Every finding on record at Ashton Health and Rehabilitation

Based on record review, and Nurse Practitioner (NP), Medical Director, and staff interviews, the facility failed to provide care in a safe manner when Resident #1 rolled out of her bed that was raised to just below the hip onto the floor during incontinence care. Resident #1 was sent to the emergency room (ER) for pain in her right shoulder and right hip with some deformity and external rotation. Resident #1 was diagnosed with an unusual right hip impaction fracture (occurs when a bone is broken and the broken ends are forced into each other) of the femoral head (the rounded end of thigh bone that fits into the socket of the hip joint). Resident #1 was admitted to the hospital and underwent hip replacement. This was for 1 of 3 residents (Resident #1) reviewed for accidents. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis (infection of the bone) of vertebra in the lumbar region, type 2 diabetes mellitus and infection of her heart valve. The Nursing Assistant (NA) Care Guide dated 2/3/25 indicated Resident #1 was marked as needing set-up for eating, 2 person-assist for bed mobility, 2 person-assist for transfers and was dependent on staff for incontinent care. A physician order for Resident #1 dated 2/3/25 indicated an apixaban (anticoagulant) 5 milligrams (mg) twice a day to be given orally. The care plan for Resident #1 dated 2/4/25 revealed a problem area identified was an Activities of Daily Living (ADL) self-performance deficit related to cognitive impairment. Another problem area identified was the resident being at risk for falls/injury from falls related to impaired mobility, impaired cognition, and incontinence. The approaches included assisting with transfer, mobility, and toileting. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was moderately cognitively impaired. She was coded as totally dependent for rolling left and right side. She was coded for upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities impairment. She was also coded for use of anticoagulants and her recorded weight was 248 pounds. The occupational therapy assessment notes dated 2/19/25 revealed Resident #1 required maximal assistance for bed mobility. The physical therapy evaluation notes dated 2/19/25 revealed Resident #1 was dependent for bed mobility (roll left and right, sit to lying, lying to sitting on side of the bed). The Event Report completed by Nurse #1 for Resident #1 dated 4/9/25 at 2:36 pm indicated Resident #1 had a witnessed fall during care in the resident's room. The report detailed Resident #1 was in pain with a pain level marked as 6 (0-10 scale with 10 being the worst pain possible). A body observation indicated no injury was noted and range of motion (ROM) was painful in lower extremity. The positioning assessment revealed that there was no rotation/deformity/shortening noted. It was documented that Resident #1 was alert and oriented to name and place. There were no contributing factors marked for this event and the intervention recorded was that Resident #1 was transferred to the ER. A progress note on 4/9/25 at 1:50 pm revealed Resident #1 was ordered by the NP to be transferred to ER via Emergency Medical Services (EMS). The hospital records from the ER dated 4/9/25 revealed Resident #1 was complaining of pain in her shoulders and her right leg after the fall. The admission notes assessments indicated an abrasion overlying the anterior (front) portion of the left shoulder. There was some mild underlying tenderness, mild pain on the palpation (a method of feeling with the fingers or hands during a physical examination) of the right shoulder. There was some external rotation of the right leg and tenderness in the hip, knee and ankle. The radiology reports from the hospital dated 4/9/25 for the right hip revealed an unusual fracture of the right hip, superior subluxation (partial/incomplete dislocation) of the proximal (closer to the center of the body) femur with impaction fracture of the femoral head which may be impacted on the acetabulum (hip socket). The clinical data report revealed that Resident #1 complained of pain in her right and left shoulder, right knee, chest, and right ankle. The Computed Tomography (CT) scan result from the hospital on 4/9/25 revealed a superolateral subluxation (partial separation of joints) of the right femoral head with respect to the acetabulum (concave surface of the pelvis) with impacted appearance of the femoral head on the superior acetabulum. A fracture involving the anterosuperior acetabulum (a prominent landmark that lies in the superior hip that can be palpated called lighthouse of the hip) with displaced fracture fragments. The Orthopedic consultation from the hospital on 4/9/25 revealed Resident #1 had severe pain from the right hip. It was noted that any movement or mobilization of the bed was excruciatingly painful. Review of the hospital records revealed Resident #1 required medical treatment for other health issues before she could have surgery. Resident #1 went through orthopedic surgery for hip replacement on 4/14/25. The hospital records indicated that Resident #1 was discharged from the hospital on 4/17/25 and did not return to the facility. NA #2 was interviewed on 4/29/25 at 3:01 pm and revealed that she took care of Resident #1 before the day of the fall. NA #2 stated the resident was always marked in the NA Care Guide for 2 person-assist for bed mobility. NA #2 stated she called for help anytime she took care of the resident. NA #2 further stated that they kept a binder in the nurses' station where staff could find the Care Guide for each resident. Interview with NA #1 via telephone on 4/29/25 at 12:54 pm revealed she was assigned to Resident #1 and was providing incontinence care before lunch around 11:30 am on 4/9/25. NA #1 stated she rolled Resident #1 away from her onto the resident's right side to clean her backside. NA #1 stated she lifted and crossed the resident's left leg over towards the top of the right leg. Resident #1 rolled too far over and went straight to the floor. NA #1 stated she didn't see if Resident #1 hit anything as she couldn't see the other side (right side) of the bed (NA #1 was on the left side). When she looked at the resident on the other side of the bed, Resident #1 was on her the right side of her body on the floor. NA #1 stated she called out for the nurses to help while staying with Resident #1. She stated that Resident #1 was talking and complaining of pain in her right hip. NA #1 stated the height of the bed when the resident fell was just below the hip. NA #1 stated she was alone doing the incontinent care and she thought she could do it herself. NA #1 stated she had not always taken care of Resident #1 because the nurse aides rotated their schedule daily and she knew where the Care Guide was at the nurses' station binder. An interview with Nurse #1 on 4/29/25 at 12:22 pm revealed she was working the morning shift on 4/9/25 and was called into the room for Resident #1 at around 11:30 am. Nurse #1 stated NA #1 called out for help for Resident #1 who fell out of bed during incontinence care. Nurse #1 stated when she got in the room Resident #1 was lying flat on her back on the floor. She stated Resident #1 was talking and complained of right leg pain. According to her the resident stated she hit her head on the nightstand before reaching the floor. Nurse #1 stated she assessed Resident #1 and vital signs were normal. Nurse #1 stated there was no bruising and nothing out of position on the resident's shoulders and legs. She stated the resident complained of pain around 7-8 on the pain scale. Nurse #1 and the other staff transferred the resident to her bed. Nurse #1 stated the in-house NP was in the building that day and was called to assess Resident #1. The NP came and talked to Resident #1 and ordered EMS to transport the resident to the ER for treatment. The NP was interviewed via telephone on 4/29/25 at 3:26 pm. The NP stated she was called in the room of Resident #1 for a fall just before noon (12:00 pm) on 4/9/25. The NP stated she went straight to the resident's room and the resident's vital signs were normal. The NP stated Resident #1 was back in bed when she saw the resident and spoke with her. She was told by Resident #1 she hit her head on the nightstand. She knew that it was important to send the resident out for evaluation due to Resident #1 was taking blood thinner (anticoagulant) medication. The NP stated that Resident #1 was complaining of pain all over and refused to be touched for examination. The NP stated that she suspected a hip fracture from the fall due to the resident's right leg being externally rotated and it was noticeably shorter. The NP stated Resident #1 was not able move her legs and there were no lacerations noted. The NP stated she ordered the resident to be evaluated at the ER. The interview with the Medical Director of the facility on 4/29/25 at 4:42 pm revealed Resident #1, as he recalled, needed 2 person-assist because of her immobility status. The Medical Director stated that if a resident was immobile and needed 2 person-assist, the facility staff should move the resident by two nurse aides. The Medical Director declined to rule out the cause of the fracture but deferred to the NP's assessment and what was revealed in the hospital records. An interview with the Director of Nursing (DON) on 4/29/25 at 1:11 pm revealed that Resident #1 was marked for 2 person-assist and that NA #1 did not follow the facility protocol to have another NA help with bed mobility during incontinent care. An interview with the Administrator on 4/29/25 at 1:12 pm revealed that the Rehab Department was in communication with the Nursing Department for mobility and transfers of each resident. She stated that NA #1 failed to follow the Care Guide for Resident #1 that was provided in the binder. The facility provided the following corrective action plan with a corrective date of 4/11/25. Address how will the corrective action be accomplished for those residents found to have been affected by the deficient practice. On 4/9/25 Nurse Aide (NA) #1 was providing incontinence care for Resident #1 with no assistance when the care guide called for a 2 person assist with care. NA #1 rolled Resident #1 on her side to clean her back and she rolled off the bed hitting her head on the nightstand and was complaining of right hip pain, NA #1 called out for help and Nurse #1 came to the room to assess the resident. The Nurse Practitioner (NP) was in the building and assessed Resident #1, who complained of right hip pain and noted a possible abnormality of the right leg but was unable to do a thorough assessment due to resident refusal, she then gave an order to send the resident to the ER for evaluation. Resident #1 was diagnosed with severe/aggressive changes of septic arthritis and osteomyelitis involving the right hip. The right hip is subluxed superiorly and laterally and the femoral head and neck are partially destroyed with pathological fracture. On 4/9/25 NA #1 was immediately retrained by the Director of Nursing (DON) to check the care guide for staff assistance for 1 or 2 staff before providing resident care. The DON also provided education to NA #1 on never turning a resident away from you when providing care alone, they should be turned toward you when providing care alone. NA #1 was required to repeat back to the DON what she had been educated on to ensure understanding. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 4/10/25 the Administrator, Director of Nursing, Unit Managers, and the MDS Nurse audited 100% of all current resident care guides to ensure they were up to date and correct. Changes were made at the time of the audit if needed. On 4/10/25 the DON and the Regional Clinical Manager completed an audit of all current residents with falls for the past 30 days to ensure no other adverse events took place due to deficient practice. No other issues were found. On 4/10/25 residents who have a care guide stated maximum assistance of 2 people with activities of daily living (ADL) have been identified as having the potential to be affected by the deficient practice. The DON and the Regional Clinical Manager completed an audit of current residents with a care guide of the maximum assistance of 2 people with Activities of Daily Living (ADL), and 22 residents were identified to have the potential to be affected by the deficient practice by requiring maximum assistance of 2 people with ADLs. On 4/10/25 an audit was conducted by the DON or designee to verify by observation that residents were provided with the correct assistance with ADL care and bed mobility. No other residents were found to be affected as ADL care was provided by maximum assistance of 2 people for the 22 residents identified. Residents were interviewed while observations were completed, and none had concerns with ADL care or assistance. What measures will be put in place or systemic changes will be made to ensure deficient practice will not recur. On 4/10/25 education was completed with current Nurse Aide staff by the DON and the Regional Clinical Manager on ADL care and bed mobility for residents that require maximum assistance of 2 people for safety. NAs that did not receive the education will receive education prior to his/her next scheduled shift. The DON will keep a list to ensure all Nurse Aide staff receive education and will add the education to the new hire orientation education. New NA staff will not be allowed to begin work until education has been completed. On 4/10/25 the Administrator and Director of Nursing made the decision to switch to pocket care guides for staff. All residents care guides transitioned to pocket care guides on 4/10/25. The Unit managers, Staff development Coordinator and aides were notified of this change on 04/10/25. The facility will establish a pocket care guide, which is updated daily (Mon-Fri) by the DON or designee. This care guide will be printed for each shift daily and will be distributed by the Unit Managers or designee to the NAs to carry with them during their shift. The pocket guide will consist of the following information: Resident name and room number, any isolation precautions, dining location, dining assistance, assistance needed with transfers, assistance needed with bed mobility, brief size and color, skin - float heels, turn and reposition, bowel and bladder continence, side rails, recent falls, fall interventions, Mechanical lift status, equipment, other. Indicate how the facility plans to monitor its performance to make sure solutions are sustained. On 4/10/25 an ad hoc QAPI meeting was held to discuss the deficient practice and implement a plan of correction with audit tools. Root cause analysis revealed Resident #1 was care planned for maximum assistance of 2 people however NA #1 was providing care alone. The Director of Nursing or Unit Managers will observe 10 random resident care interactions weekly for the next 90 days for residents who are 2 person-assist for ADL Care. Re-education will be provided immediately to any staff observed not providing care per the care guide. The Director of Nursing will be responsible for taking the audits to QA monthly for 3 months until substantial compliance is achieved. The facility's date of compliance is 4/11/25. On 4/30/2025, the facility's coorective action plan was validated. Resident #1 never came back to the facility after the hospitalization . During the tour of the facility, residents were observed to have 2 person-assist during incontinence care. The in-services by the facility included information on the use of pocket Care Guide and that each nursing staff should always have one with them. Staff interviews confirmed education was received for the use of the Care Guide and provided by the Unit Manager/Supervisor daily. The facility provided evidence of an Ad Hoc meeting was held to discuss the deficient practice and implement a plan of correction with audit tools. The facility provided evidence of Quality Assurance auditing of all residents with fall. Interviews with NAs revealed they have their own copy of the Care Guide with them. The alleged compliance date of 4/11/25 was validated.

Based on record review and staff interviews the facility failed to transfer the resident with a mechanical lift putting the resident at risk for injury for 1 of 3 residents reviewed for accidents (Resident #270). The findings included: Resident # 270 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction and cognitive communication deficit. The care plan dated 3/5/24 revealed a focused area for at risk for falls and required extensive/total assistance for activities of daily living (ADL) positioning, transfers, mobility, and hygiene. Interventions included the use of a mechanical lift with 2-person assistance for out of bed transfers. The Mminimum Data Set quarterly assessment dated [DATE] in Resident #270 was cognitively impaired and was dependent on staff for shower transfers. An interview was conducted with NA #1 on 4/30/24 at 12:19 pm. She revealed that she and two trainees (NA #2 and NA #3) assisted Resident #270 in taking a shower on 4/9/24. She indicated that she had worked with this resident prior but that she had never had to transfer out of bed so she did not know she required the use of a mechanical lift and forgot to check the care guide to determine her transfer requirements. She further revealed that NA #2 and NA #3 were both in training and each supported the resident under each arm while she supported her feet during the transfer. She indicated that during the time she was taken to the shower, in the shower, and transferred back to bed, there was no observed accident or reason to feel any injury had occurred. NA #1 also indicated that this resident was known to make noises when she was moved. Multiple attempts were made to interview NA #2 but unable to reach staff member for interview. Multiple attempts were made to interview NA #3 but unable to reach staff member for interview. A review of a nursing (Nurse #1) progress note dated 4/9/24 indicated that Resident #270 was given a shower on 4/9/24 and was transferred by 3 NAs.The progress note further revealed that at 7:00 pm the responsible party (RP) came back to the nurse's station and requested an x-ray just to make sure there was not an injury. Nurse #1 contacted the NP and ordered a stat x-ray. A review of the x-ray results dated 4/9/24 revealed there was no radiographic evidence of acute fracture or dislocation. An interview was conducted with Nurse #1 on 4/30/24 at 12:06 pm and she indicated that the responsible party told her that Resident #270 was complaining of pain in her leg. Nurse #1 went to residents' room with RP present, assessed for pain and Resident #270 reported pain from a headache. Nurse #1 indicated that she medicated her with acetaminophen and had no further reports of pain or injury. Nurse #1 also revealed that Resident #270 was known to not like to be moved for any reason such as turning and repositioning or incontinence care would moan or seem like it bothered her but as soon as staff would stop, she would stop making the noise. A review of progress note dated 4/10/14 indicated Resident #270 was transferred out of the facility to the emergency room per resident representative's request and that the resident will not return to the facility. An interview was conducted with the Administrator on 5/1/24 at 3:22pm. She indicated that on 4/10/24 she became aware that NA #1 had transferred Resident #270 without the use of a mechanical lift, and she initiated a performance improvement plan. The facility provided the following corrective action plan with a completion date of 4/12/2024. On 4/9/2024 the Resident's son stated that her leg stated was hurting, nurse assessed, and resident reported a headache. As needed acetaminophen was administered. On 4/9/2024 X-Ray was obtained for resident, no acute findings. On 4/10/2024 Resident #1 was sent to the hospital. Corrective action for potentially impacted residents: All residents are at risk of being affected by the deficient practice. On 4/10/24 the Administrator, Interim Director of Nursing and the Unit Managers initiated education for all nursing staff to look at care guides before providing care and following the resident's care plan for all aspects of care. On 4/10/24 skin checks were completed on non-alert and oriented residents by the Unit Managers to ensure no other resident was affected by the deficient practice. Results included: No other residents were identified to be affected. On 4/10/24 the Administrator and the Director of Clinical Services identified residents that would be potentially impacted by the alleged deficient practice by completing resident interviews for all current resident with BIMS of 10 or higher and asked if they had any concerns to ensure they had never been transferred with the inappropriate number of staff. Results included: No new findings were identified. On 4/10/2024, after concluding investigation, the Quality Assurance Committee convened to discuss the resident care plan not being followed for resident transfer. There were no additional findings at that time. Systemic Changes: On 4/10/24 the Director of Clinical Services educated the Administrator, Interim Director of Nursing, and the Unit Managers that staff must look at care guides before providing care and follow the resident's care plan for all aspects of care. On 4/11/24 the Administrator, Interim Director of Nursing and the Unit Managers educated all remaining nursing staff to look at care guides before providing care and following the resident's care plan for all aspects of care. No staff will be allowed to work until the education has been completed, the Administrator will be responsible for keeping a list of who has been trained. The Administrator will be responsible for ensuring all new hires receive this education before being allowed to work their first shift. Staff members expressed verbal understanding. Quality Assurance: Beginning the week of 4/15/2024 the Administrator and the Interim Director of Nursing will conduct observations of 4 residents care at random, 4 times a week for 4 weeks, 3 residents care at random 2 times a week for 4 weeks, then 2 residents at random weekly for 4 weeks to ensure staff look at care guides before providing care and follow the resident's care plan for all aspects of care. Results will be documented on the audit tool titled Transfer Audit results will be reported at the monthly Quality Assurance Performance Improvement Committee meetings by the Administrator where they will be reviewed and discussed for 3 months. The Quality Assurance Committee will assess and modify the action plan as needed to ensure continued compliance. Date of compliance 04/12/2024 The Corrective Action plan was validated 5/1/24 and concluded the facility had implemented an acceptable corrective action plan on 4/12/24. Interview with current nursing staff revealed they had received education on and training on following the care guide and transfers. The audits conducted starting on 4/15/24 revealed residents were asked about transfer safety. Skin checks were completed for all non-alert and oriented residents on 4/10/24. The audits continued through the validation date. The Quality Assurance Committee convened on 4/10/24 to discuss the resident care plan not being followed for resident transfer. The next QAPI meeting is scheduled for 5/15/24 to discuss the results documented on the transfer audit tool. On 5/1/24 there was sufficient evidence to support the facility's Corrective Action Plan that was implemented and carried out by 4/12/24.

Based on staff interviews and record review, the facility's Quality Assurance and Performance Improvement committee(QAPI) failed to maintain implemented effective procedures and monitor the interventions that the committee put into place following a complaint investigation dated 9/16/21 for one deficiency in the area of Quality of Care, F 689. The deficiency was also cited during the recertification and complaint survey dated 11/19/21 and subsequently recited during the recertification and complaint survey dated 05/01/24. The continued failure of the facility during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. Findings included. This tag is cross referenced to: F 689: Based on record review and staff interviews the facility failed to transfer the resident with a mechanical lift putting the resident at risk for injury for 1 of 3 residents reviewed for accidents. (Resident #270). During a complaint investigation on 09/16/21,the facility failed to protect a resident from a fall during bed mobility causing the resident to be lowered to the ground which resulted in a nondisplaced radial neck fracture (elbow). This was evident in 1 of 2 residents reviewed for accidents. During the Recertification and complaint survey 11/19/21, the facility failed to implement effective interventions to prevent further burns for a resident that experienced burns while smoking in 1 of 3 residents reviewed for smoking. Interview was conducted with the Administrator on 05/01/24 at 4:25 pm and she indicated that she expected all citations to be monitored through the center's QAPI program. Any repeat citation would require continuous monitoring through monthly QAPI meetings until the deficient practice has been resolved. After resolved, the center would continue to monitor the resolved issue through its quarterly QAPI meetings. Education would be completed to ensure staff are aware of expectations and these expectations would be tracked by way of auditing.

Based on observations, record review and resident and staff interviews, the facility failed to honor a resident's choice for going outdoors for 1 of 2 residents reviewed for choices. (Resident #71). The findings included: Resident #71 was admitted to the facility on [DATE] with diagnoses which included muscle wasting and atrophy and abnormality of gait and mobility. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was cognitively intact and felt that going outside for fresh air was very important to her. A review of the care plan 4/1/23 revealed a focused area of resident involved in activities less than 1/3 of the time with a goal that Resident #71 will express satisfaction in quality and quantity of activities. The interventions included providing a setting in which activities are preferred. On 4/24/23 at 12:39PM an interview was conducted with Resident #71. She stated she was supposed to be assisted out of bed so she could go outside for fresh air, but staff did not get her up and take her outdoors. On 4/25/23 at 2:20PM, Resident # 71 stated she did not receive assistance to get up and go outdoors on Monday 4/24/23. She further revealed that she requested to get up and go outside this morning, but the NA has not gotten her up today. ON 4/25/23 at 2:27pm an interview was conducted with Nurse #2. She revealed that she was not aware that Resident #71 wanted to get up and go outside and that there was only one NA on the hall and Resident #71 required a mechanical lift and two people to assist. On 4/25/23 at 2:28pm an interview was conducted with NA #1. She revealed that she provided care for Resident #71 during the shift but did not know that she wanted to get up or go outside. The NA further revealed that she did not ask Resident #71 if she wanted to get up because she is normally in bed and did not know that going outdoors was important to her. On 4/27/23 at 9:15am an interview was conducted with the Administrator. She revealed that her expectation was for residents' choices and preferences to be honored by staff.

Based on staff interviews and record reviews, the facility failed to determine upon admission and readmission to the facility, a resident's advanced directives (code status) for 2 of 2 residents reviewed for advance directives. (Resident #71 and Resident #295). The findings included: 1. Resident #295 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, pneumonia, cerebral infarction, and type 2 diabetes mellitus. The admission Minimum Data Set, dated dated dated [DATE] revealed Resident #295 had moderate cognitive impairment. Further review of Resident #295's medical records showed the original Medical Orders for Scope of Treatment (MOST) form was dated and signed on 4/19/23. There was a revised MOST form effective 4/25/23 with antibiotic use provisions. Review of Resident #295's physician orders and care plan revealed there were no advanced directives included. An interview was conducted on 4/26/23 at 11:20 AM with Nurse #3. She confirmed there were no advanced directives for Resident # 295 located in the electronic record on the face sheet or in the physician orders. She indicated the nurses used a notebook at the nurse station that holds every resident's advanced directives for that hall. The MOST form for Resident #295 was dated 4/19/23 present in the notebook. Nurse #3 revealed she was concerned that Resident #295's MOST form was not signed until 4/19/23 and she would not have known the code status if needed emergently. She further revealed the normal process to determine code status was during the initial admitted and the MOST form should be placed in the notebook at the nurse station. During a follow up interview with the Administrator on 4/28/23 at 9:00 AM, she revealed she was unaware that Resident #295's advanced directives were not signed and effective upon admitted . She stated all residents were automatically determined to be a full code until their MOST form was signed by the resident or responsible party and the physician. She explained Resident #295 would have remained a full code until the MOST form was signed on 4/19/23. The Administrator stated the advanced directives should be determined upon admitted and the responsibility was between the admission nurse, the charge nurse, or the social worker to have MOST forms completed. 46725 2. Resident #71 was initially admitted to the facility on [DATE]. She was readmitted to the facility on [DATE]. Resident #71's electronic health record (EHR) revealed no advance directive information. A review of the admission Minimum Data Set (MDS) dated [DATE] for Resident #71 revealed her to be cognitively intact. On 4/26/23 at 10:55am an interview was conducted with Nurse #1. She revealed that nurses utilize a resident information notebook at the station that holds all residents advance directives from that household and this information is available on the resident's EHR. Nurse #1 reviewed the resident information notebook, and she was not able to locate information regarding Resident #71's code status. Nurse #1 reviewed the EHR but was not able to locate the current code status and revealed she was not aware of the Resident #71's code status. On 4/26/23 at 11:30am an interview was conducted with the facility Administrator. She indicated that her expectation was for nursing staff to have knowledge of their assigned residents code status via the EHR, and the hard copy located in the resident information book.

Based on observation, record review, staff and resident interviews, the facility failed to implement effective interventions to prevent further [CONDITION(S)] for a resident that experienced [CONDITION(S)] while smoking in 1 of 3 residents (Resident #35) reviewed for smoking. The findings included: Resident #35 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included diabetes mellitus, right below the knee amputation and muscle weakness. An admission Minimum Data Set (MDS), dated [DATE], revealed Resident #35 was cognitively intact for decision making and was documented as not a current tobacco user. A nurse progress note, dated 3/19/2021, written by Nurse #6 read during a dressing change to abdomen, this writer noticed area presented like a full thickness burn. Due to presentation, Resident #35 was asked how this happened. Resident #35 admitted to smoking outside and later finding a burnt hole in her sweater. After this admission and going forward, the wound will be treated as a full thickness burn. A review of Resident #35's treatment orders revealed an order dated 3/19/2021 to clean burn with normal saline, apply skin prep to peri wound, apply [MEDICATION(S)] 1% cream to wound bed for suspected bioburden (the number of bacteria living on the surface that has not been sterilized), cover with collagen sheet to stimulate granulation, add calcium alginate to wick away exudate every three days. A review of Resident #35's care plan dated 3/29/2021 had a focused area that read, Resident is at risk for [CONDITION(S)] related to cigarette [CONDITION(S)] with a history of [CONDITION(S)] to the abdomen. The interventions did not include prevention plans. A second focused area read; I use tobacco products in the form of cigarettes. I am my own responsible party and sign myself in and out to smoke. A review of a progress note, dated 6/3/2021, written by the Administrator read Resident #35 was noted to be driving her motorized wheelchair into the wall in the hallway. Resident was then outside, and she stated she wanted to see the dogs outside of her window. Writer did not see any dogs in the parking lot and requested the Resident to come back inside. Resident agreed and the Resident's nurse was notified of the change of condition. An interview with this nurse was not able to be completed. A review of Resident #35's care plan revealed an update dated 6/7/2021 that read, I use tobacco products in the form of cigarettes. I am my own responsible party and sign myself out to smoke. On 6/7/2021, I am no longer able to safely smoke cigarettes independently. Resident refused [MEDICATION(S)] patches. Resident no longer safe to use motorized wheelchair. History of cigarette [CONDITION(S)]. The interventions included Resident will sign herself out to smoke. A review of a progress note, dated 6/8/2021 at 4:47 AM, written by Nurse #7, read Resident #35 noted with intermittent confusion and status post fall day two. The Assistant Director of Nursing has requested that the Resident be accompanied by staff when outside of the facility. She has also requested that the Resident's lighter be kept on the medication cart and the motorized wheelchair be replaced with a manual wheelchair. A review of a progress note, dated 6/8/2021 at 6:50 AM, written by Nurse #7, read Resident #35 has been seeing things and people that are not there. On call physician notified. A review of a progress note, dated 6/8/2021 at 2:08 PM, written by Nurse #6, read Resident #35 During wound care, full thickness burn also found to the right 3rd finger. Resident stated, I must have fallen asleep with my cigarette. New orders obtained, responsible party and physician both notified. A review of Resident #35's care plan revealed an update dated 6/8/2021 that read, Resident is at risk for [CONDITION(S)] related to cigarette [CONDITION(S)] with a history of [CONDITION(S)] to the abdomen and right 3rd finger. The interventions did not include prevention plans and were not updated with new interventions. A review of the modified quarterly MDS, dated [DATE], revealed Resident #35 continued to hallucinate during the 14 day look back and was not back to the baseline of hallucination free. A review of the modified quarterly MDS, dated [DATE], revealed Resident #35 continued to hallucinate during the 14 day look back and was not back to the baseline of hallucination free. An observation was conducted on 11/16/2021 at 2:15 PM of Resident #35 with cigarettes and a lighter in her right pocket of her jacket that was lying in the floor by the closet. An interview was conducted on 11/16/2021 at 2:15 PM with Resident #35 and she revealed she was responsible for storing her own cigarettes and lighter. She revealed she keeps them in her jacket by the closet. She stated that was where they remain when she sleeps and when she leaves the room for a shower or activity. She stated when she smokes, she signs herself out and goes alone to sit at the bottom of the hill. She denied staff accompanying here to smoke unless they had a smoke break at the same time. An interview was conducted on 11/17/2021 at 10:55 AM, with the Administrator and Regional Manager. The Administrator revealed the 3 residents that smoke were all alert and oriented and were independent with smoking. She stated they were required to sign themselves out and there was a section off of the facility property that the residents go to smoke. The areas located up a hill and the residents should go to this area. They should not smoke at the bottom of the hill because this areas on the facility property. She stated the facility does not provide supervision for any of these three residents since they are signing themselves out and are supposed to smoke in the designated area off of the property. She added the facility does not provide accommodations based on weather. The Regional manager then stated these 3 residents have been allowed to keep their cigarettes and lighters in their rooms. He added the facility had not had any incidents related to this and so the company had not changed anything. He added the facility was a smoke free campus and these 3 residents were grandfathered in since they are independent smokers. The facility does not accept any other new admissions that smoke. A review of the facility sign in and sign out log for Resident #35 revealed she signed herself out of the facility on 4/25/2021, 4/29/2021, 6/3/2021, 6/27/2021, 8/1/2021, 10/17/2021 and 11/8/2021. An interview was conducted on 11/17/2021 at 12:11 PM with Staff #1 and she revealed that Resident #35 signed herself out to go smoke, unaccompanied, in the last few months. An interview was conducted on 11/18/2021 at 10:11 AM with the Administrator and she revealed that the term Grandfathered in, regarding smoking, means that a resident had a previous right or privilege, at the time a policy change occurred and were able to keep the right or privilege and new residents would fall under the new guidelines. The Administrator stated Resident #35 was a smoker at the facility when the facility became smoke free and was grandfathered in as a smoker. She revealed she was aware Resident #35 burned herself on March 19, 2021 and stated a smoking assessment was completed by the Director of Nursing (DON), and she was assessed to be a safe smoker. She stated she was aware the care plan stated the Resident was at risk for [CONDITION(S)] related to smoking on 3/19/2021. She revealed she was aware the Resident had a change of mental condition from 3/19/2021 through 6/8/2021 when the Resident was documented to hallucinate and had begun to require assistance from nursing staff to navigate how to return into the facility from the parking lot. She added she was aware the Resident had a full thickness burn to her 3rd Right finger on 6/8/2021 and that a nurse reported this was from the Resident falling asleep from smoking. She stated a smoking assessment was completed by the DON in June and the Resident was assessed to be safe for smoking because she returned to her baseline without hallucinations after a hospitalization in June 2021. She stated the Resident was not able to go off of the property to smoke any longer because she was not strong enough to wheel herself up the hill and off of the property. The Resident wheels herself to the bottom of the hill to smoke, on property. She stated another smoking assessment had not been completed since the one in June and should have been completed due to the two [CONDITION(S)] but had not been completed since the facility was smoke free and the Resident was back to baseline and independent for smoking. A review of the electronic medical record for Resident #35 did not reveal the two smoking assessments referred to in the interview with the Administrator and copies of the two smoking assessments were not provided.

Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for the following areas: falls (Resident #78); gradual dose reduction (GDR) for an antipsychotic medication (Resident #78), administration of an anticoagulant medication (Resident #40) and hallucinations (Resident #35) for 3 of 39 sampled residents reviewed for MDS accuracy. The findings included: 1-a. Resident #78 was admitted to the facility on [DATE] with a cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation in Resident #78 ' s electronic medical record (EMR) revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #78 ' s most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. Section J (Health Conditions) of the MDS reported the resident did not have any falls since her prior assessment. An interview was conducted on 11/19/21 at 10:31 AM with the Regional MDS Consultant in the presence of the facility ' s MDS Coordinator. During the interview, the MDS nurses were asked to review Section J from Resident #78 ' s quarterly MDS dated [DATE]. Upon review, the Regional MDS Consultant reported it appeared the MDS should have been coded to report resident did experience falls between 7/29/21 (the prior MDS assessment) and 10/29/21. The Consultant stated she would review the 10/29/21 MDS in more detail and submit a modification to the assessment as needed. A follow-up interview was conducted on 11/19/21 at 11:10 AM with the Regional MDS Consultant. During the interview, the Consultant reported a modification was completed for Resident #78 ' s quarterly MDS dated [DATE]. She stated the MDS should have been coded to indicate Resident #78 did experience falls since the last assessment. The Regional MDS Consultant also reported the MDS should have specified the resident had two or more falls without injury between the 7/29/21 and the 10/29/21 MDS assessments. An interview was conducted on 11/19/21 at 12:10 PM with the facility's Interim Director of Nursing (DON). During the interview, concerns regarding the inaccuracy of MDS coding for Resident #78 ' s falls were discussed. When asked, the Interim DON stated, My expectation is that the MDS be coded accurately. 1-b. Resident #78 was admitted to the facility on [DATE] with a cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #78 ' s medications included 12.5 milligrams (mg) [MEDICATION(S)] (an antipsychotic medication) to be administered by mouth two times a day (last ordered on 8/4/21). The resident ' s medical record included a Consultant Pharmacist Communication to Physician dated 9/13/21. The communication recommended Resident #78 ' s provider evaluate each [CONDITION(S)] medication for the possibility of a trial dose reduction (gradual dose reduction or GDR) or taper to discontinuation. A [CONDITION(S)] medication is any drug that affects brain activities associated with mental processes/behavior and includes antipsychotic medications. The provider responded to the communication on 9/27/21 by indicating, GDR not possible clinically without a negative effect on the underlying psychiatric illness. Resident #78 ' s most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. A review of Section N (Medications) of the MDS revealed the resident received an antipsychotic medication routinely on 7 out of 7 days during the look back period. Information in Section N also included an antipsychotic medication review. This review indicated Resident #78 ' s provider documented on 5/10/21 that a gradual dose reduction (GDR) of her antipsychotic medication was clinically contraindicated. However, it also reported a GDR of her antipsychotic medication was last attempted on 5/14/21. An interview was conducted on 11/19/21 at 10:31 AM with the Regional MDS Consultant in the presence of the facility ' s MDS Coordinator. During the interview, the MDS nurses were asked to review Section N (Medications) from Resident #78 ' s quarterly MDS dated [DATE]. Upon review, both the Regional MDS Consultant and MDS Coordinator reported the two dates entered into the antipsychotic medication review appeared to be confusing. The Consultant stated she would review this MDS in more detail and submit a modification to the assessment if needed. A follow-up interview was conducted on 11/19/21 at 11:10 AM with the Regional MDS Consultant. During the interview, the Consultant reported the date indicated on the 10/29/21 MDS for Resident #78 ' s last GDR attempt was not accurate. She stated no GDR attempt was made. Additionally, the provider ' s response to the pharmacist ' s consult report on 9/27/21 was the most recent documentation to indicate a GDR for the resident ' s antipsychotic medication was clinically contraindicated. The Regional MDS Consultant reported modifications to the MDS record were made. An interview was conducted on 11/19/21 at 12:10 PM with the facility's Interim Director of Nursing (DON). During the interview, concerns regarding the inaccuracy of MDS coding for Resident #78 ' s antipsychotic medication review were discussed. When asked, the Interim DON stated, My expectation is that the MDS be coded accurately. 2. Resident #40 was admitted to the facility on [DATE] with a cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident ' s Electronic Medical Record (EMR) revealed her medications included 20 milligrams (mg) [MEDICATION(S)] (an anticoagulant medication) to be given by mouth once daily (last ordered on 2/7/21). Resident #40 ' s most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. Section N (Medications) of the MDS assessment did not indicate the resident received an anticoagulant medication during the 7-day look back period. An interview was conducted on 11/18/21 at 3:05 PM with the facility ' s MDS Coordinator. During the interview, the MDS Coordinator was asked to review Section N (Medications) on Resident #40 ' s quarterly MDS (dated 10/1/21). Upon review, the MDS Coordinator stated, Unfortunately, it (the anticoagulant medication) was not coded, it was an oversight. The MDS Coordinator confirmed Resident #40 ' s MDS should have been coded to indicate she received an anticoagulant medication on a daily basis. An interview was conducted on 11/19/21 at 12:10 PM with the facility's Interim Director of Nursing (DON). During the interview, concerns regarding the inaccuracy of MDS coding for Resident #40 ' s anticoagulant medication were discussed. When asked, the Interim DON stated, My expectation is that the MDS be coded accurately. 3. Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the nursing progress notes for the date of 6/28/2021 for Resident #35, documented a hallucination. A review of the quarterly MDS assessment dated [DATE] for Resident #35, did not document hallucinations for the 14 day look back period. A review of the nursing progress notes for the date of 9/13/2021 for Resident #35, documented a hallucination of seeing bugs that others did not see. A review of the quarterly MDS assessment dated [DATE] for Resident #35, did not document hallucinations for the 14 day look back period. On 11/18/2021 at 11:53 AM an interview was conducted with the Regional MDS consultant. She reviewed the MDS assessments for the dates of 7/2/2021 and 9/17/2021. She confirmed the 14 lookback periods for both MDS assessments contained documentation of hallucinations in the nursing progress notes. She stated the hallucination area should have been marked as present. She added it was her expectation that the MDS coordinator review progress notes prior to completing an MDS assessment and document accurately. She competed an MDS modification to include hallucinations for the 7/2/2021 and 9/17/2021 MDS reports on 11/18/2021.

Based on observations, staff interviews, and record review, the facility staff failed to label, store, and clean/disinfect blood glucose meters (glucometers) dedicated for individual-resident use in a manner that would protect against the inadvertent use for additional residents and/or cross-contamination from contact with other meters or equipment. This occurred for 3 out of 4 sample residents (Resident #12, Resident #64, and Resident #30) who required a blood glucose check. The findings included: A review of the facility policy entitled Blood Sampling - Capillary (Finger Sticks) (Revised December 2018) read, in part: The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees. General Guidelines #1 (of 3): Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses with EPA (Environmental Protection Agency) registered disinfectant per directions on package if it is a shared glucometer. Individual resident blood glucose meters should be cleaned from any visible materials after use or before use. Steps in the Procedure: 1. Wash hands. 2. Don gloves. 3. Place blood glucose monitoring device on clean field (paper towel or cup). 4. Wipe the area to be lanced with an alcohol pad. 5. Use sterile lancet to obtain blood sample 6. Obtain the blood sample, following the manufacturer's instructions for the device. 7. Discard lancet into the sharps container. 8. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts (if glucometer is shared, or if visible material on individual glucose meters), and/or devices after each use and store in/on a clean surface. (Company Name) prefers individual resident use glucometers. 9. Remove gloves, and discard into appropriate receptacle. 10. Wash hands. 11. Replace blood glucose monitoring device in storage area. Individual blood glucose monitoring device should be stored in a baggie or separate storage container to keep from cross contamination of other devices. Each baggie or storage container should be labeled with the resident name. The manufacturer instructions for the glucometer used at the facility indicated the cleaning and disinfection procedure should be performed as recommended to minimize the risk of transmitting blood-borne pathogens. These instructions read in part, The meter should be cleaned and disinfected after use on each patient. The (Brand Name) multi Blood Glucose Monitoring System may only be used for testing multiple patients when standard precautions and the manufacturer ' s disinfection procedures are followed. For Cleaning and Disinfection, The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfection procedure is needed to prevent the transmission of blood-borne pathogens. Only wipes with EPA registration numbers listed below have been validated for use in cleaning and disinfecting the meter. Any disinfectant product containing these EPA registration numbers may be used on this device .Wipes with EPA registration numbers not listed below should not be used to clean and disinfect the (Brand Name) multi Meter . The list of approved and tested products for this glucometer did include (Brand Name) Surface Disinfectant Wipes; however, it did not include alcohol wipes or the (Brand Name) Bleach Germicidal Disposable Wipes. 1) On 11/16/21 at 5:13 PM, Nurse #2 was observed standing at the 200 Hall Med Cart. Upon approach, a glucometer was observed sitting directly on top of the med cart next to a vial of glucometer test strips. Nurse #2 reported Resident #12's blood glucose had just been checked. This nurse was observed as he administered medication to Resident #12. A follow-up interview was conducted with the nurse upon his return to the medication cart. During the interview, Nurse #2 reported each resident had his/her own individual glucometer. The nurse opened a drawer of the med cart which revealed one glucometer was currently stored on the cart. The glucometer was not labeled with a resident's name or other identifying information; it was not stored in a baggie or any other container to prevent cross-contamination. Nurse #2 reported this glucometer belonged to Resident #12. When asked how he knew for certain the glucometer was intended for Resident #12, he reported he had just used it for the resident and placed it in the cart. He stated, There's a bag for this one somewhere, as he looked in the other drawers of the med cart for a baggie labeled with the resident ' s name. None was found on the med cart. At that time, the nurse was asked to identify the glucometer observed to be placed on top of the cart. When asked which resident this glucometer was used for, Nurse #2 stated, I need to find out where that came from. He was then asked whether or not the glucometer observed on top of the med cart was already there when he started his shift. He stated it was not. The nurse repeated, I need to find out where that came from. Upon further inquiry as to how he could be sure the glucometer in the drawer belonged to Resident #12, the nurse reported he would get rid of both of them (referring to the two glucometers). A telephone interview was conducted on 11/17/21 at 10:26 AM with Nurse #2. During the interview, the nurse was asked if he could provide any additional information about the glucometer observed on top of his med cart the previous evening. Nurse #2 reported when he took over the med cart, he could not find any glucometers in the bottom drawer of the cart (where the glucometers were normally stored). The nurse reported he went to the med room, found a brand new glucometer, and brought it to his med cart to be used for both Resident #62 and Resident #12. Nurse #2 stated he was very nervous when an inquiry was made about this glucometer on 11/16/21 and was not sure what he should say. When asked if the glucometer was cleaned/disinfected between using it for Resident #62 and Resident #12, the nurse stated he typically wiped the glucometer with either bleach wipes or two alcohol wipes after each use. Nurse #2 added that he mostly used bleach wipes to clean/disinfect a glucometer after use. An interview was conducted with the facility ' s Interim Director of Nursing (DON) on 11/17/21 at 11:40 AM. During the interview, the infection control concerns related to the facility ' s failure to label, store, and clean/disinfect glucometers were discussed. The DON reported she would expect staff to store the individual glucometers in the drawer of the med cart in a baggie labeled with the resident's name. The DON stated the glucometer should be disinfected after each use before being stored on the med cart, even if the glucometer was dedicated to a single resident. A follow-up telephone interview was conducted on 11/18/21 at 11:03 AM with Nurse #2. During the interview, the nurse was asked for additional details about using the shared glucometer on the evening of 11/16/21. Nurse #2 reported only two residents on his assigned hall needed their blood glucose to be checked that evening. The nurse stated he did wipe down the new meter he obtained from the med room with (Brand Name) Bleach Germicidal Disposable Wipes before placing the glucometer on top of tissues on the med cart to let it air dry. Nurse #2 reported he first checked Resident #62's blood glucose level with the glucometer, then wiped it off the same way with the (Brand Name) Bleach Germicidal Disposable Wipes. The nurse reported he liked to use the bleach wipes for the glucometers because he felt they were stronger than the other disinfectant wipes stored on the med cart. When asked how certain he was that he used the bleach wipes to clean / disinfect the shared glucometer between residents, the nurse stated he was absolutely sure. A follow-up interview was conducted with the Interim DON on 11/18/21 at 1:46 PM. During the interview, findings related to the infection control concerns for glucometer disinfection were again discussed, along with the most recent telephone interview conducted with Nurse #2. Information provided by the glucometer ' s user manual was also discussed. The user manual provided by the manufacturer specified the tested and approved disinfectant products for use on the glucometers used at the facility. During this interview, the DON reported she was unaware the (Brand Name) Bleach Germicidal Disposable Wipes were being used by Nurse #2 to disinfect glucometers. When asked, the DON stated she would refer to the glucometer ' s user manual as to which disinfectant wipes were tested and approved for disinfection of the facility ' s glucometers. 2) An observation was made on 11/16/21 at 4:30 PM as Nurse #1 pulled a glucometer from the medication cart in preparation to check Resident #64 ' s blood glucose. The glucometer was stored in a drawer of the medication cart in a baggie labeled with Resident #64 ' s name. The nurse removed the glucometer from the baggie and set it on top of the med cart (not a clean field) as she collected supplies for the blood glucose check. She donned gloves and entered Resident #64 ' s room carrying the glucometer and supplies. After entering the resident's room, the nurse placed the glucometer on the resident's tray table (not a clean field). She then used the glucometer to check Resident #64's blood glucose. After checking the resident's blood glucose, the nurse returned to the medication cart and placed the glucometer directly on top of the cart (not a clean field) as she disposed of the lancet and test strip. She removed her gloves and used hand sanitizer. The nurse put the results of the blood glucose check into the laptop on the med cart. She used her key to unlock the med cart, then moved the glucometer and set it on the baggie labeled with Resident #64 ' s name on top of the med cart. The nurse wiped the glucometer with an alcohol wipe for approximately 2-3 seconds, then placed the glucometer back on top of the baggie. Approximately two minutes later the nurse put the glucometer inside the baggie and placed the labeled baggie containing the glucometer back into the drawer of the med cart. Upon completion of the blood glucose check for Resident #64, inquiry was made as to whether there were any disinfectant wipes stored on the med cart. Nurse #1 opened the bottom drawer of the med cart to reveal a container of (Brand Name) Surface Disinfectant Wipes stored there. The nurse reported these disinfectant wipes were used to disinfect the medication cart at the beginning of her shift. When asked, Nurse #1 reported she worked a 12-hour shift. An interview was conducted with the facility ' s interim Director of Nursing (DON) on 11/17/21 at 11:40 AM. During the interview, the infection control concerns related to the facility ' s failure to label, store, and clean/disinfect glucometers were discussed. The DON reported she would expect staff to store the individual glucometers in the drawer of the med cart in a baggie labeled with the resident's name. The DON stated the glucometer should be disinfected after each use before being stored on the med cart, even if the glucometer was dedicated to a single resident. 3) On 11/17/21 at 4:20 pm a medication pass with Nurse #8 was observed. Nurse #8 obtained a glucometer from the medication cart bottom drawer. The glucometer was in a small plastic bag with the resident's name on the bag. There were 4 other labeled, bagged resident glucometers in the same drawer. Nurse #8 placed gloves and took the resident's bagged glucometer and test strip to the resident's room. Nurse took the glucometer out of the plastic bag and placed the bag on the tray table and the glucometer on top of the plastic bag. Nurse #8 drew and tested the blood using the glucometer. She carried the glucometer, plastic bag, test strip, and lancet with blood to the garbage and discarded the strip. She carried the glucometer and plastic bag together and the lancet to the medication cart. She placed the glucometer in the plastic bag and placed the bag into the medication cart lower drawer with the same dirty gloves on top of the other resident's bagged glucometers. The lancet was discarded in the sharps container. She removed her gloves and started the same resident's (Resident #30) medication pour. She touched the cart and poured the medication. Medication was administered and the nurse used hand hygiene. Upon return to the medication cart interview began. Nurse #8 stated she was not aware she should clean the glucometer after each use and not take the plastic bag into the resident's room and make contact with the resident's surfaces without being cleaned afterward. The nurse placed gloves and cleaned (manufacturer and EPA approved wipes) the glucometer and the plastic bag after being instructed on how to perform and why. The nurse placed the bagged glucometer back into the medication cart drawer, removed her gloves, and began to pour medication for another resident. The nurse was asked to stop and complete hand hygiene. An interview was conducted with the facility ' s Interim Director of Nursing (DON) on 11/18/21 at 1:10 PM. During the interview, the infection control concerns related to Nurse #8' s failure to clean/disinfect the glucometer and perform hand hygiene were discussed. She stated that staff were required to clean the glucometer after use with an approved cleanser, were not to take the glucometer storage bag into the resident's room to prevent contamination, and to perform hand hygiene after the glucometer was cleaned and between resident contact.

Based on staff interviews and review of the resident trust accounts, the facility failed to forward the balance of expired residents ' trust accounts within 30 days for3 of 5 residents reviewed for personal funds (Resident #196, Resident #197, and Resident #198) Findings included: Review of Resident #196 ' s closed medical record revealed she was admitted to the facility on [DATE] and expired on [DATE]. A review of the resident trust fund account revealed that Resident #196 ' s funds were not conveyed to the resident estate within 30 days of her death. A check was written out to the facility on [DATE]. Interview with the Regional Accounts Receivable Specialist on [DATE] at 10:00 am indicated she had been employed with the facility effective [DATE]. She indicated during her review of the personal fund account the resident ' s balance had not been refunded to the resident's estate. She stated the process for closing accounts for deceased residents was as follows: If we are representative payee, refund to Social Security and all other accounts are refunded to the resident's estate. Interview with the Administrator on [DATE] at 12:30 pm revealed her expectation for closing an account of deceased residents was if the facility was representative payee, they would refund Social Security. All other accounts would be refunded to the resident's estate. 2. Review of Resident #197 ' s closed record indicated she was admitted to the facility on [DATE] and expired on [DATE]. A review of the resident trust fund account revealed that Resident #197 ' s funds were not conveyed to the resident estate within 30 days of her death. A check was written out to the facility on [DATE]. Interview with the Regional Accounts Receivable Specialist on [DATE] at 10:00 am indicated she had been employed with the facility effective [DATE]. She indicated during her review of the personal fund account the resident ' s balance had not been refunded to the resident's estate. She stated the process for closing accounts for deceased residents was as follows: If we are representative payee, refund to Social Security and all other accounts are refunded to the resident's estate ' . Interview with the Administrator on [DATE] at 12:30 pm revealed her expectation for closing an account of deceased spell residents was if the facility was representative payee, they would refund Social Security. All other accounts would be refunded to the resident's estate. 3. Review of Resident #198 ' s closed medical record indicated that Resident #198 was admitted to the facility on [DATE] and expired on [DATE] A review of the resident trust fund account revealed that Resident #198 ' s funds were not conveyed to the resident estate within 30 days of her death. A check was written out to the facility on [DATE]. Interview with the Regional Accounts Receivable Specialist on [DATE] at 10:00 am indicated she had been employed with the facility effective [DATE]. She indicated during her review of the personal fund account the resident ' s balance had not been refunded to the resident's estate. She stated the process for closing accounts for deceased residents was as follows: If we are representative payee, refund to Social Security and all other accounts are refunded to the resident's estate. Interview with the Administrator on [DATE] at 12:30 pm revealed her expectation for closing an account of deceased residents was if the facility was representative payee, they would refund Social Security. All other accounts would be refunded to the resident's estate.

Based on record review, observation and staff interviews, the facility failed to protect a resident from a fall during bed mobility causing the resident to be lowered to the ground which resulted in a nondisplaced radial neck fracture (elbow). This was evident in 1 of 2 residents (Resident #2) reviewed for accidents. Findings included: Resident #2 was admitted to the facility on [DATE] with multiple diagnoses that included [CONDITION(S)] and [CONDITION(S)] affecting left non-dominant side and diabetes. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was severely cognitively impaired and required total assistance with 2 people for bed mobility and personal hygiene. Resident #2's care plan dated 7-20-21 revealed a goal that Resident #2's needs would be met by staff. The interventions for the goal were in part; Bed mobility total dependent on nursing staff, call light within resident reach, uses incontinence products with total dependance on nursing staff. Resident #2 also had a goal that she would not have a serious injury from a fall. The interventions for the goal were in part; staff education on how to position resident during care, place fall mats beside the bed and maintain bed wheels in lock position. The hospital emergency room documentation dated 6-10-21 revealed the hospital performed an assessment which included lab work, electrocardiogram, a head computed tomography (CT) scan and an x-ray of Resident #2's pelvis and chest. Documentation showed no pertinent findings, and the resident was discharged back to the facility. Nursing documentation dated 6-11-21 at 1:09am revealed Resident #2 was in her room lying face down. The nurse documented that she assessed for injuries, bleeding and bruising but did not find any. The documentation revealed Resident #2's legal representative was notified and had requested the resident be sent to the emergency room for further evaluation. Nursing assistant (NA) #1 was interviewed on 9-13-21 at 3:04pm. The NA stated he was working on 6-10-21 providing incontinence care to Resident #2. He explained when he turned the resident towards him the resident's upper body started coming off the bed, so he stated he cradled the resident and lowered her to the floor. The NA said he immediately received help from the nurse and an assessment was completed. The NA discussed Resident #2 being uncommunicative but had noticed the resident grimacing when she was being placed back into bed. NA #1 stated he did not know if Resident #2 was a 2 person assist in bed mobility but explained he had always provided care to Resident #2 by himself. During a telephone interview with Nurse #2 on 9-15-21 at 9:40am, the nurse confirmed she was working with Resident #2 the evening of her fall. She explained NA #1 had informed her that he had to lower the resident to the floor. Nurse #2 said she performed an assessment and did not find any injuries so Resident #2 was placed back in bed using an electric patient lift. She stated she did not see any signs Resident #2 was in pain. The nurse confirmed there was usually one NA to perform bed mobility. Nurse #2 discussed calling the residents legal representative and when the legal representative came to the facility, she requested Resident #2 be sent to the emergency room for further evaluation. Nursing documentation dated 6-14-21 at 6:05pm was reviewed and revealed Resident #2's family was visiting with the resident and had noticed a hardened area and swelling in the residents left arm. The nurse documented Resident #2 did not have any facial grimacing when touching the area and that she contacted the resident' provider and received an order for an x-ray to be completed. The emergency room record dated 6-14-21 was reviewed. The documentation showed the emergency room performed x-rays on Resident #2's left elbow, left forearm, left wrist, left ankle, left shoulder, left humerus and left foot due to a fall that had occurred a week ago. The emergency room records indicate a diagnosis of a nondisplaced left radial neck fracture and the resident was provided a sling then discharged back to the facility. The Director of Nursing (DON) was interviewed by telephone on 9-14-21 at 4:12pm. The DON discussed that staff had not noticed anything wrong with Resident #2's left arm until the family brought the concern to the nursing staff. She stated she had not assessed the resident's arm because she was not in the facility. Nurse #3 was interviewed by telephone on 9-15-21 at 11:35am. The nurse discussed not working with Resident #2 on 6-14-21 but had been asked by the resident's nurse to help with assessing Resident #2's left arm. Nurse #3 stated she did perform an assessment on Resident #2's left arm and found a hardened area and the arm was swollen. She explained she obtained a set of vitals and notified the Nurse Practitioner who ordered an x-ray but stated the family had requested the resident be sent to the emergency room for further evaluation. The facility's Nurse Practitioner (NP) was interviewed by telephone on 9-16-21 at 10:44am. The NP stated she could not state for certain if Resident #2's radial neck fracture came from the fall she sustained on 6-10-21 but acknowledged Resident #2 had not had any further falls since 6-10-21.

Based on record review, observation, staff and physician interview, the facility failed to provide the prescribed wound care when the nurse did not apply the physician ordered dressing to the residents wound and when wound care was not provided for 1 of 3 residents (Resident #2) observed for wound care. Findings included: Resident #2 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was severely cognitively impaired. Resident #2's care plan dated 8-17-21 revealed a goal the resident's arterial ulceration to left 5th toe would show signs and symptoms of healing without infection. The interventions for the were in part; prevelon boots and skin assessment/inspection every shift. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's Treatment Administration Record (TAR) for September 2021 revealed no documentation of wound care being completed for the arterial ulceration to left 5th toe on 9-10-21. Observation of wound care occurred on 9-13-21 at 11:32am with the facility's Assistant Director of Nursing (ADON). Resident #2 was observed to be laying on an air mattress with prevelon boots on bilateral feet. The ADON removed old dressing which was dated 9-8-21 and began, while maintaining a clean field, to clean Resident #2's wound with normal saline, wiped wound bed with [MEDICATION(S)] gauze and covered with a dry dressing. The wound was observed not to have any drainage, no signs of infection and no odor. The ADON was interviewed on 9-13-21 at 11:40am. The ADON acknowledged the date on the old dressing was 9-8-21 and she stated the wound care nurse usually did all the wound care, but she has not been here for 2 weeks. I'm not sure why the care was not completed on 9-10-21. The ADON reviewed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She acknowledged the order stated to apply gauze moistened with [MEDICATION(S)] to wound bed and that was not what she had done. During a telephone interview with the facility's wound care physician on 9-14-21 at 11:42am, the physician confirmed that the gauze moistened with [MEDICATION(S)] was to be left on the wound bed and covered with a dry dressing. He also discussed Resident #2's wound was a chronic wound and stated if the wound care was not completed as ordered it could cause a deterioration of the wound. The physician stated he expected his orders to be followed. The Administrator was interviewed on 9-14-21 at 12:00pm. She explained the wound care nurse had not been working so it was the responsibility of the nurse caring for the resident to complete wound care as ordered. Nurse #1 was interviewed by telephone on 9-15-21 at 2:14pm. The nurse confirmed she worked with Resident #2 on 9-10-21 but stated she did not perform the residents wound care. She explained she was informed by facility management that another nurse would complete the wound care.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Admissions and Re-Admits, the facility failed to implement infection control procedures for personal protective equipment (PPE) when 1 of 4 staff working on the quarantine isolation unit (new admissions/re-admissions) failed to wear a gown and gloves when entering a resident's room who was on enhanced droplet precautions. This failure occurred during a COVID-19 pandemic. Findings included: The facility's policy titled, Admissions and Re-Admits, updated 10/2020, was reviewed. The policy stated, in part, The facility will follow all Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) recommendations related to admissions and re-admissions. This will include isolation with enhanced isolation precautions for a minimum of 14 days .All occupied rooms on the isolation unit will have an 'Enhanced Droplet' isolation sign displayed outside the room, on the door or designated area for notification of precautions. This will be in effect for all residents on the designated unit, regardless of COVID-19 status. Resident #1 was admitted to the facility on [DATE]. A continuous observation of room [ROOM NUMBER] (on the quarantine isolation hall) was completed on 11/10/20 from 10:35 AM-10:47 AM. An enhanced droplet isolation sign was posted on the door, along with a bin that contained PPE (gowns, gloves and faceshields). The enhanced droplet isolation sign had the following instructions: Before entering this room, follow the instructions below- universal masking, perform hand hygiene, eye protection when entering the room, gown and gloves when entering the room. Restorative Aide (RA) #1 approached the room and wore a facemask. She donned a faceshield and entered the room. She did not put on gloves or a gown before she entered the room. RA #1 applied oxygen via nasal cannula to Resident #1 and placed a surgical facemask on her. She then placed her hands on Resident #1's wheelchair, pushed her out of the room, went down the hall and placed her on a scale. While Resident #1 was on the scale RA #1 walked to a PPE cart and donned a gown. She recorded the resident's weight and then pushed the resident back to her room. RA #1 removed and disposed of the gown, washed her hands and exited the room. RA #1 was interviewed on 11/10/20 at 10:47 AM. She explained the residents on the quarantine isolation unit were new admissions and all had tested negative for COVID-19. She said since Resident #1 was on enhanced droplet precautions staff were supposed to put on a gown, gloves, facemask and faceshield when they entered the room. When asked why she didn't don a gown or gloves prior to when she entered the resident's room, RA stated, I was just going in to get her, bring her out, get her weight and bring her back. She added she thought full PPE wasn't necessary when a weight was obtained since no other personal care was being done. RA #1 reported she decided to put a gown on once Resident #1 was on the scale because she wanted to shield my clothes from her. She added she had been educated in the last week about PPE usage and what needed to be worn when entering a room with enhanced droplet precautions. RA #1 acknowledged she should have put on all PPE prior to entering Resident #1's room. On 11/10/20 at 10:51 AM, Nurse #1 was interviewed. She was the nurse on the quarantine isolation unit. She said all staff were required to put on full PPE before they entered any resident's room on the quarantine isolation unit, even though the residents on the unit had all tested negative for COVID-19. During an interview with the Regional Clinical Manager on 11/10/20 at 1:24 PM, she shared that all new admissions (which included Resident #1) were placed on 14 day isolation on the facility's designated quarantine isolation unit (800/900 hall). Residents were treated as if they were positive for COVID-19, which included being placed on enhanced droplet precautions. Staff were required to wear gloves, gown, mask and faceshield before they entered a resident's room and then staff removed the PPE inside the room before they exited. The Regional Clinical Manager stated RA #1 should have donned full PPE before she entered Resident #1's room. She added staff had been educated that it didn't matter what task was being completed, full PPE must be worn before staff entered a resident's room on the quarantine isolation unit. An interview was completed with the Administrator on 11/10/20 at 3:05 PM. He reported he had told staff they needed to wear full PPE prior to entering a resident's room on the quarantine isolation unit. He said full PPE included a gown, gloves, facemask and faceshield.

Based on observations, record reviews, the nurse practitioner and staff interviews, the facility failed to stop providing care when a resident became combative to prevent skin tears and bruising for 1 of 2 sampled residents reviewed for accidents. (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review of the quarterly minimum (MDS) data set [DATE] indicated Resident #2 had short and long term memory problems with severely impaired decision-making skills; required extensive assistance of two staff with bed mobility, transfers, and hygiene; was always incontinent of bowel and bladder; and had two or more falls with no injuries. Review of the revised care plan dated 10/6/20 revealed Resident #2 had physical behaviors at times; combative towards staff while staff was attempting to assist in care (hitting, kicking, pushing, scratching). Approaches included: staff would avoid power struggles with the resident; maintain a calm environment and approach to resident at all times; staff would not force resident to do a task; and if the resident was to become physically abusive or combative, STOP and try the task later. The review of a nurse's progress note dated 9/25/20, a nursing assistant reported to the nurse that Resident #2 became combative during care. The nurse observed several skin tears to the resident's bilateral upper extremities with bruising and swelling to his right eye. The nursing supervisor was made aware who applied dressings to the areas. The NP (nurse practitioner) who was in the facility at the time of the incident examined the resident's injuries. Review of the NP's progress note dated 9/25/20 revealed Resident #2 had multiple new skin tears, bruising on his right arm, and bruising under his right eye. The exact mechanism of injury was unclear. Nursing staff reported the resident was observed with these injuries after receiving his morning personal care. The resident was cooperative with the exam without combative behavior and showed no distress regarding injuries. A progress note dated 9/25/20, indicated additional bruising was observed to the back of the resident's head. The resident showed no signs or symptoms of pain or distress. The wound nurse applied dressings to the skin tears. The facility reported the incident to the State Agency as resident abuse and injury of unknown origin on 9/25/20. A signed statement was obtained from the nursing assistant who provided morning ADL (activities of daily living) care to Resident #2 when the resident became combative. The nursing assistant's statement indicated he continued providing care to the resident while the resident was hitting and kicking him, the small siderail, and himself in the head. The nursing assistant was suspended pending the investigation. The facility concluded the allegation of abuse was unsubstantiated. The x-ray results dated 9/26/20 revealed no evidence of displaced fracture or osseous destructive process of the resident's right eye. Also, there was no gross acute process of the resident's right eye and right shoulder. During an observation on 10/30/20 at 2:06 p.m., Resident #2 was in a wheelchair in the dining room calmly feeding himself. The resident was wearing eyeglasses and dressed in daywear including a white tee shirt covered by an unbutton, long-sleeved shirt, tennis shoes, and a baseball cap on his head. There was no discoloration observed to the resident's right eye. There was no response from the resident to questions. An interview was conducted on 10/30/20 at 12:17 p.m. with the nursing assistant (NA) #1 who provided Resident #2's ADL care during the morning of 9/25/20. NA#1 stated that Resident #2 was alert with confusion and was frequently agitated but not combative. NA#1 recalled on 09/25/20, he observed the resident attempting to stand from a sitting position on the side of his bed. NA#1 indicated he entered the room to assist the resident because he was concerned the resident would fall due to his non-ambulatory status. He immediately became aware of the foul odor on the resident. NA#1 stated the resident allowed him to assist him in lying down on the bed so that NA#1 could provide incontinent care. He stated as he removed the resident's eyeglasses (so he could remove the resident's shirt which contained fecal material) he noticed a slightly dark, puffy discoloration beneath the resident's right eye. When NA#1 attempted to wash the left side of the resident's face, the resident began kicking and swinging his legs knocking over the washbasin from the overbed table and kicking NA#1 in the legs, arms, and ribs. NA#1 stated that he stopped attempting to clean the resident's face and calmly explained to the resident what he was doing. The resident became less agitated, stopped being combative and NA#1 continued providing care. When NA#1 rolled the resident over onto his right side, the resident attempted to hit him with his elbow 2 or 3 times and swung his arm at him 1 or 2 times when NA#1 placed his opened hand on the resident's shoulder. The resident calmed down. NA#1 denied restricting the resident's movement because the resident was able to hold onto the top of the ¼ siderail. After completing ADL care, NA#1 assisted the resident to his wheelchair and then to the nursing station. NA#1 stated he reported to Nurse #1 the resident's combativeness during care and asked if she was aware of what happened to the resident's right eye. During an interview on 10/30/20 at 2:06 p.m., Nurse #1 stated Resident #2 was alert with confusion with combative behaviors (pushing, hitting, verbal) during care. Nurse #1 stated she did not observe Resident #2 with any skin issues when she administered his medication between 7:30 a.m. - 8:30 a.m. on 9/25/20. She stated she did not observe, and no one reported to her that the resident was combative on the morning of 9/25/20. She recalled that on 9/25/20 at approximately 9:30 a.m., she overheard a nurse speaking to the resident about his skin tears. When the nurse escorted the resident to the nursing station, she observed 4 or 5 open areas on the bilateral upper and lower arms and on the knuckles of his right two end fingers. The resident's right lower eyelid began to blacken and swell. Staff Nurse #1 stated she asked the resident what happened, and he replied, look what they done to me. When she asked who did this to him, the resident did not know. Nurse #1 indicated that when she questioned NA#1 about the resident, he responded that the resident was combative during care. During a telephone interview on 11/2/20 at 10:50 a.m., the former assistant director of nursing (ADON) revealed she observed Resident #2's wounds on the day of the incident. She stated the resident had a black, raised area beneath his right eye and 2-minimum surface skin tears above the left elbow (size of a nickel) with small amount of bleeding. She stated that NA#1 informed her that Resident #2 became combative when he attempted to wash the resident's face. She stated she asked NA#1 the facility's protocol if a resident became combative. She stated NA#1 responded he was to walk away until the resident calmed, but instead he completed his task. The ADON stated NA#1 was informed that he was suspended pending investigation. She revealed she notified the resident's responsible party of the resident's injuries. During an interview on 11/2/20 at 1:20 p.m., the Treatment Nurse revealed she had observed Resident #2 when he had infrequent periods of behaviors where he would have episodes of combativeness (including swinging, hitting, grabbing staff by the arms or hair) during care, especially during bathing when staff remove his shirt. She stated these episodes would occur suddenly. She revealed she had observed the resident become more combative with the male nursing assistants during care. She indicated the sound of the female nursing assistants voices appear to calm the resident when agitated. She stated the resident was never combative towards her during treatments/evaluations. The Treatment Nurse revealed she evaluated Resident #2 for skin tears and bruising on 9/25/20. She stated she removed the bandages that had been applied by the nursing staff and observed 2 or 3 skin tears with mild to moderate bleeding. She revealed orders were initiated: [MEDICATION NAME] plus pad (transparent film dressing) every 3 days for a superficial skin tear (size of a dime) on the resident's left forearm and a tiny superficial skin tear on the right knuckle near the pinky finger; and leave steri-strips in place, cover with added pad, wrapped with [MEDICATION NAME] gauze roll every 3 days for the full thickness skin tear with jagged flap (approximately 1-2 cm (centimeters) in length on the resident's right outer, upper arm. She stated all areas healed pretty quickly. She stated that the resident bruised, easily and had some bruising beneath his eye and surrounding the skin tears. During a telephone interview on 10/28/20 at 11:56 a.m., the Nurse Practitioner (NP) stated that Resident #2 was not always cooperative with care and assessments (he would push away). The resident was alert but not oriented; only able to answer yes or no questions. She recalled that on 9/25/20 she was asked to assess the resident due to his right upper arm had bruising and two skin tears. There was also small, light linear bruising with some swelling under the right eye (lower lid). The resident was wearing his eyeglasses. The resident was cooperative during the assessment with no distress observed. The NP revealed it was difficult to determine if someone hit the resident in the eye because there were no definitive marks indicating a strike or a fist. The skin tears appeared triangular as though caused by friction. She stated no treatment was required. During a telephone interview on 10/29/20 at 3:59 p.m., the Interim Administrator stated he was notified of the bruising and skin tears on Resident #2 on 9/25/20. He stated he interviewed the resident's nursing assistant who informed him that while providing incontinent care and a bath to Resident #2, the resident became combative (swinging his arms and hitting the nursing assistant). To avoid being hit by the resident, the nursing assistant informed him that he placed his arm on the resident's shoulder. The nursing assistant laid the resident on the bed and continued to clean the resident who was combative. The Interim Administrator stated that the nursing assistant informed him that when care was completed and the resident calmed, he observed the resident had multiple skin tears and discoloration beneath his right eye. The Interim Administrator stated that he reminded the nursing assistant when the resident became combative during care, he should have de-escalated the situation by leaving the resident so that the resident could calm down. The nursing assistant responded he was afraid to leave the resident unattended due to the risk of the resident falling from the bed. The Interim Administrator stated the nursing assistant was suspended pending investigation.

Based on observations, record review and staff interviews, the facility failed to provide a two-person mechanical lift for transfers and failed to have fall floor mats on both sides of the bed for 1 of 1 resident (Resident #1) reviewed for falls. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 did not exhibit behaviors and required extensive assistance with two persons for transfers and toileting. She was non-ambulatory and utilized a wheelchair. Resident #1 had poor balance during transfers and had limitation in her range of motion on one side. Resident #1 was always incontinent of bowel and bladder. A review of the care plan updated 4/15/20 revealed a problem of risk for falls due to impaired mobility and a problem of requiring physical assistance daily with activities of daily living. Resident has [DIAGNOSES REDACTED]. The goals were for Resident #1 to have no serious injury from a fall and for Resident #1 to participate in activities of daily living as able. Interventions included no toileting due to incontinence, staff educated to read care guide before transferring resident, fall mats to both sides of bed and assistance with activities of daily living. A review of Resident #1 ' s profile under Alerts in the electronic health record indicated Resident #1 required a mechanical lift for transfers and fall mats beside bed. An incident report dated 4/28/20 indicated Resident #1 had a fall from her wheelchair at approximately 8:20 PM. Nurse Aide (NA) #1 was attempting to push Resident #1 out of the bathroom and Resident #1 attempted to stand up and fell from the wheelchair on her forehead. Resident #1 sustained a hematoma skin excoriation to her forehead. A written statement from NA #1 on 5/1/20 revealed on 4/28/20 she took Resident #1 to the bathroom and when she was finished, NA #1 successfully transferred Resident #1 to the wheelchair. She stated when she went to push Resident #1 out of the bathroom, Resident #1 leaned forward and attempted to stand up and she fell forward onto the floor. During an interview with NA #1 on 6/16/20 at 11:17 AM, she revealed she and NA #2 were making rounds during the 3-11 shift on 4/28/20. She stated she was toileting Resident #1 unassisted while NA #2 assisted Resident #1 ' s roommate. NA #1 stated after she transferred Resident #1 unassisted from the toilet to her wheelchair, she was rolling Resident #1 out of the bathroom when Resident #1 tried to stand up and fell forward. NA #1 stated she told NA #2 to get the nurse while she stayed with the resident. She stated Resident #1 had an injury to her forehead. NA #1 stated she did not review Resident #1 ' s care plan on the tablet prior to her shift and she was unaware that Resident #1 was not to be toileted or that a mechanical lift was required for transfers. A written statement from NA #2 dated 5/1/20 revealed on 4/28/20 she witnessed NA #1 transferring Resident #1 back into the wheelchair from the toilet. An interview was conducted with NA #2 on 6/17/20 at 10:03 AM. She stated she was working on 4/28/20 and was assisting Resident #1 ' s roommate when she heard a bump coming from the bathroom. She stated NA #1 was toileting Resident #1 by herself and she didn ' t see Resident #1 fall but probably saw NA #1 transferring Resident #1. NA #2 stated she did not know Resident #1 required a mechanical lift for transfers because she was not assigned to her care. NA #2 stated Resident #1 was a one person assist for transfers. A nurse ' s note dated 5/1/20 at 3:46 PM read, requires extensive assistance x 2 with transfers. On 6/16/20 at 9:30 AM, an observation was made of Resident #1 lying in her bed. There was one fall mat on the floor on the right side of the bed, but there was no fall mat on the floor on the left side of the bed. A second observation on 6/16/20 at 11:40 AM revealed Resident #1 still only had one fall mat on the floor on the right side of the bed. There was not a mat on the left side of the bed. An interview was conducted with NA #3 on 6/17/20 at 11:25 AM. NA #3 stated she worked at the facility on an as needed basis and usually worked about 3 days a week. She was familiar with Resident #1 and stated she needed total assistance with her activities of daily living. She stated she was incontinent of bowel and bladder and she did not toilet her. She demonstrated to the surveyor where to look for the resident ' s care needs but admitted she did not read through the care plan every day. She was unaware that Resident #1 had an intervention to have fall mats on both sides of the bed. An interview was conducted with the Minimum Data Set (MDS) Nurse on 6/16/20. She stated when she completed the care plan, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) put the resident care information on the resident ' s profile in the electronic health record. An interview was conducted with the DON on 6/16/20 at approximately 11:30 AM. She stated the resident care information was updated on the resident profile under alerts by herself, the ADON and other supervisory staff. She stated they transitioned to [MEDICATION NAME] in October 2019 and no longer use care guides on the resident ' s closet doors. The DON stated Resident #1 had an intervention for no toileting because she was always incontinent of bowel and bladder and wouldn ' t need to be put on the toilet, her incontinence care would be done in the bed. The DON stated NA #1 failed to check the care guide at the start of her shift. The DON showed the surveyor Resident #1 ' s profile that indicated mechanical lift x 2 and fall mats. The DON stated NA #1 neglected to check the care guide before providing care and confirmed on 4/28/20 NA #1 should not have toileted Resident #1 or transferred her by herself.

Based on observations and staff interviews the facility failed to ensure dishware were clean and allowed to air dry, maintain clean kitchen equipment and store foods in sealed containers. This was evident in 1 of 1 kitchen observations. Findings Included: An observation of the kitchen on 6/24/19 at 10:30 am with the Dietary Manager (DM) revealed the following: 1. 10 full sized steam table pans had food particles and grease in them. These pans were stacked together on a storage shelf for clean pots and pans. 2. 15 of 15 plastic plate bases were stacked together wet on the serving line ready for the lunch meal service. 3. 2 hood filters located over the fryer were saturated with a dark brown, grease like substance. 4. The condiment cart was noted with an accumulation of white powder, gritty-like substances in and below the metal insert pans. 5. A 25-pound box of white rice and a 10-pound bag of brown rice were open and exposed to the air in the dry storage room. An interview on 6/24/19 at 10:55 am with the DM revealed the steam table pans were not clean and needed to be re-washed, the plate bases and all dishware should be air dried before being stored, the hood filters needed to be cleaned and possibly replaced if they could not be adequately cleaned, the condiment cart should be clean and the bags of rice should be sealed, labeled and dated. An interview on 6/27/19 at 5:10 pm with the Administrator revealed it was his expectation that the kitchen was kept clean and orderly, food items were properly sealed, labeled and dated and dishes were clean and allowed to air-dry.

Based on observations, resident and staff interviews the facility failed to honor a resident 's choice for a bed bath. This was evident for 1 of 3 residents reviewed for choices. (Resident #98). Findings included: Resident #98 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #98's current care plan dated 3/7/19 revealed the resident was care planned for urinary incontinence related to impaired mobility and cognitive mobility. with the goal being the resident would be free from skin breakdown. Interventions included peri care after each incontinent episode. Resident #7 was also care planned for potential for urinary tract infection related to history of chronic UTI and incontinence. Resident #98 required assistance with all her activities of daily living due to left sided [MEDICAL CONDITION], history [MEDICAL CONDITION] dementia. A review of Resident #98's most recent MDS (Minimum Data Set) coded as a quarterly assessment was dated 6/10/2019. The MDS coded the resident as having no cognitive impairment. Resident #98 was coded as being totally dependent on staff assistance for bathing and toileting and as always being incontinent of bladder and bowel. Under the vision section of the MDS, Resident #98 was coded as having adequate vision. Resident #98 was able to make her needs known to staff. An interview was conducted on 6/26/2019 at 5:10 am with Resident #98. She reported she had been waiting for someone to assist her for approximately 10 -15 minutes, but no one had come in yet. The call light was still on during the interview. Resident #98 indicated that it was like this all the time on third shift. Resident #98 indicated she waited from 4:30pm until 9pm on (MONTH) 25, 2019 for someone to put her back to bed. Resident #98 included she was wet from her waist down to her knees last night. Resident #98 indicated that she asked the Nursing Assistant (NA) to give her a good bed bath because she was smelling like a piss barrel but the aide would not. At 5:25am NA #13 entered Resident #98 ' s room and Resident #98 indicated that she wanted a good bed bath because she had two appointments today and did not want to go to the appointment smelling like a piss barrel. Nursing Assistant #13 indicated that he would be back with help because she was a two person assist. An observation on 6/25/19 at 5:45am, Resident #98 was still waiting to be changed and have a bath. An observation on 6/25/19 at 6:15am, Resident #98 was still waiting to be changed and have a bath. An observation on 6/25/19 at 6:30am, Resident #98 was still waiting to be changed and have a bath. An observation on 6/25/19 at 6:45am of Resident #98 revealed NA #13 and NA #15 had arrived in to gave Resident #98 her bath. During an interview with NA #13 on 6/26/2019 at 7:10am he stated he had to wait to help with Resident #98 because she was a 2 person assist. An interview with the Administrator at 6:48am on 6/26/2019 revealed his expectation was that all residents who needed assistance with incontinence care and bathing should not have to wait a long time (his timeframe was not over 30 minutes) to receive care and all residents ' choices should be met.

Based on record reviews and staff interviews, the facility failed to accurately code the MDS (Minimum Data Set) on 1 out of 5 residents (#35) reviewed for unnecessary medications. Findings include: Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #35's most recent MDS coded as a quarterly assessment was dated 4/26/19. The MDS coded the resident as mild cognitive impairment. Active [DIAGNOSES REDACTED]. The MDS coded Resident #35's medication look back that the resident received injections 7 out of 7 days, insulin 7 out of 7 days, antipsychotics 7 out of 7 days, antidepressants 7 out of 7 days, and opioids 7 out of 7 days. A review of Resident #35's most current care plan dated 2/27/19 revealed the resident was care planned for potential for hypo/[MEDICAL CONDITION] related to a history of diabetes. A review of Resident #35's Medication Administration Record [REDACTED]. An interview was conducted with the corporate MDS coordinator. She reported it was the responsibility of the MDS nurses to correctly code all MDS assessments. She reported it was her expectation that the MDS nurse would code the active [DIAGNOSES REDACTED].

Based on observations, record review, and staff and resident interviews, the facility failed to provide incontinence care for 1 out of 4 residents (Resident #98) reviewed for ADLs (Activities of Daily Living) Findings include: Resident #98 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #98's most recent MDS (Minimum Data Set) was coded as an annual assessment and was dated 6/10/19. The MDS coded the resident as having no cognitive impairment. Active [DIAGNOSES REDACTED]. Resident #98 was coded as needing extensive 2-person assistance with Activities of Daily Living which included personal hygiene and bathing. Resident #98's most recent care plan dated 6/14/19 revealed the resident was care planned for assistance with Activities of Daily Living due to left sided [MEDICAL CONDITION] due to history of [MEDICAL CONDITION]. Interventions included to keep resident's call light within reach and staff to answer in timely manner. An interview was conducted with Resident #98 on 6/26/19 at 5:15am. She reported she sat in a urine soaked brief last night for 3 hours before the staff changed her. She reported she had urine up her back and down her legs. During interview, Resident #98 had on her call light. NA #13 (Nursing Assistant) came in the room at 5:25am and reported he had to find someone to help him and would be back in 5 minutes to bathe Resident #98. Resident #98 reported her brief was dry. An interview was conducted with NA #13 on 6/26/19 at 5:50am. He reported he had not bathed Resident #98 yet as he had to complete care on another resident and wait for NA #15 to get done with another resident. An observation was conducted on 6/26/19 at 6:40am of Resident #98 receiving a bath from NA #13 and NA #15. When NA #13 removed Resident #98's brief, it was wet. NA #13 washed hands prior to donning gloves and with glove change. He provided correct bathing technique by cleansing with warm, soapy water then rinsing and dried resident. Resident #98 tolerated bath and good rapport noted between the resident and the NAs. An interview was conducted with NA #13 on 6/26/19 at 6:55am. He reported he tried to get to the residents who liked baths early first but sometimes had to wait for the other NA when the resident required 2-person assistance. An interview was conducted with the administrator on 6/26/19 at 7:10am. He reported it was his expectation that all residents received timely incontinence care.

Based on record review, pharmacist interview, staff interviews, family member interview and resident interview the facility failed to administer 3 doses of eye drops for 1 of 6 residents (Resident #102) whose medications were reviewed. Findings included: Resident #102 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #102 was minimally cognitively impaired and needed extensive assistance with 2 people for bed mobility, total assistance with one person for dressing and personal hygiene, total assistance with 2 people for transfers and toileting and supervision with set up for eating. Resident #102's care plan dated 6-25-19 revealed a goal that Resident #102's vision would not impede her safety or satisfaction with daily activities. The interventions for that goal included; keeping the environment free from clutter, evaluate for decreased or changes in vision and aid with activities of daily living as needed. A review of the physician orders [REDACTED]. During an interview with Resident #102's family member, the family member stated the resident had not received her eye drops, [MEDICATION NAME] Balance eye drops, as ordered by the physician in the month of (MONTH) 2019. A review of Resident #102's Medication Administration Record [REDACTED]. The dispensing pharmacist was interviewed on 6-27-19 at 9:10am. The pharmacist stated the [MEDICATION NAME] Balance eye drops were over the counter, so the staff would need to retrieve the medication from the facility's central supply. An interview occurred with the central supply manager on 6-27-19 at 9:30am. The central supply manager stated she [MEDICATION NAME] each medication room daily and restocks the over the counter medications as needed. She also stated when a new resident was admitted she received a call from the nurse informing her of any new medication that may be needed. The manager stated staff had access to the central supply room during off hours and on the weekends if they were needing a medication. She also stated [MEDICATION NAME] Balance eye drops were kept in the medication room and denied receiving a call or being informed that Resident #102 was out of her [MEDICATION NAME] Balance eye drops. Nurse #1 was interviewed on 6-27-19 at 10:00am. The nurse stated she did not administer Resident #102's [MEDICATION NAME] Balance eye drops on 5-11-19 and 5-12-19 at 5:00pm because they were not on the medication cart. She also denied looking in the medication room to see if the medication was there No I didn't look in there because this was a medication ordered by the doctor, so it had to come from the pharmacy. Nurse #1 denied calling the pharmacy to try and obtain the medication. During an interview with the Medication Aide #1 on 6-27-19 at 10:15am, the medication aide stated she did not administer Resident #102's [MEDICATION NAME] Balance eye drops on 5-19-19 at 10:00am because they were not on the medication cart. She also denied looking in the medication room for the eye drops no I didn't think to look in there. The Administrator and corporate Clinical Manager were interviewed on 6-27-19 at 3:30pm. The Administrator stated he expected staff to follow the medication administration record.

Based on record review, resident and staff interviews the facility failed to accommodate resident ' s preferences to attend activities due to not being up and ready in time for the scheduled activity. This was evident for 4 of 6 residents reviewed for accommodation of needs (Resident #9, Resident #11, Resident #10 and Resident #13). Findings Included: Resident #9 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. An annual minimum data set ((MDS) dated [DATE] for Resident #9 revealed she required extensive, one-person assist with ADL ' s and her cognition was intact. An interview with Resident #9 on 12/2/18 at 3:42 pm revealed there were times the staff didn ' t have her up and ready to attend activities. She stated it was important to her to have things to do and for the staff to have her ready for activities. Resident #11 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] for Resident #11 revealed she required extensive assistance to total dependence with ADL ' s and her cognition was intact. An interview on 12/3/18 at 11:45 am with Resident #11 revealed she liked to attend Bingo and sometimes she was not gotten up in time to attend. Review of a grievance dated 9/10/18 submitted by Resident #11 revealed the resident had requested to be up in time to attend Bingo. Corrective action stated on 9/13/18 the resident was up for Bingo and the Administrator assured the resident she would be up in time to attend. An interview on 12/3/18 at 2:57 pm with the Activity Assistant (AA) revealed she had worked in this position for 7 months. She stated the facility did not currently have an Activity Director; she believed the position had been open since the 1st or 2nd week of November. The AA added resident attendance at the morning activity which typically started at 10:30 am was less than the afternoon activity. She stated some residents had told her that they weren ' t up and dressed in time to attend the morning activity. The AA added she recalled Resident #9, Resident #10 and Resident #13 had voiced concerns about missing activities due to not be ready. She stated she had reported these resident concerns to the previous Activity Director. Resident #10 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] for Resident #10 revealed she required supervision one-person assist with ADL ' s and her cognition was intact. An interview with Resident #10 on 12/3/18 at 4:02 pm revealed there were times that she missed the morning activity because she wasn ' t dressed yet. Resident #13 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. An annual MDS dated [DATE] for Resident #13 revealed she required extensive one-person assist with ADL ' s and her cognition was intact. An interview with Resident #13 on 12/3/18 at 4:35 pm revealed she loved to go to activities and if there was one going on she wanted to attend. She stated she reported a concern at the resident council meeting that there were times she wasn ' t up and dressed in time to attend the 10:30 am activity. Resident #13 added there really hadn ' t been any change since she reported her concern and there were still times she wasn ' t up and ready to go to the morning activity. Review of a grievance dated 11/14/18 for Resident #13 revealed a concern that she had not been able to go to activities in the morning due to not getting up and having her bath until close to lunch time or after. Investigation findings stated the resident had been attending activities as preferred. An interview on 12/3/18 at 4:53 pm with Nursing Assistant (NA) #5 revealed there wasn ' t a list or documentation that told the NAs what residents needed to be up in time to go to activities. He stated the residents or someone that worked in activities would tell them if they wanted to go to a specific activity. A follow-up interview on 12/3/18 at 5:17 pm with the AA revealed she would try and verbally remind the nursing staff if there was a specific activity that a resident wanted to be up for. She stated if it was her weekend to work she would sometimes leave a list of residents that needed to be up and ready for activities. The AA added she would sometimes go and get the residents herself if they were up and dressed. She stated Bingo had been changed from the morning to the afternoon because residents weren ' t up and ready to attend at 10:30 am. An interview on 12/3/18 at 5:47 pm with the Administrator revealed the facility was in the process of hiring an Activity Director. She stated the previous Activity Director ' s last day of employment was 11/9/18. The Administrator stated it was her expectation that residents would be up and ready in time to attend activities of their choice.

Based on record review, and staff, resident, and physician interviews the facility failed to notify the physician when a prescribed pain medication was unavailable for 1 of 1 residents (Resident #7) reviewed for physician notification. Resident #7 experienced increased nerve pain when staff failed to notify the physician that the prescribed dose of her nerve pain medication was not available and failed to obtain a physician's orders [REDACTED]. Findings include: 1. Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated for 7/3/18 revealed that Resident #7 was cognitively intact, required one person extensive to total assistance for all activities of daily living (ADLs). It also documented the resident was on a scheduled pain medication regimen for almost constant moderate pain and received opioids 7 of 7 days during that assessment period. Review of the resident's (MONTH) Physician order [REDACTED]. Original Order Date: 5/27/17 [MEDICATION NAME] 75 (milligrams) mg capsule (Nerve pain medication) - Take 1 tab by mouth (PO) two times (BID) daily 5/27/17 [MEDICATION NAME] 100mg capsule - Take 1 capsule PO at hour of sleep (HS) 5/27/17 Pain Assessment during every shift (6:00 AM/2:00 PM/10:00 PM) Review of the resident's (MONTH) (YEAR) Medication Administration Record [REDACTED]. In the note section of the MAR indicated [REDACTED]. On 6/25/18 at 2:16 PM it was also documented that the medication was not available. The [MEDICATION NAME] 100 mg ordered to be given at 8:00 PM was administered for all these dates. Review of Resident #7's (MONTH) (YEAR) MAR indicated [REDACTED]. On 6/26/18 the resident was documented to have a pain level of 0 at 6:00 AM, and for the 2:00 PM pain assessment the resident had reported a pain level of 10 out of 10 (worst pain level on the 0-10 pain scale) to Nurse #7. For the 10:00 PM assessment on 6/27/18 the resident reported a 7 out of 10 pain level. Review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED]. During an interview with Resident #7 on 8/12/18 at 3:55 PM she stated that she did not receive her [MEDICATION NAME] for approximately three days in (MONTH) (YEAR). She stated that her [MEDICAL CONDITION] pain was horrible during that time, that she remembered reporting to the nurse that her pain level was a 10 out of 10. When the resident had asked about the medication, the staff just kept telling her they were out of the medication and were waiting on it to be dispensed from the pharmacy. When asked if she had received other pain medications, Resident #7 stated she had received her other scheduled pain medication. She also stated that her nerve pain was only relieved by [MEDICATION NAME] and that other pain medications didn't relieve that type of pain for her. She stated that she did not think she was getting the correct dose of [MEDICATION NAME] currently (as of 8/12/18), and that she had thought she was getting less than prescribed. She had asked staff (couldn't remember who) about her night time dose of 100 mg of [MEDICATION NAME] and was told that they were administering the 75 mg dose until the 100 mg dose arrived from pharmacy. She stated that she could tell a difference in the decreased dosage due to having more pain in her legs during the night. During an interview with Nurse #2 on 8/13/18 at 3:30 PM she stated that staff tried to avoid running out of medications, but that if it happened that they would check the back-up medication kit to see if the medication was available. If it wasn't, then the on-call provider would be contacted for instructions and sometimes an order for [REDACTED]. During an interview with Pharmacy Director/Owner on 8/13/18 at 3:44 PM he stated that Resident #7's prescriptions for [MEDICATION NAME] 75mg (28 pills) and 100 mg (14 pills) were dispensed in 14-day supply due to insurance reasons. The last date that the [MEDICATION NAME] 100 mg was dispensed from the pharmacy was on 7/25/18. There were no pending refills placed for the dose of 100 mg [MEDICATION NAME] for Resident #7 at the time of this interview. During an interview with Nurse #1 on 8/14/18 at 2:54 PM she stated that she had instructed Med Aide #1 to administer the 75 mg of [MEDICATION NAME] in place of the ordered 100 mg dose. When asked if she had called the physician or the on-call provider to obtain an order to use the 75 mg [MEDICATION NAME] as an alternate dose for the prescribed 100 mg dose she stated that she did not. She also stated that she had not notified the pharmacy to refill the prescription. During an interview with the Physician on 8/14/18 at 3:15 PM he stated that medications should not run out if staff are ordering them correctly, but if it did happen that they were expected to call the on-call provider immediately if the medication is not available in the facility's back-up medication kit. Depending on the medication, an alternate could be ordered and in Resident #7's case an order to substitute the 100 mg dose of [MEDICATION NAME] with the 75 mg could have been a possibility. He stated that no one other than another physician or other licensed provider should change prescribed medication doses ordered by the physician. During an interview with the Director of Nursing on 8/14/18 at 3:35 PM she stated that it was her expectation that all medications are administered per the physician's orders [REDACTED].

Based on observations, record review, and staff, resident, and physician interviews the facility: 1) Failed to follow physician orders [REDACTED].#7) reviewed for pain management. Resident #7 experienced increased nerve pain when staff failed to administer her routine pain medication as ordered and when she received a decreased dosage of her prescribed pain medication; and, 2) Failed to initiate a new physician's order [REDACTED]. [REDACTED].#8) reviewed for pain management. Findings include: 1. Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated for 7/3/18 revealed that Resident #7 was cognitively intact, required one person extensive to total assistance for all activities of daily living (ADLs). It also documented the resident was on a scheduled pain medication regimen for almost constant moderate pain and received opioids 7 of 7 days during that assessment period. Review of the resident's (MONTH) Physician order [REDACTED]. Original Order Date: 5/27/17 [MEDICATION NAME] 75 (milligrams) mg capsule (Nerve pain medication) - Take 1 tab by mouth (PO) two times (BID) daily 5/27/17 [MEDICATION NAME] 100mg capsule - Take 1 capsule PO at hour of sleep (HS) 5/27/17 Pain Assessment during every shift (6:00 AM/2:00 PM/10:00 PM) Review of the resident's (MONTH) (YEAR) Medication Administration Record [REDACTED]. In the note section of the MAR indicated [REDACTED]. On 6/25/18 at 2:16 PM it was also documented that the medication was not available. The [MEDICATION NAME] 100 mg ordered to be given at 8:00 PM was administered for all these dates. Review of the Declining Inventory Log for [MEDICATION NAME] 75 mg dated to start on 6/8/18 revealed that the last dose of this medication supply from the pharmacy was administered on 6/22/18. Review of the resident #7's (MONTH) (YEAR) MAR indicated [REDACTED]. Review of Resident #7's (MONTH) (YEAR) MAR indicated [REDACTED]. On 6/26/18 the resident was documented to have a pain level of 0 at 6:00 AM, and for the 2:00 PM pain assessment the resident had reported a pain level of 10 out of 10 (worst pain level on the 0-10 pain scale) to Nurse #7. For the 10:00 PM assessment on 6/27/18 the resident reported a 7 out of 10 pain level. Review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the Declining Inventory Logs for [MEDICATION NAME] 100 mg revealed that the last dose of the medication was administered on 8/9/18 at 9:00 PM. During an interview with Resident #7 on 8/12/18 at 3:55 PM she stated that she did not receive her [MEDICATION NAME] for approximately three days in (MONTH) (YEAR). She stated that her [MEDICAL CONDITION] pain was horrible during that time, that she remembered reporting to the nurse that her pain level was a 10 out of 10. When the resident had asked about the medication, the staff just kept telling her they were out of the medication and were waiting on it to be dispensed from the pharmacy. When asked if she had received other pain medications, Resident #7 stated she had received her other scheduled pain medication. She also stated that her nerve pain was only relieved by [MEDICATION NAME] and that other pain medications didn't relieve that type of pain for her. She stated that she did not think she was getting the correct dose of [MEDICATION NAME] currently (as of 8/12/18), and that she had thought she was getting less than prescribed. She had asked staff (couldn't remember who) about her night time dose of 100 mg of [MEDICATION NAME] and was told that they were administering the 75 mg dose until the 100 mg dose arrived from pharmacy. She stated that she could tell a difference in the decreased dosage due to having more pain in her legs during the night. An observation and review on 8/12/18 at 4:15 PM of the current Declining Inventory Logs being used by staff to administer medications revealed that there was no log for the [MEDICATION NAME] 100 mg dose. An interview with Nurse #7 was unable to be completed during the investigation. During an interview with Nurse #2 on 8/13/18 at 3:30 PM she stated that staff tried to avoid running out of medications, but that if it happened that they would check the back-up medication kit to see if the medication was available. If it wasn't, then the on-call provider would be contacted for instructions and sometimes an order for [REDACTED]. During an interview with Pharmacy Director/Owner on 8/13/18 at 3:44 PM he stated that Resident #7's prescriptions for [MEDICATION NAME] 75mg (28 pills) and 100 mg (14 pills) were dispensed in 14-day supply due to insurance reasons. The last date that the [MEDICATION NAME] 100 mg was dispensed from the pharmacy was on 7/25/18. There were no pending refills placed for the dose of 100 mg [MEDICATION NAME] for Resident #7 at the time of this interview. During an interview on 8/14/18 at 2:45 PM with Med Aide #1 she stated that on 8/10/18 she had notified Nurse #1 that the 100 mg [MEDICATION NAME] medication had ran out. Nurse #1 told her to administer the 75 mg [MEDICATION NAME] dose instead until the 100 mg dose was ordered and delivered from the pharmacy. She stated that she administered the 75 mg dose in place of the 100 mg dose of [MEDICATION NAME] and signed it out in the Declining Inventory Logs for [MEDICATION NAME] 75 mg. When asked if she had noticed an increase in Resident #7's pain level she stated that the resident had chronic pain and she could not determine if there was a difference. Review of the Declining Inventory Logs for [MEDICATION NAME] 75 mg revealed that on 8/10/18, 8/11/18, and 8/12/18 the medication was administered three times per day confirming the 75 mg dose of [MEDICATION NAME] was being administered in place of the ordered 100 mg dose of [MEDICATION NAME]. During an interview with Nurse #1 on 8/14/18 at 2:54 PM she stated that she had instructed Med Aide #1 to administer the 75 mg of [MEDICATION NAME] in place of the ordered 100 mg dose. When asked if she had called the physician or the on-call provider to obtain an order to use the 75 mg [MEDICATION NAME] as an alternate dose for the prescribed 100 mg dose she stated that she did not. She also stated that she had not notified the pharmacy to refill the prescription. During an interview with the Physician on 8/14/18 at 3:15 PM he stated that medications should not run out if staff are ordering them correctly, but if it did happen that they were expected to call the on-call provider immediately if the medication is not available in the facility's back-up medication kit. Depending on the medication, an alternate could be ordered and in Resident #7's case an order to substitute the 100 mg dose of [MEDICATION NAME] with the 75 mg could have been a possibility. He stated that no one other than another physician or other licensed provider should change prescribed medication doses ordered by the physician. During an interview with the Director of Nursing on 8/14/18 at 3:35 PM she stated that it was her expectation that all medications are administered per the physician's orders [REDACTED]. 2. Resident #8 was admitted to the facility on [DATE] from a hospital. His cumulative [DIAGNOSES REDACTED]. [MEDICATION NAME] vertebrae comprise the middle segment of the backbone. A review of Resident #8 ' s medical record included a physician ' s progress note dated 8/2/18 which read, in part, Please note that pain control is necessary for continual participation with rehab. A review of the resident ' s physician's order [REDACTED]. [MEDICATION NAME] is a potent, long-acting opioid medication which may be administered [MEDICATION NAME] (through the skin) by the application of a patch. According to the product manufacturer, a [MEDICATION NAME] should be changed every 72 hours. The old [MEDICATION NAME] should be removed before the new patch is applied. A review of the Resident #8 ' s admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognitive skills for daily decision making. The resident required extensive assistance from staff for bed mobility, transfers, locomotion on the unit, dressing, toileting and personal hygiene. He was independent for eating. Section J of the MDS revealed the resident received scheduled and as needed (PRN) medications for frequent pain rated as a 5 out of 10 (on a scale of 0 to 10, with 0 indicative of no pain and 10 as the worst pain imaginable). A review of Resident #8 ' s care plan included an area of focus related to his potential for pain (dated 8/5/18). The interventions for this care area included, in part, to administer pain medications as ordered. Further review of the resident ' s Physician order [REDACTED]. An order was also written to discontinue the 325 mg [MEDICATION NAME] (an over-the-counter pain medication) previously prescribed as 2 tablets by mouth every 4 hours as needed for mild/moderate pain; and, to initiate a scheduled dose of 500 mg [MEDICATION NAME] to be given as 2 tablets by mouth three times daily. An observation was conducted on 8/14/18 at 8:32 AM as Nurse #4 prepared medications to be administered to Resident #8. Prior to applying a new [MEDICATION NAME] to the resident ' s skin, the nurse was observed as he found one [MEDICATION NAME] on the resident ' s right side of his back and another one on the left side of his back. One of the [MEDICATION NAME]es was dated 8/5/18 and the other one was dated 8/11/18. The nurse removed both of the patches prior to applying a new 12 mcg/hr [MEDICATION NAME] to the resident ' s skin. An interview was conducted on 8/14/18 at 8:45 AM with Resident #8. During the interview, the resident was asked whether his level of pain had changed during his stay at the facility. The resident reported it had not. The resident stated his level of pain primarily changed based on positioning. He reported having more pain when sitting up versus when he was lying down in bed. A review of Resident #8 ' s (MONTH) (YEAR) Medication Administration Record [REDACTED]. No [MEDICATION NAME] was documented as having been applied prior to 8/5/18. The [MEDICATION NAME] scheduled to be applied on 8/8/18 at 9:00 AM was not documented as done. The MAR indicated [REDACTED]. A review of the resident ' s Controlled Substance declining inventory sheet (also known as a Narcotic Log) revealed 10 [MEDICATION NAME]es were dispensed from the pharmacy for Resident #8 on 8/2/18. One [MEDICATION NAME] was removed from the inventory on each of the following dates: 8/5/18, 8/11/18, and 8/14/18. Seven [MEDICATION NAME]es remained in the inventory stored on the medication cart for this resident. An interview was conducted with the facility ' s Director of Nursing (DON) in the presence of the Administrator on 8/14/18 at 10:38 AM. During the interview, the DON stated she would expect the nurses to check for the placement / removal of a [MEDICATION NAME] every day and to change the [MEDICATION NAME] in accordance with the physician orders. An interview was conducted on 8/14/18 at 11:52 AM with Nurse #5. Nurse #5 was identified by her initials on the MAR indicated [REDACTED]. Upon review of the resident ' s (MONTH) MAR, the nurse reported it would have been the Med Aide ' s responsibility to apply the [MEDICATION NAME] on that date. An interview was conducted on 8/14/18 at 11:55 AM with Med Aide #2. Med Aide #2 was identified by her initials on the MAR indicated [REDACTED]. Upon review of the resident ' s MAR, the Med Aide stated she was, Not sure if I just didn ' t see it (the [MEDICATION NAME] needing to be applied) or if I overlooked it. A follow-up interview was conducted on 8/14/18 at 2:30 PM with Nurse #5. During the interview, Nurse #5 reported the order for Resident #8 ' s [MEDICATION NAME] was put into the computer at 2:09 PM on 8/2/18 and it was initially scheduled to be applied at 9:00 AM on 8/2/18. She explained that since the time of the initial scheduled dose was already past when the order was put into the computer, the system automatically scheduled the next dose for 72 hours later (which would have been 8/5/18 at 9:00 AM). Nurse #5 stated, It ' s an education issue. A follow-up interview was conducted on 8/14/18 at 2:50 PM with the DON. During the interview, the DON reported her expectation would have been for the [MEDICATION NAME] to start the day after the physician's order [REDACTED]. A telephone interview was conducted on 8/14/18 at 3:02 PM with the resident ' s physician. During the interview, the physician was asked when he would have expected Resident #8 ' s [MEDICATION NAME] to be applied if it was ordered on [DATE]. The physician responded by saying, Immediately. The physician was then asked for his thoughts on the delay in initiation of the [MEDICATION NAME] until 8/5/18, the missed [MEDICATION NAME] placement on 8/8/18, and the missed [MEDICATION NAME] removal (of the patch applied on 8/5/18) when a new patch was applied on 8/11/18. The physician stated that in view of the fact that the order was written and they had the medication, he would have expected the resident to receive the medication as ordered.

Based on record review, observations and Physician, resident, pharmacy and staff interviews, the facility failed to acquire and administer pain medication as ordered by the physician for 1 of 1 sampled residents (Resident #7) reviewed for medication administration. Resident #7 experienced increased nerve pain when staff failed to notify the pharmacy regarding the required refill of her nerve pain medication, which delayed the dispense of the medication, as well as the ordered treatment for [REDACTED]. Findings include: 1. Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated for 7/3/18 revealed that Resident #7 was cognitively intact, required one person extensive to total assistance for all activities of daily living (ADLs). It also documented the resident was on a scheduled pain medication regimen for almost constant moderate pain and received opioids 7 of 7 days during that assessment period. Review of the resident's (MONTH) Physician order [REDACTED]. Original Order Date: 5/27/17 [MEDICATION NAME] 75 (milligrams) mg capsule (Nerve pain medication) - Take 1 tab by mouth (PO) two times (BID) daily 5/27/17 [MEDICATION NAME] 100mg capsule - Take 1 capsule PO at hour of sleep (HS) 5/27/17 Pain Assessment during every shift (6:00 AM/2:00 PM/10:00 PM) Review of the resident's (MONTH) (YEAR) Medication Administration Record [REDACTED]. In the note section of the MAR indicated [REDACTED]. On 6/25/18 at 2:16 PM it was also documented that the medication was not available. Review of Resident #7's (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the resident's (MONTH) (YEAR) MAR indicated [REDACTED]. During an interview with Resident #7 on 8/12/18 at 3:55 PM she stated that she did not receive her [MEDICATION NAME] for approximately three days in (MONTH) (YEAR). She stated that her [MEDICAL CONDITION] pain was horrible during that time, that she remembered reporting to the nurse that her pain level was a 10 out of 10. When the resident had asked about the medication, the staff just kept telling her they were out of the medication and were waiting on it to be dispensed from the pharmacy. When asked if she had received other pain medications, Resident #7 stated she had received her other scheduled pain medication. She also stated that her nerve pain was only relieved by [MEDICATION NAME] and that other pain medications didn't relieve that type of pain for her. She stated that she did not think she was getting the correct dose of [MEDICATION NAME] currently (as of 8/12/18), and that she had thought she was getting less than prescribed. She had asked staff (couldn't remember who) about her night time dose of 100 mg of [MEDICATION NAME] and was told that they were administering the 75 mg dose until the 100 mg dose arrived from pharmacy. She stated that she could tell a difference in the decreased dosage due to having more pain in her legs during the night. During an interview with Nurse #2 on 8/13/18 at 3:30 PM she stated that staff tried to avoid running out of medications, but that if it happened that they would check the back-up medication kit to see if the medication was available. If it wasn't, then the on-call provider would be contacted for instructions and sometimes an order for [REDACTED]. During an interview with Pharmacy Director/Owner on 8/13/18 at 3:44 PM he stated that Resident #7's prescriptions for [MEDICATION NAME] 75mg (28 pills) and 100 mg (14 pills) were dispensed in 14-day supply due to insurance reasons. The last date that the [MEDICATION NAME] 100 mg was dispensed from the pharmacy was on 7/25/18. There were no pending refills placed for the dose of 100 mg [MEDICATION NAME] for Resident #7 at the time of this interview. During an interview with Nurse #1 on 8/14/18 at 2:54 PM she stated that she had instructed Med Aide #1 to administer the 75 mg of [MEDICATION NAME] in place of the ordered 100 mg dose. When asked if she had called the physician or the on-call provider to obtain an order to use the 75 mg [MEDICATION NAME] as an alternate dose for the prescribed 100 mg dose she stated that she did not. She also stated that she had not notified the pharmacy to refill the prescription. During an interview with the Physician on 8/14/18 at 3:15 PM he stated that medications should not run out if staff are ordering them correctly, but if it did happen that they were expected to call the on-call provider immediately if the medication is not available in the facility's back-up medication kit. Depending on the medication, an alternate could be ordered and in Resident #7's case an order to substitute the 100 mg dose of [MEDICATION NAME] with the 75 mg could have been a possibility. During an interview with the Director of Nursing on 8/14/18 at 3:35 PM she stated that it was her expectation that all medications are administered per the physician's orders [REDACTED].>

Based on observations, interviews with staff, interviews with the nurse practitioner (NP) and record review the facility staff failed to assess the pain level of Resident#2 and provide pain relief when Resident#2 displayed signs of pain upon movement of the left leg from 5/3/11 through 5/6/11. The facility staff failed to conduct an ongoing assessment of a bruised and swollen right leg. The facility staff failed to conduct an initial assessment or ongoing assessments of a skin tear to the right leg. On 5/6/11 Resident #2 was diagnosed with [REDACTED]. On 5/6/11 Resident #2 was diagnosed with [REDACTED]. This was evident in 1 of 2 residents in the survey sample reviewed for pain management and 1 of 3 residents in the sampled survey reviewed for accidents. (Resident#2) Findings include: The facility has a pain management tool (date unclear). Review of the pain tool revealed guidelines for assessing a resident (who was unable to verbally express pain) using facial and body language, Interview on 5/18/11 at 11:08 a.m. with staff development coordinator (SDC) revealed there was no written procedure on using the pain management tool. If pain is present the nursing assistant (NA) should notify the nurse and the nurse should use the tool to conduct an assessment. The SDC indicated the nurse should check whether there was a prn (when ever necessary) order or contact the MD (medical doctor) or NP. The SDC also indicated the facility documents by exception and has not provided training to staff on nursing assessments other than during orientation. The skin care policy was provided by DON (Director of nurses) who indicated the policy has been in effect since 11/2009. The policy in part addressed to cleansing the wound applying non-adhering protective dressings and to check the wound daily and change the dressings as necessary. A. Resident#2 had cumulative [DIAGNOSES REDACTED]. Review of the May 2011 physician orders [REDACTED]. Review of the Minimum data set (MDS) assessment dated [DATE] revealed Resident#2 had severe cognitive impairment, required the 2 person total dependence on staff for transferring between surfaces. The MDS indicated functional limitation in range of motion on both sides that interfered with the daily functions or placed the resident at risk for injury. The MDS indicated no signs of pain had been observed or documented. Review of the care plans dated 1/17/11 and revised 4/5/11 revealed no written care plan to address how to handle and care for Resident #2 ' condition of [MEDICAL CONDITION] and osteopenia. An inquiry was made on 5/17/11 at 10:15 a.m. with MDS#1 revealed she was unable to produce this written care plan. Review of the care plan dated for problem onset dated 4/5/11 revealed " unable to independently perform all activities of daily living secondary to needeing (needing) total assistance with ADL ' s (activities of daily living) " . The goal included staff to perform ADL every shift to assure resident was clean, dry, and comfortable. The approaches included " assist with positioning, transfers 2 person assist with Hoyer (mechanical lifting device) as necessary and/or requested by resident and to monitor skin condition for signs of breakdown or redness. " Interview on 5/17/11 at 3 p.m. with NA#5 (who worked night shift and assigned to resident) revealed she arrived on duty on 5/2/11 and started her 1st round. NA#5 stated that Resident#2 was asleep and was dry (referring to not experiencing an episode of urine incontinence). Then she did her second round at 2 a.m. on 5/3/11 when the ankle part of her right leg was purple looking. I told nurse Nurse#1 and he assessed her. When she moved her in the bed she was acting like she was in pain. NA#5 indicated she knew her from _______ (name of a previous nursing facility) and Resident#2 was in pain. Review of the medical record revealed on 5/3/11 at 6 a.m. the nurses ' notes indicated Resident#2 ' s right shin was swollen and bruised. The " Resident expresses extreme pain when touch " . A note was left for NP (nurse practitioner). An interview via the phone was conducted on 5/18/11 at 12:39 p.m., with Nurse#1 (author of the note) who indicated that the resident ' s right shin was bruised. When he touched the resident ' s right leg she closed her eyes and had a facial grimace of pain. When inquiring about pain management Nurse#1indicated " I informed the NA (nursing assistant) to be careful when changing her. " It was 3 a.m. and I spent much time telling the oncoming nurse about the bruise. Nurse#1indicated he followed protocol by placing a note in the NP ' s box because she was coming in that morning. Nurse#1 indicated " I would have called the on call person if it was an emergency. " Review of the incident report initiated by Nurse#1 indicated on 5/3/11 at 3 a.m., the resident was in bed. Under the description of what happened had an entry of " resident right shin swollen and bruised and warm to touch. Resident expresses pain to touch. " A second incident report dated 5/3/11 at 7 a.m. authored by Nurse#2 revealed a comment indicating " an old open area with scab intact " with a line drawn to a diagram of the right lower leg. This same incident report revealed the NP assessed the resident onsite on 5/3/11. On 5/3/11 at 3:45 p.m. the nurses ' notes revealed " bruise to the left shin. Swollen & warm to touch (referring to the right leg. Yells when touched. " The resident was seen by the NP who requested a board across foot pedals of the wheelchair. Interview on 5/17/11 at 11:40 a.m. with Nurse#2 revealed she asked the NP to check on the resident. We thought that the resident had placed her leg behind the leg rest of the wheelchair and we thought the bruises came from that. Nurse#2 indicated the NP told us to elevate her leg, get a bar across the wheelchair and to monitor the leg. Review of the NP notes dated 5/3/11 revealed a bruised area right lower leg with minimal swelling and a skin tear to the right lower leg was opened to air without signs of infection or inflammation present. Interview with the NP on 5/18/11 at approximately 10:30 am indicated that when she assessed the resident on 5/3/11 she actually touched the resident ' s right leg she did not complaint of pain. The NP indicated that she read the film and at the time did not appear to be spiral in nature but a clean break. The NP indicated that her plan was and that she had expected the staff to monitor the status of the resident ' s right foot. The NP indicated that if the staff had notified her that the resident was in pain she would have increased Resident#2 ' s pain medicine. Review of the nurses ' notes dated 5/4/11 (no time) revealed the right shin still swollen and warm to touch. There was no assessment about the resident ' s pain. Interview on 5/17/11 at 4:48 p.m. with Nurse#2 revealed she worked on 5/5/11 and monitored her leg condition but did not write it down in the nurses ' notes. Nurse#2 indicated that the nurses ' notes on 5/4/11 were most likely written after 3 p.m. as routine. Interview on 5/17/11 at 11:35 a.m. with NA#3 (working the day shift for almost a year) revealed on May 2, 2011 " I got off from work at 12 noon and nothing was wrong " with Resident#2. The next day on 5/3/11, I noticed a bruise during bathing the resident and I contacted Nurse#2. Nurse#2 then reported the bruise to the NP. When I got Resident#2 out of bed or moved her in bed she complained of pain. She (referring to Resident#2) can ' t tell you verbally that she was in pain but she did act like she was in pain by her " non-verbal " expressions on her face. We always used 2 people or Hoyer lift to transfer her. Interview on 5/17/11 at 2:15 p.m. with the (RA) restorative nursing assistant (for 2 years) revealed she provided restorative care for Resident#2. The RA indicated she usually used 2 people or the lift to transfer. RA indicated she usually provides restorative transferring, range of motion to her arms and legs, performed knee extensions, abduction and adduction her legs. RA indicated she saw a bruise on Resident#2 ' s right shin on 5/2/11. On interview RA indicated that as soon as she touched her right leg she had a facial expression like she was in pain and she does not usually act like this. I stopped during any range of motion or transferring her that day. RA indicated she reported this immediately to Nurse#3. Then on 5/3/11 she tried to do range of motion and noticed the bruise again and she tried to do range of motion on 5/3/11 in the morning (no specific time) but Resident#2 again expressed pain in her face. RA indicated she reported this to Nurse#2 but she already knew about it. Review of the " Restorative Care Flow Record " form provided on 5/18/11 revealed on 5/2/11, 5/3/11, 5/5/11 and 5/6/11 documentation that 15 minutes of restorative care for bilateral range of motion, that included " pull a parts and scissor kick " was performed despite the presence of pain and [DIAGNOSES REDACTED]. Additionally, the documentation indicated 15 minutes of standing program on 5/3/11 in the a.m. RA was not available on 5/18/11 to be interviewed about the documentation. Interview on 5/18/11 at 1:20 p.m. with the DON revealed she spoke with RA who indicated to her that she only did restorative care to her left leg and not the right leg as documented. The DON indicated that these were " documentation errors. " Review of the nurses notes from 5/4/11 (no time indicated) there were no follow-up assessments about the bruised shin, leg [MEDICAL CONDITION], pain or skin tear until 5/5/11 (no time indicated). Review of the nurses ' notes on 5/5/11(no time noted) revealed the responsible party was visiting and voiced concerns about Resident#2 ' s right lower leg bruising and [MEDICAL CONDITION] to the right ankle. The NP was notified and ordered an x-ray for the right lower extremity. Interview on 5/17/11 at 3:15 p.m. with Nurse#3 (author of this note) revealed the first time she knew about Resident#2 ' s bruised ankle and swelling was on 5/5/11 when the ???______(family member) approached her that Resident#2 ' s leg looked bad. Her right ankle was really bruised and swollen. Nurse#3 indicated at that point " I called the NP and she ordered the resident to either go to the hospital or get an x-ray in the am, Nurse#3 indicated that the family member decline for Resident#2 to be transported to the hospital, so the x-ray was scheduled for the next morning. Nurse#3 indicated that the nurses ' notes written on 5/5/11 were at 6 p.m. Nurse#3 indicated the restorative aide never told her on 5/2/11 about Resident#2 ' s leg swelling or bruises. The nurses ' notes indicated on 5/6/11 at 11:45 a.m. x-rays were done to the right shin and ankle. Review of the x-ray report dated 5/6/11 revealed a history of " pain swelling. " The results of radiology interpretation included the right tibia and fibula showed a spiral fracture extending across the distal shift of the tibia. The nurses ' notes dated 5/6/11 (no time) indicated the NP was notified of the x-ray results and ordered [MEDICATION NAME] 7.5/325 mg every 6 hours for 1 week ( and increased the [MEDICATION NAME] dose to 25 mg. An ace wrap was applied to the lower right extremity and elevated on a pillow. Review of the nurses ' notes dated 5/9/11 at 3:30 p.m. revealed the resident left the facility for an orthopedic appointment at 1:15 p.m. At 6 p.m. the resident returned with a cast applied to the lower right leg. Interview on 5/17/11 at 5 p.m. with NA#2 (who was assigned to care for the resident) revealed she usually works with the resident during the 3-11 p.m. shift. NA#2 indicated that on 5/5/11 Resident#2 started hollering when she turned her in bed. " I called Nurse#3 down to look at her then the next day (on 5/6/11) Nurse#3 told me to make her comfortable because her leg was broken. NA#2 indicated she used the sit to stand lift to transfer Resident#2 into and out of bed before the leg fracture. Interview on 5/17/11 at 5:30 p.m. with the Resident#2 ' s family member revealed several nursing assistants indicated Resident#2 was in pain each time that touched her leg. Observation on 5/17/11 at 11 a.m. revealed Resident #2 was sitting in a lounge chair with a cast applied to her right leg. Interview on 5/18/11 at 1:40 p.m. with the administrator, director of nurses, assistant director of nurses (DON), staff development coordinator, and corporate representative was held. During the interview the DON indicated that she expected documents used by her staff be accurate, nursing assessments of the resident be done as needed and a care plan be developed to address the resident ' s current needs. B. Review of the NP notes dated 5/3/11 revealed a skin tear to the right lower leg opened to air without signs of infection or inflammation present. Review of the treatment sheet or nurses notes revealed no treatments had been initiated or an initial or ongoing assessment of the resident ' s skin tear by the nurses which was noted in the NP ' s 5/3/11 note. Review of the addendum NP note dated 5/18/11 at 11:51 a.m. revealed the skin tear on the resident ' s right lower leg was approximately 1 cm (centimeters); there was [DIAGNOSES REDACTED] (redness) present. Review of the medical record revealed from 5/3/11until 5/6/11 there were no follow-up assessments or treatment of [REDACTED]. Review of the " non-pressure skin condition report " dated 5/6/11 revealed a right lower extremity skin tear measuring 0.9 by 1.0 centimeters (cm) that has a scant amount of exudates with a wound bed that was described as " pink/beefy red " in color. Review of the physician orders [REDACTED]. Interview with the NP indicated that when she assessed the resident on 5/3/11 she actually touched the resident ' s right leg she did not complaint of pain. The NP indicated that she made an addendum to a 5/6/11 because they (did not indicate who) stated the note on 5/6/11 about the skin tear was unclear. Review of the weekly documented skin checks on 5/9/11, Nurse#2 documented " I " to indicate the resident ' s skin was intact when in fact dressing to the skin tear was in progress under the cast. Interview on 5/17/11 at 4:48 p.m. and 5/18/11 at 12:58 p.m. with Nurse#2 indicated that the resident ' s ankle was swollen but did not remember seeing a skin tear to the leg and when an observation on 5/3/11 with the NP; Nurse#2 thought the area was a scab. Interview on 5/18/11 at 10:45 a.m. with Treatment nurse revealed on 5/6/11 she noted a scab on the right leg. The wound bed was pink and red measuring approximately 0.2 cm. The treatment nurse indicated she was not aware of the scab, skin tear or bruising until 5/6/11. Further interview with the treatment nurse revealed orders were obtained to clean the wound bed with Normal Saline, then apply Hydro gel with silver and foam dressing every day.

Based on interviews with staff, interviews with the nurse practitioner (NP) and record review the facility failed to consistently transfer Resident#2 using a 2 person (staff) assist or Hoyer lift. On 5/6/11 Resident #2 was [DIAGNOSES REDACTED]. This was evident in 1 of 3 residents in the survey sample reviewed for accidents. (Resident#2) Findings included: Resident#2 had cumulative [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. These medications are used to treat osteoporosis. Review of the Minimum data set (MDS) assessment dated [DATE] revealed Resident#2 had severe cognitive impairment, required the 2 person total dependence on staff for transferring between surfaces. The MDS indicated functional limitation in range of motion on both sides that interfered with the daily functions or placed the resident at risk for injury. Review of the care plan for problem onset dated 4/5/11 revealed " unable to independently perform all activities of daily living secondary to needeing (needing) total assistance with ADL ' s (activities of daily living) " . The goal included staff to perform ADL every shift to assure resident was clean, dry, and comfortable. The approaches included " assist with positioning, transfers 2 person assist with Hoyer (mechanical lifting device) as necessary and/or requested by resident and to monitor skin condition for signs of breakdown or redness. It should be noted that the resident cognition would not allow the resident to request the use of the Hoyer lift. The facility conducted a fall risk assessment updated as recent as 4/12/11 in which the resident scored 10. A score of 10 of more indicated high risk for falls. Interview on 5/17/11 at 2:15 p.m. with the (RA) restorative nursing assistant (for 2 years) revealed she provided restorative care for Resident#2. The RA indicated she usually used 2 people or the lift to transfer. RA indicated she usually provides restorative transferring, range of motion to her arms and legs, performed knee extensions, abduction and adduction her legs. RA indicated she saw a bruise on Resident#2 ' s right shin on 5/2/11. On interview RA indicated that as soon as she touched her right leg she had a facial expression like she was in pain and she does not usually act like this. I stopped during any range of motion or transferring her that day. RA indicated she reported this immediately to Nurse#3. Then on 5/3/11 she tried to do range of motion and noticed the bruise again and she tried to do range of motion on 5/3/11 in the morning (no specific time) but Resident#2 again expressed pain in her face. RA indicated she reported this to Nurse#2 but she already knew about it. Review of the " Restorative Care Flow Record " form provided on 5/18/11 revealed on 5/2/11, 5/3/11, 5/5/11 and 5/6/11 documentation that 15 minutes of restorative care for bilateral range of motion, that included " pull a parts and scissor kick " was performed despite the presence of pain and [DIAGNOSES REDACTED]. Additionally, the documentation indicated 15 minutes of standing program on 5/3/11 in the a.m. RA was not available on 5/18/11 to be interviewed about the documentation. Interview on 5/18/11 at 1:20 p.m. with the DON revealed she spoke with RA who indicated to her that she only did restorative care to her left leg and not the right leg as documented. The DON indicated that these were " documentation errors. " Review of the " Completed Care Tasks " form used by the nursing assistants to document care provided revealed: A statement " Time recorded does not necessarily reflect time care provided. Care provided within corresponding shift. " On 5/1/11 at 9:23 p.m., 1:20 a.m. and 1:25 a.m. NA#1 documented " one person physical assist " was used to provide bed mobility and/or transfer support to Resident#2. On 5/2/11 at 12:34 a.m. NA#1 documented " one person physical assist " was used to provide bed mobility and transfer support to Resident#2. On 5/2/11 at 12.35 a.m. NA# 1documented " one person physical assist " was used to provide toilet use support to Resident#2. NA#1 was not available to be interviewed during the survey. On 5/1/11 at 2:32 p.m. and 2:33 p.m. NA#2 documented " one person physical assist " was used to provide bed mobility and transfer support to Resident#2. On 5/3 /11 at 9:39 p .m. NA#2 documented " one person physical assist " was used to provide transfer support to Resident#2. On 5/4 /11 at 10:01 a.m. NA#2 documented " one person physical assist " was used to provide bed mobility and transfer support to Resident#2. On 5/5/11 at 9:26 p.m. NA#2 documented " one person physical assist " was used to provide bed mobility and transfer support to Resident#2. Interview on 5/17/11 at 5 p.m. with NA#2 (who was assigned to care for the resident) revealed she usually works with Resident#2. during the 3-11 p.m. shift. NA#2 indicated she transferred Resident#2. with the use of a sit to stand lift before the fracture. There was no comment about the documentation on the Completed Care Tasks form. Interview on 5/17/11 at 5 p.m. with NA#2 (who was assigned to care for the resident) revealed she usually works with the resident during the 3-11 p.m. shift. NA#2 indicated that on 5/5/11 Resident#2 started hollering when she turned her in bed. " I called Nurse#3 down to look at her then the next day (on 5/6/11) Nurse#3 told me to make her comfortable because her leg was broken. NA#2 indicated she used the sit to stand lift to transfer Resident#2 into and out of bed before the leg fracture. On 5/2 /11 at 11:52 a.m. NA# 3 documented " one person physical assist " was used to provide transfer support to Resident#2. On 5/3 /11 at 2:50 p.m. NA# 3 documented " one person physical assist " was used to provide bed mobility support to Resident#2. On 5/3 /11 at 2:31 p.m. NA#3 documented " one person physical assist " was used to provide bed mobility and transfer support to Resident#2. Interview on 5/17/11 at 11:35 a.m. with NA#3 (working the day shift for almost a year) revealed we always used 2 people or a Hoyer lift to transfer Resident#2. There was no explanation provided regarding the Completed Care Tasks documentation. Interview on 5/17/11 at 11:35 a.m. with NA#3 (working the day shift for almost a year) revealed on May 2, 2011 " I got off from work at 12 noon and nothing was wrong " with Resident#2. The next day on 5/3/11, I noticed a bruise during bathing the resident and I contacted Nurse#2. Nurse#2 then reported the bruise to the NP. When I got Resident#2 out of bed or moved her in bed she complained of pain. She (referring to Resident#2) can ' t tell you verbally that she was in pain but she did act like she was in pain by her " non-verbal " expressions on her face. We always used 2 people or Hoyer lift to transfer her. On 5/2 /11 at 8:09 p.m. NA# 4 documented " one person physical assist " was used to provide bed mobility and two plus persons for transfer support to Resident#2. NA#4 was not available to be interviewed during the survey. On 5/3 /11 at 12:37 a.m. NA#5 documented " one person physical assist " was used to provide bed mobility support to Resident#2. On 5/ 5/11 at 1:14 a.m. NA#5 documented " one person physical assist " was used to provide bed mobility support to Resident#2. Interview on 5/17/11 at 3 p.m. with Na #5(who worked the night shift) revealed the staff on the night shift does not transfer Resident #2 out of bed. There was no comment about the documentation on the Completed Care Tasks form. An inquiry was made on 5/18/11 at 1:20 p.m. with the (DON) director of nurses regarding the Completed Care Tasks form documentation of the use of a one person assist. The DON had no response except we need to work on our documentation. Review of the medical record revealed on 5/3/11 at 6 a.m. the nurses ' notes indicated Resident#2 ' s right shin was swollen and bruised. Review of the incident report initiated by Nurse#1 indicated on 5/3/11 at 3 a.m., the resident was in bed. Under the description of what happened had an entry of " resident right shin swollen and bruised and warm to touch. Resident expresses pain to touch. " A second incident report dated 5/3/11 at 7 a.m. authored by Nurse#2 revealed a comment indicating " an old open area with scab intact " with a line drawn to a diagram of the right lower leg. This same incident report revealed the NP assessed the resident onsite on 5/3/11. On 5/3/11 at 3:45 p.m. the nurses ' notes revealed " bruise to the left shin. Swollen & warm to touch (referring to the right leg). Yells when touched. " The resident was seen by NP who wanted a board across the foot pedals of the wheelchair. Interview on 5/17/11 at 11:40 a.m. with Nurse#2 revealed I asked the NP to check on the resident. We (Nurse#2 and NP) thought that the resident had placed her leg behind the leg rest of the wheelchair and thought the bruises came from the leg rest. The NP told us to elevate her leg, get a bar across the wheelchair and to monitor the leg. Review of the nurses ' notes dated 5/4/11 (no time) revealed the right shin was still swollen and warm to touch. The nurses ' notes on 5/5/11(no time noted) revealed the responsible party of Resident#2 was in the facility and voiced concerns about Resident#2 ' s right lower leg bruising and edema to the right ankle. The NP was notified and ordered an x-ray for the right lower extremity. On 5/6/11 at 11:45 a.m. x-rays were done on the right shin and ankle. Review of the x-ray report dated 5/6/11 revealed a history of " pain swelling. " The results of radiology interpretation included the right tibia and fibula showed a spiral fracture extending across the distal shift of the tibia. The nurses ' notes dated 5/6/11 (no time) indicated the NP was notified and ordered Vicodin 7.5/325 mg every 6 hours for 1 week and increased the Duragesic patch to 25 mg for pain management. An ace wrap was applied to the lower right extremity and elevated on a pillow. The nurses ' notes dated 5/9/11 at 3:30 p.m. revealed the resident left the facility for an orthopedic appointment at 1:15 p.m. At 6 p.m. the resident returned with a cast to the lower right leg.