Every finding on record at Central Todd County Care Center

Based on observation, interview, and document review, the facility failed to ensure a resident's call light was accessible for 1 of 1 residents (R15) reviewed for call light accessibility. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 had severely impaired cognition and had a diagnosis that included Alzheimer's disease (disease that cause dementia), non-Alzheimer's dementia. R15 needed maximal assistance with toileting and touching assistance with transfers. R15's care plan revised on 1/15/26, identified R15 was at risk for falls, and staff were to reinforce the need to call for assistance. R15's fall safety assessment dated [DATE], identified R15 of having a moderate risk for falls. During an observation on 3/17/26 at 1:03 p.m., R15 was lying in bed; the call light was not accessible. The call light was clipped to the call light wire that was coming out from the wall. The call light was approximately two feet above the bed and a foot away from the end of the bed, above a small dresser. During an interview/ observation on 3/17/26 at 1:47 p.m., nursing assistant (NA)-A and NA-B, verified R15 was able to use the call light and should have access to the call light when in room. NA-A looked at R15's call light placement and verified R15's call light was not within reach and moved the call light into R15's reach. During an interview on 3/17/26 at 4:12 p.m., director of nursing (DON) indicated R15's fall interventions were appropriate and R15 was able to use the call light. DON's expectations was for staff to follow care plan interventions and to ensure R15's call light was in reach at all times to prevent falls. Facility policy titled Call Light Response dated 7/25, lack information regarding placing call light where accessible to resident.

Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented in accordance with Centers for Disease Control (CDC) guidelines for 1 of 2 (R19) residents who were reviewed for enhanced barrier precautions. Findings include: Review of Centers for Disease Control and Prevention (CDC) guidance dated 4/1/24, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions included: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. R19's quarterly Minimum Set Data dated 1/27/26, identified R19 had severely impaired cognition and had a diagnosis which included Parkinson's disease (neurological disorder), non-Alzheimer's dementia. R19 was dependent on staff for dressing, toileting, and transfers. R19 had an unstageable pressure ulcer that was present on entry and received pressure ulcer care. R19's signed electronic medication administration record (EMAR) directed staff to change Allevyn (dressing) to buttocks measure and update skin sheet on bath days start date 1/22/26 and discontinued 3/17/26. EMAR identified dressing change was completed on 3/5/26 and 3/12/26. R19's EMAR directed staff to change to Mepilex (dressing) buttocks, measure, and update skin sheet on bath days. EMAR identified the task was completed on 3/18/26. R19's altered skin integrity sheet dated 3/12/26, identified R19 had an open area on left buttocks measuring 4 centimeters (cm) x 4.5 cm. The wound bed is shallow and consists of 10% slough (tissue in the wound bed appearing white or yellow, resulting from wound healing) and 90% granular tissue (pink or red tissue, signifying a sign of wound healing). Edges were irregular and lightly macerated (soft tissue). Blanchable erythema (tissue surrounding a wound). No drainage noted at the time of the dressing change. Skin prep was applied around the wound, and Mepilex applied over the wound. R19's altered skin integrity sheet dated 3/5/26, identified R19 had two small scab areas and one small open area. R19's altered skin integrity sheet dated 2/26/25, identified R19 wound measures 3.5 cm x 7 cm with small shallow areas are bleeding. Erythema (redness of skin) to periwound (tissue surrounding a wound) was blanchable. Large Mepilex placed over coccyx. R19's care plan revised on 10/24/25, identified R19 had alteration in skin integrity related to pressure injury on the left buttocks. The care plan lacked EBP. During an observation/interview on 3/17/26 at 10:04 a.m., there were no signs on R19's door indicating R19 was on EBP or any gowns available for staff to use. Nursing assistant (NA)-C, NA-D, and registered nurse (RN)-A sanitized hands and went into R19 's room. RN-A indicated R19 needed to have a wound dressing changed. NA-C and NA-D assisted R19 into a mechanical standing lift. RN-A brought skin protective wipes, wound wash, gauze, and dressing into the room. RN-A indicated a measuring device was not brought into the room as the wound was measured on Thursdays. RN-A indicated R19 had a pressure wound to the left upper buttocks. RN-A applied gloves and removed the old dressing and indicated there was a small amount of squamous (clear serous fluid) drainage. The wound was shallow, with 75% maturation (newly formed tissue) and 25% of red granulation (pink tissue forms during wound healing) tissue. Wound wash and gauze were used for debridement (removal of dead or damaged tissue) of the wound. RN-A removed gloves, sanitized hands, and applied new gloves. RN-A indicated the wound was approximately 4 cm x 6 cm. RN-A applied skin prep wipe around the wound to help protect the skin, then applied a new dressing. RN-A indicated the wound had been healing and was almost healed two weeks prior, but the wound has since reopened. During an interview on 3/17/26 at 12:34 p.m., RN-A indicated EBP was to be used on residents who had chronic wounds. RN-A indicated R19 was not on EBP, as R19's wound was not chronic, as it had healed in the past. RN-A indicated R19's wound had been open for approximately two weeks. During an interview on 3/17/26 at 1:13 p.m., registered nurse care coordinator (RNCC)-A indicated R19 had an open wound measuring 4 cm x 4.5 cm on 3/12/26. RNCC indicated EBP would be started on a resident who had chronic wounds. RNCC verified R19 had a chronic wound and should have been placed on EBP. During an interview on 3/18/26 at 10:21 a.m., director of nursing (DON) indicated EBP was to be used on residents with wounds. DON verified R19 should have been on EBP related to having a wound. DON's expectation would be for EBP to be used per policy to keep residents and staff safe from the spread of multidrug-resistant organisms (MDROs). During an interview on 3/18/26 at 1:56 p.m., infection preventionist (IP)-A verified R19 should have been on enhanced barrier precautions for an open wound. IP indicated EBP was important for the prevention of MDROs. Review of policy titled enhanced barrier precautions for multidrug-resistant organisms (MDROs) dated 4/25, identified Central [NAME] County Care Center would utilize enhanced barrier precautions for residents with chronic wounds, and not those with only shorter-lasting wounds such as breaks in the skin or skin tears covered with a Band-Aid or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Enhanced barrier precautions require the use of a gown and gloves during high-contact care activities, including dressing, grooming, bathing/showering, transferring, toileting, dressing changes, wound care, and changing linens. Review of policy titled wound care dated 1/26 identified EBP should be utilized for residents with chronic wounds.

Based on observation, interview and document review, the facility failed to implement standards of practice to ensure a safe transfer for 1 of 3 residents (R1) reviewed for accidents when staff failed to use a transfer belt. This resulted in actual harm when R1 fell during a staff assisted transfer, sustained a fractured and dislocated left arm, multiple rib fractures and was sent to the emergency department (ED) requiring medical treatment and kept overnight for observation and pain control. Findings include: R1's quarterly Minimum Data Set, dated [DATE], identified she was admitted to the facility on [DATE], from home/community. R1 had severe cognitive impairment with disorganized thinking, without behaviors and required substantial/maximal assistance with all transfers. No falls since admission.R1's face sheet dated 10/29/25, identified diagnoses: Alzheimer's, urge incontinence, multiple fracture of ribs left side, dislocation of left shoulder joint, morbid obesity, joint disorders, osteoarthritis, fracture of upper end of left humorous, and fracture of left acetabulum (hip joint),R1's quarterly fall safety assessment dated [DATE], identified one to two falls in the last six months, no falls since admission. Identified R1 had right upper extremity impairment due to history of right arm fracture and wore arm brace daily. Has had no impairment of the left arm. Identified R1 pivot transfers with staff assist of one and four wheeled walker (4WW). Fall risk score was18 and indicated high risk for falls.R1's occupational therapy caregiver education instructions for toileting dated 4/26/23, identified R1 may complete pivot transfers with assist of one and 4WW/grab bars in central baths during the daytime. Please use bedside commode at bedtime (HS) toileting. Discontinue EZ stand.R1's orders identified:-10/27/25, Sling to left upper extremity during day, remove for bathing and at night /bedtime for dislocated shoulder. -10/11/25, Hydrocodone/acetaminophen oral tablet 5/325 milligrams (mg) one tablet by mouth (po) every four hours as needed (PRN) for mild pain. -6/12/25, Tramadol hydrochloride (HCl) oral 50 mg tablet po PRN two times a day (b.i.d.) for chronic pain related to (r/t) chronic non-healing fracture of humerus and hip -6/12/25 Tramadol HCl oral 50 mg tablet po b.i.d. for chronic pain r/t non healing fracture of humerus and left hip.R1's Kardex 9/2/25 (posted in her room inside closet door), identified maximum assist with transfers from sitting to standing and transfers. EZ stand as needed (PRN) if in pain. Does not ambulate. Ensure appropriate mobility aides and safety devices used for transfers/positioning.R1's care plan dated 9/16/25, identified alteration in cognition related to Alzheimer's diagnosis with late onset, short/long term memory loss, severe cognitive impairment, identified on 8/2025, that varied from intact to severe historically and a history of disorganized thinking at times. Identified alterations in functional abilities/activities of daily living (ADLs) related to left acetabulum (fracture in the socket-shaped bone that forms the hip joint), history of unsafe transfers, and cognitive deficit. Staff were directed to have provided maximum assistance with all transfers with appropriate mobility aids, safety devices, and using and EZ stand when in pain, transfer and change positions slowly due to risk for falls, history of multiple falls, staff assist required for all transitions related to impaired balance, history of unsafe self-transfers, pain, minimal impairment in hearing, alteration in cognition and presence of incontinence.R1's progress notes from 10/10/25 through 10/13/25, identified: -10/10/25 at 8:10 a.m., at approximately 7:00 a.m., licensed practical nurse (LPN) notified writer resident had fallen. Upon entering room, resident sat upright on her bottom on the floor, back was up against the nursing assistant (NA) legs with her legs stretched out towards the window. NA reported that when R1 was pivot transferring with assist of one, she tripped over her feet and NA had lowered her to the ground. R1 complained of left hip pain. No redness, swelling, open areas or bruising noted to left hip. No other injuries found upon assessment. R1 denied maltreatment/abuse, stated no, no one hurt me she just fell. Denied head strike, wearing shoes, gait belt, and used 4WW at the time of fall. R1 was assisted off the floor with three assist EZ lift, transferred into her wheelchair, and assisted to commode with EZ stand. No complaints of left hip pain stated her right shoulder hurt, but shoulder pain was chronic and unrelated to fall. Range of motion (ROM) was limited in right shoulder due to previous injury and left hip was limited at first while sitting on the ground (stated it was painful when lifted to put the sling strap under her thigh). After she was placed in wheelchair and used sit to stand lift no more complaints of hip pain. Family, director of nursing (DON), and administrator notified.-10/10/25 at 12:02 p.m., Daughter called back. Writer updated her on fall. No concerns.-10/10/25 at 1:05 p.m., R1 sat in recliner with legs elevated and now complained of severe pain to her left hip/groin that radiated down to knee and numbness to buttocks and had very limited ROM, could only lift leave an inch or so off the footrest, bent knee about 10degrees. R1's left leg appeared shorter that the right while she sat in recliner. R1 winced, grimaced and verbalized pain through assessment and with light touch to her upper left leg. Ice pack applied on top of left groin. As needed (PRN) tramadol administered and primary provider (MD) here to round shortly with priority. Family updated.-10/10/25 at 1:23 p.m., Administered Tramadol orally 50 mg for severe left hip pain and non-healing fracture of the humorous.-10/10/25 at 1:57 p.m., Seen by medical doctor (MD) on rounds. Orders given for R1 to be seen in clinic or ER for pelvic/hip x-ray.-10/10/25 at 2:54 p.m., Transferred to ER.-10/10/25 at 5:56 p.m., Called received from local ER and updated R1 had broken and dislocated left shoulder and three broken ribs. R1 will be having surgery.-10/10/25 at 10:58 p.m., R1 transferred to ER at 2:54 p.m. and will be kept overnight for observation.-10/10/25 at 11:10 p.m., Call received from ER nurse. R1 shoulder relocated. Three broken ribs and possibly four noted on x-rays. Pelvis and hip looked ok on x-rays and was being kept overnight.-10/11/25 at 9:58 a.m., R1 returned from hospital. Nurse to nurse report: R1 was back to baseline. Stand/Pivot transfer. Reduction to left shoulder post fracture/dislocation. Discharge diagnoses: fracture/dislocation left shoulder and 3 to 4 rib fractures. Norco given prior to leaving hospital at 11:00 a.m. Orders: MiraLAX 17 grams (g) everyday, Hydrocodone prescription (Rx) to be sent to drug store pharmacy.-10/11/25 at 5:46 p.m., Administered Hydrocodone-Acetaminophen oral tablet 5-325 mg one by mouth. Ribs and shoulder rated pain at 6 out of 10.-10/11/25 at 8:45 p.m., Follow up on pain scale 0 out of 10; effective.-10/11/25 at 10:00 p.m., Returned from hospital status: assist of one pivot from recliner to wheelchair, wheelchair to toilet or commode. Complained of pain in her left shoulder and left ribs and shoulder, received Norco will good relief.-10/11/25 at 10:53 p.m., Exhibits pain, Norco given, some confused talk but normal for her. Pivot transfers with one.-10/12/25 at 3:25 a.m., Limited motion /movement to both upper extremities.-10/12/25 at 8:17 a.m., Rested well, denied pain and transferred well with transfer belt and two assist to pivot on and off bed side commode. No confusion.-10/12/25 at 8:17 a.m., Transfers with extensive assist of one. Denied pain.-10/13/25 at 10:35 a.m., Continued to function at baseline. No complaints of pain to left shoulder, ribs or left lower extremity (LLE) after fall and ER visit where she was diagnosed with a dislocated shoulder and multiple rib fractures. Appears back to normal. Has been a one assist pivot transfer with gait belt and 4WW. Has not needed any pharm or non-pharm pain interventions PRN.R1's ER visit dated 10/10/25 at 3:14 p.m., identified she presented to ER from nursing home for evaluation of a fall that occurred earlier this morning. According to her caregiver, she was being assisted out of bed when she suddenly complained of pain and was gently lowered to the ground. She immediately reported discomfort in her left shoulder and hip. She describes her pain as localized to the left shoulder, extending down her arm and into her hip, and ankle. Denies loss of consciousness or a strike to the head. Baseline mobility is limited with cognitive impairment. Upon examination an elderly female alert with evidence of dementia, oriented to self only, limited the reliability of the history and close observation was required for subtle changes in mental status or worsening pain. She appeared mildly uncomfortable due to pain but in no acute distress. Her left shoulder demonstrates tenderness to palpitation with limited ROM secondary to pain. Left hip tender with pain on passive movement, ROM is markedly reduced and unable to bear weight. Given the mechanism of injury, localized tenderness, her history of prior hip fracture, the differential diagnosis includes acute fracture (shoulder/hip), contusion, or exacerbation of degenerative joint disease. Review of the imagining results x-ray of left shoulder revealed a large Hill-Sachs deformity (a bone injury on the humeral head/upper arm bone ball of the shoulder joint resulting from a shoulder dislocation) with suspected nondisplaced humeral head fracture (the bone fragments, cracked or broken have not significantly shifted but remain in their correct alignment) (can be caused by trauma or fall) and anterior dislocation (front/forward movement of the arm out of socket and occurs when holding arm away from the body usually caused by trauma) along with mildly displaced posterior rib fractures on the left side (ribs 5 through 8). Pelvic and bilateral hip imaging showed no acute hip or pelvic fractures but demonstrated severe left hip joint narrowing with collapse of femoral head and advanced degenerative changes consistent with chronic pathology. On call orthopedic surgeon successfully performed a closed reduction (a non-surgical procedure completed by a healthcare provider to realign a broken bone by manually manipulating the bone back into its correct position without making an incision) of the left shoulder under fluoroscopy guidance with confirmed appropriate alignment. Given her age, underlying dementia, and associated rib fractures, admission for pain control, observation, and mobility assessment was recommended. Final diagnoses: dislocation of left shoulder/closed, traumatic closed nondisplaced fracture of anatomical neck of left humerus (initial encounter), closed fracture of multiple ribs of left side (initial encounter) and pain.R1's left shoulder x-ray dated 10/10/25 at 3:45 p.m., identified large Hill-Sachs fracture deformity with suspected nondisplaced humeral fracture. Anterior dislocation. Mildly displaced left posterior left side rib fractures 5th, 6th, 7th, and likely 8th. R1's hospital Discharge summary dated [DATE] at 10:25 a.m., identified she had a fall during a transfer early morning around 7:00 a.m., placed in wheelchair and doing fine. Sometime in the afternoon she displayed discomfort and when seen was crying in pain and complained of left leg pain. She was sent to local emergency room (ER) where x-rays were completed and showed a fracture dislocation and three rib fractures. Left hip showed advanced degenerative joint disease (DJD) and no fractures. Orthopedist was consulted, completed a reduction of the left shoulder fracture dislocation with conscious sedation and placed her on a sling and admitted into acute care at the hospital. Physical assessment identified tenderness to palpitation of the left rib area, tenderness to any rotation of both shoulders and lift hip. She was stable and will be discharged today back to the skilled nursing facility (SKF) followed up by me (primary care provider) within a week and seen by orthopedist in two weeks due to a very difficult and different fracture/dislocation that required ortho for reduction.R1's hospital discharge orders dated 10/11/25, included reason for hospitalization: fall with left shoulder fracture/dislocation, multiple rib fractures, and pain control. Orders included: Activity without restrictions. May increase daily walking as able. Call provider if getting worse or increase in problems.Facility 5-day report dated 10/17/25 at 4:54 p.m., R1 had an unsuccessful staff assisted transfer that resulted in her being lowered to the floor by staff. Element of the care plan that was not followed: R1 transfers with assist of one, while not explicitly written in the care plan, gait belt was required and not used for this transfer. R1 had refused gait belt in the past, but not with this transfer. R1 was referred to ED and evaluation showed dislocation of shoulder with fracture of the humoral head that may have been chronic due to presentation and three rib fractures were acute. Shoulder was reduced prior to return to facility.During an observation on 10/27/25 at 12:59 p.m., nursing assistant (NA)-A answered R1's call light. R1 sat in wheelchair and stated she had just returned from seeing the doctor about her left arm fracture. NA-A applied a gait belt underneath her breasts, placed the walker in front of her, connected right arm brace strap across her chest, and brakes on wheelchair. NA-A walked around wheelchair and stood behind R1, reached forward and placed her opened hands flat on top of the gait belt on each side of her waistline. NA-A instructed R1 to stand and pushed firmly against her waistline and assisted her to stand. R1pushed up with left hand on wheelchair arm rest, stood up, took one step with left foot and pivoted so that she stood in front of the recliner. NA-A held onto R1's sides to steady her taking one step to her left so that she was positioned on R1' right side next to the recliner. NA-A pushed inward with her hands flat against the gait belt, while R1 placed her left hand on the recliner armrest and lowered herself down onto the recliner. R1's wheelchair remained with left edge of seat next to recliner at an angle so that NA-A stood in between the recliner and the wheelchair during the transfer. NA-A did not place her hands/fingers underneath the gait belt during this observation. NA-A removed the gait belt, elevated R1's feet with recliner footrest, covered her with a blanket, and placed call light on top of blanket. NA-A moved quickly and rushed to complete the transfer. NA-A turned off lights, sanitized her hands and left the room. R1's Kardex was observed inside her closet door last updated on 9/2/25, ensure appropriate mobility aides and safety devices used for transfers/positioning.During an observation on 10/28/25 at 12:31 p.m., NA-B entered R1's room and applied a gait belt while she sat in her wheelchair. NA-A positioned her wheelchair sideways off to the right side of the recliner, placed walker in front of her, and brakes on wheelchair. NA-B stood behind the R1's wheelchair, placed her hands/fingers cupped underneath the gait belt on both sides of R1's waistline. R1 pushed herself up from wheelchair with her left hand on the arm rest of the wheelchair and NA-A pulled up on the gait belt to steady her. R1 stood up, held onto the walker and NA-A let go of the gait belt with both hands. NA-A took brakes off wheelchair, pushed it out of the way, moved closer behind R1 and grabbed the gait belt with both hands. R1 pivoted to the left, lowered herself down with the left hand on the arm rest of recliner. R1 verbalized confused thought process and stated there must be people upstairs she saw children sliding down the roof in the snow and she was worried about them getting hurt. NA-B removed the gait belt, elevated her legs/feet with recliner footrest, placed call light, sanitized hands and exited the room.During an interview on 10/27/25 at 1:57 p.m., NA-A stated unsure of date early a.m. she attempted to transfer R1 from recliner to commode in her room without placing a gait belt on R1 prior to the transfer. R1 refused the gait belt in the past. R1 was able to make that decision and the reason a gait belt was not applied. NA-A stated she stood between the recliner (on her left side) and the commode (on her right side) and held onto R1's backside of her pants with her left hand and right hand was placed on the commode while she stood up and tripped over her foot. NA-A bear hugged her from behind, lowered her to the ground, she did not fall. NA-A stated R1 was heavy, would not bend the left leg which made it difficult to lower her down to the floor. She complained of leg pain and wanted to get up off the floor. Once the nurse arrived, she assessed R1 and with assist of two nurses she was lifted off the floor with a Hoyer lift. NA-A stated she was not aware R1 was at risk for falls and the use of gait belt most likely would have not made a difference in the outcome. During the earlier transfer observed with R1 she stated she did not place her hands under the gait belt and grabbed her pants instead and always transferred her that way. NA-A stated R1 was heavy and easier to use her pants, usually did not grab around her waist area. NA-A stated she had learned how a gait belt should be used from the certified nursing assistant class two years ago. Staff were expected to apply a gait belt under the breasts, fit two fingers under it so not too tight, both sides of the gait belt should have been grabbed with fingers slipped underneath and lift after resident was asked to stand. There were times she grabbed the back side of a resident's pants for an extra boost up. She received gait belt education on how gait belts should be applied only about one week ago. Prior to the incident she had not received education on how a gait belt should be used correctly since she started work at facility.During an interview on 10/2725 at 2:24 p.m. registered nurse (RN)-A stated R1's cognition was not intact, and she was unable to make an informed decision as to whether a gait belt should have been used during transfers. R1's refusals were repetitive, and memory was short. R1 was assist of one with a gait belt for transfers. The Kardex located in each resident closet should have identified which residents required a gait belt for transfers. A gait belt should be used to steady a resident with unsteady gait/balance problems, help prevent falls and keep staff and residents safe. The gait belt was considered best practice and resident clothing such as pants were not allowed to be used to transfers residents. Staff were expected to use a gait belt when R1 was transferred for safely. RN-A stated on 10/10/25, at approximately 7:00 a.m., she was informed by a nurse R1 had fallen and needed assistance. RN-A entered R1's room and R1 sat on the floor with her back leaned up against NA-A's lower legs. R1 had a sling on her right arm (had worn it since admission to facility) limited motion and pain was chronic due to past injury. RN-A picked up R1's left leg and she complained of hip pain, gathered vitals and completed an assessment a Hoyer lift was used to lift her off the floor and transferred into the wheelchair. R1 stood up with an EZ stand and transferred to commode, no complaints of pain but later in the day she complained of left sided shoulder/hip/knee/ankle pain. R1 was seen by provider at facility then sent to ER. RN-A stated she thought a gait belt had been used, charted it and later realized a gait belt was not applied by NA-A prior to the transfer/fall. R1 was a large woman, hard to control when she started to go down ended up with fractured ribs and dislocated/fractured left shoulder.During an interview on 10/28/25 at 11:04 a.m., family member (FM) stated R1 was unable to stand alone, was a significant fall risk, and had a history of right arm fracture that never healed properly due to her horrible bones. FM stated she had visited R1 many times this year and observed many transfers by staff without the use of a gait belt. The first week of October staff grabbed her pants to transfer her to the commode, pulled pants down, nothing to hang onto, sat down on commode, stood her up without anything to hang onto, pulled up pants, did not seem very safe and placed her at risk for a fall. Staff had assisted R1 with a transfer from wheelchair to car holding onto her clothes without a gait belt on. FM stated that type of practice was concerning, clothes were not sturdy enough, she was not a small person, and the top of her pants could have ripped. FM had observed a gait belt on R1's wheelchair at the end of July and was used when she was taken to a family gathering by her sister-in-law to take her to the bathroom. The gait belt had not been observed in her room during the other visits since. FM had not seen or heard R1 refuse the use of a gait belt. FM stated R1 was at a point where one person assist for transfers was not sufficient and she needed at least two staff instead. FM stated another member of the family informed her R1 was in a lot of pain yesterday during the orthopedic appointment.During an interview on 10/28/25 at 11:28 a.m., occupational therapist (OT) stated when a resident was able to bear weight such as R1, staff would be expected to use a gait belt. OT stated the gait belt provided staff something to hold onto and grasp without pulling on resident arms and/or extremities and helped prevent injury to resident and staff. Gait belts should have been included in R1's care plan and used to avoid staff from grabbing onto the side of their body to lift R1 up or lower R1 down, if a resident's knees would buckle and they had fragile bones staff would possibly hold too tight or grab an arm and cause injuries. OT stated after a resident has had a fall with an injury staff were expected to communicate with therapy and be re-assessed by physical therapy to determine the safest way to transfer them especially with rib fractures to avoid further injury and falls. OT stated it seemed odd R1 was deemed back to baseline but a possibility without lower extremity involvement in the fall. Typically, we are given orders to reassess once they return from a hospital stay after fall with injury. After gait belt had been applied the staff would be expected to slide their fingers up underneath the gait belt with thumbs up so that the top side of the fingers/hand were placed against the resident's body. Staff should not have used the resident clothing/pants to grab onto during a transfer. When a resident was able to walk or used a walker the staff should stand off to the side and if the resident was to pivot from one spot to another staff would be expected to stand in front of the resident during a transfer. Staff should not stand behind a chair during a transfer; they would not be able to break a fall and lower the resident to the floor if they lost their balance.During an interview on 10/28/25 at 1:48 p.m., NA-B stated she used a gait belt on residents when it was in their care plan and/or if she thought they may be unsteady during transfers or ambulation. Staff were expected to use a gait belt with residents that were not independent during transfers/ambulation for the safety of the resident and staff, helped prevent falls and if they lost their balance the gait belt would provide a way to lower them to the floor. When a resident refused the use of the gait belt, they need to be informed it was necessary to provide a safe transfer. The nurse may be able to help convince them, if not a lift machine maybe needed for transfer. NA-B stated R1 has never refused to wear the transfer belt and always used one along with the back of her pants when she transferred her. NA-B stated she had forgotten to use a transfer belt during other resident transfers due to unable to locate one. NA-B stated she had recently received education and audits on how to apply the gait belt only. NA-A stated she stood behind R1's wheelchair during the observed transfer earlier because she thought it was the best way to transfer R1. However, If R1 would have started to fall forward she most likely would not have been able to stop the fall. NA-A stated where she stood was not safe and should have maybe stood on R1's side instead.During an interview on 10/28/25 at 3:30 p.m. DON stated R1 had dementia and poor short/long term memory. Staff were expected to use a gait belt to transfer any resident requiring assistance and should not have been needed to be spelt out in the care plan and Kardex. The Kardex would have indicated assistive devices such as walkers/EZ stand, and those residents would have required a gait belt for a transfer. The use of transfer belts helped provide safe transfers. During a fall like R1's where a gait belt was not used and resident started to fall the staff would most likely have reached out and grabbed onto an upper extremity or completed a bear hug, and any of those could have resulted in injury especially with the geriatric population. R1 had a degenerative joint disease and would have caused a higher risk for injury without a gait belt which resulted in other means used to break the fall. NA-A was expected to have used a gait belt when R1 was transferred and could have made a difference, her shoulders would have not been affected, and NA-A's hand position would have been different. Education was initiated after the incident on 10/13/25 and 10/14/25 and provided through the health academy computer system, documents (policy), texts, and audits on application of the gait belt, if it was applied before transfers, but lacked information on where to stand and how to provide a safe transfer. The staff were informed later with a new audit form where to stand during the transfers, on the resident's strong side. Staff were confused due to inaccurate information provided such as informed of the wrong side to stand on during transfer. DON stated he had misinterpreted as strong side and should have indicated weak side.During an interview on 10/29/25 at 4:22 p.m., administrator stated safety equipment indicated gait belt but was not identified as such on the resident's care plan/Kardex. ,Staff were expected to use a gait belt during R1's transfer/fall incident on 10/10/25, and a gait belt was not applied. Gait belt use was a standard of care for resident and staff safety. Facility policy Staff Assisted Resident Transfer dated October 2025, identified the facility would assess each resident and determine the safest transfer method for both resident and staff safety. Resident specific data will be used to determine the method of transfer including but not limited to resident preference, history, clinical condition, physician restrictions, therapy assessment (physical and occupational), and nursing assessment. Resident would be assessed for initial transfer method determination on admission will be per resident interview and admission documentation. Resident will then be re-evaluated after a change in condition and after any transfer related incident (fall, near fall, injury). A stand pivot transfer where resident could weight bear on legs required assist of one to two staff with a gait belt secured on waist, scoot to edge of chair/bed, stand pivot to adjacent destination surface.Facility document Resident Falls dated October 2025, identified fall safety assessment is completed on all new admissions, quarterly, and as needed to assist in determining risk for falls. Identified, the resident is evaluated for physical devices to be used to help reduce falls, injury, or incidents. Those at risk for falls or have physical devices were addressed in the care plan with approaches/interventions to be followed.

Based on observation, interview and document review, the facility failed to conduct a comprehensive, complete investigation,, including a root cause analysis (RCA) and provide sufficient protection to other residents while the investigation was completed for 1 of 3 residents (R1) who was reviewed for accidents. This had the potential to affect all 19 residents who required staff assistance with a gait belt to transfer.Findings include: R1's quarterly Minimum Data Set, dated [DATE], identified she was admitted to the facility on [DATE], from home/community. She had severely impaired cognition with disorganized thinking, without behaviors. She required substantial/maximal assistance with all transfers. No falls since admission.R1's face sheet dated 10/29/25, identified diagnoses: Alzheimer's, urge incontinence, multiple fracture of ribs left side, dislocation of left shoulder joint, morbid obesity, joint disorders, osteoarthritis, fracture of upper end of left humorous, and fracture of left acetabulum (hip joint).R1's quarterly fall safety assessment dated [DATE], identified one to two falls in the last six months, no falls since admission. Identified R1 had right upper extremity impairment due to history of right arm fracture and wore arm brace daily. Has had no impairment of the left arm. Identified R1 pivot transfers with staff assist of one and four wheeled walker (4WW). Fall risk score was18 and indicated high risk for falls.R1's progress notes from 10/10/25, identified: -10/10/25 at 8:10 a.m. At approximately 7:00 a.m., licensed practical nurse (LPN) notified writer resident had fallen. Upon entering room, resident sat upright on her bottom on the floor, back was up against the nursing assistant (NA) legs with her legs stretched out towards the window. NA reported that when resident was pivot transferring with assist of one, she tripped over her feet and NA had lowered her to the ground. R1 complained of left hip pain. No redness, swelling, open areas or bruising noted to left hip. No other injuries found upon assessment. R1 denied maltreatment/abuse, stated no, no one hurt me she just fell. Denied head strike, wearing shoes, gait belt, and used 4WW at the time of fall. R1 was assisted off the floor with three assist EZ lift, transferred into her wheelchair, and assisted to commode with EZ stand. No complaints of left hip pain stated her right shoulder hurt, but shoulder pain was chronic and unrelated to fall. Range of motion (ROM) was limited in right shoulder due to previous injury and left hip was limited at first while sitting on the ground (stated it was painful when lifted to put the sling strap under her thigh). After she was placed in wheelchair and used sit to stand lift no more complaints of hip pain. Family, director of nursing (DON), and administrator notified.10/10/25 at 1:05 p.m., R1 sat in recliner with legs elevated. She now complained of severe pain to her left hip/groin that radiated down to knee and numbness to buttocks. She had very limited ROM, could only lift leave an inch or so off the footrest, bent knee about 10 degrees. Left leg appeared shorter that the right while she sat in recliner. R1 winced, grimaced and verbalized pain through assessment and with light touch to her upper left leg. Ice pack applied on top of left groin. As needed (PRN) tramadol administered and primary provider (MD) here to round shortly with priority. Family updated.-10/10/25 at 1:57 p.m., Seen by medical doctor (MD) on rounds. Orders given for R1 to be seen in clinic or ER for pelvic/hip x-ray. Transferred to ER at 2:54 p.m.-10/10/25 at 5:56 p.m., Called received from local ER and updated R1 had broken and dislocated left shoulder and three broken ribs. R1 was going to have surgery.R1's left shoulder x-ray dated 10/10/25 at 3:45 p.m., identified large Hill-Sachs fracture deformity (a bone injury on the humeral head/upper arm bone ball of the shoulder joint resulting from a shoulder dislocation) with suspected nondisplaced humeral fracture. (the bone fragments, cracked or broken have not significantly shifted but remain in their correct alignment) (can be caused by trauma or fall) and anterior dislocation (front/forward movement of the arm out of socket and occurs when holding arm away from the body usually caused by trauma)Mildly displaced left posterior left side rib fractures 5th, 6th, 7th, and likely 8th. Facility 5-day investigative report summary dated 10/17/25 at 4:54 p.m., R1 had an unsuccessful staff assisted transfer that resulted in her being lowered to the floor by staff. Element of the care plan that was not followed: R1 transfers with assist of one. While not explicitly written in the care plan, gait blet was required and not used for this transfer. R1 had refused gait belt in the past, but not with this transfer. R1 was referred to emergency department (ED) and evaluation showed dislocation of shoulder with fracture of the humoral head that may have been chronic due to presentation and three rib fractures were acute. Shoulder was reduced prior to return to facility. Summary of interview(s) with other residents who may have had contact with the alleged perpetrator (AP) not appliable (na). Action taken to prevent reoccurrence to subjected resident and other residents: gait belt audits conducted each shift to monitor compliance. Continued transfer audit will continue indefinitely. Systemic actions taken staff education and transfer audits on each shift to ensure proper technique and safety equipment usage. The allegation could not be verified because there was insufficient information and facility investigation was inconclusive.NA-A's Corrective Action Notice dated 10/14/25, (four days after R1's fall), identified verbal, written, final warning. NA-A transferred R1 without gait belt, she tripped over her own feet and NA-A reached out grabbed resident to avoid fall and assisted in lowering her to the floor. See in ER and noted shoulder dislocation and fractured ribs. Summary of corrective action: education provided on gait belt use, policy review, and correct sizing of gait belts. Consequences for failure to take corrective action: outlined in summary and progressive disciplinary action.During an observation on 10/27/25 at 12:59 p.m., nursing assistant (NA)-A answered R1's call light. R1 sat in wheelchair and stated she had just returned from seeing the doctor about her left arm fracture. NA-A applied a gait belt underneath her breasts, placed the walker in front of her, connected right arm brace strap across her chest, and brakes on wheelchair. NA-A walked around wheelchair and stood behind R1, reached forward and placed her opened hands flat on top of the gait belt on each side of her waistline. NA-A instructed R1 to stand and pushed firmly against her waistline and assisted her to stand. R1pushed up with left hand on wheelchair arm rest, stood up, took one step with left foot and pivoted so that she stood in front of the recliner. NA-A held onto R1's sides to steady her taking one step to her left so that she was positioned on R1' right side next to the recliner. NA-A pushed inward with her hands flat against the gait belt, while R1 placed her left hand on the recliner armrest and lowered herself down onto the recliner. R1's wheelchair remained with left edge of seat next to recliner at an angle so that NA-A stood in between the recliner and the wheelchair during the transfer. NA-A did not place her hands/fingers underneath the gait belt during this observation.During an observation on 10/28/25 at 12:31 p.m., NA-B entered R1's room and applied a gait belt while she sat in her wheelchair. NA-A positioned her wheelchair sideways off to the right side of the recliner, placed walker in front of her, and brakes on wheelchair. NA-B stood behind the R1's wheelchair, placed her hands/fingers cupped underneath the gait belt on both sides of R1's waistline. R1 pushed herself up from wheelchair with her left hand on the arm rest of the wheelchair and NA-A pulled up on the gait belt to steady her. R1 stood up, held onto the walker and NA-A let go of the gait belt with both hands. NA-A took brakes off wheelchair, pushed it out of the way, moved closer behind R1 and grabbed the gait belt with both hands.During an interview on 10/27/25 at 1:57 p.m., NA-A stated unsure of date early a.m. she attempted to transfer R1 from recliner to commode in her room. A gait belt was not placed on R1prior to the transfer. NA-A stated she stood between the recliner (on her left side) and the commode (on her right side) and held onto R1's backside of her pants with her left hand and right hand was placed on the commode while she stood up and tripped over her foot. NA-A bear hugged her from behind, lowered her to the ground, she did not fall. R1 was heavy, would not bend the left leg made it difficult to lower her down to the floor. NA-A stated she was not aware R1 was at risk for falls and the use of gait belt most likely would have not made a difference in the outcome. During an earlier transfer observed with R1 she stated she did not place her hands under the gait belt and grabbed her pants instead and always transferred her that way. NA-A stated R1 was heavy and easier to use her pants, usually did not grab around her waist area. NA-A stated she had learned how a gait belt should be used from the certified nursing assistant class two years ago. Staff were expected to apply a gait belt under the breasts, fit two fingers under it so not too tight, both sides of the gait belt should have been grabbed with fingers slipped underneath and lift after resident was asked to stand. There were times she grabbed the back side of a resident's pants for an extra boost up. She received gait belt education on how gait belts should be applied only, about one week ago. Prior to the incident she had not received education on how a gait belt should be used correctly since she started work at facility.During an interview on 10/28/25 at 1:48 p.m., NA-B stated staff were expected to use a gait belt with residents that were not independent during transfers/ambulation for the safety of the resident and staff, helped prevent falls and if they lost their balance the gait belt would provide a way to lower them to the floor. R1 has never refused to wear the transfer belt and always used one along with the back of her pants when she transferred her. NA-B stated she had forgotten to use a transfer belt during other resident transfers due to unable to locate one. She had recently received education and audits on how to apply the gait belt only. NA-A stated she stood behind R1's wheelchair during the observed transfer earlier and thought it was the best way to transfer her. If R1 would have started to fall forward she most likely would not be able to stop the fall. She stated where she stood was not safe and should have maybe stood on R1's side instead, not sure.During an interview on 10/28/25 at 3:30 p.m., DON stated R1 had dementia and poor short/long term memory. Staff were expected to use a gait belt to transfer any resident requiring assistance and should have been spelt out in the care plan and Kardex. The use of transfer belts helped provide safe transfers especially with R1's fall. When a gait belt was not used and resident started to fall the staff would most have most likely reached out and grabbed onto an upper extremity or completed a bear hug, and any of those could have resulted in injury especially with the geriatric population. R1 had a degenerative joint disease and would have caused a higher risk for injury without a gait belt which resulted in other means used to break the fall. NA-A was expected to have used a gait belt when R1 was transferred and could have made a difference, her shoulders would have not been affected, and NA-A's hand position would have been different. He was notified of R1's fall on 10/10/25 right after it happened, and no injuries were identified until later that day between 1:00 p.m. and 1:30 p.m. and she was sent to ER and injuries were verified. NA-A was not removed from her duties and allowed to continue to care for residents and transfer them. NA-A did not work the weekend or scheduled but was allowed to continue to work the following dates: October 13th and 14th, 16th, 17th, 20th, 21st, 22nd, 23rd, 25th, 26th, 27th, and 28th. Monday morning, October 13th, 2025, between 7:00 a.m. and 8:00 a.m. he interviewed NA-A and realized a gait belt was not used during the transfer. Education was provided that morning regarding the use of a gait belt during transfers and position of the staff during a transfer was not discussed, thought that would just come with the proper usage of the gait belt. He was not working on site over the weekend and returned to work on Monday, October 13th, 2025. Investigation was initiated and gait belt audits were started on 10/13/25. Gait belt audits were completed on NA-A and had not recalled any issues so thought we were doing good. A root cause analysis was not completed. After NA-A was interviewed he determined the lack of using the gait belt was the problem but could have been more than that. A root cause analysis should have been done and stilled planned on doing one. R1 was interviewed. No other residents were interviewed for this investigation. Education was initiated after the incident on 10/13/25 and 10/14/25 for all nursing staff and provided through the health academy computer system, documents (policy), texts, and audits on application of the gait belt, if it was applied before transfers. The education lacked information on where to stand and how to provide a safe transfer. The staff were informed later with a new audit form where to stand during the transfers, on the resident's strong side. Staff were confused due to inaccurate information provided such as informed of the wrong side to stand on during transfer. DON stated he had misinterpreted as strong side and should have indicated weak side.Facility policy Resident Accidents/Incidents dated 10/17/25, identified all accidents/incidents involving residents must be reported to the DON and/or the administrator. The facility inter-disciplinary team will review all incident reports for potential allegations of abuse. All resident incident reports involving residents are recorded in the point click care system for review by Quality Assurance Committee and Medical Director.Facility policy Protection of Residents During Abuse Investigations dated 10/17/25, identified our facility will protect residents from harm during investigation of abuse allegations. During the abuse investigation, employees accused of participating in the allege abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended without pay until the findings of the investigation have been reviewed by the administrator.Facility policy Alleged Abuse Investigations dated 10/17/25, identified all reports of resident alleged abuse, neglect and injuries of unknown source shall be promptly reported and if additional investigation was required facility management will initiate an investigation of the incident. The individual conducting the investigation will take the following steps as appropriate: interview other resident to who the accused employee provides care and services.

Based on observation, interview, and document review, the facility failed to comprehensively reassess and implement interventions to reduce the risk of further falls and injury after re-admission from hospital for 1 of 3 residents (R1) reviewed who had fallen and sustained injuries at the facility. Findings include: R1's quarterly Minimum Data Set, dated [DATE], identified she was admitted to the facility on [DATE], from home/community. She had severely impaired cognition with disorganized thinking, without behaviors. She required substantial/maximal assistance with all transfers. No falls since admission.R1's face sheet dated 10/29/25, identified diagnoses: Alzheimer's, urge incontinence, multiple fracture of ribs left side, dislocation of left shoulder joint, morbid obesity, joint disorders, osteoarthritis, fracture of upper end of left humorous, and fracture of left acetabulum (hip joint),R1's quarterly fall safety assessment dated [DATE], identified one to two falls in the last six months, no falls since admission. Identified R1 had right upper extremity impairment due to history of right arm fracture and wore arm brace daily. Has had no impairment of the left arm. Identified R1 pivot transfers with staff assist of one and four wheeled walker (4WW). Fall risk score was18 and indicated high risk for falls.R1's medical record lacked evidence of a fall assessment completed upon R1's return from the hospital. R1's occupational therapy caregiver education instructions for toileting dated 4/26/23, identified R1 may complete pivot transfers with assist of one and FWW/grab bars in central baths during the daytime. Please use bedside commode at bedtime (HS) toileting. Discontinue EZ stand.R1's medical record lacked evidence of a therapy assessment being completed upon R1's return from the hospital. R1's care plan dated 9/16/25, identified alternation in cognition related to Alzheimer's diagnosis with late onset, short/long term memory loss, severe cognitive impairment identified on 8/2025 that varied from intact to severe historically. History of disorganized thinking at times. Alternations in functional abilities/activities of daily living (ADLs) related to left acetabulum (fracture in the socket-shaped bone that forms the hip joint), history of unsafe transfers, and cognitive deficit. Staff were directed to have provided maximum assistance with all transfers with appropriate mobility aids, safety devices, and using and EZ stand when in pain, transfer and change positions slowly due to risk for falls, history of multiple falls, staff assist required for all transitions, impaired balance, history of unsafe self-transfers, pain, minimal impairment in hearing, alteration in cognition and presence of incontinence.R1's progress note dated 10/11/25 at 9:58 a.m., R1 returned from hospital. Nurse to nurse report: R1 was back to baseline. Stand/Pivot transfer. Reduction to left shoulder post fracture/dislocation. Discharge diagnoses: fracture/dislocation left shoulder and 3 to 4 rib fractures. Norco given prior to leaving hospital at 11:00 a.m. Orders: Miralax 17 grams (g) everyday, Hydrocodone prescription (Rx) to be sent to drug store pharmacy.Progress notes lacked evidence an assessment was completed for transfers after R1 was re-admitted to facility from hospital. R1's discharge from hospital orders dated 10/11/25, included reason for hospitalization: fall with left shoulder fracture/dislocation, multiple rib fractures, and pain control. Orders included: Activity without restrictions. May increase daily walking as able. Call provider if getting worse or increase in problems.During an observation on 10/27/25 at 12:59 p.m., nursing assistant (NA)-A answered R1's call light. R1 sat in wheelchair and stated she had just returned from seeing the doctor about her left arm fracture. NA-A applied a gait belt underneath her breasts, placed the walker in front of her, connected right arm brace strap across her chest, and brakes on wheelchair. NA-A walked around wheelchair and stood behind R1, reached forward and placed her opened hands flat on top of the gait belt on each side of her waistline. NA-A instructed R1 to stand and pushed firmly against her waistline and assisted her to stand. R1pushed up with left hand on wheelchair arm rest, stood up, took one step with left foot and pivoted so that she stood in front of the recliner. NA-A held onto R1's sides to steady her taking one step to her left so that she was positioned on R1' right side next to the recliner. NA-A pushed inward with her hands flat against the gait belt, while R1 placed her left hand on the recliner armrest and lowered herself down onto the recliner. R1's wheelchair remained with left edge of seat next to recliner at an angle so that NA-A stood in between the recliner and the wheelchair during the transfer. NA-A did not place her hands/fingers underneath the gait belt during this observation. NA-A removed the gait belt, elevated R1's feet with recliner footrest, covered her with a blanket, and placed call light on top of blanket. NA-A moved quickly and rushed to complete the transfer. NA-A turned off lights, sanitized her hands and left the room. R1's Kardex was observed inside her closet door last updated on 9/2/25, ensure appropriate mobility aides and safety devices used for transfers/positioning.During an observation on 10/28/25 at 12:31 p.m., NA-B entered R1's room and applied a gait belt R1 sat in her wheelchair. NA-A positioned her wheelchair sideways off to the right side of the recliner, placed walker in front of her, and brakes on wheelchair. NA-B stood behind R1's wheelchair, placed her hands/fingers cupped underneath the gait belt on both sides of R1's waist. R1 pushed herself up from wheelchair with her left hand on the arm rest of the wheelchair and NA-A pulled up on the gait belt to steady her. R1 stood up, held onto the walker as NA-A let go of the gait belt with both hands. NA-A took brakes off wheelchair, pushed it out of the way, moved closer behind R1 and grabbed the gait belt with both hands. R1 pivoted to the left, lowered herself down with the left hand on the arm rest of recliner. R1 verbalized confused thought process and stated there must be people upstairs she saw children sliding down the roof in the snow and she was worried about them getting hurt. NA-B removed the gait belt, elevated her legs/feet with recliner footrest, placed call light, sanitized hands and exited the room.During an interview on 10/27/25 at 1:57 p.m., NA-A stated unsure of date early a.m. she attempted to transfer R1 from recliner to commode in her room. A gait belt was not placed on R1prior to the transfer. NA-A stated she stood between the recliner (on her left side) and the commode (on her right side) and held onto R1's backside of her pants with her left hand and right hand was placed on the commode while R1stood up and tripped over her foot. NA-A bear hugged her from behind, lowered her to the ground, she did not fall. R1 was heavy, would not bend the left leg made it difficult to lower her down to the floor. She complained of leg pain and wanted to get up off the floor. Once the nurse arrived, she assessed R1 and with assist of two nurses she was lifted off the floor with a Hoyer lift. NA-A stated she was not aware R1 was at risk for falls and the use of gait belt most likely would have not made a difference in the outcome. During an earlier transfer observed with R1 she stated she did not place her hands under the gait belt and grabbed her pants instead and always transferred her that way. NA-A stated R1 was heavy and easier to use her pants, usually did not grab around her waist area. NA-A stated she had learned how a gait belt should be used from the certified nursing assistant class two years ago. Staff were expected to apply a gait belt under the breasts, fit two fingers under it so not too tight, both sides of the gait belt should have been grabbed with fingers slipped underneath and lift after resident was asked to stand. There were times she grabbed the back side of a resident's pants for an extra boost up. She received gait belt education on how gait belts should be applied only, about one week ago. Prior to the incident she had not received education on how a gait belt should be used correctly since she started work at facility.During an interview on 10/28/25 at 11:04 a.m., family member (FM) stated R1 was unable to stand alone, was a significant fall risk, and had a history of right arm fracture that never healed properly due to her horrible bones. FM stated she had visited R1 many times this year and observed many transfers by staff without the use of a gait belt. The first week of October staff grabbed her pants to transfer her to the commode, pulled pants down, nothing to hang onto, sat down on commode, stood her up without anything to hang onto, pulled up pants, did not seem very safe and placed her at risk for a fall. Staff had assisted R1 with a transfer from wheelchair to car without a gait belt on and hung onto her clothing instead. That type of practice was concerning, clothes were not sturdy enough, she was not a small person, and the top of her pants could have ripped. FM had observed a gait belt on R1's wheelchair at the end of July and was used when she was taken to a family gathering by her sister-in-law to take her to the bathroom. The gait belt had not been observed in her room during the other visits since. FM had not seen or heard R1 refuse the use of a gait belt. FM stated R1 was at a point where one person assist for transfers was not sufficient and she needed at least two staff instead, and most likely if she started to fall more than one person would be required to keep her upright. Another FM informed her R1 was in a lot of pain yesterday during the orthopedic appointment.During an interview on 10/28/25 at 11:28 a.m., occupational therapist (OT) stated when a resident was able to bear weight such as R1, staff would be expected to use a gait belt. The gait belt provided staff something to hold onto and grasp without pulling on resident arms and/or extremities and helped prevent injury to resident and staff. After a resident has had a fall with an injury staff would be expected to communicate with therapy to be re-assessed by physical therapy to determine the safest way to transfer especially with rib fractures to avoid further injury and falls. Seemed odd R1 was deemed back to baseline but a possibility without lower extremity involvement in the fall. Typically, we are given orders to reassess once they return from a hospital stay after fall with injury. After gait belt had been applied the staff would be expected to slide their fingers up underneath the gait belt with thumbs up so that the top side of the fingers/hand were placed against the resident's body.During an interview on 10/28/25 at 12:09 p.m., NA-E stated R1 was at risk for falls, moves slowly, unsteady at times and loses her balance. Before R1's fall she was an assist of one pivot and gait belt for transfers. We have been told the gait belt use was a safety thing, unsure how they really help.NA-E stated if she had used a gait belt during R1's transfers and if she became unsteady or started to fall would be required to pull up on the gait belt to steady her which could have caused more injury and pain to her fractured ribs. She has used the back of her pants at times to hold her up and knew that was not appropriate. R1 has had good days and transferred well with assist of one and then she has had bad days, more confused and unaware of which way to turn and a second staff would be used to assist and/or a stand lift.During an interview on 10/28/25 at 1:48 p.m., NA-B stated she used a gait belt on residents when included in their care plan and/or if she thought they maybe unsteady during transfers or ambulation. Staff were expected to use a gait belt with residents that were not independent during transfers/ambulation for the safety of the resident and staff, helped prevent falls and if they lost their balance the gait belt would provide a way to lower them to the floor. When a resident refused the use of the gait belt, they need to be informed it was necessary to provide a safe transfer. The nurse may be able to help convince them, if not a lift machine maybe needed for transfer. R1 has never refused to wear the transfer belt and always used one along with the back of her pants when she transferred her. NA-B stated she had forgotten to use a transfer belt during other resident transfers due to not being able to locate one. She had recently received education and audits on how to apply the gait belt only. NA-A stated she stood behind R1's wheelchair during the observed transfer earlier and thought it was the best way to transfer her. NA-A stated If R1 would have started to fall forward she most likely would not be able to stop the fall. She stated where she stood was not safe and should have maybe stood on R1's side instead.During an interview on 10/28/25 at 2:15 p.m. Licensed practical nurse (LPN)-B stated R1's cognition was not the best and had a poor memory. R1 transferred with extensive assistance of one to two staff stand/pivot. On 10/11/25, she had received report via telephone from the hospital staff nurse prior to R1's readmission back to the facility that day. She informed the hospital nurse prior to her fall the day before she required extensive assistance of one to transfer. The hospital nurse indicated she transferred in the hospital the same and most likely meant she was at baseline. LPN-B stated she was unaware if a therapy assessment was completed at the hospital or upon readmission back to the facility.During an interview on 10/28/25 at 3:30 p.m., DON stated R1 had dementia and poor short/long term memory. R1 had a degenerative joint disease which would have caused a higher risk for injury without a gait belt which would have provided another means used to break the fall. A nurse-to-nurse report was completed prior to R1's readmission to the facility from the hospital. Generally speaking, the readmissions usually do not take place over the weekends however, this one did, none of the office staff were here when she returned. The staff nurse would have been expected to have completed a readmission assessment and documented it. When a resident returns back from the hospital and not at baseline therapy would have gotten involved. The report received from the hospital nurse was documented R1 was baseline with transfers and pivot. Since we had no issues with how she transferred over the weekend staff continued with assist of 1 to 2 staff and therapy was not involved. A fall risk assessment was expected to be completed if there was a change in condition/quarterly/annually. The fall risk assessment was most likely not done on R1. R1 tripped over her feet when she fell on [DATE] and was at baseline when she returned from the hospital and readmitted .During an interview on 10/29/25 at 12:57 p.m., registered nurse (RN)-C stated R1 should have been assessed upon re-admission from the hospital after her fall with fractures. We are usually really good about that, unsure why that was not done, most likely got missed. RN-C stated the nurse was expected to fill out a return from hospital check list/template on the facility electronic medical record (EMR). RN-C stated she would have been concerned about R1's fractures and seemed odd she could have been back to baseline with transfers, unsure if it was a good idea to have one assist with a gait belt. RN-C stated she would have been concerned with the gait belt applied in close proximation of her fractured ribs would not be the safest either. R1 fell and resulted in fractures, therapy should have been contacted and assessed R1 so that staff would transfer her the safest and most appropriate way with fractures and injuries.Facility policy Staff Assisted Resident Transfer dated October 2025, identified the facility will assess each resident and determine the safest transfer method for both resident and staff safety. Resident specific data will be used to determine the method of transfer including but not limited to resident preference, history, clinical condition, physician restrictions, therapy assessment (physical and occupational), and nursing assessment. Resident will be assessed for initial transfer method determination on admission will be per resident interview and admission documentation. Resident will then be re-evaluated after a change in condition and after any transfer related incident (fall, near fall, injury). A stand pivot transfer where resident could weight bear on legs required assist of one to two staff with a gait belt secured on waist, scoot to edge of chair/bed, stand pivot to adjacent destination surface.Facility document Resident Falls dated October 2025, identified fall safety assessment is completed on all new admissions, quarterly, and as needed to assist in determining risk for falls. The resident is evaluated for physical devices to be used to help reduce falls, injury, or incidents. Those at risk for falls or have physical devices will be addressed in the care plan with approaches/interventions to be followed.Requested readmission /assessment policy and not received.Requested hospital therapy assessment/evaluation and not received.

Based on observation, interview, and document review, the facility failed to ensure expired and/or outdated food products, including both dry stock and refrigerated items, were removed from rotation and not available for resident use or consumption which could cause potential foodborne illness. This had potential to affect 30 of 43 residents identified who could receive these items. Findings include: On [DATE], at 9:35 a.m. the main production kitchen was toured. A dry storage area was located adjacent to the kitchen which contained metallic shelving and various items available to resident food use or preparation. A single, unopened 8 ounce (oz) [MEDICATION(S)] container was placed on the shelving which had expired (i.e., use by) on [DATE]; however, two other containers, which had not yet expired, were placed in front of the expired container on the shelving. In addition, the walk-in cooler was examined which identified a single, unopened 7.4 pound (lb) [NAME] Kitchen coleslaw container which had expired on [DATE]. There were no other containers of coleslaw identified in the cooler which could be used instead. On [DATE], at 1:35 p.m. the main production kitchen was again toured. The items identified to be expired on the previous tour, completed on [DATE], remained in rotation and available for resident use or consumption. At 1:42 p.m. cook (CK)-A was interviewed and verified the expired products were in rotation and available for resident use. CK-A explained items should be rotated on a, first in, first out basis to ensure oldest items were used and did not expire. CK-A stated she would discard the expired items to prevent them being used. When interviewed on [DATE], at 1:54 p.m. the dietary manager (DM) verified the items found were expired and should have been removed from rotation so they would not be used in resident meals or foods. DM stated, there was no formal system to monitor or audit to ensure expired food items were not kept in rotation and available for resident use. During subsequent interview, on [DATE] at 9:05 a.m. DM stated, there was only one resident in the facility who currently used the [MEDICATION(S)] product. However, the cole slaw could be prepared and distributed to anyone residing in the facility. A provided electronic mail message (e-mail), dated [DATE], identified one container of the identified expired coleslaw could produce up to 29 servings. A facility policy titled, Preparation of Food, dated ,d+[DATE], and Infection Control for the Food service department, dated ,d+[DATE], failed to address rotating food inventory or removing from storage when expired.

Based on observation, interview, and document review, the facility failed to provide 1 of 1 resident (R16) with their hearing devices to maximize their communication ability and ensure adequate hearing to promote their quality of life. Findings include: R16's significant change Minimum Data Set (MDS), dated [DATE], identified R16 had intact cognition and required extensive assistance with most of her activities of daily living (ADLs). Further, the MDS outlined R16 had minimal difficulty with hearing and included a question which outlined, Hearing aid or other hearing appliance used[?] which was answered by staff as, No. R16's care plan included, [R16] has alteration in communication r/t [related to] hearing deficit, stroke AEB [as evidenced by] variable bilateral hearing aide use, minimal hearing deficit when not in place, slurred speech at times. Has bilateral hearing aides, independent with placement and storage. On 8/3/21, at 2:42 p.m. R16 was interviewed. R16 stated she used to have hearing aids which helped her hear better. However, she had not worn them in awhile and thought they had either gone missing or were broken. R16 expressed frustration as nobody from the facility had helped her try to find them as she wanted to wear them to help improve her hearing. R16 did not have any hearing aid(s) or devices present or on her person during this interaction and interview. When interviewed on 8/3/21, at 1:52 p.m. nursing assistant (NA)-A stated she was unaware R16 wore any hearing aides and verified she was not helping R16 to place any hearing devices on a routine, daily basis. On 8/4/21, at 12:01 p.m. registered nurse(s) (RN)-A and RN-B were interviewed. They had located R16's hearing aids in a denture cup in her room after being made aware by the surveyor they were potentially missing. The hearing aids' batteries were not working, so they replaced them and verified the hearing aids were now working. RN-A and RN-B both expressed R16's hearing aids were not assess to be placed daily. An undated nursing assistant worksheet outlined basic care needs for R16 and did not direct staff to place hearing aides for R16. A policy was requested, but not provided by the facility.

Based on observation, document review, and interview, the facility failed to comprehensively assess the use of a personal chair alarm device as a potential restraint for 1 of 1 residents (R16) reviewed who voiced they felt confined to their chair and did not move due to fear of, and dislike of, the audible noise the device created. Findings include: R16's significant change Minimum Data Set (MDS) dated [DATE], included cognitively intact with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's care plan dated 4/13/21, identified a risk for falling and an intervention included, Floor and chair alarm, with an initiation date of 4/10/21. During observation and interview on 8/2/21, at 2:44 p.m. R16 was observed in her room seated in a wheel chair. R16 had a visible device attached to the back of her wheel chair which had a cord extending under her buttocks. R16 stated it was an alarm, every time she moves, it sets off the alarm loudly. R16 stated, it restricts her from moving around and adjusting herself. R16 stated she was very frustrated by this and it causes her to sit still for fear of setting the alarm off. When interviewed on 8/4/21, at 7:33 a.m. R16 again stated the alarm really bothers her and she is fearful of moving and creating all this noise. When interviewed on 8/4/21, at 9:16 a.m. nursing assistant (NA)-A stated, R16 required extensive assistance with transfers and toileting. R16 has had a pressure alarm for a couple of months now and has expressed she does not like it. It keeps her from moving about. NA-A had discussed this with nurses, but has been told to remind R16 the alarm is to remind her not to get up by herself and wait for assistance. NA-A has done this and R16 stops complaining for a while. When interviewed on 8/4/21, at 9:30 a.m. licensed practical nurse (LPN)-A, stated, pressure alarms are generally used for those who fall frequently. LPN-A did not know who re-evaluates the effectiveness of alarms or if they are causing any issues for the resident, it is done by those higher up the chain. LPN-A was no aware of any policy concerning alarms, nor had received any training on them. LPN-A was not aware R16 was afraid to move and adjust herself due to setting off the alarm. When interviewed on 8/4/21, at 12:10 p.m. registered nurse (RN)-A and RN-B stated, alarms are initiated for residents who fall frequently and had confusion. Every resident was different and an alarm is not appropriate for every resident. R16's alarm had been initially discussed with family and the interdisciplinary team. Re-assessments are conducted quarterly. In the past R16 had complained about the alarm, family had requested it be removed, but then R16 had a stroke and family wanted it back on after that. R16 was not aware of her limitations and would attempt to transfer herself, and would fall. RN-A was not aware R16 was afraid to adjust herself or move about due to setting off the alarm. When interviewed on 8/4/21, at 12:55 p.m. the director of nursing (DON) stated, The decision to use the alarm for R16 was made at family request after a stroke. R16 was once on a bed alarm and w/c alarm on 1/15/20, but was removed on 8/19/20, due to resident and family request. Floor staff typically would only put a pressure alarm on if it were over night or on a weekend, it would be assessed on the following day or after the weekend if it were the best intervention. The team would then comes together and make a decision. She was not aware of R16's dislike of the pressure alarms or that it kept R16 from adjusting herself and moving about, effectively restraining her. A policy was requested that specifically addressed restraints and reassessment of restraint like interventions, pressure alarms, but was not provided.

Based on observation, interview, and document review, the facility failed to ensure the ceiling in 1 of 1 main production kitchens was kept in a clean and sanitary condition to prevent potential contamination of food or cooking surfaces with dust or debris. This had potential to affect all residents, staff and visitors who consumed food from the main production kitchen. Findings include: On 8/2/21, at 4:57 p.m. the main production kitchen was toured which identified four (4) large circumference ventilation openings were present which were spread throughout the kitchen ceiling over various surfaces including the convection oven and food preparation/serving counters. However, immediately surrounding each of these ventilation openings was visible, dark brown and black-colored clumping's of dust and debris which extended for several feet around the ventilation openings and, at times, covered nearby structures (i.e., fire alarm sprinklers) with the same visible clumping dust and debris. The surveyor placed their hand up next to the ventilation openings and verified the air flow was blowing out of these openings and into the kitchen above the various surfaces. On 8/4/21, at approximately 1:40 p.m. (two days later) the ceiling was again observed and continued to have the same visible clumping dust and debris present around the ventilation openings. When interviewed on 8/4/21, at 1:42 p.m. cook (CK)-A verified the condition of the ceiling and stated it needed to be cleaned; however, CK-A added she was unaware who was responsible to ensure the ceiling was cleaned. When interviewed on 8/4/21, at 1:54 p.m. the dietary manager (DM) acknowledged the dust and debris on the ceiling of the kitchen and stated it should have been cleaned prior, as dust or debris could be a potential hazard and get into food while it's being prepared or cooked. DM voiced the maintenance department was responsible to clean the kitchen ceiling and ventilation openings. When interviewed on 8/4/21, at 2:14 p.m. the maintenance manager (MM) stated he was new to his role with the facility but verified their department was in charge of cleaning the kitchen ceilings. However, added there was not a formal cleaning schedule or plan to ensure this was completed on a routine basis. The Infection Control for the Food Service Department policy, last reviewed by the facility on 10/10/19, failed to address ceiling cleaning and maintenance procedures.

Based on observation, interview and document review, the facility failed to actively screen staff and vendors for COVID-19 when entering the facility through the designated door. This had the potential to affect all 44 residents currently residing in the facility. In addition, the facility failed to ensure proper hand hygiene/glove use was conducted during personal cares along with disinfecting the standing lift after use for 1 of 2 residents (R1) who were observed during cares and utilized a standing lift. Findings include: Upon entering the facility on 4/13/20, at 10:40 a.m. the front doors were locked. Signage was on display that the facility was restricting visitors except for at end of life and to ring the doorbell. Another sign directed staff and vendors to enter the facility through the back door. During the entrance conference on 4/13/20, at 10:59 a.m. the director of nursing (DON) stated the facility had no confirmed positive COVID-19 resident or staff. Staff and residents were being actively screened for signs and symptoms of COVID-19 on a daily basis. During interview on 4/13/20, at 11:10 a.m. nursing assistant (NA)-A stated she entered the facility through the back door, put on a face mask, completed hand hygiene and then went to the nursing station to be screened by the nurse. The nurse takes their temperature and asks screening questions. They had received education that if they were symptomatic by having a sore throat, cough, fever, or shortness of breath, they were to stay home. During interview on 4/13/20, at 11:19 a.m. housekeeper (H)-B stated they entered the facility through the back door. They put on a clean mask then walked to the nursing station where they had their temperature taken and were asked COVID-19 screening questions. They were told not to come to work if they had a new cough, sore throat, shortness of breath or running a temperature. During interview on 4/13/20, at 11:30 a.m. NA-B stated she entered the facility through the back door. NA-B puts on a clean mask and then washed their hands. They go to the nursing station to have their temperature checked and are asked screening questions. During interview on 4/13/20, at 11:33 a.m. NA-E stated all staff were entering through the back door. They were to put on a mask then go to the nursing station to be screened for COVID-19 signs and symptoms prior to working with any residents. There were no residents or staff working with current signs or symptoms of COVID-19. During interview on 4/13/20, at 11:40 a.m. licensed practical nurse (LPN)-A stated she entered the facility through the back door, washes their hands and grabs a clean mask. LPN-A then goes to the nursing station to have their temperature checked and screened for health questions related to COVID-19 signs and symptoms. If she had any symptoms she would stay home. If anyone developed symptoms while at at work it would immediately be reported to the DON and then would be sent home. When interviewed on 4/13/20, at 11:48 a.m. registered nurse (RN)-B stated the nurses were tasked with screening employees, vendors and any visitors that would be allowed in the facility. Staff and vendors were to put on a mask then come to the nursing station where the nurses would then screen them for COVID-19 signs and symptoms. Staff were not stationed at the back door. On 4/13/20, at 11:50 a.m. the back door area where staff and vendors enter was observed. There was hand sanitizer located on the wall. On the opposite side of the hallway there was a table set up with a basket of clean homemade mask. Signs were posted above the table that directed the following: DO NOT PROCEED WITHOUT A MASK! If you have a COUGH, FEVER, SORE THROAT, OR SHORTNESS OF BREATH- DO NOT COME IN. No staff were observed present to actively screen staff and vendors as they entered the facility through the back door. After entering the back door, placing their masks the employees and vendors then needed to walk through a hallway of resident rooms prior to getting to the nursing station. During interview on 4/13/20, at 11:51 a.m. trained medication assistant (TMA)-A stated she entered the facility through the back door. TMA-A washes their hands, grabs a clean mask and then walks to the nurses station. Then a nurse comes to take her temperature and ask COVID-19 screening questions. During interview on 4/13/20, at 12:12 p.m. maintenance worker (M)-A stated they enter the facility through the back door. They wash their hands, put on a clean mask and then walks to the nursing station to get screened by the nurse for COVID-19 signs and symptoms, including a temperature. During interview on 4/13/20, at 12:20 p.m. (H)-A stated they enter the facility through the back door, washes their hands, places a mask then goes to the nursing station. The nurse then takes their temperature and is asked COVID-19 screening questions. After they are cleared they punch in and wash their hands. During interview on 4/13/20, at 12:55 p.m. with the DON and RN-A. The DON stated individuals who enter the front door are visitors, which is very limited at this time. All staff and vendors enter through the back door. Everyone that comes in the back door is expected to performs hand hygiene, put on a clean mask, then report to the nursing station where they are screened by the nurse. The screening consists of taking their temperatures and asked questions regarding signs and symptoms of COVID-19. The facility did not have someone stationed at the back doorway to screen staff as they entered. RN-A stated the facility didn't have the staff available to sit at door to screen individuals as they have different start times. The DON added they thought placing the mask after entering the facility would help versus staff just walking to the nursing station. The facility Coronavirus/COVID-19 policy revised on 4/14/20, identified all staff were screened prior to the start of the shift for fever, new/worsening cough, shortness of breath, and sore throat. If any criteria are met staff member was sent home and instructed to update their primary care provider. R1's quarterly Minimum Data Set ((MDS) dated [DATE], identified R1 required extensive assistance with toileting and transfers. R1 was frequently incontinent of urine. During observation on 4/13/20, at 11:25 a.m. RN-B and NA-E entered R1's room with a standing lift. RN-B and NA-E placed the harness on R1 and secured the leg straps. They transferred R1 to the bathroom. NA-E with bare hands lowered R1's pants and brief. RN-B then lowered the lift so R1 could use the bathroom. NA-E removed R1's brief, soiled with urine, with her bare hands. When NA-A went to place the soiled brief into the garbage can, the brief landed on the floor. NA-E picked the soiled brief off the floor with her bare hands and placed it into the garbage. NA-E did not perform hand hygiene. NA-E went to the closet and retrieved a clean brief. NA-E put on gloves without performing hand hygiene first. NA-E completed perineal cares with gloved hands then put the clean brief on R1. RN-B raised the standing lift and with gloved hands NA-E pulled up R1's clean brief and pants. NA-E removed their gloves and placed them in the garbage. NA-E did not perform hand hygiene. R1 was then lowered back to their recliner via the standing lift. RN-B and NA-E removed the harness and straps from the standing lift. RN-B went to the bathroom and washed their hands. NA-E moved the bedside table closer to R1 and then started to leave the room with the standing lift. R1 asked NA-E to plug in their cell phone. NA-E stopped and picked up R1's cell phone cord off the floor and then grabbed R1's cell phone off the table and plugged it in. NA-E then grabbed the lift and left the room without performing hand hygiene or disinfecting the standing lift. NA-E placed the lift in the hallway alcove and did not disinfect the lift. NA-E then went to the nursing desk and removed the cloth mask they were wearing and placed it in a paper bag. NA-E then washed her hands at the nursing station sink without their mask on. During interview on 4/13/20, at 11:33 a.m. NA-E stated R1 and other residents used the standing lift and they did not have their own harness'. NA-E did not perform hand hygiene while in R1's room before or after touching potentially contaminated items. NA-A did not use gloves while removing a urine soiled brief and should have. NA-E stated they forgot to disinfect the standing lift after use and they were supposed to prevent contamination to other residents. NA-A should have washed their hands prior to removing the mask to go on break. The mask was supposed to be on while on the floor. NA-E stated she had been educated on hand hygiene, glove use and disinfecting the lifts between resident use. NA-A stated she got nervous and made a mistake. R1's progress notes were reviewed from 3/15/20, until 4/13/20, R1's daily COVID-19 screens identified R1 was free of COVID-19 signs and symptoms. During interview on 4/13/20, at 11:48 a.m. RN-B stated there were no residents in the facility with COVID 19 signs and symptoms and the nurses screen all residents daily. NA-E needed more education on hand hygiene, glove use and disinfecting lifts. It was important to use good infection control techniques to keep staff and residents healthy and avoid cross contamination. When interviewed on 4/13/20, at 11:58 a.m. the DON stated staff were fully expected to toilet someone using proper hand hygiene and glove use. They are expected to perform hand hygiene and disinfecting equipment between residents. Further, she would provide immediate education and ensure the room and lift were disinfected. The DON provided an undated, untitled document that identified nine residents currently used the standing lift. The facility policy Handwashing/Hand Hygiene reviewed 11/19, directed staff to perform hand hygiene between tasks on the same resident, after removing gloves, after touching potentially contaminated items, after assisting a resident to use the bathroom. All staff are education upon hire and annually on proper hand hygiene. The undated facility Policy for Glove Use identified gloves should be used before touching any body fluids. Contaminated gloves must be removed before touching the resident or clean areas of the residents clothing. Hands should be wash as soon as possible after removed the gloves.

Based on observation, interview and document review, the failed to ensure proper disinfection techniques was completed following glucometer use for 3 of 3 residents (R16, R18, R33) observed for glucose monitoring. Findings include: On 4/15/19, at 10:50 a.m. registered nurse (RN)-A was observed to perform blood glucose monitoring for R16 with the use of an Assure Platinum blood glucose monitoring system. RN-A performed proper hand hygiene prior to obtaining the supplies for testing. RN-A obtained the meter, test strip, and lancet (a single use self-contained needle used to obtain drops of blood for a blood test), alcohol prep, and gloves. RN-A proceeded to R16's room, wiped R16's finger with an alcohol prep followed by wiping with a tissue. A finger prick was completed with the use of a single use lancet and a drop of blood was applied to the test strip from the finger, placed into the glucometer, and test results obtained. Appropriate hand hygiene and disposal of the lancet were observed. RN-A placed the glucometer machine into the pocket of her uniform and proceeded to walk to the med cart. RN-A wiped the machine down with an alcohol wipe and placed the monitor into the compartment for R16. RN-A stated each resident had their own meters for glucose monitoring which were cleaned with alcohol wipes after each use prior to returning to the drawer. RN-A stated the monitors were disinfected with SaniWipes at the end of each shift. RN-A sanitized her hands with the use of alcohol hand sanitizer following cleaning of the monitor. On 4/15/19, at 10:55 a.m. RN-A was observed to appropriately test and obtain R18's blood glucose reading. Following the glucometer check, RN-A returned to the med cart and proceeded to wipe off the monitor with the use of an alcohol prep. and placed the monitor into R18's compartment in the med cart and sanitized her hands with the use of a hand sanitizer. On 4/15/19, at 11:13 a.m. licensed practical nurse (LPN)-A was observed as she gathered supplies (meter, strip, alcohol prep, lancet, and gloves) to perform blood glucose monitoring for R33. RN-A proceeded to the resident in her room and appropriately performed the blood glucose check. Following the blood glucose reading, LPN-A informed R33 of the results, returned to the med cart, disposed of the debris and lancet appropriately. LPN-A proceeded to wipe the machine off with an alcohol prep and placed it into the med cart compartment designated for R33. On 4/17/19, at 11:18 a.m. LPN-A was observed to wipe down a glucometer with a SaniWipe. LPN-A stated she had incorrectly used an alcohol wipe for cleansing of the monitor on 4/15/19. LPN-A stated staff were suppose to use a SaniWipe to wipe off glucometers after each use. LPN-A stated it was important to clean with SaniWipes to disinfect because if the monitors were not disinfected properly there would a higher potential to spread infection. On 4/17/19, at 2:02 p.m. the director of nursing stated the blood glucose monitors should be disinfected with a SaniWipe after every use to prevent potential spread of blood borne pathogens for both staff and residents. The facility's 9/2018 Glucometer Policy, identified each individual glucometer was to be wiped with a germicidal wipe following use. The policy also indicated staff were to follow manufacturer guidelines for contact time when disinfecting. The Assure Platinum Blood Glucose Monitoring System User Instruction Manual directed the user to clean and disinfect with a commercially available EPA-registered disinfectant detergent or germicidal wipe. The manual directed the user to follow the product label instructions to ensure proper drying time.

Based on interview and document review, the facility failed to ensure routine lab work was drawn as ordered for 1 of 5 residents (R18) reviewed for unnecessary medications. Findings include: R18's significant change Minimum Data Set (MDS) completed on 1/23/19, indicated R18's medical [DIAGNOSES REDACTED]. R18's Medication Review Report of 4/17/19, signed by the doctor, indicated R18 was to have an A1C (A blood test that reflects your average blood glucose levels over the past 3 months) drawn every three months. Additionally, R18 was to have a lipid panel (A blood test that measures lipids-fats and fatty substances used as a source of energy by your body) and a TSH test (A test to measure the [MEDICAL CONDITION] stimulating hormone) drawn yearly. The doctor's orders indicated an R18's blood sugars were to be checked four times a day. The signed orders identified R18 was prescribed routine dosing of insulin and received additional insulin coverage based on the results of the blood sugar results and according to the oral intake of carbohydrates. A review of R18's Hgb A1C indicated the last blood test was completed on 9/25/18, however, the physicians orders of 2/3/17 indicated R18 was to have a Hgb A1C every 3 months per MD order of 2/3/17. No results are noted after 9/25/18. The physician orders [REDACTED]. R18's last known TSH on 3/6/18 and the last lipid profile was completed on 11/28/17. A review of R18's medical record lacked indication of any further testing. On 4/18/19, at 12:50 p.m. registered nurse (RN)-C stated R18's last A1C was last drawn in (MONTH) and was to have been monitored every three month. RN-C stated the A1C results reflected the average blood sugar during the previous months and indicated R18 has had multiple insulin changes and had a history of [REDACTED]. RN-C stated there was no indication of recent TSH levels or lipid panels had been completed for R18. On 4/18/19, at 1:21 p.m. the director of nursing (DON) stated lab work was to be completed as ordered by the provider. The DON stated the use of the A1C results was important for R18's management of her diabetes related to her fluctuations of blood sugars and need for the adjustment with insulin dosing. A facility policy was requested for tracking physician's orders [REDACTED].

Based on interview and document review, the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC- ) (SNFABN) to 2 of 2 residents (R27, R145) whose Medicare A coverage ended and the residents remained in the facility. Findings include: R27's CMS (Centers for Medicare and Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) indicted R27's coverage under Medicare A was complete on 11/27/18, and R27 was responsible for charges incurred following 11/27/18. R27's responsible party was provided with a facility letter titled SNF (Skilled Nursing Facility) Determination on Continued Stay which provided the information regarding the right to appeal, however, the notification was not completed with the provision of the NOMNC CMS- . R27's Resident Rate Reports identified R27's payer source changed on 11/28/18, from Medicare A coverage to private pay. R145's CMS (Centers for Medicare and Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) indicted R145's coverage under Medicare A was complete on 12/06/18, and R145 was responsible for charges incurred following completion of coverage. R145's responsible party was informed of this information by telephone on 12/4/18, and signed the facility letter titled SNF (Skilled Nursing Facility) Determination on Continued Stay in acknowledgement of notification on 12/4/18. R145's responsible party was not provided with the NOMNC via CMS- . R145's Resident Rate Reports identified R145's payer source changed on 12/6/18, from Medicare A coverage to private pay. On 4/18/19, at 9:17 a.m. the administrator stated he was responsible for administration of the notification of last day of Medicare coverage and of the right to appeal the decision. The administrator stated although he was aware of the need to use the CMS NOMNC- , he was not aware of the need to use the SNFABN CMS- document. A facility policy, Steps to Issue a Denial, revised 1/2018, indicated the CMS and SNF continuation of stay form was to be provided to the resident

Based on observation, interview and document review, the facility failed to ensure follow through with smoking interventions as assessed and care planned for 1 of 1 residents (R1) who smoked. This resulted in actual harm to R1 who went outside to smoke and sustained frostbite to both hands. Findings include: R1's quarterly Minimum Data Set ((MDS) dated [DATE], identified R1 had severe cognitive impairments and needed extensive assistance with transportation. R1 had functional limitations to his upper and lower extremities and identified R1 used tobacco. A [DIAGNOSES REDACTED]. R1's care plan dated 9/8/17, identified R1 used tobacco and instructed the staff would store R1's cigarette and lighter, place R1 in the designated smoking area. R1 would wear a smoking apron while smoking and staff were to complete smoking assessments quarterly and as needed. R1's quarterly Smoking assessment dated [DATE], identified R1 had cognitive loss, visual deficits and did not have any dexterity problems. R1 smoked 10 or more cigarettes a day morning, afternoon and evening. R1 could light his own cigarette and needed a smoking apron. Staff were to store R1's lighter and cigarettes. The assessment did not identify if R1 could exit and enter the building on his own. R1's progress note(s) identified the following: -1/29/19, At approximately 9:15 p.m. a staff member was walking towards the nursing station and the door bell rung. The staff member checked the front door and R1 was outside. Writer saw his hands were red and the ends of his fingers were pale in color. A blister was observed on his left thumb. The blister measured 3.6 centimeters (cm) x 3.2 cm. Staff asked for R1's cigarette and lighter, and R1 gave the staff them to the staff member. The staff warmed R1's hands with a warm towel . R1 removed the towel and stated his hands were fine. R1 could move and wiggle his hands and fingers without difficulty. - 1/30/19, at 3:17 a.m. R1's hands were observed. R1 had fluid filled blisters to all five of his fingers on the left hand. The four fingers were flesh colored blisters, but the blister to his thumb was dark in color. All five knuckles were reddened to the right hand. R1 refused measurements to either hands. Both hands were swollen. - 1/30/19, at 10:14 a.m. The overnight charge nurse reported R1 was outside the previous evening and had blisters to his hand. Nursing tried to assess R1's hands at 8:15 a.m. and R1 refused. At 8:45 a.m. R1 was lying in bed and had reddened 2nd, 3rd and 4th knuckles on the 2nd through 5th digits of the right hand. Anterior fingers of the right hand were red and the hand was swollen and painful to the touch. R1's left hand was also swollen and painful to the touch. There were fluid filled blisters present to the front and back sides of the 2nd through 5th digits of the left hand. The thumb had a dark purple/ blackened blistered area which measured 3 cm x 3.5 cm. R1's feet were examined and there were no identified concerns. Call was placed to the clinic at 9:00 a.m. R1's physician gave orders to transfer to the emergency department. R1 was transferred via ambulance at 9:40 a.m. - 1/30/19, at 2:15 p.m. R1 returned from the hospital. R1 was to keep both hands wrapped, all fingers were wrapped individually with [MEDICATION NAME] (non stick dressing) and then the hand was wrapped in ace bandages. R1 would be assessed on 2/1/19 by the physicians assistant (PA)-A and had an appointment scheduled on 2/4/19, with the surgeon. R1's Altered Skin Integrity Sheet A identified the following: - 1/29/19, blister to the left thumb measuring 3.6 cm x 3.2 cm. R1 had a purple bruising/blister to the left thumb. R1 denied pain. - 2/1/19, R1's left hand identified blisters intact. The 2nd finger blister measured 8 cm x 4 cm. The 3rd finger had two blisters and they measured 2 cm x 1.5 cm and 4 cm x 5 cm. The 4th finger blister measured 7.5 cm x 6 cm. The 5th finger blister measured 6 cm x 4 cm. The thumb was blistered and bruised and measured 4 cm x 5 cm. There were no signs or symptoms of infection and the capillary refill was delayed 5-6 seconds. R1 had sensation to all fingers. - 2/1/19, R1's right hand identified blisters and redness. R1's 4th finger had a blister which measured 4 cm x 4 cm. The 5th finger had a blister that measured 3 cm in length but did not identify a width. The thumb was blistered and measured 4 cm x 6 cm. The right hand was reddened. R1 had discomfort during the dressing change. There were no signs or symptoms of infection and the capillary refill was delayed 5-6 seconds. R1 had sensation to all fingers. R1's ED (emergency department) Provider note dated 1/30/19, identified R1 presented to the ED by ambulance and was transferred by the facility. Staff at the facility reported R1 had swelling, blisters and bruising to his fingers. The facility determined the swelling and blisters was a result of being outside smoking. Reportedly R1 took two trips outside to smoke. It had been -20 degrees Fahrenheit (F) and -40 degrees F below zero. He reported pain in his hands. He has no other pain or blistering. He has a history of dementia but is in the early stages. He is allowed to go outside and smoke on his own typically at the facility. He was agitated , swore al lot and wanted to go home. A focused examination of his hands was completed. R1 was diagnosed with [REDACTED]. The ED physician identified he had a significant amount of swelling to the left hand including all five digits. All five digits on the left hand were blistered and remained intact. The left thumb had a large bruised area associated with the blister. All of his fingertips were tender. There were a couple of small blisters on various fingers on the right hand. He had good strength in his upper extremities. His face is without blisters or redness. His toes are without redness or blisters. The ED physician documented the frostbite was concerning and discussed seeing a burn specialist, but R1 refused. R1 refused blood work. Although he had a history of [REDACTED]. He admitted it got pretty cold smoking cigarettes last night. He did not know how long he was outside. His primary physician came to the ED to speak with R1 and got him to agree to a surgical follow up. The plan is to have him follow up on Friday (2/1/19) with primary care to check on the blisters, with a goal to have the blisters remain intact as long as possible to avoid complications, such as infection. Secondly we need to ensure he had adequate blood supply to his fingers and hands. Debridement (process of removing dead tissue) may be an issue so would schedule a surgical consult. During interview on 2/1/19, at 1:04 p.m. nursing assistant (NA)-A stated R1 was the only resident who had been smoking at the facility. R1 was no longer smoking as he received frostbite to his hands. R1's cigarettes and lighter were kept locked up and staff would need to give them to him if he wanted to smoke. NA-A did not have any experience with obtaining R1's cigarette and lighter and was not sure what his smoking plan was as she assisted residents mainly with bathing. On 2/1/19, at 1:07 p.m. R1 was laying in bed and had both hands bandaged with ace wraps from both wrists and covered the fingers and hands completely. R1 stated he had frostbite. R1 stated he took himself outside to smoke when it was dark and cold out and staff did not take him outside. R1 did not recall if he had his cigarettes on him or if staff provided them to him. After going outside he smoked a cigarette without gloves on and then tried to open the door with the automatic switch. R1 stated he would push the button the door would open but could not get through the doors because it was windy and slippery outside. After a couple of attempts of trying to get through the doors he rang the doorbell outside the facility and a staff member let him in. It was really cold out and did not know how long he was outside. R1 stated he had a coat on but no gloves or winter hat. R1 stated he had not problems getting in and out of the building prior. R1 stated he had some pain to his hands , but it wasn't bad. R1 went to the hospital the morning after he received frostbite. He currently could not go outside to smoke and the facility provided him with a nicotine patch. Immediately following the interview, the outside doors were observed. To the left of the front doors approximately 5 feet away from the door was a handicap button to activate the front doors. On the right side of the front doors was a doorbell. Both were in working order. When interviewed on 2/1/19, at 1:15 p.m. NA-B stated R1 was the only resident at the facility who was smoking prior to the incident. R1 was feeing himself prior to receiving frostbite, but the staff needed to assist him with eating because his hands were currently wrapped. R1 was able to propel himself in his wheelchair. R1 went outside to smoke frequently and the staff had been setting a timer for 5 minutes when he went outside to ensure he made it back into the building safely. The staff started using the timer when it got cold out. R1's cigarettes and lighter were locked in a drawer in the copy room. If R1 wanted to smoke the staff would get his smoking apron and help put it on and unlock his cigarettes and lighter and given them to him. R1 would then take himself out to smoke. The staff were to then get his cigarettes and lighter and put them back in the locked drawer. R1 was not to store his own cigarettes. R1 occasionally would get his wheelchair stuck on the threshold of the outside door and would need staff assistance to get him back into the building. R1 knew how to push the automatic button for the outside doors. She would not have left R1 unsupervised during the extreme cold to smoke and would have went with him to ensure his safety. During interview on 2/1/19, at 1:15 p.m. NA-C stated she was not working the night R1 received frostbite to his hands. R1 was the only resident who smoked. When R1 wanted to smoke he would sit outside the copy room or ask staff to get his cigarettes for him. R1's cigarettes were to be locked up in the copy room drawer along with his lighter. Staff would assist with putting on the smoking apron and hand R1 his cigarettes and lighter and he would then go outside. The staff were setting a timer for 5 minutes when he was outside smoking so staff could ensure he was back in the building, due to the cold and at times R1 would get his wheelchair stuck on the outside door threshold. R1 did not like to turn in his cigarettes and lighter after smoking and staff were not always able to get them from him. NA-C stated if she had been working when it was extremely cold she would have referred it to the nurse. During interview on 2/1/19, at 1:25 p.m. registered nurse (RN)-A stated R1 had been the only smoker in the facility and was no longer smoking since he received frostbite to both his hands. Staff were storing R1's cigarettes and lighter in a locked drawer in he copy room. R1 also needed a smoking apron and needed assistance with putting it on. When R1 wanted to smoke he would sit outside the copy room or ask staff to get his cigarettes for him. Staff would give him his cigarettes and lighter and place the apron on and he would take himself outside to smoke and come in when he was finished. RN-A stated R1 was outside for about 15 minutes or so and the facility was actively investigating what occurred on 1/29/19. Staff either took him outrside and forgot he was out there or the facility staff did not get his cigarettes back from a previous time he was smoking and he took himself out without staff knowledge. When interviewed on 2/1/19, at 1:36 p.m. NA-D stated R1 was able to move in his wheelchair without help once he was in the wheelchair, but would move slowly. R1 was the only resident who was smoking in the facility. When he went out to smoke he would smoke 1-2 cigarettes at a time and would come right back inside. The designated smoking area was on the opposite side of the button to push to open the automatic door. He often needed help in and out of the outside door as he would get the wheelchair stuck on the threshold. Sometimes the door would start closing after he pushed the button, but staff would intervene and assist him into the building. Because it was cold staff had been setting a timer for 5 minutes after he went out side to smoke to remind staff to check on him and assist him into the building if it was needed. When R1 wanted to smoke he would pat the upper left pocket of his jacket to see if he had his cigarettes. When he didn't have his cigarettes and lighter he would ask and staff would then go unlock the drawer they were stored in and give them to him. Staff were supposed to take the cigarettes and lighter back and lock them up when he came in from outside, but at times would swear at the staff when asking for them back and would not give them back at times. Staff now had to assist R1 to eat because both of his hands were wrapped due to the frostbite. NA-D was not sure exactly what happened but heard he had his cigarettes and lighter and took himself outside without staff knowing and he could not get back in the building. R1 liked to sit in the front lobby by the door between cigarettes and staff did not always get them back from him when he said he was going right back out. On 2/1/19, at 1:51 p.m. trained medication assistant (TMA)-A stated R1's smoking plan was to keep his cigarette and lighter locked up and assist him with a smoking apron. The staff were to lock his cigarettes and lighter back up when he was finished smoking. R1 did not always let staff get R1's cigarettes and lighter back after smoking and they would have to wait until he flayed down to get them back. The staff had been setting a timer for 5 minutes overtime he went outside to smoke to ensure he got back into the building safely. TMA-A stated she was not working the evening R1 got frostbitten, but had heard staff were not following his care plan by not locking up his cigarettes and lighter after smoking. During interview on 2/1/19, at 2:37 p.m. NA-E stated she was not working the evening R1 was frostbitten. There were no other smokers in the facility besides R1 and he was not currently smoking. NA-E heard R1 was outside for over 15 minutes in the extreme cold. R1 refused to wear gloves so she did not think R1 was wearing gloves the evening he got frostbite. NA-E stated staff did not always get R1's cigarettes back after smoking and the only reason he went outside was to smoke. When interviewed on 2/1/19, at 2:45 p.m. RN-B stated she was not working the evening R1 received frostbite. R1 was the only resident who was a smoker. The staff were to keep R1's cigarettes and lighter locked in a drawer and relock them up after he was done smoking. Staff don't always escort R1 outside but they have had to assist him in when he has gotten stuck on the outside door threshold. The physician assistant looked at his hands earlier that morning and the bandages needed to stay on until they did the dressing change again later that evening. On 2/1/19, at 3:00 p.m. licensed practical nurse (LPN)-A stated R1 was the only resident in the facility that was smoking. R1 would occasionally get stuck coming back into the building so the staff were setting a 5 minute time to remind staff to check on him. The evening R1 got frostbite staff did not get his cigarettes back from him and he took himself out again later when staff were not aware. R1 could not get back in the building and was outside for 17 minutes or so. Staff were not aware he was out there and would not have let him smoke out there without direct supervision in the extreme cold. During interview on 2/1/19, at 3:05 p.m. LPN-B stated R1 was the only resident that smoked. He needed assistance with putting on his smoking apron and staff would need to give him his cigarettes and lighter as they were locked in a drawer. R1 was able to move wheelchair and did not need staff to bring him outside. Staff had been setting a timer for 5 minutes to remind them to check on him and started doing that because of the cold. The staff are supposed to lock up the cigarettes and lighter as soon as he was finished smoking and did not always get them back from R1. R1 needed prompts to dress warm and did not like to wear gloves. Staff were not aware he was outside that evening. When interviewed on 2/1/19, at 3:15 p.m. NA-F stated R1 was able to smoke on his own but the staff locked his cigarettes and lighter up and assisted with placing a smoking apron on him. The staff give him his cigarettes and he goes out and smokes and then comes back in staff then need to get his cigarettes and lighter and lock them back up. NA-F was not sure how R1 got frostbite. NA-F would have 1:1 supervised R1 if he wanted to smoke in the extreme cold and encouraged to dress warmly. During interview on 2/1/19, at 3:23 p.m. director of nursing (DON) stated staff were directed to put on R1's smoking apron and keep his cigarettes and lighter locked up, unless he was out smoking. DON stated R1's smoking assessment did not identify if R1 could get into and out of the building safely and thought they should make an adjustment to the smoking assessment to include the information. R1 at times needed assistance to get back in the building. R1 brings himself outside and staff are not required to bring him to the smoking area. It is care planned because R1 was not smoking in the designated spot and would bother others with the smoke. The timer was not care planned and was just a way for staff to make sure they did not forget he was outside smoking. DON became aware of R1's frostbite on 1/30/19, at about 6:30 a.m. when she reported for work. After the nurse assessed him the blistering had worsened and they contacted R1's physician and wanted him seen in the ED so they called the ambulance and had him transferred. The facility was in the process of completing their internal investigation, but had determined through facility security camera's R1 let himself out of the building at 9:15 p.m. and was wearing a baseball cap and blue winter jacket he always wore. R1 did not have gloves on. R1 was outside for a total of 17 minutes. R1 always sat in the hall with his winter coat and baseball cap on so he would not look out of place. I would like to think if the cigarettes were taken away, he would not have gone outside. His intent was to smoke and staff did not get them back from him from a previous time outside. DON was not aware when the last time R1 received cigarettes from the staff but knew the staff had difficulty getting them back from R1 at times. Frostbite was a serious condition they immediately put a wanderguard on R1's wheelchair, and got him medical treatment. The facility had changed there smoking policy and were no longer accepting residents who smoke. On 2/1/19, at 3:59 p.m. the facility security cameras for the evening of 1/29/19, were viewed with the administrator. -At 9:16 p.m. R1 self exited the building with a baseball cap and blue winter coat. R1 did not have on gloves. Staff were not seen giving him cigarettes. - At 9:23 p.m. the front doors were activated by the outside button and the doors closed before R1 could reach them. - At 9:25 p.m. the front doors were activated by the outside button and the doors closed before R1 could reach them. - At 9:26 p.m. the front doors were activated by the outside button and the doors closed before R1 could reach them. - At 9:28 p.m. the front doors were activated by the outside button and the doors closed before R1 could reach them. - At 9:30 p.m. the front doors are seen closing , but the camera did not catch them opening. - At 9:32 p.m. the front doors were activated by the outside button and the doors closed before R1 could reach them. - At 9:35 p.m. R1 was seen on the right side of the front door ringing the doorbell and a staff person immediately answered the door and brought R1 inside. The staff member retrieved R1's cigarettes and lighter. Then the staff member placed towels on his hands. The administrator stated R1 had been outside and exposed to the temperature for a total of 17 minutes. R1 had never had that much difficulty getting back into the building but it was very cold, windy and slippery. The administrator pulled up the boiler, outside temperature log and identified on 1/29/19, at 9:15 p.m. the air temperature, minus the windchlll, was - 33 degrees F. The facility investigation determined staff put on R1's smoking apron and gave him his cigarettes and lighter at 5:30 p.m. and no one retrieved them after he returned to the building. R1 let himself out of the building also at 7:30 p.m. that evening but was back inside within 3 minutes. I feel if we would have gotten the cigarettes from him after 5:30 p.m. he would have not gone outside. R1 would not have received frostbite to both hands if the cigarettes were retrieved as care planned. The facility did not have a policy on severe cold whether, but the staff would be expected to use common sense when it came to the whether and follow resident care plan.

Based on interview and document review, the facility failed to ensure their responses to food concerns raised at the resident council meetings were documented and presented back to the council. There were twelve residents (R36, R21, R22, R8, R10, R27, R17, R34, R15, R19 and R25) identified to have participated in resident council meetings in the past two months. Findings include: On 3/6/18, the facility provided resident council minutes from the past month's meetings, and a representative from the resident council, R10, gave permission for the survey team to review the meeting minutes. On 1/15/18, the resident council met and meeting minutes identified officers R8, R27 and R36, but did not list or identify other residents in attendance. The minutes indicated Food as an area of concern. The minutes had a section New Business Summary, which had five sections: Current Situation; What is our Goal?; What needs to get done to get there?; Who will help us get there?; and Current Status. Under the new business summary, there was no mention of food. However, the minutes contained a copy of a flyer inviting residents to attend a Resident Food Committee meeting set for Monday, (MONTH) 29, (YEAR). The agenda included food temperature, likes and dislikes. Fall/Winter menus, new topics? A document, Resident food Committee, Central(NAME)County Care Center, indicated food committee was held on 1/29/18, and attended by R27, R8, R22, R25, R10, R17, R34, R15 and R19. Areas of concern included: -pancakes still need to be improved upon. Dietary manager will look into purchasing a different brand to see if this will make a difference. -some residents would like to see more pudding on the menu instead of fruit, some do not. -food suggestions: -more dill pickles and bread & butter pickles with meals -more pork chops, meatloaf, summer sausage, bigger shrimp, and BBQ ribs with bone in -at 3 p.m. coffee socials, more cakes with frosting --individual likes/dislikes were let known to kitchen staff On 2/19/18, the resident council met with R17, R21, R8, R36, R17, and R10 in attendance. In the new business summary section, food was identified under current situation, and action was set up another food service meeting; Activity director contact Dietary manager to set up meeting; Activities Director and dietary manager identified as responsible. Under current status: On-going; expressed possible monthly buffet style meals. Dietary supervisor updated in person on 2/19/18. The minutes did not list or describe specific food complaints voiced by residents at the meeting, or from the food committee meeting, or what actions the facility took to address those concerns. During the survey on 3/7/18, at 3:04 p.m. a meeting was held with council members R17, R25, R21, R8, R27, and R10 in attendance. R10 stated the resident council met on a monthly basis, and except for the activities department, facility staff usually did not attend the meetings. When asked what concerns the council had, R17 responded Food!, and R25 responded, and stated the food is bad. When asked about more specific concerns, R8 stated some cooks did a better job in preparing what was on the menu. R25 stated a recent meal was kielbasa sausage that was cut up, was burnt and it got real hard and was really not edible. R21 stated some of the entrees needed to be cooked better and added but I don't have to do the dishes. R17 stated emphatically much food was sent back and wasted. R10 denied a lot of wasted food, but stated there was inconsistency in preparation of the same foods, but was unable to give a specific example. R27 had no comment about the food. Continuing the discussion at 3:18 p.m. R25 stated there was a food committee meeting where residents met with the head of the kitchen. R17 stated sure they talked to us but where's the report? R10 also stated she was a writer and they should have a follow up, because how else do you measure progress? During the discussion R8, R21, R10 and R17 agreed with R25 who stated, our beef is that we had the meeting, felt it was not acted upon. R10 stated there was no formal response at the resident council meeting about the food issues raised. When interviewed on 3/9/18, at 11:37 a.m., the dietary manager (DM) stated food concerns have been brought up in the resident council, as well as from the quarterly food committee. The DM stated she did not attend council meetings. The DM stated after a council meeting she will learn of residents' concerns, and then I go out and talk to them. The DM stated she has had numerous discussions about food complaints with R25, R17 and others, and stated has spoken with those residents individually and offered options to meet their wants. The DM stated, however, she did not go back to the council and share what has been done, for example, when residents expressed wanting summer sausages, more pork chops, or pickles on the menu more frequently. The DM stated she just made the changes. The DM stated she did not report to the resident council the findings from the food committee, because many of the same people who came to that meeting were also on the council. The DM also stated she did not have specific notes or documentation of what was done in response to residents' complaints or suggestions. The DM stated she did not go back to the council with what has done, but added, that information should be shared. When interviewed on 3/9/18, at 1:13 p.m., the administrator stated when residents voiced concerns, or had complaints about food, the dietary manager just stepped in, talked with individual residents, and made the changes. The administrator explained the process how the facility addressed concerns raised from the council, and stated after a meeting, department heads received a copy of the minutes, and it was their responsibility to review and address any concerns. The administrator stated staff do not typically attend the council unless invited, and after a meeting, the activity director told staff if they had a specific to do, like a housekeeping or maintenance request, they are addressed by staff, on a one-to-one basis. The administrator stated maybe that needed to change and have a standing agenda item to have head staff be present at the resident council and talk about specific resident concerns. The administrator stated he felt food concerns were addressed, but what's missing was the documentation to show we have discussed and addressed it with the council. A facility policy regarding resident council, and responding to grievances was requested, but none was provided.

Based on interview and document review, the facility failed to complete a comprehensive reassessment using the Resident Assessment Instrument (RAI) process, following the initiation of hospice services for 1 of 1 resident (R35) reviewed for hospice. Findings include: The MDS (Minimum Data Set) 3.0 Manual v1.15R dated 10/1/17, identified a comprehensive MDS assessments included both the completion of the MDS as well as completion of the Care Area Assessment (CAA) process. Further, comprehensive MDS's included a Significant Change in Status Assessment (SCSA), which was required when a resident was admitted to hospice services. The SCSA MDS and CAA completion date could be no later than the 14th calendar day after determination that a significant change in status occurred. R35's Certification of Terminal Illness dated 2/22/18, identified a hospice start of care date of 2/22/18. On 3/9/18, at 10:54 a.m. R35's SCSA was viewed in the electronic medical record (EMR). The SCSA was dated 3/5/18, and indicated the MDS was in progress. The summary identified the MDS was set for completion on 3/19/18, 11 days after the required completion date. The validation section included 46 errors and 2 warnings. The sign section included 531 unsigned areas with 50 signed areas. The CAA summary section indicated the section was in progress. When interviewed on 3/9/18, at 1:57 p.m. registered nurse (RN)-A , who worked with the MDS assessments, stated she was under the impression the assessment reference date needed to be set within 14 days of a hospice admission. She was not aware the MDS and CAA's were to be completed by the 14th days of a hospice admission. On 3/9/18, at 2:03 p.m. the director of nursing (DON) stated R35 was admitted to hospice services on 2/22/18. The DON viewed the MDS manual and stated the the significant change assessment was to be completed no later than 14 days following admission to hospice services. Further, R35's SCSA should have been completed the day before on 3/8/18 and was not complete.

Based on observation, interview and document review, the facility failed to ensure an assessment was completed to determine safe medication administration for 1 of 1 resident (R7) observed to self administer medication through a nebulizer (breathing treatment). Findings include: R7's quarterly Minimum Data Set (MDS) an assessment dated [DATE], identified R7 had severe cognitive impairment and required extensive assistance to complete activities of daily living (ADLs). R7's [DIAGNOSES REDACTED]. During observation on 3/9/18, at 2:38 p.m. R7 was seated with family member (FM)-A in FM-A's room, in the assisted living portion of the building. R7 had a nebulizer mask in place and had finished a nebulizer treatment as noted by the absence of mist. R7 then removed mask, and the nebulizer machine was turned off by FM-A. FM-A placed the mask next to the nebulizer machine on the table. FM-A stated the nursing staff frequently set up R7 with the nebulizer treatment and returned once the nebulizer was completed, adding They're so busy. On 3/9/18, at 2:40 p.m. trained medical assistant (TMA)-A returned to the FM-A's. TMA-A stated she had left R7 unattended, with the nebulizer running to provide assistance to another resident. R7's Medication Review Report identified an order from 2/3/18, for [MEDICATION NAME] Solution one vial four times a day for cough, shortness of breath (SOB), and wheezing. Additionally, the [MEDICATION NAME] Solution was ordered every four hours as needed (PRN) at night for cough. SOB, and wheezing. R7's Medication Administration Record [REDACTED]. R7's current MAR for 3/1/18-3/9/18 identified she had received routine dosing four times per day, however, did not require additional dosing of medication. R7's electronic medical record lacked an assessment to self administer medications. During interview on 3/9/18, at 2:31 p.m. registered nurse (RN)-B stated during administration of a nebulizer treatment , R7 at times was noted to be out of it and did attempt to self remove mask, requiring redirection on two occasions while nebulizer was completed. During interview on 3/9/18, at 3:00 p.m. the director of nursing identified a resident should only be allowed to self administer medication after set up, after an assessment had been completed to determine ability and a physician order [REDACTED]. The facility policy Self-Administration of Medications dated 3/15, directed staff to obtain a physician order [REDACTED]. The facility policy Medication Administration dated 11/17, identified under Procedure, 4. Administer oral medications and remain with residents while he/she takes the medication unless they have the order to self administer medication after set-up.

Based on interview and document review, the facility failed to implement their abuse prohibition policy and report an allegation of abuse to the State agency within two hours of occurrence for 1 of 1 resident (R21) reviewed for abuse prohibition. Finding include: The undated facility policy, Individual Resident Vulnerable Protection Plan, indicated the facility will not condone any form of resident abuse. The policy identified resident-to-resident abuse as reportable abuse, and further indicated all forms of abuse, including resident-to-resident abuse, must be reported immediately. The policy indicated the Administrator assumed the responsibility for the overall coordination and implementation of the abuse prevention program, and further that Inquiries concerning the reporting of abuse to state agencies should be referred to the administrator. R21's quarterly Minimum Data Set (MDS) an assessment dated [DATE], indicated she had severe cognitive impairment. R39's quarterly MDS dated [DATE], indicated she had severe cognitive impairment. An undated facility Investigation Report Summary identified a resident-to-resident incident between R21 and R39. The document indicated on 12/22/17, at 6:00 p.m. R39 hit R21's hand with a spoon while R21 was reaching for the sugar at the evening meal. R39 thought the sugar was hers. The report indicated staff intervened and there were no injuries or complaints of pain. The report indicated this incident was reported to the State Agency the following day, on 12/23/17, at 5:09 p.m. or approximately 23 hours after the incident occurred. When interviewed on 3/8/18, at 1:15 p.m. licensed practical nurse (LPN)-B recalled the incident in the dining room between R21 and R39. LPN-B stated R21 was touching the sugar basket on the table, trying to get a packet out or look at one, and R39 felt they were hers, and R39 hit R21. LPN-B stated she did not witness the incident, that it was reported to her, and added that if the resident hit another resident that would be abuse and a reportable incident. LPN-B stated when abuse or alleged abuse occurs, she would update the director of nursing and the family right away, and also stated in this case, she reported immediately to the administrator. LPN-B stated we follow our chain of command. When interviewed on 3/8/18, at 1:22 p.m., the director of nursing (DON) stated there was a resident-to-resident alteration between R21 and R39, and questioned if R39 had intent. The DON stated R39 reacted to R21 taking the sugar, but R39 knew enough to want to hit R21 over the knuckles. The DON stated that could be abuse, and added, that is why you investigate. The DON stated if there is an allegation of abuse, staff were trained to immediately report to the administrator and me. The DON stated this incident should have been reported immediately. During interview on 3/9/18, at 1:03 p.m., the administrator stated he took the call from the nurse regarding the incident an 12/22/17, between R21 and R29, but then did not make the report to the State Agency until the next day. The administrator stated the allegation was not reported within 2 hours. The Administrator stated the facility's focus was to recognize abuse, and make sure we put something in place to prevent any potential abuse, and in hindsight, the nurse did a good job and did it right (reported it timely). The administrator stated the were looking at changing the facility procedure to have the charge nurse be able to enter the allegation into the system to report to the state, like they already do for reporting injures of unknown origin.

Based on interview and document review, the facility failed to comprehensively assess the nutritional status using the Resident Assessment Instrument (RAI) process for 1 of 2 residents (R17) reviewed for nutrition. Findings include: R17's admission Minimum Data Set (MDS) an assessment dated [DATE], identified R17 was cognitively intact and needed set help only to eat. The MDS identified a height of 72 inches with a weight of 191 pounds. Further it was unknown if R17 had gained or lost greater than 5 percent of his body weight in the last month or 10 percent of his body weight in the last 6 months. R17 had a therapeutic diet order. R17's nutritional status Care Area Assessment (CAA) worksheet dated 10/2/17, identified a comprehensive assessment was indicated as R17's body mass index (BMI) was to high at 25.9 (18.5- 24.9) and R17 had received a therapeutic diet. The CAA identified R17's nutritional status as an actual problem. The analysis of findings included system pre-populated checks, from the MDS which included: R17 had an inability to perform ADLs (activities of daily living) without significant physical assistance; poor memory; [DIAGNOSES REDACTED]. The resident input section was blank. The CAA indicated R17's nutritional status would be care planned; however, no overall objective for the care plan was identified. No referrals were indicated as warranted. The CAA did not provide a further analysis including a review of indicators and supporting documentation identifying the problem, causes, contributing factors, strengths, needs and plan for the management of R17's nutritional status. During interview on 3/9/18, at 12:58 p.m. certified dietary manager (CDM) stated she was responsible for completing the nutritional status CAA's when they are triggered from the MDS. The CDM explained the only parts of the CAA she filled out was if it was an actual or potential problem; if they needed referrals and if the nutritional status was to be care planned. Further, she did not complete and further assessment within the CAA worksheet and stated she may be doing the CAA wrong. When interviewed on 3/9/18, at 1:31 p.m. the director of nursing (DON) stated R17's nutritional status CAA was not completed. Further, the CAA completion was important and should take into account the residents choices and preferences as well as their overall nutritional status and goals. The information was needed to effectively care plan. The MDS 3.0 Manual v1.15R dated 10/1/17, identified The Nutritional Status CAA process reflects the need for an in-depth analysis of residents with impaired nutrition and those who are at nutritional risk. CAA documentation helps to explain the basis for the care plan by showing how the IDT (interdisciplinary team) determined that the underlying causes, contributing factors, and risk factors were related to the care area condition for a specific resident; for example, the documentation should indicate the basis for these decisions, why the finding(s) require(s) an intervention, and the rationale(s) for selecting specific interventions. Based on the review of the comprehensive assessment, the IDT and the resident and/or the resident ' s representative determine the areas that require care plan intervention(s) and develop, revise, or continue the individualized care plan.

Based on observation, interview and document review, the facility failed to comprehensively assess and implement interventions to prevent weight loss for 1 of 2 residents (R17) reviewed for weight loss. Findings include: R17's admission Minimum Data Set ((MDS) dated [DATE], identified R17 was cognitively intact and needed set help only to eat. The MDS identified a height of 72 inches with a weight of 191 pounds (lbs). Further, it was unknown if R17 had gained or lost greater than 5 percent of his body weight in the last month or 10 percent of his body weight in the last 6 months. R17 had a therapeutic diet order. R17's nutritional status Care Area Assessment (CAA) worksheet dated 10/2/17, identified a comprehensive assessment was indicated as R17's body mass index (BMI) was to high at 25.9 with accepted range of 18.5- 24.9 and R17 received a therapeutic diet. The CAA identified R17's nutritional status as an actual problem. The analysis of findings included system pre-populated checks, from the MDS which included: R17 had an inability to perform ADL's (activities of daily living) without significant physical assistance; poor memory; [DIAGNOSES REDACTED]. The resident input section was blank. The CAA indicated R17's nutritional status would be care planned; however, no overall objective for the care plan was identified. No referrals were indicated as warranted. The CAA did not provide a further analysis including a review of indicators and supporting documentation identifying the problem, causes, contributing factors, strengths, needs and plan for the management of R17's nutritional status. R17's care plan dated 9/24/17, identified R17 had a therapeutic diet as ordered. R17 received a liberalized geriatric, cardiac diet with regular texture and thin liquids. Staff were to provide positive approach in support of diet regime. R17's physician notes identified the following: - H&P (history and physical) dated 9/21/18, needs placement in a setting where he can get care and good nutrition. No [MEDICAL CONDITION] was noted. - Inpatient Discharge Summary dated 10/22/18, indicated a weight of 186 lbs with 1+ pedal [MEDICAL CONDITION] bilaterally. - physician progress notes [REDACTED]. He does not like the food in the nursing home and complains about it. Extremities show 2 plus ankle [MEDICAL CONDITION] - physician progress notes [REDACTED]. On 3/6/18, at 3:31 p.m. R17 was seated in a stationary chair in his room, there was no [MEDICAL CONDITION] in R17's lower extremities. R17 stated he had lost a significant amount of weight since his admission to the facility in the fall. He stated he did not have much of an appetite and did not like the food served at the facility. R17 stated his usual body weight was 199 lbs. and currently weighed 167 lbs. R17 remembered a discussion regarding nutritional supplements; however, he had never received any. R17's weights identified the following: - 9/23/18, 191.8 lbs - 10/23/18, 192.1 lbs -11/23/18, 171.5 lbs - 12/23/18, 171.8 lbs - 1/23/18, 172.6 lbs - 2/24/18, 169.8 lbs - 3/9/18, 169.2 lbs R17's physician orders included [MEDICATION NAME] (medication for fluid overload) 40 milligrams po daily with a start date of 11/3/17. The physician orders did not include any nutritional supplements. R17's nutrition assessments identified the following: - Nutrition Assessment (Comprehensive) dated 9/29/17, identified R17's estimated nutrients provided at meals to be 1800 calories (cal) a day with a estimated nutrient requirement of 2304 cal's per day for a difference of 504 calories a day. R17 was identified as overweight. Admission weight was 191.8 pounds (lbs) with a most recent weight of 192.8 lbs on 9/25/17. The assessment did not list dietary related medications or labs. R17 had no swelling. His food intake was marked intake meets 76-110 percent of planned meals as well as 26-75 percent of planned meals. complaints about the tastes of many foods was marked no. The assessment did not include R17's goal either for weight maintenance or weight loss. The assessment lacked R17's input regarding food preferences. - Quarterly Nutritional assessment dated [DATE], identified a weight of 169.8 lbs for a loss of 22 lbs, indicating a 11.5 percent weight loss since 9/23/17. The assessment indicated R17's food intake was 75 - 100 percent of meals. The assessment did not identify why R17 had a 22 lb weight loss; nor, any interventions to minimize weight loss. no referrals to the dietician were recommended. -Progress note dated 2/27/18, identified an initial nutritional assessment via the registered dietician (RD). Current weight was 168 lbs with a weight history of: (MONTH) (YEAR), 171 lbs; (MONTH) (YEAR), 170 lbs; (MONTH) (YEAR), 169 lbs. The RD indicated R17 was fairly consistent with his weight; however, due to his [MEDICAL CONDITION] it was not a great indicator for nutritional status. The assessment did not address R17's admission weight of 191.8 lbs. The assessment did not address intake; however indicated he had a fair appetite. Further the assessment lacked lab results and resident input. The RD indicated at this point in time not at nutritional risk, will not place R17 on at risk monitoring. On 3/8/18, at 8:19 a.m. R17 ate breakfast in his room. He independently ate a cereal sized bowl of oatmeal, which he poured some milk over. R17 also drank 4 ounces of milk and 4 (oz) of a mixed juice. R17 stated he had the same meal for breakfast everyday and it was what he wanted. R17 stated at home he used to have some toast, but he did not request toast at the facility because the staff burn it. On 3/8/18, at 8:37 a.m. nursing assistant (NA)-A entered R17's room to remove his breakfast tray. NA-A stated the dietary department charted intakes on meals consumed. On 3/8/18, at 12:03 p.m. R17 entered the dining room. The menu listed on the wall of the dining room included: Italian meat sauce over spaghetti noodles, cheddar biscuits, baby carrots and berries. R17 had some berries at his place setting along with 4 oz. of juice and 4 oz of milk. R17 poured a 0.5 oz container of half and half over his berries along with a packet of sugar. At 12:15 p.m. R17 was served a plate of spaghetti with spaghetti sauce with ground burger. The plate did not contain baby carrots or a cheddar biscuit. R17 stated he did not want the baby carrots or cheddar biscuit. R17 proceeded to remove all the sauce from the top of his spaghetti. R17 stated the sauce was sour and the facility did not know how to make anything. At 12:30 p.m. R17 finished his meal stating he was full. R17 drank 100 percent of his beverages ate only the noodles of the spaghetti along with the berries. When interviewed on 3/9/18, at 11:00 a.m. NA-B stated R17 did not like the food the facility served. R17 selects from the menu what he wants. If he does not like the food choices he can order a soup and sandwich. She stated R17 had lost weight since his admission and was weighed daily. NA-B stated the dietary staff record the meal intakes in the electronic medical record (EMR) During interview on 3/9/18, at 12:58 p.m. certified dietary manager (CDM) stated R17 was not at risk for weight loss and the dietary staff are not currently monitoring his meal intakes, and only monitors R17's intakes during his MDS assessment. The CDM stated she reviewed weights on a monthly basis and reviewed them with the nurse manager, who was out on leave. The nurse manager though his weight loss was fluid related as he fluctuated about 5 lbs throughout the month. She stated she referred R17 to the dietician for review in (MONTH) (YEAR), and she did not identify R17 at risk for weight loss. After CDM reviewed R17's admission weight to his current weight, along with his dislike for the facility meals she stated his weight loss was likely a combination of fluid loss as well as poor food intake. During interview on 3/9/18, at 1:31 p.m. the director of nursing (DON) stated R17 was very picky with the foods he liked. R17's weight loss was likely a combination of fluid and poor appetite. The dietician did do an assessment on 2/27/18; however, she did not do a face to face with the resident, as she does not visit the facility. The DON stated it was important to get the residents input to accurately assess his nutritional status. On 3/9/18, at 3:42 p.m. the facility registered dietician had been contacted via telephone with no response. The facility policy Resident Nutritional assessment dated ,[DATE], indicated resident needs would be determined by a completed assessment. Assessments would be completed on admission and quarterly, unless significant changes occur which was identified by the team.

Based on observation, interview and document review the facility failed to provide immediate emergency care (initiate cardiopulmonary resuscitation (CPR) and call 911) when 1 of 1 residents (R1) stopped breathing, had no pulse and died . This had the potential to effect 5 of 55 residents who had been identified as requesting CPR in the event of a cardiopulmonary arrest. The immediate jeopardy (IJ) began on on [DATE] at 9:40 a.m. when R1 stopped breathing and did not have a pulse and was identified on [DATE]. Staff failed to initiate CPR in accordance with the R1's advanced directives and failed to call 911 in accordance with facility policy. The director of nursing (DON) and administrator were informed of the IJ on [DATE] at 4:45 p.m. The IJ was removed on [DATE] at 3:15 p.m. but non-compliance remained at the lower scope and severity of a G (actual harm that is not immediate jeopardy.) Findings include:R1's medical record was reviewed and revealed that R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's physician orders [REDACTED]. An admission progress note dated [DATE] at 16:45 (4:45 p.m.) revealed "Chosen CPR, antibiotics and hospital care". R1's short term care plan dated [DATE] identified R1 as "full code". A progress note dated [DATE] at 9:52 a.m. revealed the following "Resident propelled self to breakfast. Resident was up for breakfast, ate and drank poorly. 0800 (8:00 a.m.) medications were administered as ordered. Resident was seen propelling around. Was pushed to room, where he was there to be helped back to bed. When CNA's (certified nursing assistants) walked back in, resident was not breathing. When writer ran in, resident was slumped over in w/c, gray/ashen in color. Apical pulse taken for full minute." The progress text entitled: Time of death or found with no pulse/respirations "9:40 (a.m.), CPR initiated. Social services spoke with wife and she stated that "he wouldn't want that" CPR was stopped at that time." A progress note dated [DATE] at 10:21 a.m. further revealed "Author informed of code status and assisted LPN (licensed practical nurse) with CPR...."A social service progress note dated [DATE] at 10:22 a.m. revealed " per administrator's request, writer contacted wife... and asked if she would like us to attempt CPR. Wife stated "I thought you said he was dead". Writer explained that indeed his heart had stopped but we had to ask if she wanted us to attempt as he was a full code or call 911. Wife stated "No, he would not of wanted that"..."The administrator was interviewed on [DATE] at 10:30 a.m. and stated that the day of the incident ([DATE]) the DON was out of the building and that around 9:40 a.m. LPN-A entered a stand-up report meeting stating that R1 had died . The LPN-A then called R1's wife to inform her of R1's death. The administrator went on to say that the LPN-A returned 15 minutes later and informed registered nurse (RN)-B that R1 had physician orders [REDACTED]. The administrator stated that RN-B then went with LPN-A and began CPR. At that time, the administrator directed the social worker (SW) to call R1's wife regarding the situation. The SW spoke with R1's wife who wanted CPR stopped. The SW then informed LPN-A and RN-B to stop CPR. The administrator stated that CPR should have been immediately initiated and that the facility policy is to initiate CPR and call 911 in a witnessed or unwitnessed event for any resident that requests CPR. The administrator also stated that LPN-A was aware of the facility policy but not aware of R1's code status (CPR). The administrator stated that LPN-A was not suspended and not formally disciplined. The administrator went on to say that re-education and training on the facility policy on CPR had not been provided to nursing staff following the incident. An interview with LPN-A on [DATE] at 2:15 p.m. revealed that LPN-A was informed of R1 not breathing around 9:40 a.m. by nursing assistant (NA)-C. LPN-A ran to R1's room and found R1 slumped over in his wheelchair. R1 was not breathing and LPN-A listened for R1's apical pulse and did not hear a pulse. LPN-A stated that she went to the stand-up report meeting and informed administration of R1's death. LPN-A then called R1's spouse to inform her of R1's death. After LPN-A's phone call to R1's spouse, LPN-A saw on R1's electronic medical record that R1 had physician orders [REDACTED]. LPN-A stated CPR was initiated ,[DATE] minutes after she found R1 not breathing with no pulse. LPN-A stated that CPR was attempted for approximately 10 minutes until the SW entered R1's room and informed them of R1's spouse's request to stop CPR. LPN-A stated that she "isn't 100% sure" but thinks that the policy at the facility is to initiate CPR even if a resident has an unwitnessed cardiac event and to call for an ambulance. LPN-A stated that resident code status information is kept on the electronic medical record and on a quick reference sheet in a flip book at the nurse's station desk. LPN-A stated that the flip book at the desk is never up-to-date and is not sure who is responsible for updating the sheet. LPN-A stated that she did not look for R1's code status on the sheet in the book at the nurse's station and was not sure if R1's code status was located on the care plan in R1's closet. LPN-A confirmed that she did not look at the care plan in R1's closet for R1's code status. LPN-A confirmed that she was not aware of R1's code status when she found R1 slumped over in his chair and not breathing. LPN-A stated that following the incident, she continued to work for the remainder of the day and received no re-training or education from administration. An interview with LPN-D on [DATE] at 12:30 p.m. revealed that resident code status information is kept at the nurse's station on a quick reference sheet in a flip book. The code status is also visible on the resident care plan in the resident's closet and on the electronic medical record. LPN-D stated that if she found a resident with no pulse, not breathing and unresponsive she would check the code status of the resident and find an RN or another nurse to start CPR with LPN-D. LPN-D also stated that CPR would be initiated as soon as she found out the resident had orders for CPR and 911 would be called. LPN-D went on to say that CPR would be initiated if the last breath was witnessed or unwitnessed. LPN-D went on to say that she did not know the policy but it is located in a policy book some place in the facility. LPN-E was interviewed on [DATE] at 12:45 p.m. and stated that resident code status information is located on the resident's electronic medical record and on the care plan in the resident's closets. LPN-E stated that resident code status information is also located on a quick reference sheet in a flip book at the nurses station. LPN-E pointed to the quick reference sheet. The reference sheet listed the resident's names with a "D" or "C" after the name. LPN-E explained that the "D" after a resident name indicated that the resident was a DNR (do not resucitate) status and the "C" after the resident's name indicated a CPR status. LPN-E stated that some residents with a full code status have orders to initiate CPR only if a witnessed cardiopulmonary event occurs, and some resident's have CPR orders for a witnessed and/or unwitnessed event. When LPN-E was asked how she would know the difference in these orders, LPN-E again pointed to the quick reference sheet and stated that it should be included on this list. LPN-E pointed to a resident (R2) on the quick reference sheet who had a "C" after their name. LPN-E confirmed that the information regarding differences in CPR status was not included on the quick reference sheet. LPN-E stated that the information on the code status must be in the electronic medical record on the computer. When LPN-E looked up the information, LPN-E stated that R2's code status was actually a DNR. LPN-E then crossed out the "C" on the sheet and wrote in a "D" indicating DNR status. LPN-E then looked at another resident (R3) on the sheet who had a "C" after their name. When LPN-E looked up the R3's code status, LPN-E stated that the code status on the sheet was incorrect and that R3 was also a DNR status. LPN-E again crossed out the "C" and wrote in a "D" after R3's name. LPN-E then stated that the quick reference sheet was not up-to-date and informed the DON that the information should be updated. The DON agreed with LPN-E. LPN-E was again asked what she would do when finding a resident with no pulse, not breathing and unresponsive, and LPN-E stated that she was not sure what the policy would direct her to do. On [DATE] at 1:30 p.m. it was observed that the quick reference code status sheet was no longer at the nurse's station. RN-B provided the surveyor with a copy of the quick reference sheet at 1:45 p.m. R2's code status remained as a "C" on the list and R3's code status had been changed to a "D" on the list, indicating DNR status. Four residents on the list did not have a letter after their name on the list, indicating no code status. Two of the residents (R4, R5) with no code status identified on the list, were a full code status. On [DATE] at 1:50 p.m. RN-F was interviewed and stated that CPR should be initiated on a resident if they have a witnessed cardiopulmonary event. RN-F stated that residents have the choice of CPR and can choose if they would want CPR if they had a witnessed or unwitnessed cardiopulmonary event. When asked how staff know the difference between these choices, RN-F stated that the information would be located on the care plan in the residents' closet and it is also located at the nurse's station desk. RN-B was interviewed on [DATE] at 4:05 p.m. and stated that she was informed of R1's death on [DATE] during a stand-up report meeting. LPN-A later came back and informed RN-B that R1 had physician orders [REDACTED]. On her way to R1's room, RN-B told the administrator about R1's code status. RN-B stated that CPR was initiated ,[DATE] minutes after LPN-A had first informed administration of R1's death. RN-B stated that CPR was initiated by herself and LPN-A until the SW came to the room and informed them to stop CPR per R1's spouse's request. RN-B stated that resident code status is reviewed at every care conference. RN-B also stated that any person who identifies a change in the resident code status is responsible for updating the resident care plan and closet cardex sheet. No specific staff member was identified to be responsible to update the quick reference code status sheet located at the nurse's station. The DON was interviewed on [DATE] at 11:30 a.m. and stated that she was not in the building the day that R1 died and confirmed that the administrator completed the internal investigation. The DON stated that she was informed of the situation by the administrator on [DATE] between 10:00 a.m.-10:30 a.m. The DON stated that one hour later she received a call back from the administrator informing her that a report was made to the state agency due to a delay in initiating CPR and that they could discuss the situation on Monday ([DATE]). The DON stated that she spoke with LPN-A on Monday ([DATE]) and informed LPN-A that she would be written up for not initiating CPR on R1. The DON stated that this was an isolated incident and that at all staff are aware of the facility's CPR policy. A policy entitled "CPR Policy for facility" dated ,[DATE] included the following : "The policy at Central Todd County Care Center (CTCC) is to initiate cardiopulmonary resuscitation (CPR) for any resident who suffers a cardiopulmonary arrest, unless a decision to not initiate CPR has been previously made and properly recorded as a physician's orders [REDACTED]. If a resident has a witnessed or unwitnessed arrest, the initiation of CPR will depend on the resident's wishes and MD orders. " The policy also includes that "When a NO CPR order is written at CTCC, emergency medical services (i.e. ambulance, paramedics, emergency medical services, "911" telephone calls) will not be utilized in the event the resident goes into cardiac or respiratory arrest. Emergency service will, of course, be utilized by the facility when other types of emergency interventions are necessary." The policy further includes that "CTCC will provide adequately trained, 24 hour staffing to initiate basic life support within minutes of a resident's observed cardiac or respiratory arrest."The IJ that began on [DATE] was removed on [DATE] at 3:15 p.m. after the facility implemented a corrective action plan which included revising the facility's CPR policy and provided immediate education of all licensed nursing staff of the revised CPR policy. The facility also removed the quick reference sheet for resident code status from the nurse's station The implementation of these interventions were confirmed by observations, interviews conducted with licensed nursing staff on [DATE], and review of the facility's revised policies.

Based on document review and interviews, the facility failed to immediately notify the physician of a significant change in condition for 1 of 1 residents (R1) in the sample with increased pain. The failure to immediately notify the physician of the resident's increased pain caused actual harm for the resident. Findings include: Review of R1's medical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].Review of the facility's Brief Interview for Mental Status (BIMS) assessment for cognitive status dated 11/1/2012, revealed R1 was severely cognitively impaired. Review of R1's plan of care with a target date of 2/18/2013, revealed R1 required extensive assistance from two staff for bed mobility, ambulation, toileting and transfers. The care plan revealed R1 utilized a Broda (tilt and recline) wheelchair and a lap tray related to impulsivity and falls. The care planned interventions for pain included: observe R1 closely for signs of pain, administer pain medications and notify the physician immediately for break through pain. Review of the facility's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. R1 had not received [MEDICATION NAME] from 12/1/12 until 12/16/12.Review of R1's progress notes dated 12/3/2012, revealed the resident's conversation consisted mostly of repetitive comments and non-sensical statements or words. The progress notes from admission until 12/15/12, indicated R1 did not express pain or exhibit non-verbal signs of pain. Review of a progress note dated 12/15/2012, at 9:30 p.m. revealed R1 was grimacing, yelling out and refusing to ambulate with staff. The progress note indicated R1 had slight swelling of the left knee and was experiencing constant pain of the left leg that became worse with movement. R1's physician was not notified of the sudden onset of pain. At that time, R1 was offered but refused to take the [MEDICATION NAME] for pain. Review of a progress note dated 12/16/2012, at 11:45 p.m. revealed R1 was administered [MEDICATION NAME] for break through pain that had been reported by the licensed staff from the previous shift. The note indicated R1 continued to express pain (grimacing and yelling out)while being assisted by staff to the bathroom. A progress note on 12/16/2012, at 2:30 a.m. revealed R1 continued to have pain exhibited by grimacing with toileting. The note indicated the pain was constant but increased with movement. R1 was able to rest between repositioning by staff. No attempt was made to contact the physician regarding the resident's change in condition.The progress note on 12/16/2012, at 5:57 a.m. stated R1 slept most of the night but showed signs of pain (grimacing and yelling out) with movement of the legs during repositioning. At that time, the note also indicated R1's left leg had an unusual rotation which would be reported to the nurse at the next shift. No attempt was made to notify R1's physician regarding the unusual rotation and pain of the left leg.The progress note on 12/16/2012, at 1:12 p.m. revealed R1 was experiencing pain and with any leg movement the resident yelled. The documentation indicated the left hip, knee and ankle were swollen. At 9:40 a.m. a licensed nurse contacted a physician and R1 was transported at 10:15 a.m. by ambulance to the emergency room . At 12:35 p.m. the facility was notified that R1 was admitted to the hospital for pain control and a left [MEDICAL CONDITION]. Review of the facility's policy and procedure titled Significant Change in Resident Condition, not dated, directed staff to notify the physician as soon as identified of a significant change in a resident's condition which included any complaint or apparent discomfort of a sudden onset. Interview with the director of nursing on 1/7/2013, at 11:45 a.m. confirmed the licensed staff were to notify R1's physician immediately with the resident's increased pain and the resident should have been evaluated by a physician immediately with the change in condition.

Based on observation, staff interviews, and record review, the facility failed to ensure that each resident's environment remained free of accident hazards for 4 of 10 residents (#8, #3, #21 and #68). Findings include: Resident #8 was diagnosed with [REDACTED]. Resident #8 did not have surgical repair of her pelvis. She is currently on bed rest. She is transferred with a mechanical lift into a wheelchair for meals. She receives pain medication for discomfort from her pelvic fracture. She utilizes 2-1/2 side rails. Resident #8 has resided in the nursing home since August 2006. A comprehensive assessment, completed July 3, 2010, revealed that the resident has short and long term memory loss. The assessment revealed that resident weighed 197 # and was 60 inches tall. A safety risk assessment, completed 6/25/10, indicated that the resident was utilizing two half side rails to treat medical symptoms and [DIAGNOSES REDACTED]. At the time of the fall, the plan of care stated Resident #8 utilized two one-half side rails for rolling from side to side with the assist of one staff. According to progress notes in the medical record, written on September 3, 2010, at 8:48 p.m., by employee D/nurse, Employee F/nursing assistant was assisting Resident #8 with cares. She asked the resident to roll onto her side. As the resident rolled to her side she stated that she did not like not having a side rail to hold on to. The resident continued to roll, could not stop herself, nor could staff stop her (the resident rolled out of bed) and landed on the floor on her right side. The resident stated she had pain in her right hip, back, and neck. 911 was called and the resident was sent to the hospital. Hospital records indicated that the resident has a complex acetabular fracture. The facility's investigative report indicated that the facility was currently removing all side rails that were not being utilized. Staff were asked to make a list of those whose side rails could be removed. According to the investigative report Resident #8's side rails were removed because the "RN felt that she did not use them anymore for bed mobility." Resident #8's side rails were removed on September 3, 2010. Employee F was interviewed on September 14, 2010 at 3:30 p.m., and stated that at the beginning of her shift she and Employee G/nursing assistant noticed that Resident #8 did not have siderails. Employee F stated that the resident normally has side rails on her bed. They checked the care plan. The care plan indicated that Resident #8 had two side rails. Employee G asked Employee E/nurse about the side rails. Employee E said Resident #8's side rails were removed but the care plan had not been updated. Employee F stated that according to the care plan, two staff are required to get Resident #8 into bed, but only one staff person is required for cares. Employee G helped Employee F get the resident into bed but then left the room. Employee F was performing cares by herself when the resident fell from her bed. Employee E was interviewed on September 15, 2010 at 3:30 p.m., and stated that she did not remember her response when Employee G questioned her about Resident #8 being without side rails. Employee E stated that it was probably not safe to roll Resident #8 without a side rail. Employee C/nurse was interviewed on September 14, 2010 at 2:50 p.m., and stated that the facility was compling a list of residents that could have their side rails removed. Resident #8 "ended up" on the list before Employee C completed an assessment. There was a "misunderstanding" and Resident #8's side rails were removed by a maintenance staff person. Employee C thought the list was for those who could have their side rails removed "down the road." The failcity failed to provide a safe environment for Resident #3 as evidenced by the continued use of two siderails instead of one as identified through an assessment. Resident #3's assessment was not accurate. The assessment, dated 9/10/10, indicated the resident utilized 1-1/2 side rail for bed mobility. Although the assessment, dated 9/10/10, indicated 1-1/2 rail would be used, during observation on 9/14/10 at 10:12 a.m., the resident had 2-1/2 metal rails on his bed. One side of the bed was against the wall. Resident #3's care plan for bed mobility indicated that the resident needs limited assistance of one. According to the care plan, the resident preferred the side rail nearest the wall to assist with mobility. The care plan indicated the resident needs supervision from staff for transfers and supervision with the use of a folding wheeled walker for ambulation. During observation, the investigator noted a side rail on the side of the bed that was away from the wall. The metal rail on the side of the bed that was away from the wall was loose and had a button that could release if hit accidentally causing the bed rail to drop down quickly and forcibly. The facility failed to provide an environment free of hazards for Resident #21 as evidenced by leaving side rails in place, giving the resident a means for self transfers. The care plan of Resident #21's medical record was reviewed and indicated that the resident has an alteration in cognition, communication, vision related to macular degeneration, and hearing impairment. The safety risk assessment, dated 9/9/10, indicates the resident has 2-1/2 rails to position himself and aid in transfers. Documentation in the progress notes of the medical record indicated that the resident had a history of [REDACTED].#21 was found on the floor near his bed on three separate occasions (July 25, August 24, and September 13, 2010). The fall risk assessment completed after the fall on July 25, 2010, indicated that the resident's fall was likely due to self transferring. The care plan was changed to include putting the resident on the every two hour bathroom list. The resident was interviewed after the fall on August 24, 2010. He stated he did not remember falling, but stated he was probably standing to drain his urine or adjust his catheter bag. The plan was to assist the resident to a standing position every hour and as necessary to assist with emptying his bladder/catheter tubing. The progress notes for the fall on September 13, 2010, indicated that the resident probably tripped over his catheter tubing in which he sustained a fall. The plan was to place the resident in a high low bed to prevent self transfers. During observations on September 14, 2010, at 10:22 a.m., Resident #21 was noted to have 2-1/2 side rails. The rails were noted to be loose. Resident #21's assessment, dated September 9, 2010, indicated that the resident was at risk for injury on the side rails if bumped. The assessment indicates that the resident is able to demonstrate the ability to appropriately utilize the side rails. The assessment includes the question, "What were the alternatives/devices used?" The assessment form indicates "N/A." On September 13, 2010, an entry in the progress notes indicates that the resident will be placed in a high-low bed to deter self transferring. The facility failed to provide an environment free of hazards for Resident #68 as evidenced by the resident having side rails which may cause injury to the resident. The facility's plan of correction, dated September 2, 2010, for a licensing and certification survey completed 8/05/10, indicated that Resident #68 did not require side rails so they were removed. Resident #68's assessment, dated September 10, 2010, indicated that the resident did require side rails. During an observation on 9/14/10 at 10:10 a.m., Resident #68 had 2-1/2 metal side rails. These side rails were observed to be loose and could easily drop down quickly and forcibly when the button was released. The assessment completed on 9/10/10 did not identify risks or benefits of the use of a side rail. For example, the assessment did not include all aspects of the cognition of the resident, an observation of bed mobility, alternatives to side rails, or a trial of a lesser restrictive device. The assessment did not include pertinent physical characteristics, for example, that Resident #68 had limited vision and rarely opened his eyes. Resident #68 has dementia. The care plan dated 2/24/10 indicates he is confused and has minimal vision and is at risk for accidents. For example, one of the care plan interventions is, "Do not place in lift chairs as he will use hand control and lift chair on his own, only use regular recliner." Resident #68 was at risk for putting his hand in the side rail and hitting the button release causing the rail to drop down quickly and forcibly on him.

Based on observation, interview and record review, the facility failed to ensure all resident's environment remained as free of accident hazards as was possible. There was not a systematic and consistent process to comprehensively assess and employ the use of side rails for 4 of 4 residents (R10, R40, R55 and R68) reviewed in the sample. This practice had the potential to affect up to 49 residents in the facility who utilized similar metal side rail devices. Findings include: The facility failed to determine for each resident the level of risk for siderail entrapment by evaluating the dimensional limits of the gaps and overall safety of the rails for each resident who utilized siderails. R10 utilized side rails devices that were not comprehensively assessed for safety risk factors. R10 was admitted [DATE] with [DIAGNOSES REDACTED]. R10 was observed the morning of 8/4/10 from 7:15 A.M. through 8:30 A.M., both during sleep activity and during cares provided by staff, to have two unpadded side rail devices (quarter rails) in the raised position. R10 was noted to move himself from supine to sitting position with hand contact and some use of the outer side rail to assume the sitting position at the edge of the bed. Hygiene care included R10's use of the inner side rail to turn to the side. Staff transfer to sitting by NA-A was completed by manual support and pivot under the shoulders and legs without use of the outer side rail. The urinal was observed hanging on the raised outer side rail. Interview with the Maintenance supervisor-A on 8/5/10 at 11:15 A.M. verified the facility had some newer hi-low beds with smaller side rail devices and 49 beds with the older metal side rails that had larger angles and openings between the rails(up to four inches measured horizontally.) The supervisor-A also verified some wobble movement inherent in the design of the rails and that they could drop very rapidly if the single actuation lever was inadvertently pulled out. He also reported no routine maintenance was performed, but most beds had the brackets for side rails always in place; side rails in place but not being used were not secured down by any method. The supervisor-A also stated he responded to problems that were reported to him by nursing and the rails had been checked for safe dimensions several years ago with an approved measurement/testing device and were found in compliance at that time. Neither the maintenance supervisor or the Administrator were aware of the 3/10/06 U.S. Health and Human Services, Food and Drug Administration publication, "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment." Resident 40 ultilized a side rail that were not individually assessed by the facility for safe use. R 40 was admitted to the facility with [DIAGNOSES REDACTED]. An assessment of the use of the siderails was completed on 7/2/10 which indicated the rails were used as an enabler for mobility and as a fall prevention. The current care plan dated 6/18/10 indicated the resident had potential for falls related to anemia, cognitive loss, seizure potential, unsafe self tranfers, doesn't leave alarms in place, medication side effects among other risk factors. The care plan interventions indicated the resident was to get up by 0700 to 0730 to help prevent her from independent self transfers. The plan of care also indicated R40 had 2-1/2 rails to help with bed mobility, transfers and to help recognize the edges of the bed. The resident was observed on all days of the survey to have just one half rail up and the other side of the bed was against the wall. The rail was a metal siderail that was loose. The resident was interviewed on 8/4/10 at 1p.m. and stated that she had a queen bed at home and was afraid of falling out of bed, she said she would put the siderail up and down by herself. The Director of Nursing (DON) verified at 12:45 p.m., the facility did not have any evidence that the siderails used for residents had been individually checked for gaps, loose or ill-fitting parts. R55 utilized side rails that were not comprehensively assessed for safety risk factors. R55 was observed on 8/4/10 at 10:05 am, to have 2 half siderails on his bed. R55 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Safety Risk assessment dated [DATE], identified R55 to have unsteady gait, balance problems, dementia and impaired judgement. These were identified as internal risk factors for falls. The Safety Risk form identified that the resident used two (2) half side rails and sensor bed alarm. There was no evidence of an individual assessment for the safety of the rails, for example, if they were applied correctly, no gaps or unsafe ill-fitting parts. During an interview with clinical manager on 8/5/10 at 9:42 am, she reported that R55 used the side rails for bed mobility and that she did not know if alternative devices had been considered as she stated "I wasn't his care manager then and I don't know what was considered or tried". She was unaware of any other assessments that would have been done for the safety of the rails. R68 utilized side rails devices that were not comprehensively assessed for safety risk factors . R68 was admitted [DATE], with [DIAGNOSES REDACTED]. The most recent Safety Risk assessment dated [DATE], identified R68 to have Parkinson's Disease, unsteady gait, balance problems, decline in decision making skills and functional status. The summary noted R68 was at risk for impaired safety due to Parkinson's, glaucoma, weakness, anemia, incontinence and no restraints were used. R68's was observed on 8/4/10 at 4:11 p.m., his bed had two unpadded side rail devices (quarter rails) in the raised position. The Cardex for this resident indicated the use of two quarter rails. The registered nurse (RN-A) clinical manager, RN-A reported during an interview at 9:38 A.M. on 8/5/10, R68 used the side rails for bed mobility and that alternative devices had not been assessed because the quarter side rails did not pose a safety risk; however, a safety risk assessment was not completed for R68.

Based on record review, policy review, and interview, the facility failed to ensure a resident was safely transported in a wheelchair in order to prevent injury; and failed to ensure the necessary assistance was provided during a transfer to prevent injury for 1 of 1 (#1) residents in the sample that experienced actual physical harm either related to the wheelchair transport or while being assisted with a pivot transfer with one staff assistance instead of two staff assistance. Findings include: Resident #1 was admitted to the facility on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Resident #1 sustained a comminuted (broken in small pieces), impacted (driven firmly) fracture of the right tibia (larger bone below the knee) and fibula (smaller bone below the knee). On two separate occasions, (5/26 or 5/27/10 and on 5/28/10 after breakfast) Resident #1 had been observed by staff to drag or kick the right leg backwards causing the leg to be caught beneath the wheelchair, adjacent to the right front wheel, when being transported in the wheelchair by staff. Even though licensed staff observed and had been communicated to by Nursing Assistants that Resident #1 was dropping the right leg instead of picking her legs up during transport as she had previously been able to do, the staff failed to make any changes to the wheelchair to provide for the resident's safety and prevent injury. In addition, in the late afternoon of 5/28/10, when being assisted from bed, one staff transferred Resident #1 with a pivot transfer instead of two staff, as directed by Resident #1's plan of care. Review of Resident #1's annual Minimum Data Set ((MDS) dated [DATE], revealed the resident was severely cognitively impaired, was rarely or never understood by staff, had indicators of depression, anxiety, and sad mood at least five times a week and had behavioral symptoms that were not easily altered. The MDS indicated that Resident #1 was totally dependent on two staff for bed mobility and toilet use and required extensive physical assistance from two staff for transfers and had no pain. Resident #1 was unable to communicate her needs to staff. Review of Resident #1's plan of care with an initiated date of 3/31/10, revealed the resident required weight bearing assistance of two staff with transfers. The care plan indicated Resident #1 utilized a hemi-wheelchair without foot rests, with the initiation date of 1/1/04. Review of the nursing progress notes dated 5/28/10, at 11:53 p.m. stated, "...alerted to resident room by CNA (certified nursing assistant) staff as she thought resident had a hurt leg. Resident was crying out and hold (sic) right knee. Right knee appeared to be considerably more swollen than the left. Warm to touch no redness noted. Set up ice tid (three times a day) to right knee and use prn (as needed) Tylenol." Although the facility had observed changes in the status of Resident #1's right knee and the resident required Tylenol and ice packs for pain and swelling, they failed to notify a physician at that point with changes in the resident's condition. Review of the nursing progress notes for 5/26/10 to 5/28/10, revealed the facility had failed to communicate Resident #1 was dragging her feet when being transported in the wheelchair and no immediate interventions or modifications to the wheelchair had been initiated by the facility to ensure the staff were able to safely transport the resident and prevent injury. Review of the progress noted dated 5/29/10, at 8:28 a.m. with an addendum at 10:20 a.m. was an investigation of the injury to Resident #1's right knee and stated, "CN (Charge Nurse) reported that she had been informed by another CNA (Certified Nursing Assistant) that yesterday when resident was being removed from dining room following dinner, her right foot had become caught in the w/c (wheelchair) when another CNA was pushing her, and resident had hollered out at that time. CNA stopped, removed foot and continued down the hallway. P/C (phone call) placed to CNA and she stated that following removal of foot from w/c she alerted CN who stated to observe area for bruising as there was none noted at the time. She stated that another CNA informed her that this had happened the day before as well. P/C to second CNA who stated that resident had 'kicked foot backwards' as if she was trying to stop the w/c. She also stated that she had pointed this out the next day in the dining room. P/C to CN and she stated that resident had placed foot down once and staff removed it and began pushing her in her w/c again. She (Resident #1) then placed foot down and back again, at this point staff held up her legs during transportation...P/C placed to...ER (emergency room )...who stated that she (Resident #1) should just be seen in clinic on Tuesday(6/1/10) as her injury is 24 hours old, and she is non-wt bearing and they would not treat her at this point...Resident is noted to be comfortable in w/c...except with transfers and manipulation of right leg..." The progress note indicated that a foot rest had not been added to Resident #1's wheelchair until the evening of 5/28/10 or the morning of 5/29/10. A progress note dated 5/29/10, at 9:17 a.m. stated, "...P/C to staff member and she stated that resident was noted to be dragging her right foot in her w/c when she typically elevates her feet when in w/c chair (sic) is in motion. CNA stated that she did transfer resident WBA (weight bearing assist) 1 from bed to w/c and stated that at the time she was not aware that resident was WBA 2..." Review of the progress notes from 5/29/10 until 6/1/10 revealed Resident #1 required Tylenol and ice packs for continued signs and symptoms of pain to the right knee and would exhibit signs of discomfort (weeping, wincing, moaning and/or difficulty sleeping) with any manipulation or touching of the knee. Review of progress notes from 6/1/10, revealed Resident #1 was transported to the emergency room with x-rays that diagnosed the fractures of the right leg and the resident was placed in an immobilizer with new analgesic orders. An interview with Employee-A/Nursing Assistant on 6/15/10, at 1:38 p.m. revealed Resident #1 had been assisted out of the dining room one to two days prior to 5/28/10 and caught her right leg under the wheelchair. The incident occurred by the medication cart where Employee-B/Licensed Practical Nurse was dispensing medications. Employee-A/NA indicated Employee-B/LPN instructed her to monitor Resident #1 closely and Employee-A/NA revealed she had tried to inform the other employees informally (wasn't documented). Employee-A/NA witnessed Resident #1 being wheeled by staff out of the dining room on 5/28/10 after breakfast with the resident's right foot dropping and being caught behind the front wheelchair wheel. Employee-A/NA assisted Employee-C/NA to transport Resident #1 in the wheelchair by lifting the resident's legs. Employee-A/NA confirmed no modifications were made to the wheelchair to ensure Resident #1 could be safely transported. An interview with Employee-F/LPN on 7/19/10, at 9:45 a.m. revealed Employee-F/LPN had been the charge nurse on the evening shift and no report was given or documentation noted about Resident #1's right leg being caught in the wheel of her wheelchair and confirmed Resident #1 was weight bearing assistance of two staff and had been transferred with one staff. An interview with Employee-D/Registered Nurse Manager on 6/15/10, at 12:58 p.m. revealed the incidences of Resident #1 dropping her right foot behind the wheelchair had not been communicated to other staff and the resident's right leg had not been assessed by licensed staff after each incident nor had any modifications been made to the wheelchair until footrests were added on 5/29/10. Review of the facility's policy and procedure titled Transfers Nursing/CNA, not dated, stated, "Policy: The following general guidelines will be followed as closely as possible when transferring residents in this facility. Purpose: To prevent injury to the resident...Procedure:...2. If the transfer requires two people, never try the transfer alone..."

Based on observation, staff interviews and record review, the facility failed to provide an activated assistive device (floor mat alarm) for 1 of 4 residents (#1) in the sample whose mobility status was reviewed. Findings include: Resident #1 was diagnosed with [REDACTED]. Resident #1 did not have surgical repair of his hip per direction of family members. The resident returned to the facility. Since his return, Resident #1's status is non-weight bearing. He is transferred with a mechanical lift. Resident #1 has resided in the nursing home since September 2008. A mini-mental assessment, completed 9/24/09, revealed that the resident has significant cognitive impairment. The incident report log indicated that the resident had falls on 1/17/10, 2/2/10, 3/19/10 (x2) and 3/23/10. Nursing assessments were completed after each fall and each time interventions were initiated to prevent the resident from falling again. Resident #1's care plan indicated that the resident was at high risk for falls due to weakness and episodes of confusion. At the time of the fall on March 24, 2010, the following interventions were in place to prevent the fall: a lipped mattress, a hi-low bed which was in low position at the time of the incident, the bed against the wall, non-skid socks worn day and night, handrails beside the toilet, a chair sensor pad in a chair or the wheelchair, 1/2 hour checks while in bed, a floor mat alarm, and a lap buddy while in the wheelchair. The resident was assist of one with transfers and ambulation at the time of the incident. According to progress notes in the medical record, written on March 24, 2010 at 3:30 p.m., a nursing assistant (Employee I) found Resident #1 lying on the floor in the center of his room. His floor mat alarm was not sounding. The resident stated, "I was trying to walk behind that chair and I couldn't keep up with it." Resident #1 had no complaint during range of motion. There was no redness, bruising, swelling or open areas noted. The resident was helped to stand and then assisted into his wheelchair with "weight bearing assist of two" and a transfer belt. He was taken into the bathroom in his wheelchair and helped onto the toilet. When Resident #1 stood to get off the toilet he stated his hip hurt and he was not able to stand on his leg. The resident was laid on his bed and re-assessed. There was no swelling, no internal or external rotation and no increased length of the leg noted. However, per family desire, the resident was sent to the hospital. He was found to have a hip fracture. The facility's investigative report indicated that the fall occurred when Resident #1 attempted to ambulate behind his wheelchair, it rolled away from him, and he fell to the floor. During the on-site visit on April 7, 2010, at 11:27 a.m., the investigator stepped on Resident #1's floor mat. The alarm sounded. It took 20 seconds for a staff person to respond to the alarm. Employee H/nursing assistant, was interviewed on June 15, 2010 at 2:45 p.m., and stated that she laid Resident #1 down for his nap. "He seemed settled," so she went on break. When she returned from break she was told Resident #1 had fallen. "Evidently" the alarm was shut off. "I assumed it was on. I should have double-checked it, but I didn't." Employee E/nursing assistant, was interviewed on June 15, 2010 at 3:30 p.m., and stated that prior to the incident; Resident #1 was able to walk with assistance. Since the incident, Resident #1 is not able to walk. Employee E stated that the alarm in use at the time of the incident had an on and off switch. The majority of the staff left the alarm on but sometimes staff de-activated the alarm. Employee C/nurse was interviewed on June 16, 2010 at 12:00 p.m., and stated that the floor mat was connected to a box. The box had a re-set button. When the alarm sounded, staff would shut the unit off versus hitting the re-set button. Employee H was responsible for Resident #1 but "in no way" was she the only one who forgot to turn on alarms. After the incident new alarms were ordered. The new alarms do not have to be activated by staff. The alarms have an automatic re-set mechanism. New alarms had been ordered but not received at the time of the on-site visit.