Every finding on record at Tuckerman Rehabilitation and Healthcare Center

Based on record review and interview, it was determined that the facility failed to issue a 30-day notice to residents when they planned to discharge them. This was evident for 2 (#3 and #4) of 2 residents reviewed for an inappropriate discharge. The findings include:Notice of Medicare Non-Coverage (NOMNC) is issued to a resident when their Medicare Part A coverage is going to end. Medicare Part A designates a certain number of days it will cover a stay in a nursing home. 1. A medical record review for Resident #3 on 10/28/25 at 9:44 AM revealed the Social Services Director (SSD) wrote on 6/16/25 that she attempted to issue a Notice of Medicare Non-Coverage (NOMNC) with the last date of coverage as 6/18/25 and a discharge date of 6/19/25. She noted the family declined to sign it, and she explained to them that the resident cannot be in hospice care at the facility. (A NOMNC was not required for a resident who was choosing hospice care because these services were covered by Medicare, but the resident's room and board may not be covered). Further review of the medical record failed to reveal that the resident and resident representative were notified in writing the reason for the discharge at least 30 days prior to discharge. During an interview on 10/30/25 at 1:39 PM with Resident #3's representative (RR), s/he reported that the family did not want the resident to be discharged home with hospice services because they felt it would be hard on the spouse who had dementia. The RR reported they were not issued a 30 day notice to inform them of the discharge and the basis of the discharge. The RR confirmed they had been issued a NOMNC which was confusing because the resident had Medicare days left. An interview with the SSD on 10/29/25 at 11:46 AM revealed she was told during a utilization review meeting to issue the NOMNC because the resident was no longer progressing in rehabilitation services. She stated that the facility discharged their residents when they stopped participating in therapy and needed long term care or hospice services. She confirmed that the resident's family had not initiated the discharge home. She reported that she assisted the family to set up hospice care at home. The SSD confirmed that she had not sent a 30-day discharge notice to the resident and the resident representative. An interview with the Director of Nursing (DON) on 10/29/25 at 12:52 PM revealed the facility discharged the resident because s/he needed hospice services. During an interview with the Nursing Home Administrator on 10/29/25 at 1:31 PM he confirmed that the resident was discharged because of the need for hospice care and they do not provide that service at the facility. Reviewed the concerns with him. 2. A medical record review for Resident #4 on 10/30/25 at 11:40 AM revealed a progress note written by the Social Services Director (SSD) on 8/18/25 that a Notice of Medicare Non-Coverage (NOMNC) was issued to the family with services ending on 8/20/25. In another note on 8/18/25, SSD documented the attending physician was made aware of the discharge to the community, the resident was going home with continued rehab services, and the family was appealing the NOMNC. Further review of the medical record failed to reveal a 30 - day discharge notice was issued to the resident's representative. An interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 10/31/2025 9:56 AM revealed the resident was discharged because they determined the resident would benefit from a memory care unit. During an interview with the Social Services Director (SSD) on 10/31/25 at 1:02 PM, she confirmed that she issued a NOMNC to Resident #4's family and not a 30 - day notice of discharge. Concerns were reviewed with the NHA and DON on 11/5/25 at 11:00 AM. Cross Reference: F627

Based on record review and interview, it was determined that the facility discharged a resident without an appropriate reason and failed to appropriately document the discharge of a resident. This was evident for 2 (#3 and #4) of 2 residents reviewed for an inappropriate discharge. The findings include:Hospice care - focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life. It is a service covered under Medicare Part A, but if a resident is in a nursing facility, they may have to pay room and board. Notice of Medicare Non-Coverage (NOMNC) is issued to a resident when their Medicare Part A coverage is going to end. Medicare Part A designates a certain number of days it will cover a stay in a nursing home. Advanced Beneficiary Notice (ABN) is issued to a resident when services they are receiving will not be covered by Medicare any longer. Such as, therapy services. 1. A medical record review for Resident #3 on 10/28/25 at 9:44 AM revealed a discharge summary from the hospital. According to this document dated 5/8/25, the resident had metastatic skin cancer that spread to the brain and lungs, bladder cancer, thymic cancer and had been recently hospitalized on multiple occasions. The last hospitalization was for 8 days due to acute encephalopathy with generalized weakness and a history of seizures. The resident was admitted to the facility for physical and occupational therapy. A review of the resident's admission contract revealed in section 2, care and services, it read that the facility offered hospice care. There was no mention in the contract that the facility had limited their services to short-term rehabilitation.A review of the progress notes revealed a note dated 6/18/25 that was written by the Social Services Director (SSD). The note read that the resident was admitted for rehabilitation and medical management of encephalopathy. Resident received a NOMNC [Notice of Medicare Non-Coverage] and the doctor was made aware to discharge back to the community under Hospice services. A NOMNC and appeal options discussed with resident and family. Another note written by the SSD on 6/16/25 read that she attempted to issue a NOMNC with last covered date of 6/18/25 and a discharge date of 6/19/25, however, the family declined to sign it. SSD documented she explained to them that the resident cannot be in hospice care at the facility. Further review of the record failed to reveal documentation that the resident met one of the reasons, defined in this regulation, a facility could initiate a discharge. On 10/29/25 at 12:04 PM a review of the facility's assessment revealed the facility was able to provide hospice services. On 10/31/25 at 10:30 AM a review of the grievance filed by the RR on 6/9/25 revealed that s/he made the Director of Nursing (DON) aware that they did not want the resident discharged . The family voiced concerns about taking the resident home because the spouse had dementia. The resolution was to have the family appeal the NOMNC, however this was misleading because Medicare will cover hospice care in a facility, but the family may be required to pay for room and board. On 11/3/25, the NHA provided a contract the facility had with a hospice provider that stated they would provide hospice care for the residents at the facility. On 8/20/25 the Office of Health Care Quality received a complaint alleging Resident #3 was inappropriately discharged from the facility because it was medically unsafe. A telephone interview conducted on 10/30/25 at 1:39 PM with the complainant revealed that they felt the facility had inappropriately discharged the resident home because they felt that it would not be good for the resident's spouse who had dementia. The complainant confirmed that they were not made aware of limitations in the services provided at the facility at the time of admission or they would have chosen another facility. The complainant reported that once the SSD issued them the NOMNC, it felt that the SSD, the Business Office Manager, and the Director of Nursing (DON) were trying to get rid of the resident. The complainant reported that the family appealed to the NOMNC, tried to find another facility for the resident to go to but was unsuccessful because of the resident's sacral wound, and filed a grievance with the facility. The complainant reported that s/he spoke to the Nursing Home Administrator (NHA) who told them it was unacceptable to discharge a resident because they needed hospice care and that he would check into it. However, he came back and told them the facility did not have the means to care for the resident because s/he needed hospice care. The complainant reported that they took Resident #3 home because they were concerned about the care s/he would receive since the facility was trying to discharge him/her. An interview with the Social Services Director on 10/29/25 at 11:46 AM revealed that she attended utilization review meetings with the interdisciplinary team to discuss each resident's potential in rehabilitation. She reported that when it was determined the resident was no longer participating or plateaued in therapy; then she was told to issue a Notice of Medicare Non-Coverage (NOMNC) and discharge them. She stated the facility does not offer long-term care they offer short term rehab. She confirmed that she informed Resident #3's representative that they do not provide hospice care in the facility. She confirmed that the family voiced concerns about taking the resident home due to the spouse's medical condition and they tried to find another facility that would take the resident. The Director of Nursing (DON) was interviewed on 10/29/25 at 12:52 PM and she reported Resident #3 was admitted to the facility for short term rehab to get him/her back to their prior level of function and then discharge the resident. However, while the resident was at the facility s/he declined quickly and was unable to participate in therapy and needed hospice care. The DON stated this was fully expected given the resident's medical condition. She confirmed that the resident was discharged because s/he needed hospice care and they did not provide that service. The regulatory requirements for discharge was reviewed with the DON and she agreed that the resident had not met any of the regulator requirements for discharge. During an interview with the Nursing Home Administrator (NHA) on 10/29/2025 at 12:11 PM he confirmed that the facility was a dual certified facility and had an agreement with the state. He reported that since he became the administrator a little over a year ago, they accepted residents with Medicare days and in need of short-term rehabilitation services. He reported they will provide hospice care for a few days until they can discharge the resident. He reported that the facility had not been admitting residents with Medicaid and once admitted a resident in need of Medicaid was discharged to another facility for long-term care. The regulatory requirements for discharge were reviewed with the NHA, and he agreed that this resident had not met the requirement for a discharge. During a subsequent interview with the NHA and DON on 10/31/25 at 9:56 AM they denied that the facility had initiated the discharge of Resident #3, stating it was initiated by the family because they set up hospice care and transportation for the resident. When asked for documentation to support this claim, they stated they would provide it, however, they failed to do so by the end of the survey. 2. A medical record review for Resident #4 on 10/30/25 at 11:40 AM revealed a Discharge summary dated [DATE] that noted the resident had advanced dementia and that palliative versus hospice options were discussed with the resident's family. A review of the section for physical therapy participation staff noted that the resident tolerated it poorly and was unable to understand treatment and s/he had limited ability to participate due to dementia. In addition, staff noted the resident was unable to follow commands and gestures. A review of the minimum data set with an assessment reference date of 7/3/25 revealed the resident had severe cognitive impairment. Review of the progress notes revealed an attending physician progress note date 7/23/25 that noted the resident was end-stage dementia. Further noting that he discussed with the family that the resident needed 24-hour nursing care or a memory care unit. Further review of the attending physician's notes revealed no documentation that the facility was unable to meet the needs of the resident and what those needs were. A note written by Nurse Practitioner (NP) #1 on 8/18/25 revealed she wanted palliative care continued until the resident was transferred to long-term care. Further review of the NP's notes failed to reveal documentation that the facility was unable to provide care for the resident. A note written by the Social Services Director (SSD) on 8/18/25 that Notice of Medicare Non-Coverage (NOMNC) was issued to the family with services ending on 8/20/25. In another note on 8/18/25, SSD documented the attending physician was made aware of the discharge to the community, the resident was going home with continued rehab services, and the family was appealing the NOMNC. Further review revealed that there was no documentation that indicated the resident's needs could not be met at the facility. An interview on 10/30/25 at 12:25 PM with Resident #4's family member revealed they were not aware of the limited services provided by the facility. She stated that she was told that the resident was not participating in rehab so she needed to be discharged to a long-term care facility. She stated that she was trying to get the resident into a home of their choice but because of the pending Medicaid application she was unsuccessful. On 11/4/25 at 11:26 AM an interview with the attending physician revealed that Resident #4 was not a good candidate for the facility's short-term rehabilitation program. He stated that the staff were not trained to deal with the resident's behaviors due to the advanced stages of dementia. He reported the resident was sent to another facility that had a memory care unit. The findings were discussed with the DON on 11/5/25 at 10:44 AM and she confirmed the resident was discharged due to the need for a memory care unit. Cross Reference: F551 and F628

Based on record review and interview, it was determined that the facility failed to inform residents and/or resident representatives about limitations in the care services that they provided. This was evident for 1 (#3) of 2 residents reviewed for discharge.The findings include:Hospice care - focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life. On 11/3/25 at 2:15 PM a review of the facility admission packet, that was signed by Resident #3, was conducted. In section 2, care and services, ancillary it read that hospice services were provided. In section 3, transfers and discharges it read that resident will not be discharged unless the following criteria which did not include the need for hospice care or long-term care. In addition, the section regarding Medicaid coverage read, the facility participated in the Medicaid program and had a provider agreement with the state. There was no indication that there were limited services provided by the facility. A medical record review 10/28/25 at 9:44 AM revealed the discharge summary from the hospital for Resident #3. The following diagnoses were listed for the resident; metastatic (the cancer has spread to other areas of the body) scalp melanoma to the brain and lung, bladder cancer, and thymic cancer. The resident had been in the hospital for treatment of an infection and needed rehabilitation (rehab). A progress note written on 5/12/25 (4 days after the resident's admission) by Nurse Practitioner (NP) #1 revealed the family reported a decline. The resident was not talking, needed total care from staff, and she wrote the resident appeared frail and weak. Further noted the resident was considered end-of-life care. A progress note dated 6/16/25, written by the Social Services Director revealed the facility was discharging the resident back to the community for hospice care. She noted the family declined to sign the form and she explained to them that the resident cannot be in hospice care at the facility. An interview with Resident #3's representative on 10/30/25 at 1:39 PM revealed that they were not told at the time of admission that the facility was limited to rehabilitation services and planned to discharge the resident if s/he needed long-term care and/or hospice care. The representative reported that the Social Services Director (SSD) informed her that she would need to either take Resident #3 home or place him/her in an inpatient hospice facility. The representative reported that they filed a grievance with the facility, however, the SSD continued to contact them about discharging the resident. The representative reported that they finally contacted a hospice group and brought Resident #3 home.On 10/29/25 at 11:46 AM an interview with the SSD revealed she had been employed at the facility for the past 2 years. She reported that the facility had a Utilization Review meeting conducted with the interdisciplinary team to discuss each resident. When a resident was not participating in therapy or plateaued then she issued a NOMNC (Notice of Medicare Non-Coverage) form to them. If they needed long-term care or hospice care, she was told to work with them to find new placement. She confirmed she told Resident #3's family that the resident could not stay at the facility while receiving hospice care. The Nursing Home Administrator (NHA) was interviewed on 10/29/25 at 12:11 PM. He confirmed that they accepted residents with Medicare that needed skilled services, especially short-term rehabilitation. When asked what happened when a resident needed long-term care or hospice care, he stated facility staff would assist them to find new placement. He confirmed that this was not in the admission packet provided to the residents. He stated that they were told verbally. Reviewed the concerns and he acknowledged them. On 11/4/25 at 11:26 AM an interview with the Resident's attending physician confirmed that residents who need long-term care and/or hospice care were transferred to another facility. He reported that Resident #3 had a poor prognosis when s/he was admitted and was not a good fit for the facility because they specialize in rehabilitation services.

Based on record review and interview, it was determined that facility staff failed to ensure that residents were free of chemical restraints and that PRN (as needed medications) psychotropics were limited to 14 days. This was evident for 1 (#4) of 2 residents reviewed for discharge. The findings include:A review of the transferring facility's medication list for Resident #4 on 11/4/25 at 11:00 AM revealed the resident was on quetiapine (an antipsychotic medication) for sundowning since 3/12/25 and lorazepam as needed every 8 hours for anxiety since 5/16/25. A medical record review on 10/30/25 at 11:40 AM for Resident #4 revealed a an informed consent form for use of psychotropic (mind altering drugs to include antipsychotics and antianxiety medications) medications that documented the resident was on quetiapine and lorazepam because all nonpharmacological approaches had been attempted with no alleviation of the symptoms, however this form was signed on the day the resident was admitted to the facility. A review of the physician's orders revealed an order for lorazepam 0.5 mg tablet to be given by mouth every 8 hours as needed for anxiety that was dated 6/30/25 with a revision date of 10/7/25. On 6/30/25 the resident was ordered quetiapine 25 mg 2 times a day by mouth for Alzheimer's/behaviors. There was an order on 7/15/25 to increase the amount of the quetiapine to 50 mg every morning and at bedtime for psycho-affective disorder (this is not a diagnosis). Further review of the orders failed to reveal an order to monitor the behaviors for which the resident was ordered these medications. In addition, there was no evidence that a gradual dose reduction of the medications was attempted. A continued medical record review on 11/4/25 at 10:18 AM revealed the resident was seen by a contracted psychiatric Nurse Practitioner (NP) on 3 occasions during his/her stay. On 7/1/25, she noted that the resident was delusional. On 9/2/25, she documented she visited the resident due to increased agitation and aggression, and refusal of care. She documented to continue the quetiapine to modify behavior such that normal care is possible while the resident is in the nursing home. Further noted was the quetiapine was given for behavior modification. During a visit on 10/2/25 it was noted that nursing staff confirm increased cooperativeness and decreased behavioral disturbances. Resident was participating more in care routines with no recent episodes of aggression, wandering, or care refusal reported. The diagnoses listed were delusional disorders and vascular dementia, unspecified severity, with psychotic disturbances. However, a review of the behavior notes revealed the resident was not being monitored for the behaviors that the antipsychotic was being given. A review of the resident's medication administration record for July 2025 - October 2025 revealed that the resident was administered the lorazepam on 9 occasions by the same nurse, Registered Nurse (RN) #2. There was no documentation as to why the medication was given and the nonpharmacological interventions were attempted prior to giving the medication.An interview with the attending physician on 11/4/25 at 11:26 AM revealed Resident #4 had trouble adjusting to the nursing home which was why he had increased the quetiapine from 25 mg to 50 mg. He stated the indication for the medication was entered incorrectly because it was for acute psychosis. He reported that acute psychosis would not last for 3 months and he left it up to the psychiatric NP to adjust the medications. Reviewed the concerns that there was no gradual dose reduction attempted. He stated that the resident would have went back to screaming and refusing care and medications. An interview with RN #2 on 11/4/25 at 12:23 PM revealed that she should have documented the symptoms the resident was having and the nonpharmacological interventions she attempted before giving the resident the lorazepam. She stated that she gave the medication because the resident was not calm, trying to get out of bed and the chair, and s/he was a fall risk. She reported that when she gave the medication the resident would eat in dining room without screaming and yelling, she would allow staff to provide care without pulling and biting them, and s/he would stay in bed. When asked if this was chemically restraining the resident, she stated she had that concern, but thought it was better that the resident could participate in the community. On 11/4/25 at 12:46 PM the Director of Nursing (DON) reported that she expected staff to monitor residents with routine psychotropics for the behaviors they were given the medication to control. She stated that when it was an as needed medication then she expected the nurses to document the behaviors they were having to indicate why it was given. She stated the goal was to try nonpharmacological interventions and then administer the as needed medication. She agreed that Alzheimer's was not an appropriate diagnosis for the quetiapine. Reviewed that the resident had an as needed order for lorazepam with no stop date. She agreed that it should have had a stop date of 14 days. Reviewed the concerns. She reported that she would look at the resident's record for behavior monitoring and documentation for the lorazepam and get back to the surveyor. A subsequent interview with the DON on 11/5/25 at 11:01 AM revealed she was unable to provide additional documentation that the resident was adequately monitored for the quetiapine. She reported that she was unable to find the documentation for the lorazepam. She stated she spoke with RN #2, who felt that she had not explained herself well to the surveyor and wrote a statement. However, this was after surveyor intervention. She agreed that the consent stating that all nonpharmacological interventions were exhausted that was signed on admission was not appropriate. The concerns were reviewed with the Nursing Home Administrator on 11/5/25 at 4:03 PM.

Based on record review and interview, it was determined that the facility failed to honor the wishes of the resident representative and allow the resident to stay at the facility while receiving hospice services. This was evident for 1 (#3) of 2 residents reviewed for discharge. The findings include:An interview with Resident #3's representative (RR) on 10/30/25 at 1:39 PM revealed that they were informed by the Social Services Director (SSD) the facility wanted to discharge the resident because they were unable to provide hospice services at the facility. The RR reported that s/he told facility staff they wanted the resident to stay at the facility and receive hospice care instead of taking the resident home. The RR reported that it was after they appealed the discharge two times, attempted to find another nursing home but were denied because of the wound care, and feeling pressured by facility staff to take the resident home; they finally took the resident home. A medical record review on 10/28/25 at 9:44 AM revealed a progress note dated 6/18/25 written by the SSD, that documented she tried to issue a Notice of Medicare Non-Coverage (NOMNC) with a discharge date of 6/19/25, but the resident's family did not sign the NOMNC. Further noting, SSD explained again that resident can not be on Hospice at [facility name].On 10/31/25 at 10:30 AM a review of the grievance filed by the RR on 6/9/25 revealed that s/he made the Director of Nursing (DON) aware that they did not want the resident discharged . The family voiced concerns about taking the resident home because the spouse had dementia. The resolution was to have the family appeal the NOMNC, however this was misleading because Medicare will cover hospice care in a facility, but the family may be required to pay for room and board. On 11/5/25 at 10:30 AM a review of the facility's contract with a hospice provider revealed that the facility had an agreement with them to come to the facility and provide hospice for their residents. An interview with the SSD on 10/29/2025 11:46 AM confirmed that she had informed the family that the resident could not stay at the facility for hospice care. She was informed during an interdisciplinary team meeting that Resident #3 wasn't participating in rehab and needed to be discharged with hospice care. She reported that the facility provided short-term rehab services, and they discharged resident once they needed hospice care and/or long-term care. The Director of Nursing (DON) was interviewed on 10/29/25 at 12:52 PM and reported that Resident #3 was rapidly declining and failed to participate in rehab and needed hospice care. She reported that they discharge residents when they needed hospice care and/or long-term care. She further reported that the facility was able to provide care for a resident in need of hospice services, but they preferred to discharge them. On 10/29/25 at 12:11 PM an interview with the Nursing Home Administrator (NHA) confirmed that Resident #3 was discharged because of his/her need for hospice care. He stated that they will provide it for a few days until they can discharge the resident to an inpatient hospice or hospice at home. He confirmed that the facility was a dually certified facility, meaning they accepted residents for rehabilitation and long-term care. Cross reference F627

Based on record reviews and interviews, it was determined that the facility failed to ensure a thorough investigation was completed for allegations of abuse. This was found to be evident for 2 (Resident #189 & 180) out of 8 Residents investigated for abuse during the recertification and complaint survey. The findings include: A review of the Facility Reported Incident (FRI) MD00183205 conducted on 04/24/25 at 9:07 AM revealed an allegation of abuse for Resident #189. The facility investigated the allegation of abuse, however failed to interview staff and obtain statements. During an interview conducted on 04/24/2025 at 10:19 AM, the Director of Nursing (DON) reviewed the facility ' s investigation and confirmed the investigation did not include staff interviews and statements. The DON further stated that he would look for staff statements and would follow up. The DON returned on 04/24/2025 at 12:03 PM and advised this surveyor that he was unable to locate staff interviews and statements. A review of the Facility Reported Incident (FRI) MD00181282 conducted on 04/25 /25 at 7:05 AM revealed an allegation of abuse for Resident #180. The facility investigated the allegation of abuse, however failed to interview residents, staff and obtain statements. During an interview conducted on 04/25/25 at 8:00 am, the DON stated he would look to see if he could locate resident and staff interviews. The DON returned on 04/25/2025 at 11:49 AM and advised this surveyor he was unable to locate interviews and statements for residents and staff. This surveyor advised the DON of the concern of not conducting a thorough investigation for allegations of abuse.

Based on record review and staff interview, it was determined that the facility failed to develop and implement policies and procedures for COVID-19 immunization for residents and staff. This deficient practice has the potential to affect all residents, staff, and visitors in the facility. Findings include: During the entrance conference with the Director of Nursing (DON) on 10/7/2021 at 11:20 AM, surveyors requested a copy of the COVID-19 Vaccination Policy & Procedures. DON submitted a documentation name 'COVID-19 Mitigation and Response Plan' on 10/7/2021 at 12:15 PM. However, COVID-19 Mitigation and Response Plan did not contained COVID- 19 Vaccination Policy and Procedures. On 10/8/2021 at 1:46 PM, an interview was conducted with DON. During the interview, DON stated since the COVID-19 vaccine had been mandatory for all staff, there was no written policy and procedure. On 10/8/2021 at 2:30 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that residents received COVID -19 vaccine from a vendor pharmacy, and residents or responsible parties received education on the benefits and potential side effects of the COVID-19 vaccine from the vendor. However, the facility failed to provide documentation to support their policies and procedures related to their Covid-19 vaccination administration.

Based on observation, clinical record review and staff interview, it was determined that the facility's staff failed to promptly notify the ordering physician of laboratory results for 1 of 5 residents selected for review of Unnecessary Medications during the survey (Resident #122). The findings include: On 02-24-2021, review of Resident #122 physician's orders [REDACTED]. Further record review revealed a lab report dated 02-13-2021 that documented the TSH result was pending. On 02-24-2021 at 3:00 PM, surveyor interviewed the Director of Nursing (DON) about the pending TSH result and she said she would follow up. On 02-24-2021 at 4:07 PM, the DON provided the TSH result that was reported by the lab on 02-16-2021 with a result of 8.37 (H) which was out of reference range (0.35-5.50 uIU/mL). Further interview revealed the staff didn't notify the physician of the results until after surveyor inquired about the results on 02-24-2021.

Based on surveyor observation and staff interviews, it was determined that the facility staff failed to store and serve food under sanitary conditions. This finding was evident in the facility's kitchen, dining room and passing of trays during Lunch observation. The findings include: 1. On 07-01-19 at 09:01 AM, surveyor tour of the kitchen revealed the following: A. Rotting lemons in a hard carton box among other non-spoiled lemons, middle shelf of walk-in refrigerator. B. Unlabeled one bag of carrots and 2 bags of bread, upper shelf and middle shelf of walk-in refrigerator C. Uncovered one bag of salad, middle shelf of walk-in refrigerator. D. Open and unlabeled one pack of frozen chicken and one pack of frozen burgers, middle shelf freezer room. E. Unlabeled and loosely covered with paper towel one strawberry cake, middle shelf freezer room. F. Three cartridges labeled Butane sitting next to food, middle shelf dry area food. On 07-01-19 at 09: 20AM, surveyor interview with the Dietary Manager revealed no further information. 2. On 07-01-19 at 12:20 PM surveyor observed facility staff #4 in the dining room when the lunch cart was delivered. Observation of the dining room revealed a hand sanitizer mounted on the wall near the kitchenette. However, surveyor did not observe facility staff washing their hands or applying hand sanitizer prior to serving residents' meals. Additionally, surveyor observed staff #4 who took trays to resident rooms. Staff #4 delivered trays to rooms 521,523, 554, 557 and 558. Staff #4 was not observed washing his/her hand or applying hand sanitizer after delivering and setting up trays in each of these rooms. On 07-01-19 at 12:30 PM, surveyor interview with the Director of Nursing revealed no further information.

Based on surveyor observation and interview of facility staff, it was determined that the facility staff failed to inspect and maintain an electrically powered air mattress in safe operating condition. This finding was evident for 1 of 17 residents selected for review during the survey (#19). The findings include: On 07-01-19 at 1PM, surveyor observation revealed that resident # 19 was laying on an electrically powered air mattress. However, the mattress on the bed was deflated. Surveyor made staff #1 aware. He/she unplugged the mattress power cord and plugged it back in the same wall plug. He/she said it was fixed. Surveyor saw on/off switch in the mattress had light on which indicates electrical power is on. Surveyor noted that the mattress was re-inflated. On 07-02-19, at 9AM, surveyor observed resident #19 laying on the deflated mattress again. Surveyor observed mattress power cord was plugged in wall plug but the on/off switch in the mattress had no light on which indicated that the electrical power was off. Surveyor made the Director of Nursing (DON) aware. The DON came to resident #19's room and checked the mattress, cord plug, and wall plug. The DON agreed that the mattress was not inflated. The DON said new mattress will be ordered for resident #19. Staff plugged in the mattress power cord to a different wall plug and the mattress was inflated. On 07-03-19, at 11 AM, follow up with the DON revealed that new mattress was ordered but was not delivered to facility yet.

Based on resident interview, staff interview and record review, it was determined that facility staff failed to provide timely treatment and care. This was evident for 1 of 17 residents selected to review during the survey (#77). The findings include: On 07-01-19 at 10:30 AM, surveyor interview of resident #77 revealed that he/she was having a burning sensation on urination. Resident #77 was alert and oriented to self, time, place and situation. Resident #77 said he/she had not informed nursing staff or physician about it. However, resident #77 said he/she will talk to staff about his/her condition. On 07-02-19 10:54 AM, surveyor interview with resident #77 revealed that the burning sensation on urination had gotten worse and he/she talked to the evening nursing staff the night before. On 07-02-19 10:32 AM, surveyor interview with staff #2 revealed that resident #77 had not complained of burning on urination and was afebrile. Staff #2 said she/he did not get any report on the resident's condition from the previous shift nursing staff. Staff #2 said he/she will talk to resident #77 and will notify attending physician about resident #77's change in condition. At 3PM, surveyor follow up with staff #2 revealed physician was not yet notified. On 07/03/19 08:04 AM, interview with resident #77 revealed that she/he talked to staff #2 about burning on urination and staff #2 told her/him she/he would call the doctor. However, record review revealed no documentation of an assessment of resident #77 after staff #2 was made aware of the resident's complaint or that the physician was notified of resident #77's complaint about burning on urination. On 07-03-19 at 9 AM, interview with staff #3 revealed that she/he did not get any report from night shift staff of any changes in resident #77's condition in the last 24 hours but resident #77 told staff #3 that morning that she/he was having urinary burning and she/he did report that to nursing staff the day before. Staff #2 said that she/he will follow up with attending physician. On 07-03-19 at 11AM, surveyor interview with the Director Of Nursing revealed no additional information.

Based on surveyor review of the clinical records and interview of resident #3 and the facility staff, it was determined that the facility staff failed to provide medications in a timely manner. This finding was evident for 2 of 4 residents selected for review during the survey (#3, #4). The findings include: 1. On 10-12-18 at 11 AM, interview of resident #3 revealed that the resident was admitted to the facility in (MONTH) (YEAR) following a hospitalization . On 10-12-18, review of the clinical record revealed that an inhaler was ordered upon admission on 09-22-18 at 7 PM. However, review of the Medication Administration Record [REDACTED]. On 10-12-18 at 3:30 PM, interview of the Director of Nursing (DON) and the facility's administrator revealed that the delivery of medications are scheduled twice a day. They did not know why there was a delay in delivering resident #3's inhaler. 2. On 10-12-18, review of the closed record for resident #4 revealed that the resident was admitted to the facility on [DATE] following a hospitalization . Upon admission, an anti-hypertensive medication, potassium chloride supplement and a laxative were ordered. However, review of the MAR indicated [REDACTED]. On 10-12-18 at 3:30 PM, interview of the Director of Nursing (DON) and the facility's administrator revealed that the delivery of medications are scheduled twice a day. They did not know why there was a delay in delivering resident #4's medications.

Based on surveyor review of the clinical records, observation of staff practice and interview of facility staff, it was determined that the facility staff failed to provide care and treatment to meet an individual's need as ordered. This finding was evident for 4 of 16 residents selected for review during the survey process (#1, #73, #20, and #122). The findings include: 1. On 05-09-18 at 11AM, resident #1 was observed playing piano in the sitting room. The resident was alert, but only oriented to name. The facility staff provided total assistance to the resident for activities of daily living. On 05-10-18, review of a nursing note, dated 03-13-18, revealed that the director of rehabilitation (DOR) requested a physician's order to evaluate resident #1's sitting and repositioning. Further review of the Minimum Data Set (MDS), dated [DATE], revealed the resident had impairment on both lower extremities. The MDS is an assessment tool used to assess an individual's physical and functional status. However, there was no evidence that the physical therapy (PT) evaluation was ordered or done. On 05-11-18 at 9:50 AM, interview of the DOR revealed that a nursing assistant reported to the DOR in (MONTH) (YEAR) that the resident was unable to sit properly in the wheelchair. Therefore, the DOR requested a PT evaluation in (MONTH) (YEAR) to determine whether the resident's wheelchair was appropriate. Since there was no physician's order written, no PT evaluation was done. On 05-11-18 at 10 AM, interview of the director of nursing revealed no additional information. 2. On 05-11-18, review of resident #73's clinical record revealed the resident was admitted to the facility on [DATE]. The attending physician gave an admission order as follows: [MEDICATION NAME] (corticosteroids) 40 mg daily x (for) 5 days, 20 mg daily x 5 days, 10 mg daily x5 days, then D/C (discontinue) for chronic obstructive [MEDICAL CONDITION] disorder ([MEDICAL CONDITION]). However, review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Then, [MEDICATION NAME] 20 mg was scheduled to be given between 05-12-18 and 05-16-18. There was no [MEDICATION NAME] scheduled to be given to resident #73 on 05-11-18. Then, [MEDICATION NAME] 10 mg was scheduled to be given between 05-18-18 and 05-22-18. There was no [MEDICATION NAME] scheduled to be given to the resident on 05-17-18. The tapering schedule of [MEDICATION NAME] on the MAR indicated [REDACTED]. On 05-11-18 at 11 AM, interview of the director of nursing revealed no additional information. 3. On 05-09-18, review of the hospital discharge summary for resident #20 revealed that the resident was recommended to see a cardiologist weekly. In addition, the resident was to be weighed daily. Per discharge instructions, if there was a 2 lb weight gain in a day or 5 lb weight gain in a week, the dosage of a diuretic medication, [MEDICATION NAME], should be doubled until the weight returned to the baseline. On 04-24-18, resident #20 went to see the cardiologist, who instructed the facility staff to weigh the resident daily and monitor for any weight gain as stated on the hospital discharge summary. On 04-27-18, there was a 4 lb weight gain in a day. However, there was no evidence that the resident's attending physician or a cardiologist were informed to determine the course of treatment. On 05-02-18, the resident went to see the cardiologist, who ordered to double the dosage of [MEDICATION NAME], related to the 4 lb weight gain. On 05-09-18 at 4 PM interview of the director of nursing revealed no additional information. 4A. On 05-09-18 at 10 AM, surveyor review of the clinical record for resident #122 revealed the resident suffered from chronic back pain and was routinely administered [MEDICATION NAME]. [MEDICATION NAME] is a therapeutic alternative to [MEDICATION NAME] sulfate and other opiate [MEDICATION NAME] in the treatment of [REDACTED]. Further review revealed that resident #122 was admitted to the facility on [DATE] upon discharge from the hospital. The hospital discharge prescription was for [MEDICATION NAME] 10 mg tablet, start with 5 mg nightly, increase by 5 mg as needed to control the pain. However, the medication was ordered as: [MEDICATION NAME] 10 mg every 6 hours as needed for pain. On 05-02-18, the order was changed to 5 mg nightly as originally prescribed but wasn't administered until 05-03-18 because the resident had nausea. The resident didn't receive the [MEDICATION NAME] for 3 days. On 05-11-18 at 3 PM, surveyor interview with resident #122's responsible party revealed that the [MEDICATION NAME] was managed at home by a specialized provider who had advised the resident to not discontinue the medication abruptly. On 05-14-18 at 10 AM, surveyor interview with the director of nursing revealed no additional information. 4 B. On 05-08-18 at 4 PM, surveyor interview with resident #122 revealed that he/she had suffered from [MEDICAL CONDITION] recently and had received [MEDICATION NAME] to help with sleep. On 05-09-18 at 10 AM, surveyor review of the clinical record for resident #122 revealed a physician's order, dated 04-03-18, for [MEDICATION NAME] 12.5 mg every 6 hours, as needed, for [MEDICATION NAME]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. E was coded to document the medication was effective. However, there was no information written in the progress notes to describe the symptoms that resident #122 complained of or how it was effective. On 05-14-18 at 10 AM, surveyor interview with the director of nursing revealed no additional information.

Based on surveyor observation of staff practices, review of the clinical records and facility policy, and staff interviews, it was determined that the facility staff failed to use the correct transmission-based precautions for two residents with infections. This finding was evident for 2 of 16 residents selected for review during the survey process (#16 and #122). The findings include: 1. On 05-09-18 at 7:40 AM, surveyor observation of resident #16's door frame, revealed a sign stop see nurse for instructions; there was a cart near the doorway that held PPE (personal protective equipment). Personal protective equipment is equipment worn to minimize exposure to and transmission of infections. On 05-09-18 at 8 AM, surveyor review of the clinical record for resident #16 revealed a [DIAGNOSES REDACTED]. [MEDICAL CONDITION] infection ([MEDICAL CONDITION]) is a symptomatic infection due to the spore-forming bacterium, [MEDICAL CONDITION]. Symptoms include watery diarrhea, fever, nausea, and abdominal pain. In the health care setting, [MEDICAL CONDITION] bacteria can easily be transmitted from person to person through hand-to-mouth contact. On 05-09-18 at 5 PM, during surveyor observation of the nurse (staff #2) providing medication administration for resident #16, the nurse entered the resident's room with an electronic blood pressure monitor. After checking resident #16's blood pressure, it was placed in the medication cart drawer. The blood pressure monitor was not cleaned after using it on this resident. On 05-09-18 at 5:20 PM, during surveyor interview with the director of nursing (DON), it was explained per company policy, residents who are isolated with contact precautions are designated a single resident use blood pressure cuff and stethoscope. At that time, the DON checked the PPE cart; there was a blood pressure cuff and stethoscope in the bottom drawer, still in the sealed package. On 05-09-18 at 6 PM, surveyor interview with the administrator revealed no additional information. 2. On 05-09-18 at 08 AM, surveyor observation revealed a sign on resident #122's door frame stop see nurse for instructions with a PPE container near the doorway. On 05-09-18 at 9:20 AM, surveyor review of the clinical record for resident #122 revealed a laboratory result reported on 05-08-18 which showed positive for [MEDICAL CONDITION] infection and a physician's orders [REDACTED]. On 05-09-18 at 5:30 PM, surveyor observation, with the DON, of resident #122's room and PPE container revealed that the facility staff never designated a single resident blood pressure cuff and stethoscope to this resident. At that time, the DON stated the equipment should have been stored in the bottom drawer of the PPE container. On 05-09-18 at 5:30 PM, during surveyor interview with the charge nurse (staff # 2) it was revealed that he/she hadn't used a resident specific blood pressure cuff and stethoscope for resident #122 on that day. On 05-09-18 at 6 PM, surveyor interview with the administrator revealed no additional information.

Based on surveyor review of the clinical records and interview of facility staff and the consultant, it was determined that the facility staff failed to obtain a psychiatric nurse practitioner's progress notes timely. This finding was evident for 3 of 16 residents selected for review during the survey process (#12, #20, and #21). The findings include: 1. On 05-08-18 at 12:30 PM, resident #12 was observed eating lunch in the dining room with others. The resident was alert, but oriented to name only. On 04-27-18, a psychiatric nurse practitioner (NP) increased an anti-depressant, [MEDICATION NAME], from 10 mg to 15 mg for depression. However, there was no NP's progress note available for review on 05-09-18, which was 12 days after the NP wrote the order. On 05-09-18 at 4 PM, interview of the director of nursing (DON) revealed no additional information. On 05-11-18 at 8:30 AM, interview of the NP revealed that the NP documented his/her assessment electronically. Then, the progress note would be sent electronically in 24 hours after the visit. The NP did not know why the progress note for 04-27-18 was not sent to the facility. 2. On 05-08-19 at 2 PM, interview of resident #20 revealed the resident was alert and oriented. The resident preferred the surveyor to talk with the resident's adult child, due to a language barrier. On 05-09-18, review of the clinical record revealed that a psychiatric nurse practitioner (NP) added a new anti-depressant, [MEDICATION NAME], on 04-27-18 for the resident for depression secondary to appetite augmentation. However, there was no NP's progress note for review, which was 12 days after the order was written. On 05-09-18 at 4 PM, interview of the director of nursing revealed no additional information. On 05-11-18 at 8:45 AM, interview of the NP revealed the NP documented his/her assessment electronically. Then, the progress notes would be sent electronically in 24 hours after the visit. The NP did not know why the progress note for 04-27-18 was not sent to the facility. 3. On 05-10-18 at 10:30 AM, surveyor review of the clinical record for Resident #21 revealed a physician's orders [REDACTED]. There was no evidence in the clinical record that the consultation was done. On 05-10-18 at 12 PM, surveyor interview with the director of nursing (DON) revealed that the psychiatric consultation was done by the contracted psychiatric provider on 04-27-18. However, the consultation notes weren't in resident #21's chart. The DON explained that typically, the consultation notes are emailed the day after the consultation is done, at which time they are printed and filed in the chart. The DON stated that he/she never received the notes for the 04-26-18 consultation. On 05-14-18 at 1 PM, surveyor interview with the administrator revealed no additional information.

Based on surveyor review of the clinical records, observation of resident and staff practice, and interview of a resident, a family member, facility staff and a consultant, it was determined that the facility staff failed to notify the responsible parties when a change of treatment was made. This finding was evident for 2 of 2 residents selected for review of notification of change (#12 and #20). The findings include: 1. On 05-08-18 at 12:30 PM, resident #12 was observed eating lunch in the dining room with others. The resident was alert, but oriented to name only. The resident required assistance with activities of daily living. On 05-10-18, review of the interdisciplinary care conference/meeting note revealed a care plan meeting was held on 04-24-18. At that time, the resident had no change in mood. On 04-27-18, a psychiatric nurse practitioner (NP) increased an anti-depressant medication, [MEDICATION NAME], from 10 mg to 15 mg for depression for resident #12. However, there was no evidence that the resident's responsible party was notified about this change. See F 758 & F 842. On 05-10-18 at 4 PM, interview of the director of nursing (DON) revealed no additional information. 2. On 05-08-19 at 2 PM, interview of resident #20 revealed the resident was alert and oriented. The resident preferred the surveyor to discuss issues with his/her adult child, who was the Power of Attorney (POA), due to a language barrier. On 05-09-18, review of the clinical record revealed that resident #20's POA scheduled and transported the resident from the facility to a cardiologist's office every Friday. Further review of resident #20's record revealed that a psychiatric NP added a new antidepressant, [MEDICATION NAME], on 04-27-18, because of depression secondary to appetite augmentation. However, there was no evidence that the NP or the facility staff contacted the POA to review the new treatment. See F758 & F842. On 05-10-18 at 4:25 PM, interview of resident #20's POA revealed that he/she did not know that the resident had been taking [MEDICATION NAME] since 04-27-18. On 05-11-18 at 8:45 AM, interview of the NP revealed he/she could not communicate with resident #20 verbally due to the language barrier. The NP stated a call was made, but could not recall whom he/she spoke to related to changes on 04-27-18. On 05-11-18 at 12 PM, interview of the director of nursing revealed no additional information.

Based on surveyor review of the clinical record and staff interviews, it was determined that the facility staff failed to address how resident preferences and physician orders [REDACTED]. This finding was evident for 1 of 1 resident selected for review of resident death (#22). The findings include: An advance directive is a written statement of a person's wishes regarding medical treatment, made to ensure those wishes are carried out should the person be unable to communicate them. Code status refers to whether or not a person wishes to have cardiopulmonary resuscitation (CPR). On [DATE] at 1 PM, surveyor review of the closed clinical record for resident #22 revealed that, on [DATE], he/she was found unconscious, pulseless and not breathing. The facility staff initiated cardiopulmonary resuscitation (CPR) prior to determining the code status. When it was discovered that resident #22 had an advance directive for no CPR, the staff stopped CPR. On [DATE] at 3 PM, during surveyor interview with the director of nursing (DON) and the administrator, they stated that facility staff rely on the clinical chart or electronic medical record to determine the code status of a resident in the event of an emergency requiring CPR. The facility doesn't have a system to quickly identify code status. On [DATE] at 9:30 AM, surveyor interview with the director of rehabilitation revealed that, on [DATE], he/she and a nurse performed CPR while the assistant director of nursing and the social worker assisted with determining the code status of the resident. They were unable to quickly determine the code status of resident #22 so they initiated CPR in case he/she was a full code. On [DATE] at 1 PM, surveyor interview with the administrator revealed no additional information.

Based on surveyor observation, review of the clinical records and interview of a family member, facility staff and consultant, it was determined that the facility staff failed to ensure that an individual receive anti-depressants with appropriate clinical indications. This finding was evident for 2 of 7 residents selected for medication regimen review (#12 and #20). The findings include: 1. On 05-08-18 at 12:30 PM, resident #12 was observed eating lunch in the dining room with others. The resident was alert, but oriented to name only. On 05-10-18, review of the interdisciplinary care conference/meeting notes revealed a care plan meeting was held on 04-24-18. There was no change in the resident's mood status in the past 3 months. Further review of a physician's orders [REDACTED]. See F 842. In addition, review of the resident's behavior sheet for (MONTH) (YEAR) revealed no signs and symptoms of sad/depressed mood/tearfulness/crying/refusing to eat noted between 04-01-18 and 04-27-18. On 05-09-18 at 4 PM, interview of the director of nursing (DON) revealed no additional information. On 05-11-18 at 10 AM, interview of staff #1 revealed that resident #12 did not exhibit any signs or symptoms of depression on the day shift in the past 2 months. On 05-11-18 at 10:10 AM, interview of staff #2 revealed the resident was always pleasant. There was no sign or symptom of depression noted in the evenings in the past 2 months. On 05-14-18 at 12 noon, interview of the director of nursing revealed no additional information. 2. On 05-08-18 at 2 PM, interview of resident #20 revealed the resident was alert and oriented. The resident preferred the surveyor talk with the resident's adult child, who was the Power of Attorney (POA), due to a language barrier. On 05-09-18, review of the clinical record revealed that a psychiatric nurse practitioner (NP) prescribed a new anti-depressant, [MEDICATION NAME], on 04-27-18 for depression secondary to appetite augmentation. It was unknown why the NP added another antidepressant, [MEDICATION NAME], for resident #20 on 04-27-18 for appetite augmentation, because there was no NP's note available for review. See F 842. On 05-10-18 at 4 PM, interview of resident #20's POA revealed that a decision was made with the attending physician on 04-17-18 to increase an anti-depressant, [MEDICATION NAME], from 20 mg to 30 mg twice a day because the resident was upset with the facility staff and wanted to go home sooner. The POA further clarified that resident #20 did not eat much in the facility, which was unrelated to his/her appetite. The resident always preferred the ethnic food and consumed 100% when the family brought in homemade food. On 05-11-18 at 8:30 AM, interview of the psychiatric NP revealed that the NP only gathered information on 04-27-18 from the facility staff and clinical record due to the language barrier. When asked about the family's input, the NP stated he/she made a call to the family, but did not recall whom he/she spoke to. However, the NP could not explain why the resident lost their appetite. The NP stated that he/she interviewed the nursing staff, who reported that the resident lost their appetite. However, the nursing staff documented that the resident had good appetite with meals between 04-24-18 and 04-27-18. On 04-27-18, the NP still documented that the resident took [MEDICATION NAME] 20 mg twice a day, even though [MEDICATION NAME] had been increased since 04-24-18. There was no supportive documentation to indicate that another anti-depressant, [MEDICATION NAME], was needed for resident #20 on 04-27-18 due to depression after clinical review and interview of the family member and NP. On 05-11-18 at 4 PM, interview of the director of nursing revealed no additional information.

Based on surveyor review of the clinical records and interview of the facility staff, it was determined that the facility staff failed to ensure that an individual was free from excessive dosage of an antibiotic therapy for a prolonged period of time. This finding was evident for 1 of 7 residents selected for medication regimen review (#7). The findings include: On 05-11-18, review of the clinical record revealed that resident #7 was readmitted to the facility in (MONTH) (YEAR) following a hospitalization . In (MONTH) (YEAR), a new order was written to clean the suprapubic site with normal saline solution, pat dry, apply [MEDICATION NAME] ointment on the suprapubic site every day shift for infection control, and cover with a dry dressing. [MEDICATION NAME] is an antibiotics to prevent bacterial infections. Further review of Medication Administration Record [REDACTED]. However, there was no clinical rationale documented to explain the continuous use of [MEDICATION NAME] in the past 12 months. On 05-11-18 at 2:30 PM, interview of the director of nursing revealed there was no stop date for the daily use of [MEDICATION NAME].

Based on surveyor review of the clinical records, observation of resident and staff practice, and interview of a family member and the facility staff, it was determined that the facility staff failed to honor an individual's advance directives. This finding was evident for 2 of 3 residents selected for review of advance directives (#1, #22). The findings include: 1. On [DATE], review of resident #1's living will, signed in 2008, revealed the resident's instructions: not to do any form of surgery or invasive diagnostic test when he/she became incompetent, incapacitated or in any way permanently unable by reason of a physical and /or mental disability to participate in decisions regarding medical care. In (YEAR), two physicians determined that resident #1 was in a terminal condition. Further review of the [NAME]land Medical Orders for Life-Sustaining Treatment (MOLST) form, which was signed in (MONTH) (YEAR), revealed instructions were written to only perform limited medical tests necessary for symptomatic treatment or comfort. At that time, hospice services were initiated. In (MONTH) (YEAR), resident #1 was discharged from hospice services. On [DATE] at 10 AM, resident #1 was observed playing piano in a sitting room. The resident was alert, but only oriented to name. The facility staff provided total assistance to resident #1 for all activities of daily living. On [DATE] at 11:50 AM, interview of resident #1's family member, who was the power of attorney (POA) for health care, revealed the resident's code (CPR- cardiopulmonary resuscitation) status and treatment goals remained the same as while he/she was under hospice services. Review of resident #1's clinical record revealed two blood tests were ordered on [DATE] to be completed on [DATE]. However, there was no change in the resident's health status. The resident's POA was not aware of the laboratory order. On [DATE], the attending physician was informed about the abnormal result of [MEDICAL CONDITION] stimulating hormone (TSH), however, there was no change on the treatment. The clinical rationale of initiating the laboratory test on [DATE] was unknown when the current plan of care was for comfort. On [DATE] at 2 PM, interview of the director of nursing revealed no additional information 2. On [DATE] at 1 PM, surveyor review of the closed clinical record for resident #22 revealed that, on [DATE], the resident was found unconscious, pulseless and not breathing. Per the progress notes, staff initiated CPR until the code status was known. When it was determined that resident #22 had elected for no CPR, they stopped. Further review of the clinical record revealed that, on [DATE], resident #22's physician completed the MOLST form with the option No CPR, Do not intubate. According to the MOLST form, the order was entered as a result of a discussion with and the informed consent of the resident. On [DATE] at 3 PM, during surveyor interview with the director of nursing (DON) and the administrator, they stated that the staff didn't know the code status for resident #22, so CPR was initiated in case he/she was a full code. Furthermore, staff need to look for the residents' code status in the clinical record (chart) or the electronic medical record. The residents don't wear identification bands with name or code status. On [DATE] at 9:30 AM, surveyor interview with the director of rehabilitation revealed that, on [DATE], he/she and a nurse performed CPR while the assistant director of nursing and the social worker assisted with determining the code status of the resident. They were unable to quickly determine the code status of resident #22, so they initiated CPR in case he/she was a full code. On [DATE] at 1 PM, surveyor interview with the administrator revealed no additional information.

Based on surveyor review of the clinical record, review of the facility's documents, review of hospital records, and interview of facility staff, it was determined that the facility failed to ensure appropriate safety measures to prevent a fall with serious injury for resident #1. This finding was determined in the investigation of the facility self-reported incident MD 997, and found to result in harm to the resident. The findings include: On 10-16-13, review of the clinical record revealed resident #1 was residing in the facility with long term care needs significant for advanced Alzheimer's dementia, seizure disorder, and history of heart disease and stroke. The resident was non-ambulatory and dependent on staff for all activities of daily living. Based on assessments of the resident's function, he required extensive one person assistance for bed mobility and total two person assistance for transferring to bed and wheelchair. Because of these functional limitations and other multiple risk factors, the resident was identified to be at risk for falls. Record review revealed the facility developed a care plan for safety measures to minimize the risk of falls and serious injury. These measures included: 1. To keep bed in lowest position when resident was in bed, and 2. To transfer the resident with the assistance of two persons using transfer techniques. Additionally, the facility utilized a padded floor mat placed next to the open left side of the bed, from which the resident was transferred. Review of the facility's incident report and hospital records revealed that on 10-05-13 at approximately 8:00 AM, the resident had a fall out of bed that resulted in a left maxillary sinus fracture along with left facial and periorbital hematoma. According to all facility documentation regarding the fall incident and staff interviews, the GNA (geriatric nursing assistant) had finished providing morning care to the resident in bed. The resident's bed had been raised to the highest level and the padded floor mat removed for the GNA to provide easier care at bedside. When the GNA turned and left the bedside to get the resident's wheelchair across the room, the resident fell off the bed face down on the floor resulting in the serious injury. The resident was then sent out via 911 emergency services and admitted to the hospital. On 10-16-13 at 3:00 PM, interview with the day shift LPN (licensed practical nurse) on duty on 10-05-13 revealed she was made aware of the incident when the GNA caring for the resident came running down the hall calling for help. The LPN went to the room with the GNA and found the resident on the floor next to the bed, bleeding from the nose and above the left eye. The LPN stated the bed level was at the highest position and the padded floor mat was not present at the bedside. On 10-21-13 at 12:00 PM, interview with the GNA caring for the resident at the time of the fall incident, revealed the resident was his usual self when she was bathing, grooming, and dressing him in bed that morning. The GNA stated as she was getting the resident's wheelchair, she heard the resident fall from the bed and then saw the resident on the floor with his "whole body shaking," which she thought may have been a seizure. The GNA stated it was her practice to leave the bed level at the highest position to facilitate an easy transfer with the resident from his bed to the wheelchair. However, based on all facility documentation and staff interviews, there was no evidence that facility staff followed the plan for safety measures to transfer the resident with the assistance of two persons and/or used safe transfer techniques at the time of the fall incident.