Every finding on record at Woodbriar Nursing Home

Based on observations, record review, interview and facility policy review, it was determined that the facility failed to ensure the Minimum Data Set (MDS) was accurate and complete to facilitate the ability to plan and provide necessary care and services for three (Residents #4, #17 and #64) of three residents reviewed. The findings include:Resident #4Review of an admission Record indicated the facility admitted Resident #4 with diagnoses that included atherosclerotic heart disease (a buildup of fats and cholesterol in the artery walls, leading to narrowed or hardened arteries) and cerebral infarction (a stroke caused by blockage in an artery supplying blood to the brain).Review of a quarterly MDS with an Assessment Reference Date (ARD) of 02/09/2026 for Resident #4 revealed that the resident was taking medications that included an anticoagulant (medication that prevents or reduces the formation of blood clots) and an antiplatelet (medication that prevents blood platelets from sticking together. Review of an admission MDS dated [DATE] revealed, Resident #4 was not taking an anticoagulant but was taking an antiplatelet. Review of Resident #4's Order Summary dated 04/06/2026, revealed an order with a start date of 09/13/2022 for an antiplatelet to be given one time a day related to atherosclerotic heart disease.Review of Resident #4's Care Plan initiated on 12/05/2025 revealed the resident was on anticoagulant therapy as ordered by Medical Doctor. Care Plan interventions included: see black box warnings, take anticoagulant medication as ordered.During an interview on 04/09/2026 at 10:10 AM, the MDS Coordinator stated she was familiar with Resident #4. She reviewed the quarterly MDS with an ARD of 02/09/2026 and quarterly MDS with an ARD of 11/17/2025 and stated, they were coded as an anticoagulant, but the resident was taking an antiplatelet and they are not the same medication. I coded it wrong. The MDS Coordinator stated she used the Resident Assessment Instrument (RAI) Manual to code MDSs. She stated, I will fix those and submit them.During an interview on 04/09/2026 at 11:51 AM, the Assistant Director of Nursing (ADON) stated she was familiar with Resident #4. The ADON stated she did not believe the resident was taking an anticoagulant but that an anticoagulant and antiplatelet should be on the MDS because resident should be monitored for bleeding. Review of the RAI Version 3.0 Manual dated October 2025, page N-9, documented N0415: High-Risk Drug Classes: Use and Indication - do not code antiplatelet medications such as aspirin/extended release, dipyridamole or clopidogrel as N0415E, Anticoagulant. Resident #17Review of an admission Record indicated the facility admitted Resident #17 on 05/22/2025 with diagnoses that included depression, anxiety, a stroke (blockage in an artery supplying blood to the brain), a lung disease, bipolar disorder, adult failure to thrive, fatigue, a history of falling and a right hip fracture. Review of a quarterly MDS, with an ARD of 02/16/2026, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #17 was cognitively intact. The MDS indicated Resident #17 had an acute onset mental status change with behaviors present of inattention that comes and goes. The MDS also revealed Resident #17's functional abilities indicated no impairment to arms or legs, and a wheelchair was used for mobility. Resident #17 required substantial to maximal assistance for lower body dressing and putting on or taking off shoes and partial to moderate assistance with transfers. The MDS also revealed Resident #17 had no falls since admission and restraints and alarms indicated that there were no alarms on Resident #17's bed or chair. Review of Resident #17's Care Plan initiated on 12/08/2025, revealed Resident #17 had actual falls on 12/23/2025, 12/31/2025, and 02/06/2026. Care Plan interventions included floor mat at bedside, assessing reasons for falls and pressure alarm in place to wheelchair, initiated02/06/2026; added bed alarm and chair alarm, initiated12/21/2025; and electronic chair/bed alarm initiated 12/24/2025. Review of Clinical Physician Orders revealed Resident #17 had an order for a wheelchair alarm to alert staff when rising unassisted with a start date of 01/01/2026 and bed alarm to alert staff when rising unassisted with a start date of 01/01/2026. Review of Medical Administration Record-Treatment Administration Record (MAR-TAR) dated 04/2026, revealed documentation by day shift and night shift staff to monitoring the bed/chair alarm. The MAR-TAR revealed an order for bed alarm to alert staff when rising unassisted, every shift for safety and when rising unassisted, order dated 01/01/2026 and an order for wheelchair alarm to alert staff when rising unassisted every shift for safety and to alert staff when rising unassisted, order dated 01/01/20226.During an observation on 04/06/2026 at 11:00 AM, Resident #17 was observed sitting in a wheelchair in Resident #17's room, chair alarm in place on the wheelchair. During an observation on 04/09/2026 at 10:30 AM, Resident #17 was observed sitting in a wheelchair in Resident #17's room, chair alarm in place on the wheelchair. During an interview on 04/09/2026 at 12:16 PM, the MDS Coordinator indicated the information needed to update and complete the MDS assessment was obtained through chart review, resident assessment and staff relayed information through verbal report or secure communication text. The MDS Coordinator reviewed Resident #17's electronic chart and verified orders for a bed and wheelchair alarm dated 01/01/2026. The MDS Coordinator reviewed the quarterly MDS completed on 02/16/2026 and stated, no alarms had been marked, and that is an MDS discrepancy. The MDS Coordinator indicated a discrepancy could result in federal, state or the facility not being compensated correctly, could cause an issue in the payment process and a difference in the quality care measures. Review of a RAI Version 3.0 Manual dated October 2025, revealed An alarm is any physical or electronic device that monitors resident movements and alerts the staff, by either audible mean, when movement is detected, and my include bed, chair and floor. The coding instructions revealed, Identify all alarms that were used at any time (day or night) during the 7-day look back period. After determining whether or not an item listed in P0200 was used during the 7-day look back period, code the frequency of use: Code 0, not used, Code 1, used less than daily, and Code2, used daily. Coding tips revealed, Bed alarm includes devices such as sensor pad placed on the bed or a device that clips to the residents clothing. Chair alarm includes devices such a as a sensor pad placed on the chair or a wheelchair or a device that clips to the resident's clothing. Resident #64Review of an admission Record indicated the facility admitted Resident #64 on 12/09/2016 with diagnoses that included chronic kidney disease stage three (irreversible loss of kidney function, preventing the kidneys from filtering waste effectively), unspecified Escherichia coli (E. Coli) (an infection where E. Coli has been identified as the cause), retention of urine (the bladder cannot empty completely or at all).Review of a quarterly MDS with an ARD of 02/16/2026, revealed that Resident #64 had an indwelling catheter (a flexible tube inserted through the urethra into the bladder to drain urine continuously into a collection bag). The MDS also revealed the resident was on intravenous (IV) medications (medications that were given through a vein).Review of Resident #64's Order Summary revealed an order with a discontinued date of 09/30/2025 to change foley monthly on last day of the month for retention/incontinence. The Order Summary also revealed an order for an IV antibiotic every 24 hours for infection with a start date of 11/13/2025 and end date of 11/17/2025.During an interview on 04/09/2026 at 12:30 PM, the MDS Coordinator stated she was familiar with Resident #64. She reviewed the quarterly MDS with an ARD of 02/16/2026 and stated that IV medication information would have come from the Medication Administration Record (MAR). The MDS Coordinator revealed that IV medication was entered on the MDS in error. The MDS Coordinator revealed that when she coded the MDS, she would look at the MAR and Treatment Administration Record (TAR) and go back 14 days for the look back period. The MDS Coordinator stated that [name brand] catheter was not listed in the MAR and TAR, so marking indwelling catheter on the quarterly MDS was in error. The MDS Coordinator stated she used the RAI to code MDSs.During an interview on 04/09/2026 at 11:51 AM, the Assistant Director of Nursing (ADON) stated she was familiar with Resident #64. The ADON revealed that Resident #64 did not currently have a foley catheter and had not had a foley catheter for several months. Review of a RAI Version 3.0 Manual dated October 2025, revealed to code any drug or biological given by intravenous push epidural pump, or drip through a central or peripheral port in this item. During an interview on 04/09/2026 at 2:00 PM, the Administrator indicated the job of the MDS Coordinator was to process new, added, and continued orders for the residents. The Administrator stated, When it is time for a new MDS to be completed, all orders should be reviewed, and you should see what is actually happening right now with the resident. You should look at the orders and look at the patients for information. The Administrator indicated if a new order was received it was to be included in the next MDS assessment.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to protect a resident's right to be free from verbal and mental abuse for one (Resident #38) of four residents reviewed. The findings include: Review of Resident #38's admission Record revealed the facility admitted Resident #38 on 04/12/2022 with diagnoses that included dementia, mood disorder, bipolar disorder, limitations of activities due to disabilities, altered mental status, a sleeping disorder, and an excessive persistent thirst with an insatiable urge to drink fluids. Review of an annual Minimum Data Set with an Assessment Reference Date of 01/12/2026, revealed Resident #38 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. The MDS indicated no acute altered mental status present, no behaviors had been displayed towards others, and no impairment to arms or legs. The MDS also revealed Resident #38 used a wheelchair for mobility and Resident #38's eating skills were indicated as independent once the meal was placed in front of the resident. Review of Resident #38's Care Plan initiated on 04/18/2022 revealed the resident had an Activities of Daily Living (ADL) deficit, had impaired cognitive function and impaired thought process due to mental diagnosis. Care Plan interventions included Resident #38 required moderate assistance of one staff with ADLs, required a sippy cup for meals, and was able to feed self after set up. Staff were required to give cues and reminders for dehydration. Resident #38 required weighted utensils and divided plate at mealtime and was encouraged to participate to the fullest extent possible with each interaction. Review of Clinical Physician Orders revealed Resident #38 was allowed to reside on the Special Care/Memory Unit per request. Review of an undated facility Resident admission Packet revealed Federal law specifies that nursing homes protect and promote the following rights of each resident: Be treated with respect: You have the right to be treated with dignity and respect. Be free from abuse and neglect: You have the right to be free from verbal, sexual physical and mental abuse. Review of Resident #38's Reportable included documentation signed by Certified Nursing Assistant (CNA) #4 on date of hire 02/25/2021. A document titled Suspected abuse and neglect revealed, The resident has the right to be free from abuse. The resident has the right to be free from verbal, physical and mental abuse, corporal punishment and involuntary seclusion. A document titled Abuse Prohibition Program revealed, The facility is responsible to provide a safe and secure environment for residents at all times. Review of a facility document titled Residents Rights signed by CNA #4 on 02/25/2021 revealed, Each and every resident in this facility has the right to: Be treated at all times courteously, fairly, and with the fullest measure of dignity and to be free of verbal, psychological, physical, and sexual abuse. Review of an OLTC Witness Statement Form dated 03/01/2026 at 8:10 AM, revealed Licensed Practical Nurse (LPN) #1 was passing medications and heard CNA #4 screaming and cussing at Resident #38. LPN #1 indicated CNA #4 stated, Why did you drink my protein shake, don't touch any [expletive] thing that is not yours. LPN #1 indicated CNA #4 proceeded to yell at Resident #38 for a minute. Review of an OLTC Witness Statement Form dated 03/01/2026 at 8:33 AM, revealed CNA #2 was serving trays in the dining area where the incident occurred. CNA #2 indicated that CNA #4 had sat a protein shake down on the table where she was serving trays at for residents. CNA #2 stated, CNA #4 screamed at Resident #38 saying [expletive] [Resident #38], why are you touching stuff that don't [expletive] belong to you? CNA #2 indicated that Resident #38 took a drink of CNA #4's drink. Review of an OLTC Witness Statement Form dated 03/01/2026 at 8:45 AM, revealed CNA #3 was in the bathroom with a different resident and heard CNA #4 yell at Resident #38, Why did you touch my [expletive] stuff. After CNA #3 completed resident care in the bathroom, she walked into the dining room where CNA #4 and Resident #38 were. CNA #3 indicated that she heard CNA #4 call Resident #38, a [expletive] and that CNA#4 then told Resident #38 she would drink Resident #38's milk since Resident #38 drank her protein shake. Review of an OLTC Witness Statement Form dated 03/01/2026 at 8:20 AM, revealed CNA #4 indicated she did get upset and cuss at Resident #38. CNA #4 indicated she told Resident #38 That is not yours, leave [expletive] stuff alone that is not yours. Review of an Employee File for CNA #4 revealed she was terminated on 03/04/2026. There was no reason indicated for the termination. During an interview on 04/08/2026 at 10:26 AM, LPN #1 stated she was on 500 hall passing medications when she heard CNA #4 yelling at Resident #38. LPN #1 indicated CNA #4 stated that Resident #38, She drank my [expletive] shake. LPN #1 stated CNA #4 was verbally cussing Resident #38. LPN #1 stated she notified the administrator, and obtained witness statements from CNA #2, CNA #3 and CNA #4. CNA #4 was made to clock out and leave the facility. LPN #1 indicated there were lockers and a closet located on the unit for staff to store all of their personal items. LPN #1 stated they received an in-service for abuse/neglect training on 03/02/2026. During an interview on 04/08/2026 at 2:28 PM, CNA #2 stated while the CNAs were passing breakfast trays in the dining room, CNA #4 sat her weight loss protein shake on the table beside Resident #38's tray. CNA #2 indicated Resident #38 opened and drank some of CNA #4's drink. CNA #2 indicated CNA #4 stated to Resident #38, What the [expletive] are you doing? Are you [expletive] kidding me? CNA #2 indicated that CNA #4 snatched the drink from Resident #38's hand. CNA #2 stated the facility gave an in-service on abuse/neglect after the incident on 03/02/2026. During an interview on 04/08/2026 at 10:41 AM, CNA #3 indicated she was in the bathroom assisting another resident when she heard CNA #4 yelling at Resident #38. CNA #3 indicated that Resident #38 had drank CNA #4's drink and then CNA #4 called Resident #38 a stupid [expletive]. CNA #3 indicated that Resident #38 then stated, No. You are a stupid [expletive]. CNA #3 indicated that after that CNA #4 took Resident #38's sippy cup and put water in it and CNA #4 told Resident #38, since you drank mine, you can drink water. During an interview on 04/09/2025 at 12:35 PM, RN #5 indicated she had just entered into the facility, from the back door on the memory unit which leads into the dining room that morning, when she heard the word [expletive]. RN #5 indicated after entering the unit she noticed it was CNA #4 hollering at Resident #38. RN #5 stated she assessed Resident #38 after the incident and all Resident #38 would say was Bad. RN #5 indicated there were certain places for staff to store their personal items. RN #5 stated she received in-service training on abuse and neglect after the incident on 03/02/2026. During an interview on 04/09/2026 at 2:00 PM, the Administrator indicated CNA #4 was terminated for cussing Resident #38. The Administrator stated, CNA #4 admitted to cussing Resident #38. The Administrator indicated that her expectation of her staff was that there was no abuse in the facility. The Administrator listed forms of abuse as verbal, mental, sexual, physical and seclusion. The Administrator indicated there were multiple lockers and closets designated for staff to keep their personal belongings. The Administrator indicated the last in-service was completed on 03/02/2026 after the incident occurred. Review of a facility in-service titled, Abuse –Intent, Interpretive Guidelines, revealed that an all department, all staff in-service presented by the Administrator was completed on 03/02/2026, with a total of 62 signatures of attendees. The intent of the in-service indicated Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents must not be subject to abuse by anyone including but not limited to, facility staff. Interpretive guidelines listed the forms of abuse as verbal, sexual, physical, mental and involuntary seclusion. The definition of all 5 categories is listed. Verbal abuse was defined as, the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Review of a facility in-service titled In-Service Training Report, Dignity and Respect, Regulations and Meaning of Being Respectful to Residents, dated 08/15/2025 for all staff included, Dignity, Respect and Speaking to the Resident effective 11/28/2017 revealed The resident has the right to a dignified existence, self-determination and communication, with access to persons inside and outside of the facility. and A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. An insert in the in-service stated, This means you should always be respectful to all residents. You should speak to and treat them as you would expect a care giver to treat and speak to your mother, father, or grandparents. Review of an undated facility policy titled Resident Abuse, revealed The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents. The policy defines verbal abuse as, Any use of oral, written, or gestures language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance. The facility re-educated all staff on abuse, following the incident on 03/01/2026, per an in-service initiated on 03/02/2026. In addition, CNA #4 was terminated after the incident involving Resident #38. These actions were performed before the survey team entered the facility, verified by document review and staff interview resulting in this finding being cited at past non-compliance.

Based on observation, interview, and record review, the facility failed to document and complete a person-centered care plan to facilitate the ability to plan and provide necessary care and services for 1 (Residents #38) sampled resident whose care plan was reviewed. The findings are: 1. A review of an Admission Record indicated the facility admitted Resident #38 with diagnoses of cerebral infarction (stroke), hypertension (high blood pressure), and congestive heart failure (a condition in which a person heart doesn't pump correctly). The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/13/2024 revealed Resident #38 had a Brief Interview Mental Status (BIMS) score of 03, which indicated the resident had severe cognitive impairment. In Section N part N0415 subpart E Anticoagulant (blood thinner) revealed that it was marked as given within the last 7 days of ARD period. Review of Resident #38's Care Plan, with completed update on 10/9/2024, revealed the resident did not have anticoagulants nor the medication Eliquis (Blood thinner) care planned. During an interview 10/09/2024 9:00 AM, MDS Coordinator stated there wasn't anything care planned involving anticoagulants or Eliquis.

Based on interviews, employee record review, and document review, it was determined the facility failed to ensure five Nursing Assistants (NA) completed competency training and failed to complete the certification testing within 120 days from completion of their initial training. The findings are: Reviewed employee records of all reported full-time Nursing Assistants (NA) employed at the facility on10/09/2024 at 1:30 PM, all five NAs were hired within the last three months, and each had not yet completed the certification process. The only records provided were the certificates stating the completion of the initial 90-hour training. There were no records showing competencies from the initial training, nor any from the facility in which they were employed. During an interview on 10/09/2024 at 2:40 PM, the Human Resources/Social Services (HR/Social) confirmed the facility has five NAs which have not completed the requirements for certification. Records provided by the facility indicate the following are NAs awaiting testing certification and dates of completion of initial 90 hours of Nursing Assistant training: NA #1 completed on 11/21/2023, NA #2 completed on 12/21/2023, NA #3 completed on 04/08/2024, NA #4 completed on 05/02/2024, and NA #5 completed on 02/06/2024. HR/Social confirmed the facility cannot provide documentation of the training the NAs completed during their initial 90-hour training and cannot provide documentation of competencies for work duties assigned such as transfers, isolation precautions, use of mechanical lift, nail care, or showers. HR/Social stated, We do not request the proof of skills completed from the training facilities because if they pass, we know they had to complete all necessary training to pass, and we don't go through a check off list of skills here once they start. They just follow another CNA for a week or so and train with them. HR/Social stated she was told the NAs had one year to test from competition of their initial training to pass the test. During an interview on 10/10/2024 at 9:30 AM, the Administrator confirmed the facility was under the impression NAs have one year to test from the date of completing their initial training. The Administrator also confirmed the facility does not have a training protocol or policy regarding training and/or certification of NAs, and the facility assigned the NAs to a CNA to assist with training, but they do not document a skills check off list for these employees. The Administrator stated, We provide continued training and random monitoring of the NAs/CNAs to ensure good care is provided to the residents, but as far as documentation of initial skills training, I don't think we have that to provide.

Based on record review and interview, the facility failed to include the selection of a neutral arbitrator to be agreed upon by both parties and for the selection of a venue convenient to both parties in the Arbitration Agreement. The findings are: 1. On 10/07/2024 at 10:30 AM, the facility's Arbitration Agreement was received from the Administrator as part of the admission packet. 2. During an interview on 10/09/2024 at 9:30 AM, the Human Resource(HR)/Social said during admission she defined an arbitration as if a dispute comes up, it would be handled by an arbitrator instead of going to court. She explains the arbitration agreement after the resident/representative read the agreement, then she asks the questions on the 3rd page to make sure the resident/representative understands before signing. HR/Social said the agreement doesn't include the selection of a neutral arbitrator would be agreed upon by both parties and that the selection of a venue would be convenient to both parties. 3. During an interview on 10/10/2024 at 9:44 AM, the Administrator said there is a paragraph stating the dispute would be resolved under NAF's (National Arbitration Forum rules. The agreement does not specially say the agreement provides for the selection of a neutral arbitrator agreed upon by both parties or that the agreement provides for the selection of a venue that is convenient to both parties.

Based on observation, interview, and record review the facility failed to ensure residents received oxygen therapy at the physician ordered flow rate. This failed practice affected 2 (Resident #17, #19) of 3 (Resident #17, #19, #34) sampled residents, residing on the 200 Hall who had orders for oxygen, according to a list provided by the Administrator on 08/17/2023 at 10:48 AM. The findings are: 1.The following observations were made of Resident #17: a. On 08/14/23 at 3:09 PM Resident #17 was sitting in her room in her wheelchair. Her oxygen was set at 1.5 liters per minute. b. On 08/16/23 at 8:42 AM Resident #17 was sitting at bedside in a wheelchair, with oxygen off. Concentrator on and set on 1.5 liters, nasal cannula in a bag dated, 08/13/23. I usually have that oxygen on. The Surveyor asked if she puts oxygen on and off by herself. No, the nurse or Certified Nursing Assistant [CNA] puts it on me. I cough a lot and need it since I had pneumonia. c. On 08/16/23 at 10:10 AM Resident #17 was sitting in a wheelchair resting with her eyes closed, Oxygen on at 1-1.5 liters per minute. 2. In an interview on 08/16/23 at 08:55 AM while CNA #1 assisted the resident, the Surveyor asked if CNA #1 usually assisted in putting the oxygen on the resident. CNA #1 said, Yes, sometimes I do. She said, Correct me if I am wrong but I think she is supposed to wear oxygen all the time. It is set on 1.5 liters [L], maybe 2 L. It looks like 1.5 L. 3. In an interview on 08/16/23 at 11:37 AM, the Surveyor asked Licensed Practical Nurse [LPN] #1 to verify the amount of oxygen resident #17 was receiving. LPN #1 said, It is about 1.5-2 liters usually. Oh, it is a little under that. Let me fix it right now. The Surveyor observed LPN #1 adjust concentrator to 2 liters. The Surveyor asked what flow rate was ordered for Resident #17. LPN #1 said, She mostly uses it at night. She feels like she cannot breathe when laying down. If it is not set on enough oxygen, then it needs to be fixed, because it is not what the doctor ordered. 4. A review of Physician ' s Orders dated 8/12/2022 showed, Oxygen 2-4LPM per nasal cannula PRN (as needed) for SOB (shortness of breath), CP (chest pain), saturation <92%, or maintenance of medical condition. 5. A review of the Care Plan initiated on 01/27/23 showed, The resident has oxygen, resident will have no s/sx (signs/symptoms) of poor oxygen absorption through the review date.OXYGEN SETTINGS: Oxygen 2-4LPM per nasal cannula PRN for SOB, CP, saturation <92%, or maintenance of medical condition . 6. The following observations were made of Resident #19: a. 08/14/23 11:45 AM, Resident #19 was laying down wearing oxygen. Resident #19 said, I am unsure of how many liters of oxygen I wear. The oxygen tubing and humidifier bottle were dated 08/13/23, and oxygen set to 1-1.5 liters. The concentrator was pressed between the bed frame and the outer wall. b. 08/16/23 8:58 AM, Resident #19 was lying in bed, with her eyes covered. Oxygen was set to 1-1.5 liters, tubing and humidifier bottle were dated 08/13/23. c. 08/16/23 at 2:28 PM, Resident #19 ' s oxygen concentrator set on 1-1.5 liters. The Surveyor asked Registered Nurse [RN] #1 to read off the amount of oxygen on resident #19. RN #1 said, 2 liters. The Surveyor asked RN #1 if she could check it from eye level, and observed concentrator is hard to read. Concentrator pressed between the bed frame and outer wall. RN #1 said, It is slightly under 2 liters, maybe 1.5 liters. I will have to go read the doctor ' s orders. 7. In an interview with the Assistant Director of Nursing [ADON] on 08/17/23 at 1:50 PM, the Surveyor asked who was responsible for ensuring the residents were administered oxygen at the correct flow rate. The ADON said, The nurse on the floor is responsible for oxygen, and we check on Sundays when the tubing and humidifier bottles are changed. The ADON said, If the oxygen level is too low then they are not getting what they need. Their level may be too low. Certified Nursing Assistants [CNA]'s have no reason to handle the oxygen or tubing. They should get a nurse. 8. A review of the Physician Orders dated 12/16/20 showed, Pulse Ox (oxygen saturation) BID (twice a day) d/t (due/to) PRN (as needed) oxygen use. Oxygen 2-4 liters per nasal cannula PRN for SOB, CP, saturation <92%, or maintenance of medical condition every shift. 9. A review of the Care Plan dated 07/01/22 showed, The resident has oxygen therapy @ 2-4 LPM PRN, the resident will have no signs or symptoms of poor oxygen absorption through the review date, .Monitor for signs or symptoms of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia) . 10. 08/17/23 at 12:30 PM The Administrator provided a procedure titled Oxygen Administration Procedure 15 that showed, . Procedure includes to check physician's order for liter flow and method of administration .

Based on observation, interview and policy and procedure review, the facility failed to prevent the potential for infection and cross contamination in the facility laundry processing area as evidenced by staff placing half consumed food and drinks on the laundry folding table next to clean, folded resident linens. This failed practice had the potential to effect 18 (Resident #1, #3, #4, #5, #8, #16, #17, #19, #20, #26, #34, #37, #39, #40, #46, #51, #54 and #59) sampled residents, and 62 residents who have their laundry done in the facility based on a list provided by the Administrator on 08/18/23 at 8:41 AM. The findings are: a. During a facility tour of the Laundry Room on 08/17/23 at 1:58 PM, the Surveyor observed a soft drink in a plastic bottle sitting on top of the folding counter surface next to a stack of clean, pink folded transfer pads. There was a clear, plastic cup half full of a brown colored liquid covered with a plastic lid with an exposed straw sitting near the right corner end of the stainless-steel countertop. There were 2 containers of salsa in Styrofoam cups with plastic lids stacked on the countertop, and a plastic bag containing tortilla chips sitting next to the salsa on the right corner of the laundry folding counter. There were visible crumbs and smears on the countertop, and a small amount of condensation from the drinks that had dripped onto the surface of the stainless-steel folding counter. b. In an interview with the Housekeeping/Laundry Supervisor 08/17/23 at 2:10 PM, the Surveyor asked if food and drinks should be on the laundry folding counter. The Housekeeping/Laundry Supervisor answered, Well the girl that just left should have cleaned this up but left it here. The Surveyor asked why food and drinks should not be placed on the laundry counter with resident laundry. The Housekeeping/Laundry Supervisor answered, contamination. This will be cleaned up right away. c. In an interview with the Administrator at 08/17/23 02:31 PM, the Surveyor asked the Administrator if food and drinks should be placed on the laundry folding counter. The Administrator answered and confirmed, No, they should not. The Surveyor asked the Administrator why food and drinks should not be on the laundry folding counter. The Administrator answered, Well, it could be an infection control issue or an issue with staff getting chemicals in it. d. A Review of the policy titled, Infection Prevention and Control Manual, Environmental Services/Housekeeping/Laundry provided by the Administrator On 08/17/23 at 3:00 PM, showed, Purpose, All potentially contaminated linen to be handled with appropriate measures to prevent cross-transmission .

Based on observation, interview, and record review the facility failed to treat each resident with respect, dignity, and to care for residents in a manner to protect their right to a dignified existence and privacy. This failed practice affected 1 (Resident #16) of 3 (Resident #9, #16, #63), residents and had the potential to affect 10 residents residing on 100 Hall. The findings are: 1. During facility observations on 08/14/23 at 11:29 AM, Resident #16 pointed to her bathroom and said, They locked the bathroom door, and gave my roommate a bedside commode. If I want to use the bathroom, I must go down the hallway. It's a good bathroom. They said the bathroom was too small and we might get hurt. Can you help me get my door unlocked? Certified Nursing Assistant [CNA] #2 walked in and said, I could hear through the door, we locked her bathroom door. When she calls, we take her to the bathroom up front. Resident #16 said, They let my roommate use a bedside commode, but told me I could not use one. I do not understand. CNA #2 left without responding to the resident ' s comment. 2. During facility observations on 08/14/23 at 2:02 PM, CNA #2 was sitting at a table outside of (named) room. This Surveyor was standing 38.5 feet away and heard CNA #2 give a full report to another staff member. CNA #2 said, Resident #16 will fall if she goes to the bathroom, so they have locked the door. She calls and is taken to the larger bathroom upfront in a wheelchair, where she can pull herself up. If she goes to her bathroom she will fall and bust, her face. She has fallen several times. 3. During an interview on 08/14/23 at 2:28 PM, this Surveyor asked CNA #2 about the process for taking Resident #16 to the bathroom. CNA #2 said, The bathroom door is locked. She has fallen many times because she loses her balance. She tries to toilet herself. The nurses told us to lock the bathroom and take her up front to assist her in the bigger bathroom. We asked her to use the call light and we will take her up front in a wheelchair to use the bathroom. Surveyor asked if resident uses the call light and CNA #2 said, yes. CNA #2 said, She cannot use a bedside commode. CNA #2 was asked if she is familiar with resident rights. CNA #2 said, Yes, we have regular in-service and training when we are hired. CNA #2 was asked if there are any negative consequences of locking resident and her roommate out of the bathroom, and not allowing a bedside commode. CNA #2 pointed to room [ROOM NUMBER] and said, No, if she uses this bathroom here, she will fall and bust her face. In the front bathroom she can use the bars in there and pull herself up. 4. During an interview on 08/16/23 at 10:03 AM, the Surveyor asked the Physical Therapy Assistant, [PTA] if staff requested recommendations on safe toileting for Resident #16. The PTA said, I don't know I honestly do not think so. The PTA provided Resident #16's Therapy Evaluation and report showing resident Precautions: Fall Risk. 5. During an interview on 08/16/23 at 2:33 PM, The Surveyor asked LPN #1 if she was familiar with Resident #16. LPN #1 said, She is pretty new. The Surveyor asked about the resident ' s process for toileting. LPN #1 said, She is supposed to use the call light, and I think she can go to the bathroom. She has had a couple of falls. The Surveyor asked LPN #1 how she knows the procedure to provide care for resident #16, including toileting. LPN #1 pulled up the Care Plan and said, I go by the Care Plan. It says encourage to use call light, and extensive 1 person toileting assistance. The Surveyor asked if there were instructions indicating Resident #16's bathroom was to be locked, or she could not use the bathroom in her room. LPN #1 said, No, there is not. 6. On 08/17/23 at 01:50 PM The Surveyor spoke with the ADON and asked the facility ' s procedure for determining safe toileting. The ADON said, It is different for every resident. We must take a lot of things into consideration. During the interview the ADON said, It is never okay to lock the resident ' s bathroom. If they have a roommate someone might want to change clothing in there if they are not comfortable with the privacy curtain. 7. A review of a document provided by Administrator Your Rights and Protections as a Nursing Home Resident on 08/17/23 2:40 PM showed, You have the right to be informed, make your own decisions, and have your personal information kept private. You have the right to be Treated with Respect: You have the right to be treated with dignity and respect, as well as make your own schedule and participate in activities you choose. You have the right decide when you go to bed, rise in the morning, and eat your meals. 8. A review of the Confidentiality in the Workplace Policy provided by the Business Office Manager (BOM) on 08/18/23 at 09:09 AM showed, Purpose: Ensure that sensitive and personal information about residents is not shared with other residents by staff members .

Based on observation, interview, and record review the facility failed to secure confidential and private medical information on an open laptop. This failed practice had the potential to affect all 13 residents residing on 200 Hall according to a census of 200 Hall received from the Administrator [Admin] on 08/14/2023 at 11:20 AM. The findings are: 1. On 08/16/23 at 2:26 PM, during facility rounds on 200 Hall, the Surveyor observed an open laptop, sitting on a small table. The laptop was open with the 200-Hall Census, in clear view of anyone walking in the 200 Hallway. 2. On 08/16/23 at 2:27 PM, Registered Nurse [RN] #1 came out of a resident room. The Surveyor asked RN #1 if it was appropriate for a computer to be left on with resident information pulled up, and visible to anyone in the hallway. RN #1 said, No, it is absolutely not appropriate. The Surveyor observed RN #1 lock the computer screen. During the interview RN #1 said, The screen should be off or locked. Anyone, like yourself, could see medical information on any resident we have. It is Health Insurance Portability and Accountability Act [HIPAA] violation. 3. On 08/17/23 at 1:50 PM, in an interview with the Assistant Director of Nursing [ADON], the Surveyor asked if it was appropriate for resident information to be left pulled up on an open laptop in the hallway. The ADON said, Absolutely not, the laptop should have been closed down or minimized. If someone was charting, they need to stay with the laptop. During the interview the ADON said, It creates a potential for information to be out for others to see. It could be considered a breach of information. 4. A policy titled Confidentiality in the Workplace, provided by the Business Office Manager [BOM] On 08/18/23 at 9:09 AM showed, Purpose: Ensure that sensitive and personal information about residents is not shared with other residents by staff members . 3. A resident's record is a legal document and, as such, it must be kept confidential and used only for the documentation of information .

Based on observation, interview, and record review the facility failed to ensure fingernails were clean, groomed, and free from chipped nail polish to promote good personal hygiene and grooming for 1 (Resident #51) of 7 (Resident #4, #20, #37, #39, #46, #51 and #59) sampled residents that were dependent on staff for fingernail care on the Special Care Unit. This failed practice had the potential to affect 16 residents that lived on the Special Care Unit and were dependent on staff for nail care according to a list provided by the Administrator on 8/18/23 at 8:40AM. The findings are: 1. Resident #51 had a diagnosis of Alzheimer's Dementia, Anxiety, and Osteoarthritis. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/2/23 documented that she scored 1 (0-7 indicates severe impairment) on the Brief Interview for Mental Status (BIMS), required extensive assistance with dressing, toileting, personal hygiene, limited assistance with bed mobility, transfer, and supervision with eating. a. On 08/14/23 at 2:16 PM, Resident #51 was sitting up in the Day/Dining Room in her wheelchair. The residents' fingernails were ungroomed extending approximately 1/8 to 1/4 of an inch past the end of the nail bed. The pink nail polish was chipped and peeling and there was approximately 1/4 inch of growth with no polish on the nail. b. On 08/15/23 at 9:27 AM, Resident #51 was sitting in the Day/Dining Room in her wheelchair. The residents' fingernails were ungroomed extending approximately 1/8 to 1/4 of an inch past the end of the nail bed. The pink nail polish was chipped and peeling and there was approximately 1/4 inch of growth with no polish on the nail. c. On 08/16/23 at 9:21 AM, Resident #51 is sitting in her wheelchair in the Therapy Room. The residents' fingernails were ungroomed extending approximately 1/8 to 1/4 of an inch past the end of the nail bed. The pink nail polish was chipped and peeling and there was approximately 1/4 inch of growth with no polish on the nail. d. On 08/17/23 7:30 AM, Resident #51 was sitting up in the Day/Dining Room eating breakfast. The residents' fingernails were ungroomed extending approximately 1/8 to 1/4 of an inch past the end of the nail bed. The pink nail polish was chipped and peeling and there was approximately 1/4 inch of growth with no polish on the nail. e. On 8/17/2023 at 12:55PM, Resident #51 was sitting in the day/dining room. The Surveyor asked Licensed Practical Nurse (LPN) #2 to examine the resident ' s fingernails and describe them to the Surveyor. LPN #2 stated, They need to be cut, cleaned, and the nail polish taken off. They need to be trimmed, smoother, and the polish redone. The Surveyor asked Who was responsible for doing nail care on the residents and how often nail can should be done. LPN #2 stated, If the resident is not a diabetic then anyone can do the nails. The nurses do the diabetic nails. The Treatment Nurse helps with the nails and the aides let the nurses know if they have a resident who they are not comfortable doing the nails. LPN #2 stated, Nail care is done every Sunday. [NAME] and Polish is done every Monday and residents can get a manicure done at that time if they would like one. If the resident is sleeping when that is being done, we do not disturb them. The Surveyor asked if Resident #51 refused nail care. LPN # stated, She has in the past. She had long nails in the past and likes to keep them long. If a resident refuses to have their nails done, we cannot do them. The Surveyor asked, Why should the residents nails be neat and groomed? LPN #2 stated, It could be a dignity issue. We can get her nails done today. f. In an interview on 08/17/23 at 1:00 PM the Surveyor asked Certified Nurse's Aide (CNA) #3, How much assistance does Resident #51 need with her activities of daily living? CNA #3 stated, She is limited with most activities. Transfers are extensive assistance. On the days she is more confused she requires more help. How much assistance does Resident #51 need with nail care? CNA #3 stated, She is used to having long nails. She does not like them cut. She will yell and cuss at times if we try to do her nails. The Surveyor asked, Will she let staff paint her nails? CNA #3 stated, She loves to have her nails polished. She is very picky on how her nails are done. The Surveyor asked, Who is responsible for doing nail care, if the CNA ' s put nail polish on, and how often nail care should be done? CNA #3 stated, The CNA's do the nails if the resident is not diabetic, yes we paint them, and we do nail care on Sundays. Sometimes if she is asleep, we do not do them. The Surveyor asked CNA to look at Resident #51's nails. After CNA #3 looked at her nails, the surveyor asked CNA #3 if Resident #51 nails need to be groomed. CNA #3 stated, Yes. They need to be cleaned and polished. g. In an interview with CNA #4 on 08/17/23 at 1:10PM, the Surveyor asked, How much assistance does Resident #51 need with her activities of daily living? CNA #4 stated, She is dependent for everything. Since she went to the hospital and came back, she has been more confused and so needs more help with care. The Surveyor asked, Will she let you do nail care and who is responsible for nail care? CNA #4 stated, Some days she will, but some days she will not. The aides are responsible for doing the nail care. The Surveyor asked, Will Resident #51 let you paint her nails? CNA #4 stated, Sometimes she will and sometimes she does not. Just like sometimes she will let us clean them and sometimes she does not. The Surveyor asked, How often should nail care be done? CNA #4 stated, Nail care is done every Sunday because we do not do showers on Sunday, and we have more time to do the nails. It should be done throughout the week if it is needed. h. In an interview with the Assistant Director of Nursing (ADON) On 08/18/23 at 09:20 AM, the Surveyor asked how much assistance Resident #51 needed with ADL's. The ADON stated, One person can do her. She sometimes needs a little more help with the transfer if her leg is hurting her. The Surveyor asked, Does she need assistance with nail care? The ADON stated, Staff would need to assist her with her nails. I think if I gave her an orange stick, she could do that herself The Surveyor asked, Does the resident refuse care? The ADON stated, At times she refuses care and at times she requires a lot of prompting. The Surveyor asked, Does she refuse nail care? The ADON stated, Basically it is the same for nail care. It all depends on the day. Sometimes you have to walk away and come back later and try later. The Surveyor asked, Who is responsible for nail care and how often should nail care be done? The ADON stated, The CNAs are responsible as long as the resident is not a diabetic. If the resident is a diabetic the treatment nurse is responsible for making sure it is done. Nails should be looked at on shower day to see if they need to be done. They should be looked at least three times a week. If the patient is diabetic the aides are to let the treatment Nurse know if nails need to be clipped or receive any care. The Surveyor asked, Do the aides paint the residents' nails? The ADON stated, Yes they do on the Unit, and we do [NAME] and Polish on Mondays outside the unit, but the residents on the unit are welcome to come to that. This is in addition to nail care with the showers. i. A review of the Care Plan with a revision date of 03/13/23 showed, .Problem: The resident has an ADL self-care performance deficit .Goal: The resident will show no decline in current level of function through the review date . Approaches: .PERSONAL HYGIENE: The resident requires extensive assist x 1 with personal hygiene and oral care . j. A review of the policy titled, Nails (Finger and Toe), Care of with an effective date of 2001, provided by the Administrator showed, Responsibility: The following individuals may have responsibility for care of fingernails and toenails specific to state professional licensing requirements. RN, LPN/LVN, CAN. Purpose: The purpose of fingernail and toenail is to: Provide cleanliness, prevent spread of infection, comfort the resident, prevent skin problems .

Based on observation and interview, the facility failed to ensure food items in the refrigerator were dated when pulled from the freezer and placed in the refrigerator to ensure they were used within 14 days once thawed and failed to ensure equipment was maintained in clean condition and failed to ensure 1 (500 Hall) of 2 ice machines was regularly cleaned to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 63 (total census: 66) residents who receive meals from the kitchen and 18 residents who received ice from the 500 hall ice machine based on a list provided by the Dietary Employee #1 on 05/05/22. The findings are: 1. On 05/02/22 at 11:50 AM, the following observations were made in the kitchen area: a. On the second shelf of a two-door refrigerator located in the Storeroom, was a box containing 40 four ounce Chocolate nutritional milkshakes and 13 four ounce strawberry nutritional shakes with a received by date of 4/7/22. The manufacturer's guidelines for safe food handling documented on the side of each individual shake, .Use within 14 days once thawed . Dietary Employee #2 was asked how long the shakes had been thawed and he said, I don't see a pull date, so I don't know for sure how long they have been out of the freezer. He was asked, What could happen if the shakes were used past the recommended 14 days of thawing? Dietary Employee #2 said, They could be bad. b. The fan guard of the two-door refrigerator containing the nutritional shakes had blackish, gritty specks on it. Dietary Employee #2 was asked what the specks were. He said, It's some sort of dirt. 2. On 05/02/22 at 12:27 PM, the 500 Hall ice machine had a brownish jelly like substance on the top of a cube of ice and on the water plate where the ice cubes are formed. There was a black slimy debris on the splash curtain above the ice cubes. Dietary Employee #1 was asked to describe what she saw. She said, It's dirty. Maintenance cleans its. I'm not sure when it was cleaned. a. On 05/04/22 at 8:29 AM, the Maintenance Director was asked to describe what he saw inside of the 500 Hall ice machine. He said, I cleaned it Monday. I still see some brown, and black stuff. I can't remember what it's called. The Maintenance Director was asked if he was responsible for cleaning the ice machines. He said, It's usually quarterly. That's what I used to do with mine. I've only been here since the end of February. b. The facility policy titled, Cleaning Instructions: Ice Machine and Equipment provided by the Maintenance Director on 05/04/22 at 8:33 AM documented, .The ice machine and equipment . will be cleaned on a regular basis to maintain a clean, sanitary condition . Change to cleaning schedule of facility ice machines: 03-07-2021. The cleaning schedule for facility ice machine is being changed effective today to monthly. This is to be done by the maintenance staff and logged in the Maintenance book . c. On 05/04/22 at 8:35 AM, the Maintenance Director was asked for the maintenance log for cleaning the ice machine. The Maintenance Director provided a document titled, Ice Machine Check and documented 03/22 500 hall ice machine. The Maintenance Director was asked if March was the last time the ice machine was cleaned and the Maintenance Director said, Yes. It looks like it. The Administrator stated, I think he meant to say it was cleaned in April, but it wasn't documented. She reminded the Maintenance Director to document each time the ice machine was cleaned. 3. On 05/04/22 at 8:15 AM, in the kitchen there was a white oscillating cooling fan blowing toward the food prep table behind the stove. The fan was covered with grayish, translucent particles. Dietary Employee #2 was asked what the particles were. He said, It's dust. I will take care of that right now.

Based on observation, record review and interview, the facility failed to ensure the appropriate PPE (Personal Protective Equipment) was worn for a resident who was on contact isolation for 1 (Resident #33) of 1 sampled resident who was on TBP (Transmission Based Precautions) and failed to ensure staff did not remove their face mask when talking within three feet of 1 (Resident #33) of 9 (Residents #33, #159, #58, #11, #7, #50, #42, #56 and #28) sampled residents who resided on the Secured Unit (500 Hall) as documented on the Census by Hall provided by the Administrator on 5/2/22. The findings are: 1. Resident #33 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Care Plan with a revision date of 5/5/22 documented, .Resident refuses to stay in room and has adamantly refused a [urinary catheter]. Unable to remember that he is in isolation for [CONDITION(S)] with esbl+. Velcro release stop sign placed across doorway to remind resident that he is in isolation. c. On 05/02/22 at 1:08 PM, Resident #33 left his isolation room and walked to the Dining Room and stood at the door, six feet from other residents. Certified Nursing Assistant (CNA) #1 walked him back to his room and stated, You are on isolation, you will have to come back to your room. CNA #1 entered Resident #33's room only wearing her mask for PPE. Resident #33 sat in his recliner and stated, Will you hand me my trash can. CNA#1 handed him his trash can and wrote a message on his communication board and then left the room at 1:11 pm. d. On 05/02/22 at 1:11 PM, CNA #1 was asked, Is [Resident #33] on isolation? She stated, I am not sure. I am new. I have only been back here two days. She was asked, What type of isolation is he on? She stated, Droplet. I believe. CNA #3, who also was standing in the hall, stated, That's just what I was about to say, you need to dress out before you go into his room. CNA #1 then went into the hall bathroom and washed her hands with the bathroom door open. When she returned to the hallway she was asked, When you see this cart with PPE outside of the resident's room what does that mean? She stated, They are on isolation. She was asked, What PPE should you wear before entering [Resident #33's] room? She stated, Face mask, gown, gloves, goggles (while she was looking at the sign on the door with pictures of the PPE to be worn while in Resident #33's room). She was asked, What is a potential complication of you going into his room without wearing the appropriate PPE? She stated, I could get what he has. She was asked, Were you trained on isolation when you started at this facility? She stated, Yes, [CNA#2] taught me. e. On 05/02/22 at 1:19 PM, CNA #2 was asked, What type of isolation is [Resident #33] on? She stated, Droplet I think for ESBL . She was asked, What type of PPE is required when entering his room? She stated, Mask, gown, gloves. She was asked, Do you train the CNAs? She stated, Yes, different stuff like isolation . f. On 05/02/22 at 1:24 PM, CNA#2 returned and stated, He has ESBL in urine. He is on contact isolation not droplet . 2. On 05/02/22 at 2:52 PM, the Director of Nursing (DON) was down the hall and observed CNA #5 pull her mask down while she was within three feet of Resident #33's face and was talking to him. The DON was asked, Is it acceptable practice for staff to have their mask down? She stated, No. The DON was asked, What type of isolation is [Resident #33] on? She stated, Contact. She was asked, What type of PPE should be worn when entering his room? She stated, Gown, mask, gloves. She was asked, Is it an acceptable practice for your staff to enter his room while the only PPE they were wearing was a mask? She stated, No, it is not . 3. On 05/05/22 at 12:56 PM, CNA #5 was asked, When should you wear your mask when you are at the facility? She stated, All the time. She was asked, If there is a resident who cannot hear you when you are talking to him what have you been instructed to do? She stated, We use a dry erase board for [Resident #33] to communicate, but the housekeeping cart was between me and him and I could not access his dry erase board. He reads lips, so I just pulled my mask down to ask him . CNA#5 was asked, How far from [Resident #33] where you when you pulled your mask down? She stated, Four or five feet, the housekeeping cart was between us . She was asked, What is a potential complication of pulling your mask down to talk to a resident? She stated, Infection .COVID exposure . 4. The facility policy titled, Isolation Precautions (Transmission Based), provided by the DON on 05/03/22 at 12:53 PM documented, .Contact Precautions These precautions are to be used in addition to standard precautions for residents known or suspected to be infected or colonized with microorganisms transmitted by-direct contact with the resident, such as hand to skin contact or indirect contact, such as touching environmental surfaces or items in the resident's environment . 5. The facility policy titled, Staff Mask Wearing, provided by the Administrator on 05/06/22 at 10:36 AM documented, Staff are to wear a mask in the facility . The Administrator stated, We have been required to wear mask since 3/30/2020 .

Based on interview and record review, the facility failed to ensure proper bookkeeping techniques were followed to accurately reconcile individual resident funds for 22 of 22 (Residents #2, 3, 4, 6, 7, 9, 11, 15, 20, 24, 25, 28, 33, 37, 38, 40, 41, 42, 49, 56, 58 and 60) sample residents who had trust funds managed by the facility. This failed practice had the potential to affect 56 residents who had their personal trust funds managed by the facility, according to a list received from the business office manager on 5/5/22. The findings are: 1. The March 1, 2022 to March 31, 2022 Trust Fund Report provided by the Business Office Manager on 05/5/22 at 12:36 PM documented an ending balance of $44,467.66. The April 2022 statement had not yet been received and facility trust Current Account Balance as of 04/05/22 was $40,123.71. 2. On 05/5/22 at 1:06 PM, the BOM listed on post-it notes an on-hand petty cash balance of $225.04. 3. On 05/5/22 at 1:22 PM, the BOM was asked to provide documentation of the last reconciliation performed of the trust bank statement and resident trust account. I have one for February. I do not have one for March. The Office Manager from our sister facility is working on it for me. I was not aware it was something that had to be done.

Based on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) Discharge assessment was encoded correctly for 1 (Resident #59) of 2 (Resident #59 and #60) sampled who were discharged from the facility in the past 3 months. The findings are: Resident #59 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an Assessment Reference Date of 2/22/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status. a. As of 5/4/22 at 3:06 PM, the most recent MDS available in the resident's clinical record was a Discharge MDS with an ARD of 4/13/22. Section A2100. Discharge Status was coded 03 Acute Hospital. b. On 05/04/22 at 3:21 PM, the Director of Nursing (DON) was asked, Who is responsible for completing the discharge MDS? She said, The MDS Coordinator, but she is gone for the day. The DON was asked to verify if the [Resident #59] was discharged to the hospital on 4/13/22 per MDS. The DON said, It's acute hospital. The Administrator stated, That is not correct. We will have to get her to change that. The resident left the facility AMA [Against Medical Advice] with his family. c. On 05/05/22 at 8:21 AM, the MDS Coordinator was asked if [Resident #59's] discharge MDS should have been coded as discharged to the hospital. The MDS Coordinator said, No, it should have been to home. I've corrected it and resubmitted.

Based on observation and interview, the facility failed to ensure food items stored in the refrigerator and dry storage were covered and sealed and expired food was promptly removed from stock and discarded in 1 of 1 facility. These failed practices had the potential to affect 43 residents who received meals from the kitchen (total census:45), as documented on the Diet List provided by the Dietary Manager on [DATE] at 8:39 am. The facility also failed to ensure 1 of 2 ice machines were maintained in clean condition to prevent potential contamination. This failed practice had the potential to affect 16 residents who resided on the 500 Hall according to the list provided by the Director of Nursing (DON) on [DATE] at 3:19 pm. The findings are: 1. On [DATE] at 10:17 am, during initial kitchen rounds with Dietary Employee #1, in attendance, the following was observed in the refrigerator: There was an open zip-lock bag with 2 packages of hotdogs inside. A received date of [DATE] was written on the zip-lock bag and the hotdog package. One of the packages of hotdogs was opened and had 6 hotdogs inside, the juice from the hotdogs had leaked out into the zip-lock bag. Dietary Employee #1 was shown the hotdogs and was asked, Tell me how that should be stored and labeled. She replied, It should have an open date and the zip-lock bag should be sealed. The open one should not be in the same bag with the unopened package. These were opened yesterday. Photos were taken. 2. On [DATE] at 10:17 am, in the refrigerator, there was a bag of bologna that was not dated. Dietary Employee #1 reported that it was sliced yesterday. Dietary Employee #1 was asked, What should be written on the bag? She responded, It should be labeled and dated. Photos were taken. 3. On [DATE] at 10:31 am, in the dry storage area there was a container of Idahoan potatoes opened and not sealed, a box of corn starch had no open date and was open to air, and there was an open bag of vanilla wafers that had no open date, was not bagged or sealed. Dietary Employee #1 was asked, How should these things be stored? She replied, I'm not sure, it's closed. I know once it has been opened, it should be labeled with an open date. Photos were taken. 4. On [DATE] at 10:36 am, there was five boxes of Grits that had a best before date of [DATE]. Photos were taken. Dietary Employee #1 was shown the boxes of Grits and asked, Are these expired? She replied, Yes, I told them they need to be checking this stuff. I'll get that thrown away now. 5. On [DATE] at 10:49 am the ice machine in the secure unit had a black substance present inside. Dietary Employee #1 was asked to wipe it with a white napkin. Approximately 2 inches of a black substance wiped off on the white napkin. Certified Nursing Assistant (CNA) #1 stated, That looks like mold. Dietary Employee #1 and CNA #1 were asked, Who is responsible for cleaning the ice machine? CNA #1 responded, Maintenance does it. Dietary Employee #1 agreed. 6. On [DATE] at 1:54 pm Maintenance Employee #1 was asked, Who is responsible for cleaning the ice machines? He replied, I do it every 3 months. He was asked if he had a cleaning log and Manufacturers Guide for the ice machine. He stated he would get it. 7. On [DATE] at 12:06 pm the DON presented a document titled Ice Machine Check that documented, .Date [DATE] 500 Hall clean, XXX[DATE] 500 Hall cleaned . 8. A Manufacture Guide binder on Ice-O-Matic was received from Maintenance Employee #1 on [DATE] at 08:20 am which documented, Cleaning instruction for Ice-O-Matic . Proper cleaning of an ice machine requires two parts: descaling and sanitizing. Descaling should be schedule at a minimum of twice per year but no more than once per month .Sanitizing should be performed after each descaling but no more than once per month . 9. On [DATE] at 08:37 am, the Dietary Manager was asked, How is food stored once it is opened? She replied, It should be placed in a sealed container, labeled, and dated. 10. On [DATE] at 09:35 am the facility provided a policy titled, Food Storage which documented, .Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled and dated .All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods . Date marking to indicate the date or day by which a ready to eat, potentially hazardous food should be consumed, sold or discarded will be visible on all high risk food .Foods will be stored and handled to maintain the integrity of the packaging until ready for use . All foods should be covered, labeled, and dated.

Based on observation, record review, and interview, the facility failed to ensure a tube feeding, flushes, and tubing was labeled and dated according to policy and manufactures guidelines and as ordered by the physician to prevent complications for 2 (Residents #20, and #42) of 2 residents who received nutrition via a feeding tube. This failed practice had the potential to affect 2 residents who received tube feedings according to the list provided by the Director of Nursing (DON) on 3/10/21 at 12:06 pm. The findings are: 1. Resident #20 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/18/21 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS); was totally dependent on the assistance of one person for eating, received 51% or more total calories and 501cc (cubic centimeters) of fluid per day via a feeding tube. a. The Physician order [REDACTED]. Check peg tube placement with Aspiration and/or Auscultation prior to each use. Hold feeding if residual greater than 200ml and notify MD (Medical Doctor) every day and night shift . Flush peg tube before and after each use with 60ml water every day and night shift. b. The Resident's Care plan revised on 10/21/20 documented, The resident requires tube feeding r/t (related to) Dysphagia. c. On 3/7/21 at 10:33 pm, and 12:27 pm, Resident #20 had a feeding via percutaneous endoscopic gastrostomy (peg) tube running at 40ml/hr with no label on the feeding tube bag and no label on the flush bag. d. On 3/7/21 at 12:30 pm, the DON accompanied this surveyor to the resident's room and was asked, What kind of feeding is the resident on? The DON stated, [MEDICATION NAME] 1.5, I believe. The DON was asked, Should there be a label on the bag? The DON stated, Yes. The DON was asked, What should be on the label? The DON stated, Time, date, kind of feeding, infusion rate, initial of nurse hanging the feeding, date bag was changed out. The DON was asked, What's in the other bag? The DON stated, Water, that should also have a label with everything on it, date, time, initials. 2. Resident #42 had [DIAGNOSES REDACTED]. An Annual MDS with an ARD of 2/24/21 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS); was totally dependent on the assistance of 1 person for eating, received 51% or more total calories via tube feeing and 501cc per day of fluid via a tube feeding. a. The Care plan revised on 3/30/20 documented, The resident requires tube feeding r/t Weight Loss. The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. b. The physician orders [REDACTED]. Check peg tube placement with Aspiration and/or Auscultation prior to each use. Hold feeding if residual greater than 200ml and notify MD every day and night shift. c. On 3/9/21 at 11:01 am, Resident #42 received nutrition via a PEG tube, running at 50ml/hr with no label on the feeding and no label on the flush. A Glucerna bottle was setting on the bedside table. d. On 3/10/21 at 10:23 am, The DON provided a policy Enteral Nutritional Therapy, (Tube Feeding). The policy documented, .Purpose: Provide liquid nutrition through a tube, inserted into the stomach, provide hydration through a tube inserted into the stomach, Administer medications directly into the stomach . If a pump has been ordered for continuous feeding: fill container with prescribed formula or use prefilled formula container . If an enteral feeding pump is ordered, follow the manufacturer's directions for the use of the pump . documentation may include: date, time of feeding, type and amount of feeding and water administered, signature and title of person administering tube feeding and/or medication.

Based on observation, record review, and interview, the facility failed to ensure the humidity bottle for the oxygen was changed weekly as ordered by the physician to prevent potential contamination, infection and respirator complications for 1 (Resident #13) of 5 (Residents #5, #13, #38, 22, and #39) sampled residents who had oxygen / humidity in use. The failed practice had the potential to affect 17 residents who had physician's orders [REDACTED]. Resident #13 had [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set with an Assessment Reference Date of 12/28/20 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS); was totally dependent on the assistance of 2 people for bathing, and was on oxygen therapy. a. A Care Plan revised on 10/12/20 documented, The resident has oxygen therapy @ 2 LPM/NC (Liter Per Minute per Nasal Cannula) PRN (as needed) r/t (related to) [MEDICAL CONDITIONS] . Give medications as ordered by physician. Monitor/document side effects and effectiveness . b. The February 2021 Treatment Administration Record (TAR) documented, Change humidifier bottle and oxygen tubing on concentrator and bottle. Clean humidifier filter every night shift every Sun (Sunday) On Sunday February 14, 2021 the box was initialed as completed. c. The March 2021 physician's orders [REDACTED].< (less than) 92%, or maintenance of medical condition .Change humidifier bottle and oxygen tubing on concentrator and bottle. Clean humidifier filter. Every nightshift every Sun . d. On 3/8/21 at 11:01 am, the resident was in the dining room wearing oxygen at 2 Liters via nasal cannula from the oxygen concentrator. The humidity water bottle was dated 2/14. e. On 3/8/21 at 11:08 am, Registered Nurse (RN) #1 was asked, How often do you change the water bottle on the oxygen concentrators? The RN stated, They are changed weekly unless they get low and then we change them prn (as needed). RN #1 was told the humidity water bottle was dated 2/14 and was asked, Should the water bottle already have been changed? RN #1 stated, They get changed on Sunday nights, so it will be changed tonight. RN #1 was asked, I understand they are changed on Sunday, but with the date of 2/14 does that mean it was not changed last Sunday? RN #1 stated, Probably not. RN #1 was asked, Is that a potential infection control issue? RN #1 stated, Yes, I will go change it now. f. On 3/10/21 at 2:55 pm, the DON was asked, When is the oxygen tubing and humidity bottles changed? She replied, Every Sunday night. She was asked, Who changes out the oxygen tubing and humidity bottles? The DON replied, The floor nurses, it shows up on the TAR and the nurse has to initial that it was completed. She was asked, Who is responsible to ensure the oxygen tubing and humidity bottles are being changed as ordered? She replied, Whoever is assigned to that hall during morning angel rounds. g. On 3/10/21 at 10:23 a.m., the Policy on Oxygen Administration was received and documented, BASIC RESPONSIBILITY Licensed Nurse .PURPOSE: Deliver oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues .PROCEDURE . Check physician's orders [REDACTED].opened. Change humidifier and tubing per facility policy .

Based on observation and interview, the facility failed to ensure garbage was properly contained within 2 of 2 garbage dumpsters to decrease the potential for pest infestation. These failed practices had the potential to affect all 45 residents who resided in the facility, according to the resident list provided by the Medical Record Personnel on 03/07/21. The findings are: 1. On 03/07/21 at 10:41 am, there were two dumpsters located behind the facility. Both dumpsters had the lids open. One had a pile of trash bags hanging out over the edge. A photo was taken. Dietary Employee #1 was asked, Should those be closed? She replied, I honestly don't know but I'll close them. 2. On 03/11/21 at 08:43 am, the Dietary Manager was asked, How should the lids on the dumpster be kept? She stated, They should be kept closed. All the staff use the dumpsters, so the CNAs probably left them open. My staff know they are supposed to close them. 3. On 03/11/21 at 09:35 am, Registered Nurse #2 provided a policy titled, Infection Prevention and Control which documented, .In outside holding areas (for dumpsters, compactors, or cans) .Dumpster lids are closed and drain in place to limit access to pests and rodents.

Based on observations, record review and interview, the facility failed to ensure staff wore a face mask to cover the nose and mouth and wore personal protective equipment (PPE) into isolation room to prevent the development and transmission of COVID-19 and other communicable diseases and infections in 1 of 1 facility. These failed practices had the potential to affect the 45 residents who resided in the facility according to the Census list provided by the Director of Nursing (DON) on 3/7/21. The findings are: a. On 03/7/21 at 11:44 AM, Housekeeping Staff #1 was in the dining room with her mask below her nose. When she saw the surveyor, she pulled it up over her nose. Housekeeping Staff #1 was asked, What is the proper way to wear your mask? She replied, Covering your nose and mouth. b. On 3/7/21 at 12:05 PM, the door to a COVID positive room was wide open with a positive resident sitting by the door in a recliner. Certified Nursing Assistant (CNA) #2 stood outside the room at the isolation cart. CNA #2 removed surgical mask and donned N95 mask, face shield, gown and gloves. CNA #2 entered resident room. CNA #2 removed gown and gloves and placed them in the red container in resident's room. CNA washed her hands in the resident's room, then exited the room. CNA #2 removed face shield and N95 mask. CNA #2 put on a surgical mask while in the hallway. CNA #2 then sanitized her hands. c. On 3/7/21 at 12:26 PM, CNA #2 walked into a resident's room on the COVID-19 unit without donning PPE. CNA #2 went to the sink and washed her hands and discarded the paper towel in the resident's room. d. On 3/7/21 at 12:28 PM, CNA #2 was asked, Did you walk into that isolation room without your PPE on? CNA #2 stated, Yes, oops I did. I made a mistake. I had to wash my hands. CNA #2 was asked, Would that be an infection control issue? CNA #2 stated, Yes ma'am. I made a mistake and I acknowledge it. e. On 3/10/21 at 3:20 PM, the DON was asked, What is your protocol for wearing PPE (Personal Protective Equipment) on the quarantine hall? The DON stated, We use the ICAR (Infection Control Assessment and Response) tool. A lady from Arkansas Department of Health met with us and she emailed me a process that we use. We put a copy of the Precautionary Quarantine on the wall beside the room. This tells the staff what PPE is required for the room. The DON was asked, Is it ok to wear a surgical mask on the quarantine hall? DON stated, I am going to take the blame for this one. The policy says if we are short on N95 mask we can, but we are not short on N95 at this time. f. On 3/10/21 at 3:28 PM, the DON provided a copy of the Infection Prevention and Control Assessment Tool for Nursing Homes Preparing for COVID-19. The policy stated, .If there are shortages of facemasks, facemasks should be prioritized for HCP (Health Care Professional) and then for resident with symptoms of COVID-19 . Cloth face coverings are not considered PPE and should not be worn . HCP wear the following PPE when caring for residents with suspected or confirmed COVID-19, gloves, isolation gown, N-95 or higher level respirator, eye protection (goggles or face shield) . The DON provided a copy of the Precautionary Quarantine policy that is placed on the wall for staff to know the required PPE for the room they are entering. The policy documented, .Resident and staff should both put on mask. Staff should put on a facility cloth gown . g. On 3/10/21 at 3:36 PM, the Assistant Director of Nursing (ADON) was asked, Is it ok to completely remove your surgical mask and put on a N95 mask outside of a COVID positive room with the door standing wide open? The ADON stated, The door should be closed, but if it is off for a short time, I think it would be ok. The ADON was asked, Is it ok to go into an isolation room on the quarantine hall with a surgical mask as the only personal protective equipment (PPE) on? The ADON stated, No, you should be dressed out as it shows you on the door. The ADON was asked, What can happen? The ADON stated, You are putting yourself at risk without being gowned up, then you put everyone around you at risk. The ADON was asked, Is that an infection control issue? The ADON stated, Absolutely. h. On 3/11/21 at 8:31 AM, the DON was asked, Is it ok to completely remove your surgical mask and put on a N95 mask outside of a COVID positive room with the door standing wide open? The DON stated, Yes, as long as the resident is not using an aerosol, nebulizer, or [MEDICAL CONDITION] (bilevel positive airway pressure) or [MEDICAL CONDITION] (continuous positive airway pressure). The DON was asked, Is it ok to go into an isolation room on the quarantine hall with a surgical mask as the only personal protective equipment (PPE) on? The DON stated, Absolutely not. The DON was asked, What can happen? The DON stated, You can contaminate your clothes and yourself, then take it to other people. The DON was asked, Is that an infection control issue? The DON stated, Absolutely. i. A copy of the Infection Prevention and Control Manual Transmission-Based Precautions policy was copied from the Infection Prevention and Control Manual. The policy stated, .Transmission-based precautions are used for residents who are known to be or suspected of being infected . require additional control measures to prevent transmission .The category of transmission-based precaution determines the type of PPE to be used .

Based on observation, record review, and interview, the facility failed to ensure residents' fingernails were cleaned to promote good personal hygiene and grooming for 1 (Resident #22) of 14 (Residents #41, #13, #44, #29, #27, #13, #42, #38, #39, #36, #17, #20, #22 and #10) sampled residents who were dependent for nail care. The failed practice had the potential to affect 46 residents who were dependent for nail care, as documented on a list provided by the Director of Nursing (DON) on 3/10/21 at 12:11 p.m. The findings are: Resident #22 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 01/25/21 documented the resident scored 5 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status, required extensive assistance with bed mobility, transfers, dressing, and personal hygiene, and was totally dependent on one person assistance for bathing. a. The Plan of Care with a revised date of 1/3/19 documented, .The resident has an ADL (activities of daily living) self-care performance r/t (related to) Confusion .BATHING/SHOWERING: The resident requires extensive assist x (times) 1 with showers . PERSONAL HYGIENE/ORAL CARE: The resident requires (set up and cueing) to maximize independence . b. On 3/8/21 at 9:31 a.m., and at 10:26 a.m., Resident #22 was lying in bed. Both resident's hands had fingernails that extended to the tips of her fingers and there was a brownish substance under each fingernail. When asked about her fingernails, the resident stated, They just cut them today. c. On 3/8/21 at 10:27 a.m., Licensed Practical Nurse (LPN) #1, accompanied this surveyor to the resident's room, and was asked, What is that brown substance under her nail tips? She replied, Looks like food, and they need to be cleaned. She was asked, Who is responsible for cleaning the resident's nails? She replied, The CNAs (Certified Nursing Assistants) are, if they are not a diabetic. She was asked, How often are the residents nails cleaned? The LPN replied, They should check and clean their nails daily. She was asked, Who is responsible to ensure the CNAs are performing nail care? She replied, The floor nurses. d. On 3/10/21 at 2:55 p.m., the DON was asked, who performed the nail care on the residents? She replied, If they are non-diabetic the CNAs, if diabetic the treatment and floor nurses. She was asked, When is nail care completed on the residents? The DON replied, On showers days and as needed. She was asked, Who ensures the CNAs are performing nail care during showers and as needed? She replied, The treatment and floor nurses. e. The Policy on Nails (Finger and Toe), was received from the DON on 3/10/21 at 10:25 a.m. and documented, .The following individuals may have responsibility for care of fingernails . RN (Registered Nurse); LPN/LVN (Licensed Vocational Nurse); CNA .The purpose of fingernail .care is to: Provide cleanliness; Prevent spread of infection; Comfort the resident; Prevent skin problems .

Based on observation, record review, and interview, the facility failed to ensure falls were consistently evaluated for causative factors, that appropriate interventions were developed to address those causative factors, and that planned fall prevention interventions were added to the nursing and Certified Nursing Assistant (CNA) care plans and consistently implemented to prevent a fall with injury for 1 (Resident #58) of 17 (Residents #59, #27, #11, #19, #37, #58, #21, #57, #5, #53, #55, #25, #34, #44, #36, #60, and #32) case mix residents who had a history of [REDACTED]. This failed practice resulted in a pattern of actual harm for Resident #58, who had repeated falls with minor injuries and an additional fall that resulted in [MEDICAL CONDITION], and had the potential to cause more than minimal harm for 33 residents who had falls in the past 6 months, according to a list provided by the Administrator on 8/31/18 at 8:59 a.m. The findings are: Resident #58 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference date of 6.6.18 documented the resident scored 10-(8-12 indicates moderately impaired) on a Brief Interview for Mental Status, was independent in bed mobility, transfer, walk in room, walk in corridor, locomotion on and off unit, had 1 fall with no injury since the last assessment and no documented wandering behavior. a. The Fall Risk assessment dated [DATE] documented, Total score 80. A score of 45 or above indicated a high risk for falls. b. An Incident and Accident (I&A) Report dated 3/6/18 at 6:48 p.m. and completed by Licensed Practical Nurse (LPN) #2 documented, This nurse called to resident's room by CNA (Certified Nursing Assistant). Res. (Resident) noted on the floor. Resident description, 'I was trying to go to the bathroom and slid off the bed'. Resident lifted from floor, 2 assist and seated in recliner . The documented intervention was to replace the scoop mattress with a regular mattress. c. An I&A Report dated 3/7/18 at 8:05 a.m. and completed by Registered Nurse (RN) #4 documented, This nurse called to resident's room by CNA. Resident told CNA that she fell while coming out of the bathroom. Resident states that her right foot hurts. Upon inspection right foot is tender while being flexed upwards. Mobile x-ray ordered. Resident states she fell while coming out of the bathroom. States she got up and got in the recliner. The documented intervention was to obtain a urinalysis to rule out urinary tract infection and to remind the cognitively impaired resident to call for help. d. An I&A Report dated 3/13/18 at 4:50 p.m. and completed by LPN #4 documented, Noted resident sitting in floor. Resident description stated she was trying to put her shoes on and fell off her bed. The documented intervention was to provide non-skid socks. e. An I&A Report dated 4/6/18 at 5:00 p.m. and completed by LPN #4 documented, Noted resident sitting on floor in room behind door, noted bed linen in floor beside her bed, purple discolor to both knees and redness to forehead . 'I fell by the bed on that blanket and scooted over to door and knocked on door'. Stated she bumped her head and hurt her knee. There was no documentation of a planned intervention after this fall, and no documentation as to whether the non-skid socks were in place at the time of this fall, to allow staff to evaluate effectiveness of previously planned interventions. f. An I&A Report dated 4/10/18 at 2:18 p.m. and completed by RN #1 documented, Called stat (immediately) to 500 hall, resident noted laying on left side on floor. Resident states, 'I was trying to get to bed and tripped on these shoes.' Resident noted with small incision to back of head. States 'Hit the corner of the bed during the fall.' Area cleansed with saline. Hand grips equal, denies pain anywhere other than head. PERRL. (Pupils, equal, round, reactive to light). MD (Medical Doctor) notified with new orders to send (Medical Center) ER (emergency room ) for eval (evaluation) and tx. (treatment). Family notified. VS (vital signs) 185/65 58 97.0 20. 3 cm (centimeter) laceration to back of head. The planned intervention after this fall was to dispose of the resident's old shoes and provide new shoes. There was no documentation to indicate whether the non-skid socks were in place at the time of this fall or whether the shoes the resident referred to tripping over were on the resident's feet at the time of the fall or were an obstacle in the resident's walkway. g. An I&A Report dated 7/30/18 at 8:10 a.m. and completed by LPN #4 documented, Resident lying in dining room floor on left side. No complaints of pain. Staff report resident got up from chair, stumbled, tried to sit back in chair, and chair slid out from under her and she fell backwards hitting corner of food cart with the back of her head. Resident description, 'I fell backwards and hit my head . I'm not hurt'. There was no documentation of any intervention put in place after this fall and no documentation as to whether the resident was wearing non-skid footwear at the time of the fall. h. An I&A Report dated 7/31/18 at 6:00 a.m. and completed by LPN #4 documented Lying on left side in puddle of urine . 'I slipped. I can't move my leg and it hurts.' Sent to ER for eval. There was no documentation of any new interventions that were implemented after this fall and no documentation as to whether the resident was wearing non-skid footwear at the time the fall occurred. i. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/18 documented the resident scored 10 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required extensive assistance two plus people with bed mobility and required one person assist for transfer, walk in room, walk in corridor, locomotion on and off the unit and had no documented falls. j. The Comprehensive Care Plan dated 8/18/18 documented, The resident is (moderate) risk for fall, resident will be free of falls through the review date . Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . Ensure that the resident is wearing appropriate footwear with non-skid shoes . P.T. (physical therapy) evaluate and treat as ordered or PRN (as needed). The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light, a working and reachable call light, the bed in low position at night. k. An I&A Report dated 8/22/18 at 8:10 a.m. and completed by RN #3 documented, Called to 500 hallway by aides (CNAs) Res. (Resident) was received on the floor on her bottom ambulating per self-scooting down hallway towards dining room. There was no documentation of any intervention put in place after this fall. l. An I&A Report dated 8/27/18 at 3:33 a.m. and completed by RN #3 documented, Aides called me to 500 hall. Res. had gotten out of bed and was on her bottom in the floor. There was no documentation of any new interventions put in place after this fall. m. On 8/29/18 at 1:55 p.m., Resident #58 was lying in bed with an alarm attached to the bed. Non-skid shoes were under the bed. The resident's closet care plan was reviewed at this time and documented the resident was a fall risk and the planned interventions were a chair alarm and bed alarm. The closet care plan did not address the planned interventions for non-skid socks or shoes and bed in low position at night. As of the date of this observation, the bed and chair alarms were not addressed on the comprehensive care plan dated 8/18/18. n. On 8/29/18 at 2:00 p.m., the Director of Nursing (DON) was asked why there were no interventions put in place after the resident had falls that occurred on 4/6/18, 7/30/18, 7/31/18, 8/22/18 and 8/27/18. She stated, The fall on 7/31/18 resulted in a [MEDICAL CONDITION]. The resident was hospitalized [DATE] through 8/6/18, and the interventions when the resident came back were bed and chair alarms and therapy. I was unable to find interventions on the other falls. The DON was asked, Were interventions from previous falls in place when the other falls occurred. She stated, I'm sure they were, they probably just were not charted. The Administrator connected the alarm to the call light on 8/27/18. The DON was unable to provide documentation as to whether the planned interventions were in place at the time of the above falls. o. On 8/2718 at 1:43 p.m., CNA #1 was asked if she was working 7/31/18 when Resident #58 fell . She stated, (CNA #2) found her; I came down to the room about the same time as the nurse. I saw her sitting in the floor in pee. She had on non-skid socks. She kept saying 'My leg hurts.' The nurse called the ambulance. p. On 8/27/18 at 2:15 p.m., CNA 2 was asked if she recalled the resident's fall on 7/31/18 and stated, I was passing (Resident #58's) room and I saw her on the floor. She was sitting on the floor in pee. The garbage can was in the middle of the floor like she was trying to use it for a bathroom. She had on a house dress. I don't think she had anything on her feet. I think she was barefooted . LPN #4 was not available for interview during the survey. q. The facility's Fall Policy and Procedure, received from the Administrator on 8/30/18 at 8:48 a.m., documented, .General Documentation: Date, time (or Shift) as appropriate . Vital signs. Assessment. Physician and responsible party notification. Immediate interventions (action taken). Signature and title . Intervention Resources: Educate the resident on fall precautions. Keep environment clean and well lit . wear shoes with nonskid soles, correct fit and keep shoelaces tied . Encourage rest periods . Supervise ambulation . Place on restorative program if indicated . add alarms with consent and MD order if applicable .