Every finding on record at Vivo Healthcare Clewiston

Based on review of the clinical record, review of facility policy and procedure and staff interview, the facility failed to ensure freedom from significant medication error for 1 (Resident #999) of 3 residents reviewed for accuracy of medications. Failure to administer medications accurately puts residents at risk for adverse health consequences.The findings included:Review of facility provided policy and procedure titled Medication Administration with a date implemented of 9/2023 and a date reviewed/revised of 1/2026 revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . Policy Explanation and Compliance Guidelines: . Review MAR (Medication Administration Record) to identify medication to be administered. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects .Review of Resident #999's medical record revealed an admission date of 5/26/26. Diagnoses included chronic obstructive pulmonary disease, heart failure, pulmonary hypertension, adult failure to thrive and chronic respiratory failure with hypoxia (low level of oxygen in body tissues).Resident #999 received hospice services at the facility.Review of the nursing progress notes revealed that on 6/5/26 at 11:30 a.m., Licensed Practical Nurse (LPN) Staff A documented that Resident #999 complained of shortness of breath, was very anxious. The nurse documented that PRN (as needed) morphine sulfate 0.5 ml was administered with little relief. Resident #999 continued to verbalize that she couldn't breathe. LPN Staff A documented, This writer in error administered 30 mg tablet of MS Contin scheduled for q8h (every eight hours). Upon discovery of error, resident was reassessed, vital signs were stable, blood pressure was 128/80, pulse was 100, respiratory rate was 22, oxygen stats rechecked and were at 95%. Primar, family and hospice notified of error. New order received to continue to monitor resident.Review of the physician's orders revealed two orders for Morphine Sulfate:MS (Morphine Sulfate) Contin (ER) extended release oral tablet 30 milligrams (mg) give 1 tablet by mouth every 8 hours for pain. The medication was scheduled to be administered at 6:00 a.m., 2:00 p.m., and 10:00 p.m. (Start date 5/26/26).Morphine Sulfate (Concentrate) Oral Solution 100 mg/5 milliliters (ml) give 0.5 ml by mouth every 1 hour as needed for moderate to severe pain 4-10 or shortness of breath. (Start date 5/26/26).Review of the Medication Monitoring Control Record revealed that Resident #999 was administered one tablet of Morphine Sulfate 30 mg ER at 6:00 a.m. The next dose was scheduled to be administered on 6/5/26 at 2:00 p.m. The Medication Monitoring Control Record noted that on 6/5/26, Licensed Practical Nurse (LPN) Staff A administered one tablet of Morphine ER to Resident #999 at 8:30 a.m., 9:30 a.m., and 11:00 a.m.On 6/18/26 at 11:55 a.m., in an interview, the Director of Nursing (DON) said that on 6/5/26, she went to the room with LPN Staff A and assessed Resident #999. She said the resident was in distress. She was anxious and had trouble breathing. She instructed LPN Staff A to administer the PRN Morphine Sulfate and left the room. She said that LPN Staff A came to her and notified her that she had administered the wrong medication to Resident #999. She administered 3 tablets of MS Contin 30 mg ER to the resident instead of Morphine Sulfate (Concentrate) Oral Solution 100 mg/5 milliliters (ml), 0.5 ml by mouth every 1 hour as needed. She said that LPN Staff A could not explain how the error occurred.On 6/18/26 at 1:09 p.m., in an interview, the Administrator said the facility did not have an annual review for competencies for licensed nurses. The Administrator said, We follow the yearly education calendar.On 6/18/26 at 1:11 p.m., in an interview, the DON said she has been employed at the facility for 2 months and was also the Risk Manager for the facility. The DON said she did not have an investigation into the root cause of the medication error. The DON said she pulled LPN Staff A her from the medication cart and educated her 1-1 that she needed to check to make sure the medications are correct. The DON said the focus was really with LPN Staff A. The DON said she was going to in-service the nurses again on the 5 rights of medication but had not gotten to it yet.On 6/18/26 at 2:36 p.m., in an interview, the DON said that the Pharmacy completes observations of medication administration but confirmed this had not been done recently. She said that she has not completed any medication observations with the licensed nurses.

Based on observation, record review, resident and staff interviews, the facility failed to provide routine nail care to meet the needs and preferences of 1 (Resident #144) of 3 residents dependent on staff for Activities of Daily Living (ADL) needs reviewed.The findings included:Review of the facility's policy and procedure for Nail Care with a date reviewed/revised of 1/2026 revealed, The purpose of the procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health . Assessment of resident nails will be conducted on admission and readmission to determine resident's nail condition, needs and preferences for nail care, if possible . Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nails care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises.Review of the clinical record for Resident #144 revealed an admission date of 5/26/26. Diagnoses included muscle wasting and atrophy, diabetes type 2, and pneumonia.Review of the admission Minimum Data Set (MDS) assessment with an assessment reference date of 6/1/26 revealed that Resident #144 scored 13 of 15 in the Brief Interview for Mental Status, indicating intact cognition. The MDS noted that Resident #144 required substantial/maximum assistance with personal hygiene.The care plan initiated on 5/26/26 revealed that Resident #144 had an ADL self-performance deficit for bathing and showering. The goal was for the resident to maintain current level of function in ADLs through the next review date. The interventions included to check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse.Review of the Certified Nursing Assistant (CNA) documentation in the Plan of Care response revealed that nail care was performed on 5/27/26 and 5/31/26 at 2:59 p.m.On 6/1/26 at 3:47 p.m., during observation and interview, Resident #144's right hand fingernails were observed to extend approximately one inch from the fingertip. The fingernails were jagged and had a black substance under the nails. Resident #144 said that no one at the facility asked him about nail care since his admission, about a week ago. He said that he did not have a nail clipper and that he was not able to clip his fingernails himself. He said that if given the choice, he would have his fingernails clipped or filed down. On 6/3/26, review of the nurse's weekly skin observation dated 6/2/26 with an effective date of 6/2/26 at 10:18 p.m., revealed that the nurse checked Yes for the question, Nails cleaned and trimmed? On 6/3/26 at 10:15 a.m., Resident #144 was observed in his room. The resident's fingernails remained long and jagged, extending approximately 1 inch from the tip with a black substance under the nails. In an interview, Resident #144 said that he got a bed bath last night, but no one trimmed his nails. He said he would have told them he wanted them trimmed short but no one offered. Photographic evidence obtained. On 6/3/26 at 11:09 a.m., in an interview, CNA Staff C said that on 5/27/26, she performed nail care for Resident #144. She said that his nails were not long. CNA Staff C said that sometimes Resident #144 refuses care but that on 5/27/26, he did not refuse the nail care.On 6/3/26 at 11:30 a.m., in an interview, the Occupational Therapist said that she noticed Resident #144's right hand fingernails were very long, but she forgot to tell the nurse. On 6/3/26 at 11:35 a.m., in an interview, Licensed Practical Nurse (LPN) Staff E said she check the resident's blood glucose via fingerstick to the left hand fingers. She did not notice that the resident's right hand fingernails were long. She said the CNA did not notify her.On 6/3/26 at 11:40 a.m., in an interview, Unit Manager LPN Staff A verified that on 6/2/26 the nurse documented that Resident #144's fingernails were cleaned and trimmed. She said when she met with Resident #144, she did not notice that the resident's right hand fingernails were long and dirty. On 6/3/26 at 11:45 a.m., in an interview, the Director of Nursing (DON) said that on 6/2/26, the nurse should not have documented in the head to toe assessment that the resident's nails were cleaned and trimmed and should have recognized that Resident #144's fingernails needed to be trimmed. The DON said that She said that the staff should not have documented that nail care was performed when it was not.

Based on observation, clinical record review, and staff interviews, the facility failed to provide housekeeping services to maintain a clean and sanitary environment for 1 (Resident #8) of 5 residents reviewed for environment.The findings included: Review of the clinical record for Resident #8 revealed a date of admission of 8/13/23. Diagnoses included Multiple Sclerosis (chronic central nervous system autoimmune condition), seizure disorder, and malnutrition.Review of the Significant Change in Status Minimum Data Set (MDS) assessment with an assessment reference date of 4/16/26 revealed that Resident #8 received nutrition through a gastrostomy feeding tube (tube placed directly into the stomach through the abdominal wall).On 6/1/26 at 10:00 a.m., Resident #8 was observed in bed receiving enteral nutrition via the gastrostomy tube connected to a feeding pump that was mounted on a pole.The pump, the pole, the five-legged base of the pole, and surrounding floor were visibly soiled with multiple dried brown splashes and residue of enteral formula. A large puddle of dried-up residue was observed on the floor, under the base of the pole.During multiple observations on 6/2/26 at 9:30 a.m. 10:20 a.m., 12:30 p.m., 2:00 p.m., 6/3/26 at 2:00 p.m., and 6/4/26, the feeding pump, pole and surrounding floor of Resident #8's room were observed and remained soiled with multiple dried brown splashes and residue of enteral formula. The large puddle of dried-up residue remained on the floor, under the base of the pole. Photographic evidence obtainedOn 6/4/26 at 8:20 a.m., in an interview, the Director of Nursing said that the nurses should have cleaned the pump, the pole and the floor.On 6/4/26 at 11:00 a.m., in an interview, the Administrator said that there was no one specifically assigned the task to monitor residents' equipment. She said that sometimes the housekeeping department cleans the poles.

Based on observations, record review, resident representative and staff interviews, the facility failed to evaluate and determine whether the use of bed bolsters was an appropriate and effective intervention to minimize the risk of falls for 1 (Resident #5) of 2 residents reviewed for falls.The findings included:Review of the clinical record for Resident #5 revealed a readmission date of 1/7/26. Diagnoses included: Sepsis following a procedure for a wound; Respiratory failure with hypoxia (condition where body is deprived of adequate oxygen); Chronic Obstructive Pulmonary Disease (COPD); Malnutrition and Dementia.Review of the Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 4/16/26 revealed Resident #5 scored 3 out of 15 on the Brief Interview for Mental Status, indicating severe cognitive impairment. The MDS noted that Resident #5 was dependent for rolling left to right in bed and chair to bed transfer.Review of the care plan for Resident #5 revealed a focus of Risk for falls related to decreased mobility, receiving opioid analgesic, resident tends to place himself into floor from bed. The goal was for the risk for falls to be minimized through the next review.Interventions included: Bilateral bolsters to bed (date initiated 1/9/26); encourage to wear nonskid socks while out of bed; landing to left side of bed; low bed for safety (date initiated 9/29/25).On 6/1/26 at 12:08 p.m., 6/2/26 at 9:13 a.m., and 6/3/26 at 10:23 a.m., Resident #5 was observed in bed, lying on his back. Rectangular padded bolsters were positioned along the inner side of the bed, extending approximately from the head of the bed to three-quarters of the distance toward the foot of the bed. The bolsters were tied to raised grab bars on both sides of the bed and extended vertically higher than the raised grab bars. Photographic evidence obtainedOn 6/3/26 at 10:30 a.m., in an interview, the Director of Rehabilitation (DOR) stated that the purpose of the wedge bolsters were to provide lateral support for Resident #5, maintain his position in bed and keep him from falling out of bed. The DOR stated the grab bars were placed at the family's request. The DOR stated that Resident #5 can sometimes follow commands and may be able to use the grab bars for repositioning. The DOR stated that it was nursing's decision to use the bolsters.On 6/3/25 at 11:15 a.m., in an interview, Licensed Practical Nurse (LPN) Unit Manager Staff A said that the wedge bolsters were placed on the bed to prevent Resident #5 from falling out of bed. She said Resident #5 had been falling a lot and the bolsters were a fall intervention. LPN Unit Manager Staff A stated that she did not consider the bolsters to be a restraint since Resident #5 had fallen, even with the bolsters. She said that the resident was able to climb over the bolsters. LPN Unit Manager Staff A acknowledged that the bolsters were not an effective fall intervention since the resident had fallen with the bolsters in place. LPN Unit Manager Staff A acknowledged that the bolsters prevented Resident #5 from accessing the grab bars for repositioning.On 6/3/26 at 11:15 a.m., in an interview, the Director of Nursing said that the wedge bolsters were placed to keep Resident #5 from rolling out of bed. She acknowledged that the bolsters prevented Resident #5 from accessing the grab bars to reposition himself in bed and said that it was not an issue since the resident did not use the grab bars anymore.During an interview with Resident #5's daughter/Power of Attorney (POA) on 6/3/26 at 1:45 p.m., she stated that she visits with her father every day. She stated that the purpose of the assist grab bars are to keep her father in bed. The daughter stated that the purpose of the blue wedge bolsters was to keep her father in bed because he had a lot of falls. The daughter acknowledged that he has had falls even with the bolsters in place. She said that her father had to scoot himself to the bottom of the bed to get out.Review of Resident #5's clinical record revealed a progress note dated 10/9/25 that Resident #5 had a fall without injury. He was placed in bed by staff with wedges. Resident #5 had two falls prior to the fall on 10/9/25 and four falls since the implementation of the wedges.Review of Resident #5's clinical record did not reveal any assessments, informed consents, or physician orders for the placement of the wedge bolsters on his bed.During an interview with the DON on 6/4/26 at 10:00 a.m., the DON stated that the facility did not do assessments or obtain orders for the wedge bolsters.

Based on record review and staff interviews the facility failed to protect the residents' right to be free from neglect for 1 (Resident #999) of 4 sampled residents by failing to ensure staff follow safety precautions while providing care to prevent avoidable falls and fall related major injury. The findings included: Review of the facility's neglect investigations revealed on 4/1/25 at approximately 6:40 p.m., Certified Nursing Assistant (CNA) Staff A was providing care to Resident #999. The CNA turned the resident on his left side to remove his brief. The resident moved more off the bed as she placed her hand on his side to hold him he went falling. The incident investigation noted Resident #999 sustained a red discoloration to the right side of his face and a skin tear on his right hand. Resident #999 was transferred to a local hospital and diagnosed with an acute intra-axial hemorrhage (bleeding) within the left frontal lobe (front of the brain) measuring 2.0 by 1.07 by 2.4 centimeters. The investigation noted CNA staff A turned Resident #999 on his left side to remove his incontinent brief and bed sheet. As she was placing the fitted sheet on the bed she saw the resident moving more off the bed so she placed her hand on his side to hold him. The resident fell off the bed because his weight was too heavy on one side. Once the resident the floor she went out into the hallway to get help. The investigation noted the nurse arrived in the room, observed Resident #999 on his right side with a hematoma (collection of blood outside the blood vessels) on the right side of the face. As part of the investigation, on 4/2/25 CNA Staff A demonstrated she had the resident centered and as she turned him, he was more toward the other side, away from her which resulted in the resident's falling as he moved. The facility verified the allegation of neglect and noted CNA Staff A would be terminated for failure to follow the facility's policy and procedures related to reviewing residents Kardex (System of communication and organization used in nursing that helps long term care facilities document resident care summaries). Review of the Kardex revealed to turn and reposition Resident #999 every two hours and as needed. The Kardex did not specify that the resident required the physical assistance of two persons for bed mobility, including turning and repositioning as per the Nursing Admission evaluation. Review of the staff education dated 4/2/25 noted Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility new employee education and in-service training revealed, At the start of the shift, read the Kardex for updated changes such as interventions in place for bed mobility, transfer status, falls, behaviors. Review of the clinical record revealed Resident #999 was a [AGE] year-old male with an admitted [DATE]. Diagnoses included right side hemiparesis (weakness on one side of the body) and hemiplegia (paralysis of one side of the body) related to Cerebral Vascular Accident, Osteoporosis, and a history of falls. The Admission Minimum Data Set (MDS) assessment (standardized tool that measures health status in nursing home residents) with an assessment reference date of 2/21/25 documented Resident #999 was dependent for bathing, toileting, personal hygiene and bed mobility (Helper does all of the effort, Resident does none of the effort to complete the activity). The MDS noted Resident #999's cognitive skills for daily decision making were severely impaired. Resident #999 was rarely/never understood. Review of the New Admission Re-Admission Evaluation form dated 2/14/25 revealed Resident #999 required the physical assistance of two persons for bed mobility. Resident #999 scored 18 on the fall risk evaluation upon admission indicating the resident was at high risk for falls. The care plan initiated on 3/21/25 identified Resident #999 had activity of daily living self-care performance deficit due to, Confusion/decreased cognition, musculoskeletal impairment, stroke, and weakness. The interventions noted the resident had an air mattress to his bed and was, dependent with rolling left to right. The care plan did not specify the resident required the physical assistance of two persons for bed mobility as per the Admission MDS assessment. The care plan initiated on 3/21/25 noted Resident #999 was at risk for falls related to decreased cognition and decreased mobility. The goal was, The risk for falls will be minimized through the next review. The interventions included to be sure the resident's call light is within reach and encourage the resident to use if for assistance as needed and evaluate the resident's environment to identify factors known to increase risk of falls. On 4/7/25 at 8:40 a.m., in an interview Unit Manager Registered Nurse (RN) Staff B said, I was in [NAME] Garden secured unit when [Resident #999] fell . I applied ice and printed the paperwork to send him to the hospital. He went to the hospital and did not return. He was a two person assist with care. [CNA Staff A] said she did not have another person with her. On 4/7/25 at 8:48 a.m., in an interview RN Staff C said she works the 11:00 p.m. to 7:00 a.m., shift on the North Unit. She said, We regularly keep the Kardex up to date. The Unit managers and the nurses can do it. If the CNA notices any changes they tell us. If the resident has had any changes we update the Kardex. On 4/7/25 at 8:52 a.m., in an interview North Unit Manager Licensed Practical Nurse Staff C said the CNAs and nurses get resident information from the Kardex and report from the nurse. Unit Managers and MDS nurses mostly update the Kardex. We received recent education to ensure the Kardex is updated and reviewed at the beginning of every shift. On 4/7/25 at 11:05 a.m., in a telephone interview CNA Staff A said, I was working the 3:00 p.m., to 11:00 p.m., shift on 4/1/25. I had worked with Resident #999 before. I went to do my last rounds to see if he needed to be changed. I had him positioned in bed to the left side facing the door. I realized he did not have a fitted sheet on the bed, and I went to get one. Before I turned him on his back, flat on his back in bed. He had an air mattress. I did the upper part of the sheet first. I had all the soiled linen and brief rolled up and against him. I went to place the bottom of the fitted sheet on the bed and he began to roll out of the bed. I tried to stop him but I did not make it. He fell out of bed. I saw him and I did not see any blood, so I ran to get the nurse. When we got back to the room, there was blood everywhere. He had a skin tear to his right arm and it was bleeding. What I did wrong was I did not roll him toward me like I should have. I always did him by myself and no one ever told me he was a two person assist. I never knew about the care Kardex. They told me about the Kardex after the fact. I know you need to have two people with a mechanical lift, but he was already in bed, I just wanted to change him. They gave education after the fact. If I had known before, I would have had help, but no one ever told me anything about him. It all happened so fast. Review of the Certified Nursing Aide, Competency Checkoff List revealed Staff A completed Review Kardex on 1/13/25. On 4/7/25 at 11:45 a.m., in an interview the Administrator said Resident #999 was always a two person assist. From the re-enactment with CNA Staff A, using a pillow to demonstrate, she stood at the bed and he was in the center of the bed, she rolled him away from her and he was at the edge of the bed. I educated her the resident needs to be closer to you so when you turn him he is not so close to the edge, do not center the resident. On 4/7/25 at 11:55 a.m., in an interview Occupational Therapist (OT) Staff G said Resident #999 was on caseload when he was first admitted and he required two persons assist with all his care needs. He said Hospice got involved and had their own therapy seeing the resident but the resident was always two persons assist with his care.

Based on record review and interviews, the facility failed to ensure the safety interventions were documented in the care plan and failed to ensure staff used safe repositioning technique to prevent avoidable fall and fall related serious injury for 1 (Resident #999) of 4 dependent residents reviewed. The findings included: Review of the clinical record revealed Resident #999 was a [AGE] year-old male with an admitted [DATE]. Diagnoses included right side hemiparesis (weakness on one side of the body) and hemiplegia (paralysis of one side of the body) related to Cerebral Vascular Accident, Osteoporosis, and a history of falls. Review of the New Admission Evaluation form dated 2/14/25 revealed Resident #999 required the physical assistance of two persons for bed mobility. The care plan initiated on 3/21/25 identified Resident #999 was at risk for falls related to decreased cognition and decreased mobility. The resident had activity of daily living self-care performance deficit due to, Confusion/decreased cognition, musculoskeletal impairment, stroke, and weakness. The interventions noted the resident had an air mattress to his bed and was, dependent with rolling left to right. The care plan did not specify the resident required the physical assistance of two persons for bed mobility as per the Admission evaluation. The Significant Change in Status Minimum Data Set (MDS) assessment (standardized tool that measures health status in nursing home residents) with an assessment reference date of 3/5/25 documented Resident #999's cognitive skills for daily decision making were severely impaired. Resident #999 was rarely/never understood. The resident's range of motion was impaired on one side of the upper extremities and both sides of the lower extremities. Resident #999 was dependent on staff for activities of daily living, including bed mobility, rolling left and right (Helper does all of the effort, Resident does none of the effort to complete the activity). Review of the progress notes revealed on 4/1/25 Resident #999 had a fall resulting in a hematoma (collection of blood outside of the blood vessels) to the right cheek and a skin tear to the right hand. Resident #999 was transferred to the local hospital for evaluation. Review of the hospital documentation for 4/1/25 revealed Resident #999 had a CT scan (Computerized Tomography) of the head with findings of acute intra-axial hemorrhage (bleeding) within the left frontal lobe (of the brain) measuring 2.0 by 1.7 by 2.4 cm (centimeters). Review of the fall investigation initiated on 4/1/25 revealed Certified Nursing Assistant (CNA) Staff A was changing Resident #999. She turned the resident to the left side to remove the incontinent brief and change the fitted sheet on the bed. As she was placing the fitted sheet on the bed she went to tuck it under and saw the resident move more off the bed. She placed her hand on his side to hold him, he went off falling off the bed because his weight was too heavy on one side. Once the resident hit the floor CNA Staff A went into the hallway to get help from a CNA or a nurse. A nurse on duty documented CNA Staff A call to her and said Resident #999 fell . Upon arrival to the resident's room, she observed the resident on the floor on his right side. Resident #999 had a hematoma to the right side of the face. Unit Manager Registered Nurse (RN) Staff B obtained a statement from CNA Staff A who said she always cared for Resident #999 and has not had a problem with caring for him. She was changing the resident and the sheets. She rolled the resident over and saw him begin to move and when she went to hold/grab him, he fell . CNA Staff A said no one ever told her she needed two people to care for the resident. She had taken care of him several times and had no problem. CNA Staff A said it just happened so fast. The facility's investigation noted on 4/2/25 CNA Staff A demonstrated how she had Resident #999 centered and as she turned him, he was more toward the other side, away from her which resulted in him falling as he moved. The facility's investigation noted CNA Staff A was given one to one education on proper positioning and following the Kardex (System of communication and organization used in nursing that helps long term care facilities document resident care summaries) for transfer status. Review of the Kardex failed to reveal documentation Resident #999 required two persons assistance for bed mobility. Review of the Education/Training provided to CNA Staff A on 4/2/25 noted, When providing care for patients in the bed and turning patient away from you ensure patient is positioned on the side of the bed closest to you to minimize risk of fall from the bed and maintain safety. Start of shift, review Kardex for each patient to follow plan of care and transfer status. On 4/7/25 at 8:40 a.m., in an interview Unit Manager Registered Nurse (RN) Staff B said, I was in [NAME] Garden secured unit when [Resident #999] fell . I applied ice and printed the paperwork to send him to the hospital. He went to the hospital and did not return. He was a two person assist with care. [CNA Staff A] said she did not have another person with her. On 4/7/25 at 8:48 a.m., in an interview RN Staff C said she works the 11:00 p.m. to 7:00 a.m., shift on the North Unit. She said, We regularly keep the Kardex up to date. The Unit managers and the nurses can do it. If the CNA notices any changes they tell us. If the resident has had any changes we update the Kardex. On 4/7/25 at 11:05 a.m., in a telephone interview CNA Staff A said, I was working the 3:00 p.m., to 11:00 p.m., shift on 4/1/25. I had worked with Resident #999 before. I went to do my last rounds to see if he needed to be changed. I had him positioned in bed to the left side facing the door. I realized he did not have a fitted sheet on the bed, and I went to get one. Before I turned him on his back, flat on his back in bed. He had an air mattress. I did the upper part of the sheet first. I had all the soiled linen and brief rolled up and against him. I went to place the bottom of the fitted sheet on the bed and he began to roll out of the bed. I tried to stop him but I did not make it. He fell out of bed. I saw him and I did not see any blood, so I ran to get the nurse. When we got back to the room, there was blood everywhere. He had a skin tear to his right arm and it was bleeding. What I did wrong was I did not roll him toward me like I should have. I always did him by myself and no one ever told me he was a two person assist. I never knew about the care Kardex. They told me about the Kardex after the fact. I know you need to have two people with a mechanical lift, but he was already in bed, I just wanted to change him. They gave education after the fact. If I had known before, I would have had help, but no one ever told me anything about him. It all happened so fast. On 4/7/25 at 11:45 a.m., in an interview the Administrator said Resident #999 was always a two person assist. From the re-enactment with CNA Staff A, using a pillow to demonstrate, she stood at the bed and he was in the center of the bed, she rolled him away from her and he was at the edge of the bed. I educated her the resident needs to be closer to you so when you turn him he is not so close to the edge, do not center the resident. The Administrator added she thought the placement of the resident in the center of the bed was the root cause of the fall but she had 15 days to determine that.

Based on record review and staff interview, the facility failed to ensure completion of the quarterly minimum data set (MDS) within 92 days from the assessment reference date of the last completed assessment for 14 (Resident #7, #17, #41, #45, #62, #66, #67, #72, #73, #79, #82, #84, #88, and #91} of 14 residents sampled. This had the potential to delay assessment and revision of the plan of care. Quarterly assessments are used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. The findings included: On record review for Resident #7s Minimum Data Set Assessments (MDS) revealed the resident has an admission assessment done on 8/20/23 and did not have their next Quarterly assessment coded and completed for 164 days. The assessment was completed by the facilities MDS coordinator on 1/31/24. Then Signed off by RN (Registered Nurse) Assessment Coordinator Verifying Assessment Completion on 2/1/24. Transmitted to CMS (Center for Medicare and Medicaid Services) on 2/7/24. On record review for Resident #17's MDS assessments revealed the resident has an admission assessment done on 8/19/23 and did not have their next Quarterly assessment coded and completed for 130 days. The assessment was completed by the facilities MDS coordinator on 12/27/23. Then Signed off by RN Assessment Coordinator verifying Assessment Completion on 12/27/23. Then transmitted to CMS on 1/2/24. On record review for Resident #41's MDS assessments revealed the resident had an admission assessment done on 8/20/23 and did not have their next Quarterly assessment coded and completed for 130 days. The assessment was completed by the facilities MDS coordinator on 12/27/23. Then Signed off by RN Assessment Coordinator verifying Assessment Completion on 12/27/23. Then transmitted to CMS on 1/2/24. On record review for Resident #45's MDS assessments revealed the resident had an admission assessment done on 8/20/23 and did not have their next Quarterly assessment coded and completed for 170 days. The assessment was completed by the facilities MDS coordinator on 2/6/24. Then Signed off by RN Assessment Coordinator verifying Assessment Completion on 2/6/24. Then transmitted to CMS on 2/9/24. On record review for Resident #62's MDS assessments revealed the resident had an admission assessment done on 8/20/23 and did not have their next Quarterly assessment coded and completed for 159 days. The assessment was completed by the facilities MDS coordinator on 1/26/24. Then Signed off by RN Assessment Coordinator verifying Assessment Completion on 1/26/24. Then transmitted to CMS on 1/31/24. On record review for Resident #66's MDS assessmemts revealed the resident had an admission assessment done on 8/19/23 and did not have their next Quarterly assessment coded and completed for 138 days. The assessment was completed by the facilities MDS coordinator on 1/4/24. Then Signed off by RN Assessment Coordinator verifying Assessment Completion on 1/4/24. Then transmitted to CMS on 1/4/24. On record, review for Resident #67's MDS assessments revealed the resident had an admission assessment done on 8/20/23 and did not have their next Quarterly assessment coded and completed for 159 days. The assessment was completed by the facilities MDS coordinator on 1/26/24. Then Signed off by RN Assessment Coordinator verifying Assessment Completion on 1/26/24. Then transmitted to CMS on 1/31/24. On record review for Resident #72's MDS assessments revealed the resident had an admission assessment done on 8/21/23 and did not have their next Quarterly assessment coded and completed for 164 days. The assessment was completed by the facilities MDS coordinator on 1/31/23. Then Signed off by RN Assessment Coordinator verifying Assessment Completion on 2/1/24. Then transmitted to CMS on 2/7/24. On record review for Resident #73's MDS assessments revealed the resident had an admission assessment done on 8/20/23 and did not have their next Quarterly assessment coded and completed for 143 days. The assessment was completed by the facilities MDS coordinator on 1/5/24. Then Signed off by RN Assessment Coordinator verifying Assessment Completion on 1/10/24. Then transmitted to CMS on 1/12/24. On record review for Resident #79's MDS revealed the resident had an admission assessment done on 8/20/23 and did not have their next Quarterly assessment coded and completed for 138 days. The assessment was completed by the facilities MDS coordinator on 1/4/24. Then Signed off by RN Assessment Coordinator verifying Assessment Completion on 1/5/24. Then transmitted to CMS on 1/5/24. On record review for Resident #82's MDS assessments revealed the resident had an admission assessment done on 8/20/23 and did not have their next Quarterly assessment coded and completed for 183 days. The assessment was completed by the facilities MDS coordinator on 2/19/24. Then Signed off by RN Assessment Coordinator verifying Assessment Completion on 2/6/24. Then transmitted to CMS on 2/21/24. On record review for Resident #84's MDS assessments revealed the resident had an admission assessment done on 8/21/23 and did not have their next Quarterly assessment coded and completed for 137 days. The assessment was completed by the facilities MDS coordinator on 1/4/24. Then Signed off by RN Assessment Coordinator verifying Assessment Completion on 1/5/24. Then transmitted to CMS on 1/5/24. On record review for Resident #88's MDS assessments revealed the resident had an admission assessment done on 8/20/23 and did not have their next Quarterly assessment coded and completed for 163 days. The assessment was completed by the facilities MDS coordinator on 1/30/24. Then Signed off by RN Assessment Coordinator verifying Assessment Completion on 1/30/24. Then transmitted to CMS on 1/31/24. On record review for Resident #91's MDS assessments revealed the resident had an admission assessment done on 8/20/23 and did not have their next Quarterly assessment coded and completed for 168 days. The assessment was completed by the facilities MDS coordinator on 2/4/24. Then Signed off by RN Assessment Coordinator verifying Assessment Completion on 2/2/24. Then transmitted to CMS on 2/9/24. During an interview on 4/10/24 at 1:45 p.m., the MDS coordinator stated that it is correct that Residents #7, #17, #41, #45, #62, #66, #67, #72, #73, #79, #82, #84, #88, and #91. did not have a completed quarterly assessment coded, completed and transmitted within the 92 days that they should have been completed from the prior assessment. MDS coordinator said she only works part time and was unable and is still unable to get all the MDS assessments done. MDS Coordinator Nurse stated that the extent of the issues is for all the residents in the facility. During an interview on 4/10/24 at 3:29 PM, [NAME] President (VP) of Clinical Services/Risk Management stated that the facility has been struggling to be able to complete all the Minimum Data Set assessments. The VP stated the MDS nurse was working part time and was unable to complete all the assessments.

Based on observation, record review, facility policy review, resident and staff interview, the facility failed to provide an ongoing program of activities to meet the resident's interests and support the resident physical, mental and psychosocial well-being for 4 (Residents #8, #42 #51 and #82) of 4 residents reviewed for involvement in the activity program. The lack of an ongoing activity program could lead to a decline in the residents' self-esteem, physical, mental, and psychosocial well-being. The findings included: Review of the undated Activity Programs policy revealed the activity programs were designed to meet the interests of and the physical, mental, and psychosocial well-being of each resident. The activities program was provided to support the well-being of each resident and to encourage both independence and community interaction. The activity program was ongoing and included facility-organized group activities, independent individual activities and assisted individual activities. All activities were to be documented in the resident's medical record. 1. Review of the clinical record revealed Resident #8 had a readmitted [DATE] with diagnoses including dementia, psychosis, major depressive disorder, and anxiety. Review of the care plan initiated on 3/3/20 noted Resident #8 was at risk for decreased social interaction and activity participation due to cognitive impairment. The care plan specified the resident enjoyed listening to music, watching various television shows, fresh air, and religious activities. The goal for Resident #8 was for her to participate in daily group activities weekly. On 4/8/24 during observations at 10:50 a.m., and 12:15 p.m., Resident #8 was observed in her room in a reclining wheelchair wedged between the bed and a dresser. The room was dark, and she had the sheet over her head. There was no music or television turned on. Review of the activity calendar specified on 4/8/24 activities 8:00 a.m., daily puzzle, 10:00 a.m., daily breeze, 2:00 p.m., women's club, 4:00 p.m., spa day, 5:30, grooming. On 4/9/24 at 9:54 a.m., Resident #8 was observed in her room in a chair wedged between the bed and the dresser, with no television or music in the room. On 4/9/24 at 10:03 a.m., to 12:00 p.m., Resident #8 was observed in her room in the reclining chair wedged between the bed and the dresser. The resident was yelling and calling out, I'm hungry. Lord help me, repeatedly as staff in the hallway walked by her room and did not stop to assist her. The activity calendar for 4/9/24 specified 8:00 a.m., daily puzzle, 10:00 a.m., fresh air, 2:00 p.m., happy hour, 4:00 p.m., movie. 2. Review of the clinical record documented Resident #42 had a readmitted [DATE] with diagnoses including dementia, Alzheimer's, anxiety, and major depressive disorder. The record indicated the resident's primary language was Spanish. Review of the care plan initiated 3/18/22 identified the resident was at risk for decreased social interaction and activity participation due to her dementia diagnosis. The care plan specified the resident enjoys listening to Spanish music and watching Spanish television shows and movies. During random observations on 4/8/24 at 9:15 a.m.,12:30 p.m., and 3:21 p.m., Resident #42 was observed in her bed sleeping. Review of the activity calendar specified on 4/8/24 activities 8:00 a.m., daily puzzle, 10:00 a.m., daily breeze, 2:00 p.m., women's club, 4:00 p.m., spa day, 5:30 grooming. On 4/9/24 at 8:52 a.m., Resident #42 was observed in the unit dining room having finished with the morning meal and was assisted in a reclining wheelchair to sit in the hall in front of the nursing station outside of the dining room. On 4/9/24 at 9:46 a.m., Resident #42 was assisted to bed. On 4/9/24 at 11:34 a.m., Resident #42 was observed in her bed sleeping. There was no Spanish music or television on in the room. On 4/9/24 at 1:00 p.m., Resident #42 was observed in bed sleeping. On 4/9/24 at 1:00 p.m., Resident #42's roommate said she was the Resident Council President. She said, She (Resident #42) sleeps all the time. I speak Spanish and she really does not talk anymore. Maybe a few words but she is always sleeping. They just let her sleep. The activity calendar for 4/9/24 specified 8:00 daily puzzle, 10:00 a.m., fresh air, 2:00 p.m., happy hour, 4:00 p.m., movie. On 4/9/24 at 3:02 p.m., in an interview CNA Staff H said she was assigned to do activities in the memory care unit. Staff H said the Activity Director was not here every day, she goes to school during the day. They have an activity calendar they are supposed to follow, it is not the same as the one for the other residents. She said no one tells her what to do, she just keeps the residents busy. Staff H said the Activity Director does not supervise the activities during the day since she's not at the facility. Staff H said, there are two activity aides in the facility, me and the other CNA but she is not here today, she is off so it is just me and I don't do activities on the other units. On 4/9/24 at 3:10 p.m., in an interview the Activity Director said she was also a CNA. She said she was in school during the day therefore worked the evening shift from 3:00 p.m., to 11:00 p.m. Review of the activity calendar revealed activities end between 4:00 p.m., and 5:30 p.m. The Activity Director said she did, whatever the residents want me to do. Sometimes I play a movie, I do 1-1, it depends on what they want to do, I do it. The Activity Director said she tracks activity attendance in a logbook and the activity aides mark the activities the residents attend. She said she also sometimes works as a CNA in the evening, help feed residents and do CNA work. Review of the activity logbook provided by the Activity Director showed Resident #42 attended five activity programs on 4/8/24 during the time when she was observed in bed sleeping. The activity logbook documented Resident #8 attended three activity programs on 4/8/24 during the time she was observed in her room. The Activity Director said, All I know is I asked the girls if the residents were up. They said the residents were out of bed and in activities. I'm going to have to find out about that one. On 4/10/24 at 8:03 a.m., in an interview the [NAME] President of Clinical Services/Risk Management said after an investigation the activity assistant confirmed she did not know which residents actually attended the activities on 4/8/24. 25618 3. Review of the Activity Director's (AD) job description, signed and dated 8/15/22, revealed they were required to plan, organize, develop, and direct the overall operations of the Activities Department in accordance with federal, state, and local standards. They AD was required to develop a preliminary and comprehensive assessment of the activity needs of each resident, encourage the resident and family to participate in the development and review of the resident's plan of care, ensure that all activities personnel were aware of the care plan and that care plans were used in providing daily activities for the resident, review nurses' notes to determine if the activity care plans was being followed, and to review and revise care plans and assessments, as necessary but at least quarterly. On 4/8/24 from 1:09 p.m., to 4:00 p.m., Resident #51 was observed in his bedroom, laying on his bed without the television (TV) or radio on, and/or being involved in an activity program. Resident #51 was not interviewable due to cognitive impairment. On 4/9/24 at 10:15 a.m., and from 12:50 p.m., to 4:15 p.m., Resident #51 was observed in his bedroom laying on his bed without the TV or radio on and/or being involved in an activity program. Review of Resident #51's medical record revealed he was admitted to the facility was 12/22/23 with a readmission on 4/5/24. The latest Activities Admission Evaluation, dated 1/4/24, stated his primary spoken language was Creole. Resident #51's activity preferences stated he liked activities in the morning, afternoon and evening and he enjoyed being in the comfort of his room watching various TV shows and listening to Creole music. The activity plan of care initiated on 12/27/23 and revised 2/1/24 stated Resident #51 enjoyed being in his room watching various TV shows, listening to music, and talking with staff at times. The interventions/tasks section stated staff would encourage the family to bring a radio/compact disc (CD) player for the resident, and the facility staff would encourage Resident #51 to join in an activity. Review of Resident #51's activity program attendance and participation form/documentation noted music was not offered to Resident #51 in January, February, and April of 2024. Resident #51 was offered music four times in March of 2024. Documentation on the activity program attendance and participation form revealed from 2/1/24 through 2/22/24, and 3/15/24 through 3/31/24, Resident #51 had not attended nor was invited to attend any facility activity as required in his activity plan of care. 4. On 4/8/24 at 10:25 a.m., from 1:30 p.m. to 4:30 p.m., Resident #82 was observed in her bedroom laying on her bed without a radio/music on nor involved in an activity program. Resident #82 did not have a TV in her room. Resident #82 was not interviewable due to cognitive impairment. On 4/9/24 at 9:27 a.m., and from 1:00 p.m., to 4:35 p.m., Resident #82 was observed in her bedroom laying on her bed without a radio/music on nor involved in an activity program. Review of Resident #82's medical record revealed an admission to the facility on [DATE] with a readmission on 8/13/23. The Activities Admission Evaluation, dated 6/9/22, stated her primary spoken language was Creole. Resident #82's activity preferences stated she liked activities in the morning, afternoon and evening and she enjoyed independent, group and 1:1 (one to one) activity. Resident #82 was at the facility for long term care. She had some behaviors and participated in some activities which fluctuated with her mood. Resident #82 enjoyed listening to Haitian music. Resident #82's current activity plan of care initiated on 7/13/22 and revised 7/25/22 stated Resident #82 was at risk for decreased social interaction/activity participation related to language barrier, impaired cognition and a left below the knee amputation. Activity preferences included watching TV/movies and listening to music. The interventions/tasks section stated staff was to assist with television programs of choice, invite Resident #82 to daily group programs, provide assistance to daily group programs, and encourage social interactions with staff and peers. Review of Resident #82's activity program attendance and participation form revealed documentation noted music was not offered to Resident #82 in January, February, and March of 2024. Resident #82 was offered music 2 times out of 8 days in April of 2024. The activity program attendance and participation form revealed from 2/1/24, through 2/16/24, and 2/24/24, through 2/29/24, and 3/15/24, through 3/31/24, Resident #82 had not attended nor was invited to attend any facility activity as required in her activity plan of care. On 4/10/24 at 11:19 a.m., in an interview with Certified Nursing Assistant (CNA) and activity aid Staff A, she said she was one of the activity aids who conducted the activity programs on the long-term care section of the facility. She said for the 155-bed facility they had one activity aid in the memory care unit and one activity aid for the long-term care side of the facility. She said the Activity Director went to school during the day and came to the facility after school around 3:00 p.m. She said Resident #51's and Resident #82's primary language was Creole, and they did not speak English. She said both residents liked to stay in their rooms, and she did not remember the last time they attended a group or an out of room activity. She said they did not have any activity programs for residents who only speak Creole. On 4/10/24 at 11:42 a.m., in an interview with CNA Staff C, she said Resident #51 spoke primarily Creole and only knew a few words in English. She said Resident #51 stayed primarily in his room and she didn't remember Resident #51 attending any of the facility's activity programs. On 4/10/24 at 2:51 p.m., in an interview with CNA Staff B, she said Resident #82 spoke Creole only and when she needed to communicate with Resident #82, she had to find a staff member who could speak Creole. She said Resident #82 stayed in her room the majority of times and she didn't remember Resident #82 attending any out of the room facility activity programs. She said Resident #82 did not have a radio/CD player or a TV in her room. On 4/10/24 at 4:10 p.m., in an interview with the Activity Director, she said she became the Activity Director in August 2022. She said she was in school Monday through Friday, during the day, every week, and she came to work around 3:00 p.m. She depended on her activity staff to conduct the resident's activity program as written. She confirmed Resident #51's, and Resident #82's primary language was Creole, and they spent a lot of their time in their room. She said because the activity department did not have activities for residents who only speak Creole, she had put a radio/CD player in Resident #51's and Resident #82's rooms with Creole music on CDs, so the activity staff could play Creole music for Residents #51 and #82 as written in their activity plan of care. The Activity Director toured Resident #51's and Resident #82's rooms and confirmed neither resident had a radio/CD player with Creole music on CDs in their room and confirmed Resident #82 did not have a TV in her room. The Activity Director reviewed Resident #51's and Resident #82's activity program attendance and participation form and confirmed the activity staff did not conduct each resident's music activity program and did not conduct the resident's overall activity program consistently as required and documented on their activity plan of care.

Based on observation, review of the clinical record, and resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 2 (Residents #81 and #303) of 3 residents reviewed for activities of daily living (ADLs). The findings included: The facility policy Activities of Daily Living (ADL), Supporting documented Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADL's . Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care. 1. Review of the clinical record revealed Resident #81 had a readmitted [DATE] with diagnoses including pacemaker, hypertension, adjustment disorder, right eye prosthesis, history of falls and Alzheimer's disease. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 2/1/24 documented Resident #81 required supervision for showers and was independent for personal hygiene. The MDS noted Resident #81's cognitive skills for daily decision making were moderately impaired. The care plan for Resident #81 identified an ADL self-care performance deficit related to dementia. On 4/8/24 at 9:06 a.m., Resident #81 was observed in bed, and responded to simple questions. He was noted to have long fingernails extending approximately 1/2 inch with brown substance under the nails. He was unshaven with approximately four days of facial hair growth. He was dressed in long pants and a T-shirt. Resident #81 said, I'm okay. He looked at his nails and said, they need to be cleaned. When asked if was able to shave himself, he rubbed his face and said, I could use a shave. On 4/8/24 at 1:30 p.m., Resident #81 remained with fingernails extending approximately 1/2 inch with an accumulation of brown substance under the nails, and approximately four days of facial hair growth. Resident #81 had a moderate malodorous body odor. On 4/9/24 at 9:26 a.m., Resident #81 was observed in his room in bed dressed in the same clothing as the prior day. He felt his face and said, they shave me once in a while. His mouth was dry and caked food was noted on his teeth, he said he did not know how he gets his teeth brushed or who helps him. When asked if he was the receiving the care he needed he said, I can't complain, it doesn't do no good. On 4/10/24 at 1:12 p.m., in an interview Certified Nursing Assistant (CNA) Staff G said Resident #81 was showered by staff but independent with some tasks being able to transfer himself, walk in room with a walker or uses the wheelchair. He is assisted to shave and can feed himself and toilet himself. 4/10/24 at 1:42 p.m., during an observation and interview, CNA Staff G was in the room with Resident #81 and was shaving the resident. The CNA said, the shaves are done during showers and whenever needed. She said she was assigned to the resident today and usually works on his assignment, but this was her first day back as she was scheduled off for a few days. Review of the Weekly Shower List revealed Resident #81 was scheduled for showers on Tuesdays, Thursdays, and Saturdays on the 7:00 a.m., to 3:00 p.m., shift. Review of the CNA documentation did not show documentation Resident #81 received his scheduled showers. On 4/11/24 at 10:02 a.m., in an interview the Director of Nursing (DON) said the CNAs document showers on a shower sheet that is given to the nurse. Once the nurse reviews the shower sheet, it is shredded. The DON provided four CNA shower sheets documenting Resident #81 received a shower on 12/11/23, 1/23/24, 2/2/24 and 2/14/24. The DON said, That is all I have. 2. Review of the clinical record revealed Resident #303 had a readmitted [DATE] with diagnoses including bipolar disorder, lung cancer with metastasis to the brain status post chemoradiation. The care plan initiated 4/10/24 documented the resident had a self-care performance deficit related to a stroke, terminal illness, and pain. On 4/8/24 at 10:08 a.m., during an observation and interview, Resident #303 was in her bed, her fingernails extended approximately half an inch with a sticky substance under the nails and on the thumb and index fingers of the left hand. The resident said it was blood from her nose. Resident #303 said she had been picking her nose and it had bled. No active bleeding was observed at this time. She said she did not know when she was supposed to get a shower and could not remember the last time she had a shower. Review of the facility shower list revealed the resident was scheduled for showers on the 3:00 p.m., to 11:00 p.m., shift on Tuesdays, Thursdays, and Saturdays. Review of the CNA documentation, the electronic record and the paper chart for Resident #303 revealed no documentation of showers provided for the resident. The facility was unable to locate any documentation the resident received her scheduled showers. On 4/11/24 review of the CNA Care Kardex (provided instructions for care) updated on 4/10/24 showed Resident #303's showers were scheduled for Mondays, Wednesdays and Fridays, and hospice was to provide the showers. Review of the electronic record and the paper chart showed no documentation of a Hospice Care Plan or hospice aide documentation of showers provided to the resident. On 4/11/24 at 10:04 a.m., in an interview the DON said the facility had contacted the Hospice to request the aide shower documentation and the care plan. They are getting it together and are going to send it to us. The DON confirmed there was no documentation at this time that showed the resident received her scheduled showers. On 4/11/24 at 12:11 p.m., review of the Hospice Collaboration of Care provided by the facility revealed since her admission on 3/13/24, Resident #303 received a sponge bath on 4/6/24, 4/7/24, and a shower on 3/28/24 and 4/4/24.

Based on observation, review of facility policies and procedures, staff and resident interviews, and record review, the facility failed to ensure 3 (Residents #24, #42 and #100) of 29 residents with bed rails were assessed for alternative interventions prior to the use of bed rails, and failed to ensure residents were assessed for danger of entrapment prior to use of bed rails. In addition, the facility failed to inform the residents and/or their representative of the risks and benefits of bed rails or obtain an informed consent prior to use of the bed rails. The findings included: The facility policy Proper Use of Bed Rails documented, Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used the facility ensures correct installation, use and maintenance of the rails. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the residents' assessed needs. The resident assessment should assess the resident's risk of entrapment between the mattress and the bed rail or in the bed rail itself. Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails the information should be presented in an understandable manner and consent given voluntarily free from coercion. The information that the facility should provide to the residents or resident representatives includes but is not limited to what assessed medical needs would be addressed by the use of the bedrails the residents' benefits from the use of the bed rails and the likelihood of these benefits period the residents risk from the use of the bed rails and how these risks will be mitigated. Alternatives attempted that failed to meet the residents' needs and alternatives considered but not attempted because they were considered to be inappropriate. The facility will ensure the correct installation and maintenance of bed rails prior to use. This includes checking with the manufacturer to make sure the bed rails mattress and bed frames are compatible. Confirming that the bed rails are appropriate for the size and weight of the resident using the bed. Inspecting and regularly checking the mattress and bed rails for areas of possible entrapment. Checking bed rails regularly to make sure they are still installed correctly and have not shifted or loosened overtime. Conducting routine preventive maintenance of the bed rails and beds to ensure they meet current safety standards and are not in need of repair. 1. Review of the clinical record revealed Resident #42 had a readmitted [DATE] with diagnoses including falls, dementia, anxiety, major depressive disorder and Alzheimer's. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 2/7/24 documented Resident #42 was dependent on staff for mobility including rolling side to side in bed and specified bed rails were not used. The MDS noted Resident #42's cognitive skills for daily decision making were severely impaired. The care plan for Resident #42 initiated 2/12/19 identified the resident was at risk for falls. The interventions included 1/2 side-rails up in bed as an enabler, date Initiated: 10/12/2022. 1/4 side-rails up in bed as an enabler, date Initiated: 2/19/2022. On 4/8/24 at 11:00 a.m., Resident #42 was observed in bed with 1/2 rails in the raised position on both sides of the upper bed. 4/10/24 at 9:08 a.m., in an interview the Administrator said the facility did not use side rails but if the family or the resident wanted them, they provided education and have them sign the consent form. The Administrator said the nurse and therapy assess the resident and attempt alternate interventions first. She confirmed she no had additional documentation for the use of the bed rails that indicated the alternative interventions were attempted for Resident #42. On 4/10/24 at 9:36 a.m., in an interview the Maintenance Director (with the Housekeeping Supervisor interpreting) said he checks the bed rails daily to make sure they are not loose, and he tightens them. The Maintenance Director entered a resident's room where 1/4 rails were on the bed and shook the rail to show that it was secure. The rail was very loose and required tightening of the bolts. He said he puts the bed rails on when the nurse gives him a paper to put them on. The Maintenance Director said he did not keep records of inspection of the bed rails for entrapment zones or inspection for the compatibility of mattresses and the beds rails. He said, each side rail is different, and he cannot put one side on a bed because it may not match, and it has to match the bed. The Maintenance Director said several times, no resident can get their head through any of the bed rails in use. On 4/10/24 at 10:35 a.m., in an interview the Housekeeping Supervisor confirmed the Maintenance Director did not have any record the bed rails were assessed for entrapment zones. She confirmed there was no on-going, periodic assessment to ensure the bed rails were secured and mattresses did not have gaps. The Housekeeping Supervisor provided a copy of the Bed Rail and Enabler Measurement Tool. Review of the Bed Rail and Enabler Measurement Tool documented To ensure resident is not at risk for entrapment, measurements are to be completed on a quarterly basis. 25618 2. Observation of Resident #100's bed on 4/8/24 at 11:16 a.m., revealed she had 2 quarter side rails on each side of her bed in the up position. On 4/8/24 at 11:16 a.m., during an interview with Resident #100, she said when she moved to this room and bed, the bed had 2 siderails attached to the bed. She said she told the staff she did not need the siderails on the bed, but they never took the siderails off the bed as asked. She said she was never told the risks and benefits of the use for the side rails. Review of Resident #100's medical record revealed she was admitted to the facility on [DATE] and was transferred to another room on 3/4/24. The Admission Nursing Comprehensive Evaluation, dated 2/22/24, noted in section 9 (Siderails/Enablers/Restraints) that for Resident #100, siderails were not required. Further documentation revealed there were no physician orders documented for the use of siderails on Resident #100's bed. Review of the facility's Proper Use of Bed Rails policy and procedures noted it was not dated. The policy stated the facility would utilize a person-center approach when staff determined the use of bed rails. As part of the resident's comprehensive assessment, the following components would be considered when determining the resident's needs, and whether or not the use of bed rails met those needs. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail. The resident assessment must also assess the resident's risk for using bed rails, the potential risks with the use of the bed rails-to include accident/hazards, the barrier for a resident safely getting out of the bed, and the risk of entrapment between the mattress and the bed rail or in the bed rail itself. On 4/10/24 at 9:25 a.m., in an interview with the Interim Director of Nursing (DON) and Vice-President of Clinical Services (VPCS), they confirmed Resident #100 was admitted to the facility on [DATE] and was transferred to another room on 3/4/24. They said when Resident #100 was transferred to another room, the bed in that room had siderails which were not removed prior to Resident #100's transfer. They said Resident #100 was never assessed for the risk of entrapment nor explained the risks and benefits with the use of side rails on her bed. They also confirmed they did not have a physician's order for the use of side rails on Resident #100's bed as required. 49527 3. Review of the clinical record for Resident #24 revealed an admitted [DATE]. Diagnoses included chronic kidney disease, and diabetes mellitus type II. Resident #24 was assessed to have a brief interview for mental status (BIMS) of 15 which indicated the resident's cognition was intact. The 5-day Minimum Data Set (MDS) assessment with a target date of 2/23/24 noted the resident's cognition was intact with a Brief Interview for Mental Status score of 15. A physician's order in the medical record of Resident #24, dated 2/21/2024, noted Side rails- (Specify 1/2 or 1/4) specify side of bed (both sides, rt (right) side, Lt (left) side) to promote increased independence. Resident #24's care plan did not include the use of siderails. On 4/8/24 at 10:11 a.m., Resident #24 was observed in bed with 1/2 size bed rails elevated on both sides of the upper half of the bed in the upright position. On 4/10/24 at 3:45 p.m. Resident #24's bed was observed to have had the 1/2 size side rails replaced with 1/4 size side rails on both sides of the upper half of the bed. On 4/9/24 at 4:28 p.m., in an interview Resident #24 said someone came in and had her sign a consent for the side rails today but did not explain the risks of having side rails. On 4/10/24 at 3:48 p.m., in an interview Registered Nurse (RN) Staff D confirmed Resident #24 signed a consent for the bedrails on 4/9/24. Review of the consent for side rails for Resident #24 showed the form was dated 2/24/24. RN Staff D verified she wrote 2/24/24 on the consent form and it should have been 4/9/24. On 4/10/24 at 4:00 p.m., in an interview Occupational Therapist Staff F said he assessed Resident #24 today for the use of side rails. He said the resident had 1/4 rails in use on the bed when he conducted the assessment. He said he had not assessed the resident for alternatives before installation of the bed rails. On 4/11/24 at 12:20 p.m., in an interview the interim Director of Nursing verified no appropriate alternatives were tried prior to installing the bed rails for Resident #24.

Based on observation, review of facility policy and procedures, record review and staff interviews, the facility failed to maintain urinary catheters in a safe and sanitary manner for 1(Resident #303) of 3 residents reviewed with an indwelling urinary catheter. The findings included: The facility policy Catheter Care documented It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Review of the clinical record documented Resident #303 had an admitted [DATE] with diagnoses including urinary retention. The care plan for Resident #303 initiated on 4/10/24 identified the resident had an indwelling catheter (catheter inserted in the bladder to drain urine) with the goal she would have no signs or symptoms of a urinary tract infection. On 4/8/24 at 10:06 a.m., Resident #303 was in her room in bed and was observed to have an indwelling catheter. The catheter drainage bag was on the safety mat and the drainage spout was open. On 4/8/24 at 12:47 p.m., Resident #303's drainage bag spout was observed to be closed but it remained on the floor mat. On 4/8/24 at 1:19 p.m., Licensed Practical Nurse Staff I verified the catheter drainage bag was lying on the safety mat on the floor and said she was not aware it could not be on the mat but would take care of it.

Based on record review and staff interview, the facility failed to ensure completion and transmission of completed resident Quarterly Minimum Data Set (MDS) data to the Center for Medicare and Medicaid Services (CMS) System Within 14 days after a facility completes a resident's assessment for 2 (Resident #17 and 82) of 14 residents reviewed. The findings included: Record review for Resident #17's Minimum Data Set Assessments (MDS) revealed the resident has an admission assessment done on 8/19/23 and did not have their next Quarterly assessment coded and completed for 130 days. The assessment was completed by the facilities MDS coordinator on 12/27/23. Then Signed off by the Registered Nurse (RN) Assessment Coordinator verifying Assessment Completion on 12/27/23. Then transmitted to CMS on 1/2/24. Record review for Resident #82's Minimum Data Set Assessments (MDS) revealed the resident had an admission assessment done on 8/20/23 and did not have their next Quarterly assessment coded and completed for 183 days. The assessment was completed by the facilities MDS coordinator on 2/19/24. Then Signed off by RN Assessment Coordinator verifying Assessment Completion on 2/6/24. Then transmitted to CMS on 2/21/24. On 4/10/24 at 1:45 p.m., in an interview the Minimum Data Set (MDS) coordinator stated that Residents' #17, #82, MDS assessments were not transmitted to CMS within the 14-day timeline from completion. On 4/10/24 at 3:29 p.m., the [NAME] President (VP) of Clinical Services/Risk Management stated that the facility has been struggling to complete all the Minimum Data Set (MDS) assessments and get them transmitted to CMS within the time frame. The VP stated that the MDS nurse was working part time and was unable to complete all the assessments.

Based on observation, record review, and interview, the facility failed to ensure the comprehensive assessment accurately reflect the dental status of 2 (Residents #39 and #90) of 14 sampled residents. The findings included: 1. Review of the clinical record for Resident #39 revealed an admitted [DATE], and a readmitted [DATE]. An outside provider's screening report for dental services for Resident #39 dated 1/25/23 noted, Upper and lower edentulous (no teeth) with two asymptomatic root tips. The Admission Nursing Comprehensive Evaluation dated 8/9/23 noted Resident #39 did not have dentures and was missing some teeth. The Admission Minimum Data Set (MDS) assessment with a target date of 8/14/23 was not checked off for No natural teeth or tooth fragment(s). On 4/10/24 at 10:00 a.m., Resident #39 was observed to be edentulous with two teeth broken below the gum line on his bottom jaw. On 4/10/24 at 1:09 p.m., in an interview the MDS Coordinator said she uses the documentation in the nursing assessment to code the dental status on the MDS. She stated she did not assess the resident's oral status and could not say for sure if the nursing documentation accurately reflected the resident's oral and dental status. 2. Review of the clinical record revealed Resident #90 was admitted to the facility on [DATE]. Review of the Brief Interview for Mental Status dated 4/1/24 showed Resident #90's cognition was intact with a score of 15. On 4/8/24 at 12:11 p.m., in an interview Resident #90 stated he lost all his teeth in an accident when he was hit by the car. On 4/10/24 at 11:00 a.m., Resident #90's oral cavity was observed with his permission. He was completely edentulous. Review of the Admission MDS assessment dated [DATE] showed Resident #90 was not edentulous. On 4/10/24 at 1:09 p.m. The MDS Coordinator said she uses the nursing assessments to complete the dental aspect of the MDS. She stated she did not assess the resident's oral or dental condition at the time of the assessment look back. She stated she could not say for sure the nursing documentation is accurate as to the resident's oral assessment. Review of the Resident Assessment Instrument Manual 3.0 instructions for coding oral/dental status on the MDS showed to, Conduct exam of the resident's lips and oral cavity with dentures or partials removed, if applicable. Use a light source that is adequate to visualize the back of the mouth. Visually observe and feel all oral surfaces including lips, gums, tongue, palate, mouth floor, and cheek lining. Check for abnormal mouth tissue, abnormal teeth, or inflamed or bleeding gums. The assessor should use his or her gloved fingers to adequately feel for masses or loose teeth . Ask the resident, family, or significant other whether the resident has or recently had dentures or partials. (If resident or family/significant other reports that the resident recently had dentures or partials, but they do not have them at the facility, ask for a reason.

Based on record review, review of the facility's abuse and neglect policy and procedure, resident and staff interviews, the facility failed to protect residents' rights to be free abuse for 1 (Resident #900) of 3 sampled residents. The facility also failed to implement adequate supervision to prevent resident to resident physical abuse of 2 (Resident #850 and #700) of 3 sampled residents from Resident #900 with known aggressive behaviors. The findings included: The facility policy Abuse, Neglect and Exploitation, documented It is our facility policy to prohibit the mistreatment of residents. All residents have the right to be free from verbal, sexual, physical, and mental abuse. Corporal punishment and involuntary seclusion by facility staff, other residents, consultants or volunteers, staff or other agencies serving our residents, family members or legal guardians, friends, or other individuals. 1. Clinical record review revealed Resident #900 was admitted to the secured memory care unit of the facility on 9/9/21 with diagnoses including unspecified dementia with behavioral disturbance, and brief psychotic disorder. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 2/4/23 documented Resident #900 required supervision with ambulation on the unit. Resident #900 scored 00 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Resident #900's current care plan included a focus on physical and aggressive behaviors towards his wife (per admission records). Has paranoid behavior, diagnosis of dementia with behaviors. Resident #900 had episodes of verbal and physical aggression, anger and crying. The interventions included administering medications as ordered, observing for effectiveness and side effects. Approach resident in a calm manner and explain actions. Update physician of increased presence or severity of behaviors as indicated. Request psychiatric consult as needed. The plan of care did not document specific interventions to address Resident #900's behaviors when he was verbally or physically aggressive. The target behavior monitoring included agitation, anger, crying, restlessness. January 2023 documented behaviors included anger and crying occurred one time on the day and night shift on 1/6/23, 1/18/23 and two times on the night shift on 1/20/23. Agitation was documented as occurring twice on the day and night shift on 3/6/23 and twice on the night shift on 1/19/23 and 1/20/23. Restlessness was documented twice on the night shift on 1/20/23. February 2023 documented agitation occurred three times on 2/8/23 on the night shift, one episode on night shift on 2/9/23, five episodes on the night shift on 2/22/23, more than five episodes on the night shift on 2/25/23 and more than five episodes on day shift 2/26/23. Restlessness was documented five times on the night shift on 2/22/23. The behavior anger/crying was documented three times on night shift on 2/8/23 and once during the night shift on 2/9/23, and four times on the night shift on 2/22/23. March 2023 documented the behaviors of anger/crying one time on 3/14/23 day shift, and one time on 3/13/23 night shift. Restlessness was documented one time on the night shift on 3/15/23, and one time on the day shift on 1/16/23. Agitation was documented as occurring one time on the night shift on 3/10/23, four times on day shift on 3/12/23, one time on day shift on 3/14/23 and one time on night shift on 3/13 and 3/14/23. Review of the nurses' notes revealed: On 1/18/23 at 12:33 p.m., Resident #900 was verbally and physically aggressive during lunch. Using profanity towards other residents, using his walker to attempt to hit other residents. Accusing residents of stealing his car. Problem solving technique was attempted to de-escalate the situation. Resident #900 became violent towards the nurse and was removed from the dining area. On 1/22/23 at 7:30 a.m., Resident #900 has had two sleepless, restless, and agitated nights. Threatens staff and refused multiple redirections. Spent most of the night going into other rooms despite the assistance to find a room. Additional behavior included verbal aggression, refusal to use walker, leaving walker and walking in hallway. On 1/23/23 Resident #900 continues to be sleepless, displays combativeness, non-compliant with walker, entering other rooms despite assisted to his room. Implementations included redirection, snacks television. Evaluation shows ineffectiveness. On 2/6/23 at 11:12 a.m., the nurse documented Resident #900 was acting up, showing signs and symptoms of increased agitation, wants to fight peers and staff and attempting to hit them with his wheelchair. Not able to be redirected verbally. On 2/6/23 at 12:04, the nurse documented Resident #900 with increased agitation using walker to hit doors attempting to open doors, wandering in other resident's room calling it his own room, attempting to hit staff with walker. The resident was unable to be redirected. The resident's spouse called to assist with redirection with no success. The physician was notified and gave orders to administer medications with positive response. On 2/7/23 the psychiatric Advanced Practice Registered Nurse (APRN) documented Resident #900 presented alert/awake, blank stare, depressed mood and anxious. Per nursing staff patient displays intermittent periods of disruptive, aggressive behavior and uncooperative resistance with care at times. The treatment plan specified monitor mental status for any acute change in mood or behavior, promote a safe environment and continue with current pharmacological regiment and start Seroquel (antipsychotic) 25 milligrams (mg) twice a day, Buspar 5 mg three times a day and Lexapro 10 mg daily (medications used to treat mood disorders). On 2/8/23 at 10:58 p.m., the nurse documented in a behavior note the resident woke up from a nap very agitated during this shift. Resident yelling at others Go to your room, now banging his walker on the floor multiple times. On 2/25/23 at 10:32 p.m., the nurse documented Resident #900 was noted with increased anxiety, agitation and several episodes of crying. The resident required frequent redirection back to his room. The physician's orders as of 10/21/22 included to administer Lorazepam 0.5 milligram by mouth at bedtime for anxiety. The nursing progress noted dated 3/7/23 at 6:42 a.m., noted behavior was noted. The Lorazepam was not administered. The nurse documented, Medication not available on hand. On 3/7/23 at 10:06 p.m., the Lorazepam was not administered for anxiety. The nurse documented, Not available. On 3/8/23 at 8:11 p.m., the nurse documented the Lorazepam was not administered. The nurse documented the resident needed a new script. The physician was called with no answer. On 3/9/23 at 8:05 p.m., the Lorazepam was not administered. The nurse documented Resident needs new hard script per pharmacy. Awaiting new script. On 3/10/23 at 7:00 a.m., the nurse documented, I visually observed resident holding onto roommates (Resident #850) arm trying to push him out of his bed. I was unable to redirect resident. I called for nurses aide to come assist me in getting the residents apart. 3 nurses aides assist me in getting [Resident #900] hands off of his roommate arm and assist [Resident #900] into his bed. [Resident #900] was using profanity towards staff. [Resident #900] got out of his bed and walked across the hall into another resident's room. I last saw [Resident #900] approx. 5:15 am when I gave him his morning medications, both residents were laying in bed. No behaviors observed at that time. Licensed Practical Nurse Staff A assessed both residents and no injuries were noted. The physician was notified, and no new orders were received. Resident #850 was moved to a different room. Review of the clinical record revealed Resident #850 was a vulnerable resident admitted to the secured memory care unit on 3/11/22 with diagnoses including dementia, anxiety, mood disturbance, and hypertension. The annual MDS dated [DATE] documented the resident's cognition was severely impaired. On 3/20/23 at 1:30 p.m., Resident #850 was observed in his room in bed. He was pleasantly confused responding to simple greeting but not able to recall the incident with resident #900. On 3/21/23 at 9:00 a.m., in a telephone interview CNA Staff F said she works both the 3-11 and 11-7 shift. She said she was there in the morning on 3/10/23. She went into Resident #900 and #850's room when she heard the nurse yelling. She saw Resident #900 trying to push Resident #850 out of the bed. Resident #900 was trying to get him out of the room but they both lived there. Resident #900 had a hold of Resident #850's arm, pushing him. They separated the residents. On 3/21/23 at 9:45 a.m., in a phone interview, LPN Staff A said she was working on the memory care unit on 3/10/23 passing medication in another room. She heard someone yelling for help, so she went to look. She knocked and went into Resident's #900 and #850's room. She saw Resident #900 trying to push Resident #850 out of bed. He had his arm and was tugging on it but Resident #850 did not fall out the bed. She tried to separate them but Resident #900 can be really strong. She called for help. The CNAs came and helped to separate them. They both have dementia. They moved Resident #850 to another room. They were not hurt. LPN Staff A said Resident #900 has days when he yells and curses and will push things around in the dining room. He can try and hit staff, but you can calm him down easily. On 3/21/23 at 8:00 a.m., the Administrator said the last allegation of resident to resident involving Resident #900 was on 9/15/21. She said Resident #900 wanders and has behavior outbursts that is why he was on a memory care unit. She said staff watch him and keep an eye on him. Further review of the progress notes revealed on 3/10/23 at 9:03 p.m., the nurse documented the Lorazepam 0.5 mg was not available to be given to Resident #900. The nurse noted, Medication not available, script needed. The Medication Administration Record for March 2023 did not contain documentation the Lorazepam was administered as ordered on 3/10/23 ,3/11/23 and 3/12/23. On 3/12/23 at 12:20 p.m., the nurse documented in a progress note at 9:20 a.m., she was passing medications when she heard a commotion. Upon investigation, she looked to the dining room next to the patio. Resident #900 was seen with walker in both hands shoving towards dining room door, yelling and screaming as he was being assisted away from the door. Another resident (Resident #700) was seen on the floor in a sitting position. Resident #900 continued to be verbally abusive with profanities and threats. Review of the clinical record showed Resident #700 was admitted to the facility on [DATE] to the secured memory care unit with diagnoses including cirrhosis of the liver, dementia, depression, Alzheimer's disease, schizoaffective disorder, anxiety, and bipolar disorder. Review of the Quarterly MDS dated [DATE] documented resident #700 was independent with ambulation, Resident #700 scored a 12 on the BIMS score indicating mild cognitive impairment. On 3/16/23 at 10:08 a.m., the psychiatric APRN documented the resident was seen today for increased agitation and disruptive behavior, as patient is exhibiting disruptive/aggressive behavior and elevated mood. Per nursing staff patient is uncooperative with care, medication adherence and very aggressive with staff, and other patient within the unit. On 3/20/23 at 1:00 p.m., Registered Nurse (RN) Staff C said Resident #900 was a very violent man, and they keep an eye on him because he wanders. The residents on the memory care unit have behaviors and most wander, it is why they are here. The RN said with Resident #900 sometimes all you do is talk to him and he can start yelling and cursing, and it does not matter. The CNAs come and say Resident #900 is cursing and trying to hit them. All he can do is try and redirect him and if that does not work, he gives him medication. RN Staff C said, You don't want to keep talking to him sometimes when he is angry because it makes him worse, he is not a nice man. On 3/20/23 at 1:45 p.m., Resident #700 said Resident #900 was in the dining room and closed the dining room door on her as she was waiting in the hall to go outside to the smoking area. Resident #700 said she opened the dining room door and told Resident #900 to leave it open and, he pushed the door into me, and I fell backwards. I was on the floor and the nurse found me and helped me to get up. Resident #700 said she fell on to her buttocks and scratched her right knee. She said Resident #900 wanders and he tries to come into her room and the nurse has to come and get him. Resident #700 said Resident #900 scares me. On 3/21/23 at 9:30 a.m., CNA Staff G said she was working on 3/12/23. Residents #900 and #700 were in the dining room. Resident #700 was waiting to go out and smoke around 9:00 a.m. Resident #900 likes to sit in the dining room and be by himself. It was noisy, so he got up and shut the door from the hall to the dining room. Resident #700 was standing on the other side of the door. She got upset because she wanted the door open, so she pushed the door open. Resident #900 pushed it back toward her and Resident #700 fell backwards. One wanted the door open and the other wanted to close it so they both pushed on it. She said she was in the dining room at the time it happened. Resident #900 gets verbally aggressive. He will curse you up and down and yells at you. He just likes to sit in the dining room by himself. She gives him a snack and a drink and he is ok. On 3/20/23 at 1:15 p.m., observed Resident #900 sitting in the dining room on the secured unit. He was not able to answer any questions regarding the incidents with Resident #700 or Resident #850. On 3/21/23 at 8:20 a.m., LPN Staff D said she works the night shift on the secured unit. Resident #900 gets up at night sometimes and tries to wander into other residents' rooms. She has a CNA follow him from a distance to make sure he is safe and everyone else too. LPN Staff D said resident #900 has some ugly days. He will try to hit you, yell, curses and will tear up the dining room. She tries to talk with him calmly. Sometimes he cries, shouts, and just wants his wife. She would call his wife to talk to him on the phone. her and she will talk to him on the phone. She says Resident #900 would try to hit staff, not residents. On 3/21/23 at 12:30 p.m., the Director of Nursing (DON) said Resident #900 was assessed by Psychiatry services on 3/16/23 after the incidents. She said they keep an eye on all the residents in the secured unit because they all have behaviors which are documented in the behavior monitoring sheets. She staffs the unit with three CNAs each shift and a nurse to keep a close eye on the residents. The DON said she did not implement increased supervision or one to one supervision for Resident #900 after the incidents with Resident #850 and #700. She said they could not predict when a resident on the secured unit is going to have a behavior. On 3/21/23 at 12:45 p.m., the Assistant Director of Nursing said they did not implement one to one supervision for Resident #900. She said they have staff softly monitor him, keeping a distance but still observing as not to make him more agitated. She said they could not predict his behaviors, there were no real triggers. It could be anytime or anything that sets him off. Staff has been trained to de-escalate the situation. On 3/21/23 at 2:15 p.m., in a phone interview the Psychiatric Advanced Practice Registered Nurse (APRN) said there was no way to predict when Resident #900 was going to have a behavior, that is the problem. We are working to find his triggers. I get a call when he is acting up but by the time, I get to the facility he is calm. I'm at the facility twice a week. Any resident could use more supervision, it would help. If you are asking me do I think we can tell when Resident #900 is going to have an episode, no I can't. I changed his medication, so now we wait and see if it was effective. If I give too much medication then he can fall or he becomes sedated, that is not the answer either. 2. Review of Resident #999's clinical record revealed an admitted [DATE] with diagnoses including acute respiratory failure, anxiety, alcohol abuse, multiple rib fractures, and adjustment disorder. The Quarterly MDS with an assessment reference date of 12/15/22 documented Resident #999 required extensive assistance from staff with transfers, toileting, and dressing. The MDS indicated Resident #999's cognitive skills for daily decision making were severely impaired. The plan of care identified Resident #999 exhibited behaviors of physical aggression, including striking out, hits, kicks, throws things, abrasive outburst towards staff and others, and uses inappropriate language, yelling and cursing at other resident, and verbally and physically aggressive toward staff. The interventions instructed staff to redirect, administer medications as ordered and observe for effectiveness. Approach resident in a calm manner and explain actions. Intervene as needed to protect the rights and safety of the resident, and others and remove from situation as able. On 3/5/23 at 12:35 p.m., the Manager on Duty Registered Nurse (RN) Staff I documented she observed CNA Staff H grab Resident #999 by the left arm while he was seated in the wheelchair. RN Staff I yelled from the South Unit Nursing station at the CNA to get away from the resident. CNA Staff H told the RN Resident #999 had tried to scratch her. The RN told the CNA to leave the facility and she assessed the Residents left arm. No injuries were observed by the RN. The RN then contacted the NHA who filed a report with the police. On 3/20/23 at 10:45 a.m., in a telephone RN staff I said she was the manager on duty on 3/5/23 and was standing at the South Unit nursing desk after dinner time and was looking down the hallway toward the Nort Unit. RN Staff I said CNA Staff H had Resident #999 by the left arm, yanking on him like she was about to pull him form the wheelchair. She said, I could see it very clearly, they were yelling. I screamed from the hall get away from him, because I knew I was not going to get there that fast. She let him go right away when she heard me scream. RN Staff H said she got to them, the CNA kept yelling he was fitting to scratch me, I ain't fitting to let anyone scratch me. She said CNA Staff H kept yelling, I ain't fitting to let anyone scratch me. She said she escorted the CNA out of the building and notified the Administrator who is the abuse coordinator right away. She assisted Resident #999 to his room and checked him to make sure he wasn't hurt. He didn't have anything on him, no bruises or anything. She said Resident #999 was confused and couldn't tell her or recall the incident. On 3/20/23 at 3:10 p.m., in a telephone interview LPN, Staff J said she was on duty on 3/5/23 the day of the incident with Resident #999 and CNA Staff H. She was sitting at the desk charting and could hear Resident #999 in the dining room yelling and cursing and threatening to hit residents and staff which was normal behavior for him. He was always yelling and cursing. I told CNA Staff H to take him to his unit. She said Resident #999 was very combative and you can't touch his wheelchair when he is in it. He is very aggressive all the time. She said she did not witness the incident but heard RN Staff I scream Get away from him. On 3/20/23 at 12:00 p.m., Resident #999 said he did not remember a CNA hurting him. On 3/20/23 at 10:10 a.m., the Administrator said CNA Staff H was immediately suspended after the incident. She was not permitted to return to the facility and her employment terminated.

Based on record review and staff interviews the facility failed to report an alleged violation related to a fall with injury within specified timeframe to the State Survey Agency for 1(Resident #92) of 3 residents reviewed. The findings included: A clinical record review showed Resident #92 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan documented Resident #92 was at risk for falls. Resident #92 was non ambulatory, had chronic pain, and a history of fall. The interventions included to utilize a mechanical lift (total body lift) for transfers with assist of two. A Fall Risk Evaluation dated 7/27/22 documented a score of 12, indicating Resident #92 was a high risk for falls. The nursing progress note dated 7/27/22 at 4:59 a.m., documented Resident #92 was transported to the emergency room for evaluation and treatment after a fall with a [CONDITION(S)]. The facility investigation documented on 7/27/22 at 4:30 a.m., Certified Nursing Assistants (CNA's) Staff Z and Staff Y were transferring Resident #92 from the bed to a geri-chair (Large padded chair) using a mechanical lift. In the process of transferring the resident, CNA Staff Z attempted to pull the lift and it got stuck on the geri-chair causing the mechanical lift to overturn onto the floor. Resident #92 was in the mechanical lift when it overturned. Resident #92 hit his head on the floor and was transferred to the hospital. The facility's investigation did not include an Immediate Federal report to the State Survey Agency as required. On 9/13/22 at 21:00 p.m., the Administrator said the CNAs involved in the transfer of Resident #92 were suspended after the incident. On 9/14/22 at 12:30 p.m., the Administrator verified the facility did not file an Immediate Federal report within specified time frame to the State Survey Agency as required.

Based on administrative and staff interview the facility failed to ensure the activity program was directed by a qualified activities professional who is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body. The findings included: On 7/12/22 at 3:58 p.m., the Administrator said the Activities Director resigned on 5/9/22, and she was in the process of looking for a replacement. She said Certified Nursing Assistant (CNA) Staff A who had been the activity assistant for the past two years has been running the program since 5/9/22. On 7/12/22 at 4:38 p.m. CNA Staff A said she has been assisting the Activity Director for the last two years but had no other training.

Based on observation, review of the clinical record, review of facility policy and procedures, staff, and resident interviews the facility failed to provide appropriate services and interventions for the management of contractures for 1 (Resident #34) of 2 residents sampled for positioning devices. The findings included: The facility policy Assistive Devices and Equipment (revised 1/20) documented, Our facility maintains and supervises the use of assistive devices and equipment for resident. 1. Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. These may include but are not limited to splints. 3.5cm for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan. Review of Resident #34's clinical record showed a readmitted [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan revised on 3/24/22 documented Resident #34 had contractures on the left hand and fingers (refuses to participate in range of motion (ROM)/splinting program). The interventions included Resident #34 was to wear a hand roll (cone splint) on left hand seven days a week. Review of the CNA task schedule for July 2022, instructed the splint was to be applied to left upper extremity (LUE) 4 hours on daily. The CNA Task Schedule showed no documentation the left-hand splint was applied for Resident #34 on 7/6/22 and 7/10/22. The documentation on the task for 7/11/22 showed the splint was applied at 2:59 p.m. On 7/11/22 at 10:41 a.m., 11:26 a.m., and 4:00 p.m., Resident #34 was in his bed, and he did not have a splint on the left hand. The documentation on the task showed the splint was applied on 7/12/22 at 1:56 p.m. On 7/12/22 at 2:00 p.m., and on 7/13/22 at 11:00 a.m., Resident #34 was observed in bed, and he did not have a splint on the left hand. On 7/13/22 at 12:50 p.m., the Director of Nursing (DON) said Resident #34 had a ROM and splinting program with the Restorative Certified Nursing Assistant (RCNA). The DON said the CNAs are assigned to do the ROM and splints, and We make referrals to therapy if needed. The DON said Resident #34 had the contracture to his left hand since his admission to the facility in 12/2013. On 7/13/22 at 2:21 p.m., the RCNA Staff H said Resident #34 was on restorative services for ROM and splinting to the left hand and arm daily. RCNA Staff H said the resident doesn't like the splint and is not able to remove it once it was applied. RCNA Staff H said the splints are applied in the morning then removed by the RCNA in the evening. Review of Resident #34's progress notes from 6/29/22 through 7/13/22 showed no documentation Resident #34 had refused to wear the splint to the left hand. On 7/13/22 at 1:21 p.m., Resident #34 was observed in his wheelchair propelling himself in the hallway. Resident #34 had a blue splint on his left arm extending from his fingertips to approximately two inches below the elbow. Resident #34 said he did not mind wearing the splint, and said it doesn't bother me a bit, I will wear it.

Based on observation, record review, resident and staff interview, the facility failed provide an ongoing program of activities designed to meet the physical, mental and psychosocial needs of 2 (Resident #12 and #56) of 26 sampled residents. The failure to provide a structured person-centered activities program has the potential to contribute to the decline of the resident's psychosocial wellbeing. The findings included: 1. On 7/11/22 at 10:18 a.m., Resident #56 said, I don't think they have any word puzzles. I watch TV a lot. The activities they have do not interest me. An activity calendar was observed hanging near the bed in the resident's room. No times were noted for the activities being provided by the facility. On Friday the activity calendar listed Road Trip as an activity. Resident #56 said they do not take the residents on trips at this time. She said the facility used to take the resident's shopping at Walmart. Review of the Minimum Data Set (MDS) showed Resident #56's activity preferences were last assessed on 9/3/21. The MDS showed the resident scored a 12 on the brief interview for mental status (BIMS) indicative of mild cognitive impairment. Resident #56 was able to make her needs known. Review of the activity care plan showed Resident #53 was at risk for decreased social interaction/ activity participation related to dementia. Due to pandemic, all activities require social distancing. She enjoys fresh air, games, cards, reading, movies, arts & crafts, music, reminiscing, Jazz, dancing and watching television shows. She also enjoys shopping, and she is a smoker. The things that are important to her are clothes, belongings, showers, snacks, bedtime, family involvement, phone use, keeping things safe, music, pets and fresh air. The care plan goal was for Resident #53 to continue to participate in activities of choice. The interventions included to determine which individual activities the resident prefers and provide any related materials as needed. Provide assist with television programs of choice as needed. Provide monthly activity calendar in room. Invite to daily group programs; provide assist to group location as needed. On 7/12/22 at 4:38 p.m., the Activities Assistant said she has been the activities assistant at the facility for two years. She said the facility currently did not provide outings for the resident, the road trip listed on the activities calendar was staff asking questions about things that occurred on a road trip. The Activity Assistant said Resident #53 did not like to come out of the room, and liked to watch her soaps. She said all Resident #53 ever says is she wants to get out of here. On 7/14/22 at 11:43 a.m., Resident #53 said it had been about two months since the facility took them out and she would just like to go shopping occasionally. Resident #53 said she felt she did not have any say in the planned activities. The resident said would like to go to dinner and go shopping. Resident #53 said she has mentioned it to staff and they did not respond. 2. Review of Resident #12's clinical record showed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the minimum data set (a tool used to gather data) dated 7/12/22 documented Resident #12 had a brief interview for mental status of 00. A score of 00 indicated severe cognitive impairment. Review of the care plan (revised 4/18/22) identified Resident #12 was at risk for decreased social interaction, activity participation related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She requires cues and assist during activities. Due to pandemic all activities require social distancing. The interventions included, the resident will continue to participate in activities of choice thru the next review date, invite to daily group programs, provide assist to group location as needed and provide monthly activity calendar in room. Review of the activity, recreation progress note dated 4/20/22 documented Resident #12 had no significant changes in her health or behavior. Her care plan was reviewed and updated to include her current activity preferences which include watching tv, outdoors, and food socials. On 7/11/22 at 11:32 a.m., Resident #12 was observed in her room sitting in her wheelchair facing the hallway and was calling out as staff walked past the room. Resident #12 appeared anxious and restless and was not able to verbally express her needs. There was no television or radio on in the room. The resident's roommate was present and said Resident #12 called out all the time and keeps her up at night. On 7/11/22 at 2:00 p.m., Resident #12 was observed sitting in the hall in front of the nursing station calling out. There was no interaction from the staff observed in the area. On 7/12/22 at 10:27 a.m., Resident #12 was observed in her wheelchair sitting outside of the dining room, not engaged in an activity. Resident #12 was wringing her hands and had a worried facial expression. A July 2022 activity calendar was posted on a board behind Resident #12 with the daily activities listed. The activated listed for 7/12/22 were current events and coffee, board games, music, and popcorn. There were no scheduled times listed for the activities on the calendar. On 7/12/22 at 12:12 p.m., in an interview the Activity Aide Staff A said the facility did not have an Activity Director. Activity Aide Staff A said she provided 1-1 sound spa which plays calming ocean sounds such as water sounds and other calming sounds for residents who are not attending activities and who have dementia. Activity Aide Staff A confirmed she did not put time schedules on the activity calendar and confirmed without the times posted, the residents would not know when the activity begins. Activity Aide Staff A said she had no specific activities planned to meet the needs of residents who have dementia and cognitive impairment. On 7/14/22 at 10:01 a.m., in an interview the Director of Nursing confirmed the activity calendar did not have the scheduled time of the activities and said the residents would not know when the activity was occurring. The DON confirmed the facility did not have an Activity Director.

Based on observation, interview, and record review the facility failed to provide the necessary services to maintain the personal hygiene, grooming for 2 residents (Resident #34 and #53) of 4 residents who require assistance with activities of daily living. Daily grooming contributes to the resident's dignity and the failure of maintaining a resident's personal grooming habits has a potential to affect the psychosocial well-being of the resident. The findings included: 1. Review of Resident #53's Quarterly Minimum Data Set (MDS) dated [DATE] severe cognitive impairment. The assessment documented the resident required limited physical assistance of one person for personal hygiene, including combing hair. Resident #53 range of motion was impaired on both upper extremities. The MDS noted Resident #53 did not reject care. Resident #53's care plan showed she was independent to limited assist with dressing, grooming, and bathing related to dementia. The goals were for the resident to have a clean, neat appearance daily. The interventions included to provide hands on assistance with dressing, grooming, bathing as needed. The care plan did not note the presence of behavior such as rejecting care. On 7/11/22 at 10:58 a.m., Resident #53 was observed in the dining room of Rose Garden memory care dining room. The resident's hair was not brushed and looked untidy. The hair around the back of her head was standing straight up from around the back of her head in a circle. On 7/12/22 at 9:00 a.m., Resident #53 was observed dressed in a blue sun dress in the Rose Garden memory care dining room. Her hair was observed in the same condition as the previous day. The hair around the back of the resident's head was standing straight up in a circle. On 7/13/22 at 11:03 a.m. Resident #53 was observed in the Rose Garden memory care dining room. She was sitting in a chair with her hair un-brushed. The back of her head showed the hair was formed as if she had been lying with her head on a pillow. On 7/13/22 at 11:37 a.m., Certified Nursing Assistant (CNA) Staff B said she was assigned to care for Resident #53 on 7/11/22, 7/12/22 and 7/13/22. She verified she did not brush or comb the resident's hair. CNA Staff B said the day before, Resident #53 refused assistance to brush her hair. She said she did not document and did not notify the nurse of the resident's refusal to brush her hair. CNA Staff B said she knew to document, notify the nurse, and reapproach the resident later. On 7/13/22 at 11:57 a.m., observation of the resident's room with CNA Staff B failed to show a hairbrush. CNA Staff B said she would provide a hairbrush to the resident. 2. The facility policy Activities of Daily Living (ADL), Supporting (revised 3/18) documented, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's) .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. Review of Resident #34's clinical record showed Resident #34's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record showed a significant change in status minimum data set (MDS) dated [DATE], documented a brief interview for mental status score of 00, indicating the resident had severe cognitive impairment. The MDS documented Resident #34 was dependent on staff for dressing and personal hygiene. Review of the care plan revised 3/4/22 documented Resident #34 had alterations in ADL's and required extensive assistance with dressing and grooming. The goal was for Resident #34 to have his ADL needs met daily by staff, while participating as tolerated. On 7/13/22 at 3:31 p.m., the MDS Coordinator said per the MDS guidelines, hygiene included hair care, nail care, shaving, washing face and hands everything except bathing and showers. On 7/11/22 at 10:42 a.m., Resident #34 was observed lying in bed and appeared unkempt. Resident #34 was unshaven approximately three days growth. The resident was wearing an adult brief and no clothing. Resident #34's fingernails extended approximately 1/2 inch in length, with a brown substance under nail beds. The bed linen was wrinkled, soiled, and stained. Resident #34 did not respond to greeting or communication. On 7/12/22 at 8:29 a.m., Resident #34 was observed in bed and remained unshaven, unkempt, and wearing a hospital gown. The resident's fingernails were long with brown substances under the nail beds. On 7/13/22 at 12:00 p.m., Resident #34 was observed in bed, his hair was greasy and uncombed, he was not shaved with approximately with 5 days growth. The resident was unkempt with long fingernails and brown and black substances under the nail beds. Resident #34 was not responding appropriately to simple questions. Review of the Certified Nursing Assistant (CNA) documentation from 7/1/22 through 7/13/22 documented personal hygiene was provided to Resident #34 on each shift. The document showed Resident #34 had received a bath on 7/11/22 at 2:59 p.m. On 7/13/22 at 12:33 p.m., the Director of Nursing (DON) said Resident #34 never really did his own ADL's, was combative and was scratching staff when they tried to provide care. She said when the resident became agitated, they must stop, wait, and then restart the process. She confirmed there was no documentation of behaviors or refusal of care in Resident #34's clinical record. On 7/13/22 at 1:00 p.m., agency CNA Staff M said she was assigned to Resident #34 for the day and knew him briefly from her time at the facility. CNA Staff M said Resident #34 would resist care, refuse care, pull the covers over his head, say leave me alone, cover me up but did not hit anyone. CNA Staff M said it takes an hour and a half to get the resident up and ready to be in the wheelchair and she requires assistance from the other staff members. On 7/13/22 at 1:31 p.m., Resident #34 was observed propelling himself in a wheelchair in the hallways. The resident was dressed in his own clothing, shaved, his hair was combed, and his nails were trimmed. Resident #34 was pleasant, smiling and answering simple questions.

Based on clinical record review and staff interviews, the facility failed to develop a comprehensive person-centered care plan with goals and individualized interventions to meet the needs of 2 (Resident #22 and #81) of 26 sampled residents. The findings included: 1. On 7/11/22 at 3:46 p.m., a review of the clinical record showed Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant change Minimum Data Set (MDS) assessment with a target date of 4/14/22 noted Resident #22 was receiving hospice services. The clinical record lacked documentation of an individualized care plan to ensure collaboration of care between hospice and the facility. On 7/12/22 at 2:45 p.m., Licensed Practical Nurse (LPN) Staff I said the facility worked closely with hospice to ensure services were not duplicated. After reviewing the clinical record, LPN Staff I verified the lack of a care plan addressing hospice services for Resident #22. She said Resident #22 did not have a care plan for hospice. On 7/12/22 at 3:17 p.m., Minimum Data Set (MDS) Coordinator LPN Staff J said the care plan maps out needs and services supplied for a patient facing a terminal illness and helps to coordinate care. Staff J said the care plan identifies the agencies that assist with care and provides their telephone numbers and contact information. Staff J confirmed Resident #22 did not have a hospice care plan. 2. On 7/12/22 review of the clinical record for Resident #81 showed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS assessment with a reference date (ARD) of 6/7/22 documented Resident #81 had obvious or likely cavity or broken natural teeth. Resident #81 routinely received antipsychotic (medication used to treat certain mental and mood disorders) and antidepressant medications. The Care Area Assessment Summary noted the need for a care plan to address [CONDITION(S)] drug use and dental care. The care plan initiated on 6/5/22 did not address the resident's dental status or the use of [CONDITION(S)] medications. On 7/12/22 at 3:17 p.m., MDS coordinator LPN Staff J confirmed the care plan was not updated to include [CONDITION(S)] medication use or the dental care needs for Resident #81.

Based on record review, review of the policies and procedures, observation, and staff interview, the facility failed to evaluate and modify interventions to prevent avoidable accidents for 2 (Residents #94 and #68) of 3 residents reviewed who were identified as being at risk for falls and sustained multiple falls at the facility, including falls with major injury. The failure to implement appropriate interventions to prevent falls and fall related injuries resulted in Resident #94 and #68 sustaining preventable falls, including falls with major injury requiring the residents transfer to a higher level of care. The findings included: The policy and procedure for managing falls and fall risk indicated based on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks and causes tried to prevent the resident from falling and tried to minimize complications from falling. The resident centered approaches to managing falls and fall risk included if falling recurred despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remained relevant. If underlying causes couldn't be readily identified or corrected, staff would try various interventions, based on assessment of the nature or category of falling, until falling was reduced or stopped, or until the reason for the continuation of the falling was identified as unavoidable. In conjunction with the attending physician, staff would identify and implement relevant interventions (e.g., hip padding or treatment of [REDACTED]. Position-change alarms would not be used as the primary or sole intervention to prevent falls, but rather would be used to assist the staff in identifying patters and routines of the resident. The use of alarms would be monitored for efficacy and staff would respond to alarms in a timely manner. If the resident continued to fall, staff would re-evaluate the situation and whether it was appropriate to continue or change current interventions. As needed, the attending physician would help the staff reconsider possible causes that may not previously have been identified. 1. Resident #94 was admitted to the facility on [DATE] with a history of fall prior to admission resulting in a right [MEDICAL CONDITION]. The 14 days minimum data set (MDS) assessment with an assessment reference date (ARD) date of 12/21/18 indicated the resident's brief interview for mental status (BIMS) score was a 10. (The BIMS test is used to get a quick snapshot of how well the resident is functioning cognitively at the moment. The total BIMS score ranges from 0 to 15. A score of 13 to 15 is indicative of intact cognition. A BIMS score of 8 to 12 indicates moderate impaired cognition. A score of 0 to 7 indicates severe cognitive impairment.) The MDS indicated Resident #94 required extensive physical assistance of 2 persons for transfers. The quarterly MDS with an ARD date of 3/16/19 indicated Resident #94's BIMS had decreased to a 9 (Moderate cognitive impairment). The significant change in status assessment with an ARD target date of 5/7/19 indicted a cognition decline. The resident was unable to complete the interview, therefore a staff interview was conducted. Resident #94 had both short-term and long-term memory problems and his cognitive skills for daily decision making were severely impaired. The social service evaluation dated 12/11/18 indicated Resident #94 had short term memory impairment (ability to recall after 5 minutes) and was moderately impaired for decision making ability, made poor decisions and required staff supervision and assistance. The facility determined the resident was at risk for falls and initiated a care plan on 12/14/18 indicating Resident #94 was at risk for falls and/or fall related injury related to [DIAGNOSES REDACTED]. The care plan also indicated the resident had poor safety awareness. The interventions on 12/14/18 included to keep the bed in low position, keep the environment free of clutter in the walkways, appropriate footwear, assist to wheel to destinations, keep call light within reach. On 12/12/18 at 2:45 p.m., review of the clinical record revealed Resident #94 was found on the floor in the bathroom. Resident #94 was not wearing appropriate footwear. He was able to answer simple questions and said he was not ready to go home due to weakness. The facility investigated and documented the condition that could have impacted the event included the resident's attempt to self-toilet. Review of the Certified Nursing Assistant's (CNA) documentation showed the resident was last assisted to the toilet on 12/12/18 at 9:00 a.m. On 12/14/18 (2 days after the fall) the care plan was updated to provide Resident #94 with a low bed but did not address the root cause of the incident. The new intervention was not listed on the CNA care Kardex (Document that contain individual patient care interventions for the CNA to safely care for the resident). On 1/3/19 at 8:19 a.m., Resident #94 was found on the floor in his room and fell while reaching for food items on the breakfast tray. The care plan was updated and indicated to position personal belongings, equipment, and meal trays to be within reach on the right side. The new interventions were not listed on the CNA Kardex. On 1/24/19 at 6:06 p.m., Resident #94 was found on the floor in the restroom. The witness statements indicated the CNA assisted the resident to the toilet at 4:15 p.m. The bowel report on the CNA documentation indicated the resident was last toileted on 1/24/19 at 1:36 p.m. (approximately 4.5 hours prior to the fall). The investigation incident worksheet listed the resident's attempt to self-toilet as a condition that could have impacted this event. No new intervention was listed on the care plan or CNA Kardex to address the cause of the fall and minimize the risk for further avoidable falls. On 2/7/19 at 3:10 p.m., Resident #94 was found on the floor with his head resting against the dresser. The incident investigation worksheet indicated the conditions that could have impacted this event included the resident attempted to self-toilet and removed the bed/chair alarm (alarm that notified staff when an at risk resident attempted to leave the bed or chair without assistance). The care plan was not updated until 2/8/19 (1 day after the fall) to reflect the use of a bed/chair alarm for the resident. The CNA Kardex was not updated to include the use of an alarm for the resident. On 2/10/19 at 10:35 p.m., Resident #94 was found on the floor in the dining room. The resident was unattended in the dining room. The nurse documented she responded to the alarm. The resident sustained [REDACTED]. The incident investigation worksheet indicated Resident #94 had an unsteady gait and short-term memory loss. On 2/12/19, the care plan was updated with an intervention to re-direct the resident not to silence the alarm, even though it was documented the resident had short-term memory loss. No other intervention was listed on the care plan to ensure the resident's safety. On 2/12/19 at 2:35 p.m., the south wing Unit Manager Staff L documented she was passing by the resident's room and observed Resident #94 scooting on the floor at the foot of the bed. The resident sustained [REDACTED]. The incident investigation worksheet did not indicate if the alarm was on and functioning at the time of the incident. The care plan was updated with an intervention to re-direct the resident to not silence the alarm and staff to ensure the alarm was functioning. On 6/5/19 at 12:15 p.m., the Assistant Director of Nursing (ADON) said the resident had removed the alarm hence the reason they instructed the resident not to remove the alarm. On 3/23/19 at 8:00 p.m., Resident #94 reported he fell approximately a week ago on the other unit but did not want to tell anybody. The nurse documented she observed a superficial abrasion to the back of the right shoulder and the resident complained of pain to the right shoulder when he lifted his right arm over his head. At the time of the survey, the facility did not have document of an investigation. On 6/5/19 at 12:30 p.m., the Director of Nursing (DON) said she spoke to the nurse, the CNA and charge nurse on duty on 3/23/19 but did not speak to anyone else on duty on the other unit of the facility. On 3/25/19, (2 days after the alleged fall) the care plan was updated and included to position the bed/chair alarm where resident couldn't reach it. The CNA Kardex did not list an alarm as a fall intervention or where to position the alarm to prevent the resident from reaching it. On 4/7/19 at 1:35 p.m., Resident #94 was observed on the floor in supine position (face and torso facing up) in his room between the bed and the wheelchair. The witness statement indicated the resident's alarm was not on or sounding. The incident investigation worksheet indicated the resident had removed his bed/chair alarm as a condition that could have impacted this event. The care plan was updated to toilet the resident every 2 to 3 hours (which was routine). The facility still listed the use of the alarm for the resident even though the alarm had not been successful at preventing the previous falls. On 4/22/19 at 1:50 p.m., the receptionist documented she was at the front desk helping another resident when she heard a chair sliding across the floor. When she looked up, she saw Resident #94 on the floor. He said he was trying to transfer to a lounge chair. The staff developer documented she heard a commotion in the front lobby. When she arrived, she observed Resident #94 lying on the floor in front of the wheelchair, on his back. The nurse and 2 other staff members assisted the resident. The incident investigation worksheet did not list any environmental/situational condition that could have impacted this event. Review of the voiding report documented by the CNA indicated Resident #94 was last toileted on 4/22/19 at 11:25 a.m., 2.5 hours before the fall. The facility updated the care plan to educate the resident to ask for assistance for transfers even though on 12/24/18 it was noted in the care plan Resident #94 had episodes of confusion and cognitive loss as exhibited by impaired decision making skills with short term and long term memory deficit. The care plan also indicated the resident had episodes of disorganized thinking which fluctuated. On 4/27/19 at 9:30 p.m., Licensed Practical Nurse Staff V documented in the accident/incident report she heard Resident #94 screaming for help. She arrived to the resident's room and observed resident lying on the floor on his back in front of the bathroom next to his wheelchair. The resident complained of left leg pain. CNA Staff U documented at 9:10 p.m., she was in a room providing care to a resident when she heard somebody say help me. When she went to the room, she observed Resident #94 on the floor. The resident said he finished using the bathroom and missed the wheelchair. She reported the incident to the nurse. The incident report indicated Resident #94 had impaired memory and impaired decision making. The incident investigating worksheet listed the conditions that could have impacted this event included the resident removed the bed/chair alarm, attempted to self-toilet, was in unsupervised area and inappropriate use of assistive device. The resident was transferred to the local hospital emergency room where he was diagnosed with [REDACTED]. The facility updated the care plan indicating to change the resident to an A bed (bed by the door). On 6/6/19 at 3:50 p.m., CNA Staff U said perhaps her documentation was not accurate but she remembered the resident's alarm was on and sounding on 4/27/19. On 6/6/19 at 4:10 p.m., LPN Staff V said the facility already told her the surveyor would be calling. She said she didn't know why the investigation would say the alarm wasn't on. She said she heard the resident scream for help but the alarm was on. He may had removed it but it was on and sounding. On 6/3/19 at 2:05 p.m., observed Resident #94 in a wheelchair sitting on a pommel cushion (cushion designed to limit forward movement of the pelvis). Complete review of the clinical record failed to reveal documentation of an assessment or care plan for the use of the pommel cushion. On 6/5/19 at 8:55 a.m., the Director of Rehabilitation verified there was no assessment for the pommel cushion for the resident. He said the pommel cushion was not appropriate for the resident. He said Resident #94 was able to get up on his own and had not been assessed for the use of a pommel cushion. On 6/5/19 at 9:00 a.m., CNA Staff W said she didn't know when Resident #94 started using a pommel cushion. She verified the Kardex did not list a pommel cushion for the resident. She said she'd been assigned to care for the resident since 6/3/19 and the pommel cushion was already in the wheelchair so she kept using it. On 6/5/19 at 9:00 a.m., Resident #94 was observed in bed having breakfast. Resident was in a B bed (bed by the window) despite a care plan indicating to change his bed to an A bed (bed by the door). The sensor pad alarm box was on the bed to the right of the resident's shoulder. The alarm was easily accessible to the resident. The same observation was made on 6/5/19 at 4:30 p.m. The observation was verified by the ADON and CNA Staff S who said the resident was in bed when she started her shift at 3:00 p.m., and the alarm was on the bed next to the resident so she left it there. Resident #94 was able on command to pull the cord and reach for the bed alarm box. On 6/5/19 at 4:35 p.m., CNA Staff S said she'd been assigned to care for Resident #94 but did not know him very well. She said she looked to the CNA Kardex for information to take care of him. She said the alarm was not listed on the Kardex but was already on the bed next to the resident when she started her shift at 3:00 p.m., and she left it there. She said the Kardex did not list any special position for the bed but she would put the bed in a very low position since the patient was at risk for falls. The CNA agreed the Kardex did not list all the interventions necessary to prevent falls and fall related injuries for the resident. On 6/5/19 at 4:45 p.m., Unit Manager Staff L verified the fall interventions for Resident #94 were not listed on the CNA Kardex. She said the alarm shouldn't be laying on the bed where he could reach it. On 6/5/19 at 5:05 p.m., the DON was informed of the above observations. She repositioned the alarm on the resident's bed to where the resident could not reach it. 2. Resident #68 resided on the secured unit of the facility and had a [DIAGNOSES REDACTED]. Resident #68 had a fall on 7/3/18 that resulted in a fracture to her right hip. The MDS (a tool to assess care needs) dated 4/24/19 indicated Resident #68's cognition skills for daily decision making are severely impaired and she rarely understood or made herself understood. The residents care plan (provided direction on the type of nursing care a patient required) indicated Resident #68 required extensive assistance of 1 person to stand, transfer and ambulate. On 6/3/19 at 11:45 a.m., Resident #68 was observed in the dining room, sitting in a regular chair. The resident placed her hands on the arm rests and raised herself up slightly and sat back down. Resident #68 repeated the behavior several times but sat down when staff redirected her. Review of the clinical record revealed on 6/3/19 at 6:45 p.m., Resident #68 sustained a fall and was sent to the local hospital emergency room for evaluation and treatment. The imaging scan was performed and identified a non-displaced fracture in the lateral wall of the left maxillary sinus (sinus located near the nose) and hemorrhage (blood loss or bleeding) in the left maxillary sinus. Left maxillary soft tissue swelling is seen. Resident #68 also sustained a laceration to the inside of the upper lip that required sutures (stitches holding together edges of a wound). On 6/4/19 at 10:02 a.m., CNA Staff I said Resident #68 was not able to ambulate and used a wheelchair with staff assistance. The CNA said the resident would attempt to get up when sitting and then sit back down, all the time. The care plan for behaviors did not address Resident #68's constant attempt to stand up from the chair. There was no intervention listed to address this behavior. The CNA Kardex did not address the resident's behavior or interventions to ensure the resident's safety. On 6/5/19 at 8:11 a.m., CNA Staff D said Resident #68 was not able to ambulate and was not able to stand unassisted. The CNA said Resident #68 had a fall about a year ago and broke her hip and since that time she was no longer able to ambulate. On 6/5/19 at 8:51 a.m., the ADON said there was a hall monitor at all times who walked the halls to ensure safety on the secured unit. The Unit Manager said Resident #68 was able to ambulate with assistance but used the wheelchair for transport due to weakness. On 6/5/19 at 9:27 a.m., the Physical Therapist said Resident #68 was receiving therapy for ambulation but was not able to retain anything. The physical Therapist said Resident #68 was discharged on [DATE] and started on restorative ambulation program on 4/18/19 to ambulate with assist of 1. On 6/5/19 at 9:31 a.m., the restorative Licensed Practical Nurse Staff R said the resident was discharged from the restorative program on 5/27/19. Staff R said the programs run for 30 days and if they were maintaining then they were discharged from the program. She said she did not know Resident #68 was using a wheelchair. On 6/05/19 at 4:34 p.m., CNA Staff F said we were in the dining room and then brought Resident #68 to her room in the wheel chair. The CNA said she went to grab gloves at the entrance of the resident's room. Staff F said she had one hand on the resident's shoulder because she liked to stand up. The CNA said I was grabbing the gloves and the resident decided to stand up. CNA Staff F said I was holding her but her weight was too much. I tried to catch her. The nurse was at the nurse's station and I was screaming for someone to come. The nurse came and the resident was on the floor. We sat her up against the wall. I stayed with the resident until the ambulance came. CNA Staff F said the fall could have happened anywhere because the resident constantly tried to stand up and sit down. The CNA said there were 4 CNA's working when the resident fell , including a hall monitor. CNA Staff F said the hall monitor walked through the hall to check on residents, but was in the dining room when Resident #68 fell . CNA Staff F said I knew the resident was a fall risk, the other aides told me, so we watch her more. CNA Staff F said Resident #68 was a 1 person assist and stood up good with one person. CNA Staff F said the instructions for Resident #68's care were in the Kardex, and we looked at it every day. She said Resident #68 had been using the wheelchair for weeks. CNA Staff F said the resident used to walk but not anymore, she had not walked since she have been working with her in the last few weeks. The medical record revealed Resident #68 was referred to therapy on 5/8/19 and the recommendation was for Resident #68 to continue with restorative nursing and to use a wheelchair. On 6/5/19 at 5:00 p.m., the ADON verified Resident #68's sustained a fall on 5/7/19 and 6/3/19, but the care plan was not updated with interventions to prevent further falls and fall related injuries. The ADON also verified Resident #68's care plan did not include the use of a wheelchair.

Based on record review and interview the facility failed to insure that the appropriate care and services were provided to prevent complications for 1 (Resident #1) of 7 residents reviewed who were receiving Gastrostomy Tube ([DEVICE]) feedings. The facility failed to provide nursing services resulting in a continuation of the systems' failure regarding facility approaches and all staff had demonstrated understanding of facility expectations in the implementation of facility policy and procedures related to Gastrostomy Tube ([DEVICE]) replacement assessment, notification of the physician regarding condition changes. This failure created a situation that resulted in serious injury and harm to Resident #1, impairment, or death to residents and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on 08/13/2012 was identified on 02/26/2013. The immediate jeopardy was removed on 02/26/2013, based upon the implementation of corrective action. The findings are: Resident #1' record review on 2/25/13, noting an order for [REDACTED]. The Interventions include: ? Administer feeding as ordered by MD. ? Observe nutritional and fluid needs. ? Observe for tolerance of feeding: nausea, vomiting, aspiration, fecal impaction, diarrhea, or abdominal distention. ? Flush tube as ordered. ? Check for placement of tube. ? Keep HOB elevated during feeding. ? Check for [MEDICAL CONDITION] residual before administering tube feedings. ? Observe labs as available. Review of Resident #1's record on 2/25/2013 at 8:00 p.m., noting an order for [REDACTED]. She reported this to the nurse (LPN/Staff A). In the Nursing Note dated 8/13/12 at 1:15 p.m., LPN/Staff A documented "No bleeding noted to [DEVICE] site. PRN order to reinsert [DEVICE] carried out as order. [DEVICE] 14 fr/15 cc placed in stomach with assist x 2 nurses. Check tube placement x 2 nurses. Verified. [DEVICE] in placed. Flushes well. Discomfort noted with [DEVICE] placed. prn pain med given as ordered." There was no documentation of second nurse verification of placement. LPN/Staff A documented in her nursing note, dated 8/13/2012 at 1:15 p.m., discomfort noted with [DEVICE] placement. PRN (as needed) pain medication given as ordered via [DEVICE]. The next nursing note was on 8/14/12 at 9:30 a.m. A review of documentation signed by LPN/Staff A: ? Nursing Note, dated 8/13/12, at 1:45 p.m. documenting the physician (MD) was made aware. No new orders. (The next nursing note is dated 8/14/2012.) ? Nursing note, dated 8/14/2012, at 9:30 a.m. documented "[MEDICATION NAME] 1.2 @ 60 cc/hr infusing via (peg, crossed out) tube". HOB (head of bed) elevated. "[DEVICE] placement checked with + effects. Meds given via [DEVICE] without difficulty. Resident noted grimacing during [DEVICE] placement. PRN pain med giving as ordered without difficulty. [DEVICE] placement verified by another nurse also. Grimacing noted when air 30 cc push in [DEVICE]. Without residual noted. [DEVICE] feeding placed on hold." The name of second nurse was not documented. ? Nursing note dated 8/14/12 at 9:45 a.m., MD notified. Receive new orders. (Nurse/Physician Communication Record dated 8/14/12 at 9:45 a.m. documented call to Primary MD, may hold [DEVICE] feedings. Consult surgeon. ? Nursing note dated 8/14/12 at 9:50 a.m. Surgeon's office called. Dr. in surgery at this time. Left message to check [DEVICE] placement". ? Nursing note dated 8/14/12 at 11:15 a.m. resident does not look right. Resident assess labored breathing noted. Resident started on O2 at 3L via n/c." (nasal cannula) ? Nursing note dated 8/14/12 at 11:17 a.m. "Resident O2 stat 93% + pulse 72. Without labor breathing noted". ? Nursing note dated 8/14/12 at 11:20 a.m., MD notified. Receive new orders to send to ER. ? Nurse/Physician Communication Record Form documentation dated 8/14/12 at 11:20 a.m. Call made to primary MD. "Reason you are calling/current condition: decreased pulse, labored breathing+ discomfort with check tube placement: Lung Evaluation, cough with positioning. Outcome/MD order: Send to ER for evaluation. ? Nursing note dated 8/14/12 at 11:30 a.m. "nurse to nurse report given" (no names documented) ? Nursing note dated 8/14/12 @ 11:32 a.m. "911 called" ? Nursing note dated 8/14/12 at 11:35 a.m. "ambulance arrive. without resp distress noted" ? Nursing note dated 8/14/12 at 11:45 a.m. "resident transported to HRMC " (Hendry Regional Medical Center) ? Nursing note dated 8/14/12 at 3:00 p.m. resident still at ER, being worked up" ? Nursing note dated 8/14/12 at 6:30 "ER called. resident still in ER awaiting to be transported out to Palm West (hospital) ? Nursing note dated 8/14/12 at 6:40 p.m. "MD made aware" ? Resident Transfer Form Dated 8/14/12 documents [DIAGNOSES REDACTED]. LPN/Staff A documented in the nurses note, dated 8/14/12 at 9:30 a.m., [MEDICATION NAME] 1.2 at 60 cubic centimeters (cc)/hour (hr) infusing via tube. [DEVICE] placement checked with + effects. Meds given via [DEVICE] without difficulty. PRN pain medication given as ordered. [DEVICE] flushed without difficulty. [DEVICE] placement verified by another unnamed nurse. Grimicing noted when air 30 cubic centimeters (cc) push in [DEVICE]. Without residual noted. [DEVICE] feeding put on hold. Documentation of call to physician (MD) for Resident #1 because of "discomfort with peg tube placement check", "Primary Diagnosis: [REDACTED]. Documentation on Resident #1's Transfer Form, dated 8/14/12, Resident transferred to emergency room of local hospital with Altered Mental Status, decreased pulse, and discomfort with checking tube placement. The Medical Imaging form, completed at Hendry Regional Medical Center, documented for Resident #1 with Service Date/ Time of 8/14/2012 at 15:38, Impression of computed tomography (CT) scan to abd., Large free air with [MEDICAL CONDITION] tube which appears to lie in appearance the anterior abdominal wall outside of stomach with contrast layering along anterior left hepatic lobe and complex free fluid within the pelvis which may reflect [MEDICAL CONDITION] contents and or contrast. Blood cannot be excluded. Free air tracts superiorly along pericardium and inferiorly with some free air tracks superiorly along pericardium and inferiorly with some free air extending into the anterior subcutaneous tissues. Left myolipoma. Fecal impaction. During an interview on 2/25/13 at 5:04 p.m., the Director of Nursing (DON) stated she changed the procedure for [DEVICE] reinsertion after learning the nursing staff were reinserting [DEVICE]s in the facility. She stated she found out about the nurses changing the [DEVICE]s sometime in October of 2012. She stated she was not aware of the tube feeding problems with Resident #1. She stated the emergency room (ER) told the facility Resident #1 had a [DIAGNOSES REDACTED]. She stated she instructed her nursing staff to call the primary MD to inform of change in residents health status and to get an order for [REDACTED]. She stated no tubes have been replaced in the facility since Resident #1 in August 2012. During an interview on 3/01/13 at 5:00 p.m., the DON stated she has begun in-serving all nurses on a revised policy to not re-insert any tube feeding, but to send residents to the emergency room for an X-ray, effective 2/26/2013. The DON provided documentation that 33 of 44 nurses had received the in-service on the revised policy. Although immediate jeopardy was removed, deficient practice continues since the facility has not completed the in-service training for all nurses, not demonstrated through monitoring, needed modification and systematic review to ensure that regulatory compliance is maintained. The ongoing noncompliance is at the Scope and Severity Level of D.

Based on interview and review of policies and procedures the facility failed to insure that the Gastrostomy Tube ([DEVICE]) reinsertion was provided for 1 (Resident #1) of 7 residents reviewed which met the current professional standards of care and the facility policy and procedure. The facility failed to provide effective nursing services resource management to promote and ensure the health and well-being of all facility residents. The facility failed to provide nursing services resulting in a continuation of the systems' failure regarding facility approaches and all staff had demonstrated understanding of facility expectations in the implementation of facility policy and procedures related to Gastrostomy Tube ([DEVICE]) replacement and assessment or replacement, notification of the physician regarding condition changes. This failure created a situation that is likely to result in serious injury, harm, impairment, or death to residents and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on 08/13/12 was identified on 02/26/13. The immediate jeopardy was removed on 02/26/2013, based upon the implementation of corrective action. The findings include: Review of Resident #1's record on 2/25/2013 at 8:00 p.m., noting an order for [REDACTED]. She reported this to the nurse (LPN/Staff A). In the Nursing Note dated 8/13/12 at 1:15 p.m., LPN/Staff A documented "No bleeding noted to [DEVICE] site. PRN order to reinsert [DEVICE] carried out as order. [DEVICE] 14 fr/15 cc placed in stomach with assist x 2 nurses. Check tube placement x 2 nurses. Verified. [DEVICE] in placed. Flushes well. Discomfort noted with [DEVICE] placed. prn pain med given as ordered." The name of the second nurse who verified tube placement is not documented in resident record. LPN/Staff A stated to Department of Children and Families (DCF) worker, the second nurse was (LPN/Staff B). LPN/Staff B was interviewed on 3/1/2013 at 2:30 p.m. She stated "I confirmed placement of the tube with LPN/Staff A on 8/14/2012, but I was not in the room during the tube placement on 8/13/2012". LPN/Staff A was not available to interview during survey. A review of documentation signed by LPN/Staff A: ? Nursing Note, dated 8/13/12, at 1:45 p.m. documenting the physician (MD) was made aware. No new orders. (The next nursing note is datred 8/14/2012.) ? Nursing note, dated 8/14/2012, at 9:30 a.m. documented "[MEDICATION NAME] 1.2 @ 60 cc/hr infusing via (peg, crossed out) tube". HOB (head of bed) elevated. "[DEVICE] placement checked with + effects. Meds given via [DEVICE] without difficulty. Resident noted grimacing during [DEVICE] placement. PRN pain med giving as ordered without difficulty. [DEVICE] placement verified by another nurse also. Grimacing noted when air 30 cc push in [DEVICE]. Without residual noted. [DEVICE] feeding placed on hold." The name of second nurse was not documented. ? Nursing note dated 8/14/12 at 9:45 a.m., MD notified. Receive new orders. (Nurse/Physician Communication Record dated 8/14/12 at 9:45 a.m. documented call to Primary MD, may hold [DEVICE] feedings. Consult surgeon. ? Nursing note dated 8/14/12 at 9:50 a.m. Surgeon's office called. Dr. in surgery at this time. Left message to check [DEVICE] placement". ? Nursing note dated 8/14/12 at 11:15 a.m. resident does not look right. Resident assess labored breathing noted. Resident started on O2 at 3L via n/c." (nasal cannula) ? Nursing note dated 8/14/12 at 11:17 a.m. "Resident O2 stat 93% + pulse 72. Without labor breathing noted". ? Nursing note dated 8/14/12 at 11:20 a.m., MD notified. Receive new orders to send to ER. ? Nurse/Physician Communication Record Form documentation dated 8/14/12 at 11:20 a.m. Call made to primary MD. "Reason you are calling/current condition: decreased pulse, labored breathing+ discomfort with check tube placement: Lung Evaluation, cough with positioning. Outcome/MD order: Send to ER for evaluation. ? Nursing note dated 8/14/12 at 11:30 a.m. "nurse to nurse report given" (no names documented) ? Nursing note dated 8/14/12 @ 11:32 a.m. "911 called" ? Nursing note dated 8/14/12 at 11:35 a.m. "ambulance arrive. without resp distress noted" ? Nursing note dated 8/14/12 at 11:45 a.m. "resident transported to HRMC " (Hendry Regional Medical Center) ? Nursing note dated 8/14/12 at 3:00 p.m. resident still at ER, being worked up" ? Nursing note dated 8/14/12 at 6:30 "ER called. resident still in ER awaiting to be transported out to Palm West (hospital) ? Nursing note dated 8/14/12 at 6:40 p.m. "MD made aware" ? Resident Transfer Form Dated 8/14/12 documents [DIAGNOSES REDACTED]. A review documentation signed by Staff D: ? Nurse's Notes dated 8/15/12, at 10:00 a.m., "Notified HRMC spoke with Nursing supervisor in regards to resident transfer status to Palm West, report given resident sent to Palm West due to [MEDICAL CONDITION] changes + r/o(rule out) [MEDICAL CONDITION](cardio vascular accident). Primary MD made aware." Signed by Staff D. ? Nurse's Notes dated 8/16/12 at 11:30 a.m. "Resident reviewed in weekly (maagment) SOC by IDT" (inter disciplinary team). Documentation of staff in-service training for reinsertion of [DEVICE] and related competency training was requested on 2/25/2013. The facility was unable to produce documentation that LPN/Staff A or LPN/Staff B had received the in-service education/training for reinsertion of [DEVICE]s prior to 8/13/2012. On 2/25/12 at 9:00 p.m. the Staff Development Coordinator, the Director of Nursing (DON) and Administrator confirmed they were unable to find documentation of staff training or competency performance test for LPN/Staff A or LPN/Staff B prior to 8/13/2012. The facility did provide a written statement dated 2/27/2013 from LPN/Staff A that she recalls attending a training on Gastrostomy replacement provided by the LPN/Staff Developer (Staff C) in 2011. No documentation of Staff C receiving required training on [DEVICE] reinsertion. LPN/Staff C no longer employed by facility. The facility provided a written statement, dated 2/27/2013, from LPN/Staff B stating she recalls attending training on Gastrostomy Replacement provided by Staff X, sometime in May 2011. The Competency test documentation for Staff X, dated 11/9/10, is not signed by the trainer. There is a note on the bottom of the form *done by Dr. (last name) in rm #128-A. A review of the facilities policy and procedure for [DEVICE] Replacement, on 2/25/2013, at 7:30 p.m., documented: 1) Gastrostomy tube replacement will be performed by a qualified licensed nurse when: A. Allowed by the state nurse practice act B. The licensed nurse has evidence of competency testing for Gastrostomy tube replacement C. The resident has a healed fistula,>six(6) weeks: physician has ordered replacement by licensed nurse: and replacement takes place as soon as possible. If less than the stated time frame, the resident must be transferred to an appropriate setting, i.e. emergency room for Gastrostomy tube replacement. D. There is no evidence of [MEDICAL CONDITION] pathology, e.g. [MEDICAL CONDITION] bleeding, [MEDICAL CONDITION], etc. 2) The facility medical director or designee, i.e. another qualified physician, Nurse Practitioner, or [MEDICATION NAME][MEDICATION NAME] (ET) Nurse experienced in Gastrostomy tube insertion will provide appropriate in-service education to the licensed nursing staff. In-service is to include: A. Awareness of potential complications: B. Plan of action to correct complications: C. Competency performance with evidence of same in personnel file. Nurses will be competency tested with evidence of same placed in their personnel file. Licensed nursing staff may provide the in-service and competency test other licensed nurses once they have completed the above. 3) Obtain a physician order [REDACTED]. 4) The replaced Gastrostomy tube will not be used for feeding or medication administration until either the physician, his/her designee, or a second qualified licensed nurse verifies and documents placement of the new tube. Facility Practice Guidelines Include but are not limited to: 1) The licensed nurse replaces the Gastrostomy tube (balloon type): A. Only upon successful completion of the competency and performance demonstration. D As quickly as possible, delay may make insertion more difficult. 2) Replacement: A. Explain procedure to the resident and provide privacy. B. Wash hands and don gloves. C. Cleanse around site with warm water and dry thoroughly. D. Draw up 20 cc ' s of sterile water in the leur-tipped syringe. E. Check the tube by inserting the leur tip syringe into the balloon port to check for leaks. Be sure the balloon inflated evenly. If leaks are detected, obtain another tune. ? Awareness of potential complications ? Plan of action to correct complications ? C) Competency performance with evidence of same placed in personnel file. Nurses will be competency tested with evidence of same placed in their personnel file. Licensed nursing staff may provide the in-service and competency test other licensed nurses once they have completed the above. This facility policy requires the licensed nurse to perform an assessment of [MEDICAL CONDITION] pathology and an assessment of the [DEVICE] placement, both which are outside the scope of practice for a licensed nurse in the state of Florida. Florida Status Chapter 464, Part I - 464.003 Definitions.-As used in this part, the term: (16) "Licensed practical nurse" means any person licensed in this state to practice practical nursing. (19) "Practice of practical nursing" means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. A practical nurse is responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. As a result of the facility not following the current standard of practice for [DEVICE] reinsertion, Resident #1 was sent the local hospital which performed a computed tomography (CT) scan of the resident ' s abdomen. The Impression: "Large free air with [MEDICAL CONDITION] tube which appears to lie in appearance the anterior abdominal wall outside of the stomach with contrast layering along anterior left hepatic lobe and complex free fluid within the pelvis which may reflect [MEDICAL CONDITION] contents and or contrast. Blood cannot be excluded. Free air tracks superiorly along pericardium and inferiorly with some free air extending into the anterior subcutaneous tissues. Left Myolipoma. Fecal Impaction." During an interview on 3/01/13 at 5:00 p.m., the DON stated she has begun in-serving all nurses on a revised policy to not re-insert any tube feeding, but to send residents to the emergency room for an X-ray, effective 2/26/2013. The DON provided documentation that 33 of 44 nurses had received the in-service on the revised policy. Although immediate jeopardy was removed, deficient practice continues since the facility has not completed the in-service training for all nurses, not demonstrated through monitoring, needed modification and systematic review to ensure that regulatory compliance is maintained: The ongoing noncompliance is at the Scope and Severity Level of D.

Based on facility record review and staff interviews, the facility Administrator failed to effectively attain and maintain the highest practicable physical, medical, and psychosocial well-being regarding the facility processes impacting 1 (Resident #1) of the 10 residents' records reviewed receiving enthral tube feeding. The review of these records revealed the facility administration failed to identify the potential for inappropriate facility process integrity related to ensure staff follow the policy and procedure for Gastrostomy Tube ([DEVICE]) replacement assessment, coordinating care and notification of significant change in condition with attending physicians. This resulted in Resident #1 experiencing pain, discomfort, and requiring transfer to an emergency room . The facility Administrator failed to provide effective nursing services and staff and Quality Assurance and Performance Improvement resource management to promote and ensure the health well-being of all facility residents. The Administrator failed to provide administrative oversight to ensure a complete and thorough investigation was conducted resulting in the lack of Quality Assurance and Performance Improvement examination and root cause analysis resulting in a continuation of the systems' failure regarding facility approaches and all nursing staff had demonstrated understanding of facility expectations in competency to assess G- tube replacement and the notification of the physicians regarding condition changes. This failure created a situation that is likely to result in serious injury, harm, impairment, or death to residents and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on 08/13/12 was identified on 02/16/2013. The immediate jeopardy was removed on 02/26/2013 based upon the implementation of corrective action. The findings include: 1. A review of Resident #1 ' s record, on 2/25/2013, at 8:00 p.m., documenting on 8/13/2012 at 1:15 p.m. the residents Certified Nurse Assistant (CNA) (name not documented) discovered Resident #1's [DEVICE] was out. She reported this to the nurse (Staff A). In the Nursing Note, dated 8/13/12, at 1:15 p.m., Staff A documented, "No bleeding noted to [DEVICE] site. PRN (as needed) order to reinsert [DEVICE] carried out as order. [DEVICE] 14 fr/15 cc placed in stomach with assist x 2 nurses. Check tube placement by 2 nurses. Verified. [DEVICE] in placed. Flushes well. Discomfort noted with [DEVICE] placed. PRN pain med given as ordered." A review of the Nursing note, dated 8/14/2012 at 9:30 a.m., documenting "[MEDICATION NAME] 1.2 @ 60 cc/hr infusing via (peg, crossed out) tube. HOB (head of bed) elevated. [DEVICE] placement checked with positive effects. Medications given via [DEVICE] without difficulty. Resident noted grimacing during [DEVICE] placement. PRN pain med giving as ordered without difficulty. [DEVICE] placement verified by another nurse, also. Grimacing noted when air 30 cc push in [DEVICE]. Without residual noted. [DEVICE] feeding placed on hold." The name of second nurse was not documented. Reviewed documentation that Resident #1 was sent to the emergency roiagnom on [DATE] and the Magnetic Resonance Imaging (MRI) X-ray revealed "the anterior abdominal wall outside of stomach with contrast layering along anterior left hepatic lobe and complex free fluid within the pelvis which may reflect [MEDICAL CONDITION] contents and or contrast." This confirmed Resident #1's [DEVICE] was not placed correctly by the licensed nurses. 2. Interview with the Medical Director on 3/1/13, at approximately 2:00 p.m., stating he is a surgeon and does not have any primary care residents at the facility. All of the residents at the facility have primary care physicians who follow them. He stated he would have to review the chart of the Resident #1 to be able to answer any specific questions related to this case. The Medical Director stated any nurse can replace [DEVICE]s. If any pain or resistance, the nurse should stop trying to insert the [DEVICE] and should try to insert a Foley catheter into the tract to keep it open until the hospital can reinsert the [DEVICE]. He stated that the tract can close in 4 to 5 hours after [DEVICE] is out, even if the [DEVICE] has been in place for an extended amount of time. He added residents can wait several hours in the emergency room waiting to be seen. The Medical Director stated he reviewed and approved the Policies and Procedures for 2013 for the facility in January 15 2013. He stated he does not see any problem with the current policy. The current Standard of Care for [DEVICE]s: (Source: http:emedicine.medscape.com/article/ 9-overview) A [DEVICE] should be replaced as quickly as possible in the Emergency Department. 3. During an interview, on 2/25/13, at 5:04 p.m., the Director of Nursing (DON) stated she changed the procedure for [DEVICE] reinsertion after learning that the nursing staff were reinserting [DEVICE]s in the facility. She stated after the facility received a letter requesting Resident #1's clinical record she realized the nurses were changing the [DEVICE]s sometime in October of 2012. She states the emergency room (ER) told the facility that Resident #1 had a [DIAGNOSES REDACTED]. She stated she instructed her nursing staff to call the primary MD to inform of change in residents health status and to get an order for [REDACTED]. She stated no tubes have been replaced in the facility since the nurse re-inserted Resident #1's [DEVICE] in August 2012. 4. Documentation of staff in-service training for reinsertion of [DEVICE] and related competency training was requested by the surveyor on 2/25/2013. The facility was unable to produce documentation that LPN/Staff A or LPN/Staff B have received the in-service education for reinsertion of [DEVICE]s prior to 2/21/2013. On 2/25/13 at 9:00 p.m. the Staff Development Coordinator, the Director of Nursing (DON) and Administrator confirmed they were unable to find documentation of staff training or competency performance test for LPN/Staff A or LPN/Staff B prior to 2/21/2013. 5. During an interview on 3/01/13, at 5:00 p.m., the Administrator, stated as head of the Quality Assurance Committee he confirmed competency of the licensed nurse to re-insert tube feedings was not addressed by the committee. 6. During an interview on 3/01/13 at 5:00 p.m., the DON stated she has begun in-serving all nurses on a revised policy to not re-insert any tube feeding, but to send residents to the emergency room for an X-ray, effective 2/26/2013. The DON provided documentation that 33 of 44 nurses had received the in-service on the revised policy. Although immediate jeopardy was removed on 2/26/13, deficient practice continues since the facility has not completed the in-service training for all nurses, not demonstrated through monitoring, needed modification and systematic review to ensure that regulatory compliance is maintained: The ongoing noncompliance is at the Scope and Severity Level of D.

Based on interview and review of facility policies and procedures the facility failed to insure that policies and procedures approved by the Medical Director are consistent with the current standard of practice and a licensed practical nurses scope of practice, resulting in 1 (Resident #1) of 7 residents with Gastrostomy Tube ([DEVICE]) receiving inappropriate tube replacement assessment, experiencing pain and discomfort and requiring transfer to a hospital. The systems' failure regarding all of the nursing staff demonstrating understanding of facility expectations in competency to assess G- tube replacement and the notification of the physicians regarding condition changes resulted in Resident #1 experience pain and discomfort. This failure created a situation that is likely to result in serious injury, harm, impairment, or death to residents and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on 08/13/12 was identified on 02/16/2013. The immediate jeopardy was removed on 02/26/2013 based upon the implementation of corrective action. The findings include: During an interview on 3/1/2013, at approximately 1:45 p.m., the Medical Director explained the difference between insertion of a Percutaneous Endoscopic Gastrostomy (PEG) tube and a [DEVICE]. The Medical Director stated that if a [DEVICE] falls out, the nurse should determine how long the tube has been out of the patient. If the tube has recently fallen out, the nurse should replace the [DEVICE] with a [DEVICE] of the same size and send the patient to the hospital to confirm placement. If the tube has been out of the patient for an unknown period of time, the nurse should replace the [DEVICE] with a Foley catheter to keep the feeding tube tract open so the patient does not need surgery to replace the tube. He added that a stoma (the opening of the feeding tube tract) can close in 5 to 6 hours after [DEVICE] is out, even if the [DEVICE] has been in place for several months. When asked if a Licensed Practical Nurse (LPN) can reinsert a [DEVICE], he stated any nurse can insert the tube, but the patient should be sent out to hospital to verify placement via X-ray. He stated "the tube should not be used until placement is verified." He stated the tube placement should be verified by checking for residual stomach contents and listening to the abdomen while injecting air into the [DEVICE]. He stated "I think the nurses need to send patients out to hospital to verify placement." The nurse should document how long the tube has been out, replace the tube per MD (physician) orders and call the primary MD if any problems with the [DEVICE], to get orders from the primary physician. Later in the same interview the Medical Director stated "as long as the nurse does not have any difficulty placing the [DEVICE] such as pain or resistance, the nurse can use the [DEVICE] without X-ray verification." He stated "getting X-ray verification of [DEVICE] placement can be very costly to the residents, the costs involved include transportation to and from the hospital, the cost of an emergency room visit and the cost of the X-ray to verify placement. The Medical Director stated any nurse can replace [DEVICE]s. If any pain or resistance, the nurse should stop trying to insert the [DEVICE] and should try to insert a Foley catheter into the tract to keep it open until the hospital can reinsert the [DEVICE]. He stated that the tract can close in 4 to 5 hours after [DEVICE] is out, even if the [DEVICE] has been in place for an extended amount of time. He stated residents can wait several hours in the emergency room waiting to be seen. The Medical Director stated he is a surgeon and does not have any primary care residents at the facility. All of the residents at the facility have primary care physicians who follow them. He stated he would have to review the chart of the resident in question to be able to answer any specific questions related to this case. The Medical Director stated he reviewed and approved the Policies and Procedures for 2013 for the facility in January of 2013. Review of the facility policy on 2/25/2013 documented Gastrostomy Tube Replacement: Standard: 1) Gastrostomy tube replacement will be performed by a qualified licensed nurse when: A. Allowed by the state nurse practice act B. The licensed nurse has evidence of competency testing for gastrostomy tube replacement C. The resident has a healed fistula, >six (6) weeks; physician has ordered replacement by licensed nurse; and replacement takes place as soon as possible. If less than the stated time frame, the resident must be transferred to an appropriate setting, i.e. emergency room for gastrostomy tube replacement. D. There is no evidence of [MEDICAL CONDITION] pathology, e.g. [MEDICAL CONDITION] bleeding, [MEDICAL CONDITION], etc. 2) The facility medical director or designee, i.e. another qualified physician, Nurse Practitioner, or [MEDICATION NAME][MEDICATION NAME] (ET) Nurse experienced in gastrostomy tube insertion will provide appropriate in-service education to the licensed nursing staff. In-service is to include: A. Awareness of potential complications: B. Plan of action to correct complications: C. Competency performance with evidence of same in personnel file. Nurses will be competency tested with evidence of same placed in their personnel file. Licensed nursing staff may provide the in-service and competency test other licensed nurses once they have completed the above. 3) Obtain a physician order to replace the gastrostomy tube, specific to the resident. 4) The replaced gastrostomy tube will not be used for feeding or medication administration until either the physician, his/her designee, or a second qualified licensed nurse verifies and documents placement of the new tube. Facility Practice Guidelines Include but are not limited to: 1) The licensed nurse replaces the gastrostomy tube (balloon type): A. Only upon successful completion of the competency and performance demonstration. D As quickly as possible, delay may make insertion more difficult. 2) Replacement: A. Explain procedure to the resident and provide privacy. B. Wash hands and don gloves. C. Cleanse around site with warm water and dry thoroughly. D. Draw up 20 cc's of sterile water in the leur-tipped syringe. E. Check the tube by inserting the leur-tip syringe into the balloon port to check for leaks. Be sure the balloon inflated evenly. If leaks are detected, obtain another tune. This facility policy requires the licensed nurse to perform an assessment of [MEDICAL CONDITION] pathology and an assessment of the [DEVICE] placement, both which are outside the scope of practice for a licensed nurse. Florida Status Chapter 464, Part I - 464.003 Definitions.-As used in this part, the term: (16) "Licensed practical nurse" means any person licensed in this state to practice practical nursing. (19) "Practice of practical nursing" means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. A practical nurse is responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. The current Standard of Care for [DEVICE]s: (Source: http:emedicine.medscape.com/article/ 9-overview) A [DEVICE] should be replaced as quickly as possible in the Emergency Department. Confirmation of [DEVICE] placement: Prior to using the [DEVICE] for feedings, placement must be confirmed. Classically, confirmation is made by injecting 20-30 ml of water-soluble contrast solution ([MEDICATION NAME]) into the tube and taking a supine abdominal radiograph within 1-2 minutes. This is best performed in the radiography suite ... If the tube is placed properly, contrast outlines the stomach on the radiograph. A recent study compared verification of [DEVICE] replacement with air insufflation versus contrast radiograph and determined the methods to be equal in efficacy. However, obtaining a contrast radiograph is generally considered the current standard of care. The most dreaded complication of [DEVICE] replacement is misplacement of the tube into the peritoneal cavity. This is far more common in recently placed tubes but has been reported in patients with mature tracts (>30 d). Starting tube feeds into the peritoneum often leads to serious morbidity and mortality. This complication can be avoided by obtaining a verification study prior to using the tube. During an interview on 3/01/13 at 5:00 p.m., the DON stated she has begun in-serving all nurses on a revised procedure to not re-insert any tube feeding, but to send residents to the emergency room for an X-ray, effective 2/26/2013. Although immediate jeopardy was removed on 2/26/13, deficient practice continues since the facility has not completed the in-service training for all nurses, not demonstrated through monitoring, needed modification and systematic review to ensure that regulatory compliance is maintained. The DON provided documentation that 33 of 44 nurses had received the in-service on the revised policy. The ongoing noncompliance is at the Scope and Severity Level of D.

Based on interview with the administrator and review of the Quality Assessment and Assurance Committee minutes, the facility failed to identify issues with nursing assessment of [DEVICE] replacement and analysis of inconsistent nursing staff implementation of facility policy and procedures. The facility failed to develop appropriate examination of care processes related to 1 (Resident #1) the 7 Resident's with [DEVICE]s sampled. The facility failed to provide effective Quality Assurance & Performance Improvement resource management to promote and ensure the health well-being of all facility residents. The Administrator failed to provide administrative oversight to ensure a complete and thorough investigation was conducted resulting in the lack of Quality Assurance and Performance Improvement examination and root cause analysis resulting in a continuation of the systems failure regarding facility approaches and all nursing staff had demonstrated understanding of facility expectations in the assessment of replaced [DEVICE]s and notification of the physician regarding condition changes. This failure created a situation that resulted in serious injury, harm to Resident #1, impairment, or death to residents and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on 08/13/12 was identified on 02/16/2013. The immediate jeopardy was removed on 02/26/2013 based upon the implementation of corrective action. The findings include: 1. A review of the Quality Assurance program from October 2012 through January 2013 was done on 3/01/2013 at 4:30 p.m., with the Administrator. There were no reported findings related to concerns of licensed practical nurses re-inserting tube feeding tubes when the tubes come out. During an interview on 3/01/2013 at 5:00 p.m., the Administrator confirmed competency of the licensed nurse to re-insert tube feedings was not addressed by the quality assurance committee. 2. Interview on 3/01/13 at 5:00 p.m., the Director of Nursing (DON) stated a letter from an attorney came through the Medical Records Department in October 2012 requesting the clinical record for Resident #1. The DON stated she reviewed Resident #1's record and realized the facility licensed nurses were replacing [DEVICE]s. 3. Resident #1 record was reviewed on 2/25/2013, at 8:00 p.m., documenting on 8/13/2012 at 1:15 p.m. the resident ' s Certified Nurse Assistant (CNA), name not documented, discovered Resident #1's [DEVICE] was out. She reported this to the nurse (Staff A). In the Nursing Note dated 8/13/12 at 1:15 p.m., Staff A documented " No bleeding noted to [DEVICE] site. PRN (as needed) order to reinsert [DEVICE] carried out as order. [DEVICE] 14 fr/15 cc placed in stomach with assist by 2 nurses. Check tube placement by 2 nurses. Verified. [DEVICE] in placed. Flushes well. Discomfort noted with [DEVICE] placed. PRN pain med given as ordered. Review of the Nursing note, dated 8/14/2012, at 9:30 a.m., documenting "[MEDICATION NAME] 1.2 @ 60 cc/hr infusing via (peg, crossed out) tube. HOB (head of bed) elevated. [DEVICE] placement checked with positive effects. Medications given via [DEVICE] without difficulty. Resident noted grimacing during [DEVICE] placement. PRN pain med giving as ordered without difficulty. [DEVICE] placement verified by another nurse, also. Grimacing noted when air 30 cc push in [DEVICE]. Without residual noted. [DEVICE] feeding placed on hold." The name of second nurse was not documented. Resident #1 was sent to the emergency roiagnom on [DATE] and the Magnetic Resonance Imaging (MRI) X-ray revealed "the anterior abdominal wall outside of stomach with contrast layering along anterior left hepatic lobe and complex free fluid within the pelvis which may reflect [MEDICAL CONDITION] contents and or contrast." This confirmed Resident #1's [DEVICE] was not placed correctly by the licensed nurses. 4. During an interview on 3/01/13 at approximately 2:00 p.m., the Medical Director stated he is a surgeon and does not have any primary care residents at the facility. The Medical Director stated any nurse can replace [DEVICE]s. If any pain or resistance, the nurse should stop trying to insert the [DEVICE] and should try to insert a Foley catheter into the tract to keep it open until the hospital can reinsert the [DEVICE]. He stated that the tract can close in 4 to 5 hours after [DEVICE] is out, even if the [DEVICE] has been in place for an extended amount of time. He added residents can wait several hours in the emergency room waiting to be seen. The Medical Director stated he reviewed and approved the Policies and Procedures for 2013 for the facility in January 15 2013. The current Standard of Care for [DEVICE]s: (Source: http:emedicine.medscape.com/article/ 9-overview) A [DEVICE] should be replaced as quickly as possible in the Emergency Department. 5. During an interview on 2/25/13 at 5:04 p.m., the Director of Nursing (DON) stated she changed the procedure for [DEVICE] reinsertion after learning that the nursing staff were reinserting [DEVICE]s in the facility. She stated after the facility received a letter requesting Resident #1's clinical record she realized the nurses were changing the [DEVICE]s sometime in October of 2012. She states the emergency room (ER) told the facility that Resident #1 had a [DIAGNOSES REDACTED]. She stated she instructed her nursing staff to call the primary MD (physician) to inform of change in residents health status and to get an order for [REDACTED]. She stated no tubes have been replaced in the facility since the nurse re-inserted Resident #1's [DEVICE] in August 2012. 6. Documentation of staff in-service training for reinsertion of [DEVICE] and related competency training was requested on 2/25/2013. The facility was unable to produce documentation that Staff A or Staff B had received the in-service education for reinsertion of [DEVICE]s prior to 2/21/2013. On 2/25/13 at 9:00 p.m., the Staff Development Coordinator, the DON and the administrator confirmed they were unable to find documentation of staff training or competency performance test for Staff A or Staff B prior to 2/21/2013. During an interview on 3/01/13 at 5:00 p.m., the DON stated she has begun in-serving all nurses on a revised policy to not re-insert any tube feeding, but to send residents to the emergency room for an X-ray, effective 2/26/2013. The DON provided documentation that 33 of 44 nurses had received the in-service on the revised policy. Although immediate jeopardy was removed on 2/26/12, deficient practice continues since the facility has not completed the in-service training for all nurses, not demonstrated through monitoring, needed modification and systematic review to ensure that regulatory compliance is maintained: The ongoing noncompliance is at the Scope and Severity Level of D.

Based on clinical record review, resident and staff interview, the facility failed to conduct a comprehensive assessment to determine the cause of a decline in bladder continence for 2 (Resident #148 and #48) of 42 sampled residents failing ensure provision appropriate treatment and services to restore as much normal bladder function as possible. The findings include: 1. A review of the clinical record for Resident #148 documented an admitted to the facility of 8/28/12, with [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set) assessment completed on 9/14/12, documented the resident's bladder continence status was coded as a "0" in section "H" indicating the resident is always continent of bladder. Section "G" addressing the resident's functional status indicated Resident #148 required limited assistance of 1 person for transfer and toilet use. The MDS assessment dated [DATE], noted Resident #148's condition had improved and she was independent with set up only for toileting. The resident was discharged to the hospital on [DATE]. Documentation in the clinical record indicated the resident was continent of bladder at the time of discharge. A review of the hospital record documented on 10/3/12, Resident #148 presented to the local hospital with bilateral [MEDICAL CONDITION] which the physician documented was probably [DIAGNOSES REDACTED]. Resident #148 returned to the facility on [DATE]. The nursing assessment completed upon readmission to the facility contained documentation the resident experienced an "acute vision loss". The resident was alert, oriented and continent of bladder. The functional bladder assessment completed on 10/20/12, by the Restorative Nurse noted Resident #148 was alert and oriented X 3 (time, person and place) and was continent of bladder. A review of the care flow record completed by the Certified Nursing Assistant for October 2012, documented the resident was continent of bladder on 10/20/12 during the day shift. The night shift documented Resident #148 was incontinent of bladder on 10/20/12. The facility was not able to locate the care flow record for the evening shift. A review of the Care Flow Record for 11/12 and 12/12 documented Resident #148 remained incontinent of bladder since it was identified on 10/20/12. The MDS assessment completed on 10/27/12 documented Resident #148's vision was now severely impaired. The resident's functional mobility had declined and she required extensive assistance of 2 persons for transfer and extensive assistance of 1 person for toilet use. The resident remained alert and oriented to time, place and person. Resident #148 was discharged to the local hospital on [DATE], with hallucination and a [DIAGNOSES REDACTED]. The resident returned to the facility on [DATE], the significant change assessment dated [DATE] indicated Resident #148 required extensive assistance of 2 people for Activities of daily living, including transfer and toilet use. Section "H" of the assessment indicated the resident was now always incontinent of bladder. The functional bladder evaluation form contained documentation it was revised on 11/2/12, 11/6/12 and 11/13/12, but did not document the change in the resident's continence status. The assessment indicated "the resident is continent of bladder at this time. " The clinical record did not contain documentation the facility assessed Resident #148 for the cause, contributing factors and type of the sudden onset of incontinence. The care plan dated 11/13/12, indicated Resident #148 had frequent episodes of incontinence of bladder and bowel. The goal was for the resident to be free of skin breakdown related to incontinence; maintain dignity by remaining dry and clean daily. The interventions included but were not limited to toilet the resident every 2 to 3 hours and as needed. An interview was held on 12/6/12, at 10:00 a.m., with Resident #148 regarding her bladder incontinence. She stated sometimes in October she suddenly lost her vision and is now blind. The resident stated she knows when she has to urinate. She stated at first she was calling for a bed pan, but the staff told her to go in her diaper, therefore, she does not call anymore. She said sometimes when she has to go, staff is busy doing something else, she just goes in the diaper. She is hoping to restore her vision. When her vision is restored, she can go back to her previous habits. During an interview on 12/6/12, at approximately 12:00 p.m., with the Certified Assistant # 11 stated she has been taking care of Resident #148 for about one month. She stated in the morning, she changes her incontinent briefs. The resident does not use the toilet. She is usually not wet, because the night shift has already changed her; she puts on a clean brief anyway. During the day she changes her every 2 hours. Resident #148 does not urinate that much, the brief is not always wet. She offered her to go on the toilet one time, but Resident #148 refused. The Certified Nursing Assistant (CNA) stated the resident is kind of weak so she does not want to take the chance of taking her to the toiled, she just changes her. The CNA stated the resident is able to use the call light, but never calls to say she wants to go to the bathroom. During an interview on 12/6/12, at 2:10 p.m., Certified Nursing Assistant #12 stated she frequently takes care of Resident #148 in the morning shift. She stated the resident is able to say when she needs to go to the bathroom. The CNA stated she changes her incontinent briefs every 2 hours or when the resident tells her she is wet. She stated:" She knows when she goes". The CNA stated she used to take her to the toilet when she was first admitted to the facility. She required the assistance of one person to be transferred to the toilet from the wheelchair. CNA #12 added since the last hospitalization : "She became difficult. She is taller than me and it is difficult to take her to the toilet." She stated now she could use the assistance of 2 people to transfer her. She stated she just changes her incontinent brief every 2 hours. On 12/6/12 at 11:05 a.m., with the Restorative Nurse reported Resident #148 has been in and out of the hospital several times. She came back one time totally incontinent of bowel and bladder. Because of her impaired cognition and decreased perception of need to void or defecate, she was not a candidate for retraining. When asked about the assessment tool used to determine if the resident was a candidate for a bladder retraining program, he stated he only asked the resident if she had control of her bladder and the resident said "No." The Restorative Nurse did not have any documentation of the interview. He stated the facility has not been conducting a bladder assessment program, but they were in the process of implementing one. He stated he definitely needed to reassess Resident #148. After looking at the care plan for the bladder incontinence, the Restorative Nurse exclaimed: "Thank goodness we do have a care plan for it." A review of the facility's policy and procedure for management of bowel and bladder incontinence revised 3/07 documented: "Residents are assessed upon admission, quarterly, and with a significant change, utilizing the Nursing Evaluation. Reassessment should take place whenever there is a change in cognition, physical ability, or urinary tract function". The Restorative Nurse confirmed during the interview, he failed to follow the facility's policy and procedure for assessment of the urinary incontinence for Resident #148. The findings were discussed on 12/6/12 at 2:00 p.m., with the Director of Nursing. The Director of Nursing stated she can only say that the Therapy department documented a decline in the resident's functional ability. Complete review of the clinical record and staff interview confirmed the facility failed to reassess Resident #148 after a sudden decline in continence status and failed to implement interventions to restore Resident #148's bladder continence. 2. A review of Resident #48's medical records notes an admission date of [DATE], with a [DIAGNOSES REDACTED]. Review of the medical record documented the resident's nurse evaluation conducted on 10/29/2012, notes a significant change; the level of consciousness is assessed as alert with times of confusions. The nurse evaluation noted the resident is incontinent of bowel and bladder. The review of the care plan notes Resident #48 has episodes of total incontinence of bowel and bladder; one of the intervention noted, toilet resident every 2 to 3 hrs and as needed. A review of the facility's Functional Bladder Evaluation form notes quarterly assessments, the facility notes under Bladder Toileting Record and Bladder Retraining Evaluation "Due to impaired cognition, decreased perception of need to eliminate and the need for two person asses with transfer, resident is not a candidate with this trial." On 12/03/2012, 11:30 a.m., during tour on the North Wing Resident #48 was observed in room [ROOM NUMBER] sitting in a wheel chair. The resident stated he wanted to go to the bathroom, Certified Nurse Assistant (CNA) #8 was notified. CNA #8 went to get a Sara (lift) which was taken to the resident's room. The resident stated, "You brought that thing it has not worked for months." Resident #48 was never taken to the bathroom. The CNA stated, "I am not able to assist him to the bathroom due to the Sara lifter is not charged." During interview with Resident #48 he stated, "This thing has not worked for some time." During interview with the Unit Manager of the North wing it was stated, "The lifter has to be placed on charger. If is the CNAs that do not return the battery to the charger after use." The CNA stated the battery does not hold the charge, we use it once and then it goes down. During interview with on 12/06/2012, at 12:30 p.m., CNA #8 stated Resident #48 is able to tell you he needs to go to the bathroom, but by the time we get there he has already gone. I do check him every two hours. During resident interview on 12/06/2012, at 2:00 p.m. Resident #48 stated, "They have told me to do it in my diaper; I will change it in a while. This is what they always tell me." The facility failed to assess Resident #48 accurately for a bladder program. The facility noted the resident is not a candidate for a bladder program, due to the resident requiring a two person assistance for transfer.

Based on observation and staff interview it was determined that the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality for 5 (Resident's #39, #131, #40, #148 and #48) of 42 actively sampled residents. The findings include: 1. Upon review of the clinical record for Resident #148 noted an admitted to the facility of 8/28/12, with [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set) assessment completed on 9/14/12 documented the resident's bladder continence status was coded as a "0" in section "H" indicating the resident is always continent of bladder. Section "G" addressing the resident's functional status indicated Resident #148 required limited assistance of 1 person for transfer and toilet use. The MDS assessment dated [DATE] documented the resident's condition had improved and she was independent with set up only for toileting. The resident was discharged to the hospital on [DATE]. Documentation in the clinical record indicated the resident was continent of bladder at the time of discharge. A review of the hospital record documented on 10/3/12 Resident #148 presented to the local hospital with bilateral [MEDICAL CONDITION] which the physician documented was probably [DIAGNOSES REDACTED]. The Resident returned to the facility on [DATE]. The nursing assessment completed upon readmission to the facility revealed documentation the resident experienced an "acute vision loss". The resident was alert, oriented and continent of bladder. The functional bladder assessment completed on 10/20/12 by the Restorative Nurse revealed the resident was alert and oriented X 3 (Time, person and place) and was continent of bladder. Upon review of the care flow record completed by the Certified Nursing Assistant for October 2012 revealed the resident was continent of bladder on 10/20/12 during the day shift. The night shift documented the resident was incontinent of bladder on 10/20/12. The facility was not able to locate the care flow record for the evening shift. A review of the Care Flow Record for 11/12 and 12/12 revealed Resident #148 remained incontinent of bladder since it was identified on 10/20/12. The MDS assessment completed on 10/27/12 revealed the resident's vision was now severely impaired. The resident's functional mobility had declined and she required extensive assistance of 2 persons for transfer and extensive assistance of 1 person for toilet use. The resident remained alert and oriented to time, place and person. She was once again discharged to the local hospital on [DATE] with hallucination and a [DIAGNOSES REDACTED]. The resident returned to the facility on [DATE], the significant change assessment dated [DATE] indicated Resident #148 required extensive assistance of 2 people for Activities of daily living, including transfer and toilet use. Section "H" of the assessment indicated the resident was now always incontinent of bladder. The functional bladder evaluation form contained documentation it was revised on 11/2/12, 11/6/12 and 11/13/12 but did not document the change in the resident's continence status. The assessment indicated " the resident is continent of bladder at this time. " The clinical record did not contain documentation the facility assessed the resident for the cause, contributing factors and type of the sudden onset of incontinence. The care plan dated 11/13/12 indicated Resident #148 had frequent episodes of incontinence of bladder and bowel. The goal was for the resident to be free of skin breakdown related to incontinence; maintain dignity by remaining dry and clean daily. The interventions included but were not limited to toilet the resident every 2 to 3 hours and as needed. An interview was held on 12/6/12 at 10:00 a.m. with Resident #148 regarding her bladder incontinence. She stated sometimes in October she suddenly lost her vision and is now blind. The resident revealed she knows when she has to urinate. She stated at first she was calling for a bed pan but the staff told her to go in her diaper, therefore, she doesn't call anymore. The Resident stated it used to bother her because she is a very modest, private person. She said sometimes when she has to go, staff is busy doing something else, she just goes in the diaper and it doesn't bother her anymore. She is hoping to restore her vision. When her vision is restored, she can go back to her previous habits. Interview on 12/6/12 at approximately 12:00 p.m. with the Certified Assistant #11 revealed she has been taking care of the resident for about one month. She stated in the morning, she changes her incontinent briefs. The resident does not use the toilet. She is usually not wet because the night shift has already changed her but she puts on a clean brief anyway. During the day she changes her every 2 hours. She does not urinate that much but the brief is not always wet. She offered her to go on the toilet one time but the resident refused. The Certified Nursing Assistant stated the resident is kind of weak so she does not want to take the chance of taking her to the toiled, she just changes her. The CNA stated the resident is able to use the call light but never calls to say she wants to go to the bathroom. Interview on 12/6/12 at 2:10 p.m. with Certified Nursing Assistant 12 revealed she frequently takes care of Resident # 148 in the morning shift. She stated the resident is able to say when she needs to go to the bathroom. The CNA stated she changes her incontinent briefs every 2 hours or when the resident tells her she is wet. She stated:" She knows when she goes". The CNA stated she used to take her to the toilet when she was first admitted to the facility. She required the assistance of one person to be transferred to the toilet from the wheelchair. She added since the last hospitalization , :" She became difficult. She's taller than me and it's difficult to take her to the toilet". She stated now she could use the assistance of 2 people to transfer her. She stated she just changes her incontinent brief every 2 hours. On 12/6/12 at 11:05 a.m. with the Restorative Nurse revealed Resident #148 has been in and out of the hospital several times. She came back one time totally incontinent of bowel and bladder. Because of her impaired cognition and decreased perception of need to void or defecate, she was not a candidate for retraining. When asked about the assessment tool used to determine if the resident was a candidate for a bladder retraining program, he stated he only asked the resident if she had control of her bladder and the resident said "No". The Restorative Nurse did not have any documentation of the interview. He stated the facility has not been conducting a bladder assessment program but they were in the process of implementing one. He stated he definitely needed to reassess Resident #148. After looking at the care plan for the bladder incontinence, the Restorative Nurse exclaimed: "Thank goodness we do have a care plan for it. " A review of the facility's policy and procedure for management of bowel and bladder incontinence revised 3/07 revealed the following documentation: "Residents are assessed upon admission, quarterly, and with a significant change, utilizing the Nursing Evaluation. Reassessment should take place whenever there is a change in cognition, physical ability, or urinary tract function". The Restorative Nurse confirmed during the interview, he failed to follow the facility's policy and procedure for assessment of the urinary incontinence for Resident #148. The findings were discussed on 12/6/12 at 2:00 p.m., with the Director of Nursing. The facility was given an opportunity to provide pertinent documentation with none given. The Director of Nursing stated she can only say that the Therapy department documented a decline in the resident's functional ability. Complete review of the clinical record and staff interview confirmed the facility failed to reassess Resident #148 after a sudden decline in continence status and failed to implement interventions to restore the resident's bladder continence, causing Resident # 148 to verbalize feelings of embarrassment. 2. During interview with on 12/06/2012, at 12:30 p.m., the Certified Nurse Assistant #8 stated Resident #48 is able to tell you he needs to go to the bathroom, but by the time we get there he has already gone. I do check him every two hours. During resident interview on 12/06/2012, at 2:00 p.m., Resident #48 stated, "They have told me to do it in my diaper; I will change it in a while. This is what they always tell me." 3. Clinical record review revealed that Resident #39 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident is nonverbal and unable to be interviewed. Clinical record review reveals that the resident is in a vegetative state with impaired memory and decision making. Observations made on 12/03/2012 2:07 p.m., revealed that Resident #39 was observed in bed with only a hospital gown on. Observations made on 12/4/12 9:58 a.m., Resident #39 in bed. The resident is dressed in red polo type shirt. The resident does not have any pants on underneath and is only wearing an adult brief. An observation was made on 12/4/12 at 1:13 p.m., and again at 3:31 p.m., revealed that Resident #39 was currently lying in his bed. The resident has a tube feeding infusing at 70 cc/ hour. The head of the bed is elevated. The resident has the same red polo type shirt on. He is in an incontinent brief. He has no pants on. Facility record review revealed a MDS 2.0 Nursing Kardex dated 7/23/12 the resident was coded under dressing as requiring 1 person assist. A review of December 1, 2 and 3 2012 Care Flow Record Day revealed that Resident #39 was coded under dressing as (4) Total dependence (1) 1 person assist. Upon review of December 1, 2 and 3 2012 Care Flow Record Evening revealed that Resident #39 was coded under dressing as (4) Total dependence (1) 1 person assist. Clinical record review revealed that Resident #39 has an ADL care plan dated 7/11/12. Under focus state "Alteration in ADL's r/t vegetative state. Requires total assist with all ADL's, 2 person assist with bed mobility and transfers. Goals: "Res will have all needs met by staff through next review date. Interventions: Staff to anticipate all resident needs. Speak to resident while performing care/treatments informing resident what is being done, Ensure appropriate footwear. A review of MDS with reference date of 7/1/12 revealed that the resident was coded under Section B Hearing, Speech, and Vision the resident was coded as being in a persistent vegetative state/no discernible consciousness was (1) Yes. Skip to G 0110, Activities of Daily Living ADL) Assistance. A review of Section G Functional Status G0110- Activities of Daily Living (ADL) Assistance under section G. Dressing the resident was coded (4) Total dependence- full staff performance every time during entire 7-day period. (2) One person physical assist. An interview was conducted on 12/4/12 at 3:33 p.m., with Staff #1 revealed that Resident #39 requires total dependence with 1 person physical assist for activities of daily care and was assigned to him on the 3-11 shift on 12/3/12. According to the staff the morning shift is responsible for getting the resident dressed. Resident #91 gets showers in the morning during 7-3 shift. I also give him a sponge bath at night due to his excessive perspiration. I was going to get him up today but there were no more slings available so I could not get him out of bed. The only sling that was available the facility no longer has the Sara Lift. 4. An interview was conducted on 12/3/12 with Resident #131 at 2:16 p.m., when asked do staff treat you with respect and dignity. The resident stated " no", some of the older staff members tell me we are going to do it anyway weather I want to or not. There is no discussion they just do it. A follow-up interview was completed on 12/6/12 at 9:14 revealed that the staff will sometime approach her and tell her it is time to take you shower. She stated that she did not want to at that time and staff will state well we are going to do it anyway. 5. During a family interview on 12/3/12, at 10:48 a.m., the spouse of Resident #40 stated, in response to a query about assistance with personal care activities (Activities of Daily Living (ADL)), the nurse aides dress the resident and get him up in a chair in the morning after breakfast and not inspect him until he is put back into bed. The spouse stated that sometimes the resident's clothes are soaked though. The spouse stated that at times she comes into the facility, finds the resident wet and has to tell the aide so he will be changed. In an interview on 12/6/12, at 10:15 a.m., the spouse stated the resident should be checked every 2 hrs. but really is not. She stated he is changed when gotten up in the morning, and when they put him back into bed to rest, whether that is 2, 4 or 6 hours. The spouse stated she tells the aides when Resident #40 soaks through his clothes, because they do not come in to check him. Resident #40's care plan addresses the ADL deficits and states the resident is 2 person assist for toileting and changing. The resident requires mechanical lift for transfers and requires transfer to bed for peri-care. The care plan, updated on 9/26/12, states: "Toilet resident Q2-3 hrs. and PRN". The care plan does not document to check and change it states "toilet ". During an interview on 12/6/12 at 10:30 a.m., the unit manager stated the protocol for Resident #40 is for the aides to check every two hours.