Every finding on record at Timber Springs Transitional Care

Based on record review and staff interviews, the facility failed to ensure residents' representatives were provided the opportunity to participate in the development of the resident's care plan. This was true for 1 of 3 (Resident #115) whose record was reviewed for comprehensive care plans. This failure resulted in Resident #115's initial care conference being delayed beyond regulatory timeframes, creating the potential for miscommunication and unmet care needs. Findings include: Resident #115 was admitted on [DATE] with multiple diagnoses including mild cognitive impairment, cancer of multiple lymph sites, and adult failure to thrive.A Hospice agency delineation of care form, signed 9/3/25, documented that the facility was responsible for providing the date and time of interdisciplinary team meetings.On 11/18/25 at 3:20 PM, the Clinical Resource Nurse stated that initial care conferences were to be conducted within 72 hours of admission.On 11/19/25 at 11:12 AM, the Social Worker stated care conferences were to be conducted within 24-48 hours of admission. She confirmed that Resident #115's official care conference was held on 9/16/25 (13 days after admission). The Social Worker also confirmed she had not read the delineation of care and was not informed the facility was responsible for coordinating the care conference. On 11/19/25 at 11:15 AM, surveyors requested documentation of collaboration with the Hospice agency to schedule the care conference.On 11/20/25 at 10:38 AM, the Social Worker stated she did not have documentation indicating collaboration with the Hospice agency to schedule the care conference.

Based on record review, and staff interview it was determined the facility failed to ensure grievances were acted upon when facility staff were made aware of residents' missing items. This was true for 1 of 3 residents (Resident #29) whose records were reviewed. This deficient practice created the potential for psychosocial and physical harm when Resident #29's personal items were missing and not replaced. Findings include:Resident #29 was admitted to the facility on [DATE] with multiple diagnoses including dementia and anxiety.A Comprehensive MDS Assessment,dated 8/6/25, documented Resident #29 had severe cognitive impairment.A. Resident #29's care plan, initiated 7/17/25, documented Resident #29 was at risk for a communication problem related to a hearing deficit. The care plan documented ear amplifiers were ordered, and Resident #29 preferred to keep his hearing amplifiers in his shirt pocket.Nursing progress notes documented the following:On 8/7/25, Resident #29 did not have his ear amplifiers.On 8/9/25, Resident #29's ear amplifiers were still missing.On 8/10/25, Resident #29's ear amplifiers were documented as lost.On 8/12/25, Resident #29's ear amplifiers were documented as misplaced as Resident #29 was resistant to keeping them in the medication cart and preferred to leave them in his shirt pocket. Resident #29 and his family were notified.B. On 11/10/25, Resident #29's daughter contacted the facility to alert them to her father's missing shoes.Resident #29's Inventory checklist dated 11/4/25, identified the following items were missing: 10 socks, 10 underwear, and shoes/boots.Resident #29's record did not document the facility had resolved any of Resident #29's missing items.On 11/19/25 at 4:05 PM, the Administrator and LSW stated when missing items are reported, the facility takes about one week to look around the facility and the laundry room to ensure the items are not misplaced in the facility. If the items cannot be found, the facility will replace the items.On 11/19/25 at 4:10 PM, the LSW stated no one from the facility had followed up on the missing items noted in Resident #29's discharge inventory from 11/4/25, and the items should have been replaced if they were not found.

Based on record review and staff interviews, the facility failed to ensure professional standards of practice were followed. This was true for 1 of 3 residents (Resident #115) whose record was reviewed for medication management. Specifically, the facility did not implement a physician's order for Haldol prescribed for symptom management during end of life care. This failure created the potential for untreated symptoms during the death and dying process. Findings include: The National Library of Medicine website accessed on 11/19/25, defines standard of care as the benchmark that determines whether professional obligations to patients have been met.Resident #115 was admitted on [DATE] with diagnoses including mild cognitive impairment, cancer of multiple lymph sites, and adult failure to thrive.Resident #115's record documented she admitted to end-of-life services on 9/3/25 upon admission. Review of Resident #115's record located a document titled Symptom Control Prescription dated 9/3/25 and signed by a physician. The document included the following orders:Morphine 20 mg/mL, give 0.25 mL sublingually for mild pain and shortness of breath, as needed.Lorazepam 2 mg/mL, give 0.5 mL orally for mild anxiety, as needed.Haldol 2 mg/mL, give 0.5 mL orally for mild agitation/nausea, as needed.Ondansetron 4 mg orally, as needed.Bisacodyl 10 mg rectal suppository, as needed.Review of the MAR and physician orders dated 9/3/25 - 10/14/25 documented that the order for Haldol 2 mg/mL, 0.5 mL orally for mild agitation/nausea as needed, was not included or implemented.On 11/20/25 at 8:57 AM, the Interim DON stated the facility made the decision not to implement the physician's order because Resident #115 was not displaying agitation at the time of admission. When asked if a licensed nurse has the authority to supersede a physician's order, the Interim DON stated, No.

Based on record review and staff interviews, the facility failed to ensure residents drug regimens were free from unnecessary medications. This was true for 1 of 3 residents (Resident #115) whose records were reviewed for unnecessary medications. Specifically, the facility administered Keflex (an antibiotic) beyond the prescribed duration without documented physician authorization or evidence of clinical justification. This failure created the potential for adverse outcomes, including the development of multi drug resistant organisms. Findings include:Resident #115 was admitted on [DATE] with diagnoses including mild cognitive impairment, cancer of multiple lymph sites, and adult failure to thrive.Resident #115's record documented an order for Keflex 500 mg by mouth twice daily for 10 days to treat a cyst infection.A review of the MAR dated 9/3/25 - 10/14/25 documented the following physician orders:A Physician order dated 9/26/25 - 10/3/25: Keflex 500 mg by mouth twice daily for 10 days.A Physician order dated 10/3/25 - 10/9/25: Keflex 500 mg by mouth twice daily for 10 days.The record documented Keflex was administered for 13 consecutive days, exceeding the prescribed 10 day course.On 11/20/25 at 8:57 AM, the Interim DON stated the antibiotic was extended past 10 days because Resident #115's cyst was worsening.On 11/20/25 at 8:59 AM, surveyors requested documentation of physician notification regarding the worsening condition and extension of the antibiotic order.On 11/20/25 at 10:15 AM, the Interim DON stated the facility did not have documentation of physician notification or a request to extend the antibiotic order.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure resident's right were protected to be free from abuse. This was true for 1 of 1 resident (Resident #87) reviewed for abuse. This failure caused harm to Resident #87 and placed all residents at risk for ongoing abuse and potential physical and psychosocial harm. Findings include:The facility's Reporting Reasonable Suspicion of a Crime policy revision date April 2025, documented it was the policy of the facility to protect its residents from abuse, neglect, exploitation, and misappropriate of resident property.Resident #87 was admitted to the facility on [DATE], with the multiple diagnoses including parkinson's and dementia.Review of Resident #87's quarterly MDS, dated [DATE], indicated Resident #87 had a BIMS (Brief Interview For Mental Status) of 15, indicating no cognitive impairment.Resident #113 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction (when blood flow to the brain is interrupted, leading to cell death and brain damage) and anxiety.A review of Resident #113's discharge MDS dated [DATE], indicated he had a BIMS of 15, indicating no cognitive impairment.A Nurse Practitioner note dated 1/17/25, documented Resident #113 stated that while he was out of facility, he was having significant anxiety and restlessness with suicidal ideations with a plan for self-harm and means to carry this out. Now that he is in the facility, he feels safe but continues to have fluctuating moods and behaviors with anxiety, he has declined to restart citalopram (an antidepressant medication).A Nurses Notes dated 3/7/25 at 12:43 PM, documented Resident #113 approached the nurse for a Norco (opioid pain medication). The nurse explained to Resident #113 that his Norco was not due until 2 AM. The nurse offered Tylenol, and he declined it. Resident #113 stated that he needed to get out of the building so he can self-medicate. The nurse reminded Resident #113 that he was on a pain contract and that it needed to be followed. Resident #113 then told the nurse that she better have his pain pill at 2:00 AM, and she better not be late. Resident #113 then stated the nurse better not write any notes on him or else.Resident #113's Behavior Noted dated 3/8/25, documented he approached the nurse and told the nurse I am going to leave this place I am tired of waiting for you to give me my meds. Resident #113 then told the nurse he was going to go to the overpass, jump Infront of the first diesel truck he could find and kill himself. The nurse asked the patient to clarify his intentions, and the patient repeated that if he did not get his goddamn pills. that he was going to kill himself. The nurse then requested he remain at the first-floor nurses' station and CNAs monitored Resident #113 from a safe distance while the nurse contacted and spoke to the second-floor nurse regarding this change in cognition and the statement he had made.A facility incident report, dated on 3/13/25 at 4:30 PM, documented Resident #113 was observed hitting Resident #87 in the face causing bruising and facial laceration to left orbital area with redness to the sclera and nose.The facility's incident report documented the following immediate actions were taken:Residents were separated.Both residents assessed for injuries and treated as needed.Resident #113 was placed on 1:1 observation. Police were notified and Resident #113 was arrested.Psychosocial evaluation was completed on Resident #87 with no additional findings.Residents were interviewed and no reported concerns were noted.Resident #87 and Resident #113's family resident representative were notified of the incident.On 9/10/25 at 3:52 PM, the Executive Director stated the resident-to-resident abuse did happen and the staff immediately separated the residents.

Based on observation and staff interviews, the facility failed to maintain a clean and homelike environment for 1 of 1 resident (Resident #2) reviewed for environmental conditions. This failure created the potential for embarrassment and psychosocial harm when Resident #2's room was repeatedly observed to have a foul urine odor and unclean conditions. Findings include:Resident #2 was readmitted to the facility on [DATE], with multiple diagnoses including end stage heart failure, cirrhosis of the liver, and immunodeficiency.A social services progress note created on 9/8/25 at 3:51 PM, documented that on 9/8/25 at 7:47 AM, the Licensed Social Worker identified Resident #2's room to be cluttered and uncleanly. She documented she provided education to Resident #2 about decluttering his room and allowing the housekeeper to clean his room.A social services progress note dated 9/8/25 at 7:18 PM, documented when Resident #2 left the facility housekeeping services were provided. During the services provided, it was identified Resident #2 had multiple half eaten old food items, sticky residue all over his dresser, and bedside table. On 9/8/25 at 3:01 PM, during a hall observation, room [ROOM NUMBER] was located at the end of the hallway. Upon approaching the room, a foul odor was noted. Resident #2's room was observed to have sticky floors, visible wheelchair track marks, and a strong urine odor.On 9/8/25 at 3:11 PM, LPN #1 stated the odor was urine and that staff attempt to empty urinals to reduce the smell. She stated Resident #2 sometimes spills urine on himself, contributing to the odor.Resident #2's room was observed to have a foul urine smell on the following dates and times:9/8/25 at 3:01 PM9/9/25 at 11:39AM9/10/25 at 9:53 PM9/11/25 at 9:12 [NAME] 9/11/25 at 9:18 AM, Housekeeper #1 confirmed that Resident #2's room had a persistent urine odor. She stated that as of 9/8/25, she had been instructed to clean room [ROOM NUMBER] twice daily. Prior to that date, the room was cleaned once daily. She reported that despite cleaning, the room would smell like urine again by the end of the day and showed visible wheelchair marks on the floor.

Based on policy review, record review, staff interviews, and Bureau of Facility Standards Long-Term Care Reporting Portal, it was determined the facility failed to ensure interventions were implemented to prevent further resident to resident abuse incidents. This was true for 2 of 5 (Resident #87 and #113) reviewed for resident-to-resident abuse. This failure created the potential to cause psychosocial, verbal, and physical harm to residents residing in the facility. Findings include:The facility's Reporting Reasonable Suspicion of a Crime policy revised April 2025, documented it is the policy of the facility to protect resident from abuse, neglect, exploitation, and misappropriation of resident property.The facility's Reporting Alleged Violations of Abuse, Neglect, Exploitation, or Mistreatment policy revised April 2025, documented it is the policy of the facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, resident representatives, families, friends, or other individuals.In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will:Ensure that if the alleged violation is verified, and appropriate corrective action is taken.Depending on the nature of the allegation, immediately put effective measures in place to ensure that further potential abuse, neglect, mistreatment, exploitation, or misappropriation of resident's property does not occur while the investigation is in process.Assess the corrective action taken, if any, in response to the results of the investigation to determine its effectiveness.Resident #87 was admitted to the facility on [DATE], with the multiple diagnoses including Parkinson's and dementia.Review of Resident #87's quarterly MDS dated [DATE], indicated Resident #87 had a BIMS of 15, indicating no cognitive impairment.Resident #113 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction (when blood flow to the brain is interrupted, leading to cell death and brain damage) and anxiety.Review of Resident #113's discharge MDS dated [DATE], indicated Resident #113 had a BIMS of 15 indicating no cognitive impairment.A Nurse Practitioner note dated 1/17/25, documented Resident #113 stated that while he was out of facility, he was having significant anxiety and restlessness with suicidal ideations with a plan for self-harm and means to carry this out. Now that he is in the facility, he feels safe but continues to have fluctuating moods and behaviors with anxiety, he has declined to restart citalopram.A Nurses Notes dated 3/7/25 at 12:43 PM, documented the Resident #113 approached the nurse for a Norco (opioid pain medication). The nurse explained to Resident #113 that his Norco was not due until 2 AM. The nurse offered Tylenol, and he declined it. Resident #113 stated that he needed to get out of the building so he can self-medicate. The nurse reminded Resident #113 that he was on a pain contract and that it needed to be followed. Resident #113 then told the nurse that she better have his pain pill at 2 AM, and she better not be late. Resident #113 then stated that the nurse better not write any notes on him or else.Resident #113's Behavior Noted dated 3/8/25, documented he approached the nurse and told the nurse that I am going to leave this place I am tired of waiting for you to give me my meds. Resident #113 then told the nurse that he was going to go to the overpass, jump Infront of the first diesel truck he could find and kill himself. The nurse asked the patient to clarify his intentions, and the patient repeated that if he did not get his goddamn pills. that he was going to kill himself. The nurse then requested he remain at the first-floor nurses' station and CNAs monitored Resident #113 from a safe distance while the nurse contacted and spoke to the second-floor nurse regarding this change in cognition and the statement he had made.A facility reported incident documented on 3/13/25 at 4:30 PM, Resident #113 was observed hitting Resident #87 in the face causing bruising and facial laceration to left orbital area with redness to the sclera and nose.Immediate action taken:- Residents were separated.- Both residents assessed for injuries and treated as needed.- Resident #113 was placed on 1:1 observation.- Police were notified. Resident #113 was arrested.- Psychosocial evaluation completed on Resident #87 with no additional findings.- Like residents were interviewed and no reported concerns noted.- Family/POA notified for Resident #87 and Resident #113.On 9/10/25 at 3:13 PM, the Administrator stated he thought by Resident #113 being arrested, the facility had put an intervention in place. He also stated there were no other interventions put in place to prevent further potential resident-to-resident abuse.

Based on policy review, record review, and staff interviews it was determined the facility failed to ensure pertinent health information was provided to the receiving health facility for 2 of 6 residents (Resident #4 and #79) reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if the residents were not treated in a timely manner due to a lack of information provided upon transfer. Findings include:The facility’s Criteria for Transfer and Discharge policy, revised December 2023, documented when the facility transfers or discharges a resident, the facility shall ensure the transfer or discharge is documented in the resident’s medical record and appropriate information is communicated to the receiving health care institution or provider. 1.Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures) and anxiety. a) A Nurses Note dated 3/20/25, documented Resident #4 was non-responsive, with no verbal response, and pupils were pinpoint and non-reactive to light. Resident #4 developed right sided weakness. The NP (Nurse Practitioner) was notified, and an order was received to transport Resident #4 to the hospital. An eINTERACT Transfer Form (an electronic tool that helps long-term care facilities effectively communicate critical resident information when transferring them to an acute care hospital) dated 3/21/25, documented Resident #4’s representative was notified. Resident #4’s record did not include documentation that pertinent medical information was provided to the receiving hospital for his 3/20/25 discharge. b) A Nurses note dated 6/4/25, documented the nurse was notified that Resident #4 was tremoring, not responding verbally, his pupils were fixed and pinpoint, he had no strength to right hand, and his pulse was rapid and irregular. The NP was notified, and orders were given to transport Resident #4 to the hospital for evaluation of possible Cerebral Vascular Accident or Seizure. Resident #4’s sister was called, and a message was left on her phone. An eINTERACT Transfer Form, dated 6/4/25, documented Resident #4’s sister was notified. Resident #4’s record did not include documentation that pertinent medical information was provided to the receiving hospital.On 9/11/25, the CRN #1 stated the required forms were sent with Resident #4 to the hospital and report was called into the hospital, but it was not documented in his chart, and she was aware that it should have been documented. Resident #79 was readmitted to the facility on [DATE], with multiple diagnoses including partial paralysis following a heart attack, dementia, cirrhosis, depression, and anxiety. A nursing progress note, dated 8/28/25 at 9:27 PM, documented Resident #79 had slipped from her chair and bumped her head on the floor. She sustained a laceration with active bleeding to the right upper eyebrow. Staff call 911 and Resident #79 was sent out for further treatment and evaluation. A hospital encounter note, dated 8/28/25, documented Resident #79 was seen due to a fall from a wheelchair. Resident #79 had the following initial encounter concerns identified: a closed fracture of one rib on her right side, ground-level fall, laceration of right eyebrow, and contusion of face. A nursing progress note, dated 8/29/25, documented Resident #79 had sustained a new injury to just above the outer region of the right eyebrow. Sutures were placed at the ER. Resident #79's record did not include documentation of the hospital transfer paperwork. On 9/11/25 at 10:34 AM, the DON stated there was no hospitalization paperwork from the facility to the hospital related to the 8/28/25 ER visit.

Based on record review and staff interview, the facility failed to ensure residents' Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 3 residents (Resident #10) reviewed for accuracy of MDS assessments. This deficient practice created the potential for residents to not receive appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial needs. Findings include:Resident #10 was admitted to the facility on [DATE], with multiple diagnoses including cerebral palsy (a movement disorder affecting the nervous system, causing problems with muscle control, movement, and posture) and major depressive disorder.On 4/30/25, Resident #10's physician order documented hydroxyzine HCL oral tablet 25 mg (anti-anxiety medication) by mouth at bedtime for anxiety.On 5/6/25, Resident #10's History and Physical documented to give hydroxyzine HCL 25 mg tablet by mouth at bedtime for anxiety.On 5/6/25, Resident #10's admission MDS, section I5700 (anxiety disorder) and section N0415B (anti-anxiety medication) was not marked, indicating she did not have a diagnosis of anxiety and was not taking an anti-anxiety medication.On 5/6/25, Resident #10's History and Physical documented she had a diagnosis of unspecified Dementia, severe.On 5/6/25, Resident #10's admission MDS, section I4200 (Alzheimer's Disease) and I4800 (Non-Alzheimer's Dementia) was not marked, indicating she did not have a diagnosis of Dementia.On 9/12/25 at 10:21 AM, the DON stated the MDS's dated 5/6/25 and 6/18/25 for Resident #10 did not include a diagnosis of dementia or her diagnosis and treatment of anxiety.

Based on record review and staff interview it was determined the facility failed to ensure professional standards of nursing practice were followed 1 of 2 residents (Resident #17) reviewed for anticoagulant (AC) monitoring. This deficient practice created the potential for harm if Resident #17's anticoagulant therapy was not monitored for signs and symptoms of complications. Findings include: Resident #17 was readmitted on [DATE], with multiple diagnoses including cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), atrial fibrillation (a common heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly, which can cause the blood to pool in the atria and form clots, increasing the risk of stroke,) COPD (Chronic Obstructive Pulmonary Disease: a lung condition caused by damage to the lungs, leading to trouble breathing,) diabetes, schizophrenia, and high blood pressure. A physician order, dated 6/27/24, documented Resident #17 should be monitored for adverse reactions with his AC medication.A physician order, dated 2/24/25, documented Resident #17 was ordered to take Xarelto Oral Tablet 20 mg (Rivaroxaban; an anticoagulant (AC)); give 1 tablet by mouth in the morning related to atrial fibrillation.A review of Resident #17's care plan, initiated on 6/27/25, directed staff to monitor, document, and report to physician, as needed, signs and symptoms of anticoagulant complications. The Treatment Administration Record (TAR) reviewed July 2025 through September 2025, documented AC signs and symptoms were not monitored:PM Shift: 9/4/25 PM Shift: 8/7/25, 8/9/25, 8/28/25, 8/29/25 On 9/11/25 at 9:35 AM, the DON with CRN #1, stated the TAR should have been marked ‘completed' on the dates in question.

Based on observation, record review, and policy review, the facility failed to ensure physician orders were followed for 1 of 1 residents (Resident #72) reviewed for tube feeding. This failure created the potential for poor nutrition when the incorrect nutritional supplement was administered. Findings include:The facility's policy titled Medication Administration Via Feeding Tube, revised July 2025, directed staff to confirm the physician's order prior to administration.Resident #72 was admitted to the facility on [DATE] with multiple diagnoses including cancer of the mouth, cancer of the esophagus, and cancer of other unspecified sites.Resident #72's care plan, initiated on 8/24/25, documented tube feeding as ordered.A physician order dated 8/20/25 directed staff to administer Jevity 1.5 nutritional supplement at 125 milliliters per hour for 16 hours to provide a total of 2,000 milliliters daily.On 9/10/25 at 9:45 AM, Resident #72 was observed connected via PEG tube to a pump delivering Glucerna 1.5 nutritional supplement at 125 milliliters per hour.On 9/10/25 at 10:00 AM, Unit Manager #1 and LPN #2 confirmed that the nutritional supplement being administered was Glucerna 1.5.On 9/10/25 at 10:09 AM, the Unit Manager #1 stated Resident #72 had been given the incorrect nutritional supplement and that the physician's order had not been followed.

Based on observation, staff interviews, record review, and policy review, the facility failed to ensure oxygen therapy was provided as ordered by the physician for 1 of 2 residents (Resident #29) reviewed for oxygen therapy. This failure created the potential for adverse health outcomes, including poor oxygenation and impaired concentration, when Resident #29 was not receiving oxygen therapy as prescribed. Findings include:Resident #29 was admitted the facility on 7/15/25, with multiple diagnoses including chronic respiratory failure, respiratory disorder, and cognitive impairment.Resident #29's care plan, initiated 7/16/25, directed staff to provide oxygen as ordered.A physician order, dated 7/15/25, documented oxygen at 5 liters via nasal cannula continuously.A subsequent physician order dated 8/15/25 directed staff to wean oxygen therapy for oxygen saturation levels over 94%, and to administer 1-3 liters per minute via nasal cannula as needed to maintain oxygen saturation between 88-93%.On 9/10/25 at 9:03 AM, during a medication administration observation, Resident #29 was observed resting in bed without oxygen in place. RN #3 entered the room, administered medications, and then informed Resident #29 that she would be checking his oxygen saturation. RN #3 obtained a pulse oximeter and verbalized that Resident #29's oxygen saturation was 80% on room air. RN #3 then applied oxygen via nasal cannula.On 9/10/25 at 9:11 AM, RN #3 stated she would follow the physician's order dated 7/15/25 for continuous oxygen at 5 liters per minute via nasal cannula. She confirmed that Resident #29 was not wearing oxygen at the time of medication administration. When asked to describe the weaning process, RN #3 stated the oxygen flow would be gradually reduced and the resident would be monitored to ensure appropriate oxygen saturation levels. She confirmed the process did not involve removing oxygen entirely without monitoring.

Based on record review, staff interviews, and policy review, the facility failed to ensure the Medical Director and Director of Nursing Services acted upon pharmacist recommendations for 1 of 5 residents (Resident #90) reviewed for unnecessary medications. This failure created the potential for adverse effects and for residents to continue receiving medications without clinical justification. Findings include:The facility's policy titled Medication Drug Regimen Review, revised December 2023, documented that a medication regimen review (MRR) includes a review of the resident's medical chart. Identified irregularities are to be documented on a separate written report that includes the resident's name, the relevant drug, and the irregularity identified. The report is to be sent to the attending physician, the facility's Medical Director, and the Director of Nursing Services (DNS) to be acted upon.Resident #90 was admitted to the facility on [DATE], with multiple diagnoses including dementia, need for assistance with personal care, and Parkinson's disease.Resident #90's record included a pharmacy consultation report dated 5/1/25, which recommended discontinuation of the following medications due to lack of use in the past 60 days: Artificial tear drops, 1 drop in both eyes as needed for dry eyes.Triamcinolone acetonide 0.1% cream, applied topically as needed for skin irritation. On 9/11/25 at 8:15 AM, a request was made for documentation of the provider's response to the pharmacy consultation report. On 9/11/25 at 12:59 PM, the Director of Nursing stated that the pharmacy recommendation had not been acknowledged, and it was unclear whether the medications were still necessary.

Based on observation and staff interviews, the facility failed to ensure that residents were free from significant medication errors for 1 of 5 residents (Resident #50) observed during medication administration. This failure created the potential for harm when RN #3 did not assess Resident #50's apical pulse (a pulse point on your chest that gives the most accurate reading of your heart rate) prior to administering digoxin, a medication known to affect heart rate. Findings include:Resident #50 was readmitted to the facility on [DATE], with multiple diagnoses including cerebral infarction affecting the right dominant side, hypertension, and atrial fibrillation. A physician order, dated 3/14/25, documented digoxin 125 micrograms orally each morning for atrial fibrillation, with instructions to notify the provider for a heart rate less than 40 beats per minute. According to the Nursing Unbound Medicine website, accessed on 9/16/25, digoxin increases cardiac output and slows heart rate. The recommended assessment prior to administration includes monitoring the apical pulse for one full minute. If the heart rate is below 60 beats per minute, the dose should be held and the healthcare provider notified.On 9/10/25 at 8:27 AM, during a medication administration observation, RN #3 was observed taking Resident #50's vital signs using an electronic machine. RN #3 then prepared medications at the cart, including digoxin 125 micrograms. She placed one tablet into a medication cup and associated the pulse obtained from the machine with the administration of digoxin. When asked if she had obtained an apical pulse prior to administering digoxin, RN #3 stated no and returned the digoxin card to the cart. After gathering all medications, RN #3 entered Resident #50's room, performed hand hygiene, donned gloves, and proceeded with medication administration. No apical pulse was obtained prior to administering digoxin.On 9/10/25 at 10:00 AM, the DON stated that an apical pulse should be obtained prior to the administration of Digoxin.

Based on representative interview, record review, and staff interview it was determined the facility failed to ensure residents obtained routine and emergency dental care to 1 of 1 resident (Resident #68) reviewed for timely dental care. This deficient practice created the potential for harm if the resident's nutritional status was altered or if she developed an infection related to dental damage. Findings include: Resident #68 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including cellulitis of the left lower leg, diabetes, COPD, lack of coordination, delusional disorders, depression, and anxiety. A quarterly MDS Assessment, dated 7/24/25, documented Resident #68 was cognitively impaired. Resident #68's care plan, initiated 11/13/24, and updated on 3/12/25 alerted staff Resident #68 did not have teeth, would not wear dentures, and could be at nutritional risk related to additional diagnoses of diabetes and COPD. Resident #68's care plan, initiated on 7/1/25, documented Resident #68 was edentulous (toothless or someone who is missing teeth) and complaining of lower gum pain. The care plan further directed staff to monitor for signs and symptoms of oral and dental problems needing attention including pain (gums, toothache, palate), . teeth missing, loose, broken, eroded, or decayed. A Change of Condition (CIC) progress note, dated 8/17/25, documented Resident #68 stated her mouth was hurting from a broken tooth and wanted to have something put on it. During inspection, it was noted Resident #68 had few teeth remaining in her lower front jaw and her tooth appeared to be broken off at the gum line. The area [around the tooth was] red and some bleeding [was] noted. The CIC progress note further documented Resident #68 should have Orajel 3 times per day for pain relief and recommended a follow-up with a dentist. An alert charting note, dated 8/17/25, directed staff to monitor Resident #68's broken tooth in the left lower jaw for signs and symptoms of infection to include pain, drainage, temperature or trouble eating for every shift.On 9/9/25 at 3:46 PM, Resident #68's representative stated he was concerned the facility had not been able to make a dental appointment for his mother as she only had 4 teeth on her lower jaw and one of her teeth had recently broken.A review of Resident #68's record did not document the facility attempted to set up a dental appointment prior to 9/10/25. On 9/11/25 at 9:51 AM, the DON stated Resident #68 recently started complaining of oral discomfort and did not provide a reason why a dental appointment had not been scheduled in July 2025 or August 2025.

Based on observation and staff interview it was determined the facility failed to ensure resident's received hydration beverages during dining. This was true for 1 of 18 residents (Resident #3) observed coughing without a hydration beverage. This deficient practice created the potential for harm if hydration was not provided during meals. Findings include: Resident #3 was readmitted on [DATE], with multiple diagnoses including atrial fibrillation, coronary artery disease, hypertension, renal insufficiency, and hyperlipidemia. On 9/8/25 at 12:00 PM, it was observed in the second-floor dining room Resident #3 was seated at a table with Resident #85. Resident #3 did not have beverages at her dining area; whereas Resident #85 had two beverages in front of him. On 9/8/25 at 12:30 PM, Resident #3 was observed coughing at her table while eating her lunch. The Dietary Manager (DM) asked Resident #3 if she was okay, she requested ice tea, which after drinking, her coughing stopped. On 9/8/25 at 12:45 PM, the DM stated beverages are provided whenever a resident asks for them. He stated, the CNA's are responsible for handing out the beverages. The DM could not explain why there were multiple resident's without drinks, including Resident #3 when Resident #85 had beverages.

Based on observation, record review, staff interview, and the Food and Drug Administration (FDA) Food Code, it was determined the facility failed to ensure: a) ice machines and pans were cleaned and sanitized, b) appropriate glove use was followed by employees, and c) stored food and spices were not expired. This was true for 98 resident's who consumed food stored and prepared by the facility. This deficient practice placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: 1. The FDA Food Code Section 2-301.14 When to Wash documented food employees shall clean their hands immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and before donning gloves to initiate a task that involves working with food.On 9/11/25 between 11:38 AM and 12:20 PM, multiple observations were made during tray line when Dietary Aide #1 did not wash his hands between changing tasks of using his bare hands to serve resident food with ladles and then donning gloves to directly touch resident food to cut up for dietary restrictions, then doffing gloves to continue serving resident food with ladles. There was no hand hygiene performed between glove use and change of tasks. On 9/11/25 at 12:25 PM, the DM stated since Dietary Aide #1 had not left his workstation and was serving food consistently, less than 4 hours, handwashing between glove use was not needed.2. The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, documented marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.On 9/11/25 at 4:00 PM, it was observed in the Assisted Living Kitchen, which prepares the food for the [Facility], multiple items were expired:Supreme Salad Mix: Expired 11/7/20Baking Soda: Expired 6/25Moldy Tomatillos: Dated 9/1/25 (Use by date not identified)Moldy Yams: No dateOn 9/11/25 at 4:17 PM, the DM stated the main kitchen is run by a different facility and they should have identified the expired food items and thrown them away.3. The FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils, documented surfaces of utensils and equipment contacting food that is not time/temperature control for food shall be cleaned.On 9/8/25 at 11:10 AM, it was observed in the second-floor meal kitchen the ice machine had a black residue running down the right interior side of the ice machine.On 9/8/25 at 11:14 AM, the DM stated the ice machine was last cleaned on 8/25/25 and it is cleaned monthly. He was not sure why there was black residue in the ice machine.4. The FDA Food Code Section 4-602.12 Cooking and Baking Equipment documented food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use.On 9/11/25 at 4:35 PM, it was observed in the Assisted Living Kitchen, 1. A cooking skillet with black residue encrusted on the interior of the skillet, and 2. A cooking skillet with teflon coating which had multiple scratches on the cooking area of the skillet.On 9/11/25 at 4:40 pm, the DM stated the cooking skillet with the black residue was visibly dirty, and the skillet with the scratches should have been thrown away. He was not sure why the manager of the Assisted Living Kitchen had not cleaned and/or thrown away the dirty and scratched skillets.

Based on review of the Division of Occupational Licenses database, facility personnel records, staffing schedules, and staff interviews it was determined the facility failed to ensure all registered nurses were working with a valid nursing license. This deficient practice had the potential to significantly harm residents if licensed nurses did not have the knowledge, competencies, and skill sets to provide care and respond to resident's needs. Findings include:On [DATE], a review of the Division of Occupational Licenses database documented RN #1's professional license had expired on [DATE].On [DATE], a review of the nurse staffing schedule documented RN #1 worked at the facility, performing licensed nursing duties on the following dates:[DATE]/[DATE]/[DATE]/[DATE]/25On [DATE] at 1:00 PM, the DON stated he found out RN #1's license was expired on [DATE] and reassigned her to do a 1:1 observation on a resident. The DON confirmed RN #1 worked 6 shifts before re-assigning her to the 1:1 observation.

Based on observation, staff interviews, and review of the Left Ventricular Assist Device (LVAD) Management Manual, the facility failed to implement appropriate infection prevention and control practices during medication administration, medication storage, and a sterile dressing change for 2 of 2 residents (#2 and #50) reviewed for infection control. This failure created the potential for cross-contamination, infection, and life-threatening complications. Findings include: 1.On 9/10/25 at 8:25 AM, during a medication administration observation, RN #3 was preparing medications when a tablet fell from the medication cup onto the top surface of the medication cart. RN #3 donned a glove, picked up the tablet from the cart surface, and returned it to the medication cup. She continued preparing and administering medications to Resident #50.On 9/10/25 at 8:45 AM, RN #3 stated that cross-contamination may have occurred when the tablet contacted the cart surface. She reported sanitizing the cart at the beginning of her shift but did not sanitize it immediately prior to preparing medications. 2.On 9/10/25 at 9:44 AM, during a medication cart audit, an open Rock Star energy drink and an open bag of pretzels were found in the third drawer of the medication cart located in the 220 hall.On 9/10/25 at 9:46 AM, LPN #3 stated that food should not be stored in the medication cart and was unsure who had placed the items there.On 9/10/25 at 10:09 AM, the DON stated that the facility's expectation is that no food or beverages are to be stored in medication carts.3.Resident #2 was readmitted to the facility on [DATE], with multiple diagnoses including end stage heart failure, cirrhosis of the liver, and immunodeficiency. Resident #2's care plan, initiated 6/30/25, directed staff to don gown and gloves for high-contact personal care activities due to the presence of a LVAD.The LVAD Management Manual (undated) documented that dressing changes are considered sterile procedures and require the use of a mask, surgical cap, and a sterile field for dressing materials.On 9/11/25 at 11:54 AM, LPN #4 entered Resident #2's room, retrieved the dressing package from his dresser and placed it directly on the bed without a barrier. She placed her gloves on top of the packaging and proceeded to don her gown. LPN #4 then opened the dressing materials. No sterile field was established.LPN #4 assisted Resident #2 with donning a surgical mask and then placed her own mask. She removed the soiled dressing, discarded it along with her gloves, performed hand hygiene, and continued the dressing change using clean gloves. When asked whether the procedure was sterile or clean, LPN #4 stated it was a clean procedure.On 9/11/25 at 12:15 PM, the DON stated that LPN #4 should have placed a barrier between the bed and the dressing materials and confirmed that the procedure should have been performed using sterile technique.

Based on policy review, record review, review of the State Agency's Long Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure residents' rights were protected to be free from sexual abuse. This was true for 1 of 9 residents (Resident #63) reviewed for abuse. Application of the reasonable person concept caused harm to Resident #63 when she was inappropriately touched by Resident #42. Findings include: The Centers for Medicare and Medicaid Services (CMS) Psychosocial Outcome Severity Guide, dated October 2022, states: The following are examples of circumstances in which a resident's psychosocial outcome may not be readily determined through the investigative process and the reasonable person concept should be used: - When a resident may not be able to express their feelings, there is no discernable response, or when circumstances may not permit the direct evaluation of the resident's psychosocial outcome. Such circumstances may include, but are not limited to, the resident's death, cognitive impairments, physical impairments, or insufficient documentation by the facility; or - When a resident's reaction to a deficient practice is markedly incongruent (or different) with the level of reaction a reasonable person in the resident's position would have to the deficient practice. The Guide further states: In addition to the evidence gathered by the surveyor, the use of the reasonable person concept should be applied and may reveal that the resident is likely to, or may potentially, suffer a greater psychosocial outcome. For example, in the case of a sexual assault, the resident did not exhibit a change in behavior as a result of the incident. The facility's Abuse Prevention Policy, revised December 2016, documented residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. - Resident #63 was admitted to the facility on [DATE], with multiple diagnosis including heart failure and dementia. An annual MDS assessment, dated 10/20/23, documented Resident #63 was severely cognitively impaired. - Resident #42 was readmitted to the facility on [DATE], with multiple diagnoses including respiratory failure and liver disease. A quarterly MDS assessment, dated 9/14/23, documented Resident #42 was moderately cognitively impaired. a. A Facility Reported Investigation, dated 10/1/23 at 9:50 AM, documented There were two staff members sitting at the nurses' station doing some charting. On the other side of the counter [Resident #63] was sitting as she does often. At that time [Resident #42] walked up next to [Resident #63]. The staff at the desk said they were just talking but when another staff member walked up on the same side these two residents were sitting it was noted [Resident #42] was massaging [Resident #63's] breasts on top of her clothes. She was not upset and appeared to be enjoying this. The staff member who saw this separated them and alerted the nurse. Both residents are severely cognitively impaired and unable to make their own choices. The nurse assessment found no injury and no pain reported. {Resident #42] was moved downstairs to separate the two. Families were notified and facility leadership also immediately called. Both residents placed on alert charting and frequent checks. The report conclusion documented after interviews, observation, and record reviews, that Resident #42 thought Resident #63 was his wife because he remembered that she passed away. The report documented Resident #63 was pleasant and seemed to enjoy interactions with Resident #42 and did not protest when his interactions turned inappropriate. The report further documented both residents' cognition was at a level they were not able to make these kinds of decisions. The facility moved Resident #42 to a downstairs room so the residents would have little or no contact. b. A second Facility Reported Investigation, dated 10/6/23 at 4:37 PM, documented [Resident #63 was sitting in the dining room. Staff had placed her there just 10 minutes prior. [Resident 42] somehow came upstairs via the elevator and came into the dining room. No staff member had seen him come into the dining room. At 4:30 AM a CNA came into the dining room right as [Resident #42] was walking away from [Resident #63] at a quick pace. [Resident #63] was saying to him to get out of here. Staff did not see what happened, but it appeared [Resident #63's blouse was disheveled. [Resident #42] was escorted downstairs. [Resident #63] was unable to say if or what had happened. The nurse's assessment showed no bruising, swelling or any injury. Staff were alerted to redirect [Resident #42] to stay downstairs where his room is now located. There have been some staff who have been off and did not realize [Resident #42] had moved downstairs and have directed him up the elevator. All staff working have now been informed and we will ensure all staff will be informed. The report conclusion documented after interviews, observation, and record reviews the facility concluded Resident #42 possibly touched Resident #63 inappropriately. The conclusion documented the incident was not witnessed, but Resident #63 answered Yes to the nurse's question about Resident #42 touching her breast. On 6/27/24 at 11:14 AM, the DON stated Resident #42 did touch Resident #63's breast. When he did it the first time the residents were separated. She stated Resident #63 was assessed and there was no change in her behavior. When she notified Resident #63's daughter what had happened the daughter stated she understood. The DON stated Resident #42's daughter stated the female resident did look like Resident #42's late wife and he forgot that she had passed and had been looking for her, and it was determined by the facility Resident #42 would be moved to the first floor to separate the residents. The DON stated Resident #42 had not touched other female residents. He had tried touching female staff members but was redirected without incident. She said there were no further incidents with Resident #42. The facility took the following actions: - The nurse assessed both residents for harm and evidence of injury - none noted. - Administrator, Regional Director of Operations notified. - Families of both residents notified. - The State Agency Long Term Care Program was notified via the portal - Staff members were interviewed. - Care plans for both residents were reviewed and updated. - Social Services interviewed other residents and no further concerns were found. - Staff education was provided to remind and redirect Resident #42 to stay downstairs. - Frequent checks were initiated for both residents. - Resident #42 was fully moved downstairs to a new room with all of his belongings set up to his preferences. These findings represent past noncompliance with this regulatory requirement. There was sufficient evidence the facility corrected the noncompliance as of 10/6/23, and there were no other occurrences of alleged sexual abuse. At the time of this survey the facility was in substantial compliance and therefore does not require a plan of correction.

Based on policy reviews, record review, observations and interviews, it was determined the facility failed to ensure residents were not served foods at high risk for transmission of food borne illness. This was true for 2 of 73 residents (#20 and #53) reviewed, who dined in the facility. This deficient practice placed Resident #20 and Resident #53 in immediate jeopardy of serious harm, impairment, or death related to Salmonellosis, an infection with Salmonella bacteria that causes diarrhea, fever and stomach pains when they consumed undercooked, unpasteurized whole shell eggs. Findings include: The CDC website, last reviewed 3/8/23, and accessed on 5/17/23, stated Salmonella illness can be serious and was more dangerous for some groups of people. These groups include children younger than 5 years, adults [AGE] years and older, and people who have a weakened immune system because of a health problem or medicine that lowers the body's ability to fight germs and sickness. The Food Preparation and Service policy, dated 10/2017, documented unpasteurized eggs should be cooked until all parts of the egg (yolks and whites) are completely firmed (160 degree Fahrenheit). The internal cooking temperatures/times for specific foods must be reached to kill or sufficiently inactivate pathogenic microorganisms. The policy also stated only pasteurized shell eggs will be cooked and served when: residents requests undercooked, soft-served or sunny side up eggs. This policy was not followed. 1. Resident #20 was admitted to the facility on [DATE], with multiple diagnoses, including stroke, chronic pain and chronic kidney disease. Resident #20s quarterly MDS assessment, dated 3/31/23, documented she was cognitively intact. Resident #20 was independent with eating and required set-up help only. Resident #20's Breakfast Meal Ticket, dated 5/3/23, stated, Resident requests eggs every morning for breakfast - Resident likes over easy eggs. 2. Resident #53 was admitted to the facility on [DATE], with multiple diagnoses including dementia, acute kidney failure and severe sepsis (An infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever). Resident #53's quarterly MDS assessment, dated 4/14/23, documented he was moderately cognitively impaired. Resident #53 was independent with eating and required set-up help only. Resident #53's Breakfast Meal Ticket, dated 5/3/23 stated, Resident wants 2 over easy eggs for breakfast in place of menu option . On 5/2/23 at 10:02 AM, whole shell eggs were observed both in the reach-in refrigerator and walk-in refrigerator of the ALF kitchen. The label on the exterior of the top of the boxes of eggs stated, Safe handling instructions - to prevent illness keep eggs refrigerated, cook until yolks are firm. There was no P for pasteurized stamped on the eggs showing they were pasteurized. ALF food service employees prepared all the meals for the nursing home in accordance with a contract, and in the same physical building as the nursing home but operated under different ownership and management. On 5/2/23 at 4:08 PM, the DM stated he did not know the eggs in the ALF kitchen were unpasteurized. The DM stated he had been told previously by the ALF dietary staff that the eggs were pasteurized. The DM stated unpasteurized eggs could not be served to residents in the nursing home if they were not fully cooked due to risk for food borne illness, and Resident #20 and Resident #53 were served over easy fried eggs daily. The DM stated no fried eggs would be served forward until pasteurized whole shell eggs were in stock. On 5/3/23 at 8:15 AM, Resident #53 was observed sitting in the dining room, having just consumed all his meal. Resident #53 stated he consumed two fried eggs that were cooked over medium. Resident #53's tray card, documented he preferred over easy eggs (runny yolks), which he confirmed. Resident #53 was served unpasteurized fried eggs, that were not fully cooked for breakfast. On 5/3/23 at 8:23 AM, Resident #20 was just starting to eat her meal with eggs. The egg yolks were gelled in consistency, and not fully cooked. Resident #20 stated the eggs were cooked more than she preferred. She said she preferred her eggs to be prepared over easy with runny yolks which was documented on her tray card. Resident #20 was served unpasteurized fried eggs that were not fully cooked for breakfast. On 5/3/23 at 9:05 AM, Cook #3 stated he prepared over easy fried eggs for Resident #20 and Resident #53's breakfast per their preference. The surveyor and DM verified the only whole shell eggs available in the ALF kitchen were unpasteurized. The DM stated he had instructed the supervisor in the ALF kitchen the day prior not to send any fried eggs for breakfast. The DM stated he went out to buy pasteurized eggs, but he could not find any. The DM stated he ordered pasteurized eggs and it would be delivered on 5/5/23. On 5/3/23 at 12:33 PM, the RD stated unpasteurized eggs were to be fully cooked. She stated it was very serious if unpasteurized eggs were not fully cooked, residents could get sick from food borne illness and die. On 5/3/23 at 3:35 PM, the Administrator and DON were informed verbally and in writing of an Immediate Jeopardy (IJ) determination at F812 when Resident #20 and Resident #53 consumed unpasteurized eggs which were not fully cooked solid when served sunny side up eggs or over easy. On 5/4/23 at 8:56 AM, the facility provided a plan to remove the immediacy which was accepted. The facility's IJ removal plan included: - Resident #20 and Resident #53 were assessed for signs and symptoms of food borne illness including diarrhea that does not improve after three days, vomiting that lasts more than two days, signs of dehydration including little or no urination, excessive thirst, a very dry mouth,dizziness of lightheadedness or very dark urine, fever higher than 102 degrees F, bloody stools. MD was updated regarding risk of for potential exposure. - Administrator/designee educated the ALF kitchen manager to serve only pasteurized eggs when soft cooked from ALF to skilled nursing residents and to cease and desist sending any eggs that are soft cooked from ALF kitchen to SNF. - Administrator/designee educated SNF DM on requirements of serving pasteurized eggs if not cooked to required temperature, to update residents' tray cards immediately to reflect required food to be served. - No unpasteurized soft cooked eggs will be served to residents. If pasteurized eggs are not available immediately, residents preferring soft cooked eggs, educated on need to serve only scrambled or hard cooked eggs. - Skilled Nursing Facility (SNF) DM will cook soft fried egg in the SNF kitchen as soon as pasteurized eggs are able to obtained. The facility's implementation of the plan to remove the immediacy of the IJ was verified as follows: - QAPI Attendance Log dated 5/3/23 and provided by the facility revealed the Medical Director, Administrator, DON, Resident Case Manager, DM, Social Services, Medical Records Director, Infection Control/Staff Development Coordinator, Maintenance Environmental Supervisor, and Therapy Director attended the meeting. - Nurses' Notes for Resident #20 and Resident #53, dated 5/3/23, documented they would be monitored for signs and symptoms of food borne illness for three days and the residents and/or their responsible parties were notified. The Nurses' Notes stated Resident #20 and Resident #53 were also notified they might not receive over easy eggs for breakfast on 5/4/23. - Resident #20 and Resident #53's care plans were updated to include their preference for over easy eggs. - Individual Inservice/Education record, dated 5/3/23, stated the DM was educated regarding pasteurized soft cooked whole eggs. - Quick Inservice/Education record, dated 5/3/23, stated staff must verify tray cards when serving meals. The inservice attendance record showed seven dietary staff members attended. - Review of the Individual Inservice/Education record, dated 5/3/23, documented the ALF DM and General Manager were educated about the SNF regulation requiring soft cooked eggs to be pasteurized and the request not to send fried eggs to the SNF. - Audit records, dated 5/4/23, for F812 Food Procurement and the Dietary Manager's audit of tray cards were complete. On 5/4/23 at 4:43 PM, the Administrator was verbally informed the immediacy was removed. Following the removal of the immediacy, non-compliance remained at a scope and severity of a D. (No actual harm with potential for more than minimal harm).

Based on policy review, record review, review of the State Agency's Long Term Care Reporting Portal, review of facility documents, and staff interview, it was determined the facility failed to ensure residents were free from abuse by other residents and staff. This was true for 4 of 8 residents (Residents #53, #60, #63, and #233) reviewed for abuse and neglect. This failure resulted in the potential for residents to ongoing abuse and potential harm. Findings include: The facility's policy Recognizing Signs and Symptoms of Abuse/Neglect, revised 1/2011, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The facility's Abuse Investigation and Reporting policy, revised 7/2017, stated our facility will not condone any form of resident abuse or neglect. These policies were not followed. a. Resident #63 was admitted to the facility on [DATE], with multiple diagnoses including hemiparesis (weakness of one side of the body), hemiplegia (paralysis of one side of the body), and dysarthria (difficulty in speech due to weakness of speech muscles) following a stroke. An annual MDS assessment, dated 12/3/22, documented Resident #63 was cognitively intact. A facility investigation report, dated 11/19/22, documented Resident #63 was woken up at night when CNA #8 moved her to change her incontinence brief. Resident #63 was startled and cried out Ouch. CNA #8 told Resident #63 she needed to get her changed and continued. Resident #63 stated she cried out a few more times as CNA #8 was holding her tight on her legs as she was being changed. The investigation documented Resident #25 (Resident #63's roommate) was interviewed and stated she heard Resident #63 said ouch a couple of times and told CNA #8 to be careful. Resident #25 also stated she did not like how CNA #8 treated Resident #63. The investigation documented Resident #63 did have pain during incontinence care and CNA #8 was in a hurry and did not properly communicated to Resident #63. The investigation documented CNA #8 should have stopped when Resident #63 cry of pain and figured out a better way to change her. The investigation also documented CNA #8's agency was notified, and she would not be allowed to return to the facility. b. Resident #233 was admitted to the facility on [DATE], with multiple diagnoses including non-traumatic subdural hemorrhage (bleeding under the membrane covering the brain), chronic pain and osteoporosis (a condition when bone strength weakens and is susceptible to fracture). An admission MDS assessment, dated 9/1/22, documented Resident #233 was cognitively intact. A facility investigation report, dated 9/1/22, documented Resident #233's family member mentioned to a staff member Resident #233 called at 2:00 AM because CNA #10 was very disrespectful and aggressive to Resident #233. Resident #233's family member reported CNA #10 used a rough tone with Resident #233 when she asked to use the bathroom and CNA #10 stated to Resident #233 that she used a catheter and did not need to go to the toilet. Resident #233 was interviewed and stated CNA #10 was not nice to her when she told her she needed to use the restroom. Resident #233 stated CNA #10 gave her an attitude and was pushy, and did not want to attend to her needs. The investigation documented CNA #9 was giving report to CNA #10 and CNA #10 got angry because there were three call lights on. CNA #9 stated CNA #10 became real mad and started to yell by clapping her hands and was disrespectful to her. CNA #11 was also interviewed and stated CNA #10 seemed agitated and was not paying attention when she was giving her report. CNA #11 stated CNA #10 stood and cussed at her and CNA #9. CNA #11 stated CNA #10 started screaming, smacking her hands together and was becoming aggressive, and began turning the call lights off and yelling down the hallway. The investigation documented CNA #10 stated she was mad because there were three call lights that were on. CNA #10 stated there were more staff during the day and they should be able to get the residents ready for bed so that its not more work for them. CNA #10 stated she was confused that Resident #233 wanted to use the bathroom when she had a catheter. The investigation concluded CNA #10 was possibly angry when she started her shift and Resident #233 felt CNA #10 was angry with her. The investigation documented CNA #10 gave her notice of resignation due to how she treated the staff and her poor customer service towards Resident #233. c. Resident #60 was admitted to the facility on [DATE], with multiple diagnoses including hemiparesis (weakness of one side of the body), hemiplegia (paralysis of one side of the body), and dysarthria (difficulty in speech due to weakness of speech muscles) following a stroke. A Significant Change MDS assessment, dated 10/24/22, documented Resident #60 was severely cognitively impaired. A facility investigation report, dated 10/25/22, documented Resident #60 was having behaviors and flipped off a staff. Multiple CNAs witnessed CNA #13 return the hand gesture to Resident #60. The investigation report documented the following CNAs were interviewed: - CNA #14 stated he remembered Resident #60 was wandering the hallway and tried to enter into a room when CNA #13 told Resident #60 sternly not to go in the room. CNA #14 stated Resident #60 flipp [sic] us off and curse [sic] at us, and that CNA #13 flipped her off back to Resident #60. - CNA #12 stated she remembered an incident where a resident was flipping off staff. CNA #12 stated she heard CNA #13 told the resident Well I have two of them. CNA #12 stated she took it as that CNA #13 flipped off the resident back but did not see it. - CNA #13 stated Resident #60 flipped her off, but she never did it. The investigation concluded two CNAs witnessed CNA #13 flipping off the resident and the facility terminated her employment. d. Resident #53 was admitted to the facility on [DATE], with multiple diagnoses, including anxiety, depression, urinary tract infection and high blood pressure. A facility investigation report, documented on 12/28/22, Resident #53' s family member reported to the DON that on 12/25/22 in the dining room, while visiting Resident #53, Resident #377 bumped his wheelchair into Resident #53's wheelchair. This upset Resident #377 and he cussed at Resident #53. Resident #377 then grabbed the clothing protector off Resident #53, and Resident #53 grabbed the clothing protector back from Resident #377. Resident #377 then started hitting Resident #53 on his left arm. The investigation documented Resident #377 yelled obscenities to Resident #53. The investigation documented Resident #377 had a verbal outburst when things upset him but it was almost always directed at staff members or his wife when she visited him. After learning about the incident, the IDT decided Resident #377 would have his meals in the dining room downstairs and each staff member would bring him down the elevator and set him up in the dining room. The investigation concluded the incident between Resident #53 and Resident #377 did occur. Resident #53 was upset, but not injured. Resident #377 was monitored for his aggression and his care plan was revised. On 5/2/23 at 4:06 PM, the Administrator stated he started in the facility about four months ago and he was the abuse coordinator. He stated the staff were educated to report any incident of abuse such as verbal, physical or any altercation between staff and resident or any resident to resident altercations. The Administrator stated staff were educated to protect the resident and make sure they were safe first and assess for injury. The Administrator stated the alleged staff would be suspended immediately from work. When asked about Resident #63's pain during her pericare. The Administrator stated the CNA was from an agency and based on their investigation the CNA was in a hurry when she provided pericare to Resident #63. The Administrator stated the CNA should have stopped when Resident #63 stated she was hurting during pericare. The Administrator stated the CNA's agency was called and told them they would not allow the CNA to work in the facility again. The Administrator stated the previous administration terminated CNA #13. The Administrator stated if staff observed/heard any incidents of abuse, they should report it immediately to their supervisor or contact him directly. The facility failed to ensure Residents #53, #60, #63 and #233 were free from abuse.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed to prevent the development and worsening of a wound. This was true for 3 of 9 residents (Residents #1, #326, and #329) reviewed for pressure ulcers. This failure resulted in harm when Resident #1, Resident #326, and Resident #329 developed new pressure ulcers, and Resident #326 and Resident #329's pressure ulcers worsened. Findings include: The National Pressure Injury Advisory Panel website, accessed on 5/10/23, defined pressure ulcer injuries for stage 2, stage 3, and unstageable as follows. - Stage 2 - Partial-thickness skin loss with exposed dermis (thick layer of living tissue below the epidermis which forms the true skin, containing blood capillaries, nerve endings, sweat glands, hair follicles, and other structures). The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process), slough (non-viable yellow, tan, gray, green, or brown tissue), and eschar (dead or weakened tissue that is hard or soft in texture - usually black, brown, or tan in color) are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. - Stage 3 - Full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining (when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) and tunneling (channels that extend from a wound into and through the tissue or muscle below) may occur. Fascia (thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fiber, and muscle in place), muscle, tendon, ligament, cartilage, or bone is not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. - Unstageable - Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be softened or removed. The facility's Prevention of Pressure Ulcer Injuries policy, revised 2018, documented pressure ulcer injury prevention included risk evaluation, nutritional and mobility repositioning interventions, as follows: - Evaluate the resident on admission for existing pressure ulcer risk factors. Repeat the risk evaluation as needed and with significant changes in condition. - Conduct a skin evaluation upon admission, including skin integrity for any evidence of existing or developing pressure ulcers or injuries. - Use a screening tool to determine if the resident is at risk for undernutrition or malnutrition. - Inspect the skin routinely when performing or assisting with personal care or ADLs. - Monitor the resident for weight loss and intake of food and fluids. Include nutritional supplements in the resident's diet to increase calories and protein as indicated in the care plan. - Reposition based on the resident's mobility, the supportive surface in use, skin condition and tolerance, and the resident's preferences. - Reposition frequently as needed based on the condition of the skin and the resident's comfort. - Evaluate, report, and document potential changes in the skin. - Review the interventions and strategies for effectiveness. The facility's Pressure Ulcers Skin Break Down Clinical Protocol policy, revised 2022, documented the protocol was to evaluate and identify the causes, provide wound treatments, management, and monitor, including evaluating and documenting a resident's's significant risk factors for developing pressure ulcers, for example, immobility, recent weight loss, and history of pressure ulcers. The policy stated the nurses were to describe, document, and report the following: - Full assessment of pressure sore, including location, stage, length, width, depth, presence date, and necrotic tissue. - Pain assessment. - Resident's mobility status. - Current treatments, including support surfaces. - All active diagnoses. These policies were not followed. 1. Resident #326 was admitted to the facility on [DATE], with multiple diagnoses including left sided hemiplegia (paralysis on one side of body), stage 3 pressure ulcer of the right heel, stage 2 pressure ulcer of the right buttock, and left buttock. Resident #326's hospital discharge summary, dated 8/9/22, documented Resident #326 presented with a chronic non-healing pressure ulcer to his right heel and a small sacral wound. The hospital discharge instructions included daily dressing changes. a. Resident #326's MAR and TAR for 8/2022 did not include all pressure ulcer related care and monitoring as ordered by the physician was completed. Examples included the following: i. Resident #326's TAR, dated 8/2022, directed staff to question Resident #326 about presence of pain, including sore points every shift. The documentation for the following shifts were blank: - 8/11/22 night shift - 8/12/22 evening shift and night shift - 8/13/22 night shift - 8/14/22 night shift - 8/19/22 night shift - 8/20/22 evening shift - 8/26/22 day shift ii. Resident #326's TAR, dated 8/2022, directed staff to ensure he wore Prevalon boots (pressure relief boot for the heel) while in bed or sitting up in a chair every shift. The documentation for the following shifts were blank: - 8/12/22 evening shift and night shift - 8/13/21 night shift - 8/14/22 night shift - 8/20/22 evening shift iii. Resident #326's MAR, dated 8/2022, directed staff to apply Boston Butt Cream to the area around his buttock dressing and groin area every shift. The documentation for the following shifts were blank: - 8/12/22 evening shift and night shift - 8/13/22 night shift - 8/14/22 night shift - 8/20/22 evening shift b. A practitioner's visit note, dated 8/12/22 and 8/15/22, documented Resident #326 had a right foot ulcer and sacral wound. Resident #326's record did not include documentation a wound assessment was performed including location, stage, length, width, depth, presence date, and necrotic tissue upon his admission as per policy. A nurse's note, dated 8/13/22 at 11:49 AM, documented Resident #326's pressure area over coccyx (tailbone) measured 12.6 cm x 10.5 cm with no depth. c. Resident #326's admission MDS, dated [DATE], documented Resident #326 was moderately impaired. He required a two person extensive assistance for bed mobility, transfer, dressing, and bathing, and one person extensive assistance for toileting. Resident #326 was admitted with two stage 2 pressure ulcers and one stage 3 pressure ulcer. Resident #326 was not in the turning and repositioning program. Resident #326's record did not include documentation frequent position changes were completed per facility policy. d. A physician's note, dated 8/16/22, documented Resident #326 had a right heel pressure ulcer, coccyx wound, and a new left toe blister. Resident #326's record did not include treatment or prevention interventions for the newly developed toe blister. e. A weekly head-to-toe skin check assessment, dated 8/16/22, documented wound to the right heel blanchable redness to buttocks treatment in place. The assessment did not include wound measurements, or descriptions for Resident #326's pressure ulcer to his right heel, right buttock, left buttock, and the new left toe blister. f. A weekly wound review assessment, dated 8/17/22, documented Resident #326 had a right buttock stage 2 pressure ulcer which measured 0.5 cm x 0.4 cm x 0.2 cm. Resident #326's physician's wound note, dated 8/17/22 at 2:01 PM, documented Resident #326 had a stage 3 pressure ulcer to the right heel, a stage 2 pressure ulcer to the right buttock, and a stage 2 pressure ulcer to the left buttock. The right heel wound measured 9 cm x 2 cm x0.4 cm. The note instructed staff to offload the wound by using an air mattress on the bed and to reposition Resident #326 every 2 to 3 hours. Resident #326's records did not include documentation a wound assessment was completed of his right heel, left buttock, and the toe blister including location, stage, length, width, depth, presence date, and necrotic tissue as per facility policy. Resident #326's record did not include documentation he was repositioned consistently every 2 to 3 hours. g. A weekly head-to-toe skin check assessment, dated 8/23/22, documented wound to the right heel blanchable redness to buttocks treatment in place. The assessment documented Resident #326 had two pressure ulcers: one stage 2 pressure ulcer on the left buttock and one stage 3 pressure ulcer on the right heel. Resident #326's skin assessment was not consistent with the 8/17/22 physician documentation related to the second stage 2 pressure ulcer to the right buttock. The assessment did not include documentation including location, stage, length, width, depth, presence date, and necrotic tissue for all three pressure ulcer wounds as per facility policy. h. A practitioner's note, dated 8/24/22, documented Resident #326 had multiple pressure ulcers to his buttock and heels. Resident #326 stated did not sleep well last night because he was having pain on his bottom where he had a sore. He did not think he had taken any pain medication. He tried to change positions frequently but was unable to move himself. Resident #326's ADL assistance report for August 2022, documented bed mobility assistance was not completed on the 8/12/22 night shift, 8/16/22 day shift, 8/18/22 night shift, 8/20/22 day shift, and 8/27/22 night shift. i. A nurse's note, dated 8/26/22 at 11:26 AM, documented Resident #326's daughter and the provider observed a black eschar area to the bottom of his left foot. Resident #326's daughter stated it was from Resident #326's prior facility and they would attempt to locate records from the prior facility. A weekly wound review assessment, dated 8/26/22, documented Resident #326 had two pressure ulcers. One stage 2 pressure ulcer on the right buttock without measurement was first observed upon admission. One new unstageable diabetes foot ulcer with eschar was measured at 0.7 cm x 1.4 cm on the left foot and was first observed on 8/26/22. Resident #326's skin assessment was not consistent with the practitioner's documentation on 8/24/22. It was not clear how many pressure ulcers were present. Resident #326's records did not include documentation all the pressure ulcers were assessed, including location, stage, length, width, depth, and necrotic tissue per facility policy. j. A nurse's note, dated 8/28/22 at 8:39 PM, documented Resident #326 complained of pain at a 10 (the highest pain rating) out of 10 pain scale when he moved. The nurse called the physician to get an additional as-needed pain medication to replace the current Tylenol. The physician ordered Tramadol 50 mg three times a day as needed for pain. A nurse's note, dated 8/29/22 at 2:15 AM, documented Resident #326 needed the new pain medication to be filled and the physician's signature was needed for the new order. Resident #326's MAR documented the Tramadol was not administered from the time it was ordered. A nurse's note, dated 8/29/22 at 8:30 PM, documented Resident #326 was sent to the hospital. k. A discharge MDS assessment, dated 8/29/22, documented Resident #326 presented with 2 unhealed pressure ulcers, one stage 2 and one stage 3, both were present on admission. Resident #326 was not in the turning and repositioning program. Resident #326 did not have ulcers, wounds, or skin problems to his foot. Resident #326 was not receiving skin and ulcer treatment, including pressure reducing devices for the chair and bed, pressure ulcers and wound care, or in the turning and repositioning program. It was not clear how many pressure ulcers were present when Resident # 326 discharged . Resident #326's record did not include documentation frequent position changes were completed as per the facility policy. On 5/5/22 at 10:40 AM, the DON said bed mobility assistance should be performed at least 2 to 3 times every shift and documented in the CNAs' ADL task report. She stated for residents on bed rest, the staff should be providing bed mobility assistance up to 5 times every shift. On 5/5/23 at 5:20 PM, when asked, the DON reviewed Resident #326's pressure ulcer records, ADL assistance report, MAR, and TAR. The DON said there was no other documentation that Resident #326's pressure ulcers were measured. She said the ADL assistance report, MAR, and TAR for pain medication, wound care and monitoring should be completed and documented, and not have blanks. The DON stated there were only 1 or 2 progress notes documenting Resident #326's repositioning every 2 hours, and she expected it should be documented each time. 2. Resident #329 was admitted to the facility on [DATE] with multiple diagnoses including right femur fracture, dementia, and required assistance with personal care. Resident #329's admission MDS assessment, dated 7/20/21, documented Resident #329 was cognitively intact. She required one person extensive assistance for bed mobility, transfers, dressing, and required physical assistance for bathing. A progress note, dated 7/14/21 at 6:37 PM, documented Resident #329 complained of pain in the right heel. The heel was boggy but blanchable, and a pillow was to be placed under both legs to float heels, and Resident #326 was instructed to keep her heels elevated. A pressure injury risk assessment, dated 7/20/21, documented Resident #329 was at moderate risk of developing a pressure injury. a. Resident #329's MAR and TAR, dated 7/2021 through 10/2021, documented pressure ulcer related care was not consistently completed. Examples include: i. Staff were instructed to apply barrier cream to Resident #329's peri area every shift or after each incontinent episode. The following shifts were blank: - 7/15/21 day shift, evening shift, and night shift - 7/16/21 night shift - 7/17/21 night shift - 7/22/21 day shift and night shift - 7/23/21day shift - 7/25/21 day shift - 8/1/21 night shift - 9/24/21 night shift - 10/9/21 day shift - 10/20/21 night shift Resident #329's ADL assistance report, dated July 2021 through October 2021, documented the bed mobility assistance was not completed as follows: Day shift: 8/8/21, 8/15/21, 9/20/21, 10/19/21. Evening shift: 7/22/21, 7/31/21, 8/24/21, 9/26/21, 10/19/21. Night shift: 7/15/21, 7/21/21, 7/26/21, 7/28/21, 8/2/21, 8/9/21, 8/21/21, 8/27/21, 8/31/21, 9/2/21, 9/10/21, 9/12/21, 9/14/21, 9/18/21, 9/24/21, 9/28/21, 10/10/21, 10/8/21, 10/18/21, 10/20/21. b. A weekly head-to-toe skin check assessment, dated 8/16/21, documented Resident #329's heel was clear with no skin issues. A weekly head-to-toe skin check assessment, dated 8/23/21 and 8/30/21, documented Resident #329 had no skin issues. A nurse's note, dated 9/6/21 at 11:14 AM, documented Resident #329 had a change of condition on 9/1/21. On 9/6/21, a CNA reported Resident #329 had a new open area on her coccyx (tailbone). The center of the new open area had eschar measuring 0.5 cm x 0.3 cm with surrounding slough tissue, and both right and left buttocks had superficial open areas. A weekly head-to-toe skin check assessment, dated 9/6/21, documented Resident #329 developed nine new skin issues as follows: - Right elbow: red. - Left elbow: red. - Coccyx: 2.5 cm x 2 cm eschar center with yellow tissue at the center of the tailbone. - Right buttock: 1 cm x 1 cm shear area. - Left buttock: 0.5 cm x 0.5 cm shear area superficial. - Right heel: 4 cm x 4 cm mushy area and red - Left heel: 3 cm x 3 cm red area. - Right rear shoulder: 4 cm x 4 cm red area. - Left rear shoulder: 2 cm x 2 cm red area. The assessment note further documented new interventions Resident #329 were to have; air bed, heel and elbow protectors, treat the coccyx with a barrier cream and hydroid dressing (dressing for non infected wounds), and educate staff about preventive measures. The facility failed to provide consistent pressure ulcer preventive care including barrier cream use and bed mobility for position changes. c. A nurse's note, dated 9/12/21 at 12:22 AM, documented Resident #329's coccyx wound remained open with slough. Resident#392's dressing was changed and her heels were pink and slightly boggy. A weekly head-to-toe skin check assessment, dated 9/13/21 and 9/20/21, did not document Resident #329 had skin issues as the 9/6/21 weekly head-to-toe skin check assessment indicated. The assessment documented continuing the plan of care to treat the coccyx with a barrier cream and hydroid dressing and to educate staff with preventive measures. d. A weekly wound review assessment, dated 9/15/21, documented Resident #329 had a coccyx unstageable pressure wound that measured 2 cm x 1.5 cm x 0 cm. Resident #329's weekly wound review assessment was not consistent with the weekly head-to-toe skin check assessment, dated 9/6/21. It was not clear how many wounds Resident #329's had. e. A progress note, dated 9/18/21 at 10:45 PM, documented Resident #329 continued with wound care to the coccyx and reported that it was painful at times. A progress note, dated 9/19/21 at 9:43 PM, documented there was no change in wound or treatment. Resident complained of pain to the coccyx when sitting up. A progress note, dated 9/22/21 at 2:28 PM, documented Resident #329 was seen by the wound clinic. The coccyx wound was debrided, new orders were received, and the MAR was updated. A weekly wound review assessment, dated 9/22/21, documented Resident #329 had an unstageable pressure wound to her coccyx measuring 2.8 cm x 2.2 cm x 0 cm. A wound clinic progress note, dated 9/22/21 documented Resident #329's coccyx wound was deteriorating, the wound had doubled in size, and the wound was full of stringy malodorous slough. The wound was surgically debrided. f. A weekly head-to-toe skin check assessment, dated 9/27/21, documented Resident #329 had skin issues on the same nine sites as her 9/6/21 weekly head-to-toe skin check assessment had documented: - Right elbow - Left elbow - Coccyx - Right buttock - Left buttock - Right heel - Left heel - Right rear shoulder - Left rear shoulder The assessment did not include documentation including location, stage, length, width, depth, presence date, and necrotic tissue for all the pressure ulcer wounds as per facility policy. It was not clear how many pressure ulcers Resident #329 had. g. A weekly wound review assessment, dated 9/29/21, documented Resident #329 had an unstageable pressure wound that measured 4.2 cm x 4 cm x 3 cm. A wound clinic progress note, dated 9/29/21 documented Resident #329's coccyx wound had significantly deteriorated in the last week with a strong odor. Nursing expressed Resident #329's family agreed to place her on hospice. The provider suggested changing the wound dressing type and frequency to twice daily and as needed. A weekly head-to-toe skin check assessment, dated 10/4/21, documented Resident #329's coccyx had an open area, the color was black and gray with a foul odor and dark drainage. Resident #329's dressing was changed per the physician's order. A progress note, dated 10/5/21, documented the hospice nurse was in the facility and requested not to transfer Resident #329 out of bed and to change her position from side to side to maintain skin integrity and to offload pressure from the coccyx wound. A weekly wound review assessment, dated 10/6/21, documented Resident #329 had an unstageable pressure wound to her coccyx that measured 4 cm x 4 cm x 2cm. h. A weekly head-to-toe skin check assessment, dated 10/11/21, documented Resident #329 had skin issues on the same nine sites as his 9/6/21 weekly head-to-toe skin check assessment had documented: - Right elbow - Left elbow - Coccyx - Right buttock - Left buttock - Right heel - Left heel - Right rear shoulder - Left rear shoulder The assessment did not include documentation including location, stage, length, width, depth, presence date, and necrotic tissue for all the pressure ulcer wounds as per facility policy. It was not clear how many pressure ulcers Resident #329 had. i. A medication administration note, dated 10/12/21 at 1:46 PM, documented Resident #329's wound had a foul odor. It had string-like black flesh hanging around the edges and green drainage. A progress note, dated 10/14/21 at 4:31 PM, documented Resident #329's coccyx wound was deeper and wider with a foul odor. Resident #329 moaned in pain when turned and the skin was becoming darker on the bilateral lower extremities. The hospice nurse was there and was informed. Resident #329's weekly head-to-toe skin check assessment, dated 10/18/21, documented Resident #329 had no skin issues. On 5/5/23 at 10:40 AM, the DON said bed mobility assistance should be performed at least 2 to 3 times every shift and documented in the CNAs' ADL task report. For residents on bed rest, the staff should be providing bed mobility assistance up to 5 times every shift. On 5/5/23 at 10:44 AM, the DON reviewed Resident #329's record and said the MAR, TAR, and ADL task report for bed mobility was blank whcih meant there was no documentation that the tasks had been completed. She said it should be completed and documented. The facility failed to timely, accurately, and consistently, assess, measure, document, and provide pressure ulcer care to prevent pressure injury development and promote the healing of existing pressure ulcers. 48172 3. Resident #1 was admitted to the facility on [DATE] with diagnoses including protein-calorie malnutrition, fibromyalgia (a widespread pain condition affecting muscles and bones), and osteoarthritis of the right and the left shoulder. Resident #1's physician orders, dated 1/27/22- 4/21/23, documented Resident #1 was to receive the following treatments: - 1/27/22: Resident #1 was to receive barrier cream to buttocks following incontinence. - 2/20/23: Resident #1 was to have a hybrid air mattress with an air pump. - 4/17/23: Resident #1 was to have buttocks cleansed with wound cleanser. - 4/21/23: Resident #1 was to receive barrier cream every evening shift and staff were to monitor and document signs and symptoms of infection to the wounds on the buttocks until healed. A Hospice Nursing Visit note, dated 4/4/23, documented Resident #1 had 4 superficial excoriated wounds on her buttocks/sacrum area. A ROHO cushion (pressure relieving cushion) was ordered for Resident #1's recliner and a new air mattress with bolsters were ordered. Resident #1 wounds were measured and were as follows: - 2 cm x 2 cm - 1.5 cm x 1.5 cm - 1.0 cm x 1.0 cm - 0.5 cm x 0.5 cm A Wound Care Provider note, dated 4/6/23, documented Resident #1 had stage 2 wounds on her buttocks. The wounds were measured and were as follows: - 0.6 cm x 0.4 cm and the depth of the wound was less than 0.1 cm, left buttock. - 0.3 cm x 0.4 cm and the depth of the wound was less than 0.1 cm, midline. - 0.6 cm x 0.9 cm and the depth of the wound was less than 0.1 cm, right buttock. A Wound Care Provider note, dated 4/13/23, documented education was provided to Resident #1 on the importance of offloading (relieving pressure), proper nutrition, and supplemental protein to promote wound healing. A Wound Care Provider note, dated 4/20/23, documented staff were to ensure Resident #1 was offloading, and had an air mattress and seat cushion. On 4/30/23 at 11:37 AM, Resident #1 was in her room and sitting in a recliner that contained a ROHO cushion. On 4/30/23 at 3:50 PM, Resident #1 was in her room and sitting in a recliner that contained a ROHO cushion. On 5/3/23 at 8:30 AM, Resident #1 was laying in bed and was on her back. At 9:07 AM, Resident #1 was laying in bed and was on her back. At 9:30 AM, Resident #1 was in the same position in bed. At 10:21 AM, Resident #1 was in the same position in bed and her ROHO cushion was noted to be deflated. Resident #1's care plan, initiated 4/21/23, stated Resident #1 was to be provided with pressure injury treatment, her care coordinated by the facility wound nurse and the outside wound provider, and weekly pressure injury assessments were to be completed. Resident #1's care plan did not contain information related to consistently repositioning Resident #1 and her need for proper nutrition to promote wound healing. On 5/3/23 at 1:20 PM, the RD stated Resident #1 was followed weekly in Skin and Weight meetings. The RD stated Resident #1 received a nutritional supplement 3 times a day. The RD stated she did not know what type of supplement was used and stated, whatever nursing is using. The RD stated she was not monitoring Resident #1's nutritional intake. The RD stated the MDS Coordinator completed the care plans related to nutrition and skin issues, and she (the RD) only entered diet orders into the care plans. On 5/5/23 at 11:20 AM, Therapy Staff #1 stated they assessed ROHO cushions after they were notified by nursing staff. Therapy Staff #2 was present and stated therapy had been notified to look at Resident #1's ROHO cushion. Therapy Staff #2 stated he would assess the cushion during therapy with Resident #1. On 5/3/23 at 2:20 PM, the Hospice Nurse stated she had not observed Resident #1's wounds and the ROHO cushion was not properly inflated. The facility failed to ensure professional standards of practice were followed to prevent the development and worsening of wounds.

Based on observation, record review and interview, it was determined the facility failed to ensure the dignity of residents was maintained. This was true for 2 of 18 sampled residents (#'s 57 and 59). Resident # 59 experienced psychosocial harm when she had ongoing embarrassment and a decline in her feelings of self-worth after she was not provided the care and assistance necessary for bladder and bowel incontinence, and she did not consistently receive showers to prevent body odors. Resident #57 experienced the potential for harm when staff responded in a disrespectful way to his requests. Findings include: 1. Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An initial Minimum Data Set (MDS) assessment, dated 11/1/17, documented Resident #59 was cognitively intact, was frequently incontinent, and required extensive assistance of one staff member for toileting. The MDS documented Resident #59 required physical assistance of one staff member with bathing. a. Resident #59's Bowel and Bladder Elimination Care Plan, initiated 10/25/17, documented she required extensive assistance from two staff members with toilet transfers, incontinence product change, and peri-care. The care plan documented staff were to provide peri-care after each incontinent episode. The care plan documented she had a toileting schedule, and to provide as needed assistance as well. A Grievance Report, dated 10/31/17, documented Resident #59 activated her call light when she needed to go to the restroom and staff did not respond for 20-30 minutes. The report documented Resident #59 sometimes could not hold her bladder anymore and she experienced incontinence episodes. The report documented Resident #59 had a urinary rash and should not be left in soiled incontinence products. On 12/12/17 at 9:30 am, Resident #59 activated her call light and Certified Nursing Assistant (CNA) #5 entered the room. Resident #59 stated she had to go to the bathroom. CNA #5 stated she would assist Resident #59 shortly, turned the call light off, and left the room. On 12/12/17 at 9:43 am, Resident #59's room door was open and she was sitting in her room with no clothing or undergarments on her bottom half; she was exposed to the hallway. Resident #59 stated she had taken her clothes off because she had an accident with diarrhea and did not want to sit in her own feces. CNA #4, CNA #5, and CNA #6 walked by resident #59's room without noticing the state of Resident #59's undress, until notified by a surveyor that Resident #59 needed assistance. CNA #5 and CNA #6 then entered the room to assist Resident #59 with peri-care. On 12/12/17 at 9:55 am, Resident #59 stated she had activated her call light earlier and a staff member had entered her room, turned off the call light, and told her she would be right back. Resident #59 stated she waited for several minutes, but could not hold her bowels anymore and had an accident. Resident #59 stated she had [MEDICATION NAME] and IBS and when she needed to go she needed to go now. Resident #59 stated it was embarrassing having to sit in one's own excrement and it made her feel worthless. Resident #59 stated she took her incontinence product off and tried to clean herself up as best she could. Resident #59 stated she did not want to sit in feces and did not want skin breakdown. Resident #59 stated she had a sore on her side under her incontinence products and it was from incontinence issues. On 12/13/17 at 2:28 pm, Resident # 59 stated she developed a bladder infection just recently. Resident #59 contributed the bladder infection to staff not responding to her call light and staff rushing through peri-care. Resident #59 stated she experienced four incontinence episodes the previous night and the first two times, staff took 20-30 minutes to respond. Resident #59 stated the third time it happened she took herself to the bathroom and did not use her call light. Resident #59 stated she was told to not take herself to the bathroom and to wait for assistance. Resident #59 stated it was frustrating waiting for staff and having an incontinence episode while waiting. Resident #59 stated it was embarrassing to go in her incontinence product and then sit in her own urine. Resident #59 stated she also did not want to sit in urine because it could lead to skin breakdown. Resident #59 stated sometimes staff would come into her room, turn off her call light and tell her they would be back, and then wouldn't come back. Resident #59 stated she hoped staff would come sooner to prevent skin breakdown or more incontinence issues. b. Resident #59's Activities of Daily Living (ADL) Care Plan, revised 10/25/17, documented she required minimal assistance of 1 staff member with bathing and showers. Resident #59's 10/25/17 through 12/14/17 ADL Shower Documentation Survey Report documented she was scheduled to receive showers on Wednesdays and Sundays. The flowsheet documented Resident #59 did not receive a shower on 11/3/17, 11/10/17, 11/17/17, 11/20/17, 11/24/17, 11/27/17, 12/1/17, and 12/10/17. According to the flowsheet, the longest length of time Resident #59 went without a shower was 11 days, between 11/15/17 and 11/26/17. Grievance Reports, dated 11/10/17 and 11/13/17, documented Resident #59 was not receiving two showers a week. The report documented Resident #59 was being treated for [REDACTED].#59 was not receiving her showers due to staffing issues. The report documented when the facility was short staffed they reassigned the shower aides to cover the shortages in general resident care. On 12/13/17 at 2:28 pm, Resident #59 stated she was frustrated that the facility was not providing her with at least two showers a week. Resident #59 stated she was used to showering more than twice weekly and she did not receive one shower a week on some occasions. Resident #59 stated this was an ongoing concern as she did not like feeling dirty and, I hate it when I smell. On 12/15/17 at 11:39 am, the Assistant Director of Nursing (ADON) stated when staff members respond to call lights and they are instructed to not turn the call off until the residents' needs were met. The ADON stated the facility had a call light response time issue that was directly related to staffing issues. The ADON stated if people called in sick, the facility would reassign the restorative nursing aides first to general resident care, and then the bath aides. The ADON stated she was aware of residents not receiving shower and the lack of showers was related to the lack of staffing as well. On 12/18/17 at 8:17 am, Resident #59's Interested Party stated he/she frequently visited the resident. The Interested Party stated he/she had witnessed Resident #59 activate her call light and staff did not respond in time to take her to the bathroom. The Interested Party stated he/she had timed the CNAs response times and they varied from 5 minutes to 30 minutes. The Interested Party stated Resident #59 had called him/her multiple times upset about occurrences of incontinence due to staff not responding to the resident's call light, and lack of showers. The Interested Party stated the facility had not provided Resident #59 with two showers a week as promised. The Interested Party stated he/she had filed grievances related to these issues and the facility had not resolved the issues. The Interested Party stated the facility told him/her that they were short staff and were working on adding more staff. The Interested Party stated the residents should not have to suffer because the facility was short staffed. 2. On 12/12/17 at 10:00 am, Resident # 57 was observed leaning on a walker in the hallway just outside his room. Registered Nurse (RN) #3 told the resident to be patient, and stated, You will get your orange juice. The CNA knows and went to get it. Resident #57 responded in a quiet, inaudible voice and RN #3 stated, She has to go to the kitchen to get your orange juice. You have to be patient. If I asked you to make me a cake, would you be able to get it right away? No, so you have to be patient. RN #3 left Resident # 57 standing in the hallway leaning on his walker. The resident stood in place a short while longer and returned to his room. On 12/14/17 at 3:00 pm, Resident # 57 stated, No, when asked if RN #3 treated him with dignity. He then repeatedly asked, Can I get up and sit in the chair? On 12/15/17 at 3:45 pm, the RN Staff Development Director stated RN #3 had not yet received training for interacting with residents with dementia. On 12/18/17 at 2:00 pm, the facility provided the orientation training packet for RN #3 that included a Resident Rights Policy signed by RN #3 and dated 7/25/17. The policy informed staff that the residents are our highest priority. Each of our (staff) will treat all residents with kindness, respect, and dignity. '

Based on observation, record review, and interview, it was determined the facility failed to provide adequate supervision to meet resident needs. This was true for 3 of 4 residents (#s 7, 37 & 197) reviewed for supervision and accidents. Resident #7 was harmed when staff failed to provide adequate supervision while the resident was in a wheelchair; the resident fell from the wheelchair and fractured her left femur. Residents #37 and #197 were at risk for harm from accidents due to inadequate supervision and an inappropriately inflated air bed. Findings include: 1. Resident #7 was readmitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] and dementia. The 9/10/17 admission Minimum Data Set (MDS) assessment documented Resident #7 was moderately cognitively impaired, required extensive assistance of 1 staff for locomotion, frequently incontinent of bladder, and totally dependent on 2 staff for toileting. A mobility care plan, dated 8/29/17, documented Resident #7 required the extensive assistance of 1 staff to propel her wheelchair both on- and off the unit. A bowel and bladder elimination care plan, dated 8/29/17, documented Resident #7 required the assistance of 2 staff for toileting. A risk for falls care plan, dated 8/29/17, documented Resident #7 was on a fall prevention program and staff were to encourage the resident to be in a common area or activity when in a wheelchair. A physician's orders [REDACTED].#7 was discharged from hospice services. A 12/7/17 Occupational Therapy (OT) care plan documented Resident #7 used a high back wheelchair when out of bed that she was unable to propel herself. A 12/7/17 Physical Therapy (PT) daily treatment note and assessment documented Resident #7 used a high-back recliner wheelchair, but was provided a standard wheelchair when the high-backed model was returned to the hospice provider. The PT note and assessment did not document the resident was assessed for safety and locomotion in the standard wheelchair. A bladder and bowel report documented Resident #7's incontinent brief was changed on 12/9/17 at 1:14 am and 3:48 am for bladder and bowel incontinence respectively. A Nursing Note, dated 12/9/17 at 2:05 pm, documented Resident #7 had been discovered on the floor on her left hip wearing soaked through clothing. The resident said she had leaned forward to hold onto a railing at the time of the fall. A post-fall assessment determined the resident was not in pain. A 12/12/17 OT treatment note documented Resident #7 experienced an increase in pain to the left knee and hip while standing when a mechanical sit-to-stand lift was used. A radiology report, dated 12/12/17, documented Resident #7 had a fractured left femur. A 12/13/17 physician's orders [REDACTED]. A fall investigation report, dated 12/14/17, documented Resident #7 fell from her wheelchair on 12/9/17 in the hallway near her room while trying to pull herself towards her room with the handrail. The investigation documented the resident had been incontinent of bladder and staff had been educated to offer the resident a bedpan and toileting. The investigation documented the resident had not identified any other issues which could have caused the fracture and that the fracture was likely sustained at the time of the fall. On 12/12/17 at 2:01 pm, a portable X-ray machine and standard wheelchair were observed in Resident #7's room. On 12/13/17 at 10:01 am, Resident #7 was observed in bed with an immobilizer to her left leg. The resident said she had fallen the previous week when grabbing a handrail in an attempt to get to the next room. Resident #7 said she did not remember having pain at the time of the incident, but had experienced some pain since, which increased while she received therapy on 12/12/17. On 12/13/17 at 3:09 pm, CNA #12 (Certified Nurse Assistant) said Resident #7 had a recent wheelchair change and was incontinent of bowel and bladder. CNA #12 said Resident #7's care plan documented the resident was not to be left alone and was to be supervised while in her wheelchair, but a lack of staff prevented the facility from providing ongoing supervision while Resident #7 was in the wheelchair. On 12/13/17 4:06 pm, Resident #7's Interested Party said the resident received the standard wheelchair upon discharge from hospice the previous week. The Interested Party stated Resident #7 had fallen from the wheelchair observed in Resident #7's room on 12/12/17. On 12/14/17 9:37 am, LPN #2 (Licensed Practical Nurse) stated Resident #7's wheelchair had been recently changed and that staff were to keep her within sight when she was in the wheelchair because the resident was at risk for falls. On 12/14/17 at 4:08 pm and 12/15/17 at 11:48 am, the DON (Director of Nursing) said Resident #7 was on the facility's fall prevention program because she was at high risk for falls. The DON stated the resident was wet at the time of the fall, and frequently experienced urinary incontinence, which CNAs were to document into the resident's clinical record. The DON said she thought Resident #7 had been evaluated for the new wheelchair, and that the care plan directed staff to assist the resident with locomotion and keep her within view when she was in a wheelchair. The DON stated Resident #7 did not require one-to-one supervision, and that the hallway where the resident was found on the floor was considered a common area. On 12/14/17 at 5:52 pm, OT #2 (Occupational Therapist) said Resident #7 was assessed for the new standard wheelchair on 12/7/17, however that evaluation did not assess the resident's ability to move about the facility in the wheelchair. On 12/15/17 at 9:49 am and 12:17 pm, CNA #13 said she thought she changed Resident #7's incontinence brief prior to lunch on 12/9/17. CNA #13 stated she assisted Resident #7 from the dining room to the hallway in the general area outside her room after lunch on 12/9/17. CNA #13 stated she entered another resident's room and that RN #3 and another nurse were in the hallway where she left Resident #7. On 12/15/17 at 10:03 am, LPN #3 said she was not sure whether another staff member was in the hallway at the time Resident #7 fell from her wheelchair. On 12/15/17 at 2:57 pm, RN #3 said she and LPN #3 were at the nurses' station and could not see Resident #7 at the time of the fall. 2. Resident #197 was admitted to the facility on [DATE] with multiple diagnoses, including dementia and a history of falling. The 6/27/17 quarterly MDS assessment documented Resident #197 was moderately cognitively impaired and required extensive assistance of 1 staff for bed mobility. The risk for skin impairment care plan, dated 3/30/17, documented Resident #197 had been provided a specialty mattress. An 8/28/17 Nurses Note documented Resident #197 was found on the floor of her room with a large hematoma on her forehead. A fall investigation report, dated 8/29/17, documented Resident #197's specialty air mattress was not set at the recommended setting, which led to the resident sliding off the bed and onto the floor. On 12/15/17 at 10:40 am, LPN #4 said Resident #197 had an airbed and preferred lying on her right side. On 12/15/17 at 10:52 am, the DON said Resident #197 fell out of bed due to an improper air mattress inflation setting. 3. Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 9/30/17 Fall Risk Assessment documented Resident #37 was at high risk of falling. A 10/7/17 admission MDS assessment documented Resident #37 was severely cognitively impaired, required the extensive assistance of 2 staff for bed mobility, transfers, and toileting, and had experienced falls. An At Risk for Falls Care Plan, revised 10/12/17, documented staff were to ensure Resident #37's call light, eyeglasses, water, television remote, and other commonly used items were within her reach. The care plan documented Resident #37's nightly routine consisted of going to bed between 9 pm and 10 pm; awaking at 2 am to 3 am; walking/eating a snack, and then returning to bed. Additionally, the care plan documented Resident #37 was part of a fall prevention program that required staff to ensure the resident's bed was set at a marked height; non-skid strips were in place to the left side of the bed; the head of the resident's bed was elevated to 30 degrees; a locked wheelchair was positioned next to the bed; bilateral body pillows were in place; the resident was to be assisted to the toilet between 2:00 am and 3:00 am; staff were to offer toileting if the resident awoke during the night; and all devices and interventions were in place as ordered. Resident #37's clinical record documented the resident experienced 8 unwitnessed falls between 10/4/17 and 12/9/17. The facility did not complete an investigation for one of these falls; a fall risk assessment for 4 of the 8 falls; or an assessment of the resident's daily routine until after the third fall. Resident #37's Incident and Accident (I&A) Reports documented the following: * 10/4/17 - 12:45 am: Discovered on the floor following an unwitnessed fall from bed. The clinical record did not contain a completed fall risk assessment following the incident. * 10/5/17 - 3:57 pm: Unwitnessed fall from bed while wearing a soiled incontinent brief. The clinical record did not contain a completed fall risk assessment or progress note related to the fall following the incident. * 10/11/17 - 2:28 am: Unwitnessed fall from bed. The clinical record did not contain a completed fall risk assessment following the incident. A 10/11/17 Social Services Review documented Resident #37 slept 4 hours at night and napped during daylight hours. A Social Service Evaluation was not completed until Resident #37 had experienced three falls at the facility. A 10/11/17 Nurse's Note documented Resident #37's Interested Party stated the resident had sustained a [MEDICAL CONDITION] from a 2:30 am fall at a previous facility. The Nurse's Note documented facility staff would begin offering toileting assistance to Resident #37 between 12:00 am and 2:00 am, however this planned intervention was not proposed until after Resident #37 had experienced 3 falls at the facility. On 10/29/17 at 2:49 am, Resident #37 experienced an unwitnessed fall from bed while wearing soiled incontinence brief. A Nurse's Note, dated 10/29/17 at 6:44 am, documented Resident #37 was found sitting on the floor saying, 'Help me, help me.' The facility did not complete an investigation for this fall and the clinical record did not contain a completed fall risk assessment following the incident. * 11/8/17 - 3:27 am: Unwitnessed fall from bed. The resident was assisted into a wheelchair and brought to the nurses' station. An 11/8/17 Interdisciplinary Note (IDT) documented each of Resident #37's safety devices and Falling Star interventions were in place at the time of the fall. * 11/9/17 - 11:15 pm: Unwitnessed fall from bed. The resident was found with an incontinence brief around her ankles. Resident #37 was assisted into a wheelchair and brought to the nurses' station. An 11/15/17 Nurse's Note documented an Interested Party, when contacted by the facility, stated Resident #37 routinely went to bed between 10:00 pm and 10:30 pm, walked between 2:00 am and 3:00 am, and spent the remainder of the night in a common area recliner. The Note documented Resident #37 spent long periods of time sleeping in a recliner during the day, and that a nurse discussed placing an alarm on Resident #37 while in bed. The Interested Party's information concerning the recliner was not included on Resident #37's care plan or fall prevention program. An 11/16/17 Social Services Note documented the facility moved Resident #37 to a new room closer to a nurse's cart and closer to nursing aides for safety. * 12/9/17 - 3:20 pm: Unwitnessed fall in the resident's room while attempting an unassisted transfer from a wheelchair. Resident #37's Fall Care Plan, revised 12/11/17, documented staff were to continue the at-risk interventions and complete neurological assessments. On 12/11/17 at 2:37 pm, Resident #37's bed was observed with bilateral upper half siderails in the upraised position and body pillows on the lower portion of the bed. Resident #37 grasped the right siderail and unsuccessfully attempted to reposition herself on her bed. Resident #37 then attempted to swing her legs out of the bed and called out, Help, help, help, help. CNA #11, who responded to the resident's request for help, began lowering Resident #37's bed and placed a draw sheet under the resident. Resident #37 attempted to swing her legs off the bed again, and stated her back hurt and she needed to get up. CNA #8 entered the room and the two CNAs used the draw sheet to reposition Resident #37 in the bed. Resident #37 stated she felt better after the repositioning. On 12/12/17 from 11:00 am to 11:32 am, Resident #37 was observed in a wheelchair in the television (TV) room. No staff were present during the observation as the resident attempted to retrieve her eyeglasses on the floor in front of her. At 11:32 am, the DON picked up Resident #37's eyeglasses and placed them on her face. On 12/13/17 at 9:53 am, Resident # 37 was observed unattended in a wheelchair watching television in the TV room with no staff present. At 9:58 am, CNA #5 approached the resident and asked if she wanted to go to bed. Resident #37 stated she was tired, but wanted to stay where she was. Resident #37 then declined CNA #5's offer of a snack and CNA #5 left the room. At 10:20 am, while still in the TV room with no staff present, Resident #37 began leaning forward and then rocking in her wheelchair with only her toes in contact with the floor. At 10:28 am, Resident #37 declined the DON's offer of fluids. At 10:49 am, Resident #37 remained in the TV room with no staff present. On 12/15/17 at 10:54 am, the Assistant Director of Nursing (ADON) stated: * All residents were to have individualized fall care plans * Staff were to to complete a fall risk assessment following all falls * She would attempt to locate the missing fall risk assessments related to Resident #37's unwitnessed falls on 10/4/17, 10/5/17, 10/11/17, and 10/29/17

Based on observation interview, and record review, it was determined the facility failed to ensure residents' urinary care needs were met. This was true for 3 of 6 residents (#7, #51, and #59) sampled for decreased bladder control, Urinary Tract Infections (UTIs), and indwelling urinary catheters. As a result: a) Resident #51 was harmed when indwelling urinary catheter care was not consistently provided and the resident developed recurrent UTIs. b) Resident #59 was harmed when she did not receive consistent pericare and developed a UTI. c) Resident #7 had the potential for harm when the facility failed to complete a bladder retraining program after determining the resident was an appropriate candidate. Findings include: 1. Resident #51 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS) assessment, dated 10/27/17, documented Resident #51 was cognitively intact, had an indwelling (Foley) urinary catheter, and required the extensive assistance of 1 staff for toileting. The Catheter and UTI Care Plan, revised 7/12/17, documented Resident #51 experienced chronic recurrent UTIs, had a Foley catheter, and tested positive for colonized Extended Spectrum Beta Lactamase (ESBL). a. Resident #51 experienced multiple UTIs requiring antibiotic therapy. Urinalysis results from 7/5/17, 8/22/17, 9/25/17, and 10/20/17 document Resident #51's urine appeared cloudy and contained blood, other proteins, mucous, and bacteria. Resident #51's culture and sensitivity (C&S) results were requested for each of the urinalysis results. The facility provided only the 9/25/17 and 10/20/17 results, which documented the presence of Escherichia Coli (E. coli) (9/25/17) and [MEDICAL CONDITION][MEDICATION NAME] (10/25/17). A 7/6/17 physician's orders [REDACTED].#51's UTI with Bactrim (antibiotic) twice daily for five days. Medication Administration Records (MAR) for 7/1/17 through 7/14/17 documented Resident #51 received one dose of Bactrim on 7/6/17; the MAR indicated [REDACTED]. An 8/28/17 physician's orders [REDACTED].#51's UTI with [MEDICATION NAME], 100 milligrams (mg), twice daily for seven days. The antibiotic was initiated 6 days after the 8/22/17 urinalysis results were shared with the facility. A 9/30/17 physician's orders [REDACTED].#51's UTI with [MEDICATION NAME], 100 mg, twice daily for seven days. The antibiotic was initiated 5 days after urinalysis lab results were shared with the facility. b. Catheter care was not consistently provided. Resident #51's Catheter and UTI Care Plan, revised 7/12/17, documented staff were to provide catheter care at least three times daily. Foley Catheter Care Flowsheets from 9/1/17 through 12/14/17 documented Resident #51 received catheter care twice daily on 9/9/17, 9/10/17, 10/6/17, 10/13/17, 10/14/17, 10/16/17, 10/17/17, 10/24/17, 10/25/17, 10/31/17, 11/8/17, 11/16/17, 11/22/17, 11/27/17, 12/2/17, and 12/6/17. On 12/15/17 at 12:28 pm, the Assistant Director of Nursing (ADON) stated staff were to perform catheter care minimally once per shift, or three times a day. The ADON stated Resident #51's UTI attributed to E.coli was most likely due to a lack of proper peri-care. The ADON stated a lack of staffing may have contributed to the facility's failure to provide the resident with catheter care as care planned and to the development of her recurrent UTIs. 2. Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An initial MDS assessment, dated 11/1/17, documented Resident #59 was cognitively intact, frequently incontinent, and required the extensive assistance of 1 staff for toileting. The Bowel and Bladder Elimination Care Plan, dated 10/25/17, documented Resident #59 required extensive assistance from 2 staff with toilet transfers, incontinence product change, and peri-care. The care plan documented Resident #59 was to receive scheduled toileting and that staff were to provide pericare after each episode of incontinence. A 12/14/17 Physicians Order directed staff to administer a [MEDICATION NAME] antibiotic injection to Resident #59 once daily for three days. The MAR from 12/1/17 through 12/14/17 MAR indicated [REDACTED]. Resident #59's urinalysis result from 12/10/17 documented her urine was cloudy and tested positive for red- and white blood cells, as well as E.coli bacteria. On 12/12/17 at 9:30 am, CNA #5 was observed responding to Resident #59's call light. The resident stated she needed to use the toilet. CNA #5 stated she would assist Resident #59 shortly, turned the call light off, and left the room. At 9:43 am, Resident #59 was observed sitting in her room without clothing or undergarments from her waist to her feet. Resident #59 stated she had taken her clothes off in response to an episode of incontinent diarrhea and did not want to sit in her feces. The surveyor notified the CNAs that the resident required assistance. CNA #5 and CNA #6 entered the room to assist Resident #59 with peri-care. CNA #5 donned gloves and provided pericare to Resident #59. CNA #5 then took her gloves off and dressed Resident #59 in undergarments without first performing hand hygiene. At 9:55 am Resident #59 states she was not accustomed to sitting in her own excrement, which was embarrassing and caused her to feel worthless. On 12/12/17 at 10:56 am, Resident #59 stated she currently had a UTI or bladder infection, which she attributed to staff not responding to her call light and rushing through peri-care. Resident #59 stated she noticed the symptoms a few days prior as she experienced increased urinary urgency and frequency and woke up four times during the night with incontinence. Resident #59 stated that during the previous few days she experienced increased nausea and was not feeling well enough to eat much. Resident #59 stated her pain had also increased since the development of the UTI. On 12/13/17 at 2:28 pm, Resident # 59 said some staff rushed her pericare, did not wipe thoroughly, and/or wiped in both directions. Resident #59 raised her hand and demonstrated with quick motions of her hand going up and down. The resident stated she had experienced 4 episodes of incontinence the previous night and that staff took 20 to 30 minutes to respond to each of the first two episodes, and she took herself to the bathroom without activating her call light on the third episode. Resident #59 stated the staff told her not to take herself to the bathroom, but rather wait for assistance following the third episode of incontinence. Resident #59 stated she also did not want to sit in a urine-soaked incontinent brief waiting for staff assistance as that could lead to skin breakdown. Resident #59 stated that because of [MEDICATION NAME] and Irritable Bowel Syndrome, when she needed to go she needed to go now. She stated staff sometimes came into her room, turned off the call light and told her they would come back to assist her to the toilet, but then would not be return and she would become incontinent and/or wait in a soiled brief until staff could assist her. On 12/15/17 at 11:39 am, the ADON stated Resident #59's UTIs could generally . be related to poor peri-care and that a lack of staffing may have contributed to Resident #59's UTI. 3. Resident #7 was readmitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION] and dementia. A Urinary Continence and Incontinence Assessment and Management policy, dated (MONTH) 2010, documented the facility would provide residents with scheduled toileting, prompted toileting, and/or other interventions based upon incontinence evaluations. The 9/10/17 admission MDS assessment documented Resident #7 was moderately cognitively impaired, frequently incontinent of bladder, incontinent of bowel, and totally dependent on 2 staff for toileting. A bowel and bladder elimination care plan, dated 8/29/17, documented Resident #7 required the assistance of 2 staff for toilet transfers, brief changes and pericare when incontinent. The care plan did not document the frequency cares were to be provided or whether the resident was on a toileting plan. A bowel and bladder evaluation, dated 12/5/17, documented Resident #7 was a candidate for scheduled toileting (timed voiding). A (MONTH) (YEAR) bladder report documented Resident #7's incontinent brief was soaked on 5 occasions from 12/5/17 to 12/11/17. A Nurses Note, dated 12/9/17 at 2:05 pm, documented Resident #7 had been found on a hallway floor with soaked through clothing. On 12/13/17 at 3:09 pm, CNA #12 said Resident #7 was incontinent of bowel and bladder. On 12/13/17 at 4:06 pm, an Interested Party said Resident #7 was incontinent of bowel and bladder and the resident's brief was to be checked and changed as needed. On 12/15/17 at 9:49 am, CNA #13 said she was not sure what Resident #7's elimination care plan had been prior to the fall on 12/9/17, but thought' she changed the resident's brief before lunch that day. CNA #13 said she normally tried to change the resident's brief before- and after meals with assistance from another staff member. On 12/15/17 at 10:03 am, LPN #3 said she thought the resident's incontinence brief was to be changed every 2 hours as well as before- and after meals. On 12/14/17 at 4:08 pm and 12/15/17 at 11:34 am, the DON said Resident #7's elimination care plan had not documented when staff were to assist the resident to the toilet or when to check and change the resident's brief. She said the resident was not a candidate for a toileting program despite the bowel and bladder evaluation concluding the resident was a possible candidate for bladder retraining.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents received care and services necessary to achieve their highest practicable physical, emotional, and psychosocial well being. This was true for 1 of 4 residents (#37) sampled for dementia care and resulted in psychosocial harm when staff took the resident into the bathroom against her wishes and did not stop a shower after the resident repeatedly stated, Ow, Stop, and Oh God help me. Findings include: Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment, dated 10/7/17, documented Resident #27 experienced severe cognitive impairment, required extensive assistance of 2 staff for bed mobility, transfers, and toileting, and the assistance of 1 staff with bathing. Resident #37's Impaired Cognition Care Plan, revised 10/11/17, documented staff were to ask yes/no questions to determine needs, reduce distractions and speak in simple direct sentences when communicating with the resident, provide cues, and cease communication efforts if the resident became agitated. The care plan did not document Resident #37's specific behaviors nor direct staff on how to respond to the resident when behaviors were present. A 10/11/17 Admission Social Service Review documented Resident #37 was diagnosed with [REDACTED].#37's behaviors presented or how staff was to respond to those behaviors. On 12/12/17 at 8:54 am, Resident #37 was observed in a wheelchair by the nurses station with a magazine on a tray in front of her and her eyes closed. At 11:00 am, Resident #37 was observed in a wheelchair in the TV room. At 11:32 am, the Director of Nursing (DON) asked Resident #37 if she was all right; the resident, who was still in her wheelchair in the TV room, stated she was fine and thanked the DON for asking how she was doing. On 12/12/17 at 12:59 pm, multiple staff had approached Resident #37 in the TV room with offers to toilet her, to which the resident responded, No. At 2:49 pm, Certified Nursing Assistant (CNA) #8 asked Resident #37 if she would like to return to her room to lie down. Resident #37 responded, No. Leave me alone. On 12/12/17 at 3:37 pm, Resident #37 was brought to her room by a CNA #8. The resident was overheard screaming loudly, Get away from me! Leave me alone! Leave me alone! No! F***ing leave me alone! Help, help, help me! Oh God, help me, help, help, help me! F***ing leave me alone! As CNA #8 pushed Resident #37 in her wheelchair toward the open door to the bathroom in her room, RN #2 also entered the room while Resident #37 continued to scream, F***ing leave me alone! Help, help, help me! Resident #37 reached out and clutched the bathroom doorjamb with her arms to prevent staff from pushing her through the threshold and planted her feet firmly to prevent entry into the bathroom. RN #2 grasped the resident's hand from the doorjamb and asked Resident #37 to hold her hand. Resident #37 released her grasp on the doorjamb and raised her feet as CNA #8 rolled Resident #37 in the wheelchair through the bathroom door. Resident #37 then bit RN #2's hand. Throughout this observation, Resident #37 continued yelling, No, no, help, help me, help me! F***ing leave me alone! RN #2 left the room when CNA #14 entered to provide assistance. CNA #8 asked Resident #37 to stand up and grasp a support bar on the bathroom wall near the toilet. Resident #37 continued to sit in her wheelchair and yelled Help, help, help me. F***ing leave me alone! As CNA #14 attempted to place a gait belt around Resident #37's waist, Resident #37 turned and slapped CNA #14 in the face. The two CNAs asked Resident #37 to stand up and grasp the bar on the wall three more times while trying to lift her out of the chair. Resident #37 continued to refuse and called out, Help, help, help, help! F***ing leave me alone! The CNAs stopped their attempts to stand Resident #37, transported her from the bathroom, and wheeled her back to the TV room. The CNAs stated they would attempt to toilet the resident later. Resident #37's roommate stated Resident #37 cried out often in a similar fashion when staff attempted to provide cares. The resident's roommate stated staff normally continued with what they were doing and Resident #37 typically stopped yelling and fighting once staff finished with cares. On 12/13/17 at 9:53 am, Resident #37 was observed in her wheelchair watching television in the TV room. At 9:58 am, CNA #5 approached and asked Resident #37 if she wanted to go to bed. Resident #37 stated she was tired but wanted to stay where she was. CNA #5 asked Resident #37 if she wanted a snack and Resident #37 stated, No. At 10:28 am, Resident #37 declined the DON's offer of fluids. At 11:23 am, a liquid was observed under Resident #37's wheelchair as multiple staff over the next 6 minutes approached the resident with offers to take her to the toilet. Resident #37 responded to each staff by stated either, No, or Leave me alone. The volume of Resident #37's voice steadily increased with each staff offer until Resident #37 yelled, Everyone leave me alone! At 11:29 am, CNA #5 approached Resident #37, squatted down to the resident's eye level, and stated, I want to take you for a walk. I have something to show you and I want your opinion on it. Resident #37 said she did not want to go for walk and told CNA #5 to leave her alone. CNA #5 continued to ask Resident #37 if the CNA could show her something in her room and Resident #37 continued to state, Leave me alone. CNA #5 stood up and walked around to the back side of Resident #37's wheelchair and attempted to move her towards her room. Resident #37 yelled loudly, Leave me alone! No, no, no, no! CNA #5 stopped, put her hands up, and left the TV room. At 11:36 am, CNA #4 approached Resident #37 in the TV room, said, Hi, and then wheeled Resident #37 towards her room. Resident #37 was quiet until she came into view of the bathroom and then started crying out, No! Help me, help me, help! At 11:37 am, as CNA #4 continued wheeling Resident #37 towards the bathroom, Resident #37 continued crying out, Help me, help me. Whoever is out there help me. Resident #37's roommate was present as CNA #4 brought her into their room. The bathroom door was open, the window blinds were open, and the curtains were drawn back leaving an unobstructed view of Resident #37 while she was taken into the bathroom. CNA #4 continued pushing Resident #37 into the bathroom as the resident continued to resist being taken into the bathroom. People outside could be seen walking past Resident #37's window as CNA #4 began disrobing the resident. Resident #37's roommate drew the window curtain closed as Resident #37 cried out, Help me! Oh dear God, help me, help, help, help me. As the roommate wheeled herself out of the room, she stated, It's okay (Resident #37's name), you are okay. CNA #4 continued with her task while Resident #37 continued in a loud voice, Help me. Oh dear God, help me, help, help, help me. At 11:40 am, CNA #4 stated to Resident #37 she had finished and wheeled Resident #37 out of the bathroom. Resident #37 dabbed her teary eyes with a tissue and was sniffing. CNA #4 then wheeled Resident #37 past the open bathroom door blocking Resident #37's path to the room door and wheeled the resident to the dining room for lunch. On 12/13/17 at 2:20 pm, Licensed Practical Nurse (LPN) #1 approached Resident #37 in the TV room and stated, It's time for your Tylenol. Resident #37 responded, Okay, and took the medication. On 12/13/17 at 2:35 pm, the DON approached Resident #37 in the TV room and asked her if she needed to use the bathroom. Resident #37 responded, No, and thanked the DON for asking. At 2:45 pm, CNA #10 approached Resident #37 and said, We need to try and go to the bathroom. You haven't been for a while. Resident #37 responded, Okay. Resident #37 went to the bathroom quietly and stated, Help, help occasionally throughout the process. CNA #9 assisted CNA #10 clean Resident #37's urine-soaked wheelchair pad before exiting the room for more cleaning towels. As CNA #10 advised the resident they had to wait for additional cleaning towels, Resident #37 asked her hurry up and help her. On 12/13/17 at 3:00 pm, CNA #10 stated she normally worked in another area of the facility and that her interaction with Resident #37 was her first experience with the resident. CNA #10 stated residents with dementia sometimes required a different approach from that used with residents without dementia. CNA #10 stated she did not know what instructions Resident #37's care plan or the CNA Kardex provided to staff when Resident #37 refused toileting. On 12/13/17 at 3:27 pm, LPN #1 stated she normally worked in another area of the facility and was not familiar with Resident #37's normal routine. LPN #1 stated Resident #37 refused her medications that morning, but then accepted the medications when approached in a different manner that afternoon. LPN #1 stated she was aware Resident #37 refused toileting and would remain in soiled adult briefs all day if she could. LPN #1 stated she was not aware what approach worked best with the resident when she refused toileting, how to approach Resident #37 when she refused toileting, or what the resident's care plan directed staff to do when toileting was refused. LPN #1 then reviewed Resident #37's care plan and stated it did not specify what interventions staff were to take when Resident #37 refused toileting. On 12/13/17 at 3:50 pm, CNA #9 stated she sought assistance from other staff, including the DON and nurses, when Resident #37 refused cares, including toileting. CNA #9 stated she did not know what instructions the CNA Kardex provided if Resident #37 refused toileting, became combative, or insisted staff stop providing cares. CNA #9 reviewed the Kardex and stated it did not include such direction. On 12/14/17 at 9:03 am, CNA #4 stated she did not have much experience working with Resident #37, did not receive specific instruction for how to assist Resident #37 with cares, and was not familiar with the resident's care plan or CNA Kardex. CNA #4 stated other staff told her Resident #37 often refused toileting, so when the Licensed Social Worker (LSW) asked her to toilet Resident #37 the day before she decided to just take her into the bathroom instead of asking first for the resident's permission. CNA #4 stated Resident #37 was fine until she got closer to the bathroom, at which time the resident began refusing the effort and attempted to stop CNA #4 from toileting her. CNA #4 stated she would normally close the curtains or otherwise ensure resident privacy, but became distracted with Resident #37's reaction to toileting. CNA #4 stated she was not provided care instruction for those instances when Resident #37 refused cares or asked staff to stop cares already underway. On 12/14/17 at 9:10 am, Resident #37 was observed in a wheelchair near the nurses station. After initially declining an offer to shower, the DON and LSW #1 reminded the resident she had a hair appointment that day and Resident #37 consented to a shower. On 12/14/17 at 9:19 am, CNA #2 wheeled Resident #37 into the shower room. At 9:21 am, Resident #37 stated, Help me, help me, help me. Help, help, help, help. Oh dear God, oh dear God. At 9:26 am Resident #37's vocal volume increased as she continued saying, Help, help, help me. At 9:28 am, Resident #37's voice level continued to rise as she stated, Ow, that hurts. Ow that hurts. Ow, ow, help me, help me, help help, help! Oh God, no! CNA #2 stated, (Resident #37's name) you are okay, I will be done soon. CNA #2 completed the shower at 9:34 am and brought Resident #37 out of the shower room. On 12/14/17 at 5:46 pm, LSW #1 stated Resident #37 slept about 4 hours a night, could converse with staff for a few minutes before becoming distracted, had no long-term memory impairment, and experienced some short-term difficulty. LSW #1 stated Resident #37 was difficult to redirect and changed her mind easily, staff were instructed to redirect Resident #37 when she refused cares, and staff were to offer Resident #37 hot cocoa when efforts to redirect were unsuccessful. The LSW stated hot cocoa was also used as a reward with Resident #37 when cares were completed. LSW #1 stated staff should not take Resident #37 into a room she refused to enter, not leave the resident in soiled adult briefs for extended periods of time, and attempt a different approach when the resident refused toileting. LSW #1 stated Resident #37 appeared to have an issue with her bathroom and the facility would look for another way to accommodate those needs. LSW #1 stated Resident #37 seemed to respond better to staff directing her care rather than asking her yes/no questions related to care. LSW #1 stated staff should immediately cease showering the resident if she expressed discomfort or distress, and that the current care plan should provide clear descriptions and direction to staff for addressing Resident #37's behaviors and/or refusal of cares. On 12/15/17 at 10:54 am, the Assistant Director of Nursing (ADON) stated Social Services was directed to assess and determine how to best manage cares, including bowel and bladder routines, for Resident #37's advanced dementia. The ADON stated staff and social services were to work together to determine the best approach to assist residents whose needs had changed. The ADON could not provide evidence this was completed for Resident #37, but stated the care plan should reflect that effort. The ADON stated she was attempting to determine whether Resident #37 was afraid of the bathroom and what alternatives staff could use for her toileting. The ADON stated staff should not take Resident #37 into a room she resisted entering, and that staff should discontinue showering the resident if she exhibited or voiced signs of pain and/or distress.

Based on record review, review of facility water temperature logs, observations, and staff, resident, and family interviews, it was determined the facility failed to ensure residents were not exposed to hot water temperatures in showers and resident room sinks in excess of 120 degrees Fahrenheit and that a resident's wheelchair was safe for use. As a result: a) Residents were exposed to hot water temperatures of 120.5 to 131 degrees Fahrenheit in 2 of 2 facility shower rooms and 5 of 5 randomly tested resident room sinks. This deficient practice placed 4 of 4 residents (#8, #11, #23, #24) and all other residents who came into contact with hot water coming from the faucets in resident room sinks and shower rooms at imminent risk of sustaining severe burns. The Administrator was notified of the immediate jeopardy to residents' health and safety on 8/8/16 at 4:00 pm. The facility provided, and initiated, a plan to keep residents safe and remove the immediate jeopardy. Key components of the removal plan included: * A contracted maintenance technician was called to the facility on [DATE] to resolve boiler system issues which resulted in the excessive water temperatures. The technician identified a problem with the mixing valve and parts were replaced on 8/8/16. Water temperatures were rechecked and found to be less than 120 degrees Fahrenheit. * All staff and outside service providers were to be in-serviced to ensure residents did not have independent access to sink and shower faucets until assessed to independently adjust water temperatures. * An immediate cessation of all showers until water temperatures were verified to be 118 degrees F or less. * Ongoing assessment of water temperatures and systems in place to immediately respond to reports of water temperatures above 115 degrees. * Education provided to 4 staff by the contracted mechanical technician on how to perform daily checks of the tempering mixing valve station, which were to be performed daily by facility staff. Completion and initiation of the above actions were verified by an on-site survey team and the immediate jeopardy was removed on 8/10/16. b) Resident #12 sustained a hip fracture which required surgical repair when her legs were hyper-extended while being propelled forward in her wheelchair. Findings include: 1. During the initial tour of the facility from 11:30 am to 1:00 pm on 8/8/16, the following resident room temperatures were observed with the facility Maintenance Assistant present: Room 115 (sink): 131 degrees F Room 125 (sink): 127.9 degrees F Room 206 (sink): 124.0 degrees F Room 215 (sink): 129.8 degrees F Room 234 (sink): 120.5 degrees F First Floor Shower Room: 128.5 degrees F Second Floor Shower Room: 126.2 degrees F The Maintenance Assistant stated during the tour that he did not normally audit water temperatures in the building and did not know required safe water temperature ranges. The facility boiler room was observed with the maintenance assistant, who was not able to read the boiler temperature or state how the overall facility water temperature could be lessened to bring water temperatures into a safe range. * On 8/8/16 at 12:40 pm, when asked if the hot water in her bathroom ever got too hot, Resident #23 stated, Sometimes I have to cool it down. I wash my hands and face, and brush my teeth every morning. It was too hot to drink this morning. * On 8/8/16 at 12:45 pm, when asked if the hot water in her bathroom ever got too hot, Resident #24 stated, It has gotten too hot a couple of times, but they have turned it down or something. * On 8/8/16 at 1:20 pm, Resident #8 stated, The water here gets hot, way too hot. I wash my hands in my sink and I have to turn the heat down. The shower water gets too hot, too. They (staff) turn it down by adding cold water. * Resident #11 was observed on 8/8/16 while receiving a shower in the first floor shower room at approximately 1:40 pm. The resident was alone behind a privacy curtain alone when she independently turned on the water and said, That's hot! Ouch! That burns! A shower aide on the other side of the privacy curtain immediately went into the shower stall and turned down the water temperature. Resident #11 then stated, That's better. * On 8/8/16 at 1:45 pm, second floor shower aide CNA #5 stated, I am always adjusting the (shower) water. The water seems like it's gotten hotter during the last week or two. I don't have a guage to measure the temperature. I set up some of the residents, then they do their own thing, including (Resident #11). There are several other residents, maybe 10 or so, who we also set up and then they are independent with their showers. * On 8/8/16 at 1:55 pm, first floor shower aide CNA #1 stated, The water has been too hot. It goes in and out . It might be okay then change half way through a shower. The upstairs (second floor) shower does it too. Residents have told me, 'Ouch. That's way too hot!' This has been going on for the month that I have been working as a shower aide. * On 8/8/16 at 1:35 pm, LPN #2 stated, Sometimes when I turn the water all the way up it's too hot. It's not safe to touch, so I turn up the cold water. * On 8/8/16 at 1:30 pm, the Maintenance Director acknowledged the water temperatures were too hot, and stated he had just called the company who was responsible for maintaining the hot water-related equipment, which stated the issue was most likely related to a broken gasket or mixing valve. He stated he audited temperatures in 2 to 3 random resident rooms and recorded the temperatures each Monday and Friday. He stated the audited room water temperatures were not too hot. The facility's Water Temperature Logs for June, July, and August 2016 documented 2 resident room water temperatures were monitored twice weekly. No recorded resident room water temperatures were greater than 115 degrees, and there was no documentation indicating shower room temperatures were monitored by the facility. On 8/9/16 at 1:20 pm, a mechanical technician stated he was called to the facility after hot water temperatures of 128-130 degrees farenheit were identified by the survey team. He stated the water temperature was a little high at 128-130 degrees and that the system was 2-3 weeks overdue for service. The technician said the facility's Maintenance Director was on vacation and that he was turned away when he arrived at the facility for the regularly-scheduled service check. He stated he then went on vacation and the 6-month service check was not completed. The mechanical technician stated, It just fell through the cracks. The mechanical technician stated that following repairs to the system, he took temperatures at the facility for an hour and the readings ranged from 110-115 degrees. He stated he wrote on the invoice that residents in the facility were safe from hot water burns, and noted the system's tempering station needed to be checked daily. 2. Resident #12 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #12's Quarterly MDS assessment, dated 6/28/16, documented she was cognitively intact, required extensive assistance of 2 staff members with all her cares, except eating. The MDS documented Resident #12 had an indwelling catheter, was not steady with surface to surface transfer, used a wheelchair for locomotion, and required staff to propel the wheelchair. On 8/11/6 at 10:26 am, Resident #12, with one of her family member present, said she saw a doctor on 7/29/16. She said on 7/29/16 LN #1 and a CNA transferred her from her bed, via a hoyer lift, to her wheelchair which was in a reclined position. She was in her wheelchair when the CNA left to get clean linen and LN #1 stayed with her. The LN was behind Resident #12's wheelchair and pressed the lever of the wheelchair to bring the chair to an upright sitting position. Resident #12 said LN #1 was having trouble bringing the chair to an upright position because the lever was sticking. Resident #12 said she told LN #1 to stop and wait for the CNA to return, but the LN told her I think I got it and suddenly, she was lurched forward and bent at her waist, with her bottom almost at the edge of the wheelchair. Resident #12 said her legs were both hyper-extended with her knees extended backwards and her face was almost touching her toes. Resident #12 said she screamed My legs, my legs. A CNA and 2 more LNs came in and helped LN #1 to position Resident #12 back to her wheelchair. Resident #12 said she had the same problem with her wheelchair before with the lever sticking and she was told it was repaired. Resident #12's family member said the incident was a traumatic experience for her and for their family. The family member also said Resident #12 fractured her hip because of the incident and required surgery. After the surgery Resident #12 was saying Let me go, let me go because of the pain she was enduring. An Incident Report, dated 7/29/16, documented .patient sitting in reclining position back, this nurse attempted to assist patient into upright sitting position, upper chair propelled forward in rapid motion tipping wheelchair and patient forward bent @ waist with legs and wheelchair leg extension's facing towards door causing knee's to hyper extend back. I attempted to prevent injury of patient from falling forward onto face by holding back of chair and upper body of patient . Immediate action taken Therapy notified for evaluation of possible equipment malfunction and possible contributing factor upper body weight disproportion. NN documented in Resident #12's record after the incident included: *On 7/29/16 at 1:59 pm, Nurse from (name of the hospital) reported that (Resident #12) has been having pain while at hospital. *On 7/29/16 at 6:47 pm, an x-ray of the Resident #12's left knee was completed and the result was negative for fracture. *On 7/30/16 at 2:46 am, .no c/o of any unusual pain from fall out of w/c. *On 7/30/16 at 12:07 pm, .Resident was demanding to have demonstrated the functionality of her chair, explained to resident the therapist had checked out her chair and it is functioning safely. She continued to want to see it demonstrated. Covered chair with barrier for IC and had a staff member sit in her chair and demonstrated over and over the tilt mechanism .She declined to get up . *On 7/30/16 at 5:55 pm, .Stated her pain has not been less than 8 regardless of PRN use . *On 7/31/16 at 10:49 am, .Resident declines to get out of bed at this time . *On 8/1/16 at 12:13 pm, Request for pain meds due to severe pain and discomfort .Resident declines to get up again today . On 8/3/16 at 5:24 pm, Resident continues to demonstrate Behaviors (of) staff splitting, verbal aggression and accusations of neglect ie request task to be performed states she's satisfied then, reports to management that cares are not being met to her satisfaction, .Patient demonstrates constant irritability anger and tearfulness . *On 8/4/16 at 1:08 pm, Resident #12 expressed that her left hip/knee was hurting and the pain was too much and it was getting worse. She asked for an x-ray of her left leg which showed a fracture of the left femoral neck (hip). The UM interviewed the staff on duty and none reported an increase in pain reported by Resident #12. The NN also documented the UM had been in and out of Resident #12's room several times that week but never received reports of increased pain of Resident #12's left lower extremity or anywhere else. *On 8/4/16 at 10:36 pm, Resident #12 was transported to the hospital by non emergent ambulance for evaluation. On 8/10/16 at 6:05 pm, LN #1 said she and a CNA had just transferred Resident #12 to her wheelchair which was in a reclined position when the CNA left to take the trash and dirty linen out of the room. She was assisting Resident #12 to a sitting position by pressing the lever at the back of the wheelchair. She said when she pressed the lever it did not engaged when the chair was in the upright position and Resident #12 was propelled forward. LN #1 said she immediately grabbed Resident #12's upper body to prevent her from falling on the floor and yelled for help. She said Resident #12's bottom was still on the edge of the wheelchair. Two LNs and a CNA came in and they all assisted Resident #12 back to her wheelchair. On 8/11/16 at 11:20 am, PT #1 said Resident #12 could not sit on her own and had no upper or lower body strength. PT #1 said Resident #12's wheelchair was called a Tilt in Space wheelchair and could only go 5 degree forward from the vertical position and 35 degree backward from the vertical position. PT #1 said the lever periodically stuck but she would not consider it a malfunction. She said it was common for this kind of wheelchair. She said, You just have to press it (the lever) hard. PT #1 said they tried to recreate the incident with one therapist sitting on the reclined wheelchair, but they were not able to reproduce the scenario. When asked what could cause Resident #12 to lurch forward, PT #1 said she did not know. When asked if she reported it to maintenance, the PT said she had. When asked if this incident could have caused the Resident #12's hip injury, PT #1 said the increased hip flexion could possibly cause the injury. On 8/12/16 at 8:50 am, LN #1 said she did not recall Resident #12 saying anything to her after the CNA left the room. When asked if she was anticipating the CNA to return to Resident #12's room to assist her, LN #1 said there was no need for the CNA to come back and help her because Resident #12 was appropriately positioned on the wheelchair and she had worked with Resident #12 before many times. She said she had no problem using Resident #12's Tilt in Space wheelchair and had no recollection of it previously malfunctioning. LN #1 said when she pressed the lever and brought the chair to sitting position it was a smooth upward motion, however, it did not lock. On 8/12/16 at 9:50 am, the Maintenance Director said he did not receive a work order for Resident #12's wheelchair recently. When asked if he had received any work order for Resident #12's wheelchair, the Maintenance Director checked and provided a copy of a work order for Resident #12's wheelchair completed on 6/3/16. On the comments section of the order documented, Resident w/c it's good we can't find any problems, brakes good, wheels good, all w/c it's good. The Maintenance Director was also asked if he checked the lever of the wheelchair, he said everything was checked, and he did not recall any problem with it. On 8/12/16 at 10:08 am, PT #1 said they did not keep a copy of the work order. She said she spoke to (name of the maintenance person) about the wheelchair and also gave him the written request after the 7/29/16 incident. On 8/12/16 at 10:30 am, the assistant to the Maintenance Director said he did not receive a work order for Resident #12's wheelchair. The facility failed to ensure Resident #12's wheelchair was in proper working order, which resulted in Resident #12 sustaining a fractured hip. Subsequently, Resident #12's wheelchair was not checked by maintenance staff to ensure it was functioning properly.

Based on observation, staff interview, medical record review, and incident report review, it was determined the facility failed to ensure residents received adequate supervision and/or assistive devices to prevent accidents. *Resident #11 was harmed when she had at least 13 falls and multiple attempts to stand prior to falling out of a wheelchair and sustaining a fractured nose and concussion. The resident had an additional 6 falls after the injury. *Resident #1 was harmed when she fell 11 times in an 11 month period, and sustained a scalp laceration which required staple closure. *The facility did not ensure adequate interventions were in place to prevent Resident #14 from falling 5 times in a 3 month period. *Resident #7 had surgery of the hip after a fall at home. The facility did not ensure adequate interventions were in place to prevent a fall at the facility. *The facility did not ensure adequate interventions were in place to prevent multiple falls for Resident #13. This was true for 5 of 14 sampled residents (#s 1, 7, 11, 13 and 14) who had falls in the facility. Findings include: The facility's Falls Management Policy and Procedure documented: "Falls are a common source of serious injury among the elderly. At least 25% of seniors who incur fractures from falling have a survival rate of less than six months following the incident. It is also recognized that even the fear of falling can significantly limit mobility, activity, and adversely impact quality of life.... The care plan is reviewed throughout the course of treatment by the interdisciplinary team (IDT) to assure the most recent, updated, and resident specific fall reduction interventions have been incorporated as necessary into the plan of care... The IDT will review the Incident Report, fall history, the care plan, and other pertinent data to determine the need for further investigation. In order to promote a comprehensive plan of care, the need for further evaluation of the resident's health condition, the environment, equipment, medications, staff, resident practices, or other factors that may have contributed to the incident will be determined by the IDT in order to promote a comprehensive plan of care. The IDT will determine the need for development of any additional... interventions... education and training, or other follow up measures that may be needed to reduce the risk of recurrence.... The Fall Reduction Committee (a subcommittee of Performance Improvement) will review fall trends, analyze data, and determine the need for action plans designed to minimize the risk of falls." 1. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly MDS, dated [DATE], documented the resident: had short and long term memory problems, severe impaired decision making skills, delusional behaviors, required extensive assistance for transfers, dressing, eating, personal hygiene and bathing, was non-ambulatory, was incontinent of bowel and bladder, and was receiving antipsychotic, anti-anxiety and antidepressant medications. The resident's record and Incident Follow-Up & Recommendation Forms (incident and accident reports (IA)) documented the resident had 19 falls between 7/25/11 and 1/6/12. On 12/3/11 the resident fell out of a wheelchair while attempting to stand and sustained a fractured nose and concussion. Resident #11's care plan, dated 7/25/11, had an identified problem of, "At risk for injury from falls (related to) recent fall, use of high risk meds, dementia, unable to understand safety strategies, incontinence." The resident's care plan that was in the active medical record had additional problems related to dates of falls. The resident's overflow record also had two other care plans with the falls problem identified and numerous additions related to falls added. All had the same date of 7/25/11. The interventions that were put in place on 7/25/11 were: "* Non-restraining alarms to bed and w/c. * Pressure alarm to bed and wheelchair. * Hip protector waiver signed. * Ensure proper footwear maintained. * Low bed, concave mattress. * Crash mats @ Bedside. * Extensive assist of 2 for transfers. * Keep environment adequately lit as indicated and free from clutter. * Reinforce use of call light and staff assist." Each of the three care plans included hand written interventions added when the resident fell . The additions were hand written and filled the pages. It was hard to determine additional interventions and supervision that the facility added after each of the falls. The facility submitted a document on 1/12/12, after the exit meeting, for review that summarized the interventions added after each fall. After review of the document it was noted that the interventions were repetitious with multiple interventions already in place on the original care plan or started after a previous fall and did not include a planned need for increased supervision of the resident prior to or for more than a month of the 12/3/11 fall. All the interventions addressed environmental changes rather than supervision. Resident #11's "Nurse's Notes" (NN) and IA's documented the following: *8/1/11 "...found on blue crash mat at bedside, alarm sounding, call light not on...."(NN) *8/1/11 3:30 p.m. "...Family gave report/history of resident prior:...Husband passed away this month (July 1st 2011). Discussed how resident is currently doing (with) her behaviors ie., that she is asking for her husband, that she is making frequent movements to get up from wheelchair and from bed. Discussed Seroquel and Ativan orders and that resident was on Depakote prior. PT/OT to evaluate and treat for mobility...."(NN) "Concave mattress" added to care plan on 8/1/11. NOTE: Discontinued on 11/9/11 *8/2/11 2:00 a.m. "...attempting to climb out of bed saying, 'I have to go to the bathroom'..." (NN) *8/6/11 1:30 p.m. "...trying to stand up from w/c x 7 (7 times) so far since this am...."(NN) *8/18/11 3:00 p.m. "...trying to climb out of bed...brought to nurses station early am. Extreme anxiety, agitation, repetitive up et (and) down movements trying to self transfer. 'I want to go to bed', 'I want to go eat.'...."(NN) *8/19/11 "....at present 2 person transfer pt(patient) will spontaneously stand up when in w/c unaware of safety or limitations...."(NN) *8/11/11 10:15 "...calls out intermittently and attempts to stand."(NN) *8/12/11 4:00 p.m. "...Continues to try to get out of w/c. Interventions are unsuccessful have to keep on reminding her not to get (up)." The resident's "Nurse's Notes" for 8/16/11, 8/23/11, 8/24/11 and 8/25/11 documented the resident continued to attempt to stand up from the wheelchair. *9/1/11 7:00 p.m. "Resident had a non injury slide to mat from side of bed...."(NN) "Body pillow to define edges of bed" added to care plan 9/2/11; "Turn up volume on alarms" added 9/4/11. *9/12/11 10:00 a.m. "...found res(ident) laying on floor on blue mat next to bed....Requires constant supervision to maintain safety as resident will rise from chair - alarms in place...." "Falling star program" added to care plan 9/12/11. 9/14/11 3:00 p.m. "....attempts to self transfer repeatedly, roams hallways and in and out of other resident rooms. Unable to re-direct resident...." *9/14/11 3:45 p.m. "Alarms sounding...on mat - knee bent underneath her. no s/s injury." "Request permission to move closer to nurses station; Resident was moved" added to care plan 9/15/11. *9/17/11 9:00 p.m. "... found kneeling on her floor mat...."(NN) *9/17/11 10:30 p.m. "Alarm sounded...she was partially on the crash mat and partially on the floor...Given Ativan and Norco for c/o back pain. Taken to nurse's station via wc for closer observation." (NN) "Toilet every 2 hours" added to the care plan 9/17/11; "Staff educated on proper positioning of alarms when the resident is in bed and in wheelchair" added on 10/3/11; and "Crash mats changed to one at bedside" added on 10/10/11. *10/26/11 2:00 p.m. "...attempted to get out of bed. CNA entered room to see res kneal (sic) on crash mat...."(NN) 10/31/11 "Alarm was not sounding due to not positioned correctly under her...Follow-up: educated staff to ensure alarms positioned properly." (IA note for the 10/26/11 fall). *11/7/11 6:15 a.m. "...found lying on floor on belly off crash mat. Res states 'I didn't fall I crawled out of bed....."(IA) NOTE: The NN for this fall was dated 11/6/11 10:15 a.m. "Follow-up: ...Tag alarm to bed to alert staff of getting up." (I/A) "Non-restraining alarms to bed and wheelchair" added to care plan 11/7/11. *11/7/11 8:15 "...found lying on bathroom floor on back...crash mat in place, bed in low position, bed alarm in place, chair alarm in place, bathroom door alarm in place, no alarms were sounding when pt(patient) found...."(NN) "Follow-up: ...alarms not sounding + w/c not near resident. PT going to assess for mobility." (I/A) *11/8/11 10:30 a.m. "CNA responded to alarm. Resident on blue mat lying on her R(ight) side - head toward the heater...."(NN) *11/8/11 1:00 p.m. "CNA was going by resident's room. Resident was yelling out for husband - CNA found resident sitting upright (with) back on bed - again she was in the blue mat...."(NN) "Follow-up: "Bariatric bed in place." (IA) "Ensure purse is kept within reach" was added to the care plan on 11/08/11 *11/9/11 5:45 a.m. "Bed alarm sounded and resident was found lying on her stomach on the crash mat. No injury noted...."(NN) "Follow-up: Tag alarm now attached securely to bed frame to ensure alarm goes off, PT did screen and following up." (I/A) *11/9/11 9:30 a.m. "Res alarm sounded (and) found on bed risk matt in kneeling position..."(NN) "Follow-up: "Reviewed with NP on (increasing) meds to something new or stronger than Tylenol..." (IA) *11/9/11 2:00 p.m. ....Resident attempt to get out of w/c multiple times during the day (with) alarm sounding. Place in front of nurse's station to monitor d/t multiple falls (within) 48 hours...."(NN) "Bariatric bed to allow for room to move around in bed; Tag alarm securely attached to bed frame; Physical therapy to evaluate and treat" added to the care plan 11/9/11. " "Pain management reviewed Norco started" was added on 11/10/11. *11/11/11 1:00 p.m. "Increase of Zyprexa seem to be effective, decrease yelling, crying out, no attempts to self transfer..."(NN) 12/2/11 9:30 "...kept attempting to get out of chair... put to bed...kept attempting to get out of bed..."(NN) *12/3/11 4:30 a.m. "Resident not sleeping, loud verbal, confused. Unable to re-orient. Has been one to one all night. No safety awareness, multiple tries to stand up and self transfer...."(NN) *12/3/11 5:10 p.m. "...continues to have increased agitation (and) confusion...attempting to stand frequently (and) leaning forward, told to sit back in w/c. When fell head first out of wc, incident occurred at nurse's station before evening meal. Small cut to bridge of nose Large Hematoma to forehead, immed(iate) swelling to area, some bluish color...."(NN) *12/3/11 9:30 p.m. "Resident came back from (Hospital name) - status update, resident has broken nose and concussion. EMT's stated that resident's SaO2 (Oxygen levels in the body) kept dropping ...." (NN) NOTE: The NP who saw the resident on 12/5/11 documented: "Subjective - (Resident #11) had an incident yesterday where she fell out of her wheelchair onto her head. She did go to the emergency room and was diagnosed with [REDACTED]. (Resident #11) has been fairly tired this morning, staff report staying in bed, she does wake up to verbal stimuli however falls back to sleep...." "Assessment/Plan - 6. Facial fractures. Does have significant bruising and swelling, will monitor very closely. She did have a concussion diagnosed in the emergency room , she is still waking to verbal stimuli. Will keep a close eye on her." The injury the resident sustained [REDACTED]. I noticed how far forward resident was leaning. I turned to assist her back into her chair, before I could get to her her alarm beeped once and she fell face first out of the w/c. Hitting head very hard on hard wood floor. resident was moving w/c rapidly and leaning forward at same time." "Recommendations/Actions Taken: Will have therapy assess w/c positioning." There was no documentation on the IA that the resident was receiving one to one supervision that night shift staff noted was required 12/3/11 to keep the resident safe (the night prior to the fall). The resident went all day 12/3/11 without one to one supervision and had a fall at 5:10 p.m. in the afternoon. "OT for wheelchair positioning" was added to the care plan on 12/5/11. 12/14/11 12:30 a.m. "Resident found by CNA attempting to climb out of bed and sitting right on edge of mattress. Crash Mat was in place so she was lowered on it by CNA. Assisted back to bed with 3 person assist....(NN) *12/20/11 2:50 a.m. "....Repeatedly said she was waiting for a phone call. Then attempted to get out of bed because her dentures had been removed for cleaning...." (NN) *12/21/11 midnight. "Resident extremely restless and attempting to get out of bed...after numerous attempts to get out of bed she was brought to nurse's station in wc...." *12/27/11 2:30 a.m. "Ativan 0.5 mg given (orally) for numerous attempts to self transfer out of her bed...."(NN) *12/27/11 5:55 a.m. "Resident was found by CNA lying on floor next to her crash mat. She was in the supine position. Alarms sounding..."(NN) "Follow-up: ...Staff instructed to clean dentures @ hs and replace in mouth." (I/A) This intervention was added to the care plan on 12/27/11. *1/1/12 9:00 a.m. "Res found on soft mat next to low bed alarms sounding...."(NN) "Follow-up: Bed low position, crash mat, tag alarm + ADD tag while in w/c + body pillow; add tag alarm to bed and secure to wall..." (IA) "Tag alarm in bed" added to care plan 1/1/12. *1/4/12 6:30 p.m. "CNA responded housekeeping yelling help - Resident found on crash mat on knees attempting to self transfer - bed alarm sounding..."(NN) "Follow-up: "PT evaluated and now working with resident + doing 15 minute checks..." (IA) "Physical therapy to evaluate and treat, placed on 15 minute checks" added to care plan 1/4/12. *1/5/12 5:15 p.m. "at (4:30 p.m.)...heard a 'help me' and then immediately after an alarm sounded off....entered resident room to find her on her knees on top of blue crash mat." (NN) "Follow-up: Applied bolsters to bed." "Trial of regular bed; Regular bed bolsters added to both sides of the bed; Tag alarm in bed; Clean catch UA obtained and negative" added to care plan 1/5/12. *1/6/12 11:00 a.m. "Status - nurse heard a loud help me help me...found patient sitting on mat and head resting on heater - alarm sound, no tag alarm sound, nor did it pull from magnet...." (NN) "Follow-up: "Seen by NP new orders received....bolsters on regular bed trialing for 72 hours. DC bariatric bed + shortened string on tag alarm..." (IA) "Pain management review, started on Fentanyl patch. Labs ordered by physician" added to care plan 1/6/12. NOTE:The resident fell on [DATE], 1/4/12, 1/5/12 and 1/6/12. After the fall on 1/4/12 at 3:00 p.m. the plan was for the resident to have 15 minute checks. The 15 minute checks did not start until 1/5/12 at 10:30 a.m. The resident fell on [DATE] at 4:30 p.m. and again on 1/6/11 at 11:00 a.m. The facility failed to increase supervision after the fall on 1/5/12 and prior to the 1/6/12 fall. The administrator's call was returned on 1/17/12 at 3:30 p.m. The administrator wanted to discuss additional information the facility had submitted, including information related to the 12/3/11 fall with facial fracture. The administrator felt that the resident had been supervised and had been one to one with the activity staff. The activity information for 12/3/11 documented: Room visit one to one, conversation, sensory stimulation/hearing and sensory stimulation /touch. The documentation on the Record Of One-To-One Activities form listed the following for 12/3/11: "Description of Activity: (Resident #11) was in the lobby when I saw her. I held her hand and talked soothing to her." The "Resident's Reaction/Response: (Resident #11) seemed upset and anxious to get to her room. I am not sure if she was soothed by me." The "Time spent:" was 15 minutes. Other then that 15 minute time period there was no other documentation presented that showed how much time the resident spent with activity or any other staff that day. On 12/3/11 staff noticed the resident self propelling her w/c past nurse station and how far forward resident was leaning forward in the w/c; however, there was no evidence of a specific supervision plan in spite of past attempts to stand and falls as well as documentation that day of, "increased agitation (and) confusion...attempting to stand frequently (and) leaning forward" and being told to "sit back in w/c." The administrator and DON were informed of the findings on 1/11/12 at 3:45 p.m. The facility had submitted further documentation to the state agency. The information was used in the report. 2. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident's 9/7/11 Significant Change and 11/22/11 Quarterly MDS assessments both coded that the resident was severely cognitively impaired, and had 2 or more falls with minor injuries since the most recent assessment. The resident's 11/23/11 Care Plan documented the following problems and approaches: * Potential for alteration in safety r/t (related to) cognitive deficits. Offer cues for daily decisions when indicated. * Potential for injury from falls r/t fall history, dementia with impulsivity and impaired safety awareness, attempts to turn off and remove alarms. Remain with resident while toileting as indicated. Non-skid strips by bed and recliner. Check every 2 hours at night and if awake, assist to toilet. Family to use wheelchair for outings. Non-skid socks at night as she will allow. Encourage to wear socks and shoes with transfers. Falling star program. Encourage family to have resident use wheelchair when ambulating around the building. Room door alarm, bathroom door alarm, alarms to bed. Laser alarm at foot of bed when in bed. Ensure resident is going to dining room for meals. Encourage resident to place walker on "x's" placed on floor in room near recliner. Fall Risk Evaluations and Restraint Assessments were done on 6/28/11, 9/7/11, 10/30/11, 11/1/11, and 11/21/11. Each assessment documented that based on the resident's history of falls, cognitive status, behaviors, continence, mobility, balance, age, health conditions, and medications, the resident was determined to be at high risk for falls. Facility IAs documented that the resident fell on the following dates, and had the following interventions in place or added: * 4/28/11 at 6:15 AM - Self-transferred; "anticipate needs." * 5/13/11 at 2:00 AM - In the bathroom; "wait while toileting." * 6/2/11 at 6:30 PM - In own room, sustained a laceration which required an emergency room visit for "staples" in head; changed call light type. * 6/13/11 at 2:45 AM - In own room; alarm on room door, assess toileting plan, toilet promptly, check every 2 hours at night, and floor mat at night. * 6/23/11 at 10:15 AM - Self-transferred; alarms in bed, wheelchair, and recliner. * 8/7/11 at 4:15 AM - Self-transferred; nonskid socks at night, sleep monitor. * 8/16/11 at 2:45 AM - Self-transferred; nonskid strips on the floor. * 8/16/11 at 3:00 PM - In the elevator with a family member; educated family. * 8/18/11 at 1:00 PM - Missed seat on front wheeled walker (FWW); adjusted brakes. NOTE: At some time between 8/18/11 and 10/5/11, the resident was added to the Falling Star Program. * 10/5/11 at 6:15 PM - Self-transferred; meals in dining room, lift recliner, and marked the floor with bright yellow tape so the resident would be aware of where to position the walker while she was in the recliner. * 11/1/11 at 1:00 PM - Self-transferred; Velcro alarm to recliner (later discontinued because the resident did not tolerate this intervention), and try checking the resident every 30 minutes instead of using chair alarms. NOTE: Although the resident was well documented to be impulsive, not use call lights, remove and turn off alarms, abandon walker, and self-transfer frequently, the only time was supervision increased was a brief trial period after 11/1/11. Nurse's Notes dated 2/7/11-1/4/12 documented many times that the resident had memory deficits, required assistance for transfers and ambulation, had poor safety awareness, did not use the call light, removed or turned off alarms, received occupational and physical therapy, frequently abandoned her walker and attempted to ambulate or transfer without it, and was impulsive with frequent self-transfers without requesting or waiting for assistance. The DON was interviewed about Resident #1's fall interventions on 1/11/12 at 10:30 AM. She stated that 14 falls was, "too many." When asked if increased supervision had been added other than the brief trial period, she stated, "We tried it to see if we could discontinue the alarms because she took them off. We check her every 2 hours and thought that would suffice. We did track and trend the times of her falls, but there was no trend. We didn't want to take away her mobility... Every 15 minute checks would probably be a (good idea). We didn't implement keeping her in line of sight because she enjoys sitting in her recliner in her room, so that wouldn't work except at meals. She has had no falls since November 4. It seems she is slowing down a bit, not getting up as much. Staff anticipate her needs more." The Administrator was informed of the findings on 1/11/12 at 3:45 PM. On 1/12/12 at 12:40 PM, the facility provided documentation related to Resident #1's falls and interventions, which corresponded with the above information. 3. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 11/8/11 Significant Change MDS assessment coded that the resident was cognitively impaired, took antidepressants and diuretics, and had 1 fall with minor injury since the prior assessment. The resident's 11/14/11 Care Plan included a potential for alteration in safety, and risk of injury from falls. Interventions included frequent cues for daily decisions, alarms, assist with transfers, non-skid socks, meals in the main dining room, lay down first after meals, get out of bed last, concave mattress, ensure not left alone in room when in w/c, and line of sight when in w/c. The resident's January 2012 Physician order [REDACTED]. Nurse's Notes dated 9/26/11-1/9/12 documented many times that the resident had memory deficits, required assistance for transfers and ambulation, did not use the call light, received occupational and physical therapy, took frequent naps, and was impulsive with frequent self-transfers without requesting or waiting for assistance. Facility IAs documented that the resident fell while self-transferring, with intervention changes as follows: * 10/4/11 at 6:45 PM - eat in the dining room and wear non-skid socks * 11/3/11 at 3:45 PM - sustained a skin tear and hematoma, and was taken to the emergency room for evaluation; evaluate for a transfer pole * 11/18/11 at 7:15 PM - sustained a skin tear and pain, and was taken to the emergency room for evaluation; change wheelchair alarm type, and lay the resident down in bed first after meals * 11/23/11 at 7:45 PM - don't leave alone in room in wheelchair * 1/3/12 at 10:15 PM - the alarms were not "hooked up;" discipline and educate staff for not ensuring the alarms were "hooked up," audit alarms, and add a concave mattress NOTE: Although the falls all occurred in the afternoon or evening, and the resident was well documented to be impulsive, not use call lights, and self-transfer frequently, at no time was supervision increased during the afternoon and evening hours. Fall Risk Evaluations and Restraint Assessments were done on 9/26/11, 11/2/11, 11/18/11, 11/23/11, and 1/3/12. Each assessment documented that based on the resident's history of falls, cognitive status, behaviors, continence, mobility, balance, age, health conditions, and medications, the resident was determined to be at high risk for falls. The DON was interviewed about Resident #14's fall interventions on 1/11/12 at 10:30 AM. She stated, "We know he is impulsive and try to anticipate his needs, especially if we see he is going to his room." The Administrator was informed of the findings on 1/11/12 at 3:45 PM. On 1/12/12 at 12:40 PM, the facility provided documentation related to Resident #14's falls and interventions, which corresponded to the information above. 4. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's initial MDS, dated [DATE], identified a fall history as the resident had fallen at home in the last month prior to admission and also in the last 2 to 6 months. The resident had also sustained a fracture prior to admission and had fallen since admission with a superficial injury only. The resident was documented as severely cognitively impaired and required extensive assistance by 2 staff to transfer. The care plan identified the resident at risk for falls on 8/5/11 (time of admission), due to fall history, poor safety awareness, impulsivity, dementia, use of high risk medications and incontinence. Approaches included: * Extensive assist of 1-2 with transfers and toileting. * Encourage resident request staff to assist. * Non-restraining pressure alarms to bed and w/c (wheel chair). "Added 9/28/11" * Concave mattress to bed (8/14/11). * Floor mat alarm (8/14/11). * "Auto lock brakes to w/c (9/25/11). Evaluate for a different type brake system wheelchair (9/28/11). Changed to Broda chair on 11/23/11." * Anti-thrust cushion to w/c. (10/16/11) changed to wedge cushion antithrust 10/29/11. * 1/4 Side rails times two (8/18/11). * Physical therapy (PT) evaluation (9/25/11). * Occupational therapy (OT) evaluated for w/c positioning and will remain on caseload for positioning 10/29/11. * Broda Chair (11/23/11). The following IA reports were reviewed for Resident #13: 8/14/11, 4:00 am- The alarm was sounding and the resident was found on the floor on her left side next to her bed. The resident had an abrasion to her forehead. "Follow-up: floor mat alarm and concave mattress now in place." At the time of the incident the intervention in place was a low bed per IA report. 9/25/11, 3:30 pm- "I was walking down the hall and noted someone laying on the floor next to the linen cart. Upon further investigation noted that it was (Resident #13) who had fallen out of her w/c. I put a pillow under her head and notified a nurse." It was also documented upon further investigation, "...Had previously been up (and) down numerous times would not sit quietly or when in bed attempting to get out frequently. After assessment, (vital signs) done and resident assisted into chair by staff. 1: 1 (One to one) rest of shift." The recommendations/actions taken were: "PT eval(uation) for strengthig/walking (sic) - Auto lock to w/c. Review of behaviors." No injuries. 9/28/11, 7:30 pm- "I looked down the hall and saw resident sitting on buttocks in front of w/c; w/c alarm did not sound." Recommendations/Actions Taken: "Will ensure w/c alarm is functioning and will (change) out autolocks to airlock brakes." Follow-up: "Air lock brakes don't work; w/c alarm is functioning; medications being adjusted." No injuries. 10/16/11, 8:00 pm- "Res(ident) found sitting on floor next to w/c in hallway- no injury noted." Recommendations: "Res working with PT- will try wedge cushion for w/c positioning." Follow-up: "Antithrust cushion in w/c." 10/29/11, 3:00 pm- "CNA came out and resident was leaning forward in her w/c and before CNA could get to her she fell out of w/c." Documentation also indicated just minutes before a nurse saw the resident had just been repositioned farther back in her seat. Recommendations: "therapy to assess w/c positioning." Follow-up: "OT in for w/c positioning- wedge cushion anti thrust. OT to cont(inue) working on w/c positioning." OT progress notes were reviewed. Service dates were for 11/1 through 11/29/11. On 11/11/11 the therapist recommended a Broda chair. On 11/19/11 the Broda chair was ordered and was to be delivered at the beginning of the next week. It was received by 11/22/11 and therapy began to work with her on using the new chair. On 11/29/11 the discharge summary documented: "Patient has met goals and is able to maintain near midline posture while seated in Broda pedal chair for 2 (hours three times a day) and propel using (both lower extremities) 20 feet requiring distant supervision." The Unit Manager LN-2 was interviewed on 1/11/12 at 10:20 am, regarding the use of the Broda chair for Resident #13. LN-2 was asked if the Broda chair was a restraint as she had indicated the resident could not get out of it. She indicated it was as the resident could not get out of the wheel chair either, but had fallen out of her wheel chair. She said the Broda chair was for positioning, to reduce back pain, and for safety. The resident had not had any falls since the Broda chair was implemented. The resident fell on ly 10 days after she was admitted . She received an abrasion to her forehead. The resident was a known fall risk when admitted to the facility but a concave mattress or floor mats by her bed (whether or not alarmed) were not implemented until after she fell . On 9/25/11 the resident fell out of her wheel chair. It was noted how restless she was prior to the fall, but increased supervision by 1:1 staff was not implemented until after the fall and then only for the remainder of the shift. The facility failed to ensure the resident's alarm was functional on 9/28/11. She was not provided with increased supervision after the fall on 9/25/11, when it had been necessary to place her on 1:1 supervision. There was no indication of other interventions, such as: assessing for pain (LN-2 indicated she had back pain), engaging the resident in a meaningful activity, determining if 15 minute checks or line of sight supervision would be beneficial. It took several days for OT to determine the resident required a Broda chair and with time accumulated to order the chair, it was 22 days before the chair was received, and OT could start to work with her related to using the new chair. 5. Resident #7 was admitted to the facility on [DATE] after sustaining a hip fracture at home that required surgical repair. The resident also had a [DIAGNOSES REDACTED]. The resident's physician orders [REDACTED]. Tylenol 325 mg , 1 tablet by mouth every 6 hours as needed for pain (start date 12/13/11). Norco 5-325, 1 tablet by mouth every 4 hours as needed for pain (start date 12/13/11). Roxanol 20 mg/ml, give 0.25 ml sublingual every 6 hours as needed for pain, offer if resident is unable to swallow Ultram (start date 12