Every finding on record at White Oak Manor - York

Based on record review, observation, interview, staff interview, and review of facility policy, the facility failed to provide supervision consistent with the assessed needs of one of one resident reviewed for accidents (Resident (R) 111). Specifically, the facility failed to supervise R111 by leaving her unattended in the dayroom. This failure resulted in an unwitnessed fall and a right distal humerus fracture requiring emergency department evaluation and immobilization.Findings include:Record review of the facility's Fall Management Policy revealed newly admitted residents were to be evaluated for fall risk based on fall history, physical and cognitive status, symptoms, and medication regimen. The policy further revealed residents were to be placed in the Fall Management Program when they had fallen within the previous thirty (30) days, were physically or cognitively unable to request assistance, were non-ambulatory and attempted to get out of bed or a chair without assistance, or had individual factors compounding fall risk. The policy further directed staff to observe and monitor residents more closely, implement appropriate interventions based on identified risk factors, complete a fall investigation following each fall, and implement interventions to reduce the risk of future falls.R111 was admitted to the facility on [DATE] for short-term rehabilitation following hospitalization for a left intertrochanteric femur fracture sustained after a fall. Relevant diagnoses included dementia, history of cerebrovascular accident, repeated falls, hypertensive heart disease, congestive heart failure, coronary artery disease, debility, and insomnia. Record review revealed R111 was nonverbal at baseline and communicated by nodding yes and no.Record review of the admission Morse Fall Scale assessment completed on 04/29/26 revealed R111 scored 65, identifying the resident to be in the High Risk for Falls category. The assessment identified the resident as having a history of falling, multiple diagnoses, the need for staff assistance with mobility, and documented the resident overestimated or forgot personal limitations.Record review of the Physical Therapy Evaluation dated 04/29/26 revealed R111 was referred for decline in strength, endurance, balance, mobility, and independence following the recent left femur fracture. The therapist documented fall risk precautions, severe dementia, nonverbal status, impaired safety awareness, bilateral lower extremity weakness, poor sitting balance, poor standing balance, and dependence for bed mobility, transfers, and ambulation. The therapist documented R111 remained at increased risk for falls without skilled intervention.Record review of the Occupational Therapy Evaluation dated 04/29/26 revealed R111 demonstrated decreased strength, decreased functional mobility, impaired balance, impaired safety awareness, and decreased participation in activities of daily living. R111 required dependent assistance with toileting, hygiene, bathing, lower body dressing, toilet transfers, shower transfers, and mobility. The therapist documented R111 remained at increased risk for falls.Record review of the Physical Therapy Treatment Notes dated 04/30/26 and 05/07/26 revealed R111 continued to require extensive assistance for transfers and mobility. On 04/30/26, R111 required maximum assistance of two staff for bed mobility and therapeutic activities and moderate assistance of two staff for sit-to-stand activities. On 05/07/26, the therapist documented R111 remained dependent for bed mobility, transfers, and ambulation, became agitated during treatment, refused further participation, and demonstrated no improvement in functional mobility prior to the fall.Record review of the Care Plan initiated on 04/30/26 revealed interventions including referral to Physical Therapy, adaptive devices as needed, environmental safety monitoring, safety instruction, participation in the Fall Management Program, ensuring the call light and frequently used items were within reach, and assessment of contributing factors and fall patterns.Record review of Certified Nurse Aide (CNA) documentation dated 05/09/26 revealed R111 required dependent assistance for bed mobility, sit-to-stand, chair transfers, toilet transfers, ambulation, toileting hygiene, and bathing. Documentation further revealed R111 was incontinent of bowel and bladder.Record review revealed that on 05/09/26 at approximately 11:04 AM, R111 was found sitting upright on the floor against the wheelchair in the dayroom following an unwitnessed fall. Nursing documentation described the resident's right arm as twisted backward at the elbow. R111 nodded yes when asked if the arm hurt. Emergency Medical Services were activated, the Responsible Party was notified, and R111 was transferred to the emergency department.Record review of emergency department records dated 05/09/26 revealed R111 sustained a closed fracture of the right distal humerus. Radiographic studies included the right humerus, right forearm, chest, and pelvis. R111 was discharged the same day with the right upper extremity immobilized in a sling and instructions to follow up with orthopedic surgery within three to five days.Record review revealed R111 returned to the facility on [DATE]. New orders included Acetaminophen (an analgesic medication) for scheduled pain management, continuation of head trauma protocol, and orthopedic follow-up. Subsequent nursing documentation revealed R111 remained in a sling following the injury.An observation on 07/02/26 at approximately 10:00 AM, revealed the dayroom where R111 sustained the unwitnessed fall was located at the end of the 300 Hall, separate from the nurses' station. The dayroom was an enclosed room with two doorways providing visibility into the room. Due to the location and enclosed design of the dayroom, residents seated within the room were not within the direct line of sight of staff located at the nurses' station.An interview on 07/02/26 at approximately 10:15 AM, with Restorative Aide (RA) 1 revealed she provided R111 with a shower, dressed the resident, and placed R111 in the dayroom because she had been told the resident ate better when out of bed. RA1 stated she left R111 in the dayroom with other residents present but no staff while providing care to another resident. Upon returning to the dayroom, RA1 found R111 on the floor. RA1 stated another resident present in the room reported R111 had kept trying to get up.Record review of provider documentation dated 05/09/26 revealed staff reported R111 had a history of attempting to stand unassisted.Record review of the facility's post-fall quality assessment dated [DATE] revealed R111 was found sitting upright on the floor against the wheelchair following an unwitnessed fall. The investigation recommended implementation of non-skid socks, close supervision, and toileting every two (2) hours. The investigation did not identify a definitive mechanism for the fall, document why R111 was found on the floor, or explain why the supervision interventions implemented after the fall had not been implemented before the incident despite the resident's documented fall risk. Record review further revealed the Care Plan was revised following the fall to include placement of a fall mat and maintaining R111 in view of staff when out of bed.An interview with Director of Nursing (DON) on 07/02/26 at approximately 10:00 AM, revealed the facility revised R111's Care Plan following the fall to include maintaining the resident in view of staff while out of bed. The DON stated the intervention was added because the facility needed a new intervention following the fall and maintaining the resident in view of staff seemed appropriate. When asked why the intervention had not been implemented before the fall despite R111's documented high fall risk, severe dementia, impaired safety awareness, dependence for mobility, and recent left intertrochanteric femur fracture, DON stated she could not explain why the intervention had not been implemented earlier.

Based on observation, interview and policy review, the facility failed to store, prepare and serve food under accepted sanitary conditions due to failure to separate dented cans from the for-use supply and failure to remove expired items from the food supply. The deficient practice had the potential to affect the 92 of 97 residents receiving oral diets. The findings include: Review of facility policy titled Storage of Food and Supplies, revised 12/5/2017, revealed PURPOSE: To ensure foods and supplies are stored appropriately to maintain wholesomeness and to meet regulatory guidelines. POLICY: Food and supplies are received, stored and monitored according to federal, state, and legal guidelines. PROCEDURES: Food and supplies are received and checked for accuracy, damage, and appropriate temperature. Food and supplies are stored promptly by an assigned dietary employee. Any food not stamped with a manufacturer's expiration or use-by date will be marked the date of delivery. Commercially processed TCS (Time/Temperature Control for Safety) foods must be dated when opened. TCS foods must be marked with a discard date not to exceed seven days. Any prepared/ combined in-house or on-site recipes using TCS foods must be labeled with the name and date, the date prepared, and the discarded date of 72 hours/3 days from the date prepared UNLESS one of the ingredients expires before the 72 hours/3 days expiration. Dented cans are removed and stored in a designated location. Any food removed from its original package must be labeled with proper identifying information such as the name of the product, date it was opened on its original package, and discard date. Observation and interview during the initial kitchen tour on 06/30/26 at 11:30 AM, accompanied by the Dietary Director (DD) revealed multiple dented cans stored on the for-use racks in the dry storage room. Also, a commercial sized bag of spaghetti noodles was stored unsecured, and a case of tortilla wraps included 3 packages with a use by date of 06/10/26. In the walk-in cooler, 12, 32-ounce cartons of heavy whipping cream with an expiration date of 06/23/26 were observed along with four (4) commercial sized bags of salad mix with a best by date of 06/26/26. In an interview on 07/01/26 at 11:00 AM, the Administrator acknowledged the dietary food storage concerns were not what was expected.

Based on observation, interview, record review, and review of the facility policy titled, the facility failed to ensure one of one resident reviewed for unnecessary physical restraints (Resident (R) 12) was free from an unnecessary physical restraint. The resident's individualized Broda chair was switched out with a replacement Broda chair that prevented R12 from independently propelling herself and from using her customary method of locomotion. The facility failed to complete an individualized seating assessment following the equipment change, and continued use of the replacement chair for approximately one week despite R12's inability to independently propel herself. This failure restricted R12's freedom of movement and had the potential to result in avoidable decline in mobility, positioning, comfort, and psychosocial well-being.Findings include:Review of the facility policy titled, Resident Safety Device/Restraint, revised 12/2016, revealed it was the facility's goal to provide residents with an environment that was as restraint free as possible. The policy further revealed non-emergency restraint use required screening and evaluation before implementation.R12 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, major neurocognitive disorder with Lewy Bodies, dysphagia following cerebral infarction, and fibromyalgia.Review of the most recent Quarterly Minimum Data Set (MDS) assessment revealed R12 was assessed as a manual wheelchair user, consistent with wheelchair mobility as part of her usual functional status.Review of the Physician Orders revealed an order for a Broda chair to assist with leaning and rigidity secondary to hemiplegia and hemiparesis following a cerebral infarction.Review of the Care Plan revealed R12 used a Broda chair for locomotion, included a goal to maintain activities of daily living without decline, and identified wheelchair/Broda chair assessment as needed.On 06/30/26 at 2:40 PM, an observation revealed R12 seated in a fully reclined Broda chair in a common area near the unit entrance. R12 was positioned in front of a window and repeatedly stated, That's a pretty tree. I wish I could see it. R12 appeared unable to raise her head sufficiently to view the tree outside the window or the television mounted on the wall to her right. R12 remained in the fully reclined position throughout the observation.On 06/30/26 at 3:26 PM, an observation revealed R12 remained seated in the fully reclined Broda chair and stated, My neck is hurting, and that it was itching.On 06/30/26 at 3:30 PM, an observation revealed R12 attempted to sit upright from the Broda chair. Licensed Practical Nurse (LPN)3 instructed R12 to sit back. R12 responded, I've gotta sit up! LPN3 raised the back of the Broda chair approximately 10 degrees before relocating R12 beside the nurses' station, stating, So I can watch you. You've been trying to get out of that chair all day. R12 remained seated in the Broda chair following the intervention.On 07/01/26 at 2:50 PM, an observation revealed R12 remained seated in the replacement Broda chair. R12's feet were unable to contact the floor while seated in the chair. R12 was unable to independently propel herself.On 07/01/26 at 2:58 PM, an interview with Certified Nurse Aide (CNA)1 revealed R12 normally used a lower Broda chair that allowed her to propel herself using her unaffected leg. CNA1 stated the resident's usual chair had been broken for approximately one week and staff placed R12 in the replacement Broda chair for safety measures. CNA1 stated she was unaware whether R12 had been assessed following the change in chairs.On 07/01/26 at 3:01 PM, an interview with CNA3 revealed R12 normally used a lower Broda chair and propelled herself using the handrails and her unaffected leg. CNA3 stated she was unsure how long the resident's usual chair had been broken.On 07/01/26 at 3:40 PM, an interview with LPN3 revealed R12 typically propelled herself around the unit using a scooting motion and her unaffected leg. LPN3 stated the resident's usual Broda chair had been broken since Monday, I think. LPN3 stated R12 probably shouldn't be reclined, acknowledged R12 could not place her feet on the floor while seated in the replacement chair, and stated R12 did not appear able to propel herself while using the replacement chair.On 07/01/26 at 3:45 PM, an interview with the Maintenance Director revealed R12's Broda chair frame had broken either Friday or Monday. The Maintenance Director stated the chair was unusable and the repair or replacement process had not been initiated because he had never ordered a replacement chair like this one.On 07/01/26 at 4:00 PM, an interview with the Rehabilitation Director revealed R12's usual Broda chair had been broken since sometime during the previous week and had been replaced with another Broda chair. The Rehabilitation Director stated an individualized seating assessment was not completed because the replacement chair was considered pretty much an even swap. The Rehabilitation Director stated R12 normally propelled herself using a scooting motion with her feet and her unaffected leg due to a previous stroke. When asked whether R12 could propel herself in the replacement chair, the Rehabilitation Director stated he was unsure. The Rehabilitation Director further stated R12 should not normally be positioned in a fully reclined position and indicated such positioning was unusual for the resident. The Rehabilitation Director stated he would reassess R12.During a follow-up interview on 07/02/26 at approximately 10 a.m., the Rehabilitation Director stated the resident's wheelchair was evaluated and the seat heights of the resident's usual Broda chair and the replacement Broda chair were measured. The Rehabilitation Director stated the resident's usual Broda chair was approximately two inches lower than the replacement Broda chair. The Rehabilitation Director further stated, They don't make that type of chair anymore. When asked whether the replacement chair was, in fact, an even swap, the Rehabilitation Director stated, No, but what I was looking at was her ability to propel herself. The Rehabilitation Director acknowledged the replacement Broda chair was not an even swap after determining the replacement chair measured approximately two inches higher than the resident's usual Broda chair, thus not allowing her to propel herself.On 07/02/26 at 11:27 AM, an interview with the Administrator revealed the Rehabilitation Director wanted to try her in a different chair. The Administrator stated the Rehabilitation Director was cleaning another chair for R#12 and would keep us updated on the progress.On 07/02/26 at 12:05 PM, an observation revealed R12 remained seated in the replacement Broda chair pending completion of the Rehabilitation Director's reassessment. R12's feet remained unable to contact the floor while seated in the replacement chair, and R12 remained unable to independently propel herself.

Based on observation, interview, and record review, the facility failed to revise the Comprehensive Care Plan for one of one resident reviewed for Comprehensive Care Plans (Resident (R) 12). Specifically, after replacing R12's individualized Broda chair with a replacement chair that no longer allowed the resident to independently propel herself using her customary method of locomotion, the facility failed to assess and revise the resident's Comprehensive Care Plan to address the resident's change in functional mobility, positioning needs, and use of the replacement Broda chair. This failure had the potential to result in care that did not reflect R12's current needs and functional abilities.Findings include:Cross-reference F604.R2 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, major neurocognitive disorder with Lewy Bodies, dysphagia following cerebral infarction, and fibromyalgia.Review of the most recent Quarterly Minimum Data Set (MDS) assessment revealed R12 was assessed as a manual wheelchair user, consistent with wheelchair mobility as part of her usual functional status.Review of the Care Plan revealed R12 used a Broda chair for locomotion, included a goal to maintain activities of daily living without decline, and identified wheelchair/Broda chair assessment as needed. Review of the Care Plan failed to reveal interventions addressing the resident's loss of independent locomotion following use of a replacement Broda chair, inability to independently propel herself in the replacement chair, need for an individualized seating assessment following the equipment change, or interventions addressing the resident's positioning needs while using the replacement chair.On 07/01/26 at 4:00 PM, an interview with the Rehabilitation Director revealed R12's usual Broda chair had been broken since sometime during the previous week and had been replaced with another Broda chair. The Rehabilitation Director stated an individualized seating assessment was not completed because the replacement chair was considered pretty much an even swap. The Rehabilitation Director stated R12 normally propelled herself using a scooting motion with her feet and her unaffected leg due to a previous stroke. When asked whether R12 could propel herself in the replacement chair, the Rehabilitation Director stated he was unsure. The Rehabilitation Director further stated R12 should not normally be positioned in a fully reclined position and indicated such positioning was unusual for the resident. The Rehabilitation Director acknowledged no changes had been made to R12's Comprehensive care Plan following replacement of the Broda chair. The Rehabilitation Director stated he would reassess R12.

Based on observation, interview and record review, the facility failed to ensure food and prepared and distributed under sanitary conditions. The failure to ensure the ceiling and pipes above the steam table, used for holding foods and plating foods served during meals had smooth and impervious surfaces increased the risk for contamination of food items held or assembled for residents receiving meals serviced by the kitchen. Findings include: The policy entitled Food Preparation and Services, dated 11/22, identified General Guidelines and included the following: Section 1 stated the identification of potential hazards in food preparation proc ess and adhering to critical control points can reduce the risk of contamination . Section 2 stated Cross contamination can occur when harmful substances, such as chemical or disease-causing organism are transferred to food . On 10/4/23, between 11:00 a.m. through 12:30 p.m., during observation of the noon meal service in the kitchen, it was noted that a pipe was suspended below the ceiling above the steam table holding and plate preparation area. The exposed pipe had yellowed colored paint that was curled and peeling of the surface of the metal. On 10/4/23 at approximately 12:30 p.m. during the observation when asked about the damage, Staff #6, the Certified Dietary Manager said they were not aware of any efforts to resolve the issue and explained they had only worked in the facility a short time. On 10/5/23 at 9:30 a.m., the Maintenance Director was asked about the damage observed. He/she explained the steam and heat from the cooking equipment damages the ceiling and stated he/she had recently repainted the area. On 10/6/23 at 10:15 a.m., during a joint observation of the area, the Maintenance Director reiterated that the ceiling above the area had recently been repainted. When asked about the peeling paint on the exposed pipe, the staff acknowledged the damage observed.

Based on record review and interview the facility failed to ensure Center for Medicare/Medicaid Services (CMS)-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) was completed correctly by the responsible parties for Resident #198 and Resident #52. This affected two (2) of three (3) residents reviewed for notification of changes in Medicare Part A coverage. The findings include: Review of an undated facility policy, titled, Advance Beneficiary Notice of Non-Coverage (ABN) CMS-R-131 revealed: The Business Office is to initiate, and deliver, the ABN CMS-R-131 form when a Medicare beneficiary is, or will be, receiving a service that Medicare is not likely to provide coverage in a specific case under Part B items or services. The ABN must be delivered far enough in advance that the resident or resident representative has time to consider the options and make an informed choice. In the section titled Procedure, the policy noted, The ABN form should be completed in its' entirety. The form must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. The procedure also identified option boxes designated to be completed. Option boxes the beneficiary or resident representative is to personally select an option by making a mark in the chose checkbox one (1), two (2) or three (3). The procedure also noted: The resident or his or her representative must choose one (1) of the three (3) options. Under no circumstances can the notifier decide for the beneficiary which box to select. If the beneficiary cannot or will not make a choice, the notice should be annotated, for example, beneficiary refused to choose an option. Review of the medical record for Resident #198 revealed an admitted [DATE] and a last covered day for Medicare Part A service of 5/11/23. Resident #198 remained in the facility after termination of Medicare Part A services but later discharged home on 6/1/23. Review of the SNFABN Form CMS-10055 for Resident #198, revealed the form was signed on 5/11/23 on the last day of coverage for Medicare Part A services. Further review of Form 10055 revealed an option to appeal to Medicare for continuation of services, to pay privately for services that were ending, or to end services was not selected. Review of the Progress Notes revealed no documentation the responsible party had been contacted regarding the incomplete section for options to appeal after it was received by the facility incomplete from the responsible party of Resident #198. Review of the medical record for Resident #52 revealed an admitted [DATE] and a last covered day for Medicare Part A service of 5/14/23. Resident #52 remained in the facility after termination of Medicare Part A services. Review of the SNFABN Form CMS-10055 for Resident #52 revealed the form was signed on 5/14/23 on the last day of coverage for Medicare Part A services. Further review of Form 10055 revealed an option to appeal to Medicare for continuation, to pay privately for services that were ending or to end services was not selected. Review of the Progress Notes revealed no documentation the responsible party had been contacted regarding the incomplete section for options to appeal after it was received by the facility incomplete from the responsible party of Resident #52. On 10/3/23 at 3:10 p.m. during an interview with the Business Office Manager (BOM), he/she stated the forms were mailed to the responsible party three (3) days prior to the last covered day but could not guarantee the responsible party received them prior to the last covered day. He/She stated a phone call was made with an explanation of the letters, how to complete them and to sign and return them to the facility. The BOM stated that two (2) of the three (3) records reviewed were not marked to indicate: the option to appeal to Medicare for continuation of services, to pay privately for services that were ending, or to end services. The BOM stated she did not review them for completion when the forms were returned to the facility, and he/she was unaware that two (2) of Form 10055 were not completed correctly by the responsible party for Resident #198 and Resident #52. The BOM stated in the future, he/she would review the forms mailed back to the facility and ensure they were completed completely by the responsible party. On 10/5/23 at 1:30 p.m. during an interview with the Director of Nursing (DON), he/she confirmed the documentation on Form 10055 for Resident #198 and Resident #52 was incomplete as the option to appeal to Medicare for continuation of services, to pay privately for services that were ending, or to end services was not selected.

Based on observation, interview and record review, the facility failed to ensure that food received was prepared in a form designed to meet individual needs. Failure to ensure the mechanical soft diets were served foods identified on the menu increased the risk a resident could choking or could not eat the foods served for five (5) of 19 sampled residents (#1, #5, #14, #68, #80) who had orders for the altered texture diet. Findings include: On 10/4/23, during the observation of meal service between 11:00 a.m. - 12:30 p.m., it was noted the mechanical soft diets were served whole kernel corn. Review of the diet extension, a menu that identified what diets received corresponding foods, indicated that mechanical soft diets should have been served creamed corn. The food item was not observed on tray line. On 10/4/23 at 11:30 a.m. after tray preparation had started, the Corporate Registered Dietician (RD) #7 was asked about the creamed corn. RD #7 directed staff to correct the error. Although some trays had left the dietary department, after heating the menu item, it was added to the service line. On 10/5/23 at approximately 9:15 a.m., RD #7 provided a list of residents who were on the mechanical soft diets, and explained the menu was corrected and the item was delivered to rooms if the tray left the kitchen prior to having the item available.

Based on observation and interview, the facility failed to ensure the meals served were palatable and prepared according to menu specifications. Taste tests of the foods prepared for the puree diets revealed the items tasted similar to each other and appeared to be the same color, making it difficult to discern what the food item was. Six (6) of 15 residents interviewed, verbally expressed dissatisfaction with the meals. Findings include: Record review revealed Resident (R)70 was admitted to the facility on [DATE], for skilled therapy after a surgical procedure. During an interview on 10/3/23 at 2:16 p.m. Resident #70 said the food was not good and commented they did not like it. The resident stated they could not tell what type of meat she was served with the meal. During a follow up interview on 10/5/23 at 1:30 p.m., R70 said they were not aware the facility had an alternate menu that could be requested and commented the food was bland. R37 was admitted on [DATE], for skilled therapy after sustaining an injury from a fall. An interview was conducted on 10/4/23 at 8:07 a.m. with R37. When asked about the food served, the Resident commented you don't want to know. The resident went on to explain the food was bland. During a follow up interview on 10/5/23 at 2:00 p.m., R37 said they were not aware of any alternate menu that could be requested and reiterated they really did not like the food. On 10/5/23 at 1:00 p.m. during the resident council meeting, four (4) of the six (6) residents who attended the meeting, stated the food was bland. Review of the resident council meeting minutes, found that in March and May of 2023, during the monthly meetings, residents complained the food didn't have enough seasoning. The notes indicated that the Dietary Director responded to the residents and reassured them the issue would be corrected. On 10/5/23 during observation of the noon meal service between 11:00 a.m. and 12:30 p.m., the menu extension, that identified what food items were served to residents based on their diet, showed the regular diets were served a no added salt (NAS) diet. When asked what the NAS diet was, the Certified Dietary Manager explained that the staff did not use salt when cooking. On 10/5/23 at 12:30 p.m. the standardized recipe for the entrée served, meatloaf, was reviewed. The recipe included salt, pepper, and garlic. [NAME] #8 who prepared the meal, was asked about the spices identified in the recipe. Staff explained the salt, pepper, and half of the garlic were omitted from the recipe. On 10/05/23 at 12: 30 p.m. the CDM stated the facility served the NAS, diet to all residents on a regular diet. A taste test of the foods was completed with the CDM. The meatloaf tasted bland without the spices intended to compliment the food item identified in the recipe. In addition, the food prepared for the puree diet was tested for taste. The flavor of the entrée, meatloaf, was difficult to discern from the other items and the pureed corn tasted like mashed potatoes. The CDM was asked if thickener was used and explained that the staff used mashed potatoes in the puree foods. In addition, the color of the pureed food items served were similar, again making the different items difficult to identify what the food item was.

Based on observation and interview, the facility failed to ensure the meals served were palatable and prepared according to menu specifications. Taste tests of the foods prepared for the puree diets revealed the items tasted similar to each other and appeared to be the same color, making it difficult to discern what the food item was. Six (6) of 15 residents interviewed, verbally expressed dissatisfaction with the meals. Findings include: Record review revealed Resident (R)70 was admitted to the facility on [DATE], for skilled therapy after a surgical procedure. During an interview on 10/3/23 at 2:16 p.m. Resident #70 said the food was not good and commented they did not like it. The resident stated they could not tell what type of meat she was served with the meal. During a follow up interview on 10/5/23 at 1:30 p.m., R70 said they were not aware the facility had an alternate menu that could be requested and commented the food was bland. R37 was admitted on [DATE], for skilled therapy after sustaining an injury from a fall. An interview was conducted on 10/4/23 at 8:07 a.m. with R37. When asked about the food served, the Resident commented you don't want to know. The resident went on to explain the food was bland. During a follow up interview on 10/5/23 at 2:00 p.m., R37 said they were not aware of any alternate menu that could be requested and reiterated they really did not like the food. On 10/5/23 at 1:00 p.m. during the resident council meeting, four (4) of the six (6) residents who attended the meeting, stated the food was bland. Review of the resident council meeting minutes, found that in March and May of 2023, during the monthly meetings, residents complained the food didn't have enough seasoning. The notes indicated that the Dietary Director responded to the residents and reassured them the issue would be corrected. On 10/5/23 during observation of the noon meal service between 11:00 a.m. and 12:30 p.m., the menu extension, that identified what food items were served to residents based on their diet, showed the regular diets were served a no added salt (NAS) diet. When asked what the NAS diet was, the Certified Dietary Manager explained that the staff did not use salt when cooking. On 10/5/23 at 12:30 p.m. the standardized recipe for the entree served, meatloaf, was reviewed. The recipe included salt, pepper, and garlic. Cook #8 who prepared the meal, was asked about the spices identified in the recipe. Staff explained the salt, pepper, and half of the garlic were omitted from the recipe. On 10/05/23 at 12: 30 p.m. the CDM stated the facility served the NAS, diet to all residents on a regular diet. A taste test of the foods was completed with the CDM. The meatloaf tasted bland without the spices intended to compliment the food item identified in the recipe. In addition, the food prepared for the puree diet was tested for taste. The flavor of the entree, meatloaf, was difficult to discern from the other items and the pureed corn tasted like mashed potatoes. The CDM was asked if thickener was used and explained that the staff used mashed potatoes in the puree foods. In addition, the color of the pureed food items served were similar, again making the different items difficult to identify what the food item was.

Based on interviews, record review, and facility policy review, the facility failed to ensure residents were free from physical abuse for 3 (Resident #2, Resident #3, and Resident #4) of 6 sampled residents reviewed for abuse. Specifically, the facility failed to prevent an aggressive resident (Resident #1) from pinching and hitting Resident #2, grabbing and scratching Resident #4's arm, and pulling on Resident #3's arm. Additionally, the facility failed to prevent Resident #3 from hitting Resident #1. Findings included: Review of a facility policy titled, Neglect, Abuse, Mistreatment, Threatened or Alleged Abuse of Residents, revised 05/2017, revealed, It is the policy of White Oak Management, Inc. and its member facilities that all residents have the right to be free from verbal, sexual, physical, mental and emotional abuse. The policy also indicated, Resident to Resident Abuse All forms of abuse including resident-to-resident abuse must be reported immediately to the Director of Nursing or Designee and the Facility Administrator. 1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents. 2. Should a resident be observed/accused of abusing another resident, staff may implement the following interventions: a. Remove the aggressor from the situation if the aggressor is still in the area in which the incident occurred. b. Temporarily separate the resident from the other residents as a therapeutic intervention to help lower the agitation/emotional level of the resident until a comprehensive evaluation and assessment are completed for both residents. Additionally, the policy indicated, e. Obtain appropriate treatment options, i.e. [such as], referral to psychiatrist, hospitalization , behavioral monitoring, medication change, etc. [et cetera]. f. Develop or amend the Care Plans to address appropriate interventions to prevent recurrence of incident and to who protection of the victim and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Face Sheet revealed Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #1 scored 11 on a Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The MDS indicated the resident was independent with transfer and walking in the room and corridor. According to the MDS, the resident exhibited physical behavioral symptoms directed toward others and rejection of care on one to three days during the seven-day assessment period. Review of a Care Plan, dated as revised 03/15/2022, revealed Resident #1 had exhibited recent behaviors of agitation evidenced by a resident-to-resident altercation, being angry with staff, combativeness, and exit-seeking secondary to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Face Sheet revealed Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission MDS, dated [DATE], revealed Resident #3 scored zero on a BIMS, indicating severe cognitive impairment. The MDS indicated the resident exhibited physical behavioral symptoms toward others, rejection of care, and wandering on one to three days during the seven-day assessment period. According to the MDS, the resident required only supervision and set-up assistance for transfer and walking in the room and corridor. Review of a Care Plan, dated 07/12/2022, revealed Resident #3 was at risk for emotional problems related to being admitted to hospice services for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Review of a South Carolina Department of Health and Environmental Control (DHEC) Initial 24-Hour Report, dated 07/22/2022, revealed Resident #1 was trying to assist Resident #3 to sit down, when Resident #3 hit Resident #1 with a baby doll that Resident #3 was holding. A review of a South Carolina DHEC Five-Day Follow-Up Report, dated 07/22/2022, revealed Resident #1 heard staff asking Resident #3 to sit down in a chair. Resident #1 grabbed Resident #3's arm, trying to get Resident #3 to sit down in the chair. Resident #3 did not want to sit down, and Resident #1 was pulling on him/her, then Resident #3 started hitting Resident #1 with a baby doll while staff were trying to get Resident #1 to let go of Resident #3's arm. The residents were separated, and a medication review was completed for both residents. Resident #3's baby doll was replaced with a soft doll. Review of Occurrence Reports, dated 07/22/2022 for Resident #1 and Resident #3, revealed no injuries were noted. During an interview on 09/22/2022 at 10:56 AM, Certified Nursing Assistant (CNA) #5 revealed she witnessed the incident involving Resident #1 and Resident #3 on 07/22/2022. She stated Resident #1 was sitting with Resident #3 and was agitated for whatever reason and went over to Resident #3 after hearing staff ask Resident #3 to sit down. CNA #5 stated Resident #1 was trying to help by making Resident #3 sit down. Resident #1 grabbed Resident #3's arm and tried to make him/her sit down. The staff were trying to get Resident #1 to let go of Resident #3's arm, but Resident #1 had a good grip on it. The CNA indicated Resident #1 left a fingernail print on Resident #3's arm. During an interview on 09/22/2022 at 12:04 PM, the Director of Nursing (DON) stated that on 07/22/2022, she received a report that Resident #1 had tried to redirect Resident #3 to sit down. The DON indicated both residents had dementia and were confused, so when Resident #1 grabbed Resident #3, Resident #3 hit Resident #1 with the doll. The DON stated the residents were separated. The DON stated she did not feel it was abuse, because Resident #1 was trying to be helpful. During an interview on 09/22/2022 at 4:23 PM, the Administrator stated no resident should be abused but felt this incident should not be substantiated as abuse. Review of a Face Sheet revealed Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission MDS, dated [DATE], revealed Resident #2 scored 6 on a BIMS, indicating severe cognitive impairment. The MDS indicated the resident did not exhibit behavioral symptoms. According to the MDS, the resident required limited assistance with transfer and locomotion on and off the unit and used a walker and wheelchair for mobility. Review of a Care Plan, dated 07/27/2022, revealed Resident #2 was a new admit and needed to adjust to the new environment and staff. 2. Review of a South Carolina DHEC Initial 2/24-Hour Report, dated 07/23/2022, revealed Resident #1 approached Resident #2 in the hallway and began to pinch and hit Resident #2 with an open hand. Staff rushed to separate the residents immediately. Review of a South Carolina DHEC Five-Day Follow-Up Report, dated 07/23/2022, revealed Resident #1 had psychiatric services in place prior to the 07/23/2022 incident. Resident #1 and Resident #2 were separated and placed on location monitoring. Both residents were assessed for injury, and none were noted. The Summary Report indicated Resident #1 was placed on one-on-one monitoring continuously for seven days, then every 15 minutes for two weeks, then every 30 minutes for two weeks, then every hour for two weeks to ensure the safety of others. The physician saw the resident on 07/27/2022 and reviewed the medications. Review of the physician's Assessment and Plan, dated 07/27/2022 revealed the resident was to have a urine culture performed and that the physician would await the results prior to making medication adjustments, as the agitation may have been related to infection. Review of a Confidential Occurrence Statement or Interview form, dated 07/23/2022 and signed by Licensed Practical Nurse (LPN) #2, revealed Residents #1 and #2 were sitting in the hallway in front of the nurses' station. Resident #1 walked over to Resident #2, who was doing a crossword puzzle, and pinched Resident #2's left arm. Resident #1 then started to slap Resident #2 on the arm. Resident #1 was redirected away from Resident #2. No apparent injuries were noted. During an interview on 09/21/2022 at 3:26 PM, the Admissions Coordinator (AC) stated she received a call in her office on 07/23/2022 stating that Resident #1 hit Resident #2. The incident was reported to the state, and both responsible parties (RP) were called. Resident #1's family members came to the facility to sit with the resident for a while. Resident #1 did not like it when the family member left the facility and got upset. That night, Resident #1 had one-on-one monitoring in his/her room. During an interview on 09/21/2022 at 3:48 PM, the Assistant Director of Nursing (ADON) stated Resident #1 was seen by staff walking over to Resident #2 and pinching and hitting Resident #2's arm. No one knew why the resident did it, but the ADON did not think the resident meant any harm. There were no injuries noted. The residents were separated, and Resident #1 was placed on one-on-one monitoring. During an interview on 09/22/2022 at 10:23 AM, LPN #1 stated Resident #1 had location monitoring every 10-15 minutes to make sure someone saw if he/she tried to hit someone else. LPN #1 indicated there had not been any other issues since the July 2022 incidents. During an interview on 09/22/2022 at 3:15 PM, LPN #2 stated she witnessed Resident #1 walk over and pinch Resident #2 and slap Resident #2's arm. LPN #2 stated Resident #2 was doing a crossword puzzle, and Resident #1 was not provoked. During an interview on 09/22/2022 at 4:13 PM, the Director of Nursing (DON) stated Resident #1 was seen hitting Resident #2, unprovoked. The residents were separated, and Resident #1 was placed on one-on-one monitoring. The incident was investigated and reported, and interventions were put in place. The DON stated she did not feel the Resident #1's actions would be considered abuse. She stated she expected all residents to be free from abuse. During an interview on 09/22/2022 at 4:23 PM, the Administrator stated no resident should be abused but felt this incident should not be substantiated as abuse. Review of a Face Sheet revealed Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a significant change MDS, dated [DATE], revealed Resident #4 scored 11 on a BIMS, indicating moderate cognitive impairment. The MDS indicated the resident exhibited physical behavioral symptoms directed toward others on one to three days during the seven-day assessment period. According to the MDS, the resident required extensive assistance with transfer, walking, and locomotion and used a wheelchair for mobility. 3. Review of a South Carolina DHEC Initial 2/24-Hour Report, dated 07/31/2022, revealed Resident #1 reached out and got ahold of another resident's arm. Review of a South Carolina DHEC Five-Day Follow-Up Report, dated 07/31/2022, revealed Resident #1 approached Resident #4 and grabbed Resident #4's left arm, causing nail marks. The residents were separated and assessed. Resident #1 was sent to the hospital, diagnosed with a [CONDITION(S)], and started on antibiotics. The resident's dosage of [MEDICATION(S)] (an anti-anxiety medication) was also increased. The report indicated the resident was to continue to have one-on-one monitoring for two weeks, then every 15 minutes for two weeks, then every 30 minutes for two weeks, and then every hour for two weeks. During an interview on 09/22/2022 at 11:35 AM, Certified Nursing Assistant (CNA) #6 stated she witnessed that Resident #1 was agitated on 07/31/2022 and saw Resident #1 grab Resident #4's arm while trying to take the resident's doll. CNA #6 stated Resident #1 was already on one-on-one monitoring for a previous incident with another resident. Per CNA #6, Resident #1 got up and grabbed Resident #4's arm without any provocation. CNA #6 stated she was able to get Resident #1 away from Resident #4, and staff contacted Resident #1's family member, who calmed the resident down. During an interview with the DON and the Administrator on 09/22/2022 at 4:04 PM, they stated Resident #1 had [CONDITION(S)] and had issues of combativeness with staff and residents. The resident was found to have had a [CONDITION(S)] after the incidents occurred in July 2022, and there had not been any altercations involving Resident #1 since then. The DON stated she expected the facility to be abuse-free. She stated she did not feel these incidents were abuse, because Resident #1 was not trying to hurt the other residents.

Based on facility policy, record review and interview, the facility failed to follow the care plan for one (1) resident (Resident #57) reviewed for accidents/hazards. Care plan interventions included maintain environment free of clutter and safety hazards. Due to the failure of following the care plan, on 10/4/21, the resident was found on the floor by the bathroom in his/her room, which resulted in a skin tear to the lower spine and bruising to the right hand and forearm, resulting in harm to the resident. The resident's wheelchair was stored in the bathroom, which caused the resident to fall. The facility was aware the resident scored a 65 on the last quarterly fall risk assessment and had previous falls with fractures on 4/9/21 and 6/26/21. Findings include: Review of the policy titled Comprehensive Team Care Planning dated revision 5/18/2017 revealed: It is the policy of White Oak Management, Incorporated to provide care planning for all residents; to formulate individualized plans of care for each resident that will be an effective and useful approach, for providing quality care; and to help the resident meet his/her mental, emotional, social, and physical needs during his/her stay. This shall be a team approach for resolving the resident's problems or needs, with emphasis on normalization of daily life to the highest level of dignity and ability. The residents plan of care guides the necessary care and services based on the findings of the Resident Assessment Instrument (RAI). The services are implemented and updated on the care plan. Outcome evaluation and revisions for interventions/approaches are an ongoing process. Purpose: To look at a resident as a whole building on the individual resident characteristics, to develop an action plan to achieve resident objectives. Procedure: 1. Interdisciplinary Care Planning: A. The care plan team develops interventions appropriate for each resident based on the comprehensive assessment due at the completion of the Minimum Data Set (MDS) and the Care Area Assessment (CAA) summary protocol form. B. The planning for each resident must be interdisciplinary and involve at least one staff member from Social Services, Activities, Nursing, Dietary and other disciplines as indicated. C. Residents and/or their designated representatives are encouraged to participate in the development of their plan of care. Each resident will be invited to participate to the extent practicable or designated a representative to participate on his/her behalf. If a resident is unable due to mental or physical impairment, the resident's representative must be afforded the opportunity to represent the resident. An explanation must be included in the resident's medical record if the participation of the resident and his/her representative is determined not practicable for the development of the resident care plan. D. Any problems or needs that resident/representative addresses are incorporated in the Resident's Plan of Care (RPOC) by the involved discipline as appropriate. New condition existed upon admission to the facility. Any newly developed problems will have problem start date as date the problem is identified. E. The plan must specify goals and approaches to resolve the resident's identified problems or needs, accentuate resident strengths, acknowledge the resident's preferences and/or participation when appropriate, and be developed in coordination with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] F. Similar problems should be combined when like goals and approaches are applicable. G. The resident/representative and team members sign the Resident Assessment Instrument (RAI) process review sheet indicating participation into developing the Plan of Care. Physician signs approval for current plan of care on the monthly physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A registered nurse must approve and sign all care plans, which may be indicated on the RAI Process Review Sheet. H. The care plan is consistently implemented by all personnel at all times of the day unless stated otherwise. I. Failure of the care plan team to acknowledge and pursue the problems identified by the resident's assessment will invalidate the entire process and not meet Federal Requirements. Review of the clinical record revealed Resident #57 was admitted to the facility on [DATE]. The resident was assessed on the Quarterly Minimum Data Set (MDS) assessment, dated 8/31/2021, to have diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #57 had a Brief Interview for Mental Status (BIMS) score of three (3) indicating severely impaired cognition. The MDS revealed Resident #57 did not participate in skilled therapies, but received restorative nursing programs during the assessment review period. Under Section G functional status, the resident was coded as requiring one (1) person extensive assist from staff for activities of daily living including bed mobility, transfers, toileting, and the use of mobility devices such as wheelchair (manual or electric) and coded to have impairment on one side of the lower extremity. Review of the Care Plan dated, 4/19/21, and revised 6/24/2019, 7/1/2021 ongoing, revealed Resident #57 at risk for falls related to weakness, the most recent quarterly fall risk assessment score 65 resident high risk. Implement high risk fall preventions interventions. Under the goals section, maintain environment free of clutter. Under the interventions section, keep walker and/or wheelchair next to bed, check bed alarm for proper functioning, prior to resident being assisted to bed at night (HS), maintain environment free of clutter and safety hazards, increase rounds to check on resident more frequently, chair alarm until self-release belt for safety of resident related to falls, fall mats to both sides of bed with alarms, staff to apply non-skid socks, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Review of the facility's Morse Fall Risk Assessment fall risk quarterly assessment score, dated 4/19/2021, revealed Resident #57 had a total fall risk score of 65, indicating the resident was at high risk of falls. Review of the facility's Occurrence Report dated 10/4/21 at 9:00 p.m. revealed, Resident #57 got up from bed unattended to go to the bathroom and was noted to be on the floor in the doorway of the bathroom, when s/he called for assistance. Resident had skin tear in middle of lower spine from the wheelchair that was parked in the bathroom. Bed alarm not sounding however was checked post fall and did sound upon applying/releasing pressure. Recommendations, staff to ensure proper functioning of bed alarm before the resident goes down for the night. Do not store wheelchair in bathroom. Review of the facility's Occurrence Report dated 4/9/21, Resident #57 had a fall resulting in a hip fracture. Review of the facility's Occurrence Report dated 6/1/21, Resident #57 had a fall, no injury. Review of the facility's Occurrence Report dated 6/26/21, Resident #57 had a fall, resulting in a compression fracture to the Lumbar vetebra area #1. Review of the facility's Alarm Sign off Report dated 10/1/21-10/6/21, for shifts 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. revealed, the staff nurses indicated the alarm was working on each shift including 10/4/21 night of Resident#57's fall. The facility could not provide any in-services related to ensuring staff were educated on safe transfers or interventions to prevent falls; but provided in-services for safety in long term care setting dated 8/9/21 for all staff. Review of the facility's Head Trauma Protocol dated 10/4/21-10/6/21, revealed vital signs were completed every hour for four (4) hours, then every four hours (4) for 24 hours, then every shift for 48. An interview was conducted on 10/6/21 at 2:24 p.m. with Family of Resident #57 revealed, I am aware of the falls with injuries; this is tiresome. The facility can't prevent the falls, if s/he is going to get up, something needs to be done to prevent these injuries. S/he has alarms on the bed, wheelchair and anti-tippers as well, there have been times that I set off the bed alarm and they did not come or took them 20 minutes to answer the call light. S/he had falls at home and broke one hip and wrist, then broke the other hip here. The facility was aware of the fall risks upon admission. I feel they need to do more. An interview was conducted on 10/7/21 at 11:00 a.m. with the Director of Nursing (DON) and the Administrator while rounding on the unit, revealed the fall for Resident #57 just happened on Monday 10/4/21. We had not been able to fully investigate the incident. We expect staff, as much as possible, to ensure safety hazards are removed from the resident's room and the wheelchair to be out in the hallway or in the room when not in use. We may at times store the wheelchair in the bathroom but typically in the hallway. For the fall on 10/4/21, what we know is the wheelchair was in the resident's bathroom, the bed alarm did not sound, but the light was flashing when staff entered the room. Our expectation is that staff ensure the alarms are working and charted on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] An interview conducted on 10/7/21 at 11:08 a.m. with Certified Nursing Assistant (CNA) #3 revealed, Resident #57 requires one person assist with ADLs, I recall the fall back in April of this year, I was walking down the hallway and noticed the resident on the floor by the entryway of the room. We have been in-serviced on trip hazards, but since the resident is non-mobile, we store the wheelchair in the hallway. An interview conducted on 10/7/21 at 11:16 a.m., with Licensed Practical Nurse (LPN) #2 revealed, We are responsible for checking the alarms each shift and charting them in the MAR. Resident #57 has alarms on the wheelchair and bed. We do two (2) hour checks and frequently by walking past the room and looking in on the resident. S/he is one (1) to two (2) persons assist with ADLs. The wheelchair is stored in the room or the hallway when not in use. We ensure the room stays free of clutter. An interview conducted on 10/7/21 at 2:53 p.m. with Certified Nursing Assistant (CNA) #4 revealed, Resident #57 yelled out and I went into the room. S/he was on the floor outside the bathroom door with his/her back up against the wheelchair. I asked what s/he was doing, and the resident stated I was going to the bathroom. CNA #4 further revealed, I did not hear the bed alarm go off. The resident has an alarm on the bed. The light was flashing but the alarm was not sounding. I called for the nurse because the resident stated s/he was hurting. The nurse assessed the resident who had a skin tear to the lower back. I turned the alarm off and back on again, it still did not sound, the nurse checked it also. I was informed to start the hourly vitals and was not sure who stored the wheelchair in the resident's bathroom. The Licensed Practical Nurse assigned to Resident #57 was unavailable for interview, however, per the statement made on the facility's Occurrence Report, dated 10/4/21 revealed, resident got up from bed un-attended, was noted on the floor in doorway of bathroom near back of wheelchair that had been placed in bathroom, evidently scraped the residents back. Fall causing skin tear. Recommendation, do not store wheelchair in bathroom.

Based on observation, record reviews, interviews, and review of facility policy, it was determined for one (1) of 26 sampled residents (Resident #57) the facility failed to ensure that the resident's environment remained free of accidents and hazards as possible, and that the resident received adequate supervision as well as assistance to prevent accidents. The facility failed to ensure resident's safety by not ensuring the wheelchair was properly stored (located in resident's bathroom) by staff resulting in the resident falling in the doorway of bathroom and hitting his/her back on the wheelchair causing a skin tear to lower back and bruising to the right hand and forearm, resulting in harm to the resident. Resident #57 was assessed to require extensive assistance from staff for activities of daily living (ADLs) which included supervision and assistance to keep the resident safe and prevent injuries. Resident #57 was known to have a history of falls resulting in injuries that included fractures while in the facility. Findings Include: Review of the policy entitled. The Fall Management Program, no date revealed, PROGRAM: This policy applies to the staff at the healthcare center. The Fall Management Program has been developed to assist facilities in identifying strategies to minimize the risk of falls for residents and still maintain the highest practical level of functioning and mobility through comprehensive analysis of physical, mental, and psychosocial conditions and the development and implementation of an individualized plan of care. The Fall Risk Data Collection Tool (electronic user define assessment (UDA) determines program placement. 9. Fall Management Program: The following are recommended steps to carry out the Fall Management Program: Completion of Fall Risk Data Collection Tool (electronic UDA), during the admission/readmission process and quarterly. Medication review and clinical condition assessment as needed. Assessment of each resident for history of falls. Environment check of resident's immediate environment taking into consideration the listed Environmental Factors. Interim plan of care to be developed during the admission process for each resident. Newly admitted residents must be identified to all staff through the Daily Shift report, inter-department meetings, and/or the interdisciplinary team meetings. 2. Determination: The determination of the fall risk is necessary to identify those residents who are not only at risk, but also determine factors that place them at risk. Fall risk approaches can then be tailored and individualized. A resident is placed in a Fall Risk Program when one or more of the following apply: Fallen in last thirty days. Ambulatory with uncontained incontinence. Current risk symptoms for falls and not physically or cognitively able to request assistance. Non-ambulatory and attempts to get out of bed or chair without assistance. Interdisciplinary Team/Falls Committee recommends placement. Individual factors compounding risks. When initiating a Fall Management Program, current in-house residents are reviewed using the Fall Risk Data Collection Tool (electronic user defined assessment i.e., UDA) to determine program placement. An investigation will be completed after a fall, regardless if sustained injury, using the Fall Investigation Form. Following investigation, appropriate interventions will be implemented to reduce the risk of further falls. The Fall Risk Data Collection Tool (electronic UDA) is completed quarterly. Attention to environmental risk factors may reduce the incidence of falls. Attention to physical and cognitive status changes may also reduce incidence of falls. Attention to past life experiences also contribute to reducing the incident of falls. 3. Staff Education: Introduction: Falls represent a serious hazard for the older person, posing a threat to their quality of life. A fall is an unintentional change in position coming to rest on the ground, floor, or onto the next surface (e.g., onto a bed, chair, or bedside mat). The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Falls include any fall no matter whether it occurred at home, while out in the community, in an acute hospital or a nursing home. Falls are not a result of overwhelming external force. (e.g., a resident pushes another resident.) Risk Factors: Internal Psychological External Internal Factors: Aging process-Diminished sensory perception. Psychological Factors: Denial of limitations/fall External Factors: Ground surfaces Lighting Stairways Bathrooms Furniture Equipment Other 4. Determination: Determining the fall risk is necessary to identify those residents who are not only at risk, but also to determine factors that place them at risk. Fall Risk Data Collection Tool (electronic UDA). 5. Fall Risk Data Collection Tool: History of falls past ninety (90) days. Internal Risk Factors. Perceptual. Medication. Appliances. 6. Interventions: Identify and treat internal factors. Identify and reduce environmental hazards. Assess gait and balance. Evaluate footwear. Review medications. Review daily routine. Prevent unsafe transfers and ambulation. Address social and psychological needs. 7. Objective: To attempt to provide an environment as free from accidental hazards as possible and provide adequate supervision and assistive devices to attempt to reduce the risk for occurrences. A fall from a nursing home resident may result in one or more of the following: Decreased body system functioning. Decreased mobility leading to development of pressure ulcer, contractures, [CONDITION(S)]/weakness. Disability. Increased susceptibility to disease/infections. Injury. Psychological complications (fear of standing or walking). Reduction in Activities of Daily Living (ADLs). Death. 8. Definitions: For the purpose, of this program the following definitions will be taken into consideration: Accidents Hazards: Physical features in the nursing facility environment that can endanger a resident's safety. Environment: Refers to any area in the facility that is frequented by residents, including the residents' rooms, bathrooms, hallways, activity areas and therapy areas, an uncluttered environment is neat and well kept. Resident Rooms: Pathways from bed to bathroom are kept unobstructed. Cognitive Status: The residents ability to problem solve, decide, remember, be aware of and respond to safety hazards. 9. Occurrence Report: To document all occurrences to residents, employees, and visitors. Procedure: 1. Resident a.) Provide emergency care. b.) Chart occurrence on clinical record. c.) Enter on acute board. Key Points: Notify physician, family, and nursing supervisor. Include all pertinent observations. Obtain individual staff statements for current shift and at least two previous shifts for any/all occurrences not witnessed. Supervisor will investigate occurrence, complete report form, and submit to nursing office before the end of tour of duty. Submit completed Occurrence Report to nursing supervisor as soon as possible during tour of duty. Charge nurse or designee to escort the employee to the nearest hospital emergency room /and or designated physician as indicated. Give description of the circumstances surrounding the occurrence. Include findings by nursing personnel and descriptive statements of occurrence from resident, visitor, employee involved, witness, or individual who first reports occurrence. Document only the facts. Include all pertinent observations. Review of the clinical record revealed Resident #57 was admitted to the facility on [DATE]. The resident was assessed on the Quarterly Minimum Data Set (MDS) assessment, dated 8/31/2021, to have diagnoses of Displaced Fracture of Neck of Femur, Dementia with Behaviors, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], Headaches, Psoriasis, [CONDITION(S)] [CONDITION(S)], Muscle Weakness, Hallucinations, Urine Retention, Bells Palsy, Presence of Right Artificial Hip Joint, Heart Failure, Chronic Diastolic Congestive Heart Failure, Thrombophilia, Poly-[CONDITION(S)], Type 2 Diabetes Mellitus, and Alzheimer's late onset. Resident #57 had a Brief Interview for Mental Status (BIMS) score of three (3) indicating severely impaired cognition. The MDS revealed Resident #57 did not participate in skilled therapies but received restorative nursing programs during the assessment review period. Under Section G functional status, the resident was coded as requiring one (1) person extensive assist from staff for activities of daily living including bed mobility, transfers, toileting, and the use of mobility devices such as wheelchair (manual or electric) and coded to have impairment on one (1) side of the lower extremity. Review of the Care Plan dated, 4/19/21, and revised 6/24/2019, 7/1/2021 ongoing, revealed Resident #57 at risk for falls related to weakness, the most recent quarterly fall risk assessment score 65, showing resident at high risk. Implement high risk fall prevention interventions. Under the goals section, maintain environment free of clutter. Under the interventions section, keep walker and/or wheelchair next to bed, check bed alarm for proper functioning, prior to resident being assisted to bed at night (HS), maintain environment free of clutter and safety hazards, increase rounds to check on resident more frequently, chair alarm until self-release belt for safety of resident related to falls, fall mats to both sides of bed with alarms, staff to apply non-skid socks, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Review of the facility's Morse Fall Risk Assessment fall risk quarterly assessment score, dated 4/19/2021, revealed Resident #57 had a total fall risk score of 65, indicating the resident was at high risk of falls. Review of the facility's Occurrence Report dated 10/4/21 at 9:00 p.m. revealed, Resident #57 got up from bed unattended to go to the bathroom and noted to be on the floor in the doorway of the bathroom, when s/he called for assistance. Resident has skin tear in middle of lower spine from wheelchair that was parked in the bathroom. Bed alarm not sounding however was checked post fall and did sound upon applying/releasing pressure. Recommendations, staff to ensure proper functioning of bed alarm before the resident goes down for the night. Do not store wheelchair in bathroom. Review of the facility's Occurrence Report dated 4/9/21, Resident #57 had a fall resulting in a hip fracture. Review of the facility's Occurrence Report dated 6/1/21, Resident #57 had a fall, no injury. Review of the facility's Occurrence Report dated 6/26/21, Resident #57 had a fall, resulting in a compression fracture to the Lumbar area #1. Review of the facility's Alarm Sign off Report dated 10/1/21-10/6/21, for shifts 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. revealed, the staff nurses indicated the alarm was working on each shift including 10/4/21 night of Resident #57's fall. The facility could not provide any in-services related to ensuring staff were educated on safe transfers or interventions to prevent falls; but provided in-services for safety in long term care setting dated 8/9/21 for all staff. Review of the facility's Head Trauma Protocol dated 10/4/21-10/6/21, revealed vital signs were completed every hour for four (4) hours, then every four hours (4) for 24 hours, then every shift for 48. Observation of Resident #57 on 10/6/21 at 11:55 a.m., dressed well-groomed sitting up in wheelchair doorway of his/her room, seat belt alarm on and non-skid shoes. Fall mats to both sides of the bed. Observation of Resident #57 on 10/6/21 at 1:20 p.m., revealed resident was dressed and well- groomed sitting up in wheelchair at bedside table eating lunch. Dressed and well-groomed with non-skid shoes on and call light was within reach. Fall mats to both sides of the bed. Bed alarm working. Observation of Resident #57 on 10/6/21 at 2:24 p.m., revealed resident sitting up in wheelchair in the room, dressed and well-groomed had on non-skid shoes visiting with son; surveyor tested the alarm on bed, and it was working. Fall mats to both sides of the bed. Observation of Resident #57 on 10/7/21 at 10:43 a.m., revealed resident resting in bed, alarm on and call light in reach. Fall mats to both sides of the bed. Wheelchair not stored in bathroom. Bed alarm working. Observation of Resident #57 on 10/8/21 at 9:15 a.m., revealed resident sitting up in bed eating breakfast, fall mats to both sides of the bed, call light in reach and wheelchair noted in room and not the bathroom. An interview was conducted on 10/6/21 at 2:24 p.m. with Family of Resident #57 revealed, I am aware of the falls with injuries, this is tiresome the facility can't prevent the falls, if s/he is going to get up, something needs to be done to prevent these injuries. S/he has alarms on the bed, wheelchair and anti-tippers as well. There have been times that I set off the bed alarm and they did not come or took them 20 minutes to answer the call light. S/he had falls at home and broke one hip and wrist, then broke the other hip here. The facility was aware of the fall risks upon admission, I feel they need to do more. An interview was conducted on 10/7/21 at 11:00 a.m. with the Director of Nursing (DON) and the Administrator while rounding on the unit, revealed the fall on 10/4/21 for Resident #57 just happened on Monday. We had not been able to fully investigate the incident. We expect staff as much as possible to ensure safety hazards are removed from the resident's room and the wheelchair to be out in the hallway or in the room when not in use. We may at times store the wheelchair in the bathroom, but typically in the hallway. For the fall on 10/4/21, what we know is the wheelchair was in the resident's bathroom, the bed alarm did not sound, but the light was flashing when staff entered the room. Our expectation is that staff ensure the alarms are working and charted on the Medication Administration Record (MAR) each shift. An interview conducted on 10/7/21 at 11:08 a.m. with Certified Nursing Assistant (CNA) #3 revealed, Resident #57 requires one person assist with ADLs. I recall the fall back in April of this year, I was walking down the hallway and noticed the resident on the floor by the entryway of the room. We have been in-serviced on trip hazards, but since the resident is non-mobile, we store the wheelchair in the hallway. An interview conducted on 10/7/21 at 11:16 a.m., with Licensed Practical Nurse (LPN) #2 revealed, We are responsible for checking the alarms each shift and charting them in the MAR. Resident #57 has alarms on the wheelchair and bed, we do two (2) hour checks and frequently by walking past the room and looking in on the resident. S/he is one (1) to two (2) persons assist with ADLs. The wheelchair is stored in the room or the hallway when not in use, we ensure the room stays free of clutter. An interview conducted on 10/7/21 at 2:53 p.m. with Certified Nursing Assistant (CNA) #4 which revealed, Resident #57 yelled out and I went into the room s/he was on the floor outside the bathroom door with back up against the wheelchair. I asked what s/he was doing, and the resident stated I was going to the bathroom. CNA #4 further revealed, I did not hear the bed alarm go off, the resident has an alarm on the bed, the light was flashing, but the alarm was not sounding. I called for the nurse because the resident stated s/he was hurting. The nurse assessed the resident who had a skin tear to the lower back. I turned the alarm off and back on again. It still did not sound. The nurse checked it also. I was informed to start the hourly vitals and not sure who stored the wheelchair in the resident's bathroom. The Licensed Practical Nurse assigned to Resident #57 was unavailable for interview, per the statement made on the facility's Occurrence Report, dated 10/4/21, which revealed the resident got up from bed unattended, was noted on the floor in the doorway of bathroom near the back of the wheelchair that had been placed in bathroom, which evidently scraped the resident's back. Fall causing skin tear. Recommendation, do not store wheelchair in bathroom.

Based on observation, interview, and review of facility policy, the facility failed to ensure one (1) facility staff member serve residents meals utilizing proper hand hygiene. Residents affected were in the rooms #113 A, #113 B, and #118. Findings include: On 10/5/2021 at 12:19 p.m. lunch observation of Certified Nursing Assistant (CNA) #1 revealed s/he walk from a resident's room on the Oak Terrace hall. Observed CNA #1 approach the lunch tray cart and get a tray off the cart without sanitizing his/her hands. Observed CNA #1 walk down the hall to room [ROOM NUMBER] to assist one (1) resident in a private room with the lunch tray set up. CNA #1 was observed to move items around on resident's bedside table while assisting with the lunch tray set up. CNA #1 was observed to exit the resident's room and walk by five (5) hand sanitizer stations (one (1) hand sanitizer station was located near the lunch carts). Continued observation of CNA #1 revealed s/he did not sanitize his/her hands and got another lunch tray from the lunch cart. CNA #1 was observed to walk down the hall to room [ROOM NUMBER] and dropped a straw wrapped in paper on the floor. CNA #1 was observed to place room [ROOM NUMBER] A's tray on the bedside table and walk out of the room. CNA #1 was observed to then walk by three (3) hand sanitizer stations and not sanitize his/her hands. CNA #1 was observed to remove a third lunch tray from the lunch cart and bend down to pick up the straw that had been dropped on the floor. S/he was observed to carry the straw and tray into room [ROOM NUMBER] and assist resident in room [ROOM NUMBER] B with lunch set up. CNA #1 was observed to touch resident's blanket and assist resident with sitting up on the side of the bed to eat lunch. S/he was observed to open the straw that had been dropped on the floor for resident in room [ROOM NUMBER] B. S/he then sat on the side of the resident's bed (room [ROOM NUMBER] A) and assist with feeding the resident. On 10/5/2021 12:23 p.m., an observation of room [ROOM NUMBER]'s trash can revealed there was no straw in the trash. The trash can was empty. On 10/5/2021 at 1:01 p.m., an interview with CNA #1 revealed that s/he has been employed at the facility for two (2) years and receives hand hygiene education quarterly. S/he stated that s/he forgot to sanitize his/her hands and was supposed to sanitize/wash hands between each resident. CNA #1 confirmed picking the straw off the floor while carrying a lunch tray and placing the straw on the table. S/he stated that she placed the straw in the trash can. On 10/7/2021 at 10:48 a.m., an interview with Staff Development/Infection Control-Registered Nurse (RN) revealed s/he has been the staff coordinator for the facility for three (3) weeks. S/he stated that in-services will be provided as needed and every week for hand hygiene and donning and doffing Personal Protection Equipment (PPE). S/he stated that staff are expected to sanitize/wash hands before entering a resident's room and coming out of a resident room. S/he stated that if any items were to fall on the floor the staff can pick up the items, place in the trash or linen and sanitize/wash hands or leave the item on the floor for housekeeping to get. S/he stated that there was an education session given on hand hygiene on Tuesday, October 5, 2021. Review of the Hand Hygiene form undated revealed, Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: Before and after eating or handling food (hand washing with soap and water), before and after assisting a resident with meals. Review of the Hand Washing Technique policy revision date 5/8/07 revealed the alternate technique for hand hygiene objective: To prevent the spread of infection, procedure: 1. Apply a dime size dollop on palm of one hand and 2. Rub hands together covering all surfaces until hands are dry. Review of the Hand Washing checklist dated 2/5/2021 revealed CNA #1 completed a hand washing checklist. Review of CNA #1 online education tool revealed s/he completed Infection Prevention and Control for All Staff on 9/2/2021. Review of the Handwashing quiz dated 2/5/2021 revealed CNA #1 completed the handwashing quiz.

Based on observation and interview, the facility failed to remove out of date boiled eggs in the refrigerator, had rusty/baked on food on wire storage rack, and an open large trash barrel during meal serving time (1 of 1 main kitchen). The findings included: During the initial tour of the kitchen on 9/23/19 at 9 AM with both the Cook and the Dietician, a container of 10-12 boiled eggs was in the refrigerator over 72 hours. These were removed by the Dietician. There was a large gray 30 gallon trash can uncovered in the area while breakfast trays were being served. On 9/25/19 at 11:15 AM, the trash barrel was again observed uncovered while lunch trays were being served. On both days, a wire storage rack beside the stove was observed with rust and a dark brown caked on substance on the wires. Equipment and food containers were sitting on the rack. The Dietician and the Corporate Dietary Consultant both confirmed these findings.

Based on interview and record review, the facility failed to follow pharmacy recommendations for 2 of 5 residents reviewed for unnecessary medications. The pharmacist recommended that Residents #10 and #70 be given an Abnormal Involuntary Movement Scale (AIMS) on admission to establish baseline. The recommendation went unfollowed. The findings included: Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #70 orders on 9/24/19 at approximately 2:20 PM revealed the resident took 1 mg [MEDICATION NAME] twice a day. Review of Resident #70 medication regimen reviews 9/24/19 at approximately 3:29 PM revealed an admission review dated (MONTH) 31, 2019 that recommended an AIMS assessment be conducted at admission and every three months. No AIMS assessment could be found in the record at that time. Interview with Director of Nursing (DON) on 9/25/19 at approximately 11:20 AM revealed an AIMS assessment had been conducted that morning. It was the first AIMS assessment for Resident #70 since admission. The DON confirmed an AIMS assessment should have been performed when the pharmacist first recommended it in July. Resident #10's Medical Record reviewed on 9/26/19 at 10:06 AM revealed on 4/10/19 AIMS assessment was recommended by Pharmacist to be done now and every 3 months. AIMS test was completed on 6/14/19 only and none were noted in the medical record. During an interview with Registered Nurse (RN) #1 on 9/26/2019 at 10:36 AM, RN #1 stated that AIMS assessments were not being done as ordered. When asked about procedures to follow up on pharmacist recommendations, RN #1 stated that she and second shift nurse were to review all pharmacy recommendations and send all documents to the DON. An interview with the DON on 9/26/2019 at 10:44 AM revealed that the DON sends all recommendations to the night shift nurse after s/he reviews them to be followed up on and completed. The DON revealed that software had been updated and it will begin alerting staff when AIMs testing will need to be completed. The DON also confirmed pharmacist recommendations for AIMS was not completed per recommendations.

Based on record review and interview, the facility failed to implement care plan interventions for 1 of 5 residents reviewed for unnecessary medications. Resident #70 was care planned to be given 'AIMS per protocol' but when pharmacy recommended an AIMS assessment, it was not done. The findings included: Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #70 orders on 9/24/19 at approximately 2:20 PM revealed the resident took 1 mg [MEDICATION NAME] twice a day. Review of Resident #70 care plan on 9/24/19 at approximately 2:26 PM revealed the resident was care planned for [MEDICAL CONDITION] drug use and possible side effects. Interventions care planned included assessing for adverse side effects and conducting AIMS assessment per protocol. Review of Resident #70 medication regimen reviews 9/24/19 at approximately 3:29 PM revealed an admission review dated (MONTH) 31, 2019 that recommended an AIMS assessment be conducted at admission and every three months. No AIMS assessment could be found in the record at that time. Interview with Director of Nursing (DON) on 9/25/19 at approximately 11:20 AM revealed an AIMS assessment had been conducted that morning. It was the first AIMS assessment for Resident #70 since admission. The DON confirmed an AIMS assessment should have been performed when the pharmacist first recommended it in July.

Based on observations, limited record reviews, interviews, and policy reviews, the facility failed to ensure Resident #55 received the required respiratory care including monitoring of Oxygen saturation levels required to titrate Oxygen supplementation liter flow rate as ordered and use of oxygen on treatment record or electronic medical record to include oxygen rate of flow per facility policy for 1 of 1 reviewed for respiratory care. The findings included: Limited record review on 8/1/18 at 1:06 PM revealed that Resident #55 was admitted to the facility with the [DIAGNOSES REDACTED]. Medical record review on 8/1/18 at 4:36 PM revealed that Resident #55's physician orders [REDACTED]. Further review of the Physician orders [REDACTED].#55 on a routine basis or as needed. Additional medical record review on 8/1/18 at 4:45 PM of the Treatment Administration Records (TARS) for (MONTH) 1, (YEAR) through (MONTH) 1, (YEAR) revealed the following regarding Oxygen administration: (MONTH) (YEAR): dates/ times used with no specified liter flow or documented oxygen saturation level 6/2/18 10:59 AM 6/3/18 7:16 AM 6/7/18 11:29 PM 6/9/18 11:01 AM 6/10/18 11:31 AM 6/15/18 8:02 AM 6/16/18 7:52 AM 6/17/18 11:34 AM 6/22/18 9:38 PM 6/23/18 10:51 AM 6/24/18 11:13 AM 6/27/18 8:52 PM (MONTH) (YEAR): dates/ times used with no specified liter flow or documented oxygen saturation level 7/1/18 5:56 PM 7/4/18 3:10 PM 7/6/18 3:03 PM 7/24/18 8:51 PM 7/27/18 7:14 AM (MONTH) 1, (YEAR) date/ times used with no specified flow or documented oxygen saturation level NO entries for (MONTH) 1st at time of review. Review of facility policies received on 8/2/18 revealed on Oxygen Therapy policy with revision date 5/31/17, item #7 under Procedure read as follows: Record oxygen therapy on treatment record or in EMR (Electronic Medical Record) to include rate of flow. During interview with Director of Nursing on 8/2/18 at 11:25 AM, s/he reported that there was no evidence in medical record that Oxygen saturation level readings were obtained between (MONTH) 1, (YEAR)-August 2, (YEAR). S/he further reported that the last time Oxygen Saturation levels were monitored for Resident #55 was (MONTH) (YEAR) and that the Oxygen saturation levels were not consistently monitored. Additionally, s/he verified that there is no supportive documentation to reflect monitoring of Oxygen saturation levels to determine how to titrate the oxygen liter flow rate as outlined in the physician order [REDACTED].#55 had received oxygen continuously during multiple observations by surveyor from 7/30/18 through time of interview on 8/2/18. DON further agreed that the facility was not following the Oxygen Therapy policy with revision date 5/31/17 regarding documentation of oxygen therapy on treatment record or in electronic medical record to include rate of flow.

The facility failed to ensure that Residents #5, #19, #46, and #61 had comprehensive care plans that were updated to reflect changes in physician orders [REDACTED]. The facility failed to update the comprehensive care plan for Resident #5 related to use and risk of adverse effects of antipsychotic medication. The facility failed to update the comprehensive care plan for Resident #19 related to use of assistive device and episodes of coughing and choking during meals. The facility failed to update the comprehensive care plan for Resident #46 related to discontinuation of anticoagulant medication. And finally, the facility failed to update the comprehensive care plan for Resident #61 related to recurrent refusals of respiratory interventions and routine respiratory intervention equipment checks. The findings included: The limited medical record review conducted on 8/3/18 at 11:58 AM revealed that the facility admitted Resident #5 with the [DIAGNOSES REDACTED]. Review of the Monthly Physician orders [REDACTED].#5 was ordered to receive [MEDICATION NAME] 50 mg every night at bedtime with an order date of 4/27/18 and start date of 6/25/18 as well as [MEDICATION NAME] 5 mg daily with an order date of 7/31/18 and start date of 8/4/18. Review of the comprehensive care plan on 8/3/18 at 2:31 PM revealed that there were no problems or interventions on any of the 23 pages that addressed the use of and/or risk for adverse effects of antipsychotic medications. During interview with MDS(Minimum Data Set)/RAC (Resident Assessment Coordinator) Nurse #1 on 8/3/18 at approximately 3:15 PM, s/he verified that there were no specific problems or interventions outlined on care plan problem that addressed use of or risk for adverse effects of antipsychotic medications. The limited record review conducted on 8/3/18 at 11:10 AM revealed that the facility admitted Resident #46 with [DIAGNOSES REDACTED]. Further review of Resident #46's medical record on 8/3/18 revealed that page 17 of 47 of the comprehensive care plan addressed risk for abnormal bleeding related to use of anticoagulant therapy with onset date of 2/5/2010 and goal for no complications related to anticoagulant therapy through next assessment with goal target date of 9/13/18. Additional review of the record reveals a handwritten physician order [REDACTED]. During interview with MDS/RAC Nurse #2 on 8/3/18 at 11:39 AM, s/he verified that the anticoagulant xarelto was discontinued on 7/7/18 ant that the care plan had not been updated to reflect this change as of the date of the interview on 8/3/18. The limited record review conducted on 8/2/18 at 10:00 AM revealed that Resident #61 was admitted to the facility with the [DIAGNOSES REDACTED]. Review of the Treatment Administration Records (TAR) for (MONTH) 1, (YEAR) through (MONTH) 1, (YEAR), revealed that Resident #61 refused the application and/or use of Bilevel Positive Airway Pressure ([MEDICAL CONDITION]) treatments 23 out of 30 days in (MONTH) (YEAR), 28 out of 31 days in (MONTH) (YEAR), and 1 out of 1 day in (MONTH) (YEAR). Review of the Comprehensive care Plan on 8/2/18 at 12:30 PM revealed that on page 17 of 22 identified problem .is at risk for SOB (Shortness of Breath), poor endurance, and other complications related to [DIAGNOSES REDACTED]. Goal for this care plan problem was listed as .will have no extended episodes of SOB through next assessment period with goal target date of 9/30/18. Additional review of the care plan reveals that there is no mention of recurrent refusal of application and/or use of [MEDICAL CONDITION] treatments and education of risks for this decision as an approach of the plan of care. Further review of the care plan reveals that there is no intervention to correspond with the physician order [REDACTED]. During interview with MDSRAC Nurse #2 on 8/2/18, s/he verified that there were no specific interventions outlined on care plan problem that addressed Resident #61's recurrent refusal of application and/or use of [MEDICAL CONDITION] treatments and education of risk for this decision nor any interventions to reflect annual [MEDICAL CONDITION] visits to manage the settings of the [MEDICAL CONDITION] machine initiated on 1/9/18. Resident #19 was admitted with [DIAGNOSES REDACTED]. During an observation on 7/30/18 at 11:26 AM, Resident #19 was eating lunch in the dining room, feeding himself with weighted utensils and drinking from cup, he/she was coughing throughout the meal service head positioned to the left. During an interview with the Registered Dietitian on 07/31/18 at 04:57 PM he/she said that he/she was aware of resident's coughing pattern at meals and the resident has worked with speech therapy to help correct the situation. He/She said resident was non-compliant with thickened liquids and was aware that a special straw was attempted as an intervention to help with coughing at meals. Review of the Physician Telephone order on 3/3/18: which states: Speech Therapy (ST) discontinued (d/c) clarification. The Therapy note on 3/3/18 states: Patient has achieved maximum potential with dsypahgia management. Physical Therapy Assistant (PTA) and Caregiver (CG) demonstrate compliance and use of care of adaptive Bionix Safe Swallow Straw. Coughing after swallow initiation still occurs, but patient is coughing on less. Review of the Physician order [REDACTED]. Review of Resident #19's CNA Care and Data Collection Guide for the month of (MONTH) (YEAR) states, For Your Information (FYI)-Thickened Liquids/Location of Meal, Mechanical Soft Diet; built up spoon,fork,knife. Review of the Care Plan for Resident #19 states: Problem Onset: 12/16/16: Resident #19 requires a mechanically altered diet related to (r/t) difficulty chewing/swallowing. He also receives built up silverware to encourage independent eating. During an interview on 07/31/18 at 05:05 PM, The DON verified that the care plan had not been updated to reflect the resident's frequent coughing and choking at meals and the interventions attempted and the the special straw.

Based on record review and interview, the facility failed to identify and/or complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) in a timely manner for 1 of 1 resident reviewed for hospice services and 1 of 5 residents reviewed for unnecessary medications. The facility did not complete the SCSA for Resident #46 within 14 days following admission to hospice services, and further failed to identify and complete a SCSA MDS for Resident #5 when there was evidence of declines from comprehensive assessment in at least two areas on at least three different occasions. The findings included: The facility admitted Resident #46 with [DIAGNOSES REDACTED]. Record review on 7/31/18 at 10:15 AM revealed that Resident #46 was admitted to hospice services with a start date effective 5/29/18. Additional review revealed that Resident #45 had a SCSA MDS with an Assessment Reference Date (ARD) of 6/6/18 completed and signed by RN on 6/16/18. Review on 7/31/18 of the MDS Resident Assessment Instrument (RAI) Manual version 1.15 effective date 10/1/2017; Chapter 2 page 2-23 revealed the following: The MDS completion date (Item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for a SCSA were met. MDS/RAC Nurse #2 verified during interview on 8/3/18 at 11:39 AM that the SCSA initiated when Resident #46 was admitted to hospice services on 5/29/18 was not completed within the required time frame. S/he verified that the ARD for the SCSA MDS was 6/6/18 and item Z0500B was signed by RN to signify that assessment was complete on 6/16/18, which was 18 calendar days after admission to hospice services. The facility admitted Resident #5 with the [DIAGNOSES REDACTED]. Review of the medical record on 8/3/18 at 11:58 AM revealed that an Admission Comprehensive Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 10/20/17 was signed as complete on 10/25/17. Further review revealed that Section C on the MDS with ARD of 10/20/17 was coded to reflect that Resident #5 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), and that Section D was coded to reflect that Resident #5's Mood Interview score was 1 out of 30. Additional review revealed that there were no identified behaviors coded in Section E and that Section H was coded to reflect that Resident #5 was occasionally continent of bladder. Finally, review revealed that Section N was coded to reflect that Resident # 5 did not receive any antipsychotic medications during the assessment period of 10/14/17-10/20/17. Ongoing review of the medical record on 8/3/18 revealed that the Quarterly MDS assessment with ARD of 1/26/18 was signed as complete on 2/1/18. Further review revealed that Section C of the MDS with ARD of 1/26/18 was coded to reflect that Resident #5 scored a 4 out of 15 on the BIMS, and that Section D was coded to reflect that Resident #5's Mood Interview score was 21 out of 30, indicating declines in both cognitive and status compared to the comprehensive assessment with ARD of 10/20/17. Additional review revealed that Section E was coded to reflect rejection of care occurred 4-6 days during assessment period of 1/20/18-1/26/18, and Section H was coded to reflect that Resident #5 was frequently incontinent of bladder, indicating declines in both behaviors and urinary continence compared to the comprehensive assessment with ARD of 10/20/17. Finally review of section K revealed that Resident #5 sustained a significant weight loss not related to a Physician prescribed program and Section N was coded to reflect that Resident #5 received 7 days of antipsychotic medications during the assessment period of 1/20/18-1/26/18, indicating declines in status related to unplanned weight loss and onset of use of antipsychotic medication in relation to the comprehensive assessment with ARD of 10/20/17. Overall, there were 6 areas of decline identified on the Quarterly MDS assessment with ARD of 1/26/18 when compared to the comprehensive MDS assessment with ARD of 10/20/17, indicating the need for Significant Change in Status Assessment MDS with no evidence that the declines were identified or discussed by the interdisciplinary team at the time of the completion Quarterly MDS assessment on/ before 2/1/18. Additional review of the medical record on 8/3/18 revealed that the Quarterly MDS assessment with ARD of 4/25/18 was signed as complete on 5/4/18. Further review revealed that Section C of the MDS with ARD of 4/25/18 was coded to reflect that Resident #5 scored a 0 (zero) out of 15 on the BIMS, and that Section D was coded to reflect that Resident #5's Mood Interview score was 9 out of 30, indicating declines in both cognitive and status compared to the comprehensive assessment with ARD of 10/20/17. Additional review revealed that Section E was coded to reflect rejection of care occurred daily during assessment period of 4/19/18-4/25/18, indicating decline behaviors compared to the comprehensive assessment with ARD of 10/20/17. Finally review of Section N was coded to reflect that Resident #5 received 7 days of antipsychotic medications during the assessment period of 4/19/18-4/25/18, indicating declines in status related to unplanned weight loss and onset of use of antipsychotic medication in relation to the comprehensive assessment with ARD of 10/20/17. Overall, there were 4 areas of decline identified on the Quarterly MDS assessment with ARD of 4/25/18 when compared to the comprehensive MDS assessment with ARD of 10/20/17, indicating the need for Significant Change in Status Assessment MDS with no evidence that the declines were identified or discussed by the interdisciplinary team at the time of the completion Quarterly MDS assessment on/ before 5/4/18. Further review of the medical record on 8/3/18 revealed that the Quarterly MDS assessment with ARD of 7/24/18 was signed as complete on 8/1/18. Further review revealed that Section C of the MDS with ARD of 7/24/18 was coded to reflect that Resident #5 scored a 0 (zero) out of 15 on the BIMS, and that Section D was coded to reflect that Resident #5's Mood Interview score was 20 out of 30, indicating declines in both cognitive and status compared to the comprehensive assessment with ARD of 10/20/17. Finally review of section K revealed that Resident #5 sustained a significant weight loss not related to a Physician prescribed program and Section N was coded to reflect that Resident #5 received 7 days of antipsychotic medications during the assessment period of 7/19-/18-7/24/18, indicating declines in status related to unplanned weight loss and onset of use of antipsychotic medication in relation to the comprehensive assessment with ARD of 10/20/17. Overall, there were 4 areas of decline identified on the Quarterly MDS assessment with ARD of 7/24/18 when compared to the comprehensive MDS assessment with ARD of 10/20/17, indicating the need for Significant Change in Status Assessment MDS with no evidence that the declines were identified or discussed by the interdisciplinary team at the time of the completion Quarterly MDS assessment on/ before 8/1/18. Review of the MDS assessments on 8/3/18 revealed that a SCSA MDS was not initiated within 14 days of the identification of the declines in multiple sections of each Quarterly MDS assessments that were completed on or before 2/1/18, 5/4/18, and 8/1/18 as required. During an interview on 8/3/18 at 3:15 PM MDS/RAC Nurse #1 reviewed the MDS assessments with ARD's of 10/20/17, 1/26/18, 4/25/18 and 7/24/18 and confirmed that Resident #5 had a decline in at least two areas when each quarterly MDS assessment were completed and a SCSA was not completed at the time of the review for each of the quarterly MDS assessments. S/he further verified that there was no discussion between the members of the interdisciplinary team related to the need for SCSA related to at least 2 areas of change between comprehensive MDS assessment with ARD of 10/20/17, and the quarterly MDS assessments with ARD's of 1/26/18, 4/25/18, and 7/24/18.

Based on observation, interview and record review, the facility failed to provide service to prevent further Range of Motion (ROM) decline for resident #19 with a restorative ROM program in place and not consistently implemented by qualified staff related to staffing issues for 1 of 2 residents reviewed for position mobility. The findings included: Resident #19 was admitted with [DIAGNOSES REDACTED]. Resident #19's Care Plan states: Problem/Need, Problem Onset: 05/23/2014, Resident #19 has decreased joint mobility of Bilateral Upper Extremities (BUE)/ Bilateral Lower Extremities (BLE). Goal and Target Date, *Will have no further decrease in joint mobility of BUE/BLE as evidenced by (AEB) completing flexion/extension 10 reps 3 times 5 days week through next review 8/15/2018. Approaches, *Active ROM: Restorative Active Range of Motion (AROM) to all joints BUE/BLE flexion/extension 10 reps 3 times 5 days week to continue to promote joint mobility. *Explain procedure to promote understanding and cooperation. *Praise for effort and encourage participation. *Provide rest periods as needed. *Report any changes or decline to the restorative nurse. The Restorative Roster dated 7/1/2018 to 7/31/2018 for Resident #19 shows that Active Range of Motion occurred 5 days out of 31 days for (MONTH) (YEAR). During an interview on 08/01/18 at 12:14 PM with DON, he/she said that there is a Restorative Certified Nurse Assistant (CNA) and that he/she verified the inconsistency of the completion of range of motion exercises and stated this is due to staffing issues. The DON verified for the month of (MONTH) (YEAR), that Resident # 19 received ROM therapy 5 days out of 31 days. He/She stated that the facility is training other CNA and Nurses to perform ROM but they have yet completed the training. The DON said that unless the CNAs and the Nurses have completed training they are not educated and unable to document resident participation in restorative therapy.