room [ROOM NUMBER]. A random meal observation on 5/04/17 at approximately 8:40 AM revealed five (5) residents that required staff to feed them or encourage them to eat, seated at a back table in the dining room near the hallway. There was one resident feeding him/herself, three residents being fed by staff and one resident seated at a table with a food tray placed in front of him/her without being assisted by staff. At approximately 8:46 AM, Licensed Practical Nurse (LPN) #2 stood near the resident not eating or being feed, removed the top from the resident's food tray told another staff member the resident was not hungry and walked away. LPN #2 was not observed attempting to feed the resident. At approximately 8:51 AM Certified Nursing Aide (CNA) #1 was observed feeding the resident that staff stated was not hungry. An interview on 5/04/17 at approximately 9:02 AM with Licensed Practical Nurse (LPN) #2 confirmed the resident had his/her food tray in front of him/her and not eating while the other residents were eating or being fed by staff. An interview on 5/04/17 at approximately 9:06 AM with Certified Nursing Aide (CNA) #1 stated the residents seated at the back table were residents that required assistance with feeding. CNA #1 further stated the resident with the food tray required staff to feed him/her or staff needed to encourage the resident to eat.

Based on record review and interview the facility failed to maintain a complete and accurate record for Resident's #44, #74 and #75, 3 of 12 sampled residents reviewed for clinical accuracy. Resident #44 had no documentation related to a fluid restriction for March and April. Treatments for Resident #74 were not documented as done. Body Audits were not documented as done for Resident #75. The findings included: The facility admitted Resident #74 with [DIAGNOSES REDACTED]. Record review of the April, 2017 TAR (Treatment Administration Record) on 5/3/2017 at 2:39 PM revealed an order to float heels while in bed every shift. This was not documented as done 5 times from April 20-30. In addition, the TAR revealed an order for [REDACTED]. During an interview with the DON (Director of Nursing) on 5/4/2017 at 3:04 PM, the DON confirmed the treatments were not documented as done. The facility admitted Resident #75 on 4/6/2017 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the weekly skin audits on 5/3/2017 at 11:12 AM , revealed that a skin audit had been documented as part of the admission assessment. No other weekly skin audits were documented until 4/27/2017. During an interview with the DON on 5/3/2017 at 4:19 PM, the DON confirmed there were no weekly skin audits documented between 4/9/2017 and 4/26/2017. The DON stated that she/he did the weekly pressure ulcer assessments on all residents with a pressure ulcer. The DON stated that she/he did a complete skin audit on Resident #75 every week since admission during the pressure ulcer assessments. The DON stated she/he did not document this weekly skin audit because the staff nurses are supposed to be completing and documenting a weekly skin audit on all their residents. The facility's wound care protocol was requested, but not provided by the facility. The facility admitted Resident #44 with [DIAGNOSES REDACTED]. Review of medical record on 5/04/17 at approximately 19:35 AM revealed monthly cumulative physician's orders [REDACTED]. Further record review revealed there was no documentation of daily fluid restriction for the months of March and April 2017. An interview on 5/04/17 at approximately 10:56 AM with the Director of Nursing (DON) revealed a care plan dated 12/02/16 and 2/28/17 that indicated the resident was non complaint with fluid restrictions. A nurse's note dated 10/02/16 indicated the resident's daughter spoke to staff about the fluid restriction and a fluid restrictions waiver was done to discontinue the fluid restriction. The nurse's note further indicated the resident stated he/she had been in compliance with the fluid restriction. During an interview on 5/04/17 at approximately 11:10 AM with the Director of Nursing who reviewed the 10/02/16 nurse's note. The DON stated the nurse's note was written in error and that the physician's orders [REDACTED]. An interview on 5/04/17 at approximately 2:34 PM with Licensed Practical Nurse (LPN) #2 confirmed there was no documentation for the physician's orders [REDACTED].

Based on record review and interview, the facility failed to ensure physician response to pharmacy recommendations for 2 of 5 residents reviewed for unnecessary medications. Residents #44 and 28 had pharmacy recommendations for gradual dose reductions, and their physician did not act upon or respond to these recommendations. The findings included: Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Pharmacy Consultation Report dated 1/31/17 on 5/3/17 at approximately 3:21 PM revealed that Pharmacist #1 recommended a gradual dose reduction of Zoloft from 75 mg daily to 50 mg daily. Review of Pharmacy Consultation Report dated 3/30/17 on 5/3/17 at approximately 3:21 PM revealed that Pharmacist #1 recommended a gradual dose reduction of Zoloft from 75 mg daily to 50 mg daily. Interview with the Director of Nursing (DON) on 5/3/17 at approximately 4 PM revealed that there was no documentation for physician response to either gradual dose reduction. Review of Resident #28's physician orders [REDACTED]. There was a May 1 order for Zoloft to be increased to 100 mg daily. Review of Omnicare Inc. policy for Medication Regimen Review on 5/4/17 at approximately 2 PM revealed that, The attending physician should document in the residents' health record that the identified (medication) irregularity has been reviewed and what, if any, action has been taken to address it. The policy also stated, If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record. At time of survey exit, no documentation was provided indicating that the physician responded to the pharmacist recommendation. The facility admitted Resident #44 with [DIAGNOSES REDACTED]. Review of medical record on 5/03/17 at approximately 12 PM revealed monthly cumulative physician's orders [REDACTED]. The medication Ativan 0.25 mg twice a day and Ativan 0.25 mg as needed which started November 2016. A social services note dated 2/28/17 indicated the resident was able to communicate well with a Brief Interview of Mental Score (BIMS) of 15 which indicated the resident was alert, oriented and interview-able. The social services note further indicated Resident #44 had no behavior/mood issues at this time. A review of nurse's notes from February 2017 to present revealed no documented behaviors. Review of a pharmacy consult with a recommendation date of 3/30/17 indicated Resident #44 had been taking Ativan 0.25 mg twice a day, Lexapro 2.5 mg daily, Depakote 125 mg twice a day along with Depakote as needed ordered since 9/2016. The pharmacy consult further indicated It is time to provide specific documentation regarding consideration of gradual dose reductions. There was no documentation in the medical record to indicate the physician responded to the pharmacy recommendation to provide specific documentation for further use of the above mentioned medications. An interview on 5/03/17 at approximately 2:34 PM with Licensed Practical Nurse (LPN) #2 who reviewed the medical record (physician progress notes [REDACTED].#2 stated the physician would have documented his/her findings in physician progress notes [REDACTED].#2 stated he/she could not find any documentation that the physician addressed the pharmacy consult recommendations. An interview on 5/03/17 at approximately 2:57 PM with the Director of Nursing who reviewed the medical record stated he/she could not locate documentation to indicate the physician had responded to the pharmacy consult recommendations dated 3/30/17.

Based on observation, interview and review of the facility's Bedpan/Urinal, Administration of policy, the facility failed to store personal care equipment properly. Bedpans were observed stored on the floor in resident bathrooms in 2 of 23 resident bathrooms observed during the survey. The findings included: Observation of the bathroom for room 302 on 5/2/2017 at 10:12 AM, 10:40 AM, 2:56 PM and 3:44 PM revealed a bed pan stored on the floor of the bathroom. The bed pan was not bagged or covered. The bedpan was observed on the floor, un-bagged on 5/3/2017 at 8:45 AM and on 5/4/2017 at 11:07 AM. Observation of the bathroom for room 308 on 5/2/2017 at 10:23 AM, 10:49 AM, 2:58 PM and 4:02 PM revealed a bed pan stored on the floor of the bathroom. The bed pan was not bagged or covered. The bedpan was observed on the floor, un-bagged on 5/3/2017 at 8:52 AM. During an observation of rooms 302 and 308 with LPN (Licensed Practical Nurse) #3 on 5/4/2017 at 2:03 PM, the bedpans were observed on the floor, un-bagged in each bathroom. During an interview with LPN #3 on 5/4/2017 at 2:24 PM, LPN #3 stated that bedpans are supposed to be stored up off the floor and are to be bagged. Review of the facility's Bedpan/Urinal, Administration of policy revealed that bedpans are to be cleaned and stored per facility procedure. The facility did not provide a written procedure for storing bedpans.

Based on observation, interview with the Director of Nursing (DON), and record review the facility failed to post cumulative hours worked for licensed and registered staff for three of three months of nursing staff postings reviewed. The findings included: Observation on 5/2/17 at approximately 1 PM revealed that nursing staff postings did not have cumulative hours displayed for licensed and registered staff. Observation on 5/3/17 at approximately 3:50 PM revealed that the nursing staff postings did not have cumulative hours displayed for licensed and registered staff. Interview with the DON on 5/4/17 at approximately 12:02 PM revealed that cumulative hours of licensed and registered staff were not displayed on the nursing staff postings. Review of nursing staff postings for previous three months on 5/4/17 at approximately 12:12 PM revealed that cumulative hours of licensed and registered staff were not displayed on the nursing staff posting.

Based on observations, record review and interviews, the facility failed to ensure that residents had interventions in place as ordered to prevent further falls for 1 of 4 sampled residents reviewed for accidents. Resident #64 had physician's orders [REDACTED]. The findings included: The facility admitted Resident #64 with [DIAGNOSES REDACTED]. An observation on 8/10/16 at approximately 9 AM revealed resident in room on low bed. Wound dressing was noted to forehead due to a witnessed fall. An observation on 8/10/16 at approximately 4:16 PM revealed resident in room on low bed with mats to floor. Wound dressing was noted to forehead due to a witnessed fall. A review of the medical record on 8/11/16 at approximately 8:34 AM revealed that Resident #64 had a fall on 7/12/16, 7/21/16, 8/04/16 and 8/06/16. A nurse's note dated 7/12/16 indicated the resident had a fall while being provided assistance by a certified nursing aide who was pulling up the resident's pants when the resident fell . The certified nursing aide was to use a walker as an intervention to assist the resident. Intervention put in place was for resident to use call light. A nurse's note dated 7/21/16 indicated staff witnessed the resident slipping from wheelchair during dinner meal. The nurse note further indicated the physician was notified and a Dycem to wheelchair was ordered as an intervention. A nurse's note dated 8/04/16 indicated the resident fell out of bed with an intervention of falls mats to bed at night. A nurse's note dated 8/06/16 indicated the resident had a witnessed fall while being provided assistance by a nurse who was pulling up the resident's pants when the resident fell . The intervention put in place was for resident to use new walker for stability. An observation on 8/11/16 at approximately 8:50 AM revealed resident seated in dining room in wheelchair with other residents. At approximately 9:19 AM the resident was observed at the nurse's station requesting assistance. An observation and interview on 8/11/16 on approximately 9:22 AM with Licensed Practical Nurse (LPN) #2 who assisted Resident #64 to bed then looked for Dycem to wheelchair revealed the Dycem was not placed to wheelchair as ordered. LPN #2 further looked around the resident's room and could not locate a Dycem in the room. An interview on 8/11/16 at approximately 9:27 AM with Licensed Practical Nurse (LPN) #1 confirmed Resident #64 was supposed to have a Dycem under pad on wheelchair. LPN #64 then stated the resident sometimes removes the Dycem but could not provide any documentation to indicate the resident had removed the Dycem from his/her wheelchair.

Based on observations, record review and interviews, the facility failed to ensure that care plans were followed for 1 of 4 sampled residents reviewed for accidents. Resident #64's care plan was not followed related to Dycem non slip aide being placed to the wheelchair seat to prevent falls. The findings included: The facility admitted Resident #64 with [DIAGNOSES REDACTED]. An observation on 8/10/16 at approximately 9 AM revealed the resident in the room on a low bed. Wound dressing was noted to forehead due to a witnessed fall. An observation on 8/10/16 at approximately 4:16 PM revealed resident in room on low bed with mats to floor. Wound dressing was noted to forehead due to a witnessed fall. A review of the medical record on 8/11/16 at approximately 8:34 AM revealed that Resident #64 had a fall on 5/17/16, 6/01/16, 7/12/16, 7/21/16, 8/04/16 and 8/06/16. A review of the resident's care plan and fall incident report dated 7/21/16 indicated Dycem to wheelchair to prevent resident from slipping out of wheelchair. An observation on 8/11/16 at approximately 8:50 AM revealed the resident seated in dining room in wheelchair with other residents. At approximately 9:19 AM the resident was observed at the nurse's station requesting assistance. An observation and interview on 8/11/16 on approximately 9:22 AM with Licensed Practical Nurse (LPN) #2 who assisted Resident #64 to bed then looked for Dycem to wheelchair revealed the Dycem was not placed to the wheelchair per the care plan. LPN #2 further looked around the resident's room and could not locate a Dycem in the room. An interview on 8/11/16 at approximately 9:27 AM with Licensed Practical Nurse (LPN) #1 confirmed Resident #64 was supposed to have a Dycem under pad on wheelchair.

On the days of the Recertification and Complaint survey, based on record review and interview, the facility failed to provide the appropriate supervision and/or assistive devices necessary to prevent accidents for 1 of 4 sampled residents reviewed for falls. Resident #1 sustained a fall with injury when a dycem mat was not in place on the wheelchair as care planned. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set Assessment with an Assessment Reference Date of 5/14/14 revealed the resident had a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment at the time of the assessment. A review of fall incident reports on 6/17/14 at 10:52 AM revealed Resident #1 had fallen on 4/12/14 at 11:10 AM. According to the report, the resident was observed in the hallway sliding out of his/her chair. The resident sustained [REDACTED]. When the nurse checked for pain in that area the resident made no signs of pain at that time. According to the report, an intervention to keep this from happening again was that an inservice would be conducted on CNAs placing the dycem in the chair at all times and that the dycem would be placed under the alarm. An inservice was conducted on 4/12/14 for the CNAs and nursing staff to make sure the dycem pad was under the resident who was supposed to have them. A review of care plan updates for falls revealed the resident had several falls previously; one on 10/21/13 in which the intervention for the use of the dycem to the wheelchair had been implemented. Nursing staff had been initialing the Medication/Treatment Records to indicate this was in place. A fall incident report dated 6/6/14 at 1:15 PM revealed the resident was found lying on the floor in the doorway of his/her room. The resident sustained [REDACTED]. According to the intervention plan, the CNA was counseled related to the need for the dycem being in the chair. Documentation on the Safety Awareness Intervention Communication sheet revealed that CNAs and nurses were verbally counseled related to the dycem not being in the chair and to ask the resident if s/he wanted to lie down after meals. A review of the current comprehensive care plan revealed an entry "1/8/14 clarify: dycem to wc". During an interview on 6/17/14 at 11:15 AM, Licensed Practical Nurse (LPN) #1 was asked about the two incidents. According to LPN #1, s/he believed that on 4/12/14 that the dycem was not in the right spot under the alarm. For the fall on 6/6/14, the dycem had been soiled and the CNA did not replace it after it had been washed.

On the day of the complaint inspection, based on observations, interviews and record reviews the facility failed to ensure 4 of 11 resident's care plans were reviewed and revised with adequate interventions to prevent falls/injuries from occurring. Residents #1, #2, #3, and #5's care plans were not updated with adequate interventions to prevent falls. The findings included: The facility admitted Resident #1 on 6/21/2010 with [DIAGNOSES REDACTED]. Review of the Nursing Home Initial History and Physical dated 11/14/2010 stated, "...Mental Status: Oriented x2. He is cooperative. He is able to follow commands. He is generally easily directed... He has poor insight but good mentation..." Resident #1's Quarterly Minimum (MDS) data set [DATE] coded him as having problems with recall; his BIMS (brief interview for mental status) scored him as 8. Review of the Nurse's Notes on 4/26/2011 revealed Resident #1 fell 21 times between 11/15/2010 and 4/26/2011; eight of these falls resulted in skin tears and/or a laceration, one of the eight falls resulted in a laceration that required sutures. The notes showed that Resident #1's had difficulty at times standing to sitting down without dropping down that seemed to cause him to fall. "Resident is encouraged to call for assistance but is unable." Review of the Care Plan dated 11/30/2010 and revised 3/1/2011 revealed a problem area identified for "risk for further falls related to hx (history) of falls, dx (diagnosis) of dementia, and hx of traumatic fall with fx (fracture), repeated falls secondary to gait disturbance." Added to the problem area was "risk for injury, resident ambu (ambulate) noted for multiple falls ambulates with rolling walker." Approaches included: "Adequate assistance for transfers, (Resident #1) is large and he also walks very fast and has poor safety awareness. Observe closely for attempts to transfer without assist, provide reminders. Provide distractions such as reading, TV, talking with resident. Encourage use of assistance devices per therapy recommendations. Report all falls and injuries to nurse as soon as possible, attempt to identify the cause of the fall, such as tripping, walking too fast, non-use or misuse of assistance device." On 12/10 the care plan was updated with an approach to "observe resident at all times, remind resident not to throw clothes on floor." Chair alarm was added without a date and then crossed off due to "resident refused." In February 2011, the care plan was updated to include "OT in to work with resident.... Assist resident to and from meals." In March 2011, the care plan was updated to include "encourage use of wheelchair when ambulating (son to bring in)." Further review of the care plan revealed no evidence that the care plan was updated and individualized for Resident #1 assessed as have difficulty with recall and decision-making. The facility admitted Resident #2 on 1/9/2011 with [DIAGNOSES REDACTED]. Resident #2's Significant Change Minimum (MDS) data set [DATE] coded her as having problems with recall; her BIMS (brief interview for mental status) scored her as 4. Review of the Nurse's Notes revealed Resident #2 had 16 falls that resulted in 6 injuries (skin tears/lacerations and bruises) between 1/9/2011 and 4/25/2011. Review of the Care Plan dated 1/7/2011 and reviewed on 2/8/2011, 2/16/2011 and 3/3/2011 revealed a problem area identified related to "Risk for further falls /injury related to decreased cognition, communication, hx of falls with possible side effects of medications." The approaches included: "encourage use of assistance device, PT/OT evaluations and treat as ordered, provide one person assist for transfers and 1 person assist with ambulation, be sure call light is within reach and encourage to use it for assistance as needed, respond promptly to all requests for assistance, floors free from spills or clutter, personal items within reach, encourage non skid shoes when out of bed. An update on 1/7/2011 included "bed/chair alarm at all times" and "observe resident frequently related to attempts to ambulate without assist." On 3/8/2011 the care plan was updated to include "Seatbelt to wheelchair due to resident's trying to ambulate unassisted/unsupervised." Eight falls occurred prior to the seatbelt being added to Resident #2's wheelchair. After the seatbelt was added the resident fell out of her wheelchair 3 times and was found twice on the floor in the bathroom. No additional interventions were added related to these falls. The facility admitted Resident #3 on 2/3/2010 with [DIAGNOSES REDACTED]. Resident #3's Quarterly Minimum (MDS) data set [DATE] coded her as having short and long term memory problems with severely impaired decision-making skills. Review of the Nurse's Notes between 11/20/2010 and 4/22/2011 revealed Resident #3 fell 26 times. On 12/13/2010 he complained of pain in the right wrist, an x-ray revealed a fracture; on 3/14/2011 and 4/19/2011 he sustained lacerations due to falls. Review of the Care Plan revealed a problem area related to "risk for further falls/injury." The Care Plan was dated 12/3/2010. The care plan was updated with the falls on 11/21, 11/22, 11/23 and 11/30. "Continues to roll self out of bed without injury. Resident aware of rolling from bed. Bed pad alarms tried prior to readmit, resident destroys alarms." On 12/1/2010, the care plan was updated with "will continue to observe resident for safety/injury. On 12/2/2010, the care plan was updated to include "encourage resident to remain in common areas when out of bed." On 12/5//2010, the care plan was updated to include the same approach of "encourage resident to remain in common areas when out of bed." On 12/10/2010, the care plan was updated to include "observe resident frequently when in room or out of room." On 12/14/2010, the care plan was reviewed and included the following: "Continues with multiple falls, resident rolls self to floor, psych consults ordered, meds reviewed, continues to remove/destroy alarms." The care plan was last reviewed 12/14/2010, the resident fell or was found on the floor 15 times between 12/14/2010 and 4/22/2011; no additional interventions were put in place after 12/14/2010. The facility admitted Resident #5 on 7/2/2009 with [DIAGNOSES REDACTED]. Resident #5's Quarterly Minimum (MDS) data set [DATE] coded her as having short and long term memory problems with severely impaired cognitive skill for daily-decision making. Review of the Nurses Notes between 10/9/2010 and 4/5/2011 revealed on 10/9/2010, Resident #5 fell in the hallway. On 10/28/2010 at 7:30 PM, the resident fell out of the wheelchair while bending over. On 11/4/2010 at 6:45 PM, the resident was found on the floor. On 12/17/2010 at 3:45 PM, the resident stood up out of the wheelchair and fell . On 1/27/2011 at 8:35 PM, Resident #5 fell out of the wheelchair while bending over. On 3/22/2011 at 12:40 AM, Resident #5 fell and sustained lacerations and abrasions to her forehead. On 4/5/2011 at 9:40 PM, the resident's alarm sounded and the resident was found on the floor. The resident sustained [REDACTED]. Review of the Care Plan revealed a problem area identified related to "Risk for falls, has not had recent fall but has had a slow cognitive decline in cognitive abilities. On 12/2/2010 the care plan was reviewed and to "continue with current problem." The care plan was reviewed again on 3/2/2011. Approaches included: "walk with resident at times during the day, do not allow to ambulate without assistance, provide one person assistance with transfers, remember to transfer out of wheelchair into dining room chair for all meals. Be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance. (Resident #5) typically does not remember how or why to use call light. Pressure alarm for her wheelchair, she will stand up unassisted. Bed alarm. Monitor resident frequently. Encourage not to stand or ambulate without assistance." On 10/11/2010, Resident #5's care plan was updated to include the following approach: "Remind resident not to stand without assist. Keep resident in common area when out of bed." Review of the care plan revealed no intervention related to the concern that Resident #5 fell on [DATE] and 1/27/2011 from the wheelchair while bending over. During an interview with the surveyor on 4/26/2011 at 1:15 PM, the Director of Nurses (DON) confirmed the Care Plans were not updated with the falls and interventions for Resident's #1, #2, #3 and #5. Cross Refers to F-323 as it relates to the facility's failure to implement new and appropriate interventions for each resident to prevent falls/injuries.

On the day of the complaint inspection, based on observations, interviews and record reviews the facility failed to ensure residents received adequate supervision and assistance devices for 4 of 11 residents reviewed for falls. Residents #1, #2, #3 and #5 had multiple falls and injuries without adequate interventions put in place to prevent further injury. The findings included: The facility admitted Resident #1 on 6/21/2010 with [DIAGNOSES REDACTED]. Review of the Nursing Home Initial History and Physical dated 11/14/2010 stated, "...Mental Status: Oriented x 2. He is cooperative. He is able to follow commands. He is generally easily directed... He has poor insight but good mentation..." Resident #1's Quarterly Minimum (MDS) data set [DATE] coded him as having problems with recall; his BIMS (brief interview for mental status) score was 8. Observation of Resident #1 on 4/26/2011 at 7:20 AM, revealed the resident sitting on the side of the bed attempting to dress. Resident #1 had no alarms in place, no fall mats were seen and no wheelchair observed. A recliner with a manual footrest was observed. No lift chair was observed. Resident #1 also did not have a wheelchair. Observation of Resident #1's bathroom revealed bright red blood on the floor between the vanity and the toilet. The outside of the toilet bowl was smeared with bright red blood. The surveyor obtained staff assistance. Resident #1 stated that he fell this morning in the bathroom. The fall was reported to the CNA (certified nursing assistant) present in the room. Review of the Cumulative physician's orders [REDACTED]." Further review of the Cumulative Orders revealed the Chair Alarm was originally ordered on [DATE] and the Lift Chair was originally ordered on [DATE]. Review of the "Fall Risk Assessment" revealed only one entry dated 11/15/2011 that scored Resident #1 as a "6" indicating he was not at "High Risk" for falls. Review of the Nurse's Notes revealed the following entries: On 11/15/2010 at 12:30 PM, Resident #1 was found on the floor; a foam mattress was placed by the bed. On 11/16/2010 at 9:30 PM, Resident #1 fell and sustained a skin tear to the left forearm. It was noted that he was hanging clothes and slipped on a foam mattress. The foam mattress was removed. On 11/21/2010 at 9:30 AM, Resident #1 fell in the bathroom and sustained a laceration to the arm. On 11/23/2010 at 5:00 AM, Resident #1 fell on the floor in the room and sustained a rub burn to his/her knee. (A chair alarm was ordered per the telephone orders). On 12/8/2010 at 4:30 PM, Resident #1 fell in the bathroom and sustained a skin tear. On 12/10/2010 at 6:00 PM, Resident #1 fell in the bathroom and sustained a laceration to his head requiring sutures. (An order was written to send to the ER (emergency room ) status [REDACTED]. On 1/7/2011 at 9:30 AM, Resident #1 fell in the room no injuries were noted. On 1/9/2011 at 2:00 PM, Resident #1 fell in his room while trying to go to the bathroom. At 6:30 PM, Resident #1 fell again next to his recliner. (An order was written on 1/17/2011 for a "Lift Chair.") On 1/21/2011 at 6 PM, Resident #1 fell in his room and was found "scooting towards bathroom." On 2/11/2011 at 6 PM, Resident #1 fell in the bathroom. On 2/16/2011 at 9:45 PM, Resident #1 fell in the bathroom and hit his back on the shower bench. On 2/23/2011 at 4:20 PM, Resident #1 fell in the hallway no injuries were noted. On 3/3/2011 at 2:00 PM, revealed the following entry: "On February 16, 2011, this committee met to discuss new interventions that would decrease or prevent risk of falls. At this time the team implemented having a staff person assist resident to and from meals/walking. Resident's impulse control is effected due to [DIAGNOSES REDACTED]. This is what seems to have the resident fall. Resident continues to walk with walker but does need some reminders. Resident is encouraged to call for assistance but is unable. The resident had been offered a chair alarm x 2 but declined. In 12/2010 a seat belt was offered and both resident and family declined. The resident is taken/asked every 1-2 hours for toileting needs but resident is continent and does not have a toileting pattern. Resident is also independent and becomes agitated at times when you offer assistance with bowel and bladder needs. Discussed the usage of a merry walker and at this time therapy could not see how this would work. Decided as a team to have resident use wheelchair for ambulation. Resident's family and resident are aware that resident is a fall risk any time he is up ambulatory and agreed that we should encourage the use of wheelchair. Family to bring wheelchair in from home. Care Plan revised." On 3/5/2011 at 12:15 PM, Resident #1 fell in the bathroom sustaining an abrasion to his right temple. On 3/10/2011, Resident #1 fell in his room. On 3/16/2011 at 5:15 PM, Resident #1 was found on the floor of his room with scalp laceration. The resident was sent to the emergency room for evaluation. On 4/1/2011 at 4:00 PM, Resident #1 fell in the bathroom. On 4/9/2011 at 12:30 PM, Resident #1 fell in the dining room. On 4/16/2011 at 9:30 PM, Resident #1 fell attempting to go the bathroom and sustained an abrasion to the right side of the face. On 4/24/2011 at 7:00 AM, Resident #1 was found on the floor in his room and had "hit his head." Review of the Incident Reports provided by the facility revealed the following: On 11/15/2011, the corrective actions taken to prevent further falls were "Resident unaware of safety measures due to disease process. Can ambulate safely once up from sitting position. At times resident may fall backwards. Resident refuses tab alarm due to the same agitation. Talked with family about helmet-family refuses. Family wants resident to remain independent with walking and states they are aware of the consequences." The incident report dated 11/23/2011 revealed the corrective action taken related was "encourage resident to take his time while attempting to get up out of chair." On 1/7/2011 the corrective actions taken were to "encourage resident to go slow when ambulating in room and to use walker at all times." On 1/9/2011 the actions taken to prevent further falls was to "attempt to check in more frequently. Hopefully he will allow is to keep his door open". The corrective actions taken for the second fall on 1/09/2011 were "reminded resident to call for assist, notified door would be left ajar while in room." On 1/21/2011, the corrective actions taken were to "remind resident to call for help-re-attach chair alarm." On 1/25/2011, the actions taken were to "monitor patient closely." On 2/12/2011, the corrective actions taken were "assisted resident in getting dressed and cleaning up his bathroom." On 2/16/2011, the corrective actions taken to prevent falls were "reminded to call for assist." On 3/5/2011, the actions taken were "will continue fall precautions." On 3/10/2011, the corrective actions taken were "patient is checked at least every 1-2 hours but due to dementia never asks for help rings call bell." On 3/16/2011, the summary of actions taken to prevent further falls was "pressure applied- call to doctor and family." On 4/1/2011, the actions taken were to "continue to check on patient every 1-2 hours for toileting." On 4/9/2011, the corrective actions taken were "instruct patient to call for assistance." On 4/16/2011, the corrective actions taken were to "monitor closely." No other incident reports were provided at the time of the survey. Review of the Care Plan revealed a problem area identified for "risk for further falls related to hx (history) of falls, dx (diagnosis) of dementia, and hx of traumatic fall with fx (fracture), repeated falls secondary to gait disturbance." Added to the problem area was "risk for injury, resident ambu (ambulate) noted for multiple falls ambulates with rolling walker." The original date of the care plan was 11/30/2010 and reviewed 3/1/2011. Approaches included: "Adequate assistance for transfers, (Resident #1) is large and he also walks very fast and has poor safety awareness. Observe closely for attempts to transfer without assist, provide reminders. Provide distractions such as reading, TV, talking with resident. Encourage use of assistance devices per therapy recommendations. Report all falls and injuries to nurse as soon as possible, attempt to identify the cause of the fall, such as tripping, walking too fast, non-use or misuse of assistance device." On 12/10 the care plan was updated with an approach to "observe resident at all times, remind resident not to throw clothes on floor." Chair alarm was added without a date and then crossed off due to "resident refused." In February 2011, the care plan was updated to include "OT (occupational therapy) in to work with resident and colostomy. Assist resident to and from meals." In March 2011, the care plan was updated to include "encourage use of wheelchair when ambulating (son to bring in)." Further review of the care plan revealed no evidence that the care plan was updated with the resident's numerous falls or that individualized interventions put in place to prevent further falls from occurring. During an interview with the surveyor on 4/26/2011 at 2:30 PM, Resident #1's son stated that he was aware of his father's multiple falls. He further stated that his father would not call for assistance. Resident #1's son stated that his father needed assistance with his colostomy and had requested the colostomy care be scheduled to reduce the risk of falls in the bathroom. He stated that his request was not followed and that the colostomy care was not scheduled. He further stated that he did attend a meeting regarding his father's falls and he stated that at no point during the meeting was a merry walker, seat belt or other type of device discussed. He stated that his father would routinely disconnect the alarms that were applied at one point. He also stated that he brought in his father's wheelchair from home, however, his father did not use it and he stated that no one in the facility encouraged its use. He also stated that he was never requested to take the wheelchair home and did not know where it was located. The facility admitted Resident #2 on 1/9/2011 with [DIAGNOSES REDACTED]. Resident #2's Significant Change Minimum (MDS) data set [DATE] coded her as having problems with recall; her BIMS (brief interview for mental status) score was 4. Observation of Resident #2 on 4/26/2011 at 8 AM revealed the resident in the living room seated in a high backed wheelchair. A chair alarm was observed in place. The resident was noted to be unable to propel herself in the wheelchair. No seat belt was observed. A bed alarm was observed in the resident's room. Review of the Physician's Cumulative Orders dated 4/1/2011 revealed the Safety Devices ordered were "seat belt and bed and chair alarms." Further review of the telephone orders revealed the original order for the bed and chair alarms was 1/11/2011. The original order for the seat belt was 3/3 for a trial of the seat belt then 3/8/2011 the seat belt was ordered. On 4/25/2011 a telephone order was written to "d/c (discontinue) the seatbelt - ineffective broken x 2." Resident #2 was noted to receive Hospice Care due to a rapid decline in April 2011. The primary [DIAGNOSES REDACTED]. Review of the Falls Risk Assessment revealed one entry dated 11/29/2010 (a previous admission) that scored the resident as a "5" indicated she was not at high risk for falls. Review of the Nurse's Notes revealed the following entries: On 1/9/2011 at 5:20 PM, Resident #2 fell in hallway and sustained a laceration to her head and bruising. On 1/16/2011 at 10:30 AM, Resident #2 fell in room while attempting to toilet self. On 1/20/2011 at 3 PM, Resident #2 fell to her knee, no injuries. On 1/24/2011 at 12:30 AM, the resident fell out of bed and abraded her/his back. On 1/26/2011 at 2:50 AM, Resident #2's bed alarm sounded and the resident was found on the floor. On 2/8/2011 at 8 PM, Resident #2 was found on floor by bathroom, she sustained a skin tear and a hematoma to the left hip. On 2/26/2011, Resident #2 fell and was found unresponsive with pupils fixed. On 3/2/2011 at 1 PM, Resident #2 was found of floor beside bed. On 3/3/3011, "meeting held with MDS coordinator, DON, Activities, and Physical Therapist to discuss resident's falls. Care Plan for falls reviewed at this time to discuss interventions." On 3/8/2011 at 2:15 PM, the resident fell in the living room and sustained a bump on the head. On 3/21/2011 at an unknown time, the resident was found on the floor with the chair alarm sounding. On 3/27/2011, the resident was found on the bathroom floor. On 4/15/2011 at 9:30 AM, the resident was found on the floor of the bathroom with the chair alarm sounding. On 4/18/2011 at 8 PM, Resident #2 fell out of the wheelchair and sustained an abrasion to her back. On 4/25/2011 at 9:40 PM, Resident #2 fell out of bed and sustained an abrasion to her nose. Review of the Incident Reports provided by the facility revealed the following: On 1/9/2011 the corrective action taken to prevent further falls was "close monitoring." On 1/16/2011 the corrective action taken was to "encourage resident not to get out of wheelchair without assistance, resident has fallen previously and has had a cognitive decline." On 1/20/2011, the alarm appropriately sounded and the corrective action taken was to "remind resident to ask for assist with transfers and to keep patient close to nursing station." On 1/24/2011, the bed alarm sounded appropriately and no corrective action was documented. On 1/26/2011 the bed alarm sounded appropriately and the corrective action taken was "encouraged resident to utilize call light when toileting is needed. Call light in reach and resident oriented to proper use." On 2/8/2011 there was no indication of any alarm. The corrective action taken was for the resident to "call for help and using the call bell." On 3/2/2011 there was no indication that the alarm sounded. The corrective action taken was "transferred to common area and needs more frequent monitoring." On 3/8/2011, there was no indication that the resident had a seatbelt in place and the corrective action taken was "will try to monitor further and more often" and "patient is scheduled to receive a belt for wheelchair." On 3/21/2011, there was no indication that a seatbelt was in place or that the alarms sounded. The corrective action taken was for the resident to "comply with instructions to call for help. Have staff check every 1-2 hours." On 3/27/2011, there was no indication that the resident's alarms sounded or that the seat belt was in place. The corrective actions taken were to "continue bed alarm, chair alarm, low bed, seatbelt." On 3/30/3011, the resident's alarm appropriately sounded and the resident had unfastened the seatbelt. The corrective action taken was "resident will not comply to instructions related to safety seat belt. Will continue to monitor, will continue to assess resident for pain, will continue to apply alarms, will continue to encourage resident not attempt to get up out of wheelchair." On 4/9/2011 the bed alarm sounded appropriately. The corrective actions taken were "continue bed alarm and low bed." On 4/15/2011, the corrective actions taken were "will check patient even more frequently than usual due to Urinary Tract Infection." On 4/18/2011, the corrective actions taken were "assessment done, v/s (vital signs) taken, continue chair and bed alarm and low bed." On 4/25/2011, the corrective actions taken were to "continue low bed with bed alarm." Review of the Care Plan revealed a problem area identified related to "Risk for further falls /injury related to decreased cognition, communication, hx of falls with possible side effects of medications. The care plan was dated 1/7/2011 and was reviewed on 2/8/2011, 2/16/2011 and 3/3/2011. The approaches included: "encourage use of assistance device, PT/OT (physical therapy/occupational therapy) evaluations and treat as ordered, provide one person assist for transfers and 1 person assist with ambulation, be sure call light is within reach and encourage to use it for assistance as needed, respond promptly to all requests for assistance, floors free from spills or clutter, personal items within reach, encourage non skid shoes when out of bed. The care plan was updated on 1/7/2011 to include "bed/chair alarm at all times" and "observe resident frequently related to attempts to ambulate without assist." On 3/8/2011 the care plan was updated to include "Seatbelt to wheelchair due to resident's trying to ambulate unassisted/unsupervised." There was no indication the care plan was updated with appropriate interventions to prevent further fall. The facility admitted Resident #3 on 2/3/2010 with [DIAGNOSES REDACTED]. Resident #3's Quarterly Minimum (MDS) data set [DATE] coded her as having short and long term memory problems with severely impaired decision-making skills. Observation of Resident #3 on 4/26/2011 at 8:40 AM, revealed the resident was in the dining room seated in a wheelchair. A chair alarm was observed in place. The resident was noted to self propel himself. Observation of the resident's room revealed Resident #3 had a bed alarm in place. The bed was note against a wall. One fall mat was observed folded in half and stored against the wall. A lift recliner was observed. Review of the Physician's Cumulative Orders dated 4/1/2011 revealed no orders for any type of alarm, fall mat, recliner etc. Review of the Falls Risk Assessment revealed one entry dated 7/19/2010 that scored Resident #3 as a "16" indicating he was at "high risk" for falls. Review of the Nurse's Notes revealed the following entries: On 11/20/2010 at 10 PM, the resident was found on the floor beside wheelchair. On 11/22/2010 at 11:50 AM, the resident was found on the floor at the end of the bed scooting towards the door. 11/23/2010 at 3:20 AM, the resident was found on the floor attempting to urinate. On 11/24/2010 at 2 AM, the resident was found on the floor and stated that he was taking a walk and fell . On 11/25/2010 at 10:15 AM, the resident was found on the floor. On 11/29/2010 at 9 PM, the resident was found sitting on the floor. On 12/3/2010 at 2:55 AM, the resident was found sitting in the floor. At 8:45 AM, the resident was found sitting "Indian style on bathroom floor." At 2:30 PM, the resident was found sitting on the floor in front of recliner. On 12/10/2010 at 4:30 AM, the resident was found sitting in his room beside the bed. At 10:35 PM, the resident was found on the floor by his dresser. On 12/13/2010 the resident reported pain in the right wrist. X-rays were obtained and were positive for a wrist fracture. On 12/15/2011 at 8:15 PM, the resident was found on the floor. At 9:20 PM, the resident was found on the floor at the head of the bed. On 12/20/2010 at 7:45 PM, the resident was found on the floor by the dresser. On 1/10/2011 at 4:30 AM, the resident was found on the floor by the bed. On 1/11/2011 at 7:25 PM, the resident fell out of the wheelchair attempting to adjust his socks. On 1/21/2011 at 11:30 AM, the resident was noted to be lying on the floor in his room. On 1/26/2011 at 7:30 PM, the resident was noted on the floor. On 2/23/2011 at 1:40 PM, the resident "repeatedly rolled forward out of wheelchair sounding the chair alarm." On 3/5/2011, 9:10 PM, the resident was found sitting on floor with legs folded, sitting on feet. At 9:20 PM, the resident was found again on the floor with legs crossed. On 3/6/2011 at 9 PM, the resident was found sitting on the floor with legs crossed. On 3/14/2011 at 12:50 AM, the resident's bed alarm was sounding; the resident was found on the floor with his head on the ground. Abrasion to right forehead noted. On 3/25/2011 at 11:20 AM, the resident's chair alarm was sounding and the resident was found on the floor in front of the wheelchair. On 4/6/2011 at 11:50 AM, the resident was found on the floor in front of the wheelchair, buttocks and coccyx reddened. On 4/19/2011 at 6:45 PM, the resident was found on the floor in the hallway in front of the wheelchair. An abrasion was noted to his forehead. 4/21/2011 at 6:40 AM, the resident was lowered to the floor by a CNA after a transfer to the wheelchair. On 4/22/2011 at 2:30 PM, the resident rolled off low bed and onto low mat, the resident was noted crawling around room. At 9:50 PM, the resident was on left side of mat on left elbow. Review of the Incident Reports provided by the facility revealed the following: On 11/20/2010, there was no documentation of alarms and no documentation of corrective action taken to prevent further falls. On 11/20/2010, there was no documentation of alarms or no documentation of corrective action taken. On 11/22/2010 there was no documentation that the alarms were sounding and the corrective action was "reminded to call for assist." On 11/14/2010 there was no documentation that the alarms sounded and the corrective action was "resident is on low bed with mats, in the past he has admitted to deliberately putting himself on the floor from the bed. This is a recurring behavior and it is unsure if this is a true fall. Intervention low bed and mat continues. Have tried tab alarms x 2 in the past but resident has destroyed them beyond repair." On 11/29/2010 there was no documentation that the alarms sounded and the corrective action taken was "is on low bed with mats, refuses tab alarm." Another corrective action was "may need to move room to closer to nurses desk, questionable 1:1 care, continue to encourage to ask for help with assist." (The resident's room did not change nor was he ever placed on 1:1 care). On 1/10/11 there was no documentation that the alarm sounded, the resident sustained [REDACTED]. There was no corrective action documented. On 1/11/2011, the corrective action taken was "nursing assessment completed assisted back to chair, monitored. Encourage resident to ask for help when reaching towards shoes, ground etc. Understood by resident." On 1/21/2011, the corrective action taken was "chair alarm in place, will follow up with doctor regarding lab results for possible reasons for decreased pulse." On 1/26/2011 there was no documentation that the alarms sounded, the corrective action taken was "we'll monitor closely, needs to be more often at common areas for monitoring." On 2/23/2011, the alarms sounded appropriately, the corrective action taken was "encouraged to ask staff for assistance" and "proper use of chair alarm, resident non compliant." On 3/5/2011, there was no documentation that the alarms sounded, the corrective action taken was continue low bed, bed alarm." On 3/5/2011, the bed alarm sounded and the corrective action taken was to "continue low bed with bed alarm." On 3/6/2011, the bed alarm sounded and the corrective action taken was "will keep resident up until Trazadone given." On 3/14/2011, the bed alarm sounded appropriately, the corrective action taken was "Neuro checks due to small abrasion on forehead." On 3/25/2011, the alarm sounded appropriately, the corrective action taken was "resident unaware of own limitations, refuses to follow instructions to call for help when assistance required. Performed Body Audit, v/s, assessed for pain, notified nurse practitioner. Will continue with chair and bed alarm and will continue to assess for pain. On 4/6/2011, there was no documentation the alarms were sounding, the corrective action taken was "will keep trying to have patient involved with activities in living room where can be supervised. All safety measures are being used as able." On 4/6/2011 the corrective action taken was "all precautions devices in use" and "resident needs to call for help." On 4/19/2011, there was no documentation that the alarms were sounding; the resident sustained [REDACTED]. The corrective actions taken were to "continue with chair alarm." On 4/22/2011, there was no documentation that the alarms were sounding, the corrective action taken were "will continue bed and chair alarm." No other incident reports were provided at the time of the survey. Review of the Care Plan revealed a problem area related to "risk for further falls/injury." The Care Plan was dated 12/3/2010. The care plan was updated with the falls on 11/21, 11/22, 11/23 and 11/30. "Continues to roll self out of bed without injury. Resident aware of rolling from bed. A Bed pad alarm tried prior to readmit, resident destroys alarms." On 12/1/2010, the care plan was updated with "will continue to observe resident for safety/injury. On 12/2/2010, the care plan was updated to include "encourage resident to remain in common areas when out of bed." On 12/5//2010, the care plan was updated to include the same approach of "encourage resident to remain in common areas when out of bed." On 12/10/2010, the care plan was updated to include "observe resident frequently when in room or out of room." On 12/14/2010, the care plan was reviewed and included the following: "Continues with multiple falls, resident rolls self to floor, psych consults ordered, meds reviewed, continues to remove/destroy alarms." The care plan was not adequately updated with appropriate interventions to prevent further falls/injuries. The facility admitted Resident #5 on 7/2/2009 with [DIAGNOSES REDACTED]. Resident #5's Quarterly Minimum (MDS) data set [DATE] coded her as having short and long term memory problems with severely impaired cognitive skill for daily-decision making. Observation of the Resident #5 on 4/26/2011 revealed the resident in the commons area seated in a wheelchair, a chair alarm was present. Observation of the resident's room revealed a bed alarm on the night table. Review of the Cumulative physician's orders [REDACTED]. Review of the Falls Risk Assessment revealed one entry dated 9/13/2010 that documented the resident's score as a "14" indicating she was at "high risk" for falls. Review of the Nurse's Notes revealed on 10/9/2010, Resident #5 fell in the hallway. On 10/28/2010 at 7:30 PM, the resident fell out of the wheelchair while bending over. On 11/4/2010 at 6:45 PM, the resident was found on the floor. On 12/17/2010 at 3:45 PM, the resident stood up out of the wheelchair and fell . On 1/27/2011 at 8:35 PM, Resident #5 fell out of the wheelchair while bending over. On 3/22/2011 at 12:40 AM, Resident #5 fell and sustained lacerations and abrasions to her forehead. On 4/5/2011 at 9:40 PM, the resident's alarm sounded and the resident was found on the floor. The resident sustained [REDACTED]. No Incident Reports were provided at the time of the survey for Resident #5. Review of the Care Plan revealed a problem area identified related to "Risk for falls, has not had recent fall but has had a slow cognitive decline in cognitive abilities. On 12/2/2010 the care plan was reviewed and to "continue with current problem." The care plan was reviewed again on 3/2/2011. Approaches included: "walk with resident at times during the day, do not allow to ambulate without assistance, provide one person assistance with transfers, remember to transfer out of wheelchair into dining room chair for all meals. Be sure call light is within reach and encourage to use it for assistance as needed. Respond promptly to all requests for assistance. (Resident #5) typically does not remember how or why to use call light. Pressure alarm for her wheelchair, she will stand up unassisted. Bed alarm. Monitor resident frequently. Encourage not to stand or ambulate without assistance." On 10/11/2010, Resident #5's care plan was updated to include the following approach: "Remind resident not to stand without assist. Keep resident in common area when out of bed." There was no evidence that Resident #5 had adequate interventions put in place to prevent further falls/injuries from occurring. During an interview with the surveyor on 4/26/2011 at 1:15 PM, the Director of Nurses (DON) confirmed the Care Plans were not updated with the falls and interventions for Resident's #1, #2, #3 and #5. The DON also confirmed the Falls Risk Assessments were not current and were not accurate for all residents. She stated that there was not a facility policy related to the assessments but stated that she expected the assessments to be completed after each fall. The DON stated that Resident #1 was not alert and oriented and was not able to make his own decisions. The DON also confirmed the actual harm and injuries sustained by Residents #1, #2, #3 and #5 related to falls and they had noticed an increase in the number of falls. The DON stated that a new Medical Director had just started but that no actions had been put in place. During an interview with the surveyor on 4/26/2011, the Medical Director stated that he started on 4/16/2011. He stated that he was not aware of the high number of falls. He stated that he had not yet attended a Quality Assurance Committee.