Every finding on record at The Neighborhoods at Brookview

Based on observation, interview, and policy review the provider failed to ensure a safe environment when the oven in Ash Neighborhood kitchenette was left on at 300 degrees and unattended by nutrition services (NS) D with four residents observed in he area. Findings include:1. Observation on 9/16/25 at 9:36 a.m. of the Ash Neighborhood revealed:*There was an odor that indicated something like an oven was hot.*There were no staff observed in the kitchenette area.*There were covered unbaked cookies on cookie sheets on the stove and countertop. *The ovens digital temperature light was on and indicated it was at a temperature of 300 degrees. *The oven door was not locked and opened easily. The oven was empty and hot.*There were four residents (19,33,44,56) observed in the dayroom near that kitchenette area. *One staff member had entered that area and left with one resident.2. Review of residents 19s electronic medical record revealed she had scored a score of 15 on her brief interview for mental status (BIMS) that indicated she was cognitively intact.3. Review of resident 33's EMR revealed she had scored 00 for her BIMS that indicated she had severe cognitive impairment. 4. Review of resident 44's EMR revealed she had scored 01 for her BIMS that indicated she had severe cognitive impairment. 5. Review of resident 56's EMR revealed she had scored 15 for her BIMS that indicated she was cognitively intact. 6. Interview on 9/16/25 at 9:42 a.m. with NS D when she entered the Ash Neighborhood kitchenette area regarding the oven revealed, she confirmed the oven was on at at temperature of 300 degrees and agreed someone should have monitored the oven while it was on and residents were in the area. She then stated she told the cook in the galley she was stepping away for a bit and he would have monitored it from the that galley kitchen. 7. Interview on 9/16/25 at 9:45 a.m. with dietary cook E in the galley kitchen revealed he thought the oven should be off if residents were in the area and no staff were there to monitor the oven. He did not state he had been monitoring that oven. 8. Interview on 9/16/25 at 9:46 a.m. with nurse supervisor/registered nurse (RN) C regarding the kitchenette oven revealed it was NS D's responsibility to stay right by the stove when it was on or when she was using it. 9. Interview on 9/16/25 at 9:50 a.m. with food services director (FSD) B revealed: *She had a general safety policy but did not have a specific policy regarding neighborhood kitchenette ovens.*She stated, that it was the understanding that if the oven was on that it would be monitored by staff. She stated she could add that to their current general safety policy.10. Interview on 9/18/25 at 10:30 a.m. with administrator A revealed, he had entered that kitchenette area on 9/16/25 during the above noted observations and did not see NS D in that area at that time. He stated he did not see anyone next to the stove and that no one was hurt. He stated the cook should have watched the oven when NS D was away from the area when the oven was on.11.Review of the provider's November 2024 General Facility Safety policy revealed:*It is the goal of the [NAME] Hospital and neighborhoods @ [at] Brookview to provide a safe facility and grounds for its patients, residents, visitors, and staff. Safety is everyone's responsibility and requires the cooperation and diligence of every employee.

Based on record review, interviews, observations, document review, and policy review, the provider failed to assess three of five sampled residents (1, 4, and 5), all of whom had either experienced a fall related to a recliner or lacked access to their recliner controls. The provider also failed to update residents' care plans and educate staff as indicated in the incident reports.Findings include:1. Review of Resident 1's EMR revealed he was admitted to the facility on [DATE]. He had diagnoses of osteoarthritis (a condition where the cartilage in joints is worn down causing pain and stiffness), Alzheimer's (a progressive brain disorder causing memory loss), mild cognitive impairment (mild confusion), hypertension (high blood pressure), depression, right hip pain, low back pain, glaucoma (high pressure inside the eye causing vision changes), atrial fibrillation (irregular heart beat), and congestive heart failure (where the heart cannot pump enough oxygenated blood to meet the body's needs, causing blood and fluid to back up in organs like the lungs, abdomen, and legs.He was hospitalized on [DATE] for confusion/disorientation, pale/dusky (pale blueish color of the skin), coarse lung sounds (rattling sound), and shortness of breath with ambulation. He returned from the hospital on [DATE] and started receiving hospice care (end-of-life care focusing on comfort).He had fall risk assessments completed on 5/20/25, 5/26/25, 8/17/25, 10/17/25, and 10/22/25 that indicated he had a high risk of falling. He fell on 9/28/25 when he lost his balance in the bathroom and did not receive a major injury. On 10/4/25, he fell near his bed and did not receive an injury. On 10/17/25, he was more confused, thinking he saw marbles on the floor and claimed to slip on them. He was found on the floor in his room and did not have an injury. On 10/22/25, he was found sitting on the floor in his room between his bed and recliner. The recliner's footrest had been elevated, and staff reported he had been sitting in his recliner prior to being found on the floor. RN, NS J assessed him, and he complained of pain in his pelvis and hips with movement and when he was touched. His right leg had been slightly longer than his left, his right leg was turned outward, and he had pain with the movement of his right hip (indicating he had a possible hip fracture). His family was updated on his fall and status, and they declined further evaluation at the emergency room for him. They wanted him to remain at the facility and to be kept comfortable. His 6/20/25 (most current in the EMR) care plan indicated he was independent with bed mobility, independent with transferring (moving from one place to another), and walking with a walker, he did not use a wheelchair, and he was independent with his dressing, eating, toilet use, and personal hygiene. On 9/18/25, it was added to his care plan that he was a high fall risk. His fall interventions, last updated on 10/22/25, were: Encourage to call for assistance with toilet hygiene., Encourage to use anti slip footwear., Reinforce safety., Remind to use of footwear during ambulation., Encourage to sit while getting his pants over his feet and lower legs, once that is done then stand for pulling them up., double call light in place, fall mat beside bed, and bed at low position.His 10/17/25 paper care plan indicated he needed the assistance of one to two staff, a gait belt, and a walker to transfer. He needed one staff member to assist him with ambulation with his walker or wheelchair, and his mental status was alert, confused, and forgetful.His 10/21/25 Hospice care plan indicated he needed the assistance of two staff members to reposition and did not include how he transferred or ambulated.His Brief Interview for Mental Status (BIMS) score was 8, per the facility-reported incident report completed on 10/23/25, which indicated he had moderate cognitive impairment.He passed away at the facility on 10/23/25 at 10:46 a.m. on hospice services.2. Review of resident 4's EMR revealed she had a fall on 8/9/25 at 3:45 a.m., where she reported she had a dream and rolled out of her bed. Her fall interventions included: To ensure her bed was in a low position, remind her to use her call light, and not to get up on her own. Staff were to complete frequent, extensive rounding and to offer her assistance to the bathroom. Her care plan did not indicate safety measures related to the use of her electric recliner. She had a lift chair/recliner assessment completed on 11/12/25, where she was considered safe to use her recliner, and her BIMS score was 4, which indicated she had severe cognitive impairment.3. Review of Resident 5's EMR revealed he had diagnoses of Parkinson's (a progressive neurodegenerative disorder that affects movement, causing tremors, stiffness, slowed movement, and balance), atrial fibrillation, hypertension, anxiety, and depression.His 9/15/25 BIMS score was 14, which indicated he was cognitively intact.He had a fall on 9/24/25 at 4:00 p.m., where he was found lying by the end of his recliner, and the recliner was in a slightly elevated position. Per the fall report, he was reaching forward to stand up and move to his wheelchair independently, but his arms were weak, and he fell. He had nonslip black strips in front of his recliner. He did not receive an injury, and the following intervention was added to prevent future falls: Shorten resting time in the recliner when awake.He fell on [DATE] at 4:45 p.m. from his wheelchair when he bent over to pick up items off the floor. He was sent to the emergency room and received stitches to a head laceration. His fall note indicated the following intervention would be added to his care plan to prevent future falls: Monitor floor for items needing to be picked up.A review of his 7/18/24 care plan revealed he required assistance from one to two staff with transfers and to encourage him to rest in his recliner with his feet up.His fall risk section of his care plan, last updated on 11/4/25, indicated his safety measures to prevent falls were: 11/4/25 lift chair assessment completed with consent despite fall risk., 10/22/25 Continue PT; Request to evaluate wheelchair and lift chair safety. New chair cushion. 9/25/25 Review fall; continue rest periods with feel elevated, PT for LE strength/transfers, restorative program. Monitor often with door open when in lift chair., Dycem [grip pad to prevent slipping] with WC [wheel chair] cushion, See board for most recent mobility recommendations per therapy., declines gripper socks while in bed., HX [history] of falls prior to admission, Therapy/restorative as directed, Double call light for use in bed, Pendant call light, not consistently used., and Gripper strips on floor at bedside.He had an 11/4/25 lift chair/recliner assessment completed, where he attempted to scoot off the footrest of the recliner to get up on his own. His family consented to his continued use of the recliner.His new interventions from his fall on 10/16/25 were not added to his care plan as indicated in his fall note. He did not have interventions in his care plan for the safe use of his electric recliner.4. Interview on 11/12/25 at 12:12 p.m. with certified nursing assistant (CNA) F revealed she was aware of what to do if a resident fell and explained the process. She started at the facility around two months ago, completed her initial new hire education, and had not received any education since 10/22/25. She stated that if residents were not able to operate their electric recliners, then they should not use the recliner, or she would leave the footrest down to prevent the resident from crawling out of the recliner over the footrest. She was unsure how to know which residents could or could not use their recliner safely or who could have their feet up while in their recliner, and she stated she would use her judgment. No one here had told her about recliner safety for the residents, and that was something she knew from working at her previous nursing home employer, where she was a CNA. She stated that to know how to care for the residents, she would look at their care plans, which were kept in a binder in the nurse's office, along with whiteboards that listed how much assistance each resident needed with transferring. Recliner safety was not listed on the communication board or the residents' care plans.5. Interview on 11/12/25 at 12:30 p.m. with CNA G revealed she started in February 2025 and finished her certification in May 2025, when she started working directly with the residents. She completed her new hire education and learned about resident falls during that. She recalled, when a resident had fallen, she received education by email, and it was posted at the nurses' station. She was unsure if she had received any education about recliner safety for residents. What she knew about resident safety and recliners was to keep a divider between the wall and the recliner, so it did not move on them, and some residents had gripper mats on their recliner seats, so they did not slide out of them. For residents using the electric recliners, she went by her experience with that resident to know when they could operate the recliner remote by themselves safely. For residents who were confused, she would run the recliner remote for them and then leave the remote in the recliner's side pocket, out of the resident's reach for their safety. As an example, she stated resident 4 was sometimes confused with the recliner remote, so she would place her recliner remote out of reach in the side pocket of the recliner and would check on the resident more often when she was in her recliner. She knew how to transfer a resident by: some residents had it listed on their census sheets (a report sheet that listed the care the residents needed), it was on the whiteboard at the nurses' station, and in the residents' care plans at the nurses' station. If a resident was at risk for falling, there would be a note at the nurses' station. Residents at risk for falling were not listed on the census sheets. The care plans, census sheets, or whiteboards did not include how residents used their recliners safely. 6. Observation and Interview on 11/12/25 at 12:40 p.m. revealed that resident 4 was sitting in her electric recliner in her room. Her feet were elevated with the footrest up, and the remote to her recliner was in the right-side pocket of the recliner. Her bedside table was along the right side of her recliner. She stated she was not able to reach the remote to her recliner, and she needed staff assistance to get up. Her call light was within reach and she stated she would use the call light to get assistance from the staff. She stated that staff responded quickly to her call light.7. Interview on 11/12/25 at 2:25 p.m. with quality director B revealed resident 1 did not have a recliner safety assessment completed.8. Interview on 11/12/25 at 2:30 p.m. with human resources generalist C revealed that fall education was completed for CNAs F and G on 10/17/25 verbally, and it was sent out via email by director of nursing (DON) A to all CNAs and nurses on 10/17/25. The education was to be completed by 10/31/25. Both CNAs F and G completed the quiz, but there was no documentation of the date the education and quiz were completed. She asked the leadership and organization development coordinator D, if she had documentation when the quiz had been completed for CNAs F and G, and she did not know. She confirmed that no documented education was completed regarding recliner safety, and no education was completed after 10/22/25 for any nursing staff.9. Interview and record review on 11/12/25 at 3:15 p.m. and 5:08 p.m. with DON A revealed that fall education went to all CNAs and nurses in an email on 10/17/25. The fall education had been sent out before the date of the facility-reported incident regarding resident 1 on 10/22/25 because she wanted staff to have it completed before the upcoming meeting, as she was going to cover falls at the meeting. She stated that the upcoming nursing staff nursing staff meeting was going to cover falls and recliner safety. She stated the meeting was not yet scheduled because she was trying to coordinate the meeting with someone else to cover other required education. She reviewed resident 4's care plan and intervention list and verified it did not include anything regarding recliner safety or the recliner safety assessment, and it should have been included.Residents had fall interventions listed in the safety measures text box in their electronic medical record (EMR). CNAs were not able to view the fall interventions in the EMR; only nurses could review those. The information in the safety measures text box was printed at the nurses' station in the safety measures binder so CNAs could view them. She expected CNAs to leave the recliner remotes within reach of the resident when they were sitting in them. The only exception would be if the family had requested the remote to be left out of the resident's reach. She verified it was considered a restraint if the remote was left out of reach of the resident when they were in their recliner with the footrest up, and it was a safety hazard for them.She stated she had conversations with the nursing supervisors on the units, and they were educating CNAs during shift change report about falls and had them review the fall policy. She was unsure if that education was documented. She expected the residents' recliner assessments to be completed as soon as possible (ASAP). She stated she received the updated Proper Use of Side Rails and Safe Use of Lift Chairs/Recliners policy on 10/30/25 from executive assistant E, who was in charge of finalizing the policy in the computer. She stated the Proper Use of Side Rails and Safe Use of Lift Chairs/Recliners policy was sent out to staff that same day.10. Interview on 11/13/25 at 8:36 a.m. with CNA H revealed she was working the day resident 1 passed away in the facility, and it was her first day. She reported she watched new hire training videos about resident falls and recalled maintenance checking resident recliners last week. She kept the residents' recliner remotes within the residents' reach when they were in their recliners with the footrest elevated. She received that education from one of the nurses during her orientation.11. Interview on 11/13/25 at 8:40 a.m. and 9:51 a.m. with registered nurse (RN) I revealed RN, nursing supervisor (NS) J completed the residents' recliner assessments. RN I recalled she reviewed the Fall and Care After Fall Follow-up policy, but was unsure when. She stated that sometimes staff education happened at the change of shift report; otherwise, the policy was printed off and left at the nurse's station for staff to initial when it had been read by them. When a resident fell, there would be a note in the medication room about it. She stated resident 1 had not fallen out of the recliner before 10/22/25, and he knew how to use the recliner remote before he returned from the hospital on hospice. Before his hospital stay, he was independent with ambulation and would sit in his electric recliner often. He was more confused after returning from the hospital.She was the charge nurse on the floor on 10/22/25 and was with another resident when Resident 1 fell. She was called to the resident 1's room because the resident had fallen. RN, NS J was already in the resident's room when she arrived to evaluate him. He was sitting on the floor with his back against the recliner. His right leg was shorter and slightly rotated out. He did not have pain when touching his pelvis and had chronic back pain, so he had always complained of pain. Vital signs were completed, RN, NS J physically assessed him for injuries, and he was assisted into his bed. He did not appear to be in a lot of pain. RN, NS J contacted the resident's family and hospice staff. After that fall on 10/22/25, his overall condition declined. His breathing was faster, he was more agitated, and he tried to get out of bed by himself. He received pain medication for comfort.She stated she received education about resident falls, read the fall policy, and signed that she had completed it at the nurses' station. She did not recall if it was completed before or after the resident's incident on 10/22/25. She had not seen the recliner policy and was not a part of the recliner safety assessments for residents. She was unsure how nurses or CNAs were to know which residents were safe to use recliners because no one had told her. There was a fall safety measures binder for all staff to know fall interventions for residents, and RN, NS J kept that updated. Sometimes other nurses updated it. She was unsure if the binder had anything about recliner safety. It had what assistance the resident needed for transfers, as well as the whiteboard at the nurses' station. CNAs completed walking rounds at the change of shift to ensure residents were safe. She was unsure if it was after the resident's 10/22/25 fall that the fall policy was educated on for staff.12. Interview on 11/13/25 at 8:50 a.m. with RN, NS J revealed that RN I was the nurse on the floor the day the incident with resident 1 occurred, but she was closest to the resident's room when staff reported he was on the floor, so she responded. CNA L was the CNA who assisted the nurses after resident 1 fell. Resident 1 was generally confused, and she said he was not more confused since returning from the hospital. Before his hospital stay, he was able to control his recliner independently. When responding to his fall, he was found sitting on the floor between his recliner and his bed. The footrest on his recliner was in the elevated position, and she was unsure where the remote to the recliner was, but it was usually left on the armrest. While he was in the sitting position on the floor, she thought his right leg looked a little longer, and when he was lying down on his back, his right leg appeared to turn outward. He complained of pain when she touched his pelvis, and he was able to move his legs. Staff log rolled him on a slider board and lifted him to his bed. Later that afternoon, he was seen sitting on the side of the bed. She notified his family of the fall, and they did not want him sent to the emergency room for evaluation but wanted him to be kept comfortable at the facility. She updated hospice on the resident's fall. Fall interventions added after the fall included giving him a double call light, a split system so he had one button by him to call for help, and a soft one by his hip so it would turn the call light on and alert staff when he tried to get up. He did not get back up into the recliner after that fall.Staff were not documenting which recliner the residents used and what assistance they needed with their recliner. They had not started that process yet because they were trying to figure out where in the medical record recliner safety interventions should be documented. She thought education about falls and resident recliners was provided in an email to the staff, or at least they talked about the recliner assessments, so they could get those done. She reported that the restraint policy was recently sent out and staff were to read and sign it after they read it. She stated, educator D would have been the one to initiate that education. 13. Interview on 11/13/25 at 9:15 a.m. with physical therapy assistant (PTA), K revealed that, about 30 minutes prior to resident 1's fall on 10/22/25, she looked into his room as she walked by on her way to his neighbor's room. At that time, the resident was observed sitting in his recliner with his feet elevated on the footrest, talking to himself. She stated he appeared disoriented, and she was unsure if that was normal for him. About 30 minutes later, when she was walking in the hall with his neighbor, she noticed him sitting on the floor, and he called out, hey!. She let RN, NS J know resident 1 was on the floor. She did not see him or hear him fall, and she did not go into his room. From past observations of him, she recalled that he would sit in the recliner often, and he was not always reclined. 14. Interview on 11/13/25 at 10:35 a.m. with CNA L revealed that resident 1 was tired on 10/22/25. She said he was very sleepy, and they used the mechanical stand lift for transferring him. He did not walk with his walker after he returned from his hospitalization on 10/17/25. He required the use of a wheelchair to get around. On 10/22/25 he was sitting in the recliner with his footrest up, and he had his call light and the remote for the recliner within his reach. She stated he knew how to use his call light and remote for the recliner. She checked on him frequently that day, with the last time being 30 minutes to one hour before he fell. She assisted the nurses after his fall and helped get him back into his bed. He did not appear to be in pain after he had fallen. She recalled he slept the majority of that day.She stated she was working when he came back from the hospital on [DATE], and she used a stand aid to help transfer him with the help of another CNA. That was her first time using a stand aid for him, and she talked with the nurse before using it. CNA L reported she assisted him with using the bathroom and dressing with the help of another CNA. Then his family came to visit, and he was assisted into the recliner. She was unsure if he was on a repositioning or toileting schedule, but recalled he was able to shift himself independently in his recliner. CNA L recalled that, after resident 1's fall on 10/22/25, nursing reviewed where to find residents' care plans and the fall prevention policy. She knew that all residents were to have their recliner remote within their reach; otherwise, it could be considered a restraint. She stated there was a fall safety measures binder for staff to reference that had resident-specific interventions to prevent falls, and it included how the resident transferred. She wrote on her census sheet how the residents transferred. When asked if the binder was updated after resident 1 came back from the hospital on [DATE], she stated, They were still trying to figure out what the best method of transfer would be with the family, as the resident wanted to continue to do it by himself. 15. Interview on 11/13/25 at 11:02 a.m. with Hospice RN M. She was not working the day he fell on [DATE], and she was informed there was a voicemail that was left on the hospice and home health line about the resident's fall that night. She did not listen to the message; her supervisor did. Since she was not working, another hospice nurse was going to see him on 10/23/25, but he passed away before that nurse arrived at the facility. She admitted the resident to hospice services the week before his fall and saw him on Monday before the fall. At that time, he was doing okay, and she had emailed the resident's family and planned to see him later that week. He had pain and anxiety medications ordered as needed when he was admitted to hospice care for comfort. Hospice staff developed a care plan for him that included that he needed two staff members to transfer him with his walker. However, his walker use was very limited, and he was not walking around the facility. The care plan did not include safe recliner use for the resident. The resident's hospice care plan was kept in a binder on the unit for the nursing staff's availability. She communicated with the nursing home staff to identify changes in the resident's care.16. Interview on 11/13/25 at 12:45 p.m. with staff development nurse, D revealed, DON A, sent out the fall education to all nursing staff, and she was not sure which staff received the recliner assessments. The fall education was sent out to all nursing staff before the incident on 10/22/25, and did not contain information about recliner safety. She stated that staff were aware of the resident recliner assessments by word of mouth, but no documented education regarding recliner safety was provided to staff. She did not have any policies that were to be read and signed by the staff on or after 10/22/25, for nursing staff.17. Interview on 11/13/25 at 1:20 p.m. with DON A revealed the proper use of side rails and safe use of lift chairs/recliners policy was sent out to supervisors and household coordinator staff on 11/3/25, so they could start the residents' recliner safety assessments. The policy was not sent out for educational purposes. The policy had been updated from a previous version. Before the update, it just included side rail safety, not lift chairs/recliners. She verified that no education regarding falls or recliner safety had been completed since 10/22/25 for staff.18. Interview on 11/13/25 at 3:45 p.m. with RN I revealed RN, NS J readmitted all the residents on that unit. Sometimes the nurses would do a head-to-toe skin assessment, vital signs, and weight as delegated, but RN, NS J did the rest of the readmission process. When residents came back from the hospital, she thought that RN, NS J would update the resident's care plan with the changes needed. She thought physical or occupational therapy staff evaluated how the resident should transfer after they returned from a hospitalization.When a resident fell, nurses were to document the fall and the new fall interventions on the fall assessment intervention located on the nursing worklist (an area in the EMR that alerted nurses of duties to complete or review regarding residents' care). The fall assessment intervention included an area to document new care plan interventions to prevent further falls. Nurses did not have access to update the resident's actual care plan in the EMR. 19. Interview on 11/13/25 at 4:10 p.m. with RN, NS J revealed she completed temporary care plans on paper for residents who were readmitted from the hospital, and the temporary care plan included any changes from the previous stay. A copy of the temporary care plan would be hung at the nurses' station, go into the communication book, and go into the resident's paper chart for staff to reference. After she completed the resident's minimum data set (MDS) assessment (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs), she would update the care plan in the EMR. Resident 1 had a paper care plan once he returned from the hospital on [DATE]. His EMR care plan was not updated, since he passed away before his MDS assessment was completed. Staff could refer to the resident's outdated care plan in the resident's EMR, and the CNAs were able to see the activities of daily living (ADL) section when they documented, which indicated resident 1 was independent with care. She confirmed that after a resident fell, nurses did not have access to update the resident's care plan. The nurse could go into the resident's intervention and update a text box, which would then flow into the care plan, but she was the one who usually updated the care plans. She knew when a resident needed to have a fall intervention updated because when a resident fell, the nurse filled out a red sheet that included what interventions needed to be added. After the resident was monitored by the nurses for changes for three days, she would then update their care plan. The red sheet was to be hung at the nurses' station for the three days to reference it.20. A review of an email from DON A to executive assistant E on 10/30/25 at 10:19 a.m. revealed that DON A requested executive assistant E to make changes to the current policy. Executive assistant E replied on 10/30/25 at 1:14 p.m. to DON A that she updated it. [An interview with DON A confirmed this was regarding the recliner safety policy].21. A review of an email sent out by DON A to nursing supervisors and household coordinators on 11/3/25 revealed that she sent them the recliner assessments and the updated Proper Use of Side Rails and Safe Use of Lift Chairs/Recliners policy. She requested the recliner assessments to be completed by 11/4/25 for all residents who had recliners.22. A review of a 10/17/25 email sent out by DON A to all staff at the nursing home revealed that she sent the mandatory fall education and quiz and requested it to be completed by 10/31/25.23. A review of the 10/22/25 facility reported incident for resident 1's 10/22/25 fall from his recliner revealed: DON A reported the incident to the Department of Health. She stated, Re-education regarding fall prevention is provided to all staff., .we are in the process of assessing all the residents and updating/educating these resident families of the risk of using a manual recliner or a power lift chair. The type of chair agreed upon will be added to the [residents''] care plans. Staff will chart once per shift the type of chair used [by the resident] and how much assistance they required with that chair, and Education has been provided to staff, explaining the assessment tool and the policy. This was also discussed with the therapy department. 24. A review of the provider's 8/2022 Safe Lifting and Movement of Residents policy revealed: Staff document resident transferring and lifting needs in the [resident's] care plan. 25. A review of the provider's 7/2025 Care Planning policy revealed: Care is provided according to a written plan of care, which is a dynamic, individualized document utilized by those providing care to the resident. The care plan must address all aspects of the resident's care needs regardless of who is providing the care. The comprehensive care plan must be periodically reviewed and revised by a team of qualified person as resident condition changes.26. A review of the provider's 8/2022 Prevention and Management of Falls policy revealed: .implement numerous and varied strategies to minimize fall risk with little or no restraint use., Post fall risk nursing assessment should assess for injury and for possible causes of the fall: such as change in condition.need for environmental changes, etc., Fall is noted in care plan.team input is sought in preventing further falls., and Care plan is updated as appropriate.27. A review of the provider's 7/2025 Restraint Use policy revealed: Each resident has the right to freedom of chemical and physical restraints. and Some examples of nontraditional restraints include: .Placing a resident in a chair that prevents a resident from rising.28. A review of the provider's 10/30/25 Proper Use of Side Rails and Safe Use of Lift Chairs/Recliners policy revealed: An assessment will be made to determine a reason for using the side rails and recliners/lift chairs. and The use of the recliner or lift chair should be addressed in the resident's care plan.

Based on observation, interview, expiration date cheat sheet review, and policy review, the provider failed to properly label and store: *Juice cartons in two of six kitchenette refrigerators. *Food items in one of one main kitchen walk-in cooler. Findings include: 1. Observation and interview on [DATE] at 9:14 a.m. with nutrition and food service worker E in the Ash Boulevard neighborhood kitchenette revealed: *A side-by-side refrigerator with several fruit juice cartons on the top two shelves. *A grape juice carton in the refrigerator was dated [DATE] and [DATE]. *Food service worker E explained the first date was when the carton was opened. -The second date on the carton is considered the expiration date once it was opened. -Sometimes the juice is still good after one week. -She would taste the juice to ensure it was still good before serving it if it was after the expiration date. -She agreed the grape juice was expired. 2. Interview on [DATE] at 9:52 a.m. with food service worker F revealed: *When they open any food or beverage product, they write the date on it so they know when it was opened. *They count out seven days and write that date on it and that is the expiration date. 3. Observation and interview on [DATE] at 10:38 a.m. with nutrition and food service worker G in the Birch Way neighborhood kitchenette revealed: *A side-by-side refrigerator with several fruit juice cartons on the top two shelves. *A grape juice carton in the refrigerator was dated [DATE] and [DATE]. *An apple juice carton in the refrigerator was dated [DATE] and [DATE]. *She stated they label resident food and drink items when they are opened. -They put a second date on the package dated a week later that would be considered the expiration date. -Items would be discarded after the expiration date. *She agreed the cartons of grape juice and apple juice had expired and should have been thrown away. 4. Observation on [DATE] at 2:02 p.m. in the walk-in cooler in the main kitchen revealed: *An open package of smoked [NAME] cheese wrapped in plastic cling wrap dated ,d+[DATE] and ,d+[DATE]. *A package of bacon bits wrapped in plastic cling wrap dated ,d+[DATE] and ,d+[DATE]. *Three unopened gallons of vitamin D milk with a best by date of [DATE]. 5. Interview on [DATE] at 1:41 p.m. with nutrition and food supervisor D in the main kitchen revealed: *They had an expiration date cheat sheet to follow for the expiration dates for food and beverage items once opened. *The cheat sheet was not all-inclusive. *She thought the smoked [NAME] cheese was categorized with parmesan cheese and expired 30 days after it was opened. *She stated the three gallons of milk had another seven days past the best by date according to the label. -She went into the main kitchen walk-in cooler. -Looked at a gallon of milk label. -There was nothing on the label that indicated milk was good for seven days past the best by date. *She would have expected staff to have labeled food items when opened and to have followed the expiration dates on the cheat sheet. *She agreed staff should not have been tasting juice to ensure quality if it had been open more than seven days. *She stated the juice cartons and bacon bits were past their expiration date and should have been discarded. 6. Review of the provider's [DATE] Expiration Date Cheat sheet revealed: *Milk-2%, Whole date on package, up to 7 days past date on package. *Cheese-Parmesan date on package, 30 days once opened. *If not listed 7 days. 7. Review of the provider's [DATE] Sanitation in Food Handling policy revealed:*Storage of perishable items . 7. Opened packages of commercially packaged foods are bagged, dated and immediately frozen and stored in the Main Kitchen Freezer. Staff can then pull individual packages as needed and date them 5 days from the date they pulled them to expiration.*D. Expired/Outdated Product Any product expired or outdated will be removed from shelf/refrigeration/etc. and properly disposed of.

A. Based on observation, interview, and policy review, the provider failed to ensure appropriate glove use and hand hygiene had been performed during one of two residents (44) observed catheter care and personal care by certified nursing assistant (CNA) J. Findings include: 1. Observation and interview on 5/30/24 at 8:35 AM of catheter care for resident 44 by CNA J revealed: * CNA J had a gown and gloves on when the surveyor entered resident 44's room. *With those gloved hands she: -Held a pen, moved the call light, and bedding, and touched the sink faucets. -Prepared for catheter care by opening a wet wipe packet, removing wipes, and cleansing the resident's perineal area, including the the area around the catheter entrance with no-rinse soap and water. -Stated she cleansed around the catheter with no-rinse soap and water, and cleansed only at the entrance of the catheter tubing. -Removed the resident's brief and cleansed her buttocks and rectum with wet wipes. *With those same gloved hands she walked to the bathroom, opened and closed a cabinet two times, and removed a clean brief and skin cream from the cabinet. -Applied the skin cream on the resident's buttocks, removed the glove from her right hand, and put a clean glove on the right hand, and without washing her hand she put a clean glove on her right hand. -She did not remove the soiled glove from her left hand. --She then put lotion on her legs, and removed both gloves. 2. Interview on 5/31/24 at 3:30 p.m. with director of nursing (DON) B regarding the observed glove use and lack of hand hygiene revealed CNA J should have washed her hands or used hand sanitizer before she had put gloves on, and after she had removed gloves. 3. Review of the provider's October 2013 Infection control program policy regarding hand hygiene revealed: *Hand hygiene: -Was the single most important method of preventing the spread of infection. -Removes dirt, organic and inorganic materials, and transient microorganisms. -During patient care was necessary to remove microcontamination from recent contact with infected, colonized patients or environmental sources. *The use of gloves was not a substitute for hand hygiene. *Care givers should perform hand hygiene: -Before and after contact with the patient or environment. -After contact with a source of microorganisms. -After removing gloves, masks, or other protective gear. *Alcohol-based hand sanitizer should have been used in conjunction with soap and water and not the sole source of hand hygiene. B. Based on observation, interview, and policy review, the provider failed to ensure residents' clean laundry had been covered when delivered to resident's rooms by one of one CNA (J) observed during laundry pass. Findings include: 1. Observation and interview on 5/31/24 at 9:30 a.m. with CNA J while walking down Elm hall with a laundry cart revealed: *The cart had a place to hang clothing on hangers. *The cart was not covered and left the laundry at risk of contamination. *CNA J stated she had worked for the provider for over two years and had never heard anyone state the laundry was to have been covered while it was in the hallway. 2. Interview on 5/31/24 at 3:00 p.m. with CNA K regarding covering the residents' laundry while delivering the laundry sometimes the CNAs cover it, and sometimes they had not covered it. 3. Interview on 5/31/24 at 3:30 p.m. with the DON B regarding delivering resident laundry revealed she did not know the laundry had been delivered uncovered. The laundry should have been covered. 4. Review of the provider's revised March 2024 Infection Control Practices policy revealed:*Staff could use a clean cart to deliver laundry and would leave the cart outside of the room to ensure appropriate hand hygiene. *If the carts were not used staff will carry laundry away from their uniforms so it did not contaminate the clean laundry. *Staff would cover laundry during deliveries.

Based on observation, interview, and call light log report review, the provider failed to ensure call lights were answered promptly for one of two sampled residents (29) who used the call light to alert staff of assistance needs. Findings include: 1. Observation and interview on 5/29/24 at 3:55 p.m. with resident 29 revealed: *She stated she had waited for over an hour on a few occasions in the last few months for staff to respond to her call light. 2. Interview on 5/30/24 at 3:35 p.m. with administrator A regarding call light times revealed: *They had budgeted to replace the call light system next year. *It took more deliberate review to utilize the information because of the age of the system. *He was not sure if they could determine staff response times for individual room call lights. 3. Interview on 5/31/24 at 8:32 a.m. with director of nursing B regarding call light times revealed: *The goal was for staff to have answered call lights within an average of five minutes. *She had printed off the requested rooms call light times. *It would have been very labor-intensive to review call light response times by individual rooms. 4. Review of resident 29's call light report from 3/1/24 to 5/30/24 revealed: *There were 82 times when over 20 minutes had passed until the staff responded to her call light. *The longest call light response wait time was one hour and 21 minutes. 5. Interview on 5/31/24 at 1:12 p.m. with certified nursing assistant H regarding call lights revealed: *He had a walkie-talkie that notified him when a call light was activated. *He would also get notified when a call light was answered. *The goal was to answer all call lights within five minutes. 6. Interview on 5/31/24 at 2:33 p.m. with nursing supervisor I regarding call light times revealed: *The goal was to average less than five minutes for call lights to be answered by staff. *They reviewed call light times during monthly quality assurance meetings. *If they noticed an issue, they would have reviewed call light response times more closely. 47416 7. Interview on 5/31/24 at 3:18 p.m. with the DON B regarding the quality assurance and performance improvement (QAPI) program and call light response times revealed: *The QAPI committee met monthly. *The medical director attended quarterly. *They had a performance improvement plan (PIP) in place for call light times. *Call light reports were emailed to administration weekly for review. *The goal was for staff to answer a resident's call light within 5 minutes. *The report can be compiled by resident room but must be counted manually for an average time to be calculated. *They have had problems with the current call light system, but it was to be updated soon. A call light policy was requested on 5/31/24 DON B stated they did not have a call light policy.

Based on observation, interview, and policy review, the provider failed to prevent potential cross-contamination through improper glove use and hand hygiene when handling ready-to-eat foods by two of two nutrition and food service (NAFS) employees (I and K) during three of three meal service observations in two of six neighborhood kitchens. Findings include: 1. Observation on 8/29/23 at 11:41 a.m. in the Elm Pass neighborhood kitchen revealed NAFS cook K: *Folded a hoagie bun filled with Philly cheesesteak meat and vegetables using a gloved hand. *With the same gloved hand, she lifted a bowl filled with butter to scrape up some butter onto a knife and then spread the butter onto a plated serving of mashed potatoes. *She removed those gloves and put on another set of gloves without washing her hands before she prepared a bowl of thickened soup and minced some strawberries using one of her gloved hands, during which time she also touched the door handles of the microwave, cupboard, and the refrigerator, and other potentially soiled surfaces, including plates and utensil handles. *She then folded another hoagie bun to make a Philly sandwich with those same gloved hands that had touched all the potentially soiled surfaces. *She removed the gloves, washed her hands, then put on another set of gloves. *With that set of gloves, she: -Removed the strawberry container from the refrigerator, placed the container in a sink, opened the container, and turned on the faucet to rinse the strawberries. -Picked up the container out of the sink after the water had drained and held onto the strawberries with one gloved hand while she sliced them. -Touched the toaster handle to make toasted waffles, removed the waffles using a set of tongs. -Picked up the butter bowl to spread butter with a knife onto the toasted waffles while holding onto the waffles with a set of tongs. -Sliced the waffles with a pizza roller that she had retrieved from a drawer while holding onto the waffles with the tongs. -Folded another hoagie bun to make another Philly sandwich. Observation on 8/30/23 at 11:06 a.m. in the Elm Pass neighborhood kitchen revealed NAFS cook K: *Was using gloved hands to tear lettuce leaves and then placed them into small serving bowls. *While wearing the same pair of gloves, she touched the refrigerator handle, then pulled out a tomato and sliced it. Interview on 8/30/23 at 4:05 p.m. with NAFS cook K revealed she: *Understood she was not to touch ready-to-eat foods with her bare hands. *Initially thought that it was acceptable to touch ready-to-eat food if she was wearing gloves. *Agreed it was difficult to not potentially contaminate her gloved hands due to touching multiple objects and surfaces when she was having to go back and forth from serving to preparing foods based on special requests from the residents. *Was unsure how she could have folded the Philly cheesesteak sandwiches if she had not been able to use her gloved hand. *Was unsure how she could slice tomatoes without holding onto them with her gloved hand. *Had to use her gloved hands to open the baked potatoes, and put on butter and sour cream for the lunch meal today. 2. During interview and observation on 8/30/23 at 11:22 a.m. in the Maple Ridge neighborhood kitchen, NAFS cook I revealed she: *Had removed the head of lettuce from the refrigerator and washed it. *Put on a glove to chop it and placed the chopped lettuce into a medium-sized container with a lid that she pointed to in the refrigerator. *Followed the same process for the tomatoes, which she also pointed to in the refrigerator. *Would serve the lettuce and tomatoes from the containers for the lunch meal using a gloved hand to place the lettuce and tomatoes into the serving bowls. Interview on 8/30/23 at 5:36 p.m. with Supervisor M of FANS revealed: *Education had been provided to FANS staff on glove use after she started to ensure they were using them properly. *She agreed it was difficult to not potentially contaminate gloved hands when touching multiple objects and surfaces, which was the reason for the recent education that had been provided. *She confirmed utensils could have been used to fold the Philly cheesesteak sandwiches and to prepare the other foods that were touched with the gloved hands. Review of the provider's procedure, General Food Handling, effective 3/15/2013 revealed: *No bare hands contact to ready to eat foods. *Dietary will provide tongs, tissues, or serving utensils to departments who serve meals, nourishments or snacks.

Based on observation, interview, and record review, the provider failed to follow a physician's order for a mechanically altered diet for one of one sampled resident (26). Findings include: 1. Observation and interview on 8/29/23 at 11:32 a.m. with resident 26 revealed: *They [the staff] have started something different for me [with his food]. *He pointed to the upper part of his esophagus below his throat while stating he had been having trouble with a cough when swallowing. *Bacon was not good for him to eat. Interview and observation on 8/29/23 at 12:04 p.m. in the Elm Pass neighborhood kitchen revealed: *Nutrition and food service (NAFS) cook K reported resident 26 was on thickened liquids now. *She stirred two teaspoons of thickening powder into a bowl of tomato soup that she had warmed up in the microwave. *When asked what was the level of thickened consistency for resident 26, she replied, nectar thick. *When asked if two teaspoons was the correct amount for nectar thick, she replied, I think so. *She also prepared a bowl of minced and moist strawberries for resident 26, and said that was the required level of food consistency that he could eat. Interview on 8/30/23 at 4:05 p.m. with NAFS K revealed: *She had to prepare apple crisp for resident 26 to a minced texture because she had not received a serving with that texture from the main kitchen. *She explained she put one serving of the apple crisp in the blender, pushed the blend button for three pulses, scraped it into a small serving dish, and then added whipped cream and cinnamon on top. Review of the electronic medical record (EMR) for resident 26 revealed: *The admission, annual, and quarterly Minimum Data Set (MDS) assessments between 7/14/20 and the current MDS dated [DATE] included: -The scores for the Brief Interview for Mental Status between 12 to 15, which indicated he had a range of mild cognitive impairment to cognitively intact. The 7/28/23 MDS score was 12. -Swallowing problems, including coughing and choking, had not been checked on any of those MDS assessments. *The care plan last reviewed on 8/16/23 with a start date of 7/14/20 included: -A problem for nutritional status that stated, I am at nutrition risk related to .HTN [hypertension], DM2 [diabetes mellitus type 2], stroke, hyperlipidemia, BPH [benign prostatic hyperplasia]. There were no interventions related to swallowing or choking difficulties. -Interventions for the problem of activities of daily living (ADL) status: --I often choose to eat items/food textures that are not appropriate for my order diet (e.g. bacon). --My family and I have been educated on the risks of choking. --My family and I understand the risk, and are choosing to allow me to eat what I prefer. *A 9/17/21 physician order that displayed in the EMR as current on the morning of 8/29/23 included a dietary order for IDDSI [International Dysphagia Diet Standardisation Initiative] 6 [level] soft and bite-sized, thickened liquids mildly thick [level 2]. Further review of resident 26's EMR revealed: *A nutrition assessment on 7/20/23 documented no nutrition data. *A physician recertification report dated 7/28/23 revealed an assessment of chronic cough. *A nurses note dated 8/19/23 documented the resident: -Has been having a harder time with meals and drinking fluids. -Is leaving more food on his plate and leaving the table coughing. -Had a strange squeal to his voice and runny nose. -Is sleeping more and seems tired from eating. -Daughter agreed it was in his best interest to have Speech Therapy [ST] evaluate. *A physician progress note dated 8/21/23 revealed: -An assessment of cough, congestion of throat, and acid reflux. -The plan included speech therapy for swallowing and reflux problems. *A physician communication report dated 8/24/23 revealed After consultation, Speech therapy recommended Video Swallow study and recommended to downgrade to a IDDSI 5. *A nurses note on 8/29/23 revealed: Per ST evaluation, order received from CNP [certified nurse practitioner] for mildly thick liquids and swallow study. family and dietary notified. Interview on 8/30/23 at 10:48 a.m. with registered nurse nursing supervisor (RN-NS) D, who was also the household coordinator (HC) for Elm Pass, revealed: *Both she and the registered dietitian monitored for resident nutritional concerns. *Resident 26 had been doing more coughing after eating and he felt something in his throat after eating. *The family had been declining speech therapy previously because they wanted resident 26 to be able to eat what he wants, and he likes bacon. *That time the family agreed to have a speech therapy evaluation and his food texture changed from level 5 to 6. *When asked about resident 26's physician order dated 9/17/21 regarding IDDSI level 6 and thickened liquids level 2, she stated that thickened liquids started yesterday. *She was not aware of the 9/17/21 order and was not able to find it during the interview. Interview on 8/30/23 at 5:36 p.m. with Food and Nutrition Services (FANS) supervisor M revealed she: *Was able to correctly identify what would have been considered a level 6 texture for food and a level 2 for liquids. *Agreed she would need to complete some further education on IDDSI levels with the FANS employees, in particular with FANS cook K, since she had not followed the level 6 food texture and was unsure if she had prepared the tomato soup to a level 2 for liquids. Interview on 8/31/23 at 11:24 a.m. with RN-NS D revealed: *Resident 26 had not been on thickened liquids; he may have been when he initially was here. *She reported she had put the mildly thick in [the orders] myself the other day on 8/29/23. *When asked if there had been any action taken in response to the physician communication report dated 8/24/23 with a recommendation to change to IDDSI 5, she said no order [had been] received [for that]. Interview on 8/31/23 at 12:23 p.m. with RN-NS D revealed she: *Reached out to the CNP to clarify if the IDDSI food texture should have been changed to level 5. *Changed the diet order to level 5 based on the CNP's confirmation. *Was not sure what had happened with the 9/17/21 order for mildly thick liquids and had been unable to find it upon a request for a copy. Interview on 8/31/23 at 3:47 p.m. with FANS supervisor M and director of nursing (DON) B revealed: *The DON would look through resident 26's EMR for the 9/17/21 physician order for IDDSI 6 soft and bite-sized, thickened liquids mildly thick, and determine when the order for mildly thick liquids had been discontinued. *FANS supervisor M was unable to confirm whether two teaspoons of thickener used by FANS cook K was appropriate for mildly thick without looking at the label on the thickener container. Further clarification on the implementation or discontinuation of the original physician order dated 9/17/21 for thickened liquids was not received before the survey exit.

Based on observation, interview, record review, and policy review the provider failed to ensure their policy for re-weighing residents had been followed for one of one sampled resident (48) with a significant weight variance. 1. Observation and interview on 8/31/23 at 9:09 a.m. of resident 48 revealed: *She was in her room, sitting in a recliner. *She was wearing blue jeans that appeared to be tightly fitting, and a shirt. *She thought the food was very good. *She had been gaining weight and did not like that. *She had to lay down on the bed to get her jeans buttoned. *She was not sure how often she was weighed or what her weight currently was. *No one had visited with her about her weight. Review of resident 48's electronic medical record revealed: *She was admitted on [DATE]. *Her diagnoses included the following: long term use of antibiotics, recurrent Clostridium difficile (C-diff), depression, generalized anxiety, mild cognitive impairment, gastro-esophageal reflux disease, dyspepsia (indigestion), and constipation. *She was on a a regular diet. *Her weight record indicated that: -On 7/7/23 she weighed 142 pounds (lbs.) and 5 ounces (oz.). -On 7/29/23 she weighed 140 lbs. and 8 oz. -On 8/4/23 she weighed 128.0 lbs. --That was a 12-pound weight loss which was a 8.57% weight loss. --She had not been re-weighed to determine if that weight was correct. --Her next weight was on 8/11/23 and she was 136 lb. 10.986 oz. *Her 8/30/23 care plan included the following: -On 11/17/22 the initiated problem was that she was at nutritional risk related to her diagnoses. --The preferred outcome for that was for her to have adequate intake to maintain her current weight of 125 lbs. with a plus or minus variance of five percent. *Her 8/7/23 Minimum Data Set [(MDS), a set of clinical and functional status screening elements, which form the foundation of a comprehensive assessment], revealed: -She was independent with eating. -Her weight was 128 lbs. -That was a significant weight loss of 5% or more in one month. *There had been no notification to her physician regarding that significant weight loss. *On 8/29/23 Boost (a supplemental nutritious drink) was ordered. *Her progress notes indicated that: -On 7/9/23 she had high fever, high blood pressure and had been vomiting. --She was sent to the emergency room . -On 7/10/23 she had loose stools and vomiting, her physician had ordered a culture C-diff. -On 7/11/23 she had been weak and unsteady, had a poor appetite, and had nausea and vomiting. -On 8/9/23 she had a urinary tract infection. Interview on 8/31/23 at 9:15 a.m. with certified nursing assistant Q regarding process for weighing residents revealed: *Residents had been weighed weekly on their bath days. *The nurse reviewed the weights to determine if there was an unusual difference between the week prior weight and the current weight. -If there had been an unusual weight, the nurse would have requested a reweigh of that resident the next day. *She was familiar with the care needs of resident 48. -She was not aware of resident 48 having had a weight loss. Interview on 8/31/23 at 9:21 a.m. with registered nurse R regarding the process for monitoring residents for weight gain or weight loss revealed: *Residents were weighed on their bath day or more often with a physician order. -A nurse would monitor each resident's weight for a significant change by comparing the current weight with the: --Previous weeks weight. --Previous years weight. *A difference of more than three pounds in a week would have prompted a re-weigh of the resident the following day. -If the next day the weight of that resident showed the same significant weight difference, the dietary manager and the physician would have been notified. *The cause of weight loss would have been evaluated. Interview on 8/31/23 at 11:09 a.m. with certified dietary manager S regarding resident 48's weight loss revealed: *The nurses had monitored weights. *Registered dietitian (RD) T had come to the facility a couple of times a week for consultations and she: -Would have provided direction to the dietary staff on what nutritional interventions to do for residents with weight loss. *She was not aware of resident 48 having had a weight loss. -Completed the residents Minimum Data Set (MDS) for the nutrition and weight loss sections. Telephone interview on 8/31/23 at 11:25 a.m. with RD T regarding residents' weight loss revealed: *The process was: -Each month a report would have been completed that compared each residents' percentage of weight loss or gain on a monthly, six months, and yearly basis. -Any resident who had triggered for a significant weight loss would have been reviewed at the residents' next months' care conference by the resident's case manager, the director of nursing (DON), and herself. --There would have been documentation in the residents' electronic medical record of the discussion at the care conference and the interventions initiated for that resident. --One of those three staff members would have been assigned to notify the physician and the family. *She had not monitored the residents weight loss each week. *A nurse would monitor the residents for weight loss on a weekly basis. *A resident with a three lb. weight loss would have been reported to the nurse and a re-weigh of that resident would have been completed. *She was unable to determine if resident 48 had a significant weight loss as she was unable to view the documentation at the time of the telephone interview. -She had completed the 8/7/23 MDS nutrition and weight section for resident 48. *She stated if resident 48 had no weight loss, the MDS for that time period would need to have been 'fixed' to record there had not been a significant weight loss. Interview and record review on 8/31/23 at 12:21 p.m. with DON B regarding resident 48'sweight loss revealed: *The process for monitoring of residents' weights was the following: -A residents' weight with a difference of three lbs. or more from their previous weight would have required that resident ot have been reweighed. -Residents who had a three lb. weight difference would have required a nurse to update the nurse practitioner who would come to the facility twice per week. *Resident 48 had seen her physician on 7/13/23, 7/28/23, 8/21/23, and 8/22/23. -There was no documentation to support that her physician was notified of the changes in her weight on any of the above visits. *She was not able to find documentation to support that the physician or family had been notified of the weight loss for resident 48 for the time 7/29/23 through 8/11/23. Review of the providers 12/2012 Nutritional Assessment policy revealed: *Purpose/Explanation -To maintain documentation of weights, meal intakes, and to achieve a consistent manner to track weight gain or weight loss and outline necessary interventions of resident nutrition. -F. Any needed re-weights should be obtained when weight differs from the prior weight by 3# (pounds) more or less. Re-weights are desirable to be obtained the following day if possible. -I. Weights will be recorded per EMR (electronic medical record). -J.staff should consult with the dietician and/or physician when significant weight loss/gain is noted. *III. EXCESSIVE WEIGHT LOSS AND/OR GAIN. -B. Dietician and Nursing Director review weights regularly. Any weight concerns are communicated to the interdisciplinary team. -D. Any necessary interventions for excessive weight loss and/or gain will be care planned. -E. Collaboration with the dietician and/or physician as necessary.

Based on observation, interview, record review, and policy review, the provider failed to ensure appropriate infection control practices were followed for the coronavirus (COVID-19) pandemic related to: *Infection control practices for five of twenty-three residents who reside on two separate units Ash Boulevard and Maple Grove within the same neighborhood. (5, 17, 22, 33, and 71) to prevent exposure and potential spread of COVID-19. *Informing staff and visitors of the current outbreak status in the facility. *Two of two nutrition and food service (NFS) employees (L and M) had been educated on proper infection control precautions and had not been working while sick. *Changing N95 masks after exiting two of two COVID-19 quarantined units (Ash Boulevard and Maple Grove). *Two of two certified nurse aides (CNA) F and G while providing fresh drinking water. *Providing appropriate personal protective equipment (PPE) donning (putting on) and doffing (removing) stations outside the quarantined areas. *Quarantine for two of two unvaccinated residents (46 and 64) during a facility outbreak. *Quarantine for potentially COVID-19 exposed residents. *Education for all staff on proper PPE usage within quarantined areas. *One of one CNA H disinfecting medical equipment after use on three of three observed (5, 17, and 30) quarantined residents. *One of one CNA H removing soiled gloves and performing hand hygiene after contact with three of three observed (5, 17, and 30) quarantined residents. Findings include: 1. Observations and interviews on 5/17/22 from 9:11 a.m. through 10:42 a.m. of NFS staff L and M in the Maple Grove neighborhood revealed: *At 9:11 a.m., NFS L's face mask was below her nose while she was standing at the dining area island. *At 9:50 a.m., her face mask was below her nose, and she coughed while she walked behind resident 22 who was seated at a dining room table. *At 10:03 a.m., NFS L walked up to resident 22, coughed as she pulled her mask up over her nose, and asked what resident 22 wanted for breakfast. *At 10:22 a.m., her mask was below her nose as she pushed resident 22 in his wheelchair away from the dining area. *At 10:34 a.m., NFS M's face mask was below her nose while she washed dishes in the kitchen. *At 10:42 a.m., NFS M reported she did not know if she was supposed to wear goggles (eye protection) when they were working in the kitchen. Every time this comes up (a quarantine), we all don't know what we are supposed to wear, and her manager doesn't know. NFS M's face mask was missing the top strap so it did not fit tight over her nose. *At 10:38 a.m., NFS L reported she had her mask below her nose because she could not breath, she was getting over a cold, and she was going to get a note from her doctor so she doesn't have to wear it. 2. Observation on 5/17/22 at 9:58 a.m. of the facility's front entrance revealed: *Receptionist A sitting at the front desk with a surgical mask that was sitting underneath her nose. -She was not wearing any eye protection. *Approximately less than four feet away was an unidentified male who was seated in a wheelchair not wearing a mask and talking with receptionist A. 3. Interview on 5/17/22 at 10:49 a.m. with director of nursing (DON) D revealed: *The facility had one COVID-19 positive resident. *They had no residents who were being quarantined. *They had two staff members who had tested positive for COVID-19 on 5/15/22 and 5/16/22. Continued observation on 5/17/22 at 1:21 p.m. revealed receptionist A was: *Wearing a surgical mask that had been pulled down underneath her nose. *Not wearing any eyewear protection. Interview on 5/18/22 at 9:16 a.m. with infection preventionist K revealed: *The facility had two COVID-19 positive residents on two different units, but within the same neighborhood. *She had been informed of the positive case via text message on 5/16/22 from DON D. Observation and interview on 5/18/22 at 1:37 p.m. in the [NAME] Center with infection preventionist K revealed: *She was wearing a surgical mask. *She was not wearing eye protection. *There were four positive COVID-19 residents at that point on two units (Ash and Maple units). -She stated Ash Boulevard and Maple Grove units were considered quarantine units. --Both units had potential exposure due to having huddled together into a small interior room because of a tornado warning on 5/12/22 . *An email was sent to the facility's All Staff Email List on 5/16/22 informing staff about the positive cases. *She confirmed that two staff members had tested positive for COVID-19. *She stated when there was more than one positive COVID-19 resident, those resident's units were considered under quarantine and communal dining stops for the entire building. *She indicated the facility's PPE supply was adequate and they were to be using disposable aprons/gowns. *She confirmed that staff and visitors should have been: -Disposing of their face mask after exiting the quarantined units. -Sanitizing/disinfecting their goggles, face shields, or other eye protection after exiting the quarantined units. *She indicated the resident's doors on the quarantined units should have been shut unless the resident had safety concerns. 4. Observation and interview on 5/18/22 from 2:46 p.m. through 3:06 p.m. of the Ash Boulevard and Maple Grove units revealed: *People coming and going had to enter through a double door. *There were no signs indicating the area was quarantined and what precautions needed to be taken. *There were no PPE changing/sanitation stations set-up. *Upon entering through the double doors, there was hand sanitizer. -PPE stations were set-up outside of the COVID-19 positive residents' rooms. -The stations contained gloves and N95 masks. *At 2:51 p.m. administrator B walked into Ash Boulevard wearing an N95 mask and no eye protection. -He left Ash Boulevard wearing the same N95 mask. *At 2:52 p.m. NFS O exited the Ash Boulevard unit service kitchen, pushing a cart, headed toward the facility kitchen. -She was wearing a surgical mask and no faceshield, stating she could not wear an N95 because of medical reasons. *At 3:01 p.m. CNAs F and G walked into Ash Boulevard with only surgical masks and goggles. *At 3:06 p.m. an unidentified employee left Maple Grove without changing or sanitizing her PPE. -She exited the unit without changing her mask or performing hand hygiene. 5. Observation and interview with 5/18/22 at 3:16 p.m. with CNA H and quarantine resident 30 revealed CNA H had: *Put on new pair of gloves before entering resident 30's room. *Entered resident 30's room and the door remained opened. *Placed her clipboard and paper on the resident's bedside table, next to her water cup. *Measured her vitals with a pulse oximeter and a digital forehead thermometer. *Exited the room wearing the same gloves and went into the nurse's station. *She went back into resident 30's room wearing the same gloves. *Her clipboard with paper and pen remained on the resident's bedside table next to her water cup. *Grabbed her clipboard and medical equipment and had begun to exit resident 30's room. *Not removed her soiled gloves and performed hand hygiene. *Not cleaned, disinfected, or sanitized the medical equipment. *The door remained open throughout the entire observation. Further observation and interview on 5/18/22 at 5:22 p.m. with CNA H and residents 5 and 17, who were quarantined revealed she: *Walked down the hallway and entered resident 5's room with the same soiled gloves and soiled pulse oximeter and thermometer. -Resident 5's door had remained open. *Walked into resident 5's bathroom and asked if she could obtain their vitals. *Took resident 5's vitals and left the bathroom and room with the same soiled gloves, soiled clipboard, and soiled equipment. *Had not changed her gloves, or disinfected the medical equipment prior to entering resident 17's room. *Then exited resident 17's opened door wearing the same soiled gloves and carrying equipment she had used on residents 30, 5, and 17. -Surveyors observed she was not wearing her N95 mask appropriately as there were visible gaps around her nose and the straps were placed together on the back of her head. *Surveyor inquiry confirmed she had: -Not put on new gloves before entering a new resident's room, she never does. -Not sanitized the pulse oximeter or thermometer before entering a new resident's room. -Revealed the residents were staying in their rooms because of COVID-19. -Measured the vitals on residents first that had not been confirmed positive for COVID-19, then measured vitals on the residents that had tested positive last. -Not known how to wear her N95 mask correctly. -Not known if she had been fit-tested for wearing an N95. -Changed her PPE and cleaned medical equipment after being in the COVID-19 positive rooms. -Not known which residents should have been on isolation and which residents should have been quarantined. 6. Observation and interview on 5/18/22 at 3:27 p.m. with CNA F and G revealed they: *Were both wearing gloves while pushing a cart with water cups. *Had not change gloves before entering another resident's room. 7. Interview on 5/18/22 at 3:34 p.m. with licensed practical nurse (LPN) J revealed: *She was the charge nurse for the Maple Grove and Ash Boulevard units. *There were two confirmed COVID-19 resident cases on Ash and two confirmed cases on Maple. -Everyone else on the unit should have been quarantined. *She considered the residents positive for COVID-19 to be quarantined. *Staff members were screening residents for symptoms of COVID-19 three times per day. *All residents had been tested for COVID-19 that morning. *Staff members were to: -Remove their masks upon leaving the isolation COVID-19 positive rooms. -Put on a new mask. *She confirmed that staff do not put on disposable gowns/aprons, or change their N95 masks in between resident's rooms who were not confirmed cases of COVID-19. *She stated they put a new N95 mask on when arriving at work and do not change it after contact with quarantined residents. 8. Interview on 5/18/22 at 3:52 p.m. with infection preventionist (K) revealed she: *Had not been back on the COVID-19 units to watch infection control practices or check the set up of units. -She had been busy with the survey and had been at the hospital. *In regards to observations of administrator B and social worker (SW) C, she: -Believed from a microbiology standpoint it was highly unlikely that any COVID-19 germs spread by wearing the same N95 into other areas of the building. -Agreed there was still a risk of contamination. -Agreed it could confuse staff about what precautions to take and when to wear their N95 mask. *Stated the unit manager of Ash and Maple made the decision to not implement gowns for quarantined residents because, she: -Was worried staff would not use them appropriately with surveyors in the building. *Stated staff clean off their goggles or face shields but they do not change their N95 mask. -When asked if they follow centers for disease control and prevention (CDC) guidance, she stated yes. 9. Observation on 5/19/22 at 9:25 a.m. of the Pine dining room revealed: *Unvaccinated residents 46 and 64 were eating breakfast in the communal dining room. *They were sitting at a table with four other residents. *There were other unidentified residents in the dining room as well. 10. Observation on 5/19/22 at 9:49 a.m. revealed unvaccinated resident 46 had been sitting in a chair in the [NAME] Center. Review of facility email from nursing supervisor N on 5/16/22 at 3:10 p.m. revealed: *Steps for residents on isolation precautions. *All staff should have worn gowns, gloves, goggles, and N95 face masks before entering the isolation rooms. *There was no mention of any quarantine precautions. 11. Review of the provider's July 2020 Infection Control Practices-A COVID-19 Addendum for the (provider's name] revealed: *All employees must refer to the [provider name] Infection Control Program in addition to this document. Standard precautions, including universal masking and wearing eye protection, must be used on all residents regardless of diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] *The following steps would be taken for a resident suspected or known to have COVID-19, which included: -Open dining and small activities may continue once neighborhood has had initial testing and all are negative. This may be subject to change if the situation warrants an entire quarantine. -ALL UNVACCINATED RESIDENTS on an affected neighborhood may need to quarantine depending on results of in-house contact tracing. REGARDLESS of [CONDITION(S)] testing. -All vaccinated residents on an affected neighborhood should wear masks depending on results of in-house contact tracing. -Removal from isolation or quarantine will be based on signs/symptoms, along with consultation from the IP [infection preventionist], Medical Director, DON, and/or DOH [department of health]. -If the resident is in quarantine/isolation, visitors may be required to additionally wear gloves, gown, and eye protection .*If two or more residents from different neighborhoods were suspected or known to have COVID-19, the following would happen: -ALL UNVACCINATED RESIDENTS in the facility will quarantine regardless of [CONDITION(S)] testing. *Infection prevention considerations included: -Limit only essential personnel to enter the room with appropriate PPE and bundle care as needed. PPE includes: Gloves, gowns, and respiratory protection (N95 or PAPR). -Follow the recommended donning and doffing instructions. -Dedicated or disposable patient-care equipment should be used for residents on quarantine or isolation. If equipment must be used for more that one resident, it will be cleaned and disinfected before use on another resident.

Based on interview, record review, and policy review, the provider failed to ensure advance directives were current for seven of seven sampled residents (30, 41, 47, 49, 53, 54, and 68). Findings include. 1. Review of resident 47's electronic medical record revealed: *He had a [DATE] signed power of attorney (POA) form that stated: -I desire that cardiopulmonary resuscitation (CPR) be used only when there is a good chance that the use of such a procedure shall result in a full recovery . *Admission paperwork on [DATE] from the hospital stated: -CODE STATUS is switched to DNR [do not resuscitate] after reviewing paperwork from [assisted living facility's name]. He is a DNR/DNI [do not intubate] per their paperwork. 2. Review of resident 53's electronic medical record revealed: *She was under guardianship. *The guardianship documentation had not addressed her code status. Interview on [DATE] at 10:35 a.m. with registered nurse (RN) unit manager E regarding residents 47 and 53's advance directive revealed: *The social worker (SW) C has all of the resident's code status' and advance directives. *The information is gone over at care conferences. Interview on [DATE] at 11:02 a.m. with Social Worker (SW) C revealed: *Code statuses and advance directives are handled by the nurses. *She obtains living wills and POAs upon admission, otherwise nursing goes over the information at care conferences. *They do not have a period in which they update code statuses or advance directives. *Resident 47 was a DNR according to his medical record. *Surveyors informed her his POA form stated he wanted to be of full code status and asked when it had changed. *She had been unable to find any documentation related to education regarding code status or when it may have changed. Interview on [DATE] at 1:35 p.m. with SW C regarding resident 53 revealed: *The guardianship paper was all they had for an advance directive/code status. *She agreed that the paper had not addressed code status or advance directive for resident 53, it was only for financial topics. 3. Review of resident 49's electronic and paper medical record revealed: *She had been admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) had been fifteen. That score indicated she had no cognitive impairment. *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] *There had been a [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *There had been no signed documentation that identified her choice for her code status. 4. Review of resident 54's electronic and paper medical record revealed: *She had been admitted on [DATE]. *Her BIMS had been twelve. That score indicated she had mild cognitive impairment. *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] *There had been a [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *There had been no signed documentation that identified her choice for her code status. 5. Review of resident 68's electronic and paper medical record revealed: *She had been admitted on [DATE]. *Her BIMS had been fifteen. That score indicated she had no cognitive impairment. *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *There had been a [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *Had a living will dated [DATE] as full code which had been signed [DATE]. 6. Review of resident 30's electronic medical record revealed: *She had been admitted on [DATE]. *Her BIMS had been nine. That score indicated she had moderate cognitive impairment. *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *There had been a [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *There had been no signed documentation that identified her choice for her code status. 7. Review of resident 41's electronic medical record revealed: *She had admitted on [DATE]. *Her BIMS had been fifteen. That score indicated she was cognitively intact. *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *There had been a [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *There had been no signed documentation that identified her choice for her code status.

Based on interview, record review, and policy review, the provider failed to ensure: *One of one sampled resident's (47) care plan had been updated to include the addition of a WanderGuard. *Two of two residents (47 and 53) advance directives had been updated on their care plans. Findings include: 1. Review of resident 47's 5/19/22 care plan revealed the use of a WanderGuard had not been mentioned or included. Refer to F604. 2. Review of resident 47's 5/19/22 care plan regarding his advance directive revealed: *Advance Directive. -I have a DPOA [directive power of attorney] document that names my daughter, [daughter's name] in my POA [power of attorney]. I have no specific healthcare preferences listed in my DPOA document. *There was no code status included in his care plan. Refer to F578. 3. Review of resident 53's 5/19/22 care plan revealed: *Advance directive: -My son, [son's name], is my guardian and conservator He is able to assist with my finances and decision making as needed. *There was no code status included in her care plan. Refer to F578, finding 2. Interview on 5/19/22 at 10:35 a.m. with registered nurse (RN) unit manager E revealed: *They did not update care plans regarding code status. *Agreed resident 47's WanderGuard had not been placed on his care plan. Review of the provider's February 2013 Care Planning policy revealed: *A comprehensive care plan must be prepared by an interdisciplinary team (ex: Food Service Worker, CNA [certified nursing assistant], Household Coordinators/Social Services Designee, etc.) that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs. and, the extent practicable, the participation of the resident, the resident's family or the resident's resident representative. *The comprehensive care plan must be periodically reviewed and revised by a team of qualified persons as a resident condition changes.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (47) had been appropriately assessed and documented to indicate the use of the WanderGuard as a restrictive or enabling device. Findings include: 1. Observation and interview on 5/17/22 at 3:25 p.m. with resident 47 revealed: *He was sitting in a recliner in his room. *His feet had been propped up on his walker. *There was a WanderGuard bracelet attached to his walker. *Throughout the interview he was able to answer questions but seemed confused. Review of resident 47's electronic medical record revealed: *He had been admitted to the facility on [DATE]. *He had a WanderGuard on his walker due to exit-seeking and elopement. *The device had been placed approximately three weeks after he first arrived at the facility. *He had elopement assessments completed and he had been always determined to be at no risk for elopement. *There was no physician acknowledgement or order documentation for the use of the WanderGuard. Interview on 5/19/22 at 10:35 a.m. with registered nurse (RN) unit manager E revealed: *The WanderGuard had been placed because resident 47 had situations of exit-seeking events. *She stated there was an audible alarm heard if the resident went near an exit door or the entrance to the unit. *She stated the alarm had deterred the resident from wandering. *When he heard the alarm going off, he had said Oh, I guess I am not supposed to be going over there. *They had not done an assessment for the device. *She agreed he had not been marked to be at risk for elopement. *Had not talked to the physician regarding the device. Review of resident 47's physical therapy notes revealed: *He had an issue with his neck. *He often walked with his head down. *Therapy believed he may have seemed like he was lost but he was unable to see as well because he had to walk with his head down and was still getting acclimated to his new home. Review of the provider's August 2012 Restraint Use policy revealed: *The facility creates and maintains a homelike environment that emphasizes alternative/minimal restraint use while progressing towards achieving a restraint-free environment. *The system is utilized until the goal is achieved, recognized and protects residents rights and when used, restraints are safe and appropriate for each resident based on agreed plan of care. *The goal of this policy is for each person to attain and maintain his/her highest practical well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. *Each resident has the right to freedom from chemical and physical restraints. except as authorized in writing by a physician. The use of restraints is prohibited except to treat a medical symptom. Restraints will be used only as a last resort, not to be used to limit mobility for convenience of staff, for discipline, or as a substitute for supervision.

Based on observation, record review, interview, and policy review, the provider failed to ensure medication had been administered according to policy and procedure by one of one licensed practical nurse (LPN) (A) causing a medication error rate of 6.67% for: *One of one observed resident's (6) nasal inhalation medication had administered incorrectly. *One of one randomly observed resident's (2) insulin had been administered incorrectly. Findings include: 1. Observation and interview on 8/15/18 at 7:34 a.m. of LPN A during resident 2's Toujeo insulin pen injection revealed she:*Had not primed the insulin pen prior to administering the insulin. *Stated that was her usual practice when administering an insulin pen injection. *Stated she always primed the insulin pen the first time after it was opened but not after that. 2. Observation on 8/15/18 at 8:20 a.m. of LPN A while she administered resident 6's [MEDICATION NAME] inhaled medication revealed she: *Removed the cap from the medication and inserted it approximately one-half inch into the resident's left nostril. -Pressed the device to release the spray of medication. -Did not hold the opposite nostril closed. -Repeated the same method for the right nostril. 3. Interview on 8/15/18 at 10:45 a.m. with the director of nurses confirmed the above medication administrations had been incorrect. Review of the provider's (MONTH) 2014 Insulin Administration: Sq and Continuous IV infusion policy made no mention of the use of an insulin injection pen. Review of the provider's 1/31/13 Medication Administration policy revealed no mention of nasal inhaled medications.

Based on interview, record review, and policy review, the provider failed to ensure one of one sampled resident (3) who desired to be discharged had been involved in any discussion regarding that decision. Findings include: 1. Interview on 5/30/17 at 9:15 a.m. with resident 3 revealed she: *Had been a resident there for over a year. *Had required more assistance from staff when she was admitted . *Was independent with her most of her daily care. *Could not recall having attended a meeting to discuss her care or the possibility of her discharge. *Was sometimes frustrated with some of the residents who were more confused or who she could not visit with. *Hoped she would not have to live there the rest of her life. Review of resident 3's 2/14/17 and 5/16/17 Minimum Data Set assessments revealed: *She was alert and oriented to person, place, and time. *She was independent with her activities of daily living including transferring, ambulating, dressing, eating, and toileting. *She did not have an active discharge plan. Review of resident 3's entire medical record revealed the only care conference she had attended was on 8/24/16. Review of resident 3's 5/18/17 care plan revealed it did not address her desire for discharge. Interview on 5/30/17 at 2:15 p.m. with the Oak and Birch house coordinator D regarding resident 3 revealed: *She confirmed the resident was independent with her care. *Residents did not come to care conferences. *They usually talked to the resident before the care conference to complete the assessment. *She was unaware the resident was hoping she did not have to live there the rest of her life. Interview on 5/30/17 at 3:45 p.m. with the Oak and Birch nursing supervisor D regarding resident 3 revealed: *They invited family members to care conferences. -Most of them chose not to come. *Resident 3's family had been invited, but they usually had not attended. -They visited enough, so they just stopped in and asked the nurse questions when they were here. *She confirmed resident 3 was alert and oriented and could have participated in her care conferences. *She was unaware the resident was hoping she might be a candidate for discharge. *She confirmed the resident could function at a lower level of care such as assisted living, but that had not been addressed with the resident or her family. Review of the provider's February 2013 Care Planning policy revealed: *Resident care is planned within put from the resident/resident representative, in conjunction with the multiple disciplines involved in resident care to promote/maintain the resident's mental, spiritual and physical health at an optimal level for the individual resident. *A comprehensive care plan must be prepared by an interdisciplinary team that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and the extent practicable, the participation of the resident, the resident's family or the resident's resident representative. Review of the provider's May 2013 Discharge Panning procedure revealed: *It is the policy of this facility to provide each resident with planned and coordinated care to meet his/her individual needs, both within the facility and after discharge. *To achieve this purpose, a discharge plan shall be developed within seven days of admission and implemented by the social services designee. *The individual discharge plan shall be coordinated using input from the attending physician, each discipline involved in the resident's care, the resident and resident representative. The discharge plan shall be reviewed and re-evaluated quarterly or more often if necessary. It will also be included as part of the resident's medical record.

Based on interview, resident group interview, and policy review, the provider failed to ensure residents were encouraged to participate in their care conference for five of five neighborhoods (Birch, Oak, Pine, Elm and Ash), and for one of one sampled resident (3). Findings include: 1. Interview on 5/30/17 at 10:30 a.m. with ten residents of the resident council/neighborhood meetings for all five neighborhoods throughout the facility revealed: *They were unfamiliar with what a care conference was. *They could not recall having been invited to attend a meeting that individual residents met with staff to discuss their care. 2. Interview on 5/30/17 at 9:15 a.m. with resident 3 revealed: *She had been a resident there for over a year. *She could not recall having attended a meeting to discuss her care. -She did not know what a care conference was. 3. Interview on 5/30/17 at 2:00 p.m. with the social work designee revealed: *She sent out cards to family members inviting them to care conferences. *She was unsure how residents were informed of their care conferences. -She thought maybe the house coordinators invited them. Interview on 5/30/17 at 2:15 p.m. with the Oak and Birch house coordinator D revealed: *They did not invite residents to care conferences. -She thought the nurse manager invited them. Interview on 5/30/17 at 3:45 p.m. with the Oak and Birch nursing supervisor D revealed: *They invited family members to care conferences. -Most of them chose not to come. *She had not been inviting the residents to care conferences. *Resident 3's family had been invited, but they usually had not attended. -They visited enough,so they just stopped in and asked the nurse questions when they were here. *She confirmed resident 3 was alert and oriented and could have participated in her care conferences. *She had worked at the facility for four years, and that was how care conferences had been handled when she had started here. Interview on 5/30/17 at 5:30 p.m. with the Elm and Pine nursing supervisor manager C confirmed residents were not always invited to their care conferences. Review of the provider's February 2013 Care Planning policy revealed: *Resident care is planned within put from the resident/resident representative, in conjunction with the multiple disciplines involved in resident care to promote/maintain the resident's mental, spiritual and physical health at an optimal level for the individual resident. *A comprehensive care plan must be prepared by an interdisciplinary team that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and the extent practicable, the participation of the resident, the resident's family or the resident's resident representative.

Based on record review, interview, and policy review, the provider failed to ensure two of two licensed nurses (A and C) followed the facility policies for one of one sampled resident (3) identified as a full code (resuscitation) when discovered without a pulse, heartbeat, and not breathing. Findings include: 1. Review of resident 3's medical record revealed: *He had been admitted on [DATE]. *The [DATE] transfer form from another provider indicated Code status: Full Code. *A [DATE] healthcare power of attorney form signed by resident 3 listing two sons as appointed powers of attorney to consent to, reject, or to withdraw consent for medical procedures, treatment, or intervention. *A [DATE] living will declaration signed by the resident indicated With respect to life-sustaining treatment, I direct the following: -A check mark had been marked by the sentence, If my death is imminent or I am permanently unconscious, I choose not to prolong my life. If life sustaining treatment has been started, stop it, but keep me comfortable and control my pain. -A check mark had been marked by the sentence, I choose neither of the above options, and here are my instructions should I become terminally ill and my death is imminent or I become permanently unconscious: -No further instructions had been listed below the above statement. *His last reviewed [DATE] care plan had listed additional problems/interventions: Yes Code Status. *A page at the front of the paper chart contained an adhesive sticker indicating YES CODE. Review of RN A documentation in Care Coordinator Notes regarding resident 3: *On [DATE] at 8:00 p.m. she had given the resident his medication; he had eaten a protein bar at that time. -At 9:00 p.m. she had performed a dressing change on him, and he had participated with repositioning. *On [DATE] between 3:30 a.m. and 4:00 a.m. staff had checked on him and changed his brief. He had voided into a urinal during his scheduled rounds. *On [DATE] at 5:00 a.m. he was found sitting on the floor next to his bed. RN A's assessment notes on [DATE] at 5:00 a.m. regarding resident 3 revealed: *His pulse was absent. *His skin was cool to the touch and very pale/white in color with purple lips. *He was limp and unresponsive. *His pupils were fixed and nonresponsive. *There was no audible heart beat heard when listening through a stethoscope (a device with earpieces used to amplify noise) for one minute. *There was no obvious injury such as bruising, lacerations (cuts), or bumps. *Staff had lifted him onto his bed. *She contacted the immediate supervisor case manager (RN B) who had directed her to contact the director of nursing (DON). *She contacted the DON who had directed her to contact the emergency department (ED) at the provider's hospital with information. *She called the ED and informed the nursing supervisor at the ED that the resident is a full code and was found sitting on the floor with no pulse and no breath sounds noted and that the DON inform writer not to use the standing order for a release of body. *She received an order for [REDACTED]. *The ED supervisor called back and informed staff the police needed to be notified due to the unexpected death. *Police arrived at 6:00 a.m. *Ambulance personal arrived at 6:05 a.m. to check for signs of life. *After the police were contacted five family members were contacted with information on the resident's status. Interview on [DATE] at 10:55 a.m. with household coordinator E revealed: *When asked how she would know if a resident had orders for full code resuscitation she would either: -Look for resuscitation orders in the medical record on the computer. 'Full code' meant the staff were to have attempted to resuscitate the resident. -Look in the resident's care plan. If the care plan had indicated 'Yes Code status', it had meant the staff were to have attempted to resuscitate the resident. -Look on the face of the chart for a green dot that indicated staff were to resuscitate them. Interview on [DATE] at 3:05 p.m. with the director of nursing (DON) regarding the events on [DATE] and [DATE] with resident 3 revealed: *She was aware resident 3 had orders for full code resuscitation. *She and other facility staff had visited with the resident's medical power of attorney (POA) and other family members on [DATE], [DATE], [DATE], [DATE], and [DATE] regarding his overall physical and mental declines. *They had encouraged the family to change his code status from full code to do not resuscitate. *The physician's assistant had also visited with the family about changing the code status. -She was unable to locate documentation of that visit in the medical record. *The family had thought the resident had already changed the code status to DNR prior to being admitted to the provider's facility. *The POA had agreed the code status should have changed but wanted to visit with other family members and with the resident before making the change. *The POA or other family members had not visited with him about changing the status before he expired. Interview on [DATE] at 4:00 p.m. with RN A regarding the above events of [DATE] and [DATE] revealed: *During her medication pass and dressing change with resident 3 there were no signs of a change in condition. *He had exhibited some confusion for a few days prior to the event, but he had responded to her as she was caring for him. *She had last seen resident 3 around 10:30 p.m. The certified nursing assistants (CNA) had done resident rounds every two hours. *CNA D had called for help between 4:30 a.m. and 5:00 a.m. *She had entered resident 3's room and found him sitting on the floor. *She reached to remove his C-PAP (continuous positive airway pressure) (used to assist with breathing) mask and could see that he had expired. *She wanted him placed on the bed. so she called for other nurses in the building for assistance. *She could not find a pulse, heartbeat, or blood pressure. The pupils of his eyes were fixed and dilated (enlarged). *He was not cold but not warm like he had been earlier. *She was unable to lift so she left the room to assist another resident while the CNAs and nurse lifted him onto the bed. *I was in shock because it was totally unexpected. *She had not known he had orders for full code resuscitation, but RN C knew he was full code and had told her. *She asked RN C if she should gather CPR/AED equipment, and she told her no, that he was already gone. *So then I called (the nursing supervisor) (RN B)), who told me to call (the DON), and she said to call the ER (hospital emergency department). *None of the above had instructed her to begin resuscitating the resident. *Although he had exhibited physical and mental declines for the past few weeks she did not believe his death was imminent (about to occur at any moment), because it had been unexpected to her. *When asked why she had not started CPR she stated, He was white. He was gone. *She had not seen any rigor mortis (stiffness of the joints after death), or mottling (pooling of blood causing purple/black discoloration). Interview on [DATE] at 4:20 p.m. in a phone call with resident 3's physician and the provider's medical director revealed: *He had not been surprised by resident 3's death due to gradual overall declines. *He believed the resident probably had a [MEDICAL CONDITION]. *He stated the nursing staff responded appropriately by not starting resuscitation attempts. *It was quite apparent he needed to be DNR (do not resuscitate), but that (obtaining the DNR orders) had not been accomplished. *The resident did not have the mental capacity to make the decision regarding his resuscitation. *The physician's opinion is CPR doesn't work for this age group. *I know there are a certain set of rule to abide by, but we need common sense as well. Interview on [DATE] at 5:30 p.m. with CNA D revealed:*He had been working the night resident 3 had expired. *He had assisted with the resident's care at least every one and one-half to two hours. *The resident called often for a urinal. *He had found the resident on the floor, checked for a pulse, and called for help. *No one had attempted to start CPR. *The nurse had said he was cool so nothing could be done. *No one called 911 until they called the emergency room and were instructed to get the police involved. Interview on [DATE] at 8:20 a.m. with nursing supervisor B revealed: *She was the nursing supervisor in charge of resident 3. *She had not been working the night of [DATE] - [DATE]. *There were no nurses on-call for emergencies. *RN A had called her to tell her what had happened to resident 3. *She had told RN A to call the DON. *She was aware that resident 3 had orders for a full code resuscitation. *She had been involved with the DON during visits with the POA regarding getting his code status changed. *She had never visited with resident 3 about his wishes regarding his resuscitation status, because the family wanted to talk to him about it. *Resident 3 had some episodes of confusion but would have been able to verbalize his resuscitation wishes to his son. *When RN A called her on [DATE] she (nursing supervisor B) had not told RN A resident 3 was a full code resuscitation. *She had assumed RN A had known he had full code orders. *When asked about full code resuscitation she stated, If a resident is cool, I am not going to start CPR in a nursing home. You can do so much damage with CPR. *When asked if she felt resident 3's death was imminent she stated he had a bad heart and could have had a [MEDICAL CONDITION] at any time. Interview on [DATE] at 8:40 a.m. with RN C revealed: *She had been working on another neighborhood unit on the night of [DATE] - [DATE]. *She had received a call about 5:00 a.m. from one of the CNAs to come right away to (neighborhood room #) because someone was on the floor. *They didn't tell me he was unresponsive or anything. *She had been drawing blood from another resident, so she finished what she was doing, cleansed her hands, and put things away. It had taken her approximately five minutes to finish her work. *The resident was on the floor when she entered the room, and they lifted him onto the bed. *RN C had not been told the resident had expired. *She had not known he had orders for a full code resuscitation. *She proceeded to clean the resident. *RN A had not been in the resident's room. She had been making phone calls in the nursing area. *When RN A came into the resident's room she told RN C he was a full code status. *RN C stated she had already been in the room fifteen minutes before she had been told of the status. *I told her he was already gone. *I called the ED and told them to call an ambulance. The ambulance was already on the way. *There was no rigor mortis. *There was some mottling, More like a pink flushed color on his cheeks, face, and hands. He was always flushed. His legs had a purple color. But he had very bad circulation. *She stated if she were his nurse and had known he had full code resuscitation orders she would not have initiated CPR, because he was cold and had some mottling. Interview on [DATE] at 9:30 a.m. with the DON revealed: *She believed her nurses had followed the provider's policy for resuscitation/code blue, because the policy stated that at times it was necessary to deviate from the procedure based on the status of the patient (resident) and judgment of the nursing staff regarding a resident's status. *She agreed emergency services had not been contacted appropriately for a full code resident with an absent pulse, heartbeat, and breathing. *She had not instructed RN A to begin resuscitation efforts when she had called on [DATE]. *She had not visited with resident 3 regarding his wishes for resuscitation, because the family wanted to visit with him. *A BIMS (brief interview for mental status) test had not been conducted for resident 3 since [DATE], when the score had been 14 (indicating his mental status was intact at that time). *He had exhibited recent periods of confusion. *She was aware of the American Heart Association's guidelines for when resuscitation should not occur, but they were only guidelines, and the provider's policy had allowed room for deviation. *She understood the resident's wishes had not been followed according to the living will declaration he had signed. *There was a very fine line for nursing to make decisions on behalf of the resident. Review of the provider's [DATE] Code Blue policy revealed:*Patient care policies and procedures were written to guide staff in providing direct care. *At times it was necessary for staff to deviate from the established procedure. *Deviation would be based on the clinical needs/status of the patient, and the judgement of the staff determined to be in the best interest of the patient. *A staff member would initiate the code using the overhead paging system announcing code blue followed by the location of the room. *Nursing staff would gather supplies (back board, oxygen, AED), dial 911, and notify the family and physician. *CPR and AED use would continue per American Heart Association guidelines until care was taken over by the ambulance staff. Review of Laurie J. Morrison et al, Part 3: Ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, WWW. http://circ.ahajournals.org/content/,[DATE]_suppl_3/S665.full.pdf+html, accessed on [DATE] revealed: Criteria for Not Starting CPR in all OHCA (out-of hospital [MEDICAL CONDITION]: *While the general rule is to provide emergency treatment to a victim of [MEDICAL CONDITION], there are a few exceptions where withholding CPR might be appropriate as follows: -Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril. -Obvious clinical signs of irreversible death (e.g rigor mortis, dependent lividity, decapitation, transection, or decomposition). -A valid signed, and dated advance directive indicating that resuscitation is not desired, or a valid, signed, and dated DNAR order. Review of the provider's [DATE] policy for Do Not Resuscitate (DNR) revealed: *The competent person should be encouraged to discuss his or her desires in regards to the resuscitation or life-sustaining measures with his/her personal physician and family members. *The person's decision would be respected above the desires of the family or anyone else unless this decision was deemed to be irrational or otherwise in violation of policies. *If there was family disagreement as to the person's decision on no code status, this was to have been brought to the attention of administration and the Ethics Committee as appropriate. *An incompetent person should be involved in the decision making process in regards to his or her care and treatment to the extent of his capacity. *If the incompetent person has previously, while being competent, presented an appropriate advance directive containing his or her wishes regarding life-sustaining measures, then those wishes should be respected unless deemed inappropriate, irrational, or otherwise in violation of policy or state law. *If no family members are available, after reasonable efforts are made to identify and contact such members, and the attending physician thinks that there may be potential question regarding prognosis of the person, the Ethics Committee may be asked to review the case and express its opinions regarding life-sustaining measures. *If an appropriate personal representative is in a position to make a decision for the incompetent person, or if there is a disagreement among other family members, the matter will be reported to the nursing home administrator and, if appropriate, the Ethics Committee may be convened. *Do not resuscitate requires a physician's orders [REDACTED]. *2 c. The physician's progress notes in writing or dictation will reflect evidence that the physician had discussed the decision with the patient and that they have mutually reached a decision. *3. If the patient is judged by the physician not to have the capacity to make decisions, that fact should be documented along with other evidence supporting the decision not to resuscitate *In cases where cardiopulmonary resuscitation would be clearly futile (a treatment is clearly futile .if it will not achieve it's physiologic objective and so offers no physiologic benefit to the patient.) the physician may issue a DNR order without item 2 c or 3 above. Reasonable efforts should be made to inform the patient or surrogate of this decision. The physician should document clear futility in the medical record.

Based on record review, interview, and policy review, the provider failed to ensure resident wishes had been followed for one of one sampled resident (3) who had died with full code (resuscitation) orders and did not receive emergency cardiopulmonary resuscitation. Findings include: 1. Review of resident 3's medical record revealed: *He had been admitted on [DATE]. *The [DATE] transfer form from another provider indicated Code status: Full Code. *A [DATE] healthcare power of attorney form signed by resident 3 listing two sons as appointed powers of attorney to consent to, reject, or to withdraw consent for medical procedures, treatment, or intervention. *A [DATE] living will declaration signed by the resident indicated With respect to life-sustaining treatment, I direct the following: -A check mark had been marked by the sentence, If my death is imminent or I am permanently unconscious, I choose not to prolong my life. If life sustaining treatment has been started, stop it, but keep me comfortable and control my pain. -A check mark had been marked by the sentence, I choose neither of the above options, and here are my instructions should I become terminally ill and my death is imminent or I become permanently unconscious: -No further instructions had been listed below the above statement. *His last reviewed [DATE] care plan had listed additional problems/interventions: Yes Code Status. *A page at the front of the paper chart contained an adhesive sticker indicating YES CODE. Review of RN A documentation in Care Coordinator Notes regarding resident 3: *On [DATE] at 8:00 p.m. she had given the resident his medication; he had eaten a protein bar at that time. -At 9:00 p.m. she had performed a dressing change on him, and he had participated with repositioning. *On [DATE] between 3:30 a.m. and 4:00 a.m. staff had checked on him and changed his brief. He had voided into a urinal during his scheduled rounds. *On [DATE] at 5:00 a.m. he was found sitting on the floor next to his bed. RN A's assessment notes on [DATE] at 5:00 a.m. regarding resident 3 revealed: *His pulse was absent. *His skin was cool to the touch and very pale/white in color with purple lips. *He was limp and unresponsive. *His pupils were fixed and nonresponsive. *There was no audible heart beat heard when listening through a stethoscope (a device with earpieces used to amplify noise) for one minute. *There was no obvious injury such as bruising, lacerations (cuts), or bumps. *Staff had lifted him onto his bed. *She contacted the immediate supervisor case manager (RN B) who had directed her to contact the director of nursing (DON). *She contacted the DON who had directed her to contact the emergency department (ED) at the provider's hospital with information. *She called the ED and informed the nursing supervisor at the ED that the resident is a full code and was found sitting on the floor with no pulse and no breath sounds noted and that the DON inform writer not to use the standing order for a release of body. *She received an order for [REDACTED]. *The ED supervisor called back and informed staff the police needed to be notified due to the unexpected death. *Police arrived at 6:00 a.m. *Ambulance personal arrived at 6:05 a.m. to check for signs of life. *After the police were contacted five family members were contacted with information on the resident's status. Interview on [DATE] at 10:55 a.m. with household coordinator E revealed: *When asked how she would know if a resident had orders for full code resuscitation she would either: -Look for resuscitation orders in the medical record on the computer. 'Full code' meant the staff were to have attempted to resuscitate the resident. -Look in the resident's care plan. If the care plan had indicated 'Yes Code status', it had meant the staff were to have attempted to resuscitate the resident. -Look on the face of the chart for a green dot that indicated staff were to resuscitate them. Interview on [DATE] at 3:05 p.m. with the director of nursing (DON) regarding the events on [DATE] and [DATE] with resident 3 revealed: *She was aware resident 3 had orders for full code resuscitation. *She and other facility staff had visited with the resident's medical power of attorney (POA) and other family members on [DATE], [DATE], [DATE], [DATE], and [DATE] regarding his overall physical and mental declines. *They had encouraged the family to change his code status from full code to do not resuscitate. *The physician's assistant had also visited with the family about changing the code status. -She was unable to locate documentation of that visit in the medical record. *The family had thought the resident had already changed the code status to DNR prior to being admitted to the provider's facility. *The POA had agreed the code status should have changed but wanted to visit with other family members and with the resident before making the change. *The POA or other family members had not visited with him about changing the status before he expired. Interview on [DATE] at 4:00 p.m. with RN A regarding the above events of [DATE] and [DATE] revealed: *During her medication pass and dressing change with resident 3 there were no signs of a change in condition. *He had exhibited some confusion for a few days prior to the event, but he had responded to her as she was caring for him. *She had last seen resident 3 around 10:30 p.m. The certified nursing assistants (CNA) had done resident rounds every two hours. *CNA D had called for help between 4:30 a.m. and 5:00 a.m. *She had entered resident 3's room and found him sitting on the floor. *She reached to remove his C-PAP (continuous positive airway pressure) (used to assist with breathing) mask and could see that he had expired. *She wanted him placed on the bed. so she called for other nurses in the building for assistance. *She could not find a pulse, heartbeat, or blood pressure. The pupils of his eyes were fixed and dilated (enlarged). *He was not cold but not warm like he had been earlier. *She was unable to lift so she left the room to assist another resident while the CNAs and nurse lifted him onto the bed. *I was in shock because it was totally unexpected. *She had not known he had orders for full code resuscitation, but RN C knew he was full code and had told her. *She asked RN C if she should gather CPR/AED equipment, and she told her no, that he was already gone. *So then I called (the nursing supervisor) (RN B)), who told me to call (the DON), and she said to call the ER (hospital emergency department). *None of the above had instructed her to begin resuscitating the resident. *Although he had exhibited physical and mental declines for the past few weeks she did not believe his death was imminent (about to occur at any moment), because it had been unexpected to her. *When asked why she had not started CPR she stated, He was white. He was gone. *She had not seen any rigor mortis (stiffness of the joints after death), or mottling (pooling of blood causing purple/black discoloration). Interview on [DATE] at 4:20 p.m. in a phone call with resident 3's physician and the provider's medical director revealed: *He had not been surprised by resident 3's death due to gradual overall declines. *He believed the resident probably had a [MEDICAL CONDITION]. *He stated the nursing staff responded appropriately by not starting resuscitation attempts. *It was quite apparent he needed to be DNR (do not resuscitate), but that (obtaining the DNR orders) had not been accomplished. *The resident did not have the mental capacity to make the decision regarding his resuscitation. *The physician's opinion is CPR doesn't work for this age group. *I know there are a certain set of rule to abide by, but we need common sense as well. Interview on [DATE] at 5:30 p.m. with CNA D revealed:*He had been working the night resident 3 had expired. *He had assisted with the resident's care at least every one and one-half to two hours. *The resident called often for a urinal. *He had found the resident on the floor, checked for a pulse, and called for help. *No one had attempted to start CPR. *The nurse had said he was cool so nothing could be done. *No one called 911 until they called the emergency room and were instructed to get the police involved. Interview on [DATE] at 8:20 a.m. with nursing supervisor B revealed: *She was the nursing supervisor in charge of resident 3. *She had not been working the night of [DATE] - [DATE]. *There were no nurses on-call for emergencies. *RN A had called her to tell her what had happened to resident 3. *She had told RN A to call the DON. *She was aware that resident 3 had orders for a full code resuscitation. *She had been involved with the DON during visits with the POA regarding getting his code status changed. *She had never visited with resident 3 about his wishes regarding his resuscitation status, because the family wanted to talk to him about it. *Resident 3 had some episodes of confusion but would have been able to verbalize his resuscitation wishes to his son. *When RN A called her on [DATE] she (nursing supervisor B) had not told RN A resident 3 was a full code resuscitation. *She had assumed RN A had known he had full code orders. *When asked about full code resuscitation she stated, If a resident is cool, I am not going to start CPR in a nursing home. You can do so much damage with CPR. *When asked if she felt resident 3's death was imminent she stated he had a bad heart and could have had a [MEDICAL CONDITION] at any time. Interview on [DATE] at 8:40 a.m. with RN C revealed: *She had been working on another neighborhood unit on the night of [DATE] - [DATE]. *She had received a call about 5:00 a.m. from one of the CNAs to come right away to (neighborhood room #) because someone was on the floor. *They didn't tell me he was unresponsive or anything. *She had been drawing blood from another resident, so she finished what she was doing, cleansed her hands, and put things away. It had taken her approximately five minutes to finish her work. *The resident was on the floor when she entered the room, and they lifted him onto the bed. *RN C had not been told the resident had expired. *She had not known he had orders for a full code resuscitation. *She proceeded to clean the resident. *RN A had not been in the resident's room. She had been making phone calls in the nursing area. *When RN A came into the resident's room she told RN C he was a full code status. *RN C stated she had already been in the room fifteen minutes before she had been told of the status. *I told her he was already gone. *I called the ED and told them to call an ambulance. The ambulance was already on the way. *There was no rigor mortis. *There was some mottling, More like a pink flushed color on his cheeks, face, and hands. He was always flushed. His legs had a purple color. But he had very bad circulation. *She stated if she were his nurse and had known he had full code resuscitation orders she would not have initiated CPR, because he was cold and had some mottling. Interview on [DATE] at 9:30 a.m. with the DON revealed: *She believed her nurses had followed the provider's policy for resuscitation/code blue, because the policy stated that at times it was necessary to deviate from the procedure based on the status of the patient (resident) and judgment of the nursing staff regarding a resident's status. *She agreed emergency services had not been contacted appropriately for a full code resident with an absent pulse, heartbeat, and breathing. *She had not instructed RN A to begin resuscitation efforts when she had called on [DATE]. *She had not visited with resident 3 regarding his wishes for resuscitation, because the family wanted to visit with him. *A BIMS (brief interview for mental status) test had not been conducted for resident 3 since [DATE], when the score had been 14 (indicating his mental status was intact at that time). *He had exhibited recent periods of confusion. *She was aware of the American Heart Association's guidelines for when resuscitation should not occur, but they were only guidelines, and the provider's policy had allowed room for deviation. *She understood the resident's wishes had not been followed according to the living will declaration he had signed. *There was a very fine line for nursing to make decisions on behalf of the resident. Review of the provider's [DATE] Code Blue policy revealed:*Patient care policies and procedures were written to guide staff in providing direct care. *At times it was necessary for staff to deviate from the established procedure. *Deviation would be based on the clinical needs/status of the patient, and the judgement of the staff determined to be in the best interest of the patient. *A staff member would initiate the code using the overhead paging system announcing code blue followed by the location of the room. *Nursing staff would gather supplies (back board, oxygen, AED), dial 911, and notify the family and physician. *CPR and AED use would continue per American Heart Association guidelines until care was taken over by the ambulance staff. Review of Laurie J. Morrison et al, Part 3: Ethics: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, WWW. http://circ.ahajournals.org/content/,[DATE]_suppl_3/S665.full.pdf+html, accessed on [DATE] revealed: Criteria for Not Starting CPR in all OHCA (out-of hospital [MEDICAL CONDITION]: *While the general rule is to provide emergency treatment to a victim of [MEDICAL CONDITION], there are a few exceptions where withholding CPR might be appropriate as follows: -Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril. -Obvious clinical signs of irreversible death (e.g rigor mortis, dependent lividity, decapitation, transection, or decomposition). -A valid signed, and dated advance directive indicating that resuscitation is not desired, or a valid, signed, and dated DNAR order. Review of the provider's [DATE] policy for Do Not Resuscitate (DNR) revealed: *The competent person should be encouraged to discuss his or her desires in regards to the resuscitation or life-sustaining measures with his/her personal physician and family members. *The person's decision would be respected above the desires of the family or anyone else unless this decision was deemed to be irrational or otherwise in violation of policies. *If there was family disagreement as to the person's decision on no code status, this was to have been brought to the attention of administration and the Ethics Committee as appropriate. *An incompetent person should be involved in the decision making process in regards to his or her care and treatment to the extent of his capacity. *If the incompetent person has previously, while being competent, presented an appropriate advance directive containing his or her wishes regarding life-sustaining measures, then those wishes should be respected unless deemed inappropriate, irrational, or otherwise in violation of policy or state law. *If no family members are available, after reasonable efforts are made to identify and contact such members, and the attending physician thinks that there may be potential question regarding prognosis of the person, the Ethics Committee may be asked to review the case and express its opinions regarding life-sustaining measures. *If an appropriate personal representative is in a position to make a decision for the incompetent person, or if there is a disagreement among other family members, the matter will be reported to the nursing home administrator and, if appropriate, the Ethics Committee may be convened. *Do not resuscitate requires a physician's orders [REDACTED]. *2 c. The physician's progress notes in writing or dictation will reflect evidence that the physician had discussed the decision with the patient and that they have mutually reached a decision. *3. If the patient is judged by the physician not to have the capacity to make decisions, that fact should be documented along with other evidence supporting the decision not to resuscitate *In cases where cardiopulmonary resuscitation would be clearly futile (a treatment is clearly futile .if it will not achieve it's physiologic objective and so offers no physiologic benefit to the patient.) the physician may issue a DNR order without item 2 c or 3 above. Reasonable efforts should be made to inform the patient or surrogate of this decision. The physician should document clear futility in the medical record. Review of the provider's undated Resident Handbook revealed: *Page 13: The resident's rights were valued and respected by all our staff. *Page 19: Resident Bill of Rights: Every resident of the (provider) had the right to: -2. Know the facility's policies regarding living will, advance directives, durable power of attorney, record access, and privacy practices. The resident had the right to formulate and communicate wishes regarding health care decisions as it related to any of those issues and to expect they would be recognized. -7. Be fully informed in advance about care and treatment, and of any changes in that care or treatment that may affect the resident's well being. -8. Participate in planning care and treatment.

Preceptor: Based on observation, interview, and disinfection instructions review, the provider failed to follow manufacturer's instructions for disinfecting two of two whirlpool tubs during cleaning observations by two of two certified nurse aides (CNA) A and B. Findings include: 1. Observation on 3/10/15 at 9:14 a.m. with certified nurse aide (CNA) A revealed she: *Added approximately three inches of disinfectant to the foot well of the tub. *Added water in the tub until it covered the backrest of the shower chair. *Did not: -Start the air blower. -Allow air blower to run for 30 seconds. Interview on 3/10/15 at 9:24 a.m. with CNA A revealed she "Always cleans it this way." Observation on 3/10/15 at 9:46 a.m. with CNA B revealed she: *Added disinfectant to the foot well of the tub until it just covered the jets on the bottom of the tub. *Added water in the tub until it reached above the seat of the shower chair. *Did not: -Use one to one half gallons of disinfectant. -Rinse the air jets. -Perform the final rinse of the whirlpool. Interview on 3/10/15 at 10:06 a.m. with CNA B revealed she: *Was not sure exactly how much disinfectant she used. *Had been told to hold the disinfectant button down for 20 seconds. *Added enough disinfectant to cover the jets on the bottom of the tub. *Had been trained "By whoever I followed and showed me how." *Had attended neighborhood "Refresher training meetings here and there." Review of the undated manufacturer's Cascade Aqua-Aire Bathing System Disinfection Instructions revealed: *"Press and hold the Rinse button located on the left side of the control panel until clear water runs from all the air jets. Then release the Rinse button." *"Finish rinsing the interior surfaces of the tub with the shower sprayer." Interview on 3/11/15 at 2:00 p.m. with the director of nursing and the administrator regarding the whirlpool tub cleaning observations revealed: *Their expectation had been the whirlpool tub should have been cleaned according to the manufacturer's guidelines. *The policy the staff were to have followed was the manufacturer's instructions. *Those instructions had been posted in each whirlpool tub location. *Staff received their training from the whirlpool tub manufacturer's representative. *The administrator had phoned their whirlpool representative and was informed: -The whirlpool tub automatically mixed the correct amount of water with disinfectant as it was sprayed into the tub. -For proper disinfection no more water should have been added to the tub. *Staff had not followed the manufacturer's instructions for tub disinfection. Review of the manufacturer's undated Bathing System Disinfection Instructions revealed the bathing assistant was to: *"Press and hold the Disinfect Button located on the left side of the tub. As the button is held down, the properly mixed cleaning solution is running through the air injection system and out all the air jets. Release the button after you see solution coming out of the air jets and you have 1 to 1 1/2 gallons of disinfectant solution in the foot of the tub." *After the tub had been scrubbed the disinfectant was to have been allowed to set for ten minutes then the tub and jets were rinsed with water. *After rinsing, the bathe aid was to have pressed the air blower button and allowed it to run for thirty seconds. "This pushes the rinse water out of the air injection system."

Based on observation, interview, and policy review, the provider failed to have a system in place to secure Fentanyl (government-controlled narcotic medication) awaiting destruction. Findings include: 1. Interview on 3/11/15 at 10:05 a.m. with registered nurse (RN) E revealed: *When Fentanyl patches were removed from a resident's skin they were signed off by two nurses as removed, then placed in a sharps container (a box that contained sharp objects such as used needles) on the medication cart. *After the sharps container was full it was placed in a storage container in the Elm/Pine medication room until it could be incinerated. Interview on 3/11/15 at 10:20 a.m. with RN F in the Elm/Pine medication room revealed a sharps biohazard (substances that pose a threat the humans, such as medical waste) collection storage box. RN F reported: *When the collection storage box was full she called the maintenance department to pick it up. *The maintenance person then placed the container in the service wing until it was hauled away for incineration. Observation of the service wing revealed: *Staff members had access to the wing by using their badges to open the secured door. *A room on that wing had a locked door with push-button numbers. *The access code was the same code all staff used to access secured neighborhood doors. Interview on 3/11/15 at 2:00 p.m. with the director of nursing and the administrator revealed: *The push-button entry door was accessible to all staff (licensed and unlicensed) who had access to the other push-button doors in the building with the same code. *Narcotic medications in the sharps containers awaiting destruction in the service wing had not been secured. Review of the provider's January 2014 Controlled Medication Disposal policy revealed: *Only authorized licensed nursing and pharmacy personnel had access to controlled medications. *If a resident refused a controlled medication two licensed staff witnessed disposal of the medication in the sharps container. *Two licensed staff were to have destroyed Fentanyl patches into the sharps container. *No indication where the sharps container was to have been stored awaiting incineration.

Based on observation, record review, interview, and policy review, the provider failed to ensure side rail assessments for restrictive versus enabling use had been completed for four of four sampled residents (2, 4, 11, and 12) who had been observed with side rails on their beds. Findings include: 1. Observation on 2/18/14 at 3:07 p.m. of resident 2 revealed she had been in her bed with a half side rail up at the top of her bed. Review of resident 2's 2/6/14 Minimum Data Set (MDS) assessment revealed for bed mobility she required total assistance from one staff person. Observation and interview on 2/18/14 at 4:00 p.m. with the director of nursing (DON) and the administrator revealed: *Bottom and top half side rails were on the beds in residents rooms Oak 3 and Elm 3. *They had not considered the side rails restraints and had not completed assessments. *Most of the residents had used the side rails for positioning while in bed. 2. Observation on 2/19/14 at 2:00 p.m. in resident 4's room revealed: *She had three side rails on her bed. *Two of those side rails were placed on each side on the top of the bed and there was one side rail on the left side at the foot of the bed. Review of resident 4's complete medical record revealed no assessment for the side rails. 3. Observation on 2/20/14 at 9:20 a.m. revealed resident 12 in her bed with side rails up at the top of her bed. Interview on 2/20/14 at 9:25 a.m. with RN E confirmed resident 12 had two side rails on her bed and had used them for repositioning. She stated the side rails had not been assessed for the appropriate use by resident 12. 4. Random observations on 2/19/14 and 2/20/14 of resident 11's bed revealed one raised half side rail attached to the upper half of her bed. Review of resident 11's medical record revealed: *There had been no assessment indicating a need for a side rail. *There had been no physician's order for a side rail. *Her 2/3/14 care plan: -Had not indicated how she moved in bed. -Had not indicated she required a side rail. *Her 1/24/14 MDS indicated bed rails (side rails) had not been used. Interview on 2/20/14 at 10:30 a.m. with RN C revealed: *She had not considered the side rails to be restraints. *The rails were used to assist with bed mobility. *They had not needed to be written on the care plan. 5. Interview on 2/20/14 at 11:20 a.m. with the DON revealed: *She had not considered the rails to be restraints, and therefore: -The residents had not been assessed for the medical necessity of a restraint prior to using the side rails. -The physicians had not been contacted for an order to use the rails. -The side rails had not been care planned. -They had not been coded on the MDSs. Review of the provider's August 2012 Restraint Use policy revealed: *Physical restraints had included using side rails that would have kept a resident from voluntarily getting out of bed. *The need for a restraint was to have been assessed on admission and with each care plan review. *The provider and staff were ultimately responsible for determining if the restraint had been appropriate. *A physician's order was required prior to the restraint application. *The resident and family were to have been informed and educated about the restraint use. *Documentation regarding restraints was to be included in the clinical nursing notes and in the care plan.