Every finding on record at Belknap County Nursing Home

Based on observation, interview, and record review, it was determined that the facility failed to follow professional standards for 1 of 1 resident observed for medication administration via gastrostomy tube (g-tube) (Resident identifier is #2).Findings include:Review on 9/4/25 of [NAME] A. [NAME] and [NAME], Clinical Nursing Skills & Techniques. 10th ed. St. Louis, Missouri: Elsevier, 2022. revealed on Page 617-Administering Medications Through Feeding Tube 12.b. To administer more than one medication, give each separately and flush between medications with 15ml [milliliter] to 30ml of water.Observation on 9/3/2025 at approximately 8:45 a.m. with Staff C (Medication Nursing Assistant (MNA)) during Resident #2's medication administration via g-tube revealed that Staff C was administering five crushed medications (amlodipine 10mg (milligrams), Aspirin 81mg, Levothyroxine 50mcg (micrograms), Gabapentin 100mg, and Pepcid 20 mg) without flushing the g-tube with water in between medications. Interview on 9/3/2025 at approximately 8:45 a.m. with Staff C confirmed the above observation.Review on 9/3/25 of Facility policy titled Enteral Nutrition & Medication Administration Policy dated reviewed and revised 7/17/25 revealed .IV. Medication Administration via Feeding Tube .6. Flush between meds with [greater than or equal to] 15 ml water .

Based on observation, interview, and record review, it was determined that the facility failed to implement infection control policies and procedures for hand hygiene and glove for 1 of 1 resident reviewed for skin condition in a final sample of 15 residents. (Resident identifier is #33).Findings include:Review on 9/4/25 of Resident #33's physician's order dated 7/2/25 revealed a wound treatment for the right buttocks to gently cleanse area with wound wash, pat dry, apply non-sting barrier wipe, apply santyl to wound bed and cover with small Mepilex border (3x3), change dressing daily.Observation on 9/4/25 at 10:30 a.m. of Resident #33's wound dressing change with Staff A (Licensed Practical Nurse) revealed Staff A wore a gown and gloves, removed the dirty dressing from Resident #33's right buttock and discarded it in the trash. Staff A opened the clean dressing supplies with the same gloves and did not perform hand hygiene. Staff A removed the dirty gloves and revealed that Staff A had worn a second pair of gloves underneath the first pair. Staff A cleanse the wound, applied santyl ointment on the wound bed, and covered the wound with mepilex (foam) dressing. Staff A did not remove gloves and perform hand hygiene between cleaning the wound and applying the santyl ointment and mepilex dressing. Interview on 9/4/25 at approximately 10:30 a.m. with Staff A confirmed the above findings.Review on 9/4/25 of facility's policy titled Infection Control-Standard Precautions, date of revision 6/19/25, revealed .1. Hand washing should be done a) After contact with blood, body fluids, excretions., whether gloves are worn b) after gloves are removed, e) before and after touching wounds., j) When indicated between tasks and procedures on the same resident to prevent cross-contamination. Gloves 7. Gloves must be replaced as soon as possible when contaminated.

Based on interview, observation, and record review, it was determined that the facility failed to follow manufacturer's instructions for care and cleaning of the Hydrocollator. Findings include: Review on 9/19/24 of the manufacturer's instructions for the Hydrocollator, undated revealed: .Care and cleaning: .Water is constantly lost during operation due to evaporation. Therefore, it is essential that water be added daily. The tank should also be drained and cleaned systematically, at a minimum interval of every two weeks . Observation on 9/19/24 at approximately 9:00 a.m. in the rehab department revealed that there was a hydrocollator. Interview on 9/19/24 at approximately 9:00 a.m. with Staff A (Director of Nursing) revealed that residents who were in the restorative program would utilize the heat pads from the hydrocollator and that Staff B (Assistant Director of Nursing (ADON)) oversees the program. Review on 4/13/23 of the facility form Hydrocollator Maintenance - Cleaning Log for July, August, and September 2024 revealed the following: July 2024: One cleaning on 7/23/24; August 2024: No cleaning was done; September 2024: One cleaning on 9/18/24. Review on 9/19/24 of the facility's report for hydrocollator use for September 2024 revealed that the heat pads from the hydrocollator were used on 8 residents on 9 out of 18 days. Interview on 9/19/24 at approximately 10:20 a.m. with Staff B confirmed the above findings. Review on 9/19/24 of the facility policy titled, Application of Hot Packs, dated 6/25/24 revealed: .Maintenance .Hydrocollators are cleaned bimonthly and prn [as needed], according to the manufacturer specifications in the manual .

Based on interview and record review, it was determined that the facility failed to ensure that the resident and/or resident representative was provided the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) form CMS-10055 (Centers form Medicare and Medicaid) for 3 out of 3 residents reviewed for beneficiary notices.(Resident Identifiers are #39, #41, and #57). Findings include: Resident #39 Review on 9/18/24 of the Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #39's last covered day of Medicare Part A Services was on 8/7/24 and he/she remained in the facility. Review on 9/18/24 of Resident #39's beneficiary forms revealed that Resident #39 was not provided the SNF ABN form CMS-10055. Resident #41 Review on 9/18/24 of the Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #41's last covered day of Medicare Part A Services was on 6/19/24 and he/she remained in the facility. Review on 9/18/24 of Resident #41's beneficiary forms revealed that Resident #41 was not provided the SNF ABN form CMS-10055. Resident #57 Review on 9/18/24 of the Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #57's last covered day of Medicare Part A Services was on 4/1/24 and discharged home. Review on 9/18/24 of Resident #57's census tab in the electronic record revealed that Resident #57's payer changed from Medicare Part A to Private Pay on 4/2/24. Resident #57 discharged home on 4/12/24. Review on 9/18/24 of Resident #57's beneficiary forms revealed that Resident #57 was not provided the SNF ABN form CMS-10055. Interview on 9/18/24 at 12:00 p.m. with Staff C (Director of Social Services) revealed that Resident #39, #41, and #57 were provided the wrong form, form CMS-R-131 not the form CMS-10055. Review on 9/19/24 of the facility's policy titled, Discharge Care Plan Facility Policy, revised on 6/9/23, revealed: .Social Services or designee will provide Advanced Beneficiary Notice [ABN] information as required .

Based on observation, interview, and policy review it was determined that the facility failed to insure the storage of expired needles, culture swabs, dressings, and syringes according to professional standards for 2 out of 2 medication rooms and 2 out of 2 treatment carts reviewed for storage of medical supplies. Findings include: Observation on [DATE] at 8:45 a.m. of the East Wing medication room with Staff B (RN Unit Manager) revealed the following: -Ten blue cap culture swabs containing liquid medium with manufacturer's expiration date of [DATE] -Nine red cap culture swabs containing liquid medium with manufacturer's expiration date of [DATE] -Four individual needles with a manufacturer's expiration date of ,d+[DATE]. Observation on [DATE] at 8:50 a.m. of the East Wing's Treatment Cart revealed two (2) 28 gauge TB ([MEDICATION(S)]) syringes with a manufacturer's expiration date of [DATE] Interview on [DATE] at 8:50 a.m. with Staff B confirmed that the culture swabs and needles should not have been in the medication room or on the treatment cart if they were expired. Observation on [DATE] at 10:00 a.m. of the West Wing Medication Room twenty-Five (25) TB syringes with 1 ml (milliliter) with manufacturer's expiration date of [DATE]. Thirty (30) 10 ml luer lock syringes without needles with a manufacturer's expiration date of [DATE] Interview on [DATE] at 10:10 a.m. with Staff D confirmed the above findings and that they should have been discarded. Observation on [DATE] at 10:10 a.m. of the West Wing Treatment cart revealed eighteen (18) Simplicity Foam Dressings with a manufacturer's expiration of [DATE] Interview on [DATE] at 10:10 a.m. with Staff D confirmed the above findings and stated that they should not have been in the treatment cart if they were expired. Review on [DATE] of the facility's policy Storage and Expiration Dating of Medications, Biologicals revised on [DATE] revealed, . This Policy . sets for the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles . Procedure . 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are store separate from other medications until destroyed or returned to the pharmacy or supplier . 17. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. 18. Facility should request that Pharmacy perform a routine nursing unit inspection for each nursing station in Facility to assist Facility in complying with its obligations . Review on [DATE] of the Center for Disease Control and Prevention retrieved from https://www.CDC.gov/vaccines/hcp/admin/prepare-vaccines.html revealed .5. Always check the expiration dates on the vaccine and diluent, if needed. Some syringes and needles have expiration dates, so check those too. Never use expired vaccine, diluent or equipment . Review on [DATE] of the Manufacturer's BD ([NAME]) BBL CultureSwab Plus- 6 Vitality Medical with a revision date of ,d+[DATE], revealed .Frequently Asked Questions . How Long is a culture swab good for? Healthcare professionals should always check the expiration date on the box or swab itself before use . Expired culture swabs should not be used .

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that expired medications, were not kept longer than the manufacturer's or supplier guidelines, for 1 out of 2 medication rooms and 1 out of 2 treatment carts observed for medication storage. Findings include: Observation on 8/23/22 at 9:00 a.m. of the Ease Wing Treatment cart with Staff B (Registered Nurse) revealed two (2) open bottles of Vashe Wound Solution 4 oz (ounces) one with a manufacturer's expiration date of 3/2022 and one with a manufacturer's expiration date on 1/2022. Further observation revealed an unopened bottle of Mineral Oil Lubricant [MEDICATION(S)] with manufacturer's expiration date of 8/2021. Interview on 8/23/22 at 9:00 a.m. with Staff B (Registered Nurse) confirmed the Vashe Wound Solution was in current use and that the expired Mineral Oil should not have been in the treatment cart. Observation on 8/23/22 at 10:00 a.m. of the West Wing Medication Room with Staff D (Unit Manager) revealed that in the refrigerator were eighty-four (84) single dose syringes of Influenza Vaccine with a manufacturer's expiration date of 6/2022. Interview on 8/23/22 at 10:10 a.m. with Staff D confirmed the above findings. Review on 8/25/22 of the facility's policy Disposal/Destruction of Expired or Discontinued Medications revised on 1/1/22 revealed, .Procedure .4. Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction . Review on 8/25/22 of the facility's policy Storage and Expiration Dating of Medications, Biologicals revised on 7/21/22 revealed, . This Policy . sets for the procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles . Procedure . 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacture or supplier guidelines; or (3) have been contaminated or deteriorated, are store separate from other medications until destroyed or returned to the pharmacy or supplier . 17. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. 18. Facility should request that Pharmacy perform a routine nursing unit inspection for each nursing station in Facility to assist Facility in complying with its obligations . Review on 8/26/22 of the Center for Disease Control and Prevention retrieved from https://www.CDC.gov/vaccines/hcp/admin/prepare-vaccines.html revealed .5. Always check the expiration dates on the vaccine and diluent, if needed. Some syringes and needles have expiration dates, so check those too. Never use expired vaccine, diluent or equipment .

Based on interview and record review, it was determined that the facility failed to ensure that the MDS (Minimum Data Set) was accurate for 3 residents in a final sample of 16 Residents (Resident Identifiers are #3, #11, and #29). Findings include: Resident #3 Review on 8/25/22 of Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/11/2022 revealed in Item N0410A Medication Received: Days: Antipsychotics was coded as 7, which indicated that the resident received an antipsychotic medications in the past seven days (of the ARD). Review of 8/25/22 of Resident #3's May 2022 MAR (Medication Administration Record) revealed that there was no antipsychotic medication documented as being administered and no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 8/25/22 at 11:58 a.m. with the with Staff A (MDS Coordinator) confirmed that Resident #3 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11 Review on 8/25/22 of Resident #11's Quarterly Minimum Data Set (MDS) with an ARD of 5/25/2022 revealed in Item N0410E Medication Received: Days: Anticoagulant was coded as 7, which indicated that the resident received anticoagulant medications in the past seven days (of the ARD). Review of 8/25/22 of Resident #11's May 2022 MAR (Medication Administration Record) revealed that there was no anticoagulant medication documented as being administered and no physician's order for an anticoagulant medication. Interview on 8/25/22 at 11:56 a.m. with the with Staff A (MDS Coordinator) confirmed that Resident #11 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #29 Review on 8/24/22 of Resident #29's Quarterly MDS with an ARD of 6/29/22 revealed in Section N0410C Medication Received: Days: Antidepressant was coded as 7 which indicated that the resident received antidepressant medications in the past seven days (of the ARD) Review on 8/24/22 of Resident #29's June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 8/25/22 at 11:53 a.m. with Staff A confirmed that that Section N0410C Medications Received: Days: Antidepressant of Resident #29's most recent Quarterly MDS was marked in error and should have been coded as 0.

Based on observation and interview, the facility failed to provide a clean, comfortable, and homelike environment in the activities room. Findings include: Observation on 7/8/21 at approximately 10:15 a.m. in the East Unit Activities Room revealed ceiling areas that had water staining, damage and were falling apart around the ceiling skylights. Observation on 7/8/21 revealed 6 water stained areas with sheet rock peeling around the main ceiling skylight, 8 stained ceiling tiles on the west side of the room and 2 water stained ceiling tiles on the east side of the room. Interview on 7/8/21 at approximately 11:50 a.m. with Staff F (Administrator), Staff G (Director of Nursing) and Staff H (Maintenance Director) confirmed the above findings.

Based on observation, interview and record review, the facility failed to follow physician's orders for 1 of 1 resident reviewed for wounds in a final sample of 17 residents. (Resident identifier #16). Findings include: Practice Standard: Patricia A. Potter & Ann Griffin Perry, Fundamentals of Nursing. 7th edition St. Louis, Missouri: Mosby Elsevier, 2009 Page 336. .Physicians' Orders. The physician is responsible for directing medical treatment . Observation on 7/7/21 at approximately 9:45 a.m. of Resident #16 revealed a dressing on their right outer elbow with no date or initials. Observation on 7/8/21 at approximately 9:10 a.m. of Resident #16 revealed a dressing on their right outer elbow with no date or initials. Review on 7/8/21 at approximately 9:15 a.m. of Resident #16's medical record revealed no progress notes identifying an area to their right outer elbow. Further review of record revealed no current treatment orders for the right outer elbow area. Review on 7/8/21 at approximately 9:15 a.m. of Resident #16's most recent weekly bath skin assessment dated [DATE], revealed no skin conditions observed. Observation on 7/8/21 at approximately 9:20 a.m. of Resident #16's area on right outer elbow with Staff A (unit manager) revealed area to be closed with dried drainage on old dressing and small area scabbed at lower aspect of wound. Interview on 7/8/21 at approximately 9:20 a.m. with Staff A confirmed above findings. Review on 7/9/21 of facility Policy titled Skin/Wound Care Protocol revised 7/18/19, revealed .1. When a skin issue is initially observed the licensed nurse will immediately initiate treatment and documentation via incident report and progress note. Orders for treatment will be obtained to ensure continuation of treatment .

Based on observation, interview, and record review the facility failed to properly clean the fryolator and surrounding area in the main kitchen. Findings include: Observation on 7/7/21 at approximately 1:15 p.m. in the main kitchen revealed an approximately 18 inch by 6 inch black, greasy fry oil like build up on the ground directly under the fryolator, and a greasy soiled build up along the entire backside of the fryolator and on the top surface of the utility lines running into the fryolator. Interview on 7/7/21 at approximately 1:20 p.m. with Staff D (Floating Chef) confirmed the above findings. Interview on 7/7/21 at approximately 1:45 p.m. with Staff C (Food Services Director) confirmed the above findings. Staff C further confirmed that it had been cleaned approximately 2 weeks ago. Review on 7/7/21 of the Fryer Cleaning Policy revised 6/23/21 revealed that it did not include any mention of cleaning behind or below the fryolator. Review on 7/7/21 of Kitchen Cleaning Schedule revealed .Saturday-Fryolator . with no mention of what areas of the fryolator should be cleaned.

1. Based on observation, interview and standards review, the facility failed to adhere to infection control practices for universal masking recommend by the Centers for Disease Control and Prevention (CDC) during observation on 1 of 2 units. Observation on 7/8/21 at approximately 11:14 a.m. of the west unit, birch hall, revealed Staff B (dietary aide) walking from the serving station, down the birch hall with mask under chin eating a cookie as they pushed a cart down the hall past 3 residents and 6 rooms. When approached by surveyor they pulled their mask up over mouth but leaving nose exposed. Interview on 7/8/21 at approximately 11:14 a.m. with Staff B revealed that they were aware of the mask mandate in the facility and were aware that the mask needed to cover the nose and mouth. Interview on 7/8/21 at approximately 1:00 p.m. with Staff C (Infection Preventionist) revealed that all staff are to be wearing a mask covering mouth and nose when in the facility and in patient areas. Review on 7/9/21 at approximately 9:00 am of Staff B education files revealed that they had been last educated and competency for PPE (person protective equipment) on 6/10/21, Further review of Staff B education file revealed that on 4/20/21 they had acknowledged education on how COVID-19 (coronavirus disease 2019) is spread, how to protect yourself and others, PPE use and facemask do's and don'ts. Review on 7/9/21 at approximately 9:00 a.m. of employee COVID-19 vaccination list revealed that Staff B declined COVID-19 vaccine when offered. Review on 7/9/21 of the CDC (Centers for Disease Control and Prevention) website titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated February 10, 2021,retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html revealed the following: .Source control refers to use of well-fitting cloth mask, face mask, or respirators to cover a person's mouth and nose to prevent the spread of respiratory secretions when they are breathing, talking, sneezing, or coughing .HCP [healthcare personnel] should wear a well-fitting source control at all times while they are in the healthcare facility . 2. Based on observation, interview and record review, the facility failed to adhere to infection control practices for Coronavirus 2019 (COVID-19) symptom screening for all residents recommended by the Centers for Disease Control and Prevention (CDC) in a facility with a census of 67 residents. Interview on 7/8/21 at approximately 11:00 a.m. with Staff A (unit manager), revealed that resident VS (vital signs) are monitored daily and recorded in a log book that is kept at each nurses desk. Staff A stated an assessment for COVID-19 (coronavirus 2019) symptoms is completed and documented in same location only when there is an outbreak. Review on 7/8/21 at approximately 11:00 a.m. of the West unit VS book revealed that each resident on the unit had daily VS tracking completed. Further review of VS revealed that the temperature, pulse, respiration rate, blood pressure and oxygen saturation are monitored on the VS tracking record. Further review revealed no further COVID-19 symptom monitoring is being documented. Interview on 7/9/21 at approximately 11:45 a.m. with Staff I (Assistant Director of Nursing) stated that the last time COVID-19 symptom monitoring was completed for facility residents was during their last outbreak in May 2021. Staff I stated that VS are monitored daily and documented in a binder on each unit. Interview on 7/9/21 at approximately 12:00 p.m. with Staff G (Director of Nursing) revealed that VS are monitored daily for each resident. If any abnormal vital signs are noted then staff would also complete a COVID-19 symptom assessment and document by exception in the resident record. Review on 7/9/21 of Centers for Disease Control and Prevention (CDC) website titled, Testing guidelines for nursing homes, updated January 7,2021, retrieved from, https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-testing.html revealed .At least daily, take the temperature of all residents and ask them if they have any COVID-19 symptoms . Review on 7/9/21 of Centers for Disease Control and Prevention (CDC) website titled, Symptoms of COVID-19, updated February 19, 2021, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html revealed .People with COVID-19 have a wide range of symptoms .People with these symptoms may have COVID-19: fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, and/or Diarrhea .

Based on medical record review, interview and policy and procedure review, it was determined that the facility failed to ensure respiratory care is provided for 1 out of 2 residents reviewed for respiratory care in a final sample of 19 residents. (Resident identifier is #7.) Findings include: Review on 12/6/19 of Resident #7's current physician orders [REDACTED]. Fill portable 02 (oxygen) tanks prior to end of shift every day shift, dated 9/6/19. 02 @ 3L/min (Liters per minute) via (by means of) n/c (nasal cannula) continuously while at rest, 4 L/min when ambulating, dated 3/29/19. Review on 12/5/19 of Resident #7's nursing notes revealed the following: Nursing note dated 9/5/19 at 15:55, Resident upset and complained to staff that 02 tanks are empty and not being filled consistently. Task entered for LNA's (Licensed Nursing Assistant) to fill prior to end of shifts. Nursing note dated 11/1/19 at 13:57. Call from social services stating that (pronoun omitted) was having SOB (shortness of breath) and c/o (complaints of) chest pain. VS (vital signs) 98.2 65 20 140/44 92% room air. Noted oxygen tank empty. Oxygen tanks filled by LNA (Licensed Nursing Assistant). After sitting for a while was feeling better. Able to walk to room (short distance) and was put on the wall 02 (oxygen). Review on 12/6/19 of Resident #7's oxygen care plan revealed the following: Focus Oxygen: I require oxygen therapy related to my [DIAGNOSES REDACTED]. Interventions, . Observe oxygen precautions. Keep portable 02 tanks filled at all times and anticipate the need to refill prior to shift change. Review on 12/6/19 of the liquid oxygen tank duration chart which was provided by the facility revealed the following: Portable oxygen tanks at 3 lpm (liters per minute) have a run time of 5.3 hours. Portable oxygen tanks at 4 lpm have a run time of 4.1 hours. Review on 12/6/19 of the facility's policy and procedure titled, Liquid Oxygen [MEDICATION NAME], revision date 7/7/19 revealed: .Monitoring . 3. The LNA assigned to the resident who is using liquid oxygen portable canister is responsible for checking the oxygen level in the canister during care. If the oxygen level is found to be one-quarter or less, the canister shall be refilled Interview on 12/6/19 at approximately 9:15 a.m. with Staff A (Unit Manager) revealed that there would be a 1-2 hour window that Resident #7's portable oxygen tank would be empty on a regular basis due to lpm's that the resident is on. Interview on 12/6/19 10:45 AM interview with Staff B (Director of Nursing) revealed that the LNA's are filling the 02 tanks at the end of each shift.

Based on interview, record review, policy and procedure review and review of manufacturers instructions it was determined that the facility failed to ensure that 1 resident out of 4 residents reviewed for falls were free from falls and accidents in a final survey sample of 19 residents. (Resident identifier is #91). Findings include: Interview on 12/4/19 at approximately 9:15 a.m. with Resident #91 revealed, I slid right out off of my pad out of my chair yesterday. Review on 12/5/19 of the post fall report dated 12/3/19 revealed: .Describe incident (FACTS ONLY) include injuries sustained): Scooting forward in wheelchair from middle of room to get to (pronoun omitted) lunch, lift pad in wheelchair, fell on floor Interview on 12/6/19 at approximately 9:00 a.m. with Staff A (Unit Manager) revealed that lift pads are not left under residents in wheelchairs unless they have been assessed and it is care planned. Staff A confirmed that Resident #91 had not been assessed and was not care planned to leave the lift pad on after transfer to wheelchair. Review on 12/6/19 of the manufacturers instructions for the Vancare Lift, dated (MONTH) (YEAR) revealed: .Leaving slings positioned under patients in wheelchairs, etc. There are times when leaving the sling under a patient while he or she is seated in a wheelchair or chair would promote patient comfort and would enable staff to provide care. Before this can be done, however, the patient's posture must be evaluated by a nurse or professional rehabilitation department staff member to see if leaving the sling under the patient might contribute to the patient sliding out of, or falling off of, a wheelchair or chair. Secondly, the patient's clothing, the sling fabric, and the surface of the chair or wheelchair must be assessed for slipperiness. WARNING If leaving the sling under the patient places the patient at risk for sliding out of, or falling off of, the chair or wheelchair, the sling may not be left under the patient Interview on 12/6/19 at approximately 10:30 a.m.with Staff B (Director of Nurses) confirmed that the lift pad should not have been left under Resident #91 after the transfer to the wheelchair. Staff B revealed that there was no assessment done by therapy or nursing to evaluate Resident #91's safety to leave the lift pad on after transfer. Review on 12/6/19 of the facility's policy and procedure titled, Transfer, Transport, and Repositioning of Residents-Minimal Lifting, Revision date 8/5/19 revealed: .Procedure 1. Transfer of a Resident .c.ii. Use mechanical lifting devices and other approved resident handling aids in accordance with instructions and training

Based on interview it was determined that the facility failed to retain the posted daily nursing staff data for a minimum of 18 months. Findings include: Interview on 12/6/19 at approximately 1:00 p.m. with Staff B (Director of Nursing) revealed that the facility was unable to produce any daily posting of nursing staff to review except for today. Staff B stated the the facility does not retain the posted daily nursing staff data and these postings are thrown out.

Based on interview and review of the facility daily nursing department schedules, it was determined that the facility failed to ensure that a Registered Nurse was on duty 8 consecutive hours a day 7 days a week. Findings include: Review on 12/6/19 of the facility daily nursing department schedules revealed that there was no Registered Nurse (R.N.) scheduled on duty for three shifts, 7A-3P . 3P-11P . 11P-7A, on both the East and West units on the following days: - Sunday, (MONTH) 19, 2019 - Sunday, (MONTH) 25, 2019 - Sunday, (MONTH) 3, 2019 Review on 12/6/19 of the facility daily nursing department schedules revealed that there was no Registered Nurse scheduled on duty for two shifts, 3P-11P . 11P-7A and the R.N. scheduled 7A-3P scheduled 7 hours, 7a-2p and not 8 consecutive hours on Saturday, (MONTH) 19, 2019. Interview on 12/6/19 at 1:00 p.m. with Staff B (Director of Nursing) confirmed that there was no R.N. on duty for 8 consecutive hours on the three days listed in the above findings. Staff B also confirmed that the R.N. on duty for Saturday, (MONTH) 19, 2019 was scheduled for 7 hours and there was no R.N. on duty for 8 consecutive hours on Saturday, (MONTH) 19, 2019.

Based on record review and interview, it was determined that the facility failed to have evidence that alleged violations were thoroughly investigated for 1 of 19 residents in the final sample. (Resident identifier is #35.) Findings include: Review on 10/05/18 at 10:13 a.m. of Resident #35's Behavior/Intervention Monthly Flow Record for (MONTH) (YEAR) revealed 5 of 30 days (9/4/18, 9/6/18, 9/9/18, 9/14/18, and 9/20/18) in which Resident #35 kissed 1 or 2 female residents and 1 of 30 days (9/19/18) in which Resident #35 got into bed with another resident. Review on 10/5/18 at 11:50 a.m. of Resident #35's nursing notes from 9/4/18 revealed the following: Resident kissed 2 residents in dayroom. (Initials removed) (who was very upset at (pronoun removed) . There were no other nursing notes for the above incidents when Resident #35 kissed residents or when Resident #35 got into bed with another resident. There was no indication who the above residents were and no evidence that an assessment was done to determine if the behaviors were unwanted or if the residents were impacted negatively. Interview on 10/5/18 at 12:30 p.m. with Staff D (Director of Nursing) confirmed the above findings and revealed that the above behaviors were not reported to the State Agency. Interview also revealed that Staff D would report and investigate the above behaviors if the resident that was kissed or crawled into bed with were psychologically impacted. Interview on 10/5/18 at 1:30 p.m. with Staff C (Unit Manager) revealed that when Staff C intervenes with Resident #35's above behaviors, Staff C made sure the residents that are being kissed were okay.

Based on record review and interview, it was determined that the facility failed to provide form NOMNC (CMS Notice of Medicare Non-Coverage), for 2 out of 3 residents reviewed for Beneficiary Protection Notification. (Resident identifiers are #26 and #46). Findings include: On 10/4/18 at approximately 11:00 am, a Beneficiary Protection Notification Review was conducted on 3 resident records requested. As per record review on 10/4/18 at approximately12:30 pm and interview with Staff A (Administrator) on 10/4/18 at approximately 1:00 pm, it was revealed that Resident #26 and Resident #46 remained in the facility but were reaching their last covered day of Medicare Part A services. Resident #26 and Resident #46 were only issued a SNF ABN (Skilled Nursing Facility Advanced Beneficiary Notice form CMS- ), which informs the beneficiary of any liability for payment of any services that the beneficiary wants to continue that will no longer be covered by Medicare. Resident #26 and Resident #46 were not issued a NOMNC (Notice of Medicare Non-Coverage) which informs the beneficiary of their rights to an expedited review of a service termination, but does not fullfill the obligation of the facility to inform the beneficiary of any liability for payment for continued services. Facilities are required to provide both forms SNFABN and NOMNC in this instance. Interview with Staff A, Administrator revealed that the facility misunderstood the requirements for which forms were to be provided for their residents when Medicare Part A services were ending. After Staff A reviewed the requirements, Staff A agreed with the above statements regarding issuing of the NOMNC.

Based on observation, interview, and record review, it was determined that the facility failed to have smoking policies and procedures that address that individual's risk of smoking for 1 of 1 resident reviewed who smoked. (Resident identifier is #23.) Findings include: Interview on 10/4/18 at 9:55 a.m. with Resident #23 revealed Resident #23 goes outside to the designated smoking area to smoke. Resident #23 revealed they can not keep their cigarettes or lighter on their person and can only smoke if a friend or family member is outside with them. Review on 10/5/18 at 9:49 a.m. of Resident #23's assessments revealed no smoking assessment. Review of Resident #23's current care plan revealed no goals/interventions for smoking. Review of Resident #23's demographics revealed that Resident #23 was admitted to the facility on [DATE]. Observation on 10/5/18 at 11:30 a.m. revealed Resident #23 was outside smoking with a man in the designated smoking area (in front of the facility at a bench and an ash tray). Review on 10/5/18 at 12:00 p.m. of the policy titled Resident Smoking Policy, last revised 3/1/16, revealed the following: Our facility has been designated a resident smoke-free facility as of 6/1/08., 2. Smoking materials, matches, lighters or any other incendiaries devices may not be kept in the resident's room or nursing home common area., and Residents may smoke outside the facility, at least twenty-five (25) feet away front he building, with the supervision of a family member. The facility's smoking policy did not address assessing the resident's ability to independently smoke. Interview on 10/5/18 at 12:45 p.m. with Staff D (Director of Nursing) confirmed that there was no smoking assessment or care plan interventions for smoking for Resident #23. Interview revealed that the facility does not do a smoking assessment on residents who smoke because they require a resident to smoke with a friend or family member and do not allow residents to have smoking materials. Observation on 10/5/18 at 3:36 p.m. revealed Resident #23 sitting outside at the above designated smoking area. Resident #23 took a cigarette out of their pocketbook and put it in (pronoun removed) mouth until a woman arrived to smoke with resident.

Based on observation, medical record review and interview it was determined that the facility failed to accurately code the Minimum Data Set (MDS) of two residents in a survey sample of 19 residents. (Resident identifiers are #11 and #84.) Findings include: Resident #11 Observation on 10/3/18 at 11:45 AM of Resident #11 revealed no presence of a [MEDICAL CONDITION] or the aftermath of tissue disruption indicative of the resident having had a recent [MEDICAL CONDITION]. Interview with Resident #11 at the same time as the observation reveal Resident #11 denial that they ever had a [MEDICAL CONDITION]. Review on 10/4/18 review of Resident #11's medical record of revealed no documentation that Resident #11 had a tracheosteomy. Review of Resident #11's Admission MDS dated [DATE] revealed that in Section O; question 0100; line E; under the column 'While a Resident', Resident #11 was coded 'Yes' as to receiving trachostomy care at the time the entry was made. Resident #84 Observation on 10/3/18 at 12:17 AM of Resident #84 revealed no presence of restraints. Review of Resident #84's living accommodations revealed no use of restraints. Short siderails were noted in use on Resident #84's bed, and the bed was not located against the wall on either of the sides of the bed. Review on 10/4/18 at approximately 10:00 AM of Resident #84's medical record and the care plan revealed that Resident #84 was not subjected to restraints. Review of Resident #84's 5-Day MDS assessment dated [DATE] revealed that in Section P; question 0100; line H (Other), Resident #84 was coded 'Used Daily' as to receiving restraint care. Interview on 10/5/18 at 2:30 PM with Staff E, RN (Registered Nurse), revealed that the two entries were coded incorrectly for Residents #11 & #84. When asked if there was a process in place to ensure the accuracy of entries in to the MDS template, Staff E replied that there was no such process.

Based on interview and record review it was determined that the facility failed to fully inform residents of the risk of treatment from [MEDICAL CONDITION] medications for 4 of 4 residents reviewed in a standard survey sample of 19. (Resident identifiers are #26,#53, #35, #39) Findings include: Resident #53 Review on 10/5/18 at approximately 10:30 a.m. of Resident #53's medical record revealed that Resident #53 had a physician's orders [REDACTED].#53 has a [DIAGNOSES REDACTED]. Review on 10/5/18 at approximately 10:45 a.m. of Resident #53's informed consent for Psychopharmacologic medication revealed the boxes indicating that the resident or representative was given information pertaining to the black box warning associated with [MEDICATION NAME], Trazadone, [MEDICATION NAME], and [MEDICATION NAME] were not checked off. Interview on 10/5/18 at approximately 10:45 a.m. with Staff B (Unit Manager) revealed that the staff would check off the boxes to indicate the resident or representative was given information pertaining to black box warnings. Staff B confirmed that the boxes were not checked off on Resident #53's informed consent for [MEDICATION NAME], Trazadone, [MEDICATION NAME], and [MEDICATION NAME]. Resident #35 Review on 10/5/18 at 2:37 p.m. of Resident #35's physician orders [REDACTED].#35's Medication Administration Record [REDACTED]. Review on 10/5/18 at 2:40 p.m. of Resident #35's Informed Consent for Psychopharmacologic Medication, dated 2/2/18, signed by the Power of Attorney, revealed the boxes indicating that the resident or representative was given information pertaining to the black box warning associated with [MEDICATION NAME] were not checked off. Interview on 10/5/18 at approximately 2:45 p.m. with Staff C (Unit Manager) revealed that staff would check off the boxes to indicate the resident or representative was given information pertaining to black box warnings. Staff confirmed that the boxes were not checked off on Resident #35's informed consent for [MEDICATION NAME]. Resident #39: Record review on 10/5/18 at approximately 1:00 pm for Resident #39 revealed a consent form dated 6/15/17 signed by the resident for the Antipsychotic medication [MEDICATION NAME] 25 mg (milligrams), 1 tab PO (by mouth) BID (twice per day), and [MEDICATION NAME] 50 mg PO at HS (Bedtime). Further record review at the same time revealed that there were lines with check boxes on the consent form that were meant to indicate that the responsible party/parties had received the required information in order to make an informed consent to the use of this drug, and, that the Black Box Warning had been clearly explained in order to provide an informed concent for the resident to receive the drug. The check boxes that indicate that a copy of the FDA Patient Information Sheet, and FDA warning letter (Black Box Warning) for the drug were left blank, and, as a result, the consent form did not indicate that the responsible party/parties had the information necessary to make an informed decision regarding consent for the resident to receive this medication. Interview with Staff D (Director of Nursing) revealed that this form was not utilized as it was designed to be, and therefore, does not indicate that the responsible parties had the information necessary to make an informed decision regarding consent for the resident to receive this medication. Resident #26 Review on 10/5/18 at approximately 2:05 PM of Resident #26's medical record revealed a Psychopharmacological Medication-Informed Consent for the use of [MEDICATION NAME] for the condition of Alzheimer/Dementia with Behaviors. The consent had a telephone consent dated 11/1/16 and a signature from Resident #26's Responsible Party dated for 11/4/16. There is no documentation in the medical record that the Responsible Party was provided information that users of Antipsychotic medication experienced increased rates of mortality (Food & Drug Administration Mortality Warning). Interview on 10/5/18 at 2:45 PM with Staff C (Unit Manager) regarding the lack of documentation that residents and their responsible parties are informed about the FDA mortality warning when notified of the addition or change of psychopharmacologic medication to a resident's pharmacy orders. Staff C confirmed that the unit staff did not document that the FDA Mortality Warning was provided when obtaining consent from responsible parties.

Based on record review and interview, the facility failed to implement its written policies and procedures that prohibit neglect of a resident to provide a safe method of transfer and transport and to provide appropriate post fall assessment and treatment for 1 resident that sustained a [MEDICAL CONDITION]. (Resident identifier is: #1.) Findings include: Review on 11/3/10 of the facility policy and procedure titled "Fall Assessment and Treatment" with revision date of 1/21/10 indicates that it is the policy of the facility to assess all residents after they have incurred any type of fall. Under the heading "Procedure" it indicates the following: 1. Keep the resident on the floor, comfortable and warm. Do not move (underlined) the resident until a full assessment has been completed. 2. Physical assessment will include a body check to assess for cuts, bruising, vital signs, capillary blood glucose, level of consciousness, range of motion and any abnormalities. 4. If there is no apparent injury the resident will be transported according to the nurse's professional judgment... Review of the facility policy and procedure titled "Transfer, Transport, and Repositioning of Residents-Minimal Lifting" with revision date of 7/30/10 indicates that it is the policy of the facility to provide safe methods of transfer and transport of residents at all times. Under the heading "Procedure" it indicates the following: 1. Transfer of a resident- b. It is the duty of employees to take reasonable care of their own health and safety, as well as that of their co-workers and their residents during resident handling activities by following this policy. c. Patient handling and movement requirements: i. Avoid hazardous resident handling and movement tasks whenever possible...ii. Use mechanical lifting devices and other approved resident handling aids in accordance with instructions and training. 2. Gait Belt Policy a. Gait belts are used to transfer and ambulate all residents who require hands on assistance with mobility... Review of Resident #1's medical record on 11/3/10 reveals that Resident #1 has [DIAGNOSES REDACTED]. Care plan with review date of 7/19/10 indicates that Resident #1's locomotion requires extensive assist of 1 in room with gait belt, wheelchair use in corridors able to self propel short distances, wheeled by other for long distances. Review of Resident #1's nurses notes dated 8/1/10 at 10:30 p.m. indicates that while LNA assisting for bed Resident #1 yelling out and saying legs hurt, given scheduled Tylenol at 9:00 p.m. resident continued to yell out in bed saying it hurt in different areas. Nurses note dated 8/2/10 at 9:00 a.m. indicates left hand swollen and bruised, tender to touch. X-ray obtained with results phoned to facility at 3:20 p.m., no acute fracture. Nurse's notes at 3:30 p.m. indicate that Resident #1 is crying in pain on left lower leg unable to touch left leg due to crying out in pain. Left hip is noted to be internally rotated and Resident #1 is unable to straighten leg. Medical doctor notified and order to send to emergency room for evaluation with Resident #1 being transferred at 5:00 p.m. to hospital. At 9:45 p.m. nurses note indicates a call to hospital to check status and informed by emergency room that Resident #1 has a left [MEDICAL CONDITION] and another X-ray at the hospital revealed a fractured left fourth finger and that Resident #1 was being admitted . Review of the facility investigation reveals documented statements that on 8/3/10 at 7:15 a.m. Staff F, RN was giving report to the LNA's regarding Resident #1 going to the hospital on the evening of 8/2/10 and the finding of a [MEDICAL CONDITION] when Staff C, LNA left the nurses station and started to cry. Staff C reported having something to tell Staff F about Resident #1. Staff C reported that on 8/1/10 at 5:20 p.m. Resident #1 had slid out of the wheelchair when returning from dinner in the center hallway. Staff C had a trainee Staff D, LNA along side who was wheeling Resident #3. Staff C indicated that Staff C was pushing Resident #2 in a wheelchair and pulling Resident #1from behind Staff C at the same time in a wheelchair by the front arm rest and began having difficulty steering the pushing of Resident #2 and pulling of Resident #1. Staff C then told Resident #1 to grab onto the tail of the gait belt that Staff C was wearing and then as they proceeded Resident #1 lunged forward (in attempt to regrasp the tail end of the gait belt) and fell on to the floor onto left side. Staff C asked Resident #1 if Resident #1 was alright with Resident #1 indicating yes and then Staff C grabbed Resident #1 under the arms and lifted up to standing upright and then Staff s placed arm's around Resident #1's waist without the use of a gait belt and asked Staff D, LNA to put the wheelchair behind Resident #1. Staff C then went back to pushing and pulling both Resident #1 and #2 at the same time. Staff C indicates informing Staff E, RN about the incident however Staff E indicates that Staff C told Staff E that while pushing Resident #2 and pulling Resident #1 in their wheelchairs Resident #1 had slid forward in the wheelchair and needed to be pulled back into the chair but did not fall. Staff E informed Staff C never to transport two residents at one time. Review of Resident #1's medical record reveals no documented evidence of Resident #1 having had a fall. A statement from Staff G, LNA indicates that Staff G and Staff H, LNA put Resident #1 to bed the evening of 8/1/10 using the sit to stand lift and were not told that Resident #1 had fallen earlier. Staff I, LPN indicates in a statement that Staff H on 8/1/10 reported that Resident #1 is moaning and yelling out when transferring more that usual and saying that knee hurts. Staff I went into Resident #1's room Resident #1 was in bed saying "owww, owww" when asked where pain is Resident #1 was not able to be specific indicating my neck, my back, my knees and asked Resident #1 if had fallen and stated "yeees and then noooooo my back." Staff I went to Staff E and asked if this was Resident #1's normal behavior and Staff E said yes Resident #1 has anxiety with transfers as afraid of falling and yells out. During interview with Staff A, Administrator and Staff B both confirmed that Resident #1 had a 24 hour delay in treatment as a result of a Resident #1's fall being unreported During observation of a surveillance video on 11/3/10 and interview with Staff B, DON Staff B indicated that the incident was viewed on surveillance camera verifying Resident #1's fall forward out of wheelchair to floor on left side and Staff C's inappropriate handling of a resident during transport and adherence to policy and procedures of gait belt use and placement of resident back into wheelchair post fall without nurse assessment. .

Based on medical record review and interview the facility failed to provide the necessary care and services for the control of pain after sustaining an unreported fall for 1 resident in an investigation survey. (Resident identifier is #1.) Findings include: Review of Resident #1's medical record on 11/3/10 reveals that Resident #1 has [DIAGNOSES REDACTED]. The care plan with review date of 7/19/10 indicates that Resident #1's locomotion requires extensive assist of 1 in room with gait belt, wheelchair use in corridors able to self propel short distances, wheeled by other for long distances. Review of Resident #1's medical record reveals no documented evidence of Resident #1 having had a fall until 8/3/10. Review of facility investigation reveals statements indicating that Staff G, LNA and Staff H, LNA put Resident #1 to bed the evening of 8/1/10 using the sit to stand lift and were not told that Resident #1 had fallen earlier. Staff I, LPN indicates in a statement that Staff H on 8/1/10 reported that Resident #1 is moaning and yelling out when transferring more that usual and saying that knee hurts. Staff I went into Resident #1's room, Resident #1 is in bed saying "owww, owww" when asked where pain is Resident #1 was not able to be specific indicating my neck, my back, my knees and was asked if had fallen and Resident #1 stated "yeees and then noooooo my back." Staff I went to Staff E and asked if this was Resident #1's normal behavior and Staff E said yes Resident #1 has anxiety with transfers as afraid of falling and yells out. Review of Resident #1's nurses notes dated 8/1/10 at 10:30 p.m. indicates that while LNA assisting for bed Resident #1 yelling out and saying legs hurt, given scheduled Tylenol at 9:00 p.m. resident continued to yell out in bed saying it hurt in different areas. Nurses note dated 8/2/10 at 9:00 a.m. indicates left hand swollen and bruised, tender to touch. X-ray obtained with results phoned to facility at 3:20 p.m., no acute fracture. Nurse's notes at 3:30 p.m. indicate that Resident #1 is crying in pain on left lower leg unable to touch left leg due to crying out in pain. Left hip is noted to be internally rotated and Resident #1 is unable to straighten leg. Medical doctor notified and order to send to emergency room for evaluation with Resident #1 being transferred at 5:00 p.m. to hospital. At 9:45 p.m. nurses note indicates a call to hospital to check status and informed by emergency room that Resident #1 has a left [MEDICAL CONDITION] and a fractured left fourth finger and being admitted . The facility investigation of 8/3/10 reveals that on 8/1/10 at 5:20 p.m. Resident #1 had slid out of the wheelchair returning from dinner in the center hallway. The incident was viewed on the facility surveillance camera verifying Resident #1's fall forward out of wheelchair to floor on left side with Staff C, LNA inappropriately handling Resident #1 during transport and failed to adhere to policy and procedures of gait belt use and placement of resident back into wheelchair post fall without nurse assessment. Staff C indicates informing Staff E, RN about the incident however Staff E indicates that Staff C told Staff E that while pushing Resident #2 and pulling Resident #1 in their wheelchairs Resident #1 had slid forward in the wheelchair and needed to be pulled back into the chair but did not fall. During interview on 11/3/10 with Staff A, Administrator and Staff B both confirmed that Resident #1 sustained a fall with a 24 hour delay in treatment as a result of Resident #1's fall being unreported by Staff C until 8/3/10.

Based on observation, interview and record review the facility failed to ensure that the resident environment remains as free of accident hazards as possible and that a resident receives adequate supervision and assistance devices to prevent accidents for 1 resident that sustained fractures. (Resident identifier is: #1.) Findings include; Review of Resident #1's medical record on 11/3/10 reveals that Resident #1 has [DIAGNOSES REDACTED]. Care plan with review date of 7/19/10 indicates that Resident #1's locomotion requires extensive assist of 1 in room with gait belt, wheelchair use in corridors able to self propel short distances, wheeled by other for long distances. Review of Resident #1's nurses notes dated 8/1/10 at 10:30 p.m. indicates that while LNA assisting for bed Resident #1 yelling out and saying legs hurt, given scheduled Tylenol at 9:00 p.m. resident continued to yell out in bed saying it hurt in different areas. Nurses note dated 8/2/10 at 9:00 a.m. indicates left hand swollen and bruised, tender to touch. X-ray obtained with results phoned to facility at 3:20 p.m., no acute fracture. Nurse's notes at 3:30 p.m. indicate that Resident #1 is crying in pain on left lower leg unable to touch left leg due to crying out in pain. Left hip is noted to be internally rotated and Resident #1 is unable to straighten leg. Medical doctor notified and order to send to emergency room for evaluation with Resident #1 being transferred at 5:00 p.m. to hospital. At 9:45 p.m. nurses note indicates a call to hospital to check status and informed by emergency room that Resident #1 has a left hip fracture and a fractured left fourth finger and being admitted . Review of facility investigation reveals documented statements that on 8/3/10 at 7:15 a.m. Staff F, RN was giving report to the LNA's regarding Resident #1 and the finding of a hip fracture on the evening of 8/2/10 at the hospital when Staff C, LNA left the nurses station and started to cry. Staff C reported having something to tell Staff F about Resident #1. Staff C reported that on 8/1/10 at 5:20 p.m. Resident #1 had slid out of the wheelchair returning from dinner in the center hallway. Staff C had a trainee Staff D, LNA along side who was wheeling Resident #3 and Staff C indicated that Staff C was pushing Resident #2 in a wheelchair and pulling Resident #1 in a wheelchair by the front arm rest behind Staff C and began having difficulty steering the pushing of Resident #2 and pulling of Resident #1. Staff C then told Resident #1 to grab onto the tail of the gait belt Staff C was wearing and as they proceeded Resident #1 lunged forward (in attempt to regrasp the tail end of the gait belt) and fell on to the floor onto left side. Staff C asked Resident #1 if alright with Resident #1 indicating yes and then Staff C grabbed Resident #1 under arms and lifted up to standing upright and then placed arm's around Resident #1's waist without the use of a gait belt and asked Staff D, LNA to put the wheelchair behind Resident #1 and then Staff C went back to pushing and pulling both Resident #1 and #2 at the same time. Staff C indicates informing Staff E, RN about the incident however Staff E indicates that Staff C told Staff E that while pushing Resident #2 and pulling Resident #1 in their wheelchairs Resident #1 had slid forward in the wheelchair and needed to be pulled back into the chair but did not fall. Staff E informed Staff C never to transport two residents at one time. Review of Resident #1's medical record reveals no documented evidence of Resident #1 having had a fall. Statement from Staff G, LNA indicates that Staff G and Staff H, LNA put Resident #1 to bed the evening of 8/1/10 using the sit to stand lift and were not told that Resident #1 had fallen earlier. Staff I, LPN indicates in a statement that Staff H on 8/1/10 reported that Resident #1 is moaning and yelling out when transferring more that usual and saying that knee hurts. Staff I went into Resident #1's room Resident #1 in bed saying "owww, owww" when asked where pain is Resident #1 was not able to be specific indicating my neck, my back, my knees and was asked if had fallen and Resident #1 stated "yeees and then noooooo my back." Staff I went to Staff E and asked if this was Resident #1's normal behavior and Staff E said yes Resident #1 has anxiety with transfers as afraid of falling and yells out. During interview with Staff A, Administrator and Staff B both confirmed that Resident #1 had a 24 hour delay in treatment as a result of Resident #1's fall being unreported During observation of a surveillance video on 11/3/10 and interview with Staff B, DON Staff B indicated that the incident was viewed on surveillance camera verifying Resident #1's fall forward out of wheelchair to floor on left side and Staff C's inappropriate handling of a resident during transport and adherence to policy and procedures of gait belt use and placement of resident back into wheelchair post fall without nurse assessment.