Every finding on record at Wildewood Downs

Based on review of facility policies, record review, observations and interviews, the facility failed to ensure proper personal protective equipment (PPE) was used for Resident (R)2 during a dressing change. In addition, the facility failed to follow proper procedures related to dressing changes for 1 of 1 resident reviewed.Findings include:Review of the facility's policy titled, Enhanced Barrier Precautions with a copyright dated 2001 Med-Pass, Inc. states, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents.Policy Interpretation and Implementation1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organism (MDROs) during high contact resident care activities.2. Enhanced barrier precautions apply when:b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; and4. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status.6. Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen.7. EBPs employ targeted gown and glove use in addition to standard precautions during high-contact resident care activities when contact precautions do not otherwise apply.a. Gloves and gown are applied prior to performing the high-contact resident care activity (as opposed to before entering the room).8. Examples of high-contact resident care activities requiring the use of a gown and gloves for EBPs include:a. dressingj. wound care (any skin opening requiring a dressing).Review of the facility's policy titled, Dressings, Dry/Clean with a copyright dated 2001 Med-Pass, Inc. states, The purpose of this procedure is to provide guidelines for the application of dry, clean dressings.Steps in the Procedure5. Wash and dry your hands thoroughly.6. Put on clean gloves. Loosen tape and remove soiled dressing.7. Pull glove over dressing and discard into plastic or biohazard bag.8. Wash and dry your hands thoroughly.9. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface.10. Label tape or dressing with date, time and initials. Place on clean field.11. Using clean technique, open other products (i.d., prescribed dressing; dry, clean gauze).12. Wash and dry your hands thoroughly.13. Put on clean gloves.14. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage.15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward).16. Use dry gauze to pat the wound dry.19. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly.22. Clean the bedside stand.23. Wash and dry your hands thoroughly.Review of R2's Face Sheet revealed R2 was admitted on [DATE] with diagnoses including, but not limited to, muscle weakness (generalized), dysphagia, oral phase, and fusion of spine, lumbar region.Review of R2's Care Plan with a start date of 12/19/25, documented Pressure ulcer-stage II pressure injury to the sacrum. Further review of the care plan revealed the following interventions: Provide skin care per facility's guidelines and prn as needed, monitor ulcer for signs of progression or declination, and educate resident/resident representative (RR) about proper skin care to prevent skin breakdown.During an observation on 01/22/26 at 01:58 PM, Licensed Practical Nurse (LPN)1 entered R2's room without donning [putting on] a gown. The surveyor observed LPN1 washing hands and donning gloves to change R2's sacral dressing. LPN1 cleaned R2's sacral wound with wound cleanser with a 4x4 dressing. LPN1removed the gloves and rewashed hands. LPN1 opened the bordered gauze, placed Medi honey on the gauze, and placed on R2's sacral wound. LPN1 removed the black marker from her pocket and labeled the dressing. LPN1 placed the dressing on R2's sacral area. During an observation on 01/22/26 at 02:05 PM, LPN1 removed R2's sock and donned gloves to remove the bordered gauze. The nurse washed her hands before labeling the gauze. LPN1 cleaned the wound with wound cleanser. LPN1 did not clean off the bedside table or the black marker. During an interview on 01/22/26 at 02:22 PM, LPN1 stated, When asked about the use of PPE, LPN1 stated, I forgot to put it on. I know we need to wear our PPE, I don't know why I forgot it. When asked about training related to PPE requirements, LPN1 stated, We do have in-person in-services and on Relias. Sometimes our training is one-on-one. On the weekend, staff are trained by our weekend nurse managers.During an interview on 01/22/26 at 04:58 PM, the Administrator stated, We will provide additional training on wound dressing changes.

Based on review of the facility policy, observations, and interviews, the facility failed to ensure medications and biologicals remained sterile in 1 of 1 treatment carts reviewed.Findings include:Review of the facility's policy titled Medication Labeling and Storage copyrighted 2001 Med-Pass, Inc, revealed The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.Policy Interpretation and Implementation:2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.During an observation on 01/21/26 at 11:37 AM, the treatment cart on the Rehabilitation Unit revealed the following:Xerofoam Gauze Dressing with 3% Bismuth Tribromophenate and petroleum 4x4 Lot F-20250110 exp 20280109. The DermaRite Sterile packet was cut and packet open. PolyMem, 4x4 non-adhesive pad, reference #5044, expires 2028/07. The pack was marked sterile, however it was observed to have been left open.Medline TheraHoney HD sheet honey impregnated wound dressing 4x5 rectangle, marked as sterile and left open.3M Silvercel, non-Adherent Antimicrobial alginate dressing, marked as sterile and left open. [NAME] Medical Surgical Inc. Lot CZI10-01 MFR#240P Suture Removal Kit metal forceps, open in a sterile container.During an interview on 01/21/26 at 12:00 PM, the Assistant Director of Nursing (ADON) stated, The door is locked behind the nursing station, so the treatment cart can be unlocked. We will do an in-service on infection control of the open sterile dressings.During an interview on 01/22/26 at 5:15 PM, the Administrator stated, The expectation is we will use it or dispose of it. I will look more into this. We initiated education when it was brought to my attention. We will have the Infection Preventionist (IP) Nurse go through the process for Infection Control.

Based on observation, interview, and facility policy the facility failed to ensure that opened food items were properly labeled and stored, 2 of 2 kitchens reviewed. Findings include: Review of an undated policy titled, Food Receiving and Storage, revealed Foods shall be received and stored in a manner that complies with safe food handling practices. Initial tour of the Skilled Nursing Kitchen on 10/08/24 at 10:00 AM revealed the following items opened, but not dated: In a overhead shelf: -2 bottles of Steak Sauce -A bottle of Ketchup -A bottle of Malt Vinegar -1 container of house blend coffee Observation and interview with the Dietary Manager for the Skilled unit on 10/08/24 at 10:05 AM revealed that staff did not update the Food Storage Bin Log to reflect the sugar that was added to the bin on 10/07/24. Review of the Food Storage Bin Log revealed that it was last updated in July 2024. Observation on 10/08/24 at 10:07 AM of a drying rack revealed several wet cups stacked on top of each other. An observation on 10/08/24 at 10:10 AM of a storage rack revealed personal items, belonging to some of the kitchen staff and a bin of bananas stored beside each other. During an interview with the Dietary Manager and Kitchen Staff, it was confirmed that personal items are not be stored in the kitchen. An observation on 10/08/24 at 10:15 AM of a double door refrigerator/cooler revealed the following item not labeled after opening: -1 gallon of milk An observation on 10/08/24 at 10:17 AM of the Main Kitchen revealed the following items not labeled after opening: In the dry storage room: -1 container of peanut butter -1 bag of cereal (corn flakes) In the freezer: -1 box of biscuit dough -1 box of stew vegetable mix -1 freezer bag of salami -1 freezer bag of cubed cheese An interview with the Kitchen Manager on 10/08/24 at 10:30 AM revealed that all food items are to be labeled and dated after opening and personal items are not be stored near food items.

Based on interview, record review, and facility policy, the facility failed to ensure Resident (R)4 had adequate supervision to prevent a fall. 1 of 3 reviewed for accident/hazards. Findings include: Review of facility policy, date unspecified, titled, Falls and Fall Risk, Managing revealed Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The staff, with input of the attending physician, will implement a resident-centered fall prevention plan the specific risk factor(s) of falls for each resident at risk or with a history of falls. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention has resolved. R4 was admitted to the facility on [DATE] with diagnoses including but not limited to fracture of left lower femur, encounter for orthopedic aftercare, and morbid severe obesity due to excess of calories. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date of 08/05/24 revealed that R4 has the Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicates that she is cognitively intact. Further review of the Admission MDS revealed that R4 is dependent on staff for toileting hygiene. Record review of R4's Nurses Notes dated 08/05/24 revealed At approximately 7:45 PM Certified Nursing Assistant (CNA) approached nurse in hallway and requested help. Nurse entered room and bed was in highest position, resident was on floor lying on her left side. CNA stated that she was providing incontinent care without a second person. Nurses assessed resident for injury, resident stated repeatedly that she was okay. Nurse and CNA used Hoyer lift to assist resident back to her bed. Resident did not lose consciousness during this episode. She remained alert. Nurse assessed resident again when she was back in bed, and noted swelling and bruising to her left forearm, and a swollen spot to her head. Resident stated that she was in pain to her arm and head and needed pain medication. As needed pain medication administered to resident notified R4's resident representative informing her of incident. Nurse suggested to resident that she go to the hospital for evaluation, resident refused. Nurse re-emphasized the importance of going considering she hit her head, and her injured leg. She then agreed to go hospital. Resident left facility via stretcher to hospital. Director of Nursing (DON) and Resident Care Coordinator (RCC) notified of transfer and incident. Record review of R4's Nurses Notes dated 10/07/24 revealed At around 3:00 pm reported by another nurse, patient noted sitting in front of her wheelchair. Per Therapy during her sliding board transfer training, patient begin to scoot off board interiorly and unable to scoot back in bed, patient requires maximum assist to slowly lower to ground with slide onto buttocks. Then other nurse and Therapy get patient up from floor using Hoyer lift to put back in the wheelchair. Assessment done no noted any injury and no verbalizes complaint of pain. Patient placed on monitoring; patient informed us to place a call to daughter at around 5-6 pm after her work from school. Review of R4's Care Plan dated 07/30/24 - present revealed R4 is at risk for falls related to overall weakness, history of fall resulting in left hip fracture. Interventions include resident requires two-person assist for all bed mobility and Activities of Daily Living (ADL)s. Re-educated therapy staff and nursing staff on safety precautions and ADLs. Footwear will fit properly and have non-skid soles. Keep areas free of obstructions to reduce the risk of falls or injury. Place call light within easy reach. An interview on 10/09/24 at 12:30 PM with R4 revealed that back in August (08/05/24), a CNA was providing incontinence care to them without a second person, and they rolled off the bed. R4 stated that she went to the hospital and had some bruising after the fall but did not have any injury. R4 continued to talk about having a second incident with therapy staff where she had to be lowered to the ground due to weakness. R4 stated that normally there are always two people with me, but the therapy staff member was working alone as well. A phone interview on 10/10/24 at 10:13 AM with R4's Resident Representative (RR) revealed that R4 had a fall due to the facility not having adequate staffing and not providing the resident with two-person assistance. R4's RR stated that she was told by staff that the CNA that assisted R4 with ADL care did not want the resident sitting in her waste for a long period of time and knew that the other CNAs were busy at the moment and that it would be a while before another person could assist the resident. When the CNA provided care, R4 accidently rolled off the bed. R4's RR was upset during the interview due to a second incident with therapy staff (10/07/24) having to lower R4 to the floor because they were also working alone. An interview on 10/10/24 at 2:11 PM with CNA5 revealed that the resident has had 2 falls at the facility due to staff not following the resident's care plan for two- person assist. CNA5 stated that the first fall occurred due to CNA attempting to provide ADL care for R4 without another CNA in the room and the second fall occurred because therapy staff did not have a 2nd person, and the resident had to be lowered to the floor. An interview with 10/10/24 at 3:46 PM with Physical Therapy Assistant (PTA) revealed they were working with the resident attempting to stand her up from a chair without assistance. PTA stated that resident should have been two-person assist and was re-educated related the incident. PTA confirmed that they were aware the resident had a fall with a CNA in August where they were also working alone as well. An interview on 10/10/24 with the Administrator and Director of Nursing (DON) revealed that the resident is a two-person assist and staff (therapy and nursing) have been re-educated on the importance of having adequate assistance when providing ADL care with R4.

Based on observation, interviews, record review, and policy review, the facility failed to provide respiratory care in accordance with professional standards. The facility failed to clarify one of one sampled resident (Resident (R1) physician's orders regarding the correct CPAP Support Therapy mode and settings. Findings Include: A review of the facility policy titled CPAP/ BiPAP Support, with a complete revision date of March 2015 states - Preparation 3. Review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure (CPAP, IPAP, and EPAP) for the machine. 4. Review and follow the manufacturer's instructions for CPAP machine setup and oxygen delivery. Steps in the procedure 8. Set mode, CPAP, IPAP, and EPAP settings on the machine, as prescribed. Documentation- Document the following in the resident's medical record: 3. Mode and settings for the CPAP/IPAP/EPAP. A review of R1's Face Sheet revealed that R1 was admitted to the facility on [DATE] at 2:15 PM with diagnoses that included Pneumonia, Sleep Apnea, Parkinsonism, and Hypertension. A Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 08/22/24 revealed a Brief Interview for Mental Status (BIMS) score of 07 out of 15, indicating R1 was severely, cognitively impaired. A Review of R1's Physician Orders revealed Orders: Hour of Sleep Continuous Positive Pressure (CPAP) AC Start Date: 08/18/2024 Start Time: 12:00 am Scheduled First scheduled time is 8/18/2024 on the Hour of sleep time period. Instructions: Use with home settings already set. Observation and interview with R1 on 10/08/24 at 12:18 PM revealed R1 in her room, sitting in a non-mechanical wheelchair with CPAP noted at the bedside, R1 stated that staff will put on a CPAP machine at night, R1 also stated she was unsure of the settings on the machine. An interview with a Licensed Practical Nurse, (LPN)1 on 10/09/24 at 11:42 AM revealed LPN1 confirmed he knew R1 and had provided care to her prior. LPN1 stated the doctor's order has the right pressure for the CPAP in it. LPN1 stated that distilled water, not regular water goes in the machine. When the machine comes in, it's the nurse's responsibility to ensure that the machine is set to the correct mode and settings per physician orders. A phone interview with the facility's Nurse practitioner, (NP) on 10/10/24 at 1:31 PM revealed the following, NP confirmed she was familiar with the resident. NP stated typically when a resident brings a CPAP from home, the settings are just monitored. NP stated if the staff does not know the settings, oxygen is used until the staff finds out what the settings are on a resident's CPAP machine. NP stated if something occurs with the CPAP machine, the nursing staff is to call her. She then stated at that point she would then write an order for oxygen. She stated if the machine was in the incorrect setting, the CPAP machine will alarm, and that's how staff will know if something is wrong with that machine. NP stated there is no standard setting for the CPAP machine. The settings are determined by the sleep study. NP stated that R1's CPAP equipment was present upon admission. NP stated she was not aware that the mode and settings needed to be included in the CPAP order. NP verbalized the nursing staff can look at the display screen located on the CPAP to determine the mode and settings. NP thanked the surveyor for the information related to the CPAP policy. An interview with Registered Nurse (RN)3 on 10/10/24 at 3:05 PM revealed RN3 confirmed she was familiar with R1. RN3 stated when R1 was admitted she did not have a CPAP machine upon admission, however, she received one a few days after. RN3 stated R1 is required to wear a CPAP at night. RN3 verified R1's order and stated she was unsure of what the resident's home settings were. RN3 stated that nursing staff can call the resident's family to obtain more information in regard to the CPAP machine mode and settings. RN3 stated she would usually expect to see the mode and settings clarified in the physician orders in the case something happens to the machine such as if the CPAP machine falls or if the resident touches or changes the setting. An interview with the Director of Nursing (DON) on 10/10/24 at 3:16 PM revealed the DON confirmed she was familiar with the resident. DON stated R1's CPAP machine settings should be between 5-12. DON stated, R1's order needs to be more specific and confirmed the CPAP settings should have been included in the physician's order. DON stated moving forward, her expectation are for the nurses to be aware of the importance of the order to include CPAP mode and settings. DON stated if mode and settings are not included in the order, it would be the nurse's responsibility to clarify the physician's orders.

Based on review of the facility policy titled, Storage of Medications, and Controlled Substances, observations, and interviews, the facility failed to ensure a small metal box containing narcotics was permanently affixed in one of one medication refrigerators located in one of one medication storage rooms. The facility further failed to ensure discontinued narcotics were secured and double locked, while awaiting destruction. The facility additionally failed to ensure 4 insulin pens, in use, were dated with an open date and expiration date once opened in one of two medication carts. Findings include: Review of the undated facility policy titled, Storage of Medications, states, The facility stores all drugs and biological's in a safe, secure, and orderly manner. Number eight states, Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications. Review of the undated facility policy titled, Controlled Substances, states, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Storing controlled substances, 1. Controlled substances are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. Number 8. Medications returned to the pharmacy are recorded and signed by the director of nursing services (or designee) and the receiving pharmacy. Number 13, Controlled substances remaining in the facility after the order has been discontinued or the resident has bed discharged are securely locked in an area with restricted access until destroyed. An observation on 05/17/2023 at 09:17 AM of the medication storage room revealed, narcotics locked in a metal box in the refrigerator. The metal box was not permanently secured within the refrigerator. Inside the metal box were 2 vials of Ativan 2 milligrams (mg) per milliliter (ml). During an interview on 05/17/2023 at 09:17 AM, the Director of Nursing (DON) confirmed the narcotics in the metal box and the fact that the box was not permanently affixed in the medication storage refrigerator, in the medication room. An observation on 05/17/2023 at 09:25 AM of the container used to store discontinued narcotics awaiting disposal by the DON and the Pharmacist revealed, a locked foot locker under the DON's desk in her office. The office door remained open and was observed open on multiple occasions on 05/16/2023 and no one inside. Observation on 05/17/2023 at 09:25 AM revealed multiple medication blister packs containing discontinued narcotics. The DON stated that the narcotics needed to be written up and placed inside the foot locker. She stated that the Pharmacist comes once a month to destroy the medications. The medications on top of the foot locker and not secured were: 1) Morphine Sulfate Sol 100 mg/5 ml - 30 mls are in the bottle 2) Morphine Sulfate Sol 100 mg/5 ml - 29.5 mls are in the bottle 3) Tramadol 50 mg- 13 tabs on the blister pack 4) Lorazepam 1 mg- 2 tabs 5) Tramadol 50 mg tabs- 30 tabs 6) Hydrocodone 5-325 mg- 8 tabs 7) Oxycodone 10 mg- 13 tabs 8) Oxycodone 10 mg- 28 tabs 9) Oxycodone 5 mg- 20 tabs 10) Morphine 20 mg/1 ml -12.75 mls 11) Morphine 30 mls 12) Lorazepam 1 mg- 19 tabs An observation on 05/18/2023 at 11:25 AM of Medication Cart #2 revealed: One Glargin Insulin (Lantus) Pens in use with no open date and no expiration date after opening. Two Lispro Insulin (Humalog, Novolog) Pens in use with no open date and no expiration date after opening. One Levemir Insulin Pen in use with no open date and no expiration date after opening. Review of a Cheat Sheet, for nurses, provided by Registered Nurse (RN)1 indicated: Humalog, Novolog and Lantus Flex pens once opened will expires in 28 days from the open date. Levemir once opened will expire in 42 days from the open date. An interview on 05/18/2023 at 11:25 AM with RN1 confirmed that the open date was not on the insulin pens and could not be sure of the date when the pens were first opened and used.

Based on observations, interviews, and facility policy review, the facility failed to ensure food was stored and labeled properly in the dry goods storage, walk-in fridge, and walk- in freezer to prevent the spread of foodborne illnesses. The facility also failed to ensure the ice machine was properly sanitized and/or cleaned. Findings include: 1. A review of the facility's policy titled, Food Receiving and Storage, revised 07/2014, revealed, . 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by' date). During the initial tour of the main kitchen with the Executive Chef (EC) on 05/16/2023 at 10:43 AM, revealed the following: In the dry goods storage: - One package of tortillas in a plastic bag. The original package had been opened and the current package was sealed but there was no opened date or end date. The EC stated she did not know the open date and the package should be dated. - One package of breadcrumbs in a plastic bag. The original package had been opened and the current package was sealed but there was no opened date or end date. The EC stated she did not know the open date and the package should be dated. In the walk-in freezer: - One box of frozen premade hamburger patties. The package inside of the box contained seven frozen hamburgers. The package was open, exposing the frozen hamburgers. The EC stated the kitchen staff must have come into the freezer and got some of the hamburger patties out of the package to prepare for the next meal and they did not close the packaging. - One brown paper package of Arancini (small balls of rice stuffed with a savory filling, coated in breadcrumbs, and fried) was opened, not sealed, and was undated. The EC picked up the package and three Arancini balls fell out of package and fell to the floor due to it not being sealed. The EC stated she did not know the date the package was originally opened and the package should be dated and sealed. - Two brown paper packages of French fries were stacked on top of each other. The bottom package had a visible cut in the package, exposing a French fry. The EC picked up the top package of French fries, which exposed a cut on the right side of the package. When the EC picked up the package, the packed burst open, making the French fries fall to the floor. The EC stated the packages should have been sealed. In the walk-in fridge: - One metal cart with shelves containing eight baking trays. Each tray had raw bacon and raw sausage patties that were covered with wax paper. The bacon was draped over the lip of the tray and was uncovered. None of the trays were sealed and only had wax paper not fully covering the raw meat. The EC stated she was told on a previous inspection that it was okay to store the raw meat with only wax/parchment paper as a covering. The EC stated by not having the meat properly sealed, cross contamination could occur. During an interview on 05/18/2023 at 9:43 AM, the EC stated all food located in the dry goods storage, walk-in fridge, and walk-in freezer should be wrapped and/or sealed, labeled, and have an opened and end date. During an interview on 05/18/2023 at 3:37 PM, the Director of Nursing (DON) stated food located in the dry goods storage, walk-in fridge, and walk-in freezer should be labeled and sealed if the product had been opened. During an interview on 05/18/2023 at 4:00 PM, the Administrator stated there should be no open containers of food located in the dry good storage, walk-in fridge, and walk-in freezer and all items should be dated and labeled. The Administrator stated meat should be in a sealed package. 2. A review of the facility's undated policy titled, Ice Machines and Ice Storage Chests, revealed, Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. 1. Ice-making machines, ice storage chests/containers, and ice can all become contaminated by .b. Waterborne microorganisms naturally occurring in the water source; c. Colonization by microorganisms . f. Clean and sanitize the tray and ice scoop daily . j. Flush and clean the ice machine and dispense after lengthy water disruptions . During the initial tour of the main kitchen on 05/16/2023 at 10:43 AM, the EC opened the lid of the commercial ice machine and used a clean paper towel and wiped the backside of the gray baffle (diverter that directs ice to the back of the machine) and the paper towel came up clean. There were 7 white plastic pieces that extended out from the back of the baffle. On each plastic piece, there was a pink/brown residue. The EC wiped one of the plastic pieces with a paper towel and stated there was a pinkish brown residue on the paper towel. The EC then looked inside the ice machine and stated she was able to see the pinkish brown residue on the plastic pieces. The EC stated the facility has a company that comes out once a month to service the machine. The EC stated the residue should not be present. During an interview on 05/18/2023 at 9:43 AM, the EC stated the ice machine should be cleaned once a week by kitchen staff and she had been doing it until there was a change in management and she had stopped cleaning it weekly. During an interview on 05/18/2023 at 3:37 PM, the Director of Nursing (DON) stated she was not sure how often the ice machines were cleaned and the kitchen staff were responsible for maintaining a clean ice machine. The DON stated the pink/brown residue indicated the machine was not clean. During an interview on 05/18/2023 at 4:00 PM, the Administrator stated the kitchen staff should follow the facility policy regarding the cleaning schedule of the ice machine, however, she was unsure of what the policy was. The Administrator stated if there was pink/brown residue inside the ice machine, she expected the kitchen staff to clean the machine.

Based on review of facility policy, interview and record review, the facility failed to track and trend antibiotic usage, infections and perform infection surveillance for six of the twelve months reviewed. This failure placed all residents at risk for potential transmission of infections and communicable diseases. The facility census was 16. Findings include: Review of facility's policy titled Antibiotic Stewardship revised in December 2016 revealed, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. Review of the facility's monthly line/log listing of infections and antibiotics prescribed, revealed that for six out of twelve months, no documentation identifying the type of infection, the type of antibiotic prescribed for treatment, or the resident's room number had been completed. Review of the facility's Antibiotic Stewardship monthly line/log book revealed tracking and trending completed from May 2022 thru January 2023. An interview with the Infection Control Coordinator on 5/18/23 at 12:10 PM revealed, she would have to ask the Director of Nursing (DON) about previous months not included in the Antibiotic Stewardship Program log/book. She stated when she started this job, she began the Antibiotic Stewardship log/book and monitorization. She stated the DON and her are completing this task together now, but the DON was completing this prior to her starting the job. In an interview on 5/18/2023 at 12:21 PM, the DON revealed, she could not find her December 2022 - May 2023 infection control log/antibiotic stewardship book. In an interview on 5/18/2023 at 2:42 PM, the Administrator revealed her expectations of her staff in regard to antibiotic stewardship is for staff to follow policy and procedures. She stated the responsible person for this task is the DON. She stated the DON monitors, but if it is passed, it is passed to the Assisstant DON. She stated she was not aware of any outbreaks during the timeframe of 2022, when the antibiotic stewardship log cannot be located.

Based on interviews, record review, and facility policy review, the facility failed to review and revise a comprehensive person-centered care plan for 1 (Resident (R)17) of 10 residents whose comprehensive care plans were reviewed. Specifically, the facility failed to revise the comprehensive care plan for R17 after a pressure ulcer was identified. Findings include: The facility's policy titled, Goals and Objectives, Care Plans, revised 04/2009 indicated, Care plan goals and objectives are defined as the desired outcome for a specific resident problem. The policy further indicated, Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and are resident oriented. A review of R17's Face Sheet revealed the facility admitted the resident with diagnoses which include; type 2 diabetes mellitus, end stage renal disease, stage three pressure ulcer of unspecified site, muscle weakness, dependence of renal dialysis, presence of a cardiac pacemaker, and acute on chronic combined heart failure. A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2023, revealed R17 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Per the MDS, R17 had a stage three pressure ulcer during the time of the assessment. A review of R17's Care Plan, initiated on 04/06/2023, revealed the resident did not have a care plan for pressure ulcers. Further review of the care plan revealed the care plan indicated the resident was only at risk for alteration in skin integrity related to decreased mobility and did not indicate the resident had actual skin impairment. A review of a progress note on 04/18/2023 at 11:50 AM, LPN2 indicated, Resident c/o [complained of] pain to sacrum. Upon assessment, nurse observed resident to have open area to sacrum. Area cleansed with wound cleanser, pat dry, Medi-honey ointment applied, covered with 2x2 gauze, and secured with tape. Resident stated felt better. Provider notified of new treatment order. A review of 24 Hour Report/Change of Condition Report indicated on 04/18/2023, R17 had an open area to the sacrum, treatment was initiated, and the resident was placed on a list for the provider to evaluate. A review of April 2023 Physician Order Sheet indicated on 04/19/2023 a treatment order was created to, Cleanse open area to sacrum with wound cleanser, pat dry, apply medi-honey ointment, over with 2x2 gauze, and secure with tape, daily and as needed until healed. A review of Skin Observation Form dated 04/20/2023 was not completed and had been locked by the Director of Nursing (DON). During an interview on 05/18/2023 at 08:39 AM, MDS Coordinator stated that if there was a wound coded on the MDS, there should have been a care plan developed and implemented for the wound. She was unsure why there was not a care plan for the pressure ulcer or why R17 had a care plan for being at risk for alteration in skin integrity if the resident was admitted with a wound. The MDS Coordinator confirmed she is responsible for updating the care plan along with the staff nurses. The nurses will alert the MDS Coordinator of changes that need to be made to a resident's care plan by speaking with her or by adding acute changes with resident to the 24-hour report that is reviewed in the morning meetings with the leadership team to include the DON and Administrator. During an interview on 05/18/2023 at 9:23 AM, LPN1 stated the MDS Coordinator was responsible for updating the resident's care plan. LPN1 stated she was unsure how to make changes to a resident's care plan. LPN1 stated the MDS Coordinator is alerted of acute changes of the residents by the DON looking through the resident's chart and updating the MDS Coordinator and the 24-hour report. She was unsure of when the pressure ulcer was first identified, however, remembered coming to work and the resident had wound care orders for the pressure ulcer. LPN1 stated she had not spoken with the MDS coordinator about any wounds. During an interview on 05/18/2023 at 11:02 AM, LPN2 stated she couldn't remember if R17 had a pressure ulcer on admission, but she identified a pressure ulcer a few weeks ago. Once she identified the pressure ulcer, she notified the Provider and treated the wound. She also made note of the wound on the 24-hour report. LPN2 stated the MDS Coordinator updates the care plans, and she was not sure if she had access to update the care plan or how to update the care plan if she had access. LPN2 stated the MDS coordinator gets the information to update the care plan from the nurses or the DON. The DON gets the acute changes regarding residents from the 24-hour report. During an interview on 05/18/2023 at 3:28 PM, the DON stated the MDS Coordinator updated the care plans, but the MDS Coordinator, the Administrator, and the DON talk about residents' care plans during the morning meetings. The DON stated the nurses do not update the care plans, only the MDS Coordinator. The DON also stated that if a resident is identified as having a wound, she expects the care plan to be updated to reflect the resident having a wound immediately, but definitely within 24 hours. During an interview on 05/18/2023 at 3:54 PM, the Administrator stated she expects staff to complete skin assessments on admission. The Administrator stated the MDS Coordinator is responsible for developing and updating care plans. The Administrator also stated she expects the MDS to be completed accurately and care plans should be updated immediately once a problem is identified.

Based on review of the facility policy titled, Abuse Prevention Program, and Abuse Investigation and Reporting, record review, and interview, the facility failed to ensure an allegation of staff to resident abuse was reported within the 2 hour time frame, as required by the Centers for Medicare and Medicaid, to the state agency for 1 of 3 residents reviewed for an allegation of abuse. Findings include: Review of the facility policy titled, Abuse Prevention Program, states under the Policy Statement, Our residents have the right to be free from abuse and neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual and physical abuse, and physical and chemical restraint not required to treat the resident's symptoms. Further review of the facility policy titled, Abuse Investigation and Reporting, states, under reporting, number 2, An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury. The facility admitted Resident(R)1 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 8/24/22 at 10:50 AM of the facility reportable of an allegation of rough handling by a Certified Nursing Assistant, revealed that the incident occurred between 6:30 AM and 6:45 AM. The incident was not reported to the state agency between 11:30 AM and 11:45 AM. There was no documentation or receipt from the state agency to confirm the time provided by the facility. During an interview on 8/24/22 at 11:50 AM with the Director of Nursing, (DON) also the Abuse Coordinator, confirmed that the allegation of abuse towards R1 was not reported to the state agency within the 2 hour time frame per the requirements.

Based on observations, interviews, and the review of facility policies, the facility failed to maintain the dishwasher, garbage disposal, ice machine, handwashing sink, bins, floors, and surface areas clean, in good repair and properly working. In addition, the facility failed to maintain food items labeled and dated and did not ensure kitchen staff wear facial hair-covers, dried/stored, and used cooking dishware appropriately for the main kitchen observed during the survey. Findings: Policy review titled Food and Nutrition Services Policy and Procedure Manual (Revised October 2017) and Production, Purchasing, Storage (issued 5/95 and revised 5/21) Under Preparation Area 3. Areas for cleaning dishes and utensils are located in a separate area from the food services line to assure that a sanitary environment is maintained. 5. Food preparation staff will adhere to proper hygiene and sanitary practice to prevent the spread of foodborne illness. 6. Handwashing sinks will be separate from ware washing sinks and will be located near food preparation and clean dish areas. Under food Services/Distribution 7. Food and nutrition services staff shall wear hair restraints (hair net, beard restraint, etc.) so that hair does not contact food. Policy review titled Production, Purchasing, Storage (issued 5/95 and revised 5/21) Subject: Food and Supply Storage Under procedures second and eighth bullet points Cover, label, and date unused portion of open packages . Arrange items neatly on shelves in the same order as the inventory book The initial tour of the kitchen conducted on 12/06/21 at 9:35 AM revealed the following: The handwashing sink appears filthy, with cloudy dried water stains and brown buildup around the drain and faucet. The cook was stirring an Alfredo sauce with a large whisk and an old-looking frying pan. When inquiring about the reason for the use of the frying pan and whisk, the cook said to stir the sauce. Am I not supposed to use these? then the cook took the frying pan out of the sauce left the whisk in and grabbed a large spoon. There was a large amount of water and food debris on the floor of the dishwasher area. The garbage disposal had standing water. The kitchen staff was not able to say whether or not the dishwasher was a low or a high temp and no one knew whether or not the chlorine was used to sanitize the dishes or how to test the dishwasher sanitation concentration. The kitchen floor appears unkempt, food debris, dark and greasy around the edges, doors, and behind ice-machine and under food prep area. In the area where clean dishware was stored, there were over 20 wet nesting pans, some were greasy to the touch and some with food particles on them. The ice machine had dried up water stains on the outside and a slight pink buildup on the inside of the door. The base rubber molding on the ice machine was unglued with brown buildup around it. There was an offensive odor coming out in the walk-in cooler. The walk-in freezer contained unlabeled and undated foods items such as waffles, onion rings, sausages, and other foods. The certified dietary manager (CDM) was present during the observation and confirmed the above findings. During a revisit to the main kitchen on 12/07/21 at 2:02 PM, observation showed one of the kitchen staff with a long beard without a cover. The wet nesting pans, the filth on the floor, and offensive odor in the walk-in cooler remained the same, the dishwasher and garbage disposal was not working properly. The sugar, rice, flour bins, and trash cans had dried dark water stains on them. On 12/09/21 at 04:13 PM, a contractor was observed working on the dishwasher. He said that the dishwasher was a low temp and that a valve for the chlorine dispenser was bad. He added that he did not know how long it has been like that, but he replaced it. In an interview with the foodservice consultant, on 12/09/21 at 4:25 PM, s/he stated that s/he is aware of the issues brought forward during the survey. S/he added that the facility is working to resolve these issues.

Based on observations and interviews, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. Furthermore, the facility failed to maintain the dishwasher and garbage disposal, in good repair and working condition for the main kitchen observed during the survey. Findings: The initial tour of the kitchen conducted on 12/06/21 at 9:35 AM revealed the ice machine has dried water stains on the outside and a slight pink buildup on the inside of the door. The base rubber molding on the ice machine was unglued with brown buildup around it. The certified dietary manager (CDM) was present during the observation and confirmed the above findings. During a revisit to the main kitchen on 12/07/21 at 2:02 PM, observations revealed the dishwasher and garbage disposal not working properly. On 12/09/21 at 04:13 PM an observation revealed a contractor was working on the dishwasher. He stated the dishwasher was a low temp and that a valve for the chlorine dispenser was bad. He added that he did not know how long it has been like that, but he replaced it. In an interview with the foodservice consultant, on 12/09/21 at 4:25 PM, s/he stated that s/he is aware of the issues brought forward during the survey. S/he added that the facility is working to resolve these issues.

Based on observation, interview, and review of manufacturer guidelines revealed the facility failed to ensure expired supplies were removed from the resident treatment areas. Findings include: Review of manufacturer guidelines titled, Blood Glucose Test Strips dated [DATE] revealed, .Write date opened on test strip vial label when removing the first test strip. Discard all unused test strips in vial after either date printed on the test strip vial label or 4 months after date opened, whichever comes first. Using test strips past these dates may cause inaccurate results . 1. During a fingerstick blood sugar observation on [DATE] at 4:46 PM with Registered Nurse (RN) 1 revealed glucometer strips with no date when opened on the bottle. During an interview on [DATE] at 4:50 PM with RN1 stated, The test strips just used was not a new bottle. I think they are good for 30 (thirty) days once opened . 2. During an observation on [DATE] at 1:46 PM of the nurses treatment cart revealed the following expired items: one [MEDICATION(S)] Bottle with no date or time when opened, nine hema-screen slide test for fecal occult blood expired [DATE], and five 22 (twenty-two) g (gauge) x (by) 1 ,d+[DATE] inch sterile needles expired [DATE]. During an interview on [DATE] at 1:46 PM with RN1 stated the items were expired. During an interview on [DATE] at 12:45 PM with Director of Nursing (DON) stated, We do not have an expired supplies policy. 3. During an observation of the medication refrigerator on [DATE] at 8:25 AM revealed missing days for temperature checks on the log sheets for the months of [DATE] with twelve missing dates, October with ten missing dates, November with eighteen missing dates, and December with seven missing dates. During an interview on [DATE] at 8:25 AM with Licensed Practical Nurse (LPN) 1 stated, The night shift is responsible for checking the temperatures of the refrigerators. During an interview on [DATE] at 3:35 PM with the Assistant Director of Nursing (ADON) stated, The expectation is that the night shift will check the medication refrigerators. 4. During an observation of the supply room on [DATE] at 8:45 AM revealed the following expired items: ten Bio Patch protective disk expired [DATE], one catheter securement device expired [DATE], three catheter stabilization device ([MEDICATION(S)]) expired [DATE], eighteen adhesive tape remover pads expired ,d+[DATE], nine alcohol [MEDICATION(S)] expired ,d+[DATE], and twenty-five alcohol [MEDICATION(S)] expired ,d+[DATE]. During an interview on [DATE] at 2:06 PM with LPN2 stated, We are responsible for checking expired meds (medications) and pharmacy comes to check as well. During an interview on [DATE] at 2:23 PM with Certified Nursing Assistant (CNA)1 stated, I'm responsible for expired supplies. I check supplies during the truck order days which is usually once a week. Any expired supplies we just throw them away. We also do first in and first out for supplies. During an interview on [DATE] at 3:35 PM with the Assistant Director of Nursing (ADON) stated, CNA1 is responsible for expired supplies .

Based on observation and interview, the facility failed to ensure 1 of 1 (Resident (R) 2) had oxygen tubing and humidifier changed per physician orders. Findings include: Review of R2's Face Sheet dated 10/15/21 revealed R2 was admitted to the facility for the following pertinent Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R2's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact and in need of oxygen therapy. Review of R2's Care Plan dated 10/25/21 revealed R2 Unable to maintain O2 (oxygen) saturation. Receives oxygen at 2 L (liters)/min (minute). Change tubing, 1 (one) time weekly . Review of R2's Resident Medication Profile revealed oxygen not listed on the profile list. During an observation on 12/06/21 at 10:36 AM revealed R2's disposable humidifier bottle dated 11/28/21 with no date on the oxygen tubing. Resident unable to remember last time tubing and humidifier was changed. During an observation on 12/07/21 at 1:25 PM revealed R2's disposable humidifier bottle dated 11/28/21 with no date on the oxygen tubing. During an interview on 12/07/21 at 1:32 PM with Licensed Practical Nurse (LPN) 1 stated, the resident's oxygen level is usually very good. She gets it for her personal comfortable .The night shift nurse changes the tubing and nasal cannula every Sunday. The settings for the resident are communicated by the nurses during report. The tubing is changed every 7 days for cleanliness and to ensure the humidifier doesn't run out and/or it's dirty. We have a supply closet for any needed supplies. During an interview on 12/08/21 at 9:28 AM with LPN1 stated, The humidifier should have been changed on Sunday and I changed it. There is a ticker in the system to notify the nurse that it needs to be done.

Based on observation, interview, and review of facility policy and procedure, the facility failed to ensure ongoing Covid-19 screening for visitors. Findings include: Review of facility policy titled, Coronavirus Disease (COVID-19) -Visitors revised date 07/20 revealed, .4. Visitor entrances are staffed by personnel who have been trained on the current visitation policies and are qualified to conduct visitor screening. 5. Health screens are conducted on any potential visitor prior to being allowed in the building. Anyone showing signs or symptoms of respiratory infection or other signs/symptoms of possible COVID-19 infection or exposure are not allowed to enter the facility, regardless of the compassionate care situation. 6. If visitation is permitted, strict adherence to infection precautions are required. Any visitors permitted in the facility are required to: a. wear a facemask b. adhere to all infection precautions c. restrict their visit to a designated area of the facility . 7. Visitor logs and Visitor Health Screens are completed with each visitor and archived until further notice . 1. During an observation of the main entrance on 12/07/21 at 5:04 PM revealed no staff member present for Covid-19 screening. Family member (F) 1 entered building through front entrance without screening, hand hygiene, and/or mask donned. F1 went to the unmasked resident's room. At 5:07 PM, F1 came to the resident's door entrance and requested assistance for the resident. The nurse did not acknowledge F1 did not have a mask donned. A Certified Nursing Assistant (CNA) went to the room to assist the resident with no acknowledgement of unmasked F1. During an observation of the dining room area on 12/09/21 at 12:20 PM revealed two residents and one F2 observed sitting at the dining room table with mask not donned. One resident and F2 playing games with one of the residents observed folding towels. The dining area was located across from the Director of Nursing (DON)'s office with another staff member of the facility noted sitting in the dining area. No intervention noted from the staff to F2 and/or the residents. During an interview on 12/09/21 at 2:00 PM with CNA2 stated, Usually someone is here to direct the visitors to be screened or the admission director is here and will stop them .I check temps (temperatures), have them answer the screening questions, and provide a name sticker. I usually work eight hours and the admission director is here from 4:30 PM to 5:00 PM. During an interview on 12/09/21 at 4:05 PM with Registered Nurse (RN)1 stated, When the person from the front door leaves than the nurses are responsible to screen in visitors for Covid-19.

Based on observation, record review, and interviews, the facility failed to effectively manage and/or prevent a resident from pain. Furthermore, the facility failed to treat the resident's pain consistently with his/her comprehensive assessment, plan of care and current professional standards of practice for one of one resident reviewed for pain. Findings: Review of the facility's policies titled Pain Assessment and Management and Administering Medications Pain assessment and management under general guidance: 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Administering medications under policy interpretation and implementation: 8.or a medication has been identified as having potential for adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident attending or the facility medical director to discuss the concerns. The facility admitted Resident (R)3 on 10/19/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed R3 scored a 13 out of 15 in the Brief Interview for Mental Status (BIMS) indicating intact cognition. In the area of functional status on the MDS, R3 requires extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene and is totally dependent on staff for eating and bathing. The MDS indicates that R3 has a catheter and is always incontinent for the bowel. In the area of pain, the MDS indicates that R3 is not on scheduled pain medication. S/he receives medication for pain as needed (PRN) but does not receive non-medication intervention for pain. The interview for pain assessment was conducted and the pain was present and frequently at the time. The present pain has not made it hard for the resident to sleep but has limited the resident's day-to-day activities. His/her pain intensity was at a 6 out of 10. A review of R3's care plan with an effective date of 10/22/21 revealed that s/he may have the need for pain management related to seizures and [CONDITION(S)]. R3's goal is to return to an acceptable comfort pain level. Care plan interventions indicated that assessments and monitoring of his/her pain medications are adequately managing pain and signs/symptoms of complication. On 12/06/21 at 12:47 PM, R3 was observed in his/her wheelchair at the nurse's station. During an interview at this time, the resident stated that it hurts when s/he goes (pointing to his/her genital area). When asked if s/he was in pain and if s/he has told anyone, s/he said yes. R3 added that s/he was told it is broken (referring to the catheter). During an interview on 12/06/21 at 12:55 PM with Licensed Practical Nurse (LPN)3, s/he was informed that the resident was complaining of pain. LPN3 stated that R3 got his/her pain medication already and it wasn't time for another dose. A review of R3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This medication was put on hold on 10/22/21 and not given to the resident at any point during November and December. There was no other pain medications ordered/given. In an interview with LPN2 on 12/07/21 at 9:35 AM, LPN2 stated that R3 was not on or given pain meds. In an interview with the Director of Nursing (DON) and ADON on 12/09/21 at 2:00 PM, the ADON stated that R3's Tylenol was put on hold because s/he said that s/he was allergic to it. The ADON was unable to elaborate on the type of adverse reactions the resident suffers when ingesting Tylenol. ADON and DON confirmed that R3 did not receive Tylenol or any other medication to alleviate his/her pain.

Based on record review and staff interview, the facility failed to provide adequate supervision and assistive devices, consistent with a resident's needs. In addition, the facility failed to monitor the effectiveness of the interventions and modify the care plan as necessary for one of four sampled resident reviewed for accident. Resident #1 was found on the floor which resulted on a fracture of (his/her) left wrist. Findings: The facility admitted Resident #1 on 11/25/20 with [DIAGNOSES REDACTED]. Physician's notes review on 2/1/20 states that Resident #1 was admitted to the facility after hospital stayed related to confusion, aggressions, and [MEDICAL CONDITION]. Nurses' notes reviewed on 2/1/21 at approximately 1:30 PM revealed that on 12/01/20 Resident # 1 was observed ambulate by (his/her) self with very unsteady gait, grabbing a hold to objects to keep balance. A tab alarm applied for safety. On 12/05/20 Resident #1 was found on the floor in front of his/her wheelchair. Wheelchair unlocked and tab alarm not clipped to clothing. Resident #1 suffered a distal radial and ulnar fracture. On 12/10/20 Resident #1 was observed on the floor, on (his/her) buttocks, in front of wheelchair. According to the nurses' notes Resident continue to be non-compliant with call light and independent ambulation. On 12/14/20 Resident was found on the floor. Resident had unclipped the tab alarm. No post-fall assessment performed and fall preventions interventions were not revised for effective or modified to meet the resident's needs. Review of facility investigation report does not contain supporting documentation to indicate that a fall-risk assessment and staff/residents' interviews and education related to fall prevention was conducted. Care plan reviewed on 2/1/21 at approximately 2:45 PM revealed the care plan was not reviewed/revised or fall-prevention interventions modified after each fall. In an interview with the care plan coordinator on 2/1/21 at approximately 3:00 PM (s/he) claims not knowing why the falls for 12/10 and 12/14 were not revised. In an interview with licensed practical nurse (LPN) #1 (s/he) said that on 12/5/20 (s/he) found Resident #1 on the floor holding the left wrist. The LPN stated there was no sound coming from the tab alarm. LPN said that the resident would unclip the tab alarm from her clothing often. In an interview with the DON on 2/1/21 at approximately 3:45 PM (s/he) acknowledged that the fall-preventions interventions put in placed did not meet the resident's need. S/he stated not knowing why the tab alarm was not place out of Residents' reach, or why the resident was not provided adequate supervisor. S/he stated is new in this roll.

Based on record review and staff interview, the facility failed review/revise resident's care plan after each fall. In addition, the facility failed to monitor the effectiveness of the interventions and modify the care plan as necessary for one of four sampled resident reviewed for accident. Resident #1 sustained falls on 12/5/20, 12/10/20, and 12/14/20 Findings: The facility admitted Resident #1 on 11/25/20 with [DIAGNOSES REDACTED]. Nurses' notes reviewed on 2/1/21 at approximately 1:30 PM revealed that on 12/01/20 Resident # 1 was observed ambulate by (his/her) self with very unsteady gait, grabbing a hold to objects to keep balance. A tab alarm applied for safety. On 12/05/20 Resident #1 was found on the floor in front of his/her wheelchair. Wheelchair unlocked and tab alarm not clipped to clothing. Resident #1 suffered a distal radial and ulnar fracture. On 12/10/20 Resident #1 was observed on the floor, on (his/her) buttocks, in front of wheelchair. According to the nurses' notes Resident continue to be non-compliant with call light and independent ambulation. On 12/14/20 Resident was found on the floor. Resident had unclipped the tab alarm. No post-fall assessment performed and fall preventions interventions were not revised for effective or modified to meet the resident's needs. Care plan reviewed on 2/1/21 at approximately 2:45 PM revealed the care plan was not reviewed/revised or fall-prevention interventions modified after each fall. In an interview with the care plan coordinator on 2/1/21 at approximately 3:00 PM (s/he) claims not knowing why the falls for 12/10 and 12/14 were not revised.

Based on observation, record review, and interview, the facility failed to ensure food safety requirements for 1 of 1 refrigerator units by not maintaining the temperature within acceptable parameters. The findings included: Observation of the refrigerator unit in the resident dinning room on 02/20/2019 at approximately 1:45 PM revealed the refrigerator temperature gauge was at 46 degrees. On 02/20/2019 at approximately 02:15 PM, observation of the refrigerator unit in the resident dining room revealed the refrigerator temperature gauge was still at 46 degrees. On 02/20/2019 at approximately 02:30 PM, observation of the refrigerator unit in the resident dining room revealed the refrigerator temperature gauge was still at 46 degrees. Observation of the contents of the refrigerator revealed it included three cartons of yogurt cups. Each carton contained 12 six ounce yogurt cups. In addition, there were approximately 10 pudding cups and 10 small milk cartons inside the refrigerator. Record review of the Temperature Daily Freezer/Refrigerator Log for the refrigerator in the dining room dated (MONTH) 20, 2019 revealed the entry for (MONTH) 20, 2019 was 36 degree for AM; however there was no time recorded and it was initialed by a staff member. On 02/20/2019 at approximated 02:35 PM, interview with the Director of Nursing (DON) revealed that s/he agreed that the refrigerator was above the normal temperature. The DON did not have any explanation for the recorded entry on the Temperature Log.

Based on record review and interview, the facility failed to afford Resident #134 the opportunity to formulate their own advance directive, 1 of 12 residents reviewed for Advance Directives. Record review revealed the resident was not involved in discussion and election of Do Not Resuscitate (DNR) status. The findings included: The facility admitted Resident #134 with [DIAGNOSES REDACTED]. Record review of the Code Status form on 2/20/19 at 8:48 AM, revealed a discussion of code status was held on 2/14/19. DNR status was elected and signed for by the resident's spouse. There was no documentation to indicate the resident was involved in this discussion. Record review of physician's orders [REDACTED].#134. Record review of documentation regarding Resident #134's ability to consent to healthcare decisions on 2/20/19 at 4:16 PM revealed the physician determined the resident was able to make his/her own healthcare decisions on 2/15/19. During an interview with the Director of Nursing (DON) and the the Assistant Director of Nursing (ADON) on 2/20/19 at 4:11 PM, the DON confirmed there was no documentation to indicate it was Resident #134's choice to elect DNR status. The DON confirmed the DNR status was elected by the resident's spouse. In addition, the DON also stated the physician determined the resident was competent to make his/her own healthcare decisions. The ADON stated s/he had just had a discussion with Resident #134 and the resident stated s/he did desire to be DNR status. The ADON provided an updated Code Status form, dated 2/20/19, with the resident's signature for DNR status.

Based on record review, interviews, and review of the facility's admission information, the Resident Bill of Rights, and Wildewood Downs Policy for Advanced Directives, the facility failed to provide the opportunity to formulate an Advance Directive for 2 of 22 residents reviewed for Advance Directives. The facility failed to document Resident #87's choice to be a full code and communicate this choice to the Interdisciplinary Team and failed to ensure orders and treatment reflected this choice. The facility failed to document why a Do Not Resuscitate (DNR) order was obtained for Resident #50 or that family or the resident was consulted prior to obtaining the order. It was determined on [DATE] at approximately 5:50 PM Immediate Jeopardy existed as of [DATE] for F-155 which was identified at a scope and severity level of J. The findings included: The facility admitted Resident #87 with [DIAGNOSES REDACTED]. Review of the Advance Directives section of the closed medical record revealed a form signed by the physician indicating Resident #87 was able to consent to health care decisions . Further record review revealed a form entitled Advanced Directives. The bottom section of the form was signed by the resident upon admission indicating Yes related to having a Living Will and Yes related to having a Healthcare Power of Attorney. In the middle of the form, information indicated in bold type,DO NOT CHECK 'YES' UNLESS YOU HAVE THE PAPERS ON YOUR PERSON WHILE YOU ARE COMPLETING THIS FORM!!!!!!!!! A copy of a Durable Power of Attorney (for financial decisions), ending with page 8, was included in the record; however, the record did not contain a copy of a Living Will or Healthcare Power of Attorney. Handwritten documentation on the bottom half of the form indicated, Resident wishes to be a DNR. The handwritten notation was not dated nor signed to indicate who wrote the documentation. In addition, there was no documentation that this was the resident's choice or how/when this information was obtained. During an interview on [DATE], the Director of Admissions reviewed the Advance Directive paperwork and stated that he/she handwrote the notation Resident wishes to be a DNR on the form entitled Advanced Directives. He/she stated that no other paperwork related to Advance Directives is completed by the Admissions Department. He/she stated that after completing paperwork for newly admitted residents, the information is given to the Social Services Director for completion. During an interview on [DATE] at approximately 12:33 PM, the Admissions Director was asked to clarify the process after completion of the admissions paperwork related to Advance Directives. The Admissions Director indicated that there was no process because the social worker and the doctor come behind me and ask the resident . The Admissions Director indicated that the social worker will place Advance Directive information related to needed orders in a book for the physician to review. Review of the Social Service notes on the day of admission indicated, Pt (patient) has chosen to be a full code. The documentation was signed by the Director of Social Services. During an interview on [DATE] at approximately 3:20 PM, the Social Services Director reviewed the record with the surveyor. The Social Services Director confirmed that he/she documented the Social Services notation dated the day of Resident #87's admission. The Social Services Director stated that he/she talked with Resident #87 about code status, explained the meaning of full code status, and Resident #87 indicated that he/she wanted to be a full code. The Social Services Director stated that he/she always talks with residents about code status, and that the physician does not always address code status with new admissions. During the interview, the Social Services Director stated that paperwork concerning Advance Directives used to be under social services years ago and then got added to the admission paperwork. The Social Services director stated that he/she reviews the paperwork from admissions prior to speaking with newly admitted residents. Review of the physician's orders revealed an order dated [DATE] at 11:25 PM for a DNR order which was received by Licensed Practical Nurse (LPN) #1. Review of the 24 Hour Report dated [DATE] indicated Resident #87 expired at 11:25 PM. Review of the Nurse's Notes dated [DATE] indicated the resident was noted at 11:25p with no vital signs. During an interview on [DATE] at approximately 4:30 PM, LPN #1 stated that he/she checked the medical record when Resident #87 was found with no vital signs, and the record indicated the resident was a full code. LPN #1 stated that he/she called the resident's family member to check to see if he/she still wanted the resident to be a full code or sent out to the hospital. In a facility-obtained, signed statement dated [DATE], LPN #1 wrote that, I perused (resident's) chart for a DNR order, checked (his/her) advanced directive noted that it stated, 'I do not want CPR.' I placed a call to the responsible party (resident's family member) to notify of ceased respirations & inquire if (resident's family member) wanted CPR instituted. During an interview on [DATE] at approximately 8:59 AM, the Medical Director reviewed the policies entitled Wildewood Downs Policy for Advanced Directives, Resident Bill of Rights, and the closed medical record with the surveyor. The Medical Director confirmed that there were no physician's orders related to code status written upon admission. The Medical Director confirmed that the medical record contained documentation in the social services notes indicating the resident wanted to be a full code and a handwritten notation on paperwork completed upon admission indicating the resident wanted to be a DNR. The Medical Director stated, A procedure gap here is definitely a problem .I have concerns over making sure we follow procedures and better documentation. We need to .make sure everyone is aware of the policy and make sure the documentation is in place. The Medical Director indicated that social services is to make sure all paper work is done, and sometimes it takes a while depending on when we get here to actually sign. The Medical Director stated that it needs to be more clear as to what the resident actually wants and makes their own decision. During the interview, the Medical Director indicated he/she had recently signed several DNR forms to help correct this issue. As part of the facility's Allegation of Compliance, staff conducted a Code Status Audit of all resident charts on [DATE]. Review of the audit revealed that corrections related to code status were identified as needed on 5 out of 25 resident records reviewed by staff. During an interview on [DATE] at approximately 12:42 PM, Resident #87's physician of record reviewed the closed medical record with the surveyor. After review of the Advance Directive paperwork, physician's orders, Nurse's Notes, and 24 Hour Report/Change of Condition Report, the physician agreed there was no physician's order related to Resident #87's code status written until the time that the resident expired and staff obtained an order for [REDACTED]. The physician stated that when staff called him/her for the DNR order on [DATE], he was told the resident wanted to be a DNR, and the nurse had spoken with the family. The physician reviewed the form indicating the resident was deemed capable of making healthcare decisions and the social services documentation indicating the resident wanted to be a full code. The physician stated he/she had been unaware of the social services documentation indicating the resident wanted to be a full code. The physician indicated that he/she relies on staff to provide capacity forms and information for orders related to Advance Directives that need to be signed when he/she makes rounds. The physician indicated he/she should talk with the resident and not rely on the staff for information, the resident may change their minds. Review of the Resident Bill of Rights indicated, Residents have the right to have an advanced directive or a living will executed on their behalf. This document, if already executed prior to admission or thereafter, should be given to the Social Services Director and attending physician to (sic) it can be included in the medical record. Review of the Wildewood Downs Policy for Advanced Directives revealed #2 indicated, MD will discuss Advanced Directives (Full Code or DNR) with the resident and/or representative to determine code status. If MD is not present at time of admission and resident/POA has stated that they wish to be DNR, MD will be called for orders. Information under #4 indicated, If resident is made a DNR, a doctor's order .will be completed and placed in chart. The facility admitted Resident #50 with [DIAGNOSES REDACTED]. Review of the closed medical record indicated Resident #50 expired on the fifth day following admission. Review of the Advanced Directives form completed upon admission indicated the resident's responsible party signed the form. Further review of the form revealed a handwritten notation which indicated, resident wants to remain a full code. The notation was not signed nor dated. A form dated [DATE] was signed by one physician indicating the resident lacked the ability to consent to healthcare decisions. Information located at the top of the form stated, According to the South Carolina Adult Health Care Consent Act, Section [DATE], a patient's inability to consent must be certified by two licensed physicians. Review of the Nurse's Notes dated [DATE] on the ,[DATE] PM shift indicated staff attempted unsuccessfully to contact Resident #50's family regarding a skin tear. Documentation dated [DATE] on the ,[DATE] PM shift indicated new orders were written on that date related to giving medications. Review of the physician's orders revealed an order dated [DATE] which indicated the resident's code status was DNR. Record review revealed no social services documentation was located in the medical record. Review of the Nurse's Notes revealed there was no documentation as to why the DNR order was obtained on [DATE], who requested the order, or that the family or resident was consulted prior to obtaining the order. Review of the 24 Hour Report/Change of Condition Report dated [DATE] revealed that Resident #50 expired at 3:35 AM. Review of the Nurse's Notes dated [DATE] revealed the Assistant Director of Nursing documented that staff was unable to reach the resident's family member until 6:15 AM. Based on record review, interviews, and review of facility policies, it was determined on [DATE] at approximately 5:50 PM Immediate Jeopardy existed in the following area: CFR 483.10 (b)(4) F-155 Right to formulate an Advance Directive was identified at a scope and severity level of J. The facility failed to afford all residents the right to formulate an Advance Directive. The facility Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at approximately 5:50 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on [DATE] at approximately 5:45 PM, and the Immediate Jeopardy at F-155 was removed and lowered in scope and severity to a D. The AOC included the following: 1. The Advanced Directives Policy and the CPR Policy have been reviewed by the Medical Director and the DON. No changes have been made at this time. 2. All residents in the Nursing and Rehabilitation Unit have been interviewed and have had their code status confirmed. If residents were unable to confirm their code status, due to dementia, altered mental status, etc., or have been deemed unable to make medical decisions by the physician, their responsible parties (person with legal rights to make decisions for the resident), have been completed as of [DATE] and code statuses on all residents are current. 3. A complete chart audit has been conducted to confirm that the resident's wishes correspond with what is written on the chart. For example, if a resident states that he/she wishes to have a DNR order, it has been confirmed that there is an MD order and a signed DNR form on the chart. Any discrepancies have been corrected. An audit trail is attached to show the changes to any discrepancies. 4. All nurses and CNAs present on the unit from the time of the allegation until the current time on all shifts have been instructed by formal in-services on the Advanced Directive and CPR policies to understand that CPR is to be started on any resident who does not have an order for [REDACTED]. Signed statements have been obtained from all nurses and CNAs that they have received the training, and that they understand the content and have had an opportunity to ask questions. 5. The Administrator, DON, ADON, and attending physician and Medical Director have received in-service training by the RN nurse consult (sic) for The Hollinger Group regarding the Advanced Directive and CPR Policies. 6. The LPN who was working the night that the alleged non-compliance occurred has been counseled and also attended the mandatory in-service for Advance Directive and CPR. Her written statement of the alleged events is attached. She also attended the mandatory in-service, as evidenced by her signature on the master sign in sheet which is attached, and the signed statement that she received the policy, understands the content, and had an opportunity to ask questions. 7. The Administrator or Director of Nursing or Assistant Director of Nursing will check each shift to ensure that all staff scheduled to work have received the in-service until all facility staff have received the in-service. The in-service may be conducted by the Administrator, DON, ADON, or Staff Development nurse. This in-service will be provided to all new CNA and licensed nurse hires at Wildewood Downs. Wildewood Downs does not use any agency staff. 8. This practice will be prevented in the future by having all admissions checked for code status and the appropriate information (DNR order and DNR sheet if ordered) at the time of admission. This will be done by the DON or the ADON, or the Staff Development nurse in their absence. If the appropriate information is not present, the DON, ADON, or Administrator will get the appropriate orders or information on the chart, and notify the physician and the nurse assigned to the new resident admission that the information was not obtained per policy. These findings will be presented at the monthly QA meeting. 9. All department heads attend a daily morning meeting to go over any issues in the facility at 9 am. After this meeting, managers, including the Administrator, DON, ADON, MDS Coordinator, Admissions Nurse, Social Services Director, and Therapy Program Director attend an additional stand up nursing meeting daily to go over the 24 hour report. Each resident is discussed and any issues are brought up at this time. Any issues that require follow up are assigned at this time to the appropriate manager. Copies of all new orders are placed in the folder of the ADON for review. There is an RN on call 24 hours a days 7 days a week to address any nursing issue that requires immediate attention.

Based on record review, interviews, and review of facility policies entitled Wildewood Downs Policy for Advanced Directives, Cardiopulmonary Resuscitation, admission information including Wildewood Downs Care Policy, Understanding CPR, and review of Centers for Medicare and Medicaid Services (CMS) S&C: ,[DATE]-NH, it was determined that the facility failed to ensure that needed services for resuscitation were initiated for 1 of 4 residents reviewed for care and services upon death. The facility failed to protect Resident #87 when Resident #87 did not receive Cardiopulmonary Resuscitation when indicated. It was determined on [DATE] at 5:50 PM Immediate Jeopardy existed for F-224 which was identified at a scope and severity level of J. The findings included: Cross Refer to F155 as it relates to Resident #87 not being afforded the opportunity to formulate an Advance Directive. The facility admitted Resident #87 with [DIAGNOSES REDACTED]. Review of the Advance Directive section of the close medical record revealed a form signed by the physician indicating Resident #87 was able to consent to health care decisions . Review of a form entitled Advanced Directives revealed a handwritten notation which indicated, Resident wishes to be a DNR. The handwritten notation was not dated and was not signed, and there was no documentation on the form to indicate this was the resident's choice or how/when this information was obtained. Review of the Social Services notes on the day of admission indicated Pt (patient) has chosen to be a full code. The documentation was signed by the Director of Social Services. During an interview on [DATE] at approximately 3:20 PM, the Social Services Director stated that he/she talked with the resident about his/her wishes concerning code status upon admission, explained the meaning of full code status, and Resident #87 indicated that he/she wanted to be a full code. Review of the medical record revealed there were no physician's orders related to code status written upon admission, and no order related to code status was written and documented in the record until the date/time that Resident #87 expired on [DATE] at 11:25 PM. Licensed Practical Nurse (LPN) #1 received the Do Not Resuscitate (DNR) order on that date/time. Review of the Nurse's Notes dated [DATE] at 2:20 PM stated, Resident alert (with) some periods of confusion. Able to make needs known. Ambulates (with) walker. No c/o (complaints of) pain or acute distress noted. Will continue to monitor for (changes). Review of the 24 Hour Report/Change of Condition Report dated [DATE] indicated the resident expired at 11:25 PM. The Nurse's Notes dated [DATE] indicated at 11:25 PM the resident was noted with no vital signs and was unresponsive to tactile stimuli. The notation further states that the resident was pronounced dead, and the resident's family member was notified. During a telephone interview with LPN #1 on [DATE] at approximately 4:30 PM, the surveyor asked the staff member about the night the resident expired. LPN #1 stated that he/she did not recall any problems related to Resident #87 reported at shift change. LPN #1 stated that he/she began making rounds on the unit after receiving report, noted the resident's door was closed, he/she opened the door and found the resident unresponsive. LPN #1 stated that he/she checked the record and the record indicated the resident was a full code. LPN #1 stated that he/she called the resident's family member to check to see if he/she still wanted the resident to be a full code or sent out to the hospital. LPN #1 stated that the family member wanted the resident to be a DNR. LPN #1 stated that he/she called a nurse from the Long Term Care section of the facility, called the physician for a DNR order, and had the other nurse verify the verbal order for DNR. He/she stated that the other staff member verified that the resident was unresponsive. When asked how and what he/she checked on the medical record to determine Resident #87's code status, LPN #1 stated that he/she looked on the chart for an order and stated that he/she looked in the Advance Directive section of the record. When the surveyor spoke with LPN #1 again on [DATE] and asked why he/she did not initiate CPR when he/she found the resident unresponsive and with no vital signs, LPN #1 replied that he/she called the family member, and the family member stated that the resident was a DNR. LPN #1 again stated that he/she called the family member to ask if they wanted the code status to be changed or remain the same. LPN #1 stated that the family member stated the resident was a DNR. The facility-obtained, signed statement written by LPN #1 dated [DATE] indicated, At 11:20 PM after receiving report from each of the ,[DATE] nurses; I made rounds on the unit to visualize each client. The statement indicated LPN #1 entered the room, and the resident did not respond. The statement indicated there were no respirations or pulse at that time. The statement further indicated, I momentarily left the room, called to the CNA's on the unit to alert the LTC Nurse that I needed assistance. I perused (resident's) chart for a DNR order, checked (his/her) advanced directive noted that it states 'I do not want CPR.' I placed a call to the Responsible party (family member) to notify of ceased respirations & inquired if (resident's) (family member) wanted CPR instituted. The statement indicated that the family member stated that there was a Living Will which I will bring in the morning to the Social Service. '(He/she) does not want CPR.' The statement indicates that the LTC nurse verified that respirations had ceased and verified that the family member did not want CPR started. The statement indicates that LPN #1 called the physician and proceeded to notify the M.D. of the (family member's) statement and with the LTC nurse obtained the DNR order. The statement further indicates, I then attempted to place a call to the social service Director (name) (with) no response. The statement further indicates that the Assistant Director of Nursing (ADON) was in the facility at that time, and LPN #1 notified (the ADON) of the change in condition of (the resident) & (family member's) response. The statement indicates that LPN #1 continued with my regular nursing duties after the ADON informed LPN #1 that he/she would 'take the necessary steps from here.' Review of the Corrective Action Documentation Form completed by the facility on [DATE] and signed by the Administrator and LPN #1, the form indicated Violation of Policy under State subject or code of conduct rule violated. The section under description of misconduct or performance deficiency, contained documentation which indicated, LPN did not follow CPR policy for resident before obtaining DNR order. The section related to corrective action indicated, Nurse will start CPR on any resident if no DNR order is present. During an interview on [DATE] at approximately 8:59 AM, the Medical Director reviewed the policy entitled Wildewood Downs Policy for Advanced Directives which stated in #4, If resident is made a DNR, a doctor's order .will be completed and placed in chart. The Medical Director reviewed the information contained in the section of admission information entitled, Understanding CPR which stated, Center personnel will perform Basic CPR if a resident has a cardiopulmonary arrest unless a valid physician order has been entered in the resident's medical chart or CPR would be unsuccessful in restoring cardiac and respiratory function. The Medical Director reviewed the policy entitled Cardiopulmonary Resuscitation which stated in #2, Nurse will determine code status of resident and if resident is a full code or code status is unknown, CPR will be initiated immediately while someone calls 911 and alerts EMS to location of emergency and lets them know CPR is necessary and has been started by staff. The Medical Director reviewed the closed record with the surveyor and confirmed that there were no physician's orders related to Advance Directives written upon admission. The Medical Director stated that following our standpoint, someone should have initiated CPR while someone else should have called 911 and called the family. The nurse did not follow the policy. During an interview on [DATE] at approximately 12:42 PM, Resident #87's physician of record was asked what his/her expectation was if a resident did not have a DNR order. The physician stated that he/she expected the resident to be a full code. The physician reviewed the closed medical record with the surveyor and confirmed that there was no DNR order prior to the date/time that the resident expired. The physician stated that when staff called him/her for the DNR order on [DATE], he was told the resident wanted to be a DNR, and the nurse had spoken with the family. The physician reviewed the form indicating the resident was deemed capable of making healthcare decisions and the social services documentation indicating the resident wanted to be a full code. The physician stated he/she had been unaware of the social services documentation indicating the resident wanted to be a full code. Review of the Wildwood Downs Care Policy included in information on Refusal of Life-sustaining Products, indicates, Wildewood Downs skilled nursing policy is to provide all treatment which is medically necessary to sustain the resident's life, unless a valid order to refuse such treatment is entered in the resident's medical record by his or her attending physician, in accordance with Wildewood Downs Limited Treatment Policy or Policy on 'Do No (sic) Resuscitate Orders' ('DNR') whichever may be applicable. Review of CMS S&C: ,[DATE]-NH Section A indicates, AHA (American Heart Association) urges all potential rescuers to initiate CPR unless: 1) a valid DNR order is in place; 2) obvious signs of clinical death . are present; or 3) initiating CPR could cause injury or peril to the rescuer. AHA guidelines for CPR provide the standard for the American Red Cross, state EMS agencies, healthcare providers, and the general public. Based on record review, interviews, and review of facility policies, it was determined on [DATE] at approximately 5:50 PM Immediate Jeopardy existed in the following area: CFR 483.13 (c) F-224 Prohibit mistreatment, neglect, misappropriation was identified at a scope and severity level of J. The facility failed to protect Resident #87 from neglect when CPR was not provided when indicated. The facility Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at approximately 5:50 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on [DATE] at approximately 5:45 PM, and the Immediate Jeopardy at F-224 was removed and lowered in scope and severity to a D. The AOC included the following: 1. The Advanced Directives Policy and the CPR Policy have been reviewed by the Medical Director and the DON. No changes have been made at this time. 2. All residents in the Nursing and Rehabilitation Unit have been interviewed and have had their code status confirmed. If residents were unable to confirm their code status, due to dementia, altered mental status, etc., or have been deemed unable to make medical decisions by the physician, their responsible parties (person with legal rights to make decisions for the resident), have been completed as of [DATE] and code statuses on all residents are current. 3. A complete chart audit has been conducted to confirm that the resident's wishes correspond with what is written on the chart. For example, if a resident states that he/she wishes to have a DNR order, it has been confirmed that there is an MD order and a signed DNR form on the chart. Any discrepancies have been corrected. An audit trail is attached to show the changes to any discrepancies. 4. All nurses and CNAs present on the unit from the time of the allegation until the current time on all shifts have been instructed by formal in-services on the Advanced Directive and CPR policies to understand that CPR is to be started on any resident who does not have an order for [REDACTED]. Signed statements have been obtained from all nurses and CNAs that they have received the training, and that they understand the content and have had an opportunity to ask questions. 5. The Administrator, DON, ADON, and attending physician and Medical Director have received in-service training by the RN nurse consult (sic) for The Hollinger Group regarding the Advanced Directive and CPR Policies. 6. The LPN who was working the night that the alleged non-compliance occurred has been counseled and also attended the mandatory in-service for Advance Directive and CPR. Her written statement of the alleged events is attached. She also attended the mandatory in-service, as evidenced by her signature on the master sign in sheet which is attached, and the signed statement that she received the policy, understands the content, and had an opportunity to ask questions. 7. The Administrator or Director of Nursing or Assistant Director of Nursing will check each shift to ensure that all staff scheduled to work have received the in-service until all facility staff have received the in-service. The in-service may be conducted by the Administrator, DON, ADON, or Staff Development nurse. This in-service will be provided to all new CNA and licensed nurse hires at Wildewood Downs. Wildewood Downs does not use any agency staff. 8. This practice will be prevented in the future by having all admissions checked for code status and the appropriate information (DNR order and DNR sheet if ordered) at the time of admission. This will be done by the DON or the ADON, or the Staff Development nurse in their absence. If the appropriate information is not present, the DON, ADON, or Administrator will get the appropriate orders or information on the chart, and notify the physician and the nurse assigned to the new resident admission that the information was not obtained per policy. These findings will be presented at the monthly QA meeting. 9. All department heads attend a daily morning meeting to go over any issues in the facility at 9 am. After this meeting, managers, including the Administrator, DON, ADON, MDS Coordinator, Admissions Nurse, Social Services Director, and Therapy Program Director attend an additional stand up nursing meeting daily to go over the 24 hour report. Each resident is discussed and any issues are brought up at this time. Any issues that require follow up are assigned at this time to the appropriate manager. Copies of all new orders are placed in the folder of the ADON for review. There is an RN on call 24 hours a days 7 days a week to address any nursing issue that requires immediate attention.

Based on record review and interviews, the facility failed to implement its written policies and procedures related to abuse/neglect for 1 of 22 residents reviewed for code status. The facility failed to investigate an incident in which Resident #87 did not receive Cardiopulmonary Resuscitation (CPR) when indicated. In addition, the facility failed to implement its policy related to pre-screening procedures for 2 of 5 employees prior to date of hire. It was determined on [DATE] at 5:50 PM Immediate Jeopardy existed for F-226 which was identified at a scope and severity level of J. The findings included: Cross refer to F-224 related to the facility's failure to protect Resident #87 who did not receive cardiopulmonary resuscitation when indicated. During an interview with the Administrator and Director of Nursing (DON) on [DATE] at approximately 5:50 PM, the surveyor reviewed the findings related to the date Resident #87 expired and the finding that staff did not provide CPR for a resident who had no physician's order for Do Not Resuscitate (DNR) at the time he/she was found unresponsive. When asked if the facility had investigated the incident, the DON stated, No. The Administrator stated that this was the first (he/she) had heard of it. Review of the facility's policy entitled Abuse Policy and Procedures revealed Section III indicated the facility will investigate all incidents. During the Extended Survey, review of employee files revealed background checks and registry verification had not been completed prior to the date of hire for two Certified Nurse Aides (CNA). Record review revealed CNA #1's date of hire was listed as [DATE]. Further record review indicated the background check and registry verification was not completed until [DATE]. Record review revealed CNA #2's date of hire was listed as [DATE] with the background check and CNA registry verification not completed until [DATE]. Review of the Wildewood Downs Abuse Policy indicated, All newly hired personnel will have a background check conducted prior to being hired .All licensed and certified personnel will have their standing assessed by the appropriate agency to determine if there have been findings of abuse of any type . Based on record review, interviews, and review of facility policies, it was determined on [DATE] at approximately 5:50 PM Immediate Jeopardy existed in the following area: CFR 483.13 (c) F-226 Develop and Operationalize Policies and Procedures was identified at a scope and severity level of J. The facility failed to implement its policies to protect Resident #87 when CPR was not provided when indicated. The facility Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at approximately 5:50 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on [DATE] at approximately 5:45 PM, and the Immediate Jeopardy at F-224 was removed and lowered in scope and severity to a D. The AOC included the following: 1. The Advanced Directives Policy and the CPR Policy have been reviewed by the Medical Director and the DON. No changes have been made at this time. 2. All residents in the Nursing and Rehabilitation Unit have been interviewed and have had their code status confirmed. If residents were unable to confirm their code status, due to dementia, altered mental status, etc., or have been deemed unable to make medical decisions by the physician, their responsible parties (person with legal rights to make decisions for the resident), have been completed as of [DATE] and code statuses on all residents are current. 3. A complete chart audit has been conducted to confirm that the resident's wishes correspond with what is written on the chart. For example, if a resident states that he/she wishes to have a DNR order, it has been confirmed that there is an MD order and a signed DNR form on the chart. Any discrepancies have been corrected. An audit trail is attached to show the changes to any discrepancies. 4. All nurses and CNAs present on the unit from the time of the allegation until the current time on all shifts have been instructed by formal in-services on the Advanced Directive and CPR policies to understand that CPR is to be started on any resident who does not have an order for [REDACTED]. Signed statements have been obtained from all nurses and CNAs that they have received the training, and that they understand the content and have had an opportunity to ask questions. 5. The Administrator, DON, ADON, and attending physician and Medical Director have received in-service training by the RN nurse consult (sic) for The Hollinger Group regarding the Advanced Directive and CPR Policies. 6. The LPN who was working the night that the alleged non-compliance occurred has been counseled and also attended the mandatory in-service for Advance Directive and CPR. Her written statement of the alleged events is attached. She also attended the mandatory in-service, as evidenced by her signature on the master sign in sheet which is attached, and the signed statement that she received the policy, understands the content, and had an opportunity to ask questions. 7. The Administrator or Director of Nursing or Assistant Director of Nursing will check each shift to ensure that all staff scheduled to work have received the in-service until all facility staff have received the in-service. The in-service may be conducted by the Administrator, DON, ADON, or Staff Development nurse. This in-service will be provided to all new CNA and licensed nurse hires at Wildewood Downs. Wildewood Downs does not use any agency staff. 8. This practice will be prevented in the future by having all admissions checked for code status and the appropriate information (DNR order and DNR sheet if ordered) at the time of admission. This will be done by the DON or the ADON, or the Staff Development nurse in their absence. If the appropriate information is not present, the DON, ADON, or Administrator will get the appropriate orders or information on the chart, and notify the physician and the nurse assigned to the new resident admission that the information was not obtained per policy. These findings will be presented at the monthly QA meeting. 9. All department heads attend a daily morning meeting to go over any issues in the facility at 9 am. After this meeting, managers, including the Administrator, DON, ADON, MDS Coordinator, Admissions Nurse, Social Services Director, and Therapy Program Director attend an additional stand up nursing meeting daily to go over the 24 hour report. Each resident is discussed and any issues are brought up at this time. Any issues that require follow up are assigned at this time to the appropriate manager. Copies of all new orders are placed in the folder of the ADON for review. There is an RN on call 24 hours a days 7 days a week to address any nursing issue that requires immediate attention.

Based on full and/or limited record reviews, interviews and review of the facility policies, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain the highest practicable physical, mental, and psychosocial well-being for residents with Advance Directives. It was determined on [DATE] at approximately 5:50 PM Immediate Jeopardy existed in the facility. The findings included: Cross refer to F-155 related to residents not being afforded the opportunity to formulate advance directives. Cross refer to F-224 related to Cardiopulmonary Resuscitation (CPR) not initiated when indicated. Cross refer to F-226 related to the facility not implementing policies and procedures. Cross refer to F-501 related to failure of the facility's Medical Director to provide oversight of the implementation of resident care policies related to Advance Directives. Cross refer to F-520 related to facility Administration's failure to ensure the Quality Assurance process was utilized to identify, clarify and implement a plan of action related to Advance Directives and when to perform CPR. The facility Administration failed to ensure appropriate policies and procedures were implemented to identify and clarify Advance Directives, to ensure residents were provided appropriate services related to Advance Directives and provision of care consistent with those directives, and to ensure the Quality Assurance process was utilized to identify, clarify, and implement a plan of action related to such. Review of the facility's policy entitled Understanding CPR revealed, Center personnel will perform Basic CPR if a resident has a cardiopulmonary arrest unless a valid physician order [REDACTED]. Review of the facility's policy entitled Cardiopulmonary Resuscitation (CPR) revealed, Nurse will determine code status of resident and if resident is a full code or code status is unknown, CPR will be initiated immediately while someone calls 911 and alerts EMS to location of emergency and lets them know CPR is necessary and has been started by staff. Based on full and/or limited record reviews, interviews and review of the facility policies, it was determined on [DATE] at approximately 5:50 PM Immediate Jeopardy existed in the facility. F-490 was cited at a scope and severity of J. The facility Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at approximately 5:50 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on [DATE] at approximately 5:45 PM, and the Immediate Jeopardy at F-490 was removed and lowered in scope and severity to a D. The AOC included the following: 1. The Advanced Directives Policy and the CPR Policy have been reviewed by the Medical Director and the DON. No changes have been made at this time. 2. All residents in the Nursing and Rehabilitation Unit have been interviewed and have had their code status confirmed. If residents were unable to confirm their code status, due to dementia, altered mental status, etc., or have been deemed unable to make medical decisions by the physician, their responsible parties (person with legal rights to make decisions for the resident), have been completed as of [DATE] and code statuses on all residents are current. 3. A complete chart audit has been conducted to confirm that the resident's wishes correspond with what is written on the chart. For example, if a resident states that he/she wishes to have a DNR order, it has been confirmed that there is an MD order and a signed DNR form on the chart. Any discrepancies have been corrected. An audit trail is attached to show the changes to any discrepancies. 4. All nurses and CNAs present on the unit from the time of the allegation until the current time on all shifts have been instructed by formal in-services on the Advanced Directive and CPR policies to understand that CPR is to be started on any resident who does not have an order for [REDACTED]. Signed statements have been obtained from all nurses and CNAs that they have received the training, and that they understand the content and have had an opportunity to ask questions. 5. The Administrator, DON, ADON, and attending physician and Medical Director have received in-service training by the RN nurse consult (sic) for The Hollinger Group regarding the Advanced Directive and CPR Policies. 6. The LPN who was working the night that the alleged non-compliance occurred has been counseled and also attended the mandatory in-service for Advance Directive and CPR. Her written statement of the alleged events is attached. She also attended the mandatory in-service, as evidenced by her signature on the master sign in sheet which is attached, and the signed statement that she received the policy, understands the content, and had an opportunity to ask questions. 7. The Administrator or Director of Nursing or Assistant Director of Nursing will check each shift to ensure that all staff scheduled to work have received the in-service until all facility staff have received the in-service. The in-service may be conducted by the Administrator, DON, ADON, or Staff Development nurse. This in-service will be provided to all new CNA and licensed nurse hires at Wildewood Downs. Wildewood Downs does not use any agency staff. 8. This practice will be prevented in the future by having all admissions checked for code status and the appropriate information (DNR order and DNR sheet if ordered) at the time of admission. This will be done by the DON or the ADON, or the Staff Development nurse in their absence. If the appropriate information is not present, the DON, ADON, or Administrator will get the appropriate orders or information on the chart, and notify the physician and the nurse assigned to the new resident admission that the information was not obtained per policy. These findings will be presented at the monthly QA meeting. 9. All department heads attend a daily morning meeting to go over any issues in the facility at 9 am. After this meeting, managers, including the Administrator, DON, ADON, MDS Coordinator, Admissions Nurse, Social Services Director, and Therapy Program Director attend an additional stand up nursing meeting daily to go over the 24 hour report. Each resident is discussed and any issues are brought up at this time. Any issues that require follow up are assigned at this time to the appropriate manager. Copies of all new orders are placed in the folder of the ADON for review. There is an RN on call 24 hours a days 7 days a week to address any nursing issue that requires immediate attention.

Based on record review and interview, the facility's Medical Director failed to provide oversight of the implementation of resident care policies related to Advance Directives. It was determined on [DATE] at approximately 5:50 PM Immediate Jeopardy existed in the facility. The findings included: Cross refer to F-155 related to residents not being afforded the opportunity to formulate advance directives. Cross refer to F-224 related to Cardiopulmonary Resuscitation (CPR) not initiated when indicated. Cross refer to F-226 related to the facility not implementing policies and procedures. Cross refer to F-490 related to Administration failure to ensure appropriate policies and procedures were implemented to identify and clarify Advance Directives, to ensure residents were provided appropriate services related to Advance Directives and provision of care consistent with those directives, and to ensure the Quality Assurance process was utilized to identify, clarify, and implement a plan of action related to such. Cross refer to F-520 related to facility Administration's failure to ensure the Quality Assurance process was utilized to identify, clarify and implement a plan of action related to Advance Directives and when to perform CPR. The findings included: During an interview on [DATE] at approximately 8:59 AM, the Medical Director reviewed the policy entitled Wildewood Downs Policy for Advanced Directives which stated in #4, If resident is made a DNR, a doctor's order .will be completed and placed in chart. The Medical Director reviewed the information contained in the section of admission information entitled, Understanding CPR which stated, Center personnel will perform Basic CPR if a resident has a cardiopulmonary arrest unless a valid physician order [REDACTED]. The Medical Director reviewed the policy entitled Cardiopulmonary Resuscitation which stated in #2, Nurse will determine code status of resident and if resident is a full code or code status is unknown, CPR will be initiated immediately while someone calls 911 and alerts EMS to location of emergency and lets them know CPR is necessary and has been started by staff. The Medical Director stated, A procedure gap here is definitely a problem .I have concerns over making sure we follow procedures and better documentation. We need to .make sure everyone is aware of the policy and make sure the documentation is in place. The Medical Director stated that following our standpoint, someone should have initiated CPR while someone else should have called 911 and called the family. The nurse did not follow the policy. There was no written documentation in the medical record or information provided during the interview to indicate the Medical Director had reviewed Resident #87's care following the time the resident expired or provided oversight regarding the implementation of policies related to advance directives. Based on full and/or limited record reviews, interviews and review of the facility policies it was determined on [DATE] at approximately 5:50 PM Immediate Jeopardy existed in the facility. F-501 was cited at a scope and severity of L. The facility Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at approximately 5:50 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on [DATE] at approximately 5:45 PM, and the Immediate Jeopardy at F-501 was removed and lowered in scope and severity to a D. The AOC included the following: 1. The Advanced Directives Policy and the CPR Policy have been reviewed by the Medical Director and the DON. No changes have been made at this time. 2. All residents in the Nursing and Rehabilitation Unit have been interviewed and have had their code status confirmed. If residents were unable to confirm their code status, due to dementia, altered mental status, etc., or have been deemed unable to make medical decisions by the physician, their responsible parties (person with legal rights to make decisions for the resident), have been completed as of [DATE] and code statuses on all residents are current. 3. A complete chart audit has been conducted to confirm that the resident's wishes correspond with what is written on the chart. For example, if a resident states that he/she wishes to have a DNR order, it has been confirmed that there is an MD order and a signed DNR form on the chart. Any discrepancies have been corrected. An audit trail is attached to show the changes to any discrepancies. 4. All nurses and CNAs present on the unit from the time of the allegation until the current time on all shifts have been instructed by formal in-services on the Advanced Directive and CPR policies to understand that CPR is to be started on any resident who does not have an order for [REDACTED]. Signed statements have been obtained from all nurses and CNAs that they have received the training, and that they understand the content and have had an opportunity to ask questions. 5. The Administrator, DON, ADON, and attending physician and Medical Director have received in-service training by the RN nurse consult (sic) for The Hollinger Group regarding the Advanced Directive and CPR Policies. 6. The LPN who was working the night that the alleged non-compliance occurred has been counseled and also attended the mandatory in-service for Advance Directive and CPR. Her written statement of the alleged events is attached. She also attended the mandatory in-service, as evidenced by her signature on the master sign in sheet which is attached, and the signed statement that she received the policy, understands the content, and had an opportunity to ask questions. 7. The Administrator or Director of Nursing or Assistant Director of Nursing will check each shift to ensure that all staff scheduled to work have received the in-service until all facility staff have received the in-service. The in-service may be conducted by the Administrator, DON, ADON, or Staff Development nurse. This in-service will be provided to all new CNA and licensed nurse hires at Wildewood Downs. Wildewood Downs does not use any agency staff. 8. This practice will be prevented in the future by having all admissions checked for code status and the appropriate information (DNR order and DNR sheet if ordered) at the time of admission. This will be done by the DON or the ADON, or the Staff Development nurse in their absence. If the appropriate information is not present, the DON, ADON, or Administrator will get the appropriate orders or information on the chart, and notify the physician and the nurse assigned to the new resident admission that the information was not obtained per policy. These findings will be presented at the monthly QA meeting. 9. All department heads attend a daily morning meeting to go over any issues in the facility at 9 am. After this meeting, managers, including the Administrator, DON, ADON, MDS Coordinator, Admissions Nurse, Social Services Director, and Therapy Program Director attend an additional stand up nursing meeting daily to go over the 24 hour report. Each resident is discussed and any issues are brought up at this time. Any issues that require follow up are assigned at this time to the appropriate manager. Copies of all new orders are placed in the folder of the ADON for review. There is an RN on call 24 hours a days 7 days a week to address any nursing issue that requires immediate attention.

Based on full and/or limited record reviews, interviews and review of the facility policies, it was determined on [DATE] at approximately 5:50 PM Immediate Jeopardy existed for CFR483.75 F-520 which was identified at a scope and severity level of J. Starting on [DATE], the facility failed to identify quality deficiencies related to Cardiopulmonary Resuscitation. The facility failed to identify, clarify, and implement a plan of action related to Advance Directives for Cardiopulmonary Resuscitation (CPR) and initiation of CPR. Failure of the Quality Assurance (QA) Committee to identify and implement action plans to ensure a resident who exhibited absence of pulse and respirations did not receive CPR when indicated resulted in Immediate Jeopardy for Resident #87. The findings included: Cross refer to F-155 related to residents not being afforded the opportunity to formulate advance directives. Cross refer to F-224 related to Cardiopulmonary Resuscitation (CPR) not initiated when indicated. Cross refer to F-226 related to the facility not implementing policies and procedures. Cross refer to F-490 related to Administration failure to ensure appropriate policies and procedures were implemented to identify and clarify Advance Directives, to ensure residents were provided appropriate services related to Advance Directives and provision of care consistent with those directives, and to ensure the Quality Assurance process was utilized to identify, clarify, and implement a plan of action related to such. Cross refer to F-501 related to failure of the facility's Medical Director to provide oversight of the implementation of resident care policies related to Advance Directives. During an interview with the Administrator and Director of Nursing (DON) on [DATE] at approximately 5:50 PM, the surveyor reviewed the findings related to the date Resident #87 expired and the finding that staff did not provide CPR for a resident who had no physician's order for Do Not Resuscitate (DNR) at the time he/she was found unresponsive. When asked if the facility had investigated the incident, the DON stated, No. The Administrator stated that this was the first (he/she) had heard of it. Based on full and/or limited record reviews, interviews and review of the facility policies, it was determined on [DATE] at approximately 5:50 PM Immediate Jeopardy existed in the facility. The facility Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at approximately 5:50 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on [DATE] at approximately 5:45 PM, and the Immediate Jeopardy at F-520 was removed and lowered in scope and severity to a D. The AOC included the following: 1. The Advanced Directives Policy and the CPR Policy have been reviewed by the Medical Director and the DON. No changes have been made at this time. 2. All residents in the Nursing and Rehabilitation Unit have been interviewed and have had their code status confirmed. If residents were unable to confirm their code status, due to dementia, altered mental status, etc., or have been deemed unable to make medical decisions by the physician, their responsible parties (person with legal rights to make decisions for the resident), have been completed as of [DATE] and code statuses on all residents are current. 3. A complete chart audit has been conducted to confirm that the resident's wishes correspond with what is written on the chart. For example, if a resident states that he/she wishes to have a DNR order, it has been confirmed that there is an MD order and a signed DNR form on the chart. Any discrepancies have been corrected. An audit trail is attached to show the changes to any discrepancies. 4. All nurses and CNAs present on the unit from the time of the allegation until the current time on all shifts have been instructed by formal in-services on the Advanced Directive and CPR policies to understand that CPR is to be started on any resident who does not have an order for [REDACTED]. Signed statements have been obtained from all nurses and CNAs that they have received the training, and that they understand the content and have had an opportunity to ask questions. 5. The Administrator, DON, ADON, and attending physician and Medical Director have received in-service training by the RN nurse consult (sic) for The Hollinger Group regarding the Advanced Directive and CPR Policies. 6. The LPN who was working the night that the alleged non-compliance occurred has been counseled and also attended the mandatory in-service for Advance Directive and CPR. Her written statement of the alleged events is attached. She also attended the mandatory in-service, as evidenced by her signature on the master sign in sheet which is attached, and the signed statement that she received the policy, understands the content, and had an opportunity to ask questions. 7. The Administrator or Director of Nursing or Assistant Director of Nursing will check each shift to ensure that all staff scheduled to work have received the in-service until all facility staff have received the in-service. The in-service may be conducted by the Administrator, DON, ADON, or Staff Development nurse. This in-service will be provided to all new CNA and licensed nurse hires at Wildewood Downs. Wildewood Downs does not use any agency staff. 8. This practice will be prevented in the future by having all admissions checked for code status and the appropriate information (DNR order and DNR sheet if ordered) at the time of admission. This will be done by the DON or the ADON, or the Staff Development nurse in their absence. If the appropriate information is not present, the DON, ADON, or Administrator will get the appropriate orders or information on the chart, and notify the physician and the nurse assigned to the new resident admission that the information was not obtained per policy. These findings will be presented at the monthly QA meeting. 9. All department heads attend a daily morning meeting to go over any issues in the facility at 9 am. After this meeting, managers, including the Administrator, DON, ADON, MDS Coordinator, Admissions Nurse, Social Services Director, and Therapy Program Director attend an additional stand up nursing meeting daily to go over the 24 hour report. Each resident is discussed and any issues are brought up at this time. Any issues that require follow up are assigned at this time to the appropriate manager. Copies of all new orders are placed in the folder of the ADON for review. There is an RN on call 24 hours a days 7 days a week to address any nursing issue that requires immediate attention.

On the day of the complaint inspection, based on limited record review and interviews, the facility failed to provide medications as ordered for 1 of 4 residents reviewed for medications. Resident #1 did not receive ordered Xanax for two days following admission to the facility. The findings included: The facility admitted resident #1 on 5/5/12, with [DIAGNOSES REDACTED]. Review of the physician's admission orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 5/6/12, the resident did not receive the ordered Xanax at 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM. The dosages were circled as not given. The Nurse's Medication Notes for 5/5/12 noted, "Xanax 0.25 mg not in drawer- Pharmacy notified". On 5/6/12 the Nurse's Medication Notes stated, "Xanax 0.25 mg not available. Pharmacy Aware." The resident did not receive seven (7) doses of the ordered Xanax. Review of the Interdisciplinary Care Plan, with admission date of [DATE], included a problem of, "Medications and Treatments. The Goal was listed as, "Medications and Treatments will be administered as ordered." An Approach to the goal was, "Perform all MD (Medical Doctor) orders as ordered." Review of the Nurse's Notes dated 5/5/12, stated the resident was admitted at 11:35 AM. The Nurse's Note dated 5/6/12 at 11:30 AM stated, "...Xanax 0.25 still not available, Pharmacy called x 5, got message stating, "Net work was unavailable, please call back later, will report." At 3:15 PM a note was written, "On call Supervisor, (DON) Director of Nursing, aware." 4:00 PM, call placed to Dr. to notify of Xanax 0.25 mg not available, unable to contact pharmacy. Review of the Physician's progress notes dated May 7, 2012, stated, "...He came to facility for rehab and medical management unfortunately he did not get his xanax and is now slipping back into a mindset similar to one in the past that landed him in an inpatient psychiatric ward. I spoke with his therapist who told me he has a history of anxiety and psychotic depression..." The Progress note of May 10, 2012 stated, "...he is much improved since his last visit he's back on his xanax..." On 6/20/12 the Physician was interviewed at approximately 2:50 PM, the physician confirmed the resident did not receive the Xanax. "I believe it was over the weekend. He should have received it." At approximately 3:30 PM the ADON (Assistant Director of Nursing) was interviewed. She stated she got involved on Monday when he didn't receive his Xanax. The hospital didn't send prescription; he should have received the Xanax. Review of the Policy and Procedure for obtaining new medications stated, "...If needed before the next regular delivery, fax or phone the medication order to the pharmacy immediately upon receipt. Inform pharmacy of the need for prompt delivery. Require timely delivery of new orders so that the medication administration is not delayed... Please order all control drugs as these are needed. The facilities policy for Medication Availability was reviewed. The Policy stated, "An unavailable medication is not an acceptable condition. The pharmacy provides a pharmacist on call 24 hours a day, 7 days a week. ...Has contracts with back-up pharmacies in the state to provide medications if necessary."

On the day of the survey, based on record review and interview, the facility failed to ensure that one of four residents was free from significant medication errors. The nursing staff failed to follow specific physician's orders [REDACTED]. The findings included: The facility admitted resident #1 on 5/5/12, with [DIAGNOSES REDACTED]. Review of the physician's admission orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 5/6/12, the resident did not receive the ordered [MEDICATION NAME] at 9:00 AM, 1:00 PM, 5:00 PM and 9:00 PM. The dosages were circled as not given. The Nurse's Medication Notes for 5/5/12 noted, "[MEDICATION NAME] 0.25 mg not in drawer- Pharmacy notified". On 5/6/12 the Nurse's Medication Notes stated, "[MEDICATION NAME] 0.25 mg not available. Pharmacy Aware." The resident did not receive seven (7) doses of the ordered [MEDICATION NAME]. Review of the Nurse's Notes dated 5/5/12, stated the resident was admitted at 11:35 AM. The Nurse's Note dated 5/6/12 at 11:30 AM stated, "[MEDICATION NAME] 0.25 still not available, Pharmacy called x 5, got message stating, "Net work was unavailable, please call back later, will report." At 3:15 PM a note was written, "On call Supervisor, (DON) Director of Nursing, aware." 4:00 PM, call placed to Dr. to notify of [MEDICATION NAME] 0.25 mg not available, unable to contact pharmacy. Review of the Physician's progress notes dated May 7, 2012, stated, "...He came to facility for rehab and medical management unfortunately he did not get his [MEDICATION NAME] and is now slipping back into a mindset similar to one in the past that landed him in an inpatient psychiatric ward. I spoke with his therapist who told me he has a history of anxiety and psychotic depression..." The Progress note of May 10, 2012 stated, "...he is much improved since his last visit he's back on his [MEDICATION NAME]" On 6/20/12 the Physician was interviewed at approximately 2:50 PM, the physician confirmed the resident did not receive the [MEDICATION NAME]. "I believe it was over the weekend. He should have received it." At approximately 3:30 PM the ADON (Assistant Director of Nursing) was interviewed. She stated that she got involved on Monday when he didn't receive his [MEDICATION NAME]. The hospital didn't send the prescription; he should have received his [MEDICATION NAME].

On the day of the complaint inspection, based on record reviews and interviews, the facility failed to ensure that residents remained as free of accident hazards as possible, received assistance devices in an effort to prevent accidents, and were thoroughly assessed after a fall for 3 of 5 residents reviewed for falls (Residents #1, #3, and #5). Resident's #3 and #5 did not received adequate assessment and interventions to promote safety and prevent accidents, resulting in a fall with injury for Resident #3. Resident #1 was not thoroughly assessed after her fall on 10/26/11. The findings included: Resident #3 with [DIAGNOSES REDACTED]. Review of the Admission Evaluation and Interim Care Plan showed the resident's last fall was four months prior to admission. He scored 16 on the fall risk assessment, indicating he was at risk for falls. Review of the Nurse's Notes revealed the resident was admitted to the Long Term Care (LTC) wing of the facility, which was not certified for Medicare and Medicaid. While on the LTC, the resident became weak on 1/21/12, at 2:50 AM, while being assisted to the commode. The nurse assisted him to her leg to prevent a fall. On 1/22/12, at 10 AM, the LTC staff was alerted by the resident yelling out. He was found on the floor, face down. No injuries were noted. The resident was transferred to the Rehabilitation unit on 1/25/12. The care plan in place at that time noted a risk for falls with interventions that included: complete fall risk assessment, report any falls to MD, investigate and document cause of all falls, place on facility fall prevention program, monitor and report any injuries from falls, and answer call light promptly. No safety devices were listed on the care plan. The Nurse's Note on 1/30/12 at 11 AM stated a loud noise was heard coming from the resident's room. He was found face down on the floor, unresponsive. 911 was called. The resident began to rouse and stated "I hurt." He complained of pain in his right hip. Blood was noted on the floor and after log rolling the resident, a laceration was noted to his forehead. The resident was taken to the hospital where he stayed until 2/1/12. The resident's plan of care was reviewed by facility staff on 2/1/12. He was noted to have the potential for falls related to history, unsteady gait, and weakness. The interventions included: complete fall risk assessment, non-skid shoes, report any falls to MD, investigate and document cause of all falls, place on facility fall prevention program, monitor and report any injuries from falls, answer call light promptly. The non-skid shoes were the only new intervention added to the care plan in an attempt to keep the resident safe from accidents. A physician's orders [REDACTED]. Further review of the medical record showed the resident continued to have falls: On 2/12/12, at 5:30 PM, the resident stumbled and fell while ambulating to the dining room with his rolling walker. The documentation did not state if the resident was being assisted at the time of his fall. On 2/19/12, at 7:15 PM, a noise was heard coming from the resident's room. He was found lying on the floor against the wall. He stated he was trying to get out of bed and "just began bouncing around." No injuries were noted. The documentation did not state if the safety alarm was in use at the time of the fall. On 2/22/12, at 7:15 PM, the resident was found lying on the floor of the bathroom with half of his body in the shower stall. Swelling was noted to back of the head on the right side. The resident complained of pain in the area. There was slight bruising. He sustained abrasions on the right shin and left knee. The documentation did not show that the safety alarm was in use at the time of the fall. Review of the care plan on the day of the complaint inspection showed it was not updated after the falls and no new interventions were added, including the safety alarm. Review of the medical record failed to show evidence that the safety alarm was instituted as ordered. The resident was observed on 3/20/12, at 1:45 PM. He was in his wheelchair in his room. There was no safety alarm in view. Resident #1 with [DIAGNOSES REDACTED]. The resident was [AGE] years old. She received anticoagulant therapy with Coumadin. Review of the hospital Discharge Summary for the 10/18-25/11 hospitalization revealed the resident had a history of [REDACTED]. She presented to the hospital three times in the last few weeks. The resident underwent [REDACTED]. Review of the Admission Evaluation and Interim Care Plan dated 10/25/11 showed the resident had no history of falls. She scored a 16 for fall risk (a score of 10 or higher indicated at risk status). Review of the Nurse's Notes revealed the resident was alert and oriented. Her body audit showed bruises to both arms from venipunctures. The resident required the use of oxygen via nasal cannula to maintain an acceptable oxygen saturation level. On 10/26/11, at 11:20 PM, the resident was found on the floor in front of the bathroom of a neighboring room. She was assisted to stand and while being ambulated back to her room, her legs gave way and she was placed in a wheelchair. The resident sustained [REDACTED]. The documentation did not show evidence of a head injury but it also did not show that she was checked for a head injury. A check of the resident's oxygen saturation showed a reading of 85%, and her nasal oxygen was restarted with slow improvement in the oxygen saturation readings. Neurological checks were initiated and showed normal results. Both the physician and the resident's family were notified of the fall. Subsequent entries in the Nurse's Notes, on 10/28/11 and 10/29/11 showed an x-ray was done on 10/28/11 for complaints of arm pain but there was no other evidence of any complications from the fall and no other complaints from the resident. The resident went to a scheduled cardiology appointment on 10/31/11 and was admitted to the hospital. She did not return to the facility. Information received by this office from an interested party said the resident sustained [REDACTED]. The hematoma on the back of the resident's head was discovered on 10/28/11 and reported to the nursing staff. Although review of the Nurse's Notes failed to show any signs of a head injury, documentation was noted on the Admission Evaluation and Interim Care Plan of 10/25/11. The body assessment portion of the form showed: "1. small skin tear with bandaid 2. bruises from IV/venipuncture (3) Pacemaker (4) bruise top of head." The last entry, #4, appeared to be in different handwriting from the rest of the form. The Director of Nurses (DON) signed as completing sections A-G, which included the skin assessment, and dated her entries 10/25/11. During an interview on the day of the complaint inspection, the DON was asked if she made entry #4 on the skin assessment. The DON stated she could not independently recall assessing the resident but said entry #4 was not her handwriting. She was unable to say who might have written that documentation. Review of the medical record showed a progress note from the physician on 10/27/11 stating the resident had a fall with no injuries. The resident's neurological checks remained within normal limits. The resident complained of left arm pain and the x-ray on 10/28/11 showed no acute changes. However, review of the ADL (Activities of Daily Living) Assessment Log and the MDS (Minimum Data Set) Focused Assessment Charting did show the resident had a change in condition after her fall. Documentation in the ADL Assessment Log showed the resident was independent in bed mobility and required supervision for transfer and ambulation on 10/26 and 10/27/11. On 10/28/11, the documentation showed she required extensive assistance of one person for bed mobility and transfer. The resident needed limited assistance for ambulation in the room and she no longer ambulated in the corridor. Review of the MDS Focused Assessment Charting showed a change in the resident's short term memory, as on 10/28/11 she changed from having no short term memory problem (except for the night shift on 10/26 and 10/27/11), to consistently showing a short term memory problem on all shifts 10/28 and afterward. The documentation also showed the resident exhibited signs of delirium on 10/28/11 for all shifts. There was no evidence in the medical record to show that the facility recognized the changes in the resident's condition and provided continued assessment to determine if the changes resulted from the resident's fall, the injury to her arm, or from her cardiac condition. The resident' head injury was inappropriately documented and there was no follow-up assessment, physician notification, or interventions related to the head injury. Review of the Interdisciplinary Care Plan, reviewed by staff on 10/25/11, showed the resident was at risk for falls. Interventions included complete fall risk assessment, low bed, report any falls to MD, investigate and document cause of all falls, place on facility fall preventions program, monitor and report any injuries from falls, and answer call light promptly. It did not show an update because of the fall on 10/26/11 and did not show the added safety measure of the bed alarm. Resident #5 with [DIAGNOSES REDACTED]. The resident stayed at the facility until 3/16/12. While at the facility, she had three falls: On 2/23/12, at 7:25 PM, the resident's husband was assisting her from the bed to the wheelchair and she fell . Initially, the resident denied any pain but later said she had some soreness was to the left mid-thigh. On 3/6/12, at 12:35 AM, a loud noise was heard from the resident's room and she was heard yelling out for help. The resident was found on the floor, sitting with her head against the wall. She reported to the staff that she did not know how she fell . No new injuries were noted. Old bruises were seen on her left hip and left upper arm from the previous fall. On 3/13/12, at 10:50 AM, the nurse was called to the resident's bathroom by a nursing assistant. The resident was lying on her back on the floor in front of the toilet. She denied hitting her head and no injuries were noted. A new physician's orders [REDACTED]. The Nurse's Note on 3/13/12 stated the resident's care plan was updated to show the new order. Review of the medical record showed one entry in the Nurse's Notes documenting the use of the alarm. On 3/15/12, at 11:30 PM, the resident was restless and trying to get out of bed and the bed alarms was sounding. There was no other documentation to show that the safety alarm was in use at all times. Review of the care plan, with a care conference meeting date of 2/21/12 showed a problem of "At risk for falls d/t (due to) history of falls with injury prior to admission" that was identified on 2/13/12. The approaches included: encourage the resident to call for assistance; cue and help the resident focus to call staff to retrieve items that were out of reach; review any falls that occur for needed change in care plan; inform therapy of any falls for assessment; ensure bed in lowest position; ensure resident had proper non-skid footwear, place frequently used item and call bell in reach; and non-weight bearing on the right leg. Review of the care plan on the day of the complaint inspection revealed there were no updates showing the resident's falls and there were no additional interventions added to the care plan, including the need for a safety alarm at all times.

Amended May 14, 2012 On the day of the complaint inspection, based on record review and interview, the facility failed to ensure that medical records of residents were accurately documented to ensure appropriate care and services for 1 of 2 residents reviewed because of falls with injuries (Resident #1). Review of the medical record revealed an unknown staff member entered information about a head injury under another staff member's admission assessment. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was [AGE] years old. She received anticoagulant therapy with [MEDICATION NAME]. Review of the Nurse's Notes revealed the resident was alert and oriented. On 10/26/11, at 11:20 PM, the resident was found on the floor in front of the bathroom of a neighboring room. She was assisted to stand and while being ambulated back to her room, her legs gave way and she was placed in a wheelchair. The resident sustained [REDACTED]. The documentation did not show evidence of a head injury but it also did not show that she was checked for a head injury. Neurological checks were started after the fall and showed results within normal limits. Information received by this office from an interested party said the resident did sustain a head injury from her fall, discovered on 10/28/11, which resulted in a decline in condition. According to the interested party, the discovery of the hematoma to the back of the resident's head was reported to facility staff. Although review of the Nurse's Notes failed to show any signs of a head injury, documentation was noted on the Admission Evaluation and Interim Care Plan of 10/25/11. The body assessment portion of the form showed: "1. small skin tear with bandaid; 2. bruises from IV/venipuncture; (3) Pacemaker; (4) bruise top of head." The last entry, #4, appeared to be in different handwriting from the rest of the form. The Director of Nurses (DON) signed the form as completing sections A-G, which included the skin assessment, and dated her entries 10/25/11. When asked if she made entry #4 on the skin assessment, the DON stated she could not independently recall assessing the resident but said entry #4 was not her handwriting. She was unable to say who might have written that documentation. Review of the medical record showed a progress note from the physician on 10/27/11 stating the resident had a fall with no injuries. The resident's neurological checks continued to be within normal limits. The resident had a large bruise and complained of left arm pain. An x-ray on 10/28/11 showed no acute changes. However, review of the ADL (Activities of Daily Living) Assessment Log and the MDS (Minimum Data Set) Focused Assessment Charting did show the resident had a change in condition after her fall. Documentation in the ADL Assessment Log showed the resident was independent in bed mobility and required supervision for transfer and ambulation on 10/26 and 10/27/11. On 10/28/11, the documentation showed she required extensive assistance of one person for bed mobility and transfer. The resident needed limited assistance for ambulation in the room and she no longer ambulated in the corridor. Review of the MDS Focused Assessment Charting showed a change in the resident's short term memory, on 10/28/11 she changed from having no short term memory problem (except for the night shift on 10/26 and 10/27/11), to consistently showing a short term memory problem on 10/28 and the days following. The documentation also showed the resident exhibited signs of [MEDICAL CONDITION] on 10/28/11 for all shifts. Because the resident's head injury was documented inappropriately, the resident did not received the care and services required to thoroughly assess and monitor her condition.

On the day of the complaint inspection, based on record review, observation and interview, the facility failed to provide necessary treatment and services to prevent/treat pressure sores for 2 of 3 residents. Resident #2 and #4 developed pressure sores without necessary interventions to treat or prevent the wounds. Resident #3 admitted with a chest wound, the wound was not identified on the Minimum Data Set assessment dated [DATE], his first documented assessment by the wound nurse was dated 12/24/2011. The findings included: The facility admitted Resident # 2 on 12/13/2011 with [DIAGNOSES REDACTED]. Review of the initial/interim care plan dated 12/13/2011 identified as a problem "Potential for skin breakdown related to: NWB (No Weight Bearing) on R (right) foot. The approaches included Inspect skin weekly, dressings as ordered, skin protectant to R heels BID (twice a day) and Heel Protector to R heel AAT (at all times). Review of the "Admission Evaluation and Interim Care Plan" dated 12/13/2011, revealed a body audit that documented scars, dry skin and surgical incision with no documentation of a pressure sore. Review of the nurse's notes revealed no documentation of a pressure sore until 12/21/2011, seven days after admission. At 5:00 PM on 12/21/2011, the nurse's note stated, "Unstageable pressure ulcer noted to R calf. Measures 2 cm (centimeters) x 1.5 cm. Wound bed with 100% eschar. Left open to air and will monitor." There was no documentation the physician or the family was notified of the pressure area. Review of the physician's orders [REDACTED]. Review of the Nutritional Risk assessment dated [DATE], Under the section, "Skin Condition" documentation indicated, "Skin intact". No other Nutrition assessment was available. Observation on 1/3/2012 at 1:15 PM with the Director of Nurses (DON), of the resident's right calf wound revealed the wound covered with black eschar, approximately 2 cm x 2 cm. The resident's son and family friend was in the room at the time of the observation. They stated the area was just red on admission and over a period of time had worsened. The DON was interviewed on 1/3/2012. She confirmed the physician had not been notified of the unstageable pressure sore. She stated, "The family was not notified because the family notified us of the area". Resident #2 developed an unstageable pressure sore while a resident at the facility. No interventions were put into place to promote healing of the pressure sore. The physician had not been notified and no treatment was ordered. The care plan had not been revised to show the development of the pressure sore. The facility admitted resident #4 on 10/14/2011, with [DIAGNOSES REDACTED]. Review of the closed medical record revealed a hospital transfer summary dated 10/14/2011that did not indicate the resident had pressure sores. The Admission Evaluation and Interim Care Plan dated 10/14/2011 showed a body audit that indicated the resident was admitted with a "blister" on the left buttocks. The initial care plan, dated 10/14/2011, included as a problem, "Potential for skin breakdown related to: Actual skin problem decreased mobility, 10/14/11- admitted c (with) blister to L (left) buttock." The approaches included: "Inspect skin weekly and report any breakdown or deterioration. Dressing as ordered, Reposition a minimum of every two hours." On 10/17/2011 at 11:30 PM, the nurse's note stated, "Resident has open area on bottom, 1 cm x 2 cm [MEDICATION NAME] ordered and applied..." On 10/22/11 at 1:30 PM, the nurses note stated, Stage II ulcer noted on R buttock measures 4 cm x 2.5 cm. Wound bed is pink c (with) 10% slough noted... Stage II ulcer noted to L buttock measures 0.5 cm x 0.5 cm. Wound bed is pink c O (no) drainage noted. Skin protectant cream applied..." The resident developed two pressure sores after admission to the facility. The necessary interventions to encourage healing and prevent the development of the pressure sores were not put in place. The care plan was not revised to show the changes in the resident's condition. Review of the physician progress notes [REDACTED]. The facility admitted resident #3 on 12/06/2011, with [DIAGNOSES REDACTED]. Review of the hospital transfer summary dated 12/05/2011 stated. "...He has been receiving Santyl to a chest wound on the right anterior chest wall. Eschar that had been present was debrided 1 week ago... He requires daily dressing changes for his chest wound for the time being. It should be cleaned with saline, covered with Santyl, and then dry gauze..." Review of the admission physician's orders [REDACTED]...3. cleanse wound to (R) (right) chest wall with NS (normal saline). Pat dry. Coat with Santyl. Cover with [MEDICATION NAME]. Secure with tape. Change daily..." Review of the Physician's Telephone Orders indicated the Santyl was discontinued on 12/09/2011 and [MEDICATION NAME] was ordered as treatment to the chest wound. Review of the Minimum (MDS) data set [DATE] showed no pressure ulcers on the skin assessment. On 12/24/2011 at 11:30 PM, the nurse's note stated, "Stage II pressure ulcer noted to (R) chest. Measures 5.4 cm (centimeters) x 1.3 cm. Wound bed is pink with 100 % granulation tissue..." The nurse's note dated 12/24/2011 was the first documented assessment of Resident #3's pressure ulcer. Review of the physician progress notes [REDACTED]. Review of the wound protocol under the section "Stage II Pressure Ulcer". A Stage II ulcer was described as, "partial thickness loss of dermis presenting as shallow, open ulcer with red/pink wound bed, without slough; may present as open/ruptured serum filled blister." Guidelines for Stage II Pressure ulcers included: 1. Provide interventions to manage all risk factors as needed; a. Positioning pillows, b. Dietary referral. 2. May use skin sealant around wound edges (skin prep, etc...) 3. Dressing selection and frequency based on amount of exudate; a. Film (minimal exudates; change every 3 days and PRN) c. Foam (moderate to heavy exudates; changed every 3 days and PRN) During an interview with the DON on 1/3/2012 at 3:30 PM, when asked how the facilities system worked regarding pressure sores, she stated, "If admitted , assessed on admission. Communicate to Doctor. Continue order from hospital until Dr. (doctor) changes it. If we discover an area, we notify the Dr. and family, follow our protocol unless the doctor orders something different. _____ (wound nurse) has been trained in wound care... Weekly assessment done by ____ to document progress. If it worsens notify Dr. and change treatment. CNA's are instructed to tell nurse if they find anything. We have weekly skin checks that staff nurses are doing. We give the dietician the wound list. She comes every other week. We review the wound reports monthly in QA (Quality Assurance).

On the day of the survey, based on record reviews, the facility failed to ensure that residents' care plans were periodically reviewed an updated to reflect changing status for 2 of 2 residents reviewed who had repeated falls (#1 and #3). The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was hospitalized after a fall for evaluation of hip pain. No fractures were diagnosed at the hospital. The resident went to the facility for short term rehabilitation after hospitalization . She was discharged home on[DATE]. Review of the Resident Assessment Instrument (RAI) for 7/12/10 showed a fall in the last 30 days. Review of the Resident Assessment Protocol (RAP) noted revealed the resident was at risk for falls related to her history of falls. Review of the plan of care dated 7/15/10 showed a problem of risk for falls with interventions of: gather information about past falls; keep call light in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; and proper footwear. The resident fell three times while at the facility. One of the falls resulted in a fractured distal right clavicle. Review of the care plan showed it was not updated to show the falls and no new interventions were planned to assist the resident in fall prevention. Resident #3 with [DIAGNOSES REDACTED]. An admission nursing assessment for falls revealed a score of 22, any score above 10 indicated a risk for falls. The facility physician's history and physical dated 7/22/10, the resident had had multiple falls. Review of the RAI of 7/25/10 showed no falls. Review of the RAP notes of 7/28/10 showed the resident triggered for falls related to daily use of an antidepressant. Review of the care plan dated 8/3/10 revealed a problem of "high risk for falls related to Hx (history of) falls, decreased mobility." Interventions included: gather information on past falls; be sure call light is in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; activities for diversion and strengthening; and appropriate footwear. Review of the medical record showed the resident had 11 falls while at the facility. The care plan showed no changes throughout the resident's stay.

On the day of the survey, based on record reviews, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents reviewed who had repeated falls (#1 and #3). The findings included: Resident #1 with [DIAGNOSES REDACTED]. No fractures were diagnosed at the hospital. Resident #1 went to the facility for short term rehabilitation. Review of the admission nursing assessment showed a fall risk score of 20. A score above 10 indicated risk for falls. Review of the Resident Assessment Instrument (RAI) for 7/12/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident needed extensive assistance of one person for bed mobility, transfer, dressing, and bathing. She required total assistance for toilet use and hygiene. The resident was incontinent of bowel and bladder. A fall in the last 30 days was noted. Review of the Resident Assessment Protocol (RAP) noted revealed the resident was at risk for falls related to her history of falls. The note did not provide any history of the past falls. There was no evaluation of any pattern or triggers for the falls. Review of the plan of care dated 7/15/10 showed a problem of risk for falls with interventions of: gather information about past falls; keep call light in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; and proper footwear. The resident fell three times while at the facility: 1. A Nurse's Note on 7/27/10 at 7 AM stated the resident was found lying on the floor in her bathroom. The resident could not explain how she got on the floor. A small skin tear on the left elbow resulted from the fall. There was no evidence the facility changed or added interventions to the resident's care plan after this fall. 2. On 7/28/10, at 7 PM, the Nurse ' s Note said her Certified Nursing Assistant (CNA) put the resident on the toilet. The CNA went to get a brief out of the closet. Resident #1 tried to get up alone and fell , hitting her right shoulder. The nurse's assessment showed a red area to the shoulder, and skin tears to the right wrist and left forearm. An orthopedic assessment and x-ray done on 8/6/10 showed a fractured distal right clavicle. There was no evidence the facility changed or added interventions to the resident's care plan after this fall. An interview with the CNA providing care to the resident on 7/28/10 revealed the resident had never tried to get up by herself before when in the CNA's care. The CNA said she found out from the nurse after the fall that the resident had fallen the day before while getting up unassisted. On 8/21/10, a Nurse's Note stated the resident was alert and oriented to herself. She was up at the bedside eating breakfast and took her morning medications. "... Informed pt to call for assistance daughter found up in BR (bathroom) had concerns of safety. ..." A personal safety alarm for the wheelchair was ordered that day. 3. The Nurse's Note on 8/22/10 at 12 PM stated a nursing assistant found the resident on the floor, lying by the bed. Skin tears to the left forearm and elbow were noted. The documentation in the Nurse's Notes, and the incident report, failed to say if the safety alarm was in use at the time of the fall. Review of the medical record revealed the resident was independent and wanted to do for herself. She also participated in therapy with improving functional status. The facility failed to use this information to adapt to the resident's changing status in an effort to prevent accidents. The resident was discharged home on[DATE]. Resident #3 with [DIAGNOSES REDACTED]. An admission nursing assessment for falls revealed a score of 22. Scores above 10 indicated a risk for falls. The facility physician's history and physical dated 7/22/10, the resident had had multiple falls. Review of the RAI of 7/25/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident needed extensive assistance of one person with bed mobility, transfer, dressing, hygiene, and bathing. He was incontinent of bowel and bladder. The RAI showed no falls. Review of the RAP notes of 7/28/10 showed the resident triggered for falls related to daily use of an antidepressant. Review of the care plan dated 8/3/10 revealed a problem of "high risk for falls related to Hx (history of) falls, decreased mobility." Interventions included: gather information on past falls; be sure call light is in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; activities for diversion and strengthening; and appropriate footwear. The care plan showed no changes throughout the resident's stay. Review of the Nurse's Notes showed the resident had 11 falls without injury while at the facility: On 8/1/10, at 2 AM, the resident tried to get up and slid off the low bed. On 8/3/10, at 7:35 AM, the resident was found on the floor by his low bed. He was yelling for help and told the staff he was "trying to get up to go to therapy." On 8/9/10, at 5:20 AM, the resident was found lying on the floor with his head under the bed and his legs partially extended out on the right side. On 8/10/10 at 11:15 PM, the resident was found lying on the floor beside the bed with his head resting on the bed. On 8/14/10, at 4 AM, the resident was found lying on the floor beside his low bed with a pillow still under his head. On 8/15/10, at 10:45 PM, the resident rolled out of bed. On 8/18/10, at 4:30 AM, the resident was found on scooting on his stomach on the floor by his bed. He told the nurse "he crawled out of bed and couldn't bet back in." On 8/30/10, at 11:45 PM, the resident was found sitting on his buttocks with his back against the low bed. On 9/1/10, the resident was found on the floor in front of his wheelchair. He reported that he was trying to get something off his bedside table, leaned forward and fell . On 9/5/10, at 1:50 PM, the resident was found on the floor by his bed. "I was going to a meeting." On 9/6/10, at 3:40 AM, the resident was found on the floor by the bed. "I have to go to work." He also complained that the "bed is curved in the middle and it messed me up." The resident was discharged on [DATE]. Review of the medical record showed no evidence that the facility assessed the resident's falls in an attempt to find a pattern and possible triggers for the falls. The resident did have a bed in the low position but no other interventions were noted.