Every finding on record at West Hills Health and Rehab

Based on review of facility policy, medical record review, observation and interviews, the facility failed to ensure infection control practices were observed during medication administration for 1 resident (Resident #1) of 7 residents observed for medication administration and failed to ensure enhanced barrier precautions (EBP) were implemented for 1 resident (Resident # 45) of 17 residents reviewed for EBP. The findings include: Review of the facility policy titled, Administering Medications, revised 4/2019, revealed .Staff follows established facility infection control procedures ( .handwashing .) for the administration of medications . Review of the facility policy titled, Enhanced Barrier Precautions, revised 8/2022, revealed .Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do no otherwise apply .Gloves and gown are applied prior to performing the high contact resident care activity .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .dressing .bathing/showering .transferring .providing hygiene .changing linens .changing briefs or assisting with toileting .device care or use .wound care .EBPs are indicated .for residents with wounds and/or indwelling medical devices regardless of MDRO colonization .Signs are posted indicating the type of precautions and PPE required .PPE [personal protective equipment] .is available either in the resident room or outside of the resident rooms . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Chronic Kidney Disease, Anxiety, and Depression. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including Dysphagia (difficulty swallowing) following Cerebral Infarction (Stroke), Atrial Fibrillation, Hypertension, and Heart Failure. During observation of medication administration for Resident #51 on 11/13/2024 at 9:20 AM, Licensed Practical Nurse (LPN) A failed to perform hand hygiene after administering Resident #51's medication and prior to preparing and administering Resident #1's medication. During an interview on 11/13/2024 at 9:28 AM, LPN A confirmed she failed to perform hand hygiene after administering Resident #51's medication and prior to preparing and administering Resident #1's medication. During an interview on 11/13/2024 at 10:30 AM, the Director Of Nursing (DON) confirmed staff were expected to perform hand hygiene between each resident's medication administration. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including Encounter for Orthopedic Aftercare and Fracture of Right Lower Leg. Observation of Resident #45 on 11/12/2024 at 11:00 AM, revealed Resident #45 had an external fixator (A device to hold broken bones in place. Metal pins or screws are placed into the bone through small incisions into the skin and muscle. The pins and screws are attached to a bar outside the skin) on the right lower leg. There was no signage posted to indicate the resident was on EBP. Personal protective equipment (PPE) was not available inside or outside of the resident's room. Observation of Resident #45 on 11/13/2024 at 1:04 PM, revealed no signage was posted to indicate the resident was on EBP. PPE was not available inside or outside of the resident's room. Observation of Resident #45 on 11/14/2024 at 1:04 PM, revealed no signage was posted to indicate the resident was on EBP. PPE was not available inside or outside of the resident's room. During an interview on 11/14/2024 at 2:40 PM, the Infection Preventionist (IP) confirmed an external fixator was considered an indwelling medical device, requiring EBP and confirmed Resident #45 was not on EBP.

Based on review of facility policy, medical record review, pharmacy delivery reports, observation and interviews, the facility failed to accurately transcribe a physician's order for 1 resident (Resident #51) of 7 residents reviewed for medication administration. The findings include: Review of the facility's policy titled, Medication and Treatment Orders, revised 7/2016, revealed .Drug and biological orders must be recorded in the medical record . Review of the medical record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Dysphagia (difficulty swallowing) following Cerebral Infarction (Stroke), Atrial Fibrillation, Hypertension, Heart Failure, and Depression. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #51 scored 14 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. Review of a pharmacy delivery report for Resident #51 revealed Sertraline (Zoloft-antidepressant) 25 mg tablets were delivered to the facility from 9/20/2023-8/1/2024. Review of the Medication Administration Record (MAR) for Resident #51 for 11/2024 revealed .Zoloft [Sertraline] oral [by mouth] Tablet 25 MG [milligrams] .Give 1 tablet by mouth one time a day for DEPRESSION . Review of an electronically transmitted prescription, dated 8/1/2024, revealed the hospice agency sent an electronic order for Resident #51 for Sertraline 50 mg tablet to be administered by mouth once a day to a pharmacy contracted by the facility. Observation of a medication administration pass for Resident #51 on 11/13/2024 at 9:20 AM, revealed Sertraline 50 mg tablet was administered to the resident. During an interview and review of Resident #51's MAR and Sertraline medication package on 11/13/2024 at 10:20 AM, with Licensed Practical Nurse (LPN) A, revealed Sertraline 25 mg by mouth once a day was listed on the MAR. Further review of the medication package revealed Sertraline 50 mg. LPN A confirmed Resident #51 received Sertraline 50 mg. During a telephone interview on 11/15/2024 at 2:40 PM, the hospice Registered Nurse (RN) confirmed Resident #51's Sertraline dosage was increased from 25 mg once a day to 50 mg once a day on 8/1/2024. The hospice RN stated the process for new medication orders was the new order was sent electronically to the pharmacy. The hospice agency then faxed the new order to the facility's 2nd floor nurse's station. During an interview on 11/15/2024 at 3:15 PM, the Director of Nursing confirmed Resident #51's MAR and physician orders were not transcribed correctly.

Based on medical record review, observation and interview, the facility failed to obtain physician orders for oxygen for 1 resident (Resident #301) of 3 residents reviewed for oxygen therapy. The findings include: Review of the medical record revealed Resident #301 was admitted to the facility on [DATE] with diagnoses including Dementia, Age Related Physical Disability and COVID-19. Review of Nursing Skilled Evaluation documentation for Resident #301 dated, 11/9/2024, 11/10/2024, 11/11/2024, 11/12/2024 and 11/14/2024, indicated the resident was utilizing oxygen at 2 liters [per minute] via nasal cannula [NC-an oxygen delivery device placed in the nose]. During an observation on 11/12/2024 at 11:00 AM, Resident #301 was resting quietly in bed alert and pleasant. Resident #301 was receiving humidified oxygen at 2 liters via NC. During an observation on 11/13/2024 at 9:30 AM, Resident #301 was sitting up in bed eating breakfast. Resident #301 was receiving humidified oxygen at 2 liters via NC. During an observation on 11/14/2024 at 2:00 AM, Resident #301 was resting quietly in bed alert and pleasant. Resident #301 was receiving humidified oxygen at 2 liters via NC. During an observation on 11/15/2024 at 10:00 AM, resident resting quietly in bed with eyes closed. Resident #301 was receiving humidified oxygen at 2 liters via NC. During an interview on 11/15/2024 at 10:36 AM, the Director of Nursing (DON) stated Resident #301 was hospitalized for COVID and came to the facility on oxygen. The DON onfirmed there was not an order for oxygen and Resident #301's medical provider had been notified. The DON stated the medical provider ordered to discontinue the oxygen administration and monitor the resident to see if she needs to continue the oxygen therapy.

Based on medical record review and interview, the facility failed to resubmit a timely Level I (one) Preadmission Screening and Resident Review (PASRR) for 3 residents (Resident #29, #47 and #54) of 5 residents reviewed for PASRR. The findings include: Review of the medical record revealed Resident #29 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Metabolic Encephalopathy, COVID-19, Major Depressive Disorder, Anxiety Disorder, and Adult Failure to Thrive. Review of Resident # 29's comprehensive care plan dated 7/25/2024, revealed .The resident uses Antianxiety Medication .The resident has a mood problem .The resident has depression . Interventions were in place and implemented. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #29 scored a 14 on the Brief Interview of Mental Status (BIMS) assessment , which indicated the resident was cognitively intact and required extensive assistance of 1 staff member for bed mobility, transfers, toileting, and Activities of Daily Living (ADL) care. Review of a psychiatric progress note for Resident #29 dated 10/28/2024, revealed .Necessity of follow-up visits related to multiple psychiatric diagnoses, will encourage nursing interventions, including socialization, self-care, sleep hygiene . Review of the electronic physician's recapitulation orders for Resident #29 for 11/2024, revealed .Psych [psychiatric] .services may be obtained for the resident as indicated . Review of the medical record revealed Resident #29 had a Level I PASARR completed 7/17/2024, prior to admission to the facility. The screening concluded no mental health diagnosis is known or suspected. On admission to the facility, the resident had mental health diagnoses documented. No further screening was submitted by the facility to the state-designated authority. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Type 2 Diabetes Mellitus, Adjustment Disorder with Mixed Anxiety and Depressed Mood, and Unspecified Psychosis. Review of an annual MDS assessment dated [DATE], revealed the Resident #47 scored 15 on the BIMS, which indicated the resident was cognitively intact. Further review revealed the resident required extensive assistance of 1 staff member for bed mobility, toileting, dressing, and transfers. Review of the comprehensive care plan dated 6/19/2023, revealed .is on antipsychotic medication r/t [related to] hallucinations .at risk for decreased psychosocial well-being r/t [related to] the sudden, unexpected death of a loved one,,,a life-threatening illness/injury . Interventions were initiated. Review of the medical record revealed Resident #47 had a level I PASARR screening completed on 1/8/2021 with Anxiety Disorder and Depression captured for mental health diagnoses. Review of the medical record revealed the diagnosis of psychosis was added on 8/16/2022, and the facility failed to submit to the state-designated authority for a level II screening. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Schizophrenia, Anxiety, and Depression. Medical record review of a PASRR for Resident #54 dated 2/8/2024, revealed .Your level I screen shows you have evidence of serious mental illness .you are approved for admission for or up to 180 days in a nursing facility .If you or your care provider thinks you need to stay longer than 180 days, a nursing facility staff member must submit a new Level 1 screen .This must be done by or before the 180th day (August 8th 2024) . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a 14 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. Review of the medical record for Resident #54 from 2/8/2024 - 11/12/2024, revealed no additional PASRR had been completed or submitted by August 8th, 2024 (180th day). During an interview on 11/14/2024 at 2:20 PM, with the Director of Nursing (DON) and the PASARR Coordinator on speaker phone, the Coordinator confirmed the facility failed to resubmit a timely level 1 PASARR for Resident #54. During an interview on 11/15/2024 at 2:32 PM, the DON confirmed a submission for a level II PASARR was not submitted to the state designated authority after a new mental health diagnosis was added for Residents #29 and #47. 49786

Based on review of facility policy, medical record review and interviews, the facility failed to provide post dialysis interventions for 1 resident (Resident #151) of 1 residents reviewed for dialysis. The findings include: Review of the facility policy, Dialysis, Residents, Coordination of Care and Post-Care, dated 3/13/2015, revealed All nursing personnel will be responsible for providing safe, accurate, appropriate dialysis care with a general coordination between outside agencies that provide dialysis, post care assessment and interventions to improve resident outcomes .A. General Guidelines 1. Review and ensure orders upon admission are received for follow-up dialysis center appointments, shunt care, diet, and fluid restrictions . Review of the medical record revealed Resident #151 was admitted to the facility on [DATE], with diagnoses including Cirrhosis, Hepatitis C, Osteomyelitis, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and End Stage Renal Disease. Review of the comprehensive care plan dated 11/13/2024, revealed The resident needs hemodialysis r/t [related to] renal failure s/p [status post] permanent dialysis catheter placement 10-11-2024 right upper chest .Monitor/document/report PRN [as needed] for s/sx [signs and symptoms] of the following: Bleeding, Hemorrhage, Bacteremia, septic shock . Review of the Medication Administration Record (MAR) dated 11/8/2024, did not indicate the location of Resident #151's dialysis catheter or documentation and monitoring of the catheter post dialysis. Review of a nurse progress note dated 11/13/2024, revealed post dialysis the nurse failed to document an assessment of Resident #151's dialysis catheter. During an observation and interview on 11/15/2024 at 8:45 AM, with Resident #151's nurse revealed he left the facility to go to dialysis prior to her coming on shift. Continued interview revealed she did not know the location of his dialysis catheter because it was her first day to provide care for the resident. Observation of the resident's MAR and further interview confirmed there was no record of the location of the dialysis catheter or documentation of post dialysis care. During an interview on 11/15/2024 at 9:00 AM, with the Director of Nursing confirmed the documentation for post dialysis care was not documented on 11/13/2024.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide fingernail care for 1 resident (Resident #45) of 3 residents reviewed for Activities of Daily Living (ADL) Care. The findings include: Review of the facility policy titled, Fingernails/Toenails, Care of, undated, showed .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming . Medical record review showed Resident #45 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #45's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating he was cognitively intact. Further review showed he required extensive assistance with personal hygiene. Review of Resident #45's comprehensive care plan dated 9/12/2021, showed .dependent on staff assistance for ADL's r/t [related to] weakness, MS .Provide nail care PRN [as needed], Keep nails clean and trimmed . During an observation and interview on 1/31/2022 at 11:05 AM, Resident #45 was observed lying on the bed with all 10 nails long with dark debris under all nails. During an interview on 2/2/2022 at 9:36 AM, Certified Nursing Assistant (CNA) #1 stated Resident #45 does allow staff provide nail care. Further interview and observation of Resident #45's nails in the resident's room showed the resident lying on the bed with all 10 nails long with brown debris under the nails. During an interview and observation on 2/2/2022 at 9:43 AM, the Director of Nursing (DON) confirmed Resident #45's nails were untrimmed with brown debris under the nails. Further observation and interview with Resident #45, stated he prefers his nails to be .real short .

Based on medical record review, review of Social Security documents, review of facility billing and accounts, and interview, the facility failed to notify the resident's representative before obtaining representative payee status for 1 resident (Resident #1) of 3 residents reviewed for management of personal funds. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed Family Member #1 was Resident #1's financial representative. Review of Social Security documentation showed Form SSA-11-BK/ Representative Payee Application Form was submitted by the facility and dated 10/1/2020. A notification document from the Social Security Office addressed to Resident #1 dated 10/22/2020, indicated the facility was selected to be Resident #1's Representative Payee. Review of a Billing Note dated 11/16/2020 showed .We have applied and been granted rep [representative] payee beginning in December . Review of Resident #1's Account Statement showed on 12/9/2020, Resident #1's funds was deposited into an account .Rep Payee: [name of facility] . The resident's monthly Social Security check was deposited in January, February, and March 2021. Review of Resident #1's Quarterly Minimum Data Sheet dated 3/8/2021 showed the resident had severe cognitive impairment. Interview with the Business Office Manager on 3/22/2021 at 2:00 PM, revealed the facility had become the payee for the resident as of December 2021. She stated the previous Administrator instructed the Assistant Business Office Manager (not employed at the facility now) to apply for payee status through the Social Security Office. She stated as of December 2021, the facility was Resident #1's representative payee for Social Security. Telephone interview with Family Member #2 on 3/22/2021 at 5:45 PM, revealed when the resident was admitted to the facility, they told the facility they did not want the facility to have anything to do with Resident #1's finances. She stated she and Family Member #1 had applied and were the resident's Payee for Social Security. She stated the facility had not notified them that the facility had applied for the representative payee. During a telephone interview with the Administrator on 3/25/2021 at 12:00 PM, the Administrator stated there was no documentation that the family had been notified the facility had applied for and obtained Resident #1's representative payee status for Social Security. He stated the facility should have sent a notification letter to the family prior to obtaining Resident #1's representative payee for Social Security.

Based on the facility policy review, medical record review, facility documentation review, and interview, the facility failed to report an allegation of abuse to the Administrator and to the State Agency timely for 1 resident (Resident #2) of 3 residents reviewed for abuse. The findings include: Review of the facility's policy titled ABUSE PREVENTION POLICY & PROCEDURE, dated 2/26/2018, showed .All alleged violations involving abuse, neglect, exploitation or mistreatment .are reported to the Administrator and Director of Nursing .All allegations involving abuse, neglect, exploitation or mistreatment .are reported immediately to the state survey agency, adult protective services and to all other agencies as required, per state and federal guidelines .Immediately means as soon as possible, but no later than 2 hours after the allegation is made . Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Quarterly Minimum Data Set (MDS) dated [DATE] showed the resident had severe cognitive impairment and had unclear speech. Review of a statement by Long Term Care 1 Unit Manager showed . On 03/09/2021 after 3 pm I got a voice message from [family member] .for resident [Resident #2] .stated in the message feels resident has been sexual assault by staff .stated resident told her a person named scarecrow had been inappropriate him .She felt that need to talk to someone about this today. She did not know if she need to call authorities .I informed DON [Director of Nursing] about the [family member] concerns . Review of a psychiatric practitioner progress note dated 3/10/21 showed .Pt's [family member] has since reported more concerns about pt making an accusation of sexual harassment .Noted difficulty in assessing validity of pt's statements given pt's intellectual impairment, communication barrier, and no formal medical work up following accusations. Pt cannot name specifics related to this event. Does not appear acutely anxious or fearful today . Review of the facility's documentation dated 3/11/2021 showed the Administrator was notified of an allegation of sexual abuse of Resident #2 by Adult Protective Services (APS). The allegation was the same allegation that had been reported to the facility on [DATE] by Resident #2's family member. During an interview on 3/23/2021 at 10:40 AM, the Unit Manager stated she received a voice message from Resident #2's family member on 3/9/2021 concerned that Resident #2 had called and verbalized an allegation of sexual abuse. The Unit Manager reported the allegation to the DON. The Unit Manager stated she was not instructed to report the incident and did not report the incident to the Administrator or the State Agency. During an interview on 3/23/2021 at 11:30 AM, the Administrator stated Resident #2's family made an allegation of sexual abuse on 3/9/2021 to the Unit Manager. The DON and the Unit Manager did not report the allegation to him. He was made aware of the allegation on 3/11/2021 by APS and at that time reported the allegation to the State Agency, the Police and the Ombudsman. The facility did not report the allegation of abuse to the appropriate agencies timely. During an interview on 3/23/2021 at 1:00 PM, the DON stated on 3/9/2021 the Unit Manager reported she had received a call from Resident #2's family member who voiced a concern that the resident had been touched inappropriately. The DON stated she did not consider this an abuse allegation because the resident previously had hallucinations. The DON confirmed she did not report the allegation of abuse to the Administrator or the State Agency.

Based on the facility policy review, medical record review, facility investigation review, and interview, the facility failed to investigate an allegation of abuse timely for 1 resident (Resident #2) of 3 residents reviewed for abuse. The findings include: Review of the facility's policy titled ABUSE PREVENTION POLICY & PROCEDURE, dated 2/26/2018, showed .Any complaint, allegation, observation; or suspicion of resident abuse, mistreatment or neglect, whether physical, verbal, mental or sexual, involuntary or voluntary, is to be thoroughly reported, investigated and documented in a uniform manner .Nursing Staff duties .An incident of abuse must be reported to the charge nurse who will examine the resident, document findings in the clinical records and immediately initiate the Investigation protocol .The administrative or nursing supervisor assumes responsibility for immediate notification of the Administrator and Director of Nursing .An immediate investigation into the alleged incident, during the shift it occurred on .Personnel shall complete resident incident report at time of incident/event .The facility will take all steps necessary to ensure that further potential abuse will not occur while the investigation is in progress . Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Quarterly Minimum Data Set (MDS) dated [DATE] showed the resident had unclear speech, severe cognitive impairment, and no behavioral problems. Review of a statement by Long Term Care 1 Unit Manager showed .On 03/09/2021 after 3 pm I got a voice message from [family member] .for resident [Resident #2] .stated in the message feels resident has been sexual assault by staff .stated resident told her a person named scarecrow had been inappropriate him .She felt that need to talk to someone about this today. She did not know if she need to call authorities .I informed DON [Director of Nursing] about the [family member] concerns . Review of a psychiatric therapy practitioner progress note dated 3/10/2021 showed .Pt's [Patient's] [family member] . reported more concerns about pt making an accusation of sexual harassment .Noted difficulty in assessing validity of pt's statements given pt's intellectual impairment, communication barrier, and no formal medical work up following accusations. Pt cannot name specifics related to this event. Does not appear acutely anxious or fearful today . Review of the facility's investigation dated 3/11/2021 showed the Administrator was notified of an allegation of sexual abuse of Resident #2 by Adult Protective Services (APS). The allegation was the same allegation that had been reported to the facility on [DATE] by Resident #2's family member. The investigation was initiated on 3/11/2021 by the Administrator. During an interview on 3/23/2021 at 10:40 AM, the Unit Manager stated she received a voice message from Resident #2's family member on 3/9/2021 concerned that Resident #2 had called her and verbalized an allegation of sexual abuse. The Unit Manager reported the allegation to the DON, who instructed the Unit Manager to assess the resident and interview him. During an interview on 3/23/2021 at 11:30 AM, the Administrator stated Resident #2's family made an allegation of sexual abuse on 3/9/2021 to the Unit Manager. The DON and the Unit Manager did not report the allegation to him. The Administrator confirmed the facility did not initiate an immediate investigation for abuse at the time of the allegation on 3/9/2021. During an interview on 3/23/2021 at 1:00 PM, the DON stated on 3/9/2021 the Unit manager notified her she had received a call from Resident #2's family member who voiced a concern that the resident had been touched inappropriately. The DON stated she did not consider this an abuse allegation. She stated she advised the Unit Manager to assess Resident #1. The DON confirmed she did not initiate an immediate abuse investigation on 3/9/2021.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to maintain a sanitary for one resident (Resident #1) of 3 residents reviewed for a homelike environment. The findings included: Review of the facility's policy titled, Quality of Life-Homelike Environment, last revised on 5/2017, showed .The staff and management shall maximize to the extent possible, the characteristics of the facility to reflect a .homelike setting .these .include .Clean, sanitary and orderly environment Review of the medical record showed Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 7 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS) and required assistance of 2 or more persons for all activities of daily living (ADLS). Observation of Resident #1's room on 9/8/2020 at 1:55 PM showed 2 trash cans containing personal protective equipment (PPE) that were full and overflowing. Further observation showed a large blue opened plastic bag, which contained soiled bed linens and towels stored on the floor at the foot of the resident's bed. Observation of Resident #1's room with the Director of Nursing (DON) on 9/8/2020 at 2:05 PM showed the full trash cans containing the PPE and the bag of dirty linen continued to be stored in the resident's room. During an interview on 9/8/2020 at 2:06 PM, the DON stated the trash cans containing PPE were overfilled and should have been emptied and the soiled linens should have been removed from the room immediately after the resident's bed had been changed. The DON confirmed the facility failed to maintain a sanitary and homelike environment for Resident #1.

Based on facility policy review, observation, and interview the facility failed to maintain proper storage of biohazardous waste in 1 of 2 soiled utility rooms observed for infection control. The findings include: Review of the facility's Infectious Waste Management Plan (undated) showed .the proper handling of infectious waste will be used in the care of all residents as it is critical to the prevention of the spread of infection and disease .Wastes from Resident Care Areas: All waste contaminated with blood/body fluids shall be disposed of in the trash container . Observation of the soiled utility room located on LTC 1 was performed with the Administrator and Director of Nursing (DON) on 8/24/2020 at 5:20 PM. Findings revealed biohazard bags being stored in a single bin. The bin was filled to capacity and overflowing. Eight biohazard bags were observed on the floor beside the storage bin. During this observation the DON stated she recalled the waste being emptied by the Maintenance Department on Friday (8/21/2020). Interview with the Administrator on 8/24/2020 at 7:10 PM, confirmed the soiled utility room did not look the way it normally does .it is not the standard we want to achieve . In conclusion, the biohazard waste bin located in the soiled utility room on LTC 1 had not been emptied when it had reached maximum storage capacity. The waste was allowed to accumulate in excess and biohazard bags were being stored on the floor beside the bin.

Based on review of facility documents, medical record review and interview, the facility failed to prevent physical abuse of 1 resident (#2) from a second resident (#1) of 3 residents reviewed for abuse. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the initial Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 had severe cognitive impairment and required limited assist of 1 person for transfer and ambulation. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the initial Minimum Data Set ((MDS) dated [DATE], revealed Resident #2 had severe cognitive impairment and required assist of 2 persons for transfer and was non-ambulatory. Review of facility documents revealed on 10/30/19, at 9:45 AM, in the dining room, Resident #1 stepped to Resident #2's seat and slapped Resident #2. Continued review revealed 1 staff member was in the dining room, witnessed the slap and stated, prior to the incident, there was no indication Resident #1 and Resident #2 were interacting. Further review of the documents revealed neither resident had displayed any physical aggression toward others prior to this incident. Interview with the Administrator on 11/25/19, at 2:00 PM, in the conference room, as facility documents were reviewed, revealed Resident #1 was observed 1:1 until the resident was able to be transferred the same day of the incident to a gero-psych unit. Continued interview and review of the documentation of Resident #2's physical assessment the day of the incident, confirmed the resident did not have any mark on her face from receiving the slap and also did not remember the incident.

Based on review of facility policy, medical record review, review of facility documentation, and interview the facility failed to follow the plan of care for bed mobility for 1 resident (#9) of 5 residents reviewed for falls of 24 sampled residents. The facility's failure to follow the plan of care for Resident #9 resulted in actual harm. The findings include: Review of the facility policy Falls Management, undated, revealed, .The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program. Residents are assessed for the fall risk factors. The interdisciplinary team works with the residents and family to identify and implement appropriate interventions to reduce the risk of falls or injuries . Continued review of the facility's fall policy revealed, .Procedure .3. Discuss goals and interventions with resident/family for inclusion in the interdisciplinary plan of care. 4. Implement the Plan of Care- Fall Risk Reduction based on individual resident needs. 5 Complete the individual resident care plan. 6. Communicate interventions during shift report and clinical rounds to the care teams as appropriate . Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #9 scored a 2 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. Continued review revealed Resident #9 required the extensive assistance of 2 staff for bed mobility, and the total dependence of 2 staff for transfers, toileting and hygiene. Medical record review of the comprehensive care plan dated 12/11/18 revealed, .Risk for falls will be minimized/managed and resident will suffer no serious injury related to falls . Continued review revealed, .2 person assist for bed mobility . Medical record review of an undated Certified Nurse Assistant (CNA) ADL (Activities of Daily Living) Care Guide revealed, .two person (staff) for ADLs, bed mobility, and transfers . Medical record review of a Fall Scene Investigation form dated 3/2/19 revealed, .Rolled out of bed while being assisted by one CNA . Medical record review of local hospital History and Physical Reports dated 3/2/19 revealed, .Chest x-ray reveals .rib fractures on the left 2 through 7 .Pneumothorax (collapsed lung) . Further review revealed Resident #9 had a chest tube placed due to the collapsed lung. Review of a Personnel Action Form dated 3/6/19 revealed, .(CNA #1) was providing patient care, alone, on a person who required the assist (assistance) of 2 (staff). The patient (Resident #9) fell from the bed and sustained injury. Associate did not adhere to the ADL care guide . Interview with CNA #1 on 3/19/19 at 2:20 PM, by phone, confirmed, .changed her (Resident #9) by myself, I always changed her with 1 CNA . Interview with the Director of Nursing (DON) and the Administrator on 3/19/19 at 4:05 PM, in the DON's office, confirmed Resident #9 was care planned for requiring the assistance of 2 staff members for bed mobility. Further interview with the DON and Administrator confirmed CNA #1 had provided care to Resident #9 alone, and had failed to follow the resident's care plan resulting in Resident #9's fall from the bed and sustaining fractured ribs and a collapsed lung.

Based on facility policy review, medical record review, and interview, the facility failed to prevent a fall resulting in actual Harm for 1 resident (#9) of 5 residents reviewed for falls of 24 sampled residents. The findings include: Review of the facility policy Falls Management, undated, revealed .Residents are assessed for the fall risk factors. The interdisciplinary team works .to identify and implement appropriate interventions to reduce the risk of falls or injuries . Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #9 scored a 2 on the Brief Interview for Mental Status (BIMS) indicating the resident had severe cognitive impairment. Continued review revealed Resident #9 required extensive assistance of 2 staff with bed mobility, and total dependence of 2 staff for transfers, toileting, and hygiene. Medical record review of Resident #9's comprehensive care plan dated 12/11/18 revealed .Ensure fall precautions are in place . Continued review revealed the resident required 2 staff assistance for bed mobility. Medical record review of the untitled Certified Nursing Assistant (CNA) care guide dated 2/28/19 revealed Resident #9 required assistance of 2 staff for bed mobility. Medical record review of a Fall Scene Investigation form revealed on 3/2/19 at 5:45 AM, .Rolled out of bed while being assisted by one CNA . Medical record review of a nurse's note dated 3/2/19 at 6:43 AM, revealed .Nurse was alerted of a fall .Patient was on the floor parralel (parallel) to her bed, laying on her right side. CNA stated that she rooled (rolled) out of bed while .the CNA was trying to do peri-care (perineal care) .no s/s (signs/symptoms) of pain noted . Medical record review of a late entry nurse's note dated 3/2/19 at 5:41 PM, revealed .0700am .O2 (oxygen) sat (saturation) 82-88 on room air, res (resident) having difficulty breathing, neb (nebulizer) tx (treamtment) administered as per prn (as needed) orders, O2 sat improved to 90-93% (percent) on room air, res continues grunting noise and is continuing to be nonverbal, asking res about pain discomfort res still not answering questions. 0745am called on call doctor left voicemail requesting call back .continues to be having changes with resp (respiratory) status . Medical record review of a Physician's Telephone Order dated 3/2/19 revealed .Send to ER for eval /(evaluation) & (and) tx (treatment) due to fall .Resp. status . Medical record review of a hospital History and Physical Report dated 3/2/19 revealed .Chest x-ray reveals subcutaneous [MEDICAL CONDITION] with rib fractures on the left 2 through 7. Pneumothorax (collapsed lung) . Continued review revealed acute [MEDICAL CONDITION] associated with [MEDICAL CONDITION] and multiple left sided rib fractures .Pneumothorax .Fall from bed .Patient has a history of multiple [MEDICAL CONDITIONS] (stroke) with dense left [MEDICAL CONDITION] (paralized or weakness to one side of the body) . Further review revealed a CT (computed tomography) scan of the chest revealed enlarging pneumothorax .chest tube placed . Continued review revealed, .I (the ER physician) have spoken to the patient's sister at bedside and the patient's daughter by telephone .end of life issues were discussed. Prognosis is very poor . Review of a Personnel Consultation form dated 3/6/19 revealed CNA #1's employment was terminated from the facility. Continued review revealed .associate was providing patient care, alone, on a person who required the assist (assistance) of 2 (staff). The patient (Resident #9) fell from the bed and sustained injury. Associate (CNA #1) did not adhere to the ADL (Activities of Daily Living) care guide . Telephone interview with CNA #3 on 3/19/19 at 5:15 AM revealed CNA #3 was sitting at the nurse's station and heard CNA #1 hollered out to me from the resident's (Resident #9's) room door . Further interview revealed CNA #1 had .not asked for help all night . Telephone interview with CNA #1 on 3/19/19 at 12:55 PM, revealed CNA #1 was providing care to the resident on 3/2/19 at 5:45 AM .changed her by myself .I always changed her (alone) . Continued interview revealed Resident #9 was rolled onto the right side to provide peri-care, the left leg shifted .and threw her off the bed before I could catch her . Interview with CNA #5 on 3/19/19 at 2:46 PM, in the conference room, revealed the CNA had worked in the facility for 7 months. Continued interview revealed the CNA was aware Resident #9 required the assistance of 2 staff for bed mobility, and had always required the assistance of 2 staff since he had been employed in the facility. Interview with CNA #4 on 3/20/19 at 2:20 PM, in the conference room, revealed .we knew she was a 2 person assist by the care guide and by looking at her .she was obese, not active, non-verbal, just needed assistance with everything . Interview with Registered Nurse (RN) #4 on 3/20/19 at 2:50 PM, on the 400 Hall, revealed CNA care guides are updated daily and printed and left in a folder at the nurse's station daily for the CNAs which clearly document the level of assitance Resident #9 required. Interview with the Director of Nursing (DON) and the Administrator, on 3/19/19 at 4:05 PM, in the DON's office, confirmed Resident #9 required 2 person assistance with bed mobility, Resident #9 sustained multiple rib fractures, and the facility failed to provide the required 2 person assistance which resulted in a fall and actual harm to Resident #9. In summary, Resident #9 had been assessed as requiring the assistance of 2 staff members for bed mobility. Resident #9's MDS assessment, Care Plan, and CNA Care Guide all documented Resident #9 needed the assistance of 2 staff members for bed mobility. During interviews conducted with multiple CNAs during the survey, all were aware of the level of assistance Resident #9 required. Interviews confirmed other CNAs were available and nearby when CNA #1 assisted Resident #9, and interviews confirmed CNA #1 only asked for help after Resident #9 had already fallen from the bed.

Based on review of the facility policy, medical record review, and interview the facility failed to administer an ordered medication to 1 resident (#318) of 24 sampled residents. The findings include: Review of the facility policy Medication Administration, revised 3/16/15, revealed .administer medications within 60 minutes of the scheduled time .routine medications are administered according to the established medication administration schedule for the facility . Medical record review revealed Resident #318 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician Telephone Order dated 3/16/19 revealed .[MEDICATION NAME] (medication for itching and inflammation of the skin) cream 0.1% (percent). Apply to rash on back TID (3 times daily) x (times) 14 d (days) . for [DIAGNOSES REDACTED]. Medical record review of the MR (Medication Record) revealed no documentation Resident #318 had received the [MEDICATION NAME] cream 7 out of 11 ordered doses dated 3/16/19 to 3/20/19. Further review of the MR revealed no documentation for the explanation of the missed [MEDICATION NAME] cream administration. Interview with Resident #318 on 3/18/19 at 8:45 AM, in the resident's room, revealed she was concerned about not receiving the [MEDICATION NAME] cream three times a day as ordered. Interview with Registered Nurse (RN) #2 on 3/19/19 at 8:30 AM, at the medication cart and review of Resident #318's MR, confirmed Resident #318 had not received the medication as ordered. Interview with RN #3, Account Manager of the Pharmacy on 3/19/19 at 3:30 PM, at the main nursing station, revealed the [MEDICATION NAME] cream had been delivered to the facility on [DATE]. Interview with Licensed Practical Nurse (LPN) #1 on 3/20/19 at 8:22 AM, in the rehabilitation nursing station, revealed when an ordered medication is not given, it is to be circled and documented with the rationale on the back of the MR. Continued interview confirmed the Nurses's Medication Notes on the back of the MR had no documentation of missed or held [MEDICATION NAME] cream. Interview with the Director of Nursing (DON) on 3/20/19 at 9:00 AM, in the DON's office, confirmed the facility failed to administer a medication as ordered and failed to document the rationale for not administrating the [MEDICATION NAME] cream for Resident #318.

Based on facility policy review, observation, and interview, the facility failed to follow contact isolation precautions for 1 resident (#87) of 1 resident observed for isolation precautions of 9 halls observed for infection control. The findings include: Review of the facility's policy Contact Precautions, undated, revealed .Wear gloves when entering the room .Wear a gown . Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #87 had a Brief Interview for Mental Status (BIMS) score of 3 indicating the resident was severely cognitively impaired. Continued review revealed the resident was always incontinent of urine and required the extensive assistance of 2 staff for bed mobility, toileting and personal hygiene. Medical record review of a Physician Telephone Order dated 3/14/19 revealed .contact isolation . Continued review revealed Resident #87 had a [DIAGNOSES REDACTED]. Medical record review of Resident #87's current comprehensive care plan updated 3/18/19 revealed .Interventions .Follow facility isolation policy . Observation on 3/19/19 at 8:19 AM, on the 800 hall, revealed Hydration Aide #1 entering Resident #87's room wearing a gown not properly secured at the waist and ungloved. Continued observation revealed Hydration Aide #1 touched the resident's bed to raise the head of the bed, touched Resident #87 to assist the resident with repositioning in bed, touched the blinds, and sat on the chair. Interview with Registered Nurse (RN) #1 on 3/19/19 at 2:28 PM, at the long term care nurse's station, revealed Resident #87 is on contact isolation precautions. Continued interview revealed .I try to watch them (Hydration Aides) because they don't always gown and glove up . Observation on 3/20/19 at 12:20 PM, on the 800 hall, revealed Certified Nursing Assistant (CNA) #1 sitting on a chair inside Resident #87's room with a gown not properly secured at the waist and her arms resting on the resident's bedside table, holding her gloves in one hand. Observation and interview with the Assistant Director of Nursing on 3/20/19 at 12:22 PM, on the 800 hall, confirmed CNA #1 had not properly donned (put on) a gown and gloves prior to entering and while inside a contact isolation room. Continued interview confirmed the facility failed to follow the contact isolation policy.

Based on review of facility policy, medical record review, review of a facility investigation, observation, and interviews, the facility failed to ensure 1 resident (#3) was free from abuse of 5 residents reviewed for abuse. The findings included: Review of facility policy Abuse Prevention Policy & Procedure, last revised 1/23/17 revealed .The Resident has the right to be free from abuse, neglect, misappropriation of resident property .This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse .by any facility staff member, other residents, consultants .serving the resident . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 9/15 (moderately cognitive impaired) on the Brief Interview for Mental Status (BIMS) and required extensive assistance for bed mobility, transfer, and dressing. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's Admission Assessment MDS dated [DATE] revealed the resident scored 4/15 (severely cognitive impaired) on the BIMS and had physical, verbal, and other behavioral symptoms not directed toward others occurring 4-6 days but less than daily. Medical record review of a nursing progress notes dated 11/19/18 revealed Resident #2 was currently on 1 on 1 observation. Further review revealed Resident #2 was noted with increased agitation and confusion and was given [MEDICATION NAME] (anti-anxiety medication). Review of a facility investigation dated 11/20/18 at 8:23 PM revealed Certified Nursing Assistant (CNA) #1 reported to the nurse that she heard Resident #3 screaming and when she entered the room Resident #2 was seated in her wheelchair at the foot of Resident #3's bed and was hitting Resident #3 on the feet. Further review revealed CNA #1 immediately separated the residents and reported the incident to the nurse. Continued review revealed after the incident, Resident #2 continued to try to go into other residents' rooms and was threatening the nurse verbally. Further review revealed Resident #3 was interviewed on 11/21/18 and Resident #3 stated Resident #2 was pulling at her furniture and was shaking her leg. Interview with the Administrator on 11/29/18 at 11:30 AM revealed Resident #2 was on placed on one on one (1:1) observation after an incident on 11/18/18 and the facility had considered sending the resident for in-patient psychiatric care but the resident' son had planned on taking the resident home on 11/22/18 so the resident remained in the facility on 1:1 observation. Interview with CNA #1 on 11/29/18 at 2:05 PM, in the conference room, revealed CNA #1 was in a room across the hall when she heard Resident #3 screaming. Further interview revealed when she entered Resident #3's room she saw Resident #2 hitting Resident #3 on both lower legs with an open hand in a slapping motion. Continued interview revealed she did not remember seeing any other staff member in the room. Further interview revealed CNA #1 took Resident #2 to the nurses' desk and reported the incident to the nurse. Interview with CNA #2 on 11/29/18 at 2:40 PM, in the conference room, revealed on 11/20/18 the CNAs were taking turns watching Resident #2. Further interview revealed, at the time of the incident, CNA #2 was at one end of the hallway, close to the nurses' station while Resident #2 was rolling down the hallway in her wheelchair in the opposite direction from CNA #2. Continued interview revealed CNA #2 heard the elevator door open and she turned around for a second to make sure no one (resident) was getting on the elevator and when she turned back around she heard Resident #3 screaming .get out of here . Observation and interview with the Clinical Services Director on 11/29/18 at 3:15 PM, on the 2nd floor hallway, revealed there were 12 resident rooms between where CNA #2 was standing at the elevator and Resident #3's room. Interview with the Clinical Services Director confirmed residents who were on 1:1 observation must not be left unattended and the facility failed to maintain 1:1 observation of Resident #2. In summary, the facility failed to maintain 1:1 observation of Resident #2, resulting in Resident #2 entering Resident #3's room and hitting Resident #3 on the feet.

Based on medical record review, and interview, the facility failed to maintain dignity for 5 residents (#17, #64, #13, #22, and #21) of 10 incontinent residents reviewed of 40 residents sampled. The findings included: Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident was independent with daily decision making, required extensive assistance with transfers and toilet use, was frequently incontinent of bladder, and was always incontinent of bowel. Interview with Resident #17 on 3/28/18 at 5:00 PM, in the resident's room, revealed the resident was aware of the urge to void. Further interview revealed it often took the staff 45 minutes to an hour to respond to the resident's call light and in the past had experienced episodes of bladder and bowel incontinence related to a delay in answering her call light. Medical record review revealed Resident #64 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored a 14 (cognitively intact) on the BIMS. Further review revealed the resident was independent with daily decision making, required extensive assistance of 2 persons with transfers and toileting, and was frequently incontinent of bladder. Interview with Resident #64 on 3/27/18 at 2:10 PM, in the activity room, revealed the resident was aware of the urge to void and had experienced an episode of urinary incontinence approximately a week ago. Further interview revealed the resident had turned the call light on and it took the staff a long time to answer her call light but was unable to determine exactly how long it took the staff to respond to the call light. Interview with Resident #64 on 3/28/18 at 3:20 PM, in the resident's room, revealed the resident was able to feel the urge to void and had experienced an incontinent episode approximately a week ago, but was unable to determine exactly how long it took the staff to respond to the call light. Continued interview revealed the resident had turned her call light on early enough to allow the staff enough time to respond. Medical record review revealed Resident #13 was admitted to the facility on [DATE] and readmitted to 5/27/16 with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored a 15 (cognitively intact) on the BIMS. Further review revealed the resident was independent with daily decision making, required extensive assistance of 1 person with transfers and toilet use, and was occasionally incontinent of bladder. Interview with Resident #13 on 3/27/18 at 2:00 PM, in the activity room, revealed the facility staff would sometimes come into her room after she had turned the call light on and turned her call light off and said they would come back, but they did not always return. Continued interview revealed she needed assistance with toileting and several times had experienced bladder incontinence due to not receiving assistance with toileting. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored a 15 (cognitively intact) on the BIMS. Further review revealed the resident was independent with daily decision making, was frequently incontinent of bladder, and required extensive assistance of 2 persons with transfers and toilet use. Interview with Resident #22 on 3/27/18 at 1:50 PM, in the activity room, revealed about a month ago the resident put her call light on at 2:10 PM and the staff did not responded to the call light until 3:50 PM. Further interview revealed the resident had experienced an episode of urinary incontinence due to the delay in response time to have her call light answered. Interview with Certified Nursing Assistant (CNA) #7 on 3/28/18 at 1:20 PM, in the hallway, revealed she was very familiar with Resident #22. Further interview revealed the resident was aware of the need to void and usually placed the call light on when she felt the need to void. Continued interview revealed sometimes the resident would start to void prior to being transferred to the commode. Interview with CNA #7 on 3/28/18 at 2:10 PM, in the hallway, revealed there was not always enough staff to answer call lights timely, was aware call lights were sometimes turned off by staff members who tell the residents the will return and then do not return, and was aware of residents who have been incontinent due to their call lights not being answered timely. Medical record review revealed resident #21 was admitted to the facility 9/25/2017 with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored a 14 (cognitively intact) on the BIMS. Further review revealed the resident was frequently incontinent of bladder and bowel, and required the assistance of 2 persons for all activities of daily living. Interview with the resident on 3/27/18 at 4:00 PM, in the resident's room, revealed the resident had minimal use of her legs and could no longer walk. Continued interview revealed there was a problem with getting the call lights answered .it takes forever to get help .pushed call light for assistance once (unknown date) and the CNAs didn't get there in time. I messed myself . Interview with the Interim Director of Nursing, on 3/28/18 at 2:35 PM, in the conference room, confirmed there was not always adequate staff to answer call lights in a timely manner to meet resident needs.

Based on facility policy review, medical record review, review of facility documentation, observation, and interview, the facility failed to answer the call light in a timely manner for 2 residents (#61 and #9) of 40 residents reviewed. The findings included: Review of the facility policy Resident Rights, undated, revealed .It is our belief that you as a resident have the right to expect certain standards of care and considerations while at our facility. You have the right to: 1. Expect reasonable responses to requests for services within our capacity . Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 15 (cognitively intact) on the Brief Interview for Mental Status. Further review revealed the resident was independent with daily decision making, required extensive assistance of 2 persons with bed mobility, and had limitation in range of motion on 1 side upper and lower extremities. Interview with Resident #61 on 3/26/18 at 3:35 PM, in the resident's room, revealed a few weeks ago he and his roommate turned on the call light during the night. Further interview revealed Resident #61 wanted assistance with repositioning and a staff member told him and his roommate (Resident #9) they were using the call light too frequently. Continued interview revealed on the night in question it took about an hour for the call light to be answered. Further interview revealed the resident was unable to reposition in bed without assistance. Medical record review revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #9 (Resident #61's roommate) on 3/26/18 at 2:24 PM, in the resident's room, revealed a few weeks ago on the night shift the resident placed his call light on because he needed a clean brief. Further interview revealed the call light was answered by a nurse, approximately an hour after turning the call light on, and the nurse told him he was on the call light. Interview with the Interim Director of Nursing (DON) on 3/28/18 at 10:55 AM, in the DON's office, confirmed call lights should be answered within 5 minutes.

Based on facility policy review, medical record review, and interview, the facility failed to ensure Incontinence Risk Assessments were completed for 4 residents (#17, #64, #13, and #22) of 10 residents reviewed for urinary incontinence. The findings included: Review of the facility's policy Bladder and Bowel Assessment, undated, revealed .It is the policy of .to ensure that each resident has a Bladder and Bowel assessment performed with the goal of achieving continence or restoring as much normal bladder and/or bowel function as possible. Based on the assessment appropriate treatment and services will be offered. The continence program utilized is a structured Bladder and Bowel Rehabilitation Program designed to help resident's progress from incontinence to continence and from constipation to regularity, through guided nursing management. The program is based on current Bladder and Bowel assessment .Implement Bladder and Bowel (B&B) assessment on all residents at the time of admission, quarterly, and when there is a change in cognition, physical ability or urinary tract or bowel function .Record resident bladder and bowel patterns for 72 hours using the Bladder and Bowel Record . Medical record review revealed Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident was independent with daily decision making, required extensive assistance with transfers and toilet use, and was frequently incontinent of bladder and bowel. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored a 15 on the BIMS, was independent with daily decision making, required extensive assistance with transfers and toilet use, was frequently incontinent of bladder and was always incontinent of bowel. Medical record review of an Incontinence Risk assessment dated [DATE] revealed the assessment had not been completed. Interview with Licensed Practical Nurse (LPN) #3 on 3/28/18 at 5:20 PM, in the conference room, confirmed the Incontinence Risk assessment dated [DATE] was not complete. Continued interview confirmed the resident had not had an Incontinence Risk Assessment initiated after 8/27/17 to determine if the resident was a candidate for a bladder retraining program. Medical record review revealed Resident #64 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored a 14 (cognitively intact), was independent with daily decision making, required extensive assistance of 2 persons with transfers and toileting, and was frequently incontinent of bladder. Medical record review of the Incontinence Risk assessment dated [DATE] revealed the assessment was not complete to determine if the resident was a candidate for a bladder management program to assist the resident to regain continence. Interview with the Regional Clinical Support Nurse on 3/28/18 at 4:00 PM, in the conference room, confirmed the bladder assessment dated [DATE] had not been completed Medical record review revealed Resident #13 was admitted to the facility on [DATE] and readmitted to 5/27/16 with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored a 15(cognitively intact) on the BIMS indicating the resident, was independent with daily decision making, required extensive assistance of 1 person with transfers and toilet use, and was occasionally incontinent of bladder. Medical record review revealed the Incontinence Risk assessment dated [DATE] had not been completed. Interview with the Regional Clinical Support Nurse, on 3/28/18 at 4:10 PM, in the conference room, confirmed the Incontinence Risk assessment dated [DATE] had not been completed to determine if the resident was a candidate for a bladder retraining program. Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored a 15 (cognitively intact) on the Brief Interview for Mental Status, was independent with daily decision making, was frequently incontinent of bladder, and required extensive assistance of 2 persons with transfers and toilet use. Medical record review of an Incontinence Risk assessment dated [DATE] revealed the assessment was not complete. Interview with LPN #3 on 3/28/18 at 1:50 PM, in the conference room, confirmed the Incontinence Risk assessment dated [DATE] had not been completed and a bladder retraining program had not been developed for the resident.

Based on medical record review, facility policy review, and interviews, the facility failed to immediately provide Cardio-Pulmonary Resuscitation (CPR) in accordance with the plan of care, for one resident (#1) of twenty residents reviewed. The facility's failure resulted in CPR not being initiated for at least five minutes after the resident was found without respirations, CPR was unsuccessful , and the resident was pronounced (officially diagnosed and declared) dead at 8:05 p.m. on [DATE]. The facility's failure resulted in an Immediate Jeopardy. The Administrator, the Corporate Nurse, and the Director of Nursing were informed of the Immediate Jeopardy in the Administrator's office, on [DATE], at 11:00 a.m. The findings included: Medical record review revealed Resident #1 was initially admitted to the facility on [DATE]. Review of a history and physical dated [DATE] revealed the resident had [DIAGNOSES REDACTED]. Further review of this history and physical revealed Resident #1 was a "full code" (has advance directives for resuscitation measures, if found without breath or pulse, which may include providing respirations, chest compressions, electrical shock, and medications). Review of Departmental Notes, dated [DATE], revealed the resident fell out of the bed, at approximately 11:50 p.m., and was transferred to the hospital. Further record review revealed the resident was readmitted to the facility on [DATE], following hospitalization for surgical repair of a left [MEDICAL CONDITION]. Review of the resident's Re-admission orders Code Status: Full". Review of physician's orders [REDACTED]. Review of the resident's Care Plan, dated [DATE], revealed, "Advance Directive...Full Code...Resuscitate". Review of facility Departmental Notes dated [DATE], at 7:35 p.m. revealed, "...resident did not have signs of respirations or was a pulse palpated..." Further review of the Departmental Notes revealed, "7:40 p.m. Code was called and CPR was intiated...7:50 p.m. EMS (Emergency Medical Services) arrived...8:05 p.m. EMS called (discontinued resuscitation efforts) the code, and resident was pronounced at the facility." Review of undated policy titled, "Code Arrest - Procedure and Protocol", revealed, "General Guidelines...First person on the scene will begin CPR and call for help. Continue until otherwise directed by physician or relieved." Interview with Certified Nursing Assistant (CNA) #1, on [DATE], at 1:40 p.m., in the Director of Nurses (DON) office, revealed CNA #1 walked by the first floor dining room at approximately 7:30 p.m. and observed Resident #1 sitting alone in a geri chair. Further interview revealed CNA #1 observed Resident #1's "color looked bad" and the resident was unresponsive when spoken to. CNA #1 stated ...went to get a nurse and found Licensed Practical Nurse (LPN) #2 passing medication in the hallway. CNA #1 stated LPN #2 went to the resident, and sent CNA #1 to find another nurse (LPN #1). CNA #1 stated she was unable to find LPN #1, and returned to the dining room where LPN #2 was with the resident. CNA #1 stated the resident was still in the geri chair and no resuscitation was started. CNA #1 stated LPN #2 told...to take the resident to the resident's room. CNA #1 stated...took the resident to...room on the 200 hall, while LPN #2 went to find LPN #1. CNA #1 stated...did not know if the resident was breathing or not, but stated, "it was the first time I found someone like that...I covered...face up with a blanket..." CNA #1 stated the resident still remained in the geri chair and no resuscitation was started. CNA #1 stated she went out into the hall when LPN #1 and LPN #2 arrived. CNA #1 stated...waited in the hall for approximately 5 minutes (does not know exact time) when one of the nurses (does not remember which) came out of the resident's room and went to find Registered Nurse (RN) #1. CNA #1 stated the LPN returned with RN #1, there was no crash cart or resuscitation equipment taken into the room. CNA #1 stated...then returned to the second floor and then clocked out at 7:42 p.m. Interview with RN #1, on [DATE], at 2:07 p.m., in the DON's office revealed RN #1 was working in the treatment nurse's office on the evening of [DATE]. RN#1 stated LPN #2 came to office at approximately 7:30 p.m. (does not know exact time). RN#1 stated LPN #2, "told me that I needed to pronounce (Resident #1)...was not breathing". RN #1 stated...went to the resident's room and found the resident in a geri-chair with LPN #1 in the room. RN #1 stated there were no efforts being made to resuscitate the resident. RN #1 stated the resident did not have any respirations or pulse, and the resident's pupils were fixed (unmoving and un-reactive to light). RN #1 stated, "I was under the assumption she was a DNR (advance directive to not attempt resuscitation)". RN #1 stated...went to the nurse's station and called the resident's family, does not know the time this occurred. RN #1 stated...told the son the resident had expired. RN #1 stated LPN #1 interrupted the phone conversation, and RN #1 handed the telephone to LPN #1, and looked at the resident's medical record with LPN #2. RN #1 stated the medical record stated the resident was a full code. RN #1 stated the DON was called, and staff took the crash cart (wheeled cart with resuscitation equipment) to the resident's room, and began Cardio-Pulmonary Resuscitation (CPR). RN #1 stated residents that are full code status are to have CPR immediately when found in Cardio-Pulmonary arrest (no pulse or respirations). RN #1 stated CPR was continued by EMS until the resident was pronounced dead by EMS (time unknown by RN #1). Interview with LPN #2, on [DATE], at 11:25 a.m., in the DON's office revealed LPN #2 was working on the first floor on [DATE]. LPN #2 stated...was at the end of 400 hall when CNA #1 called Resident #1's name. LPN #2 stated...recognized something was wrong by the sound of CNA #1's voice. LPN #2 stated ...did not know what time this occurred. LPN #2 stated "I secured my medicine cart and started walking that way". LPN #2 stated CNA #1 called out that LPN #2 needed to "come in here". LPN #2 stated the resident was sitting in geri-chair in dining room. LPN #2 stated, "...was not breathing. I thought...had passed away...eyes were fixed...skin was cool to touch..." LPN #2 stated...told CNA #1 to take the resident to ...room and remove the room-mate. LPN #2 stated...went to find LPN #1, who was on the 300 hall. LPN #2 stated, "I told...was not looking good". LPN #2 stated they assessed Resident #1 in the resident's room and found no breath or pulse. LPN #2 stated no resuscitation efforts were made. LPN #2 stated...left LPN #1 with the resident and went to find RN #1. LPN #2 stated...notified RN #1 and they headed back to the resident's room. LPN #2 stated "I found out...was a full code...(from LPN #1 at the nurse's station)...and RN #1 took the crash cart to the resident's room and began CPR and attached the Automatic External Defibrillator (AED, a device that delivers a stimulating shock to the patient's heart)." Interview with LPN #1, on [DATE], at 12:49 p.m., in the DON's office revealed LPN #1 was the nurse assigned to Resident #1 on [DATE]. LPN #1 stated...was passing medications on the 300 hall, at approximately 7:35 p.m. (does not know exact time), when LPN #2 stated, "come check...something is wrong...". LPN #1 stated they went to the resident's room, where the resident was in a geri-chair. LPN #1 stated, "...color was grey, not good ...did not appear that...was breathing..." LPN #1 also stated, "my assessment was that...had no pulse or respirations...had expired". LPN #1 stated LPN #2 went to get RN #1 to "assess" the resident. LPN #1 stated, "I thought...was a DNR". LPN #1 stated...went to check the chart, at the nurse's station, and found the resident was a "full code". LPN #1 stated RN#1 and LPN #2 had just arrived at the nurses station, and...told RN #1 that the resident was a full code. LPN #1 stated RN #1 and LPN #2 took the crash cart to the resident's room to begin CPR. LPN #1 stated...stayed at the nurse's station. Interview with the DON, on [DATE], at 5:00 p.m., in the DON's office, confirmed residents with advance directives for a full code, are to have CPR intiated immediately when found without breath or pulse. In summary, the facility failed to immediately provide CPR for Resident #1, when the resident was found without breath or pulse on [DATE]. The facility failed to honor the resident advance directive for a full code, and CPR was not initiated for at least five minutes. The CPR was unsuccessful and the resident expired at 8:05 p.m., on [DATE]. The Immediate Jeopardy was effective from [DATE] to [DATE]. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on [DATE]. The surveyor verified the allegation of compliance by: 1. Reviewing the Inservices on resuscitation policy and procedures titled "Code Arrest" provided to staff from [DATE] to [DATE]. 2. Verified that 100% of the current medical records had been audited and reorganized to place the advance directives document (POST form) immediately inside the front cover of the record. 3. Conducted interviews with all nurses present in the facility to verify 100% had been inserviced and were oriented to the Code Arrest policy and procedure. All nurses knew where to find the resident's advance directives. 4. Interviewed the DON and the Staff Development Coordinator to verify the content of the Inservices and that 100% of staff had been inserviced on the Code Arrest policy and procedure. 5. Interviewed 100% of Certified Nursing Assistants (CNA) working and verified all had been inserviced and knew how to respond to a resident found without breath or pulse. 6. Interviewed the Medical Records Supervisor and confirmed 100% of records had been audited and the advance directives/POST form was correct and on the front of the record. Also confirmed the Medical Records Supervisor will continue to audit the records for three months to confirm compliance. 7. Interview with the Social Worker verified each resident's advance directives will be audited at least quarterly to ensure the document is accurate. Non-compliance continues at a "D" level for monitoring of corrective actions. The facility is required to submit a plan of correction.

Based on medical record review, facility policy review, and interviews, the facility failed to follow advance directives to provide emergency resuscitation for one resident (#1) of twenty residents reviewed. The facility's failure resulted in Cardio-Pulmonary Resuscitation (CPR) not being initiated for at least five minutes after the resident was found without respirations, CPR being unsuccessful, and the resident was pronounced (officially diagnosed and declared) dead at 8:05 p.m. on [DATE]. The facility's failure resulted in an Immediate Jeopardy. The Administrator, the Corporate Nurse, and the Director of Nursing were informed of the Immediate Jeopardy in the Administrator's office, on [DATE], at 11:00 a.m. The findings included: Medical record review revealed Resident #1 was initially admitted to the facility on [DATE]. Review of a history and physical dated [DATE] revealed the resident had [DIAGNOSES REDACTED]. Further review of this history and physical revealed Resident #1 was a "full code" (has advance directives for resuscitation measures, if found without breath or pulse, which may include providing respirations, chest compressions, electrical shock, and medications). Review of Departmental Notes (computerized multi-disciplinary notes), dated [DATE], revealed the resident fell out of the bed, at approximately 11:50 p.m., and was transferred to the hospital. Further record review revealed the resident was readmitted to the facility on [DATE], following hospitalization for surgical repair of a left [MEDICAL CONDITION]. Review of the resident's Re-admission orders Code Status: Full". Review of physician's orders [REDACTED]. Review of the resident's Care Plan, dated [DATE], revealed, "Advance Directive...Full Code...Resuscitate". Review of facility Departmental Notes dated [DATE], at 7:35 p.m. revealed, "...resident did not have signs of respirations or was a pulse palpated..." Further review of the Departmental Notes revealed, "7:40 p.m. Code was called and CPR was intiated...7:50 p.m. EMS (Emergency Medical Services) arrived...8:05 p.m. EMS called (discontinued resuscitation efforts) the code, and resident was pronounced at the facility." Review of undated policy titled, "Code Arrest - Procedure and Protocol", revealed, "General Guidelines...First person on the scene will begin CPR and call for help. Continue until otherwise directed by physician or relieved." Interview with Certified Nursing Assistant (CNA) #1, on [DATE], at 1:40 p.m., in the Director of Nurses (DON) office, revealed CNA #1 walked by the first floor dining room at approximately 7:30 p.m. and observed Resident #1 sitting alone in a geri chair. Further interview revealed CNA #1 observed Resident #1's "color looked bad" and the resident was unresponsive when spoken to. CNA #1 stated...went to get a nurse and found Licensed Practical Nurse (LPN) #2 passing medication in the hallway. CNA #1 stated LPN #2 went to the resident, and sent CNA #1 to find another nurse (LPN #1). CNA #1 stated she was unable to find LPN #1, and returned to the dining room where LPN #2 was with the resident. CNA #1 stated the resident was still in the geri chair and no resuscitation was started. CNA #1 stated LPN #2 told...to take the resident to the resident's room. CNA #1 stated...took the resident to...room on the 200 hall, while LPN #2 went to find LPN #1. CNA #1 stated...did not know if the resident was breathing or not, but stated, "it was the first time I found someone like that...I covered...face up with a blanket..." CNA #1 stated the resident still remained in the geri chair and no resuscitation was started. CNA #1 stated she went out into the hall when LPN #1 and LPN #2 arrived. CNA #1 stated...waited in the hall for approximately 5 minutes (does not know exact time) when one of the nurses (does not remember which) came out of the resident's room and went to find Registered Nurse (RN) #1. CNA #1 stated the LPN returned with RN #1, there was no crash cart or resuscitation equipment taken into the room. CNA #1 stated ...then returned to the second floor and then clocked out at 7:42 p.m. Interview with RN #1, on [DATE], at 2:07 p.m., in the DON's office revealed RN #1 was working in the treatment nurse's office on the evening of [DATE]. RN#1 stated LPN #2 came to office at approximately 7:30 p.m. (does not know exact time). RN#1 stated LPN #2, "told me that I needed to pronounce (Resident #1)...was not breathing". RN #1 stated...went to the resident's room and found the resident in a geri-chair with LPN #1 in the room. RN #1 stated there were no efforts being made to resuscitate the resident. RN #1 stated the resident did not have any respirations or pulse, and the resident's pupils were fixed (unmoving and un-reactive to light). RN #1 stated, "I was under the assumption she was a DNR (advance directive to not attempt resuscitation)". RN #1 stated...went to the nurse's station and called the resident's family, does not know the time this occurred. RN #1 stated...told the son the resident had expired. RN #1 stated LPN #1 interrupted the phone conversation, and RN #1 handed the telephone to LPN #1, and looked at the resident's medical record with LPN #2. RN #1 stated the medical record stated the resident was a full code. RN #1 stated the DON was called, and staff took the crash cart (wheeled cart with resuscitation equipment) to the resident's room, and began Cardio-Pulmonary Resuscitation (CPR). RN #1 stated residents that are full code status are to have CPR immediately when found in Cardio-Pulmonary arrest (no pulse or respirations). RN #1 stated CPR was continued by EMS until the resident was pronounced dead by EMS (time unknown by RN #1). Interview with LPN #2, on [DATE], at 11:25 a.m., in the DON's office revealed LPN #2 was working on the first floor on [DATE]. LPN #2 stated...was at the end of 400 hall when CNA #1 called Resident #1's name. LPN #2 stated...recognized something was wrong by the sound of CNA #1's voice. LPN #2 stated...did not know what time this occurred. LPN #2 stated "I secured my medicine cart and started walking that way". LPN #2 stated CNA #1 called out that LPN #2 needed to "come in here". LPN #2 stated the resident was sitting in geri-chair in dining room. LPN #2 stated, "...was not breathing. I thought...had passed away...eyes were fixed...skin was cool to touch..." LPN #2 stated...told CNA #1 to take the resident to...room and remove the room-mate. LPN #2 stated...went to find LPN #1, who was on the 300 hall. LPN #2 stated, "I told...was not looking good". LPN #2 stated they assessed Resident #1 in the resident's room and found no breath or pulse. LPN #2 stated no resuscitation efforts were made. LPN #2 stated...left LPN #1 with the resident and went to find RN #1. LPN #2 stated...notified RN #1 and they headed back to the resident's room. LPN #2 stated "I found out...was a full code...(from LPN #1 at the nurse's station)...and RN #1 took the crash cart to the resident's room and began CPR and attached the Automatic External Defibrillator (AED, a device that delivers a stimulating shock to the patient's heart)." Interview with LPN #1, on [DATE], at 12:49 p.m., in the DON's office revealed LPN #1 was the nurse assigned to Resident #1 on [DATE]. LPN #1 stated...was passing medications on the 300 hall, at approximately 7:35 p.m. (does not know exact time), when LPN #2 stated, "come check...something is wrong...". LPN #1 stated they went to the resident's room, where the resident was in a geri-chair. LPN #1 stated, "...color was grey, not good ...did not appear that...was breathing..." LPN #1 also stated, "my assessment was that...had no pulse or respirations...had expired". LPN #1 stated LPN #2 went to get RN #1 to "assess" the resident. LPN #1 stated, "I thought...was a DNR". LPN #1 stated...went to check the chart, at the nurse's station, and found the resident was a "full code". LPN #1 stated RN#1 and LPN #2 had just arrived at the nurses station, and...told RN #1 that the resident was a full code. LPN #1 stated RN #1 and LPN #2 took the crash cart to the resident's room to begin CPR. LPN #1 stated...stayed at the nurse's station. Interview with the DON, on [DATE], at 5:00 p.m., in the DON's office, confirmed residents with advance directives for a full code, are to have CPR intiated immediately when found without breath or pulse. In summary, the facility failed to immediately provide CPR for Resident #1, when the resident was found without breath or pulse on [DATE]. The facility failed to honor the resident's advance directive for a full code, and CPR was not initiated for at least five minutes. The CPR was unsuccessful and the resident expired at 8:05 p.m., on [DATE]. The Immediate Jeopardy was effective from [DATE] to [DATE]. An Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated by the surveyor through review of documents, staff interviews, and observations conducted onsite on [DATE]. The surveyor verified the allegation of compliance by: 1. Reviewing the Inservices on resuscitation policy and procedures titled "Code Arrest" provided to staff from [DATE] to [DATE]. 2. Verified that 100% of the current medical records had been audited and reorganized to place the advance directives document (POST form) immediately inside the front cover of the record. 3. Conducted interviews with all nurses present in the facility to verify 100% had been inserviced and were oriented to the Code Arrest policy and procedure. All nurses knew where to find the resident's advance directives. 4. Interviewed the DON and the Staff Development Coordinator to verify the content of the Inservices and that 100% of staff had been inserviced on the Code Arrest policy and procedure. 5. Interviewed 100% of Certified Nursing Assistants (CNA) working and verified all had been inserviced and knew how to respond to a resident found without breath or pulse. 6. Interviewed the Medical Records Supervisor and confirmed 100% of records had been audited and the advance directives/POST form was correct and on the front of the record. Also confirmed the Medical Records Supervisor will continue to audit the records for three months to confirm compliance. 7. Interview with the Social Worker verified each resident's advance directives will be audited at least quarterly to ensure the document is accurate. Non-compliance continues at a "D" level for monitoring of corrective actions. The facility is required to submit a plan of correction.

Based on medical record review, Resident Incident Report review, and interview the facility failed to provide supervision and assistance to prevent the fall of one resident (#1) of twenty residents reviewed. The facility's failure to ensure adequate staff when changing the resident's bed resulted in the resident falling out of the bed and onto the floor, resulting in the resident requiring emergency transport to a hospital. The resident was admitted to the hospital and had surgical repair of a fractured left hip. The findings included: Medical record review revealed Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) dated [DATE], revealed the resident needed extensive assistance of two people for bed mobility (how resident moves to and from lying positions, turns side to side, and positions body while in bed). Review of Departmental Notes (computerized multi-disciplinary documentation) dated May 3, 2012, at 11:50 p.m. revealed, " ...resident rolled out of bed ...". Review of a Resident Incident Report, dated May 4, 2012, revealed, "CNA (Certified Nursing Assistant) was cleaning resident and resident started reaching for something and rolled out of bed." Further review of the report revealed CNA #2's written statement, dated May 4, 2012, which stated, "...bed was wet so I went to change it...I had (the resident) rolled over in the center of the bed and (the resident) went to grab for something on the bedside...and rolled off the bed before I could grab/stop..." Review of hospital records revealed Resident #1 was admitted to the hospital on May 4, 2012, at 1:55 a.m., with [DIAGNOSES REDACTED]. Further review of the hospital record revealed the resident had surgical repair of the left hip on May 4, 2012. Medical record review revealed Resident #1's room-mate, on May 3, 2012, was Resident #2. Medical record review of Resident #2's MDS dated [DATE] , 2012, revealed the resident's Brief Interview for Mental Status (BIMS) at 15 (highest cognitive functioning score, indicating the resident is alert and oriented). Interview with alert and oriented Resident #2, on May 15, 2012, at 9:30 a.m. in room 210, revealed Resident #2 witnessed Resident #1 falling from the bed on May 3, 2012. Resident #2 stated...observed CNA #2 changing Resident #1's bed. Resident #2 stated CNA #2 was on the left side (door side) of the bed, and had Resident #1 turned onto the resident's right side, positioned on the opposite side of the bed where CNA #2 was standing. Resident #2 stated CNA #2 was standing on the left side of the bed and was "jerking" the sheet out from under the resident when the resident rolled off the right side of the bed and onto the floor. Resident #2 stated she heard Resident #1 cry out, "help me, help me". Resident #2 stated the CNA went and got nurses to help. Interview with the Director of Nurses (DON), on May 16, 2012, at 5:00 p.m., in the DON's office, confirmed the facility failed to provide adequate staff for bed mobility for Resident #1, which resulted in a fall from the bed and a hip fracture which required surgical repair.