Every finding on record at Towne Square Care of Puryear

Based on facility policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when undated, unlabeled food items were found stored in the kitchen. The facility had a census of 24 and 24 of the residents were served from the Kitchen. The findings include: 1. Review of the undated facility policy titled, Food Storage (Dry, Refrigerated, and Frozen) revealed .Food shall be stored on shelves in a clean, dry area free from contaminants Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety.All food-items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded.Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration.Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers . 2. Observation in the kitchen in the walk-in refrigerator on 5/17/2026 at 8:05 AM, revealed the following: a. 4 unlabeled, undated clear, plastic bags of unknown yellow liquid in a plastic container. b. 2 unlabeled, undated plastic wrapped watermelon halves. c. 3 unlabeled, undated plastic packages of unopened chicken breast. 3. Observation in the kitchen in the dry storage room on 5/17/2026 at 9:17 AM, revealed the following: a. 1 round, plastic container with rice with no legible use by date or expiration date. b. 1 round, plastic container with flour with no legible use by date or expiration date. 4. Observation and interview in the kitchen in the walk-in refrigerator with the Certified Dietary Manager (CDM) on 5/17/2026 beginning at 9:43 AM, revealed the CDM confirmed the undated, unlabeled yellow liquid substance in the walk- in refrigerator was a scrambled egg mixture. The CDM was asked when the bags of scrambled egg mixture were placed in the refrigerator and when do they expire. The CDM stated, I do not know. I will have to look for dates in order to put dates on them. The CDM observed that there were no use by dates, expiration dates, or stock (date the item was stored) dates on the 4 bags of scrambled egg mixtures, 2 watermelon halves, and 3 packages of chicken breast. The CDM stated, We should have the date the items were placed in the refrigerator or a use by date. 5. Observation and interview in the kitchen in the walk-in freezer with the CDM on 5/17/2026 beginning at 9:48 AM, revealed 2 undated, unopened plastic bags of spinach, an undated clear plastic bag of tater tots, an opened, undated clear plastic bag of chicken nuggets, a clear plastic storage bag of ground cooked meat dated 3/3 (3/3/2026 stocked date) with no name, expiration date or use by date listed, an opened, unlabeled, undated plastic bag with fish strips and 4 unlabeled, undated, long, clear, plastic packaged whole pork loins. The CDM was asked how the items should be labeled when placed in the freezer and refrigerator. The CDM stated, . the items need to be labeled, have the date as the day it came out of the box and the product's name. I do not know if the use by dates should be on the items. 6. Observation and interview in the kitchen in the dry storage room with the CDM on 5/17/2026 beginning at 2:56 PM, revealed the CDM confirmed the lid of the plastic container of rice had a date of 6/3/25 (6/3/2025) and the lid of the plastic container of flour had a date of 12-24 (12/24/2025). The CDM was asked what the date on the lids represents. The CDM stated, .The stock date .12/24 is not the correct date on the flour.should have the date when the flour was filled into the container. The CDM was asked if the flour should have a use by date. The CDM stated, I guess I will have to check on use by dates. The CDM was asked about the 6/3/2025 date on the rice container. The CDM stated, That is not the stock date I will have look at receipts of purchase . 7. Observation and interview in the kitchen in the walk in freezer, with the CDM on 5/17/2026 beginning at 3:01 PM, revealed 2 unopened, undated bags of spinach, an opened, undated, plastic bag of chicken nuggets, 2 clear, unopened plastic bags of ravioli with a stock date of 5/2 (5/2/2026), not labeled with a use by date or expiration date, an unopened package of bologna with a manufacturer's expiration date of 5/12/2025 and an opened plastic bag of ravioli with a date of 3/9 (3/9/2026), not labeled with a use by date or expiration date. The CDM confirmed 3/9 was the date the bag of ravioli was opened. 8. Observation and interview in the kitchen in the dry storage room with the CDM on 5/18/2026 beginning at 8:35 AM, revealed the CDM confirmed there was a plastic container with rice and a plastic container with flour in the bins with no use by or expiration date. There were 2 unopened bags of marshmallows with an expiration date of 2/17/2026 and 2 plastic containers of sugar with no use by date and no expiration date. The CDM looked at the rice and flour and stated, . should be an expiration date or use by date . 9. Observation and interview in the kitchen in the walk in freezer with the CDM on 5/18/2026 at 8:40 AM, revealed there were 2 unopened, undated packages of spinach, and 4 undated long, plastic sleeves of uncut pork loins, an unopened bag of ravioli dated 5/2 (5/2/2026), with no use by date or expiration date, an opened bag of ravioli dated 4/13 (4/13/2026), with no use by date or expiration date, and a plastic container labeled beef soup dated 3/11 (3/11/2026), with no use by date or expiration date. The CDM was asked how long the soup is good for. The CDM stated, The soup is good for 2 months. 60 days from 3/11/2026, the date the soup was labeled as stored, was 5/10/2026 . The facility failed to ensure food items were properly labeled with the items name and a date that the item should be used by or discarded and failed to ensure that expired food items were disposed of and not available for use.

Based on policy review, Centers for Medicare & [and] Medicaid Services Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual review, Quarterly Payroll Based Journal (PBJ) review, facility staffing information review, and interview, the facility failed to submit accurate staffing data for Quarter 1 for PBJ 2026 (October 1, 2025- December 31, 2025) reviewed for staffing data. The findings include: 1. Review of the facility policy titled Policy & Procedure: PBJ Reporting, dated 10/1/2024, revealed To ensure all necessary staffing hours are submitted to the Centers for Medicare & Medicaid Services as required. Review of the Centers for Medicare & Medicaid Services Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual dated June 2025, revealed .Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. Review of the facility PBJ Staffing Data Report for Quarter 1 2026 (October 1, 2025- December 31, 2025) revealed there were no daily Registered Nurse (RN) coverage for 8 consecutive hours reported on the following dates: a. 10/25/2025 b. 10/26/2025 c. 11/08/2025 d. 11/09/2025 e. 11/22/2025 f. 11/23/2025 g. 11/30/2025 h. 12/06/2025 i. 12/07/2025 j. 12/20/2025 k.12/28/2025 Review of time punches, the working schedule, staff daily postings, and the Nursing Home Licensing Checklist sheets revealed the PBJ Staffing Data Report for Quarter 1 2026 (October 1, 2025- December 31, 2025) was not accurately reported. The facility had daily RN coverage for 8 consecutive hours. During an interview on 5/19/2026 at 9:21 AM, the Administrator (ADM) was asked to tell how the PBJ Staffing Data Report for Quarter 1 2026 (October 1, 2025- December 31, 2025) indicated no daily RN covered for 8 consecutive hours. The ADM stated, Either [named Business Office Associate] is incorrectly transcribing from timeclock reading.The issue is on the reporting. maybe she [named Business Office Associate] needs to compare her findings with the Director of Nursing daily staffing sheets.she needs to find a way to see if RN coverage was really there or not before she reports. During an interview on 5/19/2026 at 11:53 AM, the ADM was asked was PBJ Staffing Data Report for Quarter 1 2026 (October 1, 2025- December 31, 2025) correct. The ADM stated, No, the report was not correct because it did not accurately or correctly reflect the actual hours worked. I expect whoever is reporting the PBJ staffing information.to report it accurately.

Based on facility policy review, medical record, observation, and interview, the facility failed to ensure medications were properly stored when 2 of 2 medication storage carts (Hall 1 and Hall 2) had expired and outdated medications. The findings include: 1. Review of the facility's policy titled, Medication Storage, dated 2/1/2017, revealed .No discontinued, outdated, or deteriorated medications should be available for use in the facility.Expired medications are to be removed from areas medication carts prior to or at the time of expiration. 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Hypertension, Kidney Disease, and Dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #3 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was cognitively intact. Review of the Physician Order dated 12/8/2025, revealed .clonidine HCI [medication used to treat high blood pressure] Oral Tablet 0.1 MG [milligram].Give 1 tablet by mouth every 24 hours as needed for Systolic blood pressure greater than 160. 3. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Anxiety, and Congestive Heart Failure. Review of the quarterly MDS dated [DATE], revealed Resident #6 scored a 08 on the BIMS assessment which indicated that she was moderately cognitively impaired. Review of the Physician Order dated 5/17/2024, revealed .Morphine Sulfate [used to treat pain] IR [immediate release] Oral Solution 20 MG/ML [milliliter].Give 0.25 ml by mouth every 3 hours as needed for SEVERE PAIN. 4. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Diabetes, Depression, and Anxiety. Review of the quarterly MDS dated [DATE], revealed Resident #8 scored a 15 on the BIMS assessment which indicated that she was cognitively intact. Review of the Physician Order dated 6/18/2025, revealed .Cymbalta [used to treat depression] Oral Capsule Delayed Release Particles 20 MG (Duloxetine HCl) Give 1 capsule by mouth one time a day for depression/nerve pain. 5. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Gastro-Esophageal Reflux Disease, Heart Failure, and Osteoarthritis. Review of the annual MDS dated [DATE], revealed Resident #25 scored a 15 on the BIMS assessment which indicated that she was cognitively intact. Review of the Physician Order dated 2/17/2026, revealed .Hyoscyamine Sulfated [used to treat stomach and intestinal disorders] Oral Tablet 0.125 MG.Give 1 tablet by mouth every 4 hours as needed for secretions. 6. During an observation and interview on the Hall 1 Medication Cart on 5/18/2026 at 10:00 AM, Licensed Practical Nurse (LPN) A confirmed the following medication were expired. a. 3 tablets of Resident # 3's Clonidine 0.1mg expired on 4/30/2026. b. 1 bottle of Resident #6's Morphine Sulfate 15 mL expired on 3/2026. During an observation and interview on the Hall 2 Medication Cart on 5/18/2026 at 10:05 AM, LPN A confirmed the following medication were expired. a. 10 capsules of Resident # 8's Duloxetine 20mg expired on 12/31/2025. b. 30 tablets of Resident #25's Hyoscyamine Sulfate 0.125 mg expired on 4/30/2026. During an interview on 5/18/2026 at 10:05 AM, LPN A was asked if expired medications should be kept in the medication cart. LPN A stated, No, they should not. During an interview on 5/18/2026 at 10:57 AM, the Director of Nursing (DON) was asked what is your procedure for checking for expired medications. The DON sated .nursing should go through the medication cart and check for any expired medication and dispose of them accordingly. The DON was asked if expired meds should be in the medication carts. The DON stated, No, expired meds should not be on the cart.

Based on policy review, observation, and interview, the facility failed to maintain a sanitary kitchen when 1 of 1 ice machines was observed to have a dark slimy build up and when 1 of 1 nourishment refrigerator had a yellow sticky substance in the freezer and refrigerator. The findings include: 1. The facility policy titled, Policy & Procedure: Sanitizing, dated 2/1/2017, revealed .food storage .areas will be kept clean and free from litter, debris .All equipment .shall be washed to clean and sanitize using hot water and/or chemical sanitization solution .Ice machines .will be .cleansed and sanitized . 2. Observation in the kitchen on 3/24/2025 at 8:40 AM, revealed a dark slimy build up on inside of the ice machine. During an observation and interview on 3/24/2025 at 8:45 AM the Certified Dietary Manager (CDM) was asked if there should be a build up of dark slime in the ice machine. She stated, No . During an interview on 3/25/2025 at 2:15 PM, the Administrator confirmed there should not be black slime in the ice machine. 3. During an observation and interview in the medication room on 3/26/2025 at 9:09 AM, revealed the nourishment refrigerator had a yellow sticky substance in the freezer and a yellow sticky substance on the 2nd shelf in the refrigerator. Registered Nurse (RN) A was asked if there should be a yellow substance in the freezer or on the refrigerator shelf below, RN A stated, .no . 48285

Based on policy review, medical record review, and interview, the facility failed to develop am elopement risk care plan for 1 of 12 (Resident #4) sampled residents reviewed for care plans. The findings include: 1. Review of the facility policy titled, .Care Planning, dated 2/1/2017, revealed .To ensure all residents have a care plan developed, implemented, revised/updated based on the needs they have .Care plans will be initiate .and updated and/or revised .with any changes that occur throughout their stay . 2. Review of the medical record review revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Impulse Disorder, Paranoid Schizophrenia, Dementia, and Anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 11, meaning Resident #4 had moderate cognitive impairment. Review of the Care Plan dated 12/29/2024, revealed there were no focus/problems or interventions on the care plan related to elopement. Review of a Nurses Note dated 2/2/2025, revealed .Heard the front door alarm going off. Resident was outside rolling in the parking lot. Assisted back inside . Review of an Incident Report dated 2/2/2025, revealed .It was reported that resident was found outside the facility in the parking lot in her wheelchair. Resident stated that she was trying to get home . The facility failed to develop a care plan to address elopement after Resident #4 eloped on 2/2/2025. During an interview on 3/25/2025 at 10:24 AM, the Director of Nursing (DON) was asked when Resident #4 exited the building, did that make her an elopement risk. The DON stated, Yes. If Resident #4 is an elopement risk, should she be care planned for elopements with interventions to prevent her from leaving the building again. The DON stated, Yes.

Based on policy review, named Hospice agreement review, medical record review, and interview, the facility failed to provide a communication process, including how the communication will be documented between the Long-term Care facility and the hospice provider to ensure resident needs are addressed and met for 1 of 12 (Resident #7) sampled residents and failed to follow Physician Orders for 1 of 12 (Resident #16) sampled residents. The findings: 1. Review of the facility policy titled, Policy & Procedure: Hospice Services, dated 2/1/2017, revealed .It is the policy of the facility to provide collaborative care with Hospice providers to ensure that our resident's end of life preferences and choices are honored .Communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met . 2. Review of the named Nursing Facility Hospice Agreement, dated July 2017, revealed .Manner of Communication .All communications between the Hospice and Nursing Facility pertaining to the care and services provided to the Resident Patient shall be documented in the Resident Patient's clinical record .Patient Care Information Provided. Hospice shall provide the Nursing Facility Designee with the following: (a) A copy of the most recent Plan of Care specific to each Resident Patient . (b) A copy of the Hospice election form and any advance directives specific to each Patient Resident . (c) A copy of the physician certification and recertification of the terminal illness for each Resident Patient . (d) Names and contact information for Hospice personnel involved in the hospice care of each Resident Patient . (e) Instructions on how to access the Hospice's 24 hour on call system . (f) A copy of Hospice medication information specific to each Resident Patient . (g) A copy of Hospice physician and Attending Physician orders specific to each Resident Patient. Copies of all physician orders provided to the Nursing Facility will be in writing .Hospice will maintain adequate records of all physician orders communicated in connection with the Plan of Care . Review of the facility policy titled, Physician Orders, dated 2/1/2017, revealed .To provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards . 3. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Encephalopathy, Chronic Obstructive Pulmonary Disease, and Pulmonary Edema. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated Resident #7 was moderately cognitively impaired. Review of the Physician's orders dated 3/14/2025, revealed . ADMIT PATIENT TO [NAMED HOSPICE] PER FAMILY REQUEST . Review of the significant change MDS dated [DATE], revealed a BIMS score of 6, which indicated Resident #7 was severely cognitively impaired. Resident #7 was assessed for Hospice. Review of Nurse's Notes dated 3/15/2025, revealed .[Named Hospice] here to admit resident. Hospice DX [diagnosis]: Hypertensive heart disease with heart failure and chronic kidney disease. New orders . During an interview on 3/25/2025 at 9:41 AM, the Director of Nursing (DON) was asked how the facility communicates with Hospice. The DON replied, They come into the facility. If they have orders, they tell us, and we put them in the chart. The DON was asked if the facility had a hospice book or somewhere for hospice to document their visits and notes. The DON replied, No. 4. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Aphasia, Contracture of Left Hand, and Cerebral Infarction. Review of the facility's Order Summary Report dated 2/28/2025, revealed .OBTAIN ROUTINE LABS: CBC [a blood test that measure types of cells in the blood] & CMP [a blood test that measure different substances in the blood and medical conditions] Q [every] 6 MONTHS (FEBRUARY/AUGUST) OBTAIN ROUTINE HGBA1C [hemoglobin, a blood test that measures the blood sugar in the blood] q4 months (January/April/August) OBTAIN ROUTINE KEPPRA LEVEL [a blood test that measures the amount of anticonvulsant medication in the blood] Q3 MONTHS (FEBRUARY/MAY/AUGUST/NOVEMBER) .Order Date .12/1/2023 . Review of the quarterly MDS assessment, dated 3/13/2025, revealed Resident #16 had a BIMS score of 15, indicating the Resident was cognitively intact and the use of anticoagulant, diuretic, hypoglycemic and anticonvulsant medications. Review of the Care Plan dated 3/25/2025, revealed .I am on diuretic therapy .I have Diabetes Mellitus .I have hypertension . Review of the medical record revealed Resident #16 had not received any labs drawn since her admission on 12/5/2024. During an interview on 3/25/2025 at 4:05 PM, the DON was asked for the lab results since Resident #16's admission on 12/5/2024. The DON stated, We don't have any .labs . During an interview on 3/26/2025 at 7:53 AM, the DON confirmed that the lab dated 4/11/2024 was the only lab that she had for Resident #16. The DON confirmed that nursing staff should follow physician orders and the lab should have been drawn in January and February 2025 for Resident #16. 49311

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe and secure environment when hazards items were found in 2 of 18 (Resident #18 and #22) resident rooms reviewed for accidents. The findings included: 1. Review of the facility's policy titled, Resident Rooms, dated 2/1/2017, revealed .To ensure residents are provided a clean room and environment and free of hazards . 2. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses including Diabetes, Asthma, and Dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #18 had a Brief Interview for Mental Status Score (BIMS) of 15, indicating the resident was cognitively intact, and required supervision with Activities of Daily skills (ADLs). Observations during medication administration in the resident's room on 3/24/2025 at 4:11 PM and on 3/25/2025 at 10:51 AM, revealed the following: a. a bottle of pink nail polish, an 18 oz (ounce) bottle of Lavender Scent body lotion, a 20 oz bottle of [NAME] Shae Butter hair conditioner labeled keep out of reach of children on the dresser near the entrance door, unsecured and unattended b. a bottle of tan nail polish, a 33 oz bottle of Skin Relief Moisturizing Lotion, a 20 oz bottle of body lotion, a 18oz bottle of [NAME] Butter lotion with Vitamin E Oil, an 8 oz bottle of Vitamin C Body Lotion all labeled keep out of reach of children During an interview on 3/25/2025 at 11:05 AM, Licensed Practical Nurse (LPN) A was shown the items on the dresser and on the bedside table and was asked where these items should be stored. LPN A stated, They can't have these in their room, they can't have nail polish in here, I will have to ask [named Director of Nursing], I don't know if they can or not . LPN A turned and exited the room. During an interview on 03/25/25 at 11:17 AM, the Director of Nursing confirmed that those items labeled keep out of reach of children and the nail polish should be secured and away from residents. 3. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Anxiety, Chronic Pain Syndrome, Hypertension, Gastro-Esophageal Reflux Disease (GERD), and Asthma. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #22 had a BIMS of 15, indicating the Resident was cognitively intact, and required supervision with ADLs. Observations in Resident #22's room on 3/24/25 at 9:09 AM, and at 10:35 AM, revealed a bottle of nail polish remover and 2 bottles of nail polish on the bedside table, unsecured and unattended During observation and interview on 3/24/25 at 10:38 AM, Licensed Practical Nurse (LPN) B was asked should the nail polish and the nail polish remover be on the bedside table unsecure and unattended. LPN B confirmed the nail polish and the nail polish remover should be stored in the locked medication cart or the medication room away from residents. 51992

Based on policy review, daily staff posting review, and interview, the facility failed to post the total number of staff, and actual hours worked by the licensed staff responsible for resident care on the facility's Daily Staff Posting form for 20 of 24 sampled days. The findings include: 1. Review of the facility policy titled, .Staffing, dated 2/1/2017, revealed .To ensure proper licensed nursing staff are provided to the residents according to regulations .Resident census will be posted daily. 2. Review of the facility's Daily Staff Posting forms dated 3/1/2025 thru 3/24/2025, revealed incomplete daily posting for the dates of 3/1/2025, 3/2/2025, 3/3/2025, 3/4/2025, 3/5/2025, 3/6/2025, 3/7/2025, 3/10/2025, 3/11/2025, 3/12/2025, 3/13/2025, 3/14/2025, 3/15/2025, 3/16/2025, 3/17/2025, 3/18/2025, 3/19/2025, 3/20/2025, 3/21/2025, and 3/24/2025. During an interview on 3/25/2025 at 4:14 PM, the Director of Nursing (DON) was asked about the missing documentation related to the daily staff posting form. The DON confirmed there was missing documentation, and the form was not accurate.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 2 (Registered Nurse (RN) A) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 26 opportunities, resulting in a medication error rate of 7.69%. The findings include: 1. Review of the facility's policy titled, Medication Error, revealed .All medication errors and drug reactions will be reported immediately to the Director of Nursing, the attending physician and will be documented according to established procedures .Medication error is defined as the preparation or administration of medications or biological that is not in accordance with the prescriber's orders, manufactures specifications regarding the preparation and/or administration of the medication or biological and /or accepted professional standards for medications or biological administration .All medication errors and drug reactions must be promptly reported to the Director of Nursing, attending physician, the pharmacist, the resident and/or responsible party . 2. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Anxiety, Chronic Pain Syndrome, Hypertension, Gastro-Esophageal Reflux Disease (GERD), and Asthma. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #22 had a Brief Interview for Mental Status Score (BIMS) of 15, indicating the resident was cognitively intact. Review of a Physician's Order dated 3/17/2025 revealed .Omeprazole .20MG .for GERD .before breakfast at 0500 [5 AM]. Observation during medication administration on the Short Hall Medication Cart on 3/25/2025 at 8:46 AM, revealed RN A removed the following medications to administer to Resident #22: a. omeprazole 20mg capsule. b. montelukast 10mg tab. c. propranolol 10mg tablet. RN A knocked and entered Resident #22's room and administered the medications and exited the room and returned to the medication cart. RN A administered the Omeprazole at 8:46 AM and it should have been administered at 5:00 AM, resulting in 1 medication error. During an interview on 3/25/2025 at 10:13 AM, RN A was asked did you administer Resident #22 an Omeprazole 20mg tablet. RN A confirmed she did administer the tablet. RN A was asked if the order said 5 AM should you have administered that tablet when it was ordered. RN A confirmed she should not have administered the tablet at 9 AM because it was due at 5 AM. 3. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Cognitive Communication Deficit, Depression, Drug Induced Myopathy, Hypertension, and Weakness. Review of the MDS assessment dated [DATE], revealed Resident #75 had a BIMS Score of 11, indicating the resident was moderately cognitively impaired. Review of the facility's Order Summary Report dated 2/28/2025, revealed .Folic Acid .1MG [milligram] .one time a day . Observation during medication administration on the Long Hall Medication Cart on 3/25/2025 at 8:33 AM, revealed RN A removed the following medications to administer to Resident #75: a. Potassium 10meq (milliequivalent) 1 tablet . b. Folic acid 400 mcg (micrograms, 1000 mcg equals 1 mg) 2 tablets (800 mcg) . c. Refresh eye drops . RN A locked the medication cart, entered Resident #75's room and administered the medications and returned to the medication cart. During an interview on 3/25/2025 at 9:29 AM, RN A was asked how many milligrams of folic acid Resident #75 is supposed to receive. RN A confirmed Resident #75 was supposed to receive 1mg of Folic Acid but she administered 2 -400 mcg (equaling less than 1 mg) tablets because she did not have 1mg of the Folic Acid. RN A confirmed she should not have administered the 2 tablets but should have consulted the Director of Nursing for instructions or called the physician to inform him and to receive further orders.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 3 (Short Hall Medication Cart) medication storage areas was found unsecured and unattended when medications were found unsecured and unattended in 1 of 18 (Resident #22) resident occupied rooms. The findings include: 1. Review of the facility's policy titled, Medication Storage, dated 2/1/2017, revealed .To ensure that medications and biological (biologicals) are stored in a safe, secure storage and safe handling .Compartments containing medications should be locked when not in use .Trays and carts used to transport such items should not be left unattended . 2. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Anxiety, Chronic Pain Syndrome, Hypertension, and Asthma. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #22 had a Brief Interview for Mental Status Score (BIMS) of 15, indicating the resident was cognitively intact and required moderate assistance with Activities of Daily Living skills. Observations in Resident #22's room on 3/24/2025 at 9:09 AM and at 10:35 AM, revealed 1 bag of cough drops on the bedside table, unsecured and unattended. During observation and interview on 3/24/2025 at 10:38 AM, Licensed Practical Nurse (LPN) B was shown the bag of cough drops on the bedside table and was asked should they be there. LPN B confirmed they should be locked on the medication cart or in the medication room and not accessible to residents. LPN B was asked does Resident #22 have a Medication Self Administration Assessment. LPN B confirmed that no resident in the facility has been assessed to self-administer medications. 3. Observation at the Nurses' Station on 3/24/2025 at 8:58 AM and at 9:00 AM, revealed the Short Hall Medication Cart was unlocked and unsecured, with no licensed nursing staff at the nurses' desk. During an interview on 3/24/2025 at 9:05 AM, LPN B, entered the Nurses' Desk from down the Long Hall and was asked should the medication cart be left unlocked and unattended. LPN B confirmed that the medication cart should be locked at all times when not in use.

Based on policy review, observation and interview, the facility failed to ensure proper infection control practices were followed during medication administration when 1 of 2 nurses (Licensed Practical Nurse (LPN) C) picked items out of trash and failed to change gloves and/or use hand hygiene, when 1 of 1 (Registered Nurse (RN) A) failed to clean reusable resident equipment in between resident use, and when 1 of 2 (RN A) nurses administered medication to a resident after dropping the medication on the resident's person. The findings include: 1. Review of the facility's policy titled, Hand Hygiene, dated 2/1/2017, revealed To provide guidelines to staff for proper and appropriate hand washing and hygiene techniques that will aid in the prevention of transmission of infections .Staff will perform hand hygiene by washing hands .and should be performed under the following conditions .After handling items potentially contaminated with blood, body fluids or secretions . Review of the facility's policy titled, Disinfecting Resident Equipment, dated 2/1/2017, revealed .To provide guidelines for disinfection in accordance with manufacturer recommendations for reusable equipment used in resident care. Reusable resident care equipment includes, but not limited to .Blood Pressure Cuff .Reusable equipment will be cleaned and disinfected after use of one resident and before use of another resident . 2. Observation during medication administration on the Long Hall Medication Cart on 3/24/25 at 4:11 PM, revealed the following LPN C donned a pair of clean gloves, began cleaning the glucometer machine and was asked what was used to clean the glucometer machine. LPN C reached into the trash can with her gloved hand and obtained the package that the cleaning cloth came out of and then continued to clean the glucometer machine with the same gloved hands. LPN C failed to change gloves and re-clean the glucometer machine after reaching into the trash can. 3. During medication administration on Long Hall Medication Cart 1 on 3/25/2025 at 8:33 AM, revealed RN A removed medication to administer to Resident #75. RN A entered the room, took the resident's blood pressure with a cuff blood pressure machine, and returned to the medication cart and placed the blood pressure cuff on top of the medication cart without cleaning or disinfecting. During medication administration on the Short Hall Medication Cart on 3/25/2025 at 8:46 AM, revealed RN A removed medications to administer to Resident #22. RN A entered Resident #22's room, took the resident's blood pressure with the same blood pressure cuff and failed to clean or disinfect after using on Resident #75 and prior to using on Resident #22. Observation during medication administration on the Long Hall Medication Cart on 3/25/2025 at 8:45 AM, revealed RN A removed medications for Resident #5 to be administered. RN A knocked and entered the resident's room, administered the medications, dropping one unidentified tablet on the resident's chest area, picked up the medication with her bare hands and placed it back into the medication up and administered it to Resident #5. RN A exited the room and returned to the medication cart. During an interview on 3/25/25 at 9:21 AM, RN A confirmed that all reusable equipment should be cleaned with a sani wipe before and after each resident use and that she failed to do that in between using the blood pressure cuff on Resident #75 and #22. RN A confirmed she should have discarded the tablet she dropped on Resident #5's chest area and replaced it with another tablet and that she should not have picked it up with her bare hands.

Based on policy review, Job Description, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by dirty trash can, carbon build-up on the pans, dirty equipment, the deep fryer with carbon build-up with food particles, carbon build-up on the flat grill, and large amount of greasy dark stain on the floor beside and behind the deep fryer, kitchen cabinets with large amount of peeling Formica laminate on the doors and drawer, cabinet under the sink with dark furry substance with an old stained cloth and the cabinet underneath in disrepair. The facility had a census of 25 with 25 of those residents receiving a meal tray from the kitchen. The findings included: 1. Review of the facility's Sanitizing, policy dated 2/1/2017, revealed .The food service area shall be maintained in a clean and sanitary manner .The Dietary Manager/Food Service Manager will be responsible for creating and maintaining a regular cleaning schedule of kitchen and dining areas to prevent the accumulation of dirt, debris and grime .Kitchen .surfaces not in contact with food shall be cleaned as a part of a regular preventative maintenance schedule . 2. Review of the undated Dietary Weekly/Monthly Cleaning Schedule, revealed .Weekly Cleaning .Griddle .Convection Oven .Pots/Pan - Carbon Removal .Monthly Cleaning .Fryer - clean & [and] replace grease .Morning Dietary .Prep tables .Afternoon Dietary .Sweep & mop floors . Review of the signed Job Description titled Director of Food Services, dated 4/3/2024, revealed .The primary purpose of your job position is to .organizing, developing and directing the overall operation of the Food Services Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility .to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner . 3. Observation in the kitchen on 4/1/2024 at 9:44 AM, 4/2/2024 at 8:06 AM, and on 4/3/2024 at 2:07 PM, with the Dietary Manager (DM) revealed the following: A trash can lid with large amount of dark stains on the inside and outside lid. Metal prep (prepare) table on the bottom shelf had 4 half pans with a large amount of thick carbon buildup on the outside and inside of the pans. A metal prep table had 2 full sheet pans on the bottom shelf with a large of carbon buildup on the outside and inside of the pans. A metal prep table had dark stain buildup on the front end of the bottom shelf. The Convection oven had a large amount of dark dried food substance. A deep fryer had a large sheet pan with a large amount of carbon buildup covering the fryer. A deep fryer had a large amount of food particles inside the fryer and carbon buildup on the left side of the deep fryer. The flat grill had a large amount of carbon buildup on the left side of the grill. The kitchen cabinets with large amount of peeling Formica laminate on the doors and drawers. The cabinet under the sink had a large amount of dark furry stains and an old stained washcloth on the bottom of the caved in floor of the cabinet, and the back wall had a large hole torn apart. Observation and interview in the kitchen on 4/2/2024 at 8:06 AM, with the DM revealed on the drying rack was 3 half pans and 1 full pan with a large amount of carbon build up on the inside and outside of the pans, and a full pan with a white food substance. The DM was asked what the food substance in the corner of the full pan is, The DM stated, .A piece of French toast . During an interview on 4/3/2024 at 11:08 AM, the DM was asked how often the deep fryers are cleaned and should there be a large amount of food particles on the on the inside of the deep fryer. The DM stated, .the cleaning list I gave you, we do our fryer monthly .of course the answer they would be no we should not have food particles in the fryer . The DM was asked should the oven have run off dripping in the bottom of the oven. The DM stated, .No .those [oven] are clean after the spills are made . The DM was asked should the sheet pans have a large amount of carbon buildup on the inside and outside of the pans. The DM stated, .No .we generally do [clean] that [carbon] once a month .I have to reeducate the staff on what to clean on those pans with .it's just been overlooked on that part of the pans . The DM was asked should the trash can at the hand sink have dark stains on the outside and inside of the lid. The DM stated, .No, the trash cans get cleaned once a month . The DM was asked should the deep fryer have carbon buildup on the sides, food particles inside, food particles on the side and behind the deep fryer and dark stains on the floor. The DM stated, .No .it's probable the grease buildup . The DM was asked should the toaster have carbon buildup. The DM stated, No. The DM was asked should the clean pans on the drying rack have food particles. The DM stated, No, ma'am. The DM was asked what the dark furry stain under the sink was and should the shelves be caved in with the back wall torn away. The DON stated, .It looks like mold .No the cabinets should not look like that . During an interview on 4/3/2024 at 5:09 PM, the Administrator was asked should the kitchen have cabinet with the Formica laminate peeling and torn off the cabinets. That Administrator stated, .No, they need to be replaced . The Administrator was asked should the cabinet under the sink have dark [NAME] stains (mold) and the bottom of the shelf caved in and the back wall torn away from the wall. The Administrator stated, .No ma'am .

Based on policy review, observation, and interview, the facility failed to maintain an adequate supply of over-the-counter medications for 3 of 3 (Medication Cart #1, Medication Cart #2, and Medication Storage Room) medication carts reviewed for medication storage. The findings include: 1. Review of the facility's policy titled Supply Ordering, dated 2/17/2027, revealed .any supplies needed to care for the residents will be ordered from an approved medical vendor .Designated staff .maintain all supplies in the stock room .Orders will be placed to the medical vendor at least monthly, but more if needed .supplies to be ordered include .Over-the-Counter medications .supplies needed to provide care to the residents .Supply list will be given to the Administrator and /or his/her Designee .Order will be submitted by the Administrator and/or his/her Designee .Orders that are delivered to the facility will be placed in the stock room .may choose to use a local vendor or store to procure any items that are unavailable or backordered . Review of the facility policy titled Physician Orders, dated 2/1/2017, revealed .Medications will be ordered from the pharmacy to ensure prompt delivery . 2. Review of the [Named Supply Company] manifest order form dated 2/13/2024, revealed, .1 box of MUCINEX (medication used for coughing), TAB [tablet] 600-30MG (milligrams) .4 boxes of OMEPRAZOLE (medication used for stomach acid) TAB 20MG . Review of the [Named Supply Company] manifest order form dated 2/26/2024, revealed, .4 boxes of MUCINEX, TAB 600MG .2 boxes of OMEPRAZOLE TAB 20MG . Review of the [Named Supply Company] manifest order form dated 3/28/2024, revealed, .4 boxes of MUCINEX, TAB ER 600MG . Review of the EMAR (Electronic Medication Administration Record (MAR) Progress Notes for Resident #7 revealed documentation of .medication not available at this time .on 2/19/2024 at 12:52, 2/20/2024 at 8:45 AM, 2/20/2024 at 1:26 PM, 2/21/2024 at 8:16 AM, 2/21/2024 at 1:10 PM, 2/22/2024 at 8:23 AM, 2/22/2024 at 4:25 PM, 3/27/2024 at 1:29 PM, 4/1/2024 at 1:09 PM, 4/2/2024 at 8:38 AM, and 4/2/2024 at 1:10 PM. Review of the 2/2024 MAR revealed, Resident #7 did not receive Mucinex on 2/19/2024, 2/20/2024, 2/21/2024, and 2/22/2024. Review of the 3/2024 MAR revealed, Resident #7 did not receive Mucinex on 3/7/2024 and 3/28/2024. Review of the MAR dated 4/2024 revealed, Resident #7 did not receive Mucinex on 4/1/2024 and 4/2/2024. Observation on 4/2/2024 at 8:25 AM, during medication administration, revealed the Registered Nurse (RN) had a plastic cup of medications and confirmed she was taking them to Resident #7. The RN exited Resident #7's room and stated, .everything was in the cup except for omeprazole and Mucinex because they were still waiting for them to come in . Observation in the medication room (Medication Storage Room) on 4/2/2024 at 10:15 AM, revealed no over the counter medication stock for Mucinex ER or Omeprazole in the medication storage room. During an interview on 4/2/2024 at 9:00 AM, the RN confirmed that the facility was out of the over the counter medication of Mucinex ER and Omeprazole. The RN was asked how long the facility had been out of the two medications. The RN stated, At least a week . During an interview on 4/3/2024 at 8:23 AM, the RN was asked what the process is for ordering over-the-counter medications. The RN stated, .we have an order form in the drawer and fill it out .when it gets down to 1-2 boxes .seems we have been having problems getting our medications for the last month or two always put a note in [the computer] so that we know that's the reason we don't give it .Been out for about a week, gave [omeprazole] the last time on last Thursday [3/28/2024] .last week sometime for the Mucinex, not sure what day . During an interview on 4/3/2024 at 2:47 PM, the Administrator was shown a copy of the order sheet and asked if this surveyor could see the order sheets from January till April. The Administrator stated, .I do not save those order sheets .once I order what is on the sheet, I throw it away .I'm aware that we [the Facility] do not have any [omeprazole and Mucinex] in stock at the present . The Administrator was asked is there any other means the facility had for obtaining medications when they do not come in. The Administrator stated, .Yes, we could get them at the [Named Retail Store] . The Administrator was asked should all medications including over-the-counter medications Mucinex ER and Omeprazole be available for administration for the residents. The Administrator stated, .Yes. During a telephone interview on 4/3/2024 at 3:20 PM, the Nurse Practitioner (NP) was asked should all medications be available for administration for residents if there was a physician's order. The NP stated, .Yes.

Based on policy review, nurse schedules, facility group hours report, facility time sheets, and interview, the facility failed to ensure there was a Registered Nurse (RN) on duty for 8 consecutive hours a day, 7 days a week for 4 of 29 days (10/8/2023, 11/5/202, 11/11/2023, and 11/26/2023) reviewed for RN coverage. The findings include: Review of the facility's policy title, Staffing, dated 2/1/2017, revealed .To ensure proper licensed nursing staff are provided to the residents according to regulation .The facility shall provide a Registered Nurse for 8 consecutive hours every day . Review of the nurse schedules from 10/2023 to 12/2023, revealed there was no RN scheduled for 10/8/2023, 11/5/2023, 11/11/2023, and 11/26/2023. Review of the facility's Group Hours, report (punch time sheet) from 10/1/2023 thru 12/31/2023, revealed no RN punched into work indicating a RN was in the building for 8 consecutive hours on 10/8/2023, 11/5/2023, 11/11/2023, and 11/26/2023. Review of the Director of Nurses (DON) Time Sheet from 10/2023 thru 12/31/2023 revealed, the DON did not sign into work as an RN, to provide 8 consecutive hours of RN coverage on 10/8/2023, 11/5/2023, 11/11/2023, and 11/26/2023. During an interview on 4/3/2024 at 7:18 PM, the DON confirmed the facility should have 8 consecutive hours of RN coverage per day. The DON confirmed the facility was unable to provide documentation that an RN worked on 10/8/2023, 11/5/2023, 11/11/2023, and 11/26/2023 for 8 consecutive hours. The facility was unable to provide documentation showing 8 consecutive hours of daily RN coverage on 10/8/2023, 11/5/2023, 11/11/2023, and 11/26/2023.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure neurological (neuro) checks were obtained after an unwitnessed fall with a head injury for 1 of 2 (Resident #127) reviewed for accident hazards. The findings include: 1. The facility's policy titled Neuro Assessment, dated 2/1/2017, revealed .Neurological assessment will be performed by a licensed nurse when .head injury .unwitnessed falls .Neurological Assessments should be performed .for a 72 hour period . 2. Review of the medical record revealed Resident #127 was admitted to the facility on [DATE], with diagnoses of Dementia, Osteoarthritis, History of Malignant Neoplasm of Uterus, and Left Artificial Hip Joint. Review of the Admission Minimum Data Set, dated dated dated [DATE], revealed Resident #127 was assessed with a Brief Interview for Mental Status score of 7, indicating the resident was severely cognitive impaired, assessed with inattention, disorganized thinking and Altered Level of Consciousness, Independent with indoor mobility, required the use of a walker, and was moderate to dependent on staff for activities of daily living skills, incontinent of both bowel and bladder, an active diagnosis of Non Alzheimer's Dementia, and having 1 fall with injury since admission. Review of the Care Plan dated 3/21/2024 revealed, .I am at risk for falls r/t [related to] Confusion, Gait/balance problems .I have limited physical mobility . Review of a Fall Incident Report, dated 3/27/2024 revealed, .4:18 AM .Incident Location .Resident's Bathroom .Heard call for help coming from resident's bathroom. Observed resident sitting in floor in doorway. Alert and responsive but noted to have small hematoma to left outer brow and skin tear dorsum of left hand .Resident Description .Resident stated she was trying to get to bathroom. She also stated she hit her head on the door facing of the bathroom .Upon assessing resident it was noted that resident had incurred a hematoma to her outer left eye brow which measured 5 cm [centimeters] x 3.75 cm . Review of the facility's fall investigation revealed no neuro checks were included in the investigation. Review of the medical record revealed the facility failed to provide neuro checks for Resident #127 for the fall that occurred on 3/27/2024. Observation in Resident #127's bathroom on 4/1/24 at 12:58 PM, revealed staff assisting resident into the bathroom, resident noted to have large purple and bluish discoloring to the left side of her face. Observation in the dining room on 4/2/24 at 8:23 AM, revealed Resident #127 sitting up in wheelchair feeding herself her breakfast meal, purple bluish discoloring remains to the left side of the resident's face. During an interview on 4/3/24 at 9:14 AM, the Director of Nursing (DON) confirmed that Resident #127 had a fall on 3/27/2024 that resulted in bruising and a hematoma to the left side of her face. The DON was asked was neuro checks obtained as a result of her unwitnessed fall that occurred on 3/27/2024, that resulted in a hematoma and bruising to her left side of her face. The DON confirmed that she was unable to locate the neuro checks and that they should be readily accessible in the resident's medical record.

Based on policy review, medical record review, facility investigation review, and interview, the facility failed to report allegations of abuse to Adult Protection Service (APS) and Long-Term Care Ombudsman for 1 of 3 (Resident #177) sampled residents reviewed for abuse, failed to report an allegation of abuse to local law enforcement, and failed to complete a 5 day follow-up report to the state agency for 3 of 3 (Resident #8, #17, and #177) sampled residents reviewed for allegations of abuse. The findings include: 1. Review of the policy Abuse and Neglect, dated 2/1/2017, revealed, .establish guidelines that prevents, identifies and report resident abuse and neglect .right to be free from verbal, sexual, physical, and mental abuse .any .allegation of abuse must be reported to the state agency and law enforcement . 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses of Schizophrenia, Cognitive Communication Deficit, Dementia, and Unsteadiness on Feet. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #8 was severely cognitively impaired. 3. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses of Dementia, Depression, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, and Adult Failure to Thrive. Review of the admission MDS dated [DATE], revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident was moderately cognitive impaired. Review of the facility's Investigation Report dated 11/17/2023, revealed the Administrator was notified by phone on 11/17/2023, that Resident #17 reported that about six days earlier he had been sitting in the dining room before lunch when Resident #8 approached him and felt around the front of his chest and his hands wandered down the front of his body around his groin area. Resident #17 was immediately assessed and no physical or mental harm could be found. Resident did display increased anxiety but when questioned stated that his sister-in-law had had hip surgery that day and he was upset about that. Resident's Representative was called to report the incident. Resident was assessed by the physician and also by the Psych Nurse Practitioner. The Psych Nurse Practitioner followed up on Resident #17 for 72 hours. Other cognitively intact residents were interviewed and no one else reported any kind of trouble with Resident #8 . The investigation concluded the allegation could not be verified due to the alleged perpetrator is severely impaired in vision and was often observed often feeling his way down the halls as he tried to find his way to where he was going. The allegation of abuse was reported to the State agency and to the Ombudsman. The Corrective Action Plan was to in-service staff on the abuse and neglect policy and to supervise the alleged perpetrator when he was in crowded areas. Review of the facility's Incident Reporting System sheet revealed the facility did not report the allegation of abuse to the police and there was no 5 day follow up. During an interview on 4/3/2024 at 10:07 AM, the Director of Nursing (DON) confirmed that the facility did not call and file a report with the police after the alleged altercation between Resident #8 and Resident #17 but that they had called the Ombudsman. During an interview on 4/3/2024 at 4:12 PM, the Administrator confirmed she did not report the allegation of abuse to the police. The Administrator also confirmed that she did not conduct and report a 5 day follow up to the state. 4. Review of the medical record revealed Resident #177 was admitted the facility on 4/10/2023 with diagnoses of Cognitive Communication Deficit, Anxiety, Depression, and Heart Failure. Review of the admission MDS dated [DATE], revealed Resident #177 had a BIMS of 8, indicating the resident was moderately cognitively impaired. Review of the facility's Investigation Report, dated 4/30/2023, revealed the Administrator was notified by phone on 4/30/2024 that Resident #177 reported that she had been hit by a staff member on 4/29/2024. The Administrator arrived at the facility on 4/30/2023 and began an investigation that started with interviewing Resident #177. The Administrator presented staff members who fit Resident #177's description of the alleged perpetrator to Resident #177 and the resident denied all as being the person who had hit her. The Administrator completed an assessment of the resident; the resident had no physical or mental harm. The Administrator obtained statements from staff members. The Administrator interviewed other residents who may have had contact with the alleged perpetrator and were cognitively intact. The investigation concluded the allegation could not be substantiated. The allegation of abuse was reported to the state. The Corrective Action Plan was to continue to in-service and train staff on the abuse and neglect policy and to address with residents to report incidents immediately. Review of the facility's Incident Reporting System, revealed the facility did not report the allegation of abuse to the police, APS, or the Ombudsman, and there was no 5 day follow up. During an interview on 4/3/2024 at 3:27 PM, the Administrator was asked and confirmed she did not report the allegation of abuse to the police, the Ombudsman, or the APS. The Administrator also confirmed that she did not conduct and report a 5 day follow up to the state.

Based on medical record review and interview, the facility failed to provide 5 of 5 sampled residents (Resident #2, #8, #21, #26, and #32) reviewed with the Advanced Beneficiary Notice (ABN), Center for Medicare and Medicaid Services (CMS)- when therapy services were discontinued, and the resident remained in the facility for long-term care services or was discharged from the facility. This failure left the residents without information related to the cost of therapy services if they desired to continue the services in the facility and did not allow for them to have an informed choice. The findings include: Review of the facility's policy titled, Policy & [and] Procedure: Advanced Beneficiary Notice, dated 2/1/2017, revealed .To provide a resident or the responsible party/representative with a notice that skilled will be discontinued as it related to financial liability and their specific rights to appeal when the resident no longer meets skilled care requirements .A resident or their responsible party/representative will be notified in a timely manner when the resident no longer meets the requirements for skilled care .the form will be reviewed with the resident or responsible party/ representative .Signatures will be obtained from the resident or their responsible party/representative and dated to acknowledge they have received . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the ABN for Resident #2 revealed her skilled days ended on 10/1/2021 and the responsible party signed the form on 9/30/2021. The facility failed to provide a timely notice, therefore, the resident and representative were not provided with the choice to continue the services, pay privately for the services, or to stop the services. Review of the medical record, revealed Resident #8 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the ABN for Resident #8 revealed her skilled days ended on 10/15/2021 and the resident signed the form on 10/15/2021. The facility failed to provide a timely notice, therefore, the resident and representative were not provided with the choice to continue the services, pay privately for the services, or to stop the services. Review of the medical record, revealed Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the ABN for Resident #21 revealed his skilled days ended on 1/14/2022 and the responsible party signed the form on 1/14/2022. The facility failed to provide a timely notice, therefore, the resident and representative were not provided with the choice to continue the services, pay privately for the services, or to stop the services. Review of the medical record, revealed Resident #26 was admitted to the facility on [DATE] with readmission on 7/14/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the ABN for Resident #26 revealed his skilled days ended on 12/14/2021 and the responsible party signed the form on 12/14/2021. The facility failed to provide a timely notice, therefore, the resident and representative were not provided with the choice to continue the services, pay privately for the services, or to stop the services. Review of the medical record, revealed Resident #32 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the ABN for Resident #32 revealed her skilled days ended on 12/31/2021 and the resident signed the form on12/31/2021. The facility failed to provide a timely notice, therefore, the resident and representative were not provided with the choice to continue the services, pay privately for the services, or to stop the services. During an interview on 3/29/2022 at 10:50 AM, the Minimum Data Set (MDS) Coordinator stated, .I don't know the timeframe for the appeal after the end of skilled services . During an interview on 3/30/2022 9:35 AM, the Director of Nursing (DON) confirmed that a one day notice or less is not acceptable for notification that services are ending.

Based on policy review, medical record review, and interview, the facility failed to update and revise the Care Plan for falls and the use of an antipsychotic and [CONDITION(S)] medications for 3 of 15 sampled residents (Resident #20, #28, and #29) reviewed for Care Plans. The findings include: Review of the facility's titled policy Policy & Procedure: Comprehensive Care Plan, dated 2/1/2017, revealed .To provide interdisciplinary communication with the resident and/or legal representative for purposes of the development of an individualized comprehensive plan of care .Knowledge of ongoing care needs .Brief audit of medical record to ensure applicable care areas are addressed, such as .fall interventions documented, appropriate and timely after each fall .[CONDITION(S)] medication review-diagnosis, reduction .Medications ordered . Review of the facility's titled policy Policy & Procedure: Fall Reporting, dated 2/1/2017, revealed .To identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries .To promote a systematic approach and monitoring process for the care of residents who have fallen and/or those who are determined to be at risk . Review of the medical record, revealed Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Notes and Incident Reports, revealed Resident #20 had falls on 1/4/2022 and 2/25/2022. Review of the Care Plan dated 2/22/2022, revealed there were no new interventions documented on the Care Plan for the falls on 1/4/2022 and 2/25/2022. Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .by moth three times a day . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .by mouth .two times day . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .by mouth .at bed time . Review of the Care Plan last revised 3/27/2022, revealed Resident #28 was not care planned for the use of an antipsychotic or antidepressant medications. Review of the medical record, revealed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .by mouth at bedtime . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .by mouth one time day .DEPRESSION . Review of the Care Plan dated 2/25/2022, revealed Resident #29 was not care planned for the use of an antipsychotic medication or antidepressants. During an interview on 3/30/22 at 12:47 PM, the Director of Nursing (DON) stated, .medication side effects and adverse reactions should be care planned . The DON confirmed that Resident #20's falls and the interventions for the falls were not addressed on the Care Plan.

Based on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect when 2 of 5 staff members (Certified Nursing Assistant (CNA) #1 and #2) failed to use courtesy titles during dining observations for 2 of 30 residents (Resident #10 and #14) observed, and when CNA #1 addressed Resident #5 with a title of endearment at the Nurses' Station during a random observation. The findings include: Review of the facility's policy titled, Policy & [and] Procedure: Resident Rights, dated 2/1/2017, revealed .to ensure each resident is treated with consideration, respect and in full recognition of his or her dignity and individuality . Review of the facility's policy titled, Policy & Procedure: Name Preference, dated 2/1/2017, revealed .To ensure resident is addressed by the name they prefer . Observation in the resident's room on 3/27/2022 at 12:30 PM, revealed CNA #2 stated to Resident #10, .ready to eat baby . Observation in the Television Room on 3/27/2022 at 12:50 PM, revealed CNA #1 stated to Resident #14, .come on baby lets go eat .come on honey . Random observation at the Nurses' Station on 3/28/2022 at 8:09 AM, revealed CNA #1 stated to Resident #5, .this way baby . During an interview on 3/30/2022 at 9:35 AM, the Director of Nursing (DON) confirmed staff should not use terms of endearment to address residents such as honey, baby, or sweetie.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure care and services were provided for 2 of 2 residents (Resident #19 and #26) reviewed for the use of an indwelling urinary catheter and when 1 of 1 (Certified Nursing Assistant (CNA) #1) failed to maintain infection control practices for 1 of 2 sampled residents (Resident #26) observed during indwelling urinary catheter care. The findings include: Review of the facility's policy titled, Catheter Care, dated 2/1/2017, revealed .Staff will maintain consistent and adequate hygiene standards for residents with an indwelling catheter in order to maintain comfort, function, and prevent infection .dispose of contaminated items . Review of the medical record, revealed Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) dated [DATE] and the quarterly MDS dated [DATE], revealed Resident #19 had an indwelling urinary catheter. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) dated 2/2022, revealed there was no documentation Resident #19 received care for the indwelling urinary catheter. Review of the medical record, revealed Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #26 had an indwelling urinary catheter. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) from 2/1/2022 to 2/28/2022 and 3/1/2022 to 3/30/2022, revealed there was no documentation that Resident #26 received care for the indwelling urinary catheter. Observation in the resident's room during indwelling urinary catheter care on 3/29/2022 beginning at 9:33 AM, revealed CNA #1 performed catheter care for Resident #26 and placed the soiled wash cloths onto the bare floor next to the resident's bed. CNA #1 used a clean towel to pick up the soiled linen from the floor, exited the room, and placed the soiled linen in a hamper. During an interview on 3/29/2022 at 1:24 PM, with the Director of Nursing (DON) confirmed there should be documentation for urinary catheter care and that there was no documentation for the catheter care. The DON further confirmed soiled linen should not be placed on the bare floor, a barrier should be used for soiled linen, and it should be placed in a plastic bag for transport out of the room. During an interview on 3/30/2022 at 3:00 PM, the DON stated, .there was no order for the indwelling urinary catheter .

Based on policy review, medical record review, review of incident reports, review of fall investigation reports, observation and interview, the facility failed to follow the facility's fall prevention policy related to implementing appropriate interventions after a fall, update the care plan for a fall and review resident falls during the weekly risk management committee meetings for 3 of 7 (Residents #24, 26 and 6) sampled residents reviewed with falls. The facility failed to ensure a body alarm was attached as care planned which resulted in actual harm when Resident #24 fell while getting out of bed sustaining a fractured nose on [DATE]. The failure to implement a new intervention after each fall resulted in actual harm when Resident #26 fell again sustaining a left hip fracture. The facility failed to ensure an evaluation was completed for gait training which resulted in actual harm when Resident #6 fell again, sustaining a laceration that required sutures. This resulted in Substandard Quality of Care. An extended survey was completed on [DATE]. The findings included: 1. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 3, indicating severe cognitive impairment and a history of falls in the last the last 6 months prior to admission. The quarterly MDS dated [DATE] documented a BIMS of 2, indicating severe cognitive impairment, and 2 falls since the admission MDS was completed. The care plan dated [DATE] documented, .I have potential for falls . Interventions . I wear a body alarm at all times . During the period of [DATE] to [DATE] there were 13 assessments that documented Resident #24 was high risk for falls. Fall investigation reports documented the following: a. [DATE] - .Fall . Resident was found on the floor in front of his chair . ROOT CAUSE . Nurse was assisting CNA's (Certified Nursing Assistants) when alarm sounded . when they reached the area . resident was in (on) the floor . INTERVENTIONS . Respond to alarm in a timely manner . b. [DATE] - .Fall . Resident's body alarm was going off and CNA went to check on resident . resident was lying in (on) the floor . Skin tear . right knee . Resident apparently climbed out from the foot of the bed . ROOT CAUSE . Alarm sounded . staff went into resident's room . found him in (on) the floor at the foot of his bed . Resident climbed out of the foot of his bed and fell on the floor causing a skin tear to his knee . INTERVENTIONS . MD (Medical Doctor) . notified . Keep resident close to nurses station while awake . check on resident often while in bed sleeping . c. [DATE] - .Fall . Resident was sitting in the hallway in broda chair . Nurse heard alarm sound . Nurse observed resident attempt to stand up before she could respond. Resident sat on floor on buttocks in front of wc (wheelchair) . INTERVENTIONS . MD notified . ensure . needs are being met (toileting, hunger, thirst, pain) . then provide activities to keep resident's mind off of standing up . d. [DATE] - .Fall . Resident was sitting in broda chair in hallway . Nurse and cna observed resident roll out to side of chair and fall in (on) floor onto R (right) side before staff able to respond . ROOT CAUSE . Resident rolled over the side of his broda chair, causing him to fall on the floor. resident was stating he was wanting to go home . INTERVENTIONS . MD notified . Call wife if resident becomes too restless . see if she will come sit with him . e. [DATE] - .Fall . Residents body alarm sounding . Went to residents room and found resident sitting in (on) the floor on mat next to bed . ROOT CAUSE Alarm sounded . staff found resident sitting in (on) floor in his room . He had attempted to get out of bed and cannot walk without assistance . INTERVENTIONS . Assessment . Tx (treatment) . to abrasion . MD . notified . f. [DATE] - .Fall . CNA called nurse to room . Pt (patient) observed sitting in (on) the floor next to his bed . transferred to wheelchair . MD and DON (Director of Nursing) made aware . ROOT CAUSE . yelling in his bed for his wife . found on floor . Alarm did not sound . resident had unclipped it from his clothes . became combative . Interventions . MD . notified . Resident was sent out to (named facility) for continuous behavior issues . g. [DATE] - .Staff heard resident's body alarm and responded to room . Resident . sitting on side of bed . staff assisted to floor on mat when began slipping off bed . ROOT CAUSE . Resident sitting on side of bed . doesn't have much muscle strength area or legs . began to slide of the bed . alarm sounded . staff came . lowered him to fall mat . INTERVENTIONS . MD . notified . Get resident out of bed if awake longer than 10- (to) 20 minutes . h. [DATE] - .Fall . Staff heard resident alarm sound . staff responded . found sitting on buttocks on floor mat in front of bed . stated he was trying to go to pee . md . don (director of nursing) aware . INTERVENTIONS . MD . notified . Toilet resident before and after meals . PRN (as needed) . i. [DATE] - .Fall . Resident was in bed after breakfast . Staff heard resident yelling help . Staff found resident sitting on floor next to bed on buttocks . Resident noted to be wet and soiled . md don . aware . Resident to be assisted to restroom before bed . ROOT CAUSE . Resident was wet and soiled . INTERVENTIONS . MD . notified . j. [DATE] - .Fall . nurse was alerted to the fall by CNA taking care of resident . patient was lying on his right side in the floor next to the blue mat beside the bed . right elbow bleeding . Elbow has . 2.4in (inch) x (by) 3. 6in (inch) area where the skin skin had peeled off . bleeding . Resident stated he wanted to get up . ROOT CAUSE . Upon awaking . resident immediately tried to get up, knocking his wedge that keeps him in the middle of the bed onto the floor as he fell . INTERVENTIONS . MD . notified . Staff to get resident up between 5 & (and) 6 AM if he slept most of . night to prevent him from trying to get up himself . k. [DATE] - .Fall . Patient started yelling for help . CNA called me into room . Observed patient lying on the floor face down in pool of blood . EMS (Emergency Medical Services) was called . patient was transferred to Hospital . ROOT CAUSE . Resident fell out of bed resident's alarm was not attached to resident at time of fall so staff did not hear an alarm that would have alerted them that he was trying to get up . INTERVENTIONS . Resident was sent to the hospital for evaluation and treatment . Staff to be in-serviced about following care guides/care plans . A hospital report dated [DATE] documented, .Impression . Remote appearing left nasal bone and nasal process fractures . Interview with the DON on [DATE] at 2:55 PM, in the DON's office, the DON was asked about Resident #24's fall on [DATE]. The DON stated, He was sent to the hospital. He fell out of bed. His alarm was not attached. The DON was asked if she would expect the alarm to be attached to the bed when Resident #24 was in bed. The DON stated, Yes, I do not know who did not attach it. The DON was asked if Resident #24 was injured after the fall. The DON stated, Apparently he fractured his nose. Interview with the DON on [DATE] at 5:20 PM, in the hall outside the Administrator's office, the DON was asked where the CNAs would document the body alarm. The DON stated, They do not document. The DON was asked if she knew who had taken care of Resident #24 the night he fell . The DON stated, I haven't found out, yet. Interview with CNA #2 on [DATE] at 8:00 AM, in the conference room, CNA #2 was asked if she worked the night shift on [DATE] when Resident #24 fell . CNA #2 stated, I worked 10 PM to 6 AM. I was working by myself that night. We were one short. Then I heard him (Resident #24) calling out, he was laying in (on) the floor. There was blood. The alarm never sounded. More than likely it was not attached. I was here working by myself and taking care of 30 people. CNA #2 was asked how often are alarms checked and if the alarm was checked on the 2:00 rounds. CNA #2 stated, I didn't check. CNA #2 was asked if there is documentation of alarms being checked every 2 hours. CNA #2 stated, No, half the time they don't work. They have tape on the back where the cover is missing and the batteries will come out. Interview with the DON on [DATE] at 8:45 AM, in the DON's office, the DON was asked, who does the scheduling. The DON stated, I do. The DON was asked who is responsible for getting someone to work if someone calls in. The DON stated, I have told them to work on it themselves. If have a lot going on, I'll do it. The DON was asked where a copy of the December, 2015 working schedule was located. The DON stated, I don't keep those. I don't have it. The DON was asked what she did about the call in for the night of [DATE] going into [DATE]. The DON stated, I don't know if the CNAs took the call or if they know how to do it. CNA #3 has been having a lot of car trouble, so she hasn't been able to come in for awhile. The DON pointed to the master schedule where CNA #3 had been marked off on 8 previous shifts for January, 2016. The DON was asked if CNA #3 had called her the 24th ([DATE]). The DON stated, No, I assume she was going to call in because I tried to get CNA #1 to work. The DON was asked if she was referring to CNA #1 who has an expired certification. The DON stated, Yes. The DON was asked if she has talked with Licensed Practical Nurse (LPN) #2 about that night. The DON stated, I haven't asked her about it. Interview with the DON on [DATE] at 9:45 AM, in the business office, the DON was asked if there was any documentation of alarms being checked. The DON stated, No. Telephone interview with LPN #2 on [DATE] at 10:10 AM, LPN #2 was asked about the night Resident #24 fell . LPN #2 stated, That night was so hectic. LPN #2 was asked if the bed alarm was on. LPN #2 stated, I didn't remember if he did or did not have an alarm. Interview with the Administrator on [DATE] at 2:25 PM, in the conference room, the Administrator was asked if she was aware that the night shift staff had been working short handed throughout December, 2015 and January, 2016 due to CNA #3 having car trouble. The Administrator stated, That particular subject has come up in the last two weeks with the DON . she would be expected to come in. The Administrator was asked if she was aware that some of the clip alarms were taped with bandage tape to keep the battery covers on or to take the place of the battery covers. The Administrator stated, That's news to me. The Administrator was asked where the CNAs document what they do for residents and their rounds and alarm checks. The Administrator stated, At one time we had it on the MARs (Medication Administration Records). The DON said no to that so we took it off. It needs to be somewhere where they can document it. The facility failed to ensure the fall intervention of a body alarm was in place as care planned which resulted in actual harm when Resident #24 fell while getting out of bed sustaining a fractured nose on [DATE]. 2. Medical record review revealed Resident #26 was admitted [DATE] to the facility and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Psychiatric Progress notes dated [DATE] revealed .paranoia is worsening . does not give correct date and time . not aware of current events . [DATE] . does not give correct date and time . not aware of current events . increased delusions . [DATE] . is always confused . self-care skills are impaired and she depends on others to perform them . not aware of current events . [DATE] . always confused . does not correctly give current location . date and time . The Prospective Payment System (PPS) MDS dated [DATE] indicated severe cognitive impairment and required assistance with mobility, toilet use and transfer. The MDS dated [DATE] indicated moderately impaired cognitive skills for daily decision making and required assistance with mobility, toilet use and transfer. The revised comprehensive plan dated [DATE] documented Resident #26 had a potential for falls and injuries related decrease mobility with interventions that were not updated with fall on [DATE]. Interventions for the fall on [DATE] was encourage with toileting, the fall on [DATE] was resident will call for assistance and the fall on [DATE] was the same intervention as on [DATE] to encourage with toileting. The care plan was not updated with a intervention for fall on [DATE]. Interventions for falls on [DATE], [DATE] and [DATE] were not appropriate for Resident #26's severe cognitive impairment. Review the fall risk assessments for Resident #26 dated [DATE] - [DATE] documented high risk for falls. Review of the Fall Investigation reports documented Resident #26 sustained ten falls from [DATE] through [DATE]. The Fall Investigation reports documented: a. [DATE] - .Resident loss balance slid to floor . Root Cause . walking fast and lost her balance causing her to fall . Interventions . encourage resident to take her time when ambulating with rolling walker . b. [DATE] - .resident observed lying supine in floor next to dining room chair . trying to sit down with my coffee and lost my footing . root cause got her coffee and carried it back to her seat . was not using her walker . Interventions . encourage resident to ask and allow staff to prepare drinks . c. [DATE] - .resident in dining room . resident holding onto rolling walker, staggering . breaks were unlocked. Resident fell in floor landing on left hand . Injury . hematoma to right hand . skin discoloration left hand . Root Cause . attempting to transfer and the brakes were not locked on her rolling walker the walker rolled causing her to fall . Intervention . remind resident to lock the breaks before transferring to prevent walker from rolling causing her to fall . d. [DATE] - .resident lying on floor . interventions . encourage resident to toilet . Injury . skin discoloration . Root Cause . trying to get to bathroom in hurry . tried to open door and fell . incontinent when staff helped her up . interventions . assist and encourage resident to toilet every two hours and as need . e. [DATE] - .resident attempting to walk to bathroom and tripped over walker wheel . Interventions resident to call for assistance . Injury none . root cause resident attempting to walk to bathroom and tripped over walker wheel . Interventions resident to call for assistance . f. [DATE] - .resident reached for walker and began to fall backwards . hit head on floor . Injury small red area to back of head . skin tear to right elbow . abrasion to left knee bruising to left knee . Root Cause .in dining room and her walker was about 5 feet away . Interventions . to keep walker close by and assist her to and from dining room . g. [DATE] - resident up ambulating . heard loud noise and noted resident lying supine in middle of hallway . Root Cause resident ambulating with walker and fell backwards to floor hitting head . Injury c/o (complained of) pain to lle (left lower extremity) with inability to flex . significant amount of blood from back of head and 2 small skin tears to both elbows . to ER (emergency room ) no fx (fracture) . Intervention - nwb (no weight bearing) on left side . treatment to head laceration . There was no intervention documented following this fall. h. [DATE] - .resident trying to walk to restroom and fell could get her . states that she was trying to go the restroom . Injury skin tear to left elbow . Root Cause resident attempting to walk to restroom and fell before nurse could catch her . Intervention assist resident to toilet every 2 hours and as needed . i. [DATE] - .resident fell in floor sitting upright against bedside table attempted to self-transfer from chair to bed . Injury . left hip . taken to hospital . fx left hip . Root Cause resident attempted to self-transfer from chair to bed and fell in the floor . Assessment . probable left hip fx noted . Interventions .body alarm to chair on return to alert staff of attempted transfer attempts . The radiology report dated [DATE] documented .Fracture left hip . j. [DATE] - resident was sitting in w/c (wheelchair) in lounge . find resident lying on r (right) side on floor . observed a quarter size hematoma with swelling noted to R (right) temple . sent to ER . Root Cause . Resident fell asleep in her chair and fell on the floor . Interventions . Staff to put resident in bed if asleep in chair . Observations in the dining room on [DATE] at 6:08 PM, revealed Resident #26 sitting in wheelchair eating supper. Slight bruising (quarter size) barely visible over left eye. Confusion noted had to be cued to finish supper meal. Observations on the A hall on [DATE] at 9:24 AM, revealed Resident #26 sitting in wheelchair by the medication cart, confusion was noted as the nurse talked to the resident. Interview with the DON on [DATE] at 10:20 AM, in the conference room, the DON was asked if a risk management committee meeting meets weekly for falls. The DON stated No. The DON was asked if Resident #26 would remember to call for help. The DON stated, She is confused. I doubt it. The DON was asked is it was appropriate to repeat the same intervention to assist with toilet every 2 hours for the falls on [DATE] and [DATE]. The DON stated, No. The DON was asked if no weight bearing to left side was an intervention or an order. The DON stated, No, it was an order. The failure to implement a new intervention after each fall resulted in actual harm when Resident #26 fell again sustaining a left hip fracture. 3. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with Dementia with Behavioral Disturbance, Anxiety, Depression, Alzheimer's Disease, Abnormalities of Gait and Mobility, Muscle Weakness, [DIAGNOSES REDACTED], Atherosclerotic Heart Disease and Hypertension. The annual MDS dated [DATE] documented a BIMS of 3, indicating severe cognitive impairment, required supervision for transfers and eating, required one person limited assistance for toileting, was totally dependent on staff for personal hygiene, balance was not steady during transitions and walking, and used a walker. The care plan dated [DATE] and continued to present documented, .I am at risk for falls/injuries r/t (related to) gait/balance problems . interventions . help to negotiate barriers in the lounge/hallway so that I may ambulate safely . provide diversions when resident is walking in hallways going door to door to help prevent falls . OT (Occupational Therapy) to evaluate and implement a treatment plan . During the period of [DATE] to [DATE] there were 11 assessments documenting that Resident #6 was a high risk for falls. The fall investigation reports documented the following: a. [DATE] - .Fall . Resident up walking down hallway near front bathrooms and fell to floor, unknown if feet got tangled in walker . Resident assessed . very difficult to arouse . this nurse having to do strong sternal rub . resident sent to ER (emergency room ) for evaluation . Staff Statement . I think she got caught up on her feet . I don't know I seen her fall . Staff Statement .I don't know if she tripped or what I just seen her go down . ROOT CAUSE . walking with walker and her feet got tangled up in the walker causing her to fall . INTERVENTIONS . PT (physical therapy) to eval (evaluate) for gait imbalance . b. [DATE] - .Fall . Resident was ambulating out of the lounge . lost balance . fell . ROOT CAUSE . Resident . ambulating with walker out of the lounge . lost her balance . fell against the recliner . landed on the floor . INTERVENTIONS . MD (Medical Doctor) notified . Help resident negotiate barriers in lounge so she may ambulate safely . c. [DATE] - .Fall . resident was on the floor lying on her stomach . another resident was beside her flipped back in her wheelchair . Bleeding noted . resident's right eye had a laceration above it . ROOT CAUSE . it appears as though this resident was about to fall and tried to catch herself or break her fall with other resident's w/c (wheelchair) . INTERVENTIONS . resident bleeding from a laceration above right eye . Sent out by EMS (emergency management services) for evaluation and treatment . MD notified . Observations in the common area on [DATE] at 2:00 PM, revealed Resident #6 stood up from her chair, used her walker, walked several feet to stand in front of another resident, then returned to the chair and sat back down without staff assistance. Observations in the common area on [DATE] at 2:15 PM, revealed Resident #6 stood up from her chair, used her walker, walked out of the common area, down the hallway, and into the dining room without staff assistance. Interview with the OT on [DATE] at 5:46 PM, in the rehabilitation office, the OT was asked about Resident #6 falling on [DATE] and the intervention for therapy to evaluate Resident #6 for gait imbalance. The OT stated, No, I don't have a report. Interview with the Administrator on [DATE] at 6:32 PM, in the Administrator's office, the Administrator was asked who does the evaluations on residents who fall. The Administrator stated, The OT is our Rehabilitation Director. He does. The Administrator was asked if therapy screenings should be documented. The Administrator stated, Yes. The facility failed to ensure an OT/PT evaluation was completed after the [DATE] fall, as planned. The failure to complete the evaluation resulted in actual harm when Resident #6 fell again on [DATE], sustaining a laceration that required sutures.

Based on policy review, review of daily staff posting, review of a consulting service agreement, medical record review, review of incident reports, review of fall investigation reports, observation and interview, the facility failed to be administered in a manner to implement appropriate interventions for each fall, failed to follow the policy related to falls, which resulted in actual harm to Residents #6, 24, and 26. The facility failed to ensure administration obtained the services of a Registered Dietician for Resident #2 with significant weight loss; administration failed ensure care plans were developed and implemented to meet the needs of the resident; administration failed ensure medications were administered to maintain resident's highest level of care, and administration failed to ensure the quality assurance program was effective in identifying issues and concerns within the facility. The findings included: 1. Administration failed to ensure the staff followed the facility's fall prevention policy related to implementing appropriate interventions after a fall, updated the care plan for a fall and review resident falls during the weekly risk management committee meetings for Residents #24, 26 and 6. The failure of the facility to follow the policy and implement appropriate interventions after each fall and to have an occupational / physical therapy evaluation for gait training and implementation of a treatment plan resulted in actual harm. The facility failed to ensure a body alarm was attached as care planned which resulted in actual harm when Resident #24 fell while getting out of bed sustaining a fractured nose on [DATE]. The failure to implement a new intervention after each fall resulted in actual harm when Resident #26 fell again sustaining a left [MEDICAL CONDITION]. The facility failed to ensure an evaluation was completed for gait training resulted in actual harm when Resident #6 fell again, sustaining a laceration that required sutures. Refer to F323. 2. Administration failed to ensure assessments were done accurately and care plans were developed and implemented to meet the needs of the resident. Refer to F278, F280 and F282. 3. Administration failed to ensure there was sufficient staffing. Interview with the Administrator on [DATE] at 3:40 PM, in the Administrator office, the Administrator was asked if Certified Nursing Assistant (CNA) #1 had worked this week. The Administrator stated, Yes, she's been doing personal care, baths, transfers and helped feed residents. The Administrator was asked if CNA #1's certification had an expired. The Administrator stated, It is. Interview with the Administrator on [DATE] at 2:25 PM, in the conference room, the Administrator was asked if she was aware that the night shift staff had been working short handed throughout December, 2015 and January, 2016 due to CNA #3 having car trouble. The Administrator stated, That particular subject has come up in the last two weeks with the DON . she would be expected to come in. Refer to F353 and F499. 4. Administration failed to identify, develop and implement appropriate plans of action to correct, monitor and reassess identified quality concerns in Quality Assurance and Assessment meetings. Interview with the Administrator on [DATE] at 2:25 PM, in the conference room, the Administrator was asked if she was aware that some of the clip alarms were taped with bandage tape to keep the battery covers on or to take the place of the battery covers. The Administrator stated, That's news to me. The Administrator was asked where the CNAs document what they do for residents and their rounds and alarm checks. The Administrator stated, At one time we had it on the MARs (Medication Administration Records). The DON said no to that so we took it off. It needs to be somewhere where they can document it. Refer to F323, F456 and F520. 5. Administration failed to ensure a [MEDICATION NAME] was administered correctly when nursing staff failed to clean the application site for 1 of 1 (Resident #3) resident observed receiving a [MEDICATION NAME] during the medication administration pass. Refer to F309. 6. Administration failed to ensure a resident was free of a significant medication error when 1 of 2 nurses (Licensed Practical Nurse (LPN) #1) failed to administer insulin within the proper time frame related to meals for Resident #4, who received an insulin injection. Refer to F333. 7. Administration failed to ensure a Registered Dietitian (RD) assessed and implemented interventions for 1 of 2 (Resident #2) nutritionally compromised sampled residents. Refer to F361 and F500.

Based on policy review, medical record review, review of incident reports, review of fall investigation reports, review of Quality Assurance (QA) Committee minutes and sign in sheets, observation, and interview, the facility failed to ensure the medical director (MD) assisted the facility with identifying and evaluating clinical concerns and failed to coordinate the medical care and provide clinical guidance and oversight regarding the implementation of resident care procedures. The facility failed to follow their fall policy and ensure the Medical Director assisted with addressing clinical concerns and provide guidance regarding resident care of the residents in the facility by failing to ensure there was appropriate interventions related to falls. The facility failed to ensure a body alarm was attached as care planned which resulted in actual harm when Resident #24 fell while getting out of bed sustaining a fractured nose on 1/25/16. The failure to implement a new intervention after each fall resulted in actual harm when Resident #26 fell again sustaining a left [MEDICAL CONDITION]. The facility failed to ensure an evaluation was completed for gait training resulted in actual harm when Resident #6 fell again, sustaining a laceration that required sutures. The findings included: The facility's Quality Improvement Committee Meeting Attendance Sign-in sheets dated 11/24/15, 12/17/15, and 1/20/16 documented the medical director was in attendance. Review of the facility's Incident by Incident Type form attached to the 11/24/15 Quality Improvement Committee Meeting sign-in sheet, revealed 16 fall incidents with 4 of those falls resulting in resident injury and documented, .Above IR (incident review) reviewed/discussed with Medical Director. Review of the facility's Incident by Incident Type form attached to the 12/17/15 Quality Improvement Committee Meeting sign-in sheet, revealed 11 fall incidents with 6 of those falls resulting in resident injury and documented, .above IR reviewed and discussed with Medical Director. Review of the facility's Incident by Incident Type form attached to the 1/20/16 Quality Improvement Committee Meeting sign-in sheet, revealed 14 fall incidents with 4 of those falls resulting in resident injury and documented, .above IR reviewed/discussed with MD. Telephone interview with Medical Director on 1/27/16 at 9:40 PM, the MD was asked if he had any concerns with falls at the facility. The MD stated, Well, I've always got concerns with falls. The MD was asked if he was concerned about the inordinate amount of falls at the facility? The MD stated, I wasn't aware of it. I don't know the average percentage of falls in facilities but I don't think we have an inordinate amount, with most of the falls it turns out they just slid down the wall and fell on their bottom. The MD was asked if he was aware that some clip alarms were missing battery covers and bandage tape was being used to hold the batteries in. The MD stated, That is totally inappropriate . The MD was asked if they discussed falls in Quality Assurance. The MD stated, Not that I recall, not a significant increase in falls. The MD was asked if he was aware that the Occupational Therapist did evaluations and screenings for residents, but did not always document them in the resident record? MD stated, No. Refer to F323.

Based on policy review, review of occurrence reports and investigations, review of staffing patterns, medical record review, observation and interview, the Quality Assessment and Assurance (QAA) committee was ineffective in identifying issues and concerns within the facility. The QAA committee failed to identify issues, develop and implement appropriate plans of action to correct quality deficiencies related to the facility not following their fall policy, not implementing appropriate interventions after each fall and failed to ensure an occupational or physical therapy evaluation was completed for gait training and implementation of a treatment plan which resulted in actual harm. The facility failed to ensure a body alarm was attached as care planned which resulted in actual harm when Resident #24 fell while getting out of bed sustaining a fractured nose on [DATE]. The facility failed to implement a new intervention after each fall resulted in actual harm when Resident #26 fell again sustaining a left [MEDICAL CONDITION]. The facility failed to ensure an evaluation was completed for gait training resulted in actual harm when Resident #6 fell again, sustaining a laceration that required sutures. The findings included: 1. The QAA committee failed to ensure care plan interventions were appropriate, revised, and followed by nursing staff to prevent falls and to prevent weight loss. Refer to F280, F282, F323, and 361. 2. The QAA committee failed to ensure that residents were protected from accident hazards related to falls resulting in actual harm for Residents #6, 24, and 26. Refer to F323. 3. The QAA committee failed to ensure the facility had sufficient staffing to care for residents or ensure a nursing assistant did not work after their certification had expired. Refer to F353 and F499. 4. The QAA committee failed to ensure Registered Dietitian (RD) services were provided. Refer to F280, F361, and F500. 5. Interview with the Administrator on [DATE] at 9:36 PM, in the Administrator's office, the Administrator was asked if the QAA committee had identified any clinical or medical issues. The Administrator stated, Yes, did have concerns about falls, tried to look at root cause, one particular resident falling a lot.

Based on policy review, medical record review, observations and interview, the facility failed to revise comprehensive care plans to reflect interventions related to weight loss and falls for 2 of 21 (Residents #26 and 2) sampled residents included in the stage 2 review. The failure to implement a new and appropriate interventions after each fall resulted in actual harm when Resident #26 fell again sustaining a left [MEDICAL CONDITION]. The findings included: 1. Review of the facility's Comprehensive Care Plan policy revealed, .i. fall interventions documented . after each fall . Medical record review revealed Resident #26 was admitted [DATE] to the facility and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Psychiatric Progress notes dated 12/15/14 revealed .paranoia is worsening . does not give correct date and time . not aware of current events . 2/27/15 . does not give correct date and time . not aware of current events . increased delusions . 3/18/15 .is always confused . self-care skills are impaired and she depends on others to perform them . not aware of current events . 4/8/15 . always confused . does not correctly give current location . date and time . The Prospective Payment System (PPS) MDS dated [DATE] indicated severe cognitive impairment and required assistance with mobility, toilet use and transfer. The MDS dated [DATE] indicated moderately impaired cognitive skills for daily decision making and required assistance with mobility, toilet use and transfer. The revised comprehensive plan dated 12/3/14 documented Resident #26 had a potential for falls and injuries related decrease mobility with interventions that were not updated with fall on 5/4/15. Interventions for the fall on 3/15/15 was encourage with toileting, the fall on 3/28/15 was resident will call for assistance and the fall on 6/15/15 was the same intervention as on 3/15/15 to encourage with toileting. The care plan was not updated with a intervention for fall on 5/4/15. Interventions for falls on 2/1/15, 3/15/15 and 6/15/15 were not appropriate for Resident #26's severe cognitive impairment. Review the fall risk assessments for Resident #26 dated 1/27/15 through 6/29/15 documented high risk for falls. The Fall Investigation reports documented: a. 2/1/15 - .resident in dining room . resident holding onto rolling walker, staggering . breaks were unlocked. Resident fell in floor landing on left hand . Injury . hematoma to right hand . skin discoloration left hand . Root Cause . attempting to transfer and the brakes were not locked on her rolling walker the walker rolled causing her to fall . Intervention . remind resident to lock the breaks before transferring to prevent walker from rolling causing her to fall . b. 3/15/15 - .resident lying on floor . interventions . encourage resident to toilet . Injury . skin discoloration . Root Cause . trying to get to bathroom in hurry . tried to open door and fell . incontinent when staff helped her up . interventions . assist and encourage resident to toilet every two hours and as need . c. 5/4/15 - resident up ambulating . heard loud noise and noted resident lying supine in middle of hallway . Root Cause resident ambulating with walker and fell backwards to floor hitting head . Injury c/o (complained of) pain to lle (left lower extremity) with inability to flex . significant amount of blood from back of head and 2 small skin tears to both elbows . to ER (emergency room ) no fx (fracture) . Intervention - nwb (no weight bearing) on left side . treatment to [MEDICAL CONDITION] . There was no intervention documented following this fall. d. 6/15/15 - .resident trying to walk to restroom and fell could get her . states that she was trying to go the restroom . Injury skin tear to left elbow . Root Cause resident attempting to walk to restroom and fell before nurse could catch her . Intervention assist resident to toilet every 2 hours and as needed . e. 6/29/15 - .resident fell in floor sitting upright against bedside table attempted to self-transfer from chair to bed . Injury . left hip . taken to hospital . fx left hip . Root Cause resident attempted to self-transfer from chair to bed and fell in the floor . Assessment . probable left hip fx noted . Interventions . body alarm to chair on return to alert staff of attempted transfer attempts . Review of a radiology report dated 6/29/15 documented .Fracture left hip . Observations in the dining room on 1/26/16 at 6:08 PM, revealed Resident #26 sitting in wheelchair eating supper. Slight bruising (quarter size) barely visible over left eye. Confusion noted had to be cued to finish supper meal. Observations on the A hall on 1/27/16 at 9:24 AM, revealed Resident #26 sitting in wheelchair by the medication cart, confusion was noted as the nurse talked to the resident. Interview with the Director of Nursing (DON) on 1/27/15 at 10:20 AM, in the conference room, the DON was asked if a risk management committee meeting meets weekly for falls. The DON stated No. The DON was asked if Resident #26 would remember to call for help. The DON stated, She is confused. I doubt it. The DON was asked is it was appropriate to repeat the same intervention to assist with toilet every 2 hours for the falls on 3/15/15 and 6/15/15. The DON stated, No. The DON was asked if no weight bearing to left side was an intervention or an order. The DON stated, No, it was an order. The failure to implement new appropriate interventions after each fall resulted in actual harm when Resident #26 fell again sustaining a left [MEDICAL CONDITION]. 2. Review of the facility's Comprehensive Care Plan policy revealed, .viii. Weight loss/gain addressed . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 required supervision and encouragement during meals and Resident #2 had no weight loss. Review of quarterly MDS dated [DATE] revealed Resident #2 had a weight loss of 5 percent (%) or more in the last month or 10% or more in last 6 months The Weights report documented Resident #2 experienced a 6.6 pound weight loss (5% loss) between 10/6/15 and 11/4/15, and a 10 pound weight loss (7% loss) between 12/12/15 and 1/11/16. The care plan dated 7/21/15 was not revised to include new interventions related to the significant weight loss. Review of the care plan meeting note dated 9/23/15 revealed, .will consult with RD (Registered Dietician) for supplement recommendations . The facility's Nutrition Alert Program policy documented, .Residents with a history of weight loss or at nutritional risk as determined by further criteria shall be followed by the Quality Assurance Team . 4. Additional approaches to increase overall calorie intake . RD/LD (Licensed Dietician) . Telephone interview with the RD, on 1/27/16 at 4:22 PM, in the conference room, the RD stated, Not been contacted about Resident #2 since May 2015. Interview with the DON on 1/27/16 at 6:39 PM, outside of the Administrator's office, the DON was asked at what point does the RD provide recommendations for a significant weight loss in October. The DON stated, The RD was not here in November. She has not been here since September. The DON was asked if the care plan should have been updated for Resident #2's significant weight loss. The DON stated, Yes.

Based on medical record review and interview, the facility failed to follow interventions related to falls for 3 of 21 (Residents #24, 6, and 2) sampled residents included in the stage 2 review. The facility failed to ensure a body alarm was attached as care planned which resulted in actual harm when Resident #24 fell while getting out of bed sustaining a fractured nose on 1/25/16. The facility failed to ensure an evaluation was completed for gait training which resulted in actual harm when Resident #6 fell again, sustaining a laceration that required sutures. The findings included: 1. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 12/2/15 documented, .I have potential for falls . Interventions . I wear a body alarm at all times . Resident #24's a body alarm was not attached on 1/25/16 when he fell getting out of bed. A fall investigation report dated 1/25/16 documented, .Fall . Patient started yelling for help . CNA called me into room . Observed patient lying on the floor face down in pool of blood . EMS (Emergency Medical Services) was called . patient was transferred to Hospital . ROOT CAUSE . Resident fell out of bed resident's alarm was not attached to resident at time of fall so staff did not hear an alarm that would have alerted them that he was trying to get up . INTERVENTIONS . Resident was sent to the hospital for evaluation and treatment . Staff to be in-serviced about following care guides/care plans . A hospital report dated 1/25/16 documented, .Impression . Remote appearing left nasal bone and nasal process fractures . Interview with the Director of Nursing (DON) on 1/26/16 at 2:55 PM, in the DON's office, the DON was asked about Resident #24's fall on 1/25/16. The DON stated, He fell out of bed and his alarm was not attached. The DON was asked if you would expect the alarm to be attached to the bed. The DON stated, Yes. The facility failed to ensure a body alarm was attached as care planned which resulted in actual harm when Resident #24 fell while getting out of bed sustaining a fractured nose on 1/25/16. 2. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with Dementia with Behavioral Disturbance, Depression, [MEDICAL CONDITION], Anxiety, Abnormalities of Gait and Mobility, Muscle Weakness, [MEDICAL CONDITION], Hypertension, and [MEDICAL CONDITIONS]. The care plan dated 12/2/14 and continued to present documented, .problem . risk for falls/injuries related to gait/balance problems . interventions . help to negotiate barriers in the lounge/hallway so that I may ambulate safely . provide diversions when resident is walking in hallways going door to door to help prevent falls . OT (Occupational Therapy) to evaluate and implement a treatment plan . The facility was unable to provide documentation the OT had completed an evaluation or implement a treatment plan for Resident #6 as documented in the care plan. Interview with the OT on 1/27/16 at 5:46 PM, in the rehabilitation office, the OT was asked about Resident #6 falling on 4/22/16 and the intervention for therapy to evaluate Resident #6 for gait imbalance. The OT stated, No, I don't have a report. Interview with the Administrator on 1/27/16 at 6:32 PM, in the Administrator's office, the Administrator was asked who does the evaluations on residents who fall. The Administrator stated, The OT is our Rehabilitation Director. The Administrator was asked if therapy evaluations should be documented. The Administrator stated, Yes. The facility failed to ensure an OT evaluation was completed after the 4/22/15 fall, as care planned. The failure to complete the evaluation resulted in actual harm when Resident #6 fell again on 9/26/15, sustaining a laceration that required sutures. 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] documented Resident #2 needed supervision oversight and encouragement during meals, had no swallowing disorder and no weight loss. The quarterly MDS dated [DATE] revealed Resident #2 needed supervision, oversight and encouragement during meals, no swallowing issues, did have a weight loss of 5 percent (%) or more in the last month or 10% or more in last 6 months. The care plan meeting note dated 9/23/15 documented, .care plan meeting held this day with residents POA (power of attorney) . will consult with RD (Registered Dietician) for supplemental recommendations . The care plan dated 10/16/12 documented, .Nutritional Evaluation quarterly. Date initiated 10/16/14 . The facility was unable to provide quarterly nutritional assessments for 2015, as care planned. Telephone interview with the Registered Dietician (RD) on 1/27/16 at 4:30 PM, in the conference room, the RD was asked about Resident #3 and the weight loss. The RD stated, Have not been contacted about Resident #3 since May 2015.