Every finding on record at The Maples at Har-Ber Meadows

Number of residents sampled: Number of residents cited: Based on record review and interviews the facility failed to ensure a resident was not administered an incorrect, unordered medication to prevent a significant medication error for one (Resident #84) of four residents reviewed for medication errors. Findings include: A review of Medical Diagnosis revealed Resident #84 had diagnoses that included right hip pain, rheumatoid arthritis (chronic autoimmune disease primarily affecting the joints), and heart failure. A review of an annual Minimum Data Set with an Assessment Reference Date of 07/20/2025 revealed a Brief Interview for Mental Status score of 15 which indicated Resident #84 was cognitively intact. The MDS also indicated Resident #84 received pain medication as needed (PRN.) A review of a Medication Administration Record, revealed a Physician Order dated 07/15/2024 for a synthetic opioid 50mg (milligrams), two tablets, four times a day PRN for pain. A review of Reportable initiated 10/28/25 at 08:45 AM, submitted on 10/28/2025 at 10:45 AM, revealed on 10/27/2025 at 08:50 PM, Licensed Practical Nurse [LPN] #1 administered two opioids (two tablets) belonging to another resident, instead of two synthetic opioid tablets to Resident #84. A telehealth visit with an on-call physician had no negative findings, a family member requested Resident #84 be assessed in the ED. A review of 800 Hall Vitals, dated 10/28/2025, revealed vital signs were monitored on Resident #84 from 10/27/25 at 10:35PM to 10/28/2025 at 6:00AM. During an interview on 12/01/2025 at 3:00 PM, Resident #84 stated, I remember LPN #1 gave me the wrong pain medication and thought it may have contained an [opioid] that I am allergic too. Resident #84 stated that they had lethargy and even days later when a nurse checked Resident #84's blood sugar, Resident #84 did not wake up. A [unknown] nurse came to give me insulin and when I asked if she was going to check my blood sugar the nurse said that she had already taken my blood sugar. Resident #84 stated that they have an allergy or intolerance to some opioids that can cause nausea and/or lethargy and I was lethargic. During an interview on 12/02/2025 at 9:35 AM, a family member of Resident #84 stated they requested Resident #84 be seen in the emergency room [ED] because Resident #84 was given an opioid that they might have an allergy to,, causing lethargy and/or nausea. Resident #84's family member stated the Administrator was unable to tell them how or why this medication error occurred During an interview with the Director of Nursing [DON] on 12/02/2025 at 11:01 AM, DON confirmed nurses could pull medications from the medication cart and take them to the resident or roll the medication cart on the hall to resident rooms during medication pass, but it was the nurses preference. The DON revealed on the evening of 10/27/2025, LPN #1 was passing medications and pulled the wrong narcotic medication card in front of Resident #84 and administered another resident's [Opioid] medication to Resident #84. The on-call physician, administration, and the family were notified, and a family member wanted Resident #84 to go to the ED. The DON revealed body audits were done on cognitively impaired residents, and cognitively intact residents were interviewed. There were no negative findings. LPN #1 and nursing staff were in-serviced on medication administration. During an interview on 12/03/2025 at 10:33 AM, the Administrator stated he was told LPN #1 was training with LPN #2 and that LPN #1 administered two [Opioids] instead of two [synthetic Opioids] to Resident #84. LPN #1 realized the mistake and contacted the on-call physician and the family of Resident #84. Resident #84 did not have any ill effects, and a family member asked for the resident to be sent to the ED, no negative findings were found. The Administrator revealed Resident #84 had allergies to aspirin, [a specific] opioid, iodine, shellfish and sulfa. The Administrator stated he had no knowledge as to how LPN #1 pulled the wrong medication, and that following the six rights of medication, specifically right person, right medication could have prevented a medication error. During an interview on 12/03/2025 at 11:02 AM, the Administrator clarified that LPN #2 was not training, but LPN #1 asked LPN #2 for help when the medication error was discovered. During a phone interview on 12/03/2025 at 2:29 PM, LPN #2 stated that on the evening of 10/27/2025, LPN #2 was taking over LPN #1's medication cart and discovered the cart was short two [opioids] during a narcotic count. LPN #1 was concerned that the [opioids] were given to Resident #84 in error and immediately assessed Resident #84 with no concerns found. LPN #1 called the on-call physician and administration, and LPN #2 called a family member of Resident #84. LPN #2 revealed the family member was super worried and wanted Resident #84 to be seen in the ED. LPN #2 stated Resident #84 denied symptoms at that time and said opioids give her nausea. LPN #2 stated part of the process to identify Resident #84 was to ask the resident to identify self, and to look at the resident and electronic record. LPN #2 revealed LPN's report to the DON and the on-call nurse manager when something occurs on shift. During a phone interview on 12/03/2025 at 2:58 PM, LPN #1 stated they were passing medications when a CNA came up to ask questions., LPN #1 thought they had Resident #84's medication card in hand but must have picked up the medication card that was behind Resident #84's narcotic card. I popped out the two pills and gave them to Resident #84. Later LPN #1 and LPN #2 realized the narcotic count was off and LPN #1 realized that Resident #84 was given the wrong medication. LPN #1 stated, I went to Resident #84's bedside and told her what happened, and resident freaked out a little bit. Resident #84 was told they were given an [opioid] but not the specific [opioid] Resident #84 was allergic too. Resident #84 stated the [opioid] resident was allergic to makes the resident feel tired. LPN #2 called the family member and may not have explained to the family that Resident #84 did not get the opioid she had a known allergy to. Resident #84 told LPN #1 that they did not want to go to the hospital but went due to family wishes. Resident #84 returned to the facility without findings. LPN #1 confirmed receiving competency training on medication administration on hire and was in-serviced after the medication error incident occurred. Review of a facility policy titled Resident Identification System, revised December 2017, revealed a photo identification system has been adopted to ensure medications and treatments are administered to the right resident. Review of a facility policy titled Administering Medications, revised April 2019, revealed medications are to be administered in a safe, timely manner as prescribed. Staffing is arranged in a manner to prevent medication errors by preventing unnecessary interruptions. The staff member administering medications identifies the correct resident by identification band, checking photo in the medical record, or having another staff member verify the identity of the resident. Nursing staff are expected to check the medication label three times for the right resident, right medication, right route, right time and right dose of medication, and allergies should be checked before giving any medication. Review of a policy titled Adverse Consequences and Medication Errors, revised February 2023, revealed an adverse consequence is an unwanted, uncomfortable, or dangerous side effect received from a medication that may cause a mental or physical decline. A medication error occurs when a drug or biologic is given to a resident without a physician's order. A significant medication error can result in disability, cognitive impairment or even death. Residents should be monitored for adverse condition after a medication error and take the action necessary to promote the safety of the resident when there is a significant medication error or adverse consequence. The physician should be contacted as soon as possible, and residents monitored over 24-72 hours. Following this incident and prior to the survey team entering the facility, the following corrective actions were performed, resulting in a citation at past non-compliance: 10/28/2025 - Nursing staff in-serviced including lecture, discussion, handouts on the six rights of medication administration. Interviews with staff, including staff involved in incident, confirmed understanding of materials covered. No further issues documented or observed during survey.

Based on record review, observation, and interview, it was determined the facility failed to ensure staff followed appropriate infection control practices when providing wound care for one (Resident #2) of three residents reviewed for skin issues.The findings include: A review of Resident #2's December Order Summary Report revealed diagnoses that included type 2 diabetes mellitus with diabetic neuropathy and non-pressure chronic ulcer of other part of left foot limited to skin breakdown. A review of a quarterly Minimum Data Set with an Assessment Reference Date of 09/15/2025, revealed Resident #2 had a Brief Interview of Mental Status score of 15, which indicated the resident was cognitively intact. A review of Physician Orders dated 12/02/2025 for Resident #2 indicated, cleanse diabetic ulcer to left Achilles area with [a brand of hypochlorous acid-based wound cleanser used to clean and irrigate various wounds], pat dry, spray with skin prep, apply [a brand of medical-grade wound dressings using Active Leptospermum Honey]to wound bed, cover with cut to fit foam, apply ABD (abdominal) pad, wrap with [a brand of woven gauze bandage] and secure with tape every day shift on every Monday, Wednesday, Friday for wound care. A review of a Care Plan with a revision date of 06/16/2025 indicated that Resident #2 had potential for pressure ulcer development related to impaired mobility and history of wounds and ulcers. The interventions included following facility policies and protocols for the prevention and treatment of skin breakdown. During an observation on 12/03/2025 at 10:53 AM, the Treatment Nurse (TN) donned gloves before cleaning the wound to Resident #2's left heel. The TN removed a soiled bandage from Resident #2's left heel. She then cleaned Resident #2's left heel with wound cleanser. The TN patted the wound dry with 4x4, then sprayed the wound with skin prep. The TN did not change her gloves or perform hand hygiene after cleaning the wound. This surveyor observed the resident had an open area to the left heel. The TN applied Medi-honey with white foam, applied ABD pad, wrapped with kerlix, and secured with tape. The TN indicated that the ulcer was a diabetic ulcer. During an interview on 12/03/2025 at 2:20 PM, the TN indicated that she should have changed gloves after the wound was clean when providing wound care. She indicated that she did not change gloves when she provided wound care because she was disoriented. She indicated that she was allergic to bleach, and she had used bleach wipes to clean the table that she had not used prior to this. During an interview on 12/03/2025 at 3:05 PM, the Director of Nursing indicated that gloves should be changed after cleaning a wound, and before touching a clean dressing. She indicated that gloves should also be changed if anything was touched, and before picking up clean supplies. A review of the CDC guidelines for infection control titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, indicated that standard precautions and hand hygiene should be used to care for all residents. The guidelines indicated that the use of an alcohol-based hand rub or washing hands with soap and water should be used before moving from work on a soiled body site to a clean body site on the same patient, and after contact with blood, body fluids or contaminated surfaces.A review of a policy titled, Handwashing/Hand Hygiene, indicated that hand hygiene should be performed before moving from work on a soiled body site to a clean body site on the same resident.

Based on record review and interview, the facility failed to ensure the resident's responsible part/legal representative was notified when a resident refused treatment to provide the necessary information to guide treatment and decrease the potential for related complications for 1 (Resident #110) of 1 sample mix residents. The findings are: Review of a facility policy titled, Change in a Resident's Condition or Status, dated February 2021, indicated our facility promptly notifies the resident, his or her primary care provider, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The nurse will notify the resident's primary care provider or physician on call when there has been a (an): significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly; refusal of treatment or medications two (2) or more consecutive times. A significant change of condition is a major decline or improvement in the resident's status that impacts more than one area of the resident's health status. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A review of an Admission Record indicated the facility admitted Resident #110 with diagnoses that included fracture of left femur, dysphagia, difficulty in walking, hemiplegia and hemiparesis. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/29/2024 revealed Resident #110 had a Brief Interview for Mental Status (BIMS) of 8, which indicated the resident had moderate cognitive impairment. The resident required set up/clean up help for eating, supervision for toileting, and was occasionally incontinent of bowel and bladder; and had no pressure ulcers upon admission. A review of Resident #110's Physician Orders, for the month of April 2024, revealed an order, dated 04/24/2024, for physical therapy, 5-7 times per week for 8 weeks for left hip fracture, to address and improve functional mobility; an order dated 04/24/2024, for occupational therapy, 5-7 times a week for 8 weeks for therapeutic exercises and self-care training; an order dated 04/24/2024, for speech therapy, 5-7 times per week for 6 weeks for cognitive communication, and dysphagia; and an order, dated 04/24/2024, triad to bilateral buttocks and intergluteal cleft every shift for skin integrity. Review of Resident #110's Care Plan, revised on 05/10/2024, revealed the resident had the potential for pressure ulcer development related to impaired mobility. Interventions included, follow facility policies/protocols for the prevention/treatment of skin breakdown; inform the resident/family/caregivers of any new area of skin breakdown (initiated 05/08/2024.) A review of Resident #110's, Progress Notes New, dated 01/01/2024 - 07/16/2024, revealed no family notification for, triad to bilateral buttocks and intergluteal cleft every shift for skin integrity. There was no family notification for Review of Resident #110's Nursing Admit/Readmit Assessment and Care Plan, dated 04/23/2024, revealed Resident #110 admitted with red blanchable area to bilateral buttocks .redness noted to intergluteal cleft with no open area noted. A telephone interview with Resident #110 responsible party on 07/15/2024 at 9:43 a.m. revealed Resident #110 admitted to the facility for therapy after surgery, should have been walking, but the facility did not Tell me he wasn't doing physical therapy, but they did call on the second week. Review of Resident #110's Occupational Therapy Treatment Encounter Note(s), dated 04/24/2024 through 05/06/2024, revealed Resident #110 refused occupational therapy on 05/02/2024. There was no family notification of Resident #110's refusal of therapy documented. Review of Resident #110's Physical Therapy Treatment Encounter Note(s), dated 04/24/2024 through 05/06/2024, revealed Resident #110 refused physical therapy on 05/01/2024 and again on 05/02/2024. There was no family notification of Resident #110's refusal of therapy documented. Review of Resident #110's Speech Therapy Treatment Encounter Note(s), dated 04/24/2024 through 05/06/2024, revealed Resident #110 refused speech therapy on 04/30/2024, 05/02/2024, 05/03/2024, and again on 05/06/2024. There was no family notification of Resident #110's refusal of speech therapy. On 07/18/2024 at 9:19 AM, Certified Occupational Therapy Aid (COTA), revealed during an interview that Resident #110 was taking physical, speech, and occupational therapy, due to a decline in (activities of daily living) ADLs ambulation, and weakness. The COTA revealed if a resident refuses therapy, they encourage the resident, as they can't make the resident do therapy, and we educate them. The COTA revealed that therapy does not notify the responsible party or Power of Attorney on a daily basis regarding refusals, they notify the nurse/APN/social worker, and the family is usually notified during the care plan meeting. The COTA revealed they did not call and notify the families and there was no documentation for Resident #110 therapy refusals. On 07/18/2024 at 9:40 AM, Licensed Practical Nurse (LPN) # 5 revealed during an interview that she had not been notified of the resident's refusal of meals, therapy, or showers, and that family/responsible party should be notified of any change in condition, new orders, refusing care or refusing ADL's and the nurse caring for the resident should document the notification. On 07/18/2024 at 9:55 AM, Social Services (SS) revealed during an interview that she had not been notified of Resident #110 refusals for showers, meals, and therapy, and she had not notified the family related to therapy, meals, or shower refusals. On 07/18/2024 at 10:06 AM, LPN # 8 revealed during an interview she was aware of resident's refusals, and that the family, DON, Advanced Practical Nurse (APN), and the physician should be notified of all changes in condition. LPN #8 was asked if she notified the power of attorney (POA) / family of the new order for triad dated 4/24/2024, in which LPN #8 replied, If it's not documented, then it wasn't done, so no. On 07/18/2024 at 10:35 AM, during interview the Director of Nursing (DON) revealed the doctor, APN, and family should be notified of any changes of condition as soon as they are happening and that it was the floor nurse's responsibility.

Based on observation, interview, and record review, the facility failed to ensure proper nail care was provided to a resident who was dependent on nail care for one (Resident #27) resident and the facility failed to ensure a resident who required assistance with personal hygiene was regularly offered hair care to maintain good grooming and hygiene for one (Resident #96) of two sampled (Resident #27 and #96) residents reviewed for activities of daily living (ADLs). Findings include: A review of a facility policy titled, Activities of Daily Living (ADLs), Supporting, revised March 2018, indicated, Policy Statement . Residents who are unable to carry out ADLs independently will receive the services necessary to maintain .grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .in accordance with the care plan .support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) .A resident's ability to perform ADLs will be measured using clinical tools .will be evaluated in reference to the ARD . MDS definitions: .Limited Assistance .Extensive Assistance .Total Dependence - Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident is unwilling or unable to perform any part of the activity . A review of a facility In-Service, dated 05/16/2024, indicated, Ensure nail care is completed every shower day! Nail care can also be completed PRN if nails become broken or took (sic) long before next nail care time! They should be trimmed and filed to residents liking . A review of a facility In-Service, dated 05/28/2024, indicated, Resident's must obtain two showers (sic) weekly . If a resident wants a shower and it is not their shower day the resident can be showered . A review of a facility In-Service, dated 07/01/2024, indicated a review of the Activities of Daily Living (ADLs), Supporting policy revised March 2018, which included, Policy Statement .Residents who are unable to carry out ADLs independently will receive the services necessary to maintain .grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .in accordance with the care plan . support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) .A resident's ability to perform ADLs will be measured using clinical tools .will be evaluated in reference to the ARD . MDS definitions: . Limited Assistance . Extensive Assistance .Total Dependence - Full staff performance of an activity with no participation by resident for any aspect of the ADL activity. Resident is unwilling or unable to perform any part of the activity . A review of a facility In-Service, dated 07/01/2024, indicated a review of the Brushing and Combing Hair procedure, revised February 2018, The purpose of this procedure is to provide hair and scalp care . General Guidelines 1. The resident's hair should be brushed and combed every morning before breakfast and whenever necessary throughout the day . A review of the Admission Record, indicated the facility admitted Resident #27 with diagnoses that included dementia, depression, trigeminal neuralgia, and hearing loss. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/20/2024 revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #27 required substantial/maximal assistance with personal hygiene, had diagnosis of dementia. A review of Resident #27's Care Plan, initiated 10/20/2023, revealed the resident lacked the capacity to understand and make decisions regarding healthcare due to the diagnosis of dementia. The resident had an ADL self-care performance deficit related to weakness, initiated 04/06/2023. Interventions included checking nail length, to trim, and clean on bath day and as necessary. To report any changes to the nurse and required extensive assistance of one (1) staff member. A review of Resident #27's Order Summary revealed Resident # 27 was to receive palliative care/comfort care. A review of a podiatry document, dated 05/29/2024, revealed Resident #27 received treatment that included debridement of two nails. A review of a document titled Follow Up Question Report, revealed Resident #27 received a shower on 07/11/2024. Review of the Grievance Tracking Log, dated 04/18/2024, revealed Resident # 27's daughter requested finger and toenails be cut. During an observation on 07/15/2024 at 7:00 AM Resident #27 was sitting up in bed, hair was greasy and uncombed. During a concurrent interview and observation on 07/15/2024 at 12:55 PM, Resident #27's Responsible Party stated staff was asked to do finger and toenails and they have not done that. Responsible Party described resident's great toes as thick and yellow, the second toe on the left foot as purple in color, and nail on right second toe was curling around end of the toe. During a concurrent observation and interview on 07/16/2024 at 3:16 PM, Certified Nursing Assistant (CNA) #6 stated Resident #27 received a shower today and we don't do nail care that is up to the doctor. CNA #6 did not know the reason nail care was not done for resident by staff. CNA #6 was asked to describe resident's toenails and stated the right second toenail is growing over around it. CNA #6 stated she did not know if a resident's toenail should be so long it wrapped over the resident's toe. During a concurrent observation and interview on 07/16/2024 at 03:22 PM, Licensed Practical Nurse (LPN) #7 stated Resident #27 received a shower earlier today and full nail care was provided if needed. Checking fingernails on both hands, LPN #7 stated it looks like this was missed. Checking toenails, LPN #7 stated they were unsure if the CNAs would feel the right second toe could be clipped because it looks like it wraps around the toe. The CNA should have notified the nurse if they were not comfortable clipping or filing a resident's nails. During an interview on 07/17/2024 at +3:55 PM, the Director of Nursing (DON) stated residents should receive a shower twice a week minimum on scheduled days and as needed. Some residents may request more showers. If a resident is visibly soiled, they should be offered a shower. Residents receive nail care on shower days twice a week and PRN if they are long and if they do not need to be cut, they would need to be filed. If a family requests nail care to be carried out and a resident refused, the family would be notified. The nurse should have been notified of Resident #27's toenails. A review of the Admission Record, indicated the facility admitted Resident #96 with diagnoses that included cognitive communication deficit, dementia without behavioral disturbance, major depressive disorder, anxiety disorder and altered mental status. The admission MDS, with an ARD of 03/31/2024, revealed Resident #96 had a BIMS score of 1 which indicated the resident had severe cognitive impairment. Section F0400, Interview for daily preferences, C. indicated it was very important to choose the type of bathing. Resident required partial/moderate assistance with bathing and personal hygiene. A review of Resident #96's Care Plan, dated 04/04/2024, revealed the resident lacked the capacity to understand and make decisions due to dementia; has an ADL deficit related to dementia; no discharge anticipated. Interventions included honor the resident's customary routine for bathing and allow healthcare agent to review the resident current status and make healthcare decisions at least quarterly and more often as needed. A review of Order Summary, revealed Resident #96 had an order to admit to the Secured Neighborhood. A review of Individual Support Plan (ISP) for Secure Neighborhood/Alzheimer's Unit - V 1, dated 04/02/2024, revealed Resident #96 had a bathing preference of showers to be done in the morning. Resident specific interventions for bathing included, Resident is self-conscious about body odor and requests showers and clean clothes, and requires minimal assistance with bathing, During an observation on 07/15/2024 at 8:08 AM, CNA #2 brought Resident #96 to the dining room, hair disheveled, un-brushed, matted to sides of head, fuzzy, and bunched at the crown. During an interview on 07/15/2024 at 12:14 PM, Resident #96's Power of Attorney stated resident needed showers and the resident's hair was greasy. During a concurrent observation and interview on 07/17/2024 at 12:36 PM, CNA #3 stated Resident #96 received a shower on 07/17/2024, prefers showers on Tuesdays and Thursdays and if resident requests extra showers, is soiled, drops food on clothing additional shower would be provided. CNA #3 could not state why resident did not receive a shower on Monday when hair was greasy. Resident #96's hair was fuzzy, bunched at crown. CNA was asked to describe resident's hair. CNA #3 stated that resident did their own hair and CNA did not assist. During an interview on 07/17/2024 at 03:55 PM, the Director of Nursing (DON) stated residents should receive a shower twice a week minimum on scheduled days and as needed. Some residents may request more showers. If a resident is visibly soiled, they should be offered a shower. If a resident refuses a shower, they are offered a PRN shower/bath on different day, notes are made in the chart, and notification of the physician and family are done.

Based on document review and interview, the facility failed to ensure a Registered Nurse (RN) worked at least 8 consecutive hours a day. The deficient practice had the potential to affect all residents. Findings include: A review of the Punch Date and Time, for 01/20/2024 revealed the RN punched in at 12:00 AM, out at 03:15 AM, total hours 3.25, punched in at 03:45 AM, out at 7:36 AM, total hours 3.85, punches totaling 7.10 hours. A second RN punched in at 11:34 AM, out at 5:27 PM, total hours 5.88 hours, punched in 5:57 PM, out at 7:57 PM total hours 2.00, punches totaling 7.88 hours. The RN punch in / punch out hours did not overlap. On 02/04/2024, an RN punched in for 7.63 total hours. On 02/11/2024, the RN punched in at 12:00 AM, punched out at 12:58 AM, total hours 0.97, punched in at 1:28 AM and out at 7:17 AM, total hours 5.82, punches totaling 6.79 hours. A second RN punched in at 10:03 AM, punched out at 12:44 PM, total hours 2.68, punched in 1:17 PM, punched out at 6:30 PM, total hours 5.22, total time punched 7.90 hours. The RN punch in /punch out hours did not overlap. On 2/17/2024, the RN punched in at 9:00 AM, out at 12:25 PM, total hours 3.42, punched in 12:57 PM, punched out 5:26 PM, total hours 4.48, punches totaling 7.90 hours. During an interview on 07/18/2024 at 8:31 AM, the Administrator stated that on 01/20/2024 the RN hours were reported as 7.88, on 01/27/2024 as 7.97 hours, on 02/04/2024 as 7.63 hours, 02/11/2024 as 7.9 hours, and on 02/17/2024 as 7.9 hours. The RN did not stay the full 8 hours those days, They clocked out a little early. During an interview on 07/18/2024 at 10:19 AM, the Administrator stated the facility has an RN every day, Pretty consistently and we just missed those and usually the RN would notify someone if not able to complete the shift. During an interview on 07/18/2024 at 10:04 AM, the Director of Nursing (DON) stated an RN is always on site and on 01/20/2024, 01/27/2024, 02/04/2024, 02/11/2024, and 02/17/2024 there was not an RN, and the DON was not notified. Floor staff would continue resident care as they are trained per their job title if an RN is not available to work. The DON stated notification should be made when there is no coverage. RNs are made aware of the 8-hour requirement when hired into the RN coverage pool and during orientation.

Based on observations, document review, and interviews, the facility failed to post the nurse staffing information on a daily basis, to include the facility name, the current date, the number and actual hours worked by staff, and the resident census. The deficient practice had the potential to affect all residents. Findings include: A review on 07/15/2024 at 6:05 AM of the Direct Care Daily Staffing posted next to the time clock in the front lobby, indicated a date of 07/12/2024, listed staffing numbers and total scheduled hours for Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified Nursing Assistant (CNA). The Direct Care Staffing document did not indicate the facility name, current census, or actual hours worked. There was no posting for 07/13/2024 or 07/14/2024. On 07/18/2024 at 10:45 AM, an observation of the posted Direct Care Daily Staffing documents dated 07/16/2024 and 07/17/2024 contained no facility name, actual hours worked or census. During a concurrent interview and observation with the Director of Nursing (DON) on 07/18/2024 at 1:13 PM, the posted documents did not contain the facility name, census, actual hours worked, or current daily staffing. The dates listed on the Direct Care Daily Staffing postings were 07/16/2024 and 07/17/2024. The DON stated the staffing and assignment sheets are posted daily by the on-call nurse. The weekend on-call would post staffing and assignment sheets from Friday to Monday. Licensed Practical Nurse (LPN) # 4 should have posted staffing and assignments for today and should contain the name of the facility, date, census, and staffing numbers. During an interview on 07/18/2024 at 1:17 PM, LPN # 4 stated sheets were posted last night, and number of staff and hours are filled in and the DON fills in the facility name and census. LPN # 4 did not do weekend staff posting.

Based on observation, record review, and interview, the facility failed to ensure the narcotic medication for Resident # 87 was recorded correctly. This failed practice had the potential to affect 1 (Resident #87) sampled resident who had a physician order for anti-convulsant medication. The findings are: 1. Review of an Admission Record indicated Resident #87 had a diagnosis of polyneuropathy (nerve damage). 2. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/30/2024 documented the resident scored a 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). 3. The Physicians Order reads, Pregabalin Oral Capsule 75 MG (Pregabalin) *Controlled Drug* Give 1 tablet by mouth two times a day for (nerve damage). 4. On 07/17/2024 at 11:13 AM, the Surveyor was checking the medication cart on Hall 500. When checking the narcotics there was a discrepancy on Pregabalin 75 mg. The narcotic book showed #34 capsules and the medication card showed #33 capsules. 5. On 07/18/2024 at 12:10 PM, Licensed Practical Nurse (LPN) #4 was asked, What is the process of administering narcotics to a resident? LPN #4 said, We pull the resident up on the Electronic Medical Record (EMR), check their residents 5 medication rights, open the narcotic box with a key, find the correct medication, check for the correct count, pop the pill in a cup, give the medication to the resident, after they take the medicine, we record it in the narcotic book, and verify time given. 6. On 07/18/2024 at 12:23 PM, LPN #5 was asked, What is the process of administering narcotics to a resident? LPN #5 said, Look at the Medication Administration Record (MAR), check the resident to see what is due, unlock the narcotic box with key, find the card with the residents name and medication, check the patients 5 medication rights, pop the pill in a cup, sign out medication in the narcotic book, put the medication back into the narcotic box, give the medication to the resident, and click yes, on the computer. LPN #5 was asked what you do to assure no medication error. LPN #5 said At the beginning of each shift the outgoing nurse and incoming nurse does a count and makes sure the count is correct. 7. On 07/18/2024 at 12: 43 PM, the Director of Nursing (DON) was asked if when nurses are hired, they receive any training on narcotic medication administration and when. The DON stated, Yes, they receive training from the manager and nurse trainer, but [DON] will train them on this, in the future. 7. On 07/18/2024 at 12:50 PM, the Director of Nursing (DON) provided, Medication Labeling and Storage policy. Policy heading . The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys . 7. Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked into permanently affixed compartments, except when using single unit package drug distribution systems in which quantity stored is minimal and a missing dose can be readily detected .

Based on observations, interviews and policy review, the facility failed to serve meals in accordance with professional standards for food service safety. Specifically, the facility failed to ensure staff performed hand hygiene after touching clothing and face before serving a meal tray to a resident. This failed practice had the potential to affect 11 residents residing on the secure unit. Findings include: A review of a facility policy titled, Employee Cleanliness and Hand Washing Technique, revised March 2005, indicated, Dietary Employees will .practice good hygiene . are required to wash their hands on the occasions listed below: e. after blowing nose or touching face or hair .any other time deemed necessary . A review of a facility policy titled, Handwashing/Hand Hygiene, revised August 2015, indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to .residents . Use an alcohol-based hand rub .Before and after assisting a resident with meals . A review of a facility in-service titled, In-Service dated 07/01/2024, included review of the facility policy titled, Assisting the Impaired Resident with In-Room Meals revised September 2013, indicated, . Preparation 11. Employees must perform hand hygiene before serving food to residents . if there is contact with . clothing . the employee must perform hand hygiene before serving food . During an observation on 07/15/2024 at 8:11 AM, Certified Nursing Assistant (CNA) #2 used both hands and adjusted scrub jacket and wiped mouth and right cheek/face with right hand, picked up a plate, used it to cover another plate containing food, placed it on a meal tray and delivered it to a resident room. Upon entering the resident room, the meal tray was placed on a table, the cover plate, lids on beverages and a bowl were removed and the meal was served to the resident. During an interview on 07/15/2024 at 8:39 AM, CNA # 2 stated they should have washed their hands after straightening their jacket and touching their face to prevent transmission of communicable disease. During an interview PM 07/17/2024 at 3:55 PM, the Director of Nursing (DON) stated hand hygiene should be done before serving a meal tray and if someone touches their clothing or face, they should perform hand hygiene again because anything is transmissible and we need to protect our elderly population.

Based on observations, interviews and record review, the facility failed to ensure a resident's food was not touched by another resident, prior to consumption for 1 (Resident #83) of 1 resident reviewed for infection control practices during dining observation. This failed practice had the potential to affect 11 residents residing on the secure unit. Findings include: The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/08/2024 revealed Resident #83 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #83 required set up and clean up assistance with meals, partial to moderate assistance with dressing, substantial to maximal assistance with personal hygiene and toileting. Resident #83 had active diagnoses of anxiety disorder, depression and psychotic disorder. A review of Resident #83's Care Plan revealed the resident required secured/special care neighborhood related to dementia diagnosis, had an activities of daily living (ADL) self-care deficit related to dementia diagnosis. Interventions included providing assistance setting up the meal and providing finger foods when having difficulty using utensils, and Resident #83 frequently used hands to eat, initiated on 02/23/2023. A review of the Order Summary, revealed Resident #83 had a regular diet, finger food texture, regular consistency. During an observation on 07/15/2024 at 7:54 AM, Resident #83 was served a meal tray by Certified Nursing Assistant (CNA) #2, containing 1 slice white toast, scrambled eggs, 1 slice bacon, and 1 sausage link. Resident #83 began using hands to eat the scrambled eggs. On 07/15/2024 at 7:55 AM, a resident seated across the table from Resident #83, placed hand on Resident #83's plate, pulling the toast and removing it from the plate. The resident then placed the palm of their right hand on the plate, placing fingers in the scrambled eggs, removed hand, placed in their mouth, removing eggs from their fingers. The resident then placed fingers on plate and attempted to pull plate away from Resident #83 and removed the sausage link from Resident #83's plate, touching the top rim of the plate. CNA #2 relocated the resident to another table. Resident #83 continued to eat eggs off the plate, using their fingers. CNA #2 did not remove or provide another plate to Resident #83. During an interview on 07/15/2024 at 8:22 AM, CNA #2 stated the plate should have been removed from Resident #83 when the other resident removed the food and provided a new meal due to contamination of the food by another resident. During an interview on 07/17/2024 at 3:55 PM, the Director of Nursing (DON) stated if a resident takes food from another resident's plate, the plate should be removed immediately and another plate should be provided. The resident should not continue to eat food, from a plate, that was touched by someone else because anything is transmissible and we need to protect our elderly population.

Based on observations, interviews, and record review, the facility failed to provide foods preferable to a resident to meet their abilities to feed them self for 1 (Resident #83) of 1 resident reviewed for meal preferences and activities of daily living (ADL). Findings include: A review of Resident Rights, dated 07/16, 09/16, indicated, .You have the right to receive service with reasonable accommodation of your individual needs and preferences . A review of the Activities of Daily Living (ADLs), Supporting policy, revised March 2018, indicated, Policy Statement Residents will (sic) provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) . 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences . A review of a facility in-service titled, In-Service dated 07/01/2024, included review of the facility policy titled, Assisting the Impaired Resident with In-Room Meals revised September 2013, indicated, .Preparation .Review the resident's care plan and provide for any special needs of the resident .3. Check the tray before serving it to the resident to be sure that it is the correct diet ordered and that the consistency is appropriate . A review of the Admission Record indicated the facility admitted Resident #83 with diagnoses that included affective mood disorder, constipation, and depression. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/08/2024, revealed Resident #83 had a Staff Assessment of Mental Status (SAMS) score of 3 which indicated the resident had severe cognitive impairment. Resident #83 required set up and clean up assistance with meals, partial to moderate assistance with dressing, substantial to maximal assistance with personal hygiene and toileting. Resident #83 had active diagnoses of anxiety disorder, depression and psychotic disorder A review of Resident #83's Care Plan, revised 09/15/2023, revealed the resident required secured/special care neighborhood related to dementia diagnosis, had an activities of daily living (ADL) self-care deficit related to dementia diagnosis, and had a potential for nutritional problem related to dementia. Interventions included providing assistance setting up the meal and providing finger foods when having difficulty using utensils, Resident #83 frequently used hands to eat, initiated on 02/23/2023, and provide and serve diet as ordered, revised on 07/04/2024. A review of the Order Summary revealed Resident #83 had a regular diet, finger food texture, regular consistency. A review of the Meal Tray Card, revealed Resident #83 had standing orders for almond milk, assorted fruit juices, one each bacon, cold cereal, a hard-boiled egg, sausage patty, water, and one slice white toast. During an observation on 07/15/2024 at 7:54 AM, a red colored beverage in a non-spill cup was on the table in front of the resident. Resident #83 was served a meal tray by Certified Nursing Assistant (CNA) #2, containing 1 slice white toast, scrambled eggs, 1 slice bacon, and 1 sausage link. Resident #83 pushed the utensils away and began using hands to eat. During an interview on 07/15/2024 at 8:20 AM, CNA #3 stated the standing orders listed on resident's meal tray card are items residents should receive each meal and Resident # 83 should have received cold cereal (name brand), a hard-boiled egg, and a sausage patty. CNA #3 stated Resident #83 did not receive those food choices because the kitchen did not send them. CNA #3 stated they usually will call the kitchen and get items that are not sent but did not on this occasion. During an interview on 07/15/2024 at 8:22 AM, CNA #2 stated Resident #83 is ordered finger food and was unsure why the resident would receive cereal. CNA #2 stated Resident #83 did not receive the hard-boiled egg or the sausage patty, and that the food items should have been provided. During an interview on 07/17/2024 at 3:55 PM, the Director of Nursing (DON) stated the aides should be looking at preferences when preparing the tray and if they do not receive the items should go and collect it from the kitchen. We do ongoing training on this. The kitchen is the first line of defense and serving staff is the second line of defense to ensure residents receive the items. We do not have a policy on this.

Based on observation, interview, and record review, the facility failed to ensure staff followed physician's orders for prescribed oxygen flow rates for 1 (Resident #105) and failed to ensure a physician order was obtained to administer oxygen for 1 (Resident #83) of 2 sampled residents. The findings are: 1. Review of physician order with a start date of 6/11/2023 for Resident #105 noted oxygen at 3-6 liters per minute per nasal canula for shortness of breath as needed. a. Review of a care plan for oxygen therapy with an initiated date of 6/12/2023, noted Resident #105 has oxygen at 3-6 liters per minute for shortness of breath. b. On 07/17/23 at 12:32 PM observed Resident #105 in bed with oxygen on and running at 1.5 liters per minute via nasal cannula. c. On 07/18/23 at 9:15 AM observed Resident #105 in bed with oxygen on and running at 1.5 liters per minute via nasal cannula. d. On 07/18/23 3:48 PM observed Resident #105 in bed with oxygen on and running at 1.5 liters per minute via nasal cannula. e. On 07/18/23 at 4:05 PM an interview with Licensed Practical Nurse (LPN) #2 who stated Resident #105 is on oxygen for shortness of breath. LPN #2 confirmed the oxygen was running at 1.5 liters per minute and confirmed it should be 3-6 liters per minute. LPN #2 stated the nurses are responsible for ensuring the residents oxygen is on at the ordered rate. f. On 07/20/23 at 12:05 PM the Director of Nursing (DON) confirmed the nurses are responsible for ensuring residents receive oxygen at the prescribed rate and confirmed oxygen use requires a physician's order. 2. On 07/17/2023 at 1:14 PM observed Resident #83 in bed. Oxygen was administered at 2 liters per minute via nasal cannula. a. On 07/18/2023 at 10:24 AM observed Resident #83 in bed. Oxygen was administered at 2 liters per minute by nasal canula. b. On 07/19/2023 at 8:38 AM observed Resident #83 in bed watching TV. Oxygen was administered at 2 liters per minute by nasal canula. c. A review of the physician's order failed to reveal an order for oxygen therapy. d. On 07/19/2023 at 8:51 AM an interview with LPN #1 revealed Resident #83 needed oxygen the week prior, and stated she got an order for oxygen from the nurse practitioner. LPN #1 accompanied the surveyor to Resident #83 room and confirmed the oxygen was flowing at 2 liters per minute. LPN #1 confirmed there should be an order for the oxygen, and confirmed the nurses on the floor are responsible for ensuring there is an order. 3. On 07/20/2023 at 12:04 PM an interview with the DON who stated oxygen is considered a medication and requires an order and confirmed the nursing staff on the floor are responsible for ensuring orders are followed. The DON stated, If a patient has oxygen ordered, and the oxygen saturations show it is required, the concentrator should be set up with a mask or cannula and the rate set up within range reflected in the order. If adjustment is needed outside of the order range, they need to do a callback to the physician to adjust the order. 4. A policy provided by the DON documented .Oxygen Administration .the purpose of this procedure is to provide guidelines for safe oxygen administration .verify that there is a physician's order for this procedure .review the physician orders .review the resident's care plan to assess for any special needs of the resident .unless otherwise ordered, start at the rate of 2 to 3 liters per minute .adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered .

Based on observation, record review and interview, the facility failed to ensure facial was removed to promote good hygiene and dignity for 1 (#3) of 4 (#1, #2, #3, #4) sampled residents that were dependent or needed assistance for Activity of Daily Living (ADL) care. The findings are: 1.Resident #3 had diagnoses of Dementia, Cataracts, and Muscle Wasting and Atrophy. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/22 documented the resident scored 5 (0-7 severe impairment) on the Brief Interview for Mental Status (BIMS), required extensive assist of two staff for bed mobility, transfer, toilet use, and personal care; and limited assist of one staff for dressing; was frequently incontinent of bowel and bladder; had no behaviors and did not reject care. a. The Care Plan with a Revision Date of 04/20/22 documented, .resident has an ADL self-care performance deficit r/t [related to] limited mobility .resident requires physical help in part of bathing activity by one staff member twice a week and PRN [as needed] .personal hygiene .resident requires limited assist by one staff with personal hygiene and oral care . b. On 03/31/23 at 8:21 a.m., Resident #3 was sitting in a wheelchair in her room. She had facial hair at approximately 1 inch length above her top lip and covering her chin area. The Surveyor asked, Do you like the hair on your chin and above your lip? Resident #3 rubbed her chin with her hand and replied, No, I used to shave it off, but I can't see to do it now. The Surveyor asked, Does it bother you to have hair on your chin and above your lip? Resident #3 replied, Yes. c. On 04/05/23 at 9:45 a.m., the Director of Nursing (DON) provided a copy of the bathing documentation. Resident #3 received a shower on 03/31/23 at 12:25 p.m. There was no documentation that she refused to be shaved. d. On 04/05/23 at 9:48 a.m., the Surveyor asked Certified Nursing Assistant (CNA) #1, Who is responsible for shaving the female residents? CNA #1 replied, the CNA. The Surveyor asked, Why should female residents not have facial hair? CNA #1 replied, Dignity. e. On 04/05/23 at 9:49 a.m., the Surveyor asked CNA #2, Who is responsible for shaving the female residents? CNA #2 replied, The CNAs, same as nail care. The Surveyor asked, Why should female residents not have facial hair? CNA #2 replied, Dignity. f. On 04/05/23 at 9:50 a.m., the Surveyor asked CNA #3, Who is responsible for shaving the female residents? CNA #3 replied, The CNAs, it should be offered every shower day. The Surveyor asked, Why should female residents not have facial hair? CNA #3 replied, Dignity. g. On 04/05/23 at 9:52 a.m., the Surveyor asked Licensed Practical Nurse (LPN) #1, Who is responsible for shaving the female residents? LPN #1 replied, The CNAs and nurses. The Surveyor asked, Why should female residents not have facial hair? LPN #1 replied, Dignity. h. On 04/05/23 at 2:43 p.m., the Surveyor asked the DON, Who is responsible for shaving the female residents? The DON replied, The CNAs. The Surveyor asked, Why should female residents not have facial hair? The DON replied, It's a dignity issue. The Surveyor asked, What are your expectations from your staff regarding following the facilities policy and procedures and the Centers for Medicare and Medicaid Services (CMS) guidelines? The DON replied, That they are abiding by the policy and procedure set in place for grooming and ADL care. i. On 04/05/23 at 3:14 p.m., the Surveyor asked the Administrator, What are your expectations from your staff regarding following the facilities policy and procedures and the CMS guidelines? The Administrator replied, That they follow them. j. The facility policy titled, Activities of Daily Living (ADLs), Supporting, provided by the DON on 04/05/23 at 10:01 a.m. documented, .residents will provided with care, treatment and services as appropriate to maintain or improve their ability to carry out Activities of Daily Living .residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .

Based on observation, record review and interview, the facility failed to ensure the physician was notified of breathing difficulties and low pulse oxygenation so other treatment options could be developed and implemented for 1 (Resident #348) of 1 sampled resident who had a significant change in condition. This failed practice resulted in actual harm for Resident #348, who exhibited respiratory distress and received no additional treatment. The findings are: Resident #348 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the facility on [DATE] and no Minimum Data Set (MDS) was complete. There was no Baseline care plan completed to understand the resident's needs. a. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The resident's Admission check list dated [DATE] documented, Vitals every shift, every shift charting if skilled. c. The Plan of Care initiated [DATE] documented, The residents' code status is Full Code . if the resident's heart stops beating or the resident stops breathing CPR [Cardiopulmonary resuscitation] will be initiated per the resident's/responsible party's wishes . d. The chest x-ray report dated [DATE] at 12:14 p.m., documented, Impression: Bilateral lung infiltrates. e. On [DATE] at 03:25 p.m., the resident was lying in the bed with the head of bed elevated. The resident was receiving oxygen (O2) via n/c [nasal cannula] at 3.5 l/m [liters a minute] from a concentrator sitting at the bedside. A Nebulizer machine was sitting on the bedside table located on the left side of the bed with mask lying on top of the machine open to air. His wife at the bedside. His wife had concerns because she had asked two different nurses to look at him due to his breathing. f. On [DATE] at 03:35 p.m., Licensed Practical Nurse (LPN) #4 entered resident's room and told his wife that his nurse was calling the doctor and getting him a mask for the oxygen. g. On [DATE] at 04:01 p.m., LPN #5 stated the resident's pulse ox [oxygen saturation] was 63% and the Physician had ordered to use a nebulizer mask to keep pulse ox above 90 percent. h. On [DATE] at 05:00 p.m., the resident's pulse ox was 91% on O2 at 4 liters a minute. i. The Nurses' notes in the residents' chart had no documentation from [DATE] at 5:18 p.m. until resident was found in room expired on [DATE] at 5:00 a.m. j. The Nurse's note documented, [DATE] 3:09 a.m., Breaths 36, Oxygen level 82%. There was no blood pressure recorded and the physician was not notified. k. On [DATE] at 9:22 a.m., Physician #1 was contacted and asked, When facility called yesterday regarding resident's chest x-ray, the x-ray showed bilateral infiltrates. There was no new order for this. He stated, Resident has recently had pneumonia and a respiratory infection, I didn't change anything because this is normal with residents getting over COVID ., I felt he just needed oxygen by mask. l. On [DATE] at 10:04 a.m., LPN #6 was asked to tell what occurred with the resident. She stated, .we were making rounds last night about midnight . She was asked, When were the vital signs taken? She stated, It was during our initial rounds at midnight . I checked on him because he was bad the morning before . She was asked, What was the resident's pulse ox when you made rounds at midnight? She stated, The resident's pulse ox was 82%. She was asked, Did you call the Doctor? She stated, No, they had called him so much that day, m. didn't want to disturb him. She was asked, During initial rounds did you take his pulse ox? She stated, No the CNA did. She was asked, Do you know what his respirations where? She stated, .They were high, but no different than the night before. I didn't count them. She was asked, Did the CNA tell you she charted 36? She stated, No. She was asked, Do you have alerts on PCC (point click care) that will let you know when vital signs are out of perimeters? She stated, Yes, but she never told me. She was asked, Did you see the resident after initial rounds and before you found that he had expired? She stated, When they called me into the room at 5 a.m. When I went into the room I did the regular checks like sternal rubs, yelling [resident name], [resident name]. And I did CPR for about a minute but there was no use he was gone . m. On [DATE] at 10:15 a.m., the Director of Nursing was asked, Do you have alerts on PCC? She stated, .The CNA would have to tell her . She was asked, How often should vital signs be charted? She stated, .At least every shift . She was asked, Were the vital signs for this resident done every shift? She stated, No. n. On [DATE] at 01:08 p.m., Certified Nursing Assistant #5 was contacted by phone and asked to talk about [Resident #348]. She stated, .I came in at midnight .we started the night by doing vital signs . She was asked, When you were doing vital signs on the resident, and he had a respiration of 36, did you notify the nurse? She stated, The nurse [LPN #6] was standing right there . She was asked, What was his pulse ox? She stated, The nurse [LPN #6] did the pulse ox, he was chilled, and the nurse had to warm his hand to get the pulse ox to read, it was 82%. She was asked, When you found the resident not breathing what occurred? She stated, I called the nurse [LPN #6], she looked at him, took his mask and placed it on his forehead, was watching for his breathing, called out his name and started like a sternal rub, then started chest compressions. Not like real compressions, but she started for about a minute then she left the room . o. On [DATE] at 1:54 p.m., Physician #1 was contacted and was asked, At midnight the resident's pulse ox was 82% and respirations were 36. If you had been called at that time, what changes would you have made to the resident's plan of care? He stated, If he was mouth breathing, I would have changed his mask, if the family had been notified and wanted, I would have sent him to hospital . p. The policy on Change in Residents Condition provided by the Nurse Consultant on [DATE] documented, .the nurse will notify the Attending Physician or physician on call when there has been a significant change in resident's physical/emotional/mental condition, need to alter the resident's medical treatment ., the nurse will notify the resident's representative when there is a significant change in the resident's condition. The nurse will record in the resident's record information relevant to changes in resident's condition or status .

Based on observation, record review and interview, the facility failed to ensure all staff and visitors were fully screened, upon entrance, and contact and droplet precautions were followed by staff entering isolation resident room, to prevent the spread of COVID-19 and other communicable diseases in 1 of 1 facility. These failed practices had the potential to affect all 101 residents who resided in the facility per the Resident Census and Condition of Resident form dated, 3/27/22. The findings are: 1. On 03/27/22 at 10:55 AM, (Sunday) the surveyors entered the facility, and the weekend Registered Nurse (RN) Supervisor informed the surveyors the temperature machine for screening was not working and she could not find covers for the thermometer. She told surveyors to put 98.6 (for the temperature) in the computer to complete the entry. The RN was asked how long it had not been working and she stated, All morning. She was asked if the staff were screened-in for the day shift. She stated, No, to be honest. 2. The COVID Policy and Procedure received from the Administrator on 03/27/22 at 5:30 PM, documented, .3. b. Anyone arriving at the facility (including staff) is screened for fever and symptoms of COVID-19 before entering .11. a. For a resident on Contact Precautions: staff don gloves and isolation gown before contact with the resident and/or his/her environment; b. For a resident on Droplet Precautions: staff don a facemask within six feet of resident .17. Signage on the use of specific PPE [personal protective equipment] (for staff) is posted in appropriate locations in the facility . 3. The policy on Isolation-Categories of Transmission Based Precautions received from the Administrator on 03/27/22 at 5:30 PM documented, .2. Transmission based precautions are additional measures that protect staff, visitors, and other residents from becoming infected .5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed . 4. On 03/28/22 at 08:32 AM, the Administrator was asked what the procedure was for new admissions and residents who returned from the hospital. The Administrator stated, They are rapid tested and if test positive the residents go outside to enter the 400 hall COVID unit and if negative and unvaccinated the resident is on isolation for 5 days until tested again. 5. On 03/28/22 at 8:59 AM, the Maintenance Assistant entered a room on the 500-hall. Resident #18 was on contact and droplet precautions. The signage posted on the wall next to the door stated, Contact and Droplet Precautions. There was a plastic container with 3 drawers full of PPE (shoe covers, gown, and goggles,) and a box of gloves on the handrail at the door's entrance. Upon exiting the room, the Maintenance Assistant was asked if he was aware that the resident was on precautions. He stated, I did not know until now. I thought that was all done with. He was asked if he noticed the signage and the plastic cabinet and pointed to them and he said, I do now. He was asked what the procedure was to enter a room with the precaution signs and cabinet of PPE, and he stated he was to wear everything in that thing, pointing to the cabinet of PPE. The Maintenance assistant was then asked what else needed to be done once he exited any resident's room that he had touched things in, and he stated he did not know. He was asked if he followed hand washing policy and he stated he did not help resident but does Wash his hands or use hand sanitizer throughout the day. 6. On 03/28/22 at 10:32 AM, the Administrator was asked when paper screenings were received. The Administrator stated he had them do them for all the employees sometime in the afternoon yesterday. The Administrator was asked, Was that once surveyors were here and he stated, Yes, that was done in the afternoon. The Administrator was asked if there was a way to get a printout of all that entered and not screening by temperature. The Administrator stated he could call and ask visitors and staff if they were screened. Surveyor reminded Administrator what Weekend RN Supervisor stated to surveyors upon entry. He stated, They have access to debit cards to go to Walmart and most of the CNAs have thermometers. He stated there was an entrance in the back with a screening temperature reader that was functioning and both nurses' stations have ways to check temperatures. The Administrator was asked if there was a way to determine who entered through the front door and who entered through the back door, and he stated he only receives emails each time a person screens in. The Administrator stated IT [information technology] said there was not a way to print a list. 7. On 03/30/22 at 10:14 AM, the Infection Control Prevention (ICP) was asked What precautions were put into place for unvaccinated staff? The ICP stated, We try to have them not take care of unvaccinated residents .We switch them out with other residents' staff .there is a list of unvaccinated residents back behind the computer at each desk and . I prefer them to wear N95 all the time. The ICP was asked How do you ensure visitors know precautions to take? The ICP stated the front desk receptionist monitors visitors and vendor book and checks COVID cards.

Based on record review and interview, the facility failed to ensure mail was delivered to the residents on Saturdays to promote resident rights and prevent potential delays in receipt of mail for 5 (Residents (R) #31, 34, 41, 49 and 20) of 48 (Residents #2, R8, R10, R16, R18, R20, R23, R25, R28, R30, R31, R32, R33, R34, R35, R40, R41, R43, R44, R45, R49, R53, R54, R55, R58, R62, R64,R65, R67, R73, R81, R83, R85, R86, R87, R96, R907, R98, R99, R100, R148, R149, R248, R249, R250, R298, and R348) sampled residents who received mail. The failed practice had the potential to affect 101 facility residents who may receive mail on Saturdays. The findings are: 1. On 03/29/22 at 10:30 AM, Resident Council President (R#20) and four regular resident council attendees (R#31, R#34, R#41, and R#49) were asked if they received mail on Saturdays. All five resident council members stated they only received mail Monday through Friday. Members were asked if they would like to receive mail on Saturdays. R#20 stated, That would be very nice. Resident #34 and R#49 stated they don't receive much mail, but it would be nice to get it when it was delivered. R#31 stated, Yes, I would like for it to be delivered each day it came. R#41 stated, Yes. 2. On 03/29/22 at 2:50 PM, the Administrator, Social Worker #1, and Social Worker #2 were asked who was responsible for resident mail. Social Worker #1 and Social Worker #2 stated they were. Social Worker #1 and Social Worker #2 were asked if mail was delivered to the residents on Saturdays. The Administrator stated mail was not. Social Worker #2 stated mail from Saturday was left in mailbox and delivered on Mondays. Social Worker #1 and Social Worker #2 were asked if they felt mail should be delivered on Saturdays and both stated Yes. 3. The Mail policy, received from the Administrator on 03/29/22 at 3:16 PM, documented, . 4. Mail and packages will be delivered to the resident as soon as possible (including Saturday deliveries). 4. On 03/30/22 at 3:00 PM, Social Worker #1 was asked if any residents received mail at other addresses than the facility. Social Worker #1 stated she was not aware of any residents having PO [post office] Boxes.

Based on observation, record review and interview the facility failed to ensure an order from the physician for nothing by mouth was followed to prevent potential aspiration complication for 1 (Resident #8) of 2 (Residents #8 and #69) sampled residents who had order to have nothing by mouth. This failed practice had potential to affect 3 residents who had nothing by mouth orders. The findings are: Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/21 documented resident scored 9 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status, required supervision with set up help only for eating. a. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Enteral feeding every 6 hours . b. The Plan of Care dated 03/21/22 documented, .resident requires tube feeding via PEG [Percutaneous Endoscopic Gastrostomy] tube r/t [related too] swallowing problem. c. On 03/28/22 at 02:58 p.m., a 32-ounce water glass was at the resident's bedside. Licensed Practical Nurse (LPN) #1 was asked, Should resident have a water cup at the bedside if she is NPO? She stated, No. She was asked, What could happen if she was to drink it? She stated, Possible aspiration. I will remove it. d. On 03/29/22 at 02:38 p.m., the resident was in her room at a personal refrigerator. The resident had a half empty gallon jug of sweet tea, in the refrigerator. When resident was asked if she drinks it, she just smiled. e. On 03/29/22 at 2:48 p.m., the Director of Nursing was asked, If a resident is NPO, should they have a water glass at the bedside? She stated, No She was asked, Should the resident have tea in their refrigerator? She stated, No, I will have to educate the son.

Based on observation, record review, and interview, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the physician, to minimize the potential for other respiratory complications for 2 (Residents #23 and #348) of 6 (Residents #23, #35, #65, #67, #73, and #348) sampled residents who had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Failed to ensure C-PAP (Continuous Positive Airway Pressure) mask and tubing were stored in a bag or other closed container when not in use to prevent potential contamination for 1 (Resident #73) of 1 resident who had orders for C-PAP therapy. Failed to ensure up-draft masks were stored in a bag or closed container when not in use to prevent potential contamination for 2 (Residents #44 and #348) of 5 (Residents: 44, 348, 96, 83 and 67) sampled residents who had orders for updrafts. These failed practices had the potential to affect 20 residents who had orders for oxygen, 2 residents who had C-PAP orders and 10 residents who used updrafts according to lists provided by the Director of Nursing (DON). The findings are: 1. Resident #23 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/3/22 documented the resident scored 5 (0-7 indicates severely impaired) on a Brief Interview for Mental Status (BIMS) and received oxygen while a resident. a. On 03/27/22 at 04:24 pm, a Trilogy Bi-pap mask was lying on the bedside table, not stored in any type of bag. b. On 03/30/22 at 1:20 pm, Certified Nursing Assistant (CNA) # 2 was asked how oxygen tubing and masks should be cared for when not in use? CNA #2 stated, They should be put in a bag that is dated. c. On 03/30/22 at 1:30 pm, Licensed Practical Nurse (LPN) #2 was asked how oxygen tubing and masks should be cared for when not in use? LPN #2 stated, They should be in a dated bag. d. On 03/30/22 at 1:35 pm, the DON was asked how oxygen tubing and masks should be stored when not in use? The DON stated, In bags that are changed out weekly on Sundays just like the oxygen tubing and humidity bottles. The DON was asked if it is acceptable for updraft or trilogy masks to be lying out on bedside table and not in a bag. The DON stated, No. 2. Resident #44 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and had no documented oxygen use. a. On 03/27/22 at 11:30 am, the updraft mask was lying on the resident's bedside table. It was not stored in a bag and was not dated. b. On 03/30/22 at 1:20 pm, CNA #2 was asked how oxygen tubing and masks should be cared for when not in use? CNA #2 stated, They should be put in a bag that is dated. c. On 03/30/22 at 1:25 pm, CNA #3 was asked how oxygen tubing and masks should be cared for when not in use? CNA #3 stated, They should be placed in a bag. d. On 03/30/22 at 1:35 pm, the DON was asked how oxygen tubing and masks should be stored when not in use? The DON stated, In bags that are changed out weekly on Sundays just like the oxygen tubing and humidity bottles. She was asked if it is acceptable for updraft or trilogy masks to be lying out on the bedside table and not in a bag. The DON stated, No. 4. Resident #73 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/2022 documented the resident scored 6 (0-7 indicates severely impaired) on a Brief Interview for Mental Status and used oxygen while a resident. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . with 2 LPM O2 at HS [at bedtime]. Oxygen as needed for shortness of breath 2 l/m [liters a minute] per nasal cannula prn [as needed]. b. The Plan of Care revised on 1/3/22 documented, The resident has altered respiratory status related difficulty breathing r/t [related to] [CONDITION(S)] . Monitor for s/s of respiratory distress and report to MD [Medical Doctor] prn . c. On 03/27/22 at 03:00 p.m., the resident was lying in bed. The C-pap machine was on the bedside table with tubing and mask lying in a chair with wet a pillowcase lying on top of the tubing. d. On 03/28/22 at 08:02 a.m., the resident was lying in the bed with O2 at 3 l/m via n/c. The C-pap tubing and mask were lying on the bedside table, open to air. e. On 03/29/22 at 08:30 a.m., the resident was lying in the bed with O2 at 3.5 l/m via n/c. The C-pap tubing and mask were lying on the bedside table, not covered. 5. Resident #348 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the facility on [DATE] and no Minimum Data Set (MDS) was complete. a. The March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . b. On 03/27/22 at 03:25 PM, the resident was lying in bed, receiving O2 via n/c at 3.5 l/m from concentrator sitting at the bedside. LPN #4 was present in the room also. The Nebulizer machine was sitting on the bedside table located on the left side of the bed with the mask lying on top of the machine open to air. c. On 03/27/22 at 04:18 PM, the resident was lying in bed and the O2 saturation rate was 81%. He was receiving O2 at 3.5 l/m via the nebulizer mask.

Based on record review and interview, the facility failed to ensure [MEDICATION(S)] dosage was reduced or discontinued, in the absence of a physician's documented evaluation of the potential risks versus benefits of continuing a prn (as needed) medication in order to determine the lowest effective dose and reduce the potential for adverse reactions to the medication effects for 1 (Resident #73) of 9 (Residents #2, #10, #54, #73, #81, #83, #85, #87 and #248) sampled residents who had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failed practice had the potential to affect 18 residents who had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: Resident #73 was admitted on [DATE] had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/2022 documented the resident scored 6 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and had no documented behavior in the past 14 days. a. The Plan of Care dated 12/08/21 documented, Review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics, opioids, benzodiazepines . b. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .give 0.5 mg by mouth as needed for anxiety related to anxiety disorder . c. A Pharmacist MRR-Antipsychotic (Medication Record Review) Report dated 3/14/22 had no documentation related to PRN [as needed] [MEDICATION(S)]. d. On 03/29/22 at 01:44 PM, the DON was asked, why Resident #73 had not had any clinical documentation from the physician on the residents PRN [MEDICATION(S)] ([MEDICATION(S)]). She stated, I am not sure. She was asked, Is there any documentation in the chart every 14 days for the use of [MEDICATION(S)]? She stated, No. e. As of 3/29/22, the March 2022 Medication Administration Records documented Resident #73 had received [MEDICATION(S)] 0.5mg on the 5th and the 8th with no documentation indicating the resident exhibited any behaviors or indicators of anxiety. f. The facility policy Tapering Medications and Gradual Drug Dose Reduction received from the DON on 03/29/22 at 03:30 p.m., documented, After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences .

Based on observation, record review and interview, the facility failed to ensure food items stored in the kitchen, the walk-in refrigerator, the walk-in freezer, and storeroom had a receive date or an expiration date, opened food items had an open date or use by date, and expired food items were promptly discarded to prevent the potential of food borne illness in 1 of 1 kitchen. This failed practice had the potential to affect 99 residents (total census: 101) who received meals from the kitchen according to a list provided by Dietary Employee #3 on [DATE]. The findings are: 1. On [DATE] at 11:25 AM the following observations were made: a. On a shelf in a 2-door stainless steel refrigerator across from the stove, there was an opened bottle of Carmel Syrup with no receive date or expiration date. b. On the shelf above a worktable located near the stove, there was jar of chicken base with no receive date or expiration date. 2. On [DATE] at 11:37 AM, in the walk-in refrigerator, there was an open bag of chili pods, a opened jar of Cream of Coconut, and a 32-ounce carton of orange juice with no dates. In the same refrigerator there was a box containing 95 single serving packets of tartar sauce with an expiration date of [DATE]. 3. On [DATE] at 11:41 AM, in the walk-in freezer there was a 5-pound bag of breaded chicken patties with no dates. 4. On [DATE] at 11:50 AM, in the dry storage room there was a box of pancake mix dated ,d+[DATE] and no year documented. The production date on the box of pancake mix was [DATE]. There were single serving packets of ranch salad dressing, and tartar sauce which had been removed from their original packaging with no dates, or expiration dates. On the can rack there was a can of grape jelly with no date.

Based on record review, and interview, the facility failed to ensure written notification of transfers was provided to the Ombudsman, and the resident, when resident was discharged from the facility for 1 (Resident (R) #86) of 1 sampled resident who was transferred to the hospital in the past 3 months. The findings are: 1. The Facility Initiated Transfer dated 3/28/2022 documented the resident was discharged from the facility to other (home, assisted living .) 2. On 3/29/22 at 1:14 pm, the Social Service Director was asked about the resident. She stated the Ombudsman, and the resident were notified when non coverage was reported to the facility, 2/17/2022. Attempts were made for alternate placement, R refused all homeless shelters in the vicinity, assisted living facilities denied having placement availability, R denied having any family he could live with, 2 adult children that he was unable to contact, 2 cousins-one he was unable to contact and the other he didn't want to contact. R stated his parents and brother were still alive, but he couldn't contact them, reason unknown and not provided. R had a 60-day letter of approval from the [State designated Professional Associates]. She stated she attempted to contact the Adult Protective Services and left a message on 3/28 and 3/29/22 but there has been no return phone call. She stated that resident had made numerous phone calls from the facility to the cousin and other family members, who she didn't know. The admission information in the resident's record had documentation that he was homeless prior to hospitalization . 3. On 3/29/22 at 1:20 PM, the Business Office Manager was asked about the resident. She stated she assisted the resident with applying for Social Security disability, it was mailed by her the end of December 2021or first of January 2022. She denied assisting the resident in any other aspect of his discharge. 4. On 03/29/22 at 01:24 PM, the Regional Ombudsman stated the facility did contact her regarding resident's denial of Medicaid. She stated she did tell the facility that discharging to a motel wasn't considered by the ombudsman's office to be a safe discharge. She stated she gave the facility several options within the community. She tried emergency housing, and nothing was available. After talking with the resident, he refused to go to a homeless shelter, which she stated was also considered a non-safe discharge but was a consideration. Resident refused to go to his cousins. Resident had options that he refused to pursue, he had capacity with a cognitive level score of 15. She stated, .I contacted the State Ombudsman who reported, that the state office didn't receive the 30-day notice of discharge as of this date 3/29/2022. 5. On 03/29/22 at 03:17 PM, The BOM was asked, Did you send a copy of the 30-day letter of discharge to the Ombudsman? She stated, .No, I didn't know I was supposed to send them one . Did the Ombudsman receive a copy, either the regional or the state? She stated, No ma'am, I don't believe so. Did the resident receive a copy of the 30-day letter of discharge? She stated, .Yes, I believe he did . Did the resident sign that he received a copy? She stated, No he didn't. How do you document that the resident received a copy, since you already informed me that the Ombudsman didn't receive a copy? She stated, I can't prove he received a copy.

Based on observation, record review, and interview, the facility failed to ensure a non-vaccinated Covid-19 negative resident (Resident #4) did not remain in the room with a non-vaccinated Covid-19 positive resident (Resident #5). This failed practice resulted in Immediate Jeopardy, which could have caused serious harm or death to Resident #4, who had tested negative for COVID-19. The failed practice had the potential to cause more than minimal harm to 10 residents who had tested negative for COVID-19 and resided on the Dementia Care Unit (Makeshift COVID-19 unit), according to the Daily Census provided by the Director of Nursing (DON) on 06/02/2021 at 1:30 p.m. The Administrator and DON were notified of the Immediate Jeopardy on 06/02/2021 at 5:20 p.m. The findings are: 1. The CMS [Centers for Medicare and Medicaid Services] COVID-19 Long Term Care Facility Guidance dated 4/2/2020 documented, .Long term care facilities should separate patients and residents who have COVID-19 from patients and residents who do not, or have an unknown status . i. To this end, long term care facilities should work with State and local community leaders to identify and designate facilities dedicated to patients and residents with known COVID-19-positive and those with suspected COVID-19, ensuring they are separate from patients and residents who are COVID-19-negative . 2. The ADH (Arkansas Department of Health) Guidance for Reducing Spread on COVID-19 in Long-Term Care Facilities dated August 4, 2020 documented, . 5. Facilities should identify a specific wing or hall in the building that can be a designated area for positive residents that is separate from negative residents. All positive residents should be placed in this area (ideally each in a private room). This wing or hall should have dedicated staff who only work in this area . Please comply with all CMS and DHS [Department of Human Services] rules related to movement and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Facilities should identify a specific wing or hall in the building that can be a designated quarantine area for residents who have had a prolonged direct exposure (within 6 feet of the person for more than 15 consecutive minutes) to a positive resident or healthcare worker. All exposed residents should be placed in this area for quarantine (ideally each in a private room) . 7. Residents that test positive can be housed together in the same room . 3. The Centers for Disease Control and Prevention (CDC) guidance titled Updated Healthcare Infection Prevention and Control Recommendations in Response to Covid-19 Vaccination dated 4/27/2021 documented, .Managing Residents with Close Contact .Residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine for 14 days after their exposure. Residents in quarantine should be placed in a single-person room. If limited single rooms are available or if numerous residents are simultaneously identified to have known [CONDITION(S)]-CoV-2 exposure or symptoms concerning for Covid-19 residents should shelter-in-place at their current location while being monitored for evidence of [CONDITION(S)]-CoV-2 infection. Residents should only be placed in Covid-19 care unit if they have confirmed [CONDITION(S)]-CoV-2 infection (i.e., with symptoms concerning for Covid-19 pending testing or with known exposure) in a dedicated Covid-19 care unit could put them at higher risk of exposure to [CONDITION(S)]-CoV-2 . 4. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 4/5/2021 documented the resident was moderately impaired in cognitive skills for daily decision making per the staff assessment for mental status and required one person assist for toileting needs. a. The Facility COVID-19 testing for Resident #4 documented, .RT-PCR [Reverse Transcription Polymerase] .Not Detected .5/17/2021 . RT-PCR .Not Detected .5/21/2021 . RT-PCR .Not Detected .5/25/2021 . RT-PCR .Not Detected .6/1/2021 . 5. Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 3/19/2021 documented the resident was severely impaired in cognitive skills for daily decision making and required one person assist with transfers and toileting needs. a. The RT-PCR Lab Report documented, .Collected: 05/21/2021 .Reported: 05/22/2021 .Positive for [CONDITION(S)]-CoV 2 . b. The Social/Activities Note documented, .5/21/2021 . [Daughter] notified that a resident on secured neighborhood has tested positive for COVID and res has been placed on isolation for preventative measures . Resident #5 was in room [ROOM NUMBER] and resided with Resident #4. Resident #5 tested positive for COVID-19 on 5/22/2021. c. The Nursing Progress Notes documented, .5/24/2021 12:57 Nsg-Hot Rack Vitals: BP 121/60, PULSE 57, RESP 16, TEMP 97.5, O2 94RA [room air] Hot Rack Charting: RESIDENT IS BEING MONITORED FOR POSITIVE COVID RESULT THIS DAY. RESIDENT AND HER ROOMMATE HAVE BEEN PLACED ON CONTACT AND DROPLET ISOLATION. RESIDENT DENIES C/O PAIN OR DISCOMFORT. NIGHT SHIFT NURSE REPORTED RESIDENT WAS DRY HEAVING THROUGH THE NIGHT, NO EPISODES OF THIS THUS FAR THIS DAY. RESIDENT HAS BEEN PLEASANT AND COOPERATIVE WITH CARE THUS FAR THIS DAY. NO COUGH OR SHORTNESS OF BREATH NOTED AT THIS TIME. RESIDENT IS CURRENTLY SITTING UP EATING LUNCH, WITH BREATHES EVEN AND UNLABORED IN NO APPARENT DISTRESS. NO OTHER ISSUES NOTED AT THIS TIME . e. The Daily Census dated 6/1/2021 documented the facility had 12 residents on the Dementia Care Unit (Makeshift COVID -19 unit). The facility had the capability to house a total of 19 residents on the Dementia Care Unit (Makeshift COVID -19 unit). The facility currently has two residents that have tested positive for COVID -19. j. On 6/2/2021 at 3:22 p.m., the DON was asked, When did you start outbreak testing? The DON stated, We started outbreak testing on 4/28/2021. We had a staff member test positive on 4/28/2021. The DON was asked, When did you have a resident test positive on the Secured, Dementia Unit? The DON stated, We had a resident go to Inpatient Hospice. He was on the Dementia Unit before he went to Inpatient Hospice. They tested him there and notified us on 5/13/2021. We started out-break testing right away. The DON was asked, How many residents are on the Dementia Unit (Makeshift COVID-19 Unit) that are positive for COVID-19? The DON stated, We currently have two residents that tested positive for COVID-19. The DON was asked, When did these residents test positive for COVID-19? The DON stated, We had a male and female resident test positive on 5/21/2021. The DON was asked, Did any of the residents have symptoms associated with COVID-19? The DON stated, The male resident did display some symptoms. He was put in isolation. The DON was asked, What about the female resident that tested positive? The DON stated, We left her in her room. She did not have any symptoms. The DON was asked, Is the female resident that tested positive in a room by herself? The DON stated, No, she has a roommate. The DON was asked, Did her roommate test positive? The DON stated, No, she has not tested positive. We are using isolation precautions for all the residents on the Dementia Care Unit (Makeshift Covid-19 Unit). The DON was asked, Is there any empty rooms on the Dementia Unit (Makeshift Covid-19 Unit)? The DON stated, Yes. k. On 6/2/2021 at 3:50 p.m., the Administrator was asked, What was the date of your most recent positive resident? The Administrator stated, We swabbed her on May 21st. The Administrator was asked, Why are a positive COVID resident and a negative COVID resident sharing the same room? The Administrator stated, When we had COVID in the building before we had the Unit closed down. Working on the assumption that the residents are already exposed, that is why we converted the Dementia Unit into a COVID unit. What would I do if I didn't have any rooms available? All the residents back there can transfer and ambulate on their own. l. On 6/3/2021 at 1:32 p.m., Licensed Practical Nurse (LPN #1) was asked, Why was (Resident #4) kept in the same room with (Resident #5) when notified that (Resident #5) had tested positive for COVID -19? LPN #1 stated, I was told that (Resident #4) had already been exposed and to keep them in the same room. We kept her in isolation. We did find out that (Resident #4) had COVID at another facility. LPN #1 was asked, Does (Resident #4) have any symptoms associated with COVID-19? LPN #1 stated, One day she did run a temperature. I tried to give her Tylenol, but she wouldn't take it. m. On 6/4/2021 at 1:10 p.m., the DON was asked, Has (Resident #4) and (Resident #5) been vaccinated for COVID-19? The DON stated, No, they have not been. Their families did not want them to be vaccinated. The DON was asked, Did the staff member that tested positive on 4/28/2021 work on the Secured, Dementia Unit (Makeshift COVID -19 Unit)? The DON stated, Yes, he was pulled to work the Unit on the previous weekend (April 24 and 25th). The DON was asked, Did the staff member come to work on those days with any symptoms associated with COVID-19? The DON stated, Not, that I am aware of. The DON was asked, When did you discover that the staff member was positive for COVID-19? The DON stated, He came to work on the 28th (4/28/2021). He did come to work with symptoms. Congestion. A low grade fever. I was notified right away by an email. As soon as it was flagged on the Kiosk. He was stopped in the hallway and rapid tested . I am typically around the office during shift change. He was working 3-11. He was sent home, immediately. 6. On 06/02/2021 at 7:30 p.m., the Immediate Jeopardy was removed, and the scope and severity reduced to E when the facility implemented the following Plan of Removal: 1). On 6/2/2021 [at] approximately 6:00 p.m. (Resident #4) was moved from room [ROOM NUMBER]A to a private room on the Dementia Care Unit. 2). On 6/2/2021 (Resident #4) was assessed by the DON [Director of Nursing] for signs and symptoms of COVID 19 with none noted. 3). On 6/2/2021 the DON/Designee assessed all residents on the Dementia Care Unit for signs and symptoms of COVID 19 with none noted. 4). On 6/2/2021 Administrator/Designee initiated an In-service with all staff on CDC [Centers for Disease Control and Prevention] Guidelines for Considerations for Memory Care Units in Long Term Care, and additional training regarding not co-horting positive and negative residents in the same room.

Complaint # was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure necessary care and services were provided to attain or maintain the highest practical physical well-being in accordance with the comprehensive assessment and plan of care for Resident #1. The facility failed to ensure licensed nursing assessments of respiratory status were conducted after identification of shortness of breath, an appropriate nursing intervention/treatment for [REDACTED].#1) of 2 (Residents #1 and #5) case mix residents who were at high risk of aspiration. The failed practices resulted in Immediate Jeopardy which likely caused or could have caused serious injury, harm or death for Resident #1, who was not provided skill nursing assessment and treatment during an episode of vomiting and aspiration. The failed practice had the potential to cause more than minimal harm for 22 residents at high risk of aspiration according to a list provided by the Director of Nursing (DON) on [DATE] at 9:30 a.m. The facility was informed of the Immediate Jeopardy on [DATE] at 3:30 p.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident had severely impaired cognitive skills for daily decision making and had a swallowing problem. a. The Interdisciplinary Care Plan last updated [DATE] documented, "Breathing Difficulty ... Goal: Resident will be maintained at their respiratory baseline with a patent airway and unlabored respirations ... Approach: Monitor for changes in/development of signs and symptoms of breathing difficulty and report to nurse if noted: SOB (shortness of breath) ... Bluish skin color ... Report changes in respiratory status to physician ..." b. Nurses Notes dated [DATE] documented, "[DATE] at 0010 (12:10 a.m.) (resident) in bed (with) eyes closed respirations (easy) (no) (complaints) pain or discomfort (related to) cut on (left) thumb. Will continue to monitor. vs (vital signs): (Blood Pressure),[DATE], (Temperature) 97.4, (Pulse) 67, (Respiration) 17, (Oxygen Saturation) 96%." "[DATE] at 1100 (11 a.m.) vs: ,[DATE], 98.0, 72, 18, 97%. (Resident) monitor for cut to (left) thumb. (No) (complaints) pain or (signs/symptoms) of infection. Will continue to monitor." After this documentation there were 3 blank lines and then the following: "[DATE] at 2340 (11:40 p.m.) This writer notified Hospice of (residents) passing. 2345 (11:45 p.m.) (Funeral Home) notified of (residents) passing. 2350 (11:50 p.m.) Coroner call and face sheet faxed to office. 0030 (12:30 a.m.) (Doctor) called and notified. Late entry 2330 (11:30 p.m.) (Daughter) asking this writer questions about mothers passing, informed her of what I received in report." As of [DATE] at 10:42 a.m., there was no documentation in the clinical record of the circumstances of the resident's death. c. Staff were interviewed regarding the circumstances of Resident #1's death: 1) On [DATE] at 1:35 p.m., Licensed Practical Nurse (LPN) #1 was asked if she remembered the condition of (Resident #1) the day she expired. The LPN stated, "She was her normal self. We had [MEDICAL CONDITION] going through the facility, vomiting and diarrhea. About 15 to 20 minutes till 11:00 (p.m.) the 11 to 7 nurse called in for my hall. Four residents started vomiting at the same time. Two were across from (Resident #1's) room and the other 2 was (Resident #1) and her roommate. I heard a CNA (Certified Nurse Assistant) say she needed help, had 4 people throwing up. A nurse was helping me because I was on the phone with the Administrator because 11 to 7 nurse had called in. Then I heard a CNA say (Resident #1) is turning purple. I went into the room, what I gathered happened was (Resident #1) was facing the wall when she vomited, they rolled her over to clean her up and when they rolled her over I'm assuming she aspirated." The LPN was asked if she or anyone else had gone for a suction machine to remove possible vomitus from the resident's mouth and she stated, "No." She was then asked if she had assessed the resident's mouth for any vomitus and she stated, "No." The LPN was then asked if she had at any time felt like the resident was dying from her terminal [DIAGNOSES REDACTED]. She had been her normal self. When the LPN was asked why she had not attempted to suction the resident she stated, "It wouldn't have done any good, we had to stand there and wait for her to take her next breath, they were longer than a minute apart." The LPN was asked if this same situation had been with a resident not on hospice what would she have done and she stated, "I would have attempted to suctioning, with this assumption I should have checked her mouth and suctioned her." 2) On [DATE] at 2:50 p.m., LPN #2 was interviewed and asked if she was present during this time with Resident #1 and she stated, "I was present during (Resident #1's) death. I was not aware of her condition prior to her death. I went in due to a CNA said her color was not good. I had heard she was 1 of 4 patients on that hall who had thrown up. (LPN #1) came in right behind me. The CNAs told us that she had thrown up. Her color was pale. (LPN #1) said to get pulse ox (oxygen saturation) reading. The CNAs told us she was facing the wall when she threw up. I was basically trying to help out. I did not try checking or suctioning her, I only did what (LPN #1) said to do. Pulse ox reading was in the low 80's. She was breathing short and shallow breaths. If this had been a resident I was familiar with and had known the resident had not been different in the days leading up to this and this happened I would have attempted to clear the air way." 3) On [DATE] at 3:20 p.m., CNA #1 was asked if she remembered the evening that (Resident #1) had expired. She stated, "We had a stomach virus going on. (Resident #1) and 2 others at the change of shift were throwing up. When I went in there I went in by myself. She was facing the wall. She had thrown up at the top corner of the sheet. She was breathing. I left to get things to clean her up. I came back, rolled her over, she hollered at me. I rolled her to her left side facing the door in case she threw up again, then I left to go clean up another resident. (CNA #2) was in there when I left. She's the one noticed she was turning purple. (LPN #1) called me about 5 till eleven and told me she aspirated and died . ... (CNA #2) called me about 10 minutes after 11 ... she said the nurses just went down there and stood." 4) On [DATE] at 4:35 p.m., CNA #2 was asked if she remembered (Resident #1) and she stated, " I was working the night (Resident #1) died . I wasn't in there when she threw up. (CNA #1) was running behind and needed help with (Resident#1's) roommate. All of them had been throwing up. The nurses were not in the room when her face started turning purple. She was gasping for air. (CNA #1) went to tell (LPN #1) and she was on the phone. (LPN #3 and #2) came in and took her pulse ox and listened to her chest. No nurse checked her mouth. I stuck my finger in her mouth and only felt her tongue. It was about 2 minutes before the other 2 nurses came in after telling them the resident was turning blue. During this time she was gasping for air." 5) On [DATE] at 4:45 p.m., LPN #3 was asked if she was present the evening (Resident #1) expired and she stated, "I was present the night (Resident #1) passed. (CNA #1) said she was turning blue. Eventually all 3 of the nurses went in. I don't remember the sequence or timing. She was on her left side, she was blue/gray, labored breathing. Not cheyne-stoke. The CNA told us she had vomited. My first thought was she possible aspirated. " When asked what was done when they had suspected she had aspirated the LPN stated, " Normally you would look to see that she was clear, raise the head of the bed and make sure she was not on her back." She was asked if anyone attempted to suction the resident and she stated, " If ordered you would suction. It would probably be general protocol to suction. It depends on if the patient is a DNR (Do Not Resuscitate) or not. I thought we would have to have an order. I was not her primary nurse so I didn't want to make that call. I should have looked in her mouth, raised the head of the bed and then possibly suctioned her." d. On [DATE] at 10:50 a.m., the Medical Director was interviewed by telephone and he was asked if he remembered (Resident #1) and if the facility had notified him when she expired. He stated, "She had been on Hospice care for a while and when the facility notified him they had told him she had passed away." He was then asked if he had been aware that the nurses had suspected she had aspirated and what he would have expected them to do in this case. He stated, "I think she needed to be suctioned and her head up and make sure she was not in discomfort. Put oxygen on her. Should have done something and make her more comfortable. You treat them even though they are on Hospice. You treat any acute condition. I was informed she was on Hospice and she passed away. It would have been nice to know she had vomited. I expect them to tell me she had a change in condition. They tell me all the time about shin tears and falls and why am I not notified about this change of condition." e. On [DATE] at 11:38 a.m., the Hospice Registered Nurse #1 was interviewed by telephone and was asked if she remembered (Resident #1) and what they expect a nurse to do if they suspect a Hospice patient has aspirated. She stated, "They should provide oxygen for support, NPO (nothing by mouth) if aspirated, attempt to suction, make sure airway is open and make comfortable. The best I remember it was a sudden thing and a major thing for her. The call came in on [DATE] at 2315 (11:15 p.m.) that (Resident #1) had vomited earlier, the nurse that called believed she had aspirated and felt now she was actively dying." 2. The facility's Notification and (&) Documentation policy provided by the Director of Nursing on [DATE] at 11:40 a.m. documented, " Policy Statement: Our facility shall promptly notify the resident, his or her attending physician, and representative or family member of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation: 1. The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: ... A significant change in the resident's physical/emotional/mental condition; ... The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. ..." 3. The Charge Nurse/Shift Supervisor Job Description provided by the Administrator on [DATE] at 9:30 a.m. documented, " Purpose of Your Job Position: The primary purpose of your job position is to provide direct nursing care to the patients ... Nursing Care Functions ... Consult with the patient's physician in providing the patient's care, treatment ... as necessary. ... Notify the patient's attending physician ... when there is a change in the patient's condition ..." 4. The Immediate Jeopardy was removed and the scope/severity reduced to a G on [DATE] at 6:37 p.m., when the facility implemented the following plan of removal: a. On [DATE] at 5:00 p.m., the facility Administrator immediately upon knowledge of said allegation initiated an initial abuse/neglect report for submission to the state survey agency/ OLTC (Office of Long Term Care). Accused party was suspended from work schedule pending the results of the ongoing abuse and neglect investigation. Appropriate notifications were initiated per Administrator including local law enforcement, MD & resident responsible party. All staff members with knowledge of alleged neglect with failure to report immediately to the administrator were also suspended from work schedules pending the results of the ongoing investigation. b. On [DATE] at 5:00 p.m., the Director of Nursing Services/designee assessed any residents at risk for aspiration with no signs or symptoms of respiratory distress, no symptoms of GI (Gastrointestinal) illness including nausea & vomiting and no urgent care needs with all residents assessed stable. c. On [DATE] the Director of Nursing Services initiated an immediate audit of the facilities emergency preparedness and response cart/equipment. No problems were identified. Appropriate equipment including but not limited to oxygen, oxygen tubing, vital sign equipment, suction machine, suction tubing were present and ready for immediate use if a need were to arise. d. On [DATE] the Director of Nursing Services/designee initiated immediate in-services to all current scheduled employees and all employees prior to next scheduled work shift including: Performing timely and thorough resident assessment & identifying changes in condition Timely & appropriate actions to take when any resident assessment findings warrants Emergency Response Appropriate notifications to initiate when a change in condition is identified including MD (Medical Doctor), family, Hospice as applicable Location of Emergency response cart; supplies maintained thereon & use of all supplies located thereon e. Immediate actions to initiate with suspected abuse &/or neglect situations In-service/Training initiated on [DATE] is ongoing to include all nursing department employees by [DATE]. The DON/Designee will monitor all 24 hr reports and nurse's notes to ensure nurses have responded appropriately to any emergency situations and/or changes in condition daily 5 x week until compliance is achieved, then randomly thereafter. Competency in the use of equipment will be verified via acceptable demonstration for all licensed nurses.

A. Based on observations, record reviews, and interviews, the facility failed to ensure Residents #5 and #17 received adequate supervision with microwave usage to prevent burns. The facility failed to ensure residents were thoroughly assessed regarding safety in heating liquids/food in the microwave and failed to consistently implement interventions to ensure the safety of hot liquid consumption for 2 of 2 (Residents # 17 and #5) case mix residents that used the microwaves. The failed practices resulted in Immediate Jeopardy, which could have caused serious harm, injury or death for 2 (Residents #5 and 17) case mix residents that used the microwaves and had the potential to cause more than minimal harm for 3 residents who used microwaves as identified by a list provided by the Administrator 11/18/11. The facility was notified of the Immediately Jeopardy on 11/16/11 at 8:30 p.m. The findings are: 1. Resident # 17 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference (ARD) date of 8/8/11 documented the resident scored 9 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS) and required supervision with eating. a. A Resident assessment for Hot Liquids Safety dated 11/2/11 documented the resident was safe for consumption of hot liquids. b. An Unusual Occurrence Report dated 11/7/11 at 9:00 a.m., documented, "Heard res (resident) yelling for help. Ran to room (with) pt (patient) sitting in motorized chair. She stated she spilled her hot tea on herself. Removed res pants, redness noted to (upper) thighs." Nurses Notes dated 11/7/11 at 9:00 a.m., documented, "Heard Res yelling for help, ran to room res sitting in motorized chair she had spilled her hot tea on herself. VS (vital signs) (blood pressure) 148/99, (temperature) 97.8, (pulse) 97, (respirations)19, and (pulse oximeter reading) 98%. CNA (certified nursing assistant) and I removed res paints - redness noted to thighs. couseled (counseled) Res on handling hot liquids. Notified physician and family. N/TX (new treatment). Silvadene cream to upper inner thighs tid (three times daily) until healed. Will continue to monitor for s/s (signs and symptoms) of infections." c. On 11/8/11 the resident was again assessed. The assessment documented the resident was not safe for consumption of hot liquids. The following interventions were documented: 1) Temperature of liquids served not to exceed 140 degrees. 2) Resident to use cup with lid. 3) Staff to assist resident with all hot liquids. d. An Inservice Education Report dated 11/8/11 documented: "Re: Resident in (room number). This resident must be assisted with heating her water to make her tea. A staff member is to heat the water in the microwave, use the thermometer that is provided in her room to check the temp, assist with using tea bags, and add a lid to her cup. Resident is not to use microwave without the supervision and assist of staff. Liquid temperature are never to exceed 140 degrees." e. On 11/16/11 at 10:30 a.m., the resident was observed in a wheelchair propelling herself to the microwave. She then opened and put something into the microwave to warm it up. There was no staff present duirng this time. f. On 11/16/11 at 5:48 p.m., the resident was interviewed and asked if she heated something in the Microwave this morning. She replied, "Yes." She was asked what she heated up and she replied, "My hot tea." She was asked if she used the thermometer. She replied, " No, I can't find it and I don't need it anyway, I used a lid." The resident was asked if she got a blister when she burned herself last week. She replied, "Yes." She lifted up her pajamas on her left leg and there was a 2 cm (centimeters) x (by) 2 cm dark red area. She replied, "I have never spilled it, it was just an accident, I don't have any feeling in this leg (pointing to her left leg). " 2. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 11/4/11 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, was independent with all activities of daily living except supervision with personal hygiene and had functional limitation in range of motion on both sides of the lower extremities." a. A Hot Liquids Safety assessment dated [DATE] documented the resident was safe for consumption hot liquids. b. The Plan of Care updated 11/7/11 identified a problem of "Resident is at risk for developing complications r/t (related to) the needing total assistance in the following ADLS: Personal hygiene and bathing" with interventions of "Res (resident) places belts around legs to keep them together. Res secures and unfastens belts himself." c. An Electrical Appliance Safety assessment dated [DATE] documented, "Resident may use electrical appliances independently." d. On 11/16/11 at 4:40 p.m., the resident was observed in his electric wheelchair at the microwave in the kitchenette on North Hall heating up liquid substance in a freezer container with a lid (plastic). The Director of Nurses (DON) noticed the Resident using the microwave while discussing another resident with a State Surveyor. She went around the bar and stopped the microwave. She instructed the resident that it was too hot to handle and not to handle it. She took the temperature and it was 145 degrees. She advised the resident that she was going to get bowls from the kitchen to make it manageable. In a couple of moments, the Treatment Nurse was talking to State and Federal Surveyor at the bar about another resident's skin treatment. The Federal Surveyor noticed the resident attempting to remove the container and she informed the treatment nurse, who ran over to the resident and stopped him. The DON returned with 2 bowls and a plastic tray and lids for the bowls. She informed the resident that she would carry it to another resident's room for them to consume. 3. On 11/16/11 at 5:30 p.m., there was a Microwave in both kitchenettes on both nursing stations that were easily assessable to residents. 4. On 11/16/11, staff were interviewed regarding residents who were assessed to not be safe to use the microwaves unassisted: At 7:15 p.m., CNA # 3 stated, "No, I have not been told of any resident who should not use the microwave- no not me personally." At 7:21 p.m., CNA #4 stated, "I don't know of anyone that is not allowed to use microwave." At 7:25 p.m., CNA #5 stated, "We had an inservice and we were told to monitor (Resident #17) to make sure she didn't put things in the microwave for too long and to take it back to her room for her." At 7:34 p.m., CNA #2 was asked if she was aware of any resident that was to have supervision to use the microwave and she replied, "Not aware of any resident that needs supervision on this hall or other halls." 5. The Immediate Jeopardy was removed on 11/16/11 at 11:00 p.m., and the Scope and Severity reduced to "H"(due to findings at part B of the F323 citation), when the facility implemented the following plan of removal: a. On November 16, 2011 at 7:15 p.m. microwave appliances were removed from the facility North and South cafe areas and the employee break areas by the Director of Operations and the DON. On November 16, 2011 at 10:00 p.m. a documented head to toe assessment was completed by the Director of Nurses/designee (s) for Resident # 5 and #17. There were no new adverse effects related to either residents ' use of the cafe microwave identified during this assessment including no new blisters, no reddened areas and no evidence of new and/or developing skin impairments. b. On November 16, 2011 between 8 and 11 p.m., the Director of Nurses/designee (s) completed staff interviews in which staff were asked if they were aware of any other residents that used the microwaves in the cafes/break room. On November 16, 2011 resident room rounds were conducted by the Director of Operations to identify any residents that might have microwaves in their rooms, with no negative findings. On November 16th interviews were started by DON/designee to identify any other resident who had the potential to utilize or are known to have used microwave appliances while unsupervised in the cafe area. These residents were immediately assessed with [REDACTED]. c. In-service training was started on 11/16/2011 at 11:00 p.m., by the DON. All staff will be in-serviced that only Nurses will be able to heat up items in the microwave. (The microwave will be moved into the nurse medication room under lock and key after all staff has been in-serviced,) The DON/designee will in-service all nurses with return demonstration on how to take a temperature of foods/liquids after being heated up in the microwave and sign understanding that all foods must be served at 140 degree or less. The thermometer will be kept in the medication room with instructions for serving items at 140 degrees or less. All nurses will log the date, resident, temp, and nurses signature every time an item is heated up for a resident. This log will be monitored 3 times a week by Unit Managers/Designee to ensure log is being completed and up to date. At least 2 random visual checks will be completed monthly by Unit Managers/designee to ensure nurses are performing task correctly. This in-service will also be added to new orientation for all new staff to be in-serviced by the DON/designee. The above in-services to be completed by the DON/designees. B. Based on observation, record review and interview, the facility failed to ensure Residents #3 and #27 received adequate supervision while toileting to prevent falls. The facility failed to ensure that 2 (Residents #3 and #27) of 13 (Residents #1 - 4, 5 - 12, and #14) case mix residents who were at risk for falls were not left unattended in the bathroom. The facility also failed to ensure that planned interventions to prevent falls were implemented for 1 (Resident #14) of 13 (Residents #1 - 4, 5 - 12, and #14) case mix residents who were at risk for falls. This failed practice resulted in a pattern of actual harm for Resident #3 who repeatedly experienced falls and suffered a fractured hip when left unattended in the bathroom and had the potential to cause more than minimal harm for 106 residents at risk for falls per a list provided by the Administrator on 11/18/11 at 7:30 p.m. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/16/11 documented the resident had short and long term memory problems; had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status, ; required limited assistance of one staff member for bed mobility, transfers and walking in and out of room and locomotion on and off the unit; was always incontinent of urine and bowel; and was at risk for developing pressure ulcers. a. The IDT (Interdisciplinary Team)/Care Meeting Notes documented a fall on 4/25/11. The Notes documented an intervention to toilet resident at 0400 (4:00 a.m.) every morning and to monitor for restlessness. b. The IDT/Care Meeting Notes dated 5/1/11 at 1:05 a.m. documented that the resident tried to get up to go to the bathroom by self, slipped and fell . The Notes documented an intervention to check every 2 hours, before meals and at night toilet schedule. c. The IDT/Care Meeting Notes dated 5/3/11 at 8:40 a.m. documented resident was found with his knees on the floor and arm on the bed. The Notes documented an intervention to change pressure alarm to pull alarm to alert staff. d. The IDT/Care Meeting Notes dated 5/8/11 at 4:49 a.m. documented a fall. The Notes documented an intervention to move pull alarm where spouse could not turn it off or unplug it. e. The IDT/Care Meeting Notes dated 5/8/11 at 11:30 p.m. documented that resident was found kneeling at bedside and that he told staff that he was fixing the wire. The Notes documented an intervention to place fall mat at bedside. f. The Incident and Accident Report (I&A) dated 5/17/11 at 10:40 p.m. documented that staff heard a thump and found resident sitting on his bottom in front of the bathroom and that he had pulled off clip alarm. The Report documented the resident had 2 red abrasions to left knee and one to back of left thigh. The Report documented that on 5/19/11 an intervention was put in place that after the p.m. meal the resident was to be toileted and assisted to bed. He was to be checked again at 8:00 p.m. and assisted to the toilet. The Report documented that a care plan meeting was to be scheduled with family to discuss placing resident in low bed. g. The I&A Report dated 5/25/11 at 12:00 p.m. documented that staff heard yell and found resident lying in bathroom floor on his left side with a skin tear times two on his left elbow. The Report also documented that the resident tried to ambulate self without request for help. The Report documented the initial x-ray did not show any fracture but resident continued to complain, was medicated for pain; resident was sent to the emergency roiagnom on [DATE] with another negative x-ray but the CT Scan was positive for left hip fracture; and underwent surgery to repair hip fracture on 5/29/11. The Report documented interventions: The CNA was counseled to stay in bathroom with resident or outside bathroom door and all staff inserviced on 5/26/11 to never leave resident unattended in bathroom. 1) On 11/17/11 at 12:20 p.m., the DON was asked about the 5/25/11 incident. The DON stated, "I haven't reviewed that I & A in a while but I think I remember that (CNA #21) said he had him (Resident #3) in the bathroom when he heard an alarm going off that made him step outside the door. He told (Resident #3) to stay there but with (Resident #3) that doesn't mean he will. If it was at lunch time there is one aide assigned to stay on each hall when the other aide goes to the dining room; however, if the hall aide is in caring for another resident they would not be able to answer the call light. Knowing (CNA #21), he is very conscientious; he kept hearing that call light and rushed to answer it. I remember counseling (CNA #21) but I will have to check for the documentation regarding the investigation. 2) At 12:50 p.m., the DON returned and stated that she was unable to find any investigation documentation as to why CNA #21 left a resident, who was at risk for falls and was severely cognitively impaired, unattended in the bathroom. She also stated that anyone with Dementia is at risk for falls and shouldn't be left unattended in the bathroom. h. The I&A Report dated 8/27/11 at 4:00 a.m. documented: Staff heard resident yelling, found him sitting on fall mat and pressure from right elbow on pressure alarm. Resident had pulled brief off, was not wet but wanted to get up. The pressure alarm was lit but did not go off. The Report documented interventions to apply seat belt to prevent falls on a trial basis and to start rounds with this resident, anticipate his needs, toilet him, check for thirst/hunger and that staff were inserviced on 8/29/11 regarding new intervention regarding this resident only. i. The I&A Report dated 10/8/11 at 5:35 a.m. documented: Staff heard resident yelling for help, found resident standing on right knee on fall mat, right elbow pressing on bed pressure alarm and it did not go off and his upper body was on the bed. The Report documented interventions to change wet brief, move to nurses station for observation, change pressure alarm to pull and keep out of reach of spouse, and on 10/10/11 staff re-educated on " starting 4 am rounds with this resident to ensure that he is dry, apply pull alarm when resident is in the bed or in the recliner and to keep the pull alarm out of reach of the spouse. " j. The I&A Report dated 11/4/11 at 3:10 a.m. documented: Resident was found on floor by the CNA. He was sitting on fall mat with his alarm still attached to him. His brief was wet and he stated that he did not want that wet thing on him. The Report documented interventions to shorten the string on the pull alarm so that it will alarm sooner. 2. Resident #27 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 5/24/11 documented the resident scored 13 (13 - 15 indicates cognitively intact) on a BIMS, required extensive assistance of two staff members for transfers and toilet use, and had a fall in the last 2 - 6 months prior to admission. a. The Interim Admission Care Plan dated 5/18/11 documented, "...Problem: Resident is at risk for falls Related to: Weakness, arthritis, CVA (Cerebral Vascular Accident), Osteoporosis...Approach: Assist for toileting and transfers, Keep environment safe..." b. Nurses Notes dated 5/19/11 at 1215 (12:15 p.m.) documented, "Increase confusion this am. " c. Nurses Notes dated 6/1/11 at 1530 (3:30 p.m.) documented, "...N/O (new order) Ativan 0.5 mg (milligram) (one) po (by mouth) Q (every) 8 (hours) PRN (as needed), (increase) Trazodone to 50 mg (every) hs (at night)..." d. The June 2011 MAR (Medication Administration Record) documented that the resident received Trazodone 50 mg on 6/2/11 at 8:00 p.m. and also received Ativan 0.5 mg on 6/3/11 at 1:08 a.m. The Nursing 2010 Drug Handbook, 30th Anniversary Edition pages 690 - 691 documented, "...Lorazepam (Ativan)...Adverse Reactions, CNS (Central Nervous System): drowsiness, sedation, insomnia, dizziness, weakness, headache..." Pages 613 - 614 documented, "...Trazodone...Adverse Reactions, CNS: drowsiness, dizziness, weakness, headache, insomnia..." e. The Nurses Notes dated 6/3/11 at 3:00 a.m. documented, "CNA assisted (resident) to bathroom (and) instructed (resident to call for assist (assistnace). (Resident ) attempted to get off toilet (and) and fell to floor. (Name) CNA (and) (name) LPN heard (resident call out (and) found (resident) on floor. (Resident) states she hit her head on wall (amd) sustained s/t (skin tear to L (left) forearm" The Unusual Occurrence Report dated 6/3/11 at 3:00 a.m. documented, "...Type of Unusual Occurrence: Fall/Slip/lowered to floor (checked)...Type of Injury: Skin Tear x 2 (checked)...Description: (Resident) fell in bathroom (after) CNA (Certified Nurse Assistant) assisted (Resident) attempted to get off toilet (with) out calling for assist, apparently she tripped on P.J. (pajama) bottoms that were around her ankles, CNA #14 and LPN #13 heard resident call out (and) found resident on floor. resident hit head on wall (and) sustained s/t (skin tear) to (left) forearm. resident assisted into bed via w/c (wheel chair) (and) drsg. (dressing) applied to (left) forearm...5. Contributing Factors: Did not request help or refused help (checked)...7a. Pajamas around ankles may have caused her to fall...8 Immediate interventions: sign placed in bathroom to not leave resident unattended...Results of action taken: 6/10/11 moved to room closer to NS (Nurses Station), sign on wall to stay (with) resident in B/R (bathroom). Decline noted in general condition, staff to keep door cracked and stand outside..." f. On 11/18/11 at 12:50 p.m. the DON stated, "I'm aware that she (Resident #27) had a fall but I don't remember the details. She was one that would not let us stay in the bathroom with her. If I remember correctly, they stepped out and she tripped on her PJ bottoms. She should have not been left alone. We did not investigate why she was left alone or where the aide went after leaving her alone in the bathroom. We did not inservice the staff about all residents at risk of falls and who should not be left alone in the bathroom." 3. Resident #14 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 10/25/11 documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status, required extensive assistance of 2 staff persons for transfers, had a fall since last assessment and used a chair that prevented rising daily. a. An undated "Nursing Assistant Care Plan" received from the unit manager on 11/17/11 at 12:07 p.m., under the heading of "Fall Risk" the resident was marked for "High Risk For Falls" and under the heading of "Alarms " the resident was marked for Chair: Seat belt." b. On 11/16/11 at 4:15 p.m., the resident was in the hall in a wheelchair with a self release alarm belt on around his waist. The alarm box was attached to the back of the resident's wheelchair. The alarm box did not have the light on that signals that the device was turned on and working. LPN #14 propelled the resident into the room. The LPN was asked if the resident's alarm was on. The LPN pushed the button on the alarm box and the light came on. The LPN stated that the alarm was not on. C. Based on observations, record reviews, and interviews, the facility failed to use a gait belt to transfer to prevent accidental falls due to the residents ' increased weakness and inability to transfer self for 3 (Residents #1, #11, and #26) of 7 (Resident #s1 - 3, #6, #7, #9 and #12) case mix residents dependent on staff for gait belt transfers. This failed practice had the potential to cause more than minimal harm for 62 residents dependent on staff for gait belt transfers per a list provided by the Administrator on 7/18/11 at 7:30 p.m. The findings are: 1. Resident #26 was admitted on [DATE] and had [DIAGNOSES REDACTED]. a. The Interdisciplinary Care Plan: Falls documented, "...Fall Risk 1/4/11 = 13, 4/15/11 = 17, 6/1/11 = 17, 7/6/11 = 17, 7/20/11 = 17 and 7/23/11 = 15 (Total Score of 10 or above represents HIGH RISK for falls)...Disease process/condition: Dementia (hand written in)...Actual Fall Date: 6/1/11 and 7/23/11 Related to: Disease process/condition: Dementia, Osteoarthritis...Functional problem: Hip prosthesis...Use of assistive devices: W/C (wheel chair) and Other: Fall score 19...Approach: Assist of 2 for transfers and ambulation; Use a Hoyer mechanical lift for transfers..." b. The Nurses Notes dated 6/1/11 at 2:38 p.m. documented, "V/S(blood pressure) 80/ (incomplete), (temperature) 97.3, (pulse) 74, (respirations) 20...Called to room by aide, resident on floor on (right) side, aide stated she was lowered to floor after legs gave way...." The Unusual Occurrence Report dated 6/1/11 at 1:30 p.m. documented: " ...Type of Occurrence: Fall/ Slip/lowered to floor...Description of occurrence: Called to room by CNA who reported resident slipped herself to floor of bathroom-stating she was transferring to toilet and she was unable to help support herself, so lowered to floor...Correct Action Taken: Inservice and counsel to CNA - recent illness causing weakness. Staff to use assist and gait belt for transfers. 2 person assist (times) (one) week and gait belt always...Results of action taken: 6/13/11 no further falls. Now one person assist and gait belt..." c. The IDT /Standard of Care Meeting Notes dated 6/9/11 documented: "...IDT Mtg. (meeting) RE (regarding): Fall on 6/1/11 at 1330 (1:30 p.m.) in bathroom. She was lowered to floor, no injuries. Has been on ABT (antibiotic therapy) for UTI (Urinary Tract Infection). Staff instructed to use gait belt (with) 2 person..." d. The Unusual Occurrence Report dated 7/23/11 at 1150 (11:50 a.m.) documented, "...Type of Occurrence: Fall/Slip/lowered to floor...Description of occurrence: This nurse called to (Resident) B/R (bathroom), Res. laying on back on floor. CNA #12 and #11 reported that they transferred Res. from toilet to W/C (wheel chair) (and) began slipping down, CNAs lowered Res. onto floor but said left shoulder bumped against floor...5. Contributing Factors: Unsafe position/posture/transfer (transfer circled)...Environmental Contributing Factors: Other unsafe condition: No Gait Belt (hand written in)...7. Summarize factors that contributed to this unusual occurrence: a. Res. transferred from toilet to W/C, began to slip, lowered to floor per staff x 2...b. Staff did not use gait belt..." 2. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change MDS with an ARD of 10/13/11 documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status and required extensive 2 plus person assist for transfers. a. The Activities of Daily Living (ADL) Interdisciplinary Care Plan dated 10/14/11 documented, "Resident has ADL Self-Care deficit as Evidenced By: ...Needs assistance with (specify Self Performance) ... extensive X (times) 1 transfer ..." b. On 11/15/11 at 4:40 p.m., CNA #18 and #5 were observed transferring the resident from her bed to the wheelchair. CNA #18 placed her hands under the resident's shoulders and CNA #5 placed her hands under the resident's lower extremities to sit the resident up on the side of the bed. CNA #18 applied the gait belt to the resident's breast area and under her arms and stated, "Since she has this feeding tube." Resident #1 was unable to bear weight and her feet were sliding as she was positioned in the wheelchair. c. On 11/17/11 at 10:10 a.m., the DON was asked if a resident is unable to bear weight how would you expect the staff to transfer a resident and the DON stated, "They should use a lift." 3. Resident #11 had [DIAGNOSES REDACTED]. a. A Transfer Assistance assessment dated [DATE] and updated 9/2/11 documented, "Gait belt/Stand-up lift with 2 person assist." b. On 11/15/11 at 10:40 a.m., CNA # 15 and #16 transferred the resident to the bed by placing the gait belt around the resident's waist. The CNA's placed one hand on the gait belt and the other arm under the resident's arm pits. When they lifted the resident out of the chair, the gait belt slid up to the upper torso and the resident was unable to bear weight. D. Based on observations, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible. The facility failed to ensure: A bag of scissors was not accessible to Resident #3. Melted Scentsy wax was not accessible to cognitively impaired mobile residents at the Nurses Station on the north hall. Cabinets with hazardous containers in all the shower rooms were locked to prevent resident access. A sharp turkey lifter and a serrated pumpkin carver were not in a drawer in the independent dining room accessible to cognitively impaired residents. The rollers on the Sara Lift was free from hair build-up to prevent malfunction. The walk-way at the end of 700 and 800 hall did not have any raised areas presenting a fall hazard. Geri chairs and wheelchairs were free from torned and jagged arm rests to prevent skin tears. Dryer filters were free from lint to prevent fires. The tables on the 400 day room were free from chipped and sharp edges to prevent skin tears. Unlabeled containers containing clear liquid was not left in the beauty shop accessible to cognitive impaired mobile residents. These failed practices had the potential to cause more than minimal harm for 126 residents residing in the facility as per the Resident Census and Condition report obtained from the facility on 11/15/11. The findings are: 1. Resident #3 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/16/11 documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision making and required supervision to limited assistance with most Activities of Daily Living. a. The Nurses Notes dated 11/13/11 at 0145 (1:45 a.m.) documented, "Resident laying in bed, yelling loudly, making multiple attempts to get out of bed. Administered ii (two) Lorazepam 0.5 mg tabs per MAR. Resident continued to yell, swing at staff, and attempting to get out of wheelchair. ...45 minutes later resident was still yelling, attempting to bite staff. Over an hour later, resident was less agitated, sitting in wheelchair in room. When aides went to check on resident at 0300 (3:00 a.m.), they found resident sitting in wheelchair, holding scissors, cutting up his underwear/brief. When asked where he got the scissors, he said, ' in the drawer'. Aides found a ziplock bag with several pairs of scissors and clippers in resident ' s bathroom drawer. LPN (Licensed Practical Nurse) put the ziplock bag in the Med cart. No cuts or scratches were noted on the resident from his use of scissors to his brief..." 2. On 11/14/11 at 1:45 p.m., there was a Scentsy electric burner sitting on the east side of the North Hall Nurses Station accessible to self mobile residents. The wax was melted and the temperature was 82 degrees Fahrenheit. The label documented, "...Warning:...Prolonged contact with skin may cause irritation. Handle hot wax with care as it may cause serious injury..." 3. Resident # 7 had [DIAGNOSES REDACTED]. A quarterly MDS with an ARD of 10/18/11 documented the resident had short and long term memory problems and was severely impaired in cognitive skills for daily decision making. a. On 11/15/11 at 3:22 p.m., the arms on the residents wheelchair was rough along the inside edges and the hard plastic edge was cracked, and broken with sharp areas. 4. On 11/15/11 at 9:28 a.m., the left arm of Resident #5 ' s motorized wheelchair was torn. 5. During environmental rounds on 11/17/11 at 11:05 a.m., the following hazards were discovered: a. Two sets of Turkey lifters with sharp spears and a serrated pumpkin carver were in an ulocked drawer in the independent dining room accessibile to anyone who came into the dining room. b. The Cabinet in the shower room between 500 hall and 600 hall was unlocked. There was a sharps container that was overflowing with disposable razors in it. c. The hazardous waste room on the South Halls had 2 boxes of hazardous waste that were not covered. d. At the top of the hall on 600, there was a 1/2 inch hole in the wall and a screw that stuck outside approximately 1/2 inch accessible to any ambulatory resident who rubbed up against the wall. e. In Room 604 there were 3 razors on the overbed table near the resident in bed B. f. The sara lift rollers had hair and string hanging off them. g. Used razors were thrown into an emesis basin in the unlocked cabinet in the Shower room between 600 hall and 700 hall. There was no red sharps container. h. There was sharp metal inside that should have been covered with a metal hook on the inside of the bathroom door in room 707. i. There was a blue G-chair in the North hall kitchenette with a tear on the top of it. j. There were 10 wheelchairs in the dining room, with armrests that were cracked and jagged. k. There was a small bottle in the beauty shop with a black sprayer that was 1/2 full of clear liquid that was not labeled sitting on a roller cart. l. In the 400 hall dayroom, there was a round table that had 2 sharp gouged areas around the edges. There was also a long white tabl

Based on observations, record reviews, and interviews, the facility Administration failed ensure that accident/incident reports were reviewed and an effective accident prevention program was established: The facility failed to ensure residents were thoroughly assessed regarding safety in heating liquids/food in the microwave and failed to consistently implement interventions to ensure the safety of hot liquid consumption for 2 of 2 (Residents # 17 and #5) case mix residents that used the microwaves. The failed practices resulted in Immediate Jeopardy, which could have caused serious harm, injury or death for 2 (Residents # 17 and #5) case mix residents that used the microwaves and had the potential to cause more than minimal harm for 3 residents who used microwaves as identified by a list provided by the Administrator 11/18/11. The facility was notified of the Immediately Jeopardy on 11/16/11 at 8:30 p.m. The facility failed to ensure Residents #3 and #27 received adequate supervision while toileting to prevent falls. The facility failed to ensure that 2 (Residents #3 and #27) of 13 (Residents #1 - 4, 5 - 12, & #14) case mix residents who were at risk for falls were not left unattended in the bathroom. The facility also failed to ensure that planned interventions to prevent falls were implemented for 1 (Resident #14) of 13 (Residents #1 - 4, 5 - 12, & #14) case mix residents who were at risk for falls. This failed practice resulted in a pattern of actual harm for Resident #3 who repeatedly experienced falls and suffered a [MEDICAL CONDITION] when left unattended in the bathroom and had the potential to cause more than minimal harm for 106 residents at risk for falls per a list provided by the Administrator on 11/18/11 at 7:30 p.m. The findings are: 1. The Job Description for Administrator obtained from the Director of Nursing services on 11/17/11 at 3:53 p.m., documented " Purpose: The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our patients at all time. The Safety and Sanitation Functions documented "Ensure that the facility is maintained in a clean and safe manner for patient comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services. Review accident/incident reports and establish an effective accident prevention program and Ensure that facility procedure manuals identify safety precautions and equipment to use when performing tasks that could cause bodily injury." 2. Resident # 17 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference (ARD) date of 8/8/11 documented the resident scored 9 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS) and required supervision with eating. a. A Resident assessment for Hot Liquids Safety dated 11/2/11 documented the resident was safe for consumption of hot liquids. b. An Unusual Occurrence Report dated 11/7/11 at 9:00 a.m., documented, "Heard res (resident) yelling for help. Ran to room (with) pt (patient) sitting in motorized chair. She stated she spilled her hot tea on herself. Removed res pants, redness noted to (upper) thighs." Nurses Notes dated 11/7/11 at 9:00 a.m., documented, "Heard Res yelling for help, ran to room res sitting in motorized chair she had spilled her hot tea on herself. VS (vital signs) (blood pressure) 148/99, (temperature) 97.8, (pulse) 97, (respirations)19, and (pulse oximeter reading) 98%. CNA (certified nursing assistant) and I removed res paints - redness noted to thighs. couseled (counseled) Res on handling hot liquids. Notified physician and family. N/TX (new treatment). [MEDICATION NAME] cream to upper inner thighs tid (three times daily) until healed. Will continue to monitor for s/s (signs and symptoms) of infections." c. On 11/8/11 the resident was again assessed. The assessment documented the resident was not safe for consumption of hot liquids. The following interventions were documented: 1) Temperature of liquids served not to exceed 140 degrees. 2) Resident to use cup with lid. 3) Staff to assist resident with all hot liquids. d. An Inservice Education Report dated 11/8/11 documented: " Re: Resident in (room number). This resident must be assisted with heating her water to make her tea. A staff member is to heat the water in the microwave, use the thermometer that is provided in her room to check the temp, assist with using tea bags, and add a lid to her cup. Resident is not to use microwave without the supervision and assist of staff. Liquid temperature are never to exceed 140 degrees." e. On 11/16/11 at 10:30 a.m., the resident was observed in a wheelchair propelling herself to the microwave. She then opened and put something into the microwave to warm it up. There was no staff present duirng this time. f. On 11/16/11 at 5:48 p.m., the resident was interviewed and asked if she heated something in the Microwave this morning. She replied, "Yes." She was asked what she heated up and she replied, "My hot tea." She was asked if she used the thermometer. She replied, " No, I can't find it and I don't need it anyway, I used a lid." The resident was asked if she got a blister when she burned herself last week. She replied, "Yes." She lifted up her pajamas on her left leg and there was a 2 cm (centimeters) x (by) 2 cm dark red area. She replied, "I have never spilled it, it was just an accident, I don't have any feeling in this leg (pointing to her left leg). " 3. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 11/4/11 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS, was independent with all activities of daily living except supervision with personal hygiene and had functional limitation in range of motion on both sides of the lower extremities." a. A Hot Liquids Safety assessment dated [DATE] documented the resident was safe for consumption hot liquids. b. The Plan of Care updated 11/7/11 identified a problem of "Resident is at risk for developing complications r/t (related to) the needing total assistance in the following ADLS (Activities of Daily Living): Personal hygiene and bathing" with interventions of "Res (resident) places belts around legs to keep them together. Res (Resident) secures and unfastens belts himself." c. An Electrical Appliance Safety assessment dated [DATE] documented, "Resident may use electrical appliances independently." d. On 11/16/11 at 4:40 p.m., the resident was observed in his electric wheelchair at the microwave in the kitchenette on North Hall heating up liquid substance in a freezer container with a lid (plastic). There was not staff assisting the resident at this time. The Director of Nurses (DON) noticed the Resident using the microwave while discussing another resident with a State Surveyor. She went around the bar and stopped the microwave. She instructed the resident that it was too hot to handle and not to handle it. She took the temperature and it was 145 degrees. She advised the resident that she was going to get bowls from the kitchen to make it manageable. In a couple of moments, the Treatment Nurse was talking to State and Federal Surveyor at the bar about another resident's skin treatment. The Federal Surveyor noticed the resident attempting to remove the container and she informed the treatment nurse, who ran over to the resident and stopped him. The DON returned with 2 bowls and a plastic tray and lids for the bowls. She informed the resident that she would carry it to another resident's room for them to consume. 4. On 11/16/11 at 5:30 p.m., there was a Microwave in both kitchenettes on both nursing stations that were easily assessable to residents. 5. On 11/16/11, staff were interviewed regarding residents who were assessed to not be safe to use the microwaves unassisted: At 7:15 p.m., CNA # 3 stated, "No, I have not been told of any resident who should not use the microwave- no not me personally." At 7:21 p.m., CNA #4 stated, "I don't know of anyone that is not allowed to use microwave." At 7:25 p.m., CNA #5 stated, "We had an inservice and we were told to monitor (Resident #17) to make sure she didn't put things in the microwave for too long and to take it back to her room for her." At 7:34 p.m., CNA #2 was asked if she was aware of any resident that was to have supervision to use the microwave and she replied, "Not aware of any resident that needs supervision on this hall or other halls." 6. The Immediate Jeopardy was removed on 11/16/11 at 11:00 p.m., and the Scope and Severity reduced to "H"(due to findings at items 7-9 in the F490 citation), when the facility implemented the following plan of removal: a. On November 16, 2011 at 7:15 p.m. microwave appliances were removed from the facility North and South cafe areas and the employee break areas by the Director of Operations and the DON. On November 16, 2011 at 10:00 p.m. a documented head to toe assessment was completed by the Director of Nurses/designee (s) for Resident # 5 and #17. There were no new adverse effects related to either residents ' use of the cafe microwave identified during this assessment including no new blisters, no reddened areas and no evidence of new and/or developing skin impairments. b. On November 16, 2011 between 8 and 11 p.m., the Director of Nurses/designee (s) completed staff interviews in which staff were asked if they were aware of any other residents that used the microwaves in the cafes/break room. On November 16, 2011 resident room rounds were conducted by the Director of Operations to identify any residents that might have microwaves in their rooms, with no negative findings. On November 16th interviews were started by DON/designee to identify any other resident who had the potential to utilize or are known to have used microwave appliances while unsupervised in the cafe area. These residents were immediately assessed with [REDACTED]. c. In-service training was started on 11/16/2011 at 11:00 p.m., by the DON. All staff will be in-serviced that only Nurses will be able to heat up items in the microwave. (The microwave will be moved into the nurse medication room under lock and key after all staff has been in-serviced,) The DON/designee will in-service all nurses with return demonstration on how to take a temperature of foods/liquids after being heated up in the microwave and sign understanding that all foods must be served at 140 degree or less. The thermometer will be kept in the medication room with instructions for serving items at 140 degrees or less. All nurses will log the date, resident, temp, and nurses signature every time an item is heated up for a resident. This log will be monitored 3 times a week by Unit Managers/Designee to ensure log is being completed and up to date. At least 2 random visual checks will be completed monthly by Unit Managers/designee to ensure nurses are performing task correctly. This in-service will also be added to new orientation for all new staff to be in-serviced by the DON/designee. The above in-services to be completed by the DON/designees. 7. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/16/11 documented the resident had short and long term memory problems; was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; required limited assistance of one staff member for bed mobility, transfers and walking in and out of room and locomotion on and off the unit; was always incontinent of urine and bowel; and was at risk for developing pressure ulcers. a. The IDT (Interdisciplinary Team)/Care Meeting Notes documented a fall on 4/25/11. The Notes documented an intervention to toilet resident at 4:00 a.m. every morning and to monitor for restlessness. b. The IDT/Care Meeting Notes dated 5/1/11 at 1:05 a.m. documented that the resident tried to get up to go to the bathroom by self, slipped and fell . The Notes documented an intervention to check every 2 hours, before meals and at night toilet schedule. c. The IDT/Care Meeting Notes dated 5/3/11 at 8:40 a.m. documented resident was found with his knees on the floor and arm on the bed. The Notes documented an intervention to change pressure alarm to pull alarm to alert staff. d. The IDT/Care Meeting Notes dated 5/8/11 at 4:49 a.m. documented a fall. The Notes documented an intervention to move pull alarm where spouse could not turn it off or unplug it. e. The IDT/Care Meeting Notes dated 5/8/11 at 11:30 p.m. documented that resident was found kneeling at bedside and that he told staff that he was fixing the wire. The Notes documented an intervention to place fall mat at bedside. f. The Incident and Accident Report (I&A) dated 5/17/11 at 10:40 p.m. documented that staff heard a thump and found resident sitting on his bottom in front of the bathroom and that he had pulled off clip alarm. The Report documented the resident had 2 red abrasions to left knee and one to back of left thigh. The Report documented that on 5/19/11 an intervention was put in place that after the p.m. meal the resident was to be toileted and assisted to bed. He was to be checked again at 8:00 p.m. and assisted to the toilet. The Report documented that a care plan meeting was to be scheduled with family to discuss placing resident in low bed. g. The I&A Report dated 5/25/11 at 12:00 p.m. documented that staff heard yell and found resident lying in bathroom floor on his left side with a skin tear times two on his left elbow. The Report also documented that the resident tried to ambulate self without request for help. The Report documented the initial x-ray did not show any fracture but resident continued to complain, was medicated for pain; resident was sent to the emergency roiagnom on [DATE] with another negative x-ray but the CT (Computerized Tomography) Scan was positive for left [MEDICAL CONDITION]; and underwent surgery to repair [MEDICAL CONDITION] on 5/29/11. The Report documented interventions: The CNA was counseled to stay in bathroom with resident or outside bathroom door and all staff inserviced on 5/26/11 to never leave resident unattended in bathroom. 1) On 11/17/11 at 12:20 p.m., the DON was asked about the 5/25/11 incident. The DON stated, "I haven't reviewed that I & A in a while but I think I remember that (CNA #21) said he had him (Resident #3) in the bathroom when he heard an alarm going off that made him step outside the door. He told (Resident #3) to stay there but with (Resident #3) that doesn't mean he will. If it was at lunch time there is one aide assigned to stay on each hall when the other aide goes to the dining room; however, if the hall aide is in caring for another resident they would not be able to answer the call light. Knowing (CNA #21), he is very conscientious; he kept hearing that call light and rushed to answer it. I remember counseling (CNA #21) but I will have to check for the documentation regarding the investigation. 2) At 12:50 p.m., the DON returned and stated that she was unable to find any investigation documentation as to why CNA #21 left a resident, who was at risk for falls and was severely cognitively impaired, unattended in the bathroom. She also stated that anyone with Dementia is at risk for falls and shouldn't be left unattended in the bathroom. h. The I&A Report Report dated 8/27/11 at 4:00 a.m. documented: Staff heard resident yelling, found him sitting on fall mat and pressure from right elbow on pressure alarm. Resident had pulled brief off, was not wet but wanted to get up. The pressure alarm was lit but did not go off. The Report documented interventions to apply seat belt to prevent falls on a trial basis and to start rounds with this resident, anticipate his needs, toilet him, check for thirst/hunger and that staff were inserviced on 8/29/11 regarding new intervention regarding this resident only. i. The I&A Report dated 10/8/11 at 5:35 a.m. documented: Staff heard resident yelling for help, found resident standing on right knee on fall mat, right elbow pressing on bed pressure alarm and it did not go off and his upper body was on the bed. The Report documented interventions to change wet brief, move to nurses station for observation, change pressure alarm to pull and keep out of reach of spouse, and on 10/10/11 staff re-educated on " starting 4 am rounds with this resident to ensure that he is dry, apply pull alarm when resident is in the bed or in the recliner and to keep the pull alarm out of reach of the spouse. " j. The I&A Report dated 11/4/11 at 3:10 a.m. documented: Resident was found on floor by the CNA. He was sitting on fall mat with his alarm still attached to him. His brief was wet and he stated that he did not want that wet thing on him. The Report documented interventions to shorten the string on the pull alarm so that it will alarm sooner. 8. Resident #27 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 5/24/11 documented the resident scored 13 (13 - 15 indicates cognitively intact) on a BIMS, required extensive assistance of two staff members for transfers and toilet use, and had a fall in the last 2 - 6 months prior to admission. a. The Interim Admission Care Plan dated 5/18/11 documented, "...Problem: Resident is at risk for falls Related to: Weakness, arthritis,[MEDICAL CONDITIONS]: Assist for toileting and transfers, Keep environment safe..." b. Nurses Notes dated 5/19/11 at 1215 (12:15 p.m.) documented, "Increase confusion this am. " c. Nurses Notes dated 6/1/11 at 1530 (3:30 p.m.) documented, "...N/O (new order) [MEDICATION NAME] 0.5 mg (milligram) (one) po (by mouth) Q (every) 8 (hours) PRN (as needed), (increase) [MEDICATION NAME] to 50 mg (every) hs (at night)..." d. The June 2011 MAR (Medication Administration Record) documented that the resident received [MEDICATION NAME] 50 mg on 6/2/11 at 8:00 p.m. and also received [MEDICATION NAME] 0.5 mg on 6/3/11 at 1:08 a.m. The Nursing 2010 Drug Handbook, 30th Anniversary Edition pages 690 - 691 documented, "[MEDICATION NAME] ([MEDICATION NAME])...Adverse Reactions, CNS (Central Nervous System): drowsiness, sedation, [MEDICAL CONDITION], dizziness, weakness, headache..." Pages 613 - 614 documented, "[MEDICATION NAME] Reactions, CNS: drowsiness, dizziness, weakness, headache, [MEDICAL CONDITION]" e. The Nurses Notes dated 6/3/11 at 3:00 a.m. documented, "CNA assisted (resident) to bathroom (and) instructed (resident to call for assist (assistnace). (Resident ) attempted to get off toilet (and) and fell to floor. (Name) CNA (and) (name) LPN heard (resident call out (and) found (resident) on floor. (Resident) states she hit her head on wall (amd) sustained s/t (skin tear to L (left) forearm" The Unusual Occurrence Report dated 6/3/11 at 3:00 a.m. documented, "...Type of Unusual Occurrence: Fall/Slip/lowered to floor (checked)...Type of Injury: Skin Tear x 2 (checked)...Description: (Resident) fell in bathroom (after) CNA (Certified Nurses Assistant) assisted (Resident) attempted to get off toilet (with) out calling for assist, apparently she tripped on P.J. (pajama) bottoms that were around her ankles, CNA #14 and LPN #13 heard resident call out (and) found resident on floor. resident hit head on wall (and) sustained s/t (skin tear) to (left) forearm. resident assisted into bed via w/c (wheel chair) (and) drsg. (dressing) applied to (left) forearm...5. Contributing Factors: Did not request help or refused help (checked)...7a. Pajamas around ankles may have caused her to fall...8 Immediate interventions: sign placed in bathroom to not leave resident unattended...Results of action taken: 6/10/11 moved to room closer to NS (Nurses Station), sign on wall to stay (with) resident in B/R (bathroom). Decline noted in general condition, staff to keep door cracked and stand outside..." f. On 11/18/11 at 12:50 p.m. the DON stated, "I'm aware that she (Resident #27) had a fall but I don't remember the details. She was one that would not let us stay in the bathroom with her. If I remember correctly, they stepped out and she tripped on her PJ bottoms. She should have not been left alone. We did not investigate why she was left alone or where the aide went after leaving her alone in the bathroom. We did not inservice the staff about all residents at risk of falls and who should not be left alone in the bathroom." 9. Resident #14 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 10/25/11 documented the resident had short and long term memory problems, had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status, required extensive assistance of 2 staff persons for transfers, had a fall since last assessment and used a chair that prevented rising daily. a. An undated "Nursing Assistant Care Plan" received from the unit manager on 11/17/11 at 12:07 p.m., under the heading of "Fall Risk" the resident was marked for "High Risk For Falls" and under the heading of "Alarms " the resident was marked for Chair: Seat belt." b. On 11/16/11 at 4:15 p.m., the resident was in the hall in a wheelchair with a self release alarm belt on around his waist. The alarm box was attached to the back of the resident's wheelchair. The alarm box did not have the light on that signals that the device was turned on and working. LPN #14 propelled the resident into room. The LPN was if the resident's alarm was on. The LPN pushed the button on the alarm box and the light came on. The LPN stated that the alarm was not on.

Based on observations, record reviews, and interviews, the Quality Assessment and Assurance (QA&A) Committee failed to identify issues with respect to which quality assessment and assurance activities are necessary; and to develop and implement appropriate plans of action to correct identified quality deficiencies related to accidents: The facility failed to ensure residents were thoroughly assessed regarding safety in heating liquids/food in the microwave and failed to consistently implement interventions to ensure the safety of hot liquid consumption for 2 of 2 (Residents # 17 and #5) case mix residents that used the microwaves. The failed practices resulted in Immediate Jeopardy, which could have caused serious harm, injury or death for 2 (Residents # 17 and #5) case mix residents that used the microwaves and had the potential to cause more than minimal harm for 3 residents who used microwaves as identified by a list provided by the Administrator 11/18/11. The facility was notified of the Immediately Jeopardy on 11/16/11 at 8:30 p.m. The facility failed to ensure Residents #3 and #27 received adequate supervision while toileting to prevent falls. The facility failed to ensure that 2 (Residents #3 and #27) of 13 (Residents #1 - 4, 5 - 12, and #14) case mix residents who were at risk for falls were not left unattended in the bathroom. The facility also failed to ensure that planned interventions to prevent falls were implemented for 1 (Resident #14) of 13 (Residents #1 - 4, 5 - 12, and #14) case mix residents who were at risk for falls. This failed practice resulted in a pattern of actual harm for Resident #3 who repeatedly experienced falls and suffered a [MEDICAL CONDITION] when left unattended in the bathroom and had the potential to cause more than minimal harm for 106 residents at risk for falls per a list provided by the Administrator on 11/18/11 at 7:30 p.m. The findings are: 1. The Administrator was interviewed on 11/14/11 at 1:30 p.m. and 11/18/11 at 2:37 p.m. regarding the Quality Assessment and Assurance (QA&A) Committee: The QA&A committee consists of the Administrator, the Director of Nursing (DON), the Medical Director, and the Department Heads. The DON leads the committee and they meet monthly. When asked how does the committee decide the manner in which improvement will be made, the Administrator stated, " We discuss it and come up with a plan. " When asked how the QA&A Committee identify current and ongoing issues for committee action, the Administrator stated, " Everybody from each discipline and they bring their documentation and meet with the Physician. They bring resident and family interviews. 2. Resident # 17 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference (ARD) date of 8/8/11 documented the resident scored 9 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS) and required supervision with eating. a. A Resident assessment for Hot Liquids Safety dated 11/2/11 documented the resident was safe for consumption of hot liquids. b. An Unusual Occurrence Report dated 11/7/11 at 9:00 a.m., documented, "Heard res (resident) yelling for help. Ran to room (with) pt (patient) sitting in motorized chair. She stated she spilled her hot tea on herself. Removed res pants, redness noted to (upper) thighs." Nurses Notes dated 11/7/11 at 9:00 a.m., documented, "Heard Res yelling for help, ran to room res sitting in motorized chair she had spilled her hot tea on herself. VS (vital signs) (blood pressure) 148/99, (temperature) 97.8, (pulse) 97, (respirations)19, and (pulse oximeter reading) 98%. CNA (Certified Nursing Assistant) and I removed res paints - redness noted to thighs. couseled (counseled) Res on handling hot liquids. Notified physician and family. N/TX (new treatment). [MEDICATION NAME] cream to upper inner thighs tid (three times daily) until healed. Will continue to monitor for s/s (signs and symptoms) of infections." c. On 11/8/11 the resident was again assessed. The assessment documented the resident was not safe for consumption of hot liquids. The following interventions were documented: 1) Temperature of liquids served not to exceed 140 degrees. 2) Resident to use cup with lid. 3) Staff to assist resident with all hot liquids. d. An Inservice Education Report dated 11/8/11 documented: " Re: Resident in (room number). This resident must be assisted with heating her water to make her tea. A staff member is to heat the water in the microwave, use the thermometer that is provided in her room to check the temp, assist with using tea bags, and add a lid to her cup. Resident is not to use microwave without the supervision and assist of staff. Liquid temperature are never to exceed 140 degrees." e. On 11/16/11 at 10:30 a.m., the resident was observed in a wheelchair propelling herself to the microwave. She then opened and put something into the microwave to warm it up. There was no staff present duirng this time. f. On 11/16/11 at 5:48 p.m., the resident was interviewed and asked if she heated something in the Microwave this morning. She replied, "Yes." She was asked what she heated up and she replied, "My hot tea." She was asked if she used the thermometer. She replied, " No, I can't find it and I don't need it anyway, I used a lid." The resident was asked if she got a blister when she burned herself last week. She replied, "Yes." She lifted up her pajamas on her left leg and there was a 2 cm (centimeters) x (by) 2 cm dark red area. She replied, "I have never spilled it, it was just an accident, I don't have any feeling in this leg (pointing to her left leg). " 3. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 11/4/11 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS score of 15, was independent with all activities of daily living except supervision with personal hygiene and had functional limitation in range of motion on both sides of the lower extremities." a. A Hot Liquids Safety assessment dated [DATE] documented the resident was safe for consumption hot liquids. b. The Plan of Care updated 11/7/11 identified a problem of "Resident is at risk for developing complications r/t (related to) the needing total assistance in the following ADLS: Personal hygiene and bathing" with interventions of "Res (resident) places belts around legs to keep them together. Res secures and unfastens belts himself." c. An Electrical Appliance Safety assessment dated [DATE] documented, "Resident may use electrical appliances independently." d. On 11/16/11 at 4:40 p.m., the resident was observed in his electric wheelchair at the microwave in the kitchenette on North Hall heating up liquid substance in a freezer container with a lid (plastic). The DON noticed the resident using the microwave while discussing another resident with a State Surveyor. She went around the bar and stopped the microwave. She instructed the resident that it was too hot to handle and not to handle it. She took the temperature and it was 145 degrees. She advised the resident that she was going to get bowls from the kitchen to make it manageable. In a couple of moments, the Treatment Nurse was talking to State and Federal Surveyor at the bar about another resident's skin treatment. The Federal Surveyor noticed the resident attempting to remove the container and she informed the treatment nurse, who ran over to the resident and stopped him. The DON returned with 2 bowls and a plastic tray and lids for the bowls. She informed the resident that she would carry it to another resident's room for them to consume. 4. On 11/16/11 at 5:30 p.m., there was a Microwave in both kitchenettes on both nursing stations that were easily assessable to residents. 5. On 11/16/11, staff were interviewed regarding residents who were assessed to not be safe to use the microwaves unassisted: At 7:15 p.m., Certified Nurse Assistant (CNA) # 3 stated, "No, I have not been told of any resident who should not use the microwave- no not me personally." At 7:21 p.m., CNA #4 stated, "I don't know of anyone that is not allowed to use microwave." At 7:25 p.m., CNA #5 stated, "We had an inservice and we were told to monitor (Resident #17) to make sure she didn't put things in the microwave for too long and to take it back to her room for her." At 7:34 p.m., CNA #2 was asked if she was aware of any resident that was to have supervision to use the microwave and she replied, "Not aware of any resident that needs supervision on this hall or other halls." 6. The Immediate Jeopardy was removed on 11/16/11 at 11:00 p.m., and the Scope and Severity reduced to "H"(due to findings at items 7-9 in the F490 citation), when the facility implemented the following plan of removal: a. On November 16, 2011 at 7:15 p.m. microwave appliances were removed from the facility North and South cafe areas and the employee break areas by the Director of Operations and the DON. On November 16, 2011 at 10:00 p.m. a documented head to toe assessment was completed by the Director of Nurses/designee (s) for Resident # 5 and #17. There were no new adverse effects related to either residents ' use of the cafe microwave identified during this assessment including no new blisters, no reddened areas and no evidence of new and/or developing skin impairments. b. On November 16, 2011 between 8 and 11 p.m., the Director of Nurses/designee (s) completed staff interviews in which staff were asked if they were aware of any other residents that used the microwaves in the cafes/break room. On November 16, 2011 resident room rounds were conducted by the Director of Operations to identify any residents that might have microwaves in their rooms, with no negative findings. On November 16th interviews were started by DON/designee to identify any other resident who had the potential to utilize or are known to have used microwave appliances while unsupervised in the cafe area. These residents were immediately assessed with [REDACTED]. c. In-service training was started on 11/16/2011 at 11:00 p.m., by the DON. All staff will be in-serviced that only Nurses will be able to heat up items in the microwave. (The microwave will be moved into the nurse medication room under lock and key after all staff has been in-serviced,) The DON/designee will in-service all nurses with return demonstration on how to take a temperature of foods/liquids after being heated up in the microwave and sign understanding that all foods must be served at 140 degree or less. The thermometer will be kept in the medication room with instructions for serving items at 140 degrees or less. All nurses will log the date, resident, temp, and nurses signature every time an item is heated up for a resident. This log will be monitored 3 times a week by Unit Managers/Designee to ensure log is being completed and up to date. At least 2 random visual checks will be completed monthly by Unit Managers/designee to ensure nurses are performing task correctly. This in-service will also be added to new orientation for all new staff to be in-serviced by the DON/designee. The above in-services to be completed by the DON/designees. 7. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 9/16/11 documented the resident had short and long term memory problems; was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; required limited assistance of one staff member for bed mobility, transfers and walking in and out of room and locomotion on and off the unit; was always incontinent of urine and bowel; and was at risk for developing pressure ulcers. a. The IDT (Interdisciplinary Team)/Care Meeting Notes documented a fall on 4/25/11. The Notes documented an intervention to toilet resident at 4:00 a.m. every morning and to monitor for restlessness. b. The IDT/Care Meeting Notes dated 5/1/11 at 1:05 a.m. documented that the resident tried to get up to go to the bathroom by self, slipped and fell . The Notes documented an intervention to check every 2 hours, before meals and at night toilet schedule. c. The IDT/Care Meeting Notes dated 5/3/11 at 8:40 a.m. documented resident was found with his knees on the floor and arm on the bed. The Notes documented an intervention to change pressure alarm to pull alarm to alert staff. d. The IDT/Care Meeting Notes dated 5/8/11 at 4:49 a.m. documented a fall. The Notes documented an intervention to move pull alarm where spouse could not turn it off or unplug it. e. The IDT/Care Meeting Notes dated 5/8/11 at 11:30 p.m. documented that resident was found kneeling at bedside and that he told staff that he was fixing the wire. The Notes documented an intervention to place fall mat at bedside. f. The Incident and Accident Report (I&A) dated 5/17/11 at 10:40 p.m. documented that staff heard a thump and found resident sitting on his bottom in front of the bathroom and that he had pulled off clip alarm. The Report documented the resident had 2 red abrasions to left knee and one to back of left thigh. The Report documented that on 5/19/11 an intervention was put in place that after the p.m. meal the resident was to be toileted and assisted to bed. He was to be checked again at 8:00 p.m. and assisted to the toilet. The Report documented that a care plan meeting was to be scheduled with family to discuss placing resident in low bed. g. The I&A Report dated 5/25/11 at 12:00 p.m. documented that staff heard yell and found resident lying in bathroom floor on his left side with a skin tear times two on his left elbow. The Report also documented that the resident tried to ambulate self without request for help. The Report documented the initial x-ray did not show any fracture but resident continued to complain, was medicated for pain; resident was sent to the emergency roiagnom on [DATE] with another negative x-ray but the CT (Computerized Tomography) Scan was positive for left [MEDICAL CONDITION]; and underwent surgery to repair [MEDICAL CONDITION] on 5/29/11. The Report documented interventions: The CNA was counseled to stay in bathroom with resident or outside bathroom door and all staff inserviced on 5/26/11 to never leave resident unattended in bathroom. 1) On 11/17/11 at 12:20 p.m., the DON was asked about the 5/25/11 incident. The DON stated, "I haven't reviewed that I & A in a while but I think I remember that (CNA #21) said he had him (Resident #3) in the bathroom when he heard an alarm going off that made him step outside the door. He told (Resident #3) to stay there but with (Resident #3) that doesn't mean he will. If it was at lunch time there is one aide assigned to stay on each hall when the other aide goes to the dining room; however, if the hall aide is in caring for another resident they would not be able to answer the call light. Knowing (CNA #21), he is very conscientious; he kept hearing that call light and rushed to answer it. I remember counseling (CNA #21) but I will have to check for the documentation regarding the investigation. 2) At 12:50 p.m., the DON returned and stated that she was unable to find any investigation documentation as to why CNA #21 left a resident, who was at risk for falls and was severely cognitively impaired, unattended in the bathroom. She also stated that anyone with Dementia is at risk for falls and shouldn't be left unattended in the bathroom. h. The I&A Report dated 8/27/11 at 4:00 a.m. documented: Staff heard resident yelling, found him sitting on fall mat and pressure from right elbow on pressure alarm. Resident had pulled brief off, was not wet but wanted to get up. The pressure alarm was lit but did not go off. The Report documented interventions to apply seat belt to prevent falls on a trial basis and to start rounds with this resident, anticipate his needs, toilet him, check for thirst/hunger and that staff were inserviced on 8/29/11 regarding new intervention regarding this resident only. i. The I&A Report dated 10/8/11 at 5:35 a.m. documented: Staff heard resident yelling for help, found resident standing on right knee on fall mat, right elbow pressing on bed pressure alarm and it did not go off and his upper body was on the bed. The Report documented interventions to change wet brief, move to nurses station for observation, change pressure alarm to pull and keep out of reach of spouse, and on 10/10/11 staff re-educated on " starting 4 am rounds with this resident to ensure that he is dry, apply pull alarm when resident is in the bed or in the recliner and to keep the pull alarm out of reach of the spouse. " j. The I&A Report dated 11/4/11 at 3:10 a.m. documented: Resident was found on floor by the CNA. He was sitting on fall mat with his alarm still attached to him. His brief was wet and he stated that he did not want that wet thing on him. The Report documented interventions to shorten the string on the pull alarm so that it will alarm sooner. 8. Resident #27 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 5/24/11 documented the resident scored 13 (13 - 15 indicates cognitively intact) on a BIMS, required extensive assistance of two staff members for transfers and toilet use, and had a fall in the last 2 - 6 months prior to admission. a. The Interim Admission Care Plan dated 5/18/11 documented, "...Problem: Resident is at risk for falls Related to: Weakness, arthritis,[MEDICAL CONDITIONS]: Assist for toileting and transfers, Keep environment safe..." b. Nurses Notes dated 5/19/11 at 1215 (12:15 p.m.) documented, "Increase confusion this am. " c. Nurses Notes dated 6/1/11 at 1530 (3:30 p.m.) documented, "...N/O (new order) [MEDICATION NAME] 0.5 mg (milligram) (one) po (by mouth) Q (every) 8 (hours) PRN (as needed), (increase) [MEDICATION NAME] to 50 mg (every) hs (at night)..." d. The June 2011 MAR (Medication Administration Record) documented that the resident received [MEDICATION NAME] 50 mg on 6/2/11 at 8:00 p.m. and also received [MEDICATION NAME] 0.5 mg on 6/3/11 at 1:08 a.m. The Nursing 2010 Drug Handbook, 30th Anniversary Edition pages 690 - 691 documented, "[MEDICATION NAME] ([MEDICATION NAME])...Adverse Reactions, CNS (Central Nervous System): drowsiness, sedation, [MEDICAL CONDITION], dizziness, weakness, headache..." Pages 613 - 614 documented, "[MEDICATION NAME] Reactions, CNS: drowsiness, dizziness, weakness, headache, [MEDICAL CONDITION]" e. The Nurses Notes dated 6/3/11 at 3:00 a.m. documented, "CNA assisted (resident) to bathroom (and) instructed (resident to call for assist (assistnace). (Resident ) attempted to get off toilet (and) and fell to floor. (Name) CNA (and) (name) LPN heard (resident call out (and) found (resident) on floor. (Resident) states she hit her head on wall (amd) sustained s/t (skin tear to L (left) forearm" The Unusual Occurrence Report dated 6/3/11 at 0300 (3:00 a.m.) documented, "...Type of Unusual Occurrence: Fall/Slip/lowered to floor (checked)...Type of Injury: Skin Tear x 2 (checked)...Description: (Resident) fell in bathroom (after) CNA (Certified Nurses Assistant) assisted (Resident) attempted to get off toilet (with) out calling for assist, apparently she tripped on P.J. (pajama) bottoms that were around her ankles, CNA #14 and LPN #13 heard resident call out (and) found resident on floor. Resident hit head on wall (and) sustained s/t (skin tear) to (left) forearm. Resident assisted into bed via w/c (wheel chair) (and) drsg. (dressing) applied to (left) forearm...5. Contributing Factors: Did not request help or refused help (checked)...7a. Pajamas around ankles may have caused her to fall...8 Immediate interventions: sign placed in bathroom to not leave resident unattended...Results of action taken: 6/10/11 moved to room closer to NS (Nurses Station), sign on wall to stay (with) resident in B/R (bathroom). Decline noted in general condition, staff to keep door cracked and stand outside..." f. On 11/18/11 at 12:50 p.m. the DON stated, "I'm aware that she (Resident #27) had a fall but I don't remember the details. She was one that would not let us stay in the bathroom with her. If I remember correctly, they stepped out and she tripped on her PJ bottoms. She should have not been left alone. We did not investigate why she was left alone or where the aide went after leaving her alone in the bathroom. We did not inservice the staff about all residents at risk of falls and who should not be left alone in the bathroom." 9. Resident #14 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 10/25/11 documented the resident had short and long term memory problems, had severely impaired cognitive skills for daily decision making per a Staff Assessment for Mental Status, required extensive assistance of 2 staff persons for transfers, had a fall since last assessment and used a chair that prevented rising daily. a. An undated "Nursing Assistant Care Plan" received from the unit manager on 11/17/11 at 12:07 p.m., under the heading of "Fall Risk" the resident was marked for "High Risk For Falls" and under the heading of "Alarms " the resident was marked for Chair: Seat belt." b. On 11/16/11 at 4:15 p.m., the resident was in the hall in a wheelchair with a self release alarm belt on around his waist. The alarm box was attached to the back of the resident's wheelchair. The alarm box did not have the light on that signals that the device was turned on and working. Licensed Practical Nurse (LPN) #14 propelled the resident into room. The LPN was if the resident's alarm was on. The LPN pushed the button on the alarm box and the light came on. The LPN stated that the alarm was not on.

Based on record review and interviews, the facility failed to ensure that incidents suspicious of neglect were reported immediately to the Administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and Certification Agency); failed to ensure the incidents were thoroughly investigated and residents were protected from further neglect for 2 (Residents #3 and #27) of 13 (Residents #1 - 4, 5 - 12, and 14) case mix residents who were at risk for falls and were left unattended in the bathroom. This failed practice resulted in a pattern of actual harm for Resident #3 who repeatedly experienced falls and suffered a [MEDICAL CONDITION] when left unattended in the bathroom and had the potential to cause more than minimal harm for 106 residents at risk for falls per a list provided by the Administrator on 11/18/11 at 7:30 p.m. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/16/11 documented the resident had short and long term memory problems; was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; required limited assistance of one staff member for bed mobility, transfers and walking in and out of room and locomotion on and off the unit; was always incontinent of urine and bowel; and was at risk for developing pressure ulcers. a. The IDT (Interdisciplinary Team)/Care Meeting Notes documented a fall on 4/25/11. The Notes documented an intervention to toilet resident at 0400 (4:00 a.m.) every morning and to monitor for restlessness. b. The IDT/Care Meeting Notes dated 5/1/11 at 1:05 a.m. documented that the resident tried to get up to go to the bathroom by self, slipped and fell . The Notes documented an intervention to check every 2 hours, before meals and at night toilet schedule. c. The IDT/Care Meeting Notes dated 5/3/11 at 8:40 a.m. documented resident was found with his knees on the floor and arm on the bed. The Notes documented an intervention to change pressure alarm to pull alarm to alert staff. d. The IDT/Care Meeting Notes dated 5/8/11 at 4:49 a.m. documented a fall. The Notes documented an intervention to move pull alarm where spouse could not turn it off or unplug it. e. The IDT/Care Meeting Notes dated 5/8/11 at 11:30 p.m. documented that resident was found kneeling at bedside and that he told staff that he was fixing the wire. The Notes documented an intervention to place fall mat at bedside. f. The Incident and Accident Report (I&A) dated 5/17/11 at 10:40 p.m. documented that staff heard a thump and found resident sitting on his bottom in front of the bathroom and that he had pulled off clip alarm. The Report documented the resident had 2 red abrasions to left knee and one to back of left thigh. The Report documented that on 5/19/11 an intervention was put in place that after the p.m. meal the resident was to be toileted and assisted to bed. He was to be checked again at 8:00 p.m. and assisted to the toilet. The Report documented that a care plan meeting was to be scheduled with family to discuss placing resident in low bed. g. The I&A Report dated 5/25/11 at 12:00 p.m. documented that staff heard yell and found resident lying in bathroom floor on his left side with a skin tear times two on his left elbow. The Report also documented that the resident tried to ambulate self without request for help. The Report documented the initial x-ray did not show any fracture but resident continued to complain, was medicated for pain; resident was sent to the emergency roiagnom on [DATE] with another negative x-ray but the Computerized Tomography Scan was positive for left [MEDICAL CONDITION]; and underwent surgery to repair [MEDICAL CONDITION] on 5/29/11. The Report documented interventions: The Certified Nurse Assistant (CNA) was counseled to stay in bathroom with resident or outside bathroom door and all staff inserviced on 5/26/11 to never leave resident unattended in bathroom. 1) On 11/17/11 at 12:20 p.m., the DON was asked about the 5/25/11 incident. The Director of Nursing (DON) stated, "I haven't reviewed that I & A in a while but I think I remember that (CNA #21) said he had him (Resident #3) in the bathroom when he heard an alarm going off that made him step outside the door. He told (Resident #3) to stay there but with (Resident #3) that doesn't mean he will. If it was at lunch time there is one aide assigned to stay on each hall when the other aide goes to the dining room; however, if the hall aide is in caring for another resident they would not be able to answer the call light. Knowing (CNA #21), he is very conscientious; he kept hearing that call light and rushed to answer it. I remember counseling (CNA #21) but I will have to check for the documentation regarding the investigation. 2) On 11/17/11 at 12:50 p.m., the DON returned and stated that she was unable to find any investigation documentation as to why CNA #21 left a resident, who was at risk for falls and was severely cognitively impaired, unattended in the bathroom. She also stated that anyone with Dementia is at risk for falls and shouldn't be left unattended in the bathroom. h. The I&A Report dated 8/27/11 at 4:00 a.m. documented: Staff heard resident yelling, found him sitting on fall mat and pressure from right elbow on pressure alarm. Resident had pulled brief off, was not wet but wanted to get up. The pressure alarm was lit but did not go off. The Report documented interventions to apply seat belt to prevent falls on a trial basis and to start rounds with this resident, anticipate his needs, toilet him, check for thirst/hunger and that staff were inserviced on 8/29/11 regarding new intervention regarding this resident only. i. The I&A Report dated 10/8/11 at 5:35 a.m. documented: Staff heard resident yelling for help, found resident standing on right knee on fall mat, right elbow pressing on bed pressure alarm and it did not go off and his upper body was on the bed. The Report documented interventions to change wet brief, move to nurses station for observation, change pressure alarm to pull and keep out of reach of spouse, and on 10/10/11 staff re-educated on " starting 4 am rounds with this resident to ensure that he is dry, apply pull alarm when resident is in the bed or in the recliner and to keep the pull alarm out of reach of the spouse. " j. The I&A Report dated 11/4/11 at 3:10 a.m. documented: Resident was found on floor by the CNA. He was sitting on fall mat with his alarm still attached to him. His brief was wet and he stated that he did not want that wet thing on him. The Report documented interventions to shorten the string on the pull alarm so that it will alarm sooner. 2. Resident #27 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 5/24/11 documented the resident scored 13 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status, required extensive assistance of two staff members for transfers and toilet use, and had a fall in the last 2 - 6 months prior to admission. a. The Interim Admission Care Plan dated 5/18/11 documented, "...Problem: Resident is at risk for falls Related to: Weakness, arthritis,[MEDICAL CONDITIONS]: Assist for toileting and transfers, Keep environment safe..." b. Nurses Notes dated 5/19/11 at 1215 (12:15 p.m.) documented, "Increase confusion this am. " c. Nurses Notes dated 6/1/11 at 1530 (3:30 p.m.) documented, "...N/O (new order) [MEDICATION NAME] 0.5 mg (milligram) (one) po (by mouth) Q (every) 8 (hours) PRN (as needed), (increase) [MEDICATION NAME] to 50 mg (every) hs (at night)..." d. The June 2011 MAR (Medication Administration Record) documented that the resident received [MEDICATION NAME] 50 mg on 6/2/11 at 8:00 p.m. and also received [MEDICATION NAME] 0.5 mg on 6/3/11 at 1:08 a.m. The Nursing 2010 Drug Handbook, 30th Anniversary Edition pages 690 - 691 documented, "[MEDICATION NAME] ([MEDICATION NAME])...Adverse Reactions, CNS (Central Nervous System): drowsiness, sedation, [MEDICAL CONDITION], dizziness, weakness, headache..." Pages 613 - 614 documented, "[MEDICATION NAME] Reactions, CNS: drowsiness, dizziness, weakness, headache, [MEDICAL CONDITION]" e. The Nurses Notes dated 6/3/11 at 3:00 a.m. documented, "CNA assisted (resident) to bathroom (and) instructed (resident to call for assist (assistnace). (Resident ) attempted to get off toilet (and) and fell to floor. (Name) CNA (and) (name) LPN heard (resident call out (and) found (resident) on floor. (Resident) states she hit her head on wall (amd) sustained s/t (skin tear to L (left) forearm" The Unusual Occurrence Report dated 6/3/11 at 0300 (3:00 a.m.) documented, "...Type of Unusual Occurrence: Fall/Slip/lowered to floor (checked)...Type of Injury: Skin Tear x 2 (checked)...Description: (Resident) fell in bathroom (after) CNA assisted (Resident) attempted to get off toilet (with) out calling for assist, apparently she tripped on P.J. (pajama) bottoms that were around her ankles, CNA #14 and Licensed Practical Nurse (LPN) #13 heard resident call out (and) found resident on floor. Resident hit head on wall (and) sustained s/t (skin tear) to (left) forearm. Resident assisted into bed via w/c (wheel chair) (and) drsg. (dressing) applied to (left) forearm...5. Contributing Factors: Did not request help or refused help (checked)...7a. Pajamas around ankles may have caused her to fall...8 Immediate interventions: sign placed in bathroom to not leave resident unattended...Results of action taken: 6/10/11 moved to room closer to NS (Nurses Station), sign on wall to stay (with) resident in B/R (bathroom). Decline noted in general condition, staff to keep door cracked and stand outside..." f. On 11/18/11 at 12:50 p.m., the DON stated, "I'm aware that she (Resident #27) had a fall but I don't remember the details. She was one that would not let us stay in the bathroom with her. If I remember correctly, they stepped out and she tripped on her PJ bottoms. She should have not been left alone. We did not investigate why she was left alone or where the aide went after leaving her alone in the bathroom. We did not inservice the staff about all residents at risk of falls and who should not be left alone in the bathroom."

Based on record review and interviews, the facility failed to ensure that the Facility ' s Abuse Prevention Policy regarding neglect was implemented and that the Policy included screening of all employees to prevent neglect. The facility failed to ensure incidents suspicious of neglect were reported immediately to the Administrator of the facility and to other officials in accordance with State law through established procedures (including to the State Survey and Certification Agency); failed to ensure the incidents were thoroughly investigated and residents were protected from further neglect for 2 (Residents #3 and #27) of 13 (Residents #1 - 4, 5 - 12, & #14) case mix residents who were at risk for falls and were left unattended in the bathroom. This failed practice resulted in a pattern of actual harm for Resident #3 who repeatedly experienced falls and suffered a [MEDICAL CONDITION] when left unattended in the bathroom and had the potential to cause more than minimal harm for 106 residents at risk for falls per a list provided by the Administrator on 11/18/11 at 7:30 p.m. The findings are: 1. The facility ' s Abuse Prevention Policy documented: " Abuse Investigation Protocol ...All reports of resident abuse, neglect, injuries of unknown source ...are promptly and thoroughly investigated by facility management ...Recognizing signs and symptoms of Abuse/Neglect ...The facility will not condone any form of resident abuse or neglect. To aid abuse prevention, all personnel are to report any signs/symptoms of abuse/neglect to their supervisor or other designee immediately. The following are some examples of signs or actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported ...Signs of Actual Physical Neglect ...Left alone but needs supervision ... " 2. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/16/11 documented the resident had short and long term memory problems; was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; required limited assistance of one staff member for bed mobility, transfers and walking in and out of room and locomotion on and off the unit; was always incontinent of urine and bowel; and was at risk for developing pressure ulcers. a. The IDT (Interdisciplinary Team)/Care Meeting Notes documented a fall on 4/25/11. The Notes documented an intervention to toilet resident at 0400 (4:00 a.m.) every morning and to monitor for restlessness. b. The IDT/Care Meeting Notes dated 5/1/11 at 1:05 a.m. documented that the resident tried to get up to go to the bathroom by self, slipped and fell . The Notes documented an intervention to check every 2 hours, before meals and at night toilet schedule. c. The IDT/Care Meeting Notes dated 5/3/11 at 8:40 a.m. documented resident was found with his knees on the floor and arm on the bed. The Notes documented an intervention to change pressure alarm to pull alarm to alert staff. d. The IDT/Care Meeting Notes dated 5/8/11 at 4:49 a.m. documented a fall. The Notes documented an intervention to move pull alarm where spouse could not turn it off or unplug it. e. The IDT/Care Meeting Notes dated 5/8/11 at 11:30 p.m. documented that resident was found kneeling at bedside and that he told staff that he was fixing the wire. The Notes documented an intervention to place fall mat at bedside. f. The Incident and Accident Report (I&A) dated 5/17/11 at 10:40 p.m. documented that staff heard a thump and found resident sitting on his bottom in front of the bathroom and that he had pulled off clip alarm. The Report documented the resident had 2 red abrasions to left knee and one to back of left thigh. The Report documented that on 5/19/11 an intervention was put in place that after the p.m. meal the resident was to be toileted and assisted to bed. He was to be checked again at 8:00 p.m. and assisted to the toilet. The Report documented that a care plan meeting was to be scheduled with family to discuss placing resident in low bed. g. The I&A Report dated 5/25/11 at 12:00 p.m. documented that staff heard yell and found resident lying in bathroom floor on his left side with a skin tear times two on his left elbow. The Report also documented that the resident tried to ambulate self without request for help. The Report documented the initial x-ray did not show any fracture but resident continued to complain, was medicated for pain; resident was sent to the emergency roiagnom on [DATE] with another negative x-ray but the Computerized Tomography Scan was positive for left [MEDICAL CONDITION]; and underwent surgery to repair [MEDICAL CONDITION] on 5/29/11. The Report documented interventions: The Certified Nurse Assistant (CNA) was counseled to stay in bathroom with resident or outside bathroom door and all staff inserviced on 5/26/11 to never leave resident unattended in bathroom. 1) On 11/17/11 at 12:20 p.m., the Director of Nursing (DON) was asked about the 5/25/11 incident. The DON stated, "I haven't reviewed that I & A in a while but I think I remember that (CNA #21) said he had him (Resident #3) in the bathroom when he heard an alarm going off that made him step outside the door. He told (Resident #3) to stay there but with (Resident #3) that doesn't mean he will. If it was at lunch time there is one aide assigned to stay on each hall when the other aide goes to the dining room; however, if the hall aide is in caring for another resident they would not be able to answer the call light. Knowing (CNA #21), he is very conscientious; he kept hearing that call light and rushed to answer it. I remember counseling (CNA #21) but I will have to check for the documentation regarding the investigation. 2) On 11/17/11 at 12:50 p.m., the DON returned and stated that she was unable to find any investigation documentation as to why CNA #21 left a resident, who was at risk for falls and was severely cognitively impaired, unattended in the bathroom. She also stated that anyone with Dementia is at risk for falls and shouldn't be left unattended in the bathroom. h. The I&A Report dated 8/27/11 at 4:00 a.m. documented: Staff heard resident yelling, found him sitting on fall mat and pressure from right elbow on pressure alarm. Resident had pulled brief off, was not wet but wanted to get up. The pressure alarm was lit but did not go off. The Report documented interventions to apply seat belt to prevent falls on a trial basis and to start rounds with this resident, anticipate his needs, toilet him, check for thirst/hunger and that staff were inserviced on 8/29/11 regarding new intervention regarding this resident only. i. The I&A Report dated 10/8/11 at 5:35 a.m. documented: Staff heard resident yelling for help, found resident standing on right knee on fall mat, right elbow pressing on bed pressure alarm and it did not go off and his upper body was on the bed. The Report documented interventions to change wet brief, move to nurses station for observation, change pressure alarm to pull and keep out of reach of spouse, and on 10/10/11 staff re-educated on " starting 4 am rounds with this resident to ensure that he is dry, apply pull alarm when resident is in the bed or in the recliner and to keep the pull alarm out of reach of the spouse. " j. The I&A Report dated 11/4/11 at 3:10 a.m. documented: Resident was found on floor by the CNA. He was sitting on fall mat with his alarm still attached to him. His brief was wet and he stated that he did not want that wet thing on him. The Report documented interventions to shorten the string on the pull alarm so that it will alarm sooner. 3. Resident #27 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 5/24/11 documented the resident scored 13 (13 - 15 indicates cognitively intact) on a Brief Interview for Mental Status, required extensive assistance of two staff members for transfers and toilet use, and had a fall in the last 2 - 6 months prior to admission. a. The Interim Admission Care Plan dated 5/18/11 documented, "...Problem: Resident is at risk for falls Related to: Weakness, arthritis,[MEDICAL CONDITIONS]: Assist for toileting and transfers, Keep environment safe..." b. Nurses Notes dated 5/19/11 at 1215 (12:15 p.m.) documented, "Increase confusion this am. " c. Nurses Notes dated 6/1/11 at 1530 (3:30 p.m.) documented, "...N/O (new order) [MEDICATION NAME] 0.5 mg (milligram) (one) po (by mouth) Q (every) 8 (hours) PRN (as needed), (increase) [MEDICATION NAME] to 50 mg (every) hs (at night)..." d. The June 2011 MAR (Medication Administration Record) documented that the resident received [MEDICATION NAME] 50 mg on 6/2/11 at 8:00 p.m. and also received [MEDICATION NAME] 0.5 mg on 6/3/11 at 1:08 a.m. The Nursing 2010 Drug Handbook, 30th Anniversary Edition pages 690 - 691 documented, "[MEDICATION NAME] ([MEDICATION NAME])...Adverse Reactions, CNS (Central Nervous System): drowsiness, sedation, [MEDICAL CONDITION], dizziness, weakness, headache..." Pages 613 - 614 documented, "[MEDICATION NAME] Reactions, CNS: drowsiness, dizziness, weakness, headache, [MEDICAL CONDITION]" e. The Nurses Notes dated 6/3/11 at 3:00 a.m. documented, "CNA assisted (resident) to bathroom (and) instructed (resident to call for assist (assistnace). (Resident ) attempted to get off toilet (and) and fell to floor. (Name) CNA (and) (name) LPN heard (resident call out (and) found (resident) on floor. (Resident) states she hit her head on wall (amd) sustained s/t (skin tear to L (left) forearm" The Unusual Occurrence Report dated 6/3/11 at 0300 (3:00 a.m.) documented, "...Type of Unusual Occurrence: Fall/Slip/lowered to floor (checked)...Type of Injury: Skin Tear x 2 (checked)...Description: (Resident) fell in bathroom (after) CNA assisted (Resident) attempted to get off toilet (with) out calling for assist, apparently she tripped on P.J. (pajama) bottoms that were around her ankles, CNA #14 and LPN #13 heard resident call out (and) found resident on floor. Resident hit head on wall (and) sustained s/t (skin tear) to (left) forearm. Resident assisted into bed via w/c (wheel chair) (and) drsg. (dressing) applied to (left) forearm...5. Contributing Factors: Did not request help or refused help (checked)...7a. Pajamas around ankles may have caused her to fall...8 Immediate interventions: sign placed in bathroom to not leave resident unattended...Results of action taken: 6/10/11 moved to room closer to NS (Nurses Station), sign on wall to stay (with) resident in B/R (bathroom). Decline noted in general condition, staff to keep door cracked and stand outside..." f. On 11/18/11 at 12:50 p.m. the DON stated, "I'm aware that she (Resident #27) had a fall but I don't remember the details. She was one that would not let us stay in the bathroom with her. If I remember correctly, they stepped out and she tripped on her PJ bottoms. She should have not been left alone. We did not investigate why she was left alone or where the aide went after leaving her alone in the bathroom. We did not inservice the staff about all residents at risk of falls and who should not be left alone in the bathroom." 4. The facility's Abuse Prevention Policy provided by the Administrator on 11/14/11 was reviewed and the policy did not support the screening of all employees to prevent abuse. a. The Background Screening Investigations area of the policy documented, " ... 3. For any individual applying for a position as a certified nursing assistant, the state nurse aide registry will be contacted to determine if any findings of abuse, neglect, mistreatment of [REDACTED]. 4. For any licensed professional applying for a position that may involve direct contact with resident's his/her respective licensing board will be contacted to determine if any sanctions have been assessed against the applicant's license. ..." b. On 11/18/11 at 1:55 p.m., the Administrator was interviewed regarding the screening documentation in the policy and she stated, " The policy should state that the registry will be checked on all employees. All licensed personnel have licensure checked whether they are going to have direct contact or not. We do a registry check on all employees, the policy is just incorrect."