November Survey Findings

F156 Notice of Rights, Rules, Services, ChargesSE: SS=E: Failed to inform residents reviewed who received Medicare non-coverage notices with complete contact information

Multiple letters provided failed to provide entire document to residents including telephone contact information & mailing address information should an appeal be desired for resident

NC: SS=D: Failed to display, in writing, a posting of Ombudsman contact information & the complaint hotline number Observed no posting of Ombudsman contact information or complaint hotline number Multiple res reported unaware of how to contact Ombudsman or where complaint hotline number was posted in building

W: SS=D: Failed to provide Notice of Medicare Provider Non-Coverage for CMS 10123 Review lacked evidence to support facility issued res CMS form 10123 prior to terminating res’ skilled services for multiple

residents

F157 Notify of Changes (Injury/Decline/Room, Etc)NC: SS=D: Failed to notify physician of not using a physician prescribed medication per family’s request

CP indicated res had skin condition of Bullous Pemphigoid & instructed staff to administer physician ordered meds; physician order for Baza cream topically with open area of Bullous Pemphigoid; NN revealed res with multiple blister like areas & staff did not administer ordered Baza cream as ordered; staff reported family against res receiving ordered medication & after cream expired family did not want it refilled but physician not notified that family did not want ordered medication

W: SS=D: Failed to immediately notify physician & legal rep when res had significant change in status when res experienced significant weight loss

60 day MDS revealed res with weight loss greater than 5% with no alterations in diet, without oral issues, with minimal depression during observation period; Nutrition CAA did not mention problems with eating; CP lacked evidence of an initial CP at time of admission; record revealed 10 pound loss in 7 days & record lacked evidence staff immediately notified physician or resp party then res with 18 pound loss in 14 days without immediate notification of physician or resp party; 4 days later fax to physician noting weight loss

F159 Facility Management of Personal FundsSE: SS=D: Failed to obtain written authorization of resident prior to facility managing funds

Observed petty cash box for res use on weekends with envelope with res’ name & cash & date & another res’ name on envelope with cash in envelope with date & staff reported no consent to handle res’ monies

F164 Personal Privacy/Confidentiality of RecordsNE: SS=D: Failed to provide privacy for resident

Observed res room door closed, staff entered room & res was on bed with pants pulled down using urinal & privacy curtain not closed; observed res turned on call light & male & female staff & revealed door open & curtain drawn while res used urinal as laid exposed on bed; res reported “they never close drape when they come in to take care of me & they often do not close door”; res reported staff never cover res when using urinal

Observed res with door open & privacy curtain not drawn closed & res laid exposed from waist down on bed

F166 Right to Prompt Efforts to Resolve GrievancesNE: SS=D: Failed to provide prompt resolution to grievances for residents involved in resident council & for grievance r/t staff being loud when providing care to res’ roommate

SS notes for multiple months did not address concerns with res’ roommate r/t staff entering room to provide care; review of res’ council meeting revealed res attended res council & voiced grievance r/t staff entering room to care for roommate & staff were too loud; interview with res revealed res felt staff were not respectful of res r/t staff entering room yelling when they provided cares to roommate & roommates’ alarm was disturbing; staff reported not following up on concern

F174 Right to Telephone Access with PrivacyNE: SS=D: Failed to investigate lost clothing

Inventory completed; NN without evidence of documentation of lost items; SS notes without documentation of lost items; Communication book notes without evidence of documentation of lost items; res’ interview revealed res with missing clothing reported over 1 month ago & did not receive any information back from staff; facility without procedure in place to keep record of missing items

F225 Investigate/Report Allegations/IndividualsNE: SS=E: Failed to thoroughly investigate & report to state agency residents for elopement & residents for falls with injury

Res with cog impairment with independent ambulation; NN reported res walked away from facility & staff saw res 2 blocks away, called res’ name & res returned to facility & staff educated res to not leave facility without permission & physician agreement & if happened again, police would be involved & res would have to live elsewhere & res verbalized understanding; res with unwitnessed fall in facility resulting in severe pain from fx arm; NN revealed staff notified res walked across street to AL facility & returned to facility with staff & code alert bracelet placed on res’ ankle; observed res sat outside front entrance smoking & door alarm did not sound when res opened & walked through door; observed res outside building & no facility staff noted in area; staff reported front door alarm unlocked & alarm turned off at 5am each day; family interview revealed family not notified of earlier elopement but reported res had history of wandering at home prior to admission; staff reported only allegations reported to state within last year were resident to resident conflict

Res with dementia; extensive assist with ADLs with fall risk; res found on floor having seizure resulting in intracranial hemorrhage; investigation r/t fall lacked evidence facility thoroughly investigated res’ unwitnessed fall to r/o abuse &/or neglect that resulted in intracranial hemorrhage & facility did not report to survey agency

Res with severe dementia with limited assist for ADLs with previous injury fall; Res with unwitnessed fall hitting head with hematoma & sent to ER; investigation revealed piece of paper with minimal information: investigation lacked evidence of thorough investigation of causal factors & lacked evidence incident reported to proper state agency; observed res without CP interventions

Res with no cognitive impairment & extensive assist; res with 1 non-injury fall & 2 injury falls without major injury; res assessed as severe elopement risk & attempted to get out doors of facility & not easily redirected; res wore code alert bracelet on ankle; staff heard door alarm & staff found res outside door lying on ground with injuries; observed res near front door & ambulated without use of walker & no staff observed in area during time; staff revealed elopement & fall not reported to state agency

W: SS=D: Failed to thoroughly investigate alleged violations involving mistreatment, neglect or abuse, including injuries of unknown origin, resident to resident altercation & immediately report to administrator of facility & to other officials including state survey agency

Res with dementia; NN indicated res screaming out in pain during transfers for few days with no history of fall; MRI revealed res with acute compression fx of L3; facility failed to provide investigation of injury of unknown injury; failed to report unknown injury to state agency

Res with moderate cognitive impairment; SS notes revealed a non-staff sitter observed one of res’ family members shaking resident & SS notified SW, police and APS; facility could not provide investigation r/t allegation of abuse or evidence allegation was thoroughly investigated; Nurse responsible for risk management revealed incident not reported to risk manager or state agency

Res without cognitive impairment; res reported another res physically & verbally abused res while sat at DR table; res reported an argument with other resident & other resident hit res on arm then res signed written complaint; facility failed to provide investigation of allegation of abuse; witnesses not asked to complete witness statements

SC: SS=E: Failed to obtain criminal background checks on multiple employees; failed to notify administrator immediately & failed to thoroughly investigate an allegation of abuse & neglect

Employee files reviewed revealed facility hired staff without completing required criminal background checks Res reported another resident touched breast & “snuck a kiss in” & res reported incident to staff but no social service staff ever

spoke to res as informed by nurse & resident “took care of it on own”; grievance report revealed SSD had received information but report did not include who the alleged perpetrator was, did not include any other resident interviews to ID if someone else had any concerns with alleged perpetrator & res reported situation had been resolved; SS reported that 3 other resident interviews had been completed but did not document interviews & unable to remember for sure other residents interviewed & administrator was not notified of alleged incident in timely manner

SE: SS=D: Failed to thoroughly investigate & report to state agency episodes of resident to resident abuse NN revealed res upset with new res coming into res’ room & res reported they had been abused by another res by threatening

to hit in head with can, came into room & made threats, res reported incidents to DON who reported would try to keep res out

of other res’ rooms but that didn’t work & confused res continued to wander in & out of others’ rooms; other res’ NN revealed confused res went into another res’ room & yelled at other res, threatened other res verbally & wanted to use other res’ BR; NN revealed confused res not always re-directable, threatened to break out glass to get out then physician order instructed staff to discharge res from facility to behavioral unit; staff reported issue was behavioral issue & did not address as potential abuse, complete investigation or report to state agency; failed to thoroughly investigate & report to state agency

Alert res reported being abused by confused discharged res when confused res grabbed arm, then yelled for help & staff came immediately & assisted; confused res was alert res’ roommate & alert res was sleeping & suddenly confused res started hollering, pushed tray & hit table & bed then grabbed arm then alert res yelled for help & aides came running; record lacked documentation of altercation; record of discharged confused res included multiple notes documenting abusive behaviors including throwing coffee on another res, threatening to slap res; waving butter knife at res; and acting rudely to other res; throwing water pitcher at staff, cursing & yelling; Adm staff unaware of incidents of potential abuse

NC: SS=D: Failed to notify state agency of an unwitnessed fall with injury Res with fall risk with unwitnessed fall with hematoma to knee & res stated rolled off side of bed & landed on floor; MDS

indicated res with severe cognitive impairment & alert with daily confusion; res with further fall involving lift chair & record indicated no education of res about use of recliner controls; observed res with bruise on forehead with sutures; observed CP fall prevention interventions not in place; electric recliner removed from room & staff reported r/t blood present; staff reported unwitnessed incident not reported to state agency r/t res able to tell staff what happened

Res with multiple unwitnessed falls some with injury; observed staff not consistently following CP interventions; incident not reported to state agency

F226 Develop/Implement Abuse/Neglect, Etc PoliciesW: SS=C: Failed to implement their written Abuse prevention program policy & procedure that prohibited mistreatment, neglect & abuse of residents & misappropriation of res’ property when failed to complete reference checks ; failed to update policies to assure compliance with Section 1150B of Social Security Act r/t reporting reasonable suspicion of a crime in a long-term care facility

Review of personnel files revealed facility failed to complete reference checks on 2 newly hired individuals Review of ANE policy revealed policy failed to include all sections required by S&C letter

SE: SS=C: Failed to adequately incorporate “Reporting Reasonable Suspicion of a Crime in a LTC Facility” into existing facility policy for ANE in accordance with S&C 11-20-NH; failed to complete reference checks & criminal background checks as required

Policy lacked ID of incorporated requirement for Reported Reasonable Suspicion of a Crime in a LTC Facility section 1150B Review of employee files revealed facility lacked completion of criminal background checks & reference checks on multiple

employees

F241 Dignity & Respect of IndividualitySE: SS=D: Failed to provide care and services to maintain & enhance dignity

Res with total dependence with short & long term memory loss; Observed res positioned in bed, tilted towards side with head on pillow for 2 hours 30 minutes; observed res in bed with sweat pants pulled down to res’ ankles just above bunny boots

NC: SS=D: Failed to treat residents with dignity & respect by not providing assistance to clean res’ face & by referring to assisted diners as “feeders” & res seated in doorway dressed in shirt & soiled incontinent brief

Observed res in W/C with lg amt of thick white drool running down face with no assist provided to res for prolonged period Observed staff refer to “room trays” and “the feeders” Observed res seated in W/C by room door in shirt & incontinent brief with legs fully exposed without trousers with strong urine

odor in room; observed res’ bed unmade in mid-afternoon with wet area on bed sheet & room with strong urine odor; observed res with visitor in room & room with strong urine odor

NC: SS=E: Failed to promote care in a manner that maintains or enhances dignity & respect for multiple residents Observed a built-in desk in hallway leading to SCU with multiple completed forms titled “Communication Form” lying face up on

desk or pinned facing out on a bulletin board; completed forms contained resident names, room numbers, physician names, room numbers, physician names & comments r/t resident; observed list of res’ names & room numbers who staff were to assist with ambulation to meals on multiple occasions

NE: SS=D: Failed to ensure staff interacted with res to enhance self-esteem & self-worth & failed to ensure res’ catheter placed in concealment container

Total dependent res & extensive assist with eating; res council meeting notes revealed a res stated res felt that res bothered staff when activated call light & res stated aides joked around res & made res feel bad; observed res ate in assisted dining & res with tremor & dropped fork & staff stated “slow down big guy”; res reported staff still joked with res & res did not like for staff to joke with res & administration aware of concern

Observed multiple times res’ room door open & res’ catheter bag uncovered; observed silver colored concealment bag located on bed frame of res’ bed & anyone who passed by res’ room could observe appearance of res’ urine

NE: SS=D: Failed to focus on resident as an individual when talking & addressing residents during daily interactions Res without behaviors or depressive symptoms with individual requests for care; Concern Form revealed res reported did not

want certain aide to work with res anymore; res reported res requested to go to BR & aide responded that res had just gone to BR & aide did not take time & left room quickly & res had concern with aides’ attitude; Concern Form findings included to remove aide from res’ care & spoke with staff r/t approach, & perception of approach by residents & resident was pleased with follow up; observed staff pushing res down hallway from beauty shop & did not interact with resident; observed res put on call light & staff knocked but did not announce self and asked res “did ya need something?” ; observed staff serve plate without saying anything to res then walked away; res reported did not want to talk about staff issues because other person reported staff confronting residents about comments which made res feel uneasy about reporting issues; res reported did not tell administration about problems for fear of it getting back to staff members on floor

NE: SS=E: Failed to provide dignity during dining & during provision of personal cares Observed staff assist 2 residents with eating while standing up & used right hand to assist both residents without sanitizing

hands between residents Observed res door closed with note “keep door closed” & room was dark, cluttered & in disrepair with bed machines in floor,

linens stored on tray tables & nothing within reach of resident & res’ appearance was oily hair, unshaven with chapped lips with whitish film, dried saliva on bottom of gums, lips & teeth, long fingernails with brown substance beneath & body odor & res unable to reach call light

Res with memory loss with extensive assist & incontinent; observed staff serve meal tray, provided set up & walked away & res ate 1 bite of food; observed 1 staff in DR for 15 residents; observed staff assist with meal while standing & alternating between residents & after extended period of time staff did not warm food for resident; observed staff engaged in personal electronic device; observed staff push res into room without addressing res or informing res of what doing then used lift to transfer without explanation to res

Res with severe cognitive impairment with extensive assist & exit-seeking; observed staff call res “sweetie” multiple times during meal; observed staff call res “baby”

Observed staff serve tray to res & res put head down & closed eyes & staff did not encourage or assist res with eating & walked away from res then 9 minutes later staff brought food tray to table mate who stated with back pain & unable to eat then staff walked away from table without assisting either resident; then staff called res “honey”; staff failed to offer to warm res’ food; observed staff call numerous res “sweetie” & “honey”

Observed dementia res in DR with fingers in pureed food which was all over table & res’ W/C then res picked up plate & poured it in res’ lap

F242 Self-Determination-Right to Make ChoicesNC: SS=E: Failed to provide substitute meal requested by res & offer alternate food items in dementia unit as other residents received in facility

Observed staff serving meal on dementia unit & staff noted lack of gravy & staff did not call kitchen for gravy as provided to other residents in facility

Observed res request a hamburger when turkey was being served and staff repeated what was on menu then served the meal provided rather than what was requested by res then res ate 2 bites, got up from table & went to room

Observed staff ask res to assist passing out butter for residents but res stated didn’t want to help then resident never received any butter or sour cream for baked potatoes

W: SS=D: Failed to ensure res had choices for baths based on past preferences & failed to offer res who received a pureed consistency diet choices at mealtimes as instructed on menu

CP noted res preferred W/P baths but lacked instructions about how much assist res needed with bathing or how many times/wk/time of day res liked the bathe; record lacked evidence staff asked res preferences r/t bath type or times

Menu for specific meal lacked mention of mashed potatoes or applesauce; observed res received pureed meat, mashed potatoes & vegetables & staff served applesauce instead of fruit included on menu; res reported staff did not offer options for fruit & disliked applesauce & would prefer fruit on menu; staff reported not asking residents preferences of fruits or vegetables

F248 Activities Meet Interests/Needs of Each ResidentSE: SS=D: Failed to provide an ongoing program of activities

Res with pre-senile dementia with total assist with ADLs; CP instructed staff to invite res to daily activities & explain purpose of visit & all procedures; Activity log revealed res attended with passive participation one activity daily with multiple holes in daily documentation; observed staff start planned activity without waking anyone that was sleeping in recliners in the room & res was not encouraged by any staff member to participate or ask if res wanted to participate or not; observed group activity & res in bed & awake & no staff encouraged res or asked res if wanted to attend activity; observed staff failed to bring multiple residents to music activity; spouse unaware of any 1:1 activities; staff reported limited number of activities at facility; staff reported failure to know CP interventions

NE: SS=D: Failed to develop & implement individualized activity program to meet needs of residents Res with dementia with behavior of wandering into other res’ rooms causing res to res altercations; staff attempted to redirect

with folding activity; staff removed res from behavioral tracking program; observed res in DR with other res while staff looked at personal electronic device; observed res & other res in activity room without staff supervision; observed res in room in bed while movie played for other residents; staff reported no activity director currently but staff provided activities for residents

Res with dementia; record lacked evidence staff assessed res for activities & lacked an activity plan for res; after admission & wandering & rummaging behaviors res transferred to secured unit & res with documented aggressive behaviors; Observed res with items belonging to other residents & res not participating in planned activities occurring or provided with any type of stimuli or activity for prolonged period of time

Res with severe cognitive impairment; family requested res be engaged in activities when up; facility lacked log of any activities res attended; observed res not offered activities or 1:1 time

NE: SS=D: Failed to provide an ongoing activity program to address interests of resident Res on memory unit with psychosis with behavioral disturbances with extensive assist ; CP lacked documentation to address

res’ previous life roles/routines, specific likes, wandering behavior, group or individual activities &/or interventions to engage res’ interest; observed staff offer no activities for residents on memory unit; observed staff turn on Wii game but did not assist or encourage residents to play game; observed Bingo activity but staff did not encourage res to play

F252 Safe/Clean/Comfortable/Homelike EnvironmentSC: SS=E: Failed to provide a safe & clean res env by failure to label personal care equipment in res BR used by 4 residents

Observed BR shared by 4 residents with unlabeled urinal hanging from grab bar on multiple occasions Observed unlabeled bed pan & collection hat

F253 Housekeeping & Maintenance ServicesSE: SS=B: Failed to maintain a clean, sanitary & homelike environment in resident rooms, entryway, living room & activity area

Observed res rooms with black debris around flooring tile edges; exhaust ceiling unit with heavy dust & lint build-up; LR, piano, & shelf with layer of excessive dust & debris; hole in BR door; activity room freezer with rusty discoloration & dark brown dried splatters

NC: SS=E: Failed to provide housekeeping & maintenance services necessary to maintain a sanitary, orderly & comfortable environment Observed strong odor of urine; wall in common area with peeling paint; broken hand sanitizer by med room; striped chair with

brown streak up center of cushion & multiple spots on chair Counter cracked & chipped with bottom of counter pulled off; carpet in special care unit soiled & stained BR with strong smell of urine; BR counter chipped & paint peeling; carpet stained; BR with sewer odor; sticky carpet Staff reported no log of what is reported by staff & what is repaired; staff reported lack of cleaning r/t lack of staff

NE: SS=D: Failed to maintain a sanitary & comfortable interior Observed BRs with cracked tiles & dark stains around base of toilet, BR with floor strip pulled up & with dirt build-up by floor

stripSE: SS=E: Failed to provide housekeeping & maintenance services necessary to maintain a sanitary & comfortable interior in living area, chapel, 3 shared res BRs & 7 res rooms & 1 DR

Observed res room with yellowish discolored areas on ceiling over bed; light over BR lavatory lacked light cover; grab bar with rust present; cove base on wall beside toilet loose from wall; res’ clothes closet lacked doors; cove molding missing next to closet; rust colored area on wall behind plumbing lines to AC; res room wall behind bed with mismatched paint & wall with rough texture above cove molding; wall paper border missing & torn; BR lights not working & water faucet loose at base

Res BR with ceiling covering cracked & peeling in numerous areas & cove molding separating from wall & curled outward; cove base & wall board missing behind a pipe with wall studs exposed; door casings with open area at floor level; uncovered & unlabeled emesis pan stored on top of plastic drawers & uncovered & unlabeled bed pan on floor on top of folded soaker pad; inside of lavatory with numerous black marks; toilet riser with missing paint/finish on legs of riser with metal exposed; BR wall marred beneath grab bar & holes on wall & grout around base of toilet missing; wall behind recliner marred & gouged in multiple rooms; closet door chipped with veneer missing from door

DR with light cover missing; chapel carpet with worn areas with discoloration; living room with multiple gouged & marred areas to walls & wall paper with multiple peeling & missing areas & based of door with gouges & discolored areas

NE: SS=E: Failed to maintain a clean & sanitary environment for residents Observed multiple rooms with dirty BR floors & wallpaper off wall; grout dark colored around base of toilet; toilet with build-up

around base Observed multiple rooms without ID of towel bars

SE: SS=E: Failed to provide necessary housekeeping & maintenance services for environment & res’ living areas Observed closet doors with scrapes at handle level where room door & closet door collide when both open; unfinished lumber

laying on floor running entire length of room behind beds & under bedside stands; screw holes in BR door, gouge on wall above baseboard and water mark on ceiling tile

Res room with divits on tiles on floorSE: SS=B: Failed to maintain res hand towels in sanitary manner in semi-private rooms

Observed multiple semi-private rooms with paper towel dispensers by handwashing sinks & grab bar next to sinks & behind toilets held cloth hand towels for use by residents in rooms &hand towel area & grab bars lacked any type of ID to let residents or staff know which towels to use for which resident

F257 Comfortable & Safe Temperature LevelsSC: SS=D: Failed to provide comfortable temperatures

Observed res’ rooms with cool temperatures & no thermometer in room; hall thermostat set on 75 degrees; thermometer placed in res’ room who complained of air cold air coming in through window & after 30 minutes temp read 63.5 degrees by window of 2 residents; res stated cold had been reported & maintenance man placed tape with ribbon on vent to prove heat was blowing out of went but res stated still cold; other res in room reported being cold all the time; temp adjusted in hallway & room temp rose to 72.5 degrees

F258 Maintenance of Comfortable Sound LevelsNC: SS=E: Failed to provide & maintain comfortable sound levels during meal times

Observed housekeeping staff vacuuming carpet adjoining hallway to DR as residents eating meal on multiple occasions

F272 Comprehensive AssessmentsNC: SS=E: Failed to conduct a comprehensive assessment utilizing CAAs to ID residents triggered care areas that assist staff in developing comprehensive CPs for multiple residents

Triggered CAA Summary included falls; record revealed no CAAs had been completed to determine causal factors for res’ risk for falls

Record revealed staff had not completed CAAs triggered by significant change MDS to determine causal factors for res’ risk for triggered areas for multiple areas for multiple residents

SC: SS=D: Failed to accurately complete comprehensive assessments r/t dental status MDS revealed res with no dental issues & dental CAA did not trigger; Observed res with front bottom teeth that were worn

down & black MDS revealed res with no dental issues & dental CAA did not trigger; Observed res with missing front teeth

F274 Comprehensive Assess After Significant Change

W: SS=D: Failed to conduct a comprehensive assessment after a sig change occurred (initiation of hospice) Res with order to admit to hospice; Record lacked evidence of completion of sig change MDS following initiation of hospice; CP

included temporary hospice CP

F278 Assessment Accuracy/Coordination/CertifiedNE: SS=D: Failed to review & interview; facility failed to accurately code MDS for falls

MDS lacked documentation res fallSE: SS=D: Failed to complete an accurate comprehensive assessment for ADLs & ROM

Res with severe cognition impairment; res with restorative program & ROM exercises not noted on MDS MDS ADL revealed decline in dressing; CAA revealed no significant change in ADLs; CP not revised to address res’ need for assist

with dressing; observed res performing dressing without assist noted in MDS; record lacked ADL flow sheets for MDS look back period

F279 Develop Comprehensive Care PlansSE: SS=D: Failed to develop comprehensive CPs for ROM, bruising, oral care

Res with extensive assist for ADLs with impairment to upper & lower extremity; CAA lacked ID of any rehab or ROM needs; CP lacked instruction to staff on res’ ROM instructions; skilled therapy notes with specific instructions & referral to restorative nsg; CP lacked inclusion in restorative book or CP to instruct staff on recommended restorative plan; restorative sheet included AAROM & PROM but lacked documentation of specific services to provide to resident, specific number of repetitions & lacked documentation of completion of AAROM & PROM for 7 days in current month

Most recent MDS lacked ID of any skin conditions; NN lacked ID of any bruising concerns but bath sheets IDd bruising to forearm by bath aide; observed res with bruising; CP lacked plan for bruising to upper extremities

MDS & CAA without ID of dental problems; observed res’ mouth with plaque & debris build-up all along gum lines & teeth; observed staff assist res with dressing but failed to offer or complete oral care; lacked dental care plan

SC: SS=D: Failed to develop a comprehensive CP r/t falls Res with fall risk IDd on MDS & CAA; interim CP IDd problem for fall/potential for injury; comprehensive CP lacked fall

prevention or interventions; res with injury fall without new fall preventions interventions; fall investigation not provided r/t being part of QAA program; NN made no mention of floor alarm in place as CPd; Observed res without floor alarm in place as CPd

NE: SS=D: Failed to provide an individualized CP Res received scheduled pain med 7 of 7 days & did not receive any non-pharmacological interventions; pain did not trigger on

CAAs; CP lacked documentation of individualized interventions for res; observed res reported pain & felt going to die today & res unable to describe what hurt

NE: SS=E: Failed to develop comprehensive & individualized CP for dental, behaviors, toileting, nutrition & G-tube feedings MDS revealed res with no natural teeth with mechanical soft diet & no eating issues; CP lacked documentation of oral status of

res or who assisted res with oral care; family reported res without teeth for several years & was not interested in wearing dentures

Res with total assist for eating & extensive assist for other ADLs & res incontinent of B&B & with G-tube for nutrition; MAR & CP lacked any reference to checking for residual stomach contents or water flushes before & after feeding & med administration; CP lacked documentation r/t checking residuals, oral cares, any signs/symptoms of decreased hydration & care & treatment of G-tube; observed res with dry mouth, chapped lips; staff revealed water flushes were administered by machine

Res with severe cognitive impairment with delusions r/t spouse; Res with conflict with other residents; observed res in DR with other residents with staff looking at electronic device; observed res in activity room without staff supervision or programming; CP lacked individualized activity programming interventions & behavior interventions; staff unaware to find interventions on CPs

Record lacked staff assessed res for activities & lacked an activity plan for resident; res documented with behaviors including exit seeking; observed res ambulating in halls & in & out of other resident rooms; observed staff take res to activity room & sat in chair but not provided any type of stimuli or activity; CP without specific activity interests of res

MDS documented no appliances, res incontinent & not on toileting program & received diuretic; CP not individualized for res’ incontinence

NE: SS=D: Failed to develop comprehensive CP to address activities, behavior monitoring

Res on memory unit with psychosis with extensive assist; CP lacked documentation to address res’ previous life roles/routines, any specific likes, wandering behavior, group or individual activities &/or interventions to engage in res’ interests or pool &/or a stationary bike

Res with neurogenic bladder with Foley catheter; & occasionally c/o severe pain; CP lacked documentation to address pain associated with res’ bladder &/or indwelling catheter; policy lacked documentation for an individualized approach to res CPs that addressed specific types of pain &/or interventions; observed res with pain r/t bladder spasms

Res with dementia with extensive assist & rejected cares; CP lacked documentation of appropriate interventions when res displayed agitation & behaviors; observed res with resistive behaviors; record documented multiple episodes of resistive behaviors

SE: SS=D: Failed to develop an individualized comprehensive plan of care for use of bed rails CAA lacked documentation of use of side rail for mobility purposes; res with total maximum assist with ADLs; CP failed to

document use of side rail for positioning; observed res in bed with winged mattress & bilat bed rails at HOB in up position on multiple occasions; record lacked & staff confirmed lack of side rail assessment

SC: SS=D: Failed to develop CP r/t severe wt loss & splinting device CP failed to include interventions to prevent weight loss or updated interventions to address weight loss & monthly weights

revealed res with 63% weight loss between 7-13 8-13; failed to develop CP for suspected weight loss Res dependent on staff for eating & with tube feeding & PU; res with continuous tube feeding; CP lacked any specific

interventions r/t potential for nutritional problems including weight loss; CP failed to include Megace or MedPass; recent dietary profile & risk assessment IDd res on regular diet, independent in eating & did not receive any alternate feedings; failed to develop CP with measurable goals for res r/t nutritional status

Res with recent falls with lt sided weakness; CP failed to ID location of res’ contractures, schedule for splint application or current restorative schedule

SE: SS=D: Failed to develop a comprehensive CP for positioning/splints needs & blood sugar monitoring Res with extensive to total assist & MDS failed to ID any impairment in ROM; CP failed to include interventions for res’ poor

body alignment including torso & neck with consistent leaning to side while seated in recliner; record revealed res DCd from OT & included need for W/C cushion & reclining back W/C for optimal seating but discharge plan failed to ID concerns r/t seating/positioning in recliner; observed recliner lacked positioning aides to assist res in maintaining upright position; observed res without positioning for extended period of time on multiple occasions

Res with diabetes; CP lacked instruction to staff r/t diabetes monitoring; POS with orders for weekly FBS checks but lacked parameters for notification to physician & MAR/TARs lacked ID of BS parameters

Res with extensive assist for ADLs; CP failed to include res’ tendency to lean to right while sitting in recliner & lacked interventions to address leaning; Observed res leaning while in recliner

SC: SS=D: Failed to develop a comprehensive CP for falls Res alert, oriented & own resp party; Fall CAA revealed res not at risk for falls; CP failed to have interventions for fall that

occurred in previous month when res slipped on wet floor in BR after staff informed res of wet floor; staff unaware of CP interventions to prevent further falls

SC: SS=D: Failed to develop a comprehensive CP for areas of positioning & ROM Res with dementia with multiple falls with 1 fx; CP lacked any information or direction to staff r/t sling to arm fx Res with MS, PUs, CP lacked any information r/t ROM for res’ lower extremities & what staff were to perform & did not address

any resistive behaviors to cares or therapies; failed to develop comprehensive CP for lower extremity ROM restorative services & failed to address any resistance to care behaviors exhibited by resident

F280 Right to Participate Planning Care-Revise CPSE: SS=E: Failed to review & revise CPs r/t fall interventions following accident; dental services; ROM & skin problems; PU interventions; restraints & alarms

Res high fall risk; CP failed to reflect interventions added for fall prevention noted in fall investigations after documented falls & staff lacked awareness of any fall interventions

Res admitted with PU; CP IDd PT to set up restorative program & CP did not address skin gaulding to buttocks & groin areas, specific dental needs or ROM exercised that dependent res required; observed res with very reddened areas to entire

coccyx/buttocks/peri area/genitals with jerking when staff wiped reddened area with cleansing wipe & no skin barrier applied as CPd; POS revealed physician order for ROM to upper & lower extremities & observed staff provide no ROM exercises; CP lacked inclusion of gaulded perineal area, lacked any provision for dental cares & lacked any ROM exercises ordered by physician

Res with total dependence; CP revealed staff to check on res every ½ hour if res is being restrained & to have personal body alarm on at all times; observed res without personal body alarm noted or a restraint; staff reported res doesn’t wear personal body alarm currently & unaware of any restraint any time during admission

Res admitted to facility with previous fall & admitted with PU; CP directed staff to use low air-loss mattress & initiate hi calorie, hi protein diet; observed pressure relieving mattress, not low air loss mattress & observed res receive regular diet; failed to review & revise specific res interventions

NC: SS=D: Failed to review & revise CP after a fall Res with non-injury fall & CP had not been updated following fall

NE: SS=E: Failed to revise CPs Res with fluid restriction r/t use of Lasix for CHF; CP did not include interventions as to how facility planned to minimize edema

in res’ lower extremities; observed res with observable edema in lower extremities Res’ MDS revealed res with obvious or likely cavity or broken natural teeth; CP revealed res with cues for oral care then staff

administered mouth wash; observed res performed oral care without reminders from staff & res reported did not received mouthwash from staff as CPd

SE: SS=D: Failed to review & revise CP after a fall CP lacked intervention after res fell which included non-skid strips on floor beside res’ bed which was recorded by staff on fall

investigation form but not documented on CP; CNAs CP lacked documentation in Accidents/Fall Risk section; observed non-skid strips too far from bed to prevent res from falling when getting out of bed

NE: SS=D: Failed to review & revise CP for accidents Res at risk for falls with CPd fall interventions; Res with multiple falls & one with intervention for IDT to review interventions; 1

fall with no interventions after fallW: SS=D: Failed to review/revise nursing CP for res r/t accidents

Res with hx of falls on restoril for insomnia; record revealed res with multiple falls when res refused to call for help; temporary CP IDd res at high risk for falls with no specific interventions implemented; ; res with fall & CP lacked revisions for fall prevention after fall on multiple occasions

NE: SS=D: Failed to revise CP to reflect changes in res’ care for PUs, urinary incontinence & falls Res with dementia with extensive assist with incontinence & behaviors & risk for PUs; CP documented res with Stage 3 PU with

interventions; failed to review & revise CP to include specific interventions to reflect interventions of pillow to offload pressure on wounds; failed to address res’ frequent incontinent needs, failed to provide interventions to address res’ inflamed perineum; & failed to address res’ inability to state toileting needs

Res with dementia with extensive assist; MDS did not address fall history; res at high fall risk; record revealed res with 9 falls since 9-3-13; CP lacked documentation res used low bed with right side landing mat, use of non-slip socks at all time, & 15 minute checks as noted in fall investigations

Res with mod cog impairment & not on current toileting program, frequent incontinent; failed to update CP to address needs for toileting & incontinence

SE: SS=D: Failed to review & revise CPs for falls & ROM Res with hx of multiple falls; CP lacked new intervention after fall on 10-15; Investigation lacked witness statements for fall MDS revealed significant limitation in ROM; restorative plan for 2-5x/wk for 4 wks for AROM & PROM; staff reported doing

ROM when undressing at PM & “don’t really chart it”; failed to revise CP when res’ restorative program changed to ensure continuity of care

SC: SS=D: Failed to revise comprehensive CP for falls & use of specialty cushion for prevention of PUs Res with fall hx; res with recent fall, transfer to ER, & return with dx of nasal fx; CP lacked interventions after fall to prevent

further falls Res with fall hx, severe cognitive impairment; res with multiple falls; multiple interventions written on incident report not

added to CP & included to remind res to use call (severe cognitive impairment); Observed multiple CPd interventions not in place including concave mattress; air mattress without any bolsters; staff with inconsistent information about CP interventions; failed to revise CP after each fall to include interventions IDd on incident report to prevent further falls

NC: SS=D: Failed to review, revise CP when T initiated a foot brace failed to follow CP Res at risk for skin impairment; PT progress notes stated to use skin precautions for leg/ankle foot brace; CP revealed no

mention of res’ leg/foot brace or skin precautions as directed by PT & res developed 4 areas to affected foot with development of staph aureus with ABT; failed to review & revise CP to direct staff to provide appropriate care for compromised skin

W: SS=D: Failed to review/revise nursing CPs for multiple residents CP lacked revision with fall prevention strategies after multiple falls for multiple residents

SC: SS=D: Failed to revise CP for falls Res with fall resulting in fx & hospitalization; CP failed to have documentation of new interventions at readmission from

hospital to provide care to res after fracture & to prevent further fallsSC: SS=E: Failed to review & revise CPs for nutrition, falls, & PUs

Res with multiple falls; CP lacked interventions of: not leaving res alone in BR, encourage use of call light, have res in commons area when awake at noc, put res in bed prior to 10pm & non-skid strips in front of res’ recliner which were addressed on fall investigations; failed to revise CP to reflect falls for res

Res with CVA; CP failed to include need for recommended Magic Cups; staff reported res with weight loss & res received magic cups BID & as needed if not eat well & staff reported % of magic cup consumed documented on dietary sheets

Physician order for Calmoseptine to sacral area BID until area clear to area present on admission; Skin assessment noted open area to buttock on 7-2; on 7-13, PUs noted to each buttock; CP failed to document additional interventions for PU on 2nd PU

CP failed to document any additional interventions other than PU risk after res developed PU on heel

F281 Services Provided Meet Professional StandardsNE: SS=D: Failed to provide an initial CP sufficient to meet needs of resident prior to completion of first comprehensive CP

Res with renal disease with BPH with chronic Foley catheter; Care plan book revealed a CP from a previous admission still in place rather than initial CP at time of most recent admission; interventions included straight cathing res PRN; Temporary CP revealed res with Foley but without interventions directing staff how to care for res’ catheter

W: SS=D: Failed to develop a temporary CP at time of admission Record lacked evidence an initial/temporary CP was developed at time of admission;

F309 Provide Care/Services for Highest Well-BeingSE: SS=D: Failed to ensure multiple resident received care & services to ensure res received highest practicable level of care, including alignment positioning, & skin wounds

CAA lacked ID of any rehab &/or positioning or ROM needs; therapy instructions in CP book IDd specific instructions for positioning facilitation; observed res without any recommended positioning aides on multiple occasions

Res readmitted to facility with PU; CP did not address res’ skin gaulding to buttocks & groin areas; observed res with large amount of reddened/gaulded skin; failed to routinely apply skin barrier as directed to improve/maintain skin integrity for res

Total dependent res; CP directed staff to sit res at 90 degrees during eating & drinking; observed res in geri chair with back of chair at 90 degrees but foot pedals remained in upright position & not used & res’ feet hung & dangled; observed res leaning without any head or neck support; observed inappropriate positioning on multiple occasions; observed res at meal with back of chair at incline of 30 degrees

NC: SS=D: Failed to provide a dressing changes as physician ordered & provide physician ordered medication Res with extensive assist, frequent incontinence & non-pressure skin condition of Bullous Pemphigoid; physician order for

treatment for skin condition & instructed staff to cleanse res’ moisture related wound on buttocks with wound treatment dressing; MAR for Sept & Oct revealed staff had not administered Baza cream as ordered; observed res with multiple blood blisters (7) on hands & res without current dressing on buttocks as ordered; staff reported family did not want the ordered med of Baza & cream was not reordered when ran out last time; staff confirmed failed to cleanse wound & apply skin prep as ordered by physician & nurse had not been notified by staff when dressing came off; nurse confirmed physician had not been notified of family’s instruction to stop Baza cream

Res with risk for skin breakdown; physician order directed staff to cleanse lesion on res’ lt forearm with wound cleanser, apply skin prep & cover with bandaid as needed; skin assessments failed to ID current skin impairment; observed res with bandaid present with brown dried substance surrounding bandaid & center of bandaid with dark spot on multiple occasions; observed dressing change & open area with foul smelling, brown bloody draninage; failed to promote & provide wound assessment & care to lesion

NE: SS=D: Failed to implement interventions to minimize lower extremity edema swelling & also failed to wrap res’ legs per physician’s order

Res on fluid restriction of 2000cc/day r/t use of Lasix for CHF & res with edema to lower extremities; CP did not include interventions for staff to minimize edema; temporary CP included res with ace wraps bilaterally to lower extremities at all time; CP did not address res non-compliant with elevating feet; physician order for staff to wrap res’ lower extremities with ace wrap; multiple NN documented 3-4+ edema; observed res without legs elevated on multiple occasions; TAR did not support facility applied ace wraps to lower extremities as ordered; observed res without ordered wraps

NE: SS=D: Failed to assess for dialysis Res with renal failure with dialysis; progress notes lacked documentation of assessment for current month; observed staff

administer numbing agent to shunt cite without vital signs obtained; MAR or TAR lacked BP before or after dialysis or assessment of shunt site

NE: SS=D: Failed to provide effective interventions to address res’ agitation & anxiety when staff provided cares Res with dementia with wandering & rejection of cares with physical aggression & PRN Ativan for anxiety & agitation; res with

frequent behaviors documented; NN revealed res went to another res’ room & other res reported slapping res r/t holding onto res’ w/c handles; res with multiple documented episodes of aggression to staff during cares; res with frequent falls; record lacked evidence staff attempted different approaches to address res’ agitation & refusals of care; failed to provide ongoing, effective interventions to address res’ agitation & resistance to cares

SC: SS=D: Failed to provide adequate skin assessments to prevent skin problems for res with indwelling catheter Res with urinary retention with extensive assist & Foley catheter; CP did not address specifics to direct staff how often to assess

skin; observed res c/o discomfort in genital area & staff opened brief to look at area & observed 2 “eroded” areas in genital area; res reported constant discomfort where catheter was; failed to provide catheter care as planned to monitor skin

SE: SS=D: Failed to provide care & services to ensure highest practicable physical, mental, & psychosocial well-being for dialysis services & proper body alignment

Res with ERSD with dialysis treatments; Facility lacked information from dialysis center for past 2 months; MAR lacked BP monitoring on dialysis days for multiple days when res at dialysis; staff failed to confirm with physician that res did not need BP monitoring on daily basis including dialysis days; recommendation for daily vitamin & need for extra calories & protein as recommended by dialysis center 2 months previously

Res with dementia with extensive assist; assessment failed to ID any impairment in ROM; CAA failed to ID any body alignment/positioning concerns; OT discharge plan failed to ID concerns r/t recliner seating/positioning; Observed res without positioning aides in recliner & res leaned significantly from torso up to neck to side on multiple occasions; lacked recent attempts to provide positioning aides to res to improve posture

Res with sig change MDS for decline in ADLs; CP failed to include res dependency to lean to right while sitting in recliner & lacked interventions to address positioning; observed res in recliner leaning for extended period of time; observed res attempt to shift weight but unable to sit up straighter by self; observed staff failed to use positioning devices to maintain res’ posture; res reported staff failed to reposition prior to survey; failed to maintain correct anatomical alignment for res in recliner

NC: SS=D: Failed to maintain highest practicable level r/t skin integrity Res with diabetes; weekly bath/skin audit sheets revealed res’ hair being washed & no documentation r/t skin evaluations; staff

revealed lack of weekly skin assessment; failed to perform weekly skin assessments as CPdW: SS=D: Failed to complete neurological assessments after falls

Res at high fall risk; res with multiple unwitnessed falls & facility could not provide evidence neuro checks were completed following unwitnessed falls

F312 ADL Care Provided for Dependent ResidentsSE: SS=D: Failed to provide bathing & oral care assistance for res

Res with total assist; CP directed staff to provide bed bath 5x/wk & offer W/P or shower 2x/wk, & provide all ADLs & hygiene needs & other cares; ADL flow sheet revealed 6 bed baths & 1 shower in August; 6 showers, 2 refusals & 1 bed bath in Sept; 4 showers Oct 1-Oct 24; observed res with greasy-appearing hair & chewed food remaining in mouth from previous meal on multiple occasions; observed staff perform peri/cath care without any assistance with oral care or offers for any oral care; family reported staff inconsistent about offering oral care

Res with MDS indicating no dental problems & dental CAA did not trigger; observed res with plaque & debris build-up all along gum lines & teeth on multiple occasions; observed staff assist with morning ADLs but failed to offer or complete oral care; no dental CP

NC: SS=D: Failed to provide assistance for meals for multiple residents in dementia units; failed to remove bones from chicken off; failed to assist res cut chicken & failed to provide fluids at mealtime

Observed res at dining table & staff assisted res with chicken breast on plate then cautioned dementia res about chicken bones & placed bones on side of plate next to meat for multiple dementia residents

Observed res attempt several times to use spoon to cut meat & after no staff assistance pushed meat away & ate dessert Observed res had not received any fluids with meal; staff followed res to room & asked res if wanted anything to drink & res

declined & remained in roomNE: SS=D: Failed to provide necessary care & services r/t grooming

Res with extensive assist with ADLs; res with baths 2x/wk (mostly bed baths) & record revealed res received 14 of 24 bathing opportunities in August, Sept & Oct & few bath sheets noted skin disruptions, presence of G tube & lacked documentation res had long fingernails; CP lacked documentation r/t res bath schedule, type of bath/shower preferred, nail care or additional information r/t res oral status; observed res with poor oral care & dry oral mucosa

SE: SS=Failed to provide adequate personal hygiene assist for oral care, failure to change clothing Res with extensive assist; res with dentures & required assist with cleaning/soaking daily; staff reported res had oral care early

in AM & res with own teeth, no dentures & confirmed no denture cup or denture cleaning tablets; res reported spouse assists with oral care; failed to assure res received oral & denture hygiene care as needed

Res with extensive assist for dressing; observed res with same clothes on 4 consecutive daysSC: SS=D: Failed to provide scheduled baths for multiple residents; failed to remove facial hair for res

Res with MS & contractures with extensive assist; Monthly bath sheets reviewed with findings of res refusal of baths with no documentation staff offered bath later in week (only on scheduled days), no documentation to support missed baths or offer for later bath to ensure res scheduled number of baths given weekly; observed res in bed with long hair on face & res reported it did not bother not to shave; staff reported res requested shaving only on shower days or per res request; staff reported staff do not chart baths in same place

Res with total assist for ADLs; review of bath records revealed res with 5/8 planned times, 3/8 planned times, 15/25 planned times for multiple months; observed res with chin hairs present

F314 Treatment/Svcs to Prevent/Heal Pressure UlcersSE: SS=D: Failed to ensure adequate treatment & services to prevent development of PUs

Res at high risk for PU development & dependent for cares with turning/repositioning q 2 hours; res without assist for repositioning for 2 hours 57 minutes, 2 hours 10 minutes, 2 hours 30 minutes; observed res with bunny boots but 1 foot turned sideways in boot; observed multiple unblanchable areas on foot & heel

NE: SS=G: Failed to develop & implement interventions to prevent development of an unstageable facility acquired PU & failed to promote healing of PU

Res with incontinence with Foley, weight loss; res with 2 Stage 2 PUs on admission with extensive assist with ADLs; res developed new breakdown; CP did not address res non-compliant with repositioning; CP did not address how staff minimized pressure on res’ elbows; record did not support that facility performed tissue tolerance testing to determine individualized repositioning schedules when in bed & in chair; res with 39 pound weight loss in 2 months; NN documented res’ air mattress bed deflated & res without injuries; res with low serum albumin level; RD noted weight loss & recommended nutritional supplements; NN documented res with new abrasion to upper buttock; record lacked evidence facility measured PU from 10-21 to 11-3 (greater than a week); observed res in bed with HOB elevated approx. 45 degrees; observed res without repositioning 2 hours 40 minutes, 2 hours 45 minutes; observed dressing not fully intact; observed res with multiple open areas & elbows red & no pressure relieving device in place; staff unaware of how to set controls on air mattress; no investigation r/t deflation of air mattress; no policy/procedure for PUs provided

NE: SS=D: Failed to properly utilize heel pressure relief cushions resulting in worsening of a heel PU Res with PVD & traumatic amputation on one leg with moderate cognitive impairment; res without PUs at last MDS but had risk

for PUs & prevention devices in place; recent skin assessment revealed bruising but no concerns r/t res’ heel on multiple occasions; 1 day after most recent skin assessment documentation revealed res with 2cm black area to heel with duoderm treatment; NN revealed duoderm missing & area soft & boggy to touch; staff made referral to wound specialist; wound

assessment failed to document wound measurements; skin assessment of 11/3 revealed blackened area with mushy center to heel without measurements; meal charting for October revealed res ate breakfast 2xs; staff did not chart 2 lunch intakes in October; & staff did not chart 4 days for supper; observed res in bed with legs flat in bed on air mattress without any cushioning under leg & foot laid directly on bed & staff assisted res’ roommate & did not check res for positioning or reposition res; observed res without device in bed to elevate/float heel on multiple occasions; observed dressing change as res c/o pain; direct care staff with inconsistent knowledge of res’ impaired skin condition; record lacked documentation of type of ulcer present; physician IDd wound as PU

NC: SS=D: Failed to initiate preventive measure for PUs Res with extensive assist at PU risk but without PU on adm MDS;9-13-13 admission nsg assessment indicated res with fragile

skin but no foot care specified on assessment form; Braden revealed PU risk high; Initial CP lacked new interventions to prevent skin breakdown after nurses’ documentation indicated res had red, fragile skin on buttocks on 9-14-13; 9-22-13 CP indicated res with left heel ulcer with CP interventions; 8 days after admit NN documented lt heel black & fluid filled & buttocks red; Observed res with special surgical shoes open at top with heel resting on floor; staff revealed physician not notified when skin issues first noted per protocol

NE: SS=G: Failed to provide timely interventions after development of PUs for 3 of 4 residents reviewed Res at risk for PUs; 10-17-13 CP interventions in place to prevent PU; 11-7-13 CP revealed res with Stage 3 PU with

interventions implemented with updates on 11-8 & 11-12; multiple risk assessments failed to document 2 PUs on left hip; wound care physician documented res with 2 stage 3 PUs on hip; observed res spill fluids & staff did not refill or provide assist with meal; staff removed res from table without assisting res with meal; physician stated wounds were pressure ulcers with yeast present & unstageable r/t slough; ADL sheet indicated res did not receive any bathing in current month

Adm MDS revealed res admitted with 1 PU & at risk for PUs & not on repositioning program & MDS did not ID stage of PU; CAA IDd PU behind ear; res at nutritional risk; CP did not include res with weight loss; assessment forms revealed res developed PU on shoulder blade not assessed on admission; 1 assessment failed to ID PUs to bilat buttocks (healed between 10/28 & 11/4; wt reports revealed res with 22 pound wt loss (15% from 10/2 to 11/15; record did not support facility performed tissue tolerance test to determine repositioning schedule; observed res in Broda without pillows to offload PUs as CPd; Observed res without repositioning for 2 hours 30 minutes; failed to perform tissue tolerance test, failed to timely implement nutritional supplements; failed to timely assess & determine if Broda provided effective pressure relief; failed to reposition as planned

Res at skin risk; physician communication documented moisture associated skin damage resolved & treatment DCd; screening form of 11/16 revealed res with open sore but lacked size, appearance, or type of open sore; record did not support facility performed tissue tolerance test; Observed res in w/c from 10:10 to 1:26; observed res in bed 2 hours 25 minutes; Adm staff in room & acknowledged Stage 3 PU on buttock; 2 physicians lacked knowledge of PUs; failed to perform tissue tolerance test, failed to timely implement treatment, failed to ensure res’ w/c had pressure relieving device & failed to reposition every 1 ½-2 hrs as CPd

SC: SS=G: Failed to provide planned repositioning services in timely manner; res with hx of PUs developed 2 avoidable PUs Res with 2 stage 2 PUs with pain IDd to both PUs; staff to reposition res q 2 hrs or more frequently; res with incontinence; staff

reported 2 wound healed & the other smaller but CP not revised to reflect current status of wound; observed res without repositioning for 2 hours 36 minutes; observed res with dime-sized PU to buttocks that staff IDd as newly developed ; staff failed to apply protective dressing over open area after staff applied protective barrier; staff explained prolonged time period to reposition was r/t res 2 person & there was not another staff member to assist with repositioning; observed res without repositioning for 2 hours 36 minutes; observed res without protective dressing as ordered; staff unaware of repositioning schedule; physician failed to return call to surveyor to discuss wound development & progress

Res CPd at skin risk with interventions to reposition q 2 hours with 2 assist; observed res without repositioning for 3 hoursSE: SS=D: Failed to implement effective interventions to prevent development of PUs

Res with extensive assist, incontinent of B&B without PUs at admission MDS & Braden without risk; sig change MDS 6-13 revealed res at risk for PUs; then 2 days later CAA related blackened area silver dollar to rt heel; 9-14 MDS revealed res at risk for PUs with 1 unstageable PU with Braden indicating no risk for PU while MDS actually documented res with PU; 4-13 CP documented unstageable PU; 9-13 CP revealed res treated at wound clinic; skin assessments for multiple occasions over multiple months without indication of PU but IDd wound as skin tear laceration/open area to rt ankle; observed res in bed with feet directly on pillow, ortho boot on foot & crossed over other ankle & remained without repositioning for 2 hours 10 minutes; observed res in bed with feet directly on pillow on multiple occasions; family reported staff found wound in 5-13 & wound now healing but wound had been painful & expensive & wound was preventable if staff had repositioned res

W: SS=D: Failed to ensure res received necessary treatment & services (documentation of daily wound assessments & limited time in W/C as CPd) to promote healing & prevent infections

Res with Stage 3 PU; CP instructed staff to restrict res’ time in W/C to 30 minutes 3x/day then place dry dressing BID; record revealed weekly skin assessments but lacked evidence of daily wound assessments during res’ dressing changes; observed res in W/C for 1 hour 37 minutes

NC: SS=G: Failed to provide care & services to prevent development of PUs Res admitted to facility without PUs with prevention interventions CPd; recent MDS revealed res with 1 stage 2 unhealed PU; 8-

13 CAA revealed PU on heel; CP lacked interventions for skin assessment or preventions of skin issues; 8-13 CP update instructed staff to float heels & ensure res without shoe; 8-13 CP update instructed staff to use off-loading boot, wrap heel & treatment for when blister opens; 8-13 fall resulted in multiple fractures; 8-13 physician order for PU treatment orders; therapy assessment revealed wound appeared to be resulted from pressure & inactivity & recommended heel be supported by pillows; 8-13 with orders for nutritional supplementation; 9-13 res referred to wound clinic by physician; wound clinic staged wound at stage 3 with treatment orders & specific measurements & to float heels; record with routine wound clinic measurements f& assessments; res currently with air mattress but unable to substantiate when air mattress was initiated; failed to provide care & services to prevent development of PU for res who experienced decline in mobility r/t fracture in pelvic area & developed stage 3 PU on heel which required care & debridement from a wound clinic & also developed open area on coccyx

SC: SS=G: Failed to adequately recognize & assess contributing factors & failed to implement interventions for a resident at risk for development of recurrent skin ulcers for resident who acquired pressure/skin ulcers in facility

Res with diabetes with extensive assist & incontinenceCP of 10-28 included concern r/t skin condition but CP failed to include any interventions to promote healing & prevent further development of ulcers & guidelines revealed res with no past history of PUs & no pre-existing signs i.e., purple or very dark areas; Braden revealed low risk for PUs; TAR revealed open ulcer indicating wound continued to worsen and PU on other side measurements indicated wound larger than previous assessment; facility waited to contact consultant for 10 days after ID of open sore; observed res without cushion in W/C to relieve pressure on multiple occasions; Observed res without repositioning for 2 ½ hours

SC: SS=G: Failed to ensure residents received necessary treatment & services to promote healing of & prevent new PUs from developing Undated CP for skin breakdown noted multiple interventions & directions but failed to document how often to reposition

resident; CP did not note res refused repositioning; Skin assessment noted open area to buttock on 7-2 then noted 2 PUs on 7-18; record lacked evidence physician notified of 2nd PU; Record lacked evidence facility followed up with dietitian’s recommendations of 7-13; record lacked evidence staff educated res about risk of refusing repositioning; record lacked evidence facility assessed res for potential skin breakdown & evidence facility provided effective & timely interventions to heal & prevent development of additional PU

Res at risk for PUs; assessment noted res with closed, dark area to left heel with appropriate measurements with order for treatment; record lacked skin assessment documenting stage 2 PU noted on MDS & lacked skin assessments prior to discovery of PU; record lacked any ongoing nutritional assessments; Observed res without repositioning for 4 hours, & 2 hr 15 minutes with heels dangling over edge of leg rest of recliner; failed to prevent development of avoidable unstageable PU & failed to timely reposition res after development of PU & to prevent development of additional PUs for res at risk

Res admitted with healing stg IV PU which was closed with total dependence; Admission Braden incomplete; weekly assessment missing 1 wk; res with subsequent wt loss; lab revealed low protein level; Res repositioned after 1 hour 15 minutes, 1 hr 45 minutes; staff revealed wound was coded as healing stage IV because of knowledge wound had been stage IV prior to admission & PU reopened after admission to facility; record revealed 2 different measurements on same day

F315 No Catheter, Prevent UTI, Restore BladderNC: SS=D: Failed to provide adequate care for res with urinary incontinence

Res with mod cognitive impairment & extensive assist with incontinent care; Observed res seated in W/C in room doorway with shirt & incontinent brief fully exposed with no pants on with strong urine odor; observed res’ bed unmade with sheet on floor with a wet area on sheet & room with strong urine odor

NE: SS=D: Failed to provide catheter care Res with urinary retention with Foley catheter; CP instructed staff to provide cath care q shift; observed staff cleanse buttocks

but did not clean catheter, staff failed to secure catheter to upper leg; raised catheter above res’ waist; observed catheter bag fall off W/C onto floor & staff wheeled res out of BR, rolling over tubing & dragging bag on floor, then staff transferred res into recliner & hung bag on lever of recliner with bag touching floor; observed staff cleanse res’ buttocks without cleaning catheter

& failed to secure catheter to upper leg & raised bag above waist & hung bag under seat with bag onto floor in both W/C & recliner

NE: SS=D: Failed to check & change or toilet residents in timely manner Res incontinent B&B not on toileting program; Observed staff provided incontinence care to res in bed & brief saturated with

urine with draw sheet & bottom sheet wet with urine & staff revealed res last checked & changed 5 ½ hours earlier Res with incontinence of B&B with CP interventions; observed staff take res to room for incontinence care from DR & observed

pants wet with urine; staff revealed res checked & changed in morning, in afternoon & in eveningNE: SS=D: Failed to provide complete perineal care & failed to monitor & assist res with fluid consumption for res with UTI

CAA revealed res on prompted toileting plan changed to habit program & wore pull-ups at risk for functional, stress, urge & overflow incontinence; at risk for frequency, retention & UTIs r/t dementia; on check & change program; CP IDd UTI on 11-13; 11-8 lab report revealed res with e coli in urine with physician order for ABT; observed res spill fluids at table & staff failed to refill spilled fluid; observed res attempt to get drink from glass but unable to maneuver cup to mouth; observed staff return res to room & did not offer fluids; observed staff hand res fluids in plastic cup with hard plastic straw at DR table but res unable to suck from straw & staff did not offer res an alternate & did not assist res with fluids & when res removed from table grabbed at table multiple times; observed staff perform peri care with peri area red & inflamed; staff wiped genital area but did not wipe entire area soiled brief covered

SC: SS=D: Failed to provide appropriate catheter care, failed to secure catheter tubing with leg strap, failed to keep catheter tubing from dragging on floor; failed to check res for incontinence every 2 hours as planned for res with incontinence

Res with Foley; CP failed to direct staff to provide cath care q shift; res c/o discomfort to peri-area & staff IDd abrasion to genitalia; observed catheter tubing drug on floor; observed res without leg strap to prevent catheter from pulling or moving with repositioning; observed staff provide peri-care to rectal area only & did not perform peri-care in front of genitalia or clean catheter; observed staff place catheter bag on floor during transfer with spigot of bag on floor; observed catheter tubing on floor under w/c; res reported that catheter felt like it was pulled on during transfers; failed to provide appropriate catheter care & management of catheter for indwelling catheter

Res with incontinence & unaware had voided; res with check & change program; observed staff using sit to stand lift to change res’ brief & staff provided incontinent care; observed res without check & change from 1:21pm to 4:33pm & res’ buttock & bak of legs with reddish purplish color that blanched when touched; observed res from 7:29am to 10:23am without check & change

SE: SS=D: Failed to ensure res with indwelling catheter received care & services to prevent UTI Res with prostate cancer with total assist & suprapubic catheter; with orders for change & specific size & balloon size; observed

catheter tubing directly on floor & staff failed to ID tubing on floor during cares; observed staff raise collection bag above chest level during transfer; observed staff lift bag above level of res’ bladder on multiple occasions; observed staff empty drainage bag & touch tube directly on inside edges of graduate container, then cleaned tip of drainage spout with perineal hygiene wipe, then during transfer dropped tubing & drainage bag directly onto floor then held bag above level of bladder near res’ head

F318 Increase/Prevent Decrease in Range of MotionSE: SS=D: Failed to ensure residents received range of motion as needed

Res with extensive assist with ADLs; CAA lacked ID of any rehab or ROM needs; CP lacked instructions to staff on res’ ROM; PT & OT notes included specific recommendations for exercises; PT restorative program IDd specific exercise programs but lacked inclusion in restorative book or CP to instruct staff on res’ restorative plan; observed restorative staff not perform restorative program; failed to ensure res with contractures received appropriate & timely restorative services following special therapy to ensure res maintained or improved ROM abilities

Res with bilat ROM impairments upper & lower; CP revealed PT to set up restorative program; physician orders for ROM to upper & lower extremities; restorative flow sheet lacked any documentation for ROM restorative exercised provided to res; observed staff perform cares for res without attempting ROM with res

SC: SS=D: Failed to provide services to prevent a decrease in ROM for multiple residents Res with increased assist for all ADLs on sig change MDS with limited ROM on 1 side; res with hoyer lift for transfers; skilled

therapy DCd r/t res’ refusal; restorative notes revealed res had not attended at all entire month, attended 6xs 1 month, 1x 1 mo, 0 times 1 mo; no teaching of risks from refusal of restorative program documented; no current program in place at time of survey; no documentation of teaching of risks for non-participation in restorative program between 7-25 and risk vs benefit signed on 11-8; res reported hated splint & refused to wear & trying to do without splint; staff with inconsistent awareness of contracture

Res with extensive assist of 2 with impaired ROM upper & lower without skilled therapy; restorative worksheets documented res with hand splint & documentation staff only completed 2xs in current month; observed res without ordered splint on multiple occasions; staff reported no training on when to have brace or arm rest applied; staff reported did not always have time to do daily restorative treatments

SE: SS=D: Failed to provide restorative nursing services including lack of ROM exercises & lack of splints Quarterly MDS lacked ID of any ROM but received AROM & transferring restorative services; CP instructed staff to provide

AROM 3-5x/wk for 15 minutes, ambulation 3-5x 15 minutes as tolerated & sit to stand restorative 3-5x/wk for 15 minutes as tolerated; CP lacked ID for specifics for AROM plan including rt or lt side, upper &/or lower extremities; observed staff lacked IDing completion of ROM exercised provided to res but documentation evidenced res received ROM on observed day; restorative log revealed res received AROM 23/31 days & transfers 23/31 days & ambulation 31/31 days in August; with similar documentation in Sept, Oct & Nov; staff acknowledged res does not ambulate or use rolling walker; nursing staff reported no restorative nursing aide & lacked time to perform ROM; failed to prevent decline in ROM & transferring ability

Res with contracture of joint & OP; CAA revealed OT for positioning & contracture management to hand & orthotic splint application with set-up for applying wearing splint; Res with documented restorative exercises but lacked actual number of minutes res received services for multiple months; observed res without hand splint on multiple occasions; observed restorative exercises lasting less than ordered 15 minutes

SC: SS=D: Failed to provide adequate & appropriate preventive care to ensure res maintained highest level of ROM Res with dementia with contractures of both knees & PROM for stretching by restorative aide; restorative CP revealed res to

have PROM bilaterally to all joints with specific reps & time & exercises 7 days a week; restorative documentation revealed res received exercises for 5-10 min/session 5 days a week rather than planned 7 days/wk; policy directed staff to provide restorative exercises for 15 minutes in 24 hour period; observed staff perform PROM & failed to attempt to stretch or hold any exercises for 30 seconds as specified in restorative CP

F320 No Behavior Difficulties Unless UnavoidableNE: SS=D: Failed to assess & implement appropriate interventions for psychosocial well-being

Res with short & long term memory impairment, extensive assist with ADLs & independent with mobility, wandered with verbal behaviors; Record revealed res wandered in & out of other res’ rooms required re-direction; SS notes revealed res transferred to secured unit r/t exit-seeking, wandering off unit & going into other res’ rooms; res threatened to “kill” someone if not left alone; Observed res walk up & down hall & into other res’ rooms & had possession of another res’ personal item & resisted staff to retrieve item easily; Res not provided stimuli or activity

SE: SS=D: failed to ensure a confused discharged res who experienced repeated inappropriate abusive behaviors to other residents & staff received psychosocial services as needed to reduce adverse behaviors

Alert res reported to surveyor being abused by a confused discharged resident; record indicated confused discharged res with multiple episodes of abusive behaviors to multiple staff & other residents including throwing coffee & water, grabbing other residents, cursing, threatening other res & staff & hatefulness to others, slapping staff in face; failed to ensure confused res with multiple abusive behaviors to others received medical psychosocial services to assist in reducing adverse mental behaviors

F323 Free of Accident Hazards/Supervision/DevicesSE: SS=K: Failed to ensure res free from harm r/t water temps reached 143.2 degrees placing multiple residents in immediate jeopardy as water accessible to residents should not reach above 120 degrees

Observed sink in activity area which was open to all residents of facility tested at 143.2 degrees F, confirmed with another thermometer with reading of 141.8 degrees; staff lacked awareness of required safe temp ranges; review of water test log IDd 7 temp results from 120 to 140 degrees from July, 2013 through October 21, 2013; on 10-21 water temp tested 114 degrees; deficiency abated to E when control panel repaired by repairman

NC: SS=E: Failed to provide an environment free of accident hazards by not repairing a broken handrail MDS revealed res with cog impairment with extensive assist with impaired balance with 1 non-injury fall; Res with fall resulting

in skin tear & fx hip & humerus requiring surgery; res stated BR door had bumped res causing loss of balance & staff confirmed BR door does not stay open & most BR doors don’t stay open; maintenance staff verified door closed on own & staff had not received report or work order to repair

Observed broken handrail in dementia unit Observed door to clean utility room open with unlocked cabinet with hazardous chemicals accessible

SC: SS=E: Failed to maintain a safe environment by failure to implement interventions to prevent further falls & by failure to secure a hydrocollator

Res with fall & post fall nsg report revealed no new interventions & NN revealed no mention of CPd floor alarm mat in place at time of follow-up; observed res without floor alarm in place as CPd; staff reported no alarms used

Observed hydrocollator in unlocked & unsupervised therapy room accessible to residents on multiple occasionsNE: SS=D: Failed to provide supervision for res to prevent res leaving facility unsupervised, failed to implement appropriate interventions & monitor neurological status post fall & failed to supervise res for elopement at CPd

NN documented res walked away from facility; nurse walked to corner of block & saw res approximately 2 blocks away & asked res to return to facility & res complied & res stated was unaware couldn’t leave without permission; res with 2nd episode of walking away from facility & CodeAlert bracelet applied to ankle; observed res outside building without supervision & door alarm did not sound when res opened & walked through door on multiple occasions; staff reported door alarms turned off at 5am each day; failed to provide supervision & prevent independently mobile res with mod impaired cognition from leaving facility unsupervised

Res with history of falls; res with unwitnessed fall resulting in hematoma on head & sent to hospital; neurochecks completed; res with repeat fall; documentation lacked evidence of neurochecks being initiated; incomplete investigation provided; investigation lacked statements of staff involved & evidence of a thorough investigation of causal factors; intervention implemented on CP was to remind this res with severe cognitive impairment to put on shoes or gripper socks for ambulation; another intervention was to remind res to use call light for assist when ill & investigate lacked statements of staff involved, lacked evidence of thorough investigation of causal factors & lacked neuro assessment for unwitnessed fall; observed res without CPd interventions

Res with history of falls with dementia; CAA IDd res with severe elopement risk r/t frequent attempts to get out of doors & difficult to redirect with resistance; res with CodeAlert bracelet on ankle; res with fall risk; NN revealed res went out front door in past on multiple occasions; staff responded to door alarm & found res outside building with fall with minor injuries; observed res ambulating without walker without supervision as CPd

SE: SS=E: Failed to provide necessary assistive devices to prevent accidents; failed to ensure res’ environment remained free of accident hazards

Res with fall prior to admission & experienced recent fall without injuries & staff recorded intervention to apply non-skid strips to floor on fall investigation form but failed to add intervention to CP or CNA CP; Observed res walking without staff as CPd on multiple occasions; observed planned non-skid strips not close to res’ bed (more than 12 inches from bed)

Observed hazardous chemicals accessible to residents; multiple handrails with nail heads protruding from railsNE: SS=E: Failed to develop & implement effective intervention to prevent falls; failed to secure hazardous chemical

Res at fall risk; res with multiple falls; failed to provide effective interventions/supervision to prevent falls Observed closet door ajar with hazardous chemicals inside closet

W: SS=D: Failed to assess for causative factors & then develop/implement appropriate interventions to prevent additional falls Res with DM, CHF, hypnotic with multiple falls with injury requiring treatment; post fall assessment lacked neuro checks when

res hit head; investigation failed to ID potential causative factors of multiple fallsNE: SS=E: Failed to implement interventions to minimize falls; failed to secure &/or monitor doors leading to stairwells

Res with multiple falls; observed fall CP interventions not in place included 30 minute checks during past 12 months & fall mat on either side of bed & placing res in center of bed

Observed exit door not monitored or locked & when door opened it led to stairwell; observed utility door leading to dietary dept not monitored or locked on multiple occasions; observed unlocked/unmonitored door leading to parking lot

Res with dementia in memory unit; res with 9 falls from 9-3 to 11-16; CP lacked interventions from fall investigations on 3 occasions; 1 intervention of 15 minute checks; failed to ensure adequate supervision & assist to prevent falls

SE: SS=D: Failed to ensure adequate supervision &/or assistive devices to prevent recurrence of bruising for multiple residents CP failed to ID risk for bruising of unknown origin & lacked measures for prevention; res on ASA BID; Observed res with bruise

on top of hand; failed to provide adequate supervision &/or assistive devices to prevent bruising Weekly skin review revealed bruising on multiple assessments; CP failed to address specific interventions to prevent bruising

SC: SS=E: Failed to provide adequate supervision to prevent further falls; failed to provide safe from hazards r/t unsecured hazardous medications in unlocked res room

Res with hx of falls; temporary fall CP lacked interventions listed on Incident Report including swallow eval; multiple staff unaware of any new interventions following fall resulting in nasal fx; failed to plan & implement interventions to prevent further falls

Observed res’ room with squeeze tube of Benadryl anti-itch cream, Xopenex breath inhaler, glass bottle of medication nasal spray & res reported used meds as needed & unaware of any need to keep meds secured & out of reach of other residents

Res with fall hx; res with multiple falls with new interventions but lacked any staff interviews for possible determination of causal factors; 1 fall without new interventions or staff interviews r/t incident; observed res without CPd interventions in place including concave mattress & air mattress without bolsters; staff unaware of all CP fall interventions

W: SS=D: Failed to ensure res environment remained free of accident hazards (unsafe gaps in side rails) CAA revealed res with dementia & side rails used per res request; Observed res in w/c with bed with upper side rail away from

wall in upright position with gaps of 5 ¼ in by 6 inches & had been labeled by staff that bed rails were not a safe gapSE: SS=D: Failed to ensure residents remained free from accidents which resulted in bruising

CP failed to include res’ current bruising to bilat forearms & lacked interventions r/t bruising; skin assessment lacked documentation of any bruising for multiple dates; observed scattered bruising to bilat forearms on multiple occasions; failed to investigate causative factors of bruising & develop interventions to prevent recurrence for resident

Skin assessment forms lacked documentation of any bruising in all but one occasions; observed res with bruising on bilat forearms; failed to investigate causative factors of bruising & develop interventions to prevent recurrence

W: SS=E: Failed to ensure res’ environment remained free of accidents & hazards when staff used unsafe grab bars for toilet use in multiple rooms; failed to ensure res with accidents received adequate supervision to prevent falls

Res with hx of falls; lacked fall risk assessment; res with multiple falls; failed to provide evidence facility evaluated circumstances of fall for causative factors or revise CP to prevent further falls

Res with total assist & high fall risk; CP lacked initiation of fall prevention strategies to prevent further falls after multiple falls; observed tab alarm not functioning appropriately as CPd

Observed multiple BR grab bars with excess leg movement which could shift with application of pressure as res stood Res with dementia with fall & fall intervention started 23 days after fall

NC: SS=G: Failed to provide adequate supervision & an environment free of accident hazards to prevent accidents with injury Res admitted to facility with no falls; res with fall in facility; CP directed staff to use sit to stand lift for transfers; current CP

revealed res with falls; res with unwitnessed fall resulting in tissue injury; res with fall r/t electric lift chair when control wedged between foot rest & frame of chair in rising position; res with repeat fall from electric lift recliner when button did not shut off & res slid onto floor resulting in tissue injury & multiple fractures & investigation concluded controls were improperly handled & res had no comprehension of chair’s functioning & facility changed recliner; NN revealed no indication staff educated res about use of recliner controls; observed chair in room not electric but staff reported will return electric chair to res’ room when appropriately cleaned because chair belongs to resident; lacked policy for assessment of res for safe use of electric recliners; failed to provide feasible interventions after res rolled out of bed & sustained injuries

Res with hx of falls & high risk for falls; Res with unwitnessed fall with tissue injury; res with repeat unwitnessed fall with fractures; res with repeat fall without injury; Observed staff inconsistently follow CP instructions

SC: SS=D: Failed to provide supervision & assistance to prevent falls Res with normal cognition & fall assessment did not place res at risk for falls; CP failed to have interventions for fall that

occurred; res slipped on wet floor & hit head after housekeeping staff reminded res of wet floor; investigation included educating res about safety of walking on wet floor; staff unaware of fall interventions; failed to plan & implement interventions to prevent further falls

Res with readmission after fall with fracture with surgical repair; CP failed to have documentation of new interventions upon admission form hospital to prevent further falls; staff unaware of CP interventions to prevent falls

SC: SS=E: Failed to ensure res environment remained as free of accident hazards as possible with call light pull cords that were not easily accessible to tubs & toilet; failed to consistently implement interventions to prevent falls as planned

Observed bathing room emergency call light not visible from tub & toilet; outlet was close enough to toilet but cord did not allow for staff or res to reach pull cord from bathtub or toilet to call for assist in emergency in multiple bathing rooms

Res with diabetes, blind & deaf with extensive assist; res with fall when staff lowered res to floor with intervention to “monitor closely”; res with fall from W/C in route from hosp to facility; observed res in W/C without pull tab alarm on as CPd on multiple occasions; staff checked computer to see what care aides needed to do to prevent falls & there was nothing on computer that directed aides what type of care they needed to provide; staff attempted to view CP from direct care staff computer & it was

viewable; nursing staff looked at CP in nursing computer & it indicated res needed a pull tab alarm in recliner; staff unable to locate alarm for res

SC: SS=D: Failed to develop & implement interventions to ensure adequate supervision to prevent falls & maintain a mechanical lift sling is safe operating condition resulting in controlled fall for resident

Res with total assist & used mechanical lift for all transfers & at fall risk; fall investigation revealed res transferred from bed to W/C & “straps on lift broke” & staff found res laying supine on floor; after sling snapped res slumped in W/C & staff lowered res to floor without injury; 10-13 TELS revealed “remind nursing staff to inspect all slings” without any documentation r/t sling maintenance checks; manufacturer notice recommends replacement of slings after 1 yr or at any time harness shows any sign of damage or wear

Res with dementia with fall hx with multiple falls since admission; fall investigations revealed multiple falls resulted in the same intervention being put in place of “encourage res to use call light” & res with BIMS score of 3; res with multiple recent falls; Observed res with lg golf ball sized bump on forehead & bruising across face & scab under eye; observed res in bed with W/C away from resident, call light on outside of rail & res did not have water or phone next to bed; Observed res in bed with curtain pulled so only legs & feet could be seen from doorway; res placed on 30 minute checks without documentation of checks;

F325 Maintain Nutrition Status Unless UnavoidableNC: SS=D: Failed to document nutritional supplement consumed

CAA revealed res with mechanical soft diet, 6 small servings per day & supplement to maintain nutritional status; CP revealed Carnation Instant Breakfast BID & res with less than significant weight loss; Record revealed no documentation of %s consumed by res of supplement; observed res in bed with supplement shake sitting on bedside table; staff reported facility does not document %s of supplements

W: SS=D: Failed to ensure resident maintained acceptable parameters of nutritional status when facility IDd res as underweight on admission & failed to monitor weights or follow-up with RD

Res with severe cognitive impairment with behavioral symptoms with BMI of 18 & admission wt of 101; RDs noted revealed lack of evidence that dietitian re-evaluated res’ weights after IDing res as underweight for 5 months; Review of monthly weights revealed res without consistent monthly weights; failed to follow weight monitoring policy; failed to follow up with dietitian when res lost 5.22% in 6 weeks

SC: SS=G: Failed to adequately monitor weight loss & develop & implement new interventions to address weight loss of 14.39% over 3 months

Res with difficulty swallowing, increased difficulty cutting food, cognitive loss, hx CVA, meds that could affect appetite & staff would assist with meals & speech therapy consult r/t swallowing; weight logs reported 8 pound loss in 30 days & record lacked evidence facility implemented interventions to prevent further loss, then 9# loss in 15 days; res with total of 27# loss over 3 months=14.36% loss; record lacked any notification of physician of wt loss after 1 notification until 2 months later with supplement order; nutritional note revealed res with downgrade of diet to mechanical soft with ground meat with gravy or sauce without order for change; after wt loss weekly weights not initiated for 4 weeks

SC: SS=G: Failed to meet nutritional needs of res resulting in 15.6% body weight loss in 5 weeks Res with recent traumatic hip fx; res with stage II PU on admit & at risk for malnutrition r/t need for additional calories &

protein for wound healing; Admission CP did not ID nutrition as a problem; Dietitian note revealed recommendation for Magic Cup BID along with vitamin supplementation; alb level revealed severe protein depletion & low iron; res with remeron for appetite stimulation; res lost 23 pounds in 5 weeks & record lacked evidence facility notified physician or dietitian r/t continued wt loss during 5 weeks; Record lacked evidence of consumption of Magic Cups; record lacked documentation from 6-29 to 8-9 from dietitian

F329 Drug Regimen is Free From Unnecessary DrugsSE: SS=D: Failed to monitor bowel movement & lacked behavior monitoring

Res with psychosis r/t Parkinson’s & dementia & constipation; CAA IDd res on Zyprexa & Mirtazepine but failed to ID any causal factors; CP failed to include alternative behavioral modifications to attempt, prior to administration of pharmaceutical medication; res with zyprexa, mirtazapine & Xanax; behavior monitoring form lacked ID of any actual behaviors experienced by resident; MAR revealed PRN Xanax “effective” but lacked ID of any actual behaviors; staff reported res confused but no other behaviors

Res with routine Colace, MOM, Dulcolax for constipation; ADL monitoring form revealed res without BM for 5 days, 5 days, 3 days & 5 days in June with administration of MOM but lacked ID of results & lacked ID of administration of any other laxative administered; July review revealed res without BM for 5 days, 4 days; August records revealed res 5 days, 11 days without BM without administration of any laxatives given for lack of BMs

Res with senile dementia & nonorganic psychosis-depressive d/o; res with Norvasc, ex-lax, Namenda, remeron, sugar free shake, acidophilus, Seroquel; July MAR with 31 blanks not indicating meds were administered or not; blood sugar monitoring with 10 blanks & 6 refusals; August MAR with 24 blanks for meds & 27 blanks & 4 refusals of blood sugar levels; Sept MAR with 21 med blanks & 15 blanks & 9 refusals of blood sugar levels; behavior monitoring sheets with multiple days without behaviors

Res with Haldol TID without behavior disturbances; behavior monitoring revealed behavior did not occur except multiple blanks in monitoring sheets; DRR recommended GDR but record lacked evidence of response from physician

NE: SS=D: Failed to monitor res for med effectiveness Res with multiple laxatives PRN; bowel monitoring records revealed res without documented BM for 6 days, 3 days, 5 days, 3

days in June & July without documentation of administration of Colace as orderedNE: SS=E: Failed to ID & monitor targeted behaviors for antipsychotic meds & failed to notify physician following blood sugars outside parameters set by physician for multiple residents

MDS documented res with behavioral symptoms & diabetes with routine & sliding scale insulin & ordered blood sugar levels; POS ordered staff to notify physician if res’ BS greater than 451; res with multiple documented BS levels outside ordered parameters & facility lacked evidence staff notified physician of elevated BSs; Res with PRN Seroquel & Depakote sprinkles routinely; Record lacked evidence staff monitored behaviors or provided non-pharmacologic interventions for res prior to administration of PRN medication; record lacked evidence staff investigated possible physical or emotional causes for res’ increased agitation & exit seeking behaviors; record lacked evidence facility provided an effective behavior monitoring system for specific targeted behaviors for each specific drug; staff with inconsistent awareness of any behaviors of res; observed no behaviors of resident

Res with diabetes with routine insulin administration with ordered blood sugars orders with parameters to notify physician; BS levels exceeded ordered parameter & record lacked evidence staff notified physician of BS reading

Res with dementia with behaviors with Seroquel, Zoloft; record lacked evidence facility provided effective behavior monitoring system that IDd specific targeted behaviors displayed by res, approaches & interventions attempted when res displayed behaviors or how staff monitored effectiveness of med; observed res without behaviors

Res with Risperidone, Effexor; facility failed to monitor for specific targeted behaviors r/t to psychoactive medsW: SS=D: Failed to monitor when staff administered meds to promote sleep without assessing cause of insomnia; failed to monitor for excessive dose of Restoril

Res with Alzheimers with insomnia; Res with Restoril 15mg PRN for insomnia; Drug reference revealed hypnotic should be administered for 7-10 days with recommended dose of 7.5mg in elderly patients; Record revealed res received PRN nearly daily during previous 4 months; record revealed no evidence staff completed an assessment for causative factors of insomnia prior to administration of hypnotic & no evidence staff consistently attempted non-pharmacologic interventions to promote sleep prior to administration of hypnotic

SE: SS=E: Failed to ensure adequate monitoring of medications including blood sugars, behaviors, bowel monitoring & BBW monitoring Res with diabetes; CP lacked instruction to staff r/t diabetes control; POS included glyburide & weekly fasting BS checks; POS

lacked BS parameters for notification; failed to monitor res adequately for blood sugar management Res with Ativan, Zoloft & Trazadone; record lacked evidence of behavior monitoring; failed to monitor targeted behaviors Res with diabetes & depression; physician orders lacked set parameters to notify if BSs out of parameters; res on Buspar, celexa

& zyprexa & record lacked any documented behaviors; behavior assessment revealed res with no behaviors, rejection of cares or wandering & staff reported res without behaviors; CP recorded appropriate BBWs but staff unaware of what a BBW is; failed to monitor behaviors consistently r/t med, failed to obtain BS parameters & failed to educate staff on BBWs

Res with anxiety & depressive d/o with Cymbalta, & remeron; behavior assessment lacked any behaviors, rejection of cares or wandering; behavior detail report lacked any documented behaviors for multiple months; staff reported res without behaviors; staff unaware of what a BBW is or what specific BBWs to monitor; failed to monitor behaviors consistently & failed to educate staff on BBWs

Res with Senna PRN; MARs for 3 months indicated staff failed to administer Senna; B&B report revealed res without BM for 7, 5, 4, 3, 4, 3, 4, 4 days without documented BM; staff reported unaware of what BBW is; failed to monitor res’ bowel movement records & implement physician orders for no BM in 3 days & failed to educate staff on BBWs

NC: SS=E: Failed to effectively monitor for adverse reactions; staff administered wrong meds to res then failed to provide ongoing assessments for adverse reactions & failed to adequately monitor BMs

Res with diabetes with insulin; NN revealed staff administered res’ roommate’s meds to res by mistake; staff notified physician with order to monitor res & notify physician of any respiratory distress; NN revealed no further documentation of res being monitored

BM record revealed no documentation res had BM for 16 consecutive days, 6 days, 6 days, & 8 days; no bowel assessments including abdominal distention or bowel sounds for any periods with no BMs; failed to adequately monitor bowel program & provide timely interventions as ordered by physician

BM record revealed no documentation of BM for 7 consecutive days & staff administered laxative 1 time without documentation of effectiveness; record lacked documentation of any bowel assessments during period

Record revealed no BM for 17 consecutive days, 5 consecutive days; lacked assessment; lacked timely interventionsW: SS=D: Failed to adequately monitor lab tests as ordered by physician

Res with Risperdal & CPd to monitor side effects, mood, behaviors & lab tests of HgbA1C q 4 months; Drug Reference recommended HgbA1C prior to initiation of drug & q 3 months, then annually; record lacked evidence staff obtained HgbA1C as ordered by physician for 16 months

Res with synthroid with order for TSH every 6 months; Record revealed no results for TSH for previous 12 months; record lacked DRR for 1 month during current year

NC: SS=D: Failed to ensure res’ drug regimen was free from unnecessary medications Res with Seroquel; CP indicated BW & specific side effects; Pharmacist recommended GDR of Seroquel & subsequent note

indicated Seroquel had been DCd; Review of MAR revealed res received DCd Seroquel from 10-23 to 11-16-13

F332 Free of Medication Error Rates of 5% or MoreNE: SS=D: Failed to ensure a medication error rate of less than 5% with 2 medication errors affecting 2 residents making med error rate 5.5%

Observed staff crush enteric coated ASA & administer in applesauce with order not to crush medication & summary lacked an order to crush res’ medications; staff reported res would not take meds unless crushed but unaware if staff contacted physician for order to crush meds

Observed staff remove tablet of calcium 600 with D 200 and administered & review of POS revealed order for calcium 600mg; staff confirmed no calcium 600 in med cart available

NE: SS=D: Failed to ensure med error of less than 5% with rate of 7.692% Observed staff prepare cup with Tylenol 500 ii tabs & emar instructed staff to administer i tab Observed staff administer ProAir HFA with 1 puff & order was for 2 puffs

F334 Influenza & Pneumococcal ImmunizationsNE: SS=E: Failed to provide documentation the pneumonia vaccine was offered, refused or received in past for multiple residents; failed to provide documentation of education given prior to administration of pneumonia vaccine & failed to provide documentation of education given prior to administration of influenza vaccine

Record revealed no documentation staff offered res pneumonia vaccine & no documentation res had received or refused vaccine in past for multiple residents

Record revealed staff did not provide education prior to administration of pneumonia vaccine or influenza vaccine individual residents

NE: SS=D: Failed to develop policies/procedures for pneumococcal immunizations which provided information about & recorded when staff gave res vaccinations & res received 2 pneumococcal injections in 2 months

POS lacked documentation any immunizations &/or dates given; consent form was signed 2 days after immunization given; documentation revealed pneumovax administered on 9-17-13 and 10-31-13; MAR lacked documentation of injection site or new order for pneumonia vaccine

W: SS=D: Failed to offer opportunity to receive pneumonia vaccine Record revealed res received influenza vaccine on 11-2-13 & 1-8-13 & no evidence facility offered pneumonia vaccination or

provided education for multiple residents; staff reported res refused pneumococcal vaccine in 2009 & facility had not offered immunization education or vaccine after resident initially decline

F353 Sufficient 24-hr Nursing Staff Per Care PlansNC: SS=E: Failed to provide nursing & related services to attain or maintain highest practicable physical, mental & psychosocial well-being of each resident in dementia unit

Observed CMA passing plates at meal, left DR multiple times to assist residents with cares, leaving DR unattended on multiple occasions

Observed res in DR for meal & attempted multiple times to use spoon to cut chicken breast without success & after no assist from staff, pushed food away & ate brownie

Observed res rise from DR table, leaving plate of food & remaining juice on table, then another res sat down at table & drank from res’ glass of juice; staff removed plate & replaced with new plate of food but did not replace juice after incident

Observed res seated at DR table & was not served any fluids with meal; res then left table & staff followed res to room & asked if wanted fluids & res said “no” and remained in room

Observed res without juice at meal drinking another res’ juice while staff prepared plates Restorative staff reported being “pulled” to dementia unit r/t call in & had not worked in SCU for a long time Res with fall with injury; staff reported fall occurred at same time another res with unsteady gait was walking down hall & staff

member had to choose between the 2 residents to assist & other resident fellNE: SS=D: Failed to provide sufficient nursing staff to meet res’ needs

Multiple residents reported having to wait a long time for care, assistance & felt facility short staffed on all shifts; observed call lights of 12 minutes, 30 seconds, 9 minutes, 29 seconds, 9 minutes 23 seconds, 12 minutes 11 seconds, 20 minutes 35 seconds, 19 minutes 43 seconds

SC: SS=F: Failed to have sufficient staff to ensure staff assisted res in timely manner & IDd weight loss issues, repositioned residents to prevent development of PUs, assessed res at risk for PUs, toileted res to prevent urinary incontinence & urinary catheter care to prevent development of UTIs & provided assist & supervision to prevent accidents & falls

Staff reported difficult to monitor & supervise direct care staff to ensure care being done & for nurse to be able to help direct care staff if needed & staff felt facility needed more staff; staff reported required to clock out then return to finish work r/t refusal of company for OT & information “lost” between shifts; staff reported often pulled to floor from restorative position multiple times a week; staff reported just not enough time to get work all done including completion of showers & staff had to prioritize on what got done & what did not & no effort to get replacements for call ins

Referenced: F314, F280, F323, F279, F325, F315SE; SS=F: Failed to provide adequate nursing staff to ensure residents of facility received all needed cares timely

Resident interviews revealed 7 residents & 1 family member reported lack of nursing staff assistance r/t: long call lights, staff turnover, staff excessive smoking, late meals, staff turning off call light without offering assistance; staff reported nurses not carrying pagers to assist with res care; lack of restorative care; CMA reported “not being allowed to help CNAs with any resident cares when working as CMA”

Observed res reported waiting to use BR & staff stated “only 1 person”; staff then provided cares to res; observed res on side of bed & reported turning on call light 30 minutes prior & now pants are wet; call light monitor revealed multiple re-pages of system; res council mtg notes revealed multiple months with issue of long call light response; failed to provide adequate nsg staff to ensure residents of facility received all needed cares in timely manner

F354 Waiver-RN 8 hrs 7 days/wk, Full-time DONSE: SS=C: Failed to ensure 8 hours of consecutive RN coverage on 2 days (Sundays) during October to ensure adequate cares provided

Review of nursing schedule revealed lack of RN on 2 Saturdays & 2 Sundays in October; staff reported forgot to put PRN staff on schedule & provided time cards on computer which revealed RN worked the Saturdays but not the Sundays; lacked RN coverage on 2 days

F356 Posted Nurse Staffing InformationSE: SS=C: Failed to maintain posted daily nurse staffing data for minimum of 18 months as required & upon request of res, staff or public

Facility lacked multiple daily posting records for previous 5 monthsSC: SS=C: Failed to ensure staff posted required nurse staffing data in prominent place readily accessible to all residents & visitors

Observed no posting of required nursing staff data for either nursing area; some staff unaware of need for posting of hours & other staff believed not necessary to post hours since facility not certified

F363 Menus Meet Res Needs/Prep in Advance/FollowedW: SS=E: Failed to follow menu for res receiving pureed foods & for residents who received meat item

Observed pureed foods served without pureed bread as instructed on menu for multiple residents Observed multiple residents receive ½ recommended serving of meat as instructed on menu

F364 Nutritive Value/Appear, Palatable/Prefer TempNC: SS=E: Failed to provide food which was palatable & at proper temperature

Staff verified lack of food temperature logs completed for dementia unit & that staff had transported food to unit in plastic containers; observed dietary staff delivered food items in separate plastic containers where staff fixed multiple residents’ plates in advance & plates set on counter uncovered with no gravy for turkey & no sour cream or butter served for baked potatoes; when staff checked temps all foods below required temps

NC: SS=E: Failed to guarantee residents who required a mechanically altered diet, a meal of adequate nutritional value Observed staff pour ½ & ½ into multiple food items without measuring it for pureed foods; staff verified no recipe for way

prepare pureed foodsW: SS=E: Failed to ensure res received food prepared by methods that conserved nutritive value when staff failed to follow a recipe to prepare pureed meals

Staff did not measure any of the liquids added to food items in blender for pureed foods; failed to follow recipe book for pureeW: SS=D: Failed to provide food prepared by methods that conserved nutritive value by not measuring foods or following recipes for pureed diets

Observed staff prepare pureed sloppy joes by adding unmeasured amount of sloppy joe mixture into food processor & unmeasured amounts of baked beans into food processor & staff did not refer to recipe during preparation of pureed food items

F371 Food Procure, Store/Prepare/Serve-SanitaryNC: SS=E: Failed to store, prepare & distribute food under sanitary conditions

Observed floors in kitchen with dark brown build-up in grout & tile on floor up to baseboards including large thick rust color stain; numerous crumbs in toaster & fridge/freezer on multiple days

Ceiling vents with thick dust & condensation dripping from vents over clean plates; fridge with thick layer of dust on top & numerous splashes on walls; dark brown thick build-up between oven & wall

Staff unable to provide log to monitor sanitation solution used to cleanse dishes in dishwasher & 3-sink dishwasher; staff verified staff did not monitor chemical balance of sanitation solution

Observed staff take foil off baked potato with ungloved hands, cut potato in ½ & opened it up then went to resident, took res’ hands to guide them on plate to assist res to know placement of food; observed no hand sanitation or use of gloves

NC: SS=E: Failed to prepare, distribute, store & serve food under sanitary conditions Observed multiple staff enter kitchen without proper hair covering; observed undated food items stored in kitchenette Observed pack of opened cigarettes, lighter, cell phone & set of keys on top of cranberry juice cartons on wire rack in dry

storage area; observed opened liquids with no lids sitting on shelf in dry storage room on multiple occasions Observed dietary staff placing dirty dishes that had been returned to kitchen into sink, proceeded to pick up clean plate & serve

food without washing hands on multiple occasions Observed staff taking temps of food without gloves & without washing hands prior to taking temp; observed staff drop

thermometer into pot of soup, retrieved with pair on tongs & continued to serve soup Staff reported staff do not record temps for monitoring dishwasher to ensure dishwasher was effectively clean dishes; staff

verified staff do not check check & record temps for low temp dishwasher Observed kitchenette with top freezer of fridge with unlabeled, undated bag of cut up green peppers, multiple cereal in open

box undated NE:SS=F: Failed to distribute & serve food under sanitary conditions during food service from main kitchen & multiple kitchenettes

Observed multiple direct care staff serve drinks to residents with hair nets which partially covered hair with unrestrained hair visible & touched drinking surface of res’ cups; observed staff serve water to residents & rested water pitcher on drinking surface of multiple res’ cups while poured water into cup; observed multiple staff members touch drinking surface of res’ cups & food surface area on plates with hands; observed staff walk around kitchen without hair or beard net in place

Observed staff don gloves, handles outside of plastic bread bag, obtain utensils, took meat from another plastic bag, touched meat then placed same gloved hand on top of sandwiches & used utensil to cut food; staff touched multiple surfaces with same gloves then touched food with contaminated gloves

Observed staff remove plastic drinking glasses form storage rack & stacked glasses & distributed to tables not wearing gloves & touched drinking surfaces of glasses; observed staff remove stack of bowls from cabinet above sink & placed fingers in food surface of tope bowl to remove dishes from cabinet; observed staff with gloved hands remove beverages from fridge & place them in ice bucket for serving without changing glove, removed a glass & touched drinking surface of glass, removed 2 plates from cabinet & touched food surface area; observed staff serve food with gloves & retrieved dietary book, opened pages then returned to serving food & touching food surface area of plates without changing gloves; observed staff use tongs at salad cart & picked up piece of fruit resting on ice & placed it back into bowls of salad served to residents; observed staff remove serving scoop from bin of serving utensils by bowl of scoop & handed it to serving staff; observed staff move a piece of meat on plate using gloved hands that previously held plates

Observed dietary staff wear cap without a hair net & hair noted to be uncovered at nape of neck Observed dietary staff open bag of bread with gloved hands that touched all surface areas in kitchen then staff reached into bag

& removed bread without changing gloves or using tongs to handle breadSE: SS=F: Failed to store & serve food under sanitary conditions

Observed walk-in fridge with: Unlabeled bag of food; milk stored on floor; raw hamburger thawed on bottom rack in plastic tray with reclosure bag open

Observed in freezer: open plastic liner of frozen chicken thighs without any closure Observed dry storage area: chips unidentified Observed in kitchen: food particles in multiple dishware; cutting boards with colored staining & multiple cut gouges; insulated

plate bases stored together wet; ice machines drained directly into floor drain which lacked air gap to decrease potential for back flow; milk with expired “use-by” date

NE: SS=F: Failed to properly store food items & dishes; failed to label food when opened & failed to serve & prepare food in sanitary manner

Observed opened, unlabeled bread & buns & cheese uncovered in fridge; unlabeled food items on bottom shelf of fridge; observed staff open package of raw hamburger & put into skillet then threw wrapper in trash can with hand touching lid 4 times without washing hands; observed dishes & cups stored in upright position

W: SS=F: Failed to serve & store food under sanitary conditions when did not label & date food in fridges, touched res’ food with contaminated gloves & served cream pie that was not held at proper temperature

Observed fridge with opened, undated & unlabeled multiple food items Observed staff with gloves while served, picked up plate & wiped off area with gloved hand, picked up roll with gloved hand &

placed on plate, removed lids from steam table & picked up scoops & placed food items on plate, picked up next plate & used same gloved hands to place dinner roll on plate, placed gloved hand in food & touched piece before placing on plate then continued to serve rest of residents with same gloves

Observed staff wash hands, don gloves, prepared pureed foods, then used same gloves to retrieve bread from inside bread sack Observed staff go to each table & offer chocolate pie to residents, wore gloves, touched handle of cart to wheel it to each table

then touched pie with gloved hands while retrieving pie from pie plate to dessert plate Observed staff take temps of food, logged temps on paper then served without removing contaminated gloves, touched dinner

rolls, touched scrub top, food items & placed on plates Observed staff place peanut butter cream pie on counter then nearly 40 minutes later took temp of pie & obtained

measurement of 60 degreesSC: SS=F: Failed to ensure to store & serve food in sanitary manner by having expired thawed health shakes in fridge & having staff without adequate hair covering in food preparation area

Observed container found in fridge with thawed health shakes with expired date & temp of fridge at 40 degrees Observed adm staff stood at table in kitchen inside boundary marked with red tape without a hair covering, cook sat plated

food on table & adm staff finished putting condiments & fruit on plate & took plate to residents multiple times without hair covering on

W: SS=F: Failed to properly maintain sanitation of equipment, monitor fridge/freezer temps twice daily, change gloves & wash hands between tasks

Observed oven with moisture stains on glass & bottom of oven with burned food debris; back splash on stove with dark burned on food debris; chest freezer with thick layer of frost on all sides & lacked evidence of adequate defrosting needed to maintain food quality; vent on fridge with small “blob” of thick yellow substance on it; walk-in fridge with onion peels on floor & golf ball size of unknown white debris that soiled crevices of mat on floor

Review of kitchen cleaning schedule for current month revealed: staff instructed to clean dishwasher weekly but documented 1x during 1st 2 weeks of month; schedule directed staff to clean outside wall of ice machine but documented no cleaning during current month; schedule directed staff to clean inside & outside of fridge weekly but documented cleaned 1 x in 1st 2 weeks of current month; schedule directed staff to clean oven canopies weekly but documented cleaned 1x in 1st 2 weeks of current month

Observed facility failed to record temp values for fridge & freezer logs twice each day with multiple missed monitors for fridge, milk machine, walk-in freezer, walk-in fridge, small freezer

Observed dietary staff don gloves, touched gloves to hot pads, used contaminated gloves to touch other food items directly including rolls & sandwiches

Observed flies landed on desserts that lacked coveringSE: SS=F: Failed to store, distribute serve food under sanitary conditions

Observed dessert mix not securely sealed & top of bag open; freezer with frozen food items wrapped in clear wrap & lacked ID of food items & another wrapped frozen food item with date not legible; deep fat fryers with food spillage, crumbs on edges & build-up of grease on edges of fryers; freezer items without label to ID food items

Observed multiple stacked dinner plates with moisture present on plates’ surfaces; failed to follow cleaning schedule for deep-fat fryers

W: SS=F: Failed to store, prepare & serve food under sanitary conditions Observed washed pots & pans in 3 compartment sink with labels for “wash”, “rinse”, & “sanitize”; disinfectant label revealed

dishware should be soaked in 200ppm solution for 1-2 minutes; observed staff place test strip in sanitize compartment fluid & strip indicated 0ppm; staff failed to document sanitizer ppm 4 times/day per policy

Observed dietary staff failed to wash hands prior to meal service & held sensor portion of thermometer in hand then failed to sanitize thermometer & placed it into baked sweet potato, then placed same thermometer into ham steak, then green beans without sanitizing sensor

Observed staff wipe hands on apron, removed plates by touching underside of plate then placed contaminated bottom of plate onto other res’ plates in stack on steam table counter; staff touched with contaminated hands inside multiple divided plates & room tray covers that staff stored inside-up & uncovered on shelf above steam table

Observed staff use tong with bare hands to serve sliced bread then placed contaminated portion of tongs on top res’ bread slices between each service

Observed staff use tong with bare hand for serving meat, then used apron to catch tongs from falling onto floor & serving portion of tongs touched apron then placed contaminated tong back into meat tray & served multiple residents using contaminated tongs

Observed unsealed, dated plastic container; ceiling vent with thick layer of dust over freezer; ceiling vent with dust & operating oscillating fan with dust positioned over cleaned dishes by dish machine

SC: SS=F: Failed to ensure res’ food was held at required temps, failed to handle food items appropriately to prevent contamination, failed to ensure staff wore hairnets per policy, failed to serve food safe for consumption

Observed staff serve meal from holding table in kitchen; when staff temped foods, mashed potatoes were at 132 degrees & chicken vegetable strips were at 115 degrees & plate was then served to res at those temps without reheating

Observed staff with hair net only covering top part of hair on multiple occasions Observed staff put containers of sauce on plate with bare hands after touching face & other surfaces & the containers touched

food on plates Observed food items in dry storage not labeled with date staff opened bags Observed staff grab bowl of a spoon with bare hand & put it into food to stir food Observed staff with gloves on open freezer, remove plastic bag with meat & reached in with same gloved hand & removed a

meat pattie with same gloved hand

F387 Frequency & Timeliness of Physician VisitSE: SS=D: Failed to ensure res received physician visits as required

Staff reported facility currently lacked system to ensure residents seen by physician initially on admission then every 30 days for 90 days

Res admitted on 7-2 with physician exam on 7-6; physician failed to visit in August & by Oct 24, record lacked any physician visit/exam for October for last 90 day visit

Record lacked any physician visit for month of July as required

F411 Routine/Emergency Dental Services in SNFsSE: SS=D: Failed to offer dental services

MDS documented res without dental concerns; admission resident data set IDd some natural teeth lost, broken/loose teeth with referral for dental consultation; observed res with broken front tooth IDd since admission & no dental consult obtained

MDS documented res without dental concerns; assessment revealed res with some/all natural teeth lost & broken/loose with staining/erosion noted; SS notes revealed no documentation r/t dental assessments completed or communication with DPOA concerning wishes r/t oral status; observed res with front tooth & next tooth missing; observed staff not assist with oral care set-up or encouragement for oral care as CPd;

F412 Routine/Emergency Dental Services in NFsSE: SS=D: Failed to provide res with routine dental services

Total dependent res with broken or loosely fitting full or partial dentures/no natural teeth/tooth fragments; dental CAA did not trigger; observed res with only a few teeth in mouth; family reported res needs dentures again; no documentation of any dental care since admission or attempt to provide dental care

F428 DRR, Report Irregular, Act OnSE: SS=D: Failed to ID unnecessary drugs r/t lack of bowel movement monitoring & behavior monitoring

Cited findings noted in F329; pharmacist failed to ID lack of actual behaviors with administration of anti-anxiety meds & appropriate monitoring, documentation & interventions r/t use of laxatives

NE: SS=D: Pharmacist failed to acknowledge lack of monitoring of medications effectiveness Cited findings noted in F329; DRR failed to recognize lack of consistent bowel monitoring

W: SS=E: Failed to ensure consultant pharmacist reported drug irregularities to DON & attending physician; failed to ensure res received monthly DRR by licensed pharmacist

Cited findings noted in F329 Review of monthly reviews by consultant pharmacist revealed no documentation of monthly reviews for multiple months since

last survey for multiple residentsSE: SS=E: Pharmacist failed to ID & recommend facility &/or physician r/t med irregularities including monitoring of BSs, & behavior monitoring

Cited findings noted in F329 Facility failed to implement pharmacist recommendations r/t behavior monitoring & failed to ID lack of blood sugar parameters

W: SS=D: Failed to ensure consultant pharmacist IDd irregularities for multiple residents when staff failed to adequately monitor lab tests as ordered by physician & ensure DRR completed at least monthly

Cited findings noted in F329

F431 Drug Records, Label/Store, Drugs & BiologicalsNC: SS=Failed to provide thermometers in fridge & freezers to ensure proper temp controls & ensure freezers were maintained & defrosted to ensure proper cooling

Observed broken thermometer & approximately 2 inches of ice build-up in freezer Observed fridge & freezer in med room with ice buildup on multiple occasions

NE: SS=E: Failed to label multiple insulin pens with open/unrefrigerated date to ensure safe administration of meds Observed multiple insulin pens without a label indicating when facility refrigerated/unrefrigerated &/or first used insulin pens

NE: SS=D: Failed to properly label medications & secure medications in multiple med rooms Observed undated open vial of flu vaccine Observed 2 tablets of antibiotic on nurses’ desk; door to nurses’ station was closed but unlocked & station unattended

SE: SS=E: Failed to ensure current IV/ER kit to use for residents

Observed IV/ER kit with outdated expiration date in multiple locationsNE: SS=D: Failed to dispose of outdated insulin

Observed med cart with multiple outdated insulin vialsW: SS=E: Failed to store all drugs in locked compartments under proper temperature controls

Observed unlocked drawer in dining area with multiple stock medications Observed med fridge with undated vials for insulin & outdated insulin Review of temperature logs for med fridge revealed missing entries for multiple days in multiple months & some logs missing Observed outdated meds in med room

SC: SS=D: Failed to store all drugs & biologicals in locked compartments & permit only authorized personnel to have access to keys Observed res’ room with 2 bottles of ZzQuil, squeeze tube of Benadryl, Xopenex breath inhaler, Delsym cough syrup; medicated

nasal spray on small set of drawers & 2 med bottles in res’ clear plastic drawers & res reported using meds as needed & had not been told of any expectation to keep meds secured

SE: SS=F: Failed to label meds, monitor expiration dates, safely dispose of meds in timely manner & failed to safely secure controlled meds under a locked system as required

Observed multiple med carts top drawer with multiple unlabeled meds in med cups that lacked res’ name for ID & which contained expired meds; observed multiple E-kits with expired dates; observed tub marked “destroy” or returned to pharmacy, & meds contained res’ names with med labels but lacked documentation of why or when meds were received a count of how many were present when originally placed in storage & date placed in storage; DCd meds placed in storage lacked a system to account for reconciliation of meds

Observed DON office door opened & unlocked at various times on all days of survey without staff present in room & scheduled controlled meds in single locked filing cabinet including 8 Fentanyl patches & Hydrocodone tablets & DON reported keeping narcotic meds to be destroyed in locked file cabinet; failed to monitor storage & expiration dates of meds & failed to safely secure scheduled II controlled substance meds in double lock as required

W: SS=F: Failed to store all drugs under proper temperature controls; failed to monitor daily temps in multiple fridges used to store meds Observed 2 fridges used for med storage with temp logs with multiple missing values for multiple months & no log for current

monthSC: SS=F: Failed to have a system in place to ID & discard all expired meds & have resident ID labels for insulins & antipsychotic meds

Observed med room with 5ml vial of antipsychotic medication opened 10-12-12 & staff found med had been DCd on 11-1-12; observed bottle of Novolog insulin with open date of 7-28-13

Observed multiple vials of insulin with no date to ID when bottles opened & staff unaware of who bottles belonged to since they were without labels; observed box of Haldol vials unlabeled with res name; observed stock bottles of multiple meds without a date to indicate when staff opened bottles

Observed on another cart Levimir insulin pen & Novolog pen without any date to indicate when staff opened them & Lanatus insulin pen with no label to indicate who it belonged to or when staff opened it; observed multiple stock meds without any labels or date opened; observed eye drops with expired date

Observed locked box of controlled meds with expired dates & bottles of medication without any ID of how long meds had remained opened

SC: SS=E: Failed to properly label medication according to accepted professional principles Observed opened influenza multiple dose vial not marked with opened date or expiration date

SE: SS=E: Failed to monitor expiration dates, failed to administer meds in accordance with standards of practice & failed to maintain accurate reconciliation of DCd meds to be sent back to pharmacy

Observed multiple bottles of expired meds Observed meds cups set-up prior to administration some initialed, some not Observed lg plastic tub in med room with multiple med cards; meds lacked any documentation of why or when meds were

discontinued or a count of how many were present; facility lacked policy to address DCd meds

F441 Infection Control, Prevent Spread, LinensSE: SS=E: Failed to appropriately cleanse glucometer to prevent cross contamination & failed to ensure IC practices followed when performing treatments

Observed staff obtain BS without wearing gloves; failed to clean multi-use glucometer prior to use as it was taken out of container which held glucometer supplies, then placed glucometer on ledge of nurses’ station & then onto desk, then without

being cleaned placed in container of supplies on top of cotton balls, then administered insulin injection without use of gloves or hand hygiene between obtaining blood sugar & administration of insulin then took glucometer to next resident without cleaning glucometer or washing hands; observed staff clean glucometer with micro-kill wipes prior to testing but did not wear gloves during test

Observed staff perform treatment; staff failed to provide barrier to lay needed supplies on & placed supplies on top of HVAC unit next to res’ bed

NC: SS=F: Failed to provide safe, sanitary environment to help prevent development & transmission of disease & infection Observed res drink from another res’ juice glass r/t staff not replacing juice after another res sat down at setting after 1st res left Observed res’ oxygen tubing & nasal cannula coiled up & placed under handle of concentrator on multiple occasions Observed res placing silverware on each of tables for meals without washing hands or wearing gloves Observe res assisting res with clearing tables after lunch, res took dishcloth & wiped table in DR but another table not washed

with dishcloth & no disinfectant used to clean either table Observed staff enter room & set glucometer basket on res’ bed while res slept, woke res & informed of procedure, performed

blood sugar test & placed glucometer directly on bed & discarded gloves in trash then placed glucometer back into basket without disinfecting it

Observed res lying in bed with nurse at bedside to change dressing; nurse placed scissors & tape on res’ bed on linen protector pad res lying on, nurse then picked up scissors & tape after dressing change & left res’ room without cleansing scissors

Observed res lying in bed & staff provided peri care; observed staff not remove gloves after providing peri care to res & touched uniform, held res’ hand & pulled up res’ blanket

NC: SS=D: Failed to provide a safe, sanitary & comfortable environment with appropriate infection control practices r/t nasal cannula storage & transportation for res & housekeeping services lack of knowledge r/t cleaning a room with C-diff

Observed oxygen cannula unbagged & lying across bedside table; observed staff held res’ oxygen cannula & power cord to oxygen concentration together in one hand while staff pushed oxygen concentrator from DR table to res’ room

Housekeeping staff stated she nor any housekeeping staff knew what C-diff was or how to cleanse/disinfect a res’ room for C-diff

NE: SS=F: Failed to properly store nebulizer apparatus; failed to maintain an effective infection control program for facility & failed to utilize disinfectant cleaning solution according to manufacturer’s recommendation

Observed nebulizer apparatus layed on res’ night stand uncovered & with no storage bag nearby on multiple occasions Infection control log during current year until August tracked & trended infections & since August facility did not include

surveillance, monitoring, trending or possible outbreaks in infection control data Observed housekeeping staff enter res room with shared BR to clean; staff flushed toilet, replace dtrash can liner, then place

disinfectant in toilet bowl then sprayed outside of toilet & other fixtures with disinfectant, then removed items from top of toilet & then wiped down areas sprayed, flushed toilet then replaced items back on top of toilet from floor; manufacturer’s directions for toilet cleaner included to let solution stand 10 minutes then flush; fixture cleaner instructed to remain wet for 10 minutes then remove excess liquid & staff reported no specific contact time

SE: SS=E: Failed to ensure proper handling of clean clothing for residents & failed to ensure proper storage of res’ bodily fluids stored in med rooms

Observed fridge in med room with cylinders filled with white milky substance in fridge without labels or dates which staff IDd as pumped breast milk for young resident

Observed laundry staff passed clean personal clothing to residents with clothing draped over open basket, uncovered on multiple occasions

NE: SS=F: Failed to maintain an effective infection control program to help prevent development & transmission of disease Record revealed residents received medication in August/September to treat scabies; August/Sept IC control tracking log failed

to document scabies Observed staff check blood sugar level, placed glucometer on res’ bed, performed test then placed glucometer in tray with

other needles staff used to check other res’ blood sugar levels then took glucometer into another res’ room & performed test then placed glucometer on dresser without cleaning glucometer between res use

NN documented res received pneumococcal vaccine on 9-17 & consent form for immunization was signed on 9-19; MAR lacked record staff gave res any immunizations & pneumococcal vaccine administered twice in 2 months

W: SS=F: Failed to establish & maintain an Infection Control Program designed to prevent development & transmission of disease & infection; failed to disinfect a BR following manufacturer’s instructions

Observed housekeeping staff spray disinfectant on toilet bowl & seat then immediately wiped tank, seat, rim of toilet bowl then base then with same cloth wiped rim of bowl and seat a second time; instructions revealed product should be left undisturbed for a minimum of 10 minutes prior to wiping chemical off

Interview revealed staff stated documented infections when informed of them without a form method of evaluating or analyzing infection data gathered for ID & prevention of spread; stated program does not include employee health/infectious disease monitoring or education; lacked IC policy/procedure

NE: SS=E: Failed to provide timely education when staff IDd a pattern of infections that included conjunctivitis & UTIs Record review revealed facility with 6 res on secured unit with UTIs in 1 month & record lacked evidence licensed staff provided

education at time infections occurred; record review revealed facility with 5 res on one unit with conjunctivitis & received ABT & record lacked evidence licensed staff provided education at time infection occurred although documentation was provided that licensed staff provided education but not in perceived timely manner or to enough staff

Observed laundry staff walk down hallway with clean items directly against staff’s clothing &/or person on multiple occasionsSC: SS=F: Failed to implement infection control program to create a standard of disinfecting res’ rooms according to manufacturer recommendations & changing potentially contaminated gloves prior to handling other items

Manufacturer directions included wet time requirement of 10 minutes, wipe dry with cloth, sponge or mop or allow to air dry; observed staff fail to leave sprayed areas wet for prescribed times

Observed staff enter room & don gloves then put a gait belt on res, had res put res’ arms over staff shoulders & then assist res to stand, removed urine soaked brief, proceeded to provide peri-care then applied barrier cream, pulled up clothing & clean brief, reached for w/c & assisted res to sit, repositioning res in w/c, removed gait belt & rolled up gait belt all with same gloves

NE: SS=E: Failed to appropriately cleanse glucometer to prevent cross contamination; failed to ensure IC practices followed when performing room cleaning & failed to use personal protective equipment when sorting out contaminated laundry

Observed staff place glucometer directly on top of treatment cart along with alcohol prep & cotton ball; all supplies then taken into res’ room & placed directly on TV stand; after use glucometer placed back into treatment cart; glucometer recommendation guidelines failed to include cleaning recommendations for multi-use; policy revealed instructions to wipe glucometer with SaniWipe wipes

Laundry staff reported use gown, gloves, goggles & mask to do laundry in red bags & when sorting but staff reported not following protocol unless laundry “really smelling bad”

Housekeeping staff reported spraying disinfectant cleaner & wiping it off; disinfectant spray bottle lacked instructions on what cleaner kills or how long to allow it to set before wiping off; product spec revealed 10 minute wet time for disinfection & 5 minute wet time for routine cleaning

W: SS=F: Failed to process linen/laundry to prevent infection; properly sanitize res’ sink & BR, properly sanitize glucometer used for multiple residents & wash hands properly between res’ cares

Observed industrial washing machines, staff failed to weigh laundry prior to placing in washers & failed to provide manufacturer’s instructions for machine & staff unaware of exact instructions for proper use of machines; staff verified facility failed to adequately sanitize clothing when staff did not ensure they placed 55 pounds or less as labeled on machines into washer to allow for adequate agitation

Observed housekeeping staff spray res’ sink & countertop with cleanser & immediately wiped off with clean rag; observed staff pour bleach into toilet bowl, scrubbed inside of bowl then used same scrub brush to scrub outside of toilet bowl & BR floor behind toilet & failed to clean/sanitize BR grab bar

Observed staff perform peri-care for res & following completion of care failed to remove soiled gloves, grasped res’ hands during transfer; staff failed to offer to assist res to wash hands after touching staff’s contaminated gloved hands

Observed staff perform gluco-check, cleaned glucometer with alcohol wipe then removed gloves, but failed to wash hands or use alcohol gel then administered insulin after donning gloves but at completion of insulin administration failed to perform hand hygiene after removing soiled gloves on multiple occasions

SC: SS=F: Failed to have a record of analysis of infection control data & trending of infections to help prevent development & transmission of disease & infection within facility

Failed to have a record of analysis of infection control data & trending of infections to help prevent development & transmission of disease & infection within facility

SC: SS=E: Failed to utilize precautions to minimize transmission of infection Observed uncovered soiled laundry bin in common bathing area & in multiple soiled utility rooms

Observed housekeeping staff clean res with C-diff room & staff failed to wear shoe protectors; took off gloves then emptied trash can then disinfected her hands with alcohol based hand rub then mopped floor with sanitizer that did not eliminate C-diff; (CDC notes alcohol based hand rubs alone do not eliminate C-diff bacteria)

Observed kit for nebulizer machine sat on machine uncovered

F456 Essential Equipment, Safe Operating ConditionSE: SS=D: Failed to maintain patient care equipment, whirlpool in operating condition

Res reported no tub in facility & preferred tub bath; observed only whirlpool with front panel open & propped forward & panel contained operating controls; observed other tubs 3 feet tall with storage of res’ care items inside tubs & tubs without any kind of chair lift device in place to assist staff in transferring residents into tubs; staff reported unable to get parts for W/P; staff reported W/P had not worked for 5 years

F463 Resident Call System-Rooms/Toilet/BathNE: SS=E: Failed to have a pull cord in res BR & failed to have a functioning call light in med room

Observed BR lacked pull cord for call lightSE: SS=E: Failed to ensure multiple resident rooms & BRs call lights produced signal at nurses’ desk; failed to ensure res’ room call light produced signal in corridor

Observed call light failed to produce visual &/or audible signal in corridor Observed res’ rooms call lights failed to provide visual signal at call light panel at nurses’ station Observed res’ BR call lights failed to produce visual signal at call light panel at nurses’ station; maintenance book revealed 4 call

light weekly checks during current year & staff reported not always checking panelSC: SS=E: Failed to provide a functioning communication system

Call test records revealed staff checked call lights monthly by checking 1 call light on each of 4 halls; observed 5 call lights did not come through pagers or show on monitor

F465 Safe/Functional/Sanitary/Comfortable EnvironmentSE: SS=F: Failed to ensure a safe, sanitary, & comfortable environment for staff & public

Observed exterior portions of building in various places on eave & fascia trim exhibited peeling & missing paint from wooden trim areas around perimeter of building

Basement storage/workshop area with heavy odor of mold; storage of med records covered with mold; basement area with res bed mattress stored in area of mold along with other resident items & workshop items; staff reported basement lacked any anti-humidity units & IDd entire area exhibited mold growth; basement windows with droplets of moisture; caulking around inside of basement windows with thick layer of moist black mold

Observed 2 res beds without mattresses on unused res back patio area with separated laminated headboardsSE: SS=D: Failed to provide a safe, sanitary & comfortable environment

Observed janitor closet with base board missing along wall & sheetrock damaged entire length of wall with gouge in wall & wall by sink with chipping paint

F490 Effective Administration/Resident Well-BeingSE: SS=F: Failed to manage facility in a manner to meet the needs of the residents

Referenced: F241, F248, F309, F312, F314, F318, F323, F329

F493 Governing Body-Facility Policies/Appoint AdmnSE: SS=C: Failed to conduct annual review to ensure facility policies & procedures r/t operating of facility, remained current & appropriate with standards of practice

Review of nursing P & P manual revealed med director & staff documented last review/revision of policy & procedure manual 3 years ago

F496 Nurse Aide Registry Verification, RetrainingSE: SS=C: Failed to receive nurse aide registry verification prior to allowing 2 CNAs for verification of registry

CNA previously worked in facility until 8-7-13 & rehired 8-30-13 & facility failed obtain verification to nurse aide registry before allowing staff to work with residents

CNA’s cert previously expired; staff stated to work in facility on 10-23-12 & 40 hour checklist completed on 11-1-12 & facility failed to check for verification on registry until 12-7-12, over 1 month later

F514 Records-Complete/Accurate/AccessibleSC: SS=F: Failed to maintain complete clinical records r/t wound & skin conditions

Review of records revealed charts lacked current wound assessments & documentation; staff reported wound & PU documentation were kept in unit manager’s offices & not put in chart until wound healed

Review of CPs revealed all CPs were not systematically organized with some res having 2 active CPS & some having 1

F516 Release Res Info, Safeguard Clinical RecordsSE: SS=C: Failed to safeguard clinical record information against destruction as facility stored res’ clinical records in damp basement with mold present

Staff reported paper records taken to basement for further storage until scanned into new computer system; area of storage with strong odor of mold in area lacking dehumidifier with obvious mold & boxes wet/dried & peeling apart

F518 Train All Staff-Emergency Procedures/DrillsSE: SS=E: Failed to train all employees in emergency procedures including bomb threat

Interviews with staff revealed staff had not been instructed on what to do in case of bomb threat; adm staff revealed lack of documentation of information covered during disaster inservices

F520 QAA Committee-Members/Meet Quarterly/PlansSE: SS=F: Failed to maintain a quality assurance program that developed & implemented appropriate plans of action to correct IDd quality of care & quality of life concerns for all residents

Referenced F241, F248, F309, F312, F314, F318, F323, F329NC: SS=F: Failed to ensure QAA committee adequately IDd deficient areas of practice & developed & implemented appropriate plans of action to correct deficient practices

Referenced: F157, F241, F242, F253, F258, F309, F312, F323, F353, F364, F371, F431, F441 Staff unable to provide specific QA performance initiatives for facility

NE: SS=F: Failed to maintain an effective QAA committee that developed & implemented a plan of action to correct quality of care deficiencies

Referenced: F164, F226, F241, F248, F253, F279, F280, F309, F312, F315, F320, F323, F329, F334, F371, F431, F441W: SS=F: Failed to ensure QAA committee developed & implemented appropriate plans of action to correct IDd quality deficiencies

Staff reported fall incidents go to hospital risk manager & committee reviews number of falls but not circumstances of falls; QAA committee does not address weight loss issues

Referenced: F225, F226, F274, F280, F323, F325, F329, F334, F364, F371, F428, F441SC: SS=F: Failed to develop & implement effective system to ensure actions plans were developed through QAA program

Referenced: F225, F257, F279, F280, F309, F314, F315, F318, F323, F325, F353, F431, F441, F463W: SS=F: Failed to ensure QAA committee developed & implemented appropriate plans of action to correct all IDd quality deficiencies

Referenced: F323, F364, F371SE: SS=F: Failed to maintain a quality assurance committee that IDd, developed, & implemented appropriate plans of action to correct IDd quality of care & facility practices to ensure residents remained free from abuse & received care needed to maintain their highest practicable physical & mental well-being for all residents of facility

Referenced: F225, 309,312,314,315,318, 320,323,353,354

S600 Dietary ServicesSE: SS=C: Failed to employ a full time CDM to supervise dietary dept

Staff reported not a CDM, that class taken but did not pass & need to retake test but not scheduled; RD visits 2x/moW: SS=F: Failed to ensure dietary services supervisor met requirements for certification

Observed dietary staff worked in kitchen area as supervisor but failed to provide certification as dietary manager & confirmed did not have certification

NC: SS=C: Failed to employ a CDM Staff confirmed facility currently without a CDM

S972 Nursing Facility Support SystemsSC: SS=F: Failed to develop & implement a preventative maintenance program that include testing of call system weekly to ensure proper functioning of call system

Review of call system test records revealed staff checked call lights monthly by checking 1 call light on each of 4 halls

S1164 Nursing Facility Support SystemNE: SS=D: Failed to ensure a visual & audible signal was in medication prep room

Observed call light in med room was non-functioning with visible or audible signal & staff confirmed call light not hooked up

S1166 Nursing Facility Support SystemNE: SS=E: Failed to provide an audible call signal in 2 soiled & 1 clean utility rooms & failed to provide emergency call system in res’ showers on 1 unit

Observed call light did not sound in 2 soiled utility rooms & 1 clean utility room; Observed res’ BR with shower & shower lacked emergency call system within reach in multiple rooms

S1170 Nursing Facility Support SystemNE: SS=D: Failed to ensure wireless call system functioned for residents on 1 unit

Observed when call light activated there was a 2 ½ minute delay before call signal reached staff’s beeper Observed not all call light signals on hall activated staff beeper; staff reported call light system not functioning correctly

currently

S1176 Door Monitoring SystemNE: SS=D: Failed to secure or maintain continuous visual control of facility front door during daylight hours for multiple days

Observed front door alarm disarmed & staff in a front office but staff did not have continuous visual control of door on multiple occasions & staff & residents exited door & door did not alarm

S1364 Electrical RequirementsSC: SS=F: Failed to have hydrocollator plugged into a GFCI outlet

Observed hydrocollator in an unlocked & unsupervised therapy room accessible to residents & plugged into regular outlet instead of a GFCI

S1400 Power of Attorney & GuardianshipNE: SS=E: Failed to ensure that anyone having a financial interest in facility, unless person was related by marriage or blood to second degree to resident should not accept a power of attorney, a DPOA for HC decisions, guardianship or conservatorship

Res’ face sheet revealed facility’s administrator & owner of facility was res’ guardian & DPOA for multiple residents