Every finding on record at Village Health & Rehabilitation

Based on interview and record review, the facility failed to submit investigation findings for an incident in a timely manner, to the State Survey Agency, for 2 (#s 5 and 6) of 9 sampled residents. Findings include: A review of a facility-reported incident, submitted to the State Survey Agency on 9/4/25, involving a resident-to-resident interaction for residents #'s 5 and 6, showed the facility's investigation findings were submitted on 9/12/25 and were due by 9/11/25.During an interview on 11/19/25 at 10:30 a.m., staff member B stated a resident-to-resident incident was to be reported to the State Survey Agency with 24 hours, and the facility investigation findings were to be submitted within five days, not including weekends and holidays.A review of a facility policy, titled Incidents and Accidents, with a last reviewed date of 10/27/25, showed:Policy:It is the policy of this facility for staff to utilize the facility on-line risk management system to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident.Policy Explanation: .Meeting regulatory requirements for analysis and reporting of incidents and accidents. [sic]

Based on interview and record review, the facility failed to ensure a resident was free from accidents for a resident who sustained a fall with pain resulting in a fracture, who was on a blood thinner; and failed to promptly notify the physician of a fall with pain resulting in a fracture impacting the physician's opportunity to determine if a higher level of care or treatment was necessary at the time of the fall for 1 (#85) of 34 sampled residents. This deficient practice contributed to delayed care, increased pain and a femur fracture.During an interview on 8/26/25 at 9:36 a.m., resident #85 explained that she was admitted to the facility in July after she developed complications from a right hip replacement. Resident #85 stated she had a fall when her leg got caught during a transfer, and she fell because the nurse went to get help and left her standing at the edge of the bed with nothing to hold on to. Resident #85 said the nurse who was on told a bunch of CNAs to say I wouldn't allow them help me. Resident #85 stated, There was nobody in the room and that's the truth. During an interview on 8/27/25 at 9:48 a.m., Staff member O stated he was in resident #85's room on the day of the fall to assist resident #85 with a dressing change. Staff member O stated resident #85 transferred with a walker and a one-person assist and was 50% weight bearing on the right leg. Staff member O said resident #85 liked to push the wheelchair to transfer. Staff member O stated resident #85 was choosing to use the wheelchair to transfer, and he asked the resident to please be extra careful. Staff member O stated the resident fell when moving from the bed to the recliner. Staff member O stated that resident #19 fell with him trying to slow her, stating, I had some influence. Staff member O stated the resident was reporting pain in her right knee at the time of the fall. Staff member O stated he did not notify the physician on call after the resident fell, and her care was delayed by a couple of hours. Staff member O reported the resident did not want to go to the emergency room. Staff member O stated he didn't realize there were other required reports to complete at the time of the fall, such as the incident and risk management charting. Staff member O stated he felt like he did not know how to do a lot of things at the facility and said, I had to fight tooth and nail to get any orientation here. I still don't feel fully enabled on how to do my job. Review of resident #85's EHR showed a clinical note, dated 8/9/25 at 5:12 p.m., Note Text: While ambulating from the bed to the recliner with a wheel chair she lost her balance and I gently helped her to the ground to sit on her butt. Her right lower leg bent at the knee and was under her L leg. It caused her pain so I helped her straighten it. Then with the help of a CNA we got her to standing and had her sit in the recliner. A while later she stated being unable to put weight on it. The pain is in her popliteal fossa. I asked her if she wanted me to send her to the ED. She does not want to go. Treated with Robaxin, oxycodone and ice after the incident. The plan to continue the same pain management for the night and if it's not better by morning send her to the ED. During an interview on 8/27/25 at 10:30 a.m., NF5 stated she was the nurse attending to resident #85 upon admission to the emergency room, on the day after resident #85's fall. NF5 stated she had concerns because the EMT who gave her a summary stated there was a different story from what the resident reported and what the facility staff reported. NF5 stated resident #85 had fallen earlier in the day and presented with her right leg internally rotated and significantly shorter than the left leg, which were indications of a broken extremity. NF5 asked resident #85 why her care was delayed and asked the resident if her leg always looked like that. NF5 stated the resident reported the nurse at the facility had advised the resident to wait to see if it was worse in the morning before transferring to the emergency department. This statement contradicts the statement from staff member O who said she did not want to go to the ER. During an interview on 8/27/25 at 3:29 p.m., resident #85 stated staff member O stated he was going to put ice on her right leg, wait until the morning, and if it (leg) was swelled up she would be sent to the ER. Resident #85 stated she did not decline transfer to the ER at the time of the event. Resident #85 stated she went by what staff member O advised, to wait until the morning, and his comment about We'll see in the morning.During an interview on 8/28/25 at 9:45 a.m., staff member A questioned this surveyor about a document that was provided by the facility, which showed the provider was notified about the fall at the time of the event. This surveyor clarified for staff member A that staff member O stated he did not notify the physician on call after resident #85 fell. Therefore, the document provided was not accurate for the physician notification. Review of resident #85's Comprehensive MDS assessment, with an ARD of 7/14/25, showed resident #85 had a BIMS score of 14, cognitively intact.Review of resident #85's EHR, showed a progress note, dated 8/9/25 at 3:07 p.m., which included, Note Text: Reason for note: Initial note (immediately after the fall), I was with her as she was using the back of her wheel chair moving from the bed to her recliner. She started to slowly tip over to her right and I helped her gently arrive on the floor. Her right leg was slightly crossed under her L leg. With the help of a CNA we got her back in the wheelchair then into the recliner. She indicates pain in the posterior medial side of her R knee. Medicated with oxy and Robaxin and placed an ice pack. No visible damage to that area noted. Resident was found sitting with legs crossed near the bed. Fall was witnessed. Was wearing non-skid shoes/socks. No changes in mental status noted. Resident reporting pain R knee Hurts Even More. Injury was noted at the time of the fall. Pain in R knee as described above. [sic] The note contradicts the residents statement about no one being in the room at the time of the resident's fall. Review of resident #85's August 2025 Medication Administration Record showed the following: Methocarbamol Oral Tablet 500 MG (Methocarbamol) Give 1 tablet by mouth as needed for muscle spasms four times daily, Start Date 7/14/2025 1215 (12:15 p.m.), was given on 8/9/25 at 1500, and it was ineffective. oxyCODONE HCI Oral Tablet 5 mg (Oxycodone HCI) Give 1 tablet by mouth every 4 hours as needed for pain 1 to 2 tablets every 4 hours .Start Date, 8/4/25 1130 (11:30 a.m.),. Resident #85 was given 2 tablets at 10:30 a.m., the pain level was a 6, and the medication was effective. The resident was given 2 tablets at 3:01 p.m., and the resident's pain level was 7, but the medication was ineffective. The resident was given 2 tablets at 7:01 p.m., and her pain was a 10. The medication was ineffective. This showed the resident's pain was not managed after the fall with the pain medication, but it was prior to the fall. Warfarin Sodium Oral Tablet 3 MG (Warfarin Sodium) Give 0.5 tablet by mouth one time a day every Mon, Wed, Thu, Fri, Sun for treating/preventing blood clots.start date 8/8/25 0700 (7:00 a.m.). [sic] The Warfarin increased the resident's risk of bleeding. Review of resident #85's EHR showed a progress note, dated 8/9/25 at 8:20 p.m., which included Note Text: Resident was sent to [Hospital name] ER at 8/9/25 8:20 PM for R leg pain 10/10.At time of discharge: Resident is oriented to person, place and time.Review of resident #85's EHR showed a Secure Conversations progress note, dated 8/11/25 at 1:54 p.m., which showed Messages: Subject ED transfer [8/9/25 22:45 PM] (10:45 p.m.)[Staff RN]: At around 1930H (7:30 p.m.), while this NOD and CNA assisting her to go to the toilet, she reports intolerable pain 10/10 above her R knee. Pain becomes worse if R leg is moved or R knee is bent, very tender to touch and unable to use it for support. R leg looks like a little bent/twisted out of shape going inward. Had an assisted fall earlier, kindly see progress notes. Talked to resident of going to ED for at least an xray just to make sure she didn't break her leg. Res agrees. Hx of R total hip arthroplasty, R knee replacement. At around 1940H (7:40 p.m.), called on call provider [provider on call], to send to ED. Res does not want this NOD to call his son but she will personally call him of the ED transfer. At around 1944H (7:44 p.m.), called [Ambulance Service], arrived at around 2000H (8:00 p.m.) and res transported to [Facility Name] ED at around 2020H (8:20 p.m.).[8/9/25 22:47 PM] (10:47 p.m.)[Staff RN]: At around 2200 (10:00 p.m.), called [Facility Name] for update. Talked to ER secretary and res will be admitted for significantly fractured femur. FYI[8/11/25 10:23AM][Staff Physician]: noted agree with ED eval after fall with significant pain, thanks for the update, will await her return. [sic]Review of a facility document title, [Facility Name] Incident Audit Report dated 8/27/25, showed, it was a follow up to resident #85's fall on 8/9/25 15:00 (3:00 p.m.), and included: .Injuries.Mental Status, Oriented to Person, Oriented to Place, Oriented to Situation; Oriented to time . Note.Resident is A&O X4 .It was determined post-fall to send [Resident #85] to the emergency room for further evaluation. [Resident #85] declined to go initially, but then was agreeable later as pain increased in her leg.Review of the admitting hospital's Discharge summary, dated [DATE], showed, .Assessment & Plan, Femur fracture (HCC), Patient had a mechanical fall while trying to get from her bed to a wheelchair on 8/9. XR identified a moderately displaced periprosthetic R femur fracture.

Based on observation, interview, and record review, the facility failed to store and prepare food under sanitary conditions, staff failed to wear hair restraints in the kitchen area, and the facility failed to provide food at a safe and appetizing temperature for 4 (#s 6, 14,72, and 154) of 34 sampled residents. These deficient practices placed all residents who consumed meals prepared by the facility at risk of exposure to food-borne pathogens and or illness. Findings include:During an observation of the kitchen on 8/25/25 at 3:12 p.m., the following concerns were identified: - The juice dispenser had a sticky liquid on the dispenser nozzles, the front panel of the dispenser, and the backsplash.- The coffee dispenser had dried coffee on the front tray and on the dispenser nozzles.- A light brown liquid was spilled on the counter by the coffee dispenser. A drawer containing utensils was open under the spill, and the brown liquid had spilled into the utensil drawer.- There was ice buildup in the freezer, and there was ice on the floor of the freezer, which made the floor slick and hazardous. The ice buildup extended on the outside of the freezer due to the worn door seal. - An open package of unlabeled meat, not dated, was observed in the walk-in cooler. The package was mixed in with other types of meat, including pork and pastrami products.- Ham was observed in a pan, covered with cellophane, which was labeled but undated.- Food particles, grease, dust, grime, and an unknown light brown sticky substance were observed in the corner to the right of the freezer door. Above this, on the outer surface of the walk-in freezer, was a black substance.- Particles of food, grease, dust, and grime were noted on the ledge of the whiteboard to the right of the freezer.- An open bin containing whole onions was stored under a food preparation sink.- Pieces of food were noted on the counter around and under the food mixer.- A cabinet to the right of the food mixer had dried splatter on it.- Particles of food, grease, dust, and grime were noted on the windowsill above the food preparation sinks.- There was hard water buildup observed on the outside of the ice machine, on top of the machine, and down the front of the lid.- A cooler in the dry storage area contained a pitcher of thick red liquid labeled tomato and the pitcher was not dated.During an interview on 8/25/25 at 3:36 p.m., staff member P, when discussing the individual condiment packages (which were not dated) stored on a shelf outside of the dietary manager's office, stated, . if they aren't marked (dated), we don't know when to get rid of them.During an observation on 8/25/25 at 3:38 p.m., staff member D entered the dietary area and walked through the kitchen without a hair cover or net. Staff member D stated she was off the clock and just gathering some personal items. She stated she would assist in the kitchen at times, and she was a certified nursing assistant. During an observation on 8/26/25 at 7:57 a.m., staff member D was observed talking to an unknown kitchen staff member in front of the walk-in cooler in the dietary department, and staff member D did not have a hair covering on at the time.During an interview on 8/26/2025 at 8:19 a.m., staff member K stated CNAs will deliver the meal trays to the resident rooms when a resident chooses not to go to the dining room for the meal. Staff member K stated the food is brought to the hall in the food carts by dietary staff, and the food stays in the cart until it is delivered to the resident. He stated that meals are delivered warm when placed in the cart, and at times, the food has to be heated before serving. He stated the CNAs heat the food, when needed, to 165 degrees Fahrenheit. During an observation and interview on 8/26/25 at 8:33 a.m., resident #6 was in bed with her meal tray on her overbed table. She was stirring food in a bowl that she reported to be oatmeal. The oatmeal was thick with large clumps and did not easily mix when she stirred it. She reported the oatmeal was not warm.During an interview on 8/26/25 at 8:51 a.m., resident #154 stated, Food is a big concern. Half the time it comes in cold. I have gotten sick off the food a couple times. I don't think they temp the food. During an observation on 8/27/25 at 8:37 a.m., food trays were stored in a cart on the 300 hall and were being delivered to the residents by staff. A tray still in the cart, labeled for resident #72, was checked for the temperature of the food by staff member M, who was using a facility thermometer. The temperature showed the temperature of the sausage on the tray was 110.9 degrees Fahrenheit.During an observation on 08/27/25 at 8:40 a.m., food trays were stored in a cart on the 300 hall and were being delivered to the residents by staff. A tray in the cart, labeled for resident #14, was checked for the temperature of the food by staff member M, who was using a facility thermometer. The temperature of the cooked eggs on the tray was 116.2 degrees Fahrenheit.During an observation on 08/27/25 at 8:46 a.m., food trays were stored in a cart on the 200 hall and were being delivered to the residents by staff. A tray in the cart, labeled for resident #154, was checked for the temperature by staff member M, who was using a facility thermometer. The temperature of the cooked sausage on the tray was 114.3 degrees Fahrenheit.During an observation and interview on 08/27/25 at 8:49 a.m., resident #6 was in bed and had just begun eating. Her tray was on the overbed table with the lid still on her plate. The temperature of the eggs on resident #6's plate was checked by staff member M using a facility thermometer. The temperature of the eggs was 110.8 degrees Fahrenheit. Resident #6 stated the food was not as warm as she would like it to be.During an observation on 8/27/25 at 8:57 a.m., it was observed that the ice bin lid was left open. There were no staff in the area at the time. There was also a Ziplock bag containing individual, single-serve creamer packets, on the floor in the dry storage area. During an interview on 8/27/25 at 9:00 a.m., staff member N stated a hair net or hat is required to be worn at all times when in the kitchen. He stated that food in the cooler should be dated so staff knew when to get rid of it. When asked about cleaning schedules in the kitchen he stated everything in the kitchen was cleaned daily and equipment was cleaned after each use. During an interview on 8/27/25 at 9:22 a.m., staff member D stated hair and beard coverings are required when in the kitchen, and staff should absolutely not be in the kitchen without them at any time.During an interview on 8/27/25 at 9:26 a.m., staff member E stated he met with the staff in the kitchen every Monday and Friday, and he reminded them that hair coverings were always required in the kitchen, but staff member E was not aware of any staff member entering the kitchen without a hair covering. When interviewed about the kitchen concerns, staff member E stated the nozzles on the coffee dispenser were cleaned two weeks ago by the distributor, but he knew it should be done more often. He stated the juice machine nozzles were cleaned once a week, and he expected staff to close the ice machine lid and never leave it open. Staff member E stated that all meat needed to be dated once the meat is thawed. Meat is thawed either in the walk-in cooler or in the sink under cool running water. Staff member E stated that different meats should be stored separately to prevent cross contamination and that meats were dated to ensure they were not used when no longer safe for consumption. When asked about the seal on the freezer door, staff member E stated it had not been sealing properly for a long time but that the facility had ordered a replacement door. He stated that he believed it took a while as it had to be special ordered. Staff member E stated the temperature of the food being held in the carts had been an ongoing problem, and the facility was trying to fix the problem. He stated the food temperature concerns were addressed last year, and they switched from the old metal lids for the plates to the current plastic insulated ones. Staff member E stated the new lids maintain the food temperatures within an acceptable range for about 30 minutes, but if it goes longer, the food cools down.During an interview on 8/27/25 at 11:53 a.m., staff member L stated food trays must frequently be reheated due to some foods not being warm enough when the trays are taken from the meal carts and then delivered to the residents in their rooms.Review of a facility provided document titled, Hair and [NAME] Restraint Policy, last reviewed 8/26/2025 showed: Policy: All employees involved in the production of food in the kitchen must have hair and facial hair covering without exception.A review of a facility provided document titled Food Safety Requirements, last reviewed 8/26/2025, showed: Policy Explanation and Compliance Guidelines:. 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage .b. Dry food storage-keep foods/beverages in a clean, dry area off the floor .c. Refrigerated storage.iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date.Review of a facility provided document titled Food Temperatures, last reviewed 8/26/25 showed: Policy: The temperatures of all food items will be taken and properly recorded prior to service of each meal.Procedure:1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees F b. Hot food items may not fall below 135 degrees F after cooking, unless it is an item which is to be rapidly cooled to below 41 degrees F and reheated to at least 165 degrees F prior to serving. 5. Food preparation and service areas will avoid the following methods:a. Holding foods in the temperature danger zone (41 degrees to 135 degrees F). [sic]

Based on interview and record review, the facility failed to provide prompt physician notification for a resident who sustained a fall resulting in injury with pain for 1 (#85) of 34 sampled residents. This deficient practice contributed to a delay in treatment, and the resident was found to have a fracture. Findings include:During an interview on 8/26/25 at 9:36 a.m., resident #85 explained that she was admitted to the facility in July after she developed complications from a right hip replacement. Resident #85 stated she had a fall when her leg got caught during a transfer, and she fell because the nurse went to get help and left her standing at the edge of the bed with nothing to hold on to. During an interview on 8/27/25 at 9:48 a.m., staff member O stated the fall protocol was to notify the family, the physician, and write up a fall report. Staff member O stated he did not notify the physician on call after resident #85 fell. Staff member O stated resident #85's care was delayed by a couple of hours.During an interview on 8/27/25 at 2:54 p.m., staff member B stated the fall protocol was to notify everyone of the fall, including the family and the doctor.Review of resident #85's EHR, showed a documentation note, dated 8/9/25 at 3:07 p.m., and the note failed to show the physician was notified of the resident's fall and increased pain.Review of resident #85's EHR showed a Secure Conversations note, dated 8/11/25 at 1:54 p.m., which included, Messages: Subject ED transfer .[8/9/25 22:45 PM] (10:45 p.m.) . she (resident #85) reports intolerable pain 10/10 above her R knee. Pain becomes worse if R leg is moved or R knee is bent, very tender to touch and unable to use it for support. R leg looks like a little bent/twisted out of shape going inward . At around 1940H (7:40 p.m.), called on call provider [provider on call], to send to ED .During an interview on 8/28/25 at 9:45 a.m., staff member A questioned this surveyor about a document that was provided by the facility, which showed the provider was notified about the fall at the time of the event. This surveyor clarified for staff member A that staff member O stated he did not notify the physician on call after resident #85 fell.Review of the facility document titled Notification of Changes, last review date of 10/14/24, showed: Policy: The facility will inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family members(s) of the following:1. An accident resulting in injury to the resident that potentially requires physician intervention. 2. A significant change in the physical, mental, or psychosocial status of the resident. Policy Explanation and Compliance Guidelines:1. In the case of a competent resident, the facility will contact the resident's physician and appropriate family member(s) .5. Document in the resident's clinical record the date and time of the notification. Review of the facility's document titled Fall Prevention Program, last review date 1/23/25, showed: . 5. When a resident experiences a fall, the facility will:.d. Notify physician and family.The delay of physician notification impacted the physician's opportunity to provide directives on the resident's care, pain, and injury.

Based on the interview and record review, the facility failed to report allegations of resident abuse to the State Survey Agency within 24 hours of an incident for 2 (#s 99 and 129) of 5 residents sampled for Facility Reported Incidents. Findings include:Review of the facility reported incident dated 6/27/25 at 8:15 p.m., showed resident #99 and resident #129 were involved in a physical altercation. Resident #99 reported to the nurse resident #129 grabbed resident #99's groin. The initial allegation of resident-to-resident abuse was not received by the State Survey Agency until 6/30/25.During an interview on 8/27/25 at 11:22 a.m., staff member A stated she was not aware the facility failed to report the allegations of resident-to-resident abuse to the State Survey Agency within 24 hours for the facility reported incident which occurred on 6/27/25, involving residents #99 and #129. Staff member A stated the facility's video surveillance of the incident was no longer available for review. During an interview on 8/28/25 at 8:52 a.m., staff members A and C were present. Staff member C stated the incident involving residents #99 and #129, on 6/27/25, was not reported to the State Survey Agency within 24 hours because resident #99 denied that the incident occurred. Staff member C stated resident #99 met with and reported to social services on 6/30/25 resident #129 touched resident #99's groin area on 6/27/25. Staff member C stated the facility then reported the incident to the State Survey Agency. Review of resident #99's nursing progress note, dated 6/28/25 at 5:21 a.m., showed resident #99 went to the nursing station on 6/27/25 at 8:13 p.m. and reported that resident #129 had touched his groin. Resident #99 was ambulating in his wheelchair, from the 700 hall, back to the nursing station. When doing so, resident #99 passed resident #129, and resident #129 had his head down looking at the rug, and he was swinging his hands down. The nursing progress note showed resident #129 stated he wasn't paying attention, and it was an accident (touching #99 on groin). Resident #99 calmed down and seemed to accept the actions of resident #129 were not on purpose. A message was sent to social services and nursing, and a text message was sent to the director of nursing, to make them all aware of the incident.Review of the facility's policy titled, ABUSE, NEGLECT AND EXPLOITATION, last revision dated 1/11/25, showed: 1. Definitions. Sexual Abuse is non-consensual sexual contact of any type with a resident. V. Identification of Abuse, Neglect, Exploitation and MisappropriationThe facility will identify factors indicating possible abuse, neglect, exploitation of residents, or misappropriation of resident property, including, but not limited to, the following possible indicators:-Resident, staff or family report of abuse; . VII. Response and Reporting of Abuse, Neglect, Exploitation, and MisappropriationAnyone with knowledge or concerns about the care of a resident in the facility must report suspected abuse to the Facility administrator, abuse agency hotline or file a complaint with the state survey agency and adult protective services (if applicable under state law) immediately (but not later than 2 hours after an allegation is made if the events that lead to the allegation involve abuse or result in serious bodily injury) or not later than 24 hours if the events that lead to the allegation do not involve abuse and do not result in serious bodily injury. Reporting and investigation should be in accordance with state law/regulation.When abuse, neglect or exploitation is suspected, the Administrator or designee should:. Contact the state agency and the local Ombudsman office to report the alleged abuse; . [sic]

Based on interview and record review, the facility failed to ensure licensed nursing staff had the necessary knowledge and skillset on the facility's post-fall protocol and physician notification, and a resident had a fall, with an injury and pain, and the proper notifications were not all made, for 1 (#85) of 34 sampled residents, and this resulted in a delay in care. Findings include:During an interview on 8/26/25 at 9:36 a.m., resident #85 explained she had a fall when her leg got caught during a transfer, and she fell because the nurse went to get help and left her standing at the edge of the bed with nothing to hold on to. During an interview on 8/27/25 at 9:48 a.m., staff member O stated resident #85 transferred with a walker and a one-person assist and was 50% weight bearing on her right leg. Staff member O stated the resident fell when moving from the bed to the recliner. Staff member O stated resident #85 was reporting pain in her right knee at the time of the fall. Staff member O stated the fall protocol was to notify the family, the physician, and write up a fall report. Staff member O stated he didn't realize there were other required reports to complete at the time of the fall, such as the incident and risk management charting. Staff member O stated he did not notify the physician on call after the resident fell. Staff member O stated he felt like he did not know how to do a lot of things at the facility and said, I had to fight tooth and nail to get any orientation here. I still don't feel fully enabled on how to do my job.During an interview on 8/27/25 at 10:30 a.m., NF5 stated she was the nurse attending to resident #85 upon admission to the emergency room, on the day after resident #85's fall. NF5 stated she had concerns because the EMT who gave her a summary stated there was a different story from what the resident reported and what the facility staff reported. NF5 stated resident #85 had fallen earlier in the day and presented with her right leg internally rotated and significantly shorter than the left leg, which were indications of a broken extremity. NF5 asked resident #85 why her care was delayed and asked the resident if her leg always looked like this. NF5 stated the resident reported the nurse at the facility had advised the resident to wait to see if it was worse in the morning before transferring to the emergency department.During an interview on 8/27/25 at 3:46 p.m., staff member O was shown a facility document titled, [Corporation name] SNF Nurse Skill Competency Checklist, undated, which showed he had met the criteria for incident charting and fall safety. Staff member O stated staff member B simply asked him if he was competent or not and checked the boxes as met. Staff member O recalled he asked to read the competency checklist before he could answer if he was competent or not. Staff member O stated he was told to sink or swim (referring to staff member O's performance). Review of resident #85's medication administration record, dated August 2025, showed, Warfarin Sodium Oral Tablet 3 MG (Warfarin Sodium) Give 0.5 tablet by mouth one time a day every Mon, Wed, Thu, Fri, Sun for treating/preventing blood clots.start date 8/8/25 0700 (7:00 a.m.). [sic]Review of resident #85's EHR, showed a documentation note, dated 8/9/25 at 3:07 p.m., which showed details of the resident's fall. The note failed to show the physician was notified or that the resident's Warfarin and risk of bleeding was considered as a concern after the fall. Review of the facility's document titled, Notification of Changes, last review on 10/14/24, showed, Policy: The facility will inform the resident; consults with the resident's physician; and if known, notify the resident's legal representative or appropriate family members(s) of the following:1. An accident resulting in injury to the resident that potentially requires physician intervention.2. A significant change in the physical, mental or psychosocial status of the resident. Policy Explanation and Compliance Guidelines:1. In the case of a competent resident, the facility will contact the resident's physician and appropriate family member(s) .5. Document in the resident's clinical record the date and time of the notification. Review of the facility's document titled, Fall Prevention Program, last review date 1/23/25, showed: . 5. When a resident experiences a fall, the facility will:.d. Notify physician and family.

Based on observation, interview, and record review, the facility failed to provide a thickened therapeutic diet as ordered for 1 (#91) of 34 sampled residents. The failure increased the risk of aspiration for the resident. Findings include:Review of resident #91's care plan, dated 8/12/25, showed resident #91 was to be provided nectar-thick fluids, as prescribed by the Speech Language Pathologist on 8/16/24.Review of resident #91's medication administration record for August 2025 showed the resident was to have Boost Breeze, which was to be thickened to a nectar-thick consistency, or the Boost may be replaced with a thickened preferred supplement.During an observation and interview on 8/27/25 at 8:05 a.m., resident #91 was sitting at the breakfast table. Staff member D was observed putting three pumps of gel thickener into a glass of cranberry juice. The thickener was observed in the bottom of the glass. The juice was floating on top of the thickener. Staff member D did not stir the thickener into the juice to mix it to a nectar-thick consistency. Resident #91 had a thin consistency liquid protein supplement and thin consistency tomato juice, also served with the meal. While staff member D was assisting resident #91 with his breakfast, staff member D gave resident #91 a drink of cranberry juice. Resident #91 immediately coughed after drinking the thin consistency juice. Resident #91 continued to cough throughout his meal. During this observation, the dietary meal ticket was observed, and it showed the fluids should be a mild to nectar-thick consistency. Staff member D spooned some juice, and the juice was a thin consistency. Staff member D stated, I put three pumps (of thickener) in the glass. It is not thick at all - I stirred it, but it floated back to the bottom. It was observed the staff did assist the resident and he had ceased coughing before the end of the meal. During an interview on 8/27/25 at 8:05 a.m., staff member E said resident #91 should have mild nectar-thick fluids, but the cranberry juice, the tomato juice, and the Ensure resident #91 had at the table weren't thickened at all. Staff member E said nursing could answer questions about education for thickening fluids because the nurses thickened the fluids. Staff member E said the kitchen would thicken fluids for the residents who received room trays.During an observation and interview on 8/27/25 at 8:33 a.m., the surveyor showed staff member F resident #91's water pitcher. Staff member F said the water consistency in the pitcher was not right at all because resident #91's care plan was for thickened fluids. Staff member F said resident #91 should have had thickened water provided in his bedside pitcher, not the regular water contained in the pitcher.On 8/27/25 at 3:35 p.m., the education on thickening fluids for the residents, provided to nursing and dietary staff, was requested. The facility provided staff member D's certified nurse assistant checklist. No other education was received by the end of the survey.

Based on observation, interview, and record review, the facility staff failed to wear appropriate PPE while caring for residents for 2 (#s 3 and 16); and failed to educate and monitor staff on cleaning practices for residents positive for c-diff, for 2 (#s 14 and 17) of 17 sampled residents. The deficient practices increased the risk to others for contracting infections due to the deficient practices. Findings include: 1. During an observation on 4/1/25 at 12:14 p.m., 12 resident rooms were identified for special droplet/contact precautions, eight resident rooms were identified for enhanced barrier precautions, and three resident rooms were identified for contact precautions. Inspection of two PPE supply containers were found to have no N-95 masks available for use in the 300 hallway. The PPE supply containers held only yellow procedural masks. Staff member D was observed entering a resident room, identified with a special droplet/contact precaution sign, wearing a yellow procedural mask, no eye protection, and a yellow gown with a pair of gloves. Inspection of two PPE supply containers located in the 100 hallway were found to have no N-95 masks available for use. During an observation and interview on 4/1/25 at 1:09 p.m., staff member O was observed exiting a resident's room, and the room was identified to have special droplet/contact precautions. Staff member O was wearing a yellow surgical mask and was not wearing eye protection. Staff member O stated, We are supposed to have face shields on, and we usually swap masks when exiting resident's rooms. We don't have any face shields on either of these carts. During an observation and interview on 4/2/25 at 9:52 a.m., staff member G was observed leaving the secured unit, walking down the 100 hallway, without a mask. Staff member G said she was not aware she needed to be wearing a mask throughout the facility. During an observation on 4/2/25 at 9:59 a.m., resident #3's room had a sign on the door showing special droplet/contact precautions . Keep Door Closed . The room door was observed open. During and observation and interview on 4/2/25 at 9:24 a.m., resident #16's room door had a Contact Precautions sign posted. The sign directed staff to wear gloves and gown before room entry, to discard them before room exit, and to clean hands before entering and when leaving the room. Resident #16 said she did not currently have an infection but was prone to infections, and the infection nurse left the sign on the door to help prevent infections. While speaking with resident #16, staff member P entered the room with no PPE. Staff member P said resident #16 did not have any active infections, so PPE was not required, unless she was providing care for resident #16. Staff member P donned gloves, and then moved resident #16's catheter bag to a position resident #16 had requested. Resident #16 said most staff do not don PPE because she does not have an active infection. Review of a facility policy, COVID Comprehensive Infection Prevention and Control Program, review dated 10/11/23, showed: .4. Personal Protective Equipment a. HCP who enter the room of a Resident with suspected or confirmed COVID-19 should adhere to standard precautions and a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection . 2. During an interview on 4/2/25 at 10:03 a.m., NF2 said he had come to visit resident #14 on 3/5/25. NF2 said he and his wife and four-month-old son had been in to visit on 3/6/25, 3/7/25, and 3/8/25. When visiting on 3/8/25, a facility staff member informed the family they should have been wearing a gown and gloves when visiting, and they should not take their son into the room. Resident #14's roommate, resident #17, had tested positive for C-Diff. NF2 said that upon returning home to Oregon, his son had tested positive for C-Diff. NF2 said staff were in and out of resident #14's room, prior to them being notified of the infection control precautions in place, for resident #14. A sign with infection control precautions was not observed to be on the resident's door until a staff member pointed it out on 3/8/25. During an interview on 4/2/25 at 1:19 p.m., staff member F said resident rooms were cleaned daily. Staff member F was not familiar with the C. diff bacteria and was not able to explain the cleaning process used for a resident with C. diff. Staff member F was not able to identify the cleaning solution for cleaning or the wait time required for the cleaning solution to kill the bacteria. During an interview on 4/3/25 at 10:06 a.m., staff member N said resident rooms with patients diagnosed with C. diff should be cleaned with a Clorox brand hydrogen peroxide cleaner and it should be left in place for 2 to 3 minutes. Staff member N said cheat sheets have been left in the nurse's stations with the different dry times for staff to reference. Staff member N said he did not know if the facility had a written process for cleaning rooms of residents with C. diff. Staff member N said housekeeping staff should be educated on the different cleaners and what should be used for cleaning. When orienting, housekeeping staff spend a week with another housekeeper for training and were then expected to clean on their own. Review of resident #17's electronic medical record showed he was diagnosed with C-diff on 2/14/25 and was treated with a 10-day course of vancomycin. Resident #17 started showing signs and symptoms of C-diff on 3/7/25 and was started on vancomycin, with a tapered dosing, on 3/8/25. He was placed on contact precautions on 3/9/25 when it was confirmed he had a C-diff recurrence. Review of a facility policy, Management of C. Difficile Infection, with a review date of 10/14/24, showed: . Clostridioides difficile, . is a bacterium that causes diarrhea and colitis . It is shed in feces and is spread by direct contact with contaminated objects or the hands of persons who have touched a contaminated object. .8. Environmental infection control: a. Housekeeping staff shall adhere to standard and contact precautions. b. Perform daily cleaning of the resident's room and high touch surfaces using a C. difficile sporicidal agent (EPA List K agent) During an interview on 4/2/25 at 11:17 a.m., staff member C said she had trained staff on proper use of PPE for the different precautions used in the facility. Staff member C said she would expect staff members to follow the instructions on the signs posted on resident doors for proper PPE use. The PPE supply containers were stocked by the night staff and the facility had enough supplies to keep the containers stocked for staff use. Staff member C said staff should be wearing a gown and gloves before entering a room with contact precautions. Staff member C said resident #16 had a contact precaution sign posted on her door to help prevent her having infections. When she does not have an active infection, she should be on enhanced barrier precautions. Staff member C said staff should be wearing a gown, gloves, eye protection, and N-95 masks when entering a room of a patient that was COVID-19 positive. Staff member C said residents with C-diff were placed on contact precautions. She was not aware if a policy or procedure was written for the cleaning of a resident room with C-diff. Staff member C had not trained housekeeping on the cleaning of a resident room with C-diff.

Based on observation and interview, the facility failed to provide clean resident rooms for 3 (#s 72, 16 and 95) of 28 sampled residents, and failed to provide clean hallways, which had the potential to affect all staff and visitors. Findings include: During an observation and interview on 11/19/24 at 3:12 p.m., resident #72 said she did not know when the last time her floor had been mopped. Resident #72 said she knows she was not always in her room, but the same sticky substance had been on her floor for several days. Resident #72 said she did not like her room and the floor being dirty. The observation made of resident #72s room showed, a plastic knife, a pen, and three clear plastic wrappers were under the bed. Resident #72's floor was observed to have a red sticky substance in the middle of her floor beneath her overbed table. A [NAME] brown sticky substance was also observed under the edge of her nightstand. The substance looked like it had leaked onto the floor spread out onto the floor. During an interview on 11/19/24 at 3:27 p.m. resident #16 and NF2 said the housekeepers only sweep and mop once a week or so and it was dirty yesterday and was still dirty today. NF2 pointed out several dark spots on the floor. NF2 said those spots had been there for several days. During an observation made on 11/20/24 at 10:00 a.m., resident #72 had a plastic knife, a pen and three clear plastic wrappers under her bed. A red colored sticky substance was on the floor in the center of the room. The nightstand was observed to have a reddish-brown stick substance under the front right edge and smeared out and onto the floor. During an observation on 11/21/24 at 7:30 a.m., resident #72 did not have any garbage under the bed. Resident #72's floor looked unchanged as it had a red sticky substance under the overbed table, and the same reddish brown sticky substance was under the edge of the nightstand. During an interview and observation on 11/19/24 at 3:17 p.m., resident #95 said the rooms occasionally get mopped and swept. Resident #95 said the room isn't great but could be worse. An observation was made of heavy black stains on the floor where the flooring meets the cove base. The edges around the door frames had dust, crumbs and debris and was stained dark brown/black in color. During an observation and interview on 11/20/24 at 11:55 a.m., staff member F said the beds are pulled out and away from the wall and cleaned under every day. Staff member F said room [ROOM NUMBER] had just been completely cleaned. An observation showed room [ROOM NUMBER]-bed 2 was pushed against the wall. There were two tissues, one paper napkin and a loose metal bar which was the same color as the bedframe was laying on the floor disconnected from the bed. Also observed was an accumulation of dirt, dust and hair balls on the floor at the foot of the bed in the corner hear the window. During an interview on 11/20/24 at 3:07 p.m., staff member G said the halls are pretty clean, but the rooms are dirty. Staff member G said the floors in the rooms could be cleaner and the garbage cans need washed. Staff member G said the sweeping and mopping under the beds was a missed opportunity and those areas are dirty, and need cleaned. During an interview on 11/21/24 at 7:55 a.m., staff member S said the facility and the resident rooms are not always clean. Staff member S said the facility has been down a housekeeper and the shifts have not been replaced. Staff member S said the nursing staff try to help, but the facility and the resident rooms are not as clean as they should be. Staff member S said there was a mop available to the nursing staff, but the CNA's (certified nurse assistants) have their own jobs to do as well.

Based on interview and record review, the facility failed to update resident care plans in a timely manner for 3 (# 1, #16 and #55) of 4 residents sampled for pressure ulcers and failed to revise a resident care plan to show effective behavior interventions following repeated resident to resident altercations for 1 (#33) of 3 residents sampled for behavior. Findings include: 1. Review of resident #1's nurses notes, dated 9/6/24, showed a new wound and the wound care was completed for a stage III pressure ulcer with full-thickness skin loss on the left heel. Review of resident #1's nurses notes written by the certified wound nurse on 9/6/24, showed resident #1 had a left heel wound. The wound nurse applied a dressing which was approved by the medical provider. Review of resident #1's nurses note documented on 9/10/24 showed the wound which was initially assessed as a stage III pressure ulcer was now noted to be a callous. Review of resident #1's care plan showed the care plan was updated on 11/18/24 and the potential for skin alteration changed from a potential to an actual wound. Resident #1's care plan was updated on 11/18/24 to include offloading the heels. 2. A review of resident #16's initial wound care nurses notes dated 10/22/24, showed the resident had a stage III full thickness wound to her right heel. The nurses note showed the physician was contacted to get verification of treatment which was started for resident #16. A review of resident #16's care plan showed no intervention for treatment for resident #16's pressure ulcer on the heel until 11/18/24. Several interventions added on 11/18/24 were to provide a low loss air mattress, off load resident #16's heels and provide Prevalon boots to her bilateral heels. 3. Review of resident #55's skin and wound evaluation dated 10/28/24 showed resident #55 had a new in-house acquired wound described as a pressure ulcer which was staged as a deep tissue injury to her right heel. Review of resident #55's care plan showed the interventions were not updated for the heel wound until 11/18, when an air overlay was placed on the bed, Prevalon boots to be placed as resident will allow. 4. Review of resident #33's nurse's notes dated 8/29/24, showed resident #33 smacked another resident on the left side of his head. Review of resident #33's nurse's noted dated 8/30/24, showed resident #33 was hit twice in the back by another resident. Review of resident #33's care plan showed the care plan had not been updated until 9/10/24. There was no further updates until 10/11/24. The care plan contained the following updates: - 9/10/2024, sitting on the opposite side of the dining room from louder residents, trying to decrease stimuli for him . Suggest he plays piano when he was feeling overwhelmed or wants to express himself through music . - 10/11/2024, Redirection/refocus/diversion/ aromatherapy, and other. 5. During an interview on 11/20/24 at 4:40 p.m., staff member U said the care plans are updated quarterly and annually with MDS assessments. Staff member U said there was a meeting every day and the management gets the updates then. Staff member U said the wound nurse monitors the wounds and the nurse does the care plan updates for wounds. Staff member U said the care plans for other issues are updated by which ever nurse catches the changes.

Based on interview and record review, the facility failed to complete accurate assessments for 1 (#33) of 3 sampled residents who had been involved in two altercations. This deficient practice had the potential to affect resident care and safety as it inaccurately depicted the residents' care needs. Findings include: Review of resident #33's vulnerable resident evaluation dated 9/30/24, showed resident #33 did not have a history of any type of abuse toward others. The evaluation also showed the resident did not have behaviors which make the resident susceptible to abuse by others or behaviors which increase the resident's risk of abuse to others. Review of resident #33's MDS with an ARD of 10/3/24 showed the resident did not have any physical, verbal or other behavior symptoms directed toward others. Review of resident #33's nurse's note dated 10/2/24 showed, .Resident increased his voice .Resident has increasing confusion and increasing upset behaviors . The resident was administered a prn antianxiety medication because of the increasing behavior, agitation and inability of staff to redirect the resident. Review of resident #33's nurse's note, dated 9/28/24, showed resident #33 had anxiety and when presented with reality, his agitation increased, and he began pacing. The behavior was disruptive to other residents who were eating dinner. The resident was medicated due to the behaviors. During an interview on 11/20/24 at 11:00 a.m., staff member E said she had completed the Vulnerable Resident Evaluation on 9/30/24. The evaluation showed the resident did not have a history of abuse toward other or self-abuse. The evaluation was also coded showing resident #33 did not have behaviors which make him susceptible to abuse by others (including other vulnerable residents or adults). Staff member said she was just doing the routine to just get through the evaluation. Staff member E said she should have looked deeper into his behaviors and made sure the evaluation was accurate.

Based on interview and record review, the facility failed to limit an as needed anti-anxiety medication order to 14 days or provide a rationale for continued extension of the medication, for 1 (# 33) of 1 sampled resident using an as needed medication. Findings include: A review of resident #33's medication administration record for September 24, showed, Lorazepam Concentrate 2MG/ML, give 0.5ml by mouth every 8 hours as needed for Anxiety for 4 days was ordered on 8/30/24. Lorazepam is the generic name for Ativan, an anti-anxiety medication. The MAR showed the medication had not been given during those 4 days. A review of the September 2024 MAR, showed, on 9/3/24, the medical provider re-ordered the Lorazepam to be continued at 1mg every 6 hours for another 14 days. During those 14 days, the Lorazepam had not been administered. A review of the Advanced Practice Nurse Practitioner note dated 9/6/24 showed she had assessed resident #33. The NP note showed, .9/3-acute visit with Doctor for agitation which had resolved at the time of the visit. As needed Ativan available, none given in the last 14 days. The NP had re-ordered the Ativan on 9/3/24 with no justification or reason indicating the medication should be continued. A review of the September 2024 MAR showed on 9/27/24, the medical provider again re-ordered for the Lorazepam to continue for 6 months. Resident #33 had not received any prn doses of Lorazepam. A review of the September MAR showed the staff began administering the anti-anxiety medication on a prn basis on 9/27/24. A review of resident #33's nurse's notes dated 11/27/24 showed the resident was angry at one staff member. The facility failed to intervene and remove the source of the agitation. An anti-anxiety medication was administered rather than the source of the agitation be addressed and changed. A review of resident #33's physician note dated 11/1/24, showed the physician was aware resident #33 was given Lorazepam 5 times in the last 30 days. The physician did not indicate the reason the medication was administered. The physician did not indicate a rationale or diagnoses why the Lorazepam should be continued. During an interview on 11/19/24, NF1 said he did not sign a consent for the use of the tranquilizer the facility was using to control resident #33. He said he doesn't remember being educated on the risks or benefits of the medication the resident receives. A request was made on 11/19/24 at 2:46 p.m. for documentation showing education and consent for use of Lorazepam for resident #33. No documentation was provided by the end of the survey. A review of a facility policy, Use of Psychotropic Drugs, dated 10/14/24, showed - .3. The attending physician will assume leadership in medication management by developing, monitoring and modifying the medication regimen in collaboration with the residents, their families and or representatives, other professionals and the interdisciplinary team. - .4. Psychotropic medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed. - . 5. Residents and or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions - . 9. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to extend beyond 14 days, he or she shall document their rationale in the resident's medical record .

Based on interview and record review, the facility failed to provide a safe environment for 1 (#90) of 36 sampled residents. This resulted in the resident falling and sustaining a significant injury. Findings include: Review of resident #90's EMR admission assessment, dated 2/3/2023, showed, .2. Fall Risks . 3. Requires use of assistive devices . 5. Impaired mobility/assist with toileting . 8. hx of falls in last month, 9. hx of falls in last 1-6 months . 4. Current fall preventative measures in place . 5. Frequent checks . 8. Call light within reach when in room . [sic] Review of resident #90's EMR nursing progress notes, dated 3/17/2024, showed, Nurse's Description: Heard CNA radio for help saying a resident is out of bed. Seen resident on the floor next to his bed, laying on his left side, with head under table metal leg . Injuries?: Left elbow skin tear with minimal bleed. Res. c/o left hip pain . Predisposing factors: Noted res bed on highest position with res saying I kept on pressing the emergency button but it doesn't work Call light not in reach . [sic] Review of resident #90's history and physical examination record from [hospital] dated 3/17/2024, showed, . [resident #90] rolled out of bed landing on his left hip .[resident #90] was unable to get up due to severe left hip pain so brought here via EMS. Noted to have a left hip fracture and will be going to OR later today for repair . Review of the Interdisciplinary Team notes dated 3/18/2024, showed, .[resident #90] fell and fractured and called 911 himself; Staff report call light had fallen to the floor and he used bed control (thinking it was call light) pushing his bed into high position; thinking staff was not coming, he tried to get up . [sic] Review of the fall investigation for resident #90, dated 4/9/2024, showed, .resident #90 was in his bed and wanted to get up. He pushed the bed remote multiple times, thinking this was the call light. This resulted in his bed being in a high position. Staff member H found him lying on the floor and called for help from the nurse on duty. During an interview on 7/30/2024 at 1:42 p.m., NF1 stated, .[resident #90] said staff was taking the call light away from him at night but I am not sure if that is accurate .I feel .he is 'safeish' there . [sic] During an interview on 7/30/24 at 3:10 p.m., staff member I stated, .he [resident #90] didn't have a call light- it was on the bedside table too far away- he called 911 himself. I argued with staff member H who tried to say he did have it [the call light]. He was mixing up the bed control with the call light- the bed was high from him pushing the button. Typically, the CNA would make sure the call light was in reach . During an interview on 8/1/2024 at 8:49 a.m., staff member H stated, I was just coming on to shift, he had his small table beside him and was holding onto something. We were passing breakfast, and he was sleeping. Then when I was in the room next to his, I heard something and went into [resident #90's] room. He had his bed really high .he was yelling but had already called 911. His call light was on the floor after he raised his bed because the cord was too short to reach. Everything was on the floor. I think he grabbed the wrong control and pushed that instead of the light. Documentation of rounds for resident #90 prior to his fall were requested on 7/31/24 at 4:15 p.m., but were not received prior to exit or before noon the following day. A copy of the facility's rounding policy was requested on 7/31/24 at 4:15 p.m., but was not received prior to the survey exit or before noon the following day.

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff wore beard coverings in the kitchen, failed to label and date food items in the walk-in freezer, and failed to properly cool left-over chicken. This deficient practice had the potential to affect all residents eating food from the facility's kitchen. Findings include: 1. During an observation on 7/28/24 at 1:35 p.m., staff member N was observed with facial hair and was not wearing a beard net in the kitchen. During an observation and interview on 7/29/24 at 1:50 p.m., staff member P was observed not wearing a beard covering in the kitchen. Staff member P stated he should have been wearing a beard covering in the kitchen. During an observation on 7/30/24 at 2:20 p.m., staff member Q had facial hair and was not wearing a beard covering in the kitchen. Review of the facility's policy, General Food Preparation and Handling, reviewed 8/10/23, showed, Hair restraints - Dietary staff must wear hair restrains (e.g., hairnet, hat and/or beard restraint) to prevent hair from contacting food. 2. During an observation on 7/29/24 at 1:35 p.m., Danish pastries, round food items wrapped in cellophane, and a yellowish substance in small drink cups, in the walk-in freezer, were not labeled or dated. During an interview on 7/29/24 at 1:50 p.m., staff member P stated the Danishes in the walk-in freezer should have been dated. During an interview on 7/30/24 at 2:25 p.m., staff member O stated the round food items wrapped in cellophane were birthday cakes. Staff member O said he knew they were made about 2.5 weeks ago before the supervisor went on vacation. During an observation on 7/31/24 at 1:51 p.m., the birthday cakes wrapped in cellophane, and yellowish substance in small drink cups, in the walk-in freezer were not labeled or dated. During an observation on 8/1/24 at 8:21 a.m., the birthday cakes wrapped in cellophane in the walk-in freezer were not labeled or dated. Review of the facility's policy, General Food Preparation and Handling, reviewed 8/10/23, showed, Leftovers must be dated, labeled, covered, cooled and stored . 3. During an observation on 7/29/24 at 1:35 p.m., diced chicken was sitting out on the counter in a metal container. Staff member P stated it was sitting out for five to ten minutes. During an interview on 7/29/24 at 1:39 p.m., staff member O said the chicken had been sitting out for 40 minutes, and he felt the bottom of the pan for the temperature during the cooling process. Staff member O said he did not know what the policy was for cooling leftovers. During an interview on 7/29/24 at 1:50 p.m., staff member O stated the chicken sitting out was at 90 degrees Fahrenheit before he put it in the walk-in cooler. During an interview on 7/30/24 at 2:41 p.m., staff member O stated the chicken cooling on the counter the previous day was, . used in soup this morning. Staff member O stated he waited until food was at room temperature or lower, and sometimes used an ice bath when cooling foods. During an interview on 8/1/24 at 1:49 p.m., staff member O was unable to locate the food cooling logs in the kitchen logbook and stated he could only locate the food temperature logs. Review of the facility's policy, General Food Preparation and Handling, reviewed 8/10/23, showed: - .All leftover or cooked food for use at a later time will be required to be handled using a time and temperature process using the following procedure. All items entering this process must be documented using a Food Cooling log sheet . - Cool from 135 degrees F to 70 degrees F in 2 hours and from 70 degrees F to 41 degrees F in 4 hours (not to exceed 6 hours).Take temperatures frequently to determine if altered methods are needed.

Based on interview and record review, the facility failed to implement a baseline care plan, for five days, for a newly admitted , nonverbal resident with a diagnosis of a subdural hematoma and stroke for 1 (#138) of 36 sampled residents. This deficient practice had the potential to affect the resident's quality of care. Findings include: A review of resident #138's EHR progress note, dated 4/26/24 at 3:08 p.m., showed: Note Text: [Resident #138] admitted on [DATE] 1:00 PM for SDH, CVA.Resident is unable to talk.Totally dependent on staff for late loss ADLs. Eating: Total dependence . A review of resident #138's care plan showed 18 focus areas. One focus area had an initiated date of 4/29/24, all other focus areas had an initiated date of 5/1/24 or later. During an interview on 7/31/24 at 10:35 a.m., staff member J stated the resident care coordinator nurse would perform an admission assessment and then trigger the baseline care plan for newly admitted residents. The expectation was the baseline care plan would be completed on the first day of the resident's stay. Staff member J stated she had forgotten to complete the baseline care plans in a timely manner on occasion. Staff member J further stated the timeframe for the completion of resident #138's baseline care plan would not meet her expectations. A review of a facility policy titled, Baseline Care Plans, reviewed 10/01/23, showed: Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Policy Explanation and Compliance Guidelines: 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident .

Based on interview and record review, the facility failed to initiate a care plan for PTSD (Post-Traumatic Stress Disorder) for 1 (#55) of 36 sampled residents. Findings include: Review of resident #55's electronic medical record showed the resident had unspecified PTSD as an admission diagnosis. Resident #55 did not have a plan of care for her PTSD. Due to the lack of a care plan, the staff would not be informed of PTSD triggers, and the best way to help resident #55 cope with events that trigger her PTSD. A SS- Trauma Screening Tool was completed on 6/18/24. Resident #55 answered no to the question of, have you ever experienced trauma in your life. There was no further documentation noted to identify trauma as shown on her diagnoses. During an interview on 7/30/24 at 11:18 a.m., resident #55 said her PTSD had been triggered because a CNA busted through her curtain and scared her. Resident #55 said if the staff knew what triggered her PTSD, the staff members would potentially knock before barging into her room. During an interview on 7/31/24 at 9:26 a.m., staff member G said she was unaware resident #55 had PTSD. Staff member G said she had not seen the physician's diagnoses list. Staff member G said a care plan had not been developed to address PTSD.

Based on interview and record review, the facility failed to update the care plan related to catheter care for 1 (#107) of 36 sampled residents. Findings include: During an interview on 7/31/24 at 3:01 p.m., staff member L stated resident #107 had been followed by a local urology clinic and they managed his catheter orders. During an interview on 8/1/24 at 8:15 a.m., staff member B stated resident #107 and his POA decided to discharge from the urology clinic and focus on comfort care. Staff member B stated the nurses were supposed to change the scheduled catheter date if they used the PRN catheter change. Review of resident #107's progress note dated 5/14/24, showed, POA requested to DC out of facility appt at [local urology] and to focus on comfort needs at this time. Provider aware. Review of resident #107's Care Plan area for suprapubic catheter last updated on 2/1/24, showed an intervention as, [Resident #107] is followed by [Local Urology Clinic] for management of his suprapubic catheter. There was no intervention listed for the scheduled and PRN catheter changes. There was no intervention for the change to comfort care with discontinuation of urology appointments.

Based on observation, interview, and record review, the facility failed to manage catheter changes as the physician ordered for 1 (#107) of 36 sampled residents. This deficient practice had the potential to increase risk of infection and complications from multiple catheter changes. Findings Include: During an interview on 7/31/24 at 3:01 p.m., staff member L stated resident #107 had something wrong with his bladder which caused the catheter to keep clogging. Staff member L stated his catheter had not gone a full month without having to be changed. Staff member L stated she was not aware of any pain or recent infections for resident #107 related to his catheter. During an interview on 8/1/24 at 8:15 a.m., staff member B stated the nurses on the floor should have been moving the scheduled catheter change date out if they used the as needed catheter change order for resident #107. Staff member B stated resident #107 and his POA decided to discontinue urology and focus on comfort care in May 2024. Staff member B stated she was not aware of resident #107 complaining of any pain or symptoms of infection related to his catheter. During an observation and interview on 8/1/24 at 9:05 a.m., resident #107 was lying in bed with a blanket covering him and his catheter. Resident #107 stated, Oh, in the bladder, it burns. They [facility staff] all know about it, when asked about having any pain. During an interview on 8/1/24 at 10:09 a.m., staff member B stated we did do the PRN catheter change, but did not do the manual change of the scheduled catheter. Review of resident #107's May 2024 MAR showed orders for: - Change SP Catheter every 3 weeks with 20f 10cc foley at bedtime every 21 day(s) with a start date of 2/23/24. The catheter was changed on 5/17/24. - Flush SP catheter as needed for clogs two times a day for suprapubic catheter, clog prevention flush with 60mL sterile saline to prevent clogging, with a start date of 3/26/24. Administered two times a day for all days except 5/3/24. - Place gauze over SP site after catheter changes at bedtime every 21 day(s), with a start date of 2/23/24. Documented as completed on 5/17/24. - Flush SP catheter as needed for clogs, with a start date of 3/26/24, had not been administered for the entire month of May. - supra pubic cath change prn if clogged / malfunction as needed for SP cath care, urinary retention document date changed and re-time routine SP change date [sic] with a start date of 4/5/24. The prn catheter change was completed on 5/12/24, 5/20/24, and 5/30/24. The scheduled catheter change was not re-timed after the PRN catheter changes. Resident #107's suprapubic catheter was changed four times in three weeks in May 2024. Review of resident #107's June 2024 MAR showed orders for: - Change SP Catheter every 3 weeks with a 20f 10cc foley at bedtime every 21 day(s), with a start date of 2/23/24. The catheter was changed on 6/7/24 and 6/28/24. - Place gauze over SP site after catheter changes at bedtime every 21 day(s), with a start date of 1/10/24. Documented as completed on 6/7/24 and 6/28/24. - Flush SP catheter as needed for clogs two times a day for suprapubic catheter clog prevention flush with 60mL sterile saline to prevent clogging, with a start date of 3/26/24. Missing documentation for five times out of the 60 flushes. - Flush SP catheter as needed for clogs as needed for suprapubic catheter . with a start date of 3/26/24. No documentation of the as needed catheter flush being administered for the entire month. - supra pubic (SP) cath change prn if clogged / malfunction as needed for SP cath care, urinary retention document date changed and re-time routine SP change date, [sic] with a start date of 4/5/24. The catheter was changed on 6/19/24. Resident #107's scheduled catheter change was not re-timed after the PRN catheter change. Resident #107's catheter was changed three times in three weeks in June 2024. Review of resident #107's July 2024 MAR showed orders for: - Change SP Catheter every 3 weeks with 20f 10cc foley at bedtime every 21 day(s), with a start date of 2/23/24. The catheter was changed on 7/19/24. - Place gauze over SP site after catheter changes at bedtime every 21 day(s), with a start date of 1/10/24. Documented as completed on 7/19/24. - Flush SP catheter as needed for clogs two times a day for suprapubic catheter clog prevention flush with 60mL sterile saline to prevent clogging, with a start date of 3/26/24. Missing documentation for 7/24/24. - Flush SP catheter as needed for clogs as needed for suprapubic catheter . with a start date of 3/26/24. No documentation of it being administered for the entire month. - supra pubic (SP) cath change prn if clogged / malfunction as needed for SP cath care, urinary retention document date changed and re-time routine SP change date, with a start date of 4/5/24. The catheter was changed on 7/8/24 and 7/28/24. Resident #107's scheduled catheter change was not re-timed after the PRN catheter changes. Resident #107's catheter was changed three times in three weeks in July 2024.

Based on interview and record review, the facility failed to ensure transportation was provided for a dialysis appointment for a resident receiving dialysis at a nearby facility for 1 (#121) of 36 sampled residents. This deficient practice had the potential to cause health complications for the resident. Findings include: During an interview on 7/30/24 at 2:51 p.m., resident #121 stated on or about the morning of 2/10/24, he was waiting for his transportation to his dialysis appointment in the reception area, near the front door of the facility and had seen the [bus company name] van pull up out front. He was unable to open the front door due to the coded keypad. Resident #121 further stated that [bus company name] would call the facility and if nobody had answered they would leave. During an interview on 7/30/24 at 3:07 p.m., NF2 stated the [Bus Company name] called the facility and nobody answered and they left. NF2 further stated that resident #121 had to go to the hospital the day after missing his dialysis appointment and was in ICU for three days. During an interview on 7/31/24 at 9:42 a.m., staff member K stated she coordinated transportation for residents. Resident #121, at the time of his missed dialysis appointment, was using [bus company name] and that she only filled out a standing order request form for days and times for resident transportation by [Bus Company name]. Staff member K further stated resident #121 came to her after missing [Bus Company name], with his concern for his transportation to his dialysis appointments and she arranged for facility transportation for future dialysis appointments. During an interview on 7/31/24 at 12:59 p.m., NF6 stated if the resident was not waiting at the door when the bus arrived, the driver would call the facility. If there was no answer at the facility the driver that was picking up a resident for transportation would leave, we don't have time to wait. During an interview on 7/31/24 at 1:22 p.m., staff member B stated that [Bus Company name] would not wait, if the facility found out that a resident had missed the [Bus Company name] bus, the facility would provide transportation for the resident to their appointment. During an interview on 7/31/24 at 2:27 p.m., staff member B stated, [resident #121] did not go to his dialysis appointment on 2/10/24 and [Bus Company name] did not pick him up. The facility transportation takes him now. A review of a progress note for resident #121 in the facility EHR, dated 2/10/24 at 8:02 p.m., showed: Note Text: Resident stated that he missed his dialysis today. A review of a facility document, titled, Memorandum of Agreement, with an effective date of April 20, 2021, between [Dialysis Facility name] and [LTC Facility name], showed: 1. Responsibilities of LTCF. a. LTCF shall be solely responsible for arranging for transportation of its patient(s) to and from the Facility .

Based on observation, interview, and record review, the facility failed to provide behavioral health services for a resident with PTSD, who had previously attended counseling for managing her mental health for 1 (#55) of 36 sampled resident. Findings include: During an interview on 7/30/24 at 11:18 a.m., resident #55 said none of the facility's staff had ever talked to her about her PTSD. Resident #55 said her PTSD was triggered once while here, but she was unable to remember the date. Resident #55 said a certified nurse assistant burst through her privacy curtain which triggered her PTSD. Resident #55 said the incident scared her. Resident #55 said the social worker came in to see her twice, maybe. Resident #55 stated she had developed no relationships here, because the staff were too busy to take any time with her. Resident #55 stated she had no one she could talk to other than one bus driver. Resident #55 said it would help to have someone to talk to and someone to help her deal with the changes going on in her life. Resident #55 was recently started on dialysis, resident #55 said she was struggling with deciding to continue or potentially discontinue this life saving treatment. Resident #55 stated she had never been offered an appointment with a mental health provider or assistance with contacting her personal mental health provider. During an interview on 7/31/24 at 9:26 a.m., staff member G stated she did not know resident #55 had a diagnosis of PTSD. Staff member G did not attempt to do any local referrals for mental health care for resident #55. Staff member G did not know resident #55 had her own mental health counselor in a local town. Staff member G did not assist the resident with contacting her counselor or assist with arranging a private place to talk with the counselor. Review of resident #55's electronic medical record, dated 6/11/24 through 8/1/24, failed to show the resident had been referred for mental health services. Resident #55's care plan failed to identify triggers or direct staff on managing the resident #55's PTSD.

Based on observation, interview, and record review, the facility failed to provide adequate nutrition to maintain a resident's desired body weight for 1 (#72), of 5 sampled residents. This deficient practice contributed to the resident having a severe weight loss of 22.6% in less than 6 months, and the resident was having swallowing difficulties and pain with swallowing. Findings include: During an interview and observation on 7/5/22 at 1:22 p.m., resident #72 was sitting in her wheelchair in her room. Her clothing appeared baggy and too large for her. Resident #72 stated she had lost a lot of weight because . her food gets stuck on the way down when she is trying to eat, and it hurts. She stated she does not really eat anything solid because it just gets stuck. She stated she does not fit in her clothes anymore; and stated, They just hang on me like a bag. During an interview on 7/6/22 at 4:00 p.m., staff member L, stated the providers would normally follow through with scheduling a procedure such as an EGD. Staff member L phoned resident #72's provider and was told no EGD was scheduled. Staff member L stated, We do quarterly meetings, and I am wondering how this fell through the cracks. During an interview on 7/6/22 at 4:18 p.m., staff member M stated, resident #72 gets two chocolate milks with her meals, and a chocolate shake in the afternoon to help with her calorie intake. During an interview on 7/7/22 at 8:28 a.m., staff member N stated resident #72's weight loss had been a gradual process. Staff member N stated the weight loss was due to the resident's GERD diagnosis. Staff member N stated, resident #72 is eating the majority of her meals so I don't see that as starving. It hasn't seemed that dramatic to me. The amount she is eating clearly isn't enough to sustain her weight though. During an interview on 7/7/22 at 10:49 a.m., resident #72 stated if there was anything at all that could be done to help her be able to swallow food, she absolutely would do it. She stated she would really like to be able to eat normally. The resident stated, I like food and I like to be able to eat. Resident #72 stated it really did not matter how many changes they make to her meals. She was afraid to eat because of the pain it caused. Review of resident #72's EMR showed the resident weighed 130.1 pounds on 1/5/22, and the resident weighed 100.7 pounds on 6/20/22. A total loss of 29.4 pounds, which was a 22.6% weight loss. Review of an electronic medical record for resident #72, titled System Note, dated 3/4/22 at 12:03 a.m., showed, Noted to have unplanned weight loss. No weight gain noted. 12% loss over the last 60 days from 130.1 (1/5) and 13.6% loss x 180 days from 132.3 (9/8). No swallowing issues noted. No requirements for altered textures or specialty diets needed at this time .is in agreement with drinking Breeze supplements BID, and numerous meal changes, per her preference, including addition of fresh fruit, cereal, Jello, cottage cheese, mashed potatoes/gravy, and tomato soup. Review of an electronic medical record for resident #72 titled, Nutrition/Dietary Note, dated 5/20/22 showed, Following [resident #72] due to unplanned . weight loss . most current weight 106.7 (4/18) represents a 6.6% loss over the previous 45 days, from 114.3 # (3/3). Meal consumptions this past week ranged 0-25% x 4, 25-50% x 3, 51-75% x 3, 76-100% x 4 with 2 meal refusals. Review of an electronic medical record for resident #72 titled, Acute visit, dated 5/26/22, showed, [Resident #72] has a history of GERD and was previously on Omeprazole and an H2 blocker both of which were discontinued, and she remained asymptomatic for many months. She had been using TUMS frequently and as such Omeprazole was resumed at 20 mg daily. Unfortunately, none of these medications have made a difference . [resident #72] is still 'eating Rolaids like candy' . add Pepcid 20 mg nightly .follow up in one week. Review of an electronic medical record for resident #72 titled, Acute Visit, dated 6/2/22, showed omeprazole and Pepcid were resumed for increasing GERD symptoms. She still states she 'takes tums like crazy' especially at night. It is worse after she eats. She feels like 'food is in a wad' in her lower esophagus. She says it hurts and she cannot breathe. As a result, she is not eating much to avoid these symptoms . Plan- -increase Omeprazole to 20 mg twice daily -SLP consult for swallow eval -despite being on comfort care we may need to refer for EGD to alleviate suffering. Review of an electronic medical record for resident #72 titled Nutrition/Dietary Note, dated 7/1/22, showed, current weight 100.7 (6/20) represents significant weight loss of 7.6% x 30 days from 109# (5/25) and 23% loss x 180 days from 130.7# (12/22/21). [Resident #72] is classified as underweight, current BMI 16.3. Review of meal consumption the past 2 weeks reveals stable fair intakes, including 6 refusals . a GI consult might be appropriate to address comfort. Review of a facility Policy and Procedure, titled Weight Monitoring, last reviewed 10/24/2021, showed, Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem.

Based on observation, interview, and record review, the facility failed to address a lack of the required employee COVID-19 screenings, when staff were working and/or providing resident care, timely and effectively; and staff failed to wear PPE properly while providing care to residents on non-COVID-19 units. The failure to address the COVID-19 employee screening concerns and innacurate PPE use by staff when working, increased the risk for the potential spread of COVID-19, to include for 9 (#s 03, 04, 08, 09, 10, 18, 21, 30, 36) residents who tested positive for COVID-19, of the 19 sampled and supplemental residents. The facility was currently managing an outbreak of COVID-19 at the time of the survey. Findings include: During an observation and interview on 11/4/2020 at 11:30 a.m., staff member P said that he comes in early to process staff in, making sure they had their PPE on prior to entering their work area. Staff member P said that he takes care of the COVID-19 screening until noon, then the staff at the front take over. Staff member P was observed sitting near the entrance to the doors where staff enter to go to their work areas. During an observation and interview on 11/4/2020 at 12:45 p.m., staff members L and M were working the resident care unit 300. Staff member M said when she tested positive for COVID-19, she had no symptoms except a temperature of 99.9 degrees, on one day. Staff member M said she lives in the same residence as staff member L. Staff member L said she had no symptoms except a headache. Staff members L and M said they were off work for ten days after testing positive. During an observation on 11/4/2020 at 12:19 p.m., staff member J was delivering room lunch trays on the 500 hall. Staff member J was observed to not be wearing her face mask appropriately. The bottom elastic was hanging down in front of her face and the mask was not secured or sealed around her chin. During an observation on 11/4/2020 at 12:30 p.m., staff member G was observed passing lunch trays on the 100 hall. Staff member G was observed to not be wearing her face mask appropriately. The bottom elastic was not worn. During an observation and interview on 11/4/2020 at 12:50 p.m., staff member J was observed with her mask not appropriately worn. Staff member J stated the bottom elastic was not worn because it was choking her. Staff member J stated that she had not been fit tested to make sure the mask fit but was trained on PPE use. During an interview on 11/4/2020 at 12:53 p.m., staff member F stated, some staff have worked with symptoms and then tested positive for COVID-19. During an interview on 11/4/2020 at 1:25 p.m., staff member B stated the facility had trained staff on PPE use including how to wear the different isolation masks, and the facility management team did random audits of PPE use. During an interview on 11/5/2020 at 1:15 p.m., staff members B and C stated the facility was missing a stack of the employee screenings for COVID-19, that contained the screenings of staff member E. During an interview on 11/5/2020 at 1:19 p.m., staff member B stated they had worked with staff member E as he had been picking up a lot of shifts on the COVID unit and complained of symptoms of not feeling well. Staff member B stated, staff member E complained of symptoms of headache and runny nose on 10/25/2020 and was rapid tested for COVID-19, with negative results. The employee was retested on [DATE] and did not work. Staff member B stated on 10/27/2020 staff member E worked as he had no symptoms, and then tested positive from the weekly testing on 10/28/2020. During an interview on 11/5/2020 at 1:23 p.m., staff member C stated the facility staff were to do their own screenings for the Mid Shift and End of Shift COVID-19 screenings, then turn them in. Staff member C stated they were reviewed by the nurse or management if there is a concern. During an observation and interview on 11/5/2020 at 2:10 p.m., staff member D was observed returning room trays from the 300 hall to the kitchen and was not wearing her mask correctly; the nose piece was folded down and resting on the end of her nose, not creating a seal or proper fit and not wearing a full face shield. Staff member D stated she was new to working at the facility and was to wear an isolation mask for five days before getting a new one. During an interview on 11/5/2020 at 2:20 p.m., staff member B stated the facility changed the employee COVID-19 screening, from one time a day, to three times a day, on 10/17/2020. Staff member B stated, in coordination with the Health Department, they discontinued use of the full PPE on the non-COVID-19 units. Staff member B stated that is why it was removed from the units, and staff were informed of the change. Record review of the Facility's Weekly Schedule for October 10/18/2020-10/29/2020 showed staff member E worked on 10/18, 10/19, 10/20, 10/21, 10/22, 10/23, 10/24, 10/25, 10/27, 10/28, and 10/29/2020. Record review of staff member E's COVID-19 screenings from 10/18/2020 to 10/29/2020 showed: 10/21/2020- No COVID-19 screening provided. 10/22/2020- Start of Shift screening showed, a temperature of 97.1. No was answered for symptoms, travel, and cruise. Yes with the addition of work here for the question, In the last 14 days, have you had contact with someone with confirmed [DIAGNOSES REDACTED]. Mid shift and End of shift screenings were not completed. 10/23/2020- Screening was completed with temperatures and No answered for all symptoms and questions. 10/24/2020- Only the Start of shift temperature of 98.0, and No answered for all symptoms and questions. The Mid shift and End of Shift screenings were not completed. 10/25/2020- No COVID-19 screening provided. 10/27/2020- No COVID-19 screening provided. 10/28/2020- No COVID-19 screening provided. 10/29/2020- No COVID-19 screening provided. Record review of staff sample list for COVID-19 showed staff member E had tested positive for COVID-19 on 10/28/2020 and had not returned to work as of 11/5/2020. Record review of the November 2020 COVID-19 screenings for staff member F showed, on the 11/1/2020 Mid shift that staff member F had a temperature 99.1 degrees, and the End of shift symptoms were not completed. The 11/4/2020 screening, showed the Mid shift and End of shift screening were not completed, with a handwritten note went to COVID unit. Record review of the staff sample list for COVID-19 showed staff member F had tested positive for COVID-19 on 10/9/2020 and returned to work on 10/26/2020. Review of the facility's Weekly work schedule from September 27th through October 3, 2020 showed both staff members L and M were on the schedule for the 300 unit on 9/28, 9/29, and 9/30/2020. Staff member L worked days and staff member M worked afternoons. Staff member M tested positive for COVID-19 on 9/28/2020. Staff member M had filled out her COVID-19 screening on 9/28/2020, which was negative for symptoms. Staff member M's date of return to work was 10/9/2020. Review of the facility's Weekly work schedules from October 4th through October 10, 2020 and October 11th through October 17, 2020 showed staff member L was on the resident care unit 300 on 10/4, 10/5, 10/6, 10/7, 10/9, 10/10, and 10/11/2020. Staff member L tested positive for COVID-19 on 10/11/2020. Staff member L had filled out her COVID-19 screening on 10/11/2020, which was negative for symptoms. Staff member L's date of return to work was 10/20/2020. Record review of the facility's COVID Resident Tracker document showed the facility COVID-19 positive residents since 10/21/2020 to 11/5/2020 had 45 new positive results. Since 10/21/2020, 14 new resident deaths had occurred. Resident #s 03, 04, 08, 09, 10, 18, 21, 30, and 36 had tested positive on the non-COVID-19 halls of 100, 300, and 500. Facility staff working on the non-COVID-19 halls, did not complete COVID-19 screenings, tested positive for COVID-19, and were not wearing their PPE appropriately.

Based on observation, interview, and record review, the facility failed to identify the root causes and contributing factors related to 11 falls, one which caused a cervical fracture, and failed to monitor the resident adequately, and evaluate the effectiveness of interventions to prevent falls, and modify the interventions as falls occurred, for 1 (#75), and failed to identify root causes and contributing factors for falls, and failed to monitor residents adequately, and evaluate the effectiveness of interventions to prevent falls and modify the interventions as falls occurred, for 2 (# 25 and 146); and failed to provide adequate supervision for residents in the bathroom, when a mechanical lift was used to transfer the resident to the bathroom, and the resident's were left unattended in the bathrooms, for 2 (# 98 and 164) and 1 (#164) had an injury from the lift in the bathroom, of 50 sampled and supplemental residents. On 4/5/18 at 10:50 a.m., the survey team announced an Immediate Jeopardy which pertained to a resident (#75) residing on the dementia unit, who had multiple falls and sustained injuries, to include a cervical fracture. The regulatory area identified was F689- Accidents and Hazards, at the Severity and Scope of J. Upon removal of the immediacy for the resident, the Severity and Scope would lower to a G. Findings include: 1. Review of the facility report, Occurrence Type, Falls, showed resident #75 fell 11 times from 4/22/17 through 4/5/18. Review of the facility's Falling Star program, showed the residents involved in the program would have a green star on the resident's door. During an observation on 4/5/18 at 4:40 p.m., resident #75's door did not include a green star. During an interview on 4/5/18 at 1:50 p.m., staff member Z stated the falling star program meant the resident was at risk for falling, and should not be left alone in the bathroom. She stated there were two residents in the Pearl Unit that were on the program. Review of resident #75's Occurrence Reports showed: -- 4/22/17; the resident fell from her bed to the floor, landing on the fall mat. The root cause was identified as Due to resident action or internal risk factor. The recommendations included, anticipate needs as able, provide frequents check as able. Resident reeducated to call for assist. The resident's record did not show the facility identified needs staff may anticipate, or show the resident's care plan was reviewed for effectiveness of fall prevention interventions. The facility did not identify why the resident may have fell from the bed. Review of resident #75's Annual MDS, with the ARD of 1/25/18, showed the resident had severe cognitive impairment. - 6/3/17; the resident fell while ambulating with a walker. She hit her right elbow on the walker. A root cause was not identified and contributing factors were not evaluated per record review. Recommendations by the IDT included, Staff to continue frequent checks and anticipate needs. Keep in line of sight as able. The facility failed to identify the needs staff may anticipate for fall prevention, and failed to show how often or frequent checks were to be completed for resident monitoring. - 7/13/17; the resident was found on the floor in her room. She stated, I want to go home. A root cause was not identified for why or how she may have fell to the floor. Recommendations included Staff to continue frequent checks, to anticipate needs as able, reassure and redirect as needed, PT evaluation and Falling Star Program. How reassurance was a fall prevention intervention was not specified, and the purpose of the PT evaluation was not specified. Contributing factors were not shown to be reviewed or discussed by the IDT, per the resident's record. - 11/6/17; the resident was being pushed in her wheelchair, out of the dining room. She put her feet down, (promptly stopping the chair) and she fell forward, hitting her forehead on the floor. Ice pack applied to her forehead. Large amount of blood from head wounds. The root cause was Other, CNA did not use foot pedals while transporting resident. The recommendation was Foot pedals to be on wheelchair when transporting resident. Bag on back of wheelchair with foot pedals to be readily available for use. Review of a facility inservice, dated 11/7/17, showed a topic of Wheelchair foot Pedal Safety was provided for the staff, after resident #75's fall with the head injury. During an observation and interview on 4/5/18 at 2:20 p.m., staff member CC was pushing resident #75 down the hall. Foot pedals were not placed on the chair to hold the resident's fee up off the floor so they would not catch under the resident as she was pushed by the staff member. When asked about her foot pedals, staff member CC stated the resident does not use them, because she gets around with her feet on the ground. This was not reflected on the resident's care plan. - 11/20/17; the resident was found lying under the sink in another resident's room. The resident was unable to say what had happened. The root cause was No Fault. The recommendations included, Staff to continue frequent checks and anticipate needs. These interventions had shown to be ineffective from the prior four falls, but these were not modified. - 11/24/17; the resident was found lying on the floor next to her bed. She had bluish-red bruising to the left elbow, and a small superficial skin tear. She sustained an abrasion to her left cheek, and a small slit to her left lateral eye. The root cause was No Fault. Recommendations included changing the mattress to a perimeter mattress to reduce the chance of rolling out of bed. Staff to continue frequent checks and anticipate needs as able. - 11/28/17; the resident was found on the floor in between her wheelchair and another residents bed. Resident #75 was complaining of neck pain. A bump was noted to the back of her head. The root cause was No Fault. Recommendations included Staff to continue frequent checks and anticipate needs as able. Staff to keep resident in line of site in common areas as able. Falling star program. The interventions implemented were not evaluated for effectiveness relating to the resident's fall history and interventions implemented. Review of resident #75's Nursing Progress note, dated 11/29/17, showed the resident complained of back pain, and medication was provided and was effective. Woke up at 4:35 p.m., and again complained of back and neck pain. At 7:41 p.m., (resident #75) kept holding her neck. Review of resident #75's Nursing Progress note, dated 11/30/17, showed resident complaining today of pain at neck stated 'really hurting.' Review of resident #75's Nursing Progress note, dated 12/1/17, showed a computed tomography scan was completed with a finding of cervical fracture. This occurred four days after the fall with neck pain. Review of resident #75's Occurrence Reports, dated 1/14/18 and 1/22/18, showed two more falls, without injury, and a root cause of Due to resident action or internal risk factors. The facility failed to identify what actions or internal risk factors were contributing to the repeated falls. Review of resident #75's Nursing Notes, dated 4/5/18, showed the resident rolled out of bed. She also fell out of her wheelchair at 11:20 a.m., the same day. The resident was sent to the ER with hip pain. An X-ray showed no fracture and no further injury to the cervical fracture. The resident returned to the facility. Review of resident #75's falls Care Plan showed the following interventions for fall prevention: - the resident could ambulate with a front wheel walker, - had foot pedals for transport, - had a perimeter mattress, - was to be in common areas while awake as able, - was on 4 Ps rounding q shift, - was to be encouraged to use call light, - staff to keep pathways free of clutter, - staff were to encourage her to rise slowly and get balance before ambulating, - staff to encourage rest periods when ambulating, - the bed was to be in the lowest position, and - there was to be a mat on floor. During an interview on 4/5/18 at 8:30 a.m., staff member EE stated resident #75 was no longer able to ambulate. 2. Review of the facility's Occurrence Type, Falls Report, showed resident #146 fell 20 times, from the day of admission in (MONTH) to his discharge date of [DATE]. The Occurrence Reports showed: - 2/14/18; the resident was assisted to the floor by the CNA. Resident was educated on waiting for CNA to remove equipment and having staff assist with positioning in bed. Falling star program and landing strip next to bed. The root cause was Due to resident action or internal risk factors. - 2/17/18; the resident stated he rolled out of bed while sleeping. The root cause was No Fault. No new interventions were implemented. The facility failed to identify the root cause or contributing factors for why the resident rolled out of the bed while sleeping. - 2/18/18; the resident rolled out of bed onto the landing strip. A perimeter mattress was applied. Consider bariatric bed due to second fall from bed due to turning over. The root cause was due to resident action or internal risk factors. The facility failed to address the resident's positioning in bed. - 2/18/18; the resident was seen slipping out of his chair. The CNA was unable to stop him from falling out and assisted the resident to the floor. The root cause was No fault. The Intervention was to add a dycem pad (non skid pad) to his wheelchair cushion. The facility failed to identify contributing factors for the fall from the chair, such as positioning, size of chair, or resident's use of the chair. - 2/19/18; the resident thought I'd go ahead and get into the chair by myself. My legs just gave out and I didn't make it and wound up on the floor. No root cause was identified, and the recommendations included anti-roll back brakes, and the Falling Star Program. The facility did not determine why the resident wanted to get up on his own, or determine if his needs could be anticipated prior to him taking action on his own. - 2/23/18; the resident slid off the bed as he was trying to get to bed from the wheelchair. The root cause was due to resident action or internal risk factors. The recommendation was Staff to continue frequent checks and anticipate needs as able. Staff to encourage call light. The facility did not identify the resident needs to be anticipated or what parameters of the frequent checks. - 3/3/18; showed the resident was on the floor next to his bed. The resident stated he had been trying to grab a pen that had fallen on the floor. The root cause was due to resident action or internal risk factors. Recommendations included Resident was educated on using call light and asking for assistance to pick items up from floor. Staff to continue frequent checks and anticipate needs as able. Staff to encourage call light use. - 3/4/18; showed the nurse was informed that the resident had fallen again. He was on the landing strip next to his bed, and reported he had just rolled out of bed trying to roll over. The root cause was due to resident action or internal risk factors. The intervention was to move the bedside table onto the landing strip to prevent future rolling out of bed. - 3/6/18; the resident was found on the floor, in the bathroom, near the sink and his wheelchair. He was trying to self transfer from the wheelchair to the toilet. The results of the fall investigation showed resident is alert and oriented and able to make his needs known. The resident has a history of involuntary movement disorder and had been seen by the physician on 3/6/18. He is being followed by neurology. The resident stated that he doesn't want to bother anyone when he gets up, and will transfer himself. He has a call light in place and demonstrates he understands how to use his call light. He stated if his chair is next to the bed, he will transfer himself. The recommendation was to keep the wheelchair away from the bed. The facility did not address how the involuntary movements may have affected the transfer, why he felt he was bothering the staff when he needed care, or how staff may anticipate the needs prior to the resident attempting to use the restroom on his own. - 3/10/18; the resident had attempted to self transfer from the wheelchair to the toilet. The root cause was due to resident action or internal risk factors. The recommendations were for PT to adjust the wheel chair and place a uno-slip pad on the wheelchair cushion, which was previously recommended after the fall on 2/18/18. - 3/11/18; the resident was in the restroom on the floor. The root cause was Due to resident action or internal risk factors. The recommendations included a tent call light, and a sign to remind the resident to call for help, and the Falling Star Program. The resident was not comprehensively assessed to determine if his fall history showed any patterns relating to the fall details, or why interventions were not successful for the prevention of falls. This was the resident's 11th fall since his admission in (MONTH) (YEAR). - 3/12/18; the resident attempted to self transfer and fell to his knees. No new interventions or root cause were identified. - 3/14/18; the resident was found lying on his stomach between his bed and the window. He stated he was moving from his wheelchair to his bed, and his tremors caused him to fall. Recommendations included a self releasing seat belt, and slide board for transfers, with red tape on the brake extensions. No root cause was identified. How the slide board transfer was a fall prevention intervention was not identified. The facility did not address the resident's desire to be independent which in turn increased his risk for falls. - 3/15/18; the resident fell in the bathroom. No root cause was identified. The recommendation was to move him to a room closer to the nurses station, for closer observation. Resident is in agreement with this, and PT is aware of resident's numerous falls, and are working with him on safety. - 3/16/18; the resident once again rolled out of bed. No root cause was identified, and no new interventions were recommended. - 3/16/18; the resident was found lying on the bathroom floor. The resident was placed in bed with a mechanical lift. The intervention was to continue to encourage call light use. - 3/18/18; the resident was found on the floor between the toilet and his wheelchair. He refuses to use his call light. He has been moved closer to the nurses station today for closer observation. The fall occurrence report for 3/15/18 showed he would be moved closer to the nurses station on that day. Review of resident #146's Occurrence Reports for 3/25/18 and 3/27/18, showed he did not lock his wheelchair brakes and fell to his knees and rolled out of bed again. The resident was discharged home on[DATE]. During an interview on 4/4/18 at 3:30 p.m., staff member D stated the resident wanted to discharge home, and PT cleared him to leave, as soon as he could get off of the floor by himself. Review of the Physical Therapy discharge summary, dated 3/26/18, did not address the frequent falls, or the resident's ability to get off the floor independently. Review of resident #146's Care Area Assessment from the Admission MDS, with the ARD of 2/19/18, showed the resident was at risk for falls, and his knees would buckle. This was not identified in the Occurrence Reports. Review of resident #146's 30 day MDS, with the ARD of 3/11/18, showed the resident used an antianxiety medication and a hypnotic, on a daily basis. These medications can contribute to the risk for falls, and were not addressed in the Occurrence Reports. During an interview on 4/5/18 at 11:38 a.m., staff member D stated falls were discussed monthly at the Quality Assurance meeting, and the facility looked at the units and halls the falls occurred on, to come up with ideas for interventions. When asked how the meeting discussions were implemented into actual fall interventions, staff member D gave an example, and for monitoring for the effectiveness of interventions, staff member D stated the facility reviews the occurrence reports daily. The frequent checks and increased supervision were not documented in the electronic records. 3. Resident #98 admitted to the facility with [DIAGNOSES REDACTED]. During an interview and observation on 4/2/18 at 4:43 p.m., resident #98 stated he fell in his bathroom, because staff did not answer his call light, and he tried to help himself. Resident #98 stated he fell on to his back. Located in the resident's bathroom was a red card (identifier for the facility fall program) on the wall behind the toilet. Review of resident #98's Annual MDS, with an ARD of 2/15/18, showed he was extensive assist of one person with all of his transfers, locomotion on and off the unit, dressing, and toilet use. The MDS showed resident #98 did not resist care. The MDS showed resident #98 was frequently incontinent of bowel and bladder. Review of resident #98's care plan, with an effective date of 3/30/11, showed a problem for falls related to history of falls, unsteady balance, and a dementia diagnosis. Interventions listed included: assist with toileting needs as needed, clip call light to clothing while up in chair, and a red card in the bathroom. Review of resident #98's occurrence report, dated 10/12/17, showed the resident attempted to self transfer and fell in the bathroom. The investigation showed the CNA placed him on the toilet then went to attend other duties. During an interview on 4/5/18 at 2:38 p.m., staff member LL stated a red card in the bathroom means the resident can not be left in the bathroom by themselves. Staff member MM stated the CNAs get the red card information and education during orientation training. Resident #98 was not supervised according to his care plan, while he was in the bathroom, resulting in a fall on 10/12/17. The occurrence report showed the root cause analysis as, other, CNA had w/c to far from the bed (sic), but this did not address the resident being left unattended. 3. Resident #164 had [DIAGNOSES REDACTED]. Review of an Occurrence Report, dated 11/29/17, showed resident #164 had a fall while sitting on a commode. The section, General Follow up Procedures, dated 12/1/17, showed the following: -Resident was placed on the commode with the use of a hoyer lift; -The hoyer lift was placed in front of the resident and to the right; -The CNA left the room; -The CNA continued to check on the resident; -Resident was found with his neck resting on the left hook of the hoyer lift and holding onto it with his hands, and his left leg was off of the commode; -The CNA lowered the resident to the ground and found that the hoyer lift had caused a wound to his neck; -The resident was sent to the ER and received stitches to the site; -There was bruising noted to the wound; -(resident's name) caused the wound when he attempted to move his left side of his body off of the commode to reposition himself after he fell forward. The CNA did not stay in the room and supervise the resident while he was hooked up to the lift and left on the commode. During an interview on 4/5/18 at 8:20 a.m., staff member B stated residents should always be supervised when in a lift. She stated the fall was unusual, and the resident was frustrated by using the lift. Staff member B stated education was provided regarding safety. The facility did not provide documentation of the education. 4. Review of a fall log provided by the facility, showed resident #25 had fallen five times since (MONTH) (YEAR). During an interview on 4/5/18 at 9:43 a.m., staff member V stated the way he knew who was on the Falling Star Program was to look for a red star on the doorway. He said if a resident was on the Falling Star Program he would check as he went by the room, looking for positioning and call light placement. He stated he regularly worked on the 200/500 unit, but he was unsure of who was currently on the Falling Star Program on the 200/500 unit because it changed frequently, and he worked other areas of the facility. During an observation and interview on 4/5/18 at 9:57 a.m., staff member B pointed out one room on the 200/500 unit which had a green star. She stated no one else was on the program, or there would have been a star on the doorway. She stated residents who have fallen in the past 30 days are included on the program, and automatically come off the program when the 30 days had passed, if no more falls had occurred. Review of resident #25's Occurrence Reports from 12/14/17 - 3/11/18, showed the following: - On 12/14/17, resident #25 was sitting in her wheelchair, and unfastened her safety belt, fell asleep, and slid out of her chair. The report showed the chair was her preferred place to sleep. - On 1/26/18, resident #25 was lying in her bed on her right side, with her head at the foot of the bed. Resident #25 said she rolled over and fell on to the floor. The interventions to prevent falls included initiating the Falling Star Program and 4Ps rounding. The root cause of the fall was identified as, Due to resident action or internal risk factors. The resident action or internal risk factors which caused the fall were not defined. - On 2/9/18, resident #25 was sitting on the foot of her bed with pillows behind her back and to her right, and with her feet dangling over the edge of the bed, fell asleep, and slid off the bed. The interventions recommended to prevent falls included continuing frequent checks, and placing a landing strip next to the bed, on the floor. The root cause of the fall was identified as, Due to resident action or internal risk factors. The resident action or internal risk factors which caused the fall were not defined. - On 2/18/18, resident #25 was dreaming, and had an incontinent bowel movement. She slipped out of her bed onto the floor. The interventions recommended to prevent falls included the Falling Star Program, 4Ps rounding, continuing frequent checks, and placing a landing strip next to the bed, on the floor. Resident #25 refused to have the landing strip on the floor next to her bed, due to the need to move her overbed table. These interventions had been previously implemented. The root cause of the fall was identified as, Due to resident action or internal risk factors. The resident action or internal risk factors which caused the fall were not defined. Staff member B stated the fall of 2/18/18, was different because resident #25 had a disturbing dream, and had an incontinent bowel movement, which was not usual for her. She stated she could not say what had been done to evaluate why resident #25 had the unusual occurrence. Staff member B stated resident #25 was transferred to the hospital the following day, 2/19/18, due to a critically elevated potassium level. She stated she could not say if the fall was related to the elevated potassium level. - On 3/11/18, resident #25 was sitting on the edge of her bed and slipped to the floor. After evaluation by the PT, it was determined resident #25's air mattress was deflating as she sat on the edge of the bed, causing her to slide off. The recommended interventions to prevent falls included replacing the air mattress, Falling Star Program, and 4Ps rounding. A different type of air mattress was provided to resident #25. The root cause of the fall was identified as equipment failure. - Resident #25 had no documented falls after the air mattress was replaced. During an interview on 4/5/18 at 9:44 a.m., staff member Q stated she would look for a red or a green star over a resident's door to determine who was on the Falling Star Program. She said the star means she was to check on the resident at least every hour for positioning and call light placement. Staff member Q stated she would set up the resident's personal items within easy reach, and be sure the call light was close, because most falls happened because the call light was not within reach. She stated she did not think there was currently anyone on the Falling Star Program on the 200/500 unit. During an interview on 4/5/18 at 2:52 p.m., staff member D stated resident #25 had a fall from her wheelchair on 10/4/17, and a fall from her bed on 10/18/17. She said the root cause of the fall from the bed was the resident kicking her legs over the edge of the bed, and falling out. She stated the bed had not been considered as a factor in the four falls from the bed between 10/18/17, and 2/18/18, because the resident rarely used her bed, and usually sat in her wheelchair. Staff member D said the bed was not identified as the common factor until the fall of 3/11/18, which was the fifth fall out of bed in five months. She stated that at the time of the falls the root cause was identified as resident #25's choice of positioning, or her movements in the bed. Staff member D stated resident #25, who resided on the 200/500 unit, was currently on the Falling Star Program. She said she had checked on Monday (4/2/18) and there was a star on the doorway at that time. Staff member D stated the effectiveness of the interventions was determined by whether a resident continued to fall. She stated continuing the interventions for frequent checks, the Falling Star Program, and 4Ps rounding had not been effective for resident #25. Staff member D stated determining the root cause, and changing the mattress had been effective and resident #25 had no falls since the mattress was changed. She stated she thought she was using the five why's of root cause analysis to establish the cause of falls, but could see that she needed to conduct a deeper investigation. No evidence was provided which indicated the use of the five why's process for any of resident #25's falls.

Based on interview and record review, the facility failed to collect measurable data, to be used during the QAPI process to identify quality deficient areas and practices, and to ensure interventions that were used to prevent falls were effective; and, failed to identify the facility staff and IDT were not identifying direct root causes for falls, for the future prevention of falls, for 5 (#s 25, 75, 98, 146, and 164) of 50 sampled and supplemental residents. Findings include: During the QAPI interview on 4/5/18 at 11:38 a.m., staff member B and D were asked for the facility process for identifying concerns, collecting data, formulating interventions, and monitoring for compliance, in regards to resident falls in the past year. Staff member D stated they had falls identified as a concern and were monitoring in QAPI. Staff member D stated falls were discussed monthly, including the times of falls, what unit, what shift, and what hall. Staff member D stated the team was coming up with ideas for interventions. She stated the team has always included falls as an identified concern in QAPI. She stated the Stop and Watch program was put into effect in (MONTH) of (YEAR). When asked what measured data the facility looked at to see if the Stop and Watch program was effective in reducing falls, staff member D stated, We don't have measured data for Stop and Watch to show it was effective. Staff member D stated the team was measuring the number of falls in a month, and the number of hospitalization s, because of the number of injuries with falls. She stated they asked for staff feed back regarding if the staff felt the interventions were working. The Falling Star Program was not mentioned, and no documentation was provided to show the Falling Star Program was monitored or implemented by the QAPI Committee. Resident concerns included: - Review of resident #25's medical record and documentation for the resident's repeated falls (four falls in less than two months), from her bed, showed the facility failed to consider the bed as a contributing factor, to include the resident's position on the bed. It was not until the resident's fourth fall that the IDT considered these factors. - Upon review of the medical records for resident #75 and #146, and fall documentation, it was identified the facility failed to identify the root cause of 31 falls, and the facility did not monitor or modify interventions to reduce the number of falls. The QAPI Committee process failed to identify individualized resident-specific fall concerns. The following was found: Review of the facility report, Occurrence Type, Falls, showed resident #75 fell 11 times from 4/22/17 through 4/5/18. Review of the facility's Falling Star program, showed the residents involved in the program would have a green star on the resident's door. Review of resident #75's medical record and Occurrence Reports, for falls, showed the resident sustained [REDACTED]. Of the falls identified, the facility failed to identify direct root causes for the repeated falls. The resident had poor cognition and recall, and put herself at risk. Interventions implemented did not correlate to the direct root causes of the falls, and individualized interventions were not monitored for effectiveness from one fall to the next. The same interventions were implemented after several falls, although the interventions were shown to be ineffective, per the medical record. During an observation on 4/5/18 at 4:40 p.m., resident #75's door did not include a green star. - Resident #146 had 20 falls from 2/14/18 to 3/27/18. Review of the Physical Therapy discharge summary, dated 3/26/18, did not address the frequent falls, or the resident's ability to get off the floor independently. Review of resident #146's Care Area Assessment from the Admission MDS, with the ARD of 2/19/18, showed the resident was at risk for falls, and his knees would buckle. This was not identified in the Occurrence Reports. Review of resident #146's 30 day MDS, with the ARD of 3/11/18, showed the resident used an antianxiety medication and a hypnotic, on a daily basis. These medications can contribute to the risk for falls, and were not addressed in the Occurrence Reports. During an interview on 4/5/18 at 11:38 a.m., staff member D stated frequent checks and increased supervision, which were documented as interventions for the residents, were not documented in the electronic records. Review of the QAPI data submitted by the facility showed falls were an identified concern. The data showed categories for: type of fall, location of fall, and the shift the fall occurred on. The information gathered under the category location showed there were 41 falls, five with an injury, in resident rooms. There was no data to show why the falls were occurring in the resident rooms on the report. Staff member D stated the falls in the rooms were looked at individually, on the occurrence reports, and then discussed. There was no trending available for review to show patterns were identified for falls in resident rooms. Review of the root cause analysis process for the falls cited during the survey showed the facility IDT did not identify true root causes of resident falls. Review of resident #98's medical record, for falls, showed the fall on 10/12/17 showed the root cause was identified to be staff not following the resident's care plan and leaving him in the bathroom without supervision. Review of the resident's Occurrence Report for the 10/12/17 fall showed the root cause analysis was, due to resident action or internal risk factors. Review of resident #164's medical record showed the staff failed to adequately supervise the resident while hooked to a lift which resulted in a fall on 11/29/17. Resident #164 sustained a laceration to his neck, which required evaluation and treatment in the ER. Review of the resident's occurrence for the 11/29/17 fall showed the root cause of the fall was due to resident action or internal risk factors. The facility failed to identify the true root cause of the fall. Documentation showed the CNA did not stay in the room and supervise the resident while he was hooked up to the lift and left on the commode, although the resident was a fall risk. During an interview on 4/5/18 at 8:20 a.m., staff member B stated residents should always be supervised when in a lift. She stated the fall was unusual, and the resident was frustrated by using the lift. Staff member B stated education was provided regarding safety. The facility did not provide documentation of the education. Review of the facility Occurrence Type, Fall report, dated 10/24/17 through 3/26/18, showed 184 residents had one or more falls in that time frame. Refer to F689 Accidents and Hazards for more detail relating to falls.

Based on observation, interview and record review, the facility failed to maintain the resident's highest well being, specifically for: the failure to provide necessary assistance for ambulation and eating; failed to monitor interventions implemented for hydration for a resident who had a decline in fluid intake when a change of condition was occurring; failed to identify root causes for exhibited behaviors, and implement interventions for the behaviors for a resident who was new to the facility, and struggling to adjust to her new surroundings; failed to provide meaningful activities of interest after the interests were identified, for 1 (#1); and failed identify and update a change in a resident's weight bearing status, and the resident's ambulation ability declined; failed to identify, monitor, evaluate and implment measures for the managment of oral pain as causal factors for weight loss and exhibited behaviors; and failed to ensure the resident had adequate fluid intake to prevent hydration concerns, for 1 (#7) out of 14 sampled residents. Findings include: 1. Resident #1 was admitted to the facility on [DATE] and discharged to the hospital on [DATE] with [DIAGNOSES REDACTED]. Resident #1 previously resided at an assisted living facility, but had admitted to a secured unit at the facility. Review of the Admission MDS, with an ARD of 8/1/16, showed resident #1 required limited assist with ambulation and eating. Review of the resident's care plan showed the following interventions: -encourage use of walker with assistance -assist of 1 for transfers -ambulates with FWW -transfer with limited assist -encourage fluid intake with and between meals -re-approach later if resident refuses -approach in calm manner -assess reasons for mood state -consider physical causes for increased agitation, respirations, or lethargy (i.e., UTI, pain, infection, constipation) Nutrition and Ambulation: Review of the resident's nurses notes, dated 7/28/16 and 7/29/16, showed resident #1 was taken to the MDR (main dining room) for meals walked by staff using 4ww (sic). Res become very argumentative when its time to come back to unit. Res was taken to MDR for breakfast meal. Dinner served in her room where she can take her time and less destruction (sic). Nurse's notes, from 7/30/16 through 8/15/16, failed to show the facility provided the needed assistance for ambulation. Review of a hand written Nutritional Assessment, no signature or date, showed a notation walk to dine. Nutritional concerns showed resident #1 needed A lot of cueing and encourage (sic). Review of the resident's dietary note, dated 7/27/16, showed the dietician observed the resident during meal time, and noted the resident needed cueing and encouragement to drink fluids and 1:1 assistance to take a bite of food. Review of the resident's meal intake record, dated 7/26/16 through 8/15/16, showed 32 out of 60 potential meals documented, and 19 out of 32 meals had less than 50% consumed. Facility documentation failed to show resident #1 received the needed assistance with eating. During an interview with a family member on 9/12/16 at 8:15 p.m., the family member stated, on one occasion she arrived at the facility at 5:00 p.m. and found a lunch tray in front of the resident with dry food and glasses full with fluids. She stated the resident was supposed to eat dinner at 6:00 p.m. in the dining room. The family member stated the resident had difficulty using eating utensils due to [MEDICAL CONDITION] arthritis, and if the resident sat for long periods of time it was difficult to move due to stiffness. The family member stated the resident walked into the facility using her walker on the day of admission. Hydration: Review of the Nutrition Assessment, dated 8/3/16, failed to identify a comprehensive list of factors that put resident #1 at risk for dehydration. Review of the resident's fluid intake record, Nutrition Assessment, clinical notes, MAR, and physician progress notes [REDACTED]. The facility failed to monitor staff implementation of the care plan interventions for hydration based on documentation of training. Refer to F327 Review of the resident's clinical notes did not show documentation from 8/10/16 through 8/14/16 regarding the resident's physical condition, except for wound care documentation on 8/10/16 and 8/12/16, for skin tears. Review of the resident's physician, history and physical, emergency room note, dated 8/15/16, showed the following regarding the resident's condition upon arrival to the ER: -O2 saturation=84% on room air -respiratory rate=38 -heart rate=159 with new onset [MEDICAL CONDITION] -white blood count=17,000 -urinalysis was consistent with urinary tract infection -severe [MEDICAL CONDITION] with sodium of 160 -dry mucous membranes -[MEDICAL CONDITION] with likely urinary tract source Psychosocial and Behavior: Review of resident #1's nurse's note, dated 7/29/16, showed the resident was Adjusting to unit (sic) as quiet and guarded. The facility did not provide further documentation of interventions implemented by staff for a resident that was new to the unit. Review of the resident's clinical notes, from 7/25/16 through 8/15/16, showed the resident refused, spit out or was unable to swallow medications on multiple occasions and often refused cares. Review of the resident's IDT notes, dated 8/3/16 and 8/10/16, showed the resident needed time to adjust to her new environment with an intervention to re-approach in a slow and calm manner if the resident refused a task. The resident's IDT notes did not reflect the possible causes for the exhibited behaviors or additional interventions to assist the resident with adjustment to the facility, or new living situation. Review of the resident's clinical notes, from 7/25/16 through 8/15/16, did not show monitoring, evaluation or modification of interventions to assist the resident with adjustment to the new environment. The resident's clinical notes did not show the resident was offered assistance to leave her room, which resulted in extended periods of time isolated in her room including meal times. A review of the resident's physician note, dated 8/1/16, showed the resident has been noncompliant often with cares, argumentative, requiring a lot of cues and frequently refusing or spitting out her medications, sometimes yelling inappropriately at the staff. Sometimes she does not understand when instructed to swallow. Review of the resident's activities note, dated 8/1/16, showed resident #1 was interested in listening to music, watching movies, being around cats, painting and spending time outdoors. The resident was provided with an activity calendar. Review of the care plan did not show the resident's interests or interventions related to her interests. Review of the resident's clinical notes, from 7/25/16 through 8/15/16, did not show the staff offered the resident activities of interest. During an interview on 9/14/16 at 1:35 p.m., staff member H stated the secure unit had a separate activities program. Staff member H stated if a resident was having difficulties with adjustment to the facility, nursing and activities would notify social services. Social services would then talk with the resident and orient the resident to where they were and where the family was. Staff member H stated there was not a specific adjustment program for resident's who were having difficulties. Review of a physician note, dated 8/1/16, (family) reports that behaviors are exacerbated each time the patient is in a new environment and that this leads to temporarily not taking medications. The physician did not address psychosocial adjustment as a possible cause of behaviors. During an interview with resident #1's physician, on 9/28/16 at 3:10 p.m., she stated the family had difficulty deciding on comfort care, and they wanted to be fairly aggressive in the resident's treatment. During an observation, on the secure unit on 9/13/16 from 11:15 to 11:20 a.m., a sensory activity was conducted with three of 33 residents participating on the secure unit, and the resident was not in attendance. During an observation, on 9/13/16 at 11:30 a.m., ten residents were seated in the common area. Staff member B stated the residents ate lunch at 12:15 p.m. due to the assistance required for eating. There was one staff member present monitoring the residents. There was no activity occurring at the time. The facility failed to engage the residents on the secure unit during the 45 minute period prior to the lunch being served. 2. Resident #7 had an original admission date of [DATE]. The resident was readmitted to the facility on [DATE] following surgical repair for a [MEDICAL CONDITION] sustained during a fall on 7/17/16. The resident was discharged to the hospital on [DATE]. Ambulation: Review of the resident's clinical notes, from 7/21/16 through 8/9/16, showed resident #7 was non-weight bearing with transfers to be done with a hoyer lift. Review of the resident's clinical notes prior to 7/17/16, showed the resident was ambulatory, therefore a decline in ambulation abilities had occurred. Review of the resident's physician note, dated 7/27/16, showed the resident went to an orthopedic appointment. The postoperative plan for the resident was weight-bearing as tolerated. Review of the resident's Physical Therapy progress notes, from 7/22/16 through 8/3/16, showed the resident was non-weight bearing to left lower extremity. Review of a Physical Therapy progress report, dated 8/10/16, showed the resident Will continue being weight bearing as tolerated based on a report received from the (bone and joint clinic), and showing the resident's weight bearing status had not been updated by the facility. A review of the resident's physical therapy notes, dated 8/10/16, showed Per the physician notes, received from the (bone and joint clinic), dated 7/27/16, Patient will continue being weight bearing as tolerated. A communication form was submitted to nursing for the resident to use the EZ stand (mechanical lift) for transfers. During an interview, on 9/28/16 at 9:25 a.m., staff member O stated when a resident goes out of the facility for a physician visit, the nurse gives the resident a packet of information for the physician to fill out regarding new orders. Staff member O stated the orders are returned in hard copy with the resident, and then communicated to the therapy department. The facility failed to notify the physical therapy department of the resident's weight bearing status, therefore the new weight bearing status was not implemented immediately following the 7/27/16 appointment. During an interview, on 9/28/16 at 9:55 a.m., staff member B stated when a resident went to the doctor an envelope was sent with the resident's face sheet, blank physician order [REDACTED]. During an interview, on 9/28/16 at 10:15 a.m., staff members M and N stated the transport list was received daily. Staff members M and N stated if the resident returns without paperwork from the physician visit, medical records faxed a request for a record of the visit. If the record was not received within a few days, medial records then called the physician to follow up. The facility failed to follow up and obtain documentation for resident #1 following an orthopedic appointment on 7/27/16. Behavior, Weight, and Pain: Review of the resident's pain evaluation, dated 7/30/16, showed the following: -Staff assessment of pain; Indicators of pain included facial expressions, non-verbal sounds, protective movements/postures and vocal complaints of pain. -Frequency; indicators of pain or possible pain observed daily. -Comments; resident seems to be in a lot of pain when she is checked and changed, also when she is being fed, her teeth are black in color and one appears to be very loose. The teeth she does have in her mouth appear very decayed. -Evaluation detail; pain presence, hip and oral pain -Character of pain; resident was unable to verbalize. Expressed pain with agitation, restlessness and anger. Review of the resident's clinical notes, dated 7/23/16 through 8/26/16, showed increased behaviors including, removing clothing while in bed and smearing feces, intermittently refusing medications, grimacing when staff attempted to change her, guarding mouth, blocking face and mouth, and refusing food and fluids. The facility failed to identify the causal factors for the resident's behaviors. Review of the resident's care plan showed poor dentician with oral pain identified as a problem on 5/27/15. The care plan lacked evidence for any modification to the plan relating to the poor dentician. Review of a clinical note, dated 8/7/16, showed staff identified the resident needed to see a dentist because of oral pain. The facility failed to obtain dental services, for resident #7, for 15 months after identification of the problem. Review of the weights for resident #7 showed the following: -7/25/16=109 lbs -7/26/16=106 lbs -7/29/16=96 lbs -8/2/16=102 lbs -8/5/16=resident refused -8/12/16=99 lbs -8/17/16=92 lbs -8/19/16=92 lbs -8/24/16=91 lbs Review of the resident's meal intake record from 7/22/16 through 8/25/16, showed 52 out of 102 potential meals documented. The resident consumed less than 50% of meals in 20 out of 52 meals documented. Review of the resident's dietary clinical note, dated 8/12/16, showed the resident had a very significant 14% weight loss and assess resident's intakes (sic), may improve once dental pain is resolved. The resident's diet was changed to puree, Ensure was discontinued and Hormel plus was added four times daily. The resident's weight continued to decline after implementation of the interventions on 8/12/16. Review of a dietary note, dated 8/18/16, showed the residents Current weight 92.4 lbs., showed significant weight loss(sic). Intakes of 11 puree meals recorded x past week (sic) averaged 37%, with 0-240 cc fluids consumed q meal (sic). Hormel plus2 continues at 120 cc qid (sic). Assess no further changes appropriate at this time, with resident's overall condition unlikely to improve until poor oral health, with accompanying pain, resolved. There was a lack of evidence in the medical record for follow up action taken up to the resident's discharge on 8/26/16. During an interview on 9/28/16 at 8:00 a.m., staff member U stated the line of communication for resident changes in condition was to notify the physician by facsimile, and notify the dietician verbally. During an interview on 9/28/16 at 8:35 a.m., staff member R stated the nurse was to be notified if a resident had a weight loss of two to three pounds. During an interview on 9/28/16 at 9:25 a.m., staff member Q stated any change in a resident would be reported to the nurse. During an interview on 9/27/16 at 11:45 a.m., staff member F stated there was no specific number for the amount of weight loss before the dietician was notified. Staff member F stated weights were done using different methods. Staff member F stated it would be preferable to have one specific person responsible for obtaining weights on each unit, but stated this hadn't been addressed with the facility. Staff member F stated the weights were reviewed in correlation with the resident's MDS schedule unless the resident was identified by nursing for weight loss. Hydration: Review of the resident's fluid intake record from 7/22/16 through 8/25/16, showed a significant decrease in fluid intake from 8/8/16 through 8/25/16. The facility failed to show the physician was notified of the reduced fluid intake. The facility failed to ensure the resident had adequate fluid intake to prevent dehydration. Refer to F327

Based on record review and interview, the facility failed to provide the necessary services, specifically to arrange for medical treatment of [REDACTED].#1) of 5 sampled residents. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Clinical Notes showed: On 12/25/15 at 2:31 a.m. nurse documented CNA reported resident with two darkened areas to R foot. This nurse observed 2 black spots to R (right) foot, one located under grt (great) toe and the other on heel. Both wounds dry, no redness to surrounding tissue, no drainage. On 12/29/15 the wound nurse documented 12/26/15 - seen resident per staff notification, residents right foot, great toe and heel has deep tissue injury black discoloration, no drainage, no exudate, no open wounds observed. Area cleansed with NS, pat dry, cover with foam, provided prevalon boots to offload pressure. MD faxed for new orders. The note continued, 12/29/15 dressing change done per policy protocol, area remained dry and intact no drainage, no open area observed, will continue care plan. Review of the fax sent to the physician showed the wound size of the great toe to be 1.2 cm X 1 cm and had black discoloration with no drainage or exudate and requested orders to cover area with foam, change every other day. This was faxed on 12/25, 12/29 and again on 1/4/16. On 1/4/16, the facility received a fax from the physician stating needs appt please. On 1/6/16 a notation was made on the fax that son will make appointment. Review of the physician note dated 1/6/16 under History of Present Illness: Has developed .a dime sized right great toe black eschar consistent with developing pressure wound. She is diabetic as well. Under Assessment and Plan: Continue with wound care. Reevaluate if not better in 3 weeks or sooner if worsening. On 1/8/16, the wound care nurse documented right great toe to be 1.3 cm X 1.3 cm black discoloration, no drainage, no exudates, no open wounds observed. Will continue care plan. The medical record did not have documentation the physician had been notified of the increase in the size of the wound. On 2/5/16 at 3:05 a.m., the night nurse documented Drsg (dressing) changed to R grt toe. Old drsg observed with light green colored drainage. On 2/5/16 at 10:45 a.m., the wound nurse documented. right great toe base - stage III - 1.2 cm X 1.2 cm slough base, no drainage, no exudates, no open wounds observed. Right great toe nail still partially separated form nail bed, scant drainage, yellowish exudates. MD faxed for new orders. Review of the fax dated 2/5/16 to the physician showed the size and appearance of the right great toe. The wound nurse requested new orders for dressing change and a request to schedule a podiatrist appointment. The fax back to the facility on [DATE] contained no documentation from the physician, only a signature. Resident #1 saw the physician on 2/8/16 with no new orders in regards to the right great toe. On 2/12/16, the wound nurse measured the R great toe wound to be 1.2 cm X 1.2 cm. On 2/19/16, the wound nurse measured the right great toe wound at 1.5 cm X 1.5 cm. On 2/26/16, the wound nurse measured the right great toe as unstageable at 1.2 cm X 1.5 cm. On 2/29/16 at 4:15 a.m,. the nurse documented, R grt (sic) toe appears with redness. Resident appeared to have much pain during handling of the R grt toe also. Wound nurse notified via email of this nurse's concerns of resident's R grt toe. On 3/1/16 at 7:25 a.m., the nurse documented did tx to right foot gr (sic) toe has a black spot on top or r toe. On 3/3/16 at 3:03 a.m., the nurse documented. R grt toe wound remains dark in color while the toe conts (sic) to appear reddened and very tender to touch. No active drainage, no foul odor noted. On 3/3/16 at 2:46 p.m. the wound nurse documented right great toe unstageable 1.8 X 1.9 cm eschar base, no drainage, no exudates, intact edges. Blanchable redness surrounding area c (with) 2 [MEDICAL CONDITION] over dorsal foot. MD faxed for new orders. Review of the fax sent to the physician on 3/3/16 showed the wound nurse gave an overview of the wound and requested labs. On 3/7/16 the facility received a fax from the physician stating needs evaluation in office. Review of the record did not reflect the resident was seen by physician. On 3/7/16 at 9:32 a.m. the nurse documented right foot was done gr (great) toe black area is lifting. On 3/8/16 at 4:29 a.m., the nurse documented R grt toe and top of foot remain reddened in color. No active drainage or odor noted. R grt toe wound appears to be the same, no better .some discomfort while cleansing R toe. On 3/9/16 at 2:46 a.m. the nurse documented, R grt toe remains unchanged since last night. Redness noted to toe and top of foot. Resident appears to have discomfort during treatment. On 3/11/16 at 11:38 a.m., the wound care nurse documented, right great toe 1.8 X 1.9 cm eschar base, no drainage, no exudates, intact edges. Blanchable redness surrounding area c 2 [MEDICAL CONDITION] over dorsal foot. no change. MD faxed for new orders. Review of the fax sent to the physician specifically addressed the heel wound, not the toe wound. On 3/11/16 at 3:27 p.m. the nurse documented the son came to visit and he informed the nurse that res (resident) would be seeing the physician on 4/11/16 regarding the wound. On 3/13/16 at 4:54 a.m. the nurse documented. R grt toe wound appears unchanged since the last time this nurse seen on 3/8/16. Surrounding tissue remains reddened, resident appeared to have discomfort during treatment. On 3/14/16 at 4:06 a.m. the nurse documented Again resident appeared to experience discomfort with treatment to grt toe. On 3/15/16 at 4:22 a.m. the nurse documented did tx to r grt toe and black area on top of toe is loosing (sic) scant drainage. On 3/16/16 at 1:52 p.m., the wound nurse documented, right great toe unstageable 1.5 X 1.5 cm eschar base, not drainage, no exudates proximal edge separates with pink viable tissue. Will continue care plan. On 3/18/16 at 4:22 a.m. the nurse documented Old drsg to R grt toe noted to have small amount tan colored drng (drainage), no odor. Surrounding tissue conts (continues) to be reddened and toe is tender to touch. On 3/22/16 at 3:45 a.m. the nurse documented Old drsg to R grt toe with tan/reddish colored drng (drainage). Toe and top of R foot remains with reddened color. Resident did not voice any c/o pain but did wince .Wound to R toe does not appear to be improving. On 3/25/16 at 7:46 a.m. the nurse documented gr toe (right) is starting to loosen on edges site is very tender. On 3/25/16 at 12:17 p.m. the wound nurse documented right great toe unstageable 1.8 X 1.8 cm slough, no drainage, no exudates, proximal edge separates with pink viable tissue. On 3/27/16 at 2:39 a.m. the nurse documented Wound center to R grt toe is loosened around the edges, pink tissue observed underneath. The toe and top of foot is not reddened but rather dark pink in color. Toe is very tender to touch. On 3/28/16 at 3:01 a.m. the nurse documented Toe remains very tender to the touch. On 3/29/16 at 7:17 p.m. the nurse documented Res has thickened nail on her 3rd toe and great to on L foot. Dressing applied to affected area. Son was in to visit and informed. MD fax if res qualify for podiatry consult as family agreed. Awaiting for reply. Review of the fax sent on 3/29/16 to the physician reflected, order received for pod. (podiatrist) consult on 3/31/16. On 3/30/16 at 3:24 p.m. the nurse documented res went to see Dr. (name) this morning. Son went with her. Res has gangrene of R great toe - concern of osteo[DIAGNOSES REDACTED]. Urgent podiatry referral for possible amputation. On 3/31/16 at 2:41 p.m. the nurse documented Please transfer to (hospital name) for IV ABX and surgery for [REDACTED]. On 4/4/16 at 8:59 a.m. the wound nurse documented 3/31/16 dressing to right great toe done per MD orders 1.8 X 1.8 eschar base, slough over edges, no drainage, no exudates, proximal edge separated with pink viable tissue. Review of the physician visit on 3/30/16 shows History of Present Illness: Chief complaint foot problem. Exam of her feet reveals a foul smelling distal great toe wound associated with great toe swelling and [DIAGNOSES REDACTED] concerning for deep tissue infection such as osteo[DIAGNOSES REDACTED]. Assessment and Plan: Gangrene of toe. Deep, purulent eschar over right great distal toe with swelling and [DIAGNOSES REDACTED] of great toe very concerning for chronic wound now with deep tissue or osteo[DIAGNOSES REDACTED]. Will arrange for urgent, hopefully today, consult with podiatry. Review of a Brief Operative Note by the podiatrist showed wet gangrene distal right hallux ulcer with suspected osteo[DIAGNOSES REDACTED] and amputation of right hallux with disarticulation at first metatarsal phalangeal joint. During an interview on 4/20/16 at 11:00 a.m., a family member stated that while visiting his mother he was concerned about the third toe. He was unable to see the great toe because it was wrapped. He requested his mother see the doctor about the third toe on her right foot. They got in to see the doctor on the 3/30/16 and she had her toe amputated on 4/1/16. He further stated he was not told that the wound on her toe was getting worse. He stated the odor of the foot was bad, almost of something dead. During an interview on 4/20/16 at 10:05 a.m., staff member D stated he would see residents with wounds weekly to assess unless, he received an email from nursing of changes with the resident. Staff member D also stated he would send faxes to the physician when there was a change in a resident's condition. Staff member D stated he did not have formal wound care training and had learned so far by following other wound care staff at his facility and another facility, and thought he would receive formal education for wound care in the future. During an interview on 4/20/16 at 2:50 p.m. staff member A stated resident #1's son would usually make the appointments for his mother and had scheduled an appointment for her foot/toe on 4/11/16. During an interview on 4/20/16 at 1:06 p.m., staff member A stated if a wound was found on a resident, the wound nurse would be notified, the physician would be contacted by phone or fax, and the family would be notified. The staff member stated if the physician did not respond to a fax within the day, depending on the seriousness of the resident, he would call the physician. The staff member stated if a resident's wound worsened, he would contact the family. During an interview on 4/20/16 at 1:15 p.m., staff member B stated if a wound was found on a resident, a fax would be sent to the physician. Depending on the severity of the wound, he would call the physician. The staff member stated he would contact the family if a wound was found on a resident. If a resident's wound worsened, he would notify the family and the physician.

Based on interview and record review, the facility failed to ensure the resident was free from verbal abuse resulting in psychosocial harm for 1 (#14) of 30 sampled and supplemental residents. Findings include: Resident #14 was admitted to the facility with the [DIAGNOSES REDACTED]. Review of the resident's most current MDS assessment dated [DATE] showed the resident had moderate cognitive impairment and required total assistance with personal hygiene and extensive assist with transfers, toileting and bathing . During the group interview on 12/15/15 at 10:00 a.m., resident #14 stated staff member B yelled at her, using profanity on Saturday (12/12/15) around 9:30 p.m. Resident #14 stated staff member C had heard staff member B yelling and using profanity at her and was told to apologize. Resident #14 stated staff member B worked Monday night (12/14/15) on the hall that she lived, which resulted in resident hiding in her room to avoid staff member B. Resident #14 stated she was worried about intimidation and retaliation from staff member B. During an interview on 12/15/15 at 9:00 a.m., resident #14 stated she had been subjected to verbal abuse on Saturday 12/12/15 at 9:30 p.m. The resident stated she was at the nurse's station working on a gingerbread house when staff member B yelled at her and was using the F-word. The resident explained that staff member B told her she did not have time to deal with her working on the gingerbread house. She was busy and didn't have f---ing time to do it, and she was the only f---ing one on the floor. Resident #14 stated there were other people nearby that witnessed the altercation. The resident stated staff member C told staff member B she needed to stop yelling at resident #14 and apologize. The resident stated staff member B refused to apologize. The resident stated she was embarrassed and cried and stayed in her room the rest of that evening. The resident stated she told staff member C she did not want staff member B to care for her. She stated staff member B worked on Monday night, and she stayed in her room to avoid looking at staff member B. She stated facility staff had not spoken with her about the incident, nor told she would not be exposed to staff member B until the allegation would be investigated. The resident stated she actively participates in the facility activities, and is a volunteer for the enrichment program. She shared one of the best things for her about living at the facility were the activities she could participate in. During the interview, resident #14 had tears in her eyes and verbalized she was upset and not sure if staff member B would continue to care for her in the near future. During an interview on 12/15/15 at 2:20 p.m., staff member C stated on Saturday (12/12/15), around 10:00 p.m., resident #14 was at the nurse's station working on a ginger bread house when staff member B was verbally abusive toward resident #14. Staff member C stated staff member B used the F-Word toward the resident. Staff member C stated she approached staff member B and told her she was inappropriate. She insisted staff member B apologize to resident #14 and arranged for staff member B to work a different hall, but did not arrange for staff member B to be removed from her duties that evening. Staff member C stated she felt staff member B was over worked and felt she was showing signs of burnout. Staff member C stated she called and left a non-detailed message with staff member D regarding the incident on the evening of Saturday (12/12/15), but did not actually report the incident until Monday morning (12/14/15) to staff member D. Staff member C stated she did not report the incident to her immediate supervisor, the charge nurse, that evening since she felt the incident was an issue with a CNA and needed to be reported to the CNA supervisor. Staff member C stated staff member B worked Monday night (12/14/15), the same hall that resident #14 resided, but was told not to assist resident #14. During an interview on 12/15/15 at 1:30 p.m., staff member D stated she was made aware of the alleged verbal abuse by resident #14 on 12/14/15. Staff member D stated currently the facility was in the middle of investigating the report. Staff member D stated the facility policy was to report to the DON and administrator within 24 hours, interview the resident, fill out a risk watch abuse form and protect the resident. Review of the facility form titled Investigation Audit Tool reflected the name of both resident #14 and staff member B with an initial report date of 12/15/15. Review of the facility staffing schedule dated 12/14/15 reflected staff member B worked on the hallway that resident #14 resided from 6:00 p.m. to 6:00 a.m. During an interview on 12/15/15 at 11:26 a.m., staff member A stated she was not aware of any concerns regarding staff to resident abuse. Staff member A stated if she was aware of any such abuse, the staff member would be suspended until an investigation could be completed. During an interview on 12/16/15 at 7:13 a.m., staff member A stated she was told about an incident involving a staff member to resident abuse, but had not been made aware of all the details.

Based on interview and record review, the facility failed to prevent further potential verbal abuse while the alleged violation was thoroughly investigated, which resulted in psychosocial harm for 1 (#14) out of 31 sampled and supplemental residents. Findings include: Resident #14 was admitted to the facility with the [DIAGNOSES REDACTED]. During an interview on 12/15/15 at 9:00 a.m., resident #14 stated she had been subjected to verbal abuse on Saturday 12/12/15 at 9:30 p.m. Resident #14 stated staff member B worked Monday night (12/14/15) and she stayed in her room to avoid looking at staff member B. Resident #14 stated no staff person came to her and asked her what had happened prior to staff member B working on Monday night. During the interview, resident #14 had tears in her eyes and verbalized she was upset and not sure if staff member B would continue to care for her in the near future. During an interview on 12/15/15 at 1:30 p.m., staff member D stated she was made aware of the alleged verbal abuse by resident #14 on 12/14/15. Staff member D stated currently the facility was in the middle of investigating the report. Staff member D stated the facility policy was to report to the DON and administrator within 24 hours, interview the resident, fill out a risk watch abuse form and protect the resident. The facility failed to report the abuse allegation to the State Agency within 24 hours of the incident. The facility was notified on 12/24/15 which was 48 hours after the allegation occurred. During an interview, on 12/16/15 at 7:00 a.m., staff member I stated any person who witnessed potential abuse or was told of a potential abusive event should report the information ASAP (within 5-10 minutes) to the unit nurse or their supervisor. The staff person should complete a written statement of the event. The unit nurse or supervisor would share findings with the charge nurse. The charge nurse or supervisor would begin the abuse investigation and a nursing note would be written in their EHR. The administrator, doctor, and the family representative should be notified within 30 minutes to one hour. The ombudsman would be notified, as needed. The state agency should be notified within 24 hours and a follow-up investigated in five days. The staff person identified as the potential abuser should be removed from the floor and interviewed by the unit nurse, charge, or supervisor. The staff person identified as the potential abuser would probably be sent home until the investigation is completed. The staff person would be removed from the unit where the resident/potential victim lived. The staff person identified as the potential abuser would usually be taken off the work schedule, and not allowed back to work until the facility deemed it safe. Staff member I stated the potential abuse event on 12/12/15, was currently being investigated. She was not sure why staff person C on 12/12/15 did not notify the administrator or the DON within one hour of the event. Staff member I was not aware that staff member B worked the evening of 12/14/15. Staff person B was taken off the work schedule effective 12/15/15. Review of the facility form titled Investigation Audit Tool, reflected the name of both resident #14 and staff member B with an initial report date of 12/15/15. Review of the facility staffing schedule dated 12/14/15 reflected staff member B worked on the hallway that resident #14 resides from 6:00 p.m. to 6:00 a.m. During an interview on 12/15/15 at 11:26 a.m., staff member A stated she was not aware of any concerns regarding staff to resident abuse. Staff member A stated if she was aware of any such abuse, the staff member would be suspended until an investigation could be completed. During an interview on 12/16/15 at 7:13 a.m., staff member A stated she was told about an incident involving a staff member to resident abuse, but had not been made aware of all the details. In an interview on 12/16/15 at 9:05 a.m., resident #14 stated she participated in her usual activities on 12/15/15 during the day. The resident stated no staff had spoken to her about whether staff member B would be working on her hall again or coming in to her room to help her roommate.

Based on record review and interview, the facility failed to provide screening and implement the policy and procedures for abuse resulting in psychosocial harm for 1(#14) of 25 sampled residents. Specifically the facility failed to run a background check on a staff member prior to hiring, did not provide abuse training during orientation, and the facility failed to report allegations of abuse to the state agency within 24 hours. Findings include: 1. Review of the 24 hour initial report provided by the facility, an allegation of abuse occurred on 12/13/15. The facility did not notify the State Agency until 12/15/15. See F223. Review of the Abuse Policy with an approval date of 11/16/2015 showed, Policy Explanation and Compliance Guidelines: l. Report allegation or suspected abuse .immediately to Administrator. Included in the Policy is an Initial 24 Hour Report Form. V11. Anyone in the facility can report suspected abuse. During an interview on 12/15/15 at 1:30 p.m., staff member D stated she became aware of the alleged verbal abuse of resident #14 on 12/14/15. The facility was in the middle of investigating the report at the time of this interview. Staff member D stated the facility policy is to report to the DON and the administrator within 24 hours, interview the resident, fill out a Risk Watch Abuse form and protect the resident. 2. Review of staff member B's personnel file showed a date of hire of 5/2015. Staff member B's file also contained a Code of Conduct Acknowledgement Form and a Policy and Procedure on abuse form. Both were signed on 5/19/15. Review of the Policy and Procedure on abuse signature form states, Abuse of any nature is not acceptable, there (sic) can include neglect, intimidation, verbal, sexual, physical, and mental abuse, involuntary seclusion or misappropriation of resident property. All abuse allegations will be investigated. Review of the Code of Conduct and Ethical Standards paperwork provided by the facility did not specifically address abuse. Review of the Abuse Policy provided by the facility showed: ll. Employee Training; New employees should be educated on abuse, neglect and exploitation during initial orientation. lll. Provide education on what constitutes abuse. Supervise staff identify inappropriate behaviors, such as using derogatory language. Review of the New Employee Orientation Outline showed between 11:15 a.m. and 12:00 p.m. Resident Rights and Recognizing and Preventing Resident Abuse Video was presented by Social Services. Review of the Inservice Sign in Sheet, titled Facility Orientation, provided by staff member E, did not show staff member B's signature of attendance. During an interview on 12/16/15 at 2:10 p.m., staff member E stated all new hires have orientation, even if it is just one employee, and sign a form showing they attended. The orientation included abuse training. 3. A review of staff member B's personnel file showed a date of hire of 5/2015. A request was made to the facility on [DATE] for a background check on staff member B. A review of the background report, provided by the facility, dated 12/15/15, showed a background check had been ordered. During an interview on 12/15/15 at 3:45 p.m. staff member A stated the background report was not the original background report. A second request for the original background report was requested at that time. The original background report was not provided before the end of the survey.