Every finding on record at Willowbrooke Court Skilled Care Center at Mease Li

Based on observation, interview, and record review, the facility neglected to assess a newly admitted resident (Resident #198) for his potential for wandering which could have prevented the resident from leaving the facility unsupervised and suffering scrapes, bruises and requiring a visit to the emergency room . Findings included: Resident #198 was admitted to the facility on [DATE] at 10:45 p.m., with diagnosis to include dementia, depression, anxiety, [CONDITION(S)], history of falling, weakness, muscle weakness and difficulty in walking. An interview was conducted on 8/16/22 at 8:34 a.m. with Staff A, Licensed Practical Nurse (LPN). Staff A stated she was notified by the day nurse upon arrival on her shift at 7:00 p.m. that she would have an admission. Staff A stated the new admit was a total care resident, was confused, and had dementia. Staff A stated Resident #198 was admitted close to 11:00 p.m. Staff A stated she conducted a skin assessment for Resident #198 but did not conduct an elopement assessment upon admission because she did not know he could walk. Staff A stated she was working with Staff B, Certified Nursing Assistant (CNA) and notified her [Staff B] Resident #198 had dementia and was a fall risk. Staff A stated she anticipated the new admit being disoriented, due to being in a new environment. Staff A said, I told her [Staff B] to check on him very often. Staff A stated close to 4:00 a.m., Staff B reported she could not locate Resident #198. Staff A stated immediately she checked the bed, under bed, the bathroom, behind the door, the closet and could not find him. Staff A stated she stayed inside while Staff B looked outside in the back. Staff A stated Staff B came back inside a few minutes later and said she found him. Staff A stated she followed Staff B outside and saw him [Resident #198] laying on his back on the grass, not too far from the back door. Staff A said, I noticed he was bleeding on the right side of his head. I ran inside and got a wet washcloth and got a blanket to cover him. I did not want to move him. I sent [Staff C, CNA] to go upstairs and get [Staff D], the nurse working upstairs. Staff A stated that Staff D and Staff B remained with the Resident while she called 911. Staff A stated, I asked him, what are you doing outside? he said, I don't know, I just want to go home. Staff A stated Resident #198 kept apologizing and appeared very confused. Staff A stated the emergency medical technician (EMT) arrived and took Resident #198 to the hospital. Staff A stated she did not know how Resident #198 got out. Staff A said, It was a short period of time between when we saw him last. I could not imagine he could walk like that. Staff A stated she did not know Resident #198 was ambulatory. Staff A, LPN said, if I had received an accurate report about [Resident #198] being an elopement risk, I would have put a Wanderguard on him. They said he was total care. I did the elopement risk later on, not upon arrival. Staff A stated she had not completed the assessment, but it did not matter. Staff A stated she did not think Resident # 198 would meet criteria because he was not ambulatory. She normally received new patients on the night shift and received information about the expected resident prior to arrival. Staff A stated she did not know Resident #198 was from a memory care unit. She did not have time to review the preadmission paperwork prior to the resident's arrival. Staff A stated new residents should be supervised every 30 minutes or 15 minutes if someone was confused and fall often. Review of a nursing Progress note time stamped 5/11/22 at 10:50 a.m., showed on Tuesday 5/10/22 about 03:50 a.m., Staff B, CNA was doing rounds and noticed the resident was not in his room. Staff B immediately notified Staff A, LPN who initiated a search. Resident #198 was last seen in bed by Staff B about 20 minutes earlier. The resident was found by Staff B, CNA at approximately 03:57 a.m., indicating Resident #198 was unaccounted for approximately 27 minutes. An interview was conducted on 08/15/22 at 12:44 p.m. with Resident #198's family member. The family member stated Resident #198 was admitted to the facility for rehabilitation because the facility had on-site rehab and therapy access. The family member stated the goal was for Resident #198 to transfer back to memory care after rehabilitation at this facility. The family member stated the resident arrived at the facility sometime after 10:00 p.m. The facility had reported they were doing 20 minutes check on him, and they had noticed the resident missing at 4:00 a.m. The family member stated the resident was confused and was probably trying to locate another family member who lived on the same campus. This family member stated the resident was found outside the back side door, having fallen, and hit his head. He was laying on the ground. A telephone interview was conducted on 08/16/22 at 2:35 p.m. with Staff B, CNA who was assigned to Resident #198 on the day he left the facility unsupervised. Staff B said, I remember we were checking him every 20 minutes because he was very confused. I did not know much about him. I last saw him around 3:30 a.m., sleeping in his bed. I noticed 20 minutes later that he was not in his room. I checked out in by the back door and saw he him just lying there, face up. I noticed he had bumped his bead and had scratches on his knees. Staff B stated Resident #198 was responding to yes and no questions. The resident did not say where he was going. Staff B said, I don't remember much about what he was saying. He probably was conversating but, he was very confused. Staff B stated when they have new patients, they check on them about every 20 minutes. There was no indication he was trying to leave. It took two people to put him to bed the night before. Staff B said, We did not know he could walk. We didn't see him leave. I think he got out of bed, there is a hallway outside the room where he stayed, he must have held on to the handrail and followed it to the Exit door. Staff B stated the door which he went through was alarmed, but it did not go off because he did not have a Wanderguard. Staff B stated it was unusual to have a new resident and not know their needs. Staff B said, usually, they give the information to us. I wasn't given any information. I don't think the nurse did either. Staff B stated they had some information, but they did not get the full report. Staff B stated she did not know the resident was at risk for wandering. When she found Resident #198, she stayed with him and Staff A, the nurse assigned to him, called 911. Staff B stated she remained with the resident until EMT arrived. Staff B stated she did not see the Director of Nursing (DON) that morning but was called to give a statement of what happened. An Interview was conducted on 08/15/22 at 2:50 p.m. with the DON. She stated Staff B, CNA noticed the resident was missing about 3:50 a.m. and immediately went to look for him. The DON stated Staff A, LPN notified her immediately they could not find the resident. The resident may have wandered to find a family who lived at the facility next door. Resident #198 had not expressed a desire to leave. The DON stated staff from upstairs came to help find the resident. Once the resident was found, Staff A assessed him and saw blood on his face. The DON stated they called the doctor and sent him out. DON stated she saw he was admitted from the hospital and came in at 10:45 p.m. It was an expected admission. The nurse received a nurse-to-nurse report from [name of hospital.] They said he was a two-person transfer. At 10:45 p.m. Staff A, LPN verified that he was a two-person transfer, Staff B and Staff A assisted the resident from the chair to the bed. The nurse stated the resident was sleepy when he came in and did not ambulate. The DON stated Staff A, LPN assumed he was non-ambulatory and put him to bed. The DON stated most of the time they try to get an accurate assessment and identify if the resident was coming from a memory care unit. The DON said, we did not have a good plan in place to identify residents who are transferring from our memory care unit. We could have identified him as a wander risk prior to admission. We have changed the process. We are discussing all the residents who are transferred out in the entire campus and anticipating their return. The DON stated the residents at the memory care have dementia / Alzheimer's diagnosis. The DON stated they found out this after the investigation. The DON said, we should have considered his diagnosis. If I knew it, it would have made a difference. If they were living in a memory care unit or coming from a secured unit, an elopement risk assessment should be conducted upon assessment. We did not anticipate that he needed a Wanderguard. The DON further stated their preadmission process involved conducting an assessment. The admissions coordinator would do ask if the resident would be at risk. The problem was the assessment from the hospital stated he was not ambulatory. We had nursing notes and doctor's notes from the hospital. We did not see that he was identified at risk or that he had come from memory care. That warrants the assessment for Wanderguard. The DON said, we should have considered his previous residence. When asked about her findings, the DON stated they did not know the Resident lived in a memory care unit and that he was ambulatory. The DON stated there was a lot going on with the nurse. She was busy. Her assessments were done a little later than we prefer. The DON confirmed the full elopement assessment was conducted after the fact. The DON stated she conducted the elopement assessment herself, after the fact. The DON said, I just wanted to see his score. I found out that he was at risk. He scored a 12, indicating he would have been at risk. The DON stated the CNAs were expected to check on residents at least every 2 hours. The DON stated Resident #198 was seen about 15 -20 minutes prior to the time he was noted missing. The DON stated he did not verbalize wanting to leave prior to doing so. The DON stated they conducted a root cause analysis. The DON said, the conclusion was the fact that we did not put a wander guard on, we did not know he was from memory care, we should have put a Wanderguard on him. That would have locked the door, the alarm would have gone on and he would not have been able to get out. The DON stated post incident they provided education on the procedure for elopement. The DON stated they educated most staff but, not all. The DON stated they discussed getting a better transferring report, get a more detailed history and physical prior to admission and ensure more frequent checks on new residents until baseline can be established. An interview was conducted with the Nursing Home Administrator (NHA) on 08/15/22 at 3:01 p.m. The NHA stated she was notified first thing in the morning, received a text message from the DON around 6:00 a.m. The NHA stated the resident was already gone, he was admitted to the hospital. The NHA stated she reviewed statements and made sure the incident was reported. An interview was conducted on 08/16/22 at 3:18 p.m., with Staff F, Director of Admissions (DOA). The DOA stated she could not speak of a particular incident but could speak of the role of an admissions director at this facility. The DOA stated her job role was to validate that they could care for the patient, submit the authorization for Medicare, and verify if they had days available. The DOA stated once they confirm insurance, they wait for the hospital to discharge the patient. The DOA stated she was the contact person for the hospital. If there were questionable items, they would check with the DON. The DOA stated she asked questions of the hospital manager related to any preadmission concerns. The DOA stated to find out if a pre- admit patient were at risk for wandering, she reviewed the hospital referral paperwork. She made notes if they were confused and if they were ambulatory, asked if the patient had been trying to get out of bed, if they were dependent on an alarm or if there was video monitoring while at the hospital. The DOA stated she would conduct a bed assessment visit if necessary. The DOA stated the hospital referral would provide a history of the resident if they were homeless or if they were coming from a skilled nursing facility, secured facility, or another type of facility. The DOA stated that was the facility protocol. A follow -up interview was conducted on 08/17/22 at 10:42 a.m. with the NHA. The NHA stated they took the incident very seriously and addressed the risk. The NHA said, we do feel the concerns were addressed. We have a new admission process which starts with clear, concise communication related to pre-admission history and diagnosis of the resident. The NHA stated they did not have memory care resident listed on the hospital list that was shared within the entire campus. The NHA stated memory care residents were now included. The NHA stated they brought the incident to QA (Quality Assurance) and concluded every new admit that came from memory care would have a Wanderguard. The NHA stated they were checking the doors and were also making sure assessments were done in a timely manner. Review of a facility policy titled, Abuse, Neglect and Exploitation, dated 9/18/18 showed the residents of this facility have a right to be free from . neglect, . and injuries of unknown origin. All residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. Under definitions: Neglect: failure or omission on the part of the caregiver or vulnerable adult to provide the care, supervision, and services necessary to maintain the physical and mental health of a vulnerable adult, including but not limited to . supervision and medical services which a prudent person would consider essential for the well-being of vulnerable adult. The term neglect also means the failure of a caregiver or vulnerable adult to make a reasonable effort to protect a vulnerable adult from abuse, neglect, or exploitation by others. Neglect is repeated conduct or a single incident of carelessness, which produces or could reasonably be expected to result in serious physical or psychological injury or substantial risk of death. Review of a facility's policy and procedure titled, elopement prevention, last revised 2/14/2017, showed the facility staff will identify and protect residents that are at risk for wandering or elopement. The purpose of this policy is to provide guidance to the nursing staff related to resident elopement. Under procedure showed upon admission the resident will be assessed for elopement risk as part of the admission data collection, upon admission and readmission. Under elopement drills, the policy showed: The facility will conduct elopement drills quarterly, in January, April, July and October. The drills will be documented, and records kept by the Risk Manager. Review of a facility policy titled, elopement prevention / missing resident, dated January 22, 2017, showed under policy facility staff will identify and protect residents that are at risk for wandering and / or elopement. Under procedure: 1. Assessment (a) Upon admission and readmission, the resident will be assessed for elopement risk. The admission data collection from will be utilized. (b) Residents determined to be at risk for elopement will be evaluated using the elopement risk assessment. The resident at risk for elopement will be reassessed quarterly and whenever there is a significant change in either physical or mental status. 2. (b.) If the resident is at risk for elopement, the elopement risk identification form is completed. 3. Wanderguard (a) If the resident is at risk, the physician will be notified and an order for a Wanderguard will be obtained. The resident's family will be notified. (b) The Wanderguard alarm will be placed on the resident's ankle. Wanderguard placement and function is checked every shift and documented in the MAR (medication administration record), and the care plan will be updated. (c) Wanderguard alarms are present on all exit doors to the outside and exits to the [facility]. Fire exit doors are locked and will alarm if opened to the outside. (d) Alarmed doors are locked from 8:00 p.m. to 6:00 a.m. (e) A security check is made on the exterior doors every hour from 7:00 p.m. to 6:00 a.m. by the security contracted by [facility name]. (f) [facility name] staff members are responsible to respond to activated door alarms. 4. (b) If it is determined the resident is missing, start the missing resident action plan. (c) Page over loudspeakers asking the resident to return to his / her room three times to alert staff members. 5. Elopement drills (a) The facility will conduct elopement drills bi -annually. (b) The drills will be documented, and records will be kept by the risk manager.

Based on observations, record reviews, and interviews, the facility failed to accurately post the required daily staffing information. Findings included: On 08/15/2022 at 9:02 a.m., upon entry into the facility, an observation of the bulletin board located on the 1st floor next to the Nurse's station, revealed there was no current Daily Staffing Sheet, a document that provided information of the number of residents and the total hours of nursing staff working all on three shifts for that day. On 08/15/2022 at 3:13 p.m., an observation revealed no Daily Staffing Sheet posted for the current day. On 08/16/2022 at 7:35 a.m., while touring the 1st floor nursing unit, an observation revealed no Daily Staffing Sheet posted for the day. On 08/16/2022 at 10:15 a.m., during an interview with the Director of Nursing (DON), the Daily Staffing Sheets for the current week to include Sunday 08/14/2022 through Thursday 08/18/2022 was requested. On 08/16/2022 at 12:20 p.m., the DON delivered copies of the requested information regarding the Daily Staffing Sheets On 08/16/2022 at 3:05 p.m., an observation was made of the Daily Staffing Sheet posted for the day with the following information: Census:45, Certified Nursing Assistants (CNA): 120.25 hours, Licensed Practical Nurses (LPN): 48.0 hours, Registered Nurses (RN): 12.0 hours, RN/DON: 8.0 hours, RN with administrative duties: 10.0 hours On 08/17/2022 at 12:35 p.m., an observation revealed the Daily Staffing Sheet was dated 08/16/2022. On 08/17/2022 at 3:05 p.m., an observation revealed the posted Daily Staffing Sheet was still showing information from 08/16/2022. On 08/18/2022 at 8:38 a.m., an observation revealed the Daily Staffing Sheet was still showing information from 08/16/2022. On 08/18/2022 at 8:42 a.m., an interview was conducted with the Staffing Coordinator. She stated the census was: 52 for Sunday 08/14/2022, 52 for Monday 08/15/2022, 51 for Tuesday 08/16/2022, and 52 for Wednesday 08/17/2022. She said she received the census numbers from the admissions office and did the calculations. The information was then given to the DON for her to post. On 08/18/2022 at 9:46 a.m., during an interview with the DON, she stated she was responsible for posting the Daily Staffing Sheet. She showed a current copy of the Daily Staffing Sheet for Thursday 08/18/2022 and said she was in the process of posting it. She also stated she forgot to post the Daily Staffing Sheet on Wednesday 08/17/2022. On 08/18/2022 at 10:26 a.m., an interview was conducted with the Nursing Home Administrator (NHA). She explained in their morning meeting, the census was discussed as of midnight the previous day. Changes were made if a resident was sent out and a discussion was conducted related to any potential new admits. The staffing numbers were then created or adjusted by the DON and the hours were calculated by the Staffing Coordinator. She said the DON completed the staffing sheet and would post it on the bulletin board, which is located next to the first unit Nurse's Station. The NHA was shown the Daily Staffing Sheets which were received from the DON on Tuesday 08/16/2022. The first was dated for Sunday 08/14/2022, the second was for Monday 08/15/2022, and the third was for Tuesday 08/16/2022. All three sheets showed a total census of 45. The NHA was made aware that during an interview with the Staffing Coordinator, she stated the census for Sunday was 52, Monday was 52 and Tuesday was 51. The NHA stated, I honestly cannot give a good reason why the numbers are different, we screwed up and no one caught it or corrected it. I will investigate it and see what happened. A review of the policy titled, Posting Direct Care Staffing Numbers, revised July 2016 revealed: Policy Statement Our facility will post on a daily basis for each shift the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation: 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to resident and visitors) in a clear and readable format.

Based on record reviews and interviews, the facility failed to ensure the representative of one (Resident #17) of two residents sampled for hospitalization s received a written notice of transfer and that the Office of the State Long-Term Care Ombudsman received copies of the facility-initiated transfer or discharge notice for residents with an unplanned transfer. Findings included: Resident #17 was originally admitted to the facility on [DATE] with a recent admitted [DATE]. The Profile Face Sheet included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet indicated the resident had a Power of Attorney (POA). The quarterly Minimum Data Set (MDS), completed 10/6/2020, indicated Resident #17 had a Brief Interview of Mental Status (BIMS) score of 9, indicative of moderate cognitive impairment. The Admission MDS, completed 1/10/2021, indicated the resident had scored 4 out of 15 on the BIMS, identifying a severe cognitive impairment. A review of Resident #17's clinical record identified that the resident was transferred to an acute care facility on 12/31/20 after the resident presented with rectal bleeding. An Interdisciplinary note, dated 12/31/20 at 9:50 a.m., indicated that 911 was called, physician's office was called, an order was received to transfer to the hospital via 911 and the resident's son was called and agreed to hospitalization . The facility provided the AHCA form 3120-0002, Nursing Home Transfer and Discharge Notice, dated 12/31/20. The form did not include the Resident Representative information and identified that the form was required for those transfers or discharges initiated by the nursing home facility, and not by the resident or by the resident's physician or legal guardian or representative. The form indicated that the reason for the transfer was your needs cannot be met in this facility. Page 2 of the Transfer and Discharge Notice was not signed by the resident or the resident representative. The notice did not include the dates that the notice was given to the resident, legal guardian, or representative, the local Long-Term Care Ombudsman Council, or when it was included in the resident's clinical record. The facility's Notice Before Resident/Legal Representative/Physician-Initiated Transfer or Discharge for Resident #17's transfer on 12/31/20, indicated that the reason for the transfer was bleeding and that neither the Nursing Home Transfer and Discharge Notice (AHCA Form 3120-0002) or the Long-Term Care Ombudsman Council Request for Review of Nursing Home Discharge or Transfer and Long-Term Care Ombudsman Council District Office (AHCA form 3120-0004) were completed and provided to the resident/legal representative or copied to the medical record. On 4/2/21 at 4:31 p.m., an interview was conducted with Resident #17's POA. When asked if he had received or had signed a notification of transfer for the 12/31/20 hospitalization , he stated, No, never. Staff Member A, Licensed Practical Nurse (LPN) was asked, on 4/2/21 at 7:43 a.m., what the procedure was to transfer a resident to the hospital. She stated when sending a resident to the hospital she looked to see if they had a Do Not Resuscitate (DNR) and would print out the physician orders. She stated the facility sends a paper bed hold policy and indicated there was another form that also was sent with the resident. The staff member opened a bottom drawer in the nursing station and pulled out an AHCA Transfer/Discharge form and placed it back into the drawer, without identifying it as a form that needed to be completed. She did not locate the other form she had been looking for in the drawer. At 1:35 p.m. on 4/2/2021, the Social Worker (SW), Nursing Home Administrator (NHA), and the Director of Nursing (DON) were interviewed regarding the notifications necessary at the time of transfer. The SW stated at the time of an unplanned transfer the nurse would complete the AHCA Transfer/Discharge form and if it was a planned transfer she would mail or email it to the representative or give it to the resident if they were their own person. She stated she dealt with planned discharges. She said, if the nurse was not able to get a signature it would seem they would make a note (in the chart). The DON stated if the resident was not their own person, she thought that the social worker would send the form to the representative. When given the scenario of Resident #17 that had a BIMS score of 4, she stated that the son would be notified to sign it. The NHA reviewed Resident #17's AHCA form 3120 and stated in an emergency situation to transfer to the hospital, the nurse would notify the representative and with a resident with a BIMS of 4 the nurse would note that the notice was received by the representative verbally. The SW stated, on 4/2/21 at 4:09 p.m., that all the planned discharge forms were sent to the Ombudsman and that her interpretation from the NHA, during the earlier conversation, was that unplanned discharge forms were not sent to the Ombudsman. On 404/02/21 at 4:16 p.m., the NHA stated, At no time are unplanned discharges sent to the Ombudsman. She stated she was never taught that and then asked this writer if they were supposed to be. The facility policy, titled Emergency Transfer or Discharge, indicated Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). The policy identified that should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures, which included d. Prepare a transfer form to send with the resident.

Based on record reviews and interviews the facility failed to ensure that the representative of one (Resident #17) of two residents sampled for hospitalization s was notified of the bed-hold policy. Findings included: Clinical record review revealed Resident #17 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The Profile Face Sheet included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet indicated the resident had a Power of Attorney (POA) and the payor source was Hospice Medicaid. The Quarterly Minimum Data Set (MDS), completed 10/6/2020, indicated Resident #17 had a Brief Interview for Mental Status (BIMS) score of 9, indicative of moderate cognitive impairment. The Admission MDS, completed 1/10/2021, indicated the resident had scored 4 out of 15 on the BIMS, identifying a severe cognitive impairment. Review of the facility's Bed Hold and In-House Transfer Policy, dated 12/31/2020, for Resident #17 indicated the resident was transferred to an acute care facility on 12/31/2020 and that the notice was given/sent to Resident #17. Resident #17's bed hold did not indicate if the facility met the 95% of the requirement or if a paid bed hold was offered. The Bed Hold policy was signed by a Licensed Practical Nurse (LPN) on 12/31/20 and did not indicate the resident representative was notified of the policy and that a copy was sent with resident at time of discharge. The instructions indicated that a copy must be given to the resident, family member or legal representative on admission and each time the resident is transferred for hospitalization or leaves the facility on a therapeutic leave. At 1:35 p.m. on 4/2/2021, the Nursing Home Administrator (NHA) reviewed the copy of Resident #17's Bed Hold and In-House Transfer Policy. She stated that for a resident with a BIMS of 4 the Bed Hold would be discussed with the representative and noted with a verbal acknowledgement. During her review of the resident's bed hold policy she stated that no it was, not appropriate to give the policy to a resident with a BIMS score of 4. A review of the Interdisciplinary notes, dated 12/31/2020, did not indicate that Resident #17's POA was informed of the Bed Hold Policy. The policy titled, Bed-Holds and Returns, dated 2001 and revised March 2017, identified that prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy.

Based on observation, interview, and record review the facility failed to ensure that dignity was maintained related to activities of daily living (ADL) care for removal of facial hair for one (Resident #194) out of 12 sampled residents. Findings included: Multiple observations were made of Resident #194, including on 3/31/21 at 10:30 a.m. and 04/01/21 at 10:45 a.m. During every observation, gray facial hairs approximately 1/4 inch in length were observed covering the resident's chin. On 04/01/21 at 10:45 a.m. the resident was asked whether she preferred to have the facial hair on her chin and she said, I don't like hair on my face, and reported that when she had been living at home home she removed it. The resident reported that nobody in the facility had asked her about it. Review of the medical record for Resident #194 revealed she was admitted to the facility on [DATE]. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which meant that the resident was cognitively intact, and revealed that she required limited assistance of one person to perform personal hygiene tasks such as grooming. The care plan revealed that the resident had a self-care deficit impacting on ADL performance, and staff interventions included providing daily assistance with grooming needs. There was nothing in the resident's record that revealed a preference for not having facial hair removed. Staff E, Certified Nursing Assistant (CNA) was interviewed 04/01/21 at 2:54 p.m. She confirmed she was the assigned CNA for Resident #194 and said, I just shaved her on Monday, I was off on Tuesday. She confirmed that shaving facial hair was part of the CNA documentation and asked Staff, F, Unit Manager (UM) to assist with revealing the documentation in the electronic health record (EHR). Documentation revealed the following for the ADL task Personal Hygiene Facial Hair (Males and Females) Check and trim facial hair as necessary: Monday 03/29/21 7:00 am. - 3:00 p.m. shift was documented by another CNA as Service Not Provided/Canceled, and there were no entries made by Staff E for that date. Tuesday 03/30/21 7:00 a.m. - 3:00 p.m. shift was documented by Staff E with a check mark in the field for Response and nothing else. Wednesday 03/31/21 7:00 a.m. - 3:00 p.m. shift was documented by Staff E with a check mark in the field for Response and nothing else. Thursday 04/01/21 7:00 a.m. - 3:00 p.m. shift was documented by Staff E as a check mark in the field for Response and nothing else Review of the staff schedule for Monday 03/20/21, the date Staff E reported she had shaved Resident 194's facial hair, revealed that she was not working at the facility on that date and was working at the facility on Tuesday, 04/01/21. Staff F confirmed that the CNA documentation was not complete and did not reveal what had or had not been done. She confirmed and revealed that part of the charting included a drop-down menu with codes including refused that should be entered in status/description field. Staff F said, I will do an in-service. She confirmed that not providing for removal of facial hair as part of ADL care was a dignity issue and said, shaving must be offered to women same as men. Staff F stated that facility policy was that if a resident refused any part of ADL care the CNA was required to re-attempt and after the second refusal was required to report that to the nurse who would re-approach and document. The Director of Nursing (DON) entered the conversation and confirmed that CNA documentation for ADL care should include details about the care performance and if the care was refused the documentation should reflect that. During these conversations Staff E had left the area. At 3:20 p.m., Staff F was asked to make a confirmatory observation of Res. #194's facial hair. Upon entry to the resident's room, Staff E was observed in the bathroom with the resident in the process of shaving her face. Afterwards, Staff E was interviewed and stated she had offered to shave the resident earlier that day but the resident had refused. Staff E did not have an explanation for the facial hair observed that morning that did not have the appearance of having been shaved on Monday as she had stated. She said, well some grow fast. At 3:50 p.m. on 04/01/21 Resident #194 was interviewed in her room with Staff F present. There was still some facial hair remaining on her chin and Staff F confirmed it was of a length that should have been addressed. The resident stated that nobody at the facility had ever offered to shave her face or remove facial hair since she had been there. At 4:00 p.m. on 04/01/21 Staff G, Registered Nurse (RN) was interviewed. She confirmed she was the assigned nurse for Resident #194 and confirmed that Staff E had not reported any refusal of ADL care for the resident that day. An interview was conducted on 04/01/21 at 4:47 p.m. with the DON. She said, facial hair is a pet peeve of mine .I tell them (CNAs) that we have to treat the people we work for just like we would treat our loved ones and I say to them, would you want to see your grandmother like that? .it must be addressed. Regarding Staff E's performance and reports she said, I'm disappointed in her that she didn't do it (shave the resident) .now because she didn't document right we can't prove that she did or didn't shave her or offer it but know if it's not documented it didn't happen. She confirmed that the expectation was that for any refusal of care a second attempt was to be offered by the CNA and if a resident continued to refuse the CNA was required to report it to the nurse for follow-up. Review of the facility policy titled, Quality of Life - Dignity revised August 2009 revealed the following policy statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Implementation components included, Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.).

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed, and two errors were identified for two (Residents #41 and #28) of 13 residents observed. These errors constituted a 7.14% medication error rate. Findings included: 1. On 4/1/21 at 9:55 a.m., an observation of medication administration with Staff Member D, Registered Nurse (RN) was conducted with Resident #41. Staff D was observed administering the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] 5 milligram (mg) tablet orally - [MEDICATION(S)] 5 mg tablet orally - Vitamin D3 25 microgram (mcg), 1000 units tablet orally - [MEDICATION(S)] 50 mg - 1.5 tablets orally A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Vitamin D3 - 2000 units by mouth once daily for Vitamin D deficiency 2. On 4/1/21 at 11:52 a.m., an observation of medication administration with Staff Member D, Registered Nurse (RN) was conducted with Resident #28. Staff D was observed administering the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - NovoLog 100 unit/milliliter (mL) 8 units subcutaneously. Blood Glucose - 303. The administration record indicated that Staff D received a blood glucose level of 303 from Resident #28 prior to the administration of NovoLog. She checked the order and reported that the resident was to receive 8 units of insulin, she removed a NovoLog [MEDICATION(S)] for the medication cart, screwed a needle onto the pen, removed an alcohol pad from the cart, and dialed the pen to 8 units. The staff member knocked on the resident door, addressed Resident #28 and asked him if he wanted to go to the dining room. She removed her gloves that were worn into the room, donned another pair and asked the resident where he wanted the injection. Resident #28 raised his shirt exposing his abdomen, as Staff D pushed the over-the-bed table from in front of the resident, moved to stand next to resident, and began to tear open the alcohol pad. The staff member was asked to step outside with this writer for a moment. When asked if she was supposed to prime the insulin pen, she stated yes she normally did then asked you mean 2 units? Staff D primed the pen with 2 units then twisted the dosage selector to 8 units which was administered to the resident. The Consultant Pharmacist was interviewed, on 4/2/21 at 4:50 p.m., regarding the priming of the insulin pens and the inaccurate dose of Vitamin D. He stated best practice is probably to prime before each use but did not believe there was anything in the manufacturer guidelines regarding having to prime the pen before each use. He stated, the expectation was that the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . At 4:55 p.m. on 4/2/21, the Director of Nursing (DON) stated she was unaware that the [MEDICATION(S)] needed to be primed, and asked if this writer meant in the beginning? She was informed Yes by this writer. She stated, I don't think so. The DON stated that the facility had done competencies on use of insulin pens but admitted it had not been done in a long time. The manufacturer's informational package insert, located at https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/NovoLog%20FlexPen%20IFU%20PDF_LOCKED.pdf, instructed users to give an airshot before each injection. The insert indicated that before injection small amounts of air may collect in the cartridge during normal use. Users are directed to turn the doses selector to 2 units, hold [MEDICATION(S)] with needle pointing up, tap the cartridge gently with your finger a few times to make any air bubbles collect at the top to the cartridge, and to while keeping the needle upwards press the push button all the way in. A drop of insulin should appear at the needle tip, if not the needle should be changed and repeat the procedure no more than 6 times. If after six attempts a drop of insulin is not seen the insert instruct users to not use the [MEDICATION(S)] and to call the manufacturer. The information indicated this process should be done to prevent injecting air and to ensure proper dosing. The policy titled Administering Medications, 2001 and revised December 2012, identified Medications shall be administered in a safe and timely manner, and as prescribed. The policy identified that The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions and Medications must be administered in accordance with the orders, including any required time frame.

Based on record review and interview, the facility failed to ensure that it transmitted a MDS (Minimum Data Set) Quarterly Assessment review in a timely manner for 1(#1) of 28 sampled residents. Findings included: A review of Resident #1's clinical chart, the Profile Face sheet, documented an admission of 12/06/17. The [DIAGNOSES REDACTED]. A review of the MDS information received from the facility revealed that the last MDS quarterly review was completed on 09/04/18 and submitted on 09/19/19. A review of the facility MDS log, Assessment Lookup for Resident #1 revealed that an assessment had been completed on 11/27/18. An interview was conducted on 02/17/19 at approximately 2:00 p.m. with Staff A, Licensed Practical Nurse (LPN), MDS Coordinator. She reviewed the log and confirmed that the assessment was done, but it had not been submitted. She stated that she would submit it. On 02/28/19 at approximately 8:40 a.m., Staff A, LPN, provided a print out for the submission of Resident #1's assessment. The printout was reviewed, and it revealed that the assessment for Resident #1 had been submitted on 02/27/19. The form showed, Care Plan Competed Late: V0200B2 (CAA process signature date) is more than 14 days after A2300 (assessment reference date). Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date).

Based on observation, record review and interviews, the facility failed to ensure that it developed and implemented an individualized plan of care to maintain mobility and prevent mobility decline for walking for 1 (#1) of 28 sampled residents. Resident #1's plan of care documented a goal for resident to walk. The plan had no structured approaches to achieve the goal of walking. Findings included: An interview conducted on 02/25/19 at 1:50 p.m. with Resident #1. Resident #1 was observed to be in her room, sitting in a wheelchair (w/c) with a bedside table in front of her. She was observed to be working on a crossword puzzle. Resident #1 agreed to be interviewed. Over all, resident stated that she was satisfied with the care and services that she received from the facility staff. She stated that the only thing that she really had a concern about was that she wanted her walks, two times a day; just around the building. She stated that she needed someone beside her. She stated, like today, I have not had my walk yet. She pointed to her rolling walker. I take that and walk; I need someone beside me. I get tired of sitting. For activities, the facility offers them, but, I am not interested in them. I am afraid that if I do not walk, I will not be able to walk. I would prefer one walk in the morning; one walk in the afternoon. An interview conducted on 02/26/19 at approximately 3:00 p.m. with Resident #1, she was in her room, sitting with a bedside table in front of her. Resident #1 was observed to be sitting in a wheelchair with no foot rests. Her feet were observed to be barely touching the ground. She was observed to have sneakers on her feet. She stated that she had received her walk earlier in the afternoon, but, had not received the second walk this afternoon. She stated again that sometimes she gets her walk with help once a day, sometimes they forget and I do not get any walk. I really want to walk two times a day. A review of Resident #1's clinical chart, the Profile Face sheet, documented an admission of 12/06/17. The [DIAGNOSES REDACTED]. A review of Resident #1's MDS (Minimum Data Set) Quarterly Review, dated 09/04/18, Section G, documented Resident #1's function ability for Walk in Corridor - how resident walks in corridor on unit, as a 2 for, Limited Assist - resident highly motivated in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance. For support, Resident #1 was coded as a 2, that indicated, One person physical assist. A review of Resident #1's Care Plan, dated 12/04/18, documented a Problem/Strength area as, (Resident #1) requires minimum to extensive assist with ADL's (Activity of Daily Living) except for eating set up help due to impaired balance and generalized weakness. Risk for decline and fluctuation due to medical hx (history) of [MEDICAL CONDITION] [MEDICAL CONDITION], depressive mood disorder. The goals of the plan included but not limited to, (Resident #1) will ambulate with aide of walker, gait belt and one assist daily 100-500 feet as tolerated through next review. A review of the listed approaches for the achievement of the goal revealed no individualized daily approaches or services for staff to provide to achieve the goal of daily walking. During an interview conducted on 02/26/19 at 3:22 p.m. with Staff A, MDS Coordinator, Licensed Practical Nurse (LPN), she reviewed Resident #1's Care Plan. She stated that the goals on the care plan were effective 09/11/18. She was asked what approaches would be used for Resident #1's goal of walking daily. She stated that sometimes restorative would be involved. She stated that Staff B, the Staff Development Coordinator Restorative Nurse in charge of the aides would provide the service. Staff A, stated that it looked like the resident came off Restorative 05/29/18 and that the resident transitioned to the floor aides for the maintenance. A review of Resident #1's clinical chart with Staff A, MDS Coordinator on 02/26/19 at approximately 3:30 p.m. revealed no documentation of any staff member recording daily walks for Resident #1. A review of the facility Restorative book with Staff A, MDS Coordinator on 02/26/19 at approximately 3:35 p.m. revealed no documentation of staff walking Resident #1. Staff A, MDS Coordinator stated, I get it. If the aides are providing the service, they should be documenting. The facility was asked to provide further documentation of any evidence that Resident #1 was provided the service of daily walking to achieve her goal. A review of a Therapy Screen Form, dated 02/25/19, documented in the comments section, Patient ambulates with Nursing 2-3 times per day. No decline in Patient function with nursing. On the back of the form was a hand written note that documented, Patient wants therapy, to progress to walking by herself. An interview on 02/26/19 at 3:30 p.m., with the Director of Rehabilitation, PTA (Physical Therapist Assistant)she confirmed she was looking for further information regarding the evidence of walking Resident #1. On 02/27/19 at 10:51 a.m., Staff A, MDS Coordinator provided a printout of Resident #1's Resident ADL/Daily Care List, which listed a task, Transfers and Ambulation/Mobility: Gait Belt, Assist x 1 with walker. Ambulates resident with a rolling walker as tolerated, start date of 12/06/17. Staff A, MDS Coordinator reported that she was updating Resident #1's Care Plan with approaches for the walking service. She confirmed that there was no documentation of the resident receiving the walking service from the aides. On 02/17/19 at approximately 10:51 a.m., Staff A, MDS Coordinator provided an updated Care Plan, which listed a new approach, Ambulate resident 2 x a day as tolerated with rolling walker and gait belt, dated 02/27/19.

Based on observation, interview and record review, the facility failed to provide wound care in a manner to promote healing and prevent infection for one (#55) of three sampled residents. Findings included: An observation of Resident #55's wound care with Staff G, Licensed Practical Nurse (LPN) on 02/28/19 at 10:10 a.m. revealed the resident had two wounds. Staff G, LPN obtained the supplies to clean both wounds on a small tray and carried the supplies to Resident #55's tray table, which was covered with a white towel and wash basin. Staff H, Certified Nursing Assistant (CNA) removed the wash basin after providing Resident #55 with a bed bath prior to the dressing change. Staff G, LPN left the white towel on the table and placed the clean supplies on the towel then washed her hands. Staff G, LPN started opening the supplies on the white towel and dated the dressing. Staff G, LPN washed hands and donned gloves. The resident was adjusted in bed to reveal the first wound, an unstageable right lateral ankle wound. Staff G, LPN cleaned the wound with normal saline and dried the area, placed the used gauze and saline back on the tray table with the clean supplies. Staff G, LPN then applied the xeroform gauze pressing with the same gloves used to clean the wound, and applied the dated foam dressing, doffed the gloves onto the tray table with the clean supplies. She washed her hands and removed the used supplies and placed them in the bathroom trash. Staff G, LPN then washed her hands, donned gloves and readjusted the resident with Staff H, CNA. Staff G, LPN cleaned the buttock area with normal saline and dabbed the area with dry gauze. She doffed gloves onto the tray table with the clean supplies. She donned gloves and used the right index finger to apply the [MEDICATION NAME] to the wound. Staff G, LPN then applied an abdominal pad over the wound, and put a brief on the resident with Staff H, CNA to adjust the resident. Staff G, LPN then doffed the gloves and discarded all supplies in the resident's bathroom trash. She washed her hands and removed the towel, and put it in the dirty line bag then she hand sanitized while holding the small tray after looking in the treatment cart. Staff G, LPN stated that she normally changed the dressings this way, and that the cart should have been stocked with bleach wipes and they may be in the medication room. Staff G, LPN confirmed she should have washed her hands in between removing the gloves. A small tray observed on the treatment cart was observed with a brown substance the nurse stated she would clean that tray as soon as she found the bleach wipes. An interview with the Director of Nursing (DON) on 2/28/19 at 10:33 a.m. confirmed that her expectation of wound care would be to wash hands after doffing gloves and the carts should be stocked with bleach wipes for immediate use cleaning of supplies. Review of the Resident #55's wound documentation revealed on 02/25/19 the sacrum/coccyx wound was Stage III measuring 1.9 cm (centimeters) x 2.4 cm x 0.1 cm, improving. The right lateral ankle was unstageable measuring 0.6 cm x 1.2 cm x UTD (undetermined), improving. Review of the physician order [REDACTED]. apply xeroform and cover with a foam dressing. once daily for the left outer ankle. Review of the physician order [REDACTED]. Review of the facility's policy and procedure titled, Wound Care, dated 11/14/18, four pages, revealed: Steps in procedure as: 1) Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached, 2) wash and dry your hands thoroughly, 5) wash and dry your hands thoroughly, 6) put on gloves, 7) use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. Review of the facility's policy and procedure titled, Hand Washing, dated 11/14/18, two pages, revealed: The facility considers hand hygiene the primary means to prevent the spread of infections. (m) after removing gloves.

Based on observation, record review and interviews, the facility failed to ensure that nursing services and nursing aide services were provided in a competent manner regarding an alteration in skin condition (swollen legs/ [MEDICAL CONDITION]) for one (#1) of 28 sampled residents. Findings included: An observation was conducted on 02/25/19 at 1:50 p.m. with Resident #1. Resident #1 was observed to be in her room, sitting in a wheelchair (w/c) with a bedside table in front of her. Resident #1 was observed to be working on a crossword puzzle. Resident #1 was observed to not have foot rests on her w/c. Resident #1 was observed to have sneakers on her feet and her feet were barely touching the ground. An interview conducted on 02/26/19 at approximately 3:00 p.m. with Resident #1, she was in her room, sitting with a bedside table in front of her. Resident #1 was observed to be sitting in a wheel chair with no foot rests. Her feet were observed to be barely touching the ground. She was observed to have sneakers on her feet. She stated that the staff were looking for something for her to put her feet on. She stated that her leg was swollen from the knee down. She stated that they gave me some stockings to wear, they were murderous when the aide put them on, this was about two weeks ago; they are rolled up in the drawer there. I do not wear them. They gave me the socks about two weeks ago. A review of Resident #1's clinical chart, the Profile Face sheet, documented an admission of 12/06/17. The [DIAGNOSES REDACTED]. A review of Resident #1's Care Plan revealed no focus area regarding a problem with [MEDICAL CONDITION] or swollen leg issue. Resident #1's care plan did not have any goals to achieve with providing care and services for the [MEDICAL CONDITION]. The care plan did not have any specific services to be provided for [MEDICAL CONDITION] care. A review of Resident #1's Nutrition Note, dated 12/10/18, signed by the Registered Dietitian, documented, Resident did trigger for a significant weight gain in (MONTH) .Weight on 12/10/18 was 150.8 lbs which does show a gain of 4.4 lbs over 9 days. Will inform RN (Registered Nurse) and inform MD (Medical doctor) via sig (significant) weight change communication form. Resident is weighted every 3rd day due to a (history) of [MEDICAL CONDITIONS] .Resident did state that her legs do feel more swollen over the past month. Informed RN Review of the clinical chart revealed no documentation of a nursing assessment completed on Resident #1's swollen legs. Further review of the clinical chart revealed no communication documented by the nursing staff to report the condition of Resident #1's swollen Legs. Resident #1's chart was reviewed for the period of 12/10/18 thru the date of survey. A review of skin assessments for 12/10/18 thru the date of survey revealed no mention of the swollen legs. A review of the Resident's nursing notes revealed no documentation of a nurse assessing Resident #1's legs. An interview conducted on 02/27/19 at 1:39 p.m. with the Staff A, Minimum Data Set (MDS) Coordinator, Licensed Practical Nurse (LPN). She was asked if the facility had focus areas for [MEDICAL CONDITION]. She stated that she would put the concern under skin risk due to [MEDICAL CONDITION] with interventions for the [MEDICAL CONDITION]. She confirmed that Resident #1 did not have a focus area specific to [MEDICAL CONDITION] or swollen legs. She reviewed Resident #1's care plan and stated that under the area of Pressure Ulcers, the resident was documented to have a history of [MEDICAL CONDITION] to bilateral leg extremities. A review of the approaches under this focus area revealed no specific monitoring interventions for [MEDICAL CONDITION], but, did list the approach of skin checks routinely during daily care and on shower days. An interview conducted on 02/27/19 at 1:50 p.m. with Staff A, MDS Coordinator, she was asked to provide any further information regarding any assessment from 12/10/18 thru the present in regards to the condition of Resident #1's legs. Staff A was also asked for further information regarding the stockings that the resident reported she was not using. Subsequently provided to the surveyor was Resident #1's Treatment Administration Record (TAR) for 02/2019. A review of Resident #1's Treatment Record for 02/2019, listed a physician order, with a start date of 02/02/19, Knee high compressing stockings. Put on at a.m. Take off at HS (evening). For [MEDICAL CONDITION]. Review of the documentation revealed staff had documented application of the stockings daily at 6:00 a.m. from 02/03 thru 02/18; 02/21; 02/22; and 02/23. Refusal of putting stockings on by the resident was documented on 02/19; 02/20; 02/24; 02/25; 02/26. A review of the removal of the stockings, documented by staff, revealed staff had removed the stockings daily for the dates of 02/03/19 thru 02/26/19. An observation conducted on 02/27/19 at 2:00 p.m. of Resident #1. Resident #1 was in her room sitting in her w/c, dressed for the day, she agreed that Staff A, MDS Coordinator and the Therapy Director could roll up her pant legs to review her legs. Resident #1 reported that her left leg was more swollen than her right. During the observation of Resident #1's legs, she was confirmed to have swollen legs up to her knees (this was the farthest part viewed. Resident #1 was observed to have diabetic socks, around the ankle tops, which, were observed to be depressed into her skin enough to make an impression. Resident #1 confirmed with Staff A, MDS coordinator that she had ted hose in her drawer and that she did not like them. Resident #1 reported that she would like to have something to lift her feet up to make it more comfortable for her. MDS asked about a recliner. Resident #1 was not keen on this idea. MDS offered raised leg rests for her w/c, which the resident agreed to. She said anything that will get my feet up. On 02/27/19 at approximately 2:30 p.m., Staff A, MDS Coordinator provided a Nursing note, dated 02/27/19 at 2:26 p.m., Meet with resident in room today to evaluate the [MEDICAL CONDITION] in her legs, left leg is more [MEDICAL CONDITION] than the right leg, resident denies pain due to [MEDICAL CONDITION]. New elevated leg rest provided to resident today, resident express she is happy to get the elevated foot rest. Writer spoke to charge nurse And asked for her to call MD and notify him that (Resident) has been refusing to wear the ted stockings and ask if alternative interventions could be ordered. In addition to the nursing note, Staff A, MDS Coordinator reported that the Care Plan was to be updated as well.

Based on observation, record review and interview, the facility failed to ensure that a [MEDICAL CONDITION] medication, [MEDICATION NAME], was not ordered continuously as an as needed medication. In addition, the facility failed to ensure that the physician orders [REDACTED].#25) of five residents sampled for the Unnecessary Medication Review. Findings included: A review of the Profile Face Sheet for Resident #25 revealed an admission of 02/25/16 and a readmission on 05/04/18. The [DIAGNOSES REDACTED]. An observation conducted on 02/25/19 at approximately 10:15 a.m. of Resident #25, revealed the resident in her bed. An attempt to interview the resident was unsuccessful. Resident #25 was observed to be mumbling incoherently. A review of Resident #25's 02/2019 Medication Administration Record [REDACTED]. The medication was documented as administered daily by staff from 02/01/19 thru the date of review, 02/28/19 for the AM (morning) administration and the HS (evening administration). Further review of Resident #25's 02/2019 MAR indicated [REDACTED]. Separate all doses by at least 6 hours for anxiety disorder unspecified, with a start date of 08/06/18. The 02/2019 MAR indicated [REDACTED] 02/06/19 at 20:38 (8:38 p.m.) 02/10/19 at 18:26 (6:26 p.m.) 02/12/19 at 17:19 (5:19 p.m.) 02/14/19 at 14:45 (2:45 p.m.) 02/17/19 at 13:14 (1:14 p.m.) 02/18/19 at 00:30 (12:30 a.m.) 02/19/19 at 21:12 (9:12 p.m.) 02/22/19 at 16:36 (4:36 p.m.) 02/24/19 at 17:30 (5:30 p.m.) 02/25/19 at 16:07 (4:07 p.m.) 02/26/19 at 15:08 (3:08 p.m.) A review of Resident #25's physician orders, documented the order as, [MEDICATION NAME] 0.5 mg tablet ([MEDICATION NAME]), 0.5 by mouth once daily as needed. Separate all doses by at least 6 hours for anxiety disorder unspecified, start date of 08/06/18. An interview conducted on 02/28/19 at 2:54 p.m. with Staff K, Licensed Practical Nurse (LPN), she confirmed that the [MEDICATION NAME] was an anti-[MEDICAL CONDITION] medication.

Based on observations, interviews and policy review the facility failed to ensure an effective infection control program was in place related to glucometer cleaning for three resident's (#11, #25 and #41) personal glucometers of three glucometers observed. In addition, the facility failed to ensure appropriate infection control practices for contact precautions for wheelchairs stored in the room of one resident (#110) of 28 sampled resident rooms. Resident #110 was identified to be on contact precautions with Personal Protective Equipment on the door. Findings included: 1. An observation of Staff J, Registered Nurse (RN) on 02/25/19 at 12:06 p.m. performing a blood sugar check on Resident #41 revealed Staff J, RN hand sanitizing, donning gloves, and obtaining the glucometer from a black case labeled with Resident #41's name. Staff J, RN obtained the blood sugar correctly, then doffing gloves and hand sanitizing. Staff J, RN prepared the insulin and administered it to the resident. Staff J, RN then took the glucometer without using bleach wipes and enclosed it in a black case labeled with Resident #41's name on the front, and placed the kit back in the medication cart and returned Resident #41 to the dining room. During observation of Staff I, Licensed Practical Nurse (LPN) on 02/27/19 at 11:30 a.m., Staff I obtained Resident #11's blood sugar. Staff I, LPN placed the supplies on Resident #11's dresser in her room. Staff I, LPN washed her hands, donned gloves and placed the glucometer on the resident's dresser. After completing the task, Staff I, LPN picked up the glucometer with bare hands and took the glucometer to the medication cart and placed the glucometer on top of the medication cart without a barrier. Staff I, LPN confirmed the medication cart does not have bleach wipes due to all the drawers having medications. Staff I, LPN went to the left side of the nursing station and removed a pair of gloves, then walked to the center bottom drawer of the nurses station and removed a bleach wipe. Staff I, LPN cleaned the glucometer and placed it in a plastic cup to dry. Another glucometer was observed on the medication cart under the laptop. Staff I, LPN confirmed that glucometer belonged to Resident #25 and confirmed the glucometer was used earlier in the morning and left in that spot until it could be cleaned. Staff I, LPN stated, I guess I should clean it now as well. Staff I, LPN went to get the supplies to clean Resident #25's glucometer. An Interview on 02/28/19 at 10:00 a.m. with the Unit Manager confirmed the glucometer should be cleaned immediately upon use and not left to sit. The Unit Manager stated the carts have bleach wipes and they should be used immediately. Staff G, LPN spoke up and stated, We do not have bleach wipes on the cart anymore because of the medications. An interview with the Director of Nursing (DON) on 02/28/19 at 10:33 a.m. confirmed her expectation of glucometer cleaning would be to clean the glucometers with bleach wipes immediately after use. Review of the facility's policy and procedure for Cleaning and disinfecting of the glucometers, blood pressure cuffs, digital thermometers should be cleaned between each patient, dated 11/14/18, one page, revealed: 1) Wipe the surface with disinfectant towel until completely wet. 4) place meter back in carrying case, and or return equipment to holder for next use. 2. An observation conducted on 02/26/19 at 09:50 a.m. of Resident #110's door revealed Personal Protection Equipment (PPE) hanging on the door. An interview with the Director of Nursing (DON), regarding what precautions to implement prior to entrance to the resident room. She stated contact precautions, gown, gloves, and mask. An interview conducted on 02/26/19 at 9:50 a.m. with Resident #110. She confirmed that she was on isolation precautions that she did not leave her room; staff come in and provide treatment. She confirmed that staff use a Hoyer lift to transfer her from the bed to the chair. An observation at the time of interview of Resident #110's room, a private room, the room had four wheelchairs in the room. One wheelchair was open and ready for use. The other 3 wheelchairs were closed and against the wall. A Hoyer lift pad was draped over one of the chairs. Resident #110 as asked if all the wheelchairs were hers. She stated no, only one. She did not know who the other ones were. An interview conducted on 02/26/19 at 10:00 a.m. with Staff C, Certified Nursing Assistant (CNA), she confirmed that she was familiar with Resident #110. She stated that when she enters Resident #110's room; that she will put on a gown, glove and mask prior to entering into the room. When asked about the extra wheelchairs in the resident's room. She stated that before the resident was moved into the room, the room was used for storage of the wheelchairs. She was not able to state if the wheelchairs could be matched up with any current residents at this time. An interview conducted on 02/28/19 at 1:00 p.m. with the DON. She stated that Resident #110 has contact precautions, meaning that precautions have to be taken with anything that comes into contact. The DON as asked about the mechanical lift pad in the room. The room was reviewed, Resident #110 was observed to be up in her wheelchairt at the side of bed; behind the door was one wheelchair and the mechanical lift pad was observed to be hanging from a hook in front of the wheel chair. The DON confirmed that she had seen the extra wheelchairs in the resident's room the prior day; she also confirmed that she had seen the mechanical lift pad hanging on the wall over the wheelchair. She confirmed that it was not what was supposed to happen.

Based on observation and interview the facility failed to properly secure and contain hazardous chemicals and a razor for 3 (rooms 116, 117, 119) of 28 resident rooms and the main nurses station between the 3 wings for three of four days. Findings included: An observation of bathroom for Room 117 on 11/13/17 at 12:59 p.m. revealed a container of Micro-Kill One alcohol wipes in the corner on top of the bathroom counter. Two residents share the bathroom and are able to independently go into the restroom. A second observation of bathroom for Room 117 on 11/14/17 at 9:23 a.m. revealed a container of Micro-Kill One alcohol wipes in the corner on top of the bathroom counter. An interview with both residents of Room 117 on 11/14/17 at 9:23 a.m. confirmed neither one of them use the Micro-Kill One alcohol wipes. They both confirmed the wipes are always on the counter. An observation on 11/14/17 10:33 a.m. revealed a container of Micro-Kill One alcohol wipes on top of the counter of the nurses' station centered between all three wings (A, B and C). It was easily accessible to residents, staff and visitors. An observation on 11/16/17 9:45 a.m. revealed an open Epi Clenz hand sanitizer container on the top of the counter of the nurses' station centered between all three wings (A, B and C). The top was open and a white wipe was pulled through the top and exposed. Several residents, staff and visitors passed the container. An observation at 10:05 a.m. revealed the wipes were removed from the nurses' station. An interview with Staff E, Housekeeping Aide, on 11/16/17 between 9:45 a.m. and 10:15 a.m. revealed the Micro-Kill One wipes are used by the certified nursing assistants (CNAs). She said, We disinfect the bathrooms. CNAs use them to clean up sinks. I see them in the corner all the time. An observation on 11/16/17 of Room 117 revealed a basin on the dresser of one of the residents residing in the room and it contained multiple personal items that were not labeled to include a disposable pink razor. The items included nail polish remover, hair products and a tube of pain relief cream/ointment. (Photographic evidence obtained) An observation on 11/16/17 of Room 116 revealed a spray bottle of odor eliminating spray set on top of the exam glove box secured to the wall outside of the bathroom. (Photographic evidence obtained.) An observation on 11/16/17 of Room 119 revealed a container of Micro-Kill One wipes on the bathroom counter. An interview with Staff D, Registered Nurse (RN) Unit Manager on 11/16/2017 at 11:21 a.m. revealed the Micro-Kill One alcohol wipes are handled by environmental services and are kept in central supply or bottom of the nurse's carts. She said, No, they shouldn't be in the bathrooms. Everyone is responsible for visualizing and if something is out of place it should be communicated. An interview with Staff A, Certified Nursing Assistant (CNA) on 11/16/17 at 11:36 a.m. revealed the Micro-Kill One wipes are the responsibility of housekeeping staff and the wipes are not supposed to be in resident rooms or bathrooms. She said, We clean up what we can and housekeeping does the rest. They are not to be left in the room to use. I have been told nothing is supposed to be in the bathroom. An interview with the Director of Nursing (DON) on 11/16/17 at 11:58 a.m. during a review of the photographic evidence revealed the wipes should not be left in the resident rooms or bathrooms. She said, Absolutely not in room at all; not even within patient's reach. She confirmed a personal disposable razor should not be in a basin on the dresser of a resident's room. She said, No. She explained personal items are to be bagged, labeled and separated by type.

Based on observation, interview and record review the facility failed to ensure their grievance process was followed for two (#66 and #103) out of 29 Residents as evidenced by not investigating concerns when Resident #66 had reported that her partial dentures were missing and Resident #103 reported her clothing items were missing. Findings included: On 11/13/17 at 11:47 a.m. during the first stage of the survey, an interview was conducted with Resident #66. Resident #66 confirmed she was missing her partial dentures and reported it to her aide. She said, My brand new partial teeth. She confirmed they had been missing for about a month. She confirmed she reported her missing dentures and said, Yes, but it doesn't do any good. A record review indicated Resident #66 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) Admission assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14. A score of 14 indicated the resident was cognitively intact. The medical record contained an inventory sheet completed upon admission, and it indicated Resident #66 did not have partial dentures at the time of admission. A review of Resident #66's care plan revealed Category 5 as ADL (Activities of Daily Living) Functional/Rehab Potential. The plan indicated, Resident #66 requires extensive assist with ADLs with the exception of eating Due to decreased endurance, weakness, [MEDICAL CONDITION], RA of B/L hands with deformities present. Approaches included but are not limited to, assist with brushing teeth/partials qd prn, with a start date of 7/18/17. On 11/13/2017 at 12:52 p.m. during the first stage of the survey, an interview was conducted with Resident #103. Resident #103 confirmed she was missing clothing items and reported it to staff. She said, I handed them a list. It was five bras, seven pairs of socks, PJs, 2 tops and a top just this week. I talked to everybody. She confirmed the items have not been returned. A record review indicated that Resident #103 was admitted to the facility on [DATE]. The MDS Quarterly Review assessment dated [DATE] revealed her BIMS score as a 15. A score of 15 indicated the resident was cognitively intact. A record review of the grievance log was conducted for the months of May, June, July, August, September and October 2017. There were no concerns logged in for Resident #66 in regards to her missing partial dentures or Resident #103 in regards to her missing clothing items. An interview with the Social Services Director on 11/14/17 at 12:55 p.m. revealed the November 2017 grievance log did not include any grievances for Resident #66 or Resident #103. She said, She did not come in with dentures. She went to a private appointment outside the facility with her Power of Attorney (POA) to get them. I wasn't aware of it. She confirmed she was aware of the list of missing items for Resident #103. She said, The bras were from six months ago. I never got the report. I just have the list. I got this on 10/30/17. She confirmed a staff member in housekeeping was investigating the missing items. She confirmed she had not completed a grievance form or logged the grievance on the November 2017 or October 2017 grievance logs. She said, No, not yet. Once I have everything together then I put together the form. I usually wait at least two weeks to do anything, because things go missing and things show up. On 11/16/2017 at 11:40 a.m., an interview with the Social Service Director revealed the POA for Resident #66 was aware of Resident #66 replacing three denture cups. She said, I talked to the POA and she said Resident #66 went through three denture cups. She kept replacing the denture cups. On 11/16/2017 at 11:49 a.m., an interview with the Director of Nursing (DON) confirmed that Resident #66 had upper dentures. She confirmed the certified nursing assistants (CNAs) use the care guide for instructions regarding care for each resident and sign off on the care that was provided by them for each resident. She confirmed the Resident Care Guide for Thursday 11/16/17 1st Shift revealed appliances listed for Resident #66 included but were not limited to upper dentures. She said, This is what they see for the patients. Her expectations of the CNAs were if they do not see an appliance, they are to report it. She said, They notify the nurse. She added, This is my first time hearing her dentures are missing. I have helped her with her dentures before within last couple of weeks. She confirmed the CNAs have been signing off on the Assist with brushing teeth/partials qd prn, portion of the care guide. An interview on 11/16/2017 at 12:04 p.m. with Resident #66 confirmed she told an aide about a month ago and could not remember if she told a nurse. The facility provided a copy of their policy titled: Grievance Policy/Procedure, that was approved by the CEO and had an effective date of August 3, 2017. The policy revealed, It is the policy of Mease Continuing Care to addresses grievances. Step two of the policy indicated the resident can file a complaint orally, in writing and anonymously. Step four of the policy indicated all reasonable efforts will be made to complete the investigation within seventy-two hours of receipt of the grievance. The procedure included nine steps. Step three of the procedure revealed grievance forms are available at the nursing stations and from any department director including the receptionist. Step four of the procedure revealed completed grievance forms can be submitted to the receptionist, a nursing unit manager, any department director or the administrator. On 11/16/17 at 2:10 p.m., an interview with the Social Services Director confirmed the POA for Resident #66 indicated the partial dentures had been missing for three weeks. She confirmed her expectation is the CNAs would let someone know. She said, The communication is to be the CNA tells the nurse or unit manager. They need to let us know it is missing. She confirmed no one let her or the nursing staff know. She said, No. On 11/16/17 at 2:13 p.m., an interview with Staff B, Registered Nurse (RN) Unit Manager confirmed Resident #66 lost her partial dentures before in August of 2017 and they were found. She said, In August I was notified. We did a search and then found them. Her expectation is the CNAs are to notify the nursing staffing if a resident has a grievance. She said, They let us know. She confirmed she was not told about the partial dentures missing. She said, No. On 11/16/17 at 2:16 p.m., an interview with Social Services Director confirmed a grievance was not filed and the partial dentures have been missing for three to five weeks based on her interview with the POA for Resident #66. She said, The POA thinks three to five weeks. She can't remember. They (meaning the partial dentures) are missing. No, I didn't know. I never received anything and probably should have.

Based on observation, record review, and interview the facility failed to store medications in a safe, secure and orderly manner for one (Resident #20) of twenty-nine sampled residents in Stage 2. Findings included: On 11/16/17 between 9:45 a.m. and 9:57 a.m., an environmental task was conducted of the facility. An observation of Resident #20's bathroom revealed a prescription bottle of Nyamyc on the bathroom counter. (Photographic evidence obtained) A review of the record for Resident #20 revealed a [DIAGNOSES REDACTED]. Resident #20 was dependent on assistance for activities of daily living and was able to self-propel with her wheelchair as needed. An interview on 11/16/17 at 9:57 a.m. with Staff B, Registered Nurse (RN), and Unit Manager confirmed the prescribed medication was unsecured and that it belonged to Resident #20. She confirmed it should not be in the bathroom. She explained that she would notify the staff of the medication found in the bathroom. A review of the record for Resident #20's roommate revealed her [DIAGNOSES REDACTED]. Staff B, RN Unit Manager confirmed residents are both able to independently propel self in wheelchair. An interview on 11/16/2017 at 11:36 a.m. with Staff A, Certified Nursing Assistant (CNA) revealed medications should be stored securely and not on a bathroom counter. She said, All medication should be in the nurse's cart. An interview and review of the photographic evidence on 11/16/17 at 11:58 a.m. with the Director of Nursing (DON) confirmed the medication should not have been in the bathroom unsecured. She said, Absolutely not. A review of the facility's policy and procedure Title: Storage of Medications dated: 2001 MED-PASS, Inc. (Revised April 2007); References OBRA Regulatory Reference Numbers 483.45 (h), Survey Tag Numbers F755, Version 1.1 (H5MAPL0851) revealed a policy statement, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Step 8 of the Policy Interpretation and Implementation documents, Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

Based on observations and interviews the facility failed to provide one (Resident #153) of forty resident rooms observed for the provision of privacy with a personal privacy curtain for her shared bedroom. Findings included: Observation on 9/27/2016 of the shared bedroom of resident #153, revealed there wasn't a privacy curtain hanging from the privacy curtain track on the ceiling, on the resident's side of the bedroom. On 09/27/2016 at 10:34 AM, the Assistant Director of Nursing (ADON) stated she thinks it might have been taken down for cleaning. On 09/27/2016 at 3:41 PM, an observation of resident #153's room revealed that there was still no privacy curtain on the track above the bed. During an interview with the Director of Housekeeping on 09/27/2016 at 3:44 PM, she stated that she is not cleaning the resident's privacy curtain. The track the curtain hangs on has to be moved because it hangs on the bed. There has never been a curtain in there for that reason. On 09/27/2016 at 3:54 PM, an interview with Employee Nurse J revealed that the resident has been in the same room since she's been here. She stated that that room used to be restorative, and they turned it into a resident room. She said there has never been a curtain in there.

Based on record review and interviews, the facility failed to develop and implement a comprehensive abuse prevention and identification policy that included training on: prevention, identification, investigation, protection, and reporting/response, for eight (Employees L, M, K, N, O, P, Q, R) of thirteen employee personnel files reviewed for abuse training, of 139 employees. Findings included: Review of the policy provided by the facility for Preventing Resident Abuse dated 2001, revised February 2014, revealed the following: Policy statement Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. 2. Our abuse program includes, but is not necessarily limited to the following: a. Training all staff and practitioners how to resolve conflicts appropriately; g. Training staff to understand and manage a resident's verbal or physical aggression Review of the policy Abuse Prevention Program dated 2001, revised August 2006, revealed the following: Policy Interpretation and Implementation 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. b. Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behaviors or catastrophic reactions, etc. In an interview with Human Resources on 9/29/2016 at 1:45 pm she stated that new employees haven't had abuse training yet. She stated that new hires haven't had orientation yet either. She confirmed the following employees have not had abuse education yet, and could not provide evidence of any training's at all provided to them, during review of their personnel files: Employee L, CNA Employee M, CNA Employee K, LPN Employee N, CNA Employee O, RN Employee P, CNA Employee Q, dietary aide Employee R, dishwasher Interview with the Assistant Director of Nursing (ADON) on 09/29/2016 at 2:23 PM revealed: she stated employees hired recently have not had abuse training because they only hire employees with at least 1 year of experience, and they were provided education at their last place of employment. She confirmed that nursing staff from the list above had not had their training yet, and was unable to produce evidence that they had. She said managers of each department are responsible for training their staff. She said they use a computer based training program with modules and they do one module a month. She stated that employees have until December 31st to complete their training. Review of the facility's staff education plan titled Curricula Mapping 2016 Draft, provided by the facility on 9/29/2016 revealed: Mandatory New Hire Orientation does not include any education or training topics, including abuse. Interview with the Director of Dietary Services on 9/29/2016 at 4:43 pm revealed: she stated that Employee W, Human Resources provides orientation to newly hired staff, and she would have their training files. At 4:56 PM she returned and stated that Human Resources did not provide her employees- Employee Q, dietary aid and Employee R, dishwasher, abuse training. She stated that she does abuse training in January and October every year. She stated they have until December 31st to complete their training. In an interview with the ADON on 9/30/16 at 8:38 am she stated that they get general orientation in human resources about the company, benefits etc. She said she reviewed some newer employee's education and some had done it but it wasn 't documented in the computer system. Interview with the Director of Nursing (DON) on 9/30/ at 9:45 a.m., revealed: She stated training is every 2 weeks, and the ADON canceled training in September because it was scheduled on Labor day. It is now scheduled for October. Normally, she schedules orientation every two weeks on Mondays. She could not comment on Human Resources, and stated that department is separate from hers. She confirmed that after hire, new employees will work on the units before receiving all their training. She was asked to print out the training transcripts of all the employees in the above list. At 10:00 a.m., she confirmed none of the employees whose training records were requested have completed their training yet. Interview with the Director of Dietary Services on 9/30/16 at 10:52 am revealed: Employee Q did his training yesterday, and Employee R is doing his this afternoon. At 11:24 a.m., on 9/30/2016 the ADON provided a complete staff list which included the date of the acknowledgment of the receipt of the Employee handbook for each. She stated abuse training is in there. At 11:31 on 9/30/2016 she provided the Mease Manor Employee Handbook revised May 2014. On page 23 there is a section entitled Reporting Elder Abuse. The last paragraph (#5) on the page states: If you suspect that a resident is being abused, neglected, or exploited, you should immediately notify your supervisor, Department Director, COO, or CEO. Immediately. You may also file a report with the Mease Manor Employee Hotline. We must all take responsibility to ensure the safety of residents; therefore, failure to report suspected abuse could lead to a fine, disciplinary action or termination of employment. A bold-lettered sentence in a box at the bottom of the page states: Remember, as a Mandated Reporter, Florida law requires you to report abuse, neglect, or exploitation whenever you become aware of it. Page 37 of the Manual contains a statement in the first paragraph that the employee acknowledges receipt of the manual, and has read it. Interview with the Director of Maintenance on 9/30/2016 at 8:49 a.m., revealed: She stated Human Resources does general orientation. We use computer based training. Department heads ensure the employees get mandatory training on that system. The employees have to take some of the courses, but don't have to take them all right away. They have abuse training, ethics, biohazard, emergency within 30 days. In an interview with the Director of Housekeeping on 9/30/16 at 8:55 a.m., she agreed that they have 30 days to complete mandatory training such as emergency training and abuse. They get general orientation in Human resources. Department managers are responsible for training of their employees. They take courses on the computer and it documents when they took the course and exam. On 9/30/2016 at 10:12 a.m., a request was made to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) for the facility's policy for orientation. At 10:50 a.m., on 9/30/16 the ADON stated there isn't a policy for general orientation of new staff members.

Based on observations, interviews and record reviews the facility failed to ensure residents were treated in a dignified manner related to 1. Referring to residents who require assistance with meals as feeders and 2. Engaging in personal communication with other employees while assisting residents with their meals. Findings included: 1. An observation was conducted on 9/26/2016 at 11:59 a.m., of the first floor dining room lunch service. Residents were observed being wheeled to the tables by certified nursing assistants (CNA). The residents table placements contained clothing protectors that were already set out. An interview was conducted with Employee #C, CNA, on 9/26/2016 at 12:00 p.m., regarding resident choices. Employee #C was asked how do you determine which residents get a clothing protector to wear. Employee #C responded that we ask the residents if they want one. Some of the residents do and some don't. Most of the feeders get them referring to clothing protectors. An interview was conducted on 9/29/2016 at 10:57 a.m., with Director of Clinical Services (DCS) regarding the use for the term feeder when referring to residents who require assistance with meals. The DCS was asked what her expectation was in regard to how staff should address residents. The DCS responded that staff should refer to the residents by name and not refer to any residents as feeders. A policy for dignity was requested at this time. The DCS responded that she would look for a policy but did not believe that there was one. 2. During a breakfast meal observation on 09/28/16 at 8:48 A.M., residents were served beverages and offered clothing protectors prior to the meal being served. After the meals were served, certified nursing assistants (CNA) G and H sat at a table to assist and/or feed residents. Their conversation was overheard including personal discussion between the staff. The only conversation observed between the CNA's and the residents was asking about the need for more food. At another table CNA's E and C were heard discussing holiday meals. Again, the conversation did not include the residents, except to encourage a resident who was feeding herself. At another table CNA's B and H were observed in conversation with each other which did not include the residents at the table. At 9:22 A.M., on 09/28/16 Staff J was interviewed about the responsibilities of the staff while assisting the resident during dining. She confirmed that the residents should be the focus and staff should not be conversing about private matters. At 9:40 AM she said that she had spoken to the staff development nurse and that there will be an in-service for all nursing staff. On 09/3016 between 10:20 AM and 11:01 A.M., CNAs B, S and T were interviewed. All expressed that conversation should be between the resident and staff.

Based on medical record review and review of facility policy, observation of the resident, and interview with facility staff, the facility failed to ensure that a resident who was continent of bladder upon admission, received the appropriate services to prevent a decline in continence, for one (#115) of 40 sampled residents. Findings included: Observation of resident #115, on 09/28/16 at 9:00 a.m., revealed the resident self propelling back from the dining room and was observed going into his room and then into the bathroom. It seemed the resident had self transferred himself to the toilet. The bathroom door remained open, with the empty wheelchair able to be seen in the bathroom door frame. Review of the Admission Data Collection form, completed upon admission, dated 05/03/2016, revealed the resident had the [DIAGNOSES REDACTED]. Nurses notes on 05/04/16, 05/18/16, and 5/23/16 documented the resident as continent of bowel and bladder and needing assist of one staff for toileting and transfers. Review of the initial Minimum Data Set (MDS) assessment, dated 05/12/2016, revealed the resident was coded as having a BIMS (brief interview for mental status) score of 6/15, indicating severe cognitive impairment. His functional abilities were coded as needing extensive assistance from one staff for transferring and toileting. The resident was coded as being occasionally (less than seven incontinent episodes a week) incontinent and not being on a toileting program. The CAA (Care Area Assessment), developed with the initial MDS assessment, documented the resident as occasionally incontinent (less than 7 episodes) of both bowel and bladder status for which he required assistance with transferring, and toileting. The resident was identified as alert with confusion. He was known to use the urinal at night and was toileted in the day. The resident had a history of [REDACTED]. The plan was to continue to monitor for a decline in bowel and bladder status and signs and symptoms of an urinary tract infection. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/02/2016, revealed the resident had improved cognitively (BIMS score was 11/15 indicating the resident had moderate cognitive impairment.). Toileting abilities remained the same, but there was a decline to frequently incontinent (more than seven episodes of incontinence) with no toileting program to assist to return to prior function. The quarterly nursing summary, dated 08/11/16, identified the resident as alert, oriented, confused, with orientation fluctuating over the course of the day. The resident was assessed as able to independently ambulate but used the wheelchair most of the day to get around. He was able to independently position himself in the bed and chair and was able to transfer independently. He was identified as occasionally incontinent of bladder with two plus episodes a week, but not daily. He was identified as using briefs at all times and pads at night. Review of the care plan, developed following the initial assessment on 05/12/2016 for occasional incontinence identified approaches that included providing adult incontinent products and monitoring for incontinence every two hours; and offering to assist to the bathroom whenever observed to be awake at night. The care plan was not revised once the resident's incontinence was identified as declining to frequently incontinent. Interview with the Assistant Director of Nurses (ADON), on 09/28/16 beginning at 9:30 a.m., reported that she was not able to locate the three day elimination schedule identified on the Admission Data Collection form, dated 05/03/2016. She reported, during that interview, that when the 08/02/2016 MDS identified the resident as having declined in incontinence, she had not been made aware, so had not completed an assessment. She reported what an assessment would have included should she have completed one: why more incontinent at night, what kind of incontinence, if he was sleeping through the night and wasn't wakened by the need to urinate, and what medications he was taking which could have made him sleepy or needing to urinate more frequently. Interview with the resident's day aide, staff E, (7a to 3p) on 09/28/16 beginning at 9:10 a.m. revealed that the resident was continent during the day shift, and usually took himself to the bathroom. She reported that he was able to self transfer and self toilet. She also reported that on occasion he would have an accident and he was able to remove his brief, clean himself up and then hand over his 'incontinent bag' , letting his aide know. Interview with the resident's evening aide, staff F, (3p to 11p) on 09/28/2016 beginning at 4:05 p.m. confirmed that the resident was currently sitting on the toilet, having taken himself there. She said that he self toilets frequently, but she also finds he has frequent incontinent episodes during her shift and the night shift as well, as she works that shift also. She agreed that he might be continent during the day, but was incontinent during the evening and night shifts. Review of the Urinary Incontinence - Clinical Protocol Policy and Procedure revealed under the heading, Assessment and Recognition: point #2: The nurse shall assess and document/report the following: a. vital signs; b.neurological abnormalities; c.assess pelvic area; d.digital rectal exam; e. residents age and sex; f.whether this is a change incustomary pattern since last physician visit; g. all active diagnosis; and h.all current medications. point #4: For incontinent individuals, the nursing staff will identify and document circumstances related to the incontinence.

Based on observations, interviews, and record reviews the facility failed to ensure that residents who required oxygen were provided an oxygen tank that had oxygen for 4 (#108, #5, #52, #177) of 40 sampled residents related to residents being observed with empty oxygen tanks while wearing their nasal cannula. Findings included: 1. Resident #108 has a [DIAGNOSES REDACTED]. An observation conducted during main dining on 9/26/2016 at 12:28 p.m. of Resident #108 revealed the resident sitting at the dining table waiting for lunch to be served. Resident had an oxygen tank secured on the back of the wheelchair. Resident #108 was observed to be wearing a nasal cannula. A closer observation of the resident's oxygen tank revealed the tank was empty. The first floor unit manager was shown the empty tank and removed the resident from the dining room to place a new oxygen tank. An observation was conducted on 9/27/2016 at 7:45 a.m. of Resident #108 sitting in the wheelchair in the activities room on the first floor. Resident #108's wheelchair had an oxygen tank secured to the back of the wheelchair. Resident was wearing a nasal cannula. The oxygen tank needle was sitting on the red indicating it was empty. The first floor unit manager was called over to verify. The first floor unit manager responded it's not empty yet, but it needs to be changed. The unit manager then removed the resident from the activity room to replace the oxygen tank. Record review for Resident #108 revealed a physician's orders [REDACTED]. The physicians order states to titrate 3 liters to maintain SPO2 (oxygen level) to greater than 92%. A record review of Resident #108's care plan revealed a care planned intervention to administer oxygen per physician's orders [REDACTED]. 2. Resident #5 has [DIAGNOSES REDACTED]. An observation was conducted on 9/26/2016 at 12:30 p.m. of Resident #5 during lunch in the main dining room. Resident #5 was observed at the dining table wearing a nasal cannula. A closer observation of the oxygen tank secured to the back of the wheelchair revealed an empty oxygen tank. The first floor unit manager was shown the empty tank and removed the resident from the dining room. On 9/29/2016 at 10:26 a.m., Resident #5 was observed in the dining room with an empty oxygen tank hooked up to the resident. Record review was conducted for Resident #5 that revealed a physician's orders [REDACTED]. The order stated may have oxygen at 2 liters nasal cannula to keep o2 saturation greater than 92%. A record review for Resident #5 was conducted that revealed a care planned intervention to administer oxygen per physician orders. 3. Resident #52 has the following [DIAGNOSES REDACTED]. An observation of Resident #52 was conducted on 9/26/2016 at 12:33 p.m. during lunch dining in the main dining room. Resident #52 was observed wearing a nasal cannula with an oxygen tank secured to the back of the wheelchair. Closer observation of the oxygen tank revealed an empty oxygen tank. The first floor unit manager was made aware and removed the resident from the dining room. On 9/28/2016 an observation was made at 11:53 a.m. of Resident #52 sitting in the dining room. Resident #52 had an oxygen tank secured to the back of the wheelchair. Resident was attached to the oxygen tank by way of nasal cannula. The oxygen flow meter was set at 2 liters per minute. The oxygen tank was empty. The tank was confirmed empty by the first floor unit manager. The resident was taken from the dining room and back to the residents room to get a new oxygen tank. Record review of the physician's orders [REDACTED]. A record review of Resident #52's care plan for cardiovascular disease revealed a care planned intervention for administration of oxygen as ordered. 4. Resident #177 has a [DIAGNOSES REDACTED]. An observation was conducted on 9/28/2016 at 12:10 p.m. of Resident #177 sitting in the second floor dining room. Resident #177 was observed to have an oxygen tank secured to the back of the wheelchair. The resident was wearing a nasal cannula that was connected to the oxygen tank set for 2 liters per minute. The oxygen tank was observed to have the needle indicating the volume of oxygen remaining sitting on the red line that showed it was empty. Employee #D, RN, responded that the tank was almost empty and it needed to be changed. Employee #D responded that the tank should be checked prior to the resident coming into the dining room. An interview that was conducted with Resident #177 on 9/29/2016 at 10:38 a.m. revealed that the resident feels short of breath when not wearing oxygen. Record review Resident #177 has a physician's orders [REDACTED]. The physicians order stated oxygen at 3 liters per minute as needed via nasal cannula for shortness of breath. A record review was conducted for Resident #177 that revealed a care planned intervention that stated oxygen as needed. An interview was conducted on 9/28/2016 at 11:48 a.m. with Employee #A, CNA, regarding transporting residents who require oxygen to the dining room. Employee #A responded that the tank is checked prior to coming to the dining room. Employee #A also responded that any residents who require special assistance receive the assistance prior to coming to the dining room. On 9/28/2016 at 11:54 a.m. an interview was conducted with Employee #B, CNA, regarding transporting residents who require oxygen. Employee # B responded that we check the tank to make sure it'll last them through the meal. We let the nurse know if it needs to be changed. An interview was conducted on 9/28/2016 at 12:20 p.m. with the Director of Clinical Services (DCS) regarding the observations made of residents with empty oxygen tanks. The DCS responded that it is her expectation that the certified nursing assistants (CNA) should be checking the tank before transferring the resident whether that be from bed to chair or chair to the dining room or at least make sure there is enough oxygen to get them through the lunch. The DCS also responded that the nurses should be checking the tanks as well. The DCS stated that all the staff should be looking at the tanks. The DCS also responded that when the tank is empty it should be changed out. The DCS responded that there was no policy available related to checking the oxygen or who should be checking it and when it should be changed. An interview on 9/30/2016 at 10:40 a.m. was conducted with the first floor unit manager (UM) regarding the training certified nursing assistants (CNA) get during orientation regarding oxygen. The UM responded that the CNAs are trained to look at the oxygen tank level and inform the nurse when the tank is low and needs to be changed.