Every finding on record at Western Reserve Masonic Comm

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview, record review, review of two Self-Reported Incidents (SRI), and policy and procedure review, the facility failed to prevent misappropriation of resident property. This affected two residents (Residents #51 and #52) of three residents reviewed for misappropriation. This facility census was 36. Findings Include: 1. Resident #52 was admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbance, Alzheimer's disease, osteoporosis, and high cholesterol. The resident expired in the facility on [DATE]. Review of the physician's orders revealed Resident #52 was admitted to hospice services on [DATE]. Review of the comprehensive Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #52 was severely cognitively impaired and required staff to provide all personal care. Review of the progress notes for Resident #52 revealed on [DATE] Resident #52's son informed Social Services Designee (SSD) #362 that his mother's wedding ring set was missing. The son described the ring as a gold band with a diamond solitaire and a gold band encircled in diamonds that she wore on her right ring finger. SSD #362 immediately notified the Administrator and an investigation was initiated. Review of SRI #243500 dated [DATE] revealed the SRI was filed with the state agency for an allegation of misappropriation. The Administrator spoke with Resident #52's son after being notified of the missing rings, the son told the Administrator he had visited the resident on [DATE] and he had planned to take the resident's rings to the jeweler and have them cleaned but he was unable to remove them from his mother's finger. When he arrived today ([DATE]) she was not wearing the rings. Resident #52 would not have been able to remove the rings herself because of bilateral hand contractures. The resident's room was searched, and the rings were not found. A police report was filed and an investigation was initiated. STNA #316 was interviewed on [DATE] and revealed the last time she had seen Resident #52's ring was when she was training STNA #308 on how to wash the resident's hands during a bed bath on [DATE]. STNA #308 also confirmed she had seen the resident's ring on [DATE]. Review of the video footage revealed the last time Resident #52's ring was observed on her finger was on [DATE] at 1:20 P.M. Agency STNA #510 was assigned to care for Resident #52 the night of [DATE] from 11:00 P.M. to 7:00 A.M. At the end of STNA #510's shift, the aide was observed meeting agency Licensed Practical Nurse (LPN) #500 in the cafe area of the nursing home and the video showed STNA #510 passed something in her hand to LPN #500 who put the object into his pants pocket then returned to his assigned unit. LPN #500 was assigned to the Assisted Living while STNA #510 was assigned to the skilled nursing facility. The video showed LPN #500 and STNA #510 exited the facility at different times but left in the same car. All the video footage was provided to the local police department. STNA #510 was scheduled to work on [DATE] but called off. 2. Resident #51 was admitted to the facility on [DATE] with diagnoses including repeated falls, dementia without behaviors, severe protein calorie malnutrition, Alzheimer's disease, chronic kidney disease, and anxiety disorder. The resident expired in the facility on [DATE]. Review of the physician's orders revealed Resident #51 was admitted to hospice services on [DATE]. Review of the Significant Change comprehensive Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #51 was severely cognitively impaired and required staff to perform all personal care. Review of SRI #243513, dated [DATE], revealed while investigating a separate incident of misappropriation of jewelry staff discovered Resident #51's tear shaped gold wedding ring was missing. The Administrator went to the resident's room and asked to see her hands but did not see her ring. Resident #51 did not know what happened to her ring. Resident #51's husband was in the room and the Administrator asked when he had last seen the resident's rings and he did not remember. Resident #51's room was searched and the ring was not found. The police were notified and a report was filed. The facility reviewed video footage to determine when Resident #51 was last seen wearing her ring. The last day the resident was observed on video wearing her ring was [DATE] at 5:56 P.M. On the night of [DATE] from 11:00 P.M. to 7:00 A.M. agency State tested Nursing Assistant (STNA) #510 was assigned to care for Resident #51. The video footage was the same as for Resident #52. Interview with the Administrator on [DATE] at 11:45 A.M. revealed he watched 10 hours of video footage from the night of [DATE] and the movements of STNA #510 did not make sense. He observed her in the cafe of the skilled nursing facility towards the end of her shift. The Administrator said STNA #510 kept looking around and then LPN #500 entered the cafe. STNA #510 handed something to LPN #500 and the two of them just looked at it. The Administrator said he was unable to see what it was. LPN #500 then returned to his assigned unit in the Assisted Living building and STNA #510 returned to the long term care unit. The facility was informed in March charges were filed against LPN #500 and STNA #510. In April the facility was informed Resident #51 and #52's rings were recovered and returned to the residents' families. Review of the facility's Freedom from Abuse, Neglect, and Exploitation policy, last revised [DATE], revealed misappropriation was the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The employee who was told about or first identified any type of abuse was to immediately report it to their immediate supervisor. The supervisor was to gather all the facts regarding the incident and inform the Administrator. The Administrator was to notify the department directors, appropriate officers of the organization, the legal guardian, spouse, and responsible party. The investigation was to consists of written statements from the person reporting the alleged violation, the suspected perpetrator, any witnesses, and the resident if possible. The Administrator would submit an SRI to the state agency and would continue a thorough investigation into the incident and file a final report with the state agency no later than five days working days of the incident. The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions. On [DATE] at 4:01 P.M. an SRI was filed with Ohio Department of Health (ODH) regarding Resident #52's missing rings and the facility began their investigation. On [DATE] at approximately 6:00 P.M. the DON and the Administrator went from resident to resident and inventoried all jewelry for each resident and interviewed them to determine if there were any concerns. On [DATE] at 8:47 P.M. an SRI was filed with ODH regarding Resident #51's missing ring and the facility began their investigation. On [DATE] the facility notified the local police department and a report was filed regarding the missing rings. On [DATE] the facility notified the responsible parties of the missing rings and that an investigation was in progress. Between [DATE] and [DATE] the facility interviewed all staff. Between [DATE] and [DATE] the Administrator reviewed all video footage available. On [DATE] at 8:45 P.M. the facility notified the local police department of findings of the video footage. Between [DATE] and [DATE] all facility staff were in-serviced on the facility's abuse, neglect, and misappropriation policies and procedures. On [DATE] at 4:00 P.M., the police came to the facility to discuss their findings. On [DATE] the facility contacted the agency which employed LPN #500 and STNA #510. LPN #500 was no longer employed by the agency and STNA #510 was placed on the do not return list. Review of misappropriation systems was ongoing via the Quality Assurance Performance Improvement committee. This deficiency represents non-compliance investigated under Complaint Number OH00155175.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on self-reported incident (SRI) review, record review and interview, the facility failed to ensure Resident #24 was free from sexual abuse. This finding affected one (Resident #24) of three residents reviewed for abuse. Findings include: Review of Resident #7's medical record revealed the resident was initially admitted to the assisted living facility (ALF) on 06/15/17 and was transitioned to the skilled nursing facility (SNF) on 02/02/23 with diagnoses including aftercare following joint replacement surgery, Parkinson's disease, and depression. Review of Resident #7's ALF Mini-Mental State Examination form dated 10/04/22 revealed the resident exhibited intact cognition. Review of Resident #7's SNF Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited intact cognition. Review of Resident #24's medical record revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including late onset Alzheimer's disease, major depressive disorder, and essential hypertension. Review of Resident #24's MDS 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and on 09/26/23 the resident's MDS 3.0 comprehensive assessment revealed the resident exhibited severe cognitive impairment. Review of the facility submitted SRI #227622 dated 10/03/22 revealed Resident #24 was sexually abused by Resident #7 who was a resident of the ALF at the time of the incident and the allegation was found to be substantiated. Review of SRI #227622 Witness Statement dated 10/03/22 authored by State tested Nursing Assistant (STNA) #810 indicated Resident #7 had his penis out and was holding Resident #24's hand on it. Review of SRI #227622 Witness Statement authored by Previous Administrator #819 dated 10/03/22 indicated Resident #7 was coming back from obtaining a snack and stopped to speak with the ladies in the television area (common lounge) of the SNF. He said that while he was talking with them, Resident #24 reached out and touched his penis on the outside of his shorts. He thought it was interesting and he asked her to do it again. He said that she began to reach for his penis again and he reached out his hand and placed it on hers and guided it to his penis. Interview on 10/23/23 at 9:50 A.M. with Administrator #2 confirmed sexual abuse had occurred and the staff were educated on abuse following the incident. Administrator #2 also confirmed Resident #7 was not allowed back into the SNF and was required to visit his wife in the ALF and Resident #7 was placed on thirty-minute safety checks while the investigation was conducted to ensure Resident #24's safety. Administrator #2 stated interviews with other residents on the SNF were not completed during the abuse investigation to determine if other residents had concerns regarding sexual abuse including residents who might have been in the common lounge area when the incident occurred. Interview on 10/23/23 at 10:32 A.M. with STNA #810 indicated she was providing care to another resident when she walked by the common area and noticed Resident #7 with his penis out and he held Resident #24's hands around his penis. STNA #810 indicated Resident #7 was gyrating back and forth while he held Resident #24's hands around his penis and Resident #24 was watching television. STNA #810 stated Resident #24 was not alert and oriented and other residents were in the common area watching television with Resident #24 when the incident occurred. She could not remember exactly who was in the common lounge. Interview on 10/24/23 at 11:51 A.M. with the Administrator confirmed the sexual incident between Residents #7 and #24 was reported to the police, skin sweeps were completed for all residents to ensure abuse did not occur, staff education was completed and Physician #827 assessed Residents #7 and #24 for any negative findings related to the sexual abuse incident. Review of the Freedom from Abuse, Neglect, and Exploitation policy revised 10/03/22 indicated the facility must take steps to ensure that the resident was protected from abuse. These steps should include evaluating whether the resident had the capacity to consent to sexual activity. The deficient practice was corrected on 10/12/22 when the facility implemented the following corrective actions: On 10/03/22, the facility contacted the police to report inappropriate sexual contact between Resident #24 and Resident #7. Charges were not filed. On 10/03/22, Resident #7 was restricted from the skilled facility and was required to visit his wife (who resides on the skilled side of the facility) in his apartment on the assisted living side of the facility. On 10/03/22, staff were educated to ensure Resident #7 was restricted to the assisted living side of the facility and the resident was not allowed in the skilled side of the facility. From 10/04/22 to 10/06/22, the facility conducted skin sweeps on all 28 residents residing in the facility including Residents #4, #5, #8, #9, #10, #12, #13, #17, #24, #25, #26, #28, #31, #36, #37, #38, #39, #40, 41, #42, #43, #44, #45, #46, #47, #48, #49, and #50. No negative findings were identified regarding abuse. Physician #827 assessed Residents #7 on 10/06/23 and Paxil was added to his medication regimen. Resident #24 was assessed on 10/06/23 by psychiatry and on 10/11/22 by Physician #827 for concerns related to the sexual abuse incident. No additional concerns were identified. On 10/12/22, the facility conducted an in-service on all staff for abuse education and the abuse policy. This deficiency represents non-compliance investigated under Complaint Number OH00147645.

Based on record review, facility policy review and interview, the facility failed to develop and implement a comprehensive pressure ulcer program to ensure ongoing assessment/monitoring of skin integrity was completed and to ensure treatments were implemented as ordered for Resident #23. This affected one resident (#23) of three residents reviewed for pressure ulcers. Findings include: Review of Resident #23's assisted living (AL) Wound Provider Consultation form dated 09/27/23 revealed the resident had a right gluteal in-house pressure ulcer measuring 4.0 cm (centimeters) by 3.5 cm by no cm depth and moisture associated skin damage (MASD). Review of Resident #23's medical record revealed the resident was readmitted from the assisted living memory care unit and status post hospitalization from a fall on 10/02/23 with diagnoses including right hip pain, non-surgical right pelvic fracture, essential hypertension and unspecified dementia. Review of Resident #23's facility admission Skin Observation Tool dated 10/02/23 indicated the resident's right and left buttocks were excoriated and the resident had pressure ulcers to the bilateral heels. No staging or sizes were identified on the form. Review of Resident #23's physician orders revealed an order dated 10/02/23 for Betamethasone Dipropionate (reduces swelling, itching and redness and was considered a corticosteriod) external cream 0.05% (percent) apply topically to affected area two times a day for preventative care and an order dated 10/19/23 to cleanse the left and right buttock wound with soap and water, pat dry and apply Triad daily every evening shift. Review of Resident #23's medication administration records (MARS) and treatment administration records (TARS) from 10/02/23 to 10/19/23 revealed no evidence the Betamethasone Dipropionate external cream was applied as ordered from 10/02/23 to 10/10/23. In addition, there was no evidence of bilateral heel pressure ulcer care, monitoring and assessments completed on 10/02/23, 10/04/23 and 10/06/23. Review of Resident #23's nursing progress note dated 10/07/23 at 10:24 P.M. authored by Registered Nurse (RN) #826 indicated the resident had skin impairments to the bilateral heels which measured 3.0 cm (centimeters) length by 2.5 cm width with less than 0.1 cm. The wound bed was reddened and open and the peri wound looked like normal healthy skin tissue. The area was cleansed and a foam dressing was applied. The family and physician were notified. Review of Resident #23's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment and had two Stage III (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) ulcers that were present upon admission/entry or reentry as well as one deep tissue injury (DTI) that was present upon admission/entry or reentry. Review of Resident #23's physician's orders revealed an order dated 10/09/23 (discontinued 10/11/23) to cleanse bilateral heels with normal saline (NS), pat dry, apply bordered foam dressing every evening shift on Monday, Wednesday and Friday for wound care; an order dated 10/13/23 (discontinued 10/18/23) to cleanse the heels with normal saline, pat dry, apply Medi honey sheet (antibacterial dressing) and cover with a foam dressing every Monday, Wednesday and Friday for wound care; an order dated 10/19/23 to cleanse the left heel with normal saline, pat dry, apply a Medi honey sheet and cover with an abdominal dressing and wrap with gauze daily every day shift for wound treatment; and an order dated 10/21/23 to cleanse the right heel with normal saline, pat dry, apply skin prep and a foam dressing three times per week and as needed every Monday, Wednesday and Friday for wound care. Review of Resident #23's Wound Provider Consultation form dated 10/11/23 revealed the resident had a right gluteal suspected deep tissue injury (DTI), a Stage III pressure ulcer to the left heel measuring 2.2 cm length by 2.0 cm width with 0.2 cm depth with moderate serous exudate and a Stage III right heel pressure ulcer measuring 2.5 cm by 2.2 cm by 0.2 cm with moderate serous exudate. Observation on 10/23/23 at 1:05 P.M. with RN #809 of Resident #23's bilateral heels revealed a Kerlix wrap was on the left foot and a foam dressing was on the right heel. Both dressings were dated 10/23/23. Interview with the Director of Nursing (DON) on 10/23/23 at 3:08 p.m. confirmed Resident #23's wound care to her coccyx, which included the Betamethasone cream, was not completed from 10/02/23 to 10/10/23 and then the wound nurse practitioner (NP) came in on 10/11/23 and changed the treatment to barrier cream as needed. She also confirmed Resident #23's bilateral heel pressure wounds were not assessed and monitored effectively including wound care on 10/02/23, 10/04/23 and 10/06/23. Review of the Skin Care Management policy revised 04/20/23 revealed a resident who enters the facility without a pressure ulcer does not develop a pressure ulcer unless the clinical condition demonstrates that the pressure ulcer was unavoidable and a resident have pressure ulcers receives's necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. This deficiency represents non-compliance investigated under Complaint Numbers OH00147645 and OH00146845.

Based on record review, policy review and staff interview the facility failed to check all potential new hires against the State nurse aide registry (NAR) to ensure no employee had a finding entered into the NAR concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. This affected four dietary staff, three housekeeping staff, one life enrichment staff, one transport staff and two administrative staff whose personnel files were reviewed and had the potential to affect all 42 residents residing in the facility. Findings include: Review of an undated list of current facility staff provided by the facility revealed four dietary staff, three housekeeping staff, one life enrichment staff, one transport staff and two administrative staff had been hired since the last annual recertification survey dated 06/28/18. These 11 staff were identified by the facility as interacting with residents in the facility. Record review revealed no evidence these employees had been checked against the NAR. On 08/20/19 at 2:19 P.M. interview with Administrative Assistant (AA) #200 revealed the AA thought the nurse aide registry was checked upon hire for new staff. On 08/20/19 at 3:15 P.M. interview with Business Office Manager (BOM) #200 revealed the facility did background checks through the Office of Inspector General (OIG) for all employees but had not been checking unlicensed staff against the NAR. The facility identified 11 staff hired since the last recertification survey who were still employed and had not been checked against the NAR: Social Service Designee #202, Dietary Aide #203, Admissions Staff #204, Dietary Aide #205, Dietary Aide #206, Housekeeper #207, Transportation Staff #208, Dietary Aide #209, Housekeeper #210, Life Enrichment Staff #211 and Housekeeper #212. Review of the facility policy titled Freedom from Abuse, Neglect and Exploitation, revised 10/31/16 revealed the facility conducted pre-employment screening for employees regarding abuse, neglect, mistreating residents, misappropriation of property and exploitation. The community would not hire anyone with disciplinary action in effect against a professional license by a state or licensing body.

Based on observation, record review and interview the facility failed to ensure resident oxygen tubing was dated to reflect when it had been changed and to ensure it was being routinely changed. This affected four residents (#7, #39, #43, and #45) of six residents reviewed for oxygen therapy. Findings include: 1. Review of Resident #7's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 was cognitively intact. This assessment reflected Resident #7's use of oxygen. Observations of Resident #7 from 08/19/19 through 08/22/19 at various times revealed the resident had oxygen in place. The oxygen tubing was observed to be not dated. Interview on 08/22/19 at 9:49 [NAME]M. with LPN #220, confirmed there was no date on the oxygen tubing, from nasal cannula to oxygen concentrator. LPN #220 stated she had only seen the attached bag the tubing was stored in have a date when changed. However, no date was on the bag either. Interview and observation on 08/22/19 from 11:10 [NAME]M. to 11:25 [NAME]M. with the Director of Nursing (DON) revealed Resident #7's oxygen tubing was not dated at this time. 2. Review of Resident #39's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS 3.0 assessment dated [DATE] revealed Resident #39 was alert and oriented and cognitively intact. This assessment reflected Resident #39's use of oxygen. Interview and observation on 08/22/19 from 11:10 [NAME]M. to 11:25 [NAME]M. with the Director of Nursing (DON) revealed Resident #39's oxygen tubing was not dated at this time. 3. Review of Resident #43's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS 3.0 assessment, dated 07/24/19 revealed Resident #43 was cognitively intact. Oxygen was not in use at the time of this assessment. Interview and observation on 08/22/19 from 11:10 [NAME]M. to 11:25 [NAME]M. with the Director of Nursing (DON) revealed Resident #43 had oxygen in place and the oxygen tubing was not dated at this time. 4. Review of Resident #45's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS 3.0 assessment dated [DATE] revealed Resident #45 was not cognitively intact. This assessment reflected Resident #45's use of oxygen. Interview and observation on 08/22/19 from 11:10 [NAME]M. to 11:25 [NAME]M. with the Director of Nursing (DON) revealed Resident #45's oxygen tubing was not dated at this time. On 08/22/19 at 10:57 [NAME]M. a telephone interview with Vendor #214 from the respiratory supply company revealed he changes the oxygen tubing every Friday for residents who have oxygen who are not on Hospice and who use a concentrator. He revealed he placed a dated sticker on the tubing when he changed it, up near the connection with the concentrator. The only reason, he reported, there would not be a sticker was if other staff had changed the tubing and didn't date it.

Based on record review and staff interview the facility failed to notify the Ombudsman's office of resident transfers from the facility. This affected three residents (#20, #30 and #46) of three residents reviewed for hospitalization and had the potential to affect all 42 residents residing in the facility. Findings include: 1. Record review revealed Resident # 46 was admitted to facility on 12/04/17 with [DIAGNOSES REDACTED]. Her code status was full measures. Review of Resident #46's medical record revealed she had been discharged to the hospital on [DATE] for a urinary tract infection [MEDICAL CONDITION] and readmitted on [DATE]. She was also discharged on [DATE] for a respiratory infection and UTI and was readmitted on [DATE]. Review of the emails of resident discharges that was sent to the State Ombudsman revealed Resident #46 was not included on the list for (MONTH) or (MONTH) 2019. Interview on 08/21/19 at 1:55 P.M. with the Director of Nursing (DON) and Social Service Designee (SSD) #202 verified Resident #46 was not included on the discharged lists sent to the State Ombudsman. The DON stated Resident #46 was not actually discharged from the facility, as if she had run out of bed hold days, so she did not make it on the list. 2. Record review revealed Resident #20 was admitted to this facility on 07/17/18 with admitting [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment (MDS) 3.0 assessment, dated 07/03/19 revealed the resident had severe cognitive impairment and was totally dependent on staff for transfers, locomotion on and off the unit, toilet use and personal hygiene. She required extensive assistance for bed mobility, dressing and eating. Review of the nursing progress notes from 03/10/19 to 03/15/19 revealed the resident had been running a high fever as high as 102.7. She was given an anti-pyretic (fever reducing medication) and the physician was notified. On 03/11/19 the physician ordered stat chest x-ray and a test to be administered for the flu. She was diagnosed with [REDACTED]. The physician also ordered antibiotics for her pneumonia. From 03/11/19 to 03/15/19 the resident continued to decline to the point where the staff were unable to get her to take her antibiotics or drink anything. Review of progress note dated 03/15/19 at 01:34 P.M. showed that the physician was contacted again regarding the resident's continued refusal to drink or take her medication. The physician ordered the resident to be sent to the emergency room for further evaluation. She left the faciity on [DATE] and was admitted to the hospital Review of the progress noted dated 03/20/19 at 11:07 P.M. revealed the resident was readmitted back to the facility at this time. Review of the facility Notification of Ombudsman documentation from the past six months revealed the facility did not notify the Ombudsman the resident was discharged to the hospital Interview with the DON on 08/21/19 at 1:55 P.M. verified the Ombudsman was not notified of the resident's discharge to the hospital. 3. Review of Resident #30's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment, dated 07/11/19 revealed Resident #30 was cognitively intact and was totally dependent on one staff for locomotion on the unit. Review of a nurse's note, dated 06/10/19 at 1:51 P.M. revealed Resident #30 was trying to walk to her room after lunch, lost her balance and fell backwards in the dining room. Resident #30's right lower extremity had been extended and sideways and the resident was complaining of pain; the family was notified. Resident #30 was admitted to the hospital for partial hip replacement due to [MEDICAL CONDITION]. Bed-hold information and discharge communication were communicated to the family. A nursing assessment dated [DATE] indicated Resident #30 returned to the facility for skilled care. Review of the facility ombudsman notification documentation, dated 07/01/19 revealed no evidence the Long-Term Care Ombudsman (LTCO) was notified of Resident #30's transfer to the hospital on [DATE]. Interview on 08/21/19 at 1:55 P.M. with the Director of Nursing (DON) and Social Service Designee (SSD) #202 verified the LTCO was not notified of Resident #30's hospitalization on [DATE].

Based on observation, interview, and record review, the facility failed to ensure Resident #63 was transferred safely resulting in a fall with facial injuries. Actual harm occurred on 09/02/17 when Resident #63 was transferred without a gait belt while using an incorrect walker, resulting in Resident #63 falling and suffering a nasal bone fracture, bruised face, bruised knee, laceration to the lip, and laceration to the knee requiring emergency room services. This affected one of three residents reviewed for falls. The facility census was 38. Findings include: Resident #63 was initially admitted to the facility on [DATE], with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Resident #63's 30-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was moderately impaired and she required extensive one person assistance for transfers. Resident #63's comprehensive care plan for being at risk of falls, initiated on 07/12/17, revealed the facility should ensure that the resident was wearing appropriate footwear when ambulating or mobilizing in wheelchair and the facility will attempt to determine possible root causes of the fall to remove any potential causes if possible. Resident #63's fall investigative reports revealed Resident #63 had a fall on 09/02/17 while being transferred to the bathroom by STNA #105. Resident #63 was observed with both legs on the carpeting and her upper torso laying face down on the bathroom floor with copious amounts of dark red blood coming from what was believed to be Resident #63's nose. Vitals were not obtained due to Resident #63 laying face down and Licensed Practical Nurse (LPN) #106 being unsure how hard Resident #63's neck was jarred during the fall. LPN #106 asked Resident #63 if she caught her foot on the carpeting while walking, and the resident responded yes. Resident #63's upper denture was broken and glasses were bent. The facility identified Resident #63 suffered a bruise to the right knee, bruise to her face, skin tear to right knee, and laceration to her face. Interventions the facility put into place were staff educated on transfer safety, and all staff to have a gait belt on their person at all times to help ensure the safety of the resident during transfers. Review of Resident #63's hospital record from the 09/02/17 fall revealed Resident #63 also had a nasal bone fracture from the fall. Observation on 09/06/17 at 10:48 A.M. revealed Resident #63 had significant bruising on her face and right knee, with a dressing applied to her nose and right knee. Interview on 09/08/17 at 8:51 A.M. with the Director of Nursing (DON) confirmed State tested Nurse Aide (STNA) #105 should have used a gait belt while transferring Resident #63 on 09/02/17. The DON revealed all residents who require extensive assistance for transfers require staff to use a gait belt during transfers. The DON explained prior to the fall on 09/02/17 Resident #63 used a wheeled walker to ambulate to the dining room and was escorted back to her room in a wheelchair because she was fatigued. At the time of the fall the wheeled walker was still by the dining room, resulting in STNA #105 using a fixed walker, that was in Resident #63's bathroom, to assist Resident #63 in ambulating. The DON explained Resident #63 should use the wheeled walker and STNA #105 used the incorrect walker. Interview on 09/08/17 at 10:40 A.M. with Physical Therapist #107 and Rehabilitation Director #108 confirmed Resident #63 was discharged from physical therapy on 08/30/17 with the recommendation to use a wheeled walker with supervision. Physical Therapist #107 explained the fixed walker would fatigue Resident #63 as she would have to pick it up and move it while ambulating. Review of Resident #105's Physical Therapy Discharge Summary, dated 08/30/17, confirmed Resident #63 should use a wheeled walker during transfers.

Based on record review and interview the facility failed to include Resident #36 with decisions related to the comprehensive plan of care. This affected one out of one resident reviewed for participation in care planning. The facility census was 38. Findings include: Resident #36 was admitted on [DATE] with [DIAGNOSES REDACTED]. An interview with Resident #36 on 09/06/17 at 10:33 A.M. revealed Resident #36 was not included in the comprehensive care plan meetings. Resident #36 stated the facility notified her of the changes after they were implemented. Resident #36 indicated she was not invited to the interdisciplinary care plan meetings. Resident #36 stated she was aggravated and would have liked to have been consulted about the changes before they were implementing. Resident #36 indicated the facility had not arranged a meeting with the interdisciplinary staff to discuss her progress towards the goals of her plan of care. Resident #36 indicated she was unaware of how the facility determined what changes were made regarding her plan of care. A review of Resident #36's clinical record from 07/2016 to 07/2017 revealed no evidence of a plan of care meeting was conducted. An interview with the Administrator on 09/08/17 at 2:10 P.M. revealed the was no documentation or evidence that Resident #36 was invited or attended an interdisciplinary plan of care meeting. At the time of the interview he verified the above findings.

The facility failed to ensure pureed beets were prepared to conserve nutritive value. This had the potential to affect three ( Resident #49, Resident #45, and Resident #1) of three residents reviewed on a pureed diet. The facility census was 38. Findings include: Review of the Resident Diet List revealed the facility had three residents on a pureed diet, Resident #49, Resident #45, and Resident #1. Observation on 09/07/17 at 1:45 P.M. of pureed beet preparation in the kitchen for meal service the next day, revealed Dietary Manager #100 used 105 ounces of pickled beets, and added one cup of hot water and began pureeing. Dietary Manager #100 then added one cup of beet juice and four ounces of thickener. Dietary Manager #100 then added another four ounces of thickener. Dietary Manager #100 was not following a recipe. Interview on 09/07/17 at 1:50 P.M. with Dietary Manager #100 revealed she used the hot water to help break down the beets for pureeing. Dietary Manager #100 revealed she used the recipe shown during her training. Review of the Pickled Beets Puree Recipe revealed the recipe did not contain adding water or beet juice. Interview on 09/07/17 at 2:19 P.M. with a second dietary manager, Dietary Manager #102 confirmed the beet puree recipe did not contain adding water or beet juice. Interview on 09/08/17 at 4:03 P.M. with Director of Dietary Service #103 revealed the beets were already cooked, so the hot water was unnecessary to break down the beets for pureeing.

Based on observation, staff interview and review of the Hand Washing policy, the facility failed to provide appropriate hand-washing during the lunch meal on 04/20/15 affecting Resident #34 in the main dining room and Residents #12, #48 and #93 in the restorative dining room. This had the potential to affect 12 residents in the main dining room and six residents in the restorative dining room. Findings include: 1. On 04/20/15 at 12:30 P.M. an observation of the restorative dining room revealed six residents assisted by State tested Nurse Aides (STNAs) #4 and #5. STNA #4 was seated between Residents #12 and #48 and provided hands on feeding assistance to both residents. STNA #5 was seated at the opposite side of the table between two residents. There was one another occupied table in the room with two residents and no staff. At 12:37 P.M. STNA #4 attempted to lower her chair by handling the controls underneath the seat. STNA #5 also sat on the chair and handled the controls underneath the seat and lowered the seat. STNAs #4 and #5 returned to the table to assist residents with their meals, and neither STNA washed their hands before assisting the residents. STNA #4 handled Resident #12 and #48's utensils to feed them. STNA #5 cued residents to eat. STNA #4 delivered a yogurt to Resident #93 and opened it for her. STNA #4 rubbed the arms of Resident #93 and encouraged her to eat. While STNA #4 was assisting Resident #93, STNA #5 got up and spooned food from the plate of Resident #48 and fed it to him. STNA #4 returned to the table without washing hands and continued to feed Residents #12 and #48. On 04/20/15 at 1:09 P.M. interview with STNAs #4 and #5 verified that hand washing did not take place between resident contacts and after adjusting the chair. 2. On 04/20/15 at 11:45 A.M. an observation of the main dining room lunch meal revealed Dietary Staff #6 delivered plated food from the steam table to the 12 residents seated in the room. After Dietary Staff #6 returned from delivering a plate of food to a resident, she stopped to move a chair into the table and touched a resident by rubbing her arm. After moving the chair the dietary staff wiped her bare hands up and down the front of her legs. Dietary staff #6 then returned to the steam table area without washing hands and prepared a bowl of salad which was given to staff to deliver with a hall tray. Dietary Staff #6 then plated food from the steam table onto a plate for Resident #34 and delivered the plate to the resident. After assisting the resident by pushing the chair in, the dietary staff washed hands and returned to the steam table. On 04/20/15 at 11:45 A.M. an interview with Dietary Staff #6 verified that hand washing between resident contact did not take place. Review of the facility policy titled Hand Washing, dated 09/30/05, documented that staff was to wash/sanitize hands between resident contacts.

Based on observation, staff interview and medical record review, the facility failed to provide an accurate Minimum Data Set (MDS) 3.0 assessment for the skin integrity and behaviors (rejection of care) for Resident #68. This affected one of three residents reviewed for skin integrity impairments. Findings include: Review of the medical record for Resident #68 revealed [DIAGNOSES REDACTED]. Review of the Skin Grid (non-pressure) initiated on 01/13/15 for two open areas on the buttocks (one on the right and one on the left) that were labeled "open [MEDICAL CONDITION]." Review of the physician progress notes [REDACTED]." Review of the Treatment Administration Record (TAR) for February 2015 revealed the resident refused treatment to the right buttocks 17 times. In March the resident refused treatment to the right buttocks four times during the MDS look back period of March 3 to 10, 2015. Review of the MDS 3.0 assessment dated [DATE] indicated the resident had no pressure ulcer; skin was intact, resident had no behaviors and was not resistive to care. Review of the resident care plan, target date 06/29/15, revealed the resident could be verbally abusive with staff and had a loss of skin integrity (ulcer). On 04/22/15 at 1:40 P.M. an observation of the wound care to Resident #68's right buttocks wound was completed by the surveyor with Licensed Practical Nurse (LPN) #3 and State tested Nurse Aide (STNA) #7. Visualization of the wound revealed an approximately ¼ inch circular open area on the right buttocks. The buttock was deep red and the tissue at and around the wound was non-blanchable. The wound edges were well defined and the wound bed was deep red and moist. The wound presented to the surveyor as a stage two pressure ulcer. On 04/23/15 at 8:20 A.M. Assistant Director of Nursing (ADON) #5 verified the 03/10/15 MDS assessment did not accurately reflect Resident #68's skin status of a pressure ulcer, and was not accurate for the resident behavior of rejecting care.

Based on record review, interview and observation, the facility failed to implement the plan of care related to assessment and monitoring of skin daily. This affected two (Residents #91, #27) of three residents reviewed for non-pressure related alterations in skin. Findings Include: 1. Review of Resident #91 ' s medical record revealed the resident was admitted to this facility on 04/14/15. His [DIAGNOSES REDACTED]. The April 2015 physician's orders [REDACTED]. [MEDICATION NAME] will cause excessive bruising on a resident's skin. Review of Resident # 91 ' s initial history and assessment dated [DATE] at 7:24 P.M. showed that the resident's general skin was dry and the resident had swelling in both legs. The assessment contained no documentation of bruises on the resident's hands and arms. Review of the Initial and Ongoing Skin Report dated 04/14/15 stated the resident had no noted areas of skin concerns. Observation of Resident #91 on 04/20/15 at 11:00 A.M. revealed the resident had bruising on the top of his left and right hand, two bruises on the left forearm and two bruises on the right forearm. The two bruises on the right hand measured approximately 2.0 centimeters (cm) by 2.0 cm. The two bruises on the left hand measured 2.0 cm by 2.0 cm. The bruise on the left lower forearm measured 7.0 cm by 4.0 cm and the bruise on the upper left forearm measured 4.0 cm by 2.0 cm. On the right arm the two bruises were located to the right of the antecubital space. The first bruise measured 5.0 cm by 5.0 cm. This bruise had a lump under the bruise. The second bruise was approximately 1.0 cm by 2.0 cm. Interview with Assistant Director of Nursing (ADON) #5 on 04/21/15 at 6:07 P.M. verified there was no documentation on the initial assessment or on the Initial and Ongoing Skin report sheet that supported an assessment of the bruises. ADON #5 verified the resident currently had bruises on his arms and hands. 2. Review of the medical record for Resident #27 revealed [DIAGNOSES REDACTED]. The resident physician orders [REDACTED]. The Risk for Bleeding care plan dated 03/22/15 documents that the resident will be monitored for signs of bleeding. On 04/20/15 at 3:09 P.M. observation of Resident #27 revealed a large circular bruise below the thumb of the right hand. The bruise was purple with some green and gold coloring present. The skin was intact. On 04/21/15 at 1:00 P.M. an interview with Licensed Practical Nurse (LPN) #8 reported that Resident #27 had been out of the facility for a medical procedure several days ago and likely obtained the bruise at the procedure. The LPN reported that bruises would be documented in the nursing progress notes and on the skin grid located in the treatment administration record. LPN #8 verified the skin grid and the progress notes did not identify a bruise on the right hand of the resident. On 04/22/15 at 11:00 A.M. Resident #27 verified that the bruising occurred from a needle used during the outpatient procedure several days ago. On 04/22/15 at 3:15 P.M., ADON #5 verified that nursing staff should document and report any changes in skin integrity or condition.

Based on observation, staff interview and medical record review, the facility failed to provide an accurate assessment and provide preventative measures to prevent the development of a Stage two pressure ulcer on Resident #68. This affected one (Resident #68) of three residents reviewed for pressure ulcers. Findings include: Review of the medical record for Resident #68 revealed [DIAGNOSES REDACTED]. Review of a Skin Grid initiated 03/17/14 documented two Stage two pressure ulcers to the right buttocks that resolved on 08/03/14. Review of the Skin Grid (non-pressure) initiated 01/13/15 for two open areas on the buttocks (one on the right and one on the left) that were labeled "open [MEDICAL CONDITION]." There was no documentation in the medical record to support the wound type as an open lesion. Review of the Skin Grid dated 01/13/15 revealed the right buttocks wound measured 0.3 centimeters (cm) long by 0.6 cm wide and 0.1 cm deep. Review of the physician progress notes [REDACTED]." Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident had no pressure ulcer and skin was intact. Review of the resident care plan, target date 06/29/15, revealed the resident had a loss of skin integrity (ulcer). The care plan for skin integrity included interventions to "continue with preventative/protective measures." The care plan did not identify the measures. Review of the physician orders [REDACTED]. The left buttocks wounds had healed prior to 04/20/15. Review of the Skin Grid dated 04/16/15 revealed the right buttocks wound measured 0.4 cm long by 0.4 cm wide and 0.1 cm deep. Review of the Treatment Administration Record (TAR) for February 2015 revealed the resident refused treatment to the right buttocks 17 times. In March the resident refused treatment to the right buttocks four times from 03/03/15 to 03/10/15 and in April had six documented refusals. Observations of Resident #68 on 04/21/15 at 5:00 P.M. revealed the resident was in the room in a recliner with upholstered cushion and waterproof cover over the seat. No evidence of a pressure relief cushion on the seat. Observation on 04/22/15 at 9:10 A.M. revealed the resident was dressed and seated in the recliner with a waterproof pad and no pressure relief cushion on the recliner. On 04/22/15 at 9:15 A.M. LPN #3 stated Resident #68 did not use the bed and slept in the chair. LPN #3 revealed the resident has had a decline and was not walking as much and spent more time in the chair. LPN #3 also verified that direct care staff did not have a plan for offloading pressure in the recliner the resident used throughout the day and for sleeping at night. On 04/22/15 at 1:40 P.M. an observation of the wound care to the right buttocks wound completed by Licensed Practical Nurse (LPN) #3 and State tested Nurse Aide (STNA) #7 revealed Resident #68 was seated in a recliner without a pressure relief cushion. The resident preferred to stand at the walker during wound care. Visualization of the wound revealed an approximately ¼ inch circular open area on the right buttocks. The buttock was deep red and the tissue at and around the wound was non-blanchable. The wound edges were well defined and the wound bed was deep red and moist. The wound presented to the surveyor as a Stage two pressure ulcer. The resident returned to the chair after the dressing change without pressure relief measures in place. Observation on 04/23/15 at 7:43 A.M. revealed Resident #68 sat in a recliner with waterproof pad underneath, and no pressure relief cushion visible. On 04/23/15 at 8:20 A.M., Assistant Director of Nursing #5 verified the 03/10/15 annual MDS 3.0 assessment did not accurately reflect the skin status of a pressure ulcer.

Based on observation, record review and staff interview, the facility failed to post and retain accurate staffing and resident census information. This had the potential to affect all 45 residents. Findings include: During the initial tour of the facility on 04/20/15 at 10:00 A.M., observation of the posting of staff and resident census information was noted to be incomplete. The posting did not include 04/40/15's census. The posting contained staffing information for the week of 04/15/15 to 04/21/15. Resident census of 43 was noted on 04/15/15. There were no entries regarding resident census after 04/15/15. Interview with Administrative Assistant #9 on 04/21/15 at 10:30 A.M. revealed the posted staffing information was completed a week to a month in advance and was not updated daily to reflect staffing changes. Administrative Assistant #9 revealed each week's posting was discarded. She verified the current census and staffing were not updated daily.

Based on record review and staff interview the facility failed to provide evidence of the need for administration of an as needed (prn) antianxiety medication ([MEDICATION NAME]) for Resident #19, five times in June 2014. This affected one resident (Resident #19) of five residents reviewed for unnecessary medication administration. Findings include: A review of the medical record for Resident #19 revealed a medical history of [REDACTED]. On 04/14/14 a physician order [REDACTED]. A review of the physician progress notes [REDACTED]. The note also indicated behaviors and agitation worsened, medications were adjusted and probable over-sedation occurred. The antipsychotic medications [MEDICATION NAME] and [MEDICATION NAME] were removed. The [MEDICATION NAME] medication order as needed for agitation remained. A review of the Behavior /Intervention Monthly Flow Record for June 2014 for Resident #19 identified a targeted behavior of agitation with an intervention (#12) to administer [MEDICATION NAME] (generic for [MEDICATION NAME]). During the month of June there were no recorded behaviors of agitation on the flow record. A review of the Medication Administration Record [REDACTED]. A review of the nursing progress notes revealed that at 12:00 P.M. on 06/23/14 and 8:00 P.M. on 06/29/14 nursing staff documented episodes of agitation and the use of [MEDICATION NAME]. The record did not reveal documentation related to the other five [MEDICATION NAME] administrations in June. On 07/08/14 at 1:58 P.M. interview with licensed practical nurse (LPN) #10 revealed the Behavior Monthly Intervention Flow Record was used for documenting behaviors, side effects, interventions and effectiveness of prn medications used. LPN #10 verified prn medications were given to Resident #19 and not documented on the flow record. On 07/08/14 at 2:10 P.M. the director of nursing (DON) verified nursing staff should document interventions and use of prn medications for behaviors on behavior tracking log. The DON also verified the June 2014 flow record for Resident #19 did not contain information for all seven doses administered and only two of the seven doses had documentation of resident behaviors of agitation in the medical record.

Based on observation, interview, and documentation review, the facility failed to ensure proper wash and rinse temperatures were maintained for the dishwashing machine to prevent foodborne illness. This had the potential to affect 46 out of 46 residents that received meals from the kitchen. Findings include: On 04/01/2013 from 8:30 A.M. to 9:07 A.M., during the tour of the kitchen with Kitchen Staff # 8 and #9 , the observation of the dishwashing machine revealed the wash temperature on the dish machine was 124 degrees Fahrenheit (F). Kitchen Staff # 8 verified the temperature was too low and stated the dishwasher was a high temperature machine. The person running the dishwasher was to check the water temperature prior to washing any dishes. Dishwasher #7 stated he had filled the tank with cold water that morning and he did not check the temperature before starting to wash the dishes. Review of the temperature logs for March 2013 revealed nine of the readings for wash ranged from 150 to 158 degrees F. Eleven of the readings for rinse were documented at 156-179 degrees F.

Based on observation, interview and record review, the facility failed to ensure catheter bags were covered for Residents #9 and #109 and failed to provide a dignified dining experience for Residents #38, #46, #63, #71 and #72. This affected seven (#9, #38, #46, #63, #71, #72 , #109) residents reviewed for dignity. Findings include: 1. On 04/01/13 between 11:58 A.M. to 12:50 P.M. the following was observed during lunch in the restorative dining room: a. On 04/01/13 at 11:45 A.M., Resident #46 was seated at the dining room table across from Resident #38. Resident #46 continuously coughed up phlegm into her napkins and clothing protector while Resident #38 was cued to eat his meal. b. On 04/01/13 at 12:23 P.M., when Resident #63 became ill at the dining room table, State tested Nurse Aide (STNA) #5 pushed the table away from the resident and pulled Resident #71, who was seated in a large Broda chair, backward out of the way to allow Resident #63 to move her wheelchair away from the table to leave the dining room. Resident #5 became startled when she was moved backward out of Resident #63's way. c. On 04/01/13 at 12:30 P.M. STNA #5 started to assist to feed Resident #38. At 12:39 P.M., STNA #5 left Resident #38 to chart meal intake in the main dining room. Resident #38 had to wait for STNA #6 to provide Resident #71 a bite of food until he could be provided a couple bites of food. 2. On 04/01/2013 at 12:26 P.M. Resident #109 was sitting in the dining room eating lunch. The resident's Foley catheter bag was uncovered and lying on the foot rest of the resident ' s scooter. Interview with Registered Nurse (RN) #3 on 04/01/2013 at 12:26 P.M. revealed a privacy cover should be in place over the catheter bag for Resident #109. STNA #4 entered the dining room with a privacy cover after speaking with RN #3. STNA #4 picked up the resident ' s Foley bag and began placing the privacy cover over the Foley bag until RN #3 intervened, and instructed STNA #4 to apply the privacy cover in the resident ' s room. Interview with STNA #4 on 04/01/2013 at 12:40 P.M., confirmed that Resident #109 ' s Foley catheter did not have a privacy cover in place.

Based on record review and interview, the facility failed to develop comprehensive care plans to address the administration of [MEDICATION NAME] for Residents #11 and #109, the maintenance and care of a Foley catheter for Resident #109, psychoactive medication use for Resident #9, and the hand contractures of Resident #1. This affected four residents reviewed for care plans. Findings include: 1. Resident #11 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. [MEDICATION NAME] is generally held and not administered when a person's heart rate is less than 60 beats per minute. This guideline is referenced in Nursing Drug Handbook 2013 and directs the nurse at an "Alert" section to hold the [MEDICATION NAME] and notify the prescriber for an excessively slow heart rate, defined as 60 beats per minute or less. At the web site, Nursing Central directs the nurse to monitor the person's apical heart rate for a full minute before administering this medication and to withhold the dose and notify the health care professional if the pulse rate is less than 60 beats per minute. At the web site Drug Guide.com, the assessment section under [MEDICATION NAME] indicated the apical pulse should be checked for a full minute before administering the medication and withhold the dose and notify the health care professional if the pulse rate is less that 60 beats per minute. Without checking for the heart rate or apical pulse the nurse would not know if it was safe to administer the medication. The care plans were reviewed and there was no care plan to address the use of [MEDICATION NAME] related to [MEDICAL CONDITION] along with a minimum of monitoring the resident's heart rate and monitoring blood levels through laboratory testing. An interview was conducted with the director of nursing (DON) on 04/02/13 at 4:43 P.M. She verified that the nurses were to obtain an apical heart rate prior to administering [MEDICATION NAME] medication. She verified there was no care plan in place related to [MEDICAL CONDITION] and the use of [MEDICATION NAME]. 2. Resident #109 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. On 04/04/13 at 9:25 A.M., the DON and the assistant director of nursing on 04/04/13 at 9:25 A.M. verified no care plan had been developed to address the use of [MEDICATION NAME] related to [MEDICAL CONDITION] along with a minimum of monitoring the resident's heart rate and monitoring blood levels through laboratory testing. 3. Resident #109 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Resident #109 currently had a Foley catheter in place for urinary function. The care plan related to the use of a Foley catheter dated 1/23/13 for altered urinary elimination did not direct staff to keep the tubing and bag off of dirty surfaces such as his wheelchair base under his feet and on the floor surface. On 04/03/13 at 3:02 P.M. the DON verified the care plan did not direct staff to make sure the Foley tubing, bag and spigot were kept off the floor. The undated facility policy and procedure for catheter care instructed staff to not allow the tubing, drainage bag or spigot to touch the floor. 4. Review of Resident 9's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. Review of Resident #9's plan of care dated 01/04/13 revealed the resident did not have a plan to address how the medication was to be evaluated for effectiveness, or monitored for side effects, abnormal laboratory values and medication toxicity. On 04/03/13 at 9:24 A.M., interview with the assistant director of nursing (ADON) revealed a plan of care had not been developed for the use of [MEDICATION NAME] for Resident #9. 5. Review of Resident 109's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #109's medical record revealed the resident fell on [DATE] and 03/14/13 resulting in minor injuries. Review of Resident #109 Plan of Care (POC) updated 02/14/13 revealed the resident was at risk for falls related to weakness. Interventions included ensure balance in wheelchair, assist in transfer and with one staff assist. Assist the resident with mobility with the wheelchair and walker. Encourage rest periods and complete wheelchair /walker safety checks. Remind the resident not to self transfer. Keep the call light with in reach. The POC dated 03/05/13 documented consider stop sign placement on the bathroom door and by toilet to remind resident to call for assistance. The stop sign and non skid secure strips had not been care planned after the falls had occurred. On 04/02/13 at 3:15 P.M., Resident #109's room revealed no stop sign on the door to the bathroom and the resident's call light was behind the resident and out of reach. On 04/02/13 at 4:40 P.M., Resident #109's bathroom did not have the stop sign on the bathroom door. Resident #109's call light was out of the resident's reach, behind the resident on his bed. On 04/03/13 at 7:20 A.M., Resident #109 was seated in his adaptive electric wheelchair with his call light on the floor and out of his reach. The bathroom door did not have the stop sign on the door to remind the resident to call for staff before attempting to self transfer to the toilet. On 04/02/13 at 4:14 P.M., interview with the assistant director of nursing (ADON) revealed Resident #109 required an assist of one staff to transfer to the toilet and into bed. The ADON stated when he fell the second time, no alarms was implemented and strips were to be placed on the floor to keep his feet more secure. The ADON verified the non skid strips and stop sign had not been assessed or care planned to determine it the interventions were appropriate for Resident #109. As of 04/03/13 at 7:20 A.M., Resident #109 did not have the stop sign on the bathroom nor the non skid strips applied to the floor. 6. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Nursing assessment dated [DATE] revealed the resident had contractures in both hands with [MEDICAL CONDITION] arthritis. A history and physical dated 03/06/13, signed by the attending physician, stated the resident had hand deformities secondary to RA with a fair rehabilitation potential. Current plan of care reviewed 04/03/13 did not include a plan of care for range of motion for contractures.

Based on observation, interview and record review, the facility failed to offer substitute menu items for residents who did not eat their lunch on 04/01/13. This affected five (#38, #46, #63, #71, #72) residents who received lunch in the restorative dining room. Findings include: On 04/01/13 at 11:58 A.M., Residents #5, #38, #46, #63, #71 and #72 were served pureed chicken salad with bread, beet salad, milk, juice, coffee and hot chocolate. Resident #38 complained of not liking the cold food. State tested Nurse Aide (STNA) #6 offered the resident a yogurt and Resident #38 refused. Resident #38 was not offered any other alternative menu items and left over 75% of his lunch meal. When Residents #63, #71 and #72 did not eat their lunches, STNA #6 only offered the residents a yogurt and each resident refused. No other food alternative was offered or provided to the residents. On 04/01/13 at 12:05 P.M., Resident #46 complained that the bread on her sandwich was soaking wet. At 12:10 P.M., the bread was tested and found to be soaking wet. At 12:11 P.M., two fresh pieces of bread were obtained for the resident. Resident #46 complained that the bread was too cold. At 12:12 P.M., toast for the sandwich was provided for the resident. Resident #46 complained the beet salad was too cold. STNA #5 stated to STNA #6, "you know she can't handle the cold." Resident #46 was not provided a hot entree for lunch or offered another warmer food alternative. Resident $46 left over 75% of the lunch meal on her plate. On 04/01/13 at 12:30 P.M., interview with STNA #6 revealed pureed diets did not have and were not provided alternative menu items to be served if the resident did not like food. STNA #6 stated pureed diets did not have substitute menu items for their meals. STNA #6 stated what the residents were served was what was available for the pureed diets. Neither STNA #5 or STNA #6 provided any of the residents with pureed diets an alternative food substitute when the residents did not consume their meal. On 04/02/13 at 1:30 P.M., interview with the dietitian revealed residents on pureed diets did have alternative menu items for each meal. The dietitian stated all staff had to do, was call the kitchen and request a meal substitution for any resident, including pureed diets.

Based on record review, observation and interview, the facility failed to demonstrate the necessity for Resident #109's indwelling urinary or Foley catheter and did not ensure it was properly handled to minimize the risk of contracting urinary tract infections. This affected one of two residents reviewed with Foley catheters. Findings include: Resident #109 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. There was no current [DIAGNOSES REDACTED]. The certified nurse practitioner's note on 01/29/13 said "still has Foley?" and the plan section at the bottom of the page said to "keep Foley in for now". There was no documented reason for why the catheter needed to remain in place. The history and physical dated 01/22/13 said "deferred" next to [MEDICAL CONDITION] section. There was a physician's orders [REDACTED]. The nurse's note on 03/12/13 at 11:29 P.M. indicated Resident #109's Foley had been removed. A nurse's note from 03/14/13 at 11:43 P.M. revealed Resident #109 complained of low abdominal pain and had only voided small amounts of urine that shift, The physician was notified and they gave an order to reinsert the Foley catheter. An interview was conducted with the director of nursing (DON), assistant director of nursing (ADON) and the administrator on 04/03/13 at 4:00 P.M. They verified they had only attempted to remove Resident #109's Foley on one occasion and could not provide any other documentation to support the continued use of the Foley catheter. On 04/03/13 at 11:15 A.M., Resident #109 was observed in his electric wheelchair in his room with his Foley catheter bag and tubing lying on the floor in front of his wheelchair. The ADON was walking down the hallway and verified this observation. She indicated the state tested nurse aides were to secure the catheter bag and tubing in a privacy bag and ensure the bag and tubing did not come in contact with the floor. The care plan related to the use of a Foley catheter dated 1/23/13 for altered urinary elimination did not direct staff to keep the tubing and bag off of dirty surfaces such as his wheelchair base under his feet and on the floor surface. The ADON on 04/03/13 at 3:02 P.M. verified the care plan did not direct staff to make sure the Foley tubing, bag and spigot were kept off the floor. The undated facility policy and procedure for catheter care instructed staff to not allow the tubing, drainage bag or spigot to touch the floor.