Every finding on record at Akron Care Center, INC

Based on observations, staff interviews and Electronic Health Record (EHR) review the facility failed to provide reasonable accommodations of needs and preferences by not placing a resident's call light to be within reach for 1 of 6 residents reviewed (Resident #1). The facility reported a census of 41 residents.Findings include:Review of the Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) of 3 that indicated severe cognitive impairment. The MDS further documented Resident #1's functional abilities as dependent with all care areas.Review of Resident #1's Electronic Health Record (EHR) titled, Medical Diagnosis documented Resident #1's diagnosis of dementia and alcohol use accompanied by an alcohol-induced psychotic disorder featuring delusions. Review of Resident #1's Electronic Health Record (EHR) titled, Care Plan documented no focus, goal, or intervention for placement of call light related to behaviors.On 6/15/26 at 2:55 PM an observation revealed Resident #1 lying in bed with a fall mat present and a circular, soft-touch call light lying on the floor, out of the resident's reach.On 6/16/26 at 9:18 AM an observation revealed Resident #1 lying in bed with a fall mat present and a circular, soft-touch call light lying on the floor, out of the resident's reach.On 6/17/26 at 9:58 AM an observation revealed Resident #1 lying in bed with a circular, soft-touch call light tied around the bedrail with Resident #1 unable to reach the call light. Call light was was tied around the upper part of the bedrail hanging on the outside of the bed out of reach of Resident #1.On 6/18/26 at 11:00 AM Staff A, Certified Nurse Assistant (CNA) stated that her process for positioning a call light depends on the resident's cognitive status. Staff A explained that she either hands the device directly to the resident or uses a clip to attach it to their clothing, blanket, or chair. Staff A further noted that staff secures the call light to the resident or nearby items if the resident does not understand its function, based on the resident's cognitive abilities.On 6/18/26 at 11:06 AM Staff B, Licensed Practical Nurse (LPN) stated based on Resident #1's cognition was how she decided if she hands the resident the call light or if she will clip it to their clothing or chair. On 6/18/26 at 11:42 AM the Director of Nursing (DON) stated she would expect call lights to be in reach of the resident. DON further stated she would expect specific behaviors to be charted in the care plan for staff awareness on what kind of call light the resident needed and interventions for if a resident is having difficulty properly using a call light. The DON stated the facility did not have a policy for call lights.

Based on observation and staff interview the facility failed to prepare food in accordance with professional standards by not completing appropriate hand hygiene during meal service to prevent cross contamination. The facility reported a census of 41 residents.Findings include:On 6/17/26 at 11:30 AM an observation of Staff D, AM [NAME] revealed Staff D prepare a grilled cheese sandwich. Staff D applied gloves, picked up bread bag with both hands, removed bread from sack with both hands, picked up butter container with both hands, picked up knife with right hand, placed bread on the counter top, applied butter to both slices of bread, removed gloves, applied gloves, no hand hygiene completed, left hand opened plastic bag, removed cheese with right hand, 1 slice of bread, 1 slice of bread and 2 slices of cheese placed in left hand, both hands utilized to stack into a sandwich in skillet, picked up the knife with right hand, knife in right hand and left gloved hand utilized to flip sandwich, gloves removed, no hand hygiene completed, obtained foil, placed foil on the table, gloves applied, placed sandwich in foil, removed gloves, completed hand hygiene. On 6/17/26 at 2:58 PM Staff C, Certified Dietary Manager (CDM) stated gloved hands should touch only the food. Staff C explained if the gloved hand touches anything else then the glove is contaminated. Staff C said hand hygiene should be completed before meal preparation before, after glove changes or when hands are contaminated. On 6/18/26 at 12:00 PM the survey team requested a policy or procedure for the puree process, serving sizes, or following the menu from facility management. Policy nor procedure was ever sent by facility management.

Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the PreAdmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 2 residents reviewed for PASRR requirements, (Resident #6). The facility reported a census of 43 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented diagnoses of anxiety disorder, depression and psychotic disorder. The MDS included a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. Review of the active diagnosis list in the clinical record revealed the following diagnosis: a. Alcohol use, unspecified with alcohol-induced psychotic disorder, unspecified b. Major depressive disorder c. Anxiety disorder Review of the MDS dated [DATE] revealed the following diagnosis: a. Anxiety disorder b. Depression c. Psychotic Disorder Review of the Physicians Progress Note signed and dated 4/16/25 included: a. Alcohol-induced psychotic disorder with delusions b. Generalized Anxiety Disorder c. Other specified depressive episodes Review of the PASRR dated 6/1/2017 lacked inclusion of psychotic disorder. The clinical record lacked an updated PASRR to include psychotic disorder. Interview on 4/29/25 at 1:47 p.m., with the MDS Coordinator revealed Resident #6 has not had any changes for a while and the diagnosis should have been on the PASRR. The facility does not have a policy and follows the guidelines for PASRR.

Based on observation, facility policy and staff interview, the facility failed to provide proper hand hygiene during incontinence care, wound care and medication administration with 3 of 3 residents (Resident #11, #13 and #32) observed. The facility reported a total census of 43 residents. 1. Observation on 5/15/24 at 10:10 AM Resident #13 showed during incontinence care Staff A, Certified Nursing Assistant (CNA) held the resident on her right side while Staff B, CNA cleansed urine and bowel movement from the resident ' s buttock. Staff B with soiled gloves assisted the resident onto her left side and held the resident in place while Staff A cleansed urine and BM from the other side of the buttock. Staff A replaced the soiled incontinence brief and removed soiled gloves. Staff A failed to perform hand hygiene, then placed her hands on the blankets to cover the resident. Staff B removed gloves, failed to perform hand hygiene, then placed a bag of soiled clothes into the garbage. Staff B retrieved the bag and placed the bag into a laundry receptacle. Staff B failed to perform hand hygiene, then touched the bed controls, call light device and assisted the resident with eye glasses. 2. Observation on 5/16/24 at 7:01 AM showed Staff D, Licensed Practical Nurse (LPN) administered artificial tears to Resident #11 then removed gloves, threw the gloves into the garbage, then placed her hands into her pants pocket without performing hand hygiene. In an interview on 5/16/24 at 8:10 AM, the DON acknowledged staff should remove gloves and perform hand hygiene after contact with urine and BM during incontinence care. In an interview on 5/16/24 at 9:28 AM, the Infection Preventionist (IP) agreed the staff should remove gloves then immediately perform hand hygiene after contact with urine, BM, bodily fluid or other potentially infectious material. 49056 3.Observation on 5/15/24 at 9:20 AM observed Staff C, LPN with wound care to buttocks. Resident #32 observed sitting on the couch and able to stand up with a walker. Staff C washed hands and applied gloves, with gloved hands Staff C opened up the mepilex and wrote the date on it with black permanent marker, Staff C placed the mepilex on the table. Staff C then removed gloves and applied new gloves, Staff C failed to do hand hygiene between changing gloves, Staff C proceeded to clean the buttock area. Staff C then removed gloves and applied new gloves, Staff C failed to do hand hygiene between changing gloves. Staff C placed mepilex on buttocks and helped Resident #32 pull up her pants. During interview on 5/15/24 at 9:20 AM Staff C stated she should have used the hand sanitizer in between changing gloves while doing wound care. Review of the undated facility provided policy titled Infection Control Program revealed the following information: The facility will investigate, control, and prevent infections in the facility; Staff will be educated, trained and monitored for proper hand washing as follows: When coming on duty. When hands are visibly soiled. Before and after assisting a resident with personal care(oral care, bathing etc.). Before and after changing a dressing.

Based on observations, facility record review and staff interviews the facility failed to process and initiate medication orders until two days after the orders were received for 1 of 13 residents reviewed (Resident #22). The facility reported a census of 43 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #22 documented diagnoses of heart failure, renal insufficiency and a history of malignant neoplasm of the bladder. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. 1. The Provider ' s written order dated and faxed 3/7/24 revealed Resident #22 ordered to receive Diflucan 150mg one time a week for three weeks. The Order Entry for Resident #22 showed the facility failed to enter the Diflucan order into the electronic orders until 3/9/24, two days after the order was received. The electronic order showed Diflucan was ordered for a yeast infection. Review of April and March 2024 Medication Administration Record (MAR) for Resident #22 revealed Resident #22 received the first dose of Diflucan on 3/10/24, three days after the order was received. 2. The Urology provider ' s written order dated and faxed 4/22/24 revealed Resident #22 ordered to receive Cipro (Cipromycin) 500 (milligrams) mg twice a day by mouth for 7 days. The Order Entry for Resident #22 showed the facility failed to enter the Cipro order into the electronic orders until 4/24/24, two days after the order was received. The electronic order showed Cipro was ordered for a urinary tract infection. Review of April and May 2024 Medication Administration Record (MAR) for Resident #22 revealed Resident #22 received the first dose of Cipro on 4/24/24, two days after the order was received. In an interview on 5/16/24 at 7:15 AM, Staff D (Licensed Practical Nurse) reported the practice of when orders are received via fax the orders are processed the same day, then doubled checked by the next shift, then tripled checked by the shift after that. Staff D reported when she entered the Cipro order on 4/24/24, Staff D didn ' t know why the order wasn ' t processed sooner. Staff D reported medications are usually started the same day as they are ordered. Staff D reported the pharmacy usually delivers medications the same day, or a staff member will retrieve the medication from the pharmacy. In an interview on 5/16/24 at 8:10 AM, the Director of Nursing (DON) reported that she expected staff to process orders the same day as orders are received. The DON reported medications are usually started on the same day as they are ordered. When asked if the Cipro and Diflucan orders should have been processed the same day as the order was received, the DON replied, absolutely, especially the antibiotic.The facility lacked a policy related to medication and processing of orders. The DON reported the facility followed standard practice but would provide a copy of the policy if she found a policy. No policy received during the survey.

Based on clinical record review, facility record review and staff interviews the facility failed to assess and provide appropriate intervention to a left lumbar skin tear which resulted in a decline to cellulitis which required use of antibiotic for 1 out of 1 residents reviewed (Resident #39). The facility reported a census of 43 residents Findings included: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #39 documented diagnoses of anemia, hypertension, depression, and dementia. The MDS showed a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. Review of the Braden Scale assessment dated [DATE] showed Resident #39 scored a 16 which indicated at risk for skin impairment. Review of the facility provided form named Non Decub Skin Condition Report revealed Resident #39 received a skin tear from a fall on 5/5/24 in the left lumbar region measuring 9.5 centimeters (cm) by 4.5 cm. The next entry of wound assessment was 5/12/24. Review of the Progress Notes for Resident #39 lacked documentation of wound assessments for the following date: 5/7/24, 5/8/24. Review of the Progress Notes for Resident #39 showed an order for Cephalexin 500 milligrams four times a day for five days. Review of the Treatment Administration Record (TAR) for Resident #39 for May 2024 failed to show wound treatments being completed daily for left lumbar region skin tear. Interview with DON on 5/15/24 at 11:48 AM reports the facility does not have a skin or pressure ulcer policy. Interview with DON on 5/15/24 at 4:00 PM revealed the expectation of the nursing staff regarding skin tears or skin issues would be to notify the doctor, initiate standard treatment order, request an order or treatment plan from the physician. The DON agreed the standard treatment should have been on the treatment sheet.

Based on observation, facility policy, and staff interview, the facility failed to date food in storage, store utensils in a sanitary manner, and discard expired food. The facility reported a census of 41 residents. Findings include: Observation on [DATE] at 9:27 AM in the main kitchen revealed a measuring scoop stored inside a thickener container and storage bins containing flour and sugar were not dated. Observation on [DATE] at 10:49 AM in the blue neighborhood kitchen revealed a measuring scoop stored inside a thickener container and an open can of soup in the refrigerator dated [DATE]. Observation on [DATE] at 12:17 AM in the blue neighborhood kitchen revealed the same open can of soup from observation on [DATE] at 10:49 AM in the refrigerator dated [DATE]. The Food Storage policy dated 2013 revealed scoops are not to be stored in food or ice containers. The same policy directed that plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods, additionally all containers must be legible and accurately labeled and dated. The Food Brought Into Resident's Rooms From Outside Sources policy dated [DATE] directed all cooked or prepared food brought in for a resident and stored in the kitchenette refrigerator or personal room refrigerator will be dated when accepted for storage and discarded after 72 hours. In an interview on [DATE] at 12:17 PM, the Certified Dietary Manager (CDM) reported all neighborhood refrigerators are cleaned weekly and residents are informed when their food has expired to be discarded, the expired soup must have been overlooked. In an interview on [DATE] at 12:37 PM, the Registered Dietician (RD) reported all containers of bulk food should be dated and she would expect scoops would be stored outside their containers.

Based on record review and staff interview, the facility failed to ensure a resident's complete and updated list of diagnosed mental illness were submitted for review with PASARR (Pre-admission screen and resident review), ensuring a resident with serious mental illness receives the services they need, for 1 of 1 residents reviewed (Resident # 15). The facility reported a census of 41 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The MDS documented the resident required extensive assistance of 2 persons in bed mobility, transfers, locomotion, dressing, toilet use and bathing. The MDS described the resident having physical impairment on both sides of his lower extremities and utilized a wheelchair only for mobility. The MDS revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan, dated 11/4/21, identified a focus of increased depressive mood symptoms, impacted by grief and loss issues of a brother, with a goal of mood improvement and engagement in cares and activities. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physicians Order dated 4/6/21 prescribed [MEDICATION(S)] (antidepressant) related to a Major Depressive Disorder, recurrent, moderate. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Electronic Medical Record identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [CONDITION(S)] disorder has an added date of 12/28/20 with the Major Depressive Disorder added 2/15/21. A review of the paper medical records revealed a PASARR, dated 11/12/18, identified mental illness diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The review directed no further screening was required unless changes occur or new information refutes the original screening assessment, a new screen must be submitted. On 1/19/22 at 4:03 PM, an interview with the DON, stated she expects an updated PASARR be submitted when a resident is diagnosed with new or additional serious mental illness, such as [CONDITION(S)] disorder. Stated she will ensure an updated PASSAR will be submitted.

Based on observations, record reviews, and staff interviews, the facility failed to ensure appropriate infection control procedures related to the screening practice of staff entering the facility. The facility reported a census of 41 residents. Findings Include: Review of the Staff Covid-19 Screening for Start and End of Shift Log showed staff is self-screening as there is no witness signature for temperatures or screening questions. Log directed if you have two or more of the following symptoms or fever, do not come into the facility any further. You need to go back to your car immediately and call a nurse that is working and get tested that day. Review of the Staff Covid-19 Screening for Start and End of Shift Log show staff A, Certified Nurse Assistant ( CNA) answered yes to having a cough, headache, congestion, muscle aches, and sore throat on 9/17/20. Staff A answered yes to ask to go home. Staff A entered the facility for COVID testing. Review of the working schedule for 9/6/20 through 9/19/20 showed Staff A was not scheduled to work on 9/17/20 but came to the facility to complete the outbreak testing requirements. Review of the Staff Covid-19 Screening for Start and End of Shift Log on 9/18/20 show Staff B, Dietary Cook answered yes to headache and congestion. Yes was answered to asked to go home at 6:30 am. Review of time card punches showed Staff B punched in and entered the facility at 5:44 am on 9/18/20. Review of Staff Covid-19 Screening for Start and End of Shift Log show Staff C, CNA answered yes to cough and congestion on 9/16/20, answered yes to cough, headache, and congestion on 9/15/20, answered yes to cough and congestion on 9/14/20. Review of time card punches showed Staff C punched in and entered the facility at 5:37 am and punched out at 4:00 pm on 9/14/20, punched in and entered the facility at 5:38 am and punch out at 2:08 pm on 9/15/20, and punched in and entered the facility at 5:37 am and punched out at 1:47 pm on 9/16/20. During interview on 9/22/20 at 2:30 pm Staff C stated that nobody from the facility has questioned her about answering yes to the screening questions. Staff C stated staff self-screen and thought she just had a small cold. During interview on 9/22/20 at 9:00 am Staff D, CNA stated she enters the building, sanitizes hands, takes her own temperature and answers the signs and symptoms questions, then starts her shift. Staff D stated she self-screens at mid and end of shift. During interview on 9/22/20 at 10:40 am Staff E, CNA stated staff always screen themselves in and out. On 9/22/20 at 12:23 Staff F, Dietary Aid was observed screening herself into work. Staff F answered the screening questions and took her own temperature and documented it on the screening log with no other staff around the location. Review of the Coronavirus Surveillance Policy dated 9/9/20, noted staff who have signs and symptoms of a respiratory infection shall not report to work. Any staff that develops signs and symptoms while on the job shall: stop work, apply facemask, and self-isolate at home. Inform the Infection Preventionist, include information on individuals, equipment, and locations the person came in contact with. On 9/23/20 at 10:10 am the Director of Nursing (DON) stated she expects staff to notify the nurse on duty of any signs or symptoms before the start of work. The DON stated staff has been educated on reporting signs and symptoms several times and understands the current screening process has issues. DON stated they are working on a new screening process.

Based on clinical record review, observation, staff interview and facility policy review, the facility failed to utilize appropriate infection control practices during resident care for 1 of 3 residents reviewed (Resident# 43) and failed to maintain cleanliness of oxygen tubing for 4 of 4 residents reviewed for oxygen use (Resident #42, #45, #2 and #34). The facility reported a census of 45 residents. Findings included: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #43 had a BIMS score of 8, indicating moderate cognitive impairment. The MDS included [DIAGNOSES REDACTED]. The MDS indicated Resident #43 required extensive assistance of one staff for bed mobility, transfer, and toilet use and he required an indwelling urinary catheter. Review of Resident #43's Care Plan, with a revision date of 2/7/20, revealed he had an indwelling urinary catheter and required staff assistance with catheter cares twice per day. The Care Plan further stated Resident # 43 had a history of [REDACTED]. Observation on 3/3/20 at 9:32 a.m. revealed Staff A, Certified Nursing Assistant (CNA) performed catheter care on Resident #43 while seated on the toilet. Staff A applied gloves without washing hands, gathered washcloths, peri-wash and an alcohol wipe. Staff A wet the washcloth in sink, applied peri-wash and used left hand to hold tip of penis, and used her her right hand to cleanse it in a circular motion. She moistened the second washcloth and cleansed both sides of groin using an up and down motion. Staff A did not turn the washcloth for a clean surface each time she wiped the Resident #43's perineal areas. Staff A discarded second washcloth into garbage bag and used alcohol swab to cleanse around the tip of the penis at the catheter insertion site. Staff A used the alcohol swab to wipe the catheter tubing all of the way down to the hub of the catheter, (approximately 11 inches). Staff A discarded alcohol swab, kept her soiled gloves on and applied gait-belt to Resident #43. With the same soiled gloves, Staff A placed his walker in front of him, stood him up, pulled up his clean incontinence brief, pulled up his pants, and adjusted his suspenders. Staff A removed her soiled gloves into the garbage and zipped up resident's pants. Staff A then walked Resident #43 out of the bathroom. During interview on 3/5/20 at 8:10 a.m., the Director of Nursing (DON) stated Staff A should have removed her gloves and sanitized her hands during catheter care. She stated she expected CNA's to provide peri-care in a downward motion to decrease risk of infection and to turn the washcloth with each wiping motion in order to have a clean surface. DON stated Staff A should have removed her gloves and washed hands before touching the clean items- gait-belt, walker, brief, pants and suspenders. Review of the facility's Handwashing Procedure, dated 2015, revealed staff is to be educated, trained, and monitored for proper hand washing as follows: -When hands are visibly soiled (hand washing with soap and water); before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); -Before and after assisting a resident with toileting (hand washing with soap and water); -After removing gloves or aprons. Review of the facility's Nurse Aide Skills checklist for catheter care, dated 2012, stated CNA's are to: assemble equipment, perform hand hygiene, cleanse around the meatus (urinary opening), then wash from the meatus using soap and water, 4 inches down the tubing. Remove gloves and complete hand hygiene. Review of the facility's Nurse Aide Skills checklist for Handwashing using soap and water, dated 2012, stated CNA's are to: Wet hands completely, apply soap, hold hands lower than elbows, work up a good lather, clean your nails, perform hand hygiene by using a rotating, rubbing motion, rubbing palms and between fingers for minimum of 15-20 seconds. Wash at least 3-4 inches above wrist, rinse washed areas well, hands should not touch sink, dry hands thoroughly with paper towel, and turn of faucet. Take dry paper towel and turn off faucet, discard paper towel in wastebasket. Staff A failed to perform appropriate hand hygiene during catheter care for Resident #43. 2. The MDS completed for Resident #42 with an ARD of 2/6/2020, showed a BIMS score of 7, indicating moderate cognitive impairment. The MDS listed [DIAGNOSES REDACTED]. During an observation on 3/4/20 at 10:20 a.m., Resident #42's oxygen tubing was dated for 2-19-20. During record review of Resident #42's Treatment Administration Record (TAR) on 3/4/20 at 11:12 a.m.,, noted an active order for the oxygen tubing to be changed every Wednesday. The next date the tubing was due to be changed was 3/4/20. During record review of the TAR on 3/5/20 at 7:33 a.m., Resident #42's oxygen tubing was signed off as completed by the nurse on 3/4/20. During an observation in Resident #42's room on 3/5/20 at 7:42 a.m., noted the date of 2/19/20 remained on the oxygen tubing, which indicated the tubing had not been changed. During an observation in Resident #42's room with the DON on 3/5/20 at 8:00 a.m., DON verified the date on the tubing was 2/19/20. DON stated the nurse's had changed only the cannula (prongs for in the nose) piece of the tubing and not the extension part of the oxygen tubing. DON further stated the facility did not have a policy on changing the tubing weekly and she would be sure to get this fixed to assure nurses changed all of the oxygen tubing, which included the extension tubing piece. 3. The MDS completed for Resident #45 with an ARD of 2/13/2020, showed a BIMS score of 15, indicating no cognitive impairment. The MDS listed [DIAGNOSES REDACTED]. During an observation on 3/4/20 at 10:30 a.m., Resident #45's oxygen tubing was dated for 2/19/20. During record review of Resident #45's TAR on 3/4/20 at 11:22 a.m., noted an active order for the oxygen tubing to be changed every Wednesday. The next date the tubing was due to be changed was 3/4/20. During record review of the TAR on 3/5/20 at 7:33 a.m., Resident #45's oxygen tubing was signed off as completed by the nurse on 3/4/20. During an observation in Resident #45's room on 3/5/20 at 7:38 a.m., noted the date of 2/19/20 remained on the oxygen tubing that indicated the tubing had not been changed. During an observation in Resident #45's room with the DON on 3/5/20 at 8:00 a.m., DON verified the date on the tubing was 2-19-20. 4. The MDS completed for Resident #2 with an ARD of 11/21/2019, showed a BIMS score of 15, indicating no cognitive impairment. The MDS listed [DIAGNOSES REDACTED]. During an observation on 3/4/20 at 10:25 a.m., Resident #2's oxygen tubing was dated for 2/25/20. During record review of Resident #2's TAR on 3/4/20 at 11:17 a.m., noted an active order for the oxygen tubing to be changed every Wednesday. The next date the tubing was due to be changed was 3/4/20. During record review of the TAR on 3/5/20 at 7:38 a.m., Resident #2's oxygen tubing was signed off as completed by the nurse on 3/4/20. During an observation in Resident #2's room on 3/5/20 at 7:32 a.m., noted the date of 2/25/20 remained on the oxygen tubing that indicated the tubing had not been changed. During an observation in Resident #2's room with the DON on 3/5/20 at 8:00 a.m., DON verified the date on the tubing was 2/25/20. 5. The MDS completed for Resident #34 with an ARD of 1/30/2020, showed a BIMS score of 8, indicating moderate cognitive impairment. The MDS listed [DIAGNOSES REDACTED]. During an observation on 3/4/20 at 10:20 a.m., Resident #34's oxygen tubing dated for 2/19/20. During record review of Resident #34's TAR on 3/4/20 at 11:12 a.m., noted an active order for the oxygen tubing to be changed every Wednesday. The next date the tubing was due to be changed was 3/4/20. During record review of the TAR on 3/5/20 at 7:33 a.m., Resident #34's oxygen tubing change was signed off as completed by the nurse on 3/4/20. During an observation in Resident #34's room on 3/5/20 at 7:40 a.m., noted the date of 2/19/20 remained on the oxygen tubing that indicated the tubing had not been changed. During an observation in Resident #34's room with the DON on 3/5/20 at 8:00 a.m., DON verified the date on the tubing was 2/19/20. DON stated the nurse's had changed only the cannula (prongs for in the nose) piece of the tubing and not the extension part of the oxygen tubing piece.

Based on clinical record review and staff interview, the facility failed to accurately complete 1 of 15 resident's Minimum Data Set (MDS) assessments (Resident #27). The facility reported a census of 45 residents. Findings included: According to the 1/9/20 MDS assessment, Resident #27 had a Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive or memory impairment. The MDS listed [DIAGNOSES REDACTED]. Review of Resident #27's Care Plan, with revision date of 1/14/20, revealed he had a stage 2 pressure ulcer to his right heel that started on 9/19/19. Rrecord review of Resident #27's Pressure Documentation skin sheet noted he had a Stage 2 pressure ulcer to his right heel that started on 9/19/19. According to Resident #27's 10/10/19 MDS assessment, he had a BIMS score of 3, indicating severe cognitive impairment due to an acute mental status change. The MDS listed [DIAGNOSES REDACTED]. The 10/10/19 MDS lacked documentation of Resident #27's stage 2 pressure ulcer from 9/19/19. During an interview on 3/4/20 at 4:00 p.m., the MDS nurse stated she had not included the stage 2 pressure ulcer for Resident #27's on the MDS and wasn't sure why she had overlooked it. During an interview on 3/5/20 at 8:08 a.m., the Director of Nursing agreed Resident #27's stage 2 pressure ulcer should have been coded on the 10/10/19 MDS.

Based on observations and interviews, the facility failed to have a call light accessible while residents are in bed for 1 of 22 residents (Resident #37). The facility reported a census of 45. Findings: The Minimum Data Set (MDS) for Resident # 37 with Assessment Reference Date (ARD) of 1/30/2020, showed a short and long term memory problem with severely impaired cognition and extensive assistance for bed mobility. During an observation on 3/3/20 at 3:36 p.m., Resident #37 was lying in bed awake which was positioned across the room from the call light location. Call light cord was draped behind a nightstand and button end sitting on top of nightstand located on the other side of the room, which made the call light inaccessible to Resident #37. During an observation on 3/4/20 at 7:25 a.m., Resident #37 was lying in bed awake on her side. The bed was positioned across the room from the call light location. Call light cord was draped behind a nightstand and button end sitting on top of the nightstand making the call light inaccessible to Resident #37. During an observation on 3/4/20 at 3:45 p.m. Resident #37 was seen sitting on the right side of her bed which is against the wall, with her legs between the bed and the wall heating unit. The Director of Nursing (DON) was present during observation and placed a gait belt on Resident #37 and assisted her across the bed to the other side where she could exit the bed. Resident #37 was assisted to the restroom. DON then took call light cord and stretched it over to Residents #37 bed and it would not safely reach. DON stated that they would fix it. During an interview with the DON, she stated it is expected every resident have a call light within reach when they are in their beds.

Based on observation, record review, and staff interview, the facility failed to assure a resident received care consistent with professional standards of practice to prevent pressure ulcers, and necessary treatment and services to promote healing for 2 of 2 residents with pressure sores (Resident #1 and #11). The facility reported a census of 45 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment, dated 5/4/17, Resident #1 scored 9 on the Brief Interview for Mental Status (BIMS) indicating cognitive impairment. Resident #1 required supervision with bed mobility, transfer, ambulation and locomotion. Resident #1's [DIAGNOSES REDACTED].#1 was not at risk for developing pressure ulcers. Resident #1 had a pressure reducing device for the bed, but not for the chair. A Stage I pressure ulcer defined as intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. A Stage II pressure ulcer defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. A Braden scale dated 5/17 documented Resident #1 scored 19 indicating low risk for developing a pressure ulcer. A hospital Emergency Department Note dated 7/5/17 at 9:33 p.m. documented Resident #1 had a right [MEDICAL CONDITION]. Additional notes from the hospital documented Resident #1 had a stage 1 pressure ulcer of the coccyx. A Braden scale dated 7/17 documented Resident 1 scored 14 indicating moderate risk for developing pressure ulcers (a significant increase in risk). A Re-Admission Nursing Note dated 7/17/17 at 3:45 p.m. showed the coccyx area circled on a body diagram for skin conditions. The note lacked any assessment of the area. The note also documented Resident #1 needed 2 assist with transfer and ambulation (a significant change in need for assistance). A handwritten note dated 7/17/17, regarding the Re-admit of Resident #1 directed to reposition every 2 hours, and use a gerichair. Repositioning sheets directed to turn Resident #1 every 2-3 hours (contradictory to the handwritten instructions of every 2 hours). An undated repositioning sheet showed greater that 3 hours between positioning documented 6 times (in about a 5 day period). A repositioning sheet with the date 8/12 approximately 2/3 the way down the page documented Resident #1 went greater than 3 hours between repositioning 4 times. A repositioning sheet with the date 9/5 approximately 3/4 the way down the page documented Resident #1 went greater than 3 hours between repositioning 4 times. A repositioning sheet with a date of 9/15 and 9/18 showed Resident #1 went greater than 3 hours between repositioning 7 times. A repositioning sheet dated 9/20 to 9/24 documented Resident #1 went greater than 3 hours between repositioning 8 times. On 11/16/17, at the time of the exit conference no additional records of repositioning were provided. A Pressure Ulcer Documentation form dated 7/21/17 identified Resident #1 with a stage 2 area of the coccyx measuring 2 by 5 cm with a pink wound bed. The form documented the area healed on 8/27/17. A Pressure Ulcer Documentation form dated 7/21/17 identified Resident #1 with a stage 2 area of the right heel, a 5 cm callous with a 2 cm blister on the outside. The same form documented a stage 2 area of the left heel, 2 cm round, pink, with loose skin. The form documented area healed, and a new treatment to the right right heel per the physician. The pressure ulcer record dated 8/1/17 documented the right heel debrided measuring 5 by 4 cm. The area healed 8/22/17. A Podiatry note dated 8/1/17 documented Resident #1 had non-pressure chronic ulcer of the right heel and midfoot limited to breakdown of skin, and non pressure chronic ulcer of other part of the left foot limited to breakdown of skin. The Care Plan initiated 8/1/17 documented Resident #1 depended on staff for mobility due to a recent [MEDICAL CONDITION], and unfortunately developed pressure areas to his/her heels and coccyx as a result. The interventions included: a. Blister areas to right and left heels would be assessed and documented weekly until healed. b. Resident needed staff assistance to make changes throughout the day because he/she could not do independently (with no direction on frequency), c. The nurse would treat the pressure areas as ordered by the physician, d. Staff would assess and document on the coccyx weekly until healed, e. Staff would assist with placing heel protectors to bilateral feet while in bed, f. Staff would assist with changing soiled undergarments as necessary. g. Staff would observe skin for areas of redness and/or breakdown reporting to the nurse as necessary. A Nutritional assessment dated [DATE] documented Resident #1 had intact skin, and did not address the pressure areas. During an observation on 11/14/17 at 2 p.m. Staff A Certified Nursing Assistant and Staff C CNA took Resident #1 to the bathroom, and assisted him/her into bed. Staff covered Resident #1 and did not put boots on his/her bilateral feet. During an observation on 11/15/17 at 12:20 p.m. Resident #1 laid in bed on his/her back with no boots to his/her bilateral feet. During an interview on 11/16/17 at 7:45 a.m. the Director of Nursing and the MDS Coordinator both stated they thought Resident #1 still used the boots. They knew he/she didn't like them, but not that he was not using them. During an interview on 11/15/17 at 2:30 p.m. the Director of Nursing (DON) provided information to show staff were to reposition Resident #1 every 2 hours and use a gerichair for comfort. She stated Resident #1 did not have a pressure reduction cushion but the (gerichair) seats were very soft. She would look for information to show if they provided pressure reduction. During an interview on 11/15/17 at 2:30 p.m. the DON stated the nurse who completed the re-admission (7/17/17) said there was an area on Resident #1's coccyx, but could not remember the stage (no treatment from 7/17-21/17). During an interview on 11/16/17 at 7:45 a.m. the DON stated they had not found information indicating the gerichair provided pressure reduction. The chair Resident #1 currently used was a recent acquisition. 2. According to the Minimum Data Set (MDS) assessment, dated 9/21/17, Resident #11 demonstrated long and short term memory problems and severely impaired skills for daily decision making. Resident #11 depended on staff for activities of daily living including bed mobility, transfer, and personal hygiene. Resident #11's [DIAGNOSES REDACTED]. Resident #1 was at risk for developing pressure ulcers, and had a stage 1 pressure ulcer. Resident #1 had a pressure reducing device for the bed and the chair. A Braden scale dated 9/17 documented Resident #11 scored 11 indicating high risk for developing pressure ulcers. A Non-Decub. Skin Condition Report dated 8/31/17 documented Resident #11 had areas on the coccyx measuring 1.3 by 0.4 cm and 0.9 by 0.3 cm. The report documented the type of injury as abrasion caused by pressure. The areas were open, reddened, soft and documented at stage 1 (open skin indicates a stage 2 pressure ulcer). The area healed 10/18/17. The Care Plan dated 9/26/17 identified Resident #11 at an increased risk of skin breakdown due to daily episodes of bladder incontinence as well as dependence on staff for mobility. The interventions included: a. Apply [MEDICATION NAME] as ordered to buttocks. b. Assure pressure reduction cushion to resident's geri/recliner. The October 2017 Treatment Administration Record documented healed 10/18/17 regarding the [MEDICATION NAME] to the coccyx with no further documentation of it's application. During an observation on 11/15/17 at 7:50 a.m. Staff D CNA and Staff E CNA lifted Resident #11 into bed with the mechanical lift from the gerichair. Observation revealed no pressure reduction cushion in the geri chair. At 10:43 a.m. Staff D and Staff E provided pericare for Resident #11. Resident #11 had a dressing to the coccyx area. Staff D and Staff E transferred Resident #11 to the gerichair without the benefit of a pressure reduction cushion. During an interview on 11/16/17 at 7:45 a.m. the DON stated she talked with the nurse who applied the [MEDICATION NAME] recently, and she applied it for protection. The DON stated she told the nurse she needed an order. The DON checked Resident #11's coccyx and stated the resident had no current pressure area. She obtained an order for [REDACTED].>

Based on observation, record review and staff interview, the facility failed to assure a resident received care plan interventions as planned for 2 of 11 residents reviewed (Resident #1 and #11). The facility reported a census of 45 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment, dated 8/13/17, Resident #1 scored 7 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Resident #1 required extensive assistance with bed mobility, transfer, ambulation and locomotion. Resident #1's [DIAGNOSES REDACTED]. A Podiatry note dated 8/1/17 documented Resident #1 had non-pressure chronic ulcer of the right heel and midfoot limited to breakdown of skin, and non pressure chronic ulcer of other part of the left foot limited to breakdown of skin. The Care Plan initiated 8/1/17 documented Resident #1 depended on staff for mobility due to a recent [MEDICAL CONDITION], and unfortunately developed pressure areas to his heels and coccyx as a result. The interventions included: a. Staff would assist with placing heel protectors to bilateral feet while in bed. During an observation on 11/14/17 at 2 p.m. Staff A Certified Nursing Assistant and Staff C CNA took Resident #1 to the bathroom, and assisted him into bed. Staff covered Resident #1 and did not put boots on his bilateral feet. During an observation on 11/15/17 at 12:20 p.m. Resident #1 laid in bed on his back without the benefit of boots to his bilateral feet. During an interview on 11/16/17 at 7:45 a.m. the Director of Nursing and the MDS Coordinator both stated they thought Resident #1 still used the boots. They knew he didn't like them, but not that he was not using them. 2. According to the Minimum Data Set (MDS) assessment, dated 9/21/17, Resident #11 demonstrated long and short term memory problems and severely impaired skills for daily decision making. Resident #11 depended on staff for activities of daily living including bed mobility, transfer, and personal hygiene. Resident #11's [DIAGNOSES REDACTED]. [MEDICAL CONDITION] means a slight paralysis or weakness on one side of the body) Resident #1 had a pressure reducing device for the bed and the chair. The Care Plan dated 9/26/17 identified Resident #11 at an increased risk of skin breakdown due to daily episodes of bladder incontinence as well as dependence on staff for mobility. The intervention included staff would assure Resident #11's pressure reduction cushion was in his geri/recliner chair. During an observation on 11/15/17 at 7:50 a.m. Staff D CNA and Staff E CNA transferred Resident #11 from his gerichair into bed with the mechanical lift. Observation revealed no pressure reduction cushion in the gerichair. At 10:43 a.m. Staff D and Staff E transferred Resident #11 to the gerichair observation revealed no pressure reduction cushion in the gerichair. During an interview on 11/15/17 at 2:30 p.m. the Director of Nursing (DON) stated the (gerichair) seats were very soft.

Based on observation and staff interview the facility failed to replace outdated insulin pens for 1 of 2 residents reviewed (Resident #1). The facility reported a census of 45 residents. Findings included: On 11/15/17 at 1:42 p.m. the Blue Unit medication cart held a [MEDICATION NAME] pen for Resident #1. Staff had written on the label the insulin had been opened on 10/15/17, 31 days prior. Staff B, Registered Nurse stated the pen should have been discarded and replaced after 28 days. The cart also held a Humalog insulin pen which Staff B stated had been in use. The pen had no date to indicate either when it had been opened or when it should be discarded. Staff B stated the insulin's should be dated when opened. According to the minimum data set (MDS) dated [DATE], Resident #1 had a [DIAGNOSES REDACTED]. A document in the facility Medication Administration Record [REDACTED].

Based on record review, observation and staff interviews the facility failed to provide restorative interventions for 1 of 7 residents identified with limitations in range of motion (Resident #4). The facility further failed to provide interventions as planned for 1 of 1 resident with limitations in range of motion who had a restorative plan in place (Resident #5). The facility reported a census of 45 residents. Findings included: 1. According to the Minimum Data Set ((MDS) dated [DATE], Resident #4 required total assistance with all activities of daily living and did not ambulate. The resident had impairment of functional range of motion in both upper extremities and both lower extremities. Observation on 11/14/17 at 8:08 a.m., revealed Resident #4 in the dining room feeding self with noted contracture of the right hand/wrist. The facility Roster/Sample Matrix dated 11/13/17 indicated Resident #4 had concerns with Range Of Motion, Contracture, and Positioning. Review of Resident #4's care plan lacked interventions to improve the resident's range of motion. The resident's record lacked any documentation indicating the resident received exercise, restorative or functional maintenance program. During interview on 10/15/17 at 9:14 a.m. the DON stated the MDS Coordinator had responsibility for Restorative Programs. The DON didn't know what criteria had been used to determine who needed restorative programs. She thought Resident #4 had received restorative programs in the past and didn't like them. During interview on 10/15/17 at 1:52 p.m. the DON stated no documentation indicating the resident had received or declined restorative programs had been found. 2. According to the MDS dated [DATE] Resident #5 had no impairment of cognitive function. The resident required total assistance of staff for transfers and did not ambulate. The resident had impairment of functional mobility in both upper and both lower extremities. The resident's Care Plan included a problem which stated the resident had early onset cerebella ataxia which had caused his muscles to slowly deteriorate. The intervention stated the resident would continue working with the restorative nursing assistant as scheduled to maintain the resident's strength. A 5/9/17 Functional Maintenance Program directed staff to assist the resident with heelcord and hamstring stretches holding 30 seconds and Active Assisted and Passive Range of Motion to the upper and lower extremities 3 times weekly. During observation on 11/14/17 at 1:10 p.m. the resident laid in bed. The resident's hands and elbows appeared contracted. The Restorative flow sheets documented the following: a. August 2017, staff assisted the resident with exercises 5 times. Staff documented the resident declined to participate once. b. September 2017, staff assisted the resident with exercises 6 times. Staff documented the resident declined to participation once. c. October 2017, staff assisted the resident with exercises 8 times. Staff documented the resident declined participation twice. On 10/3/17 the MDS Coordinator wrote the resident's range of motion continued to slowly decline. d. November 14, 2017, staff assisted the resident with exercises 4 times. The record lacked resident refusals. On 11/6/17 the MDS Coordinator documented Resident #5's contractures continue to worsen.

Based on record review and staff interview the facility failed to care plan [MEDICAL CONDITION] medications and monitoring for adverse side effects for 5 of 7 residents reviewed (Residents #1, #2, #3, #4, and #11). The facility reported a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 8/12/16, documented Resident #1 had moderately impaired cognitive skills for daily decision making. The October 2016 Medication Administration Record [REDACTED]. Resident #1's current Care Plan, initiated on 8/17/16 lacked specific documentation of the use of an antidepressant and monitoring the adverse side effects of the medication. 2. The Minimum Data Set (MDS) assessment tool, dated 7/7/16, documented Resident #3 with intact cognitive skills for daily decision making. The October 2016 Medication Administration Record [REDACTED]. Both medications were ordered for [DIAGNOSES REDACTED]. The MAR indicated [REDACTED]. The [MEDICATION NAME] start date was 1/6/16. The MAR indicated [REDACTED]. Resident #3's current Care Plan, with Goal Target Date of 1/4/17, lacked specific documentation of the use of antidepressants, antianxiety and antipsychotic medications and monitoring the adverse side effects of the medications. 3. The MDS assessment tool, dated 8/3/16, documented Resident #2 had severely impaired cognition. The October 2016 MAR for Resident #2 directed staff to administer [MEDICATION NAME] (an antidepressant) 20 milligrams (mg) daily for a [DIAGNOSES REDACTED]. daily restarted 6/28/16. The Resident #2's current care plan, initiated on 12/14//14 and a goal date of 11/10/16, revealed the resident had episodes of resistive behavior, directed staff the resident had received [MEDICATION NAME] in the past, and directed staff to inform the physician if the resident developed signs of depression. The care plan lacked documentation the antidepressant had been restarted and lacked documentation directing staff to monitor the resident for specific side effects of the medication. During an interview 10/12/16 at 2:50 p.m., the Director of Nursing and the MDS (Minimum Data Set) nurse stated they were unaware of the need to document [MEDICAL CONDITION] side effects on the care plan. 4. The MDS assessment tool, dated 8/4/16, documented Resident #4 with intact cognition. The October 2016 MAR for Resident #4 directed staff to administer [MEDICATION NAME] (an antidepressant) 15 mg. daily for [MEDICAL CONDITION], start date 4/6/16. The resident's care plan, initiated on 4/6/16 and a goal date of 11/10/16, documented the resident received an antidepressant medication daily. The care plan lacked documentation directing staff to monitor the resident for specific side effects of the medication. 5. The MDS assessment tool, dated 7/14/16, documented Resident #11 with severely impaired cognition. The October 2016 MAR for Resident #11 directed staff to administer Quetiapine [MEDICATION NAME] (an antipsychotic) 25 mg. twice daily for Lewy Bodies Dementia (start date 8/8/16) and [MEDICATION NAME] (an antipsychotic) 1 mg. twice daily and 1 extra tablet every 2 hours when needed for anxiety (start date 8/11/16). The resident's care plan, initiated 7/18/16 with a goal date of 10/20/16. documented the resident had hallucinations and delusions and received [MEDICATION NAME] (same as Quetiapine), and antipsychotic medication. The care plan directed staff to monitor the resident for changes in mental, physical, and continence changes. The care plan lacked documentation the resident received 2 antipsychotic medications and direction to staff to monitor for specific side effects of the medications.

Based on record review and staff interview the facility failed to provide adequate supervision to prevent a fall and potential injury for 1 of 4 residents with falls reviewed (Residents #4). The facility reported a census of 41 residents. Findings included: The Minimum Data Set (MDS) assessment tool, dated 5/1/15, documented Resident #4 with a Brief Interview for Mental Status (BIMS) score of 11 and a score from 8 to 12 indicated moderately impaired cognition. The MDS revealed the resident required limited staff assistance for bed mobility, transfers, and toilet use, extensive staff assistance for personal hygiene and bathing, and without falls since the prior assessment. The MDS documented the resident's [DIAGNOSES REDACTED]. The resident's Quarterly Nursing Assessment completed 4/30/15 documented the resident had a score of 3 and a score of 3 to 5 indicated the resident had a potential risk for falls. A resident care plan with an original date of 2/6/15, revealed the resident had a steady gait, several factors that made the resident at risk for falls, and required 1 staff for bathing. A Nursing Notes entry dated 5/13/15, at 8:00 p.m., documented a staff member assisted the resident out of a bath chair, the resident unable to balance, the bath chair slid away, and the resident lowered to the floor. An Incident Assessment report dated 5/13/15, at 8:00 p.m., documented the resident had no injury from the incident and the staff member present during the incident had been educated to lock the bath chair wheels during transfers to prevent the chair from rolling away. During an interview 11/4/15, at approximately 1:00 p.m., the DON (Director of Nursing) verified staff needed to make sure the bath chair wheels locked during transfers and the staff member received education after the incident.

Based on record review and staff interview the facility failed to assure a gradual reduction of [MEDICAL CONDITION] medications to assure lowest possible dose for 1 resident (Resident #9). Seven residents receiving [MEDICAL CONDITION] medications were reviewed. The facility reported a census of 41 residents. Findings include: 1. An MDS dated [DATE], documented Resident #9 with a BIMS score of 7 and a score of 0 to 7 indicated severe cognitive impaired. The MDS revealed the resident without [MEDICAL CONDITION], hallucinations, and delusions, and had other behaviors that occurred daily. The resident required extensive staff assistance with bed mobility, transfers, and dressing, and total staff dependence with personal hygiene. The MDS revealed the resident's [DIAGNOSES REDACTED]. The resident care plan documented a Focus dated 2/27/14, that revealed the resident had a short attention span and short term memory that resulted in restlessness. Interventions included to take the resident outside, encourage activities of interest, and to offer lap activities. The resident care plan documented a Focus dated 2/11/15, that revealed the resident had severe dementia due to alcohol dependency and oxygen deprivation. The resident care plan documented a Focus dated 2/11/15, that revealed the resident received daily antianxiety, antidepressant, and antipsychotic medications. An intervention documented the physician reviewed the medications routinely and assisted to make changes if needed and the psychiatrist visited routinely to assist with medication adjustments. The resident's November 2015 MAR indicated [REDACTED]. daily for depression, Quetiapine (same as [MEDICATION NAME], an antipsychotic) Fumarage 100 mg twice daily for depression and unspecified anxiety, and [MEDICATION NAME] 0.75 mg. three times daily for anxiety. During an interview 11/4/15 at 11:25 a.m., the DON (Director of Nursing) and MDS nurse stated the resident had remained on the same [MEDICATION NAME] dose since 8/25/11, the same [MEDICATION NAME] dose since 9/9/11, and the same [MEDICATION NAME] dose since 7/3/12. The DON and MDS nurse stated the resident admitted to the facility in 2011, had various [MEDICAL CONDITION] medication changes, and the resident the best he/she had been on this regimen. A mental health physician note dated 4/30/15, documented the resident had no new concerns, friendly, cooperative, and train of thought wandered and without focus. The note directed to continue the same medications. A Psychiatric Medication Check sheet dated 6/26/15, documented the staff without any new resident concerns and very stable on the medications. The note documented there is a pharmacy consult regarding reduction in [MEDICATION NAME]. The Treatment Recommendation documented; we will leave the resident on her medication as is. A Note To Attending Physician/Prescriber signed by the physician 10/15/15, documented the physician disagreed with a gradual dose reduction for [MEDICATION NAME] 20 mg. daily and direction to ready the dictation. A mental health physician note dated 10/15/15, documented the facility reported the resident doing about the same and had no concerns, and the resident reported he/she had not been sleeping well, smiled easily, affect appropriate. The physician directed to leave the resident's [MEDICAL CONDITION] medication doses the same because a dose reduction may exacerbate the resident's anxiety, dementia, and depression.

Based on record review and interviews, the facility failed to provide adequate supervision to protect one (1) of seven (7) residents from hazards. Record review and staff interviews identified staff failed to monitor and implement services to meet Resident #11 ' s safety needs. The facility reported a census of 44 residents. Findings included: According to a Medication Review Report dated [DATE] -[DATE], Resident #11's [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) with an assessment reference date of [DATE] identified Resident #11's mental status as severely impaired with a Brief Interview for Mental Status (BIMS) of 5. The MDS identified Resident #11 as required supervision with transfer and walking, and required limited assistance from staff with toilet use. Following the resident's fall on [DATE], an updated MDS assessment with an assessment reference date of [DATE] identified Resident #11's mental status as severely impaired with a BIMS of 7. Resident #11 required extensive assistance from staff with bed mobility, transfer, walking and toilet use. The MDS identified the resident's birthdate of [DATE] ([AGE] years of age) and documented the resident's weight of 80 pounds. A care plan with a date initiated date of [DATE], included interventions for Resident #11 to ambulate with the use of a walker for all weight bearing activities. According to the initial care plan Resident #11 allowed to ambulate independently in the unit. Staff will turn on the pressure alarm for Resident #11 at bed time. According to the care plan dated [DATE] Resident #11 required assistance of ,[DATE] staff members for all cares due to advancing dementia. A falling potential assessment dated [DATE], identified the resident as potentially at risk for falling. Review of an Incident Assessment form dated and timed [DATE] at 8:00 A.M., revealed staff documented Resident #11as observed lying on the floor in a bathroom and complained of right hip and back pain. According to the incident report Resident #11 failed to have pants, under wear or shoes on at the time of the fall. Review of Physician hospital notes dated and timed [DATE] at 10:15 A.M. and 12:20 p.m. revealed Resident #11 presented to an emergency room following his/her fall on [DATE] at 8:00 A.M. The Physician documented Resident #11 with an acute comminuted, mildly displaced fracture of the right inferior pubic rami, acute non-displaced fracture of the right superior pubic rami which extends into the anterior column of the right ischium and an acute non-displaced fracture of the distal right superior pubic rami at its junction with the pubic bone. The physician indicated Resident #11 needs bed rest and pain control for the pelvic fracture with weight bearing as tolerated. Resident #11 received an order for [REDACTED]. Review of Nursing Notes dated [DATE] at 8:00 a.m. revealed documentation of Resident #11 found on the floor in the bathroom lacking pants, under wear or shoes. The documentation identified the presence of a tee shirt and socks with Resident #11 complaining of right hip pain. The Nursing progress note further stated an order received to transfer Resident #11 to the hospital for an evaluation by ambulance. The Nursing Notes dated [DATE] at 2:50 P.M., Staff documented the resident returned to the facility following an emergency room visit. Staff documented orders for the resident as being on bed rest with the use of a bedside commode. Staff documented orders for the resident to bear weight as tolerated and the use of Hydrocodone ,[DATE]mg ,[DATE] tablets every 6 hours as needed (prn). The progress note stated Resident #11 has a bed and body alarm in place along with a fall mat. The bed is down in the lowest position. Nursing Notes dated [DATE] at 3:00 a.m. revealed Resident #11 restless and attempting to get out of bed. Staff administered pain medications as ordered and provided 1:1 supervision as Resident #11 fell asleep. Further review of Resident #11' s care plan revealed staff reviewed the resident's care plan on [DATE] and discontinued Resident #11's independent ambulation status in the unit and added the following interventions: place a bed alarm at all times when in bed, place a clip alarm at all times on the resident , place a fall mat by the resident's bed and put the resident's bed in the lowest position while in bed. A falling potential assessment dated [DATE], identified the resident at high risk for falls. Review of an Incident Assessment form dated and timed [DATE] at 9:45 P.M., revealed staff documented Resident #11 ambulated to the bathroom with a walker and fell . Resident #11 ' s alarm was sounding and as staff responded to find Resident #11 lying in his/her bathroom on the left side, next to a toilet. Staff documented the resident as unable to move his/her left arm, complained of left hip pain and sustained a laceration to his/her left temple area. The Incident Assessment Fall investigative tool identified on ,[DATE] at 9:45 p.m. the clip alarm for Resident #11 as on and the pressure alarm intervention failed to be turned on at the time of the incident. Review of Nursing Notes dated [DATE] at 9:45 P.M., staff documented the following: Staff heard the resident's alarm, entered Resident #11's room and observed the resident lying on his/her bathroom floor next to a toilet with his/her walker at his/her side. Staff documented an observation of the resident's room and described the resident's bed as not in the lowest position, fall mat as not in place and the bed (pressure alarm) as not turned on. Staff documented the resident's clip alarm as sounding. Staff documented notifying a Physician and the resident transferred to the hospital emergency room via ambulance. Review of a Physician emergency room note dated [DATE], a Physician documented the resident sustained [REDACTED]. The Physician documented an obvious deformity of the resident's left hip with shortening and internal rotation of the lower left extremity. Also noted swelling and tenderness of the shoulder, consistent with a fracture. Review of x-ray reports dated [DATE] revealed the following: Left shoulder - complete destruction of the left shoulder joint and non-displaced comminuted fracture of the proximal left humerus. Left Hip - possible acute fracture of the left superior pubic ramus (pelvis). Review of a Discharge Summary dated [DATE], revealed a Physician documented a decision made for no operative interventions and would be managed non-operatively and medically. Discussed with the family and agreed to send Resident #11 back to the nursing home to make comfortable and pain free. A Clinical Summary form dated [DATE], included the following discharge Physician orders [REDACTED]. Activity to chair, weight bearing as tolerated, non-weight bearing left arm, left shoulder immobilize. The same form included orders for Acetaminophen-Hydrocodone (Lortab) 5mg- 325 mg, every 6 hours PRN for pain. A medication administration record and PRN record sheet dated [DATE] - [DATE], revealed Resident #11 received PRN Lortab for pain as follows: ,[DATE] - 1 time ,[DATE] - 2 times ,[DATE] -2 times ,[DATE] - 2 times ,[DATE] - 2 times ,[DATE] - 2 times ,[DATE] - 3 times ,[DATE] - 2 times ,[DATE] - 2 times ,[DATE] - 2 times ,[DATE] - 2 times ,[DATE] - 1 time ,[DATE] - 1 time ,[DATE] - 2 times ,[DATE] - 3 times According to a Physician order [REDACTED].#11's Lortab order to every 4 hours, PRN. A medication administration record and PRN medication record sheet dated [DATE] - [DATE] revealed Resident # 11 received PRN Lortab for pain as follows: ,[DATE]- 3 times ,[DATE] - 4 times ,[DATE] - 6 times ,[DATE] - 5 times ,[DATE] - 5 times ,[DATE] - 5 times ,[DATE] - 6 times ,[DATE] - 6 times ,[DATE] - 5 times ,[DATE] - 2 times Review of Nursing Notes [DATE] - [DATE] included the following: [DATE] at 3:00 P.M. - Staff documented Resident #11 returned to the facility via ambulance following an emergency room visit. [DATE] at 9:00 A.M. - Staff documented Resident #11 continued to decline, ate and drank poorly and received orders for Hospice services. [DATE] at 12:45 P.M. - Staff documented Resident #11 refused breakfast and dinner, complained of pain all over and a Hospice nurse visited and inserted a Foley catheter. [DATE] at 10:00 A.M. - Staff documented the resident as unresponsive and Resident #11's family at his/her bedside. [DATE] at 11:58 P.M. - Staff documented Resident #11 as deceased . Review of a nursing schedule dated [DATE] , revealed Staff E, Registered Nurse (RN) scheduled to work the 100 hall area from 6:00 P.M. - 6:00 A.M., Staff F, Certified Medication Aid (CMA) scheduled to work the 100 hall area from 6:00 P.M. - 6:00 A.M. and Staff C, CNA, scheduled to work the 100 hall area from 4:00P.M.-9:00P.M. During interview on [DATE] at 1:10 P.M., the facility Director of Nursing (DON) stated the above schedule (for [DATE]) is typical staffing for the 100 hallway evening shift. During interview on [DATE] at 4:20 P.M., Staff F, CNA gave the following account of Resident #11's care prior to his/her fall on [DATE]: Staff F described Resident #11 as restless and attempted to stand independently often from his/her wheelchair (w/c), recliner and/or bed. Staff F stated at times Resident #11 laid in bed with his/her bed in the lowest position, the resident could not stand up independently. Staff F stated at the time she came on duty on [DATE], Resident #11 sat at the dining room table in his/her w/c. Staff F described Resident #11as restless, ate ,[DATE] of his/her meal and told Staff F he/she wanted to go to bed. Staff F stated on [DATE] at approximately 6:30 P.M., she propelled the resident to his/her room via a w/c and the resident brushed his/her teeth at a bathroom sink and Staff C, (CNA) assisted Staff F with transferring the resident from his/her w/c to a commode next to his/her bed. Staff F stated not being able to recall if the resident urinated in the commode. Staff F stated she and Staff C stayed in the room while the resident used the commode and then transferred the resident from the commode to his/her bed. Staff F stated after the resident transferred to his/her bed, Staff C got called away and left the resident's room. Staff F stated she completed the resident's perineal care, lowered the resident's bed. Staff F stated she thought she had lowered the resident's bed all the way, but realized after the resident's fall, she had not lowered the bed as low as possible. Staff F stated the bed /frame remained approximately 12 inches off the floor. (Note: During observation of Resident #11's bed on [DATE] at 9:00 A.M., the surveyor measured the resident's bed in the lowest position between the bottom of the bedframe and the floor at approximately 9 inches). Staff F stated she told Resident #11 she would return to the room "in a few minutes" and left Resident #11's room at approximately 7:00 P.M.to go and assist other residents. Staff F stated prior to leaving Resident #11's room, she turned the pressure alarm on the resident's bed, placed the resident's clip alarm on the resident and forgot to place the fall mat on the floor next to the resident's bed. Staff F stated she continued to assist other resident's with cares up until the time she heard alarms going off in Resident #11's room (according to an incident summary report, Resident #11 was found on the floor on [DATE] at 9:45 P.M.) Staff F stated at the time she heard Resident #11's alarms, she was in the process of ambulating a different resident, who also required alarms, from the bathroom to his/her bed and could not leave that resident. Staff F stated she guessed approximately 5 minutes went by between the time she heard Resident #11's alarms and the time she made it to Resident #11's room. Staff F stated by the time she got to Resident #11's room, Staff E (RN) was in with Resident #11. Staff F stated she could not get back to Resident #11 because she got busy with other residents. Staff F stated sometimes when residents are restless, "it gets busy". Staff F stated at times she wore a Walkie-talkie and could radio her co-workers about who would respond to an alarm, but stated that evening she did not have a Walkie-talkie on and had left it on the desk. Staff F stated after Staff C left on [DATE] at 9:00 P.M., things got kind of busy. During telephone interview on [DATE] at 2:20 P.M., Staff F stated on [DATE] she did not check in on Resident #11 between approximately 7:00 P.M. and the time she heard the resident's alarms sounding at 9:45 P.M. During interview on [DATE] at 3:40 P.M., Staff C (CNA) described Resident #11 as often restless and attempted to stand independently quite a bit unless Resident #11 was given books or magazines to keep him/her busy. Staff C stated on [DATE] she helped transfer Resident #11 to bed at approximately 6:30 P.M., Staff C stated she and Staff F decided to put Resident #11 to bed to see if he/she would be more comfortable as Resident #11 talked about feeling tired. Staff C stated she could not recall if she and Staff F provided an opportunity for Resident #11 to use a commode or toilet. Staff C stated she and Staff F transferred the resident from his/her recliner in his/her room to bed and Staff C then left the resident's room. During telephone interview on [DATE] at 1:56 P.M., Staff C again stated she had not remembered Resident#11 being on a commode to toilet prior to being transferred to bed on [DATE]. During telephone interview on [DATE] at 11:07 A.M., Staff C stated after she helped transfer Resident #11 to bed on [DATE] at approximately 6:30 P.M., she did not check on the resident again for the rest of her shift. Staff C stated both of the CNA/CMA's on duty during her shift are responsible for the care of the residents. Staff C stated Staff F finished all of Resident #11's cares on [DATE] during the shift. Staff C stated she assumed the resident slept after assisted to bed as the resident's alarms had not sounded between the time Resident #11 went to bed and the time her shift ended at 9:00 P.M. During interview on [DATE] at 5:45 P.M. Staff E (RN) stated some evenings when she works are quiet after 9:00 P.M., and sometimes it isn't and there are many call lights going off. Staff E stated she helps answer call lights and alarms, but her med pass usually runs until 9:00 or 9:30 P.M. Staff E stated some residents want medications past 9:30 P.M. Staff E identified Resident #11's room as close to the nurses station (Note- Observation on [DATE] at 1:05 P.M., revealed Resident #11's room measured approximately 12 paces from his/her room door to the nurses station). Staff E stated being able to hear Resident #11's alarms going off in the resident room if she sat at the nurse ' s station, but stated if behind a closed door in a different area of the 100 hall, she described Resident #11's alarms as difficult to hear. Staff E stated Resident #11 attempted to stand on his/her own from the w/c, recliner and his/her bed. Staff E stated she had heard reports of Resident #11 turning off his/her pressure alarm, but never witnessed that behavior herself. Staff E reported finding Resident #11 on his/her bathroom floor on [DATE] at 9:45 P.M. Staff E stated on [DATE], prior to finding Resident #11 on the bathroom floor, she had been in room 116 (approximately 41 paces from Resident #11's room), set up and administered 1 pill for the resident residing in room 116. Staff E stated at the time she exited room 116, she heard an alarm going off in Resident #11's room, hurriedly went to Resident#11's room and heard a crash (she described the crash sound as the resident's walker falling to the floor). Staff E stated she entered Resident #11's bathroom and found the resident laying on the bathroom floor. Staff E stated she had just walked past Resident #11's room on her way to room116 had glanced in Resident #11's room and he/she appeared to be sleeping. Staff E, reported not wearing a Walkie-talkie and stated none of the nursing staff wear Walkie-talkies as there is much static when used. Staff E, described Resident #1's clip alarm as the only alarm sounding and described the pressure alarm as in the off position. Staff E described the resident's bed height as at approximately 2 feet off the floor and the floor mat as not in place on the floor. During interview on [DATE] at 3:30 P.M., Staff A, Licensed Practical Nurse (LPN) described Resident #11 as attempting to stand on his/her own often and stated the resident often stated he/she needed to use the bathroom During interview on [DATE] at 9:00 A.M., the DON stated the facility nursing staff did not use Walkie-talkies. The DON stated the facility never made Walkie-talkies mandatory and described the Walkie-talkies as loud and noisy and staff didn ' t care for them. During interview on [DATE] at 10:07 A.M. Staff D, CNA identified Resident #11 as attempting to get up on his/her own often. Staff D described the resident as anxious and restless. During telephone interview on [DATE] at 10:25 A.M., Resident #11's primary Physician described Resident #11 as very elderly and fragile and described the resident as at high risk for fracture. The Physician stated she felt Resident #11's passed away from complications being bed bound. The Physician stated Resident #11's osteoporosis and frailness contributed to Resident#11's fractures. During interview on [DATE] at 11:15 A.M., the DON confirmed 22 residents resided in the 100 hallway on [DATE], and 5 residents required alarms in the 100 hallway on [DATE]. During interview on [DATE] at 2:40 P.M. the DON confirmed Resident #11's care plan lacked direction for toileting the resident. The DON stated she expected staff to toilet residents every ,[DATE] hours. The DON stated she didn ' t know how staff communicated to one another while busy in a room with residents and alarms sounded in other resident rooms.

Based on record review and staff interviews the facility failed to ensure residents received medications as ordered by the physician for one of seven residents reviewed (Resident #7). Resident #7 received another resident ' s medication by error which required hospitalization due to confusion, lethargy and [MEDICAL CONDITION]. The facility reported a census of 45 residents. Findings included: 1. The Minimum Data Set (MDS) assessment tool dated September 22, 2011 documented Resident #7 with severe cognitive impairment, minimal depression, usually understood others and usually made self understood, required supervision with bed mobility, transfers, toilet use, and ambulation, and required extensive staff assistance with dressing, personal hygiene, and bathing. The October 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A Resident Care Plan with a Team Conference Date of 1/31/2011 documented the resident had problems with [MEDICAL CONDITION], hallucinations, and decision making and a goal date of 12/29/2011 for the resident to maintain a sense of security at the facility. A Nursing Notes entry dated 9/28/2011 at 8:00 a.m. and a Medication/Treatment Error Report attachment sheet documented Resident #7 received another resident's (Resident #8) medications that included [MEDICATION NAME] (anti-psychotic) 300 milligrams (mg), [MEDICATION NAME] 5 mg (antipsychotic), Senna Plus (a stool softener with laxative), [MEDICATION NAME] (anti-Parkinson ' s agent) 1 mg., [MEDICATION NAME] (antipsychotic) 5 mg., [MEDICATION NAME] ER (anticonvulsant) 500 mg., and [MEDICATION NAME] 134 mg (to lower triglycerides). A Medication/Treatment Error Report attachment sheet and the September 2011 at 8:00 a.m. MAR indicated [REDACTED]., Aspirin ([MEDICATION NAME]/delays clotting time) 81 mg., [MEDICATION NAME] (antidepressant) ([MEDICATION NAME]) 20 mg., [MEDICATION NAME] 0.5 mg., [MEDICATION NAME] 160 mg., Vitamin B 12 1000 micrograms (mcg), Actos 30 mg., [MEDICATION NAME] 10 mg., [MEDICATION NAME] Extended Release 5 mg., and [MEDICATION NAME] 150 mg. by mouth. The September 2011 MAR indicated [REDACTED]., and Milk of Magnesia 15 milliliters (ml). The Medication/Treatment Error Report sheet dated 9/28/2011 documented the resident had received another resident's medications, the nurse had not compared Resident #7"s name on the medication package to the resident's name on the MAR, and the nurse had recognized the medication error within 15 minutes, and notified the physician and Director of Nursing promptly. The facility Nursing 2010 Drug Hand Book 30th Anniversary Edition published by Wolters Kluwer/Lippincott Williams and Wilkins listed the following information about the medications the resident received: 1. [MEDICATION NAME]: an antipsychotic medication used to treat [MEDICAL CONDITION]. Adverse Reactions include: dizziness, headaches, somnolence, orthostatic [MEDICAL CONDITIONS] leukopenia, and [MEDICAL CONDITION]. 2. [MEDICATION NAME]: an antipsychotic medication used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorders. Adverse Reactions include: somnolence, [MEDICAL CONDITION], parkinsonism, dizziness, [DIAGNOSES REDACTED], suicide attempt, abnormal gait, tardive dyskinesia, orthostatic [MEDICAL CONDITIONS] hypertension, leukopenia, and [MEDICAL CONDITION]. 3. [MEDICATION NAME]: an antiparkinsonian medication used to treat tardive dyskinesia, dystonic reactions, and Parkinsonism. Adverse Reactions include: confusion, memory impairment, nervousness, depression, disorientation, hallucinations, toxic [MEDICAL CONDITIONS] and paralytic ileus. 4. [MEDICATION NAME]: [MEDICATION NAME], an antipsychotic medication used to treat [MEDICAL CONDITION], chronic [MEDICAL CONDITION], and nonpsychotic behavior. Adverse Reactions include: severe extrapyramidal reactions, tardive dyskinesia, [DIAGNOSES REDACTED], [MEDICAL CONDITION], sedation, drowsiness, lethargy, headaches, [MEDICAL CONDITION], confusion, [MEDICAL CONDITION], [MEDICAL CONDITIONS], hypertension, electrocardiogram changes, blurred vision, leukopenia, and leukocytosis. 5. [MEDICATION NAME] ER: [MEDICATION NAME], an anticonvulsant use to treat [MEDICAL CONDITION], mania, and prevent migraine headaches. Adverse Reactions include: asthenia (loss of strength and energy, weakness), dizziness, headache, [MEDICAL CONDITION], nervousness, somnolence, tremor, abnormal thinking, amnesia, ataxia, depression, emotional upset, blurred vision, diplopia, bone marrow suppression, hemorrhage, [MEDICAL CONDITION], and hepatotoxicity. 6. [MEDICATION NAME]: a medication used to treat elevated lipids and uric acid. Adverse Reactions include: dizziness, headache, asthenia, fatigue, [MEDICAL CONDITION], paresthesia, cardiac arrhythmias, blurred vision, eye floaters, infection, pruritis, and rash. A Nursing Notes entry dated 9/28/2011 at 8:05 a.m. documented the resident's physician had been notified Resident #7 received another resident's medications and the facility had received physician orders [REDACTED]. four times daily), hold [MEDICATION NAME] ER (1000 mg. at bedtime, and hold [MEDICATION NAME] (5 mg. at bedtime) on 9/28/2011. The physician directed staff to administer the resident's Aspirin 81 mg., Actos 30 mg., and [MEDICATION NAME] 150 mg. twice daily on 9/28/2011. The physician directed staff to check the resident's vitals immediately and four times daily, call the physician if the resident's blood pressure was less than 100/60 or higher than 140/90, check the resident's blood sugar four times daily, and call if the blood sugar was less than 100 or greater than 200. The Nursing Notes entries documented the following after Resident #7 had received the wrong medications at 8:00 a.m. and the physician had been notified at 8:05 a.m. on 9/28/2011: a. At 8:30 a.m. the resident's blood pressure (BP) was 110/64, pulse 70/minute (min) and regular, and the resident was alert and had no adverse reactions at that time. b. At 8:45 a.m. the resident's BP was 108/60, pulse 70/minute and regular, and the resident remained alert and answered questions appropriately. c. At 9:00 a.m. the resident's BP was 92/50, pulse 64/minute and regular, the resident was more lethargic, speech slightly slurred, and had more difficulty keeping eyes open. d. At 9:15 a.m. the resident's BP was 80/46, pulse 70/minute and regular, respirations (resp) 16/minute, oxygen saturation (O2 Sat) 89 to 91% on room air, temperature 97.1 degrees Fahrenheit, the physician had been notified of the resident's condition and decrease in BP, and the physician had directed the facility staff to transport the resident to the hospital by ambulance. e. At 9:35 a.m. the resident had been transferred to the hospital. A hospital Emergency Department Clinical Record sheet documented the resident arrived at the hospital on [DATE] at 10:30 a.m., the resident's BP had been 126/52, pulse 68/minute and regular, respirations 18/minute and without distress, oxygen saturation 94%, lung sounds diminished, and the resident was disoriented and lethargic. An untimed entry documented the resident had an intravenous (IV) solution started by emergency medical services (EMS) and infused at 30 milliliters/hour. An entry at 11:10 a.m. documented the IV rate had been increased to an open rate, 1000 ml had infused by 11:50 a.m., and 1000 ml of Normal Saline had been administered at 150 ml/hour. The emergency room sheet documented the following on 9/28/2011: a. At 11:30 a.m. the resident's BP was 100/80, pulse 70/min., resp. 24/min., O2 Sat. 93%. b. At 12:30 p.m. the resident's BP was 108/45, pulse 70 per minute, resp. 20 per minute., O2 Sat. 92%, and Oxygen had been applied at 2 liters/min. c. At 1:30 p.m. the resident's BP was 124/64, pulse 57 per minute, respirations 20 per minute, O2 Sat. 97%, and the resident remained somnolent. d. At 1:46 p.m. the resident's BP was 141/96, pulse, 54 per min., resp. 14 per minute, O2 Sat. 99%, the resident had been without pain, became more alert to verbal stimulation, speech garbled, and the resident quickly fell back to sleep. e. At 2:15 p.m. a physician had been consulted for admission (observation). f. At 2:35 p.m. the resident's BP was 142/64, pulse 58 per minute, respirations 16 per min., and the resident remained somnolent. g. At 3:09 p.m. admission orders [REDACTED] h. At 3:40 p.m. the resident's BP was 147/59, pulse 56/min., resp. 16/min., O2 Sat. 100%, and the resident opened his/her eyes temporarily when the nursed asked questions and the fell asleep again. A hospital Physician Notes sheet documented the physician had seen the resident September 28, 2011 at 10:53 a.m. after the resident had been given the wrong medication, the resident had [MEDICAL CONDITION], decreased cognition and alertness, the resident was normally awake and alert, and had mental [MEDICAL CONDITION] and some assessment information had been unobtainable. A physician note at 1:45 p.m. documented the resident continued with a depressed mental status, the resident had been oriented to person, and the resident remained at the hospital for observation. A hospital note dated September 29, 2011 documented the resident had been admitted to the hospital for observation with somnolence, confusion, and [MEDICAL CONDITION] following accidental drug ingestion and the resident had been discharged back to long term care facility. During an interview on 10/7/2011 at 7:27 a.m. a hospital emergency room nurse stated she had cared for Resident #7 on 9/28/2011 after the resident had received the wrong medications. The nurse stated the resident's Glasgow Coma Score was 14 out of a possible 15 and indicated good response, the resident had been sleepy on arrival, and slept when staff had not been engaged with the resident. The nurse stated the resident had a Triage Level of 3, level one was the most acute, level two was acute but not imminent, and level three included close observation and run tests for diagnostic reasons. The nurse stated level three residents were admitted for close observation and no long term affects had been anticipated. During an interview on 10/7/2011 at 9:10 a.m., the physician that saw Resident #7 in the emergency roiagnom on [DATE] stated the resident had been mild to moderately somnolent on arrival to the emergency room , sleepy, and responded to command. The physician stated the resident had been hypotensive at the facility and the [MEDICAL CONDITION] had resolved spontaneously. The physician stated he/she didn't feel the resident had any [MEDICATION NAME] harm, the medications received made the resident sleep for awhile, the potential for harm to the resident had probably been small, and a potential for harm existed with medications prescribed by the resident's own physician. During an interview 10/6/2011 at 10:45 a.m. Staff G stated she realized right afterwards that she gave Resident #7 his/her medications on 9/28/2011 at 8:00 a.m. she had administered Resident #8's medication to Resident #7 and reported the error. Staff G stated the two resident's medications had been stored next to each other in the medication cart and she had grabbed Resident #8's by mistake. Staff G stated she began employment at the facility on 9/6/2011 and had not worked alone passing medications very long when the medication error occurred. Staff G stated she now made sure she checked each medication container to make sure the right resident, medication, dose, time, and route were the same as the resident's MAR, and made sure she checked the resident's picture and name outside of the resident's room or on the MAR, asks the resident, or another staff member the resident's name in order to make sure the resident received the right medication. During an interview at 12:35 p.m. Staff G stated the facility had performed medication administration audits with her after the resident had received the wrong medication. Review of Medication Administration Observation/Skills Checklist sheets revealed the DON had performed audits with Staff G on 9/30/2011 and 10/4/2011 and 10/5/2011 and the residents had been identified correctly. During an interview on 10/6/2011 at 2:35 p.m. Staff B and the Administrator stated the facility lacked an orientation check list and the Director of Nursing (DON) stated she planned to implement a check list. During an interview on 10/5/201, the DON stated she had began employment at the facility 9/19/2011 as a Nurse Consultant until a temporary license had been obtained from another state and once the temporary license had arrived she would be the DON. During an interview on 10/6/2011 (no time) the DON informed the surveyor her temporary license had arrived. During interview 10/6/2011 at 2:35 p.m. Staff C stated Staff G had received orientation on 9/6-8,13,15,20 and 21,2011 Staff C stated Staff G oriented upstairs (Resident #7 and #8 resided upstairs) on 9/6-8, 9/20 and 9/21/2011 because Staff G planned to work primarily upstairs. Staff C stated she had reviewed the six rights of medication administration with Staff G: the right medication, dose, time, route, resident, and documentation. Staff C stated Staff G observed medication administration upstairs on September 6 and 7, would have passed some medications on September 8. Staff B stated Staff G observed medication administration down stairs on September 13 and 14, and may have passed all the medications with a nurse observing on September 15, 2011. Staff B stated Staff G worked upstairs again September 20 and 21 and passed medications with another nurse observing. Staff B stated Staff G worked alone upstairs on September 22, 2011 following orientation, had been informed to ask questions any time, and Staff G had been very good about asking questions. During an interview on 10/6/2011 at 2:45 p.m. Staff G stated she had been aware of the five rights of medication administration: medication, dosage, time, route, and resident. Staff G verified she had performed the medication task for the upstairs residents alone during orientation 9/21/2011 and felt like she was getting to know some of the residents, but not all. Staff G stated she told the DON after the medication administration error occurred that she probably could have used a little more orientation and the DON had stated the orientation Staff G received was typical of the orientation other facilities had performed. During an interview on 10/6/2011 at 4:10 p.m. the DON stated the facility lacked any type of policy for medication administration. The DON stated she expected staff to follow Standards of Practice for medication administration. The DON stated she expected staff to triple check the MAR prior to medication administration. The first check had been to compare the medication in the cassette to the name of the medication on the MAR indicated [REDACTED]. The second check had been to compare the medication in the cassette to the MAR indicated [REDACTED]. The third check had been to sign off the medications given. During an interview on 10/7/2011 at 8:55 a.m. the DON stated she expected staff to follow through on the five rights of medication administration with the triple check of the MAR.

Based on record review and staff and physician interviews, the facility failed to assess and implement interventions for bowel management for 1 of 10 residents reviewed (Resident # 1). The facility identified a census of 43 residents. Findings Include: 1. Resident #1 had an Minimum Data Set (MDS) assessment with a reference date of 6/17/11 which identified [DIAGNOSES REDACTED]. The MDS documented a Brief Interview for Mental Status (BIMS) score of 3 which signified the resident had severe cognitive skills for decision making. The MDS documented the resident continent of bowel movements. The MDS documented the resident required 2 person assist for toilet use, bed mobility, and transfers. The Resident Care Plan, with a review date of 6/22/11 revealed the resident had problems with constipation due to decreased activity and improved eating. Staffs were to observe the resident's bowel patterns and administer medications if needed for constipation. The Monthly Care Plan for July 2011 revealed the resident did not have a bowel movement (BM)t on 7/7/11, had a small BM on 7/8 and did not have a BM on 7/9 and 7/10/11. Review of the physician's orders [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Staff interview with Staff A 9 Licensed Practical Nurse on 8/10/11 at 6:15 am revealed the unwritten policy for monitoring bowel movements instructed staff to administer MOM on the evening of the second day without a BM and to administer a [MEDICATION NAME] suppository on the 3rd morning without a BM. She stated the documentation did not reveal an accurate description and consistency of the resident's BM. The Nursing Notes revealed the resident on 7/11/11 at 9:00 PM had difficulty leaning to the left, falling forward when on the toilet or in the wheelchair. On 7/12/11 at 8:30 AM the resident's physician ordered the resident to be transferred to the hospital. Record review of the Emergency Doctor Notes, dated 7/12/11, revealed the laboratory data revealed the abdomen showed increased stool. Record review of the hospital Diagnostic Radiology report, dated 7/12/11, revealed clinical data as diffuse abdominal pain. The report revealed an impression of a large amount of stool throughout the colon with inspissated fecal matter in the rectum and sigmoid as well as the descending left colon indication fecal impaction. Paucity of the small bowel. Record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] a. On 7/13/11 at 11:57 AM the resident received 300 ml of magnesium [MEDICATION NAME] ( a laxative used to alleviate constipation). b. On 7/14/11 at 10:38 the resident received 600 ml of magnesium [MEDICATION NAME]. Record review of the Preliminary Report, dated 7/16/11, revealed the physician documented the patient continued to do pretty well. The resident had several stools and the fecal impaction had resolved. Staff interview on 8/11/11 at 8:00 am with A 37, acting Director of Nursing revealed the facility did not have a written policy related to BM monitoring. She stated the resident to have MOM on the second day and a suppository on the 3rd day if no BM. An interview with the Emergency Physician on 8/16/11 at 8:30 am revealed the x-ray report documented a fecal impaction. He said a fecal impaction can occur after 2 days, but the average time period for a person to incur a fecal impaction is 7- 10 days without a BM. He said other factors to consider are decreased activity and medications received. The resident had MOM and [MEDICATION NAME] suppository as needed PRN) medications that should of been administered. The facility failed to monitor the resident's BM's accurately. He said he would expect the facility to monitor the resident BM more closely to prevent an impaction and utilize the medication ordered.

Based on observation and staff interview, the facility failed to provide adequate supervision to a resident with a history and at high risk of falls ( Resident #1) and failed to provide nursing services to meet the needs of Resident #1 and #3 to prevent falls. The facility reported a census of 43 residents and the reviewed sample consisted of 10 residents. Record review revealed a cognitively impaired resident (Resident #1) with a fall history prior to admission and experienced a fall in the facility on 7/1/2011. The staff had been aware the resident had cognitive impairments and a decline in condition, however, the staff continued to remind the resident to use the call light when needed assistance. The facility placed a visual reminder on the resident's walker to call for help. Staff had also been aware the resident desired independence and had not always used the call light when help needed. The record lacked any documentation additional interventions had been implemented to prevent the resident from further falls. On 7/31/2011, the resident had another fall with injury and a hospitalization . Findings included: 1. The admission record identified Resident #3 had an admitted into the facility on [DATE]. The August 2011 Medication Administration Record (MAR) indicated Resident #3 had the following [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment was performed due to a significant change in condition, dated 7/8/2011, which reflected Resident #3 with a Brief Interview for Mental Status (BIMS) with a score of six. A BIMS score of 0-7 indicated severe cognitive impairment. The MDS documented the resident required extensive staff assistance and one person physical assistance with bed mobility, transfers, walking in the room and corridor, dressing, toileting, personal hygiene, and bathing, and the resident had occasional urine incontinence. The MDS documented the resident's balance had not been steady, but the resident had been able to stabilize without human assistance and the resident had bilateral upper and lower extremity range of motion impairment. The MDS identified the resident had a fall with an injury that had not been a major injury. A Care Area Assessment (CAA) For Cognitive Loss/Dementia & Communication sheet dated 7/12/2011 documented the resident had a moderate amount of dementia especially with short term memory, moderate difficulty recalling recent events, oriented to time, place, and person 100% of the time, and required extensive assistance of one staff with activities of daily living, except for eating, due to an overall physical and mental decline. The CAA documented the resident had more difficulty with hearing, stated the hearing aids made hearing worse and refused to wear the aids some days, and the resident needed things repeated especially if not in a quiet environment. The CAA documented the resident had a decline in physical condition with some mental components, and the resident's family had noticed a small decline in mental status and agreed the resident had some days better than other days. Clock Draw sheets dated 1/24/2011 and 7/13/2011 documented the resident had a score of 2 out of a possible 4. During an interview on 8/12/2011 at 9:56 a.m., Staff A14 stated a score of 2 meant the resident had cognitive impairment A CAA for Activities of Daily Living (ADL) sheet dated 6/12/2011, documented the resident had a gradual decline in ability to ambulate, had a recent fall on 7/1/2011 which caused a further decline in walking, and the resident's cognition had declined. The CAA documented the resident required extensive staff assistance with ADL's due to unsteadiness on feet and balance issues while ambulating. A CAA for Falls sheet dated 7/12/2011 identified the resident had the first fall at the facility on 7/1/2011 at 7:10 a.m. when the resident had attempted to sit in a chair and had toppled over. The CAA documented the resident had a fall prior to admission to the facility and the family had been uncertain how long the resident had been on the floor. The CAA documented the resident had weakness, moderate cognitive impairment, difficulty hearing, and a recent infection, ambulated in the room with extensive assistance of one staff, a walker, and tired easily and became unsteady, and used a wheel chair for distances outside of the room. A Fall Risk Assessment sheet documented the resident's score had been a 6 on 1/16/2011, 2 on 4/26/2011 and 12 on 7/12/2011. The sheet identified a score of ten or above represented the resident at a high risk for falls. A Resident Care Plan with a Team Conference Date of 2/3/2011 indicated the resident had a problem with recalling recent events and directed staff to give gentle reminders for meals and activity times. The care plan documented the resident had weakness, had been unsteady at times, had a risk for falls and injury, and directed staff to give gentle reminders to call for assistance while regaining strength. The care plan had an entry dated 3/1/2011 which directed staff to allow the resident to walk ad lib per the physical therapist. An entry dated 4/20/2011 documented the resident used a four wheeled seated walker to ambulate. A Resident Care Plan with a Team Conference Date of 7/14/2011 indicated the resident had a problem with experiencing more memory difficulty and directed staff to give gentle reminders for meals and activity times. The care plan documented the resident had more difficulty with walking and had decided to stay at the facility for assistance with ADL's and directed staff the resident used a four wheeled seated walker for ambulation and preferred to use a wheel chair outside of the room. The care plan lacked documentation of the number of staff the resident required to ambulate even though the 7/8/2011 MDS documented the resident required extensive assistance of one staff for ambulation in the room an corridor and transfers. A nursing IDPN-Interdisciplinary Plan Notes sheet dated 7/7/2011 documented the resident had an overall change in condition, cognition somewhat worse, short term memory very poor, BIMS score 6 and was not able to immediately recall words, required more assistance with ambulation, gait unsteady, and the resident had a fall. A Nursing Notes entry dated 7/1/2011 at 7:10 a.m. documented the resident missed the chair when attempted to sit down in his/her room. An Incident Assessment sheet dated 7/1/2011 at 7:10 a.m. documented the resident had toppled over when attempted to sit in a recliner in the room, had not had any type of personal, floor, or bed alarm, and used a walker and wheel chair. An area of the sheet titled Ambulated independently: Yes___ No___ had been left blank. The sheet documented the resident had a 1.5 centimeter skin tear to the right forearm without bleeding and steri-strips had been applied. The sheet documented the resident's care plan had been updated with an intervention that directed the resident to use the call light for all transfers and movement. A Fall Investigation Tool dated 7/1/2011 indicated the resident had not used the call light prior to the fall and the resident had fallen when used a walker and missed the recliner chair when sat down. The investigation sheet documented new safety interventions implemented to decrease falls had been to remind the resident to use the call light and a visual reminder to use the call light had been placed on the walker. The Resident Care Plan with a Team Conference Date of February 3, 2011 had entries dated July 1, 2011 that directed staff to continue to give the resident gentle reminders to use the call light for assistance and a visual reminder had been placed on the resident's walker. Nursing Notes entries documented the following: a. On 7/16/2011 at 5:10 p.m. the resident had been found gripping the walker with knees bent and stated he/she felt dizzy. The resident sat and felt better. b. On 6/18/2011 at 11:00 a.m. the resident ambulated with a slow steady and shuffling gate. The resident stated his/her legs felt weak and requested assistance to walk off the unit. c. On 6/28/ 2011 at 7:30 a.m. the resident requested to take a wheel chair to breakfast. (The resident's room was on second floor and the resident ate all meals on the first floor). d. On 7/4/2011 at 6:00 a.m. the resident tried to be independent but balance had not been good lately, the resident had not gotten used to using the call light to ask for assistance and the nurse reminded the resident to use the call light for assistance. The resident needed daily reminders to use the call light when assistance needed. e. On 7/4/2011 at 10:00 a.m. the resident had been weak and used the wheel chair to go down stairs for meals, ambulated only short distances, had been found taking self to the bathroom without assistance, and the nurse reminded the resident to use the call light for assistance. f. On 7/11/2011 at 9:00 a.m. documented the resident's physician had given an order for [REDACTED]. g. On 7/11/2011 at 1:45 p.m., the resident continued to be alert and oriented to time, place, and person, had some forgetfulness, used the call light for assistance, required one staff assistance and walked short distances, and used the wheel chair due to leg weakness. h. On 7/18/2011 at 6:00 a.m. the resident required staff assistance for all ADL's. The physical therapist documented on 7/14/2011 that the resident had been admitted to physical therapy; had administered gait training and therapy exercises, range of motion (ROM) had been poor and the resident ' s safety awareness had been poor. A physical therapy sheet dated 7/19/2011 indicated the resident shuffled when walked and the therapist continued to work with the resident with gait training, safe positioning with the walker, and safe transfers. A physical therapy sheet dated 7/22/2011 indicated the resident required verbal cues to increase stride length, increase floor clearance with steps, and stand upright. The therapist documented the resident tired more easily and tried to cut corners to shave inches off of his/her path which sometimes caused the resident to bump into things or get the walker wheels hung up. The therapist documented the resident used "short cuts" that could adversely affect safety. A physical therapy sheet dated 7/28/2011 indicated the resident's second long term goal to consistently transfer to bed had been achieved, or close to achieved, and documented the resident needed to work on transfers a little more. A Nursing Notes entry dated 7/31/2011 at 6:15 a.m. reflected a nurse had found the resident on the floor by the bed on right side with a four centimeter laceration to the right side of the resident's head. The physician had been notified and the resident had been transferred to the hospital via ambulance. An Incident Assessment sheet dated 7/31/11 at 6:15 a.m. documented a pool of blood had been found on the floor underneath the resident. The resident had been unable to recall any events prior to the fall. The resident had been aware of his/her name and location. The sheet documented the resident had been without any type of alarm and the resident had a 4 cm (centimeter) long by 3 cm wide laceration to the right side of the head. A physical therapy Discharge Summary dated 8/2/2011 documented the resident had been discharged from therapy due to a fall and subsequent hospitalization . The discharge note documented the resident's progress had been slow but coming. A Fall Investigation Tool dated 7/31/2011 documented the resident had been found without footwear on, without pants, the floor dry and without clutter and the resident had not used the call light. A hospital History and Physical (H&P) dated 7/31/2011 documented the resident had been admitted to the hospital for observation and a surgical consult. The H&P documented the resident had a Computerized Tomography (CT) of the head that showed a right frontal subdural parafalcine hematoma that measured 5.4 mm (millimeters) by 3 to 4 mm. he H&P documented the resident had a laceration of the soft tissue of the head that had been stapled in the emergency room . A hospital physician Consultation sheet dated July 31, 2011 documented the resident had a small interhemispheric subdural hemorrhage and surgery had not been required. The physician recommended to allow the lesion to absorb. A Nursing Notes entry dated 8/3/2011 at 4:30 p.m. documented the resident had returned to the facility. The Resident Care Plan with a Team Conference date of 7/14/2011 had an entry dated 7/31/2011 which documented the resident needed a fall mat placed by the bed. An entry dated 8/3/2011 documented the resident needed a clip alarm at all times. An entry dated 8/8/2011 documented the resident required one to two staff with transfers in the room and cares. On 8/11/2011 at 8:30 a.m., Staff K was questioned if it would be an appropriate intervention for a cognitively impaired resident to be reminded to use the call light when needing assistance. Staff K stated the staff had placed a verbal reminder on the resident's walker to use the call light when help needed. Staff K stated when she provided cares to residents, the resident used the call light. During an interview on 8/11/2011 at 1:30 p.m. Staff A5 stated no matter how many times the staff reminded the resident to use the call light when needing assistance, the resident felt he/she would be a bother and wanted to remain independent. Staff A5 stated she had no memory of the resident wearing any type of alarm prior to the 7/31/2011. During an interview on 8/12/2011 at 8:40 a.m., Staff S stated the resident had wanted to be independent prior to the 7/31/2011 fall and had rarely used the call light. Staff S stated the resident had used the call light after the 7/31/2011 fall. During an interview on 8/12/2011 at 8:41 a.m., Staff A8 stated she agreed with Staff S and the resident had not used the call light very often prior to the 8/31/2011 fall. 2. Record review of the Minimum Data Set (MDS), dated [DATE] for Resident # 1 revealed [DIAGNOSES REDACTED]. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which signified the resident's cognition intact. The MDS documented the resident required 2 person extensive assist for bed mobility and transfers. Record review of the Resident Care Plan, dated 12/9/10 with a review dated of 6/9/11, revealed the resident at risk for Activities of Daily Living (ADL) decline related to Parkinson's disease manifested requiring 1-2 staff assist with mobility. Staff were to assist the resident with all ambulation efforts and be alerted for "freezing" of feet when ambulating-give verbal cues and/ or assist in shifting weight slightly. Observation on 8/10/11 at 6:31 AM revealed Staff M (Certified Nursing Assistant) assist the resident to the edge of his/her bed. He did not put shoes, socks or slipper socks on the resident. Staff M walked the resident, using a gait belt, to the bathroom with the resident having bare feet; freezing and cues were necessary for the resident to continue to walk.

Based on observation, record review and staff interviews the facility failed to provide adequate supervision to prevent accidents and failed to reassess resident ' s health care needs and direct services to evaluate a systematic approach for two residents with falls (Resident #1 and Resident #2). The facility reported a census of forty (40) residents. Findings included: 1. According to Physician order [REDACTED]. A Minimum Data Set (MDS) with an assessment reference date of 1/20/2011 indicated the resident's cognition had been severely impaired, had difficulty with memory recall and continuously experienced inattention, disorganized thinking and psychomotor retardation. The same MDS further indicated the resident required extensive assistance with bed mobility, required total dependence on staff with transfers and the resident had not walked in his/her room of the facility corridor during the seven (7) day assessment period. The MDS revealed the resident had impairment in both lower extremities with range of motion and had a history of [REDACTED]. A Fall Risk Assessment completed 1/11/2011 indicated the resident had been at high risk for falls on 10/10/10 and 1/11/2011. Review of Significant Event Forms in regards to falls revealed Resident #1 experienced falls on 5/27/2010 (pain in back and hip and a raised bump on head), 7/30/2010 (no apparent injuries), 8/10/2010 (no apparent injury-just red knees), 8/29/2010 (no apparent injury) 10/6/2010 (right groin pain and small bump on head) and 1/14/2011 (abrasions on shins). Further review of a Significant Event Form in regards to a fall dated 10/6/2010 revealed the resident fell and required transfer to a hospital with a higher level of care. Review of a History and Physical form completed by a physician dated 10/6/2010, revealed the resident had suffered a fracture of the right hip. Review of the Nursing Notes dated 10/13/2010 revealed the resident had returned from the hospital following the hip fracture and had been positioned in a geriatric (geri) chair. During an interview on 2/3/2011 at 8:19 A.M., the facility Director of Nursing (DON) confirmed the resident remained in a geri chair when not in bed as she/he felt it had been the most appropriate for comfort purposes and the resident could not bear weight. Review of a Resident Care Plan with a team conference date of 10/28/2010 revealed the resident had been at risk for injury due to a history of falls and the resident's inability to comprehend his/her physical limitations. The same Resident Care Plan included an approach for a pad alarm at all times. A Physical Therapy (PT) Evaluation and Plan of Treatment form signed by a Physical Therapist on 10/21/2010 documented the resident had been very mobile prior to his/her hip fracture. The PT evaluation form further revealed the resident had toe touch weight bearing only and the resident's cognition would not allow the resident to learn new skills. A Therapy Documentation note written by a Physical Therapist on 10/21/2010 revealed the resident had been seen in Physical Therapy on five (5) separate occasions and had not progressed. The therapist documented a range of motion program had been set up for the resident until the resident's weight bearing status changed. Review of the Resident Care Plan with a team conference date of 10/28/2010 revealed the resident's approach for a pad alarm had been discontinued on December 28 (no year documented). During an interview on 2/4/2011 at 8:19 A.M., the DON stated the resident's pad alarm had been discontinued as the resident had been not making any attempts to get up on his/her own. A Physician visit form dated 1/3/2011 revealed a Physician had ordered the resident to begin Physical Therapy once again and ordered the resident's weight bearing to be as tolerated on the right leg. A Therapy Documentation form dated 1/6/2011 revealed the resident began Physical Therapy. The Therapy Documentation form revealed the resident's treatment on that day had entailed sit to stand maneuvers with the assist of two staff members. A Therapy Documentation form dated 1/11/2011 indicated a Physical Therapist documented the resident had been seen in therapy while the resident had been seated in a geri chair and had been difficult for the resident, The Physical Therapist documented the geri chair had the resident leaning back a bit and had been difficult for the resident to overcome. The Physical Therapist documented the resident had participated in sit to stand maneuvers with the assistance of two staff members. The Physical Therapist documented a plan to work more from a wheelchair at the next PT visit and work on some self propelling movements. A Therapy Documentation form dated 1/12/2011 revealed a PT Assistant documented the staff had the resident in a wheelchair to accommodate therapy. Review of the Nursing Notes dated 1/14/2011 at 9:25 a.m., revealed staff documented the resident had been heard screaming in the upstairs dining room and the resident had been found on the floor with a wheelchair behind the resident. Review of a physician consultation form dated 1/15/2011 revealed the resident had suffered a right leg tibia and fibula fracture. Review of a Significant Event form in regards to the fall on 1/14/2011, staff documented the resident had fallen at 9:25 A.M. Staff documented the resident stated he/she had tried to stand up but could not stand. Further review of the same Significant Event form and the investigation form of the fall lacked documentation of the circumstances that had led up to the fall. The investigation form revealed canned questions such as: Was the floor wet? What footwear had been on the resident's feet?, Was there anything on the floor?, Was the toilet seat attached?, How is the lighting?, Is the call light functioning?, Were the resident's pants too long?, Ask the resident's roommate if the resident pulled the call light?, etc. The investigation form contained questions mostly that had not applied to the resident's fall, yet no further investigation had been documented. During an interview on 2/3/2011 at 11:05 A.M., Staff P (Certified Nurse Aid-CNA) confirmed she/he had been on duty upstairs (where Resident #1 resided) on 1/14/2011. Staff P stated the resident had been placed in a wheelchair on the morning of 1/14/2011 at approximately 7:30 A.M. or 8:00 A.M. Staff P stated it to be her/his understanding physical therapy had left a note on a daily assignment sheet stating the resident needed to be in a wheelchair in order for the resident to start moving his/her feet more. Staff P confirmed the resident had been routinely placed in a geri chair in the mornings up until 1/13/2011. Staff P stated the resident had been routinely placed in the dining room as the resident had no television in his/her room and the dining room had a television, and because the resident was supposed to be watched. The surveyor asked Staff P the reason for the resident needing to be watched and Staff P stated she guessed it had been because of prior falls but had not been sure. Staff P stated at the time the resident fell on [DATE], it had been appropriate to leave the resident alone in a dining room in a wheelchair without an alarm as someone had always been looking in on the resident. Staff P stated someone had always been passing by the dining room and there had been a window into the dining room next to the nurses ' station. Staff P confirmed on the morning of 1/14/2011 at the time of the resident's fall, three (3) CNA's and one (1) nurse had been working on the floor the resident resided. Staff P confirmed all 3 CNA's left the floor at approximately 9:00 A.M. for a break. Staff P stated all 3 CNA's go to morning break together every day. Staff P confirmed the charge nurse had been the only staff member on the floor at the time of the resident's fall. While all 3 CNA's had been off the floor, the resident fell and fractured his/her right leg. During an interview on 2/3/2011 at 11:25 A.M., Staff A1 (CNA) confirmed she had worked upstairs on 1/14/2011 the morning Resident #1 fell . Staff A1 stated she had questioned why the resident had been in a wheelchair and she/he stated had thought the nurse in charge (Staff B) told her PT wanted the resident in a wheelchair because it had been easier for physical therapy staff to stand the resident from a wheelchair rather than a geri chair. Staff A1 stated she/he had spoken to the physical therapy assistant and she/he had intended for the staff to put the resident in a wheelchair only on the days the resident had physical therapy and then only immediately prior to the resident's scheduled time for physical therapy. Staff A1 confirmed Resident #1 had sat in a dining room when up and out of bed as the resident had no television in his/her room and the staff could keep a better eye on the resident. Staff A1 confirmed all 3 CNA's had left the floor at approximately 9:00 A.M. to take a break. Staff A1 stated the resident had fallen at the time all 3 CNA's had left the unit and had received call to come back to the floor after the resident fell . Staff A1 stated she had not felt it was safe for the resident to be in a wheelchair unattended. During an interview on 2/3/2011 at 11:40 A.M., a physical therapy assistant (who had routinely worked with Resident #1) stated she/he had spoken to a staff member (and had not been able to remember which staff member), had asked for a note to be left for staff to put the resident in a wheelchair on the morning of 1/12/2011 for physical therapy treatment only. The physical therapy Assistant stated she/he had planned to see the resident right away in the morning of 1/12/2011 and had not been her intention for staff to routinely put the resident in a wheelchair. The physical therapy assistant stated she/he had outpatients to see on 1/14/2011 and had not planned on working with the resident on 1/14/2011. During an interview on 2/3/2011 at 12:00 P.M., Staff B (Registered Nurse-RN) confirmed she/he had worked upstairs the morning of the resident's fall Jon 1/14/2011. Staff B stated she had been told by the staff working on 1/14/2011 the resident needed to be in a wheelchair as physical therapy had been working with the resident and it had been easier for the therapist to have the resident in a wheelchair. Staff B stated it had been nice to have the resident sit in the dining room as the staff had always been able to see what he/she had been doing. Staff B confirmed all 3 CNA's had been off the floor at the time the resident had fallen and Staff B had not witnessed the fall. During an interview on 2/3/2011 at 12:35 P.M., a physical therapist who had routinely worked with the resident stated he/she may have had been somewhat uncomfortable leaving Resident #1 unattended in a wheelchair. The Physical Therapist stated the resident hadn't walked in such a long time. During an interview on 2/3/2011 at 1:25 P.M., the DON stated she/he had first learned the resident had no longer been in a geri chair when up, after the resident had fallen on 1/14/2011. The DON stated she/he felt it had been appropriate for the resident to be in a wheelchair unattended without alarms as the resident routinely sat in a dining room. The DON stated because the resident had sat in a dining room she/he felt the resident had been "...pretty well supervised..." as staff passed by the dining room often. The DON further stated it had not been a concern for her for all 3 CNA's to go on a break at the same time. The DON stated the nurse could always call for help if needed. Review of the Resident Care Plan with a team conference date of 10/28/2010, lacked any approach for the resident to be in a wheelchair at any time. The Resident Care Plan did include approaches for the resident to be transferred with a Hoyer lift (mechanical lift) and the assistance of 2 staff. During the investigation, the note reportedly left on a daily assignment sheet regarding the resident being in a wheelchair could not be located by the facility. The DON confirmed the daily assignment sheets had not been a record the facility had kept. 2. According to a Medication Administration Record (MAR) dated 2/1/-28/2011, Resident #2's [DIAGNOSES REDACTED]. The MDS with an assessment reference date of 12/27/2010 indicated the resident had moderately impaired cognition. The same MDS further indicated the resident required extensive assistance from staff with transfers, bed mobility, walking, dressing, toilet use, personal hygiene and had experienced a fall since admission. A Fall Risk Assessment completed 12/9/2010 indicated the resident had been at high risk for falls. Review of a Daily Care Plan and identified by Staff C (Registered Nurse) as the initial care plan person, lacked any approach to prevent accidents/falls such as the use of alarms. Review of the Nursing Notes dated 12/16/2010 at 9:40 P.M.; staff documented a loud noise heard. The staff entered the resident's room and had found him/her sitting on his/her left side leaning against a wall. Review of a Significant Event form regarding a fall dated 12/16/2010 revealed the resident had been observed on the floor after staff had heard a loud noise. The same Significant Event form stated the resident had hit head and back against a wall and had suffered a two (2) centimeter laceration on the scalp and complained of a headache and back pain. Further review of the Significant Event form revealed staff documented new measures taken to prevent re-occurrence and included the discontinuation of a pressure alarm and application of a Tab alarm on the resident. (Even though no approach had been on the care plan for any type of alarm). A facility investigation in regards to the fall of 12/16/2011 lacked any documentation regarding the use of alarms and if an alarm had sounded. During an interview on 2/4/2011 at 8:19 A.M., the DON had been asked the reason for not performing an investigation into the use of an alarm or if the alarm had sounded. The DON stated she/he felt if the resident's alarm had not sounded then the staff would have documented the fact. The DON state she would assume an alarm had been sounding, but had not investigated the matter. Further review of the initial care plan revealed a hand written entry had been made on the care plan and had not been dated or initialed. The entry included an approach " ...Tab alarm in Bed and chair...". Ongoing review of the initial care plan revealed a line had been drawn through the approach for a Tab alarm in bed and chair. Immediately following the lined out approach for a Tab alarm and bed alarm, staff documented "...pressure alarm while in chair & Bed... " Again the care plan lacked staff initials as to who had made the entries. The care plan included the date 12/23 with no year documented and the abbreviation "...D/C..." in the vicinity of the hand written approaches. During an interview on 2/4/2011 at 8:19 A.M., the DON stated she/he felt the hand written entry on the initial care plan had been confusing. Review of a Resident Care Plan with a team conference date of 12/23/2010 revealed an approach for the resident to have a pressure alarm while in his/her bed, which varied from the Daily Care Plan (or initial care plan) which directed staff to apply a pressure alarm while in a chair and bed. During a telephone interview on 2/4/2011 at 9:12 A.M., Staff N (Certified Medication Aid-CMA) confirmed she/he had worked the night Resident # 2 fell on [DATE]. Staff N stated she had thought the resident had been changed from a pressure alarm to a Tab alarm as the resident's pressure alarm had at times been toward the end of his/her bed due to the resident's movements in his/her bed. Staff N stated at the times the pressure alarm had been towards the end of the resident's bed, the alarm could not be heard if the resident attempted to get up. During a telephone interview on 2/4/2011 at 9:50 A.M., Staff K (Licensed Practical Nurse-LPN) stated she/he had been on duty on 12/16/2010 the night the resident fell . Staff K confirmed the resident had a pressure alarm on his/her bed but had not sounded. During an interview on 2/4/2011 at 10:20 a.m., Staff B (RN) confirmed alarms had been routinely checked, but there had been no documentation of such. Review of a Significant Event form regarding a fall dated 1/3/2011, staff documented Resident # 2 had returned from breakfast in a wheelchair and assisted by staff. The resident had been left sitting in a wheelchair outside an elevator door and had been waiting for staff to assist him/her to his/her room. Staff further documented a thump had been heard and staff found the resident on the floor next to his/her wheelchair. Staff documented the resident sustained [REDACTED]. During a telephone interview on 2/4/2011 at 9:17 A.M., Staff A (RN) stated an alarm had not been sounding when the resident had been found on the floor next to his/her wheelchair as the resident had not had an alarm in his wheelchair. Staff A stated she/he thought an alarm had been placed in the resident ' s wheelchair after the fall on 1/3/2011. Staff A stated the resident had been under supervision at all times, but just the one time staff had left the resident sitting next to the elevator in a wheelchair instead of taking the resident to his/her room. Staff A stated if the staff had taken the resident to his/her room, the resident would have been placed in his/her recliner chair and then an alarm would have been placed on the resident. During an interview on 2/4/2011 at 10:37 A.M., Staff C (RN/MDS Coordinator) stated she/he expected staff to initial and date entries when documented on a care plan. Observation on 2/4/2011 at 8:40 A.M. and 10:22 A.M., revealed no staff in the corridor/hallway in the resident's living area upstairs in the facility.