Every finding on record at Countryside

Based on observations, return demonstration, record review and staff interviews, the facility failed to provide care in a safe manner when Resident #8 rolled out of bed with the bed raised to a high position hitting the floor during incontinence care. Resident #8 was transported to the Emergency Department and diagnosed with a mildly displaced fracture of the proximal metaphysis of the tibia, likely subacute (a break in the upper part of the shinbone [tibia] near the knee, where the bone is slightly out of alignment and has likely been healing for a few days to weeks). The facility also failed to provide care in a safe manner when Resident #3 was left alone with the bed in the highest position and the bed rail down. This deficient practice affected 2 of 4 residents reviewed for supervision to prevent accidents (Resident #8 and #3).The findings included: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses that included neurocognitive disorder with Lewy bodies (a progressive brain disease caused by abnormal protein deposits called Lewy bodies), restlessness and history of agitation, right sided hemiparesis/hemiplegia (paralysis of one side/muscular weakness) status post cerebrovascular accident (CVA) (a stroke), cognitive impairment related to dementia, generalized weakness and debility, bowel and bladder incontinence, and decreased mobility and functional abilities. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed an interview could not be completed for Resident #8. There were no behaviors present and Resident #8 was dependent for all activities of daily living (ADL) care. The Resident was dependent in rolling left and right, and with sit to lying. He was dependent in transfers. Resident #8 was always incontinent in bowel and bladder. Resident #8 did not have any falls since admission/entry or reentry or the prior assessment. A review of Resident #8's care plan dated 5/29/26 revealed a focus problem that started 2/26/25 that required staff to assist with ADLs secondary to decrease in self-care and mobility secondary to hemiplegia/hemiparesis. Resident was noted to have an increase in staff support for his functional abilities. Interventions with a start date of 4/16/26 included extensive assistance times 1 staff for grooming, extensive assistance times 1 to 2 staff for dressing, extensive assistance of 2 staff with bathing and transfers related to use of a total mechanical lift.A review of Resident #8's care plan dated 5/29/26 revealed a focus problem of falls that started on 2/26/25 where resident was at risk for falls due to right hemiplegia/hemiparesis status post cerebrovascular accident (CVA), cognitive impairment related to dementia, bowel and bladder incontinence, decreased mobility and functional abilities. Resident #8 was dependent on staff assistance with transfers and mobility. Interventions with a start date of 4/16/26 included assess fall risk potential per facility protocol, bed in low position, and ensure brakes were locked for fall prevention measures.An incident report dated 5/25/26 at 3:53 AM written by Nurse #3 revealed Resident #8 was rolled off the bed onto the floor on 5/24/26 at 10:15 PM. Nurse #3 was notified by Nurse Aide (NA) #2 that Resident #8 rolled off the bed during care. Resident #8 experienced a witnessed fall in his room. Nurse #3 entered the room and observed Resident #8 lying on his right side on the floor alongside his bed. A skin assessment was completed by Nurse #3 which revealed Resident #8 with a contusion under his right eye, swelling and redness was noted to his right elbow and a skin tear to his mid right arm and top of his left hand. There were no other apparent injuries noted. The on-call provider, resident's spouse, the Director of Nursing, and nurse supervisor were contacted. Resident #8 was transferred to the emergency room for further evaluation. Interventions following the fall included an update to Resident #8's plan of care for 2-person assist with bathing, turning, and repositioning as well as transfers. A Fall Assessment was also completed by Nurse #3 with the same information as stated above.The post fall assessment dated [DATE] indicated Resident #8 was nonverbal and there was no numerical pain level recorded.On 6/22/26 at 6:42 AM, Nurse #3 was interviewed and reported that she was on duty the night Resident #8 fell (5/24/26). Nurse #3 stated the resident did not talk, was total care, was incontinent of bowel and bladder and required a two person assist. According to Nurse #3, NA #2 was in the room with Resident #8 at the time of the fall. NA #2 had informed her that the resident had a skin tear on his upper left arm. As she was preparing to call the resident's spouse regarding the skin tear, she heard NA #2 yelling that Resident #8 had fallen. She went to the room and found the resident on the floor. Nurse #3 stated she assessed the resident, then called 911 and notified the resident's spouse, the provider, the Director of Nursing (DON), and the supervisor. Nurse #3 stated Resident #8 fell during personal care, and to her knowledge, he had never had a fall before during the time she worked at the facility. The Nurse stated Resident #8 had a soft leg brace on his left leg and interventions put into place since the fall included checking the resident's left leg every shift and elevating his leg on a pillow.A telephone interview with Nurse Aide (NA) #2 was conducted on 6/23/26 at 9:12 AM. NA #2 reported that Resident #8 was dependent on staff for all personal care. He stated that he was putting Resident #8 to bed and had begun providing incontinent care. While turning the resident onto his left side, he attempted to remove either the incontinent pad or the total mechanical lift sheet from underneath the resident but could not recall which item he pulled. Resident #8 was already positioned at the head of the bed. NA #2 explained that while the resident was on his left side, the resident's legs extended over the edge of the bed, and gravity caused the resident's body to slide off the bed and onto the floor. He noted that the bed rail was raised on the side the resident was facing. NA #2 stated he was standing next to the wall and rolled the resident away from him, onto the resident's left side. The NA stated due to his tall height, the resident's bed was raised to a higher position at the time. According to NA #2, due to the resident's stature, the side rails reached the resident's upper chest area. He described that Resident #8's feet went off the bed first, followed by the rest of his body, which gravity then pulled downward. When the resident reached the floor, his legs made contact first, beginning with the left leg and he rolled off the bed onto his left shoulder before ending up on his right side. NA #2 stated the resident's body grazed the edge of the nightstand, and the resident's face also grazed it, causing the bruise or small cut observed on the right side of his face. NA #2 reported that immediately after the resident reached the floor, he notified Nurse #3. He stated he had been positioned right beside the resident the entire time and had not walked away prior to the fall. After the incident, he discussed what happened with Nurse #3. The following day, he spoke with Nurse #4 (the nurse supervisor), and received guidance on safe rolling techniques, the need for two-person assistance with this resident, avoiding rolling the resident away from his body, ensuring the resident was properly positioned up in bed, and maintaining correct body posture during care. NA #2 stated when the incident occurred, this was only the second weekend he had worked with Resident #8 as he had only been employed with the facility a month and a half.On 6/24/26 at 4:10 PM, NA #2 provided a demonstration of how Resident #8 fell. NA #2 stated he used the resident's incontinence pad to turn the resident onto his left side. He demonstrated pulling the pad as he turned the resident. During the demonstration, NA #2 explained that Resident #8's foot jerked. NA #2 stated that Resident #8's foot went off the side of the bed, and then the resident slid off the bed and onto the floor.Review of the hospital emergency department (ED) report dated 5/24/26 indicated Resident #8 arrived following a fall at the facility that occurred during a transfer back into bed. The ED report indicated Patient is holding his left leg in a flexed position and exhibits pain with movement. Radiology was completed. The Final diagnoses: Fall at the nursing home. Other closed fracture of proximal end of the left tibia (a broken left shinbone [tibia] near the knee joint). Resident #8 was discharged back to the facility in good condition on 5/25/26. The discharge order included oxycodone (pain medication) 5 milligrams (MG) immediate release tablet every 6 hours as needed (PRN). Radiology results revealed a left knee x-ray that showed a mildly displaced fracture of the proximal metaphysis of the tibia, likely subacute (a break in the upper part of the shinbone [tibia] near the knee, where the bone is slightly out of alignment and has likely been healing for a few days to weeks). The treatment plan for the fracture included pain medication and the application of a splint. Resident #8 was referred to an orthopedic surgeon to discuss surgical versus nonsurgical options.Review of a nursing progress note written by Nurse #4 dated 5/25/26 at 12:43 PM indicated Resident #8 returned to the facility from the emergency department via stretcher at 9:43 AM.An interview with Nurse #4 was held on 6/22/26 at 10:44 AM. She reported that Resident #8 was a total mechanical lift resident. Nurse #4 stated Nurse #3 called her the night Resident #8 fell. Nurse #4 stated she was told by Nurse #3 that NA #2 informed Nurse #3 when he went to roll Resident #8 for incontinent care, he rolled the resident towards the door, and the resident fell off the bed. Nurse #4 stated she wasn't sure if the resident's bedrail was up. She stated she spoke to all NAs and changed Resident #8 to a 2-person assist with all care. Nurse #4 stated Resident #8 had no other falls since her employment at the facility for 5 years, and that the 5/24/26 fall had been the only fall Resident #8 had. Nurse #4 stated staff were educated on fall prevention after the resident's fall. Staff are also educated on falls/prevention during their skills fair every October/November.On 6/24/26 at 2:44 PM, an interview was held with the Director of Nursing (DON). The DON stated NA #2 pulled the sheet to assist with turning Resident #8 and the resident rolled out of bed. The DON stated she did a one-to-one training with NA #2 following the incident. She re-educated NA #2 that residents were never rolled away from you unless there was another person assisting. She stated the facility implemented a 2-person assist with all care for Resident #8, and his care plan had been updated related to that fall.During a follow-up interview with the DON on 6/25/26 at 8:59 AM, she stated Resident #8 was not a 2-person assist prior to the fall as he never needed to be one for personal care, but he was a 2-person assist only for transfers. The DON stated no one had voiced any concerns regarding needing additional assistance during resident's personal care.An interview with the Administrator was held on 6/24/26 at 2:44 PM. The Administrator stated staff were educated about fall prevention during orientation and every year at their annual skills fair. Education on fall prevention included putting beds in the lowest position, fall mats down, and call bell within reach.During a follow-up interview with the Administrator on 6/25/26 at 8:59 AM, she reported Resident #8 had a foam topper on his bed the night he fell out of bed. However, the foam topper was no longer on his bed. The Administrator stated Resident #8's POA requested the topper for resident's comfort. The Administrator stated education was previously provided to the POA that [mattress] overlays were not recommended due to resident safety. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and debility, cardiorespiratory conditions.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed an interview could not be conducted for Resident #3. There were no behaviors present and Resident #3 was dependent in self-care and mobility. She was dependent in rolling left and right, and with sit to lying. Resident #3 did not have any falls since admission/entry or reentry or the prior assessment.Review of Resident #3's Fall Risk Assessment Tool dated 3/24/26 indicated resident had not falls within the previous 6 months. Resident #3 required assistance or supervision for mobility, transfer, or ambulation.A review of Resident #3's care plan dated 5/29/26 revealed resident was at risk for falls related to medication side effects, impaired mobility, limited mobility related to hand contractures, cognitive impairment, and dependence on staff assistance for all her activities of daily living (ADLs). Interventions included keeping bed in low position with brakes locked and monitor resident for position in bed. Ideal position for resident would be in the center of the bed to assist with fall prevention measures.An observation and interview were conducted on 6/22/26 at 6:13 AM with Nurse Aide (NA) #1. She was performing incontinent care on Resident #3. The NA needed an additional washcloth and stepped outside of the room (linen cart was right outside of resident's door). Resident #3 was observed left unattended on her left side, bed in the highest position, and the side rail that was opposite from how the resident was turned was down. When NA #1 returned to the room, she went to the bathroom to wet the washcloth before returning to the bedside. During the continuous observation and interview with NA #1, she stated she normally would move the rail back up and the bed down when leaving the resident's bedside. During the interview, NA #1 did not state why she left the bed up and the side rail down. Interview with the Director of Nursing (DON) on 6/22/26 at 8:23 AM revealed prior to leaving a resident's bedside if a Nurse Aide (NA) had to obtain additional linen, the NA was expected to ensure the resident was positioned in a safe position with the bed in the lowest position, and bed rails raised.On 6/24/26 at 1:54 PM, an interview with the Administrator revealed staff were expected to make sure residents were safe, and that residents were placed onto their back and the bed lowered before stepping away from the bed. The Administrator stated NA #3 would receive one on one training regarding resident safety.

Based on observations and staff interviews, the facility failed to remove loose and unsecured pills of various shapes, sizes and colors in 2 of 2 medication carts (Front Hall Medication Cart #1 and Back Hall Medication Cart #1) reviewed for medication storage.The findings included:a. An observation was conducted on 6/23/26 at 3:10 pm of Front Hall Medication Cart #1 in the presence of Nurse #1. The observation revealed the following medications were stored in the medication cart:-Two loose small round white tablets with the marking EP 116 found in the second drawer of the medication cart,-One loose medium round white tablet with the marking 502 found in the second drawer of the medication cart,-Two loose small oblong white tablets with marking A found in the second drawer of the medication cart,-One loose small oblong orange capsule found in the second drawer of the medication cart,-One loose small oblong white tablet with the marking 152 found in the fourth drawer of the medication cart,-One loose large oblong orange tablet with marking 50/50 found in the fourth drawer of the medication cart.An interview was conducted on 6/23/26 at 3:10 pm with Nurse #1. When asked, Nurse #1 confirmed that loose tablets of medication were observed on Front Hall Medication Cart #1. Nurse #1 was unable to explain why medications were stored without minimum information required, including the name of the resident or prescribing information. Nurse #1 was unable to provide any additional information related to facility process for checking medication carts or pharmacy audits of the medication carts. b. An observation was conducted on 6/23/26 at 3:24 pm of Back Hall Medication Cart #1 in the presence of Nurse #2. The observation revealed the following medications were stored on the medication cart: -Two loose small round white tablets found in the first drawer of the medication cart,-One loose small oblong white tablet with the marking A10 found in the first drawer of the medication cart,-Two loose medium round white tablets found in the third drawer of the medication cart,-Two loose small round white tablets found in the third drawer of the medication cart,-One loose small round orange tablet found in the third drawer of the medication cart.An interview was conducted on 6/23/26 at 3:24 pm with Nurse #2. When asked, Nurse #2 confirmed that loose tablets of medication were observed on Back Hall Medication Cart #1. Nurse #2 indicated that the pharmacy was using new packaging that was not as durable as the previous packaging. Nurse #2 also stated the carts were audited by the pharmacy monthly. She further indicated that the lack of durability of the new packaging could be a contributing factor to the loose medications. Nurse #2 could not give a definite explanation to why medications were stored without the minimum information required, including the name of the resident or prescribing information.An interview was conducted on 6/23/26 at 3:53 pm with the Director of Nursing (DON) to discuss the concerns that were identified during the medication storage observation. The DON could not give an explanation to why loose tablets were observed on the Front Hall Medication Cart #1 or the Back Hall Medication Cart #1. The DON stated there was no system in place by the facility to audit the medication carts, but the carts were audited monthly by the pharmacy. She indicated she would expect the staff to dispose of loose medication according to policy. The DON stated she was not aware of the issue concerning the durability of the new pill packages being distributed by the pharmacy. An interview was conducted on 6/23/26 at 4:39 pm with the Administrator to discuss the concerns that were identified during the medication storage observation. The Administrator could not give an explanation to why loose tablets were observed on the Front Hall Medication Cart #1 or the Back Hall Medication Cart #1. The Administrator indicated she would expect staff to follow the policy and procedure for storing and disposing of medication. She further indicated that she was made aware of staff concerns related to the durability of the new pill packages being distributed by the pharmacy the day of the observation.

Based on observations, record reviews, and staff interviews, the facility failed to follow their Infection Control policies and procedures for hand hygiene when Nurse Aide (NA) #1 failed to remove her gloves and sanitize her hands before opening Resident #3's room door to obtain additional washcloths during incontinent care, and when Nurse #3 failed to sanitize her hands after medication administration and contact with Resident #19. The deficient practice occurred for 2 of 7 staff observed for infection control practices (NA #1 and Nurse #3).The findings included:Review of the facility's Standard Precautions policy and procedure last revised on 10/2025 revealed the following:Hand hygiene:Hand hygiene refers to hand washing with soap or the use of alcohol-based hand rub, which does not require access to water.Hand hygiene is performed with alcohol-based hand rub or soap and water:before and after contact with the resident,before performing an aseptic task,before moving from work on a soiled body site to a clean body site on the same resident,after contact with items in the resident's room, andafter removing gloves.Gloves:Gloves are removed promptly after use, before touching non-contaminated items and environmental services, and before going to another resident.After gloves are removed, hands are washed immediately to avoid transfer of microorganisms to other residents or environments. 1. An observation and interview were conducted on 6/22/26 at 6:13 AM with Nurse Aide (NA) #1. NA #1 donned her gloves as she was about to perform incontinent care on Resident #3. NA #1 removed Resident #3's brief that contained urine and cleaned her buttocks with a washcloth. NA #1 stated that she needed an additional washcloth to continue providing incontinent care. Without removing her gloves, NA #1 touched the door handle with her soiled gloves and stepped outside of the room (linen cart was right outside of resident's door) to obtain an additional washcloth. When NA #1 returned to the room, she still had on the same pair of gloves. She proceeded to the bathroom to wet the washcloth. NA #1 returned to Resident #3's bedside and continued providing incontinent care with washing the resident's buttocks and donning a new brief. Continuous observation of NA #1 revealed she did not remove the gloves she used to remove a soiled brief prior to touching the door handle and exiting the room to obtain clean bath linen. During the continuous observation and interview with NA #1, she stated the gloves should have been removed and hand hygiene performed prior to opening the door and stepping outside the room to obtain additional washcloths. During the interview, NA #1 did not state why she did not perform hand hygiene. Interview conducted with the Infection Control Preventionist (ICP) on 6/24/26 at 8:44 AM revealed staff have been educated to never have gloves on in the hallway. If staff need to leave a resident's room, they should remove their gloves, sanitize their hands, then when they re-enter, they should sanitize their hands again and don new clean gloves. The ICP stated she would provide re-education to NA #1 regarding hand hygiene.Interview with the Director of Nursing (DON) on 6/22/26 at 8:23 AM revealed staff were to remove gloves and sanitize their hands after resident contact. The DON stated that staff were expected to perform hand hygiene when entering and leaving a resident's room. 2. On 6/22/26 at 6:37 AM, an observation and interview with Nurse #3 revealed Nurse #3 had entered Resident #19's room to administer her medication and obtain an oxygen saturation reading (measures the percentage of red blood cells carrying oxygen in your bloodstream) using a pulse oximeter (a small, noninvasive device that clips onto your finger and uses light absorption to estimate your oxygen saturation). Nurse #3 did not have on gloves. The medications were administered and a pulse oximeter was used. After Nurse #3 obtained the reading she placed the pulse oximeter into her pocket, exited the resident's room, and proceeded to the medication cart without sanitizing or washing her hands. As Nurse #3 approached the medication cart, she began typing on her computer. Nurse #3 did not sanitize her hands nor clean the pulse oximeter which remained in Nurse #3's pocket. During the continuous observation and interview with Nurse #3, she indicated hand hygiene should have been completed after each resident during medication administration pass. When asked about hand hygiene after administering medication and obtaining an oxygen saturation for Resident #19, Nurse #3 stated she did not perform hand hygiene because she was not going to another resident. Interview conducted with the Infection Control Preventionist (ICP) on 6/24/26 at 8:44 AM revealed staff were educated to perform hand hygiene between each resident contact during medication pass or if their hands become soiled. Staff were supposed to clean equipment that was used on residents with Sani wipes after each use. Equipment should be cleaned between each resident. The ICP stated she would provide re-education to Nurse #3 regarding hand hygiene and cleaning equipment.Interview with the Director of Nursing (DON) on 6/22/26 at 8:23 AM revealed Nurse #3 was to use hand sanitizer between residents during medication pass and after each resident contact. Staff were expected to perform hand hygiene when entering and leaving a resident's room. Devices used during resident care, such as a pulse oximeter, should be cleaned after each use.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of respiratory care and active diagnosis for 2 of 14 residents reviewed for MDS accuracy (Residents #32 and #41). The findings included: 1. Resident #32 was admitted to the facility on [DATE] with diagnoses that included pneumonia. A record review indicated Resident #32 had a physician order dated 9/1/24 for oxygen via nasal canula at 2 liters per minute to maintain oxygen level of greater than 92%. A record review of Resident #32's February 2025 Medication Administration Record (MAR) revealed oxygen therapy was administered daily. The quarterly Minimum Data Set (MDS) assessment dated [DATE] did not indicate Resident #32 had received oxygen therapy. An interview was conducted on 5/1/25 at 3:39 PM with Minimum Data Set (MDS) Nurse #1. She stated it was an oversight that MDS Nurse #2 did not code the use of oxygen therapy in the Special Treatments and Programs section of Resident #32's quarterly MDS assessment dated [DATE]. An interview was conducted on 5/1/25 at 3:56 PM with the Director of Nursing. She stated she expected the MDS assessments to be coded accurately. 2. Resident #41 was admitted to the facility on [DATE] with a diagnosis that included anxiety disorder. A record review indicated Resident #41 had an active diagnosis of bipolar disorder since 7/3/23. A review of the Medication Administration Record from 3/18/25-3/24/25 revealed Resident #41 received antipsychotic medication daily for bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] did not indicate Resident #41 had an active diagnosis of bipolar disorder in the Psychiatric/Mood Disorder section. An interview was conducted on 5/2/25 at 9:33 AM with Minimum Data Set (MDS) Nurse #1. She stated it was an oversight that the MDS Nurse #2 did not code an active diagnosis of bipolar disease in the Psychiatric/Mood Disorder section of Resident #41's quarterly MDS assessment dated [DATE]. An interview was conducted on 03/06/25 at 10:50 AM with the Administrator. He stated she expected the MDS assessments to be coded accurately.

Based on record review and staff interviews, the facility failed to develop a care plan in the area of respiratory care for 1 of 14 residents reviewed for comprehensive care plans (Resident #32). The findings included: Resident #32 was admitted to the facility on [DATE] with diagnosis that included pneumonia. A record review indicated Resident #32 had a physician order dated 9/1/24 for oxygen via nasal canula at 2 liters per minute to maintain oxygen level of greater than 92%. The quarterly Minimum Data Set (MDS) assessment dated [DATE] did not indicate Resident #32 had received oxygen therapy. A record review of Resident #32's February 2025 Medication Administration Record (MAR) revealed oxygen therapy was administered daily. Review of Resident #32's comprehensive care plan dated 2/27/25 did not reveal a care plan for respiratory care. On 4/29/25 at 11:12 AM, Resident #32 was observed in room in bed with the oxygen concentrator in use, but the oxygen tubing was not on Resident #32 who was observed to be coughing. An interview was conducted with Nurse #1 on 4/30/35 at 3:05 PM. Nurse #1 indicated Resident #32 was known to remove her oxygen tubing from her nose and forget to replace it therefore nursing staff had to monitor and reposition the oxygen tubing as needed to ensure her oxygen saturation remained above 92%. An interview was conducted with MDS Nurse #1 on 5/1/25 at 3:39 PM and she indicated that Resident #32 should have had a care plan developed for respiratory care and that it was an oversight. An interview was conducted with the Director of Nursing on 5/1/25 at 4:05 PM and she indicated that Resident #32 should have had a care plan developed for respiratory care.

Based on observation, record review, staff, Responsible Party (RP) and Nurse Practitioner (NP) interviews, the facility failed to prevent injury to a resident who sustained a laceration to his head when a corner shelf fell from the wall. This was for 1 of 2 residents reviewed for accidents. (Resident #55) The findings: Included: Resident #55 was admitted to the facility on [DATE] with diagnosis that included hemiparesis following cerebral infarction affecting right dominant side, unspecified dementia, dysphagia. Review of Resident #55 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and was dependent on staff for Activities of Daily Living (ADL's.) Review of incident report completed by Nurse#1 dated 8/31/23 revealed nurse aide (NA)#1 and NA#2 were getting Resident#55 ready to perform care when a corner overhead shelf fell landing on the bed and right side of the residents' forehead/scalp. The report further revealed Resident #55 sustained a laceration above his right forehead. The wound measured 2(cm) centimeters by .02 is width to the top of the resident forehead. The laceration had a very small amount of bleeding, was cleansed, and steri- strips were applied. The report indicated Resident #55 remained at baseline for his neurological status and he was unable to voice pain due to his cognition during the assessment. The RP and Nurse practitioner (NP), Director of Nursing (DON) and Administrator were notified. Resident #55's overall status was monitored. Review of facility summary of incident dated 8/31/23 revealed 2 NA's (NA#1 and NA#2) were preparing to perform morning care on Resident #55 when an overhead corner shelf fell from the wall and landed on the bed and hit Resident #55 in the frontal section of the forehead. One NA stayed with Resident #55 while the other went to retrieve a nurse. The nurse immediately entered the room to assist and ensure the resident was safe. The summary further revealed the DON and the facility Administrator were summoned to the room. Upon arrival the Administrator assisted with the removal of the shelving unit. The Administrator spoke with the aids about what happened. Next, the Administrator called for the Maintenace Director to come to the room to see if a conclusion could be made as to how or why the shelf fell . A definitive answer could not be made regarding how or why the shelf fell , and as a result the Administrator requested that all corner shelves be removed from residents' rooms to prevent further accidents and or injury. Review of Nurses Progress Note dated 8/31/23 revealed around 9:40 am NAs were getting ready to perform care on Resident #55. The shelf over the head of bed (in corner to the right side of resident room) had fallen. The shelf (top part) was lying on resident with the top part of the shelf on Resident #55 forehead. The shelf was removed, and Resident #55 had a laceration to the top of his forehead which measured 2 cm in length and 0.2 in width. The laceration was cleansed with Saline and patted dry, a Steri-Strip applied until bleeding stopped and antibiotic ointment applied. An ice pack was applied the first 20 minutes after incident. The forehead had no swelling and no drainage. The resident was alert and mumbling the whole time. The NP was notified as was the RP. No new orders were given and the NP stated to monitor vital signs (VS). If VS were out of range, and/or Resident #55 had a change in condition, send him out to emergency room . However, if Resident #55 VS remained stable do not send him out. Neuro Checks were initiated at 9:45 am and recorded onto a Neuro work sheet. Maintenance removed the shelf from Resident #55's room. Written by Nurse # 1. Review of Medical Record 04/17/24 revealed Resident #55 revealed he was not on anticoagulant. Review of Provider Progress Note dated 9/14/23 stated there were no new complaints. Resident #55 had recovered from the laceration. The assessment further stated his 2cm laceration on his forehead had well approximated edges and no surrounding erythema. Written by NP # 1. Observation of Resident #55 room on 4/17/24 at 9:30 am revealed resident room did not contain any overhead shelves. Interview with NA #1 on 4/17/24 at 10:00 am revealed the was in the room with Resident #55 preparing him for a shower on 8/31/23 and was awaiting assistance from NA #2 when the incident occurred. A corner shelf fell from the right corner of the room falling onto the bed and Resident #55. She stated the bed took most of the impact of the shelf falling, but it did hit Resident#55 on the top of his head. NA was unaware of what caused the shelf to fall off the wall. While NA #2 stayed with Resident #55. NA #1 went to get Nurse #1. NA #2 was interviewed on 4/17/24 at 10:10 am. She was assisting NA #1 with Resident #55 preparing to transfer Resident #55 for bathing. As she entered the room the shelf came off the wall barely catching the top of Resident #55's head. NA #2 further stated that NA #1 left the room to get the nurse, and notify the DON, the Administrator. Nurse #1came into the room and did an assessment. Multiple attempts were made to reach Nurse# 1 by phone. A message was left with no return phone call. An interview with the NP was conducted on 4/17/24 at 10:30 am. The NP declined to answer questions regarding the event as she was longer responsible for residents in the facility. She further stated that the event happened so long ago she was fearful of providing inaccurate information. An interview with the Director of Maintenance on 4/17/24 at 11:00 am revealed she recalled being summoned to Resident #55's room on 8/31/23 to determine how or why the shelf fell . She stated that no root cause could be identified and as a result, the Administrator requested that all corner shelves be removed from residents' rooms. The Maintenance Director stated no loose screws and no missing dry wall were observed. Resident #55's RP was interviewed on 4/17/23 at 1:30 pm. She stated she was notified by Nurse # 1 Resident #55 had sustained a laceration to the forehead after a shelf fell from the wall. She further stated by the time she arrived to the facility all the corner shelves had been removed from all resident rooms. The RP was unaware of how the shelf had fallen from the wall. Resident #55 did not have a scar and in her opinion did not suffer any ill effects from the incident. An interview was conducted with the DON on 4/17/23 at 2:15 pm. She could not recall specifics of how she learned of the event, but recalled going to the room where the nurse was conducting a head-to-toe assessment of Resident #55. She stated the resident had a small laceration on the top of his forehead near the scalp. The DON continued by stating that she was unsure if a root cause was determined for the shelf falling, but it was decided that removing all corner shelves would prevent potential harm. The RP and NP were notified, and the resident was not sent to the hospital for further evaluation. The Administrator was interviewed on 4/17/23 at 3:15 pm. She became aware of the incident regarding a shelf falling on Resident #55 during a daily morning meeting on 8/31/23 around 9:30 am. She stated that she and the DON reported to Resident #55 room and began to assist staff as needed. The Administrator stated that she assisted the nurse with removal of the shelving unit from the room. She further stated she began interviewing staff that witnessed the shelf fall and recalled summoning the Director of Maintenance to the room to assess the shelving. No root cause could be determined as to what or how the shelf came off the wall. To prevent injury to others the Administrator requested the removal of all corner shelves from resident rooms. The facility provided the following corrective action with a completion date of 09/4/23. The Administrator is the individual responsible for compliance with this action plan. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; Address how the facility will identify other residents having the potential to be affected by same deficient practice. After a review, Resident # 55 was affected by the shelf falling from the wall. The resident was immediately assisted and assessed. Resident NP and POA notified. The Maintenance Director immediately was notified to assess the corner shelf. This was completed on 8/31/23. After a thorough review, no other residents were affected at this time. To ensure all Resident safety, all corner shelves were removed in every room due to unknown cause of the shelf falling. This was completed on 8/31/23. Due to unknown cause of the shelf falling, education was conducted to all staff by Administrator/Maintenance Director on reporting any equipment, outlets, furniture, shelving etc. that may be compromised and/or damaged to be reported immediately to maintenance and also put on maintenance order board. Address what measure will be put into place or systemic changes made to ensure what the deficient practice. All corner shelves removed on 8/31/23. Ad Hoc QA Meeting was held to review incident on /8/31/23. The QA committee consists of DON, Administrator, MDS Coordinator, Nursing Supervisor, Human Resources, Social Worker, Plant Operations Manager, and other department managers. Maintenance Director assed the corner shelf to understand the cause of it falling. No known cause was made therefore the facility removed all corner shelves. Due to uknown cause of the shelf falling, education was immediately started on 8/31/23-9/4/23 conducted to all staff by Administrator/Maintenance Director on reporting any equipment, outlets, furniture, shelving, etc. that may be compromised and or damaged to be reported immediately to maintenance and also put on maintenance order board. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and Include dates when corrective action will be completed. On 8/31/23, Administrator held an Ad hoc Quality Assurance Meeting. Due to unknown cause, Education started in every department to review on reporting any equipment, outlets, furniture, shelving etc. that may be compromised and or damaged to be reported immediately to maintenance and also put on order board. All corner shelves were removed on 8/31/23. Due to removing all corner shelves, no monitoring or performance needed. Corrective actions were implemented 8/31/23 to remove all corner shelves. All corner shelves were removed and completed 8/31/23. All education was conducted between 8/31/23-9/4/23. All corrective actions were completed on 9/4/23. On 4/18/2024 the facility's correction action plan was validated by the following: The facility provided documentation to support their corrective action plan including education provided to the Maintenance Director, and every department. The Maintenance Director audited and removed all corner shelving units in all resident rooms on 8/31/23. Observations were conducted of all residents' rooms and revealed no corner shelving. QAPI meetings were discussed with the Administrator and meeting notes were reviewed. There have been no further incidents accidents of falling objects onto residents. The facility's date of 9/4/23 for the corrective action plan was validated on 4/18/24.

Based on observations, residents and staff interviews, the facility failed to maintain walls in good repair for 2 of 2 rooms (rooms [ROOM NUMBERS]) reviewed for environment. The findings included: 1a. An observation on 4/15/24 at 1:01 PM in room [ROOM NUMBER] revealed multiple black marks and marring on the drywall next to Resident #32's bed. The drywall appeared to have been patched in an area that included the marred area, but not painted. A second observation was conducted on 4/18/24 at 10:10 AM in room [ROOM NUMBER]. The observation revealed the same black marks and marring next to Resident #32's bed. Some areas appeared to have been patched but not painted. 1b. An observation on 4/15/24 at 1:06 PM in room [ROOM NUMBER] revealed the wall behind Resident #36's chair to have multiple black marks of various sizes and marring. A second observation of room [ROOM NUMBER] on 4/17/24 at 10:09 AM revealed the wall behind Resident #36's chair to have black scuffs and marring at the top of the height of the chair. An interview with the Maintenance Director 4/18/24 01:20 PM revealed she had been the Maintenance Director since July 2023. She stated that staff, residents, and visitors were able to enter maintenance requests through an electronic kiosk in the hallway. These requests were reviewed by Maintenance several times a day. She stated she checks the system first thing each morning. The Maintenance Director further revealed staff could alert her to Maintenance concerns that required more immediate attention by stopping her in the facility. When completed, the request would be initialed by the Maintenance staff. A facility tour with the Maintenance Director occurred on 4/18/24 at 1:28 PM. She was not aware of the black marks and marring on the drywall in rooms [ROOM NUMBERS]. The Maintenance Director had the expectation that other staff would have reported these concerns. She stated she completed regular rounding of rooms and safety rounds every month. An interview and facility tour with the Administrator on 4/18/24 at 1:33 PM revealed she was not aware of the marks and marring on the walls in rooms [ROOM NUMBERS]. She stated that the marks were due to furniture and equipment against the walls. She stated that anyone can fill out a work request and staff would assist residents with the kiosk if needed. The Administrator revealed she and other management staff completed rounds and the safety committee met monthly to discuss concerns.

Based on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments no later than 14 days after the Assessment Reference Date (ARD, the last day of the look-back period) for 4 residents (Residents #8, #7, #14, and #16) reviewed for resident assessments. The findings included: 1. Resident #8 was admitted to the facility on [DATE]. Review of the resident's Minimum Data Set (MDS) assessment revealed a quarterly MDS had an Assessment Reference Date (ARD, the last day of the look-back period) of 11/21/22. As of 12/15/22, 24 days after the ARD, the quarterly MDS dated had not been completed. An interview was conducted on 12/15/22 at 12:25 PM with the facility's MDS Coordinator and she indicated she was behind in completing some assessments, which caused the assessment to be overdue. She indicated she was working to get them completed. She indicated she had been pulled from the MDS department to work on the medication cart and had fell behind in completing the assessments. She indicated the assessments should be completed in 14 days from the ARD. An interview was conducted on 12/15/22 at 4:30 PM with the facility's Administrator. During the interview, the Administrator indicated she was aware of concerns regarding the MDS assessments being overdue and not completed. She indicated resident care was their priority and had to assign the MDS coordinator to the medication cart at times. She indicated the MDS coordinator was working to get the assessments completed and caught up. The Administrator indicated it was her expectation that the MDS assessments are completed timely. 2. Resident #7 was admitted to the facility on [DATE]. Review of the resident's Minimum Data Set (MDS) assessment revealed a quarterly MDS had an Assessment Reference Date (ARD, the last day of the look-back period) of 11/21/22. As of 12/15/22, 24 days after the ARD, the quarterly MDS dated had not been completed. An interview was conducted on 12/15/22 at 12:25 PM with the facility's MDS Coordinator and she indicated she was behind in completing some assessments, which caused the assessment to be overdue. She indicated she was working to get them completed. She indicated she had been pulled from the MDS department to work on the medication cart and had fell behind in completing the assessments. She indicated the assessments should be completed in 14 days from the ARD. An interview was conducted on 12/15/22 at 4:30 PM with the facility's Administrator. During the interview, the Administrator indicated she was aware of concerns regarding the MDS assessments being overdue and not completed. She indicated resident care was their priority and had to assign the MDS coordinator to the medication cart at times. She indicated the MDS coordinator was working to get the assessments completed and caught up. The Administrator indicated it was her expectation that the MDS assessments are completed timely. 3. Resident # 14 was admitted to the facility on [DATE]. Review of the resident's Minimum Data Set (MDS) assessment revealed a quarterly MDS had an Assessment Reference Date (ARD, the last day of the look-back period) of 11/22/22. The quarterly MDS dated [DATE] was signed/dated on 12/14/22 by the Assessment Coordinator to verify the assessment was completed (22 days after the ARD). An interview was conducted on 12/15/22 at 12:25 PM with the facility's MDS Coordinator and she indicated she was behind in completing some assessments, which caused the assessment to be overdue. She indicated she was working to get them completed. She indicated she had been pulled from the MDS department to work on the medication cart and had fell behind in completing the assessments. She indicated the assessments should be completed in 14 days from the ARD. An interview was conducted on 12/15/22 at 4:30 PM with the facility's Administrator. During the interview, the Administrator indicated she was aware of concerns regarding the MDS assessments being overdue and not completed. She indicated resident care was their priority and had to assign the MDS coordinator to the medication cart at times. She indicated the MDS coordinator was working to get the assessments completed and caught up. The Administrator indicated it was her expectation that the MDS assessments are completed timely. 4. Resident #16 was admitted to the facility on [DATE]. Review of the resident's Minimum Data Set (MDS) assessment revealed a quarterly MDS had an Assessment Reference Date (ARD, the last day of the look-back period) of 11/5/22. The quarterly MDS dated [DATE] was signed/dated on 11/21/22 by the Assessment Coordinator to verify the assessment was completed (16 days after the ARD). An interview was conducted on 12/15/22 at 12:25 PM with the facility's MDS Coordinator and she indicated she was behind in completing some assessments, which caused the assessment to be overdue. She indicated she was working to get them completed. She indicated she had been pulled from the MDS department to work on the medication cart and had fell behind in completing the assessments. She indicated the assessments should be completed in 14 days from the ARD. An interview was conducted on 12/15/22 at 4:30 PM with the facility's Administrator. During the interview, the Administrator indicated she was aware of concerns regarding the MDS assessments being overdue and not completed. She indicated resident care was their priority and had to assign the MDS coordinator to the medication cart at times. She indicated the MDS coordinator was working to get the assessments completed and caught up. The Administrator indicated it was her expectation that the MDS assessments are completed timely.

Based on record review and staff interviews the facility failed to develop a comprehensive care plan for 1 of 2 residents (Resident #219) reviewed for pressure ulcers. The findings included: Resident #219 was admitted to the facility on [DATE] with a diagnosis that included joint replacement surgery, paraplegia, and unspecified fracture of shaft of left tibia. Resident was discharged to home from the facility on 2/26/22. A review of the comprehensive minimum data set (MDS) dated [DATE] revealed Resident #219 was cognitively intact and at risk for developing pressure ulcers. The care area assessment (CAA) dated 11/16/21 indicated to proceed to care plan for the prevention of developing pressure ulcers. A review of the care plan dated 11/16/21 revealed that Resident #219 was not care planned for being at risk to develop pressure ulcers. An interview with the MDS coordinator on 12/15/22 at 3:00 pm. She indicated that Resident #219 was coded correctly to be at risk for pressure ulcers and this should have been care planned and that it must have missed and not carried over as planned. A review of nursing progress note dated 11/17/21 indicated that Resident #219 developed a stage 2 pressure ulcer. An interview with the Administrator on 12/15/22 at 3:45 pm revealed that it was her expectation for the MDS nurse to have care planned this resident for being at risk for pressure ulcers.

Based on record review and staff interviews the facility failed to have a Registered Nurse (RN) scheduled for 8 consecutive hours a day for 1 (11/24/22) of 30 days reviewed. Findings included: The daily nursing schedules from 11/12/22 through 12/12/22 were reviewed and revealed there was no registered nurse (RN) on 11/24/22. Review of the timecards and RN scheduled staffing assignment sheets revealed the facility had no documentation of an RN present in the facility on 11/24/22 to meet the requirement for an RN at least 8 consecutive hours per day on each day. During an interview conducted with the Administrator on 12/15/22 at 9:30 am she stated there should have been an RN scheduled every day. However, on Thanksgiving Day (11/24/22) no RN was present in the facility An interview was conducted with Nurse #2 on 12/15/22 at 1:19 pm she indicated she was a RN and that she believed she worked on 11/24/22. Review of Nurse #2's timecard for 11/24/22 indicated she did not work. An interview was conducted with the Director of Nursing on 12/15/22 at 3:10 pm. She stated she expected the facility to have an RN staffed to meet the regulation for 8 consecutive hours a day, 7 days a week. During an interview conducted with the Administrator on 11/15/22 at 3:30pm she stated she expected the Scheduler to staff an RN for 8 hours per day, 7 days a week.

Based on record review and staff interviews, the facility failed to complete Minimum Data Set (MDS) discharge assessments for 5 of 8 discharged residents reviewed (Residents #29, #62, #24, #47, #37). Findings included: 1. Resident #29 was admitted to the facility on [DATE]. Nursing documentation dated 7/2/22 noted the resident had discharged from the facility to the community. There was no discharge MDS completed for Resident #29. An interview was conducted on 12/15/22 at 12:25 PM with the facility's MDS Coordinator. She indicated she was behind in completing some assessments, had not completed the discharge assessments, and was working to get them completed. She indicated she had been pulled from the MDS department to work on the medication cart and had fallen behind. She indicated the assessments should be completed within 14 days from the discharge date . An interview was conducted on 12/15/22 at 4:30 PM with the facility's Administrator. During the interview, the Administrator indicated she was aware of concerns regarding the MDS assessments being overdue and not completed. She indicated resident care was their priority and had to assign the MDS coordinator to the medication cart at times. She indicated the MDS coordinator was working to get the assessments completed and caught up. The Administrator indicated it was her expectation that the MDS assessments are completed timely. 2. Resident #62 was admitted to the facility on [DATE]. Nursing documentation dated 7/8/22 noted the resident had discharged from the facility to the community. There was no discharge MDS completed for Resident #62. An interview was conducted on 12/15/22 at 12:25 PM with the facility's MDS Coordinator. She indicated she was behind in completing some assessments, had not completed the discharge assessments, and was working to get them completed. She indicated she had been pulled from the MDS department to work on the medication cart and had fallen behind. She indicated the assessments should be completed within 14 days from the discharge date . An interview was conducted on 12/15/22 at 4:30 PM with the facility's Administrator. During the interview, the Administrator indicated she was aware of concerns regarding the MDS assessments being overdue and not completed. She indicated resident care was their priority and had to assign the MDS coordinator to the medication cart at times. She indicated the MDS coordinator was working to get the assessments completed and caught up. The Administrator indicated it was her expectation that the MDS assessments are completed timely. 3. Resident #24 was admitted to the facility on [DATE]. Nursing documentation dated 7/29/22 noted the resident had discharged from the facility to an assisted living facility. There was no discharge MDS completed for Resident #24. An interview was conducted on 12/15/22 at 12:25 PM with the facility's MDS Coordinator. She indicated she was behind in completing some assessments, had not completed the discharge assessments, and was working to get them completed. She indicated she had been pulled from the MDS department to work on the medication cart and had fallen behind. She indicated the assessments should be completed within 14 days from the discharge date . An interview was conducted on 12/15/22 at 4:30 PM with the facility's Administrator. During the interview, the Administrator indicated she was aware of concerns regarding the MDS assessments being overdue and not completed. She indicated resident care was their priority and had to assign the MDS coordinator to the medication cart at times. She indicated the MDS coordinator was working to get the assessments completed and caught up. The Administrator indicated it was her expectation that the MDS assessments are completed timely. 4. Resident #47 was admitted to the facility on [DATE]. Nursing documentation dated 8/3/22 noted the resident had discharged to from the facility to the community. There was no discharge MDS for Resident #47. An interview was conducted on 12/15/22 at 12:25 PM with the facility's MDS Coordinator. She indicated she was behind in completing some assessments, had not completed the discharge assessments, and was working to get them completed. She indicated she had been pulled from the MDS department to work on the medication cart and had fallen behind. She indicated the assessments should be completed within 14 days from the discharge date . An interview was conducted on 12/15/22 at 4:30 PM with the facility's Administrator. During the interview, the Administrator indicated she was aware of concerns regarding the MDS assessments being overdue and not completed. She indicated resident care was their priority and had to assign the MDS coordinator to the medication cart at times. She indicated the MDS coordinator was working to get the assessments completed and caught up. The Administrator indicated it was her expectation that the MDS assessments are completed timely. 5. Resident #37 was admitted to the facility on [DATE]. Nursing documentation dated 8/25/22 noted the resident had discharged from the facility to an assisted living facility. There was no discharge MDS completed for Resident #37. An interview was conducted on 12/15/22 at 12:25 PM with the facility's MDS Coordinator. She indicated she was behind in completing some assessments, had not completed the discharge assessments, and was working to get them completed. She indicated she had been pulled from the MDS department to work on the medication cart and had fallen behind. She indicated the assessments should be completed within 14 days from the discharge date . An interview was conducted on 12/15/22 at 4:30 PM with the facility's Administrator. During the interview, the Administrator indicated she was aware of concerns regarding the MDS assessments being overdue and not completed. She indicated resident care was their priority and had to assign the MDS coordinator to the medication cart at times. She indicated the MDS coordinator was working to get the assessments completed and caught up. The Administrator indicated it was her expectation that the MDS assessments are completed timely.

Based on observations, staff and resident interviews, and record review, the facility failed to maintain accurate advance directive information throughout the medical record for 1 of 6 residents reviewed for formulation of advance directives (Resident #45). The findings included: Resident #45 was admitted to the facility on [DATE]. He had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #45's admission Minimum Data Set, dated dated dated [DATE] revealed he had intact cognition. The hospital records dated [DATE] revealed Resident #45 was determined to be a Do Not Resuscitate (DNR) and indicated for no cardiopulmonary resuscitation (CPR). The hospital Medical Provider documented a DNR status for Resident #45 on the discharge instructions. A completed and signed DNR dated [DATE] accompanied Resident #45 to the facility. Resident #45's electronic medical record (EMR) revealed a signed physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet revealed a signed DNR form under the advance directive tab dated [DATE] with the no expiration date box checked on the document. An interview was conducted with Nurse Aide #1 on [DATE] at 01:08 PM. She revealed she reviewed a resident's code status in the EMR and she used the EMR as a source of information for a resident's code status. In an Interview with Nurse #1 on [DATE] at 01:10 PM, she explained there were multiple places in the EMR to view code status information. Nurse # 1 stated, it never hurts to check all areas of code status documentation. An interview with Medical Records on [DATE] at 01:38 PM revealed she scanned DNRs into the EMR after she received the document in her items-to-be scanned box. She explained DNR forms mostly come from the hospital. She stated all DNRs should be scanned into the EMR. An Interview with the Social Worker was conducted on [DATE] at 3:40 PM. The Social Worker indicated she did not speak with Resident #45 or his family regarding his code status. In a follow up interview and observation with Nurse # 1 at [DATE] at 03:57 PM she reviewed Resident #45's EMR. Nurse #1 stated he was a full code. When she reviewed the DNR form under the advance directives tab, Nurse #1 stated she did not know he had a scanned DNR. An interview was conducted with Resident #45 on [DATE] at 08:54 AM. Resident #45 revealed the facility had not spoken with him regarding his wishes for full code or DNR status. In a follow up interview with Medical Records on [DATE] at 12:06 PM, she indicated a DNR form remained scanned in the EMR once the DNR was rescinded. An interview with the Admission Coordinator on [DATE] at 12:01 PM explained the process for formulating advance directives. She communicated if a resident was admitted to the facility from a hospital with a DNR, she asked the resident or resident representative for verification of the current code status. If the DNR was accurate, it was scanned into the EMR. A follow up interview with the Admission Coordinator was completed on [DATE] at 12:14 PM. The Admission Coordinator voiced she had spoken with Resident #45's family upon admission regarding Resident #45's code status. The family determined Resident #45 was a full code. An interview was conducted with Resident #45's family member on [DATE] at 01:26 PM. The family member indicated she believed she had spoken with staff during the admission process and thought she and her brother had made Resident #45 a full code status. The family member stated she needed to clarify this statement with her brother. In a follow up interview with Resident #45 on [DATE] at 4:03 PM, the resident indicated he would want to be resuscitated. In an interview with the Director of Nursing (DON) on [DATE] at 04:12 PM, she revealed the admission coordinator speaks with the family or resident upon admission to review code status information. She further indicated the care plan team discussed code status changes as needed. The DON explained all resident information had to be scanned into the EMR. She further explained staff go by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the DON and Administrator on [DATE] at 05:11 PM. The DON reviewed Resident #45's EMR and confirmed the full code order and scanned DNR order were both dated for [DATE] and both signed by a provider with no expiration dates indicated. The DON stated the scanned DNR was part of the EMR and cannot be changed. She further explained code statuses could change at the time of admission. The Administrator explained everything gets scanned into the EMR that comes to the facility with the resident. When a code status changes, the doctor's order would be updated.

Based on observations, staff interviews and record review, the facility failed to ensure daily nurse staffing information was completed for 30 of 30 days reviewed for completed staffing information. Findings Included: A review of facility staffing information dated 08/17/21 through 09/15/21 (30 days), revealed the resident census number was not entered for 2nd and 3rd shifts on all days. An interview was conducted on 09/17/21 at 03:18 PM with the scheduler who was responsible for posting daily staffing. She explained that she and the Director of Nursing (DON) share the responsibility for completing the staff census information. An interview was conducted with the DON on 09/17/at 03:47 PM. The DON explained the process for making changes or updates to the staffing information. During workdays, it was the responsibility of the scheduler or DON to update the staffing information. The DON revealed afterhours it was the responsibility of whoever was at the facility that took the call out from staff members (usually a nurse). The DON revealed the resident census number was updated when the information changed. She stated if the resident census number didn't change, it was not rewritten each shift.

Based on record review, observations, review of facility's policies and staff interviews, the facility failed to implement their transmission based precautions policy for donning personal protective equipment (PPE), when 2 of 4 staff members ( certified medication aid (CMA) #1 and nursing assistant (NA) #2) failed to wear gowns and/or gloves when providing care to residents on Enhanced Droplet Isolation precautions. These failures occurred during the COVID19 pandemic. Findings included: Review of the facility's [MEDICAL CONDITION] Prevention and Control policy dated October 2020 revealed in part; new admissions will be placed on isolation in a private room for 14 days and precautions will be used while caring for residents. Review of the facility's Isolation-Categories of Transmission Based Precautions policy dated 2020 revealed in part; mask, gloves, gown, and goggles will be worn when entering the resident room. Resident #1 was observed on 1-25-21 at 12:30pm. The resident's door had an Enhanced Droplet Isolation sign posted and a receptacle hanging from his door containing gowns and gloves. During the observation of Resident #1's door, CMA #1 was observed entering Resident #1's room with oral medication. The CMA was noted not to be wearing a gown or gloves and was observed handing the resident the medicine cup and a glass of water from his table. The CMA did perform hand hygiene prior to exiting the room. CMA #1 was interviewed on 1-25-21 at 12:35pm. The CMA explained she was in a hurry because she was behind on her medication pass and was trying to go to fast. The CMA acknowledged Resident #1 was on Enhanced Droplet Isolation and she should have been wearing a gown and gloves when entering his room. She confirmed she had received training on COVID19, PPE and isolation. Observation of the facility's Tyndall Hall occurred on 1-25-21 at 12:40pm. The staff were observed gathering lunch trays from the resident rooms. Resident #9 and Resident #10 resided in different rooms on Tyndall Hall and had Enhanced Droplet Isolation signage and receptacles hanging from their door containing isolation gowns and gloves. NA #2 was observed in Resident #9's room with no gown or gloves on while she touched the resident's table and a package of briefs. She exited the room without performing hand hygiene with Resident #9's lunch tray, placed it in the meal cart, returned to Resident #9's room without a gown or gloves, touched the resident on her shoulder, picked up bananas from the resident table, exited the room without performing hand hygiene and placed the bananas on the meal cart. NA #2 touched the meal cart without performing hand hygiene and moved it down the hall then proceeded into Resident #10's room without performing hand hygiene and not donning a gown or gloves. While in Resident #10's room she touched the resident's walker, the resident, a chair and the resident's table. The NA attempted to close the resident's door to perform activities of daily living (ADL) care. During an interview with NA #2 on 1-25-21 at 12:45pm, NA #2 acknowledged she had not donned a gown or gloves when she was in Resident #9's room and Resident #10's room. She also confirmed she had not performed hand hygiene between each encounter with the residents. NA #2 acknowledged she was preparing to provide ADL care to Resident #10 without donning a gown. She stated she was not aware Resident #9 and Resident #10 were on Enhanced Droplet Isolation. She explained she worked for an agency and was not informed the residents were on precautions. NA #2 confirmed she saw the Enhanced Droplet Isolation signage and the receptacle but stated she did not read the signage. She also said she had not received education on infection control, precautions, PPE, and hand washing from the agency in several months. The Administrator was interviewed on 1-25-21 at 1:00pm. She discussed staff had received training on donning proper PPE when a resident was on Enhanced Droplet Isolation and COVID19. The Administrator stated she did not know why the CMA would enter an isolation room without a gown or gloves and the CMA could have asked for assistance if she was behind on passing her medication. She also discussed NA #2 was from an agency and she would call the agency to discuss training for their employee. The Administrator stated she would increase observations of staff to ensure proper PPE and hand hygiene were being implemented. The facility's medical director was interviewed by telephone on 2-1-20 at 9:30am. The medical director discussed the need for staff to wear gowns, gloves, face mask and eye protection when entering a resident room who was on Enhanced Droplet Isolation and maintain hand hygiene. He stated without following the infection control guidelines, staff risk spreading the [MEDICAL CONDITION].

Based on record review, policy review and staff interview the facility failed to include the 2-hour reporting requirement for abuse allegations to the state agency in their abuse policy. This was evident for 2 of 2 residents reviewed for abuse (Resident #1 and Resident #2). Findings Included: Review of the facilities policy titled Abuse, Neglect, Mistreatment and Misappropriation of Property and Crime against a Resident with a revision date of 8/23/19 stated in part: The Administrator or Designee should send a 24-hour report to state agency / healthcare personnel registry postmarked or faxed within 24 hours of the alleged incident or 24 hours of notification of the incident. If the resident sustained [REDACTED]. 1. Resident #1 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Review of the facilities abuse investigation revealed Resident #1 had reported to the Physical Therapy Assistant (PTA) and to Nurse #1 that Nursing Assistant #1 had hit her on her left cheek. The initial allegation report was completed by Administrator #1 and identified the allegation as resident abuse. The report identified the incident occurred on 9/3/20 at 6:45 am. The report did not identify when the facility became aware of the incident. A fax transmission verification report identified the initial abuse allegation report was sent to the state agency on 9/3/20 at 10:46 am. During an interview on 10/21/20 at 2:35 am with the DON and Administrator #1 they both stated it was their understanding they had 24 hours to submit an initial allegation report of resident abuse to the state agency unless the abuse involved an injury; then they needed to submit the initial allegation report within 2 hours of becoming aware of the incident. Administrator #1 stated she would need to follow-up to make sure their abuse policy was correct regarding reporting requirements to the state agency. 2. Resident #2 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Review of the facilities abuse investigation revealed the facility was notified by a family member of Resident #2 that a Nursing Assistant (NA) was verbally and emotionally abusive to Resident #2. The initial allegation report was completed by Administrator #2 and identified the allegation as resident abuse. The report identified the facility became aware of the abuse allegation on 11/11/19 at 10:30 am. A fax transmission verification report identified the initial abuse allegation report was submitted to the state agency on 11/12/20 at 12:22 pm. An interview on 10/26/20 at 11:00 am with Administrator #2 revealed he had been the Administrator at the facility and had completed the abuse investigation for Resident #2. He stated an initial abuse investigation report had to be submitted to the state agency within 24 hours of the facility becoming aware of the alleged abuse. He added if the abuse allegation included an injury then the initial investigation report had to be submitted within 2 hours. Administrator #2 stated he was not aware of the requirement to report all abuse allegations within 2 hours to the state agency and he had followed the facility abuse policy regarding reporting requirements.

Based on record review and staff interview the facility failed to submit an initial resident abuse allegation to the state agency with the required 2-hour timeframe for 2 of 2 residents reviewed for abuse. (Resident #1 and Resident #2). Findings Included: 1. Resident #1 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. An admission minimum data set ((MDS) dated [DATE] for Resident #1 identified her cognition was moderately impaired and she required extensive one-person assistance with personal hygiene, toilet use and bed mobility. No behaviors were identified during the look-back period. Review of the facilities abuse investigation revealed Resident #1 had reported to the Physical Therapy Assistant (PTA) and to Nurse #1 that Nursing Assistant #1 had hit her on her left cheek. The initial allegation report was completed by Administrator #1 and identified the allegation as resident abuse. The report identified the incident occurred on 9/3/20 at 6:45 am. The report did not identify when the facility became aware of the incident. A fax transmission verification report identified the initial abuse allegation report was sent to the state agency on 9/3/20 at 10:46 am. Review of the facilities 5-day report summary dated 9/7/20 stated the Director of Nursing (DON) arrived at the facility about 9:00 am on 9/3/20 and was immediately notified by the PTA and Nurse #2 of the alleged abuse allegation by Resident #1. An interview on 10/22/20 at 11:25 am with the PTA revealed she had received an allegation of staff to resident abuse from Resident #1. She stated she had received training on abuse, and it was her understanding that she reported any suspected abuse to the resident ' s nurse and the nurse would report it up the chain of command. An interview on 10/22/20 at 1:00 pm with Nurse #1 revealed she did recall the abuse allegation from Resident #1 and confirmed she became aware of the incident at 6:45 am on 9/3/20. She explained she had notified Nurse #2 around 7:15 am who was the Nurse Manager on duty. Nurse #1 stated she was not sure if Nurse #2 contacted the DON or Administrator about the abuse allegation. An interview on 10/22/20 at 3:00 pm with Nurse #2 revealed she worked as both a floor nurse and a charge nurse. She stated when she arrived to work on 9/3/20 Nurse #1 did notify her of Resident #1 ' s allegation of abuse. Nurse #2 stated she could not recall if she called the Administrator to notify her of the abuse allegation or if she had notified the DON when she arrived to work around 9:00 am. Nurse #2 added she had been trained on abuse reporting and the Administrator was supposed to be contacted as soon as an abuse allegation occurred. An interview on 10/21/20 at 2:30 pm with the DON revealed she was notified of the alleged abuse allegation for Resident #1 at approximately 9:00 am on 9/3/20 when she arrived at the facility. She added Nurse #1 should have contacted her or the Administrator when she became aware of the incident at 6:45 am. During an interview on 10/21/20 at 2:35 am with the DON and Administrator #1 they both stated it was their understanding they had 24 hours to submit an initial allegation report of resident abuse to the state agency unless the abuse involved an injury; then they needed to submit the initial allegation report within 2 hours of becoming aware of the incident. Administrator #1 confirmed the current 24-hour report they were using did not have a section to document when the facility became aware of the abuse allegation. She added she would need to follow-up to make sure their abuse policy was correct regarding reporting requirements and that they were using the most recent 24-hour report. 2. Resident #2 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. A quarterly minimum data set ((MDS) dated [DATE] for Resident #2 identified her cognition was intact; she required extensive one-person assistance with toilet use, dressing and bed mobility and she had no behaviors identified during the look-back period. Review of the facilities abuse investigation revealed the facility was notified by a family member of Resident #2 that a Nursing Assistant (NA) was verbally and emotionally abusive to Resident #2. The initial allegation report was completed by Administrator #2 and identified the allegation as resident abuse. The report identified the facility became aware of the abuse allegation on 11/11/19 at 10:30 am. A fax transmission verification report identified the initial abuse allegation report was submitted to the state agency on 11/12/20 at 12:22 pm. An interview on 10/22/20 at 11:20 am with the Social Worker (SW) revealed she did recall the abuse allegation submitted by the family of Resident #2. She explained the family member had written a statement that NA #2 was verbally and emotionally abusive to the resident on a care plan invitation and mailed it to the facility. The SW stated when she received the care plan invitation and saw the written abuse accusation, she notified Administrator #2 and he completed the investigation. An interview on 10/26/20 at 11:00 am with Administrator #2 revealed he had been the Administrator at the facility and had completed the abuse investigation for Resident #2. He stated an initial abuse investigation report had to be submitted to the state agency within 24 hours of the facility becoming aware of the alleged abuse. He added if the abuse allegation included an injury then the initial investigation report had to be submitted within 2 hours. Administrator #2 explained the facility had received an allegation of abuse from the family of Resident #2 and he had initiated an abuse investigation. He added he could not recall the exact date or time the initial abuse investigation report was sent to the state agency.

Based on observation, record review, staff interviews, physician interview the facility failed to (1) establish and implement a surveillance/tracking system for residents with signs and symptoms of COVID19 and (2) failed to implement their policy to ensure reusable screening equipment, which included an oral thermometer, was properly sanitized after each use. This failure occurred during a COVID19 pandemic. Findings included: 1.Review of the facility's Coronavirus (COVID19) Prevention and Control policy and procedure dated May 2020 revealed in part; The Director of Nursing/ designee is responsible for establishing and overseeing the active surveillance and monitoring of COVID19. During an interview with the Administrator on 6-16-20 at 9:20am, the Administrator stated there were no positive cases of COVID19 in the building and there had not been any residents hospitalized due to having COVID19. She explained the facility had some suspected cases due to the residents having an increase in their temperature, but the residents had been tested and their results were negative. A facility tour occurred on 6-16-20 at 9:30am. The tour revealed no residents on quarantine status or droplet precautions. The Director of Nursing (DON) was interviewed on 6-16-20 at 11:10am. Initially the DON questioned what type of surveillance this surveyor was asking to see, but once the DON understood she stated, honestly no I have not been using any type of surveillance or tracking system. She further stated she believed the nurses taking the residents temperatures each shift and reporting to her any increase in temperature was enough. The Administrator was interviewed on 6-16-20 at 12:00pm. The Administrator stated she was not aware a surveillance and tracking system needed to be established but she would work with the DON to have a system established and followed. During an interview with the facility's Medical Director on 6-17-20 at 12:30pm, the Medical Director stated he was informed of the residents' symptoms and ordered the testing for COVID19 but was not directly involved in tracking or surveillance of the suspected cases so he did not know if the process had been done. 2. Review of the facility's Infection Control policy and procedure dated December 2007 revealed in part; ensure reusable equipment has been appropriately cleaned. An observation of the visitor screening table on 6-16-20 at 9:00am revealed an oral thermometer with a box of probe covers, a screening notebook to record temperatures and hand sanitizer. There were no sanitation wipes to clean the thermometer between uses. An observation was made on 6-16-20 at 9:51am of an employee entering the facility through the employee entrance, taking her temperature, applying her mask and sanitizing her hands. She was observed to throw away the thermometer's probe cover and return the oral thermometer to the table without cleaning it before leaving the screening area. The employee screening area was observed on 6-16-20 at 9:52am. The area revealed a small table that contained a daily temp log with the employee's name, initials of the employee and their temperature which was obtained by each employee, an oral thermometer with a box of probe covers and hand sanitizer. There were no sanitation wipes present to clean the thermometer between each employee use. During an interview with Social Worker (SW) #1 on 6-16-20 at 9:55am, SW #1 was noted to be sitting at the employee screening area and said she was sometimes assigned to the area to make sure each employee took their temperature and recorded it. She also stated, there are different people assigned, it just depends on people's workload. SW #1 said she had received training on infection control but could not recall the date or specific information. She also stated she had not realized the employee had not cleaned the thermometer or that there were not any sanitation wipes to clean the thermometer but that the thermometer should be cleaned after each use. The Administrator was interviewed on 6-16-20 at 12:00pm. The Administrator stated there were supposed to be alcohol wipes by the oral thermometer so the thermometer could be cleaned after each use. She further stated staff were responsible to let management know if there were no alcohol wipes available. The Administrator said she and the Director of Nursing would correct the issue and perform more frequent monitoring of the screening tables. The facility Medical Director was interviewed on 6-17-20 at 12:30pm. The Medical Director stated he believed if staff sanitized their hands before using the oral thermometer and after using the thermometer, that would be enough to stop any potential spread of the [MEDICAL CONDITION]. He also said he realized that practice was not happening and needed to be implemented if the oral thermometer was not being cleaned between each use.

Based on record review and staff interviews, the facility failed to develop a baseline care plan within 48 hours of admission with measurable objectives and timetables to address the immediate needs of Pain Management and Urinary Catheter Care for 1 of 2 residents (Resident #253). Findings included: Resident #253 was admitted to the facility on [DATE]. The resident's cumulative [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment was in progress and had not been completed. Review of Resident #253's baseline care plan dated 3/18/19 revealed a care plan had been developed for Activities of Daily Living, Dehydration/Fluid Maintenance, Falls and Return to Community Referral. 1. Pain Management: A review of the physician orders [REDACTED]. a. [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 10-325 mg (milligrams) 1 tablet every 4 hours as needed for pain b. [MEDICATION NAME] 10 mg 1 tablet every 6 hours as need for pain c. [MEDICATION NAME] ([MEDICATION NAME]) 500 mg 1 tablet four times a day for muscle spasm d. [MEDICATION NAME] 72-hour one patch [MEDICATION NAME] (to skin) once every 3 days for pain e. [MEDICATION NAME] 300 mg 1 capsule at bedtime for pain f. [MEDICATION NAME] sodium 2 grams: place onto skin four times a day as needed for pain A review of the baseline care plan dated 3/18/19 revealed no mention of Pain Management. 2. Urinary Catheter Care: A review of the physician orders [REDACTED]. a. Catheter care every shift b. Catheter to remain in place until Urology follow-up c. Record urinary catheter care output every shift A review of the baseline care plan dated 3/18/19 revealed no mention of Urinary Catheter care. During an interview with the MDS Coordinator on 3/27/19 at 11:16 AM, she stated that she completed the baseline care plan after a care plan meeting with Resident #253, Resident #253's family member, social worker and rehab director. The MDS Coordinator also indicated that the baseline care plan was expected to include activities of daily living, dehydration/fluid maintenance, falls and discharge home goals. The MDS Coordinator further stated that pain management and urinary catheter care did not need to be included in the baseline care plan. She stated it will be included in the Comprehensive Care Plan after the admission MDS is completed. An interview was conducted with the Director of Nursing on 3/27/19 at 2:12 PM. During the interview, she stated that she did not expect the baseline care plan to include pain management and urinary catheter care. The DON further stated that pain management was already covered on the Medication Administration Record. The DON also stated that urinary catheter care was a basic nursing skill that was expected of every nursing assistant. She further indicated the baseline care plan was enough as written. During an interview with the Administrator on 3/27/19 at 3:09 PM, he stated that he did not have the proper credentials to decide whether the baseline care plan should include pain management and urinary catheter care for Resident #253. After the administrator reviewed the regulation related to baseline care plan, he indicated he still did not have the credentials to say if either problem should or shouldn't be included on the baseline care plan, but that he did expect the baseline care plans to be completed according to the regulations.

Based on observation, interview and record review the facility failed to clean scissors used for treatment dressing and was applied to a stage 3 pressure ulcer for 1 of 1 (Resident #41) observed in pressure ulcer treatment. Findings included: Resident #41 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the treatment records indicated a treatment for [REDACTED]. The treatment order stated the right hip be cleaned with normal saline or wound cleanser. Then apply skin prep to around the wound and pack with calcium alginate dressing. Cover the wound with foam dressing and change the treatment three times a week. An observation for the dressing change was conducted on 3/26/19 at 3:09 PM. Nurse #1 got in the room of Resident #41 with all her treatment needs and placed it in a clean bedside table. She cleaned her hands with alcohol-based hand rub and donned a clean glove. Nurse #1 removed the old dressing and proceeded to clean the stage 3 wound with wound cleanser. After cleaning the wound, she applied the skin prep around the wound. She then picked up a whole pack of calcium alginate dressing and started looking for her scissors. She reached in with her gloved right hand to her right scrub pocket. It was observed that the nurse also picked up several pens and markers together with the scissors from her pocket. After she isolated the scissors, she used the scissors without cleaning to cut a small piece of the calcium alginate dressing and directly applied it to the stage 3 pressure sore. Nurse #1 then covered the wound with foam dressing. She was also observed putting the scissors back in her scrub pocket without cleaning. An interview with Nurse #1 at 3/26/19 at 3:15 PM right after the dressing change was conducted. Nurse #1 stated that she did not clean the scissors before using to cut the dressing. Nurse #1 also stated she forgot to clean it after the treatment and before placing it back to her scrub pocket. She further stated that her scissors were clean and that she cleans it every couple of days. An interview with the Director of Nursing (DON) was conducted on 3/27/19 at 3:35 PM. The DON stated that she expected the nurse to clean the scissors before using it to cut the treatment dressing.

Based on record review, observations, and staff interviews, the facility failed to provide dignity with dining by making one of three dependent residents wait to receive assistance with a meal while residents seat at the same table were provided assistance to eat and finish their meals. (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with the current [DIAGNOSES REDACTED]. Resident #1's Minimum (MDS) data set [DATE] revealed that the resident was rarely or never understood. The resident had short term and long-term memory problems. The resident required extensive assistance with eating with 1-person assistance. The resident had limited range of motion in her upper and lower extremities on both sides. Review of Resident #1's care plan revealed a care plan for nutrition dated 5/10/18. A meal was observed on 6/19/18 at 12:01 PM in the dining room Resident #1 eats her meals. Resident #1 was observed sitting at a table with Resident #2 and Resident #3 at 12:01 PM. Staff were observed to begin passing out resident meal trays in this dining room at 12:07 PM. All trays were delivered by 12:17 PM to the 13 residents eating in this dining room. Nursing Assistant (NA) #1 was observed feeding Resident #2 and Resident #3 at the table where Resident #1's was seated table. Resident #1's covered meal tray was observed to be on the dining room table positioned in close proximity to Resident #1. Resident #1 was observed not being fed as the 2 other residents (Resident #2 and Resident #3) were being fed at her table by NA #1. Resident #1 verbalizing noises and sounds and had her eyes open as she sat at the table. Resident #1 tray remained covered and untouched as of 12:28 PM as the resident was unable to feed herself. NA #1 was observed to continue to feed Resident #2 and Resident #3. Resident #1's food was never offered to her as of 12:34 PM and the tray remained untouched. At 12:35 PM, Resident #2 and Resident #3 were finished with their meal. At 12:40 PM, NA #1 sat beside Resident #1 and began to feed her after Resident #2 and Resident #3 were finished with their meals. NA #1 finished feeding Resident #1 at 12:55 PM and she ate 80 percent of her meal. The NA #2 was interviewed on 6/19/18 at 1:55 PM. She stated that Resident #1 did not answer questions or talk to the staff. Resident #1 would holler out or keeps to herself. She stated that Resident #1 usually ate 30 to 40% but today ate a lot for lunch, which was unusual. She added that Resident #1 required total dependence for all care needs and had to be fed. She stated that usually another NA helped serve meals in this dining room, but today there were only two NAs available. NA #2 further stated on a good day there would be 2 NAs and a nurse to fed residents in this dining room, but lately staffing has gotten worse. NA #2 stated there have been times when she had to feed all the residents in this dining room on her own and many times there have been only two NAs to feed residents in this dining room. She stated there is not enough NAs and it has been an issue since (MONTH) (YEAR). NA #2 stated there are supposed to be two NAs scheduled on the memory care unit, but today only herself and another NA who is floating between two hallways are working on this hall. NA #2 further explained that she does the best she can, but many times she is the only NA working on this hallway. Nursing Assistant #1 was interviewed on 6/19/18 at 2:23 PM. She stated that today was the first day she has worked in the facility. She stated that she was the floating NA for 2 halls. She stated that she was told to feed the residents on the memory care unit. She stated she knew that residents who were seated at the same dining room table should all be fed at the same time. She stated that she could not fed resident #1 because she was feeding the 2 other residents seated at the table. She stated that after she fed the 2 residents at the table, she fed Resident #1 because Resident #1 had not eaten yet. Nurse #1 was interviewed on 6/19/18 at 2:37 PM. She stated that most of the time, the residents seated at the same dining room table are not all fed at the same time. She stated she feels like there needs to be more nurses and NAs on this hallway (memory care unit) to assist residents. She explained there are times it is just her and an NA feeding residents in the memory care dining room so not all residents can be fed at the same time. She stated staffing has gotten worse in the last month and she is hoping more staff do not quit. The Administrator was 6/20/18 at 3:00 PM. He stated that he hopes that if Resident #1 waited to be fed that they at least heated up the resident's food.

Based on observations, interviews, and record review, the facility failed to provide a safe transfer for 1 of 3 residents (Resident #8) reviewed for fall that resulted in Resident #8 sustaining a left knee fracture. Findings included: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Prior to admission to this facility, Resident #8 was being transferred with a mechanical lift. Her body was very rigid. The Minimum Data Set (MDS) documentation dated 01/09/17, revealed Resident #8 had short-term and long-term memory loss and was moderately impaired with cognitive skills for daily decision making. Resident #8 required extensive assistance with bed mobility, dressing and personal hygiene while being total dependent with transfers and eating. Resident #8 required a 2 person assist with bed mobility and transfers. Resident #8 was totally dependent on staff for bathing. Review of Care Plan dated 05/30/16 stated that Resident #8 was at risk for falling. The resident had poor safety awareness due to [DIAGNOSES REDACTED]. It was further complicated by amputation of all toes to right foot and poor sitting balance. Review of Care Plan dated 05/30/16 stated that Resident #8 was also at risk for functional decline and began receiving restorative nursing care to include assisted active range of motion to both arms and hands 6 days per week. Resident #8 to maintain range of motion in both arms within functional limits and to maintain the ability to turn and position self in bed with minimal assistance. Review of Care Plan dated 08/22/16 stated that Resident #8 was at risk for decrease muscle strength and balance to promote independence. Resident #8 received assisted active range of motion exercises to both arms 6 days per week. Review of Care Plan dated 10/23/16 stated that Resident #8 was at risk for decrease range of motion to both arms 6 days per week. Resident #8 received assisted active range of motion exercises to both arms 6 days per week. Interview with the Administrator on 03/02/2017 at 9:37 AM, Administrator and staff members collaborated in reassessing resident's need to include policy/procedure for mechanical lift/sling, manufacturer's instructional information and new employee/updated training for current employees. Administrator reports that the staff was correct in their actions and the equipment was used properly but that the sling was not the appropriate sling for increased decline in condition for Resident #8. Administrator states that Resident #8 had a bed bath on 1/27/17 and was wearing a cotton gown. Interview with the Administrator on 03/02/17 12:07 PM revealed Resident #8 was admitted to facility with lift status meaning that a mechanical lift was being used for this resident for transfers prior to entering this facility. The Administrator further stated the facility only used one kind of sling for all of their residents who use mechanical lifts. CNA note by CNA #5 on 01/27/2017 02:28 PM Resident #8 had assisted active range of motion for 15 minutes to both arms. She was very tight today and did not want to exercise. CNA #5 was able to get resident to loosen up with time. Splint was applied to hand from 6:20 am to 12:20 pm. No complaints with therapy today. Fall Scene Investigation Report dated 01/27/17 at 3:45pm, Resident #8 slipped out of the sling while being transferred via the mechanical lift with a 2 person assist; after a bath, in her room, hit her head on the nightstand and fell on to the floor. Nurse #1 and Physician assessed Resident #8 after the fall, Emergency Medical Services (EMS) transported Resident #8 to the emergency room at hospital for evaluation. A written statement reports on 01/28/17 that a Certified Nursing Assistant (CNA) #1 and CNA #2 were getting Resident #8 up to get ready for supper. The lift pad was under Resident #8 with the leg straps crisscrossed so it would cradle the right way. The lift pad was hooked on the black straps (smallest they could go). CNA #1 lifted Resident #8 up and all seemed fine until we moved her out from over the bed, then Resident #8 suddenly slipped out of the lift pad and to the floor. When Resident #8 fell , her legs went under her and she hit her head on the door on the nightstand. CNA #1 cradled her head while CNA #2 went to get help. Additional written statement reports on 01/28/17 that CNA #2 and CNA #1 had completed a bed bath for Resident #8. The lift pad was positioned under Resident #8 and CNA #2 and CNA #1 made sure to crisscross the legs of it before Resident #8 was transferred to her chair. Resident #8 was being lifted and as CNA #2 and CNA #1 turned Resident #8 towards her chair, then she suddenly she slipped out of the lift pad. Resident #8 slid out so fast that she hit her head pretty hard on the door of her nightstand and ended up on the floor with one of her legs tucked under her. A telephone interview with CNA #1 on 03/02/2017 2:40 PM CNA #1 stated she was with CNA #2 and just completed bed bath for Resident #8. They used the mechanical lift as directed. Resident #8; legs were crossed and sling was crossed underneath both legs. Resident #8 slipped out of the sling onto floor so fast. CNA #1 secured neck until Emergency Medical Service (EMS) arrived. Telephone interview with CNA #2 on 03/02/2017 2:17:15 PM CNA #2 stated they just completed a bed bath for Resident #8 and she was being transferred from her bed to her chair. The pad/sling was positioned under her correctly and CNA #1 and CNA #2 made sure her legs were crossed. CNA #1 was at the head and CNA #2 was at the feet. When Resident #8 was turned, CNA #1 positioned her hand near head of Resident #8 for support and resident slipped out. An interview with Nurse #1 on 03/02/2017 2:49 PM, Nurse #1 was the Supervisor that evening. CNA #1 and CNA #2 reported that Resident #8 had slipped through the sling on was on the floor. Resident #8 hit the back of her head; swelling was present and there was no active bleeding. Both legs were flexed up under resident and abrasion was noted to left shin. No prior incidents noted with this specific lift/sling or staff with this resident. Review of the Nursing note/Nurse #1 on 01/28/2017 at 01:08 AM (Recorded as Late Entry on 01/28/2017 01:15 AM) for 1/27/2017 3-11 shift. At approximately 3:30 pm, resident slipped out of the sling while being transferred via mechanical lift by from her bed to her chair by 2 CNAs. Physician was in the facility, assessed the resident and gave order to send resident to the emergency room for evaluation. Emergency Medical Services (EMS) contacted and family also notified. Resident left the facility around 4:45pm being transported to hospital. At approximately 8:30pm, hospital notified this writer that Resident #8 would be returning to the facility. Chest, pelvis and left leg x-ray as well as CT scan of head and neck were unremarkable. Awaiting resident's return to this facility. The Physician note on 01/27/17 at 4:07 pm, Physician assessed Resident #8 immediately after the incident. He reported that Resident #8 hit her back of her head and sustained abrasion. Resident #8 was lying on the floor, on her back with her left knee flexed with the thigh internally rotated. Resident #8 stated she hurts all over and complained of pain in many places with palpation but was greater with when externally rotating left thigh. The Physician ordered to send the resident to hospital for evaluation due to multiple trauma, pain over left hip and abrasion to back of head. emergency room notes dated 01/27/17, Resident #8 had a history of [REDACTED]. Resident #8 complaining of soreness to anterior chest. Observations included: vomiting, swollen areas to scalp, left knee and over left clavicle, superficial abrasion to right lower leg and hematoma (bruise) on posterior scalp. Multiple tests conducted to include: Chest x-ray, Pelvis x-ray, CT head without contrast and CT cervical spine without contrast. Test results were within normal limits. Left knee x-ray also completed and showed no acute abnormality. Left knee replacement is in place. No hardware complication is identified. Bones loss present. The fracture wasn't seen on the this x-ray. The Nurse's note by Nurse #2 on 01/28/2017 at 02:02 AM indicated patient arrived from the emergency room visit at 12 midnight. No acute distress. Left knee noted with swelling. Tylenol given (as needed per order). Abrasion to left lower leg noted. Dressing changed. Patient denies any discomfort. No other skin abnormalities noted. Family requested their mother be fed all meals in bed for the next few days. A note provided to surveyors on 01/28/17, Mechanical lift inspected on 01/28/17 per Plant Operation Manager (POM) after incident on 01/27/17. Lift sling/pad and mechanical lift to function as designed. The Nursing note by Nurse #3 dated 01/28/2017 at 11:05 AM revealed that Resident #8 stay in bed per family's request for next couple of days due to fall. Patient reported no pain upon assessment. Tylenol was given on midnight shift and was effective. Left knee was noted to be swollen. Family members were in room visiting with patient and husband. The call light was in reach and the bed was in low position. CNA note by Restorative Aide on 01/28/2017 02:52 PM Resident #8 had assisted active range of motion for 15 minutes to both legs. Slow stretching done due to soreness from fall. Splints on at 7:30 am and removed at 1:30 pm. Tolerated therapy well today even though body was sore while touched. Nursing note by Nurse #3 on 01/28/2017 at 3:02 PM Resident #8 with skin tear to left lower leg. Area cleansed and dressing applied. Post fall bruising noted to left lower leg measuring 3.0 x 2.0 cm. Bruising noted to right lower leg (below knee) measuring 8.0 x 4.0 cm and right mid shin measuring 2.7 x 2.0 cm. Nursing note by Nurse #2 on 01/28/2017 at 10:22 PM revealed family requested Resident #8 be evaluated for pain and stronger pain relief medication. Resident was red in the face, vital signs as follows: 130/78-110-20-97.1; Tylenol 500mg was administered for pain. Norco 5/325mg 1/2 tablet by mouth was ordered every 6 hours as needed for severe pain per Physician. The order was faxed to the pharmacy. Nursing note by Nurse #2 on 01/28/2017 at 2:37 AM Post fall, no injuries noted. No indication of pain or discomfort. No facial flushing, moans or grimacing. Resident #8 rested comfortably with eyes closed since the start of this shift. Nursing note by Nurse #3 on 01/29/2017 at 11:22 AM Patient was lying in bed and moaning noted during CNA changing the resident. Physician was contacted and an order was received to start Oxycodone 5-325 mg 1/2 tablet by mouth every 6 hours as needed for pain. The medication was administered to patient and was effective. Patient was noted to be resting comfortably in bed with no signs of discomfort. Nursing note by Nurse #2 on 01/30/2017 at 01:31 AM Post fall, no injury noted. No indication of pain or discomfort. Swelling of the left knee is improving. Resident #8 has voiced being very sore since the fall but currently denies being in pain. A CNA note by CNA #3 on 01/30/2017 03:03 PM indicated left knee was swollen and Norco was given at 1:30pm; as needed order. Physician note dated 01/30/2017 05:43 PM revealed assessment of Resident #8 after fall on 01/27/17. Resident #8 was evaluated at the hospital and no significant injury was found. This, despite the fact that she has no sensation in her legs (it is noteworthy that her multiple toe amputations were accomplished without anesthesia). Her pain complaints are not explainable, but she seems to benefit from having a low dose of analgesia. Since returning to the facility, Resident #8 has complained of knee pain which sustained much of the trauma of the fall. Family were present for this evaluation. Bilateral legs appear symmetrical though there is a large bruise on the inner aspect of her right lower leg. No joint tenderness is found. It seems to induce pain when either knee is flexed - even a small amount. Hydrocodone dose changed to routine administration. CNA note by CNA #5 on 01/31/2017 03:10 PM Resident #8 had assisted active range of motion for 15 minutes to both arms and performed well. Splints on at 7:00 am and removed at 1:30 pm. Nursing note by Nurse #8 on 02/01/2017 at 03:37 AM Rested well all night. Routine Norco given earlier and will repeat later. CNA note by CNA #5 on 02/01/2017 02:32 PM Resident #8 had assisted active range of motion for 15 minutes to both arms and was able to do all exercises. Splints on at 6:45 am and removed at 2:15 pm. No complaints with therapy today. Nursing note by Nurse #4 on 02/01/2017 at 10:34 PM no complaints of pain this shift, ate in dining room and took medications without difficulty. CNA note by CNA #5 on 02/02/2017 02:42 PM Resident #8 had assisted active range of motion for 15 minutes to both arms. Splints on at 7:00 am and removed at 1:00 pm. No complaints with therapy today. CNA note by Restorative Aide on 02/03/2017 02:14 PM Resident #8 had assisted active range of motion for 15 minutes to both legs. Resistant at first but was more relaxed with time. Splints on at 8:00 am and removed at 2:00 pm. Nursing note/Nurse #4 on 02/03/2017 09:55 PM Nurse #4 changed dressings to chin and leg per family's request. No notes documented on 02/04/17 and none 0n 02/05/17 until 1:53 PM. Nursing note/Nurse #5 on 02/05/2017 01:53 PM indicated the left knee remains swollen. Resident #8 to be reassessed by Physician. Nursing note/Nurse #6 (Diagnostic Test Result): 02/06/2017 09:53 PM Increased swelling and pain to left knee noted. An X-ray was ordered, completed and results received via fax from mobile imaging company. The result came back positive for fracture to left knee. Physician was notified and Resident #8 was referred to orthopedist. Family notified the facility staff to make appointment immediately. A phone interview with Physician on 03/02/2017 at 2:28 PM revealed that he was in the facility when Resident #8 was found on the floor. The Physician further stated that by his professional opinion the knee fracture was related to the fall. Facility Plan of Correction: The facility provided the following corrections that had been completed on 02/02/17. Interview with Restorative Aide and Director of Nursing (DON) on 03/01/17 at 11:21 AM, the Restorative Aide and DON stated they have assessed the needs for Resident #8. The types of slings: full body sling (which is the newly ordered sling) and the sling (which is the type Resident #8 was previously using and the most commonly used in the facility) were discussed. The Care Plan was modified on 02/01/17. The care plan was updated to state that Resident #8 was to be transferred to and from bed using only the sling via the mechanical lift with 2 people assisting while being supervised by a nurse or restorative CNA. The MDS #2 notes on 01/30/17 indicated they have in-service, meetings and reenactment of fall was conducted. The sling was properly applied and lift was properly used by staff. The sling failed to guide the resident in a cradle position due to stiffness of her body. Another type of sling was required and new hip sling provided for resident safety and comfort. On 01/30/17 new hip slings were ordered, as soon as the company opened for the day, for Resident #8 and 5 other residents. 01/27/17 Initial interventions to prevent future falls included assuring proper placement of proper/correct size sling and in-servicing the staff on 3-11pm shift. The facility conducted multiple meetings to address proper technique, lift safety, updated the policy, re-educated staff, reviewed the root cause and ordered 5 hip slings for lifts to prevent reoccurrence. 01/27/17 List of topics addressed by facility post fall: Equipment check for proper functioning, sling check for safe usability, staff demonstration of events leading up to event, statements gathered from all staff involved, event form per protocol, audit of all residents for hip flexion. 100% of staff in-service of use of mechanical lift (initiated 01/27/17 and completed on 01/30/17). 01/31/17 Staff in-service for new hip slings initiated on 01/31/17 and completed on 02/02/17 prior to any use of new hip sling. An observation was done for CNA#5, CNA#6 and Nurse #7on 03/01/2017 at 10:07 AM. CNA#5, CNA#6 and Nurse #7 transferred Resident #8 from recliner type wheelchair to bed without incident using the mechanical lift and new style (full body) sling. Staff explained the process to Resident #8 and encouraged Resident #8 throughout transfer. Resident #8's husband was present in room during transfer; as he is her roommate. On 03/01/17 at 1:56 PM the Restorative Aide stated that CNA #1, CNA #2 and other staff members were re-trained with new mechanical lift, pads/slings, oxygen tanks and shower stretcher. Dates of in-services were on 01/31/17, 02/01/17 and 02/02/17. An interview conducted with the Quality Assurance staff of the facility on 03/02/17 at 1 PM revealed the mechanical lift and sling were included in their quarterly meeting to monitor and prevent reoccurrence of the incident. On 03/02/17 at 12:00 PM, the Plan of Correction was validated. The survey team confirmed the mechanical lifts were working properly and that other residents who were identified as a fall risk were being assessed; the facility implemented auditing tools to validate to review residents who uses mechanical lift; staff was re-educated on the policy and procedure for transfer and care plans were instituted; a system was in place for evaluating residents who uses mechanical lift.