Every finding on record at Uintah Health Care Special Service District

Based on interview and record review it was determined, for 2 out of 22 sampled residents, that the facility failed to ensure that each resident received and the facility provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, the facility failed to provide behavioral health care and services to a resident who had expressed a desire to commit suicide and interventions and monitoring were not implemented prior to the resident successfully committing suicide. Additionally, another resident made statements of wanting to hang himself and behavioral health care and services were not provided and interventions and monitoring were not implemented. The deficient practice identified was cited at an Immediate Jeopardy level for both residents. Resident identifiers: 22 and 40. NOTICE On 9/24/25 at 5:31 PM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to ensure each resident had the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, resident 40 successfully committed suicide after expressing this desire to staff and behavioral health services, interventions, and monitoring were not implemented. Additionally, resident 22 made statements of wanting to hang himself and behavioral health services, interventions, and monitoring were not implemented. Notice of the Immediate Jeopardy was given verbally and in writing to the Administrator (ADM) and Director of Nursing (DON). On 9/25/25, the Administrator provided the abatement plan for the removal of the Immediate Jeopardy effective on 9/25/25 at 11:00 AM. The abatement plan for suicide prevention included the following:1. All residents will undergo a mental health screening by a qualified profession (sic) on September 27, 2025. Residents identified as being at risk for suicidal ideation and/or self-harm will receive intervention from the screening professional. Care plans will be updated to reflect these changs {sic} and interventions. In order to keep the residents safe, we will interview each resident today and ask the following questions. I'm here because we want to keep you safe. Have you had any thoughts of harming yourself or wanting to die? If yes: Do you have a plan - what, when, and how? (if yes escalate immediately). If the answer is yes, we will immediately implement our Suicide Prevention/Protocol. If the answer is no, there will be no further action. All documentation will be filed in the resident's chart.2. All current staff will receive suicide prevention training at the beginning of their next scheduled shift. New staff will receive this training during employee orientation. Additionally, all licensed nurses will be trained on the [NAME] Protocol and our suicide prevention policy who are working today and all other nurses will complete before their next shift.3. Charge nurses will monitor progress notes daily starting immediately, revieing the past 36 hours for resident safety risks to be communicated according to our suicide prevention policy/protocol. This monitoring will continue for 90 days. Charge nurses will sign a daily log confirming completion and the Director of Nursing (DON) will monitor this log weekly compliance, communicating any findings to the Administrator.4. [Registered Nurse (RN) 1] interviewed [Resident 22] on 9/25/2025 @ 10:45 using the [NAME] Protocol worksheet. RN 1 has had training from previous employment at the hospital and used this protocol during her employment there. [Resident 22] answered No to questions 1, 2 & 6. He will continue with his current care plan since he is not in immediate danger. On 9/25/25, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 9/25/25. Findings included: 1. Resident 40 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, major depressive disorder, anxiety disorder and insomnia. Resident 40 passed away on 9/13/25 due to a successful suicide attempt. Resident 40's medical record was reviewed from 9/22/25 through 9/25/25. On 5/30/24, resident 40's admission Minimum Data Set (MDS) documented under the resident mood interview that the resident answered yes to “Little interest or pleasure in doing things”; “Feeling tired or having little energy”; “Trouble concentrating on things, such as reading the newspaper or watching television”; and “Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.” Resident 40 had a severity score of 10, indicating a moderate level of depression. On 8/29/24, resident 40's Quarterly MDS documented under the resident mood interview that the resident answered yes to “Little interest or pleasure in doing things”; “Feeling down, depressed, or hopeless”; “Trouble falling or staying asleep, or sleeping too much”; “Feeling tired or having little energy”; “Poor appetite or overeating”; “Feeling bad about yourself - or that you are a failure or have let yourself or your family down”; “Trouble concentrating on things, such as reading the newspaper or watching television”; “Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual”; and “Thoughts that you would be better off dead, or of hurting yourself in some way.” Resident 40 had a severity score of 26, indicating a severe level of depression. Resident 40's progress notes revealed the following: a. On 5/24/25 at 1:35 PM, the admission Note documented, “Patient is having a hard time; states he wants to hurry and get things going. Friend has brought patient's own brown smooth cover electric chair. [Resident 40] states I want my own chair I don't want to sit in a chair that someone died in, I know how these places are. [Resident 40's] chair was set next to his bed. Medications taken from daughter and reviewed and counted. When going thru [sic] the check list of his room he states I'm not one of these people that are old I'm [AGE] years old and I can do things for myself. I just came in and lost my kids and everything I have to be here. I just want to go to sleep.” b. On 5/27/24 at 2:35 PM, the Behavioral Symptoms note documented, “Resident went into the dining room around 1300 (1:00 PM) and said, ‘I don't know what the hell that noise is, but somebody better get off their ass and fix it or I'm going to blow my fucking top.' Staff reported another resident's call light was going off and the noise upset him. When nurse went to residents room he appeared anxious, he kept rubbing his face with his hands, stating ‘that noise set me off' ‘I'm sorry, I'm too nice of a person for this, this isn't me' ”. c. On 5/27/24 at 4:04 PM, the Behavioral Symptoms note documented, “Resident states his Klonopin medication was increased prior to administration [sic] to [name omitted]. Dosage increase was not reflected in admission medication list. Due to increased agitation this afternoon and treats [sic] to leave the facility to self-medicate Physician was notified. [Physician name omitted], through thorough search of [physician name omitted] notes and clinic records was able to find note of resident's call to clinic on 5/20/24 and Klonopin increased to 2mg [milligram] TID [three times a day]. Dosage clarification received and telephone order to increase dose as follows; 1) Klonopin 2mg PO [by mouth] TID for anxiety.” d. On 5/31/24 at 10:00 AM, the Social Worker Psychosocial Assessment documented that resident 40's “mood varies from pleasant and thankful for his care to anger/agitated/swearing.” The assessment of behavioral concerns documented, “Per staff: Delusions and verbally aggressive.”. The assessment recommendations were, “Staff will listen to [Resident 40's] wants and needs and make sure his needs are met. 2. Staff will help with redirection, cues, prompts and validation. 3. Staff will help [Resident 40] with making sure he can attend his activities of choice.” It should be noted that this was the only documented assessment of resident 40 by the Licensed Clinical Social Worker or mental health provider. e. On 6/8/24 at 5:25 PM, the Behavioral Symptoms note documented, “Resident voiced to nurse that he is feeling anxious and very agitated. Stated ‘if my medication doesn't get figured out I'm going to lose my shit'. Voices that klonopin ‘isn't helping anymore'. Notified [physician name omitted] of resident concern, new order received for quetiapine 50 mg po [by mouth] now and then one Q [every] am [morning]. Brought medication into resident and he refused to take it. Stated ‘quetiapine puts me to sleep in 30 minutes. I've taken that before during the day and can't function because I'm too tired'. Informed [physician name omitted], ordered Rexulti 0.5 mg po now and Q am.” f. On 6/9/24 at 7:28 AM, the Telephone Order note documented, “[Physician name omitted] notified that the pharmacy won't cover Rexulti and the med is $1300.00 out of pocket. Order given to switch to Zyprexa 5 mg one po daily.” g. On 6/9/24 at 2:40 PM, the Mood State note documented, “Spoke to resident about his frustrations. Became tearful stating that he doesn't want to be that guy that's a jerk to everyone. Voices that last night he felt like killing himself. Today is better but he still doesn't feel right in the head.” The note documented that the physician was notified. It should be noted that no documentation could be found for any interventions or monitoring that was implemented. h. On 6/9/24 at 5:02 PM, the Physician Visit note documented that resident 40's physician visited the resident and discussed “concerns and medications. No new med changes made at this time.” i. On 6/10/24 at 12:48 PM, the Telephone Order note documented, “Psychotropic review done today with consultant pharmacy. Recommendations: Change Zyprexa for qhs [every night] to qam [every morning] and consider adding antidepressant to help with anxiety. Recommendations sent to [physician name omitted]- Orders received: Change Zyprexa to QAM”. j. On 6/12/24 at 5:28 PM, the Behavioral Symptoms note documented that the resident reported feeling agitated today. k. On 6/14/24 at 3:46 PM, the Medication note documented, “[Physician name omitted] into visit resident. Care plan and orders reviewed. POLST [Physician Order for Life Sustaining Treatment] signed. New orders are as follows: 1) start Sertraline 50mg PO AM.” l. On 6/30/24 at 4:19 PM, the Behavioral Symptoms note documented, “resident asked for 2 o'clock medications early stated he didn't feel right in the head and needed to be left alone. Resident placed a note on the door not to bother him until 1630 [4:30 PM]”. m. On 7/1/24 at 10:30 PM, the Behavioral Symptoms note documented, “At times the resident will be confused about the time of day it is, and express some agitation, with some queing [sic] and redirecting he calms down, ”. n. On 7/12/24 at 2:48 PM, the Physician Visit note documented, “New Order: 1. Increase Zoloft (Sertraline HCL [hydrochloride] 50mg to 100mg po AM 2. Decrease Zyprexa to 2.5mg daily.” o. On 7/12/24 at 3:00 PM, the Behavioral Symptoms note documented, “ “Patient is up to the Nursing Station. He states tell [physician name omitted] I think about Suicide daily. I ask if he had talk [sic] with [physician name omitted] about this, he states no, there where [sic] to many people in the room. Call was made to [physician name omitted] to inform him of patient's statement. [Physician name omitted] request to monitor patient closely and that he has increase his antidepression [sic] medication.” p. On 7/16/24 at 5:47 PM, the Behavioral Symptoms note documented, “resident isolated himself in his room for a majority of the day.” q. On 8/2/24 at 4:16 PM, the Physician Visit note documented, “[Physician name omitted] here to see resident and review plan of care. Discussed how he has been feeling since increasing the zoloft to 100mg and decreasing the zyprexa to 2.5mg. Resident voices he has felt better but feels like it could be adjusted just a little more, and also added he could use something to help him sleep. New order received to discontinue zyprexa and add trazodone 50mg one po QHS [every hour of sleep].” r. On 8/2/24 at 8:36 PM, the progress note documented that resident 40 stated, I am losing my memory fast. I wish I would lose it faster so that I don't have to remember I have kids or a family. s. On 8/7/24 at 8:04 PM, the Behavioral Symptoms note documented that resident 40 had increased confusion. t. On 8/8/24 at 11:18 AM, the Late entry note for 8/7/24 documented, “Resident reported ‘It takes about a half hour when I wake up to remember where I am' He also reports feeling overwhelmed and anxious when there are too many people or noises around him. Resident shows poor recall, he uses his phone alarm and printed schedules to remember meal and snack times.” u. On 8/16/24 at 1:57 PM, the Behavioral Symptoms, Mood State note documented, “While administering 1400 [2:00 PM] scheduled medication I asked resident if there was anything that I could get for him and he responded ‘a bullet ‘. I asked resident if he was having thoughts of self-harm. Resident responded ‘It was just a joke but yes I do think about it sometimes.' Resident declined want [sic] to talk but did thank me for being nice to him. I advised resident that I would be checking in frequently but that If he needed anything further or before I came to check in to call for assistance. Resident stated understanding”. It should be noted that no documentation could be found that the physician was notified of the resident's statement or any interventions or monitoring that was implemented. v. On 8/20/24 at 1:39 PM, the Behavioral Symptoms note documented, “Resident brought sticky note to the nurses' station that read my irritated short fuse has increased since the med change.” “Resident reported he has had a hard time falling asleep at night and when he is in his room during the day he is resting but not sleeping.” w. On 8/20/24 at 3:00 PM, the Behavioral Symptoms note documented, “Resident came to nurses' station and said, ‘I need you to get a hold of the doctor and tell him that my agitation is getting worse' ‘I am not sleeping and whatever adjustments he made to my medication is not working.' Physician notified per resident request.” x. On 8/20/24 at 4:59 PM, the Medication note documented, “New orders given per Physician regarding residents increased agitation and [complaints of] trouble sleeping: 1) Increase Seroquel to 125 mg PO at bedtime”. y. On 8/22/24 at 1:13 PM, the Mood State note documented, “[Physician name omitted] notified that resident is voicing concerns that he is having increased agitation and irritability. Feels like he ‘wants to rip someone's head off'. Adds that he is no longer having issues sleeping since adding the trazodone. Order received to increase his sertraline from 100mg to 150mg daily.” z. On 8/22/24 at 9:13 PM, the Behavioral Symptoms note documented, “Resident states ‘no one understands what it is like for me. Everyone around me has lost their minds and I can still remember things, I just want to not feel anything. I am laying in this bed wasting away. I really wish the Dr. [doctor] would over medicate me so I don't have to deal with all of this.' “ aa. On 8/24/24 at 4:43 PM, the note documented, “Resident spent the vast majority of the day isolating himself. He went to bingo and meals but was the first to leave meals and spent the rest of his time alone.” bb. On 8/24/24 at 4:57 PM, the Mood State note documented, “Resident reported to activities aid that he was feeling suicidal.” It should be noted that no documentation could be found that the physician was notified of the resident's statement or any interventions or monitoring that was implemented. cc. On 8/25/24 at 5:44 PM, the Behavioral Symptoms note documented, “This am resident while in room administering medications resident appeared very upset over the events of the night. He stated to me I don't fucking like how they just come in at 4 am and turn every fucking light on. I can't sleep as it is and this is how I get when I don't sleep. resident was speaking in elevted [sic] tone of voice and appeared to be very upset making gestures like throwing or shaking his hands and arms. At dinner resident was seen by staff taking a knife to the walls and scraping away at the lines.” dd. On 8/26/24 at 4:30 PM, the Mood State note documented, “Resident noted to be pacing up and down the hall and seemed irritable with some staff members. Maintenance man who is also a long-time friend spoke to him and resident voiced that he has to sign over his rights to his children Friday and that has him pretty upset.” ee. On 8/30/24 at 2:33 PM, the Behavioral Symptoms, Mood State note documented, “Resident has spent most of day thus far in his room with the door shut, blinds closed and lights off. Also noted to wear his sunglasses while in the dark room. Has refused hydration mug. Does not want it in his room. Has been short tempered with staff. Resident does not want staff in his room.” ff. On 8/31/24 at 3:40 AM, the Behavioral Symptoms note documented, “Resident came up to nurse's station states that he was upset because CNA [Certified Nurse Assistant] woke him up when she delivered a water pitcher and checked on him…. After CNA delivered water cup and checked on resident, he became agitated and aggressive to CNA, he threw his water cup out in the hall. CNA cleaned up the water and replaced the water cup; it was then that resident came to nurse and complained that he is not happy with the way this facility is handling his care. He states I am here to die, why can't you people just let me die? I don't need anyone in my room hovering over me. Staff attempted to deescalate confrontation; Nurse explained that if he is unhappy with his care that he is welcome to address his concerns with [name omitted] the resident advocate. however, resident stormed to his bedroom and slammed his door.” gg. On 8/31/24 at 11:09 AM, the Mood State note documented, “Nurse went into residents room to speak to him about his recent behaviors and concerns. Stated to nurse that he doesn't want to be ‘the asshole but nobody listens'. Voiced that he doesn't recall conversations that he has with someone 5 minutes after they occur…. When asked resident if he was having thoughts of self harm stated ‘I told myself long ago that I would never take my life with my own hands, but if there was a way for me to just die I would welcome that'. Voices feelings of increased agitation that he contributes to sleep deprivation…. Told him that I would reach out to Dr [NAME] to express his agitation concerns.” It should be noted that no documentation could be found for any interventions or monitoring that was implemented. hh. On 8/31/24 at 2:57 PM, the Medication note documented, “Order received from [physician name omitted] to increase residents seroquel from 125 mg to 150 mg QHS”. ii. On 9/4/24 at 9:49 AM, the Behavioral Symptoms note documented, “Resident refused breakfast this am x2…. This am resident has been pacing hallway end to end. When asked if resident needed anything or if he was feeling okay resident continued to ignore nurse. At this time resident is showing signs of agitation but shows no s/sx of distress. He prefers to wear darkened sunglasses in room and in hallway.” jj. On 9/5/24 at 7:28 AM, the note documented, “Talked to him about his mood score being high. He said I'm not depressed. Voiced he is just upset about his kids and the situation. Also said he does not want more medication for depression. Asked if he would like me to setup an appointment for a counselor to see him and he said my counselor comes here to see me and I talk to her.” It should be noted that the note was authored by the Director of Nursing. kk. On 9/6/24 at 9:30 PM, the note documented, “Nurse into resident bedroom to administer HS [hour of sleep] medication, resident was asked if pain medication that was administer [sic] by AM [morning] nurse was effective. He states that stuff works great I wish the doctor would let me have that medication every day. I don't like to use drugs but man that pill made me relax enough that I could get some much-needed rest.” ll. On 9/8/24 at 7:26 AM, the Behavioral Symptoms note documented, “Has been ambulating up and down the hall for 20-30 mins, is requesting something for general pain”. mm. On 9/8/24 at 2:05 PM, the note documented, “Patient is c/o back pain is requesting a Percocet. Patient states his low back is aching. I have no refills on this medication.” nn. On 9/8/24 at 4:52 PM, the Medication note documented, “New order Discontinue Percocet 325/5mg. Use prn [as needed] orders Ibuprofen 400mg for pain or discomfort. [Physician name omitted] will be making rounds this week.” oo. On 9/9/24 at 9:00 PM, the not documented, “Nurse and CNA into resident's bedroom to administer HS med and ask if he need anything before, he goes to bed. Resident sates ‘no just shut my door and stay out of my room.' “ pp. On 9/10/24 at 12:35 PM, the Dietary Concerns note documented, “Spoke about low meal intake and wt lose [sic]. Informed him that they had come in and adjusted the juice machines. Also informed him again about the alternative meals. He hinted that he did not want to be a bother. Told him we were all set up for it and would not be any extra for the staff. He said ‘I will just keep losing weight until I die and get to see heavy [sic] father.' “ It should be noted that no documentation could be found that the physician was notified of the resident's statement or any interventions or monitoring that was implemented. qq. On 9/11/24 at 4:20 PM, the note documented, “resident c/o back pain, prescribed prn medications were offered, Acetaminophen, ibuprofen, and cyclobenzaprine. Resident refused any medications. stated that he would like to talk to his physician face to face first. That he needs something stronger for pain. He states that he is unable to sleep because the pain is so bad…. Spends most of the day in his bed asking everyone to leave him alone.” rr. On 9/12/24 at 11:40 AM, the note documented, “Resident had appointment with LCSW [Licensed Clinical Social Worker] [name omitted]. No concerns expressed at this time.” ss. On 9/12/24 at 2:40 PM, the Behavioral Symptoms note documented, “at this time resident approached nurses station and says that he is going to bed and will be refusing to get up for dinner. Nurse explained the importance of getting up and eating meals. Resident stated, ‘I will not be going to dinner and I don't care.' “ tt. On 9/13/24 at 3:00 PM, the note documented, “[Name of physician omitted] into see resident. Plan of care reviewed. Resident is c/o [complaining of] pain. Would like pain medication scheduled. [Name of physician omitted] inquired about location of pain. Resident states he has back pain from ‘sitting too much, laying too much, walking too much.' Resident states he is sleeping okay. Resident also states that he spends ‘17 hours a day in bed., but they [sic] denies being in bed. Resident also states that he had a back injury in his L [lumbar] 4-L5 from a car accident 20 years ago. States he has been ‘pissing himself'. Dr. [NAME] asked if resident if he has lost control of his bowel or bladder. Resident states ‘no.' Denies numbness in legs or in the saddle area of his crotch. Resident again states ‘no.' [Name of physician omitted] suggested increased activity and also attending facility activities. Resident states, ‘Not gonna happen.' [Name of physician omitted] inquired reason why? Resident states, ‘They are 80 and I'm not. That activity today was a wheelchair activity. I'm not going.' Resident states he wished marijuana was legal. [Name of physician omitted] states he will not order marijuana. Resident talked in circles and states that ‘this hospital doesn't even know what goes on here.' States he has been seeing his psychiatrist. [Name of physician omitted] stated he didn't know that resident was seeing a psychiatrist. Resident became angry and states, ‘How is it that you don't know me??' [Name of physician omitted] inquired who his psychiatrist is. Resident states, ‘[name omitted]' [Name of physician omitted] states he knows [name omitted] and that she is a counselor and not a psychiatrist. Resident then states he is not depressed and argued about his medication. [Name of physician omitted] states he is happy to help, but will not do it with bad medicine. When resident asks about pain medication, [Name of physician omitted] states he will not prescribe narcotics. Resident becomes upset and states the other stuff doesn't work. Resident states that he can't remember to ask for medication and wants medication scheduled. [Name of physician omitted] states he is able to ask. New orders received: 1) Discontinue flexaril 2) Methocarbamol 750mg 2 tabs Q 8 hours at 0800 [8:00 AM], 1400 [2:00 PM], and 2200 [10:00 PM] x [times] 3 days. then 3) Methocarbamol 750mg 2 tabs PO TID PRN [as needed]- back pain.” uu. On 9/13/24 at 11:33 PM, the note documented, “Call from East side nurse telling nurse to come over for help around 2040 [8:40 PM]. This nurse and [name omitted], RN [Registered Nurse] came over to East side immediately. All nurses ran into resident's room at that time. Curtain was pulled. Resident was laying sideways on the bed, left foot out on the floor and right foot and leg tucked under bottom. Black trash bag was over head and knotted tightly around neck with string, appeared to be from a jacket. Feet, hands, neck were blue. Resident's legs were assisted onto bed, small hand towel was placed over face, bag was ripped and cord was unable to be unknotted, so scissors were obtained to cut off. Face was blue. No pulse found. Resident with DNR [Do Not Resuscitate] status. DON, Administrator, 911, physician notified. All staff out of room at that time until police arrived. DON and Administrator arrived right before police arrived. Police took over investigation at that time.” On 5/31/24, resident 40's signed POLST order documented Do not attempt or continue any resuscitation (DNR) (Allow Natural Death). Resident 40's physician orders revealed the following: a. On 5/24/24, an order was initiated for Klonopin 1mg two times a day (BID) for anxiety disorder. b. On 5/24/24, an order was initiated for Quetiapine 100mg QHS for major depressive disorder. c. On 5/29/24, the Klonopin was increased to 2mg three times a day (TID) at 8:00 AM, 2:00 PM, and 10:00 PM for anxiety disorder. d. On 6/8/24, an order was initiated for Zyprexa 5mg daily (QD) for major depressive disorder. It should be noted that this medication was initiated because Rexulti was not covered by insurance. e. On 6/14/24, an order was initiated for Sertraline 50mg QD for major depressive disorder. f. On 7/12/24, an order was initiated to increase the Sertraline to 100mg QD for major depressive disorder. g. On 7/29/24, an order was initiated to decrease Zyprexa to 2.5mg QD for major depressive disorder. h. On 8/2/24, an order was initiated to discontinue Zyprexa. i. On 8/5/24 an order was initiated for Trazodone 50mg QHS for insomnia. j. On 8/22/24, an order was initiated to increase Sertraline to 150mg QD for major depressive disorder. k. On 8/20/24, an order was initiated for Quetiapine 25mg QHS, give with 100mg tablet to equal 125 mg for major depressive disorder. l. On 8/31/24, an order was initiated for Quetiapine 50mg QHS, give with 100mg tablet to equal 150 mg for major depressive disorder. Resident 40's Antipsychotic Medication Monitor Form Documented the following: a. On 5/26/24 and 5/27/24 for day shift, the Seroquel form documented 4 events for throwing objects and striking out at others. The form documented behavior management interventions utilized were positive reinforcement, “Live the Moment” validation, food/fluids offered, and music activity offered. The form documented that the outcome after intervention was effective or improved. b. June 2024 monitoring for the Seroquel documented zero events. It should be noted that documentation was missing for 6/3/24 day shift, 6/6/24 night shift, 6/23/24 night shift, 6/24/24 night shift, and 6/25/25 night shift. c. July 2024 monitoring for the Seroquel documented 2 events on 7/25/24, 2 event on 7/27/24, and 2 events on 7/29/24 for behaviors of delusions. The form documented behavior management interventions utilized were positive reinforcement, redirection, and “Live the Moment” validation. The form documented that the interventions were effective on 7/25/24 and 7/29/24. The form did not have documentation for the interventions or outcome for the 7/27/24 events. It should be noted that documentation was missing for 7/6/24 day shift. d. July 2024 monitoring for Zyprexa documented a behavior for suicidal thoughts. The form documented 2 events on 7/12/24 and interventions utilized were documented that all of the following interventions were provided: taken to bathroom, positive reinforcement, redirection, “Live the Moment” validation, food/fluids offered, music/activity offered, medication offered. The outcome was documented as “N” for not observed/unchanged. On 7/13/24 one event was documented, interventions were documented as all and outcome was “N”. On 7/14/24, 7/15/24, and 7/16/24 two events were documented, interventions were documented as all and outcome was “N”. It should be noted that no documentation could be found that the physician was notified of the suicidal thoughts on 7/13/24, 7/14/24, 7/15/24, or 7/16/24. e. August 2024 monitoring for the Seroquel documented 6 events on 8/7/24, 2 events on 8/8/24, 3 events on 8/17/24, 1 event on 8/18/24, 2 events on 8/19/24, and 3 events on 8/20/24 for behaviors of delusions. The form documented the interventions utilized were positive reinforcement, redirection, and “Live the Moment” validation. On 8/7/24, 8/8/24 and 8/17/24 the outcome was documented as not observed or unchanged. On 8/30/24 two events were documented for throwing things and on 8/31/24 one event was documented for throwing things. The interventions documented as utilized for the behavior of throwing things were “all” for taken to bathroom, positive reinforcement, redirection, “Live the Moment” validation, food/fluids offered, music/activity offered, medication offered. f. September 2024 monitoring for the Seroquel documented 1 event on 9/3/24 and 9/4/24, 2 event

Based on interview and record review it was determined, for 3 out of 22 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued. Specifically, residents were prescribed psychotropic medications and monitoring was not conducted for episodes of behavior, adverse side effects, and non-pharmacological interventions. Resident identifiers: 3, 5, and 22. Findings included:1. Resident 3 was admitted to the facility on [DATE] with diagnoses which included neurocognitive disorder with Lewy Bodies, Schizophrenia, delusional disorder, and insomnia. Resident 3's medical records were reviewed from 9/22/25 through 9/25/25. On 10/12/23, resident 3 had an order initiated for Trazodone Hydrochloride 50 milligram (mg) by mouth at hour of sleep for insomnia. Resident 3's Medication Administration Record (MAR) and Treatment Administration Record (TAR) was reviewed for September 2025. No documentation could be found for monitoring of Adverse Side Effects (ASE), and non-pharmacological interventions for the Trazodone. On 9/23/25 at 2:07 PM, an interview was conducted with Certified Nurse Assistant (CNA) 2. CNA 2 stated that resident 3 had not been sleeping well and did not sleep great most of the time. CNA 2 did not report any non-pharmacological interventions that were provided for resident 3's insomnia. On 9/25/25 at 11:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that they recorded hours of sleep for hypnotics in the TAR. The DON stated that they did not monitor for ASE or non-pharmacological interventions for the hypnotics. 2. Resident 5 was admitted to the facility on [DATE] with diagnoses which consisted of anxiety disorder and dementia. Resident 5's medical records were reviewed on 9/22/25 through 9/25/25. On 4/7/25, resident 5 had an order initiated for Buspirone 10 mg by mouth two times a day for anxiety disorder. On 6/12/25, resident 5 had an order initiated for Seroquel 50 mg by mouth two times a day for striking out, resisting care, delusions, and unspecified dementia. On 6/17/25, resident 5 had an order initiated for Sertraline 50 mg by mouth daily for anxiety disorder. Resident 5's September 2025 MAR and TAR were reviewed. No documentation could be found for monitoring of episodes of behavior, ASE, and non-pharmacological interventions for Buspirone and Sertraline. On 9/23/25 at 1:50 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 5 did not really have any behaviors. CNA 1 stated that resident 5 would refuse cares such as dressing and showering. On 9/23/25 at 2:00 PM, an interview was conducted with CNA 2. CNA 2 stated that resident 5 had behaviors of exit seeking on admission and there were times he would pull back his hand like he was wanting to hit you. CNA 2 stated that those behaviors were much less often, if at all, now. On 9/23/25 at 2:28 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 5 had behaviors of verbal and physical aggression and struggles on shower days the most. RN 2 stated that the Seroquel was prescribed for the aggressive behaviors and striking out, resisting care, and delusions. RN 2 stated that resident 5 had days that he thought staff took his clothes and moved his stuff around. RN 2 stated that she was not sure if this was a delusion or just an opinion. RN 2 stated that they documented behaviors, ASE and non-pharmacological interventions on antipsychotics but not on the anti-depressants or anti-anxiety medications. RN 2 stated that they charted a change in condition in a progress note. RN 2 stated that typically the MAR had monitoring for behaviors and number of episodes for the anti-depressants and anti-anxiety medication. On 9/24/25 at 8:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 5 initially upon admission had behaviors of aggression towards residents and staff, but that had decreased and was managed by Seroquel. LPN 1 stated that resident 5 did not have Bipolar or Schizophrenia. LPN 1 stated that the Seroquel was prescribed for severe anxiety and dementia and behaviors were striking out, resisting cares and delusions. LPN 1 stated that resident 5's delusions were paranoia that someone was in his room taking his things, and he would report seeing someone who was not there. On 9/24/25 at 9:17 AM, an interview was conducted with the DON. The DON stated that they did not document episodes of behavior or monitor for ASE and non -pharmacological interventions for anti-depressants, anti-anxiety, and hypnotics. The DON stated that resident 5 had monitoring for his anti-psychotics but not for the other psychotropics. The DON stated that resident 5's monitoring was missed. On 9/25/25 at 11:30 AM, the DON stated that resident 5 was aggressive, struck out at staff, and refused cares. The DON stated that the pharmacy recommendation was to start a Selective Serotonin Reuptake Inhibitor (SSRI) and then start a gradual dose reduction of the Seroquel. The DON stated that the indication of use for Seroquel was a danger to self. The DON stated that the Seroquel was not prescribed for what it should be indicated for. The DON stated that indications of use for the Seroquel were Schizophrenia, Schizoaffective disorder, and Bipolar disorder. The DON responded no when asked if Seroquel was an appropriate use for dementia. On 9/25/25 at 1:12 PM, a follow-up interview was conducted with the DON. The DON stated that she spoke to the Medical Director and he knew that the resident did not have a diagnosis for the use of Seroquel. The DON stated that resident 5 was started on the Seroquel for anxiety and aggression. 3. Resident 22 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Down Syndrome, major depressive disorder, anxiety disorder and dementia. Resident 22's medical record was reviewed 9/23/25 through 9/25/25. A review of resident 22's physician orders revealed: a. A physician's order dated 5/23/23 documented, VENLAFAXINE HYDROCHLORIDE 75 MG [milligram] CAPSULE, EXTENDED RELEASE (Venlafaxine Hydrochloride) ORAL 1 CAP [capsule] 0800 [8:00 AM] for F32.9, F41.9 Major depressive disorder, single episode, unspecified, Anxiety disorder, unspecified. b. A physician's order dated 9/23/25 documented, CLONAZEPAM 0.5 MG TABLET (Clonazepam) Oral 0.5 mg BID [twice a day] with breakfast and dinner.for F41.9 Anxiety disorder, unspecified. c. A physician's order dated 7/15/25 documented, HALOPERIDOL 0.5 MG TABLET (Haloperidol) Oral 1 TAB Every 6 hours.**Target Behaviors; Paranoid statement, Delusions** For 02.B2 [sic] Dementia in other diseases classified elsewhere, moderate with psychotic disturbance. No documentation could be found of monitoring for adverse side effects, episodes of behaviors, and non-pharmacological interventions for the venlafaxine and clonazepam. On 9/25/25 at 10:22 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 22 was monitored for delusions and paranoid statements with his antipsychotic use throughout the day and a log was kept in a binder at the nurse's station. LPN 1 stated there was not a binder that recorded any behaviors or monitored for any side effects from the use of venlafaxine and clonazepam.

Based on observation, interview, and record review, it was determined that for 1 out of 22 sampled residents, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, enhanced barrier precautions (EBP) were not implemented for a resident with a chronic abdominal abscess wound. Resident identifier: 5.Findings Included: Resident 5 was admitted to the facility on [DATE] with diagnoses which included, cutaneous abscess of abdominal wall, weakness, and unspecified severe protein-calorie malnutrition. Resident 5's medical record was reviewed 9/22/25 through 9/25/25. On 9/23/25 at 9:09 AM, an observation was made of resident 5's room. There was no signage that indicated that resident 5 required EBP. A review of resident 5's physician orders revealed the following: a. On 8/8/25 an order documented, Monitor chronic abdominal opening. Clean area with NS [normal saline], cover with ABD [abdominal] and 2 large tegaderm bandages Q [every] shift. b. On 9/9/25 an order documented, Cavilon Advanced Skin protectant Q shift Apply to area surrounding abdominal abscess every Tuesday. A review of resident 5's progress notes revealed the following: a. On 3/19/25 at 4: 51 PM, a note documented, .Abscess present on abdomen with scant yellow discharge and pungent smell. An ostomy waver [sic] and bag has been placed on abdominal abscess. b. On 3/27/25 at 5:24 AM, a note documented, .cnas [Certified Nursing Assistant] took to bathroom changed all clothes due to drainage from abd wound, when back in bed nurse cleaned abd and put new bag and wafer over wound to collect drainage. c. On 4/5/25 at 4:51 AM, a note documented, .Given warm blanket, nurse came in and changed wafer and appliance for wound to abdomen. Leakage noted to bottom side of new appliance. d. On 8/23/25 at 2:10 PM, a note documented, During drsg [dressing] change on abdomen, skin noted to have red-speckled areas. Noted change from yesterday. Area washed with soap and water during shower. New drsg applied. e. On 9/9/25 at 3:26 PM, a note documented, Abdominal dressing removed, area cleaned with hibiclens and NS, Cavilon advanced skin protectant applied to abdomen to prevent breakdown from draining chronic abdominal abscess. On 9/25/25 at 9:44 AM, an interview was conducted with CNA 1. CNA 1 stated that there were no signs placed on resident's doors to alert staff about residents that required EBP. CNA 1 stated that signs were placed for residents if they required isolation. On 9/25/25 at 9:52 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she had not heard of EBP. LPN 1 stated that resident 8 had a chronic abscess on his abdomen that required dressing changes because it weeped. LPN 1 stated that she only wore gloves when she changed resident 8's abdominal dressings. On 9/25/25 at 11:04 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff should be wearing gloves and gowns for residents who required EBP. The DON stated that the facility did not put up signage for EBP and expected staff to pass what residents required EBP in the shift report. The DON stated that resident 8 had a chronic abdominal abscess that was open and draining and she would classify that as a wound. The DON stated that resident 8 did require EBP.

Based on interview and record review it was determined for 1 out of 22 sampled residents, the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, the resident's laboratory results were not located in the electronic medical record. Resident identifier: 21Findings included: Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included other amnesia, borderline intellectual functioning, bipolar disorder, obsessive-compulsive disorder, and drug induced movement disorder.Review of resident 21's medical record was completed on 9/22/25 through 9/25/25.On 8/28/25 at 4:20 PM, a progress note revealed the following, physician was into see resident and new orders received to check complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid stimulating hormone (TSH), and lipid panel on 9/2/25.On 8/28/25, a Physician's Order was entered for the following labs to be completed: CBC, CMP, TSH, and lipid panel to be drawn on 9/2/25.A review of resident 21's medical record revealed:There were no CBC, CMP, TSH, or lipid panel laboratory results located in resident 21's medical record. On 9/25/25 at 11:08 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that laboratory results are faxed over from the local hospital. RN2 stated the nurse will inform the physician and enter the results as a progress note in the electronic medical record. RN 2 stated the paper fax copy of the laboratory results are filed into the resident's hard chart located at the Nursing Station.On 9/25/25 at 1:59 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility draws all the laboratory requests per the physician's orders, a laboratory requisition form which has multiple copies is filled out. The drawn labs are taken to the local hospital by facility staff for processing. The hospital faxes over the laboratory results, the nurse will contact the physician, enter the results in the electronic medical record as a progress note and place faxed results into the resident's hard medical chart. The Minimum Data Set coordinator gets a copy of the laboratory requisition form, and it is their responsibility to track any laboratory request and to ensure the labs have been completed and the result gets placed into the resident's chart, both the electronic and hard medical chart. On 9/25/25 at 2:52 PM, The DON stated that the floor nurse had called the physician's main office to get laboratory results for CBC, CMP, TSH, or lipid panel that were completed on 9/2/25. The DON stated that the laboratory sent the results were sent to the physician's office and not the facility due to the orders coming from the physician's main office.

Based on interview and record review, it was determined for 1 out of 22 sampled residents, that the facility failed to send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. Specifically, the facility was only notifying the Ombudsman of residents who transferred to a hospital. Resident Identifier: 38. Findings Included: Resident 38 was admitted to the facility on [DATE] with diagnoses which included, unspecified fracture of left femur, unspecified fracture of right humerus, and unspecified fall.Resident 38's medical record was reviewed 9/23/35 through 9/25/25.A review of resident 38's progress notes revealed:a. On 8/11/25 at 6:08 PM, a progress note documented, Medication, follow up appointments and Home health PT [physical therapy] with [name redacted] discussed and answered any questions resident and husband had. Assisted resident to PMV [private motor vehicle] via W/C [wheelchair]. Resident expressed appreciation for care. b. On 8/12/25 at 4:33 PM, a late entry note documented, [Medical Doctor] into visit resident. Care plan and orders reviewed. Resident requesting to go home. New orders are as follows: 1) resident may d/c [discharge] to home; 2) P.T. orders; 3) Medications released to resident.On 09/25/25 at 8:31 AM, an interview was conducted with the Medical Record Coordinator (MRC). The MRC stated that she notified the Ombudsman of unexpected transfers and discharges of residents from the facility to the hospital. The MRC stated that she had not notified the Ombudsman regarding resident 38's discharge because resident 38 discharged home. The MRC stated that she did not report to the Ombudsman for any community discharges. On 9/25/25 at 11:09 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was only aware of having to notify the Ombudsman regarding residents that were discharged to a hospital.

Based on interview and record review it was determined the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments, during required visits. Specifically, for 4 out of 21 sampled residents, the physician did not include an evaluation of the resident's condition and total program of care, including medications and treatments, and a decision about the continued appropriateness of the resident's current medical regimen. Resident identifiers: 11, 22, 25, and 28. Findings included: 1. Resident 11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 11's medical record was reviewed on 2/8/22. On 11/3/21 at 10:50 AM, an Interdisciplinary Progress Note documented Category:Physician Visit (name of physician] in to see him, no new changes. The note was created by nursing staff. [Note: A physician visit note was unable to be located in the medical record.] On 11/9/21 at 7:31 AM, a Progress Note-Physician Final Report documented [Resident 11] is sitting up in his wheelchair in the common area of the west side. He tells me that he is happy. He denies any pain. He overall says that he is doing well. Nursing reports no new change or concern. Vitals his weight is down to 173 his temperature is 97 his pulse is 87 respiratory rate 16 blood pressure 140/75 and a 94% room air saturation. I do not see any reason to make any changes at this point so we will continue with his current outlined regimen. The note was created by the Medical Doctor (MD). On 12/1/21 at 11:17 AM, an Interdisciplinary Progress Note documented Category: Physician Visit [name of physician] came and saw resident. Order received: D/C (discontinue) [MEDICATION(S)] 0.25 mg (milligrams) PO (by mouth) BID (twice a day) . The note was created by nursing staff. On 12/1/21 at 11:32 AM, a Progress Note-Physician Final Report documented Is in his room when I visit with him today he is very pleasant and comfortable. Pharmacy is asking us to do a dose reduction with his [CONDITION(S)] medications which we will do by discontinuing his [MEDICATION(S)]. Objectively his weight is 181.6 temperature 98.5 pulse is 81 respiratory rate 20 blood pressure is 143/72 and he has a room air saturation of 93% exam is basically unchanged from previous exams and he seems to be very comfortable so our plan at this time will be to continue with his overall current plan of care. The note was created by the MD. On 1/5/21 at 10:02 AM, an Interdisciplinary Progress Note documented Category: Physician Visit [name of physician] into visit; reviewed medications and plan of care. No new orders received. The note was created by nursing staff. [Note: A physician visit note was unable to be located in the medical record.] On 1/8/21 at 8:59 AM, a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . In review of his charting his blood pressures have been in the low over the last month or so and continue to be a little bit variable but mostly low during the entire or during all of his his (sic) checks he is on both calcium channel blocker and a beta-blocker were going to discontinue the calcium channel blocker today at his visit otherwise he has been pretty stable his weights up a little bit this this (sic) month at 157 his temperature is 97.9 pulse is 60 respiratory rate is 16 blood pressure today is 94/57 and he has a room air saturation of 95% discussion with the nursing staff he really is pretty stable other than the blood pressure issue so we will continue all of his other therapies and medications as noted but discontinue his [MEDICATION(S)] at this time. The note was created by the MD. On 2/2/22 at 11:38 AM, an Interdisciplinary Progress Note documented Category: Physician Visit [name of physician] into visit, plan of care and medication reviewed. The note was created by nursing staff. [Note: A physician visit note was unable to be located in the medical record.] [Note: The MD visit notes did not include resident 11's total program of care. The total program of care should include medical services and medication management, physical, occupational, and speech/language therapy, nursing care, nutritional interventions, social work and activity services that maintain or improve psychosocial functioning.] 2. Resident 22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 22's medical record was reviewed on 2/8/22. On 11/12/21 at 2:22 PM, an Interdisciplinary Progress Note documented Category: Physician Visit [name of physician] in to see resident this afternoon, no changes made at this time, continue w/ (with) plan of care. The note was created by nursing staff. [Note: A physician visit note was unable to be located in the medical record.] On 12/10/21 at 3:00 PM, an Interdisciplinary Progress Note documented Category: Physician Visit [name of physician] into see resident. Plan of care reviewed. No new orders at this time. The note was created by nursing staff. On 12/10/21, a Rounds/Progress Note documented Subjective: [resident 22] is a [AGE] year-old caucasian male with Dementia and hypertension. He is seen eating lunch in the cafeteria. Nursing notes that he is essentially unchanged over the last month. Objective: VS (vital signs): Weight: 169.9, Temp (temperature) 98 [degrees], Pulse: 82, Resp (respirations): 16 Blood Pressure: 121/80, SpO2 (oxygen saturation) 95% (RA) (room air) General: Cooperative [AGE] year-old caucasian male in no visible distress. He is chewing on his shirt. Heart: RRR (regular rate and rhythm) without murmur Lungs: Clear to auscultation bilaterally. Assessment: 1. Dementia. Stable. 2. Hypertension. Stable. Plan: 1. Continue the current regimen. The note was created by the MD. On 1/12/22 at 2:16 PM, an Interdisciplinary Progress Note documented Category: Physician Visit [name of physician] into visit; reviewed plan of care and medications. No new order received. The note was created by nursing staff. [Note: A physician visit note was unable to be located in the medical record.] On 2/4/22 at 1:00 PM, an Interdisciplinary Progress Note documented Category: Physician Visit [name of physician] in to see resident. No new orders at this time. The note was created by nursing staff. On 2/4/22, a Rounds/Progress Note documented Subjective: [resident 22] is a [AGE] year-old caucasian male with Dementia and hypertension. He is seen eating lunch in the commons area off the east side. Nursing notes that he seems to be at baseline and has had no urinary issues. Catheter is working well. Objective: VS: Weight: 171.6, Temp 97.7 [degrees], Pulse: 80, Resp: 16, Blood Pressure: 115/74, SpO2 92% (RA) General: Cooperative [AGE] year-old caucasian male in no visible distress. Heart: RRR without murmur Lungs: Clear to auscultation bilaterally Assessment: 1. Dementia. Stable. 2. Hypertension. Stable. 3. Recent patient mediated extraction of foley catheter. Plan: 1. Continue the current regimen. The note was created by the MD. [Note: The MD visit notes did not include resident 22's total program of care. The total program of care should include medical services and medication management, physical, occupational, and speech/language therapy, nursing care, nutritional interventions, social work and activity services that maintain or improve psychosocial functioning.] 3. Resident 25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 25's medical record was reviewed on 2/8/22. On 12/10/21 at 3:00 PM, an Interdisciplinary Progress Note documented Category: Physician Visit [name of physician] into see resident. Plan of care reviewed. No new orders at this time. The note was created by nursing staff. On 12/10/21, a Rounds/Progress Note documented Subjective: [resident 25] is a [AGE] year-old caucasian male with Down's Syndrome, Alzheimer's-type Dementia and Celiac Sprue. He states that he hurts 'in my body' but is unable to localize or further qualify his pain. He notes that he has difficulty walking. Nursing notes that he is doing well otherwise and is baseline. Objective: VS: Weight: 258.8, Temp: 97.5 [degrees], Pulse: 80, Resp: 20, Blood Pressure: 117/80, SpO2: 91% (RA) General: Cooperative [AGE] year-old caucasian male in no acute distress. Heart: RRR, no murmurs noted Lungs: Coarse breath sounds bilaterally Assessment: 1: Down's Syndrome. Continue on current regimen. 2: Alzheimer's-type Dementia. 3. Celiac Sprue. The note was created by the MD. On 2/4/22 at 1:00 PM, an Interdisciplinary Progress Note documented Category: Physician Visit [name of physician] in to see resident. No new orders at this time. The note was created by nursing staff. On 2/4/22, a Rounds/Progress Note documented Subjective: [resident 25] is a [AGE] year-old caucasian male with Down's Syndrome, Alzheimer's-type Dementia and Celiac Sprue. He denies any specific concerns. Objective: VS: Weight: 282, Temp: 97 [degrees], Pulse: 62, Resp: 20, Blood Pressure: 116/64, SpO2: 95% (RA) General: Cooperative [AGE] year-old caucasian male in no acute distress. Heart: RRR, no murmurs noted Lungs: Coarse breath sounds bilaterally Assessment: 1: Down's Syndrome. Continue on current regimen. 2: Alzheimer's-type Dementia. 3. Celiac Sprue. The note was created by the MD. [Note: The MD visit notes did not include resident 25's total program of care. The total program of care should include medical services and medication management, physical, occupational, and speech/language therapy, nursing care, nutritional interventions, social work and activity services that maintain or improve psychosocial functioning.] 4. Resident 28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 28's medical record was reviewed on 2/8/22. On 11/3/21 at 10:52 AM, an Interdisciplinary Progress Note documented Category: Physician Visit [name of physician] in to see her, no new changes. The note was created by nursing staff. [Note: A physician visit note was unable to be located in the medical record.] On 11/9/21 at 7:39 AM, a Progress Note-Physician Final Report documented [Resident 28] is up in the commons area of the west side. She is holding a small cup of strawberry milk which she is not drinking. When asked her why she is not drinking it she laughs and tells me she is. She continues to lose weight which is very worrisome the nursing staff is helping her eat but she just does not eat very much. Her weight is down to 75 pound her temperature is 97.3 pulse is 72 respiratory rate 18 blood pressure is 137/75 and she has a room air saturation of 94%. Overall she is doing poorly because of weight loss but she [NAME] well she denies pain she denies any other concerns overall she is happy her memory continues to decline. In review of her chart I do not see any changes that can be made other than continuing to encourage her at mealtime and help with her feedings. The note was created the MD. On 12/1/21 at 10:30 AM, an Interdisciplinary Progress Note documented Category: Physician Visit [name of physician] into visit, reviewed plan of care, weight and medications. No new orders received. The note was created by nursing staff. On 12/1/21 at 11:35 AM, a Progress Note-Physician Final Report documented [Resident 28] continues to decline. She is very pleasant when I talked to her in the commons area today she indicates that she is completely comfortable and when I asked her specifically about eating she tells me that she eats enough her weight is down to 69.9 pounds her temperature is 98 pulse is 76 respiratory rate of 16 blood pressure is 130/81 and she has a room air saturation of 97%. Exam very frail-appearing thin female who is pleasant and indicates that she does not have any pain or concerns at this time I have encouraged nursing staff to help feed her and continue to encourage p.o. intake 1 (sic) needed completely denies any lunchtime food and even while eating she is she (sic) struggles to eat very much at breakfast and dinner 1 (sic) idea is putting it in a cup as she seems to like to drink more so we will try thickened liquids in a cup such as oatmeal to see if we can get more calories in her. Otherwise we will continue with her current outlined regimen. The note was created by the MD. On 1/5/22 at 10:05 AM, an Interdisciplinary Progress Note documented Category: Physician Visit [name of physician] into visit; reviewed medications and plan of care. No new orders received. Note created by nursing staff. The note was created by nursing staff. [Note: A physician visit note was unable to be located in the medical record.] On 2/2/22 at 10:16 AM, an Interdisciplinary Progress Note documented Category: Physician Visit [name of physician] into visit and review plan of care, medications and current diagnoses. New order: Add DX (diagnoses):Chronic gingivitis ([MEDICATION(S)]). The note was created by nursing staff. [Note: A physician visit note was unable to be located in the medical record.] On 2/8/22 at 8:55 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the nursing staff would note in the electronic medical record progress note when the physician made a visit with a resident. The DON stated the physician note would be filed in the resident's paper medical record. On 2/8/22 at 9:11 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that each physician had their own way of charting. RN 1 stated the physician would dictate their notes after they visited the residents and would fax them to the facility. RN 1 stated that some of the physicians were more thorough and would review the entire system of the resident. On 2/9/22 at 11:37 AM, a follow up interview was conducted with the DON. The DON stated that she would do rounds with the physician if she was at the facility. The DON stated she would make a list of the resident's vital signs and problems for the physician.

Based on observation, interview, and record review it was determined the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff were not sanitizing the vital signs cart contents between residents including the forehead thermometer. In addition, staff did not use hand hygiene while assisting residents during dining resulting in cross contamination. Resident identifiers: 7 and 20. Findings included: 1. The following observations were made of the dining meal service: a. On 2/7/22 at 12:53 PM, Certified Nursing Assistant (CNA) 2 was observed to assist resident 7 and resident 20 with dining, no hand hygiene was performed in between feeding the residents. CNA 2 was observed to touch the drinking portion of three of resident 20's straws after touching resident 7 on the arm. b. On 2/7/22 at 12:55 PM, CNA 2 was observed to touch the eating end of resident 20's spoon after rubbing resident 7's back. CNA 2 did not perform hand hygiene. c. On 2/9/22 at 9:39 AM, CNA 2 was observed to touch the drinking portion of resident 20's straw after the handle of a wheelchair was touched. CNA 2 did not perform hand hygiene. The Infection Control Policy for dining in the facility revealed, in order to ensure residents have a safe dining experience, frequent handwashing, cleaning, and sanitizing of contact surfaces must be adhered to by staff. On 2/8/22 at 2:32 PM, an interview was conducted with CNA 4. CNA 4 stated the staff should sanitize their hands in between each resident interaction, when assisting with dining, doing resident vital signs, and caring for residents. On 2/9/22 at 10:01 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the staff should perform hand hygiene in between feeding each resident, doing cares, or assisting residents. The DON stated infections can be spread if hand hygiene was not done, and despite ongoing training the lack of hand hygiene had been a recurrent problem with some staff. 2. The following observations were conducted of the vital signs cart: a. On 2/8/22 at 1:39 PM, CNA 3 was observed to obtain vital signs from a resident. CNA 4 did not clean the blood pressure (BP) cuff, thermometer, or the pulse oximeter after use. CNA 4 returned the vital signs cart to the nurses station. b. On 2/8/22, at 1:53 PM, CNA 3 was observed to obtain vital signs from a resident. CNA 3 did not clean the BP cuff, thermometer, or the pulse oximeter after use. c. On 2/8/22 at 1:55 PM, CNA 3 was observed to obtain a temperature from a resident. The thermometer was swiped against the resident's forehead. CNA 3 did not clean the thermometer after use. d. On 2/8/22 at 3:04 PM, CNA 3 was observed to obtain vital signs from a resident. CNA 3 did not clean the BP cuff, thermometer, or the pulse oximeter after use. e. On 2/9/22 at 9:11 AM, CNA 2 was observed to obtain vital signs from a resident. CNA 2 did not clean the BP cuff, thermometer, or the pulse oximeter after use. f. On 2/9/22 at 9:14 AM, CNA 2 was observed to obtain vital signs from a resident. CNA 2 did not clean the BP cuff, thermometer, or the pulse oximeter after use. g. On 2/9/22 at 9:16 AM, CNA 2 was observed to obtain vital signs from a resident. CNA 2 did not clean the BP cuff, thermometer, or the pulse oximeter after use. h. On 2/9/22 at 9:18 AM, CNA 2 was observed to obtain vital signs from a resident. CNA 2 did not clean the BP cuff, thermometer, or the pulse oximeter after use. i. On 2/9/22 at 9:20 AM, CNA 2 was observed to obtain vital signs from a resident. CNA 2 did not clean the BP cuff, thermometer, or the pulse oximeter after use. j. On 2/9/22 at 10:00 AM, CNA 1 was observed to obtain vital signs from a resident. CNA 1 did not clean the BP cuff, thermometer, or the pulse oximeter after use. k. On 2/9/22 at 10:09 AM, CNA 1 was observed to obtain vital signs from a resident. CNA 1 did not clean the BP cuff, thermometer, or the pulse oximeter after use. l, On 2/9/22 at 10:24 AM, CNA 1 was observed to obtain vital signs from a resident. CNA 1 did not clean the BP cuff, thermometer, or the pulse oximeter after use. On 2/9/22 at 9:28 AM, an interview was conducted with CNA 1. CNA 1 stated she would sanitize the vital signs cart after every use. An observation was conducted of the vital signs cart. 5% alcohol wipes were observed on the vital signs cart. CNA 1 stated she used the alcohol wipes to clean the vital signs cart. On 2/9/22 at 9:55 AM, an interview was conducted with CNA 2. CNA 2 stated she was not sure how often the vital signs cart should be sanitized. CNA 2 stated she usually bathed the residents. On 2/9/22 at 10:01 AM, an interview was conducted with the DON. The DON stated each unit of the facility had an instruction sheet on how to clean and what cleaning solution to use on each piece of equipment after it was used. The DON stated the vital signs cart should be cleaned in between each resident, especially right now with COVID. The DON stated the CNA's were trained yearly on routine training's like the Health Insurance Portability and Accountability Act, fire safety, etc. The DON stated that she would add in other areas that were of concern and those training's would be done monthly. The DON stated the facility had a training program they use, with staffing being short and COVID in person training's had been decreased. The DON stated she was not surprised by the lack of hand hygiene or cleaning of equipment, it had been an ongoing issue with some staff. The DON provided the instruction sheet on how to clean and what cleaning solution to use on each piece of equipment after it was used. A review of the instruction sheet documented: All equipment must be disinfected between each use on a resident. Include all areas the resident and staff touched. Equipment such as: Lifts, Sit-to stands, all vital equipment. Including: Stethoscopes, Pulse oximeter finger probe and machine, Blood pressure cuffs and machine, Use only alcohol wipes on temporal thermometer. To disinfect: Use Peroxide Multi-Surface Cleaner. Wear gloves. Saturate Dry wipe with enough sloution (sic) to wipe down equipment used. You must wait 45 Seconds between use.

Based on observation, interview, and record review, it was determined the facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. Specifically, for 1 out of 21 sampled residents, a resident did not receive the feeding assistance she needed at meal time. Resident identifier: 28. Findings included: Resident 28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 28's medical record was reviewed on 2/8/22. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 28 required extensive assistance of one person with eating. In addition, the MDS assessment documented that resident 28 had a Brief Interview for Mental Status (BIMS) score of 5. [Note: A BIMS score of 0 to 7 points indicates severely impaired cognition.] A Plan of Care problem with an effective date of 10/15/21, documented that resident 28 was at nutritional risk as evidenced by leaving 25% plus at most meals. An intervention implemented on 10/15/21, documented that resident 28 would receive assistance as needed with meals. On 12/14/21 at 1:30 PM, an Interdisciplinary Progress Note documented Category: Dietary Concerns . Accepting puree diet better. Needing assist (assistance) with meals. Eating 25% of breakfast and dinner, still skips lunch. Using cups with handles. She is not holding regular cups well. Encourage meal and fluid intake, encourage supplements, assist as accepted. Offer preferred foods and alternative foods. On 1/15/22 at 7:56 AM, an Interdisciplinary Progress Note documented Category: Dietary Concerns 1/14/22 HT (height)-59 (inches) WT (weight)-75.4 Down 5%, . BMI (body mass index)-15.2, Diet Reg (regular)/puree. Needs cueing at meals. Refusing assist most of the time. Eating 15-25%. Still skips lunch. Eating only breakfast and dinner. Will sleep in and eat a late breakfast, this has been a life long history. Continue to encourage meal intake, and offer alternative foods and snack though out the day. Continue to monitor. On 2/8/22 at 10:17 AM, Resident 28 was observed in the dayroom area in a tilted wheelchair. A breakfast meal tray was observed on a bedside table placed in front of resident 28. Resident 28 was observed to be drinking a fluid from a cup. The pureed food on the breakfast meal tray appeared to be untouched. The utinsels were placed out of resident 28's reach. On 2/8/22 at 11:09 AM, Resident 28 was observed to spill a cup filled with water on the bedside table. On 2/8/22 at 11:55 AM, Registered Nurse (RN) 1 was observed to assist resident 28 with a health shake. RN 1 then removed resident 28's breakfast meal tray. [Note: Resident 28 was not offered queuing or assistance from staff to eat the breakfast meal. RN 1 did not encourage meal intake or offer alternative foods to resident 28.] On 2/8/22 at 11:56 AM, an interview was conducted with RN 1. RN 1 stated that resident 28 drank the 2.0 [MEDICATION(S)] Supplement and the health shake. RN 1 stated that resident 28 had one bite of egg and drank all of the juices. On 2/9/22 at 9:45 AM, Resident 28 was observed to be placed by a staff member in the dayroom area in a tilted wheelchair. On 2/9/22 at 10:18 AM, Certified Nursing Assistant (CNA) 1 was observed to set up resident 28's breakfast meal tray on a bedside table placed in front of resident 28. CNA 1 was observed to assist resident 28 with a scoop of food from the breakfast meal tray. CNA 1 placed resident 28's utinsel on the plate at the one o'clock spot. Resident 28 was observed to reach for the cup closest to her and was drinking the contents through a straw. On 2/9/22 at 10:30 AM, CNA 2 was observed to reposition resident 28 in the tilted wheelchair. [Note: Resident 28 was not offered queuing or assistance from CNA 2 to eat the breakfast meal. CNA 2 did not encourage meal intake.] On 2/9/22 at 10:39 AM, Resident 28 was observed chewing on a drinking straw. [Note: Resident 28 was observed to only reach the one drink that was the closest to her.] On 2/9/22 at 10:54 AM, RN 2 was observed to ask resident 28 if she would like her to feed her. RN 2 was observed to assist resident 28 with feeding. [Note: Resident 28 was provided feeding assistance 36 minutes after the breakfast meal tray was set up.] On 2/9/22 at 10:56 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 28 was able to feed herself if she wanted to. CNA 1 stated that resident 28 would not eat at all. CNA 1 stated if she fed resident 28 she would spit the food out. CNA 1 stated that resident 28 would drink the liquids, eat the oatmeal, and soup. CNA 1 further stated that resident 28 would get up at 9:30 AM for breakfast and would go back to bed until dinner time. On 2/9/22 at 11:00 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 28 would eat if she wanted to. CNA 2 stated that resident 28 had always been concerned about her weight and the weight of the other residents. CNA 2 stated resident 28 would drink every liquid you put in front of her. CNA 2 stated that resident 28 did not require queuing with eating. On 2/9/22 at 11:07 AM, an interview was conducted with RN 2. RN 2 stated that resident 28 would get up late for breakfast and that was resident 28's preference. RN 2 stated that resident 28 would drink all of her drinks on her own. RN 2 stated that resident 28 was not able to feed herself. RN 2 stated she had fed resident 28 a few bites of pancake and the oatmeal but resident 28 would not eat the meat. On 2/9/22 at 11:23 AM, a follow up interview was conducted with CNA 2. CNA 2 stated a resident that was extensive assistance with eating could help a little but not to much. CNA 2 stated a resident that was extensive assistance would not be considered total dependant. On 2/9/22 at 11:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated if the staff were doing most of the work the resident would be considered an extensive assistance. The DON stated that resident 28 would let the staff help her sometimes and had gotten better but resident 28 did not want help. The DON stated resident 28 had good days and would frequently refuse meals. The DON stated that resident 28 was a slow eater and would take her time. The DON stated the staff had tried putting the hot cereal in a cup with a handle for resident 28. The DON stated resident 28 could do items that were in a cup. The DON also stated the staff had tried easier food items that resident 28 could pick up.

Based on observation, record review, and interview, the facility did not employ sufficient staff to carry out the functions of the food and nutrition service. Specifically, meals were served approximately 25 minutes past the posted start times. Findings include: 1. The meal times posted at the nurses station in the Memory Lane unit were as follows: Breakfast: Memory Care 7:45 AM Memory Lane 8:15 AM (Note: The meal times were not posted in the dining rooms.) 2. On 8/27/19, the breakfast meal was observed in Memory Lane. The first meal was not served until 8:36 AM, approximately 21 minutes after the posted start time. 3. On 8/28/19, the breakfast meal was observed in Memory Lane. The steam table was observed to arrive at 8:30 AM, but there were only 4 residents in the dining room at that time. The first meal was not served until 8:33 AM, approximately 18 minutes after the posted start time. 4. On 8/29/19, the breakfast meal was observed in Memory Care. The first meal was not served until 8:10 AM, approximately 25 minutes after the posted start time. 5. On 8/29/29, the breakfast meal was observed in Memory Lane. The first resident did not arrive in the dining room until 8:19 AM. The steam table was observed to arrive at 8:37 AM. The first meal was not served until 8:40 AM, approximately 25 minutes after the posted start time. On 8/29/19 at 9:25 AM, an interview was conducted with the Dietary Manager (DM). The DM confirmed that the meals had been served past the posted start times over the previous few days. The DM stated that the same dietary staff member served the residents in Memory Care, and then went to Memory Lane. The DM stated that sometimes her staff were late, and sometimes the nursing staff did not have the residents ready. The DM stated that if residents were hungry, they could ask for something off of the grill.

Based on interview, observation, and record review, the facility did not provide the appropriate care and services to maintain or improve 3 of 37 sample residents' ability to carry out the activities of daily living. Specifically, 3 residents were not assisted with dining. Resident identifiers: 19, 23, and 47. Findings include: 1. Resident 19 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident 19's medical record was reviewed on 8/26/19. Resident 19's Annual Minimum Data Set (MDS) assessment dated [DATE] indicated that resident 19 required extensive assistance with a one person physical assist to eat. Resident 19's Quarterly MDS assessment dated [DATE] indicated that resident 19 required extensive assistance with a one person physical assist to eat. A care plan originally dated 3/13/15 and reviewed 3/13/19 indicated that resident 19 was . at nutritional risk AEB (as evidenced by) leaving 25% (plus) at most meals . due to her [DIAGNOSES REDACTED]. Resident requires oversight, encouragement, or cueing at mealtime . Another care plan originally dated 3/13/19 indicated that resident 19 . needs extensive assistance with eating, with one person related to poor appetite and Alzhiemers. Interventions listed on the care plan included . provide limited assistance with meals, weigh at least every month with follow up as indicated, monitor meal intake A document entitled Restorative nursing program dated (MONTH) 2019 revealed that facility staff were documenting that they were providing assistance with Activities to improve or maintain self performance in feeding oneself food and fluids, or improve or maintain ability to ingest nutrition and hydration by mouth seven days a week. On 3/26/19, a Nutrition Risk Review was completed for resident 19. The review indicated that resident 19 required . increased calorie needs (related to) refusal of help eat (sic), refusing puree food and on mechanical soft except puree meats AEB consistant (sic) weight loss. BMI 17. continue to assist pt (patient) when she allows . Staff members also documented that resident 19 required assistance with dining. On 6/14/19, dietary progress notes indicated that resident 19 . 97 wt (weight) (decrease) x 1 mo-3 mo (month) diet moved to puree, accepting 20-25% needs assist but will often refuse, health shake tid (three times daily) (with) snacks 30% accept. 3 (ounces) 2.0 [MEDICATION NAME] supplement 20-30% will refuse meds often . continue to encourage (resident 19) to eat, assist as accepted, continue to monitor . On 8/22/19, dietary progress notes indicated that resident 19 . continues to need more assist, below IWR (idea weight range), Refusing most supplements, staff try to encourage (resident 19) to eat, (resident 19)is very determined, when she dose (sic) not want assist she make's (sic) it known continue to encourage (and) offer alt (alternate) foods, snacks and supplements . On 8/28/19, resident 19 was observed during the breakfast meal. Resident 19 was observed to be served her meal at 8:35 AM. Resident 19 was not served any beverages until 8:50 AM. Resident 19 was not cued or assisted until 8:55 AM, approximately 20 minutes after being served. Prior to that time, resident 19 had not made any attempt to feed herself. At 8:55 AM, a staff member put a beverage with a straw to resident 19's lips which the resident accepted. The staff member then fed resident 19 during which time resident 19 ate all of her breakfast. Resident 19 was observed to not make any attempts to help staff as staff spooned all of resident 19's food into her mouth over the course of the breakfast meal. 2. Resident 23 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident 23's medical record was reviewed on 8/26/19. Resident 23's Quarterly MDS dated [DATE] indicated that resident 23 required limited assistance with a one person physical assist to eat. Resident 23's Quarterly MDS dated ,[DATE] indicated that resident 23 required limited assistance with a one person physical assist to eat. A care plan dated 12/19/18 indicated that Resident needs limited assistance, resident requires oversight, encouragement, or cueing at mealtime with eating, with one person related to dementia. The interventions included Provide limited assistance with meals, resident requires oversight, encouragement, or cueing at mealtime. Another care plan dated 10/18/16 and reviewed 12/19/18 says resident is at nutritional risk as evidenced by . Dementia, [MEDICAL CONDITION], obesity, hyperlipid, low [MEDICATION NAME] level . Interventions included .resident requires oversight, encouragement or cueing at mealtime. A document entitled Restorative nursing program dated (MONTH) 2019 revealed that facility staff were documenting that they were providing assistance with Activities to improve or maintain self performance in feeding oneself food and fluids, or improve or maintain ability to ingest nutrition and hydration by mouth six days a week. A Nutrition Risk Review dated 12/19/18 indicated that resident 23's dining ability was cueing needed. On 8/28/19 resident 23 was observed during the breakfast meal. Resident 23 was observed to be served her meal at 8:35 AM. Resident 23 was not served any beverages until 8:48 AM. Resident 23 was not cued until 8:54 AM, approximately 19 minutes after being served. Resident 23 initially stated she did not need assistance with dining at 8:54 AM, and then began to eat independently at 8:59 AM. 3. Resident 47 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident 47's medical record was reviewed on 8/26/19. Resident 47's Quarterly MDS dated [DATE] indicated that resident 47 required extensive assistance with a one person physical assist to eat. Resident 47's Quarterly MDS dated [DATE] indicated that resident 47 required extensive assistance with a one person physical assist to eat. A care plan dated 10/30/18 with a review date of 7/30/19 indicated that resident 47 . needs extensive assistance with eating, with set up, cueing related to dementia . Interventions included . Provide extensive assistance with meals . Another care plan dated 10/30/17 with a review date of 10/30/18 indicated that resident 47 . is at nutritional risk AEB: leaving 25% (plus) at most meals, dementia, low back pain . Interventions included Resident is involved in feeding self, but may require staff assistance . A document entitled Restorative nursing program dated (MONTH) 2019 revealed that facility staff were documenting that they were providing assistance with Activities to improve or maintain self performance in feeding oneself food and fluids, or improve or maintain ability to ingest nutrition and hydration by mouth seven days a week. The dietary progress notes for resident 47 were reviewed and revealed the following: a. 1/28/19 . observed needs some assist and cueing . b. 4/29/19 . needs some assist and cueing with meals. c. 7/30/19 . needs some cueing, meal (percent) is slowly going down . continue to encourage resident to eat offer snacks, offer supplement when meal is refused . On 8/27/19, resident 47 was observed during the breakfast meal. Resident 47 was served at 8:48 AM, but not cued until 9:08 AM, approximately 20 minutes later. After resident 47 was cued, she began eating her meal. On 8/29/19 at 9:10 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that resident 19 required total assist from staff to eat. CNA 2 stated that residents 23 and 47 could eat independently, but that they were slow or fell asleep. On 8/29/19 at 9:25 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 19 required total assist from staff to eat, but that sometimes she refused help. CNA 3 stated that residents 23 and 47 needed cueing because they often fell asleep or got distracted.

Based on observation and interview, the facility failed to follow standard precautions during the performance of routine testing of blood glucose. Specifically, for 3 of 37 sample residents, blood glucose meters were not properly cleaned and disinfected after each use according to manufacturer's instructions for multi-patient use. Resident identifiers: 21, 50, and 54. Findings include: 1. Resident 50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/28/19 at 11:00 AM, Licensed Practical Nurse (LPN) 1 was observed taking a blood sugar reading from resident 50. After taking the blood sugar reading, LPN 1 placed the glucometer on the resident's side table (high touch environmental surface). LPN 1 then picked up the dirty glucometer, wiped it down with a PDI Sani-Cloth Bleach Disinfectant Wipe, and placed it back on the contaminated surface. Less than one minute later, LPN 1 picked the glucometer up and put it in her pocket. The PDI Sani-Cloth Bleach Disinfectant Wipes label states, Effective against 50 microorganisms in 4 minutes. Bactericidal, fungicidal, tuberculocidal and virucidal in 4 minutes. LPN 1 did not observe the required 4 minute dry time that is required for the wipe to be effective. LPN 1 also placed the glucometer in her pocket, which is not considered clean. 2. Resident 54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/25/19 at 11:10 AM, LPN 1 was observed taking a blood sugar reading from resident 54. After taking the blood sugar reading, LPN 1 wiped down the glucometer with a PDI Sani-Cloth Bleach Disinfectant Wipe and placed the glucometer in her pocket. LPN 1 did not observe the required 4 minute dry time that is required for the wipe to be effective. 3. Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/29/19 at 7:15 AM, LPN 2 was observed taking a blood sugar reading from resident 21. LPN 2 first wiped down the glucometer with a PDI Sani-Cloth Bleach Disinfectant Wipe and then placed the glucometer on the resident's bed. After resident 21's blood sugar was tested the glucometer was again laid down on the resident's bed. The glucometer was then picked up and wiped down with the same, used wipe. LPN 2 then placed the glucometer in her pocket. LPN 2 did not observe the 4 minute dry time that is required for the wipe to be effective. LPN 2 also placed the glucometer in her pocket, which is not considered clean. On 8/29/19 at 7:30 AM, the Central Supply Director (CSD) was interviewed. When asked why she chose to order the PDI Sani-Cloth Bleach Disinfectant Wipes for staff to use to clean glucometers, the CSD stated, They were the only ones that had what we needed. When asked if staff had been trained on the 4 minute drying time that is required for sanitization, she stated, I believe staff had training, but the instructions are right on the box so they can just read them. Per the PDI Sani-Cloth Bleach Disinfectant Wipe Medical Equipment Compatibility Guide, the wipes are not compatible with the AgaMatrix [MEDICATION NAME]-Pro glucometer. PDI. (2019). MEDICAL EQUIPMENT COMPATIBILITY GUIDE. Orangeburg, NY. Page 12.

Based on observation, interview, and record review, it was determined for 5 of 35 residents, that the facility did not ensure that the resident environment remained as free of accident hazards as possible or each resident received adequate supervision and assistance devices to prevent accidents. Specifically, residents with multiple falls did not have interventions to prevent future accidents and one resident accident resulted in a fractured femur. Resident identifiers: 7, 18, 52, 54, and 61. Findings include: 1. Resident 18 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/31/18, a review of resident 18's medical record was conducted. The review revealed the following entries: a. On 4/13/18 at 5:01 PM, Resident in wheel chair in memory lane lobby watching TV, resident undone (sic) his lap belt stood up and fell to floor nurse tried to get to him before fall, unsuccessful. Resident landed on left side of body and did not hit head no abrasions or red marks noted. resident states he is okay. Son (name withheld) notified 'he is doing this all the time, I think we need to glue that belt on him.' (physician) notified. VS (vital signs) 97, 65, 0, 68, 95, RA (room air). This note was completed by Licensed Practical Nurse (LPN) 1. b. On 4/13/18 at 8:12 PM, Resident sitting in WC (wheelchair), c/o (complains of) 'leg broke,' but wheeling self around lobby, talking to other residents and staff. This note was completed by Registered Nurse (RN) 3. c. On 4/13/18 at 10:30 PM, CNA's (Certified Nursing Assistants) attempting to put resident to bed, and he does not bear weight as typical for him. Most likely due to Fall today. Nurse assess and assist CNA's. He c/o left leg pain 'my leg is broke', but minimal grimacing noted. He informs nurse that 'he was chasing a calf, but missed.' Assessed for injury. Leg left is warm, and dry, with c/o some discomfort when ROM (range of motion) performed, moves toes, ankle and knee, pulses equal posterior tibial. Tylenol given per order earlier when in WC (wheelchair) and complaining of discomfort. This note was completed by RN 3. d. On 4/14/18 at 3:08 AM, Resident partly out of bed, undressed and kneeling on bedside mat next to side of bed. Resident doesn't know what he is doing, when asked. He c/o pain when asked. Staff assisted resident in getting dressed in new pad and gown, and back into bed. Given Tylenol per order. This note was completed by RN 3. e. On 4/14/18 at 3:30 AM, Placed O2 (oxygen) on resident due to low saturation-86% (Percent) RA. Increases 89% to 2L (liters)/NC (nasal cannula). Then increased to 94% on 3l/nc. This note was completed by RN 3. f. On 4/14/18 at 8:27 AM, Resident awake this am, c/o pain in left hip area, left foot rotated outwards. Resident dressed assisted x (times) 2 staff one weight bearing on left leg. Notified (physician's name withheld) of condition okay to transport if family okay with it. Called son (name withheld) of condition okay to transport to ER (emergency room ). This note was completed by RN 3. g. On 4/14/18 at 9:20 AM, When resident fell last night Nurse (LPN 1's name withheld) was pushing another resident with in 10 feet of resident and was unable to get to resident quick enough to prevent fall. Another resident sitting close by indicated resident had reached behind his chair and wiggled in his hair (sic) removing lap belt. This note was completed by RN 3. h. On 4/14/18 at 9:21 AM, Resident transported to (hospital name) .family (son's name withheld) will meet at ER. This note was completed by RN 3. i. On 4/14/18 at 1:13 PM, Residents son (name withheld) notified facility that the resident left hip is broken and he will be having surgery in (nearby city) (physician) notified. This note was completed by LPN 1 The incident report for the fall dated 4/13/18, stated the following Resident in wheelchair on memory lane watching tv, resident undone his lap belt, stood up and fell to floor, nurse tried to get him before fall, unsuccessful. Resident landed on left side of body did not hit head, no injuries noted . Outcome/recommendations/corrective action(s) 4/14-sent to ER for c/o pain-fx (fracture) hip. Transported to (hospital name) for hip surgery. A review of resident 18's medical record revealed that he had falls on the following dates: a. On 9/30/17, Description of incident: Resident found on the floor in the lobby laying by the recliner. He stated he tried to get into the chair and fell . Resident stated he tried to get into the chair and fell . Resident stated he hit the back of his head on the chair. No injuries were noted. Will do neuro (neurological) checks. Denies any pain at this time Restraints: lap belt when in w/c (wheelchair) (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) b. On 11/26/17, Description of incident: pt (patient) was in his room when the bed alarm went off the aide went to check on the pt and found him standing at the side of his bed, pt tried to walk when he fell his his head on the nightstand. Pt was placed in his wheelchair and brought to the lobby. (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) c. On 12/9/17, Description of Incident: (Resident 18) stood up from recliner in lobby. I ran over from nurses station to assist resident back into seat. Resident fell before I reached him. As he fell , his back slid against a chair. Resident was assisted back into recliner, vital signs obtained. He was then toileted et (and) assessed. No changes in L[NAME] (level of consciousness), reddened area on R (right) side of back from hip up to mid scapula region. Resident c/o pain in hip. (Resident 18) was given a warm blanket pain medication for his pain. Resident currently sitting in w/c watching television in lobby. (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) d. On 1/10/18, Description of Incident: (Resident 18) was in the lobby in a recliner, stood up to fall before anyone could get to him. He hit the recliner with his back before hitting the floor. C/o pain to R side of lower back. He did not hit his head and has no (changes) in mental state. (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) e. On 2/26/18, Description of Incident: F.O.F. (found on floor) room [ROOM NUMBER] wheel chair and lap belt next to him. Patient states he is ok, he has abrasion on left lateral palm of hand. We'll call family and for physician. (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) Resident 18 had a fall risk assessment completed quarterly. The results of the assessments were as follows: (Note: a ten or above was high risk.) a. 5/16/16, resident 18's fall risk score was 16 b. 8/20/16, the fall risk score was 20 c. 11/20/16, the fall risk score was 18 d. 2/20/17, the fall risk score was 18 e. 5/20/17, the fall risk score was 19 f. 8/20/17, the fall risk score was 19 g. 11/20/17, the fall risk score was 15 h. 2/20/18, the fall risk score was 17 On 8/1/18, a review of Resident 18's care plan was conducted. Resident 18 had a care plan for falls which stated the following: Orignal (sic) Date 5/23/16, Effect. Date: Fall Potential R/T (related to) Weakness, Poor safety awareness. Goals: Will remain free of injury AEB (as evidenced by) free of falls of accidents Q (every) Day TNR (through next review). Interventions: a. Monitor/anticipate/intervene for factors causing prior falls (Effect. Date 5/23/16) b. Answer calls quickly; anticipate needs. (Effect. Date 5/2/16) c. Ambulate/transfer with appropriate devices (Effect. date 5/23/16) d. Lap belt when in wheelchair. Check lap belt placement and release Q2 hrs x 10 minutes and PRN (as needed) Q shift. Rev. #1 (Effect. date 5/23/16) (Note: the care plan was not updated after any of the previously mentioned falls.) On 8/2/18 at 4:10 PM, an interview was conducted with LPN 1. LPN 1 stated that she had worked on the wing of the facility where resident 18 was located for most shifts for almost a year. LPN 1 was asked to describe resident 18's fall. LPN 1 stated that resident 18 was at the TV. LPN 1 stated she was pushing another resident at the time. LPN 1 stated resident 18 got up out of his chair and she could not get to him fast enough. LPN 1 stated resident 18 did have a lap belt in place at the time of the fall. LPN 1 stated that immediately after resident 18 fell , she assessed him by moving his joints and asking if he had any pain. LPN 1 stated that resident 18 was able to move all joints and denied any pain. LPN 1 stated she helped resident 18 back to his wheelchair. LPN 1 stated she informed the oncoming nurse about the fall. LPN 1 stated she had notified the physician by either fax or a phone call but could not recall which one. LPN 1 stated she could not recall if resident 18 had incidents of falls before the incident on 4/13/18. LPN 1 stated that the soft waist belt was the main deterrent to prevent resident 18 from falling. LPN 1 stated that residents were encouraged to be in the lobby area for close monitoring. LPN 1 stated she could not remember if she took care of resident 18 the day after he fell . LPN 1 did not recall contacting family or sending resident 18 out to the hospital on [DATE]. On 8/2/18 at 3:57 PM, an interview was conducted with RN 3. RN 3 stated that she took care of resident 18 frequently. RN 3 stated that she came on shift on 4/13 at approximately 6:00 PM. RN 3 stated that it was reported to her that resident 18 had fallen. RN 3 stated that she assessed resident 18 and watched him throughout the night. RN 3 stated that she felt uncomfortable as the night progressed. RN 3 stated that at 10:00 or 11:00 PM, she felt especially nervous about resident 18. RN 3 stated she was concerned that resident 18 had a broken leg. RN 3 stated that she had a different RN who worked at the facility come and assess resident 18. RN 3 stated that one of resident 18's legs looked shorter than the other. RN 3 stated that the other facility nurse stated that resident 18's leg was a little bit bent and that could account for the difference. RN 3 stated that the other nurse felt the resident was likely okay and to watch him closely. RN 3 stated that during the evening, resident 18 was telling other residents that he broke his leg. RN 3 stated that the resident was in his wheelchair like he typically was. RN 3 stated that resident 18's joints were tested , hips were pushed on and appeared to be okay. RN 3 stated that resident 18 told the other residents that he had pain and that probably meant he was uncomfortable. RN 3 stated she was unable to recall if resident 18 required pain medications. RN 3 stated that resident 18 slept through the night. RN 3 stated that typically, resident 18 wasn't very mobile and wouldn't get up on his own during the night. RN 3 stated she couldn't recall if resident 18 had pain during the night or not. RN 3 stated she assessed resident 18 the next morning and felt pretty nervous about him. RN 3 stated she spoke with the day shift nurse and the day shift nurse was going to talk with the family to see if they would want to send the resident out to be evaluated in the emergency room . RN 3 stated that interventions in place to prevent resident 18 from falling were a lap belt, a hi-low bed, and a mattress at the side of his bed. RN 3 stated she was under the impression that the previous nurse had contacted the physician. RN 3 stated she did not contact the physician. RN 3 stated a physician would have been called if a resident fell and they knew without a doubt the resident needed to be transported. RN 3 stated that the physician would be called if there was excessive bleeding, a broken appendage, uncontrolled pain, or if the resident was in pain upon movement. RN 3 stated the doctor would be called if the resident's vital signs showed indications of shock such as higher blood pressure or decreased heart rate, or if oxygen decreased. RN 3 stated that resident 18 didn't usually require oxygen. (Note: Resident 18 had an episode of low oxygen saturation during the night of 4/13/18 which required supplemental oxygen.) On 8/1/18 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident's with dementia are unreliable historians. The DON stated that because of this, we really have to go off of weight bearing status. The DON stated that if a resident who normally bore weight suddenly was not, that would be concerning. The DON read through the progress notes of the night resident 18 fell on (MONTH) 13th. The DON stated that by 10:30 PM, when the resident was not bearing weight on his transfer to bed, that the physician should have been contacted. The DON stated that sometimes the doctors would say it was okay to leave the resident at the facility overnight when a fracture was suspected. The DON stated this was because it was better to have the resident comfortable at the facility rather than laying in a gurney in the ER for 7 hours. The DON stated she did not know what the conversation was between the nurse and the physician when LPN 1 contacted the physician. The DON did not know if the physician was notified by fax or phone call. The DON stated it would indicate on the incident report whether the physician was notified by phone call or fax. When incident report was later reviewed, it was unclear which form of communication the physician was notified by. The DON stated that the care plan would be updated only if there was a new intervention implemented. The DON acknowledged that the care plan should have been updated for resident 18's multiple falls. 2. Resident 52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 52's medical record was reviewed on 8/1/18. An Annual Minimum Data Set (MDS) assessment dated [DATE], documented resident 52 with a Brief Interview for Mental Status (BIMS) score of 4. (Note: A resident with a severe impairment cognitively would have a BIMS score of 0 to 7.) The facility staff assessed resident 52 as requiring extensive assistance of one person for bed mobility and transfers. The facility further assessed resident 52 as requiring extensive assistance of two persons for toilet use. A Quarterly MDS assessment dated [DATE], documented resident 52 with a BIMS score of 10. (Note: A resident with a moderate impairment cognitively would have a BIMS score of 8 to 12.) The facility staff assessed resident 52 as requiring total dependence of one person for bed mobility, transfers, and toilet use. A Plan of Care dated 3/29/17 with an effective date of 3/29/18, documented a Problems/Strengths of Fall Potential R/T Dementia, Acquired absence of left foot. The goal developed was, Will remain free of injury AEB free of falls or accidents Q day TNR. The interventions developed were, Monitor/anticipate/intervene for factors causing prior falls. Answer calls quickly. Encourage resident to use call light when in need of assistance. Staff education-Safety measures; Injury potential avoidance; What to do if a fall occurs. Transfer with appropriate devices. A Plan of Care worksheet dated 4/26/17, documented a problem of Fall risk poor posture, safety awareness, very mobil (sic). The intervention developed was, Lap belt when in w/c - release Q 2 (hours) x 10 min (minutes). A review of the Incident/Accident reports documented the following entries: a. On 1/2/18 at 4:00 AM, Resident was found on floor next to his bed. The resident stated that he was getting up to go to the bathroom. Resident did not have his prosthetic leg on. Resident had a skin tear to his right elbow and an abrasion on his right shoulder. The resident's bed alarm was on and the bed mat was in place. No interventions implemented. b. On 2/23/18 at 9:15 PM, Resident was found by CNA sitting on the edge of his bed. The residents hands, bed, and wall were covered with feces. Resident stated that he fell trying to get to the bathroom. Resident had a reddened area to his right knee. No interventions implemented. c. On 3/20/18 at 1:15 PM, Resident was found on the floor in his room in front of the night stand. The resident had blood dripping from his nose, right eye was purple and swollen, hematoma to forehead, and an abrasion to his right knee. Therapy was notified regarding the resident's wheelchair needing to be repaired. No interventions implemented. d. On 4/27/18 at 9:44 PM, Resident was calling out for the nurse. Resident was found on the floor on his left side propped up on his left arm between the bed and his wheelchair. Resident stated that he did not know what happened but he thought he was trying to go to the bathroom. No interventions implemented. e. On 5/1/18 at 9:56 AM, Resident was found on the floor sitting in front of his wheelchair. Resident was scooting towards the recliner. Resident had a skin tear on his left hand. No interventions implemented. f. On 5/6/18 at 8:15 PM, Resident was found on the floor by his bed with his wheelchair in front of the bed side table. No interventions implemented. g. On 6/9/18 at 9:15 PM, Resident was in the lobby self transferring from his wheelchair to chair and back several times. The resident was found walking down the hall 20 minutes prior. The CNA and nurse both watched the resident slip from his wheelchair during a self transfer. No interventions implemented. h. On 6/17/18 at 7:00 PM, The staff heard a loud noise and found the resident sitting on the floor in front of his bed next to the night stand. Resident was trying to ambulate without his prosthetic leg. No interventions implemented. i. On 6/18/18 at 10:30 AM, Resident was found on the floor sitting next to his wheelchair in his room. Lap belt placed on the resident and moved rooms. (Note: On 6/18/18, an order for [REDACTED].> j. 6/24/18 at 3:45 PM, Resident was found on the floor in the dining area of the memory care unit. Resident appears to have fallen asleep in the recliner and fell forward hitting his head on the floor. Resident had a reddened area noted on the right side of his forehead. No interventions implemented. k. On 7/9/18 at 2:00 AM, Resident was found on the floor next to his bed. Resident has an abrasion to his right knee. Resident's bed alarm was on. No interventions implemented. A review of the Fall Risk Assessments documented the following entries: (Note: A total score of 10 or above represents HIGH RISK.) a. On 12/25/17, a score of 20; b. On 3/25/18, a score of 20; c. On 6/25/18, a score of 20. On 7/31/18 at 9:03 AM, an interview was conducted with resident 52's wife. The wife stated that the facility staff had called her one night after resident 52 had a fall. The wife stated that the facility staff reported that resident 52 had bumped his head. The wife further stated that the facility staff admitted that the fall matt was not next to resident 52's the bed. On 8/2/18 at 11:00 AM, an interview was conducted with LPN 1. LPN 1 stated that resident 52 has had a lot of falls. LPN 1 stated that the staff have tried supervision, one on one, and the lap buddy. LPN 1 was not aware of any other interventions that have been implemented for resident 52 to prevent falls. 3. Resident 61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 61's medical record was reviewed on 7/31/18. A Quarterly MDS assessment dated [DATE], documented resident 61 with a BIMS score of 4. (Note: A resident with a severe impairment cognitively would have a BIMS score of 0 to 7.) The facility staff assessed resident 61 as requiring limited assistance of one person for bed mobility, transfer, and toilet use. A Significant Change in Status MDS assessment dated [DATE], documented resident 61 with a BIMS score of 8. (Note: A resident with a moderate impairment cognitively would have a BIMS score of 8 to 12.) The facility staff assessed resident 61 as requiring limited assistance of one person for bed mobility, extensive assistance of one person for transfers, and total dependence of one person for toilet use. A Quarterly MDS assessment dated [DATE], documented resident 61 with a BIMS score of 11. (Note: A resident with a moderate impairment cognitively would have a BIMS score of 8 to 12.) The facility staff assessed resident 61 as requiring total dependence of one person for bed mobility. The facility staff further assessed resident 61 as requiring total dependence of two persons for transfer and toilet use. A Plan of Care dated 12/27/17 with an effective date of 4/12/18 documented a Problems/Strengths of Fall Potential R/T Dementia, Medication. The goal developed was, Will remain free of injury AEB free of falls or accidents Q day TNR. The interventions developed were, Staff education-Safety measures; Injury potential avoidance; What to do if a fall occurs. Monitor/anticipation/intervene for factors causing prior falls. Answer calls quickly; anticipate needs. Transfer with appropriate devices. A review of the Incident/Accident reports documented the following entries: a. On 4/7/18 at 9:45 PM, Resident was found on the floor in his room. Resident was trying to take himself to the bathroom. No interventions implemented. b. On 4/15/18 at 9:30 PM, Resident was found on the floor in the doorway of his room. Resident was trying to take himself to the bathroom. Resident's bed was in the lowest position with the bedside mattress in place next to the bed. No interventions implemented. c. On 5/3/18 at 4:30 PM, Resident was sitting in a recliner and stood up falling to the floor. Resident hit the back of his head. No interventions implemented. (Note: On 5/3/18, an order for [REDACTED].> d. On 5/21/18 at 11:10 PM, Resident was sitting in front of the nurses station and tried to stand tipping his wheelchair. The resident tipped over on his left side onto the floor with the lap belt still attached. The staff released the lap belt and repositioned the resident into the wheelchair. No interventions implemented. e. On 7/17/18 at 2:30 AM, Resident was found on the floor next to a recliner in the lobby. No interventions implemented. f. On 7/25/18 at 9:00 AM, Resident was found on the floor next to his bed not on his fall matt. The bed alarm was off. No interventions implemented. g. On 7/26/18 at 12:30 AM, Resident was sitting in the lobby eating a snack. The resident scooted his bottom forward in the wheelchair, pushing the chair pad, and tipping the wheelchair forward. The resident landed on his bottom with the wheelchair and lap belt still attached. No interventions implemented. A review of the Fall Risk Assessments documented the following entries: (Note: A total score of 10 or above represents HIGH RISK.) a. On 12/14/17, a score of 13; b. On 3/22/18, a score of 16. On 8/1/18 at 9:53 AM, an interview was conducted with RN 5. RN 5 stated that interventions implemented for resident 61 to prevent falls were supervision, one on one, recliners, and a lap belt. RN 5 stated that resident 61 has a lot of anxiety and will yell out at times. RN 5 stated that resident 61 also has hallucinations and delusions. 4. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7's medical record was reviewed on 8/1/18. An Admission MDS assessment dated [DATE], documented resident 7 with a BIMS score of 7. (Note: A resident with a severe impairment cognitively would have a BIMS score of 0 to 7.) The facility staff assessed resident 7 as requiring extensive assistance of two persons for bed mobility, transfers and toilet use. A Quarterly MDS assessment dated [DATE], documented resident 7 with a BIMS score of 11. (Note: A resident with a moderate impairment cognitively would have a BIMS score of 8 to 12.) The facility staff assessed resident 7 as requiring total dependence of one person for bed mobility and transfers. The facility staff further assessed resident 7 as requiring extensive assistance of two persons for toilet use. A Plan of Care dated 1/23/18 with an effective date of 1/23/18 documented a Problems/Strengths of Fall Potential R/T Spondylosis w/o (without) myolopathy or radiculopathy, Low back pain, Radiculopathy; lumbosacral region, [MEDICAL CONDITION]; unspecified. The goals developed were, Will remain free of injury AEB free of falls or accidents Q day TNR. Will remain free of restraint-related complications AEB mobility maintained, skin intact TNR. The interventions developed were, Monitor/anticipate/intervene for factors causing prior falls. Hi Low bed with bed alarm in place, resident uses call light when in need of assistance. Staff education-Safety measures; Injury potential avoidance; What to do if a fall occurs. Release restraint Q2 hrs and PRN (as needed) x10 minutes. Transfer with appropriate devices. A review of the Incident/Accident reports documented the following entries: a. On 1/11/18 at 3:10 AM, Resident was found on the floor in her bedroom lying on her stomach. Resident has red marks on both her knees. No interventions implemented. b. On 1/11/18 at 7:10 PM, Resident was found on the floor by her bed. Family stated that it was okay to place a bed mat and bed alarm to prevent falls. c. On 1/13/18 at 2:45 PM, Resident was found lying face down on the floor in the hallway by a visitor. Resident had a hematoma noted to the left eyebrow, abrasion to the left cheek, and a skin tear to the left forearm. Family stated that the resident had a belt on at home to keep her from falling. (Note: On 2/26/18, an order for [REDACTED].> d. On 1/21/18 at 5:22 PM, Resident was found on the floor in the bathroom next to the wheelchair. The resident had removed her self releasing lap belt and stated that she slipped. No interventions implemented. e. On 1/27/18 at 2:45 PM, Resident was found on the floor in the bathroom. Resident undone her restraint and took herself to the bathroom. The resident tripped over the foot peddles on the wheelchair while getting back up from the toilet. Resident had a skin tear to her left elbow. No interventions implemented. f. On 2/9/18 at 7:45 PM, Resident was found in her room in the wheelchair. The wheelchair had the back wheels off the ground and the front hand rails of the wheelchair resting on the bed and bedside table. The resident was held into the wheelchair with her lap belt and her knees were on the floor and she was leaning over. No interventions implemented. g. On 2/16/18 at 7:00 PM, A CNA was assisting the resident in the restroom when another CNA knocked on the door. While the CNA was answering the door the resident stood up from the commode and fell to the floor. The resident hit the left side of her back striking the garbage can and causing a welt and bruising to the left side of her upper back. CNA educated on resident's poor safety awareness and the need for constant supervision in assistive situations. h. On 3/11/18 at 4:50 PM, Resident was found on the floor early this morning. The bed alarm was turned off. At 4:50 PM, the family was at the facility to visit with the resident and they were unable to find her. Resident was found in different resident bathroom on the floor. The resident had removed the lap buddy. No interventions implemented. i. On 3/13/18 at 7:30 AM, Resident's bed alarm was sounding. When the CNA entered the room the resident was sliding from bed and landed on her bottom. The bed was noted to be in the low position. While transferring the resident back to bed she obtained a skin tear to her right hand. Resident using lap buddy in wheelchair and will not stand and bear weight. No interventions implemented. j. 3/17/18 at 8:00 PM, The Nurse returned to the lobby to find the resident out of the wheelchair and leaning on the chair. The resident lowered herself to the floor. No interventions implemented. k. On 3/26/18 at 4:16 PM, Resident was resting in a recliner when she leaned over the arm of the recliner and upon standing she lost her balance. No interventions implemented. l. On 4/6/18 at 6:45 PM, Resident was anxious and agitated and went into her room to be alone. The CNA was walking past the resident's room when she saw the lap buddy on the floor and the wheelchair rolled across the room. The staff documented that the lap buddy was to easy for the resident to remove. The staff placed a lap belt for resident safety and the floor alarm was activated. (Note: On 4/6/18, an order for [REDACTED].> m. On 4/12/18 at 5:33 PM, Resident was sitting in her wheelchair next to her bed making an attempt to get out of the wheelchair. The resident had tipped the wheelchair over next to her bed when the staff found her. No interventions implemented. n. On 4/27/18 at 6:20 AM, Resident was found on the floor next to her bed. No interventions implemented. o. On 6/18/18 at 7:50 PM, Resident's bed alarm was triggered and she was found standing in front of the bed bent over forward with both hands on the bed. The resident fell to her left side and bumped into and slid down the edge of the head board. No interventions implemented. A review of the Fall Risk Assessments documented the following entries: (Note: A total score of 10 or above represents HIGH RISK.) a. On 1/10/18, a score of 10; b. On 4/19/18, a score of 11; c. On 7/19/18, a score of 13. On 8/1/18 at 2:19 PM, an interview was conducted with RN 5. RN 5 stated that interventions implemented for resident 7 to prevent falls were supervision, one on one, recliners, and a lap belt. RN 5 stated that resident 7 had a lap buddy but she was removing the lap buddy and having falls. RN 5 stated that the lap buddy was changed to a soft lap belt for safety. RN 5 was unsure of the other inventions implemented to keep resident 7 safe. 5. Resident 54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 54's medical record was reviewed on 8/2/18. A Admission MDS assessment dated [DATE], documented resident 54 with a BIMS score of 6. (Note: A resident with a severe impairment cognitively would have a BIMS score of 0 to 7.) The facility staff assessed resident 54 as requiring total dependence of two persons for bed mobility, transfers, and toilet use. A Plan of Care dated 4/5/18 with an effective date of 4/5/18 documented a Problems/Strengths of Fall Potential R/T Aftercare following joint replacement, Presence of left artificial hip, Fx of left artificial hip, Fx of left neck of femur, Dementia with behavioral disturbances, [MEDICAL CONDITION] and disorder of bone density. The goals developed were, Will remain free of injury AEB free of falls or accidents Q day TNR. Will remain free of restraint-related complications AEB concracture (sic)-free, mobility maintained, skin intact TNR. The interventions developed were, Monitor/anticipate/intervene for factors causing prior falls. Answer calls quickly; anticipate ne (TRUNCATED)

Based on interview and record review, it was determined for 1 of 35 sampled residents, that the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, after a resident fell and demonstrated symptoms of an injury, facility staff did not notify the physician or send the resident to be assessed in a higher level of care until the next 28 hours later. Resident identifier: 18. Findings include: Resident 18 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/31/18, a review of resident 18's medical record was conducted. The review revealed the following entries: a. On 4/13/18 at 5:01 PM, Resident in wheel chair in memory lane lobby watching TV, resident undone (sic) his lap belt stood up and fell to floor nurse tried to get to him before fall, unsuccessful. Resident landed on left side of body and did not hit head no abrasions or red marks noted. resident states he is okay. Son (name withheld) notified 'he is doing this all the time, I think we need to glue that belt on him.' (physician) notified. VS (vital signs) 97, 65, 0, 68, 95, RA (room air). This note was completed by Licensed Practical Nurse (LPN) 1. b. On 4/13/18 at 8:12 PM, Resident sitting in WC (wheelchair), c/o (complains of) 'leg broke,' but wheeling self around lobby, talking to other residents and staff. This note was completed by Registered Nurse (RN) 3. c. On 4/13/18 at 10:30 PM, CNA's (Certified Nursing Assistants) attempting to put resident to bed, and he does not bear weight as typical for him. Most likely due to Fall today. Nurse assess and assist CNA's. He c/o left leg pain 'my leg is broke', but minimal grimacing noted. He informs nurse that 'he was chasing a calf, but missed.' Assessed for injury. Leg left is warm, and dry, with c/o some discomfort when ROM (range of motion) performed, moves toes, ankle and knee, pulses equal posterior tibial. Tylenol given per order earlier when in WC and complaining of discomfort. This note was completed by RN 3. d. On 4/14/18 at 3:08 AM, Resident partly out of bed, undressed and kneeling on bedside mat next to side of bed. Resident doesn't know what he is doing, when asked. He c/o pain when asked. Staff assisted resident in getting dressed in new pad and gown, and back into bed. Given Tylenol per order. This note was completed by RN 3. e. On 4/14/18 at 3:30 AM Placed O2 (oxygen) on resident due to low saturation-86% (percent) RA (room air). Increases 89% to 2L (liters) /NC (nasal cannula). Then increased to 94% on 3l/nc. This note was completed by RN 3. f. On 4/14/18 at 8:27 AM, Resident awake this am, c/o pain in left hip area, left foot rotated outwards. Resident dressed assisted x (times) 2 staff one weight bearing on left leg. Notified (Doctor name withheld) of condition okay to transport if family okay with it. Called son (name withheld) of condition okay to transport to ER (emergency room ). This note was completed by RN 3. g. On 4/14/18 at 9:20 AM, When resident fell last night Nurse (LPN 1's name withheld) was pushing another resident with in 10 feet of resident and was unable to get to resident quick enough to prevent fall. Another resident sitting close by indicated resident had reached behind his chair and wiggled in his hair (sic) removing lap belt. This note was completed by RN 3. h. On 4/14/18 at 9:21 AM, Resident transported to (hospital name) .family (son's name withheld) will meet at ER. This note was completed by RN 3. i. On 4/14/18 at 1:13 PM, Residents son (name withheld) notified facility that the resident left hip is broken and he will be having surgery in (nearby city) (physician) notified. This note was completed by LPN 1. The incident report for the fall dated 4/13/18, stated the following Resident in wheelchair on memory lane watching tv, resident undone his lap belt, stood up and fell to floor, nurse tried to get him before fall, unsuccessful. Resident landed on left side of body did not hit head, no injuries noted . Outcome/recommendations/corrective action(s) 4/14-sent to ER for c/o pain-fx (fracture) hip. Transported to (hospital name) for hip surgery. A review of resident 18's medical record revealed that he had falls on the following dates: a. On 9/30/17, Description of incident: Resident found on the floor in the lobby laying by the recliner. He stated he tried to get into the chair and fell . Resident stated he tried to get into the chair and fell . Resident stated he hit the back of his head on the chair. No injuries were noted. Will do neuro (neurological) checks. Denies any pain at this time Restraints: lap belt when in w/c (wheelchair) (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) b. On 11/26/17, Description of incident: pt (patient) was in his room when the bed alarm went off the aide went to check on the pt and found him standing at the side of his bed, pt tried to walk when he fell his his head on the nightstand. Pt was placed in his wheelchair and brought to the lobby. (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) c. On 12/9/17, Description of Incident: (Resident 18) stood up from recliner in lobby. I ran over from nurses station to assist resident back into seat. Resident fell before I reached him. As he fell , his back slid against a chair. Resident was assisted back into recliner, vital signs obtained. He was then toileted et (and) assessed. No changes in L[NAME] (level of consciousness), reddened area on R (right) side of back from hip up to mid scapula region. Resident c/o pain in hip. (Resident 18) was given a warm blanket pain medication for his pain. Resident currently sitting in w/c watching television in lobby. (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) d. On 1/10/18, Description of Incident: (Resident 18) was in the lobby in a recliner, stood up to fall before anyone could get to him. He hit the recliner with his back before hitting the floor. C/o pain to R side of lower back. He did not hit his head and has no (changes) in mental state. (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) e. On 2/26/18, Description of Incident: F.O.F. (found on floor) room [ROOM NUMBER] wheel chair and lap belt next to him. Patient states he is ok, he has abrasion on left lateral palm of hand. We'll call family and for physician. (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) Resident 18 had a fall risk assessment completed quarterly. The results of the assessments were as follows: (Note: a ten or above was high risk.) a. 5/16/16, resident 18's fall risk score was 16 b. 8/20/16, the fall risk score was 20 c. 11/20/16, the fall risk score was 18 d. 2/20/17, the fall risk score was 18 e. 5/20/17, the fall risk score was 19 f. 8/20/17, the fall risk score was 19 g. 11/20/17, the fall risk score was 15 h. 2/20/18, the fall risk score was 17 On 8/1/18, a review of Resident 18's care plan was conducted. Resident 18 had a care plan for falls which stated the following: Orignal (sic) Date 5/23/16, Effect. Date: Fall Potential R/T (related to) Weakness, Poor safety awareness. Goals: Will remain free of injury AEB (as evidenced by) free of falls of accidents Q (every) Day TNR (through next review). Interventions: a. Monitor/anticipate/intervene for factors causing prior falls (Effect. Date 5/23/16) b. Answer calls quickly; anticipate needs. (Effect. Date 5/2/16) c. Ambulate/transfer with appropriate devices (Effect. date 5/23/16) d. Lap belt when in wheelchair. Check lap belt placement and release Q2 hrs x 10 minutes and PRN (as needed) Q shift. Rev. #1 (Effect. date 5/23/16) (Note: the care plan was not updated after any of the previously mentioned falls.) On 8/2/18 at 4:10 PM, an interview was conducted with LPN 1. LPN 1 stated that she had worked on the wing of the facility where resident 18 was located for most shifts for almost a year. LPN 1 was asked to describe resident 18's fall. LPN 1 stated that resident 18 was at the TV. LPN 1 stated she was pushing another resident at the time. LPN 1 stated resident 18 got up out of his chair and she could not get to him fast enough. LPN 1 stated resident 18 did have a lap belt in place at the time of the fall. LPN 1 stated that immediately after resident 18 fell , she assessed him by moving his joints and asking if he had any pain. LPN 1 stated that resident 18 was able to move all joints and denied any pain. LPN 1 stated she helped resident 18 back to his wheelchair. LPN 1 stated she informed the oncoming nurse about the fall. LPN 1 stated she had notified the physician by either fax or a phone call but could not recall which one. LPN 1 stated she could not recall if resident 18 had incidents of falls before the incident on 4/13/18. LPN 1 stated that the soft waist belt was the main deterrent to prevent resident 18 from falling. LPN 1 stated that residents were encouraged to be in the lobby area for close monitoring. LPN 1 stated she could not remember if she took care of resident 18 the day after he fell . LPN 1 did not recall contacting family or sending resident 18 out to the hospital on [DATE]. On 8/2/18 at 3:57 PM, an interview was conducted with RN 3. RN 3 stated that she took care of resident 18 frequently. RN 3 stated that she came on shift on 4/13 at approximately 6:00 PM. RN 3 stated that it was reported to her that resident 18 had fallen. RN 3 stated that she assessed resident 18 and watched him throughout the night. RN 3 stated that she felt uncomfortable as the night progressed. RN 3 stated that at 10:00 or 11:00 PM, she felt especially nervous about resident 18. RN 3 stated she was concerned that resident 18 had a broken leg. RN 3 stated that she had a different RN who worked at the facility come and assess resident 18. RN 3 stated that one of resident 18's legs looked shorter than the other. RN 3 stated that the other facility nurse stated that resident 18's leg was a little bit bent and that could account for the difference. RN 3 stated that the other nurse felt the resident was likely okay and to watch him closely. RN 3 stated that during the evening, resident 18 was telling other residents that he broke his leg. RN 3 stated that the resident was in his wheelchair like he typically was. RN 3 stated that resident 18's joints were tested , hips were pushed on and appeared to be okay. RN 3 stated that resident 18 told the other residents that he had pain and that probably meant he was uncomfortable. RN 3 stated she was unable to recall if resident 18 required pain medications. RN 3 stated that resident 18 slept through the night. RN 3 stated that typically, resident 18 wasn't very mobile and wouldn't get up on his own during the night. RN 3 stated she couldn't recall if resident 18 had pain during the night or not. RN 3 stated she assessed resident 18 the next morning and felt pretty nervous about him. RN 3 stated she spoke with the day shift nurse and the day shift nurse was going to talk with the family to see if they would want to send the resident out to be evaluated in the emergency room . RN 3 stated that interventions in place to prevent resident 18 from falling were a lap belt, a hi-low bed, and a mattress at the side of his bed. RN 3 stated she was under the impression that the previous nurse had contacted the physician. RN 3 stated she did not contact the physician. RN 3 stated a physician would have been called if a resident fell and they knew without a doubt the resident needed to be transported. RN 3 stated that the physician would be called if there was excessive bleeding, a broken appendage, uncontrolled pain, or if the resident was in pain upon movement. RN 3 stated the doctor would be called if the resident's vital signs showed indications of shock such as higher blood pressure or decreased heart rate, or if oxygen decreased. RN 3 stated that resident 18 didn't usually require oxygen. (Note: Resident 18 had an episode of low oxygen saturation during the night of 4/13/18 which required supplemental oxygen.) On 8/1/18 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident's with dementia are unreliable historians. The DON stated that because of this, we really have to go off of weight bearing status. The DON stated that if a resident who normally bore weight suddenly was not, that would be concerning. The DON read through the progress notes of the night resident 18 fell on (MONTH) 13th. The DON stated that by 10:30 PM, when the resident was not bearing weight on his transfer to bed, that the physician should have been contacted. The DON stated that sometimes the doctors would say it was okay to leave the resident at the facility overnight when a fracture was suspected. The DON stated this was because it was better to have the resident comfortable at the facility rather than laying in a gurney in the ER for 7 hours. The DON stated she did not know what the conversation was between the nurse and the physician when LPN 1 contacted the physician. The DON did not know if the physician was notified by fax or phone call. The DON stated it would indicate on the incident report whether the physician was notified by phone call or fax. When incident report was later reviewed, it was unclear which form of communication the physician was notified by. The DON stated that the care plan would be updated only if there was a new intervention implemented. The DON acknowledged that the care plan should have been updated for resident 18's multiple falls.

Based on observation, interview, and record review, it was determined for 1 of 35 sampled residents, that the facility did not follow therapeutic diets prescribed by the attending physician. Specifically, a resident did not receive nectar thick liquids as ordered by the physician and Dietary Staff members were not thickening liquids per manufacturers recommendations . Resident identifiers: 15. Findings include: 1. Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/1/18 at 7:23 AM, an observation of the medication administration was conducted with Registered Nurse (RN) 5. RN 5 was observed while she prepared resident 15's medications. RN 5 was observed to crush all of resident 15's medications, mix them in applesauce, and pour a cup of water. RN 5 spooned resident 15's medications into her mouth. When resident 15 swallowed the medications RN 5 gave resident 15 a drink of the water. Resident 15 was observed to cough when the water was administered and her face turned red. RN 5 was observed to give resident 15 three more drinks of the water and resident 15 coughed with each drink. Resident 15's medical record was reviewed on 8/1/18. A physician's orders [REDACTED]. (Note: During the medication administration RN 5 was observed to not thicken resident 15's water.) On 8/1/18 at 1:27 PM, an interview was conducted with RN 5. RN 5 stated that resident 15 usually gets a thickened supplement with her medications. RN 5 stated that she was use to giving resident 15 the supplement and it was not listed on the Medication Administration Record [REDACTED]. RN 5 further stated that when resident 15 started to cough she realized that she had done something wrong. 2. On 7/30/18 at 4:28 PM, an observation was made of Dietary Staff (DS) 1 thickening liquids. On a tray in front of DS 1 a variety of 10 cups were filled with a variety of liquids to various levels. The following was identified on the tray: a. Two of the cups were four ounces. One cup was filled with a red liquid, the other cup with an orange liquid. b. Four were mugs. Three mugs were filled with milk and one was filled with a red liquid. c. Four were eight ounce cups. Two of the cups were filled with milk and the other two were filled with water. All the cups had differing amounts of liquids. Some were filled to close to the top, others were filled halfway. DS 1 was observed to use a regular spoon to add a spoonful of thickener to each cup regardless of the size of the cup, type, or amount of liquid. DS 1 was observed to place the tray of cups in the refrigerator. On 7/30/18 at 4:37 PM, the cups were observed in the refrigerator. Some of the cups did not appear to be thickened adequately. The viscosity appeared to be less than nectar thick. Some appeared to be adequately thickened to nectar thickness. However, the small 4 ounce cup of red liquid appeared to be very thick and was unable to be poured from the cup. On 8/2/18 at 11:12 AM, Dietary Staff (DS) 2 was observed to be thickening liquids. On a tray in front of DS 2 a variety of 10 cups were filled with a variety of liquids to various levels. The following was identified on the tray: a. Two were four ounce cups filled with juice. b. Four were eight ounce cups, two filled with milk and the other two with water. c. Four were mugs. The liquid which was in the mugs was not observed. DS 2 was observed to fill all the cups with the large side of the thickener scoop provided in the package of thickener. There was a single scoop provided for each cup regardless of the size of the cup or the type or amount of liquid within the cup. On 8/2/18 at 12:02 PM, an interview was conducted with DS 2. DS 2 stated that she prepared thickened liquids according to the directions on the thickener package. DS 2 stated that all of the liquid observed to be prepared was supposed to be nectar thick. On 8/2/18 at 12:05 PM, the package directions for the thickener was reviewed. The following mixing chart was on the back of the package of thickener: 4 fl (fluid) oz (ounces), Nectar like: 1 T (tablespoon) 6 fl oz Nectar like 1 T + 2 1/2 tsp (teaspoon) 8 fl oz Nectar like 2 T On 8/2/18 at 12:07 PM, an interview was conducted with Dietary Staff 3 (DS 3). DS 3 stated that she prepared thickened liquids according to the chart hanging in the kitchen. On 8/2/18 at 12:08 PM, the thickening chart hanging in the kitchen was reviewed and revealed the following directions: To thicken 4 fl oz liquid: Water 1 T + 1 tsp Apple juice 1 T Cranberry juice 1 T Grape juice 1 T Orange juice 2 1/2 tsp Prune juice 1 T Fruit Nectar 1 1/2 tsp Tomato/Vegetable Juice 1 tsp [MEDICATION NAME] Sodas 1 T Lemonade/punch 1 T Coffee/tea 1 T + 1 tsp Broth 1 T + 1 tsp Skim/1% (percent) milk 1 T + 1 tsp 2%/Whole milk 1 T + 1 tsp On 8/2/18 at 12:29 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that it had been a while since the last inservice on thickening liquids. A request was made to observe documentation for the last known inservice where instruction on thickening liquids was provided. The DM stated that in (MONTH) thickening liquids was mentioned, but instruction was not provided. When accounts of the two observations were described, the DM acknowledged the discrepancies and inaccuracies in the preparation. The DM stated she wished her staff would utilize the machines which automatically thickened liquids in the kitchen more often.

Based on observation, interview, and record review, it was determined for 8 of 35 sample residents, that the facility did not ensure that the resident was free from physical restraints imposed for the purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Specifically, the facility lacked documentation of interventions attempted prior to initiating potential restraints such as lap belts. Resident identifiers: 7, 18, 51, 52, 54, 58, 61, and 65. Findings include: 1. Resident 18 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Throughout the survey, resident 18 was observed to be in his wheelchair with a soft waist belt on a majority of the time. On 7/31/18, a review of resident 18's medical record was conducted. A physician order [REDACTED]. Release Q (every) 2 hrs (hours) (times) 10 min (minutes) for personal hygiene, repositioning, to maintain independent mobility with poor cognition and safety awareness. Interdisciplinary team (IDT) restraint review forms documented the following: a. On 5/18/17, in the section titled alternatives attempted the following were marked: pillows/pads, saddle seat, lapbuddy. b. On 8/17/17, in the section titled alternatives attempted no alternatives were marked. c. On 11/16/17, in the section titled alternatives attempted the following was marked: frequent repositioning. d. On 2/15/18, in the section titled alternatives attempted the following was marked: frequent repositioning. e. On 4/26/18, in the section titled alternatives attempted the following was marked: resident re-education. f. On 7/19/18, in the section titled alternatives attempted the following was marked: frequent repositioning. A form dated 4/17/18, and titled Resident Functional Assessment-Restraint Determination identified the medical symptom to be treated was that the resident was unaware of safety, non wt (weight) bearing . A review of resident 18's medical record revealed that he had falls on the following dates: a. On 9/30/17, Description of incident: Resident found on the floor in the lobby laying by the recliner. He stated he tried to get into the chair and fell . Resident stated he tried to get into the chair and fell . Resident stated he hit the back of his head on the chair. No injuries were noted. Will do neuro checks. Denies any pain at this time Restraints: lap belt when in w/c (wheelchair) (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) b. On 11/26/17, Description of incident: pt (patient) was in his room when the bed alarm went off the aide went to check on the pt and found him standing at the side of his bed, pt tried to walk when he fell his his head on the nightstand. Pt was placed in his wheelchair and brought to the lobby. (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) c. On 12/9/17, Description of Incident: (Resident 18) stood up from recliner in lobby. I ran over from nurses station to assist resident back into seat. Resident fell before I reached him. As he fell , his back slid against a chair. Resident was assisted back into recliner, vital signs obtained. He was then toileted et assessed. No changes in L[NAME] (level of consciousness), reddened area on R (right) side of back from hip up to mid scapula region. Resident c/o (complains of ) pain in hip. (Resident 18) was given a warm blanket pain medication for his pain. Resident currently sitting in w/c watching television in lobby. (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) d. On 1/10/18, Description of Incident: (Resident 18) was in the lobby in a recliner, stood up to fall before anyone could get to him. He hit the recliner with his back before hitting the floor. C/o pain to R side of lower back. He did not hit his head and has no (changes) in mental state. (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) e. On 2/26/18, Description of Incident: F.O.F. (found on floor) room [ROOM NUMBER] wheel chair and lap belt next to him. Patient states he is ok, he has abrasion on left lateral palm of hand. We'll call family and for physician. (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) f. On 4/13/18, Description of the Incident: Resident in wheelchair on memory lane watching tv, resident undone (sic) his lap belt, stood up and fell to floor .Resident landed on left side of body did not hit head, no injuries noted . Outcome/recommendations/corrective action(s) 4/14-sent to ER (emergency room ) for c/o pain-fx (fracture) hip. Transported to (hospital name) for hip surgery. On 8/2/18 at 11:26 AM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated that she frequently took care of resident 18. RN 4 stated no matter what we do, we will use a lap belt or buddy because it's a reminder they (referring to the resident's with dementia) have to ask for help. RN 4 stated that interventions implemented after resident 18's falls included cuing, reminding, medications, and snacks. RN 4 stated these interventions were not documented anywhere. RN 4 stated that resident 18's lap belt was in place to prevent his [MEDICAL CONDITION] from getting worse. (Note: the lap belt was in place since at least 5/31/17. The resident's [MEDICAL CONDITION] was obtained 4/13/18.) 2. Resident 51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/31/18, a review of resident 51's medical record was conducted. A telephone order dated 6/20/18, stated the following Lap belt when in wheelchair d/t impaired decision making hallucinations/delusional thoughts. Release q 2 hours (times) 10 mins for personal hygiene, repositioning tp (sic) maintain indepentent (sic) mobility with poor codition (sic) and safety awareness . An IDT restraint review form dated 6/20/18, documented the following in the section titled alternatives attempted the following was marked: frequent repositioning. A review of the nursing progress notes revealed the following events: a. On 7/9/18 at 10:50 AM, Resident found in doorway, standing in front of w/c. Lap belt had been removed and wrapped around one leg. Assisted to room, pants changed, lap belt reapplied. Resident angry, asking for scissors to cut the belt off. Unable to redirect or reorient as to why she has the lap belt. b. On 7/30/18 at 3:25 PM, Resident out of room propelling self to lobby CNA (Certified Nursing Assistant) and nurse noticed had loosened safety restraint (lap belt) was pulling down pants about to fall out of w/c assist to room redressed cueing with redirection became combative/agitation saying pants to tight assist with new pants with larger waist noticed skin tear to right arm above wrist 4 cm (centimeters) cleansed with steri strips applied and dressing, son aware stated would be in with larger pants. On 8/2/18 at 11:26 AM, an interview was conducted with RN 4. RN 4 stated that prior to resident 51 having a restraint put in place they tried everything. RN 4 stated resident 51 will fall if she stands up and something needs to be put in place to remind them (referring to the resident's with dementia) to ask for help. RN 4 stated resident 51 would ask for help before getting up because resident 51 was used to having the restraint on. At the time of the interview, resident 51 was observed to not have a lap belt in place. When asked why resident 51 did not have the lap belt on, RN 4 stated it was a trial and I think we're trying to see if she can go without it. RN 4 stated I don't know when trials start. RN 4 stated she was told about trials in report and charts on them. RN 4 did not know how long trials go on for or who initiated it. 3. Resident 52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/31/18 at 7:23 AM, an observation was made of resident 52 in the dayroom with a soft lap belt restraint applied to his waist and tied at the back of the wheelchair. The restraint was not self releasing. The observation was ended at 10:23 AM. (Note: Resident 52's restraint was not released during the 3 hour observation.) Resident 52's medical record was reviewed on 8/1/18. A physician's orders [REDACTED]. Release Q 2 (hours) x (times) 10 minutes for personal hygiene, repositioning, to maintain independent mobility with poor cognition and safety. Q shift. A review of the Incident/Accident repots documented the following entries: a. On 1/2/18 at 4:00 AM, Resident was found on floor next to his bed. The resident stated that he was getting up to go to the bathroom. Resident did not have his prosthetic leg on. Resident had a skin tear to his right elbow and an abrasion on his right shoulder. The resident's bed alarm was on and the bed mat was in place. No interventions implemented. b. On 2/23/18 at 9:15 PM, Resident was found by CNA sitting on the edge of his bed. The residents hands, bed, and wall were covered with feces. Resident stated that he fell trying to get to the bathroom. Resident had a reddened area to his right knee. No interventions implemented. c. On 3/20/18 at 1:15 PM, Resident was found on the floor in his room in front of the night stand. The resident had blood dripping from his nose, right eye was purple and swollen, hematoma to forehead, and an abrasion to his right knee. Therapy was notified regarding the resident's wheelchair needing to be repaired. No interventions implemented. d. On 4/27/18 at 9:44 PM, Resident was calling out for the nurse. Resident was found on the floor on his left side propped up on his left arm between the bed and his wheelchair. Resident stated that he did not know what happened but he thought he was trying to go to the bathroom. No interventions implemented. e. On 5/1/18 at 9:56 AM, Resident was found on the floor sitting in front of his wheelchair. Resident was scooting towards the recliner. Resident had a skin tear on his left hand. No interventions implemented. f. On 5/6/18 at 8:15 PM, Resident was found on the floor by his bed with his wheelchair in front of the bed side table. No interventions implemented. g. On 6/9/18 at 9:15 PM, Resident was in the lobby self transferring from his wheelchair to chair and back several times. The resident was found walking down the hall 20 minutes prior. The CNA and nurse both watched the resident slip from his wheelchair during a self transfer. No interventions implemented. h. On 6/17/18 at 7:00 PM, The staff heard a loud noise and found the resident sitting on the floor in front of his bed next to the night stand. Resident was trying to ambulate without his prosthetic leg. No interventions implemented. i. On 6/18/18 at 10:30 AM, Resident was found on the floor sitting next to his wheelchair in his room. Lap belt placed on the resident and moved rooms. (Note: On 6/18/18, an order for [REDACTED].> j. 6/24/18 at 3:45 PM, Resident was found on the floor in the dining area of the memory care unit. Resident appears to have fallen asleep in the recliner and fell forward hitting his head on the floor. Resident had a reddened area noted on the right side of his forehead. No interventions implemented. k. On 7/9/18 at 2:00 AM, Resident was found on the floor next to his bed. Resident has an abrasion to his right knee. Resident's bed alarm was on. No interventions implemented. A Resident Functional Assessment - Restraint Determination form dated 6/18/18, documented unaware of safety as the medical symptom to be treated. The section Must try the least restrictive restraint first (mark all that apply) was not completed. The section Least Restrictive Restraint Device Needed: (After trying and failing least restrictive device) was marked Soft waist belt. A Rehab Therapy Note dated 6/19/18, documented . Lap belt while in wc (wheelchair) appropriate to promote functional mobility while enhancing safety & (and) reducing fall risk. On 8/2/18 at 11:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 52 has had a lot of falls. LPN 1 stated that the staff have tried supervision, one on one, and the lap buddy. LPN 1 was not aware of any other interventions that have been implemented for resident 52 to prevent falls. 4. Resident 61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 61's medical record was reviewed on 7/31/18. A physician's orders [REDACTED]. Release Q 2 hrs x 10 min for personal hygiene, repositioning, to maintain independent mobility with poor cognition and safety awareness. A review of the Incident/Accident repots documented the following entries: a. On 4/7/18 at 9:45 PM, Resident was found on the floor in his room. Resident was trying to take himself to the bathroom. No interventions implemented. b. On 4/15/18 at 9:30 PM, Resident was found on the floor in the doorway of his room. Resident was trying to take himself to the bathroom. Resident's bed was in the lowest position with the bedside mattress in place next to the bed. No interventions implemented. c. On 5/3/18 at 4:30 PM, Resident was sitting in a recliner and stood up falling to the floor. Resident hit the back of his head. No interventions implemented. (Note: On 5/3/18, an order for [REDACTED].> d. On 5/21/18 at 11:10 PM, Resident was sitting in front of the nurses station and tried to stand tipping his wheelchair. The resident tipped over on his left side onto the floor with the lap belt still attached. The staff released the lap belt and repositioned the resident into the wheelchair. No interventions implemented. e. On 7/17/18 at 2:30 AM, Resident was found on the floor next to a recliner in the lobby. No interventions implemented. f. On 7/25/18 at 9:00 AM, Resident was found on the floor next to his bed not on his fall matt. The bed alarm was off. No interventions implemented. g. On 7/26/18 at 12:30 AM, Resident was sitting in the lobby eating a snack. The resident scooted his bottom forward in the wheelchair, pushing the chair pad, and tipping the wheelchair forward. The resident landed on his bottom with the wheelchair and lap belt still attached. No interventions implemented. No care plan specific to the restraint could be located in the medical record. A Resident Functional Assessment - Restraint Determination form dated 5/3/18, documented poor gait-inability to stand without assistance as the medical symptom to be treated. It was documented that the restraint would be used to reduce falls. The section Must try the least restrictive restraint first (mark all that apply) was marked Lap Buddy (not a restraint if can be removed by patient) failed. The section Least Restrictive Restraint Device Needed: (After trying and failing least restrictive device) was marked Soft waist belt. (Note: Resident had 2 falls while in the wheelchair after the lap belt was implemented.) On 8/1/18 at 9:53 AM, an interview was conducted with RN 5. RN 5 stated that interventions implemented for resident 61 to prevent falls were supervision, one on one, recliners, and a lap belt. RN 5 stated that resident 61 has a lot of anxiety and will yell out at times. RN 5 stated that resident 61 also has hallucinations and delusions. 5. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/30/18 at 11:57 AM, an observation was made of resident 7 in the dayroom with a soft lap belt restraint applied to her waist and tied at the back of the wheelchair. The restraint was not self releasing. The observation was ended at 2:57 PM. (Note: Resident 7's restraint was not released during the 3 hour observation.) Resident 7's medical record was reviewed on 8/1/18. A physician's orders [REDACTED]. Release Q2 x 10 min. for personal hygiene to maintain independent mobility with poor cognition, safety awareness . A physician's orders [REDACTED]. Release Q2 x 10 min. for personal hygiene to maintain mobility with poor cognition, safety awareness. A review of the Incident/Accident reports documented the following entries: a. On 1/11/18 at 3:10 AM, Resident was found on the floor in her bedroom lying on her stomach. Resident has red marks on both her knees. No interventions implemented. b. On 1/11/18 at 7:10 PM, Resident was found on the floor by her bed. Family stated that it was okay to place a bed mat and bed alarm to prevent falls. c. On 1/13/18 at 2:45 PM, Resident was found lying face down on the floor in the hallway by a visitor. Resident had a hematoma noted to the left eyebrow, abrasion to the left cheek, and a skin tear to the left forearm. Family stated that the resident had a belt on at home to keep her from falling. (Note: On 2/26/18, an order for [REDACTED].> d. On 1/21/18 at 5:22 PM, Resident was found on the floor in the bathroom next to the wheelchair. The resident had removed her self releasing lap belt and stated that she slipped. No interventions implemented. e. On 1/27/18 at 2:45 PM, Resident was found on the floor in the bathroom. Resident undone her restraint and took herself to the bathroom. The resident tripped over the foot peddles on the wheelchair while getting back up from the toilet. Resident had a skin tear to her left elbow. No interventions implemented. f. On 2/9/18 at 7:45 PM, Resident was found in her room in the wheelchair. The wheelchair had the back wheels off the ground and the front hand rails of the wheelchair resting on the bed and bedside table. The resident was held into the wheelchair with her lap belt and her knees were on the floor and she was leaning over. No interventions implemented. g. On 2/16/18 at 7:00 PM, A CNA was assisting the resident in the restroom when another CNA knocked on the door. While the CNA was answering the door the resident stood up from the commode and fell to the floor. The resident hit the left side of her back striking the garbage can and causing a welt and bruising to the left side of her upper back. CNA educated on resident's poor safety awareness and the need for constant supervision in assistive situations. h. On 3/11/18 at 4:50 PM, Resident was found on the floor early this morning. The bed alarm was turned off. At 4:50 PM, the family was at the facility to visit with the resident and they were unable to find her. Resident was found in different resident bathroom on the floor. The resident had removed the lap buddy. No interventions implemented. i. On 3/13/18 at 7:30 AM, Resident's bed alarm was sounding. When the CNA entered the room the resident was sliding from bed and landed on her bottom. The bed was noted to be in the low position. While transferring the resident back to bed she obtained a skin tear to her right hand. Resident using lap buddy in wheelchair and will not stand and bear weight. No interventions implemented. j. 3/17/18 at 8:00 PM, The Nurse returned to the lobby to find the resident out of the wheelchair and leaning on the chair. The resident lowered herself to the floor. No interventions implemented. k. On 3/26/18 at 4:16 PM, Resident was resting in a recliner when she leaned over the arm of the recliner and upon standing she lost her balance. No interventions implemented. l. On 4/6/18 at 6:45 PM, Resident was anxious and agitated and went into her room to be alone. The CNA was walking past the resident's room when she saw the lap buddy on the floor and the wheelchair rolled across the room. The staff documented that the lap buddy was to easy for the resident to remove. The staff placed a lap belt for resident safety and the floor alarm was activated. (Note: On 4/6/18, an order for [REDACTED].> m. On 4/12/18 at 5:33 PM, Resident was sitting in her wheelchair next to her bed making an attempt to get out of the wheelchair. The resident had tipped the wheelchair over next to her bed when the staff found her. No interventions implemented. n. On 4/27/18 at 6:20 AM, Resident was found on the floor next to her bed. No interventions implemented. o. On 6/18/18 at 7:50 PM, Resident's bed alarm was triggered and she was found standing in front of the bed bent over forward with both hands on the bed. The resident fell to her left side and bumped into and slid down the edge of the head board. No interventions implemented. A Resident Functional Assessment - Restraint Determination form dated 1/13/18, documented poor safety awareness as the medical symptom to be treated. The section Must try the least restrictive restraint first (mark all that apply) was marked Self release lap belt. The section Least Restrictive Restraint Device Needed: (After trying and failing least restrictive device) was marked Soft waist belt Lap Buddy 1/24/17 failed 2/26/18 restarted. A Resident Functional Assessment - Restraint Determination form dated 4/6/18, documented poor safety awareness as the medical symptom to be treated. It was documented that the restraint would be used for fall prevention. The section Must try the least restrictive restraint first (mark all that apply) was marked Lap Buddy (not a restraint if can be removed by patient). The section Least Restrictive Restraint Device Needed: (After trying and failing least restrictive device) was marked Soft waist belt restarted 4/6/18 Lap Buddy failed 4/6/18. (Note: Resident had 6 falls while in the wheelchair after the lap belt was implemented 2/26/18.) On 8/1/18 at 2:19 PM, an interview was conducted with RN 5. RN 5 stated that interventions implemented for resident 7 to prevent falls were supervision, one on one, recliners, and a lap belt. RN 5 stated that resident 7 had a lap buddy but she was removing the lap buddy and having falls. RN 5 stated that the lap buddy was changed to a soft lap belt for safety. RN 5 was unsure of the other inventions implemented to keep resident 7 safe. 6. Resident 54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/30/18 at 11:57 AM, an observation was made of resident 54 in the dayroom with a soft lap belt restraint applied to her waist and tied at the back of the wheelchair. The restraint was not self releasing. The observation was ended at 2:57 PM. (Note: Resident 54's restraint was released for 7 minutes from 1:11 PM until 1:18 PM during the 3 hour observation.) On 7/31/18 at 7:23 AM, an observation was made of resident 54 in the dayroom with a soft lap belt restraint applied to her waist and tied at the back of the wheelchair. The restraint was not self releasing. The observation was ended at 10:23 AM. (Note: Resident 54's restraint was released for 4 minutes from 9:32 AM until 9:36 AM during the 3 hour observation.) Resident 54's medical record was reviewed on 8/2/18. A physician's orders [REDACTED]. Release Q 2 hrs x 10 minutes for personal hygiene, repositioning, to maintain independent mobility with poor cognition and safety awareness. A Admission MDS assessment dated [DATE], documented resident 54 with a BIMS score of 6. (Note: A resident with a severe impairment cognitively would have a BIMS score of 0 to 7.) The facility staff assessed resident 54 as requiring total dependence of two persons for bed mobility, transfers, and toilet use. A Plan of Care dated 4/5/18 with an effective date of 4/5/18 documented a Problems/Strengths of Fall Potential R/T Aftercare following joint replacement, Presence of left artificial hip, Fx of left artificial hip, Fx of left neck of femur, Dementia with behavioral disturbances, [MEDICAL CONDITION] and disorder of bone density. The goals developed were, Will remain free of injury AEB free of falls or accidents Q day TNR. Will remain free of restraint-related complications AEB concracture (sic)-free, mobility maintained, skin intact TNR. The interventions developed were, Monitor/anticipate/intervene for factors causing prior falls. Answer calls quickly; anticipate needs. Staff education-Safety measures; Injury potential avoidance; What to do if a fall occurs. Release restraint Q2 hrs and PRN x10 minutes. Ambulate/transfer with appropriate devices. A review of the Incident/Accident repots documented the following entries: a. On 4/27/18 at 3:00 PM, Resident was found sitting on the floor in front of the wheelchair. The resident had removed the lap buddy. No interventions implemented. b. On 5/5/18 at 2:20 PM, Resident was in the lobby and fell out of the wheelchair when she removed the lap buddy. No interventions implemented. c. On 6/8/18 at 9:10 PM, Resident was found on the floor in the hallway. No interventions implemented. d. On 6/10/18 at 4:15 PM, Resident was found on the floor in the south east dining room. Resident was kneeling at a dining room table and the lap buddy was on the floor next to her. Evaluate to reinstate lap belt. (Note: On 6/11/18, an order for [REDACTED].>A Resident Functional Assessment - Restraint Determination form dated 3/29/18, documented Medical symptom to be treated was blank. It was documented that the restraint would be used for a reminder due to poor safety awareness. The section Must try the least restrictive restraint first (mark all that apply) was not marked. The section Least Restrictive Restraint Device Needed: (After trying and failing least restrictive device) was marked Lap Buddy. A Resident Functional Assessment - Restraint Determination form dated 6/11/18, documented hx of falls as the medical symptom to be treated. The section Must try the least restrictive restraint first (mark all that apply) was marked Lap Buddy (not a restraint if can be removed by patient) and Pillows and/or pads. The section Least Restrictive Restraint Device Needed: (After trying and failing least restrictive device) was marked Soft waist belt. 7. Resident 58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 58's medical record was reviewed on 8/2/18. A physician's orders [REDACTED]. Release Q 2 hrs x 10 min for personal hygiene, repositioning to maintain independent mobility with poor cognition and safety awareness. A Resident Functional Assessment - Restraint Determination form dated 5/17/17, documented hallucinations/delusions, no safety awareness, poor cognition, falls, impaired decision making as the medical symptom to be treated. It was documented that the restraint would be used to maintain independent mobility when in the wheelchair. The section Must try the least restrictive restraint first (mark all that apply) was marked Lap Buddy (not a restraint if can be removed by patient) and Pillows and /or pads. The section Least Restrictive Restraint Device Needed: (After trying and failing least restrictive device) was marked Soft waist belt when in wheelchair. A review of the Incident/Accident reports from (MONTH) (YEAR) through (MONTH) (YEAR) documented no incidents for resident 58. 8. Resident 65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/30/18 at 11:57 AM, an observation was made of resident 65 in the dayroom with a soft lap belt restraint applied to her waist and tied at the back of the wheelchair. The restraint was not self releasing. The observation was ended at 2:57 PM. (Note: Resident 65's restraint was not released during the 3 hour observation.) On 7/31/18 at 7:23 AM, an observation was made of resident 65 in the dayroom with a soft lap belt restraint applied to her waist and tied at the back of the wheelchair. The restraint was not self releasing. The observation was ended at 10:23 AM. (Note: Resident 65's restraint was not released during the 3 hour observation.) Resident 65's medical record was reviewed on 8/2/18. A physician's orders [REDACTED]. Release Q 2 hrs x 10 min for personal hygiene, repositioning - to maintain independent mobility with poor cognition and safety awareness. A Resident Functional Assessment - Restraint Determination form dated 5/18/17, documented hallucinations/delusions, poor safety awareness, poor cognition, hx falls, impaired decision making as the medical symptom to be treated. It was documented that the restraint would be used to allow independent mobility. The section Must try the least restrictive restraint first (mark all that apply) was marked Lap Buddy (not a restraint if can be removed by patient), Pillows and /or pads, Postural Support, and Chair Alarm. The section Least Restrictive Restraint Device Needed: (After trying and failing least restrictive device) was marked Soft waist belt. A review of the Incident/Accident reports from (MONTH) (YEAR) through (MONTH) (YEAR) documented no incidents for resident 65. On 7/30/18 at approximately 1:50 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that the residents that fall frequently or wander throughout the facility had a soft restraint. On 8/1/18 at 7:31 AM, an interview was conducted with RN 5. RN 5 stated that the facility staff did not use self releasing restraints because the residents would release them and fall. On 8/1/18 at 2:28 PM, an interview was conducted with CNA 2. CNA 2 stated that the staff did not chart when the resident restraints were released. On 8/2/18 at approximately 11:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the staff have tried several interventions with the residents that have had falls. The DON stated that the staff have implemented soft lap belt restraints for residents that are unsteady on their feet and have poor decision making to prevent falls. The DON provided no additional information.

Based on interview and record review, it was determined for 4 of 35 sample residents, that the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality care within 48 hours of a resident's admission. Specifically, resident baseline care plans did not include information necessary to properly care for residents including; initial goals based on admission assessments and physician orders. Resident identifiers: 4, 18, 51, and 217. Findings include: 1. Resident 217 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 217's medical record was reviewed on 7/31/18. A review of the physician's orders [REDACTED]. a. On 7/12/18, [MEDICATION NAME] 500 milligrams (mg) 1 to 2 tablets every 6 hours as needed for pain/fever; b. On 7/12/18, [MEDICATION NAME] 325-5 mg 1/2 to 1 tablet every 12 hours as needed for pain. A Baseline Care Plan completed 7/12/18, (day of admission) did not address pain management for resident 217. An Interdisciplinary Team (IDT) meeting document was completed 7/19/18. The document did not address pain management for resident 217. On 8/1/18 at 12:56 PM, an interview was conducted with the Director of Nursing (DON). The DON described the facility's care planning process. The DON stated that the care planning process starts with an admission assessment and baseline care plan when the resident was admitted . The DON stated that each resident was discussed in an IDT Meeting within 14 days of admission and then a comprehensive care plan should be completed within 21 days of admission. The DON reviewed the baseline care plan and IDT Meeting document for resident 217. The DON stated that she would expect pain management addressed on resident 217's baseline care plan and also addressed in the IDT Meeting. 2. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/31/18, a review of resident 4's record was conducted. The baseline care plan was identified. The date listed was 1/2018. The specific day which the baseline care plan was implemented was not recorded. The baseline care plan was a generic form. There was no care plan area discussing the resident's dementia or joint replacement care. 3. Resident 18 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/31/18, a review of resident 18's record was conducted. The baseline care plan was identified. The date listed was 4/2018. The specific day which the baseline care plan was implemented was not recorded. The baseline care plan was a generic form. There was no care plan area discussing the resident's dementia or after fracture care. 4. Resident 51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/31/18, a review of resident 18's record was conducted. The baseline care plan was identified. The date listed was 6/2018. The specific day which the baseline care plan was implemented was not recorded. The baseline care plan was a generic form. There was no care plan area discussing the resident's dementia, nicotine dependence, or hearing loss. On 8/2/18 at 12:19 PM, an interview was conducted with the DON. When the DON was asked about the above baseline care plans, she stated that the baseline care plan was generic and stated she was aware it was not adequate.

Based on interview and record review, it was determined for 5 of 35 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, residents with restraints did not have a care plan developed as required and residents with multiple falls did not have the care plan revised. Resident identifiers: 7, 18, 52, 54, and 61. Findings include: 1. Resident 52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 52's medical record was reviewed on 8/1/18. A Annual Minimum Data Set (MDS) assessment dated [DATE], documented resident 52 with a Brief Interview for Mental Status (BIMS) score of 4. (Note: A resident with a severe impairment cognitively would have a BIMS score of 0 to 7.) The facility staff assessed resident 52 as requiring extensive assistance of one person for bed mobility and transfers and extensive assistance of two persons for toilet use. A Quarterly MDS assessment dated [DATE], documented resident 52 with a BIMS score of 10. (Note: A resident with a moderate impairment cognitively would have a BIMS score of 8 to 12.) The facility staff assessed resident 52 as requiring total dependence of one person for bed mobility, transfers, and toilet use. A review of the Incident/Accident repots documented the following entries: a. On 1/2/18 at 4:00 AM, Resident was found on floor next to his bed. The resident stated that he was getting up to go to the bathroom. Resident did not have his prosthetic leg on. Resident had a skin tear to his right elbow and an abrasion on his right shoulder. The resident's bed alarm was on and the bed mat was in place. No interventions implemented. b. On 2/23/18 at 9:15 PM, Resident was found by Certified Nursing Assistant (CNA) sitting on the edge of his bed. The residents hands, bed, and wall were covered with feces. Resident stated that he fell trying to get to the bathroom. Resident had a reddened area to his right knee. No interventions implemented. c. On 3/20/18 at 1:15 PM, Resident was found on the floor in his room in front of the night stand. The resident had blood dripping from his nose, right eye was purple and swollen, hematoma to forehead, and an abrasion to his right knee. Therapy was notified regarding the resident's wheelchair needing to be repaired. No interventions implemented. d. On 4/27/18 at 9:44 PM, Resident was calling out for the nurse. Resident was found on the floor on his left side propped up on his left arm between the bed and his wheelchair. Resident stated that he did not know what happened but he thought he was trying to go to the bathroom. No interventions implemented. e. On 5/1/18 at 9:56 AM, Resident was found on the floor sitting in front of his wheelchair. Resident was scooting towards the recliner. Resident had a skin tear on his left hand. No interventions implemented. f. On 5/6/18 at 8:15 PM, Resident was found on the floor by his bed with his wheelchair in front of the bed side table. No interventions implemented. g. On 6/9/18 at 9:15 PM, Resident was in the lobby self transferring from his wheelchair to chair and back several times. The resident was found walking down the hall 20 minutes prior. The CNA and nurse both watched the resident slip from his wheelchair during a self transfer. No interventions implemented. h. On 6/17/18 at 7:00 PM, The staff heard a loud noise and found the resident sitting on the floor in front of his bed next to the night stand. Resident was trying to ambulate without his prosthetic leg. No interventions implemented. i. On 6/18/18 at 10:30 AM, Resident was found on the floor sitting next to his wheelchair in his room. Lap belt placed on the resident and moved rooms. (Note: On 6/18/18, an order for [REDACTED].> j. 6/24/18 at 3:45 PM, Resident was found on the floor in the dining area of the memory care unit. Resident appears to have fallen asleep in the recliner and fell forward hitting his head on the floor. Resident had a reddened area noted on the right side of his forehead. No interventions implemented. k. On 7/9/18 at 2:00 AM, Resident was found on the floor next to his bed. Resident has an abrasion to his right knee. Resident's bed alarm was on. No interventions implemented. A Plan of Care dated 3/29/17 with an effective date of 3/29/18, documented a Problems/Strengths of Fall Potential R/T (related to) Dementia, Acquired absence of left foot. The goal developed was, Will remain free of injury AEB (as evidenced by) free of falls or accidents Q (every) day TNR (through next review). The interventions developed were, Monitor/anticipate/intervene for factors causing prior falls. Answer calls quickly. Encourage resident to use call light when in need of assistance. Staff education-Safety measures; Injury potential avoidance; What to do if a fall occurs. Transfer with appropriate devices. A Plan of Care worksheet dated 4/26/17, documented a problem of Fall risk poor posture, safety awareness, very mobil (sic). The intervention developed was, Lap belt when in w/c (wheelchair) - release Q 2 (hours) x (times) 10 min (minutes). (Note: There were no updated interventions after each of resident 52's falls.) On 8/2/18 at 11:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 52 has a lot of falls. LPN 1 stated that the staff have tried supervision, one on one, and a lap buddy. LPN 1 was not aware of any other interventions that have been implemented for resident 52 to prevent falls. 2. Resident 61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 61's medical record was reviewed on 7/31/18. A Quarterly MDS assessment dated [DATE], documented resident 61 with a BIMS score of 4. (Note: A resident with a severe impairment cognitively would have a BIMS score of 0 to 7.) The facility staff assessed resident 61 as requiring limited assistance of one person for bed mobility, transfer, and toilet use. A Significant Change in Status MDS assessment dated [DATE], documented resident 61 with a BIMS score of 8. (Note: A resident with a moderate impairment cognitively would have a BIMS score of 8 to 12.) The facility staff assessed resident 61 as requiring limited assistance of one person for bed mobility, extensive assistance of one person for transfers, and total dependence of one person for toilet use. A Quarterly MDS assessment dated [DATE], documented resident 61 with a BIMS score of 11. (Note: A resident with a moderate impairment cognitively would have a BIMS score of 8 to 12.) The facility staff assessed resident 61 as requiring total dependence of one person for bed mobility and total dependence of two persons for transfer and toilet use. The facility further assessed resident 61 as using a trunk restraint daily. A review of the Incident/Accident repots documented the following entries: a. On 4/7/18 at 9:45 PM, Resident was found on the floor in his room. Resident was trying to take himself to the bathroom. No interventions implemented. b. On 4/15/18 at 9:30 PM, Resident was found on the floor in the doorway of his room. Resident was trying to take himself to the bathroom. Resident's bed was in the lowest position with the bedside mattress in place next to the bed. No interventions implemented. c. On 5/3/18 at 4:30 PM, Resident was sitting in a recliner and stood up falling to the floor. Resident hit the back of his head. No interventions implemented. (Note: On 5/3/18, an order for [REDACTED].> d. On 5/21/18 at 11:10 PM, Resident was sitting in front of the nurses station and tried to stand tipping his wheelchair. The resident tipped over on his left side onto the floor with the lap belt still attached. The staff released the lap belt and repositioned the resident into the wheelchair. No interventions implemented. e. On 7/17/18 at 2:30 AM, Resident was found on the floor next to a recliner in the lobby. No interventions implemented. f. On 7/25/18 at 9:00 AM, Resident was found on the floor next to his bed not on his fall matt. The bed alarm was off. No interventions implemented. g. On 7/26/18 at 12:30 AM, Resident was sitting in the lobby eating a snack. The resident scooted his bottom forward in the wheelchair, pushing the chair pad, and tipping the wheelchair forward. The resident landed on his bottom with the wheelchair and lap belt still attached. No interventions implemented. A Plan of Care dated 12/27/17 with an effective date of 4/12/18, documented a Problems/Strengths of Fall Potential R/T Dementia, Medication. The goal developed was, Will remain free of injury AEB free of falls or accidents Q day TNR. The interventions developed were, Staff education-Safety measures; Injury potential avoidance; What to do if a fall occurs. Monitor/anticipation/intervene for factors causing prior falls. Answer calls quickly; anticipate needs. Transfer with appropriate devices. (Note: There were no updated interventions after each of resident 61's falls. There was no development of a plan of care for the usage of a trunk restraint.) On 8/1/18 at 9:53 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that interventions implemented for resident 61 to prevent falls were supervision, one on one, recliners, and a lap belt. RN 5 stated that resident 61 has a lot of anxiety and will yell out at times. RN 5 stated that resident 61 also has hallucinations and delusions. On 8/1/18 at 12:21 PM, an interview was conducted with the MDS coordinator. The MDS coordinator stated that a plan of care for the restraint was never developed for resident 61. 3. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7's medical record was reviewed on 8/1/18. A Admission MDS assessment dated [DATE], documented resident 7 with a BIMS score of 7. (Note: A resident with a severe impairment cognitively would have a BIMS score of 0 to 7.) The facility staff assessed resident 7 as requiring extensive assistance of two persons for bed mobility, transfers and toilet use. A Quarterly MDS assessment dated [DATE], documented resident 7 with a BIMS score of 11. (Note: A resident with a moderate impairment cognitively would have a BIMS score of 8 to 12.) The facility staff assessed resident 7 as requiring total dependence of one person for bed mobility and transfers and extensive assistance of two persons for toilet use. A review of the Incident/Accident reports documented the following entries: a. On 1/11/18 at 3:10 AM, Resident was found on the floor in her bedroom lying on her stomach. Resident has red marks on both her knees. No interventions implemented. b. On 1/11/18 at 7:10 PM, Resident was found on the floor by her bed. Family stated that it was okay to place a bed mat and bed alarm to prevent falls. c. On 1/13/18 at 2:45 PM, Resident was found lying face down on the floor in the hallway by a visitor. Resident had a hematoma noted to the left eyebrow, abrasion to the left cheek, and a skin tear to the left forearm. Family stated that the resident had a belt on at home to keep her from falling. (Note: On 2/26/18, an order for [REDACTED].> d. On 1/21/18 at 5:22 PM, Resident was found on the floor in the bathroom next to the wheelchair. The resident had removed her self releasing lap belt and stated that she slipped. No interventions implemented. e. On 1/27/18 at 2:45 PM, Resident was found on the floor in the bathroom. Resident undone her restraint and took herself to the bathroom. The resident tripped over the foot peddles on the wheelchair while getting back up from the toilet. Resident had a skin tear to her left elbow. No interventions implemented. f. On 2/9/18 at 7:45 PM, Resident was found in her room in the wheelchair. The wheelchair had the back wheels off the ground and the front hand rails of the wheelchair resting on the bed and bedside table. The resident was held into the wheelchair with her lap belt and her knees were on the floor and she was leaning over. No interventions implemented. g. On 2/16/18 at 7:00 PM, A CNA was assisting the resident in the restroom when another CNA knocked on the door. While the CNA was answering the door the resident stood up from the commode and fell to the floor. The resident hit the left side of her back striking the garbage can and causing a welt and bruising to the left side of her upper back. CNA educated on resident's poor safety awareness and the need for constant supervision in assistive situations. h. On 3/11/18 at 4:50 PM, Resident was found on the floor early this morning. The bed alarm was turned off. At 4:50 PM, the family was at the facility to visit with the resident and they were unable to find her. Resident was found in different resident bathroom on the floor. The resident had removed the lap buddy. No interventions implemented. i. On 3/13/18 at 7:30 AM, Resident's bed alarm was sounding. When the CNA entered the room the resident was sliding from bed and landed on her bottom. The bed was noted to be in the low position. While transferring the resident back to bed she obtained a skin tear to her right hand. Resident using lap buddy in wheelchair and will not stand and bear weight. No interventions implemented. j. 3/17/18 at 8:00 PM, The Nurse returned to the lobby to find the resident out of the wheelchair and leaning on the chair. The resident lowered herself to the floor. No interventions implemented. k. On 3/26/18 at 4:16 PM, Resident was resting in a recliner when she leaned over the arm of the recliner and upon standing she lost her balance. No interventions implemented. l. On 4/6/18 at 6:45 PM, Resident was anxious and agitated and went into her room to be alone. The CNA was walking past the resident's room when she saw the lap buddy on the floor and the wheelchair rolled across the room. The staff documented that the lap buddy was to easy for the resident to remove. The staff placed a lap belt for resident safety and the floor alarm was activated. (Note: On 4/6/18, an order for [REDACTED].> m. On 4/12/18 at 5:33 PM, Resident was sitting in her wheelchair next to her bed making an attempt to get out of the wheelchair. The resident had tipped the wheelchair over next to her bed when the staff found her. No interventions implemented. n. On 4/27/18 at 6:20 AM, Resident was found on the floor next to her bed. No interventions implemented. o. On 6/18/18 at 7:50 PM, Resident's bed alarm was triggered and she was found standing in front of the bed bent over forward with both hands on the bed. The resident fell to her left side and bumped into and slid down the edge of the head board. No interventions implemented. A Plan of Care dated 1/23/18 with an effective date of 1/23/18 documented a Problems/Strengths of Fall Potential R/T Spondylosis w/o (without) myolopathy or radiculopathy, Low back pain, Radiculopathy; lumbosacral region, [MEDICAL CONDITION]; unspecified. The goals developed were, Will remain free of injury AEB free of falls or accidents Q day TNR. Will remain free of restraint-related complications AEB mobility maintained, skin intact TNR. The interventions developed were, Monitor/anticipate/intervene for factors causing prior falls. Hi Low bed with bed alarm in place, resident uses call light when in need of assistance. Staff education-Safety measures; Injury potential avoidance; What to do if a fall occurs. Release restraint Q2 hrs and PRN (as needed) x10 minutes. Transfer with appropriate devices. (Note: There were no updated interventions after each of resident 7's falls.) On 8/1/18 at 2:19 PM, an interview was conducted with RN 5. RN 5 stated that interventions implemented for resident 7 to prevent falls were supervision, one on one, recliners, and a lap belt. RN 5 stated that resident 7 had a lap buddy but she was removing the lap buddy and having falls. RN 5 stated that the lap buddy was changed to a soft lap belt for safety. RN 5 was unsure of the other inventions implemented to keep resident 7 safe. 4. Resident 54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 54's medical record was reviewed on 8/2/18. A Admission MDS assessment dated [DATE], documented resident 54 with a BIMS score of 6. (Note: A resident with a severe impairment cognitively would have a BIMS score of 0 to 7.) The facility staff assessed resident 54 as requiring total dependence of two persons for bed mobility, transfers, and toilet use. A review of the Incident/Accident repots documented the following entries: a. On 4/27/18 at 3:00 PM, Resident was found sitting on the floor in front of the wheelchair. The resident had removed the lap buddy. No interventions implemented. b. On 5/5/18 at 2:20 PM, Resident was in the lobby and fell out of the wheelchair when she removed the lap buddy. No interventions implemented. c. On 6/8/18 at 9:10 PM, Resident was found on the floor in the hallway. No interventions implemented. d. On 6/10/18 at 4:15 PM, Resident was found on the floor in the south east dining room. Resident was kneeling at a dining room table and the lap buddy was on the floor next to her. Evaluate to reinstate lap belt. (Note: On 6/11/18, an order for [REDACTED].>A Plan of Care dated 4/5/18 with an effective date of 4/5/18 documented a Problems/Strengths of Fall Potential R/T Aftercare following joint replacement, Presence of left artificial hip, Fx (fracture) of left artificial hip, Fx of left neck of femur, Dementia with behavioral disturbances, [MEDICAL CONDITION] and disorder of bone density. The goals developed were, Will remain free of injury AEB free of falls or accidents Q day TNR. Will remain free of restraint-related complications AEB concracture (sic)-free, mobility maintained, skin intact TNR. The interventions developed were, Monitor/anticipate/intervene for factors causing prior falls. Answer calls quickly; anticipate needs. Staff education-Safety measures; Injury potential avoidance; What to do if a fall occurs. Release restraint Q2 hrs and PRN x10 minutes. Ambulate/transfer with appropriate devices. (Note: There were no updated interventions after each of resident 7's falls.) On 8/1/18 at 9:53 AM, an interview was conducted with RN 5. RN 5 stated that the MDS coordinator updates the resident care plans but all the staff have a part in updating the care plans. On 8/1/18 at 10:44 AM, an interview was conducted the MDS coordinator. The MDS coordinator stated that she will update the care plans with the goal dates and when the MDS assessments are due. The MDS coordinator stated that she does not up date the care plans with interventions. On 8/2/18 at approximately 11:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the staff have tried several interventions with the residents that have had falls. The DON stated that the staff have implemented soft lap belt restraints for residents that are unsteady on their feet and have poor decision making to prevent falls. The DON provided no additional information. 5. Resident 18 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/31/18, a review of resident 18's medical record was conducted. A review of resident 18's medical record revealed that he had falls on the following dates: a. On 9/30/17, Description of incident: Resident found on the floor in the lobby laying by the recliner. He stated he tried to get into the chair and fell . Resident stated he tried to get into the chair and fell . Resident stated he hit the back of his head on the chair. No injuries were noted. Will do neuro (neurological) checks. Denies any pain at this time Restraints: lap belt when in w/c. (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) b. On 11/26/17, Description of incident: pt (patient) was in his room when the bed alarm went off the aide (CNA) went to check on the pt and found him standing at the side of his bed, pt tried to walk when he fell his his head on the nightstand. Pt was placed in his wheelchair and brought to the lobby. (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) c. On 12/9/17, Description of Incident: (Resident 18) stood up from recliner in lobby. I ran over from nurses station to assist resident back into seat. Resident fell before I reached him. As he fell , his back slid against a chair. Resident was assisted back into recliner, vital signs obtained. He was then toileted et assessed. No changes in L[NAME] (level of consciousness), reddened area on R (right) side of back from hip up to mid scapula region. Resident c/o (complains of) pain in hip. (Resident 18) was given a warm blanket pain medication for his pain. Resident currently sitting in w/c watching television in lobby. (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) d. On 1/10/18, Description of Incident: (Resident 18) was in the lobby in a recliner, stood up to fall before anyone could get to him. He hit the recliner with his back before hitting the floor. C/o pain to R side of lower back. He did not hit his head and has no (changes) in mental state. (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) e. On 2/26/18, Description of Incident: F.O.F. (found on floor) room [ROOM NUMBER] wheel chair and lap belt next to him. Patient states he is ok, he has abrasion on left lateral palm of hand. We'll call family and for physician. (Note: The Outcome/Recommendations/Corrective Action(s) section was left blank. No interventions implemented.) f. On 4/13/18, Description of event: Resident in wheelchair on memory lane watching tv, resident undone his lap belt, stood up and fell to floor, nurse tried to get him before fall, unsuccessful. Resident landed on left side of body did not hit head, no injuries noted . Outcome/recommendations/corrective action(s) 4/14-sent to ER (emergency room ) for c/o pain-fx hip. Transported to (hospital name) for hip surgery. A review of Resident 18's care plan was conducted. Resident 18 had a care plan for falls which stated the following: Orignal (sic) Date 5/23/16, Effect. Date: Fall Potential R/T Weakness, Poor safety awareness. Goals: Will remain free of injury AEB free of falls of accidents Q Day TNR. Interventions: a. Monitor/anticipate/intervene for factors causing prior falls (Effect. Date 5/23/16) b. Answer calls quickly; anticipate needs. (Effect. Date 5/2/16) c. Ambulate/transfer with appropriate devices (Effect. date 5/23/16) d. Lap belt when in wheelchair. Check lap belt placement and release Q2 hrs x 10 minutes and PRN Q shift. Rev. #1 (Effect. date 5/23/16) (Note: the care plan was not updated after any of the previously mentioned falls.) On 8/1/18 at 2:30 PM, an interview was conducted with the DON. The DON stated that the care plan was updated at the interdisciplinary team (IDT) meetings. The DON stated that the nurses update the care plan with any changes to the resident's treatment not already on the care plan. On 8/2/18 at 11:26 AM, an interview was conducted with RN 4. RN 4 stated the care plan was updated by IDT at their meetings. RN 4 stated nurses communicate to representatives from all departments to inform them of any changes. RN 4 stated the IDT gathered data to update the care plan from nursing progress notes and logs. RN 4 stated that the care plan was not updated by the nursing staff. On 8/2/18 at 12:10 PM, an interview was conducted with RN 2. RN 2 stated that the nurses did not update the care plans. RN 2 stated she did not have access to the care plans on the computer. RN 2 stated the care plans were updated by the IDT reviewing nurses logs and assessments. On 8/2/18 at 12:19 PM, an interview was conducted with the DON. The DON stated that the care plan would be updated only if there was a new intervention implemented. The DON acknowledged that the care plan should have been updated for resident 18's multiple falls.

Based on interview and record review, it was determined for 2 of 35 sample residents, that the pharmacist did not report irregularities in the drug regimen review to the attending physician, the facility's Medical Director (MD), and Director of Nursing (DON), nor were the reports acted upon timely. Specifically, the attending physician, MD, and DON did not document in the resident's medical record that the identified irregularity had been reviewed and what action had been taken to address the irregularity. Resident identifiers: 7, 52, and 61. Findings include: 1. Resident 61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 61's medical record was reviewed on 7/31/18. A Consultation Report from the Pharmacist with a recommendation date of 5/17/18, documented to consider decreasing the dose of rivaroxaban to 15 milligrams (mg) once daily with the evening meal. The MD reviewed the report on 6/1/18, and marked I accept the recommendation(s) above, please implement as written. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. (Note: The medication recommendation was implemented 35 days after the recommendation from the Pharmacist.) 2. Resident 52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 52's medical record was reviewed on 8/1/18. A Consultation Report from the Pharmacist with a recommendation date of 4/27/18, documented the following entries: a. Resident 52 has an order for [REDACTED]. b. Resident 52 has received [MEDICATION NAME] 100 mg daily for management of depressive symptoms since 3/16/17. The recommendation from the Pharmacist was to consider a gradual dose reduction and if the therapy was to continue at the current dose, provide rationale describing a dose reduction as clinically contraindicated. No documentation was located in resident 52's medical record indicating that the attending physician, facility's MD, and DON agreed or disagreed with the pharmacist recommendations. A review of the (MONTH) (YEAR) MAR indicated [REDACTED]. (Note: The medication recommendation was implemented 40 days after the recommendation from the Pharmacist.) 3. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7's medical record was reviewed on 8/1/18. A Consultation Report from the Pharmacist with a recommendation date of 6/22/18, documented that resident 7 has an order to crush medications and has orders for medications that are not recommended to be crushed per manufacturer's guidance, omeperazole 20 mg daily. The recommendation from the Pharmacist was to consider a trial discontinuation of this medication or switch medication to [MEDICATION NAME] 20 mg twice daily. No documentation was located in resident 7's medical record indicating that the attending physician, facility's MD, and DON agreed or disagreed with the pharmacist recommendations. On 8/2/18 at 11:30 AM, an interview was conducted with the DON. The DON stated that she would expect the Pharmacist drug regimen review to be acted upon within 15 days of the recommendations. The DON stated that the MD was out of town and that was why the recommendations were not reviewed timely. The DON stated that she would fax the reports to the MD's office and she would just expect that the MD had received them and would return them to the facility when completed. The DON further stated that she did not follow up with the MD.

Based on interview and record review, it was determined for 3 of 35 sampled residents, that the facility did not notify a representative of the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the move in writing. Specifically, when residents were discharged to the hospital, the Ombudsman were not notified. Resident identifiers: 1, 18, and 60. Findings include: 1. Resident 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/31/18, a review of resident 18's medical record was conducted. The medical record revealed resident 18 was discharged to the hospital for a left [MEDICAL CONDITION] on 4/14/18. Resident 18 was readmitted to the facility on [DATE]. 2. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/1/18, a review of resident 1's medical record was conducted. The medical record revealed that resident 1 requested to be sent to the hospital for an assessment on 7/23/18. Resident 1 was discharged and did not return to the facility. 3. Resident 60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/31/18, a review of resident 60's medical record was conducted. The medical record revealed that resident 60 went to the emergency roiagnom on [DATE]. Resident 60 returned to the facility that day. On 8/1/18 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the Ombudsman was only contacted if help was needed on a discharge. The DON stated that she did not know the Ombudsman needed to be informed when a resident went to the hospital. On 8/2/18 at 11:20 AM, an interview was conducted with Resident Advocate (RA). When asked about notifying the Ombudsman when the above mentioned residents went to the hospital, the RA stated that she had no idea we had to do that.

Based on observation, interview, and record review, it was determined for 1 of 35 sample residents, that the facility did not accurately assess residents. Specifically, the residents Minimum Data Set (MDS) assessment did not reflect that he had a trunk restraint. Resident identifier: 52. Findings include: Resident 52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/30/18 at approximately 11:57 AM, an observation was made of resident 52 with a soft lap belt restraint applied to his lap, criss crossed behind the wheel chair, and tied to the bars behind the wheelchair. Resident 52's medical record was reviewed on 8/1/18. A physician's orders [REDACTED]. Release Q (every) 2 (hours) x (times) 10 mintues (sic) for personal hygiene, repositioning, to maintain independent mobility with poor cognition and safety Q shift. A review of the Quarterly MDS assessment dated [DATE], documented that resident 52 used a bed alarm daily. On 8/2/18 at 10:30 AM, an interview was conducted with the MDS coordinator. The MDS coordinator stated that the restraint should have been coded on the most recent quarterly MDS assessment and it was missed.

Based on observations, interviews, and record review, it was determined that the facility did not ensure the necessary cares and services were provided to prevent the development of pressure sores for 2 of 17 sampled residents. Resident Identifiers 6 and 13. Findings include: 1. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations were made of resident 6 from 4/19/10 through 4/22/10. The following observations were made: a) On 4/20/10, from 1:00 PM through 4:20 PM, resident 6 was observed to be seated in a recliner, in the Special Needs Unit (SNU) lobby. The observation of resident 6 was continuous during this period of time. At no time during the observation was resident 6 approached by any staff member to be repositioned or assisted to the bathroom. During the observation, resident 6 did not reposition herself. At 4:20 PM, resident 6 was assisted from the recliner to the dining room. b) On 4/21/10 from 1:30 PM until 4:20 PM, resident 6 was observed to be seated in a recliner in the SNU lobby. The observation of resident 6 was continuous during this period of time. At no time during the observation was resident 6 approached by any staff member to be repositioned or assisted to the bathroom. During this observation, resident 6 did not reposition herself. At 4:20 PM, resident 6 was assisted from the recliner to the dining room. On 4/21/10 at 4:45 PM, the surveyor requested staff assist resident 6 back to her room so that an observation of the resident's skin condition could be made. The observation of resident 6's skin condition was made in the presence of Registered Nurse (RN)1. Once placed in bed, staff removed an incontinence brief from the resident. The incontinence brief was noted to be saturated in addition to being soiled with fecal matter. Resident 6 was observed to have a one centimeter, stage II pressure sore on her right inner gluteal area. Resident 6's coccyx area was noted to be extremely red but blanchable. RN 1 commented that the pressure sore was "very superficial" and that the facility staff would have to "start up treatment again. We only do bag balm. We can't use the [MEDICATION NAME] because it tears up her skin." On 4/19/10, resident 6's medical record was reviewed. Resident 6's "Pressure Ulcer (sore) Reports", dated March 2009 through December 2009, documented that resident 6 had experienced several open areas on her gluteal area that were subsequently healed. Nursing notes for resident 6 documented the following on 12/17/09: "CNA noted pressure ulcer on L (left) buttocks, covered (with) [MEDICATION NAME] et (and) noted in tx (treatment) book for monitoring until healed." No other nursing notes regarding resident 6's pressure sore were located. Resident 6's "Pressure Ulcer Reports", dated December 2009 through April 2010, documented that resident 6 had two stage II pressure sore on her gluteal area. A third stage II pressure sore was noted to be on resident 6's gluteal area on 1/12/10. Facility staff did not document the status of the third pressure sore after 1/27/10. Facility staff documented that the first two pressure sores were healed as of 4/3/10. No nurses notes or treatment records were located that documented the presence of the pressure sore observed, by the surveyor and RN 1, on 4/21/10. Resident 6's physician progress notes [REDACTED]. A "Nutritional Risk Review" was completed for resident 6 on 11/30/09 by the facility Dietary Manager (DM). The DM stated that resident 6's skin was intact and that there were no new recommendations at that time. The facility Registered Dietitian (RD) co-signed the review on 12/21/09, indicating that she agreed with the accuracy of the DM's note. On 4/22/10 at 11:00 AM an interview was held with the facility RD. The RD stated that she visited the facility every month and would co-sign any notes that the DM had made. The RD stated that the DM normally gave her a report of any new skin or weight issues. The RD further stated that when she co-signed the DM's note on 12/21/09 she "did not get any notification" that resident 6 had a pressure sore. The RD also stated that if a pressure sore "lingers on" in a resident, she would recommend a supplement of Vitamin C and Zinc to assist in wound healing. A document entitled "Braden Scale for Predicting Pressure Sore Risk" for resident 6 was located. On 2/26/09, 5/26/09, 8/26/09, 11/25/09 and 2/28/10 facility staff documented that resident 6 was at a lower risk for pressure sores. Resident 6's Resident Assessment Protocol, dated 8/26/09, documented that "due to weakness, (resident 6) is not able to indepdendently (sic) reposition herself in bed. Staff members provide repositioning assistance at least every two hours and PRN (as needed)." A "Skin Care Plan" for resident 6 was reviewed. The care plan, dated 3/16/09, documented that resident 6 had a stage II pressure ulcer in her left gluteal crease. The interventions listed included ". . .monitor (wound) daily . . . .reposition every two hours. . . .minimize exposure to moisture, keep skin clean. . . " The skin care plan had not been updated or revised since 3/16/09. Resident 6's "Plan of Care", dated February 2010, was reviewed. The care plan for pressure sore risk documented the following interventions: follow approaches for dehydration and nutrition care plan, turn and reposition every two hours, and assess/record/report skin status to nurse and physician. Resident 6's "Plan of Care" regarding pressure sore risk, dated February 2009, May 2009, August 2009, and November 2009 were also reviewed. No differences in the care plan regarding resident 6's pressure sore risk were noted. On 4/22/10 at 7:30 AM, an interview was held with Certified Nurse Aide (CNA) 1 regarding resident 6. CNA 1 stated that "every resident gets toileted every two hours." CNA 1 further stated that she assisted resident 6 by repositioning or toileting her every two hours, and putting ointment on her buttocks after resident 6 used the bathroom. CNA 1 stated that all incontinent residents were assisted to the bathroom before and after each meal and as needed. When asked about resident 6's mobility, CNA 1 stated "we have to reposition her in bed. She can't reposition herself" but that resident 6 could move "a bit" if she was in a chair. CNA 1 stated that she was aware that resident 6 had a history of [REDACTED]. On 4/22/10 at 8:00 AM, an interview was held with Licensed Practical Nurse (LPN) 2 regarding resident 6. LPN 2 stated that resident 6 should be repositioned and assisted to the bathroom every two hours due to her history of pressure ulcers. On 4/22/10 at 8:15 AM, an interview was held with CNA 4 regarding resident 6. CNA 4 stated that resident 6 was unable to move if she was on her side in bed, but that if she was on her back, she could move to her side. CNA 4 further stated that resident 6 could not reposition herself in the chair. CNA 4 also stated that all residents should be repositioned and assisted to the bathroom before and after all meals. On 4/22/10 at 8:30 AM, an interview was held with the facility DM. The DM stated that if a resident had a healed pressure sore, the resident was kept on a protein supplement to "help prevent" further pressure sores. The DM also stated that if a resident developed a pressure sore, the facility staff "don't wait for the RD to do an intervention. I'm sure the charge nurse would have started some interventions as soon as possible. We have a good system." On 4/22/10 at 9:15 AM, an interview was held with the facility Administrator and the Director of Nursing (DON). The DON stated that resident 6's sore was "more of a moisture area" and was not a sore caused by pressure. The DON also stated that if a resident had a pressure sore, the resident's skin care plan should be changed. When asked about assisting incontinent residents the DON stated that it was the facility's "standard of practice to toilet (the residents) before they eat." 2. Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/22/10 resident 13's medical record was reviewed. It was documented on the Resident Admission Data Collection form, dated 10/02/09, that the only skin issue resident 13 had, at admission, was some excoriation to her inner thighs. On 10/02/09, it was documented on the Braden Scale for Predicting Pressure Sore Risk that resident 13 was at risk for developing pressure sores. Per documentation on the risk assessment, this meant that facility staff should provide frequent turning, maximal remobilization, protect heels, manage moisture, nutrition, friction, and shear, and implement pressure reduction support surface if bed or chair bound. On 10/15/09, it was documented on the Resident Assessment Protocol that resident 13 triggered for Pressure Ulcers. "Due to weakness, she is unable to reposition herself independently in bed or the wheelchair. Staff members provide repositioning assistance every two hours and PRN (as needed)." On 10/15/09, it was documented on the Plan of Care that resident 13 was at risk for pressure ulcer due to a bed mobility problem. The goal for this problem was for resident 13's skin to remain intact until next review. The documented interventions for this problem were for staff to: "Follow approaches for POC (plan of care) #062, 022." ?, Turn and reposition Q2 (every two) hrs (hours) and PRN (as needed), Assess/record/report to RN/MD (Registered Nurse/Medical Doctor) PRN: Skin status." On 11/2/09, it was documented on a Skin Care Plan that resident 13 had a pressure ulcer blister caused by pressure - friction, with white wound edges. Documented interventions were: " Monitor daily by LN (Licensed Nurse), Dressing change Q (every) d (day), Repositioning Q 2 hours, and Pressure off boot." The documented treatment was dry dressing and pressure off boots. No documentation could be found in the chart that the physician was notified to the pressure ulcer/blister resident 13 had developed. The first documentation in the Nursing Staff Notes regarding the pressure ulcer resident 13 developed was on 11/17/09. It was documented on these notes to monitor the blood blister on resident 13's left heel. No documentation could be found in resident 13's medical record to indicate staff were monitoring the blood blister on resident 13's left heel. No documentation could be found in resident 13's medical record to indicate staff had instituted a pressure off boot for protection and healing. On 11/13/09, resident 13 was seen by the physician. The physician documented, resident 13, "seems to have a significant pressure sore on her left heel and staff is doing significant intervention to keep pressure off of it with frequent monitoring.....There is a significant purple brownish - black eschar noticed on the patient's left heel...." No documentation could be found in the physician progress notes [REDACTED]. On 12/18/09, it was documented in the physician progress notes [REDACTED]." On 3/10/10, it was documented on Physician Telephone Orders for resident 13 to have, "Podus Boots bilateral on AM/PM (on in the morning and night) Pressure off heels." This intervention was instituted 128 days after it was documented to begin on the Skin Care Plan. On 4/22/10 at 8:45 AM, resident 13's left heel was observed. The outer aspect of the left heel contained 5cm by 5cm reddened circle with a 1 cm white area in the middle of the red area. The reddened circle and white area were very painful to the resident. No observations were made at this time of resident 13 having the Podus boots in place. On 4/22/10 at 8:45 AM, RN 1 stated she would get some [MEDICATION NAME] to put on the area of the heel to "soften it up." Review of Dietary Progress Notes reveal an entry dated 10/06/09 made by the facility Dietary Manager. The Dietary Manager recommended that resident 13 be placed on a protein supplement for her decreased [MEDICATION NAME] of 2.8. Normal [MEDICATION NAME] is 3.5. On 11/23/09, the RD recommended that resident continue on the protein supplement for the decreased [MEDICATION NAME] and also for healing of the stage II pressure ulcer resident 13 had acquired. The RD documented healing the pressure ulcer was the priority and the facility would continue weight loss efforts after the pressure ulcer had healed. On 12/21/09, the RD documented that resident 13 had desirable weight loss while her pressure sore was healing. She recommended that resident 13's [MEDICATION NAME] be rechecked to see if the protein supplement intervention was making a difference. No documentation could be found in resident 13's medical record to indicate that the facility followed up on the RD's recommendation in December 2009 to get another [MEDICATION NAME] level for resident 13. Review of resident 13's laboratory values revealed the facility did not get another [MEDICATION NAME] level for resident 13 until 4/13/10, which was 112 days after the recommendation was made by the RD. No other entries could be found in resident 13's medical record, in the Dietary Progress Notes, after 12/21/09 about the pressure ulcer or the RD's continued efforts to assist in the healing of the pressure ulcer. No other documentation could be found in the Dietary Progress notes to show that resident 13 was reassessed after the development of the pressure ulcer or that new interventions were instituted to assist in the healing process of the pressure ulcer. During a five month period, it was documented in the Dietary Progress notes that resident 13 also had a 29 pound weight loss. Refer to F325.

Based on interview and medical record review, it was determined that for 1 of 17 sampled residents the facility did not ensure that the resident maintained acceptable parameters of nutritional status such as body weight and protein levels. Resident identifier: 13. Findings include: Resident 13 was an [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/22/10 resident 13's medical record was reviewed. Resident 13's "Plan of Care" dated 10/15/09, documented that resident 13 was at nutritional risk as evidenced by therapeutic diet and leaving 25% or more of food uneaten at most meals. Nutrition goals listed for resident 13 included the following: No significant weight change (greater than a 10% weight change in 6 months), and resident 13 would have a normal [MEDICATION NAME] level by the next care plan review. Interventions for resident 13 included the following: monitor the amount of food resident 13 was eating, include resident 13 in the nutrition at risk meeting, monitor labs as available, weight as scheduled, and encourage intakes greater than 75%. No updates to the care plan were made after 10/15/09. Resident 13's "Nutritional Status Care Plan," that was not dated, documented that resident 13 was at nutritional risk as evidenced by her [DIAGNOSES REDACTED]. Nutrition interventions listed for resident 13 included the following: multivitamin with minerals, and monitor labs. A document was provided to surveyors by facility staff entitled "Guidelines for Nutrition Needs & Interventions for Healing Pressure Ulcers and Wounds." The document indicated that appropriate interventions for a stage II pressure ulcer included the following: provide 1.2 grams of protein per kilogram of body weight, and provide a multivitamin with minerals with a 75% or less food intake. Resident 13's April 2010 physician recertification orders were reviewed. Per documentation resident 13 was not receiving a multivitamin. Review of Dietary Progress Notes revealed an entry, dated 10/06/09, made by the facility Dietary Manager (DM). The DM recommended that resident 13 be placed on a protein supplement for her decreased [MEDICATION NAME] of 2.8 grams per deciliter (gm/dL). (Note: Normal [MEDICATION NAME] is 3.5 gm/dL.) On 11/13/09, resident 13 was seen by the physician. The physician documented resident 13 "seems to have a significant pressure sore on her left heel and staff is doing significant intervention to keep pressure off of it with frequent monitoring.....There is a significant purple brownish - black eschar noticed on the patient's left heel...." Per Dietary Progress Notes written on 11/23/09, the facility Registered Dietitian (RD) documented that resident 13 was overweight and that resident 13 had acquired a pressure ulcer "which requires additional protein for healing." The RD documented that weight loss in resident 13 was desireable (sic) , but that healing the pressure ulcer was "priority" at that time. The RD also documented that protein needs would be met if resident 13's food intake was adequate. The RD did not document what resident 13's average food intake was. The RD calculated resident 13's protein needs based on 1 gram of protein for every kilogram of the resident's body weight. The RD documented that resident 13 had not experienced a significant weight change at this time. Per documentation, however, resident 13 weighed 225.6 pounds on 11/23/09, which was a 12.4 pound (5.3%) weight loss since admission, approximately 59 days prior. On 12/16/09 the DM documented in resident 13's Dietary Progress notes that resident 13 was eating 90% of meals. The DM acknowledged that resident 13 had experienced a weight loss, and that she had a pressure ulcer, but documented "no new recs (recommendations) at this time." On 12/21/09, the RD documented that resident 13 had "desirable weight loss" while her pressure sore was healing. She recommended that resident 13's [MEDICATION NAME] be rechecked to see if the protein supplement was "making a difference." The RD calculated resident 13's protein needs based on 1 gram of protein for every kilogram of the resident's body weight. The RD also documented that resident 13 had not experienced a significant weight change at this time. Per documentation, however, resident 13 weighed 220.8 pounds on 12/21/09, which was a 17.2 pound (7.3%) weight loss since admission, approximately 79 days prior. No other entries were made by the RD after 12/21/09 regarding resident 13's pressure ulcer or the RD's continued efforts to assist in the healing of the pressure ulcer. On 1/15/10 the DM documented in resident 13's Dietary Progress notes that resident 13 weighed 216 pounds, which was a 22 pound (9.3%) weight loss since admission, approximately 105 days prior. The DM documented that resident 13 was eating 60 to 70% of her meals. The DM acknowledged that resident 13 had a decreased [MEDICATION NAME], but did not recommend adding an additional protein supplement to resident 13's diet "due to wt." The DM did not make any new recommendations for resident 13. On 1/20/10, per resident 13's Dietary Progress notes, the RD recommended the continued use of a protein supplement. The RD documented that the facility had not rechecked resident 13's [MEDICATION NAME] level. The RD calculated resident 13's protein needs based on 1 gram of protein for every kilogram of the resident's body weight. No new recommendations were made. On 2/26/10, per resident 13's Dietary Progress notes, the RD stated that resident 13 was "slowly losing wt which is desireable (sic) if she can maintain good nutrition." Per documentation, however, resident 13 weighed 212 pounds on 2/26/10 which was a 26 pound (11%) weight loss since admission, approximately 147 days prior. The RD also stated "we will reassess dietary needs as labs are available. . . receiving (protein supplement) for protein repletion. . . more supplements may be needed." No other entries were made by the RD after 2/26/10 regarding resident 13. On 3/19/10, per resident 13's Dietary Progress notes, the DM stated that resident 13 had experienced a significant weight change in the last six months. The DM documented resident 13's "skin intaked (sic)" and that there were "no new labs" and no new dietary recommendations. The DM calculated resident 13's protein needs based on 1 gram of protein for every kilogram of the resident's body weight. Per documentation resident 13 weighed 209 pounds on 3/19/10 which was a 29 pound (12.2%) weight loss since admission, approximately 168 days prior. On 4/14/10, per resident 13's Dietary Progress notes, the DM stated that there were no new labs available for resident 13, but that her [MEDICATION NAME] had been low in the past. The DM also stated that no supplements were recommended because resident 13 was above her ideal body weight. The DM also stated "will re-evaluate with next lab." Review of resident 13's laboratory values revealed the facility did not get another [MEDICATION NAME] level for resident 13 until 4/13/10, which was 112 days after the recommendation was made by the RD. The lab values on 4/13/10 documented that the resident's [MEDICATION NAME] level was 3.0 gm/dL. On 4/28/10 a telephone interview was held with the facility Dietary Manager (DM). When asked about resident 13, the DM stated that she had provided extra eggs and meat to increase resident 13's protein stores. The DM further stated that all interventions, including the extra eggs and meat, were documented on the resident's care plan. When asked about other dietary interventions, the DM stated that a diabetic protein supplement was available, but that they had not given it to resident 13. The DM also stated that resident 13's physician "doesn't give recommendations for a low [MEDICATION NAME] if the resident is overweight" and that the physician was "more concerned about her weight than her pressure sore." The DM further stated that "with situations like (resident 13's) we watch the labs closely." When asked about resident 13's labs, the DM stated that resident 13's protein levels "were going up, so we didn't do anything." When asked how the DM knew resident 13's protein levels had gone up if the [MEDICATION NAME] had not been checked since admission, the DM stated that she did not know.

Based on interviews, medical record review, and facility policy review, it was determined that for 2 of 17 sampled residents the facility did not provide the necessary care and services to attain or maintain the highest practicable physical and mental well-being. Specifically, residents were not assessed for a change in condition in a timely manner. Resident identifiers: 1 and 4. Findings include: 1. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/20/10 resident 4's medical record was reviewed. Between 1/12/10 and 1/25/10, facility staff documented resident 4's condition as follows: a) 1/12/10 - A facility nurse documented a Nursing Staff Note that resident 4 was alert and oriented to person, place and time. b) 1/15/10 at 3:00 AM - A facility nurse documented a Nursing Staff Note that resident 4 requested assistance transferring from bed to the recliner. c) 1/15/10 - A facility nurse documented a Nursing Staff Note that resident 4 was seen by facility physician. d) 1/15/10 - Resident 4's physician documented on the admission history and physical that resident 4 was transferred to the facility in a severely weakened condition with a plan for rehabilitation. The physician further documented that resident 4's white blood cell count was 9.6 on 1/11/10 and that repeat laboratory work should be done on 1/18/10. (Note: Normal range for white blood cells (WBC) is 4.8 - 10.8). e) 1/17/10 at 7:00 AM - a facility nurse documented a Nursing Staff Note that resident 4 was weak but transferred well with standby assist and that resident 4 was complaining of tenderness all over. f) 1/18/10 - Laboratory report, complete metabolic panel. Resident 4's potassium (K+) was "HIGH" at 5.4. Per documentation on the laboratory report, the reference range for K+ was 3.3 to 5.1. Included on the laboratory report was a handwritten note, "Faxed to Dr. (name of physician) 1/18/10 (signature) 1415 (2:15 PM)". g) 1/18/10 - Laboratory report, complete blood count. Resident 4's WBC count was "HIGH" at 13.7, her [DIAGNOSES REDACTED]s were "HIGH" at 76.4, and her Basophils were "HIGH" at 1.6. Per documentation on the laboratory report, the reference ranges for WBC, [DIAGNOSES REDACTED]s and Basophils were 4.8 to 10.8, 43.0 to 65.0 and 0.2 to 1.0, respectively. Included on the laboratory report was a handwritten note, "Faxed to Dr. (name of physician) 1/18/10 (signature) 1415 (2:15 PM)". h) 1/18/10 - A facility nurse documented a Nurse Progress Note that resident 4's laboratory values for the complete metabolic profile and complete blood count. According to Laboratory and Diagnostic Tests with Nursing Implications Seventh Edition, Joyce LeFever Kee, 2005 pgs. 349, 350 & 457, an increased K+ level can indicate acute [MEDICAL CONDITION]. Increased potassium levels greater that 5.3 should be reported because high serum potassium levels can cause [MEDICAL CONDITION]. Furthermore, an increase in WBC and [DIAGNOSES REDACTED]s indicate an acute infection. i) 1/19/10 - A facility nurse documented that resident 4's laboratory results were faxed to the resident's physician's office. j) 1/21/10 at 2:15 PM - A facility nurse documented a Nursing Staff Note that resident 4, "... is complaining of 'back pain'. Assessed et (and) no evident reason for pain. Discussed possibility of slept wrong. She requests Tylenol et Hall nurse will give it. We will monitor. She was working with therapy et they also reported her complaint of pain. No other complaints or requests at this time. She does report 'No appetite' but eats multiple popsicles et Graham crackers a day." k) 1/23/10 at 8:15 AM - A facility nurse documented a Nursing Staff Note that resident 4 was disoriented to place and time and had an irregular cardiac heart rate. l) 1/24/10 at 12:45 PM - A facility nurse documented a Nursing Staff Note that resident 4 was disoriented at times, was non-cooperative, had an irregular cardiac heart rate and had been found on floor by facility staff. "Husband was with her, he had tried to help her move from recliner to w/c (wheelchair), when she could not stand he lowered her to the floor. Assessed for injury, none found @ (at) this time..." m) 1/25/10 at 10:20 AM - A facility nurse documented a Nurse Progress Note that resident 4 was, "...laying in bed, very weak. Recognizes me but speech is very soft - delerium (sic) present. Pt. (patient) states she is tired. ..... Pt. has lost 13 lbs. in 12 days. Call placed to Dr....." n) 1/25/10 at 11:00 AM - A facility nurse documented a Nurse Progress Notes, "Dr..... requests pt. go to ... (local hospital) today for evaluation - possible admission." o) 1/25/10 at 3:00 PM - A facility nurse documented a Nurse Progress Note, "Patients husband here - states patient very sick - will be life flighted to ... (Acute Care Hospital) today. Son in law states patient has UTI (urinary tract infection), elevated [MEDICATION NAME] labs, high potassium....." A review of the acute care hospital records for resident 4 was completed. On 1/25/10, resident 4's Admission History and Physical (HP) included documentation that the resident had been complaining of increased lethargy and sleepiness for two days. It was also documented that EMS (Emergency Medical Services) reported a decrease in appetite and increase in weakness over the last 2 days at the nursing home, and malaise and nausea were also present without vomiting. The Admission HP also included documentation that resident 4 had: 1. " Urosepsis: The patient's urine is frankly purulent...... 2. [MEDICAL CONDITION]: Secondary due to altered mental status. We will continue mechanical ventilation.... 3. [MEDICAL CONDITION]: This is likely due to the patient'[MEDICAL CONDITION]. 4. Pancreatitis: This is likely due to ischemia from shock,.... 5. Acute kidney injury: This is likely pre-renal with possible ATN ? picture.... 6. [MEDICAL CONDITION]: (Elevated Potassium) This is likely due to patient's acute kidney injury......." On 4/21/10, the Director of Nursing provided survey staff copies of the facility's Change in Condition protocol. This protocol included the following statement; "An acute confusional state presumably reflects a disturbance in cerebral metabolism. . . ." The protocol listed Common Causes of Acute Confusion, which may be intermittent. The list of common causes included: clouding of consciousness; reduced wakefulness; disorientation of time and space; and variability of symptoms over time. According to the facility's protocol for a change in condition, the following actions must be taken: "1. Obtain a current set of vital signs, blood sugar, and oxygen saturation; 2. Notify the physician and family; 3. Notify the Director of Nursing; 4. Obtain tests as directed by physician order: CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), Urinalysis, Chest X-ray; 5. Begin treatments per orders." On 4/21/10 at 9:10 AM, Charge Nurse 2, a Registered Nurse, was interviewed regarding abnormal labs and change of condition in residents. Charge Nurse 2 stated that if laboratory results were abnormal, facility staff were to call the physician and depending on how "bad" the labs were, staff would possibly have left a message with office staff or may have insisted on talking with the physician. She further stated that a resident's behavior and activity level were good indicators of a change in condition. She stated that staff should watch for changes in resident's behavior and activity and then assess for abnormalities and monitor to figure out what is going on. On 4/21/10 the Director of Nursing was interviewed regarding labs. The Director of Nursing stated that if resident laboratory values were out of range, facility policy directed staff to call the physician. Between 1/18/10 and 1/25/10, per documentation, resident 4 was found to have abnormal laboratory values and changes in condition that included decreased alertness; increased confusion; decreased mobility; and changes in behavior. However, facility staff did not notify resident 4's attending physician of the resident's changes in condition until 1/25/10, at which time the resident was tranferred to an acute care hospital. Cross refer to F-157, example 1. 2. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/20/10 resident 1's medical record was reviewed. Review of Nurse Progress Notes revealed an entry dated 1/19/10 at 9:00 PM, "urine sample obtained. Res. (resident) pos (positive) for leukocytes, neg (negative) for [MEDICATION NAME]. Res. stated, 'My back hurts et it hurts to urinate.' " No documentation could be found in resident 1's medical record to indicate resident 1's physician had been notified of the urine sample dipstick results or if resident 1 was treated for [REDACTED]. On 4/20/10 at 10:00 AM, Charge Nurse 1, a Registered Nurse, was asked if resident 1's physician had been notified of the results of the urine sample. Charge Nurse 1 stated that there were no notes to indicate if the doctor had been called or how staff followed through when abnormal results were identified. On 4/21/10 at 9:10 AM, Charge Nurse 2 was interviewed regarding indicators staff would follow to determine when to use a dipstick to test a resident's urine. Charge Nurse 2 stated that indicators included changes in behavior, complaints of urgency for urination, frequency of urination, burning with urination as well as general complaints of not feeling well. She further stated that if the dipstick result was positive for leukocytes and negative for [MEDICATION NAME] staff were to call the doctor for consideration of treatment. On 1/19/10, when resident 1 was found to have an abnormal urinary dipstick result, as well as complaints of pain with urination, facility staff did not notify the resident's attending physician. Cross refer to F-157, example 2.