Every finding on record at Avir at Kingsland

Based on observation, interview and record review the facility failed to ensure each resident was provided and received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen reviewed for palatable food. 1. The facility failed to provide meal services in a manner to ensure palatable food served was appetizing to residents.2. The facility failed to provide palatable food served at an appetizing temperature or taste to Residents #7, #13, and #28.These failures could place residents at risk of weight loss, altered nutritional status, and diminished quality of life. Findings include:During an interview on 5/26/26 at 8:30 a.m., Resident #7 said the food at the facility was not good. She stated that she rarely eats the food in the facility because it isn't good. She stated that she had to get the backup meal, which is mainly salads. She stated that she has reported the food being a problem. During an interview on 5/26/26 at 8:35 a.m., Resident #13 said the food at the facility was not good. She stated that he rarely ate the food in the facility because it was not good. She stated that she would have to get the backup meal, which was mainly salads.During an interview on 5/26/26 at 10:05 a.m., Resident #28 said he liked living in the facility. He stated that he got the same food over and over again. He stated that there were times when the food was unappealing. He stated that he ate the food anyway, because he did not want to eat the sandwich. He stated that often the food did not taste good.An observation on 05/27/2026 12:50 PM lunch tray revealed it was served to the residents on 5-27-2026. The lunch consisted of black beans, corn, carnitas, and a tortilla. The carnitas did not look appealing and appeared to have been boiled. The Carnitas had little flavor and tasted like it was boiled. During an interview on 05/28/2026 at 11:15 AM, CK A stated that she had cooked the food that was given to her. She was shown a picture of the food that had been cooked on 5/27/2026. She stated that the food was carnitas. She stated that she had not been working the day that food was cooked. She stated that the food cooked on 5/27/2026 did not look appealing and she would not have eaten it. She stated that residents could have lost weight if they did not eat the food. During an interview on 05/28/2026 11:15 AM, with the ADM, a picture of the food that was prepared for residents on 5/27/2026 was shown to him. He stated that the food did not look good. He stated that he would not eat that food unless someone made him. He stated that they were in the process of getting a different food provider. He stated that unappealing food could lead to weight loss. On 5-28-2026 at 2:30 PM ADM stated there was no policy for food palatability.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 10 of (10/05/25, 10/15/25, 10/18/25, 10/19/25, 10/23/25, 11/01/25, 11/06/25, 11/16/25, 12/27/25 and 12/28/25) of 15 days reviewed for RN coverage.The facility failed to ensure they had an RN coverage for the facility on 10/05/25, 10/15/25, 10/18/25, 10/19/25, 10/23/25, 11/01/25, 11/06/25, 11/16/25, 12/27/25 and 12/28/25.This failure could place residents at risk of missed nursing assessments, interventions, care and treatment. Findings included:Review of daily HR total employee hours report (lists total clocked in hours worked daily by staff across all departments) provided by the ADM for the following dates: 10/05/25, 10/15/25, 10/18/25, 10/19/25, 10/23/25, 11/01/25, 11/06/25, 11/16/25, 12/27/25 and 12/28/25 reflected zero RN hours were registered as worked. During an interview on 05/28/26 at 01:24 PM with the DON, she stated she was not the DON during the infraction dates found with no RN coverage and could not speak as to why there was no RN coverage since she started her time at the facility February of 2026. She stated the facility was required to have 8 consecutive hours every day 7 days a week of RN coverage and that being without an RN is unacceptable for her. The DON stated that having an RN in the facility gave an extra layer of professionalism and resident care. During an interview on 05/28/26 at 02:49 PM with the ADM, he stated he did not know why there were no RN hours on the reports for the infraction dates 10/05/25, 10/15/25, 10/18/25, 10/19/25, 10/23/25, 11/01/25, 11/06/25, 11/16/25, 12/27/25 or 12/28/25 since he only started as administrator March of 2026. He stated it was the expectation that they would have the minimum 8 RN hours required daily. He stated it was ultimately the responsibility of the administrator to ensure staffing coverage. He stated a potential negative outcome of not having daily RN hours would be not having the clinical oversight that you need. He stated he attempted to look for anything that indicated an RN worked on those dates but could not find documentation that indicated an RN was in the facility for the 8 hours required. The ADM stated there was not a facility policy specific to RN hours, but that they follow state and federal guidelines.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the 1 of 1 kitchen reviewed. 1.The facility failed to label and date food correctly. 2.The facility failed to staff properly sanitized their hands while passing out trays during food service on 5-26-2026. 3.The facility failed to maintain a clean kitchen, 4.The facility sanitizes the thermometer while taking the temperatures of food. These failures could place residents at risk for foodborne illness. Findings included:An observation on 05/26/2026 at 6:48 AM of Refrigerator #1 revealed the following: Juice in a single serve cup was not labeled with the name or date on the tray. Jello in a clear container that was dated 5-25 with no use by date. Ketchup with an open date of 4-20 and no use by date. Cheese in a zip lock bag with no open date and no use by date. Pudding in a single serve container on a tray that was not dated. Single Serve sugar, mayo, tarter, and tater sauce that was in a bin and not labeled with any dates. An observation on 05/26/2026 at 6:53 AM of the kitchen revealed the following: The storage shelf that contained food trays had food debris on the shelf. Onion in a clear container was dated 5-20-2026 had no use by date. A bin container with serving utensils had food debris in the bottom of the container. A tray of coffee mugs had food debris on the tray. During an observation on 05/26/2026 at 7:50 AM, CNA B and RN G were passing out breakfast trays in dining room [ROOM NUMBER] on the secured 400 hall. While CNAs B and RN G they did not sanitize their hands. During an observation on 05/26/2026 at 11:45 AM with CK A, she rinsed the thermometer off with water and used it to take the temperatures of other foods. She would rinse the thermometer in water, wipe it with her glove, and then take the food's temperature. She would push the thermometer all the way into the food, leaving the top that was not cleaned in the food. She wore the same gloves throughout the temp process, and while taking the food's temperature, the gloves touched the food. During an interview on 05/27/2026 at 10:41 AM with CK A, she stated that she was supposed to change gloves when she started another task and returned to take the temperature of a different food item. She stated that each time she took the temperature of a food item, she was supposed to use an alcohol pad and clean the thermometer, then take the temperature of another food item. She stated that she was not supposed to use water to clean the thermometer. She stated that she had gotten in a hurry and did not have an alcohol pad close to her. She stated that she should not have cleaned the thermometer with water. She stated that the gloves should not have been in contact with food after performing other tasks in the kitchen. She stated that doing these things could have contaminated the food and that residents could have gotten sick. During an interview on 05/28/2026 at 11:15 AM with DA C, she stated that it was everyone's responsibility to label and date food in the kitchen. She stated that it is everyone's responsibility to clean the kitchen. She stated that if these things are not done, the residents could get sick. She stated that she had in-service training on labeling, dating, and cleaning the kitchen. She stated they get training every month. During an interview on 05/28/2026 at 11:23 AM with DA D, she stated that it was everyone's responsibility to label and date food in the kitchen. She stated that it was everyone's responsibility to clean the kitchen. She stated that if these things were not done, then residents could have gotten sick. She stated that she had had in-service training on labeling, dating, and cleaning the kitchen. She stated they received training every month. An interview on 05/28/2026 11:23 AM CK A. She stated that it was everyone's responsibility to label and date food in the kitchen. She stated that it is everyone's responsibility to clean the kitchen. She stated that if these things are not done, then residents could get sick. She stated that she has had in-service training on labeling, dating, and cleaning the kitchen. She stated they get training every month. An interview on 05/28/2026 11:23 AM the DM. She stated that when taking food temperatures, a clean thermometer should be used between food measurements. She stated that all staff were responsible for labeling and dating all food in the kitchen. She stated that she checks dates weekly. She stated that residents could get sick and spread gems. The DM stated that everyone should be cleaning the kitchen. She stated that she goes over this daily and weekly. Inservice not long ago on all the above. During an interview on 05/28/2026 at 4:05 PM with the DON, she stated that all staff were expected to knock on the door when entering the room. She stated that she had not seen any staff not knocking on residents' doors. She stated that if she saw staff not knocking on the door, then she would correct them. She stated it was a privacy and dignity issue for the residents when staff did not knock on residents' doors. She stated that if a staff member did not knock, a resident could have been getting care. She stated that staff were expected to sanitize their hands in between passing trays to each resident. She stated that when this was not done, it was an infection control issue. She stated that she had not seen any staff not sanitizing their hands in between residents. She stated if she saw staff not doing that, she would have stopped them and reminded them to do it. She stated that she would have had staff retrained on infection control.An Interview on 05/28/2026 4:20 PM with the ADM. The ADM stated that staff were expected to regularly check for dates in the kitchen, and ensure there is no out-of-date food. She stated that all staff are expected to sanitize their hands in between each resident when passing out to residents. She stated all staff were supposed to be cleaning the kitchen. She stated that if these are not followed, residents could get sick, Record review of the facility's Food and Storage policy updated December 2021 reflected, Refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded.All food preparation items should be sanitized before use. Kitchen should be cleaned regularly.

Based on interview and record review the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs without indications for its use for 2 of 3 Residents (Resident #2 and Resident #1) reviewed for the right to be free from chemical restraints.1.The facility failed to obtain a current active consent from Resident #2's family representative for the use of Quetiapine Fumarate (antipsychotic) used for agitation/anxiety related to dementia, Depakote ER (extended release) antiepileptic/ antimanic, Buspirone (anti-anxiety), Paroxetine (antidepressant), and donepezil (used for dementia) and failed to have an active diagnosis of anxiety and depression to correspond with medications prescribed from November 2025 through May 2026.2.The facility failed to have a consent on file for the administration of Quetiapine Fumarate and failed to have a corresponding diagnosis of insomnia or depression for Resident #1. These deficient practices could affect residents who received medications for mood disorders and could contribute to the use of unnecessary medications.The findings were:Review of Resident #2's face sheet dated 05/28/26 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia-severe-with psychotic disturbance, dementia in other diseases classified elsewhere- mild- without behavioral disturbance- psychotic disturbance- mood disturbance and anxiety, and need for assistance with personal care. There was no active diagnosis information for depression or anxiety. Review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 03 indicating severe cognitive impairment. Active diagnosis reflected non-Alzheimer's dementia. Psychiatric/ mood disorders were NOT listed as an active diagnosis, this included anxiety, depression, and psychotic disorders (other than schizophrenia). The MDS reflected Resident #2 was actively taking an antipsychotic, antianxiety, antidepressant, and anticonvulsant. Review of Resident #2's care plan last revised 05/13/26 reflected there was no focus for the use of any antipsychotic/ antidepressant/ antianxiety medications with any interventions. Review of Resident #2's physician orders reflected the following active medications: -Quetiapine Fumarate oral tablet 50MG; one table by mouth at bedtime for agitation/ anxiety with an order start date of 04/09/26. This is a recent increase from Quetiapine Fumarate oral tablet 25MG order start date 11/13/25 and ending 04/09/26. -Buspirone HCI oral tablet 10MG; give one tablet by mouth in the afternoon for anxiety with an order start date of 04/25/26. -Depakote ER (extended release) oral tablet extended release 24 hours 250 MG; give 1 tablet by mouth at bedtime related to dementia in other diseases classified elsewhere, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with an order start date of 01/23/26. -Paroxetine HCI oral tablet 20MG; give 1 tablet by mouth at bedtime related to dementia in other diseases classified elsewhere, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with an order start date of 01/23/26.-Donepezil HCI oral tablet 5MG; give 2 tablets by mouth at bedtime related to dementia in other diseases classified elsewhere, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with a start date of 01/21/26. Review of resident #2's MAR reflected medications being provided as prescribed from order start date (listed above) through review end date of 05/28/26 (medications reviewed from November 2025 through May 2026). Review of Resident #2's consents on 05/28/26 reflected: -Consent signed on 11/18/25 by NP H (prescriber) for Seroquel (Quetiapine Fumarate) 25MG at bedtime, NP H indicated Pt doesn't have the psychiatric condition required for medication. She has dementia with no behavioral problems. It was signed by NP H without further signatures by Resident #2 or family. There were no other consents for the use of Seroquel (Quetiapine Fumarate) 25MG or Seroquel (Quetiapine Fumarate) 50MG prescribed and provided to Resident #2. -A consent was observed effective 12/05/25 for Buspirone being used to treat anxiety; the proposed course of the medication for which the consent was obtained was 3 months. There was no other consent that was active for the current prescribed order of Buspirone HCI oral tablet 10MG still being administered effective after the prior 3-month consent ended. -A consent was observed effective 02/17/26 for Paroxetine being used to treat depression; the proposed course of the medication for which the consent was obtained was 1 month - There was no other consent that was active for the current prescribed order of Paroxetine HCI oral tablet 20MG still being administered effective after the prior 1-month consent ended. -A consent was observed effective 02/17/26 for Depakote being used to treat marked other with no listed condition to be treated listed. The proposed course of the medication for which the consent was obtained was 1 month- There was no other consent that was active for the current prescribed order of Depakote ER (extended release) oral tablet extended release 24 hours 250 MG still being administered effective after the prior 1-month consent ended. -There was no consent at all for the use of Donepezil HCI oral tablet 5MG. During an interview on 05/28/26 at 01:24 PM with the DON, she stated that she did not find any of the consents needed for Resident #2's medications (listed above) either in the chart or in the consent binder. She stated she only saw the consent for the 11/18/25 by NP H (prescriber) for Seroquel (Quetiapine Fumarate) 25MG that indicated Pt doesn't have the psychiatric condition required for medication and she did not know why the consent stated that and why the medication was still provided after not having a valid consent. She stated she only arrived at the facility in February 2026, so she had no knowledge of it. She stated she placed a call to NP H to ask about it and that NP H did not recall or have information that could help her. The DON stated the purpose of the consents for these medications is to make sure the family is involved in the decision-making process, it's a holistic approach so everyone is on the same page. The DON stated, if the resident was on a lot of different psychoactive medications that would not be good; there is the potential for polypharmacy if family is not aware of the medications being given. The DON stated she had not observed the combination of medications being administered having an overly sedative effect on Resident #2, or other concerns. She stated medications should have consents on file as required. During an interview on 05/28/26 at 02:48 PM with the ADM, he stated it was his expectation that nursing staff be compliant with pharmacological expectations and that they do the best for the resident. He stated he expected to have consents on file as required and that the purpose of the consents was so that the family or RP was in the know or aware of what was being used, could ask questions, and refuse the medication if they did not want to give consent. The ADM stated failing to gather a consent for psychotropic medication quality of life can suffer if they do not have a consent or medical necessity. During an interview on 05/28/26 at 03:27 PM with NP H, she stated that she had been treating Resident #2 since November 2025. She stated that she did not recall why the consent for Seroquel (Quetiapine Fumarate) indicated that Resident #2 did not have behavior problems and why the medication was still administered. She stated she would help with orders and sign off on them to help the facility because nobody else was available. She stated she was not able to sign off on those medications because the medications having a history of being used as chemical restraints and that it would normally be psychiatric services, however, she felt the doses and the medications were appropriate for Resident #2 based on anxiety and other behaviors initially on admission. NP H stated that the purpose of the consents was, so the family was aware of what was being ordered. She stated psychotropic medications required consents and the family had to consent in order for the resident to receive it. She stated if the consent was only obtained for 1 month as indicated on the consent, it should have been revisited to see how the resident was responding and a new consent obtained, if the medication was still needed. She stated a negative outcome of not getting the consents would be residents could have reactions to medications administered that were not consented to. During an interview on 05/29/26 at 12:36 PM with FM A, she stated Resident #2 did have behaviors on admission and described Resident #2 as being anxious, trying to run away, and other behaviors that warranted psychotropic medications. She stated she knew Seroquel to have been used for anxiety but was not aware of the other medications or giving consent to them recently. She stated it was alarming to hear Resident #2 was on multiple medications without family giving consent. She stated, in her visits, she had not seen any concerns with the resident being heavily sedated, increased falls, or other concerns due to the medications she is on. She stated during visits, Resident #2 was alert, up and talking and not in any distress. During an interview on 05/29/26 at 1:26 PM with FM B, he stated that he had not provided consent for the use of any psychotropic medications. He stated he visited Resident #2 and had not observed any issues with heavy sedation, sleeping all day, increased falls etc. He stated when he arrived for visits she was in bed but alert, or in the day room at the table and was awake with no concerns noted. He stated the facility did alert him if there were any falls, but he had not received any calls where the resident had a fall with a major injury or required hospitalization.2. Review of Resident #1's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] and discharged on 5/26/2026. She was admitted for rehab services following a fall and surgical repair of a fracture to her left hip. Diagnoses information included: Displaced fracture of the base of neck of left femur with routine healing, epistaxis (nose bleeds), Cachexia (complex metabolic condition leading to muscle and or fat loss), Restless leg syndrome, lack of coordination, history of fall with injury to head, idiopathic gout (painful inflammatory arthritis caused by excess uric acid in the blood), Dementia unspecified severity without behavior disturbances, hearing loss, hypertension (high blood pressure), Paroxysmal Atrial Fibrillation (heart arrythmia), Chronic heart failure, acute kidney failure, history of falling.Review of Resident #1's physician orders revealed orders for Trazodone HCl oral tablet (50 MG, give 1 tablet by mouth at bedtime for insomnia) and Quetiapine Fumarate oral tablet (25 MG, give 1 tablet by mouth at bedtime for depression). Orders were scheduled to start on 3/31/2026 and were both signed for approval by the MD. Resident #1 does not have a diagnosis of insomnia or depression listed. In a telephone interview on 5/28/2026 at 4:40 PM with the MD, he stated that he did quite a bit of psych medication for dementia behaviors. He stated the process for orders is he gives the orders verbally or he will enter the orders himself, and depending if they are on hospice care, then the orders have to come through hospice. He stated that the consent is based on nursing home policy and the facility is responsible for obtaining signed consent. He stated that consent is only needed for certain psych medications. He agreed that medications like Seroquel, trazadone and Depakote needed consent. When other medications such as Buspar, Fluoxetine he stated, A lot of these medications you are listing are prescribed by psych services and they would get consent. When asked about prescribing Resident #1 Trazadone for Insomnia and Quetiapine for depression, he stated, I would never treat depression with Seroquel. Seroquel is a medication also known as Quetiapine in generic form. He stated that if the order for Quetiapine stated it was for depression, then the order was entered wrong. He stated that he does review the verbal orders placed in point click care after they have been entered and checks them for accuracy before signing. He stated he may have missed the error in the order. He did not explain why the medication was prescribed without a matching diagnosis. He stated that he needed to go back to work and ended the interview incomplete.Review of the facility's Resident Rights policy revised 02/2021 reflected:Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to-Be free from chemical restraints not required to treat the residents' symptoms. -Be informed of and participate in his or her care planning and treatment

Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 24 resident (Resident #50 reviewed for resident rights.The facility failed to ensure the HK knocked on Resident #50's door when entering their room on 5-26-2026. These failures could place residents at risk of poor self-esteem, and not a home-like environment. Findings include:Record review of Resident #50's face sheet revealed that Resident #50 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #50 had diagnoses that included: Acute and Chronic Respiratory Failure (oxygenate the blood), Type 2 Diabetes (body cannot properly use or make enough insulin), Psychotic Disturbance, and Mood Disturbance (mental health disruptions that cause a person to lose touch with reality)Record review of Resident #50's admission MDS assessment, dated 03/18/2026, revealed that Resident #50 had a BIMS score of 11 (moderate cognitive impairment).Record review of Resident #50's care plan dated 05/21/2026 did not reflect anything about Resident #50 not wanting staff knocking on the door. During an interview and observation on 06/26/26 at 8:36 AM with Resident #50, the HK entered the room with laundry without knocking on the door. Resident #50 stated that staff knock most of the time, but occasionally staff don't knock. Resident #50 stated that it bothered her when staff do not knock on the door. During an interview on 05/28/2026 at 3:32 PM with RN G, she stated that staff were expected to knock on residents' doors before entering the room or announce their arrival. She stated that that was a resident's rights issue. She stated HK could have walked into the room while Resident #50 was receiving care. She stated that she had not seen any staff not knocking on residents' doors. She stated that if she saw staff not knocking on residents' doors, she would have reminded them to do so.During an interview on 05/28/2026 at 4:05 PM with the DON, she stated that all staff should knock on the door when entering the room. She stated that she had not seen any staff not knocking on residents' doors. She stated that if she saw staff not knocking on the door, then she would correct them. She stated it was a privacy and dignity issue for the residents when staff did not knock on residents' doors. She stated that if staff did not knock, a resident could have been receiving care.During an interview on 05/28/2026 4:20 PM with the ADM. He stated that it was his expectations for staff to knock on residents' doors He stated that staff were trained on knocking on doors before going in. Record review of the facility's Resident Rights policy updated on February 2021 reflected:Residents are to be treated with respect, kindness, and dignity.

Based on interview and record review the facility failed to ensure each resident the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 2 of 3 Residents (Resident #2 and Resident #1) reviewed for pharmacy services.1.The facility failed to obtain a current active consent regarding the risks and benefits of the medications prior to administration of the medication from Resident #2's family representative for the use of Quetiapine Fumarate (antipsychotic) used for agitation/anxiety related to dementia, Depakote ER (extended release) antiepileptic/ antimanic, Buspirone (anti-anxiety), Paroxetine (antidepressant), and donepezil (used for dementia) and failed to have an active diagnosis of anxiety and depression to correspond with medications prescribed from November 2025 through May 2026.2.The facility failed to have a consent regarding the risks and benefits of the medications prior to administration of the medication on file for the administration of Quetiapine Fumarate and failed to have a corresponding diagnosis of insomnia or depression for Resident #1. These deficient practices could affect residents who received medications for mood disorders and could contribute to the use of unnecessary medications.The findings were:Review of Resident #2's face sheet dated 05/28/26 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia-severe-with psychotic disturbance, dementia in other diseases classified elsewhere- mild- without behavioral disturbance- psychotic disturbance- mood disturbance and anxiety, and need for assistance with personal care. There was no active diagnosis information for depression or anxiety. Review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 03 indicating severe cognitive impairment. Active diagnosis reflected non-Alzheimer's dementia. Psychiatric/ mood disorders were NOT listed as an active diagnosis, this included anxiety, depression, and psychotic disorders (other than schizophrenia). The MDS reflected Resident #2 was actively taking an antipsychotic, antianxiety, antidepressant, and anticonvulsant. Review of Resident #2's care plan last revised 05/13/26 reflected there was no focus for the use of any antipsychotic/ antidepressant/ antianxiety medications with any interventions. Review of Resident #2's physician orders reflected the following active medications: -Quetiapine Fumarate oral tablet 50MG; one table by mouth at bedtime for agitation/ anxiety with an order start date of 04/09/26. This is a recent increase from Quetiapine Fumarate oral tablet 25MG order start date 11/13/25 and ending 04/09/26. -Buspirone HCI oral tablet 10MG; give one tablet by mouth in the afternoon for anxiety with an order start date of 04/25/26. -Depakote ER (extended release) oral tablet extended release 24 hours 250 MG; give 1 tablet by mouth at bedtime related to dementia in other diseases classified elsewhere, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with an order start date of 01/23/26. -Paroxetine HCI oral tablet 20MG; give 1 tablet by mouth at bedtime related to dementia in other diseases classified elsewhere, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with an order start date of 01/23/26.-Donepezil HCI oral tablet 5MG; give 2 tablets by mouth at bedtime related to dementia in other diseases classified elsewhere, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with a start date of 01/21/26. Review of resident #2's MAR reflected medications being provided as prescribed from order start date (listed above) through review end date of 05/28/26 (medications reviewed from November 2025 through May 2026). Review of Resident #2's consents on 05/28/26 reflected: -Consent signed on 11/18/25 by NP H (prescriber) for Seroquel (Quetiapine Fumarate) 25MG at bedtime, NP H indicated Pt doesn't have the psychiatric condition required for medication. She has dementia with no behavioral problems. It was signed by NP H without further signatures by Resident #2 or family. There were no other consents for the use of Seroquel (Quetiapine Fumarate) 25MG or Seroquel (Quetiapine Fumarate) 50MG prescribed and provided to Resident #2. -A consent was observed effective 12/05/25 for Buspirone being used to treat anxiety; the proposed course of the medication for which the consent was obtained was 3 months. There was no other consent that was active for the current prescribed order of Buspirone HCI oral tablet 10MG still being administered effective after the prior 3-month consent ended. -A consent was observed effective 02/17/26 for Paroxetine being used to treat depression; the proposed course of the medication for which the consent was obtained was 1 month - There was no other consent that was active for the current prescribed order of Paroxetine HCI oral tablet 20MG still being administered effective after the prior 1-month consent ended. -A consent was observed effective 02/17/26 for Depakote being used to treat marked other with no listed condition to be treated listed. The proposed course of the medication for which the consent was obtained was 1 month- There was no other consent that was active for the current prescribed order of Depakote ER (extended release) oral tablet extended release 24 hours 250 MG still being administered effective after the prior 1-month consent ended. -There was no consent at all for the use of Donepezil HCI oral tablet 5MG. During an interview on 05/28/26 at 01:24 PM with the DON, she stated that she did not find any of the consents needed for Resident #2's medications (listed above) either in the chart or in the consent binder. She stated she only saw the consent for the 11/18/25 by NP H (prescriber) for Seroquel (Quetiapine Fumarate) 25MG that indicated Pt doesn't have the psychiatric condition required for medication and she did not know why the consent stated that and why the medication was still provided after not having a valid consent. She stated she only arrived at the facility in February 2026, so she had no knowledge of it. She stated she placed a call to NP H to ask about it and that NP H did not recall or have information that could help her. The DON stated the purpose of the consents for these medications is to make sure the family is involved in the decision-making process, it's a holistic approach so everyone is on the same page. The DON stated, if the resident was on a lot of different psychoactive medications that would not be good; there is the potential for polypharmacy if family is not aware of the medications being given. The DON stated she had not observed the combination of medications being administered having an overly sedative effect on Resident #2, or other concerns. She stated medications should have consents on file as required. During an interview on 05/28/26 at 02:48 PM with the ADM, he stated it was his expectation that nursing staff be compliant with pharmacological expectations and that they do the best for the resident. He stated he expected to have consents on file as required and that the purpose of the consents was so that the family or RP was in the know or aware of what was being used, could ask questions, and refuse the medication if they did not want to give consent. The ADM stated failing to gather a consent for psychotropic medication quality of life can suffer if they do not have a consent or medical necessity. During an interview on 05/28/26 at 03:27 PM with NP H, she stated that she had been treating Resident #2 since November 2025. She stated that she did not recall why the consent for Seroquel (Quetiapine Fumarate) indicated that Resident #2 did not have behavior problems and why the medication was still administered. She stated she would help with orders and sign off on them to help the facility because nobody else was available. She stated she was not able to sign off on those medications because the medications having a history of being used as chemical restraints and that it would normally be psychiatric services, however, she felt the doses and the medications were appropriate for Resident #2 based on anxiety and other behaviors initially on admission. NP H stated that the purpose of the consents was, so the family was aware of what was being ordered. She stated psychotropic medications required consents and the family had to consent in order for the resident to receive it. She stated if the consent was only obtained for 1 month as indicated on the consent, it should have been revisited to see how the resident was responding and a new consent obtained, if the medication was still needed. She stated a negative outcome of not getting the consents would be residents could have reactions to medications administered that were not consented to. During an interview on 05/29/26 at 12:36 PM with FM A, she stated Resident #2 did have behaviors on admission and described Resident #2 as being anxious, trying to run away, and other behaviors that warranted psychotropic medications. She stated she knew Seroquel to have been used for anxiety but was not aware of the other medications or giving consent to them recently. She stated it was alarming to hear Resident #2 was on multiple medications without family giving consent. She stated, in her visits, she had not seen any concerns with the resident being heavily sedated, increased falls, or other concerns due to the medications she is on. She stated during visits, Resident #2 was alert, up and talking and not in any distress. During an interview on 05/29/26 at 1:26 PM with FM B, he stated that he had not provided consent for the use of any psychotropic medications. He stated he visited Resident #2 and had not observed any issues with heavy sedation, sleeping all day, increased falls etc. He stated when he arrived for visits she was in bed but alert, or in the day room at the table and was awake with no concerns noted. He stated the facility did alert him if there were any falls, but he had not received any calls where the resident had a fall with a major injury or required hospitalization.2. Review of Resident #1's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] and discharged on 5/26/2026. She was admitted for rehab services following a fall and surgical repair of a fracture to her left hip. Diagnoses information included: Displaced fracture of the base of neck of left femur with routine healing, epistaxis (nose bleeds), Cachexia (complex metabolic condition leading to muscle and or fat loss), Restless leg syndrome, lack of coordination, history of fall with injury to head, idiopathic gout (painful inflammatory arthritis caused by excess uric acid in the blood), Dementia unspecified severity without behavior disturbances, hearing loss, hypertension (high blood pressure), Paroxysmal Atrial Fibrillation (heart arrythmia), Chronic heart failure, acute kidney failure, history of falling.Review of Resident #1's physician orders revealed orders for Trazodone HCl oral tablet (50 MG, give 1 tablet by mouth at bedtime for insomnia) and Quetiapine Fumarate oral tablet (25 MG, give 1 tablet by mouth at bedtime for depression). Orders were scheduled to start on 3/31/2026 and were both signed for approval by the MD. Resident #1 does not have a diagnosis of insomnia or depression listed. In a telephone interview on 5/28/2026 at 4:40 PM with the MD, he stated that he did quite a bit of psych medication for dementia behaviors. He stated the process for orders is he gives the orders verbally or he will enter the orders himself, and depending if they are on hospice care, then the orders have to come through hospice. He stated that the consent is based on nursing home policy and the facility is responsible for obtaining signed consent. He stated that consent is only needed for certain psych medications. He agreed that medications like Seroquel, trazadone and Depakote needed consent. When other medications such as Buspar, Fluoxetine he stated, A lot of these medications you are listing are prescribed by psych services and they would get consent. When asked about prescribing Resident #1 Trazadone for Insomnia and Quetiapine for depression, he stated, I would never treat depression with Seroquel. Seroquel is a medication also known as Quetiapine in generic form. He stated that if the order for Quetiapine stated it was for depression, then the order was entered wrong. He stated that he does review the verbal orders placed in point click care after they have been entered and checks them for accuracy before signing. He stated he may have missed the error in the order. He did not explain why the medication was prescribed without a matching diagnosis. He stated that he needed to go back to work and ended the interview incomplete.Review of the facility's Resident Rights policy revised 02/2021 reflected:Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to-Be free from chemical restraints not required to treat the residents' symptoms. -Be informed of and participate in his or her care planning and treatment

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #2) reviewed for abuse.The facility failed to ensure Resident #2 did not experience physical abuse when Resident #1 struck Resident #2 with a cane, resulting in an abrasion on the head on 4/20/26. Findings Included:Resident #1Record review of the Quarterly Minimum Data Set (MDS) dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted on [DATE] with diagnoses including non-Alzheimer's dementia (a function cognitive decline in memory), alcoholic fibrosis and sclerosis of the liver (scaring of the liver tissue), chronic pain, cataracts (a clouding of the lens on the eye affecting vision), and constipation. The resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The MDS reflected no physical behavior. Record review of Resident #1's care plan dated 10/14/25 reflected moderately impaired decision-making related to dementia and included interventions such as encouraging participation in activities of daily living and following directions. The care plan did not address or include interventions for potential aggressive or combative behaviors.Record review of Resident #1's progress note dated 04/20/2026 at 10:45 PM reflected staff heard yelling and observed Resident #1 striking Resident #2 with a cane two times to the head and two times to the arm while stating, I'm going to kill him. Staff intervened, removed the cane, and separated the residents. Emergency Medical Services (EMS) and law enforcement were notified, and Resident #1 was transferred to the hospital for evaluation.Resident #2Record review of Resident #2's Quarterly MDS dated [DATE] reflected he was a [AGE] year-old male with diagnoses including Alzheimer's disease and muscle wasting, with impaired memory.Record review of Resident #2's progress note dated 04/21/2026 reflected he sustained two superficial scratches to the posterior scalp and exhibited guarding of the right upper extremity. Resident #2 reported pain to his head and arm.During an interview conducted on 04/29/2026 at 12:22 PM, Resident #2 stated he had been struck in the head with a cane by another resident. He stated staff intervened immediately and reported he felt safe at the time of the interview.During an interview on 4/29/26 at 2:30 pm CNA A stated Resident #1 had not previously demonstrated physical aggression but had been wandering prior to the incident. CNA A stated that after hearing yelling, staff observed the altercation, intervened immediately, removed the cane, and placed Resident #1 on 1:1 supervision until transfer to the hospital. He stated Resident #1 was easily redirected back to his room and laid down in his bed until EMS arrived. During an interview on 04/29/2026, at 4:15 pm the Director of Nursing (DON) stated Resident #1 had experienced increased confusion and paranoia prior to the incident. The charge nurse had notified the medical doctor, laboratory tests and referrals had been initiated; however, the behavior escalated prior to further interventions being implemented. She stated Resident #1 remained 1:1 supervision after the altercation until he was transferred to the Hospital. She stated Resident #1 had not had any behavioral outburst prior to this episode. The DON stated the hospital did confirm Resident #1 had a urinary tract infection. She stated an initial assessment that was completed on Resident #2 found two superficial scratches to the posterior scalp and exhibited guarding of the right upper extremity. She stated for safety an x ray was obtained of the right extremity. The Xray was negative except for an old injury from a motorcycle accident prior to admission. The DON stated all other residents residing on the 500 hall were provided safe resident surveys in which no other residents reported any incidents of abuse or neglect. The DON stated all staff were in-serviced on abuse and neglect, and dealing with residents who have aggressive behaviors. During an interview on 04/29/2026 4:30 PM the Administrator stated staff had notified him immediately following the incident and confirmed Resident #1 was transferred to a hospital and subsequently discharged to another facility better equipped to manage behavioral health needs. He stated the facility followed policy for abuse and neglect. He stated 911 was in the building within 8 minutes of the incident, also the county had a mental health coordinator that arrived with the police. All staff were educated on abuse and neglect and dealing with residents with aggressive behaviors. Staff were able to verbalize understanding of education. Facility Policy Review:Record review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2001 reflected Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms.

Based on interview and record review, the facility failed to ensure each resident /Resident Representative had the right to be informed of, and participate in, his or her treatment for one (Resident #1) of six residents reviewed for resident rights. The facility failed to notify Resident #1's family when he had a fall on 01/17/2026 during the night shift. This failure could place the residents at risk of not being informed of their health status, in order to make informed decisions regarding their care. Findings included:Review of Resident #1's face sheet printed 01/27/2026 reflected a [AGE] year-old male who was admitted on [DATE] with the following dx. Type 1 Diabetes Mellitus with other diabetic kidney complications (a chronic autoimmune condition where the pancreas produces little to no insulin, causing high blood glucose (sugar) levels.), Sepsis, unspecified organism,( a life-threatening, emergency response to infection where the immune system damages the body's own tissues and organs) nontraumatic subarachnoid hemorrhage (is a life-threatening, often fatal emergency involving bleeding between the brain and surrounding membranes, typically caused by a ruptured intracranial aneurysm), hemiplegia (paralysis affecting one side of the body, resulting from brain or spinal cord damage, often from stroke, traumatic injury, or cerebral palsy, causing weakness, stiffness (spasticity), and impaired movement in the face, arm, and leg on that side) and hemiparesis(a neurological condition causing weakness or partial paralysis on one side of the body) following cerebral infarction (a critical medical condition where restricted blood flow causes tissue death (necrosis) in the brain.), Acute Bronchiolitis(a common, self-limiting lower respiratory tract viral infection) due to respiratory syncytial virus, Orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down.). Resident #1's face sheet also reflected an RP. Review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score of 09, indicated moderate cognitive impairment. Section GG Functional Abilities reflected Resident #1 was 06. Independent - Resident completes the activity by themself with no assistance from a helper 05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity with transfers and toileting. Section J-Falls 0. Review of Resident #1's care plan initiated 12/31/2025 reflected Resident #1 had an ADL selfcare performance deficit related to confusion, moderate risk for falls related to confusion. Review of Resident #1's incident report dated 01/17/2026 at 09:00 p.m. completed by LVN A reflected: Res found on floor near Nurses station. he slipped. vitals, Neuro checks, blood sugar check, given glucose. Bg at 118 post treatment. Ambulatory without assistance.Agencies/people Notified_ No Notifications found. Review of Resident #1's progress notes dated 01/17/2026 reflected no evidence of Resident #1's family being notified of his fall on 01/17/2026. During an interview on 01/27/2026 at 10:40 a.m., Resident #1's family stated they were not notified of Resident #1's fall on 01/17/2026. Family stated they found out about Resident #1's fall the following day when family was visiting. During an interview on 01/27/2026 at 1:09 p.m., the ADON stated, If a resident fell or there was a change in a resident's condition, the nurse on duty would evaluate the resident, depending on the outcome, send the resident to the hospital. The ADON stated the nurse would notify the MD, family, DON, the on-call staff and the resident's family. The ADON stated it was important to notify the resident's family of every change of condition for the coordination of care. The ADON stated, unless the family does not want to be notified. The ADON also stated the nurse should document everything that was done including notification of the family. During an interview on 01/28/2026 at 1:32 p.m., the Regional Nurse stated she had been filling in as the DON since the facility did not have a DON at the time. The Regional Nurse stated if there was a fall or change of condition, she expected the nurse on duty to notify the RP and the MD. The Regional Nurse looked at Resident #1's incident report dated 01/17/2026 at 09:00 p.m. and stated, according to this incident report, Resident #1's family was not notified along with the MD. The Regional Nurse stated that it did not matter the time of the day that the fall occurred, the nurse should have notified the RP/Family and the MD.During an interview on 1/28/2026 at 3:30 p.m., the Administrator stated when a resident falls, the nurses should notify the RP and communicate with the NP/MD, that was the facility's protocol to notify the family and physician. During an interview on 01/29/2026 at 09:14 a.m., LVN A stated she was the nurse on duty for Resident #1 on 01/17/2026. LVN A stated that it was her first night working at the facility and with Resident #1. LVN A stated Resident #1 was found on the floor next to the nurse's station. LVN A said she called the staff for directions because she was not familiar with the protocols. LVN A said she was not told by the on-call staff to call Resident #1's RP/Family so she did not call the family. LVN A stated most facility would want the family to notify after a fall that is why she called the on-call for direction, but she was not told to notify Resident #1's family. Review of facility's policy titled Change in a Resident's Condition or Status revised April 2025 reflected: Policy Statement ---Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).Policy Interpretation and Implementation-- I. The nurse will notify the resident's attending physician or physician on call when there has been a(an):a. accident or incident involving the resident.b. discovery of injuries of an unknown source.c. adverse reaction to medication.d. significant change in the resident's physical/emotional/mental condition.e. needs to alter the residents' medical treatment significantly.f. refusal of treatment or medications three (3) or more consecutive times);g. needs to transfer the resident to a hospital/treatment center.h. discharge without proper medical authority; and/or i. specific instructions to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the residents' status that:a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting);b. impacts more than one area of the president's health status.c. requires interdisciplinary review and/or revision to the care plan; andultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when:a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source.b. there is a significant change in the residents' physical, mental, or psychosocial status.c. there is a need to change the resident's room assignment.d. a decision has been made to discharge the resident from the facility; and/ore. it is necessary to transfer the resident to a hospital/treatment center. Review of facility's policy titled Resident Rights dated February 2021 reflected: Policy StatementEmployees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation--appoint a legal representative of his or her choice, in accordance with state law.--be notified of his or her medical condition and of any changes in his or her condition.--be informed of, and participate in, his or her care planning and treatment.

Based on interviews and record review the facility failed to develop and implement a person-centered comprehensive care plan to meet the preferences and goals of each resident and address the resident's medical, physical, mental and psychosocial needs for one (Resident #1) of six residents reviewed for care plans. The facility failed to include in Resident #1's care plan that he had Type 1 Diabetes Mellitus and needed insulin for blood glucose management. The facility failed to update Resident #1's care plan after a fall on 01/10/2026 and was sent to the ER for further evaluation and diagnosed with Right sided zygomaticomaxillary complex fracture (often high-impact facial injury involving the cheekbone (zygoma) and its articulations with surrounding bones, causing significant facial asymmetry, flattening, swelling, and numbness.) These deficient practices placed residents at risk for not receiving care and services. Findings included: Review of Resident #1's face sheet printed 01/27/2026 reflected a [AGE] year-old male who was admitted on [DATE] with the following dx. Type 1 Diabetes Mellitus with other diabetic kidney complications (a chronic autoimmune condition where the pancreas produces little to no insulin, causing high blood glucose (sugar) levels.), Sepsis, unspecified organism,( a life-threatening, emergency response to infection where the immune system damages the body's own tissues and organs) nontraumatic subarachnoid hemorrhage (is a life-threatening, often fatal emergency involving bleeding between the brain and surrounding membranes, typically caused by a ruptured intracranial aneurysm), hemiplegia (paralysis affecting one side of the body, resulting from brain or spinal cord damage, often from stroke, traumatic injury, or cerebral palsy, causing weakness, stiffness (spasticity), and impaired movement in the face, arm, and leg on that side) and hemiparesis(a neurological condition causing weakness or partial paralysis on one side of the body) following cerebral infarction (a critical medical condition where restricted blood flow causes tissue death (necrosis) in the brain.), Acute Bronchiolitis(a common, self-limiting lower respiratory tract viral infection) due to respiratory syncytial virus, Orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down.). Review of Resident#1's admission MDS assessment dated [DATE] reflected a BIMS score of 09, indicating moderate cognitive impairment. Section I -Active Diagnoses reflected Diabetes Mellitus. Section N-Medication reflected Resident #1 received insulin injection 5 days a week. Review of Resident #1's care plan initiated 12/31/2025 reflected Resident #1 had an ADL selfcare performance deficit related to confusion, moderate risk for falls related to confusion. Resident #1's care plan did not address Type 1 diabetes and the use of insulin. Resident #1's care plan did not address facial fracture as well. Review of Resident #1's physician orders reflected the following:Lantus SoloStar Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Glargine) Inject 15 unit subcutaneously one time a day for DM -Start Date- 12/28/2025 at 0600 am. HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if151 - 200 = 2u;201 - 250 = 4u;251 - 300 = 6u;301 - 350 = 8u;351 - 400 = 10u,subcutaneouslybefore meals for DM -Start Date- 12/29/2025 at 4:30 pm. Review of Resident #1's ER visit record dated 01/10/2026 reflected:Exam: CT (Computed Tomography is a non-invasive medical imaging test that combines specialized X-ray equipment with computers to produce detailed, cross-sectional, 3D images of bones, blood vessels, and soft tissues inside the body) Maxillofacial (relating to the jaw and face) without contrast.Impression: Right sided zygomaticomaxillary complex fracture. (often high-impact facial injury involving the cheekbone (zygoma) and its articulations with surrounding bones, causing significant facial asymmetry, flattening, swelling, and numbness.) Review of Resident #1's progress note dated 01/10/2026 at 09:25 p.m. written by LVN B reflected: Patient return from ER at this time with Dx: Facial Fractures. No new orders at this time. Will continue to monitor. During an interview on 01/27/2026 at 10:51 a.m., the MDS nurse stated she had just taken over the MDS position and was not sure who completed Resident #1's care plan. The MDS nurse stated she had just started working on care plans, she was only doing MDSs. The MDS nurse stated there is a section in the MDS that triggers the comprehensive care plan, and she just learned that. The MDS Nurse stated care plan was supposed to be done continuously as events occur to a Resident. The MDS Nurse stated Resident #1's facial fracture should have been care planned. The MDS nurse stated Resident #1's diagnosis of Type 1 Diabetes should have been care planned so that everyone was aware to monitor his blood sugars. The MDS Nurse stated the Regional Nurse was the one completing care plans. During an interview on 01/28/2026 at 1:32 p.m., the Regional Nurse stated baseline care plans were done on admission and when there was unique things, they keep adding until day 21 when the comprehensive care plan is ready. The Regional Nurse stated comprehensive care is usually trigger from the MDS on day 21, that is when a comprehensive care plan is to be completed. The Regional Nurse stated Resident #1 was in the facility for more than 12 days so his comprehensive care plan should have been completed. The Regional Nurse stated she would expect Resident #1's diagnoses of Diabetes Mellitus to be on the care plan, monitoring Resident #1's blood sugar, and making sure the appropriate care was given. The Regional Nurse stated, if Resident #1's diabetes was not care planned, there would have been adverse outcome of not getting his blood glucose. The Regional Nurse stated after she looked at Resident #1's care plan, she realized Resident #1 had 6 things care planned. The Regional Nurse stated Resident #1's comprehensive care plan should have been completed and it was not done. The Regional Nurse stated usually the DON, ADON, Dietary all work together, IDT approach. The Regional Nurse also stated Resident #1's facial fracture should have been added on the comprehensive care plan. Review of facility's policy titled Care Plans' Comprehensive Person-Centered dated 2001 reflected: Policy Statement-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Policy Interpretation and Implementation--1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required M DS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:(1) services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.i2e any specialized services to be provided as a result of PASARR recommendations; and(3) which professional services are responsible for each element of care.c. includes the resident's stated goals upon admission and desired outcomes.d. builds on the resident's strengths; ande. reflects currently recognized standards of practice for problem areas and conditions. 12. The interdisciplinary team reviews and updates the care plan:a. when there has been a significant change in the residents' condition.b. when the desired outcome is not met.c. when the resident has been readmitted to the facility from a hospital stay; andd. at least quarterly, in conjunction with the required quarterly MDS assessment.13. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.

Based on interview and record review the facility failed to give each resident a special diet to help when there was a nutritional problem for one (Resident #1) of four residents reviewed for therapeutic diet. The facility failed to administer therapeutic diet for Resident #1 from 12/27/2025 through 12/31/2025 as was recommended by the hospital upon discharge. The failure place residents at risk for aspiration, choking and hospitalization.Findings included: Review of Resident #1's face sheet printed 01/27/2026 reflected a [AGE] year-old male who was admitted on [DATE] with the following dx. Type 1 Diabetes Mellitus with other diabetic kidney complications (a chronic autoimmune condition where the pancreas produces little to no insulin, causing high blood glucose (sugar) levels.), Sepsis, unspecified organism,( a life-threatening, emergency response to infection where the immune system damages the body's own tissues and organs) nontraumatic subarachnoid hemorrhage (is a life-threatening, often fatal emergency involving bleeding between the brain and surrounding membranes, typically caused by a ruptured intracranial aneurysm), hemiplegia (paralysis affecting one side of the body, resulting from brain or spinal cord damage, often from stroke, traumatic injury, or cerebral palsy, causing weakness, stiffness (spasticity), and impaired movement in the face, arm, and leg on that side) and hemiparesis(a neurological condition causing weakness or partial paralysis on one side of the body) following cerebral infarction (a critical medical condition where restricted blood flow causes tissue death (necrosis) in the brain.), Acute Bronchiolitis(a common, self-limiting lower respiratory tract viral infection) due to respiratory syncytial virus, Orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down.). Review of Resident#1's admission MDS assessment dated [DATE] reflected a BIMS score of 09, indicating moderate cognitive impairment Review of Resident #1's care plan initiated 12/31/2025 reflected Resident #1 had an ADL selfcare performance deficit related to confusion, moderate risk for falls related to confusion. Initiated 01/05/2026 Dietary- resident's nutritional needs willbe met through next review with intervention of a NCS diet with puree texture and thin liquids. Review of Resident #1's physician order dated 12/31/2025 reflected: Regular diet, Pureed texture, Regular liquid consistency. Review of Resident #1's discharged Hospital records dated 12/22/2026 reflected: During the course of patient treatment these goals or recommendations may change, depending on functional progress, and further recommendations will be made. The interdisciplinary care team will collaboratively determine final discharge plans considering the overall care needs of the patient.If patient discharges from acute care before next treatment, please let this document serve as a discharge status.Speech-Language Pathology-Dysphagia (difficulty swallowing) Intervention. Recommendations:Diet Consistency: thin liquids, pureed. Review of Resident #1's dietary communication slip to the kitchen dated 12/27/2026 completed by LVN B reflected: New admission, Regular /Liberalized, NCS, Regular texture and thin liquid. Review of Resident #1's dietary note completed by the Dietary Manager on 12/29/2026 reflected pureed consistency.Review of Resident #1's dietary communication slip to the kitchen dated 12/31/2026 completed by LVN C reflected pureed texture with thin liquids.During an interview on 01/28/2026 at 11:57 a.m., LVN C said she was the admitting nurse for Resident #1. LVN C stated she could not remember if she got nurse-to-nurse report that Resident #1 was on a pureed diet or if she got report at all. LVN C stated she would assume she completed and sent Resident #1's dietary communication slip to the kitchen because she was his admitting nurse. LVN C stated she would have looked at Resident #1's discharge papers to be able to know what Resident #1's diet was. LVN C stated she could not remember what Resident #1's admitting diet was. LVN C stated there was a risk for aspiration for a Resident who was supposed to get a pureed diet but got a regular texture diet.During an interview on 01/28/2026 at 1:18 p.m., the Dietary Manager stated usually when there is a new admission, the dietary department gets the dietary communication slip from the nursing department. The Dietary Manager stated the dietary department does not see clinical for new admissions except the dietary communication slip from the nursing department. The Dietary Manager reviewed her records and stated when Resident #1 was admitted , she first got dietary communication from nurse for regular texture and thin liquids of 12/27/2025. The Dietary Manager stated there was another dietary communication slip completed on 12/31/2025. The Dietary Manager stated Resident #1 received regular texture food from 12/27/2025 to 12/31/2025 because that was the communication she got from the nursing department and then his diet was changed to pureed texture. The Dietary Manager stated that when a resident who was supposed to get pureed texture food gets regular food, they could choke on the regular food. The Dietary Manager stated Therapy sometimes assess the resident and let dietary know of the change of diet.During an interview on 01/28/2026 at 1:32 p.m., the Regional Nurse stated the admitting nurse was responsible for sending the dietary communication slip to the kitchen based on the diet on the resident's clinical from the hospital. The Regional Nurse stated if the recommended diet for Resident #1 while in the hospital was pureed texture, that is what the admitting nurse should have communicated to the dietary department. The Regional Nurse stated if the admitting nurse did not know what the resident's diet was, the nurse should have called the hospital for clarification. The [NAME] Nurse stated the dietary department gets what the nursing department send to them and follows the order. The Regional Nurse stated there was a risk of aspiration and choking, weight loss because the residents cannot eat it. Review of facility's policy titled Therapeutic Diets dated 2021 reflected: Policy Statement--Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.Policy Interpretation and Implementation-- Diet will be determined in accordance with the residents' informed choices, preferences, treatment goalsand wishes. Diagnosis alone will not determine whether the resident is prescribed to a therapeutic diet.2 . A therapeutic diet must be prescribed by the resident's attending physician ( or non -physician provider).The attending physician may delegate this task to a registered or licensed dietitian as permitted by statelaw.3. Diet order should match the terminology used by the food and nutrition services department.4. A 'therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part oftreatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the textureof a diet, for example:a. diabetic/calorie controlled diet;b. low sodium diet;c. cardiac diet; andd. altered consistency diet.5. If a mechanically altered diet is ordered, the provider will specify the texture modification.

Based on interview and record review the facility failed to provide therapy services that evaluate and treat a function that was impaired by illness or injury and increased the resident's functioning for one (Resident #1) of three residents reviewed for Rehab services. The facility's failed to ensure the therapy department evaluated Resident #1 upon admission to the facility per physician order. The facility failed to evaluate and treat Resident #1 after a fall on 01/07/2025 as per care plan intervention. This failure placed residents at risk of not being evaluated in order to get appropriate treatment as needed.Findings included: Review of Resident #1's face sheet printed 01/27/2026 reflected a [AGE] year-old male who was admitted on [DATE] with the following dx. Type 1 Diabetes Mellitus with other diabetic kidney complications (a chronic autoimmune condition where the pancreas produces little to no insulin, causing high blood glucose (sugar) levels.), Sepsis, unspecified organism,( a life-threatening, emergency response to infection where the immune system damages the body's own tissues and organs) nontraumatic subarachnoid hemorrhage (is a life-threatening, often fatal emergency involving bleeding between the brain and surrounding membranes, typically caused by a ruptured intracranial aneurysm), hemiplegia (paralysis affecting one side of the body, resulting from brain or spinal cord damage, often from stroke, traumatic injury, or cerebral palsy, causing weakness, stiffness (spasticity), and impaired movement in the face, arm, and leg on that side) and hemiparesis(a neurological condition causing weakness or partial paralysis on one side of the body) following cerebral infarction (a critical medical condition where restricted blood flow causes tissue death (necrosis) in the brain.), Acute Bronchiolitis(a common, self-limiting lower respiratory tract viral infection) due to respiratory syncytial virus, Orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down.). Review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score of 09, indicated moderate cognitive impairment. Section GG Functional Abilities reflected Resident #1 was 06. Independent - Resident completes the activity by themself with no assistance from a helper 05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity with transfers and toileting. Section J-Falls 0. Review of Resident #1's physician order dated 12/31/2025 reflected: PT, OT, ST to eval and treat as indicated active 12/31/2025. Review of Resident #1's care plan initiated 12/31/2025 reflected Resident #1 had an ADL selfcare performance deficit related to confusion, moderate risk for falls related to confusion. Fall on 01/07/26 with intervention for fall, PT to evaluate and treat PRN. Review of Resident #1's incident report dated 01/07/2025 at 07:50 p.m. reflected, Resident #1 had a fall next to the kitchen door. Review of Resident #1's Nursing to Therapy Screen Request in PCC dated 01/07/2026 and was locked on 1/28/2026 reflected:Reason-Post FallDiscipline requested to screen-PTPhysical function-recent fall. During an interview on 01/27/2026 at 12:38 p.m., the DOR stated usually all residents are screened/evaluated upon admission. The DOR stated after evaluation or screening, if treatment was needed, the therapy department verify with the BOM if the resident's insurance authorized therapy services. The DOR stated she did not screen or evaluate Resident #1 upon admission because she asked the BOM and was told Resident #1 did not come from the hospital with authorization from the hospital, so she did not bother to screen/evaluate Resident #1. The DOR stated she had to have a form of funding, usually the therapy department does not treat a resident without funding. The DOR stated that sometimes the Administrator would give a direct order to treat residents without funding based on the screening result.During an interview on 01/27/2026 at 12:54 pm the BOM stated all new admissions were screened/evaluated by the therapy department unless they were only admitted for nursing services. The BOM stated treatment was based on the payer source. The BOM stated the therapy department would send the verification of benefit to the BOM after screening/evaluation and she would send it back with payer source. The BOM stated, if the resident did not have a payer source, based on the screening report, an Admin Auth (administrative authorization) form is sent to the Administrator, and the resident would get some therapy visits/treatments. The BOM stated she told the DOR that Resident #1's was Admin Auth and the DOR was supposed to fill out the form and give it to the administrator. The BOM stated treatment would have been based on the evaluation/screening. During an interview on 01/27/2026 at 2:20 p.m., the Administrator stated all new admission was supposed to be screened by the therapy department regardless of payment source. The Administrator stated Resident #1 was assessed by nursing staff upon admissions. During an interview on 1/28/2026 at 1:32 p.m., the Regional Nurse stated PT should evaluate with every fall, that was the facility's standard, but she was not sure of what their fall policy indicated. The Regional Nurse stated that usually the IDT team discuss falls in their morning meetings. The Regional Nurse stated that once there is a fall, it triggers a form to be sent to the therapy department in electronic record System to evaluate the Resident. The Regional Nurse stated payer source did not stop therapy from evaluating a Resident upon admission or after a fall. The Regional Nurse stated therapy should screen every resident; there is no cause for the evaluation, further treatment was what mattered. The Regional Nurse stated if the initial intervention for Resident #1's fall on 01/07/2026 was not addressed, there was a risk for further falls. The Regional Nurse stated the interventions was to minimize the injury that could occur from a fall because some falls could not be prevented. During another interview with the DOR on 1/28/2026 at 2:55 p.m., she stated there was a communication from nursing in the electronic medical record regarding Resident #1 dated 1/7/2026. The DOR stated she had just seen the communication on 01/27/2026 after the State Surveyor began asking questions. The DOR stated that she did not see the communication, she was supposed to check the dashboard in PCC daily. The DOR stated she was new to the position and was still learning the process. It was brought to my attention yesterday. The DOR stated her regional boss was sending over an in-service for her to review. The DOR stated she did not believe screening Resident #1 would have prevented him from falling. The DOR stated she was not notified of Resident #1's falls on 01/07/26 and 1/10/2026 and it was not discussed in the morning meeting. During another interview with the Administrator on 1/28/2026 at 3:30 p.m., the Administrator stated Resident #1 should have been screened by therapy if there was a request in PCC to minimize the resident from falling. The Administrator stated the therapy department should have assessed Resident #1, assessment was assessment, and the payer source was not the factor for the need to conduct the assessment. Review of facility's policy titled Fall Risk assessment dated [DATE] reflected: Policy StatementThe nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information.Policy Interpretation and ImplementationAssessment data shall be used to identify underlying medical conditions that may increase the risk of injury from fallsThe staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, continence, and cognition. Review of facility's policy titled Falls - Clinical Protocol revised September 2012 reflected: Assessment and Recognition- 1. As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling.Staff will ask the resident and the caregiver or family about a history of falling.The staff and physician should document in the medical record a history of one or more recent falls (for example, within 90 days).While many falls are isolated individual incidents, a significant proportion occur among a few residents/patients. Those individuals may have a treatable medical disorder or functional disturbance as the underlying cause.2. In addition, the nurse shall assess and document/report the following:a. Vital signs;b. Recent injury, especially fracture or head injury;c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.;d. Change in cognition or level of consciousness;e. Neurological status;Cause Identification-For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall.The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or that finding a cause would not change the outcome or the management of falling and fall risk.Review of facility's policy titled Resident Screening Guidelines updated 07/28/2025 reflected: Policy --It is Reliant Rehabilitation policy, that screenings be completed by Reliant Rehabilitation team members and/or contractors on all new admissions, readmissions, or upon referral by the medical and/or nursing department of a facility, when accompanied by resident or resident representative consent.This is done to:1. facilitate and aid the facility in regard to OBRA compliance and care planning, and2. help identify indications of functional loss or aptitude that may require the need for a rehabilitation referral to evaluate additional skilled services.Procedure1. At Reliant Rehabilitation, resident screening will be conducted by licensed OTs, PTs, SLPs; or otherwise, qualified OTAs or PTAs according to the nursing facility's policies, methodologies, and timing. All such screening policies must comply with state regulations that govern rehabilitation professional practices.2.Reliant Rehabilitation staff (Reliant team members and/or contractors), as an important part of the interdisciplinary process, will work with facility administration in establishing appropriate screening policies. Facility policy may address rehabilitation screening following a resident's admission or readmission to the facility, a referral by nursing or other facility department, and in conjunction with quarterly MOS processes.4. Screening processes will be efficient and brief, include a medical record review and at least one of the following data-gathering methods: direct observation of functional performance and/or caregiver, resident, or resident representative interview.

Based on interviews and record review, the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 2 nurses (LVN A) reviewed for nursing services.The facility failed to ensure LVN A assessed and performed necessary interventions to stop Resident #1 from bleeding from skin tears on 09/13/25.This failure could place residents with wounds at risk for bleeding related complications.Findings included: Record review of Resident #1's face sheet dated 10/08/25 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included shortness of breath, Alzheimer's disease, muscle weakness, chronic pain, hypertension and other abnormalities of gait and mobility. Record review of Resident #1's quarterly MDS dated [DATE] revealed that a BIMS interview could not be conducted as she rarely/never understood the interview questions. Record review of Resident #1's Care Plan dated 06/08/25 revealed Resident #1 had potential for impaired skin integrity and was at risk of bleeding. The relevant intervention was evaluating skin for integrity and impaired coagulation (Bruising, petechia (pinpoint red spots on skin from bleeding from capillaries) , bleeding from orifices) Record review of Resident #1's MAR of September 25 revealed Resident#1 was not blood thinners. Record review of physician's order reflected: Skin Tear to Right Distal Lower Leg: Cleanse with wound cleanser, dry, apply Xeroform, ABD pad, and wrap with Kerlixdaily and PRN. Everyday shift. Record review of the wound assessment profile revealed substantial improvement in healing. The dimensions of the wound during the assessment on 09/15/25 was 4cm L x 0.5cms W x 0.1cm D and on 10/06/25 it was 0.9cm L x 0.4cm W x UTD A phone call made to LVN A on 10/08/25 at 11:20am and left to VM to call back. No return call was received as on 10/08/25 at 5:00pm. During an interview on 10/08/25 at 12:30pm the RP stated she visited Resident #1 almost every day. She said Resident #1 was on prednisone (An anti-inflammatory drug) for a very long time and due to that she had very vulnerable skin ( as side effect of prednisone medication) with bilateral edema (swelling on both legs). The RP said Resident #1's skin was prone to skin tears very easily . The RP reported on 09/13/25 early in the morning CNAs who took care of Resident #1 noticed she was bleeding from newly developed skin tears on her left leg. The RP said CNA B who noticed the bleeding threw a towel on the wound to stop the bleeding and reported to LVN A however she did not do any interventions and let Resident #1 bleed until a nurse from the next shift came and fixed it. She said LVN A left the facility without even look at Resident#1 to see what was going on. The RP stated Resident #1's condition is stable currently and there was no further complication from the wound and bleeding. During an observation on 10/08/25 at 1:15pm she was in her room in her wheelchair and napping. She appeared calm and relaxed without any distress. The wound was covered by dressing. She could not answer any of the interview questions and responded with unrelated answers. During a phone interview on 10/08/25 at 1:33pm CNA B stated she was the night CNA who worked on the night shift on 09/12/25 and finished the next day at 7:00am. CNA B stated, on 09/13/25 at about 5:10am she and CNA E were changing Resident #1 and getting her for the day. She said, while separating Resident #1's crossed legs, a skin tear occurred on her right lower leg from rubbing her left leg on the other leg, as her skin was sensitive even to mild pressure. CNA B stated Resident #1 was bleeding from the skin tears. She said as the bleeding was not stopping, she reported immediately to LVN A who was in the same hall administering medications. CNA B reported that LVN A told her that she was busy with administering medications and would go and assess Resident #1 once she completed administering medications to the residents in the hall. CNA B said she returned to Resident #1 and wrapped a towel around the wound to minimize further damage until LVN A's visit and intervention. CNA B stated she clocked out at about 7:20am and went home thinking Resident #1's bleeding was taken care of by LVN A. She said, at around noon she received a phone call at her home from LVN A asking her how severe Resident #1's wound was and stated she got busy with administering medications and had forgotten to take care of Resident #1's bleeding. CNA B stated on 09/15/25 she attended Inservice on abuse and neglect, reporting to the oncoming nursing team and competent nursing. A phone call made to CNA E on 10/08/25 at 2:15pm and left a VM to call back. She returned the call on 10/10/25 at 3: 13pm. CNA E stated, on 09/13/25 early in the morning, she was helping CNA B in changing Resident #1. She stated since Resident #1 had contracted legs it was very difficult to change her. She stated in the process of separating her legs she had seen Resident#1 bleeding from her right leg. CNA E said, CNA B rushed out of the room to report it to LVN A. She stated they wrapped a towel around Resident #1's leg to put some pressure on to stop the bleeding. She stated the bleeding was pretty bad and non-stopping. Since she was on duty in another hall and had other tasks to accomplish with her residents in her hall, she left Resident #1 with CNA B. When investigator asked about in services she attended, CNA B stated at the facility there were in services at least once a week. She stated she attended an in-service of reporting abuse and neglect, and importance of reporting concerns related to residents in handover meetings. A phone call was made to CNA D on 10/08/25 at 1:50 pm and left a voice message to call back. No return call was received from CNA D, prior to the investigation exit. A phone call made to RN C on 10/08/25 at 2:05pm and left a VM to call back and she returned the call on 10/10/25 at 11:06am. RN C stated on 09/13/25 she worked in the day shift. She said, at about 7:20am CNA D reported to her that Resident #1 was bleeding in her bed. RN C stated she rushed to Resident #1's room to take care of her bleeding. RN C stated on arrival she noticed Resident #1 was bleeding heavily from 3 skin tears on her right lower leg from knee to ankle and the bed sheet was visibly wet with blood. RN C stated she had to change 3 bandages that were saturated with blood and eventually managed to contain the bleeding. RN C stated Resident #1 lost copious amount of blood from the bleeding. She said, neither she nor CNA D received any handover in the morning from the previous shift regarding Resident #1. RN C stated CNA D found out about the bleeding when she entered Resident #1's room for the routine check at the beginning of the shift. RN C stated Resident #1 was a fragile person and had a very sensitive vulnerable skin that could be easily torn with minor stresses on the skin. She stated Resident #1 was on her observation the whole day and her vitals were within normal range. RN C stated she contacted MD and received an order for wound care. She stated attended an Inservice related to the incident a few days after the incident and could not remember exactly what day it was. During an interview on 10/08/25 at 2:30pm the WN stated she was not working on the day the incident occurred however she had done the wound care when she was back at work on Monday. She said the wound doctor who visited on that day had assessed Resident #1 and made no changes to the existing treatment plan as he found the wound was not significant enough to have a change in the treatment plan. During an interview on 09/08/25 at 12:45pm the DON stated LVN A did not assess Resident #1 and perform interventions to stop the bleeding in a timely manner. She stated loss of excessive blood is a threat to Resident #1's life. She said RN C did the wound care to stop the bleeding at 7:20am immediately after she commenced her shift. The DON stated Resident #1 was under observation and her wound was assessed many times that day to ensure her safety. The DON stated LVN A and other staff were in- serviced regarding the importance of triaging nursing care and reporting issues that needed continuity of care, during handover at shift changes. The DON stated staff were observed and reviewed by the DON and ADON daily and issues if any were discussed during the daily staff meeting. During an interview on 09/08/25 at 12:30pm the ADM stated, on 09/13/25 in the afternoon the RP of Resident #1 met him at his office. He stated the RP was visibly upset and complained about the competency of LVN A . The ADM stated, the RP told him to terminate LVN A and demanded a drug test on her as she did nothing to stop Resident #1 from bleeding. The ADM stated LVN A did not do her job correctly. He said though she was busy with administering medications she should have triaged and prioritized assessing Resident #1 when CNA B reported to her about skin tears and bleeding. He stated he did a facility investigation on the incident. The ADM said, though LVN A had not done her job in a timely manner, Resident #1 was taken care of by RN C immediately after she commenced her shift and subsequent follow up throughout the day. When the investigator pointed out that although RN C attended to Resident#1 at 7:20am, Resident #1 was left unattended bleeding for about two hours until 7:20am, the ADM responded that LVN A should not have allowed that happened. He stated LVN A and other nurses received an in-service on preventing, recognizing and reporting abuse and neglect and expectations of reporting during shift changes. The ADM stated he included an employee disciplinary report in LVN A's file as well. The ADM stated they have an annual performance evaluation program for all the employees, in place Record review of facility in service revealed on 09/15/25 an in service conducted on the shift to shift report must be given to oncoming staff. Nurses and CNAs must be given a detailed report after every shift'. Record review of the in services revealed about 20 staff members attended the in service that was conducted on 9/15/25. Record review of facility policy staffing, sufficient and competent Nursing revised in August 2022 reflected: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents with resident care plans and the facility assessment. 1. Competency is a measurable pattern of knowledge and skills abilities , behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully . 2. All nursing staff must meet specific competency requirements of their respective licensure ad certification requirements defined by state law. 3. Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) following areas: .Resident rights, person centered care, communication, Basic nursing skills, medication management, infection control , Skin, and wound care.Licensed nurse and nursing assistance are trained and must demonstrate competency in identifying, documenting, reporting resident changes of condition consistent with their scope of practice and responsibilities .

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed in notifying Resident #1's physician right away when the resident had a significant change in condition. Resident #1 had was bleeding from skin tears on 09/13/25.) This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition. Findings included:Record review of Resident #1's face sheet dated 10/08/25 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included shortness of breath, Alzheimer's disease, muscle weakness, chronic pain, hypertension and other abnormalities of gait and mobility. Record review of Resident #1's quarterly MDS dated [DATE] revealed that a BIMS interview could not be conducted as she rarely/never understood the interview questions. Record review of Resident #1's Care Plan dated 06/08/25 revealed Resident #1 had potential for impaired skin integrity and was at risk of bleeding. The relevant intervention was evaluating skin for integrity and impaired coagulation (Bruising, petechia (pinpoint red spots on skin from bleeding from capillaries) , bleeding from orifices) Record review of Resident #1's MAR of September 25 revealed Resident#1 was not blood thinners. Record review of the wound assessment profile revealed substantial improvement in healing. The dimensions of the wound during the assessment on 09/15/25 was 4cm L x 0.5cms W x 0.1cm D and on 10/06/25 it was 0.9cm L x 0.4cm W x UTD A phone call made to LVN A on 10/08/25 at 11:20am and left to VM to call back. No return call was received as on 10/08/25 at 5:00pm.During an interview on 10/08/25 at 12:30pm the RP stated she visited Resident #1 almost every day. She said Resident #1 was on prednisone (An anti-inflammatory drug) for a very long time and due to that she had very vulnerable skin ( as side effect of prednisone medication) with bilateral edema (swelling on both legs). The RP said Resident #1's skin was prone to skin tears very easily . The RP reported on 09/13/25 early in the morning CNAs who took care of Resident #1 noticed she was bleeding from newly developed skin tears on her left leg. The RP said CNA B who noticed the bleeding threw a towel on the wound to stop the bleeding and reported to LVN A however she did not do any interventions and let Resident #1 bleed until a nurse from the next shift came and fixed it. She said LVN A left the facility without even look at Resident#1 to see what was going on. The RP stated Resident #1's condition is stable currently and there was no further complication from the wound and bleeding. During an observation on 10/08/25 at 1:15pm she was in her room in her wheelchair napping. She appeared calm and relaxed without any distress. The wound was covered by dressing. She could not answer any of the interview questions and responded with unrelated answers.During a phone interview on 10/08/25 at 1:33pm CNA B stated she was the night CNA who worked on the night shift on 09/12/25 and finished the next day at 7:00am. CNA B stated, on 09/13/25 at about 5:10am she and CNA E were changing Resident #1 and getting her for the day. She said, while separating Resident #1's crossed legs, a skin tear occurred on her right lower leg from rubbing her left leg on the other leg, as her skin was sensitive even to mild pressure. CNA B stated Resident #1 was bleeding from the skin tears. She said as the bleeding was not stopping, she reported immediately to LVN A who was in the same hall administering medications. CNA B reported that LVN A told her that she was busy with administering medications and would go and assess Resident #1 once she completed administering medications to the residents in the hall. CNA B said she returned to Resident #1 and wrapped a towel around the wound to minimize further damage until LVN A's visit and intervention. CNA B stated she clocked out at about 7:20am and went home thinking Resident #1's bleeding was taken care of by LVN A. She said, at around noon she received a phone call at her home from LVN A asking her how severe Resident #1's wound was and stated she got busy with administering medications and had forgotten to take care of Resident #1's bleeding. CNA B stated on 09/15/25 she attended Inservice on abuse and neglect, reporting to the oncoming nursing team and competent nursing. A phone call made to RN C on 10/08/25 at 2:05pm and left a VM to call back and she returned the call on 10/10/25 at 11:06am. RN C stated on 09/13/25 she worked in the day shift. She said, at about 7:20am CNA D reported to her that Resident #1 was bleeding profusely in her bed. RN C stated she rushed to Resident #1's room to take care of her bleeding. RN C stated on arrival she noticed Resident #1 was bleeding heavily from 3 skin tears on her right lower leg from knee to ankle and the bed sheet was visibly wet with blood. RN C stated she had to change 3 bandages that were saturated with blood and eventually managed to contain the bleeding. RN C stated Resident #1 lost copious amount of blood from the bleeding. She said, neither she nor CNA D received any handover in the morning from the previous shift regarding Resident #1. RN C stated CNA D found out about the bleeding when she entered Resident #1's room for the routine check at the beginning of the shift. RN C stated Resident #1 was a fragile person and had a very sensitive vulnerable skin that could be easily torn with minor stresses on the skin. She stated Resident #1 was on her observation the whole day and her vitals were within normal range. RN C stated she attended an in-service related to the incident , few days after the incident and could not remember exactly what day it was. A phone call made to CNA E on 10/08/25 at 2:15pm and left a VM to call back. She returned the call on 10/10/25 at 3: 13pm. CNA E stated, on 09/13/25 early in the morning, she was helping CNA B in changing Resident #1. She stated since Resident #1 had contracted legs it was very difficult to change her. She stated in the process of separating her legs she had seen Resident#1 bleeding profusely from her right leg. CNA E said, CNA B rushed out of the room to report it to LVN A. She stated they wrapped a towel around Resident #1's leg to put some pressure on to stop the bleeding. She stated the bleeding was pretty bad and non-stopping. Since she was on duty in another hall and had other tasks to accomplish with her residents in her hall, she left Resident #1 with CNA B. When investigator asked about in services she attended, CNA B stated at the facility there were in services at least once a week. She stated she attended an in-service of reporting abuse and neglect and importance of reporting concerns related to residents in handover meetings. A phone call was made to CNA D on 10/08/25 at 1:50 pm and left a voice message to call back. No return call was received from CNA D, prior to the investigation exit. During an interview on 09/08/25 at 12:45pm the DON stated LVN A did not assess Resident #1 and perform interventions to stop the bleeding in a timely manner. She stated loss of excessive blood is a threat to Resident #1's life. She said RN C did the wound care to stop the bleeding at 7:20am immediately after she commenced her shift. The DON stated Resident #1 was under observation and her wound was assessed many times that day to ensure her safety. The DON stated LVN A and other staff were in- serviced regarding the importance of triaging nursing care and reporting issues that needed continuity of care, during handover at shift changes. The DON stated staff were observed and reviewed by the DON and ADON daily and issues if any were discussed during the daily staff meeting. During an interview on 09/08/25 at 12:30pm the ADM stated, on 09/13/25 in the afternoon the RP of Resident #1 met him at his office. He stated the RP was visibly upset and complained about the competency of LVN A . The ADM stated , the RP told him to terminate LVN A and demanded a drug test on her as she did nothing to stop Resident #1 from bleeding. The ADM stated LVN A did not do her job correctly. He said though she was busy with administering medications she should have triaged and prioritized assessing Resident #1 when CNA B reported to her about skin tears and bleeding. He stated he did a facility investigation on the incident . The ADM said, though LVN A had not done her job in a timely manner , Resident #1 was taken care of by RN C immediately after she commenced her shift and subsequent follow up throughout the day. When the investigator pointed out that although RN C attended to Resident#1 at 7:20am , Resident #1 was left unattended bleeding for about two hours until 7:20am, the ADM responded that LVN A should not have allowed that happened. He stated LVN A and other nurses received an in-service on preventing , recognizing and reporting abuse and neglect and expectations of reporting during shift changes. The ADM stated he included an employee disciplinary report in LVN A's file as well. The ADM stated they have an annual performance evaluation program for all the employees, in placeRecord review of facility in service revealed on 09/15/25 an in service conducted on the shift to shift report must be given to oncoming staff. Nurses and CNAs must be given a detailed report after every shift.' Record review of the in services revealed about 20 staff members attended the in service that was conducted on 9/15/25. Record review of facility policy staffing, sufficient and competent Nursing revised in August 2022 reflected: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents with resident care plans and the facility assessment.Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas:a. Resident Rights .m. Identification of changes in condition .Licensed nurse and nursing assistance are trained and must demonstrate competency in identifying, documenting, reporting resident changes of condition consistent with their scope of practice and responsibilities .

Based on observation, interview, and record review, the facility failed make sure that drugs are stored properly and only authorized persons have access for 2 of 3 medication carts (MC #1, and TC #2) reviewed for drug storage and labeling.The facility failed to ensure MC #1, and TC #2 were locked, medications secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings included: During an observation on 11/10/2025 at 8:03a.m., revealed MC #1, was near the nurses' station, and unlocked. There were no nurses around MC #1. MC #1 contained residents' prescription drugs, over the counter medications, and narcotics in a locked box in the medication cart.During an observation on 11/10/2025 at 8:10a.m., revealed TC #2, was near the nurses' station and unlocked. No staff were in sight of TC #2. TC #2 had residents' prescription creams in the top drawer. During an interview with LVN A on 11/10/2025 at 10:53a.m., revealed that he had been trained on medication storage. He said the policy for the medication carts was the medication cart must always be locked when not around it. He said whoever is on the medication cart was responsible for ensuring the cart was locked, when not using the medication cart. He said if the medication cart was left unlocked and unattended someone or a resident could get into the cart. He said all staff monitored to ensure the medication carts were locked. He said staff monitored the medication carts by observations. He said he had to go into the medication room to get some medications and did not lock the cart. He said he should have locked the medication cart when he walked away. During an interview with TN on 11/10/2025 at 11:02a.m., revealed she had been trained on medication storage. She said the policy for the medication carts was the medication cart was to be locked any time staff were away from it. She said the nurses and other staff walking by were responsible for ensuring the medication carts were locked. She said the medication carts were to be locked at all times when not in use. She said if a medication cart was left unlocked and unattended a resident could get into the medication cart and take medications they are not supposed to have. She said nurses and all administrative staff monitored to ensure staff were locking the medication carts. She said the nurses and administrative staff monitored by observations. She said she did not know why the treatment cart was unlocked. She said she had not been to the cart by the time the surveyor saw it was unlocked. She said she did not know who used the cart last or who left the cart unlocked. During an interview with the DON on 11/10/2025 at 2:38p.m., revealed she had been trained on medication storage. She said the policy for the medication cart was that it needed to be locked and only nurses and medication aides were to have access to it. She also said if the cart is not within the nurses' eyesight it should be locked. She said if the medication was left unlocked and unattended someone who was not authorized to be in the medication cart could take something out. She said leadership monitors to ensure staff are locking the medication carts. She said when leadership sees a medication cart unlocked when they go by the cart leadership will tell the nurse or medication aid to lock the medication cart. She said she did not know why the medication cart and the treatment cart were unlocked. During an interview with the ADM on 11/10/2025 at 2:44p.m., revealed that he had not been formally trained on medication storage. He said from experience he knew the medication storage policy was the medication cart had to be locked. He said the medication cart should be locked when the nurse or treatment nurse and medication aide was not actively using the cart. He said if the mediation cart was left unlocked or unattended someone could take something from the cart that someone should not have. He said that the administrative team and peer to peer monitored to ensure the carts are locked. He said the administrative staff monitor through observation. Said that he did not have a good explanation as to why the medication cart and treatment cart were unlocked. Record review of Medication Labeling and Storage Policy dated 2/2023, revealed The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on interviews and record review, the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 2 nurses (LVN A) reviewed for nursing services.The facility failed to ensure LVN A assessed and performed necessary interventions to stop Resident #1 from bleeding from skin tears on 09/13/25.This failure could place residents with wounds at risk for bleeding related complications.Findings included: Record review of Resident #1's face sheet dated 10/08/25 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included shortness of breath, Alzheimer's disease, muscle weakness, chronic pain, hypertension and other abnormalities of gait and mobility. Record review of Resident #1's quarterly MDS dated [DATE] revealed that a BIMS interview could not be conducted as she rarely/never understood the interview questions. Record review of Resident #1's Care Plan dated 06/08/25 revealed Resident #1 had potential for impaired skin integrity and was at risk of bleeding. The relevant intervention was evaluating skin for integrity and impaired coagulation (Bruising, petechia (pinpoint red spots on skin from bleeding from capillaries) , bleeding from orifices) Record review of Resident #1's MAR of September 25 revealed Resident#1 was not blood thinners. Record review of physician's order reflected: Skin Tear to Right Distal Lower Leg: Cleanse with wound cleanser, dry, apply Xeroform, ABD pad, and wrap with Kerlixdaily and PRN. Everyday shift. Record review of the wound assessment profile revealed substantial improvement in healing. The dimensions of the wound during the assessment on 09/15/25 was 4cm L x 0.5cms W x 0.1cm D and on 10/06/25 it was 0.9cm L x 0.4cm W x UTD A phone call made to LVN A on 10/08/25 at 11:20am and left to VM to call back. No return call was received as on 10/08/25 at 5:00pm. During an interview on 10/08/25 at 12:30pm the RP stated she visited Resident #1 almost every day. She said Resident #1 was on prednisone (An anti-inflammatory drug) for a very long time and due to that she had very vulnerable skin ( as side effect of prednisone medication) with bilateral edema (swelling on both legs). The RP said Resident #1's skin was prone to skin tears very easily . The RP reported on 09/13/25 early in the morning CNAs who took care of Resident #1 noticed she was bleeding from newly developed skin tears on her left leg. The RP said CNA B who noticed the bleeding threw a towel on the wound to stop the bleeding and reported to LVN A however she did not do any interventions and let Resident #1 bleed until a nurse from the next shift came and fixed it. She said LVN A left the facility without even look at Resident#1 to see what was going on. The RP stated Resident #1's condition is stable currently and there was no further complication from the wound and bleeding. During an observation on 10/08/25 at 1:15pm she was in her room in her wheelchair and napping. She appeared calm and relaxed without any distress. The wound was covered by dressing. She could not answer any of the interview questions and responded with unrelated answers. During a phone interview on 10/08/25 at 1:33pm CNA B stated she was the night CNA who worked on the night shift on 09/12/25 and finished the next day at 7:00am. CNA B stated, on 09/13/25 at about 5:10am she and CNA E were changing Resident #1 and getting her for the day. She said, while separating Resident #1's crossed legs, a skin tear occurred on her right lower leg from rubbing her left leg on the other leg, as her skin was sensitive even to mild pressure. CNA B stated Resident #1 was bleeding from the skin tears. She said as the bleeding was not stopping, she reported immediately to LVN A who was in the same hall administering medications. CNA B reported that LVN A told her that she was busy with administering medications and would go and assess Resident #1 once she completed administering medications to the residents in the hall. CNA B said she returned to Resident #1 and wrapped a towel around the wound to minimize further damage until LVN A's visit and intervention. CNA B stated she clocked out at about 7:20am and went home thinking Resident #1's bleeding was taken care of by LVN A. She said, at around noon she received a phone call at her home from LVN A asking her how severe Resident #1's wound was and stated she got busy with administering medications and had forgotten to take care of Resident #1's bleeding. CNA B stated on 09/15/25 she attended Inservice on abuse and neglect, reporting to the oncoming nursing team and competent nursing. A phone call made to CNA E on 10/08/25 at 2:15pm and left a VM to call back. She returned the call on 10/10/25 at 3: 13pm. CNA E stated, on 09/13/25 early in the morning, she was helping CNA B in changing Resident #1. She stated since Resident #1 had contracted legs it was very difficult to change her. She stated in the process of separating her legs she had seen Resident#1 bleeding from her right leg. CNA E said, CNA B rushed out of the room to report it to LVN A. She stated they wrapped a towel around Resident #1's leg to put some pressure on to stop the bleeding. She stated the bleeding was pretty bad and non-stopping. Since she was on duty in another hall and had other tasks to accomplish with her residents in her hall, she left Resident #1 with CNA B. When investigator asked about in services she attended, CNA B stated at the facility there were in services at least once a week. She stated she attended an in-service of reporting abuse and neglect, and importance of reporting concerns related to residents in handover meetings. A phone call was made to CNA D on 10/08/25 at 1:50 pm and left a voice message to call back. No return call was received from CNA D, prior to the investigation exit. A phone call made to RN C on 10/08/25 at 2:05pm and left a VM to call back and she returned the call on 10/10/25 at 11:06am. RN C stated on 09/13/25 she worked in the day shift. She said, at about 7:20am CNA D reported to her that Resident #1 was bleeding in her bed. RN C stated she rushed to Resident #1's room to take care of her bleeding. RN C stated on arrival she noticed Resident #1 was bleeding heavily from 3 skin tears on her right lower leg from knee to ankle and the bed sheet was visibly wet with blood. RN C stated she had to change 3 bandages that were saturated with blood and eventually managed to contain the bleeding. RN C stated Resident #1 lost copious amount of blood from the bleeding. She said, neither she nor CNA D received any handover in the morning from the previous shift regarding Resident #1. RN C stated CNA D found out about the bleeding when she entered Resident #1's room for the routine check at the beginning of the shift. RN C stated Resident #1 was a fragile person and had a very sensitive vulnerable skin that could be easily torn with minor stresses on the skin. She stated Resident #1 was on her observation the whole day and her vitals were within normal range. RN C stated she contacted MD and received an order for wound care. She stated attended an Inservice related to the incident a few days after the incident and could not remember exactly what day it was. During an interview on 10/08/25 at 2:30pm the WN stated she was not working on the day the incident occurred however she had done the wound care when she was back at work on Monday. She said the wound doctor who visited on that day had assessed Resident #1 and made no changes to the existing treatment plan as he found the wound was not significant enough to have a change in the treatment plan. During an interview on 09/08/25 at 12:45pm the DON stated LVN A did not assess Resident #1 and perform interventions to stop the bleeding in a timely manner. She stated loss of excessive blood is a threat to Resident #1's life. She said RN C did the wound care to stop the bleeding at 7:20am immediately after she commenced her shift. The DON stated Resident #1 was under observation and her wound was assessed many times that day to ensure her safety. The DON stated LVN A and other staff were in- serviced regarding the importance of triaging nursing care and reporting issues that needed continuity of care, during handover at shift changes. The DON stated staff were observed and reviewed by the DON and ADON daily and issues if any were discussed during the daily staff meeting. During an interview on 09/08/25 at 12:30pm the ADM stated, on 09/13/25 in the afternoon the RP of Resident #1 met him at his office. He stated the RP was visibly upset and complained about the competency of LVN A . The ADM stated, the RP told him to terminate LVN A and demanded a drug test on her as she did nothing to stop Resident #1 from bleeding. The ADM stated LVN A did not do her job correctly. He said though she was busy with administering medications she should have triaged and prioritized assessing Resident #1 when CNA B reported to her about skin tears and bleeding. He stated he did a facility investigation on the incident. The ADM said, though LVN A had not done her job in a timely manner, Resident #1 was taken care of by RN C immediately after she commenced her shift and subsequent follow up throughout the day. When the investigator pointed out that although RN C attended to Resident#1 at 7:20am, Resident #1 was left unattended bleeding for about two hours until 7:20am, the ADM responded that LVN A should not have allowed that happened. He stated LVN A and other nurses received an in-service on preventing, recognizing and reporting abuse and neglect and expectations of reporting during shift changes. The ADM stated he included an employee disciplinary report in LVN A's file as well. The ADM stated they have an annual performance evaluation program for all the employees, in place Record review of facility in service revealed on 09/15/25 an in service conducted on the shift to shift report must be given to oncoming staff. Nurses and CNAs must be given a detailed report after every shift'. Record review of the in services revealed about 20 staff members attended the in service that was conducted on 9/15/25. Record review of facility policy staffing, sufficient and competent Nursing revised in August 2022 reflected: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents with resident care plans and the facility assessment. 1. Competency is a measurable pattern of knowledge and skills abilities , behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully . 2. All nursing staff must meet specific competency requirements of their respective licensure ad certification requirements defined by state law. 3. Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) following areas: .Resident rights, person centered care, communication, Basic nursing skills, medication management, infection control , Skin, and wound care.Licensed nurse and nursing assistance are trained and must demonstrate competency in identifying, documenting, reporting resident changes of condition consistent with their scope of practice and responsibilities .

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed in notifying Resident #1's physician right away when the resident had a significant change in condition. Resident #1 had was bleeding from skin tears on 09/13/25.) This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition. Findings included:Record review of Resident #1's face sheet dated 10/08/25 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included shortness of breath, Alzheimer's disease, muscle weakness, chronic pain, hypertension and other abnormalities of gait and mobility. Record review of Resident #1's quarterly MDS dated [DATE] revealed that a BIMS interview could not be conducted as she rarely/never understood the interview questions. Record review of Resident #1's Care Plan dated 06/08/25 revealed Resident #1 had potential for impaired skin integrity and was at risk of bleeding. The relevant intervention was evaluating skin for integrity and impaired coagulation (Bruising, petechia (pinpoint red spots on skin from bleeding from capillaries) , bleeding from orifices) Record review of Resident #1's MAR of September 25 revealed Resident#1 was not blood thinners. Record review of the wound assessment profile revealed substantial improvement in healing. The dimensions of the wound during the assessment on 09/15/25 was 4cm L x 0.5cms W x 0.1cm D and on 10/06/25 it was 0.9cm L x 0.4cm W x UTD A phone call made to LVN A on 10/08/25 at 11:20am and left to VM to call back. No return call was received as on 10/08/25 at 5:00pm.During an interview on 10/08/25 at 12:30pm the RP stated she visited Resident #1 almost every day. She said Resident #1 was on prednisone (An anti-inflammatory drug) for a very long time and due to that she had very vulnerable skin ( as side effect of prednisone medication) with bilateral edema (swelling on both legs). The RP said Resident #1's skin was prone to skin tears very easily . The RP reported on 09/13/25 early in the morning CNAs who took care of Resident #1 noticed she was bleeding from newly developed skin tears on her left leg. The RP said CNA B who noticed the bleeding threw a towel on the wound to stop the bleeding and reported to LVN A however she did not do any interventions and let Resident #1 bleed until a nurse from the next shift came and fixed it. She said LVN A left the facility without even look at Resident#1 to see what was going on. The RP stated Resident #1's condition is stable currently and there was no further complication from the wound and bleeding. During an observation on 10/08/25 at 1:15pm she was in her room in her wheelchair napping. She appeared calm and relaxed without any distress. The wound was covered by dressing. She could not answer any of the interview questions and responded with unrelated answers.During a phone interview on 10/08/25 at 1:33pm CNA B stated she was the night CNA who worked on the night shift on 09/12/25 and finished the next day at 7:00am. CNA B stated, on 09/13/25 at about 5:10am she and CNA E were changing Resident #1 and getting her for the day. She said, while separating Resident #1's crossed legs, a skin tear occurred on her right lower leg from rubbing her left leg on the other leg, as her skin was sensitive even to mild pressure. CNA B stated Resident #1 was bleeding from the skin tears. She said as the bleeding was not stopping, she reported immediately to LVN A who was in the same hall administering medications. CNA B reported that LVN A told her that she was busy with administering medications and would go and assess Resident #1 once she completed administering medications to the residents in the hall. CNA B said she returned to Resident #1 and wrapped a towel around the wound to minimize further damage until LVN A's visit and intervention. CNA B stated she clocked out at about 7:20am and went home thinking Resident #1's bleeding was taken care of by LVN A. She said, at around noon she received a phone call at her home from LVN A asking her how severe Resident #1's wound was and stated she got busy with administering medications and had forgotten to take care of Resident #1's bleeding. CNA B stated on 09/15/25 she attended Inservice on abuse and neglect, reporting to the oncoming nursing team and competent nursing. A phone call made to RN C on 10/08/25 at 2:05pm and left a VM to call back and she returned the call on 10/10/25 at 11:06am. RN C stated on 09/13/25 she worked in the day shift. She said, at about 7:20am CNA D reported to her that Resident #1 was bleeding profusely in her bed. RN C stated she rushed to Resident #1's room to take care of her bleeding. RN C stated on arrival she noticed Resident #1 was bleeding heavily from 3 skin tears on her right lower leg from knee to ankle and the bed sheet was visibly wet with blood. RN C stated she had to change 3 bandages that were saturated with blood and eventually managed to contain the bleeding. RN C stated Resident #1 lost copious amount of blood from the bleeding. She said, neither she nor CNA D received any handover in the morning from the previous shift regarding Resident #1. RN C stated CNA D found out about the bleeding when she entered Resident #1's room for the routine check at the beginning of the shift. RN C stated Resident #1 was a fragile person and had a very sensitive vulnerable skin that could be easily torn with minor stresses on the skin. She stated Resident #1 was on her observation the whole day and her vitals were within normal range. RN C stated she attended an in-service related to the incident , few days after the incident and could not remember exactly what day it was. A phone call made to CNA E on 10/08/25 at 2:15pm and left a VM to call back. She returned the call on 10/10/25 at 3: 13pm. CNA E stated, on 09/13/25 early in the morning, she was helping CNA B in changing Resident #1. She stated since Resident #1 had contracted legs it was very difficult to change her. She stated in the process of separating her legs she had seen Resident#1 bleeding profusely from her right leg. CNA E said, CNA B rushed out of the room to report it to LVN A. She stated they wrapped a towel around Resident #1's leg to put some pressure on to stop the bleeding. She stated the bleeding was pretty bad and non-stopping. Since she was on duty in another hall and had other tasks to accomplish with her residents in her hall, she left Resident #1 with CNA B. When investigator asked about in services she attended, CNA B stated at the facility there were in services at least once a week. She stated she attended an in-service of reporting abuse and neglect and importance of reporting concerns related to residents in handover meetings. A phone call was made to CNA D on 10/08/25 at 1:50 pm and left a voice message to call back. No return call was received from CNA D, prior to the investigation exit. During an interview on 09/08/25 at 12:45pm the DON stated LVN A did not assess Resident #1 and perform interventions to stop the bleeding in a timely manner. She stated loss of excessive blood is a threat to Resident #1's life. She said RN C did the wound care to stop the bleeding at 7:20am immediately after she commenced her shift. The DON stated Resident #1 was under observation and her wound was assessed many times that day to ensure her safety. The DON stated LVN A and other staff were in- serviced regarding the importance of triaging nursing care and reporting issues that needed continuity of care, during handover at shift changes. The DON stated staff were observed and reviewed by the DON and ADON daily and issues if any were discussed during the daily staff meeting. During an interview on 09/08/25 at 12:30pm the ADM stated, on 09/13/25 in the afternoon the RP of Resident #1 met him at his office. He stated the RP was visibly upset and complained about the competency of LVN A . The ADM stated , the RP told him to terminate LVN A and demanded a drug test on her as she did nothing to stop Resident #1 from bleeding. The ADM stated LVN A did not do her job correctly. He said though she was busy with administering medications she should have triaged and prioritized assessing Resident #1 when CNA B reported to her about skin tears and bleeding. He stated he did a facility investigation on the incident . The ADM said, though LVN A had not done her job in a timely manner , Resident #1 was taken care of by RN C immediately after she commenced her shift and subsequent follow up throughout the day. When the investigator pointed out that although RN C attended to Resident#1 at 7:20am , Resident #1 was left unattended bleeding for about two hours until 7:20am, the ADM responded that LVN A should not have allowed that happened. He stated LVN A and other nurses received an in-service on preventing , recognizing and reporting abuse and neglect and expectations of reporting during shift changes. The ADM stated he included an employee disciplinary report in LVN A's file as well. The ADM stated they have an annual performance evaluation program for all the employees, in placeRecord review of facility in service revealed on 09/15/25 an in service conducted on the shift to shift report must be given to oncoming staff. Nurses and CNAs must be given a detailed report after every shift.' Record review of the in services revealed about 20 staff members attended the in service that was conducted on 9/15/25. Record review of facility policy staffing, sufficient and competent Nursing revised in August 2022 reflected: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents with resident care plans and the facility assessment.Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas:a. Resident Rights .m. Identification of changes in condition .Licensed nurse and nursing assistance are trained and must demonstrate competency in identifying, documenting, reporting resident changes of condition consistent with their scope of practice and responsibilities .

Based on observation, interview, and record review, the facility failed make sure that drugs are stored properly and only authorized persons have access for 2 of 3 medication carts (MC #1, and TC #2) reviewed for drug storage and labeling.The facility failed to ensure MC #1, and TC #2 were locked, medications secured, and not accessible to other staff, residents, or visitors.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings included:During an observation on 11/10/2025 at 8:03a.m., revealed MC #1, was near the nurses' station, and unlocked. There were no nurses around MC #1. MC #1 contained residents' prescription drugs, over the counter medications, and narcotics in a locked box in the medication cart.During an observation on 11/10/2025 at 8:10a.m., revealed TC #2, was near the nurses' station and unlocked. No staff were in sight of TC #2. TC #2 had residents' prescription creams in the top drawer. During an interview with LVN A on 11/10/2025 at 10:53a.m., revealed that he had been trained on medication storage. He said the policy for the medication carts was the medication cart must always be locked when not around it. He said whoever is on the medication cart was responsible for ensuring the cart was locked, when not using the medication cart. He said if the medication cart was left unlocked and unattended someone or a resident could get into the cart. He said all staff monitored to ensure the medication carts were locked. He said staff monitored the medication carts by observations. He said he had to go into the medication room to get some medications and did not lock the cart. He said he should have locked the medication cart when he walked away.During an interview with TN on 11/10/2025 at 11:02a.m., revealed she had been trained on medication storage. She said the policy for the medication carts was the medication cart was to be locked any time staff were away from it. She said the nurses and other staff walking by were responsible for ensuring the medication carts were locked. She said the medication carts were to be locked at all times when not in use. She said if a medication cart was left unlocked and unattended a resident could get into the medication cart and take medications they are not supposed to have. She said nurses and all administrative staff monitored to ensure staff were locking the medication carts. She said the nurses and administrative staff monitored by observations. She said she did not know why the treatment cart was unlocked. She said she had not been to the cart by the time the surveyor saw it was unlocked. She said she did not know who used the cart last or who left the cart unlocked.During an interview with the DON on 11/10/2025 at 2:38p.m., revealed she had been trained on medication storage. She said the policy for the medication cart was that it needed to be locked and only nurses and medication aides were to have access to it. She also said if the cart is not within the nurses' eyesight it should be locked. She said if the medication was left unlocked and unattended someone who was not authorized to be in the medication cart could take something out. She said leadership monitors to ensure staff are locking the medication carts. She said when leadership sees a medication cart unlocked when they go by the cart leadership will tell the nurse or medication aid to lock the medication cart. She said she did not know why the medication cart and the treatment cart were unlocked. During an interview with the ADM on 11/10/2025 at 2:44p.m., revealed that he had not been formally trained on medication storage. He said from experience he knew the medication storage policy was the medication cart had to be locked. He said the medication cart should be locked when the nurse or treatment nurse and medication aide was not actively using the cart. He said if the mediation cart was left unlocked or unattended someone could take something from the cart that someone should not have. He said that the administrative team and peer to peer monitored to ensure the carts are locked. He said the administrative staff monitor through observation. Said that he did not have a good explanation as to why the medication cart and treatment cart were unlocked. Record review of Medication Labeling and Storage Policy dated 2/2023, revealed The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 4 of 4 residents (Resident #1, #3, #13, and #51) reviewed for infection control. The facility failed to ensure LVNA sanitized equipment/work surfaces between Residents #1, #3, #13, and #51. This failure could place residents at risk for development of communicable diseases and infections. Findings included: 1. Record review of Resident #1's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of Vascular Dementia, High Blood Pressure, Stroke affecting Right dominant side, Alzheimer's disease and lack of coordination. Record review of Resident 01's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 10, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident #01's Care Plan, reflected a Focus area was initiated on 4/22/2021 for resident having Cognitive Loss/Dementia. The goal was set to maintain current level of cognitive function by maximizing her involvement in daily decision making. 2. Record review of Resident #03's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of Chronic pain, Repeated falls, Diabetes Type II, Chronic Obstructive Pulmonary Disease (lung disease), and Bipolar disease. Record review of Resident #03's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated the resident's cognitive ability was intact. Record review of Resident #03's Care Plan, reflected a Focus area was initiated 12/6/2024 for resident being at risk for infection related to Covid-19. Her goal was to remain free from serious infection. 3. Record review of Resident 13's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of Senile degeneration of brain, Anxiety disorder, Congestive Heart Failure, and Respiratory Failure. Record review of Resident 13's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident 13's Care Plan, reflected a Focus area was initiated on 1/22/2025 for resident having impaired cognitive function/dementia. Her goal was to improve current level of cognitive function. 4. Record review of Resident 51's undated face sheet, revealed he was a [AGE] year-old male admitted [DATE] with diagnoses of Colon Cancer, Open wounds, Hyponatremia (low sodium), and Congestive Heart Failure. Record review of Resident 51's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident 51's Care Plan, reflected a Focus area was initiated on 12/5/2024 for resident requiring Hospice for terminal disease. The goal was to maintain dignity and keep pain free. Observation on 3/12/2025 at 8:43 AM, during medication pass, LVN-A removed a blood pressure cuff from the top of the medication cart and used it to take Resident #13's blood pressure. After taking the blood pressure, the cuff was replaced on the top of the medication cart without being sanitized. LVN-A proceeded to prepare Resident #13's medications on the cart then administered them to her. The blood pressure cuff remained on the top of the cart. Hand hygiene was done after leaving Resident #13's room Observation on 3/12/2025 at 9:08 AM, revealed LVN-A moved the medication cart to Resident #01's room and picked up the unclean blood pressure cuff. He proceeded to take Resident 01's blood pressure then returned the unclean blood pressure cuff to the top of the medication cart without sanitizing it. He then proceeded to prepare and administer the medications. LVN A performed hand hygiene but did not clean the medication cart surface or the blood pressure cuff on the medication cart. His hands had contact with both areas. Observation on 3/12/2025 at 9:17 AM, revealed LVN-A moved the medication cart to Resident #51's room and picked up the unclean blood pressure cuff. He proceeded to take Resident 51's blood pressure then returned the unclean blood pressure cuff to the medication cart without sanitizing it. He then proceeded to prepare the medications for Resident #51 and to administer the medications. When Resident 51's medications were completed he performed hand hygiene but did not clean the medication cart surface or the blood pressure cuff on the medication cart. His hands had contact with both areas. Observation on 3/12/2025 at 9:28 AM revealed LVN-A moved the medication cart to Resident #03's room The unclean blood pressure cuff remained on the medication cart. LVN-A then proceeded to prepare the medications for Resident #03 on the unclean medication cart surface and to administer the medications. When Resident 03's medications were complete he performed hand hygiene but did not clean the medication cart surface or the blood pressure cuff on the medication cart. In an interview with LVN-A on 03/12/25 at 09:39 AM, he stated that per policy he should have cleaned the blood pressure cuff between residents. He stated that equipment was cleaned to prevent cross contamination between residents. He also stated that the negative outcome to residents if equipment was not cleaned would be the spread of diseases and germs. In an interview with CNA-A on 3/13/2025 at 1:14 PM she stated, the policy for sanitizing between residents was to wear gloves and wipe the blood pressure cuff with sanitizing wipes. She stated this has to be done between every resident. She stated, it was important to sanitize equipment/work surfaces for infection control to prevent the spread of germs. She also stated that failure to sanitize could make the residents sick or potentially kill them if they can't fight off infections. In an interview with LVN-B on 3/13/2025 at 1:18 PM she stated, the policy was to sanitize hands and blood pressure cuffs between residents. She stated it is important to sanitized equipment and work surfaces for infection control on wounds, lesions or anything else that a resident could have. She further stated the negative outcome if equipment/work surfaces are not sanitized was germs could go from one resident to another and make them sick. In an interview with DON on 3/13/25 at 1:44 PM she stated, the policy for sanitizing equipment /work surfaces between residents was they should be wiped with sanitizing wipes between residents for any multiple use items. She stated it was important to sanitize equipment/work surfaces to prevent the spread of contaminates and the negative outcome to residents if this was not done is was you could spread contaminates from resident to resident and cause illnesses. In an interview with the ADM on 3/13/25 at 1:28 PM he stated, the policy for sanitizing equipment /work surfaces between residents was to use specific sanitizers between use. He stated it was important to sanitize equipment/work surfaces because if not you could potentially spread an infection to another resident and the negative outcome if equipment/work surfaces are not sanitized was that residents could get a virus, or an infection transmitted to them. A record review of the facility policy titled, Nursing Policy and Procedure-Infection Control-Cleaning and Disinfecting Resident Care Items and Equipment dated 10-2020, reflected the following: Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). Non-critical items (blood pressure cuffs) can be decontaminated where they are used.

Based on observations, interviews, and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 9.38% based on 3 errors out of 32 opportunities, which involved 2 of 4 residents (Resident #3 and #13) reviewed for medication errors. The facility failed to ensure LVN-A administered medications according to physician's order and manufactured guidelines for resident #13 when LVN-A crushed an extended release medication and failed to ensure a medication was in the medication cup. LVN-A failed to give resident #03 the correct number of tablets. This failure could place residents at risk for incorrect dosages resulting in reduced healing and unnecessary hospitalization s. Findings include: 1. Record review of Resident #13's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of Senile degeneration of brain, Anxiety disorder, Congestive Heart Failure, and Respiratory Failure. Record review of Resident #13's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident #13's Care Plan, reflected a Focus area was initiated on 1/22/2025 for resident having impaired cognitive function/dementia. Her goal was to improve current level of cognitive function. Record review of Resident #13's orders reflected a 10/30/24 order for Desvenlafaxine Succinate (antidepressant) Tablet Extended Release 24 hour: 100mg oral tablet daily. Order reflects Do Not Crush. Record review of Resident #13's orders reflected a 11/05/2024 order for Lorazepam-Schedule IV tablet: 0.5mg: 1 orally twice daily. 2. Record review of Resident #3's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of Chronic pain, Repeated falls, Diabetes Type II, Chronic Obstructive Pulmonary Disease (lung disease), and Bipolar disease. Record review of Resident #3's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated the resident's cognitive ability was intact. Record review of Resident #3's orders reflected a 4/19/2024 order for Torsemide tablet (fluid pill) 20mg-3 tablets once daily. Observation of medication pass on 3/12/2025 at 8:43 AM, revealed the following for Resident #13: 1. LVN-A crushed a Desvenlafaxine succinate Tablet Extended Release 24-hour 100mg tablet and administered it to Resident #13. 2. LVN-A failed to ensure a Lorazepam 0.5mg tablet was in the medication cup. Examination revealed the tablet had not fallen out of the packaging. Observation that the narcotic count was 3 versus the 4 seen in the pack by the surveyor revealed the error and it was corrected. Observation of medication pass on 3/12/2025 at 9:28 AM, revealed the following for Resident #03: 1. LVN-A placed 2 Torsemide 20mg tablets into Resident #3's medication cup. When her medications were completed and count was verified by Surveyor, the cup was short 1 Torsemide. Observed LVN-A correcting the error and adding the 3rd Torsemide to the cup . In an interview with LVN-A on 03/12/25 at 09:06 AM, he stated that the medications in the cup for Resident #13 were completed and he was ready to give the medications. He stated, he Desvenlafaxine ER 100 was allowed to be crushed, he stated the resident has to have all medications either crushed or capsules opened. When he was asked by surveyor if crushing the medication could affect the medication time release, he stated unsure and proceeded to give the medication. In an interview with LVN-B on 3/13/2025 at 1:18 PM, she stated, the policy was to administer medications exactly as the order was written and that was important to maintain patient safety. She stated that administering a fluid tablet incorrectly could cause a resident to have fluid overload, electrolyte imbalances, or respiratory problems. She further stated that administering an anti-anxiety medication incorrectly could cause a resident to withdraw (socially) and refuse therapy. She stated it was standard practice not to crush extended-release medications and that it could cause the resident to get medications release too fast and have burning. She stated the dose would be changed if crushed. In an interview with DON on 3/13/25 at 1:44 PM, she stated the policy for is that when a nurse receives an order, she is to put them in the computer and follow the order. She said changing an order must be clarified with a physician. She stated it was important to follow doctor's orders exactly to prevent medication errors, prevent harm to the resident and so the medication could fix what it was intended for. She stated that administering a fluid tablet incorrectly could cause a resident to retain fluid and could cause a hospitalization . She further stated that administering an anti-anxiety medication incorrectly could cause a resident emotional harm or could cause them to harm themselves or others. She stated it was standard practice not to crush extended-release medications, but an alternative medication should be obtained for the resident if required. In an interview with the ADM on 3/13/25 at 1:28 PM, he stated the policy was to follow physician's orders exactly to administer medication as indicated on the Medication Administration Record. He stated this was important because the physician was the person overseeing the clinical care of the resident and if the order was not followed, the medication wouldn't have the intended effect on the resident. He stated the resident's health outcome could be changed and an example if a fluid pill was not given correctly, was that a resident could have fluid retention. Interview attempted with RPH (Pharmacy Rep) on 3/13/25 at 2:05 PM. A message was left but no return call received. A record review of the facility policy titled, Nursing Policy and Procedure-Medication Administration dated 10-2020 reflected the following: It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. If it is safe to do so, medication tablets may be crushed. Record review of manufacture package insert for Desvenlafaxine-Extended-Release tablets reflected the following: Take tablets whole; do not divide, crush, chew, or dissolve.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 1 medication rooms reviewed for medication storage. The facility failed to ensure expired medications were removed from the over-the-counter medication supply cabinet in the medication storage room. This failure placed residents at risk of not receiving the intended therapeutic effects of their medications. Findings included: An observation on 01/30/24 at 12:35 PM, revealed five bottles of Saccharomyces Boulardii Probiotics (a nutritional supplement used for gut health), with an expiration date of 12/23, in the cabinet of the medication storage room. During an interview on 01/30/24 at 12:35 PM, the DON stated, MRD was just there the other day, and she cleared all the expired medication. When the medication was found, she was shocked as she stated the MRD supposedly had pulled all the expired medications. After all other medications were checked, that appeared to be the only medication that was expired in the med room. During an interview on 01/31/24 at 08:10 AM, RN A stated the MRD was responsible for ordering and stocking the OTC medications in the med room. She stated the MRD checked expiration dates on the medication bottles. She stated the pharmacist is responsible for getting in the electronic medications that has expired. She stated it is the nurse's responsibility to check the expiration date when they take a bottle of medication from the medication room. She stated the nurses were responsible for monitoring the prescription medications that were stored in the medication room. She stated whoever is using the med cart is responsible for getting rid of the expired medications. She stated she checks them herself. She stated the additives in expired medications could cause adverse reactions. She stated expired meds could not be potent or have no effect, or they could be too strong. She stated residents may not get the desired effectiveness from expired medications. During an interview on 01/31/24 at 08:36 AM, the DON stated, the MRD was responsible for ordering over-the counter-medications. She stated the MRD rotated the stock and checked expiration dates routinely. She stated the pharmacy consultant was in monthly and completed checks of the medication room and medication carts. She stated if the meds are expired or DC, they put the meds in a box. The DC control meds are placed in a lock box in her office and when the pharmacist come in, they destroy them together. She stated there should not have any expired medication in the med room. The nurses are responsible for meds in the fridge. She stated ultimately the nursing staff was responsible for checking expiration dates on all medications. She stated the ADON does a spot check randomly. She stated expired medications may have lost their effectiveness and the resident may not receive the therapeutic benefits of the medication, the medication can be too strong, and the medication can have a reverse reaction, and the resident can die. The DON stated having expired medication in the cabinet did not meet her expectations. Record review of the facility policy titled, Medication Storage - in the Home dated 10/20, reflected in part, It is the policy of this home that medications will be stored appropriately as to be secure from tampering, exposure, or misuse . 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of per procedures for medications destruction, and reordered from the pharmacy, if a current order exists.

Based on observation, interview and record review the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 7 of 19 residents (Residents #1, #6, #11, #16 #17, #18, and #19). The facility failed to ensure each resident's Comprehensive Care Plan reflected individualized, appropriate interventions to prevent falls although the Residents had a history of [REDACTED]. This deficient practice placed 14 residents at risk of not having their individualized needs met and appropriate interventions put in place to prevent accidents including accidents with injuries. The findings included: Resident #1 Review of Resident #1's admission Face Sheet indicated she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the hospital Admission History and Physical dated 01/01/14 indicated the resident had been admitted to the hospital with [REDACTED]. Review of Resident #1's Fall Risk Evaluation dated 01/16/14 indicated a score of 22. (A resident who scores 10 or higher is at high risk for falls.) No other Fall Risk Evaluations were found in the resident's clinical record. Review of Resident #1's quarterly MDS assessment dated [DATE] indicated her cognition was moderately impaired. She required extensive assistance of two people for transfers. She was not ambulatory. She required extensive assistance of one person for bathing and dressing. She was incontinent of bladder. She was receiving Physical and Occupational Therapy. Review of the consolidated Physician order [REDACTED].#1 [MEDICATION NAME](a sleep medication) 5mg every night at bedtime. The order originated on 02/13/14. Review of the physician orders [REDACTED].#1 included the following: 01/07/14 - an order for [REDACTED]. 01/13 /14 - an order for [REDACTED]. 03/03/14 - discontinue bed and chair alarms per policy for no fall for over 30 days 03/04/14 at 8:00 p.m. - Resident was found on the floor in her room near the bathroom. She had a red mark in her right cheek approximately 2.0 inches x 1.5 inches. Resident Condition at Time of Incident included tranquilizer/sedatives taken in the last 8 hours, fall history, inability to understand directions, fracture, and confusion/disorientation. 03/14/14 at 8:45 p.m. - Resident was found sitting on the floor beside her bed. She said she got up to go to the bathroom. She had a skin tear on her left hand 6.0 cm long, and a skin tear on her left forearm 11 cm long. The Resident Condition at Time of Incident was not filled out. 03/21/14 - discharge home with home health and a bedside commode 03/24/14 at 9:00 p.m. - Resident was found sitting on the floor between the foot of her bed and the closet door. She said she was putting her shoes in the closet and fell when she turned around to walk back to the bed. No injuries were noted. Resident Condition at Time of Incident included [MEDICATION NAME] taken during last 8 hours, tranquilizer/sedatives taken in the last 8 hours, fall history, and confusion/disorientation. 03/25/14 @ 5:30 a.m. - send to ER status [REDACTED]. Review of the radiology report from the hospital dated 03/25/14 indicated a CT of the pelvis revealed a nondisplaced [MEDICAL CONDITION] inferior pubic ramus, and the suggestion of a nondisplaced fracture involving the proximal aspect of the left superior pubic ramus. The report also indicated Resident #1 had osteopenia (loss of bone density). 03/31/14 - discontinue fall mat 05/10/14 at 9:25 p.m. - Called to the room by Resident's roommate. Resident was sitting on the floor beside her bed. Resident Condition at Time of Incident included [MEDICATION NAME]/narcotics taken during last 8 hours, tranquilizer/sedatives taken in the last 8 hours, fall history, inability to understand directions, arthritis/[MEDICAL CONDITION], and sensory limitations. 05/31/14 at 6:30 a.m. - CNA reported resident was yelling. Resident was found sitting on the floor. She said she had on her socks and was walking to the restroom and slipped and fell . Resident Condition at Time of Incident included fall history, confusion/disorientation, and incontinence. Review of a Physical Therapy Evaluation and Plan of Treatment indicated a start of care date of 04/17/14. The Assessment Summary contained Clinical Impressions that the patient had progressed well with rehabilitation after an upper extremity fracture, but had a fall resulting in a pelvic fracture and significant decline now with decreased upright mobility skills. Review of Resident #1's care plans included a care plan addressing risk of injury related to falls dated 01/21/14. Approaches included rule out medical complication with increased falls, and fall assessment on admission, quarterly, and with changes or falls. Falls were listed on the care plan for 02/03/13, 03/04/14, 03/14/14, and 03/24/14. It was noted that the resident was sent to theER on [DATE] and returned to the facility with a [DIAGNOSES REDACTED]. There were no updates listed on the care plan regarding approaches to reduce Resident #1's fall risks. In an interview with the DON on 06/18/14 at 2:30 p.m. he said he could not find any care plan updates on Resident #1 regarding her falls. He said she was ready to go home when the order was written on 03/21/14 for her to be discharged home with home health. He said he thought he remembered that a transportation problem was the reason she did not go home at that time. Then she fell on the 03/24/14 and fractured her pelvis. In an interview on 06/18/14 at 3:15 p.m. with the RNC she said the corporation was in the process of becoming alarm free. She said statistics show that alarms do not prevent falls. In a subsequent interview on 06/20/14 at 10:25 a.m. the RNC said the facility had no policy and procedure for eliminating the use of alarms. She said it was a spoken recommendation by the corporation. Resident #19 Review of Resident #19's admission Face Sheet indicated he was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Admission (MDS) data set [DATE] indicated Resident #19 was 6'1" tall and weighed 223 pounds. He was oriented to person and place only. He had poor short term and long term memory. Review of the Fall Risk (MDS) data set [DATE] indicated a total score of 10. (Score of 7 - 18 indicates resident is high risk.) Review of the consolidated Physician order [REDACTED]. There was also an order [REDACTED].) He was also receiving [MEDICATION NAME], anticoagulant used to prevent blood clots, which can cause abnormal bruising and bleeding. On 06/19/14 at 2:40 p.m. a staff member was heard calling "Help! Bring the Hoyer lift!" Staff members responded to the room. Resident #19 was observed lying prone on the floor on the left side of his bed. He had an [DEVICE] (a system of pins or screws placed into the bone on both sides of a fracture and secured together outside the skin with clamps and rods) on his right lower leg. LVN K asked Resident #19 what he was doing when he fell out of bed. She said this was the second time in 30 minutes that the resident had fallen out of bed. Resident #19 was mumbling and difficult to understand. It was finally understood that he wanted a wash cloth. After he was assessed by LVN L a sling was placed under him and five staff members used a Hoyer lift to transfer him back to bed. He was reminded to use his call light if he needed something and not to try to get out of bed without assistance. The right side of the bed was against the wall and had an enabler bar near the head of the bed. The left side of the bed had no enabler bar. There was no fall mat on the floor beside the bed to cushion the resident's fall. The bed was approximately 2 ? to 3 feet high. Review of the Resident Incident Report dated 06/19/14 at 2:05 p.m. indicated a CNA reported Resident #19 was on the floor. He was assisted back to bed by 5 staff members. He complained of pain and an [MEDICATION NAME] was administered. The bed was in the low position and he was reminded to use the call light. Review of Departmental Notes by LVN L dated 06/19/14 at 2:05 p.m. indicated she gave Resident #19 [MEDICATION NAME] for pain. Review of the Resident Incident Report dated 06/19/14 at 2:41 p.m. indicated Resident #19 was found on the bare floor in the prone position. He had a superficial skin tear to his left wrist and an abrasion to his left knee. He was alert and oriented to person only. External rotation of the right ankle and increased swelling to the right foot was noted. He was exhibiting symptoms of DTs, sweating, tremors, incoherence and altered mental status. He was sent to the ER for evaluation due to recurring falls, DTs, confusion and pain to the fractured right ankle. On 06/20/14 at 9:35 a.m. Resident #19 was observed in bed. The right side of the bed was against the wall and had an enabler bar near the head of the bed. The left side of the bed had no enabler bar. There was no fall mat on the floor beside the bed to cushion the resident's fall. The bed was approximately 2 ? to 3 feet high. In an interview with the DON on 06/20/14 at 10:00 a.m. he said he could not remember what fall prevention measures were discussed in the stand-up meeting that morning for Resident #19. He said the administrator took notes. In an interview with the administrator, RNC, and the RD on 06/20/14 at 10:10 a.m. the administrator said they had discussed maybe getting a hospice bed for Resident #19. He acknowledged that no interventions had been put in place except for medication adjustments made by the physician. The RNC said she would have a fall mat put beside the resident's bed immediately. On 06/20/14 at 4:30 p.m. Resident #19 was observed on a low bed, approximately 1 ? feet high with a thick fall mat on the floor next to the bed. The bed had ? side rails on both sides. Resident #6 Review of the admission Face Sheet in Resident #6's clinical record indicated he was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] indicated Resident #6 had moderately impaired cognition, meaning his decisions were poor and required reminders, cues, and supervision. He required extensive assistance of one person to transfer. He was not ambulatory. He used a wheelchair. Review of the Fall Risk Evaluation form indicated the last fall risk assessment was done on 10/21/13. The fall risk score was 14. (A score of 10 or above indicates high risk for falls.) No interventions were listed on the back of the form. Review of Resident Incident Reports involving Resident #6 indicated he fell on [DATE] at 10:25 a.m. He was heard yelling for help from his room. He was found sitting on the floor between his wheelchair and his bed. He said he was trying to get in bed and missed, and sat on the floor. He had no apparent injury. On 06/03/14 at 12:50 p.m. he was found sitting on the floor between his wheelchair and the dresser. He said he was on his way to the bathroom and slid out of the wheelchair. He had no apparent injury. Review of Resident #6's Care Plan included a problem of risk for injury related to falls dated 04/09/14. The approaches listed included rule out medical complication with increased falls, notify the MD and family, periodic medication reviews and to provide a safe environment free of clutter. The approach also lists for the Resident to be transferred with assist of one staff and have a fall assessment on admission, quarterly, and with changes or falls. No updates were listed on the Care Plan for the falls the resident experienced on 05/19/14 and 06/03/14. In an interview with the DON on 06/18/14 at 11:40 a.m. he said he could not find any fall risk evaluation for Resident #6 after 10/21/13, either in his clinical chart or in his electronic record. The DON said he recalled that Resident #6 had fallen recently. Resident #16 Resident #16 was observed multiple times during the survey. He had a scab and bruising on his forehead and had bruising around his eyes and down both cheeks. Review of Resident #16's admission Face Sheet indicated he was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Fall Risk (MDS) data set [DATE] indicated a total score of 9. (Score of 7 - 18 indicates resident is high risk.) Review of Resident #16's 30-day MDS assessment dated [DATE] indicated he had moderate cognitive impairment. He required extensive assistance of 2 people for transfers, dressing and hygiene. It was documented that he had not had any falls. Review of Resident Incident Reports involving Resident #16 included the following: 04/17/14 at 1:15 a.m. - CNA reported resident was on the floor beside his bed. He said he was trying to get up to go outside. He sustained a skin tear to his left hand measuring 1.5 cm x 0.5 cm. 04/23/14 at 9:30 a.m. - CNA reported resident on the floor. He had previously been in bed. He sustained a skin tear to his left arm measuring 1 cm x 2 cm. 04/23/14 at 9:26 p.m. - Resident was heard yelling for help from his room. He was found with his legs hanging off the bed and he was holding onto the nightstand and sliding down to the floor. Staff lowered him to the floor. He sustained a skin tear to his left knee measuring 1.5 cm x 1.5 cm. 05/04/14 at 5:46 a.m. - CNA found resident lying on his back on the floor beside his bed. The resident was transferred to his wheelchair using a Hoyer lift. He sustained no injury. 06/04/14 at 10:56 p.m. - CNA heard resident yelling for help. He was found on the floor, face down, next to the bed. He said he was trying to reach over and use the bathroom. He sustained a hematoma to the left forehead with a 3.5 cm x 0.3 cm laceration. 06/05/14 at 5:50 a.m. - Resident was yelling for help. He was found on his hands and knees beside his bed. He said he fell out of bed. He sustained a skin tear to his left upper arm measuring 1.7 cm x 1.0 cm. Review of the Departmental Notes dated 06/05/14 indicated the EMS was called to transport Resident #16 to the ER for evaluation. Further review of the clinical record included hospital Patient Care Instructions dated 06/05/14 at 8:39 a.m. to continue home medications, fall precautions, and to follow up with doctor next week. Review of the Care Plan for Resident #16 indicated he was at risk of injury related to falls. Approaches included to transfer with a Hoyer lift and assistancance of two staff, and to conduct fall assessments on admission, quarterly, and with changes or falls. The Care Plan was not updated until 06/18/14 after the issue was brought to the facility's attention by the surveyors. Resident #17 Review of Resident #17's Admission Face Sheet indicated the [AGE] year old female resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #17's admission Minimum (MDS) data set [DATE] indicated the following; Resident #17 was identified as requiring extensive assistance of one to two staff members for all activities of daily living. Resident #17's balance was identified as: Not steady, only able to stabilize with staff assistance. Resident #17 was identified as occasionally incontinent of bowel and bladder. The resident was 60 inches tall and weighed 277 lbs. Review of Resident #17's Care Plan dated 3/27/14 indicated the following; Problem: General Weakness - At risk for falls/injuries from falls. Goal: Will transfer safely to and from all surfaces. Review by next 90 days. Approaches: Notify the physician and family of falls or injuries when needs. Periodic medication review. Ensure safe environment, free of clutter, adequate lighting, clean spills promptly. Fall assessment on admission, quarterly and with any changes or falls. Ensure proper footwear when out of bed. Call bell in reach. Wheelchair/walker within reach. PT to evaluate as indicated. Review of a Resident Incident Report dated 5/03/14 at 6:01 a.m. indicated the following; Found on floor: Reported by CNA that resident was on the floor. Resident alert and oriented sitting next to the bed with 2 abrasions (1.2 cm X 1 cm and 2.3 cm X 2 cm) noted to her left lower extremities. The resident stated she was trying to go to the bathroom and slid onto the floor. Medical risk factors possibly related to incident: fall history, inability to understand others and confusion/disorientation. Review of a Resident Incident Report dated 5/06/14 at 3:00 p.m. indicated the following; Found on floor: Resident was heard yelling, when the nurse went to check on the resident, the resident was noted to be sitting on the floor next to her wheelchair facing the bed. When the resident was asked what had happened, she stated she had got up to get a plastic thing to go pick up berries and raisins and sat on her butt. Resident assisted to bed with a hoyer lift. No apparent injuries after head to toe assessment. Has multiple bruises on back and right hip, but had a fall three days ago. Medical risk factors possibly related to incident: fall history. Review of a Resident Incident Report dated 5/16/14 at 5:11 a.m. indicated the following; Fall/no head injury. Resident stated she was trying to get water on her bedside table. She fell and hit her right leg and right axilla on the bedside table. Right axilla had a large amount of bruising and redness to the area. Abrasions are superficial. Right lower leg anterior shin has pinpointed superficial abrasion. Right lateral thigh has two pinpoint superficial abrasions. Medical risk factors possibly related to incident: fall history, confusion/disorientation, incontinency, and bowel and bladder urgency. Review of a Resident Incident Report dated 5/17/14 at 3:30 p.m. indicated the following; Fall/unobserved. Called to room by CNA. Resident was on the floor in supine position with feet straddling the toilet and head below the sink. Vital signs checked and stable. Range of motion performed with no complaint of pain. Resident assisted up by hoyer lift. Resident was able to take steps into the bathroom. Medical risk factors possibly related to incident: fall history, confusion/disorientation, and incontinency. Review of a Resident Incident Report dated 6/10/14 at 10:40 a.m. indicated the following; Fall/no head injury. CNA notified the nurse that resident was sitting on the floor in her room. Upon entering the room, the resident was noted to be sitting on the floor leaning against the bed. Resident had previously been in the bed. Upon head to toe assessment no injuries were noted. No complaints of pain. No head injury. Assisted the resident into the bed per 3 staff members and hoyer lift. Medical risk factors possibly related to incident: fall history and incontinency. Review of a Resident Incident Report dated 6/10/14 at 3:45 p.m. indicated the following; Fall with head injury. CNA reported that resident was on the floor. Resident found lying on the floor on her back with her head against the bathroom door and wheelchair in front of her legs. The resident stated she had been trying to put her pants on. The resident had a hematoma with a 1 cm X 0.2 cm laceration. Medical risk factors possibly related to incident: fall history, inability to understand others, confusion/disorientation and incontinency. During an observation on 6/17/14 at 3:30 p.m. Resident #17 was observed resting in her bed with her eyes closed. The call light was observed within reach. The resident ' s bed was observed to be at a normal level with no side rails and/or enablers in place. Review of Resident #17's Care Plan dated 6/18/14 indicated the following; Problem: General Weakness - At risk for falls/injuries from falls. Goal: Will transfer safely to and from all surfaces. Review by next 90 days. Approaches: Notify the physician and family of falls or injuries when needs. Periodic medication review. Ensure safe environment, free of clutter, adequate lighting, and clean spills promptly. Fall assessment on admission, quarterly and with any changes or falls. Ensure proper footwear when out of bed. Call bell in reach. Wheelchair/walker within reach. PT to evaluate as indicated. The following updates were implemented on 6/18/14: Ensure the resident is dressed the way she wants to dress per the resident statement on 6/10/14 that she was trying to put her pants on. Frequently offer bathroom privileges with rounds, do not leave the resident on the toilet unattended. Offer water on rounds. Offer activities to engage resident related to fall on 5/06/14 when resident was going to pick up berries with a plastic bucket. Monitor oxygen saturation level and labs per physician orders. There had not been any update or changes made to the resident's care plan related to falls until 06/18/14 despite the resident falling on 05/03/14, 05/06/14, 05/16/14, 05/17/14, and 06/10/14 (2 falls on this date). Review of Resident #17's Fall Risk (MDS) data set [DATE] indicated the resident was identified with a score of 9 which indicated the resident was High Risk for falls. Resident #18 Record review of Resident #18's Admission face sheet dated 4/28/14 indicated he was admitted to the facility on [DATE] and re-admitted on [DATE]. He was admitted with the following diagnoses; [MEDICAL CONDITION], hypertension, coronary [MEDICAL CONDITIONS], cardiac pacemaker, [MEDICAL CONDITION], chronic [MEDICAL CONDITION] and [MEDICAL CONDITION] reflux. The Resident was 87 at the time of survey. Record review of the facility incident and accident log dated 6/16/14 indicated Resident #18 had six (6) falls (05/02/14, 05/03/14, 05/06/14/ 05/07/14 and 06/08/14). Record review of the 30 day MDS dated [DATE] indicated the Resident had a BIMS score of 9 out of 15 indicating he had moderate impaired cognition. He had disorganized thinking and difficulty focusing listed as present and fluctuating. His functional status indicated he needed extensive assistance with two staff assist with bed mobility, transfers, dressing and toileting. He was totally dependent on one staff for his bathing. The Resident had urine retention and was catheterized; he was frequently incontinent of his bowel. He used a wheelchair for mobility. Review of the fall risk (MDS) data set [DATE] indicated the Resident fall risk score was 13 indicating the resident was at high risk for falls. Review of the resident's clinical record indicated fall risks assessments were done on 5/6/14 with a score of 13, 5/7/13 with a score of 10 and 6/8/14 with a score of 10. There was no fall risk assessment completed after the falls on 05/02/14, 05/03/14, or 05/14/14. Review of the care plan dated 5/1/14 the problem onset listed risk for injury related to falls due to a history of falls, weakness and altered mental status. The approach were to notify MD and family of falls, rule out medical complications [REDACTED]. There was a handwritten insert on the care plan noting falls but no changes or interventions related to the falls on May 2, 3, 6, 8, 14, and June 8, 2014. There was one undated approach handwritten noting ? side rails to bed for positioning and wheelchair with anti-tip. Record review of physician orders [REDACTED].? side rails were ordered for the Resident's bed to aid in bed mobility also anti-tips for the wheelchair for resident's safety. There were no further updates or notes indicating safety precautions that addressed the Resident's risk for falls. On 06/20/14 at 4:00 p.m. Resident #18 was observed on a low bed with ? side rails on both sides. The Resident was napping and refused to be interviewed. During an interview on 6/19/14 at 4:00 p.m. Resident #18's responsible party said she was the one who asked the facility to provide side rails for the resident to help prevent falls. The facility complied and the side rails were placed on the bed on 5/23/14. Resident #11 Review of the closed record of Resident # 11's MDS dated [DATE] indicated the [AGE] year old female was admitted to the facility on [DATE] with the following diagnoses; anxiety disorder, [MEDICAL CONDITION], dysphagia, coronary [MEDICAL CONDITIONS], reflux, hypertension and [MEDICAL CONDITION]. The Resident's speech was slurred; she is sometimes understood, and sometime understands. Her BIMS score was 3 out of 15, indicating severe impaired cognition. Her functional levels indicated she needed extensive assistance with two person physical assist for transfers. She required extensive assistance with one staff for her eating and hygiene needs. The Resident was totally dependent for staff assistance for locomotion on and off the unit. She was frequently incontinent of bowel and bladder and required a wheelchair for mobility. Review of Resident #11's closed clinical records indicated prior to her admission to the skilled nursing facility she was living in an assisted living facility. She was hospitalized for [REDACTED]. She was discharged back to the assisted living facility on 6/3/14. Review of the facility incident and accident reports from 3/17/14 until 6/15/14 indicated Resident #11 fell four (4) times during her stay. The falls are listed below; 1) 4/23/14 at 10:11 a.m. fell in room; no injury (unwitnessed) 2) 4/23/14 at 4:36 p.m. found on floor face down on floor in front of wheelchair sent to ER which she required sutures(unwitnessed) 3) 5/1/14 at 1:37 a.m. found on floor next to bed said she slid out of bed no injury (unwitnessed) 4) 5/11/14 at 10:30 a.m. scooted self out of recliner and slid onto floor no injury (unwitnessed) Review of the nursing care plans dated 5/1/14 indicated the resident had a history of [REDACTED]. The approach listed are to rule out medical complication with increased falls, notify the MD and family, periodic medication reviews and to provide a safe environment free of clutter. The approach also lists for the Resident to be transferred with assist of one staff and have a fall assessment on admission and with changes or falls. The care plans dated 5/1/14 did not indicate any of the falls listed above and did not address any new interventions or changes needed to provide further safety to Resident #11 who continued to fall. Review of the Resident's clinical closed record indicated that an initial fall assessment was not done on Resident #11 upon admission. A fall assessment was not completed by the facility after the 4/23/14 fall. Review of all of the Resident's incident and accident reports only indicated the facility did a fall assessment on 5/4/14 and 5/11/14. The Resident had four documented falls and only two fall assessments completed. During an interview on 5/19/14 at 3:20 p.m. RNC said she could not find where an admission fall risk assessment had been completed on Resident #11 and she did not know why the care plans were not updated after each fall. RNC said changes were made after Resident #11 ' s fall in which the doctor had decreased her [MEDICATION NAME] and discontinued her [MEDICATION NAME]. However these were the only changes made after the Resident fell on [DATE]. No further fall precautions or safety interventions were implemented. An undated algorithm titled Fall Prevention was received from the RNC on 06/18/14 at 9:30 a.m. She said this was the procedure the facility should have been following: * Resident is admitted to the Center; * Residents admission assessment is completed including fall risk assessment. Interventions to prevent serious injury with falls are implemented and noted on the resident's fall prevention plan of care; * Resident experiences a fall; * The assigned nurse assesses the resident and completes an Accident and Incident report and Investigation. The cause of the fall is identified and appropriate interventions are implemented to prevent further falls and seriious injury...; * The IDT reviews A&I reports during daily QA metting for recommendations; * The DON or designaed nurse manager will review the A&I as well as Investigation to assure that the Investigation is complete and appropriate interventions are in place. The DON or disignated Nurse Manager will complete within 72 hours the CAA worksheet ot assure all risk factors and changes to risk factors are addessed in the resident's plan of care; * Results of the investigation are reviewed with the IDT fall committee during weekly fall committee QA... The resident's plan of care will be updated as needed. According to CMS 802, Roster Sample Matrix, provided by the facility on 06/16/14, 14 residents were listed as having had falls.

Based on observation, interview and record review the facility failed to provide 8 of 19 sampled residents (Resident #s 1, 2, 6, 11, 16, 17, 18, and 19) with the necessary supervision and assistive devices to prevent falls. a) Resident #1 fell on [DATE], 03/14/14 and 03/24/14. The fall on 03/24/14 resulted in a pelvic fracture. The resident fell again on 05/10/14 and 05/31/14. The facility did not perform fall risk assessments following falls, develop and implement care plans for falls, or revise interventions after falls to prevent further falls. b) Resident #2 fell out of a hoyer lift while being transferred by CNA A who had not requested assistance of another staff member per the facility policy. with subsequent bruising and pain, c) Resident #19 was admitted to the facility on [DATE] with a fracture of the tibia and fibula and had [DEVICE]s in place. He was at high risk for falls. He was also experiencing DTs and was oriented to person only. He had been in the facility less than 24 hours and fell out of bed twice in 30 minutes. No interventions were initiated until identified during the survey. d) Resident #s 6, 11, 16, 17 and 18 had multiple falls. The facility did not perform fall risk assessments following falls, develop and implement care plans for falls, or revise interventions after falls to prevent further falls. This deficient practice placed 6 residents who required use of a hoyer lift with transfers, and 14 residents who had fallen at risk for additional falls with injuries. Findings include: Resident #1 Review of Resident #1's admission Face Sheet indicated she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the hospital Admission History and Physical dated 01/01/14 indicated the resident had been admitted to the hospital with [REDACTED]. Review of Resident #1's Fall Risk Evaluation dated 01/16/14 indicated a score of 22. (A resident who scores 10 or higher is at high risk for falls.) No other Fall Risk Evaluations were found in the resident's clinical record. Review of Resident #1's quarterly MDS assessment dated [DATE] indicated her cognition was moderately impaired. She required extensive assistance of two people for transfers. She was not ambulatory. She required extensive assistance of one person for bathing and dressing. She was incontinent of bladder. She was receiving Physical and Occupational Therapy. Review of the consolidated Physician order [REDACTED].#1 received Ambien (a sleep medication) 5mg every night at bedtime. The order originated on 02/13/14. Review of the physician orders [REDACTED].#1 included the following: 01/07/14 - an order for [REDACTED]. 01/13 /14 - an order for [REDACTED]. 03/03/14 - discontinue bed and chair alarms per policy for no fall for over 30 days 03/04/14 at 8:00 p.m. - Resident was found on the floor in her room near the bathroom. She had a red mark in her right cheek approximately 2.0 inches x 1.5 inches. Resident Condition at Time of Incident included tranquilizer/sedatives taken in the last 8 hours, fall history, inability to understand directions, fracture, and confusion/disorientation. 03/14/14 at 8:45 p.m. - Resident was found sitting on the floor beside her bed. She said she got up to go to the bathroom. She had a skin tear on her left hand 6.0 cm long, and a skin tear on her left forearm 11 cm long. The Resident Condition at Time of Incident was not filled out. 03/21/14 - discharge home with home health and a bedside commode 03/24/14 at 9:00 p.m. - Resident was found sitting on the floor between the foot of her bed and the closet door. She said she was putting her shoes in the closet and fell when she turned around to walk back to the bed. No injuries were noted. Resident Condition at Time of Incident included hydroxyzine (an antihistimine that may cause sedation) taken during last 8 hours, tranquilizer/sedatives taken in the last 8 hours, fall history, and confusion/disorientation. 03/25/14 @ 5:30 a.m. - send to ER status [REDACTED]. Review of the radiology report from the hospital dated 03/25/14 indicated a CT of the pelvis revealed a nondisplaced fracture of the left inferior pubic ramus, and the suggestion of a nondisplaced fracture involving the proximal aspect of the left superior pubic ramus. The report also indicated Resident #1 had osteopenia (loss of bone density). 03/31/14 - discontinue fall mat 05/10/14 at 9:25 p.m. - Called to the room by Resident's roommate. Resident was sitting on the floor beside her bed. Resident Condition at Time of Incident included analgesics/narcotics taken during last 8 hours, tranquilizer/sedatives taken in the last 8 hours, fall history, inability to understand directions, arthritis/osteoporosis, and sensory limitations. 05/31/14 at 6:30 a.m. - CNA reported resident was yelling. Resident was found sitting on the floor. She said she had on her socks and was walking to the restroom and slipped and fell . Resident Condition at Time of Incident included fall history, confusion/disorientation, and incontinence. Review of Resident #1's care plans included a care plan addressing risk of injury related to falls dated 01/21/14. Approaches included rule out medical complication with increased falls, and fall assessment on admission, quarterly, and with changes or falls. Falls were listed on the care plan for 02/03/13, 03/04/14, 03/14/14, and 03/24/14. It was noted that the resident was sent to theER on [DATE] and returned to the facility with a [DIAGNOSES REDACTED]. There were no updates listed on the care plan regarding approaches to reduce Resident #1's fall risks. In an interview with the DON on 06/18/14 at 2:30 p.m. he said he could not find any care plan updates on Resident #1 regarding her falls. He said she was ready to go home when the order was written on 03/21/14 for her to be discharged home with home health. He said he thought he remembered that a transportation problem was the reason she did not go home at that time. Then she fell on the 03/24/14 and fractured her pelvis. Review of a Physical Therapy Evaluation and Plan of Treatment indicated a start of care date of 04/17/14. The Assessment Summary contained Clinical Impressions that the patient had progressed well with rehabilitation after an upper extremity fracture, but had a fall resulting in a pelvic fracture and significant decline now with decreased upright mobility skills. In an interview on 06/18/14 at 3:15 p.m. with the RNC she said the corporation was in the process of becoming alarm free. She said statistics show that alarms do not prevent falls. In a subsequent interview on 06/20/14 at 10:25 a.m. the RNC said the facility had no policy and procedure for eliminating the use of alarms. She said it was a spoken recommendation by the corporation. Resident #2 Review of Resident #2's Admission Face Sheet indicated the [AGE] year old female resident was readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's consolidated Physician order [REDACTED]. Review of Resident #2's annual Minimum (MDS) data set [DATE] indicated the following: The resident was identified with a BIMS score of 12, indicating she had moderate cognitive impairment. The resident was identified as requiring extensive assistance of two staff for most activities of daily living. The resident was identified with lower extremity impairment on both sides. Balance: surface to surface transfers indicated the resident was; Not steady, only able to stabilize with staff assistance. The resident's fall history was left blank. Review of Resident #2's comprehensive Care Plan dated 4/03/14 indicated the following; Problem: At risk for falls. Goals: Resident will have no significant injury related to falls. Approaches: Ensure the call light is within reach and answered promptly. Encourage resident to await assistance. Notify MD and family of falls or injuries when needed. Periodic medication review. Rule out medical complications [REDACTED]. Utilize non-skid footwear. Therapy services; OT for upper body strengthening and PT for lower body strengthening. Review of Resident #2's comprehensive Care plan indicated no identified problems, goals and/or approaches related to the resident requiring hoyer lift transfers. Review of an Incident and Accident Report dated 6/15/14 at 5:00p.m.; indicated the following, CNA A came to the nursing station and informed the nurse (LVN B), she needed help with Resident #2 as the resident was on the floor. CNA A stated during a hoyer lift transfer, the hoyer lift had tilted and pulled the resident out of the wheelchair, throwing her to the floor onto her back. Upon entering the room, Resident #2 was found lying on her back with the sling from the hoyer lift under her. The resident was lying partially on the hoyer lift base bar. The resident had no visible injuries with the exception of a small red area to the residents mid back, however the resident complained of pain to the rib area all the way across her back to included lumber and cervical spine. The resident stated she had " smacked her head also " . No injuries found. Incident reported to the DON and physician. Orders received for STAT X-rays. Review of Resident #2's Fall Risk (MDS) data set [DATE] at 7:17 p.m. indicated the resident had been identified with mild to moderate cognitive impairment, stable general health, maximum assist with transfers, non-weight bearing, appliances used: wheelchair, vision: wears glasses, incontinence: daily, and Medications; Antihypertensive, Psychotropic, diuretic, anticonvulsant: receives two or more. The resident's total score was 13 which indicated high risk for falls. Review of Resident #2's Nursing Note dated 6/15/14 at 7:22 p.m. indicated the following; --At 5:00 p.m. CNA A came to the nursing station to notify this nurse she needed help in the residents room, as the resident was being transferred via the hoyer lift, the lift had tilted causing the resident to fall to the floor. The resident was found lying in the floor on her back which was partially lying on the hoyer base bars. The resident was moaning and complaining that her back and ribs hurt. The resident was asked if she hit her head and had responded " Yes, I smacked my head on the floor. "Upon assessment the resident was found to have a small red area to her mid back and slight discoloration to the right rib area. The resident was grabbing her head and complaining of her back. The resident stated her pain was at a 10 on a scale of 1-10. The resident was assisted up to the bed with 5 person assist using the sling and careful movements. The resident was positioned comfortably. Vital signs were temperature-97.6, blood pressure-131/93, pulse-113 and respirations-24. Neurological checks were initiated. Message left for Resident #2's physician. --At 5:30 p.m. Resident #2's physician called and orders were received for STAT x-rays of all concerned areas. The resident was given Tramadol 50 mg (2) for pain. The DON was notified of the incident. Mobile X-ray ordered and confirmed. Review of a hospital X-ray/CT report dated 6/15/14 at 10:52 p.m. indicated; No acute traumatic injury identified. No cervical spine fracture. No intracranial hemorrhage. Review of the initial Provider Investigation Report dated 6/16/14 at 7:20 a.m. indicated on 6/15/14 at 5:00 p.m. Description of the Allegation: Resident was being transferred to her wheelchair and fell in her room requiring evaluation in the emergency room due to bruising to her chest and complaints of pain with Lumbar spine, ribs and back area. No deformities noted to the area. Description of Assessment: Resident was able to fell touch, move legs and hands, and responded to questions appropriately. Decision made to send the resident to the emergency room for evaluation due to mobile x-ray taking an extended amount of time to respond. Provider Response: Evaluation of report and statement revealed CNA A was not using the hoyer lift per protocol and was inserviced by LVN B at that time. Resident was evaluated at the emergency room and found to have no fractures per report. Resident #2 was returned to the facility. Investigation Summary: CNA A failed to follow the protocol for using a hoyer lift, the resident required evaluation outside of the facility. "I do not believe the CNA intended to harm the resident. " Provider Action Taken Post-Investigation: CNA A was inserviced by charge nurse and return demonstration was done before the CNA was allowed to work again, coaching session completed as well. The hoyer lift was inspected per maintenance. Signed by the DON. During an initial tour interview on 6/16/14 at 3:20 p.m. LVN C said there had been an incident on 6/15/14 involving Resident #2 being dropped from a hoyer lift. She said a CNA had been attempting to transfer the resident without the assistance of another CNA and the hoyer lift had tilted causing the residents wheelchair to flip over and throwing the resident on the floor. She said the resident had been sent to the emergency room and was found to have no fractures; however the resident had bruising from under her breast, around her side and on her back. LVN C said the resident had landed on one of the hoyer lift legs (base bar) and was lucky to have not fractured her ribs. LVN C said she was unaware of the reason for the CNA to be attempting to transfer Resident #2 with the hoyer lift without assistance. She said it was the facility's policy and procedure to have two staff members for all hoyer lift transfers. Review of Resident #2's Care Plan dated 6/17/14 indicated the following; Problem: At risk for falls. Goals: Resident will have no significant injury related to falls. Approaches: Previous approaches with the addition of; Use hoyer lift for transfers with 2 staff for safety. During an interview on 6/17/14 at 9:20 a.m. the DON said there had been an incident reported to him on 6/15/14, regarding Resident #2 falling from a hoyer lift. He said CNA A was transferring Resident #2 with a hoyer lift when the lift tilted and fell , pulling the resident to the floor. He said the physician was notified and orders were received for mobile x-ray; however the mobile x-ray unit was taking too long to get to the facility and the decision was made to send the resident to the emergency room . He said the resident had no identified fractures and had only suffered bruising. The DON said the CNA had on the spot inservicing from the charge nurse and he had performed formal inservicing of the CNA on 6/16/14. He said the facility policy and procedure indicated 2 staff to be present for all hoyer lifts, and CNA A had not followed the policy and procedure. During an interview on 6/17/14 at 11:58 a.m. the Administrator said the facility policy and procedure indicated 2 staff to be present for all hoyer lifts. He said the staff received inservice upon orientation and yearly regarding hoyer lift transfers. During an interview on 6/17/14 at 2:20 p.m. Resident #2 said when CNA A had informed her she was going to transfer her from her bed to the wheelchair; she had told the CNA that she needed to go get some help. She said CNA A informed her she knew what she was doing and did it all the time by herself. Resident #2 said "CNA A was a little bit full of herself, because I ended up on the floor with my wheelchair and the hoyer lift on top of me." Resident #2 said she thought she had broken her back and all of her ribs from the fall. Resident #2 said all of the other girls come in 2 at a time to assist with transferring her with the hoyer lift. During an interview on 6/17/14 at 3:37 p.m. the ADON said the CNA's did not have written CNA Care Plans for each resident. She said all of the resident care needs were prompted in the AccuNurse system; which specified areas of care such as incontinent care, lifts, transfers, etc. During a telephone interview on 6/17/14 at 4:12 p.m. LVN B said she had been the charge nurse on 6/15/14 at the time of Resident #2's incident. She said CNA A had reported to her that she had been transferring Resident #2 to her wheelchair and the hoyer lift had tilted resulting in the resident falling to the floor. She said CNA A had attempted to transfer Resident #2 with the hoyer lift without assistance of another staff member. She said CNA A knew she was supposed to have 2 staff members to use the hoyer lift to transfer a resident. LVN B said there were no problems with staffing that shift and the facility had a float CNA to assist when needed. She said none of the other staff was aware of CNA A being in Resident #2's room until after the incident. LVN B said she had immediately inserviced CNA A and had stressed the importance of 2 staff members being present for all hoyer lifts. During an interview on 6/17/14 at 4:22 p.m. LVN D said she was responsible for developing the resident's care plans. She said following a review of Resident #2's care plan, that there was no care plan which reflected any identified safety risks regarding a hoyer lift being used to assist Resident #2 with transferring. She said Resident #2 had required the use of a hoyer lift for transfers since her admission to the facility. She said the problem area of the resident being at risk for injury due to utilization of a hoyer lift must have dropped off the resident's care plan or been left out entirely. During a telephone interview on 6/17/14 at 4:25 p.m. CNA A said 6/15/14 had been a regular day. She said the facility was not short staffed and there had been a float CNA scheduled to assist with resident care. She said she had been getting the residents up for supper and had gone to Resident #2's room. She said she had not requested assistance from another CNA due to feeling "impatient" and "not wanting to go find help" . She said she had transferred Resident #2 from her bed to the wheelchair, had lowered the resident into the wheelchair and began to unhook the straps of the sling from the hoyer lift. She said she had unhooked one strap and the hoyer lift tilted, the wheelchair fell straight back to the floor. She said the resident fell on the hoyer lift base bar. She said the resident was moaning and groaning and stating she was hurting "really bad" . She said she pulled Resident #2 two to three inches in order to get her off of the base bar and placed a pillow under her neck prior to going to get the nurse. She said it was just a freak accident and she was very familiar with transferring Resident #2 with the hoyer lift. She said she was aware that 2 staff members needed to be present during hoyer lift transfers; however she had made a bad judgment and attempted to do it herself. She said she had not received any specific inservicing regarding hoyer lift transfers until the night of the incident, when LVN B had inserviced her. Review of Inservice Training Report dated 6/18/14 at 7:00 a.m. indicated the nurses, CNA's and CMA's had been inserviced on using the hoyer lift. The inservice indicated all residents that require a hoyer lift must have 2 CNA's (trained staff) to assist with no exceptions. During an observation on 6/18/14 at 10:40 a.m. CNA A, the DON, ADON and Administrator were present in an empty room. CNA A was asked to reenact the placement of the wheelchair and hoyer lift as they had been placed during the incident with Resident #2. CNA A was observed to place the wheelchair facing a north/south direction and place the wheelchair in an east/west direction with one of the hoyer base bars underneath the wheelchair near the front wheels. When asked why she positioned the wheelchair in the opposite direction of the hoyer lift, CNA A said it was easier for her to position the resident in the wheelchair by herself that way. She said she had lowered the resident down into her wheelchair and had taken one of the sling straps off the hoyer lift hooks. She said the hoyer lift had tilted and the wheelchair had flipped backwards with the resident coming to rest on the base bar of the lift. CNA A said she was not sure what had happened to cause the hoyer to tilt and the wheelchair to flip back. CNA A said she had unhooked only one of the sling straps, and the hoyer lift had only tilted not fallen to the floor. She said the sling was under the resident when she came to rest on the base bar of the lift. The DON and ADON said the positioning of the wheelchair and hoyer lift was not the way the staff head been taught to use the hoyer lift. The ADON said if the wheelchair is facing north/south then the hoyer lift needs to be facing north/south and the legs of the hoyer lift should be surrounding the wheelchair, not underneath. CNA A said this had never happened to her before while using the hoyer lift. CNA A said she had used the hoyer lift to transfer Resident #2 on more than one occasion without the assistance of another CNA. She said she knew she was supposed to have 2 staff members present. During an observation on 6/18/14 at 11:10 a.m. CNA E and CNA F were observed transferring Resident #2 from the bed to her wheelchair via the hoyer lift. The CNA's placed the sling underneath the resident, coordinated the colored straps and hooked the straps to the lift. CNA E lifted Resident #2 off of the bed with the hoyer lift base bars in the closed position. CNA F moved the resident's wheelchair in place and locked the wheels. During the observation, CNA E was observed to transport Resident #2, who was hanging in the air from the lift, approximately 6 feet across the room while maneuvering the lift to the wheelchair with the hoyer base bars in the closed position.(Note: Per the manufacturer's user manual: Ensure the legs (base bars) of the lift with the patient in the sling are in the open position to create a wide base for balance.) When CNA E got close to the wheelchair, she then opened the hoyer lift base bars in order to accommodate the wheelchair. CNA F said she always had herself and another CNA when using the hoyer lift. She said 2 people were needed due to one running the hoyer lift and one assisting with positioning of the resident. CNA E said two staff should be present for all hoyer lifts. She said she was not sure why anyone would want to attempt to transfer a resident with a hoyer lift alone due to it being too dangerous for the CNA and the resident. Review of a Provider Investigation Report dated 6/20/14 indicated the Administrator had investigated the incident for neglect. Post Action taken Post Investigation indicated the following: The entire CNA staff which performs lifts has been inserviced on proper Hoyer lift protocol by return demonstration. The Perpetrator CNA A has been terminated and her certification will be referred. Resident Handling Observations are being done daily on Hoyer lift transfers for 30 days by the DON/LNFA or designee to ensure continued compliance. Results of the Resident Handling Observations will be reviewed through monthly QA meeting process. The investigation findings confirmed Neglect by CNA A. Investigation Summary: CNA A was called in to demonstrate events of the incident in question. The Demonstration revealed that CNA A knowingly violated the Hoyer lift protocol by not getting additional help and improper wheelchair placement. When CNA A was asked if she was inserviced on proper protocol she responded affirmatively. When the CNA was asked why she did not get additional help, she responded that there was sufficient staff however she was impatient. Further questioning revealed that the CNA had transferred Resident #2 in this fashion previously. The CNA also violated standards of practice by moving the resident and placing a pillow under her head before the resident was able to be properly evaluated by the LVN. Review of an Inservice: No Lift Policy indicated CNA A had received Inservicing on 4/02/14 regarding the use of transfer devices to be used by non-ambulatory residents. CNA A signed the policy to acknowledge her understanding. Review of CNA A's personnel file indicated the CNA had received Silver Chair Inservicing on Resident lifting and transfers on 4/06/14; however there was no documentation available to determine CNA A had received any orientation Competency Check Off/Return Demonstration upon her re-hire to the facility in April 2014. Review of the Policy and Procedure: Using a Portable Lifting Machine revised March 2004 indicated the following; General Guidelines: All Hoyer lift transfers are to be performed by two staff members. Review of the Invacare Reliant Electric Portable Patient Lift User Manual dated 2011 indicated the following: Warning; the Invacare patient lift is not a transport device. It is intended to transfer an individual from one resting surface to another. Thoroughly read the instructions and observe a trained team of experts perform the lifting procedure and then perform the entire lift procedure several times with proper supervision. Transferring to a wheelchair: Lift the patient from the bed. Ensure the legs of the lift with the patient in the sling are in the open position. Press the legs open button until it is in maximum open position. Move the wheelchair into position and engage the rear wheel locks to prevent movement of the chair. Two assistants are recommended; one assistant standing behind the chair and the other operating the lift. The assistant behind the chair pulls back on the grab handle to seat the patient into the back of the chair. This will maintain a good center of balance and prevent the chair from tipping forward. Resident #19 Review of Resident #19's admission Face Sheet indicated he was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Admission (MDS) data set [DATE] indicated Resident #19 was 6'1" tall and weighed 223 pounds. He was oriented to person and place only. He had poor short term and long term memory. Review of the Fall Risk (MDS) data set [DATE] indicated a total score of 10. (Score of 7 - 18 indicates resident is high risk.) Review of the consolidated Physician order [REDACTED]. There was also an order [REDACTED]. (Norco is a narcotic used to treat moderate to severe pain and may cause drowsiness and light headedness.) He was also receiving enoxaparin, anticoagulant used to prevent blood clots, which can cause abnormal bruising and bleeding. On 06/19/14 at 2:40 p.m. a staff member was heard calling "Help! Bring the Hoyer lift!" Staff members responded to the room. Resident #19 was observed lying prone on the floor on the left side of his bed. He had an [DEVICE] (a system of pins or screws placed into the bone on both sides of a fracture and secured together outside the skin with clamps and rods) on his right lower leg. LVN K asked Resident #19 what he was doing when he fell out of bed. She said this was the second time in 30 minutes that the resident had fallen out of bed. Resident #19 was mumbling and difficult to understand. It was finally understood that he wanted a wash cloth. After he was assessed by LVN L a sling was placed under him and five staff members used a Hoyer lift to transfer him back to bed. He was reminded to use his call light if he needed something and not to try to get out of bed without assistance. The right side of the bed was against the wall and had an enabler bar near the head of the bed. The left side of the bed had no enabler bar. There was no fall mat on the floor beside the bed to cushion the resident's fall. The bed was approximately 2 ? to 3 feet high. Review of the Resident Incident Report dated 06/19/14 at 2:05 p.m. indicated a CNA reported Resident #19 was on the floor. He was assisted back to bed by 5 staff members. He complained of pain and an analgesic was administered. The bed was in the low position and he was reminded to use the call light. Review of Departmental Notes by LVN L dated 06/19/14 at 2:05 p.m. indicated she gave Resident #19 Norco for pain. Review of the Resident Incident Report dated 06/19/14 at 2:41 p.m. indicated Resident #19 was found on the bare floor in the prone position. He had a superficial skin tear to his left wrist and an abrasion to his left knee. He was alert and oriented to person only. External rotation of the right ankle and increased swelling to the right foot was noted. He was exhibiting symptoms of DTs, sweating, tremors, incoherence and altered mental status. He was sent to the ER for evaluation due to recurring falls, DTs, confusion and pain to the fractured right ankle. On 06/20/14 at 9:35 a.m. Resident #19 was observed in bed. The right side of the bed was against the wall and had an enabler bar near the head of the bed. The left side of the bed had no enabler bar. The bed was approximately 2 ? to 3 feet high. There were no safety measures in place to prevent the resident from falling off the bed. In an interview with the DON on 06/20/14 at 10:00 a.m. he said he could not remember what fall prevention measures were discussed in the stand-up meeting that morning for Resident #19. He said the administrator took notes. In an interview with the administrator, RNC, and the RD on 06/20/14 at 10:10 a.m. the administrator said they had discussed maybe getting a hospice bed for Resident #19. He acknowledged that no interventions had been put in place except for medication adjustments made by the physician. The RNC said she would have a fall mat put beside the resident's bed immediately. On 06/20/14 at 4:30 p.m. Resident #19 was observed on a low bed, approximately 1 ? feet high with a thick fall mat on the floor next to the bed. The bed had ? side rails on both sides. Resident #6 Review of the admission Face Sheet in Resident #6's clinical record indicated he was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] indicated Resident #6 had moderately impaired cognition, meaning his decisions were poor and required reminders, cues, and supervision. He required extensive assistance of one person to transfer. He was not ambulatory. He used a wheelchair. Review of the Fall Risk Evaluation form indicated the last fall risk assessment was done on 10/21/13. The fall risk score was 14. (A score of 10 or above indicates high risk for falls.) No interventions were listed on the back of the form. Review of Resident Incident Reports involving Resident #6 indicated he fell on [DATE] at 10:25 a.m. He was heard yelling for help from his room. He was found sitting on the floor between his wheelchair and his bed. He said he was trying to get in bed and missed, and sat on the floor. He had no apparent injury. On 06/03/14 at 12:50 p.m. he was found sitting on the floor between his wheelchair and the dresser. He said he was on his way to the bathroom and slid out of the wheelchair. He had no apparent injury. Review of Resident #6's Care Plan included a problem of risk for injury related to falls dated 04/09/14. The approaches listed included rule out medical complication with increased falls, notify the MD and family, periodic medication reviews and to provide a safe environment free of clutter. The approach also

Based on observation, interview, and record review, the facility failed to develop and/or implement their written policies and procedures to prohibit neglect for 3 (Resident #1 and #2, and #11 ) of 19 residents sampled for neglect. a)The facility failed to ensure policies and procedures were followed to prohibit neglect for Resident #1. Following the discontinuation of the bed and chair alarms on 03/03/14, Resident #1 fell on [DATE], 03/14/14 and 03/24/14. The fall on 03/24/14 resulted in a pelvic fracture. The resident fell again on 05/10/14 and 05/31/14. b)The facility failed to ensure CNA A followed the facility policy and procedure regarding hoyer lift transfers which resulted in Resident #2 falling to the floor during a transfer. This deficient practice placed 6 residents who required use of a hoyer lift with transfers, and 14 residents who had fallen at risk for additional falls with injuries. Resident #1 Review of Resident #1's admission Face Sheet indicated she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the hospital Admission History and Physical dated 01/01/14 indicated the resident had been admitted to the hospital with [REDACTED]. Review of Resident #1's Fall Risk Evaluation dated 01/16/14 indicated a score of 22. (A resident who scores 10 or higher is at high risk for falls.) No other Fall Risk Evaluations were found in the resident's clinical record. Review of Resident #1's quarterly MDS assessment dated [DATE] indicated her cognition was moderately impaired. She required extensive assistance of two people for transfers. She was not ambulatory. She required extensive assistance of one person for bathing and dressing. She was incontinent of bladder. She was receiving Physical and Occupational Therapy. Review of the consolidated Physician order [REDACTED].#1 [MEDICATION NAME](a sleep medication) 5 mg every night at bedtime. The order originated on 02/13/14. Review of the physician orders [REDACTED].#1 included the following: 01/07/14 - an order for [REDACTED]. 01/13 /14 - an order for [REDACTED]. 03/03/14 - discontinue bed and chair alarms per policy for no fall for over 30 days 03/04/14 at 8:00 p.m. - Resident was found on the floor in her room near the bathroom. She had a red mark in her right cheek approximately 2.0 inches x 1.5 inches. Resident Condition at Time of Incident included tranquilizer/sedatives taken in the last 8 hours, fall history, inability to understand directions, fracture, and confusion/disorientation. 03/14/14 at 8:45 p.m. - Resident was found sitting on the floor beside her bed. She said she got up to go to the bathroom. She had a skin tear on her left hand 6.0 cm long, and a skin tear on her left forearm 11 cm long. The Resident Condition at Time of Incident was not filled out. 03/21/14 - discharge home with home health and a bedside commode 03/24/14 at 9:00 p.m. - Resident was found sitting on the floor between the foot of her bed and the closet door. She said she was putting her shoes in the closet and fell when she turned around to walk back to the bed. No injuries were noted. Resident Condition at Time of Incident included [MEDICATION NAME] taken during last 8 hours, tranquilizer/sedatives taken in the last 8 hours, fall history, and confusion/disorientation. 03/25/14 @ 5:30 a.m. - send to ER status [REDACTED]. Review of the radiology report from the hospital dated 03/25/14 indicated a CT of the pelvis revealed a nondisplaced [MEDICAL CONDITION] inferior pubic ramus, and the suggestion of a nondisplaced fracture involving the proximal aspect of the left superior pubic ramus. The report also indicated Resident #1 had osteopenia (loss of bone density). 03/31/14 - discontinue fall mat despite the fall on 03/24/14. 05/10/14 at 9:25 p.m. - Called to the room by Resident's roommate. Resident was sitting on the floor beside her bed. Resident Condition at Time of Incident included [MEDICATION NAME]/narcotics taken during last 8 hours, tranquilizer/sedatives taken in the last 8 hours, fall history, inability to understand directions, arthritis/[MEDICAL CONDITION], and sensory limitations. 05/31/14 at 6:30 a.m. - CNA reported resident was yelling. Resident was found sitting on the floor. She said she had on her socks and was walking to the restroom and slipped and fell . Resident Condition at Time of Incident included fall history, confusion/disorientation, and incontinence. Review of Resident #1's care plans included a care plan addressing risk of injury related to falls dated 01/21/14. Approaches included rule out medical complication with increased falls, and fall assessment on admission, quarterly, and with changes or falls. Falls were listed on the care plan for 02/03/13, 03/04/14, 03/14/14, and 03/24/14. It was noted that the resident was sent to theER on [DATE] and returned to the facility with a [DIAGNOSES REDACTED]. There were no updates listed on the care plan regarding approaches to reduce Resident #1's fall risks. In an interview with the DON on 06/18/14 at 2:30 p.m. he said he could not find any care plan updates on Resident #1 regarding her falls. He said she was ready to go home when the order was written on 03/21/14 for her to be discharged home with home health. He said he thought he remembered that a transportation problem was the reason she did not go home at that time. Then she fell on the 03/24/14 and fractured her pelvis. Review of a Physical Therapy Evaluation and Plan of Treatment indicated a start of care date of 04/17/14. The Assessment Summary contained Clinical Impressions that the patient had progressed well with rehabilitation after an upper extremity fracture, but had a fall resulting in a pelvic fracture and significant decline now with decreased upright mobility skills. In an interview on 06/18/14 at 3:15 p.m. with the RNC she said the corporation was in the process of becoming alarm free. She said statistics show that alarms do not prevent falls. In a subsequent interview on 06/20/14 at 10:25 a.m. the RNC said the facility had no policy and procedure for eliminating the use of alarms. She said it was a spoken recommendation by the corporation. Review of an algorithm titled Fall Prevention (undated) was received from the RNC on 06/18/14 at 9:30 a.m. She said this was the procedure the facility should have been following: * Resident is admitted to the Center; * Residents admission assessment is completed including fall risk assessment. Interventions to prevent serious injury with falls are implemented and noted on the resident's fall prevention plan of care; * Resident experiences a fall; * The assigned nurse assesses the resident and completes an Accident and Incident report and Investigation. The cause of the fall is identified and appropriate interventions are implemented to prevent further falls and serious injury...; * The IDT reviews A&I reports during daily QA meeting for recommendations; * The DON or designated nurse manager will review the A&I as well as Investigation to assure that the Investigation is complete and appropriate interventions are in place. The DON or designated Nurse Manager will complete within 72 hours the CAA worksheet to assure all risk factors and changes to risk factors are addressed in the resident's plan of care; * Results of the investigation are reviewed with the IDT fall committee during weekly fall committee QA... The resident's plan of care will be updated as needed. Resident #2 Review of Resident #2's Admission Face Sheet indicated the [AGE] year old female resident was readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's consolidated Physician order [REDACTED]. Review of Resident #2's annual Minimum (MDS) data set [DATE] indicated the following; the resident was identified with a BIMS (Brief interview for Mental Status) of 12, indicating she had moderate cognitive impairment. The resident was identified as requiring extensive assistance of two staff for most activities of daily living. The resident was identified with lower extremity impairment on both sides. Balance: surface to surface transfers indicated the resident was; Not steady, only able to stabilize with staff assistance. The resident ' s fall history was left blank. Review of Resident #2's comprehensive Care Plan dated 4/03/14 indicated the following; Problem: At risk for falls. Goals: Resident will have no significant injury related to falls. Approaches: Ensure the call light is within reach and answered promptly. Encourage resident to await assistance. Notify MD and family of falls or injuries when needed. Periodic medication review. Rule out medical complications [REDACTED]. Utilize non-skid footwear. Therapy services; OT for upper body strengthening and PT for lower body strengthening. Review of Resident #2's comprehensive Care plan indicated no identified problems, goals and/or approaches related to the resident requiring hoyer lift transfers. Review of an Incident and Accident Report dated 6/15/14 at 5:00p.m.; indicated the following, CNA A came to the nursing station and informed the nurse (LVN B), she needed help with Resident #2 as the resident was on the floor. CNA A stated during a hoyer lift transfer, the hoyer lift had tilted and pulled the resident out of the wheelchair, throwing her to the floor onto her back. Upon entering the room, Resident #2 was found lying on her back with the sling from the hoyer lift under her. The resident was lying partially on the hoyer lift base bar. The resident had no visible injuries with the exception of a small red area to the residents mid back, however the resident complained of pain to the rib area all the way across her back to included lumber and cervical spine. The resident stated she had " smacked her head also " . No injuries found. Incident reported to the DON and physician. Orders received for STAT X-rays. Review of Resident #2's Fall Risk (MDS) data set [DATE] at 7:17 p.m. indicated the resident had been identified with mild to moderate cognitive impairment, stable general health, maximum assist with transfers, non-weight bearing, appliances used: wheelchair, vision: wears glasses, incontinence: daily, and Medications; Antihypertensive, [MEDICAL CONDITION], diuretic, anticonvulsant: receives two or more. The resident ' s total score was 13 which indicated high risk for falls. Review of Resident #2's Nursing Note dated 6/15/14 at 7:22 p.m. indicated the following; --At 5:00 p.m. CNA A came to the nursing station to notify this nurse she needed help in the residents room, as the resident was being transferred via the hoyer lift, the lift had tilted causing the resident to fall to the floor. The resident was found lying in the floor on her back which was partially lying on the hoyer base bars. The resident was moaning and complaining that her back and ribs hurt. The resident was asked if she hit her head and had responded " Yes, I smacked my head on the floor. " Upon assessment the resident was found to have a small red area to her mid back and slight discoloration to the right rib area. The resident was grabbing her head and complaining of her back. The resident stated her pain was at a 10 on a scale of 1-10. The resident was assisted up to the bed with 5 person assist using the sling and careful movements. The resident was positioned comfortably. Vital signs were temperature-97.6, blood pressure-131/93, pulse-113 and respirations-24. Neurological checks were initiated. Message left for Resident #2 ' s physician. --At 5:30 p.m. Resident #2's physician called and orders were received for STAT x-rays of all concerned areas. The resident was given [MEDICATION NAME] 50 mg (2) for pain. The DON was notified of the incident. Mobile X-ray ordered and confirmed. Review of a hospital X-ray/CT report dated 6/15/14 at 10:52 p.m. indicated; No acute traumatic injury identified. No cervical spine fracture. No [MEDICAL CONDITION]. Review of the initial Provider Investigation Report dated 6/16/14 at 7:20 a.m. indicated on 6/15/14 at 5:00 p.m. Description of the Allegation: Resident was being transferred to her wheelchair and fell in her room requiring evaluation in the emergency room due to bruising to her chest and complaints of pain with Lumbar spine, ribs and back area. No deformities noted to the area. Description of Assessment: Resident was able to feel touch, move legs and hands, and responded to questions appropriately. Decision made to send the resident to the emergency room for evaluation due to mobile x-ray taking an extended amount of time to respond. Provider Response: Evaluation of report and statement revealed CNA A was not using the hoyer lift per protocol and was inserviced by LVN B at that time. Resident was evaluated at the emergency room and found to have no fractures per report. Resident #2 was returned to the facility. Investigation Summary: CNA A failed to follow the protocol for using a hoyer lift, the resident required evaluation outside of the facility. " I do not believe the CNA intended to harm the resident. " Provider Action Taken Post-Investigation: CNA A was inserviced by charge nurse and return demonstration was done before the CNA was allowed to work again, coaching session completed as well. The hoyer lift was inspected per maintenance. Signed by the DON. During an initial tour interview on 6/16/14 at 3:20 p.m. LVN C said there had been an incident on 6/15/14 involving Resident #2 being dropped from a hoyer lift. She said a CNA had been attempting to transfer the resident without the assistance of another CNA and the hoyer lift had tilted causing the residents wheelchair to flip over and throwing the resident on the floor. She said the resident had been sent to the emergency room and was found to have no fractures; however the resident had bruising from under her breast, around her side and on her back. LVN C said the resident had landed on one of the hoyer lift legs (base bar) and was lucky to have not fractured her ribs. LVN C said she was unaware of the reason for the CNA to be attempting to transfer Resident #2 with the hoyer lift without assistance. She said it was the facility ' s policy and procedure to have two staff members for all hoyer lift transfers. Review of Resident #2's Care Plan dated 6/17/14 indicated the following; Problem: At risk for falls. Goals: Resident will have no significant injury related to falls. Approaches: Previous approaches with the addition of; Use hoyer lift for transfers with 2 staff for safety. During an interview on 6/17/14 at 9:20 a.m. the DON said there had been an incident reported to him on 6/15/14, regarding Resident #2 falling from a hoyer lift. He said CNA A was transferring Resident #2 with a hoyer lift when the lift tilted and fell , pulling the resident to the floor. He said the physician was notified and orders were received for mobile x-ray; however the mobile x-ray unit was taking too long to get to the facility and the decision was made to send the resident to the emergency room . He said the resident had no identified fractures and had only suffered bruising. The DON said the CNA had on the spot Inservicing from the charge nurse and he had performed formal Inservicing of the CNA on 6/16/14. He said the facility policy and procedure indicated 2 staff to be present for all hoyer lifts, and CNA A had not followed the policy and procedure. During an interview on 6/17/14 at 11:58 a.m. the Administrator said the facility policy and procedure indicated 2 staff to be present for all hoyer lifts. He said the staff received inservice upon orientation and yearly regarding hoyer lift transfers. During an interview on 6/17/14 at 2:20 p.m. Resident #2 said when CNA A had informed her she was going to transfer her from her bed to the wheelchair; she told the CNA that she needed to go get some help with the transfer. She said CNA A informed her she knew what she was doing and did it all the time by herself. Resident #2 said " CNA A was a little bit full of herself, because I ended up on the floor with my wheelchair and the hoyer lift on top of me. " Resident #2 said she thought she had broken her back and all of her ribs from the fall. Resident #2 said all of the other girls come in 2 at a time to assist with transferring her with the hoyer lift. During an interview on 6/17/14 at 3:37 p.m. the ADON said the CNA's did not have written CNA Care Plans for each resident. She said all of the resident care needs were prompted in the AccuNurse system; which specified areas of care such as incontinent care, lifts, transfers, etc. During a telephone interview on 6/17/14 at 4:12 p.m. LVN B said she had been the charge nurse on 6/15/14 at the time of Resident #2's incident. She said CNA A had reported to her that she had been transferring Resident #2 to her wheelchair and the hoyer lift had tilted resulting in the resident falling to the floor. She said CNA A had attempted to transfer Resident #2 with the hoyer lift without assistance of another staff member. She said CNA A knew she was supposed to have 2 staff members to use the hoyer lift to transfer a resident. LVN B said there were no problems with staffing that shift and the facility had a float CNA to assist when needed. She said none of the other staff were aware of CNA A being in Resident #2's room until after the incident. LVN B said she had immediately inserviced CNA A and had stressed the importance of 2 staff members being present for all hoyer lifts. During an interview on 6/17/14 at 4:22 p.m. LVN D said she was responsible for developing the resident's care plans. She said following a review of Resident #2's care plan, that there was no care plan which reflected any identified safety risks regarding a hoyer lift being used to assist Resident #2 with transferring. She said Resident #2 had required the use of a hoyer lift for transfers since her admission to the facility. She said the problem area of the resident being at risk for injury due to utilization of a hoyer lift must have dropped off the residents care plan or been left out entirely. During a telephone interview on 6/17/14 at 4:25 p.m. CNA A said 6/15/14 had been a regular day. She said the facility was not short staffed and there had been a float CNA scheduled to assist with resident care. She said she had been getting the residents up for supper and had gone to Resident #2's room. She said she had not requested assistance from another CNA due to feeling " impatient " and " not wanting to go find help " . She said she had transferred Resident #2 from her bed to the wheelchair, had lowered the resident into the wheelchair and began to unhook the straps of the sling from the hoyer lift. She said she had unhooked one strap and the hoyer lift tilted, the wheelchair fell straight back to the floor. She said the resident fell on the hoyer lift base bar. She said the resident was moaning and groaning and stating she was hurting "really bad" . She said she pulled Resident #2 two to three inches in order to get her off of the base bar and placed a pillow under her neck prior to going to get the nurse. She said it was just a freak accident and she was very familiar with transferring Resident #2 with the hoyer lift. She said she was aware that 2 staff members needed to be present during hoyer lift transfers; however she had made a bad judgment and attempted to do it herself. She said she had not received any specific inservicing regarding hoyer lift transfers until the night of the incident, when LVN B had inserviced her. Review of Inservice Training Report dated 6/18/14 at 7:00 a.m. indicated the nurses, CNA's and CMA's had been inserviced on using the hoyer lift. The inservice indicated all residents that require a hoyer lift must have 2 CNA's (trained staff) to assist with no exceptions. During an observation on 6/18/14 at 10:40 a.m. CNA A, the DON, ADON and Administrator were present in an empty room. CNA A was asked to reenact the placement of the wheelchair and hoyer lift as they had been placed during the incident with Resident #2. CNA A was observed to place the wheelchair facing a north/south direction and place the wheelchair in an east/west direction with one of the hoyer base bars underneath the wheelchair near the front wheels. When asked why she positioned the wheelchair in the opposite direction of the hoyer lift, CNA A said it was easier for her to position the resident in the wheelchair by herself that way. She said she had lowered the resident down into her wheelchair and had taken one of the sling straps off the hoyer lift hooks. She said the hoyer lift had tilted and the wheelchair had flipped backwards with the resident coming to rest on the base bar of the lift. CNA A said she was not sure what had happened to cause the hoyer to tilt and the wheelchair to flip back. CNA A said she had unhooked only one of the sling straps, and the hoyer lift had only tilted not fallen to the floor. She said the sling was under the resident when she came to rest on the base bar of the lift. The DON and ADON said the positioning of the wheelchair and hoyer lift was not the way the staff had been taught to use the hoyer lift. The ADON said if the wheelchair is facing north/south then the hoyer lift needs to be facing north south and the legs of the hoyer lift should be surrounding the wheelchair, not underneath. CNA A said this had never happened to her before while using the hoyer lift. CNA A said she had used the hoyer lift to transfer Resident #2 on more than one occasion without the assistance of another CNA. She said she knew she was supposed to have 2 staff members present. Review of the Invacare Reliant Electric Portable Patient Lift User Manual dated 2011 indicated the following: Two assistants are recommended; one assistant standing behind the chair and the other operating the lift. The assistant behind the chair pulls back on the grab handle to seat the patient into the back of the chair. This will maintain a good center of balance and prevent the chair from tipping forward. Review of a Provider Investigation Report dated 6/20/14 indicated the Administrator had investigated the incident for neglect. Post Action taken Post Investigation indicated the following: The entire CNA staff which performs lifts has been inserviced on proper Hoyer lift protocol by return demonstration on 6/18/14. The Perpetrator CNA A has been terminated and her certification will be referred. Resident Handling Observations are being done daily on Hoyer lift transfers for 30 days by the DON/LNFA or designee to ensure continued compliance. Results of the Resident Handling Observations will be reviewed through monthly QA meeting process. The investigation findings confirmed Neglect by CNA A. Investigation Summary: CNA A was called in to demonstrate events of the incident in question. The Demonstration revealed that CNA A knowingly violated the Hoyer lift protocol by not getting additional help and improper wheelchair placement. When CNA A was asked if she was inserviced on proper protocol she responded affirmatively. When the CNA was asked why she did not get additional help, she responded that there was sufficient staff however she was impatient. Further questioning revealed that the CNA had transferred Resident #2 in this fashion previously. The CNA also violated standards of practice by moving the resident and placing a pillow under her head before the resident was able to be properly evaluated by the LVN. Review of an Inservice: No Lift Policy indicated CNA A had received Inservicing on 4/02/14 regarding the use of transfer devices to be used by non-ambulatory residents. CNA A signed the policy to acknowledge her understanding. Review of CNA A's personnel file indicated the CNA had received Silver Chair Inservicing on Resident lifting and transfers on 4/06/14; however there was no documentation available to determine CNA A had received any orientation Competency Check Off/Return Demonstration or Resident Handling Observations upon her re-hire to the facility in April 2014. Review of the Policy and Procedure: Using a Portable Lifting Machine revised March 2004 indicated the following; General Guidelines: All Hoyer lift transfers are to be performed by two staff members. Review of the Abuse and Neglect Policy revised 09/2008 indicated the following; Purpose: To promote the well-being of residents by providing a safe and supportive environment. Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. According to a list provided by the ADON on 06/18/14 their were a total of 6 residents who required the assistance of a hoyer lift to transfer. Review of the CMS 672 dated 06/16/14 indicated there were 22 residents in the facility who required assistance with ambulation or assistive devices.

Based on interview and record review the facility failed to implement their written policies and procedures that prohibit neglect of residents for 3 ( Resident #1, #2, and #3) of 19 residents reviewed for neglect. a) The facility failed to ensure policies and procedures were followed to reduce fall risks for Resident #1. Following the discontinuation of the bed and chair alarms on 03/03/14, Resident #1 fell on [DATE], 03/14/14, and 03/24/14. The fall on 03/24/14 resulted in a pelvic fracture. The resident fell again on 05/10/14 and 05/31/14. b) The facility failed to ensure CNA A followed the facility policy and procedure regarding hoyer lift transfers which resulted in Resident #2 falling to the floor during a transfer. c) The facility failed to immediately report to the State Agency an unwitnessed incident involving Resident #11 in which she was found on the floor in front of her wheelchair and sustained a laceration above her right eyebrow. These failures resulted in Resident #1 sustaining a pelvic fracture, Resident #2 experiencing pain and bruising, and Resident #11 sustaining a [MEDICAL CONDITION]. These failures could affect 14 resident who have had falls and 6 residents who require a hoyer lift for transfers. This failure affected one resident and could have placed 65 residents at risk for injuries of unknown origin not being investigated or reported as required to rule out possible abuse and/or neglect. Findings include: Review of the facility policies indicated the following: Abuse and Neglect Policy revised 09/2008 indicated the following; Purpose: To promote the well-being of residents by providing a safe and supportive environment. Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Policy and Procedure: Using a Portable Lifting Machine revised March 2004 indicated the following; General Guidelines: All Hoyer lift transfers are to be performed by two staff members. Hoyer Lift Policy/Manufacturers instructions: Invacare Reliant Electric Portable Patient Lift User Manual dated 2011 indicated the following: Warning; the Invacare patient lift is not a transport device. It is intended to transfer an individual from one resting surface to another. Thoroughly read the instructions and observe a trained team of experts perform the lifting procedure and then perform the entire lift procedure several times with proper supervision. Transferring to a wheelchair: Lift the patient from the bed. Ensure the legs of the lift with the patient in the sling are in the open position. Press the legs open button until it is in maximum open position. Move the wheelchair into position and engage the rear wheel locks to prevent movement of the chair. Two assistants are recommended; one assistant standing behind the chair and the other operating the lift. The assistant behind the chair pulls back on the grab handle to seat the patient into the back of the chair. This will maintain a good center of balance and prevent the chair from tipping forward. Texas DADS Provider Letter dated January 3, 2007, #06-43 - Guidelines for Reporting Incidents states; Facilities are required at 40 TAC 19.601 (c) (2) to ensure that all alleged violations involving mistreatment, neglect or abuse including injuries of unknown source and misappropriation of resident property, are reported immediately to DADS. Facilities are also required to report certain other incidents, which may or may not constitute abuse, neglect or exploitation. Injury of unknown source; an injury must be classified as an " injury of unknown source " when both of the following conditions are met: Resident #1 Review of Resident #1's admission Face Sheet indicated she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the hospital Admission History and Physical dated 01/01/14 indicated the resident had been admitted to the hospital with [REDACTED]. Review of Resident #1's Fall Risk Evaluation dated 01/16/14 indicated a score of 22. (A resident who scores 10 or higher is at high risk for falls.) No other Fall Risk Evaluations were found in the resident's clinical record. Review of Resident #1's quarterly MDS assessment dated [DATE] indicated her cognition was moderately impaired. She required extensive assistance of two people for transfers. She was not ambulatory. She required extensive assistance of one person for bathing and dressing. She was incontinent of bladder. She was receiving Physical and Occupational Therapy. Review of the consolidated Physician order [REDACTED].#1 [MEDICATION NAME](a sleep medication) 5mg every night at bedtime. The order originated on 02/13/14. Review of the physician orders [REDACTED].#1 included the following: 01/07/14 - an order for [REDACTED]. 01/13 /14 - an order for [REDACTED]. 03/03/14 - discontinue bed and chair alarms per policy for no fall for over 30 days 03/04/14 at 8:00 p.m. - Resident was found on the floor in her room near the bathroom. She had a red mark in her right cheek approximately 2.0 inches x 1.5 inches. Resident Condition at Time of Incident included tranquilizer/sedatives taken in the last 8 hours, fall history, inability to understand directions, fracture, and confusion/disorientation. 03/14/14 at 8:45 p.m. - Resident was found sitting on the floor beside her bed. She said she got up to go to the bathroom. She had a skin tear on her left hand 6.0 cm long, and a skin tear on her left forearm 11 cm long. The Resident Condition at Time of Incident had not filled out. (left blank) 03/21/14 - discharge home with home health and a bedside commode. 03/24/14 at 9:00 p.m. - Resident was found sitting on the floor between the foot of her bed and the closet door. She said she was putting her shoes in the closet and fell when she turned around to walk back to the bed. No injuries were noted. Resident Condition at Time of Incident included [MEDICATION NAME] (an [MEDICATION NAME] that may cause sedation) taken during last 8 hours, tranquilizer/sedatives taken in the last 8 hours, fall history, and confusion/disorientation. 03/25/14 @ 5:30 a.m. - send to ER status [REDACTED]. Review of the radiology report from the hospital dated 03/25/14 indicated a CT of the pelvis revealed a nondisplaced [MEDICAL CONDITION] inferior pubic ramus, and the suggestion of a nondisplaced fracture involving the proximal aspect of the left superior pubic ramus. The report also indicated Resident #1 had osteopenia (loss of bone density). 03/31/14 - discontinue fall mat despite fall on 03/24/14. 05/10/14 at 9:25 p.m. - Called to the room by Resident's roommate. Resident was sitting on the floor beside her bed. Resident Condition at Time of Incident included [MEDICATION NAME]/narcotics taken during last 8 hours, tranquilizer/sedatives taken in the last 8 hours, fall history, inability to understand directions, arthritis/[MEDICAL CONDITION], and sensory limitations. 05/31/14 at 6:30 a.m. - CNA reported resident was yelling. Resident was found sitting on the floor. She said she had on her socks and was walking to the restroom and slipped and fell . Resident Condition at Time of Incident included fall history, confusion/disorientation, and incontinence. Review of Resident #1's care plans included a care plan addressing risk of injury related to falls dated 01/21/14. Approaches included rule out medical complication with increased falls, and fall assessment on admission, quarterly, and with changes or falls. Falls were listed on the care plan for 02/03/13, 03/04/14, 03/14/14, and 03/24/14. It was noted that the resident was sent to theER on [DATE] and returned to the facility with a [DIAGNOSES REDACTED]. There were no updates listed on the care plan regarding approaches to reduce Resident #1's fall risks. In an interview with the DON on 06/18/14 at 2:30 p.m. he said he could not find any care plan updates on Resident #1 regarding her falls. He said she was ready to go home when the order was written on 03/21/14 for her to be discharged home with home health. He said he thought he remembered that a transportation problem was the reason she did not go home at that time. Then she fell on the 03/24/14 and fractured her pelvis. Review of a Physical Therapy Evaluation and Plan of Treatment indicated a start of care date of 04/17/14. The Assessment Summary contained Clinical Impressions that the patient had progressed well with rehabilitation after an upper extremity fracture, but had a fall resulting in a pelvic fracture and significant decline now with decreased upright mobility skills. In an interview on 06/18/14 at 3:15 p.m. with the RNC she said the corporation was in the process of becoming alarm free. She said statistics show that alarms do not prevent falls. In a subsequent interview on 06/20/14 at 10:25 a.m. the RNC said the facility had no policy and procedure for eliminating the use of alarms. She said it was a spoken recommendation by the corporation. Resident #2 Review of Resident #2's Admission Face Sheet indicated the [AGE] year old female resident was readmitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's consolidated Physician order [REDACTED]. Review of Resident #2's annual Minimum (MDS) data set [DATE] indicated the following: The resident was identified with a BIMS score of 12, indicating she had moderate cognitive impairment. The resident was identified as requiring extensive assistance of two staff for most activities of daily living. The resident was identified with lower extremity impairment on both sides. Balance: surface to surface transfers indicated the resident was; Not steady, only able to stabilize with staff assistance. The resident's fall history was left blank. Review of Resident #2's comprehensive Care Plan dated 4/03/14 indicated the following; Problem: At risk for falls. Goals: Resident will have no significant injury related to falls. Approaches: Ensure the call light is within reach and answered promptly. Encourage resident to await assistance. Notify MD and family of falls or injuries when needed. Periodic medication review. Rule out medical complications [REDACTED]. Utilize non-skid footwear. Therapy services; OT for upper body strengthening and PT for lower body strengthening. Review of Resident #2's comprehensive Care plan indicated no identified problems, goals and/or approaches related to the resident requiring hoyer lift transfers. Review of an Incident and Accident Report dated 6/15/14 at 5:00p.m.; indicated the following, CNA A came to the nursing station and informed the nurse (LVN B), she needed help with Resident #2 as the resident was on the floor. CNA A stated during a hoyer lift transfer, the hoyer lift had tilted and pulled the resident out of the wheelchair, throwing her to the floor onto her back. Upon entering the room, Resident #2 was found lying on her back with the sling from the hoyer lift under her. The resident was lying partially on the hoyer lift base bar. The resident had no visible injuries with the exception of a small red area to the residents mid back, however the resident complained of pain to the rib area all the way across her back to included lumber and cervical spine. The resident stated she had " smacked her head also " . No injuries found. Incident reported to the DON and physician. Orders received for STAT X-rays. Review of Resident #2's Fall Risk (MDS) data set [DATE] at 7:17 p.m. indicated the resident had been identified with mild to moderate cognitive impairment, stable general health, maximum assist with transfers, non-weight bearing, appliances used: wheelchair, vision: wears glasses, incontinence: daily, and Medications; Antihypertensive, [MEDICAL CONDITION], diuretic, anticonvulsant: receives two or more. The resident's total score was 13 which indicated high risk for falls. Review of Resident #2's Nursing Note dated 6/15/14 at 7:22 p.m. indicated the following; --At 5:00 p.m. CNA A came to the nursing station to notify this nurse she needed help in the residents room, as the resident was being transferred via the hoyer lift, the lift had tilted causing the resident to fall to the floor. The resident was found lying in the floor on her back which was partially lying on the hoyer base bars. The resident was moaning and complaining that her back and ribs hurt. The resident was asked if she hit her head and had responded " Yes, I smacked my head on the floor. "Upon assessment the resident was found to have a small red area to her mid back and slight discoloration to the right rib area. The resident was grabbing her head and complaining of her back. The resident stated her pain was at a 10 on a scale of 1-10. The resident was assisted up to the bed with 5 person assist using the sling and careful movements. The resident was positioned comfortably. Vital signs were temperature-97.6, blood pressure-131/93, pulse-113 and respirations-24. Neurological checks were initiated. Message left for Resident #2's physician. --At 5:30 p.m. Resident #2's physician called and orders were received for STAT x-rays of all concerned areas. The resident was given [MEDICATION NAME] 50 mg (2) for pain. The DON was notified of the incident. Mobile X-ray ordered and confirmed. Review of a hospital X-ray/CT report dated 6/15/14 at 10:52 p.m. indicated; No acute traumatic injury identified. No cervical spine fracture. No [MEDICAL CONDITION]. Review of the initial Provider Investigation Report dated 6/16/14 at 7:20 a.m. indicated on 6/15/14 at 5:00 p.m. Description of the Allegation: Resident was being transferred to her wheelchair and fell in her room requiring evaluation in the emergency room due to bruising to her chest and complaints of pain with Lumbar spine, ribs and back area. No deformities noted to the area. Description of Assessment: Resident was able to fell touch, move legs and hands, and responded to questions appropriately. Decision made to send the resident to the emergency room for evaluation due to mobile x-ray taking an extended amount of time to respond. Provider Response: Evaluation of report and statement revealed CNA A was not using the hoyer lift per protocol and was inserviced by LVN B at that time. Resident was evaluated at the emergency room and found to have no fractures per report. Resident #2 was returned to the facility. Investigation Summary: CNA A failed to follow the protocol for using a hoyer lift, the resident required evaluation outside of the facility. "I do not believe the CNA intended to harm the resident. " Provider Action Taken Post-Investigation: CNA A was inserviced by charge nurse and return demonstration was done before the CNA was allowed to work again, coaching session completed as well. The hoyer lift was inspected per maintenance. Signed by the DON. During an initial tour interview on 6/16/14 at 3:20 p.m. LVN C said there had been an incident on 6/15/14 involving Resident #2 being dropped from a hoyer lift. She said a CNA had been attempting to transfer the resident without the assistance of another CNA and the hoyer lift had tilted causing the residents wheelchair to flip over and throwing the resident on the floor. She said the resident had been sent to the emergency room and was found to have no fractures; however the resident had bruising from under her breast, around her side and on her back. LVN C said the resident had landed on one of the hoyer lift legs (base bar) and was lucky to have not fractured her ribs. LVN C said she was unaware of the reason for the CNA to be attempting to transfer Resident #2 with the hoyer lift without assistance. She said it was the facility's policy and procedure to have two staff members for all hoyer lift transfers. Review of Resident #2's Care Plan dated 6/17/14 indicated the following; Problem: At risk for falls. Goals: Resident will have no significant injury related to falls. Approaches: Previous approaches with the addition of; Use hoyer lift for transfers with 2 staff for safety. During an interview on 6/17/14 at 9:20 a.m. the DON said there had been an incident reported to him on 6/15/14, regarding Resident #2 falling from a hoyer lift. He said CNA A was transferring Resident #2 with a hoyer lift when the lift tilted and fell , pulling the resident to the floor. He said the physician was notified and orders were received for mobile x-ray; however the mobile x-ray unit was taking too long to get to the facility and the decision was made to send the resident to the emergency room . He said the resident had no identified fractures and had only suffered bruising. The DON said the CNA had on the spot inservicing from the charge nurse and he had performed formal inservicing of the CNA on 6/16/14. He said the facility policy and procedure indicated 2 staff to be present for all hoyer lifts, and CNA A had not followed the policy and procedure. During an interview on 6/17/14 at 11:58 a.m. the Administrator said the facility policy and procedure indicated 2 staff to be present for all hoyer lifts. He said the staff received inservice upon orientation and yearly regarding hoyer lift transfers. During an interview on 6/17/14 at 2:20 p.m. Resident #2 said when CNA A had informed her she was going to transfer her from her bed to the wheelchair; she had told the CNA that she needed to go get some help. She said CNA A informed her she knew what she was doing and did it all the time by herself. Resident #2 said "CNA A was a little bit full of herself, because I ended up on the floor with my wheelchair and the hoyer lift on top of me." Resident #2 said she thought she had broken her back and all of her ribs from the fall. Resident #2 said all of the other girls come in 2 at a time to assist with transferring her with the hoyer lift. During an interview on 6/17/14 at 3:37 p.m. the ADON said the CNA's did not have written CNA Care Plans for each resident. She said all of the resident care needs were prompted in the AccuNurse system; which specified areas of care such as incontinent care, lifts, transfers, etc. During a telephone interview on 6/17/14 at 4:12 p.m. LVN B said she had been the charge nurse on 6/15/14 at the time of Resident #2's incident. She said CNA A had reported to her that she had been transferring Resident #2 to her wheelchair and the hoyer lift had tilted resulting in the resident falling to the floor. She said CNA A had attempted to transfer Resident #2 with the hoyer lift without assistance of another staff member. She said CNA A knew she was supposed to have 2 staff members to use the hoyer lift to transfer a resident. LVN B said there were no problems with staffing that shift and the facility had a float CNA to assist when needed. She said none of the other staff was aware of CNA A being in Resident #2's room until after the incident. LVN B said she had immediately inserviced CNA A and had stressed the importance of 2 staff members being present for all hoyer lifts. During an interview on 6/17/14 at 4:22 p.m. LVN D said she was responsible for developing the resident's care plans. She said following a review of Resident #2's care plan, that there was no care plan which reflected any identified safety risks regarding a hoyer lift being used to assist Resident #2 with transferring. She said Resident #2 had required the use of a hoyer lift for transfers since her admission to the facility. She said the problem area of the resident being at risk for injury due to utilization of a hoyer lift must have dropped off the resident's care plan or been left out entirely. During a telephone interview on 6/17/14 at 4:25 p.m. CNA A said 6/15/14 had been a regular day. She said the facility was not short staffed and there had been a float CNA scheduled to assist with resident care. She said she had been getting the residents up for supper and had gone to Resident #2's room. She said she had not requested assistance from another CNA due to feeling "impatient" and "not wanting to go find help" . She said she had transferred Resident #2 from her bed to the wheelchair, had lowered the resident into the wheelchair and began to unhook the straps of the sling from the hoyer lift. She said she had unhooked one strap and the hoyer lift tilted, the wheelchair fell straight back to the floor. She said the resident fell on the hoyer lift base bar. She said the resident was moaning and groaning and stating she was hurting "really bad" . She said she pulled Resident #2 two to three inches in order to get her off of the base bar and placed a pillow under her neck prior to going to get the nurse. She said it was just a freak accident and she was very familiar with transferring Resident #2 with the hoyer lift. She said she was aware that 2 staff members needed to be present during hoyer lift transfers; however she had made a bad judgment and attempted to do it herself. She said she had not received any specific inservicing regarding hoyer lift transfers until the night of the incident, when LVN B had inserviced her. Review of Inservice Training Report dated 6/18/14 at 7:00 a.m. indicated the nurses, CNA's and CMA's had been inserviced on using the hoyer lift. The inservice indicated all residents that require a hoyer lift must have 2 CNA's (trained staff) to assist with no exceptions. During an observation on 6/18/14 at 10:40 a.m. CNA A, the DON, ADON and Administrator were present in an empty room. CNA A was asked to reenact the placement of the wheelchair and hoyer lift as they had been placed during the incident with Resident #2. CNA A was observed to place the wheelchair facing a north/south direction and place the wheelchair in an east/west direction with one of the hoyer base bars underneath the wheelchair near the front wheels. When asked why she positioned the wheelchair in the opposite direction of the hoyer lift, CNA A said it was easier for her to position the resident in the wheelchair by herself that way. She said she had lowered the resident down into her wheelchair and had taken one of the sling straps off the hoyer lift hooks. She said the hoyer lift had tilted and the wheelchair had flipped backwards with the resident coming to rest on the base bar of the lift. CNA A said she was not sure what had happened to cause the hoyer to tilt and the wheelchair to flip back. CNA A said she had unhooked only one of the sling straps, and the hoyer lift had only tilted not fallen to the floor. She said the sling was under the resident when she came to rest on the base bar of the lift. The DON and ADON said the positioning of the wheelchair and hoyer lift was not the way the staff head been taught to use the hoyer lift. The ADON said if the wheelchair is facing north/south then the hoyer lift needs to be facing north/south and the legs of the hoyer lift should be surrounding the wheelchair, not underneath. CNA A said this had never happened to her before while using the hoyer lift. CNA A said she had used the hoyer lift to transfer Resident #2 on more than one occasion without the assistance of another CNA. She said she knew she was supposed to have 2 staff members present. During an observation on 6/18/14 at 11:10 a.m. CNA E and CNA F were observed transferring Resident #2 from the bed to her wheelchair via the hoyer lift. The CNA's placed the sling underneath the resident, coordinated the colored straps and hooked the straps to the lift. CNA E lifted Resident #2 off of the bed with the hoyer lift base bars in the closed position. CNA F moved the resident's wheelchair in place and locked the wheels. During the observation, CNA E was observed to transport Resident #2, who was hanging in the air from the lift, approximately 6 feet across the room while maneuvering the lift to the wheelchair with the hoyer base bars in the closed position. When CNA E got close to the wheelchair, she then opened the hoyer lift base bars in order to accommodate the wheelchair. CNA F said she always had herself and another CNA when using the hoyer lift. She said 2 people were needed due to one running the hoyer lift and one assisting with positioning of the resident. CNA E said two staff should be present for all hoyer lifts. She said she was not sure why anyone would want to attempt to transfer a resident with a hoyer lift alone due to it being too dangerous for the CNA and the resident. Review of a Provider Investigation Report dated 6/20/14 indicated the Administrator had investigated the incident for neglect. Post Action taken Post Investigation indicated the following: The entire CNA staff which performs lifts has been inserviced on proper Hoyer lift protocol by return demonstration. The Perpetrator CNA A has been terminated and her certification will be referred. Resident Handling Observations are being done daily on Hoyer lift transfers for 30 days by the DON/LNFA or designee to ensure continued compliance. Results of the Resident Handling Observations will be reviewed through monthly QA meeting process. The investigation findings confirmed Neglect by CNA A. Investigation Summary: CNA A was called in to demonstrate events of the incident in question. The Demonstration revealed that CNA A knowingly violated the Hoyer lift protocol by not getting additional help and improper wheelchair placement. When CNA A was asked if she was inserviced on proper protocol she responded affirmatively. When the CNA was asked why she did not get additional help, she responded that there was sufficient staff however she was impatient. Further questioning revealed that the CNA had transferred Resident #2 in this fashion previously. The CNA also violated standards of practice by moving the resident and placing a pillow under her head before the resident was able to be properly evaluated by the LVN. Review of an Inservice: No Lift Policy indicated CNA A had received Inservicing on 4/02/14 regarding the use of transfer devices to be used by non-ambulatory residents. CNA A signed the policy to acknowledge her understanding. Review of CNA A's personnel file indicated the CNA had received Silver Chair Inservicing on Resident lifting and transfers on 4/06/14; however there was no documentation available to determine if CNA A had received any orientation Competency Check Off/Return Demonstration regarding the lift procedure upon her re-hire to the facility in April 2014. Resident #11 During an interview on 6/19/14 at 3:00 p.m. the RD said the facility did not have a policy and procedure on when to report injuries and accidents. The RD said they follow the provider letter DADS Guidelines as their policy for reporting incidents. a) No one saw the incident that resulted in the injury or the source of the injury could not be explained by the resident; and b) The injury is suspicious because of the extent of the injury or the location of the injury; or the number of injuries observed at one particular in time or the number of the injuries over time. Record review Resident # 11 's closed record MDS dated [DATE] indicated the [AGE] year old female was admitted to the facility for rehabilitation on 4/18/14 with the following diagnoses; anxiety disorder, [MEDICAL CONDITION], dysphasia, coronary [MEDICAL CONDITION], Parkinson ' s disease, reflux, hypertension and [MEDICAL CONDITION]. The Resident ' s speech was slurred; she is sometimes understood, and sometime understands. Her BIMS score was 3 out of 15, indicating severe impaired cognition. Her functional levels indicated she needed extensive assistance with two person physical assist for transfers. Resident # 11 required extensive assistance with one staff for her eating and hygiene needs. The Resident was totally dependent for staff assistance for locomotion on and off the unit. She was frequently incontinent of bowel and bladder and required a wheelchair for mobility. Review of facility incident and accident reports from March 17, 2014 until 6/15/14 indicated Resident # 11 fell four (4) times during her stay. The falls are as follows; 1) 4/23/14 10:11 a.m. fell in room; no injury (unwitnessed) 2) 4/23/14 4:36 p.m. found on floor face down on floor in front of wheelchair sent to ER where she received sutures to forehead (unwitnessed) 3) 5/1/14 1:37 a.m. found on floor next to bed said she slid out of bed no injury (unwitnessed) 4) 5/11/14 10:30 a.m. scooted self out of recliner and slid onto floor no injury (unwitnessed) Review of Resident # 11's incident report dated 4/23/14 at 4:36 p.m. indicated the Resident had a non-witnessed fall and was found face down on floor in front of wheelchair. Her condition at the time of incident indicated her mobility needs as transfers from bed to chair with assist. Her mental condition was listed as disoriented, not follow commands. Her medical risk factors indicated she had a fall history. The incident report was signed by the DON, ADON, LNFA, PTA (physical therapy assistant). Review of the facility nursing note dated 4/23/14 indicated at 4:50 p.m. the Resident was found face forward on floor in front of her wheelchair with moderate amount of blood noted around her head and face. The nurse noted the Resident had a laceration above her right eyebrow on her forehead. Approximate size of laceration was noted to be 5.0 to 5.0 x 1.1 cm in triangular shape. The note stated the Resident was alert and oriented to self only. The Resident also received a skin tear to the right outer forearm near elbow with jagged edges in a V shape pattern. The approximate size of the V shape skin tear was 2.0 x 2.0 x 0.02 cm. The nursing note stated the DON was notified at 5:00 p.m. and a call was placed to 911 for ambulance transport at 5:05 p.m. The Resident was placed on the emergency transfer board and continued to holler out frequently while attempting to climb off the stretcher as she was being wheeled to the ambulance. Once the Resident returned from the emergency room the doctor was notified and the facility received new orders to discontinue the Resident ' s [MEDICATION NAME], to discontinue her [MEDICATION NAME] 1 mg in the morning and start [MEDICATION NAME] 0.5 mg one tab every morning. The Resident was transferred to her bed with two staff assist. During an interview on 5/19/14 at 2:45 p.m. the DON said the facility did not do an investigation of Resident # 11 ' s 4/23/14 fall which required an ER visit and sutures to her forehead. The DON did not offer an explanation of why the facility did not investigate an unwitnessed fall that could not be explained by the resident. During an interview on 5/19/14 at 3:20 p.m. RNC said she didn't know the 4/23/14 fall of Resident # 11 was a reportable incident. When asked if it was witnessed or unwitnessed the RNC said the incident was unwitnessed but knew she must have fallen out of her wheelchair. According to a list provided by the ADON on 06/18/14 and the CMS 802 dated 06/16/14 there were a total of 6 residents who required the assistance of a hoyer lift to transfer and 14 residents who had falls and were at risk of falls. . .