Every finding on record at Croasdaile Village

Based on observations, record reviews, and interviews with staff, the facility failed to provide a safe transfer for Resident #2 when Nurse Aide (NA) #1 transferred Resident #2 from her wheelchair to the bed without using a mechanical lift causing Resident #2 to sustain a laceration to her lower left leg. The resident was prescribed a blood thinner twice a day which increases the risk of bruising and bleeding. Resident #2 was transferred to the hospital for evaluation and treatment where it was noted the laceration was 25 centimeters (9.8 inches) in length and had a depth of 20 millimeters (0.7 inches) with extensive bleeding. The laceration was closed with 11 sutures and a dressing was applied. The deficient practice occurred for 1 of 2 residents reviewed for supervision to prevent accidents (Resident #2).Findings included:Resident #2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia and atrial fibrillation.The physician order dated 2/23/2025 revealed Resident # 2 was prescribed Eliquis 2.5 milligrams (mg) twice daily for atrial fibrillation.Review of the Medication Administration Record (MAR) for December 2025 and January 2026 revealed Resident #2 received Eliquis 2.5mg twice daily through the morning dose on 1/8/2026. Further review of the January 2026 MAR revealed Eliquis was held from the evening dose on 1/8/2026 through 1/11/2026.A physician order dated 10/11/2025 specified Resident #2 required mechanical lift for transfers. Review of the active care plan implemented on 3/18/2025 revealed that Resident #2 required a mechanical lift for transfers. The interventions included for Resident #2 to be transferred by mechanical lift using a small size sling. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was severely cognitively impaired and dependent on all movements including being dependent on staff for transfers. The MDS revealed Resident #2 did not have any functional limitation in range of motion.The facility's initial allegation report dated 1/8/2026 revealed Resident #2 received a skin laceration to her left leg while being transferred from the wheelchair to the bed by NA #1.A physician order dated 1/12/2026 revealed Resident #2's Eliquis 2.5mg twice daily for atrial fibrillation was resumed.The facility's investigation report dated 1/14/2026 revealed while NA #1 was transferring Resident #2 from the wheelchair to the bed Resident #2's left leg went behind a protruding part of the wheelchair where the footrest was attached. The facility investigation report stated it was a blunt protrusion on the wheelchair which caused a laceration. Resident #2 was transferred to the hospital and received sutures. Resident #2's wheelchair was padded on the protruding part. The facility later replaced Resident's wheelchair with a medical recliner. The facility unsubstantiated the neglect allegation.NA #1 was contacted via phone. A voicemail was left on 4/7/2026 at 1:26PM and 4/8/2026 at 8:57AM as well as a text message on 4/7/2026 1:45PM. NA #1 was not interviewed during the investigation due to no response.Review of NA #1's undated witness statement revealed she confirmed she was assigned to Resident #2 on 1/7/2026 and had previously cared for the resident and was familiar with her needs. NA #1 reported as she was preparing to transfer Resident #2 into bed there was no sling under her, so she assumed Resident #2 was a stand pivot transfer. NA #1 indicated she was able to transfer Resident #2 to bed without difficulty and the resident participated. There were no signs or symptoms of pain during or after the transfer. NA #1 stated while she was placing Resident #2's legs in the bed she saw blood dripping from her, and she immediately stopped and got the nurse because she did not know where the blood was coming from. It was further documented NA #1 stated she was aware of the care guide and received orientation when she started working at the facility through the agency.Nurse #1 was interviewed via telephone on 4/7/2026 3:04PM. She stated that she was familiar with Resident #2 and knew Resident #2 was a mechanical lift transfer as Resident #2 had been the entire time of Nurse #1's employment, which had been about 2 years. Nurse #1 confirmed she was working 1/7/2026 at the time of the incident and was assigned to Resident #2. Nurse #1 stated NA #1 transferred Resident #2 without the mechanical lift when the laceration occurred. Nurse #1 stated that NA #1 ran from the room and retrieved her for help. Nurse #1 said when she entered the room, she saw a lot of blood coming from Resident #2's left lower leg and noticed the skin was split. She said she had to apply a lot of pressure on the wound to get the bleeding under control. Nurse #1 stated she could tell Resident #2 was in pain because Resident #2 was grimacing. Nurse #1 discussed not being familiar with NA #1, as NA #1 was an agency employee. Nurse #1 thought the laceration was an accident and NA #1 did not mean to hurt Resident #2.Review of the hospital Discharge summary dated [DATE] at 9:22AM for encounter dated 1/7/2026 revealed Resident #2 presented with a quite extensive left lower leg laceration. Document revealed uncontrolled bleeding upon arrival to emergency department. Laceration wrapped from posterior ankle up to below the left knee. The laceration had a length of 25 centimeters and depth of 20 millimeters. Wound was closed with 11 sutures and dressing was applied.Interview with Nurse #3, the wound care nurse, on 4/7/2026 at 1:52PM revealed she performed wound care with the wound physician for Resident #2 beginning on 1/9/2026.Record review showed Resident #2's wound was resolved on 1/29/2026 per the wound care physician's documentation. Interview with the Administrator on 4/8/2026 at 11:15AM revealed the facility believed the incident with Resident #2 was an accident and was unsure why NA #1 did not use the mechanical lift. She discussed education was completed with NA #1 related to following resident care plans and transfers.The facility provided a corrective action plan for past noncompliance which was reviewed and not acceptable.

Based on record reviews and staff interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within the required time frame for 1 of 7 residents (Resident #45) reviewed for resident assessments. Findings included:Record review revealed Resident 45's admission MDS assessment was dated 4/2/25. There was no quarterly MDS assessment within 92 days available for review. On 8/14/25 at 2:10 PM, during an interview, the MDS Coordinator indicated that Resident #45 was discharged and readmitted three times in two months. After the 4/2/25 admission MDS assessment, the quarterly MDS assessment should have been set up within 92 days, on 7/3/25, but it was missing. On 8/14/25 at 2:30 PM, during an interview, the Administrator indicated MDS assessments should be completed and transmitted timely.

Based on record reviews and staff interviews, the facility failed to transmit quarterly Minimum Data Set (MDS) assessments within the required time frame for 2 of 7 residents (Resident #53, Resident #68) reviewed for resident assessments. Findings included: 1. Resident #53 was admitted on [DATE]. Review of Resident 53's quarterly MDS assessment, dated 6/26/25, revealed the MDS assessment was signed as completed by the MDS Coordinator on 7/1/25 and indicated as ready to export. The MDS assessment was transmitted to the national database on 8/12/25.On 8/14/25 at 1:55 PM, during an interview, the MDS Coordinator indicated the 6/26/25 assessment was completed and signed on 7/1/25 and should have been transmitted within 14 days of completion. MDS Coordinator further stated that the facility was transitioning from old to new electronic medical records program, and the transmission process was not triggered. He found that it was missing and transmitted the MDS on 8/12/25. The MDS Coordinator continued that all completed MDS assessments were transmitted every other week. On 8/14/25 at 2:30 PM, during an interview, the Administrator indicated MDS assessments should be completed and transmitted timely. 2. Resident #68 was admitted on [DATE].Review of Resident 68's quarterly MDS assessment, dated 7/7/25, revealed it was signed as completed by the MDS Coordinator on 7/2/25 and indicated as ready to export, but was not transmitted to the national database. On 8/14/25 at 2:00 PM, during an interview, the MDS Coordinator indicated that the Assessment Reference Date (ARD) for the quarterly MDS assessment was 7/7/25. Due to transition process from old to new electronic medical records program in the facility, the 7/7/25 quarterly MDS assessment was signed late, on 7/12/25, and the transmission process was not triggered. The MDS Coordinator continued that all completed MDS assessments were transmitted every other week.On 8/14/25 at 2:30 PM, during an interview, the Administrator indicated MDS assessments should be completed and transmitted timely.

Based on record reviews and staff interviews, the facility failed to transmit Quarterly Minimum Data Set (MDS) assessments within the required time frame for 2 of 3 residents (Resident #16, Resident #67) selected to be reviewed for Resident Assessments. Findings included: 1. Resident #16 was admitted on [DATE]. Review of Resident 16's most recent MDS assessment revealed an Assessment Reference Date (ARD) of 5/8/24 and was coded as a quarterly assessment. The MDS was signed as completed by the MDS Coordinator on 5/9/24 and indicated as ready to export. The MDS assessment was transmitted to the national database on 7/10/24. On 7/11/24 at 1:55 PM, during an interview, the MDS coordinator indicated the assessment was completed and signed on 5/9/24. The MDS coordinator stated the assessment should have been transmitted within 14 days of completion. The submit by date was 5/23/24. MDS coordinator further stated that the nurse, who signed the completed MDS assessment, did not trigger the transmission process. He found that it was missing and transmitted the MDS on 7/10/24. The MDS coordinator mentioned that all completed MDS assessments were transmitted every other week. On 7/11/24 at 2:35 PM, during an interview, the Administrator expected that all MDS assessments should be completed and transmitted on time. 2. Resident #67 was admitted on [DATE]. Review of Resident 67's most recent MDS assessment revealed an Assessment Reference Date (ARD) of 5/5/24 and was coded as a quarterly assessment. The MDS was signed as completed by the MDS Coordinator on 5/6/24 and indicated as ready to export. The MDS assessment was transmitted to the national database on 7/10/24. On 7/11/24 at 1:55 PM, during an interview, the MDS coordinator indicated the assessment was completed and signed on 5/6/24. The MDS coordinator stated the assessment should have been transmitted within 14 days of completion. The submit by date was 5/20/24. MDS coordinator further stated that the nurse, who signed the completed MDS assessment, did not trigger the transmission process. He found that it was missing and transmitted the MDS on 7/10/24. The MDS coordinator mentioned that all completed MDS assessments were transmitted every other week. On 7/11/24 at 2:35 PM, during an interview, the Administrator expected that all MDS assessments should be completed and transmitted on time.

Based on observations, staff interviews, and record review, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 28 opportunities, resulting in a medication error rate of 10.7% for 1 of 3 residents (Resident #20) observed during medication pass. The findings included: 1. Resident #20 was admitted to the facility on [DATE]. Her cumulative diagnoses included Parkinson's disease and atherosclerotic heart disease (a build-up of plaque in the arteries). On 2/21/23 at 9:11 AM, Nurse #1 (an agency nurse) was observed as she prepared and administered 10 oral medications for administration to Resident #20. The medications included two - 25 milligram (mg) / 100 mg tablets of carbidopa/levodopa (an immediate release formulation of a medication indicated to treat Parkinson's disease). No carbidopa/levodopa Extended Release (ER) tablets were observed to have been pulled from the medication cart for administration to the resident. A review of Resident #20's current physician's orders revealed her medications included the following, in part: one - 25 mg carbidopa / 100 mg levodopa tablet (immediate release formulation or IR) to be given by mouth four times a day for Parkinson's disease; and two - 25 mg carbidopa / 100 mg levodopa Extended Release (ER) tablets to be given 5 times a day for Parkinson's disease. An interview was conducted with Nurse #2 (a staff nurse) on 2/21/23 at 10:01 AM. During the interview, inquiry was made with regards to the discrepancy observed between the physician's orders for carbidopa/levodopa and the medications administered to Resident #20. Nurse #2 reviewed the resident's electronic medical record (EMR) and reported Resident #20 should have received both the IR and ER formulations of carbidopa/levodopa, including one - 25 mg carbidopa / 100 mg levodopa IR tablet and two - 25 mg carbidopa / 100 mg levodopa ER tablets. On 2/21/23 at 10:03 AM, Nurse #2 was accompanied as she approached the hall medication (med) cart where Nurse #1 was working. As an observation of the medication cards on the hall med cart was initiated, Nurse #1 stated, I didn't see an extended release [carbidopa/levodopa formulation] in here [referring to the med cart]. The observation conducted at that time revealed both the IR and ER formulations of carbidopa/levodopa were stored on the med cart. When the medication orders for Resident #20 were discussed, Nurse #1 reported she gave Resident #20 two carbidopa/levodopa ER tablets but missed giving the IR formulation of the medication to the resident. Upon sharing the observation made during the resident's medication pass, Nurse #1 again stated she was certain she gave two ER tablets of the carbidopa/levodopa but none of the immediate release tablets to Resident #20. An interview was conducted with the facility's Interim Director of Nursing (DON) on 2/22/23 at 2:45 AM. During the interview, the concern(s) involving med administration observations for Resident #20 were discussed. The Interim DON stated she would expect nursing staff administering medications to observe the administration rights (referring to the right patient, the right drug, the right dose, the right route, and the right time). 2. Resident #20 was admitted to the facility on [DATE]. Her cumulative diagnoses included Parkinson's disease and atherosclerotic heart disease (a build-up of plaque in the arteries). On 2/21/23 at 9:11 AM, Nurse #1 (an agency nurse) was observed as she prepared 10 oral medications for administration to Resident #20. The medications included one - 10 milliequivalent (mEq) Extended Release (ER) tablet of potassium chloride. Nurse #1 was observed as she placed all of the oral tablets into one of 3 small plastic pouches used for crushing medications. On 2/21/23 at 9:29 AM, the nurse was observed as she crushed 4 of the tablets together (including the ER potassium chloride tablet). On 2/21/23 at 9:32 AM, a request was made for the nurse to stop prepping the medications for administration and to review the medication bubble pack card containing the potassium chloride ER tablets. The medication card had an auxiliary sticker placed on it by the dispensing pharmacy which indicated the medication should not be crushed or chewed. Upon review of the medication card, inquiry was made as to who the nurse could go to with questions about medication administration. Nurse #1 left the med cart to get a staff nurse. After she returned to the med cart, Nurse #2 joined her. Nurse #2 confirmed at that time the potassium chloride Extended Release tablet should not be crushed. Nurse #2 instructed Nurse #1 to re-pull the medications and to administer all of Resident #20's oral medications whole, stating the resident did not require her meds to be crushed. Nurse #1 re-pulled the medications as instructed and administered them to Resident #20 on 2/21/23 at 9:41 AM. The resident was observed to take her oral medications whole with water and without difficulty. A review of Resident #20's current physician's orders revealed her medications included 10 mEq potassium chloride ER to be given as one tablet by mouth every day for hypokalemia (low potassium level in the blood). According to Lexi-Comp, a comprehensive electronic medication database, potassium chloride ER tablets should be swallowed whole; tablets should not be crushed, chewed, or sucked on. An interview was conducted with the facility's Interim Director of Nursing (DON) on 2/22/23 at 2:45 AM. During the interview, the concern(s) involving the med administration observations for Resident #20 were discussed. The Interim DON stated the nursing staff should be aware of which medications could and could not be crushed when they administered meds to a resident. 3. Resident #20 was admitted to the facility on [DATE]. Her cumulative diagnoses included Parkinson's disease and atherosclerotic heart disease (a build-up of plaque in the arteries). On 2/21/23 at 9:11 AM, Nurse #1 (an agency nurse) was observed as she prepared 10 oral medications for administration to Resident #20. The medications included one -81 milligram (mg) Delayed Release (DR) tablet of aspirin. Nurse #1 was observed as she placed all of the oral tablets (including the DR aspirin) into one of 3 small plastic pouches used for crushing medications. On 2/21/23 at 9:29 AM, the nurse was observed as she crushed 4 of the tablets together When asked if she was planning to crush all of the tablets placed into the small plastic pouches, she stated she was and reported all medications needed to be crushed for Resident #20. On 2/21/23 at 9:32 AM, a request was made for the nurse to stop prepping the medications for administration and to review the medication bubble pack card containing the 81 mg DR aspirin tablets. The medication card had an auxiliary sticker placed on it by the dispensing pharmacy which indicated the medication should not be crushed or chewed. Upon review of the medication card, inquiry was made as to who the nurse could go to with questions about medication administration. Nurse #1 left the med cart to get a staff nurse. After she returned to the med cart, Nurse #2 joined her. Nurse #2 confirmed at that time the Delayed Release aspirin tablet should not be crushed. Nurse #2 instructed Nurse #1 to re-pull the medications and to administer all of Resident #20's oral medications whole, stating the resident did not require her meds to be crushed. Nurse #1 re-pulled the medications as instructed and administered them to Resident #20 on 2/21/23 at 9:41 AM. The resident was observed to take her oral medications whole with water and without difficulty. A review of Resident #20's current physician's orders revealed her medications included 81 mg aspirin DR to be given as one tablet by mouth every day for coronary artery disease. According to Lexi-Comp, a comprehensive electronic medication database, aspirin DR tablets should be swallowed whole; tablets should not be cut, crushed, or chewed. An interview was conducted with the facility's Interim Director of Nursing (DON) on 2/22/23 at 2:45 AM. During the interview, the concern(s) involving the med administration observations for Resident #20 were discussed. The Interim DON stated the nursing staff should be aware of which medications could and could not be crushed when they administered meds to a resident.

Based on facility staff, Nurse Practitioner (NP) and Medical Doctor (MD) interviews and record reviews, the facility failed to administer an anticoagulant medication to a resident for a period of 10 days during his stay in the facility. This occurred for 1 of 6 residents (Resident #240) whose medications were reviewed. The findings included: Resident #240 was admitted to the hospital from 10/27/21 to 11/17/21. His Hospital Discharge Summary dated 11/17/21 reported the resident was admitted for a diagnoses which included an acute embolic cerebral vascular accident (CVA). An embolic CVA is a stroke caused by a blood clot that formed elsewhere in the body and traveled through the bloodstream to the brain. During his hospital stay, Resident #240 was also diagnosed with new onset atrial fibrillation (a type of irregular heart beat) and started on apixaban (an anticoagulant medication) to help prevent blood clots and strokes due to atrial fibrillation. A notation on the Hospital Discharge Summary read, He should now continue apixaban for embolic CVA. The Hospital Discharge Medication list dated 11/17/21 included, in part, apixaban to be given as one tablet (5 mg [milligram] total) by mouth every 12 hours for 30 days. The resident was admitted to the facility on [DATE]. A review of Resident #240's November 2021 Physician Orders and Medication Administration Records (MAR) revealed a verbal order was received and initiated on 11/17/21 for 5 mg apixaban to be given by mouth every 12 hours for atrial fibrillation/CVA. The apixaban order included an end date of 12/18/21. A review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE] (the date of admission) indicated Resident #240 had moderately impaired cognition and received an anticoagulant medication. A Progress Note dated 11/18/21 and authored by Resident #240's Medical Doctor (MD) at the facility reported his medication list included, in part: 5 mg apixaban twice daily. The resident's history was noted in the Progress Note and read in part, .He should now continue apixaban for embolic CVA. Resident #240's care plan included the following area of focus initiated on 12/12/21: Anticoagulant: I am currently on an anticoagulant and I am at risk for abnormal bleeding. The interventions included, Please provide me my meds as ordered (Start Date 12/12/21). The resident's electronic medical record (EMR) revealed the facility's Nurse Practitioner (NP) saw him on 12/14/21 for follow-up. The progress note reported Resident #240's Medication List included 5 mg apixaban to be given twice daily. A notation made under the topic of Diagnosis and Assessment read, in part: Cerebrovascular accident (CVA) due to bilateral embolism of anterior [towards the front] cerebral arteries continue Eliquis [apixaban] . Resident #240's December 2021 MAR indicated the resident's last dose of apixaban was administered on 12/17/21 at 8:00 PM. Apixaban was discontinued on 12/18/21 in accordance with the stop date of the initial medication order dated 11/17/21. Further review of Resident #240's December 2021 Physician Orders and MAR revealed a verbal order was received on 12/28/21 for 5 mg apixaban to be administered by mouth every 12 hours for history of CVA/atrial fibrillation (with no end date). This MAR indicated apixaban was re-started for Resident #240 on 12/28/21 at 8:00 PM. The MAR also documented no doses of apixaban were administered to Resident #240 from 12/18/21 through 12/27/21 (a period of 10 days). The resident was seen by the NP on 1/3/22 due to his upcoming transfer to an Assisted Living Facility (ALF). The NP's progress note included a notation which read, .continue Eliquis [apixaban] and transfer to ALF . Resident #240 was discharged from the facility on 1/7/22. An interview was conducted on 2/22/23 at 9:40 AM with the facility's NP. During the interview, the discontinuation of Resident #240's apixaban for a period of 10 days during his stay at the facility was discussed. Upon review of the initial order for the apixaban (dated 11/17/21), the NP stated verbal orders were received from an on-call physician for Resident #240's admission medications. The NP reported the hospital MD should not have included an end date in the Discharge Medication List for apixaban. An interview was conducted on 2/23/23 at 9:12 AM with the facility's Interim Director of Nursing (DON) and Administrator. During the interview, the concern regarding a lapse in the medication orders for Resident #240's apixaban was discussed. Information obtained during the NP's interview on 2/22/23 was shared. The NP reported an on-call physician had initially approved the hospital discharge medications at the time of Resident #240's admission. The order for 5 mg apixaban to be given twice a day included times 30 days and was apparently input into the facility's computer system with an end date for the medication as 12/18/21. When asked what their thoughts were, the DON stated the resident would have been seen by the NP or MD within the first 30 days of his stay. The NP or MD would have had an opportunity to review of the resident's medication orders at the time of these visit(s). An interview was conducted on 2/23/23 at 11:41 AM with the resident's MD (who also served as the facility's Medical Director). The MD reported she had been made aware of the concerns expressed about a lapse in Resident #240's apixaban and had an opportunity to review his medical record prior to the interview. The MD reported she was aware the facility had previously encountered some issues with the hospital discharge med orders as a resident was transferred to the facility. She stated the issues were addressed in the past and most of them had been fixed. However, the MD stated, It's up to us as the physicians to catch this. I should have looked at the H&P [History and Physical] and meds to be sure no inappropriate stop date .There's a glitch here and it's fortunate it was caught and not a bad outcome.

Based on observation, staff interview and facility policy and procedure review it was determined that the facility failed to screen 1 of 1 visitor entering the facility during a COVID 19 pandemic. Findings included: Per review of the facility infection Control and Prevention of COVID-19 policy dated March 2020, Facilities should screen or monitor visitors for the following: 1. International travel within the last 14 days to restricted countries 2. Signs or symptoms of a respiratory infection, such as a fever, cough, and sore throat 3. Has had contact with someone with or under investigation for COVID-19. If visitors meet the above criteria, facilities may restrict their entry to the facility. Review of the facility policy revealed that the same screening performed for visitors should be performed for facility staff. This surveyor entered the facility on 8/18/20 at 4:50 PM. The surveyor's temperature was taken by the receptionist. The surveyor was then allowed to enter the facility. Facility staff did not ask the surveyor screening questions nor request that the surveyor complete a form with screening questions. During interview with the receptionist at 4:58 PM on 8/18/2020 she revealed that persons entering the facility are suppose to complete a screening form on a table to the right side of the reception area. When asked if she asks people to complete the form, she responded, Everybody knows, it's standard now but I make sure. Interview with a nursing assistant #1 on 8/20/20 at 4:02 PM revealed that entered the facility through the front door, washed his hands and got a mask before entering his work area. After prompting the staff stated that his temperature was taken at the gate and again upon entry to the facility. Interview with nursing assistant #2 on 8/20/20 at 4:07 PM revealed that his temperature was taken at the gate, his temperature was taken upon entering the facility and that there's a sheet/questionnaire every time you come in.

Based on observation, staff interview and record reviews the facility failed to provide a dignified dining experience for 2 of 5 residents (Resident # 23 and Resident # 9) reviewed for dignity. Findings included: 1. Resident #23 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] marked as a quarterly assessment, revealed resident was assessed as cognitively impaired. The assessment indicated the resident required extensive to total dependence with one-person assistance for activities of daily living (ADL) including eating. Review of the recent updated care plan dated 8/11/19 revealed resident was care planned for nutrition and for ADL's due to dementia and immobility. Goal was to maintain current weight, no decline in functions related to ADL dependence. Interventions included providing ADL care and ensure adequate time for completion. Assistance with meals, offering a prescribed diet and supplement. Monitor intake, change in chewing and swallowing abilities. Resident on pureed diet. During lunch observation on 8/19/19 from 12:05 PM to 1:20 PM, Resident # 23 was observed at around 12:15 PM being wheeled into the dining room in her Geri chair and was seated at a table with other residents who needed feeding assistance. Resident # 23 was seated at the table with other residents who were served and assisted by staff with their lunch meals at around 12:25 PM. From 12:25 PM until around 12:55 PM, Resident #23 remained seated at the dining room table while her four tablemates were assisted by staff with their lunch meals. Observation revealed Resident # 23 was not served lunch until around 12:55 PM by Nurse Aid (NA)# 1. During an interview on 8/19/19 at 1:13 PM, NA # 1 stated she was told she could only feed one resident at a time and she was providing Resident #9 with assistance with her meal, so she was not able to assist Resident# 23. She indicated Resident # 23 and Resident # 9 were tablemates and were not served their lunch meal at the same time. During an interview 8/19/19 at 1:16 PM, Nurse#1 indicated staff could only feed one resident at a time and hence Resident # 23 had to wait to be assisted with feeding until NA# 1 finished assisting Resident #9 with her lunch meal. During an interview on 8/21/19 at 9: 57 AM, the administrator stated the staff should ask for help when needed. Administrator also stated it was her expectation that all residents who needed feeding assistance be fed approximately at the same time in the dining room for a dignified dining experience. 2. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] marked as an annual assessment, revealed resident was assessed as cognitively impaired. Assessment indicated the resident requires extensive with one-person assistance for activities of daily living (ADL) including eating. Review of the care plan dated 8/12/19 revealed resident was care planned for nutrition and for ADL, needing extensive assistance due to dementia. Goal was to maintain current weight, no decline in functions related to ADL dependence. Interventions included the resident can occasionally self-feed and occasionally able to utilize utensils with meals but needed more cueing and assistance. When the utensil in hand, cued needed to put the food in her mouth. Aid with meals as needed. Assist with ADL's as needed to ensure adequate completion and allow adequate time for completion. Resident # 9 was observed on 08/19/19 at 12:10 PM sitting in a chair near the table with other residents who were assisted with feeding in the dining hall. Resident #9 was fed by NA # 1 at the dining table. Review of the dietary meal ticket and meal tray revealed dessert was not served to the residents at the table. Interview with dietitian on 8/19/19 at 12:23 PM revealed desserts were served later to encourage residents to consume their main meal. Continuous observation revealed on 08/19/19 at around 12:50 PM, Nurse Aide (NA) # 1 left the dining table to retrieve a meal tray and began feeding another resident. Resident # 9 was at the dining room table without direct supervision and was served dessert (Chocolate cream Pie) by the dietary staff. Resident # 9 was observed looking at the chocolate cream pie for few minutes and started eating the dessert with her hand. Nurse # 1 who was feeding another resident came over, cleaned Resident # 9 hand and offered her a spoon, and encouraged her to consume the dessert with the spoon. Resident # 9 attempted to feed herself the pie with the spoon but was unable. The resident was observed to spill pie on the table. Staff did not intervene further to stop the resident from spilling and dropping food as she attempted to fed herself. During an interview on 8/19/19 at 1:13 PM, NA#1 indicated Resident # 9 had stopped consuming her meal and she moved to assist another resident with her meal. She stated she did not observe that Resident #9 was served dessert and had not offered it to her before going to provide another resident with meal assistance. During an interview on 8/19/19 at 1:16 PM, Nurse # 1 stated she had observed Resident # 9 eating the dessert with her fingers and offered her the spoon. Nurse # 1 further stated she was unsure if NA had offered the resident her dessert. During an interview on 8/21/19 at 9: 57 AM, administrator indicated the NA # 1 was focused on completing the feeding task for the residents. Administrator stated the staff should complete their feeding task with one resident before assist another resident for a dignified dining experience for the resident. She indicated that all residents who needed feeding assistance be assisted approximately.

Based on record review and staff interviews, the facility failed to accurately code the discharge Minimum Data Set (MDS) assessment to reflect the discharge status for 1 of 20 residents, reviewed for resident assessment (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the 30 day MDS assessment, dated 4/1/19, revealed Resident #1 had a change in therapy. Record review of physician's note, dated 4/10/19, revealed that Resident # 1's may discharge home on 4/11/19. Record review revealed Resident 1's Discharge Summary note, dated 4/11/19, read in part Resident has met the goal of therapy and may transition home with home health therapy for continuity of services. Reviewed with resident and resident son discharged medication, upcoming PCP appointment and post discharge plan to prevent rehospitalization . Resident to receive services from Kindred at home. Resident provided a copy of discharged medication list, discharge medications and copy of safe transition packet. Record review of the nurses' notes, dated 4/12/19, read in part Resident discharged on [DATE], spoke with discharged resident's son who states that resident is doing well, resident has taken medication, 24 hour care giver is present. He reported he has prepared medication for self-administered. Reminded how to contact healthcare navigator if needed. Record Review revealed no discharge MDS assessment. On 8/22/19 at 8:20 AM, during an interview, the MDS coordinator indicted that she was responsible for MDS assessment of Resident # 1. She stated the resident went home with his family on 4/11/19. The nurse stated she had missed, and had not completed the discharge MDS assessment. On 8/22/19 at 8:31 AM, during an interview, the Associate Executive Director stated the resident's MDS assessments should be completed timely and accurately for all residents.

Based on observation, staff interview and record review, the facility failed to discard expired one Omelet station tray, one glass jar of Caper, one plastic wrap of chees, two plastic containers of mixed vegetables and Ginger in walk in cooler and one plastic bag of marshmallow in the dry storage room, failed to label one plastic bag of pasta shell and discard one dented can of Evaporated Milk, one dented can of Condensed Milk and two dented cans of Red Paper in the dry storage room. The findings included: 1a. On 5/22/17 at 10:30 AM, during the observation of the walk-in cooler in the kitchen, there were five plates of omelet in the Omelet station tray expired on 5/20/17, one glass jar of Caper expired on 5/21/17, one plastic wrap of chees expired on 5/19/17, one plastic containers of mixed vegetables expired on 5/19/17, one plastic container of Ginger expired on 5/21/17. On 5/22/17 at 10:30 AM, during an interview, the Director of Dining indicated that all the expired food needed to be removed from the walk in cooler. 1b. On 5/22/17 at 10:35 AM, during the observation of the dry storage room, there was one plastic bag of marshmallow expired on 4/22/17. On 5/22/17 at 10:35 AM, during an interview, the Director of Dining indicated that all the expired food needed to be removed from the dry storage room. 2a. On 5/22/17 at 10:40 AM, during the observation of the dry storage room, there was one plastic bags of pasta shell without the label. On 5/22/17 at 10:40 AM, during an interview, the Director of Dining indicated that all the food needed to be labeled in the dry storage room. 2b. On 5/22/17 at 10:40 AM, during the observation of the dry storage room, there were one dented can of Evaporated Milk, one dented can of Condensed Milk and 2 dented cans of Red Paper. On 5/22/17 at 10:40 AM, during an interview, the Director of Dining indicated that all the dented cans needed to be removed from the dry storage room. On 5/22/17 at 10:45 AM, during an interview, the Sous-Chef indicated that he was responsible for keeping all the food labeled with the date of opening and appropriate expiration date. He was not aware that some food in the dry storage room and walk in cooler was not labeled or expired. On 5/22/17 at 10:50 AM, during an interview, the Director of Dining indicated that all the staff was responsible for keeping the food labeled with correct expiration date and date of opening. All the expired food and dented cans needed to be removed from the kitchen.

Based on observation and staff interviews, the facility failed to store multiple medications in labeled packaging to identify the medication name, strength and expiration date in four of seven medication carts inspected. Findings included: 1. During an inspection of the single medication cart on Unit 1 South on 05/23/17 at 3:48 p.m., seven loose white tablets and one loose capsule were found in the bottom of the second drawer on the left-hand side of the cart. Medication Nurse #5 acknowledged that these medications were not labeled or stored correctly and she wasted them. 2. During an inspection of medication cart #1 on Unit 1 North on 05/24/17 at 8:56 a.m., two loose whole white tablets and one quarter white tablet were found in the bottom of the second drawer on the left-hand side. When the loose pills were shown to Nurse #6 who was giving medications, she disposed of them in the sharps container. She indicated in an interview that had she seen them underneath the bulk medications in the drawer, she would have disposed of them on discovery. 3. During an inspection of medication cart #2 on Unit 1 North on 05/24/17 at 9:04 a.m., one loose white tablet was found in the bottom of the third drawer on the left-hand side. Nurse #6 was unable to identify the medication and disposed of the tablet in the sharps container. 4. During an inspection of medication cart #1 on Unit 2 North on 05/23/17 at 9:16 a.m., two loose white tablets were found in the bottom of the second drawer on the left-hand side. Nurse #7 retrieved the medications and wasted them. In an interview with the Director of Nursing on 05/25/17 at 1:41 p.m., she shared her expectation that any nurse who dropped a pill into a drawer on the medication cart or who saw a loose pill in the cart would remove and waste it. She acknowledged that loose medications were not stored or labeled properly.

Based on observations, resident and staff interviews, the facility failed to remove facial hair for 1 of 3 sampled residents that required extensive assistance with activities of daily living (Resident #104). The findings included: Resident #104 was admitted on [DATE]. The [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #104's cognition was severely impaired and she required extensive assistance of one person with activities of daily living (ADLs) and preferred sponge baths. The care plan dated 05/20/16 revealed Resident #104 required extensive assistance with bathing, grooming, dressing, mobility and eating. The goal included the resident needs would be met by staff, she would be kept clean, neat, dressed appropriately for the season, and free of body odor with no decline in function or range of motion through next review. The interventions were to assist with activity of daily living (ADLs) as needed to ensure safety and ensure adequate completion. During an observation on 05/23/2017 at 11:28 AM, Resident #104 was sitting in the common area listening to music with other residents and had multiple long chin hairs. During an observation on 05/25/17 at 9:00 AM, Resident #104 was sitting in bed had multiple long chin hairs. During an interview on 5/25/17 at 9:18 AM, Nurse Aide (NA) # 2 indicated the nurse assigned the showers/ baths. The shower list designated shower days. NA #2 indicated during shower days the hair and nails were groomed, and resident's facial hair was trimmed or shaved daily. NA #2 indicated Resident #104 permitted her chin hairs to be trimmed. A review of the shower list revealed Resident # 104's shower days were Monday, Wednesday and Friday from 3:00 PM - 11:00 PM. During an observation and interview on 05/25/17 at 9:39 AM, NA #2 indicated to Resident #104 she needed to trim her chin hairs. Resident #104 responded with a nod and a smile. During the interview, NA #2 indicated chin hairs need to be removed when they were observed. During an interview on 05/25/17 at 10:18 AM, Nurse #4 indicated that Resident #104 had not refused ADL care. A review of the assignment sheet revealed NA #4 was assigned to Resident #104 for a shower or bath on Monday 05/22/17 during the 3-11pm shift. A review of the assignment sheet revealed there was no documentation to support the shower/bath was completed. A review of the 5/22/17 MDS ADL tracker revealed a bath was completed on the first shift. During a telephone interview on 05/25/17 at 1:24 PM, NA #4 indicated the last time she worked with Resident #104 was on 05/22/17. NA #4 indicated Resident #104 preferred a tub bath, and during the bath, hair, nails and facial hair were to be groomed. NA #4 was unable to recall what care she had provided on this date. A review of the assignment sheet revealed NA #5 was assigned to Resident #104 on Wednesday 05/24/17 to provide a shower or bath during the 3-11pm shift. There was no documentation on the assignment sheet to support the bath had or had not been provided. A review of the MDS ADL tracker on 05/24/17 revealed no bath was completed. During a telephone interview on 05/25/17 at 2:30 PM, NA #5 indicated she had not given any showers or baths during her shift to any resident on 05/24/17. NA #5 stated she had provided Resident #104 with a good bed bath and indicated she didn't see facial hair. NA #5 further added she documented on the assignment sheet when she completed ADL care and the nurse documented in the computer. NA #5 stated there was no place to document a bath or shower in the computer. A review of the nursing notes for the week of May 22- 25 revealed Resident #104 had not refused her bath or hygiene care. During an interview on 05/25/17 at 3:15 PM, the Director of Nursing indicated her expectation was that residents' facial hair be removed during bathing.

Based on observations, staff interviews and record review, the facility failed to update the face sheet reflecting the residents change in legal responsible party information (Resident #1) and failed to notify the residents legal responsible party (RP) of the development of a pressure ulcer (Resident #1) for 1 of 3 residents reviewed for notification of significant changes in condition. Findings included: Resident #1 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. The most recent quarterly Minimum (MDS) data set [DATE] indicated Resident #1 had severe cognitive impairment and no pressure areas to the skin. Resident #1 was care planned for dementia and memory deficits. In an observation and interview on 4/19/16 at 10:15 AM, Resident #1 was sitting in the day room watching television. On interview, Resident #1 was cooperative but pleasantly confused. A review of Resident #1 medical record indicated the resident was her own RP party on admission (7/16/15) but a copy of the power of attorney (POA) dated 8/10/15 listed Resident #1 had designed someone else as her RP. In an interview on 4/19/16 at 11:00 AM, the social worker stated she was not aware of the existence of the power of attorney and was not aware it was it her medical record. She stated the face sheet should have been updated to reflect the accurate information. In an observation on 4/19/16 at 12:00 PM, nursing assistant (NA) stated Resident #1 had a history of [REDACTED]. NA #1 stated Resident #1 was prone to scratch the rash and had been known to break the skin. NA #1 stated they keep Resident ' s nails trimmed short to prevent injury. There was no evidence of any pressure areas observed. In an interview on 4/19/16 at 1:45 PM, Nurse #1 stated Resident #1 developed the fungal rash on 2/20/16 and had been receiving treatment using creams and ointments to the rash. Nurse #1 stated the rash was discussed with the RP during a care plan conference on 2/25/16. Nurse #1 stated the RP called on 4/15/16 and questioned why she was not notified of a pressure ulcer to Resident #1 ' s coccyx. Nurse #1 stated Resident #1 did not have a pressure ulcer but she did have one in March but it healed. Nurse #1 stated when an area is found, the treatment nurse is notified and she initiates the treatment and notifies the RP. A review of the care plan conference meeting notes dated 2/25/16 indicated the RP was aware of the vaginal and rash to Resident #1 ' s buttocks. In an interview on 4/19/16 at 2:04 PM, the treatment nurse stated she was not currently involved in Resident #1 ' s care since her pressure ulcer healed on 3/11/16 and Resident #1 only had a fungal rash at present. She recalled she was made aware of a pressure ulcer on 2/26/16 during the wound rounds and asked the wound physician to go and assess Resident #1. She stated she received treatment orders that day but neglected to notify the RP because she thought Resident #1 was her own RP. The treatment nurse stated she was not aware of the POA and would have assumed the face sheet would have been updated to reflect the accurate information. In an interview on 4/19/16 at 4:50 PM, the administrator stated it was her expectation the face sheets be kept current and accurate and the director of nursing stated her expectation the RP be notified any time there was a significant change such as the development of a pressure ulcer or a change in a treatment.

Based on staff interview and record review, the facility Quality Assessment and Assurance Committee failed to maintain implement, monitor and revise as need the action plan developed to correct a deficiency at notification of significant changes (F157) cited during a compliant survey of 12/10/15. As a result, a deficiency in the area of notification was again cited on the current recertification/complaint survey of 04/19/16. This tags is cross referenced to: F 157: Based on observations, staff interviews and record review, the facility failed to update the face sheet reflecting the residents change in legal responsible party information (Resident #1) and failed to notify the residents legal responsible party (RP) of the development of a pressure ulcer (Resident #1) for 1 of 3 residents reviewed for notification of significant changes in condition. The administrator and the director of nursing acknowledged understanding of reciting of F157 during complaint survey of 04/19/16.

Based on staff interview and record review the facility failed to follow a care plan intervention for staff to supervise residents in commons areas. This resulted in a fall causing a subdural hematoma which was later identified as the primary cause of death on a death certificate for 1 of 4 residents (Resident #1) whose care plans for falls were reviewed. Findings included: Immediate Jeopardy began on [DATE] during the lunch meal (exact time could not be established from review of progress notes and accident/incident reports) when Nurse #2 found Resident #1 lying on the floor of the dining room without staff being present in this commons area. The resident was diagnosed with [REDACTED]. Immediate Jeopardy was removed on [DATE] at 5:00 PM when the facility provided and implemented a credible allegation of compliance. The facility will remain out of compliance at a scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy (D). The facility was in the process of full implementation of corrective action at that time. Resident #1 was admitted to the facility on [DATE]. Her documented [DIAGNOSES REDACTED]. Review of progress notes revealed Resident #1 fell on [DATE] and [DATE]. A [DATE] interdisciplinary team (IDT) progress note documented Resident #1 fell on [DATE] at 4:32 PM when she attempted to stand unassisted from a chair in the living room. The intervention was Continue to encourage resident to be in commons areas while awake as appropriate for safety and supervision. A [DATE] Resident Care Guide for Resident #1 documented, Safety: Walks with walker. No alarms. Staff to provide stand by assist for transfers and ambulation for safety. Encourage resident to be in common areas for safety. Apply non-skid surface to w/c (wheelchair). Encourage resident to participate in diversional activities while in common area for safety. Do not leave resident unsupervised in common areas or hallways. Review of progress notes revealed Resident #1 fell on [DATE] and [DATE]. A [DATE] progress note documented Resident #1, Attempts to get up w/o (without) assistance while oblivious to safety. Maintained in common area for observation r/t hx (due to history) of falls and fall risk On [DATE] I have a potential for fall related injuries. Resident requires assistance with transfers and requires 1 with ambulation (wears a left knee immobilizer) was identified as problem in the resident's care plan. Approaches to this problem which were developed on [DATE] included 1. I require assistance with transfers and ambulation. Follow facility policy and MD orders for safe transfers. 2. Staff to provide cueing and supervision when ambulating. 3. Staff to provide safety checks Q (every) 45 minutes - 1 hour while in room. Staff to provide safety checks and offer toileting. Review of progress notes revealed Resident #1 fell on [DATE] and [DATE]. A [DATE] progress note documented Resident #1 was sitting in her wheelchair in the hallway, at 5:40 AM attempted to get up and ambulate without assistance, lost her balance, and fell backwards hitting her posterior head on the floor. Swelling the size of a golf ball was observed to the left side of the resident's head. The resident complained of pain to her head, and was transported to the emergency room . A [DATE] IDT progress note documented not to leave Resident #1 unsupervised in commons areas or the hallway. .[MEDICATION NAME] CT showed T8 fx (fracture) of unknown chronicity--surgery not beneficial, fitted with a . brace, instructed to wear for 3 mos (months), f/u (follow-up) in 6 wks (weeks) with neurosurgery. On [DATE] an approach was added to Resident #1's care plan for fall risk: 4. Staff to not leave resident unsupervised in common area or hallways. An accident/incident report documented Resident #1 had an unwitnessed fall on [DATE]. The resident was found on the dining room floor during the lunch meal, and it was surmised the resident hit her head due to a lump on the back right side of her head. The resident complained of pain all over, and was sent out to the ER. A [DATE] late entry progress note related to the fall on [DATE] documented the intervention put in place due to the fall was staff re-education about staying in dining room (a commons area) during meal times when residents were in the dining room eating. A [DATE] hospital discharge summary documented Resident #1 was hospitalized from [DATE] until [DATE]. The primary [DIAGNOSES REDACTED]. .On [DATE], patient was afebrile with stable vital signs and was transferred to an in-patient hospice facility for end of life care and comfort measures. Review of Resident #1's [DATE] death certificate identified the primary cause of death as subdural hematoma. Review of in-servicing to all disciplines from [DATE] through [DATE] revealed staff were instructed to make sure residents in the commons areas (living rooms and dining rooms) were supervised, and staff were to sign off on a sheet every thirty minutes that they were present with audits to be completed twice each shift on a daily basis. There was no documentation that staff received in-servicing in regard to reviewing the care plan or care guide for updated fall interventions. During interviews with nursing assistants (NAs)#5, #6, and #7 at 2:11 PM, 3:12 PM, and 3:35 PM respectively on [DATE] they stated they were aware that Resident #1 was supposed to be supervised by staff when in the commons areas. They reported this information was communicated to them by the nursing staff who reviewed the resident care plans and updates to those plans. They also commented this information was documented in Resident #1's electronic care guide which could be accessed using the hall computer kiosks. At 5:40 PM on [DATE] the assistant director of nursing (ADON) stated all nurses had access to resident care plans via the computers located at the nursing stations, and NAs had access to resident care guides via the electronic kiosks located on the corridor walls of each unit. At 11:15 AM on [DATE] the minimum data set (MDS) coordinator stated interim care plans were developed by the admissions nurse, and the MDS team developed a more detailed care plan in conjunction with the completion of resident admission MDS assessments. She reported all nurses could and should be assessing the care plans on the computers at the nurse's stations. She commented supervisors developed care guides for the NAs to use in providing resident care. According to the MDS coordinator, supervisors pulled information from the care plans that was pertinent to the duties of the NAs and included it in the resident care guides. She reported all NAs could and should be assessing the care guides on the computer kiosks in the halls. At 1:28 PM on [DATE] Nurse #2 stated she did not know how to access care plans in the facility's computer system. She explained the facility used to have care plan books which she used, but these books had been done away with since the facility began use of a new electronic record keeping system. She also commented she had not seen NAs accessing the computer kiosks to view resident care guides. However, she remarked that she had shared with the NAs that cared for Resident #1 that the resident needed supervision in commons areas when out of her room due to frequent falls. According to Nurse #2, she did not receive information about how to access electronic care plans/care guides or the importance of referring to the care plans/care guides for fall interventions during [DATE] - [DATE] staff in-servicing. At 1:37 PM on [DATE] Nurse #3 stated she was a prn nurse, and since the facility began use of a new medical record system, she did not refer to the nursing care plans in the electronic record. She reported she received important information about residents in huddles between outgoing and incoming staff during change of shift. She commented she did not receive information about how to access electronic care plans/care guides or the importance of referring to the care plans/care guides for fall interventions during [DATE] - [DATE] staff in-servicing. At 2:19 PM on [DATE] NA #4 stated she did not know how to access the electronic resident care guide system to obtain resident care information. She explained she received care information from the nursing assistant or nurse who had been working the previous shift during report. She commented she did not receive information about how to access electronic care plans/care guides or the importance of referring to the care plans/care guides for fall interventions during [DATE] - [DATE] staff in-servicing. At 3:48 PM on [DATE] the acting director of nursing (DON)/facility administrator and the unit administrator stated the nursing staff should refer to the nursing care plans to become familiar with interventions in place to prevent resident falls, and the NAs should refer to the resident care guide for this information. They reported information about how to access electronic care plans/care guides and the importance of referring to the care plans/care guides for fall interventions was not part of the [DATE] - [DATE] staff in-servicing. However, they commented that at risk meetings were being held daily instead of weekly as of [DATE], and supervising nurses were required to report new fall interventions to the hall staff as of [DATE]. The acting DON/facility administrator and the unit administrator were notified of the immediate jeopardy on [DATE] at 5:15 PM. The facility provided the following credible allegation on [DATE] at 2:40 PM: The acting DON/facility administrator and the unit administrator were notified of the immediate jeopardy on [DATE] at 5:15 PM. The facility provided the following credible allegation on [DATE] at 2:40 PM: 1. How the facility corrected the deficient practice for each resident found to have been affected by the deficient practice: On [DATE], the facility completed an internal investigation for Resident #1 due to a fall on [DATE]. In-servicing with team members began on [DATE] regarding resident supervision in common areas. Common area sign-off sheets were implemented [DATE] to assure supervision of residents in common areas. Unfortunately, the first resident passed away on [DATE] and (did not) return to our facility. On 01//,[DATE], the facility began an internal investigation for Resident #2 due to a fall on [DATE]. In-servicing with team members began on [DATE] regarding resident supervision in common areas and continued until 100% of team members were in-serviced. Common area sign-off sheets were implemented [DATE] to assure supervision of residents in common areas. The second resident involved was transferred from the hospital to another facility on [DATE] in (city) to receive extensive therapy. The resident's family said that she should be there ,[DATE] weeks and that their plan was to bring her back here once (she is) ready for discharge. We will continue supervising the common areas/dining rooms when she returns to assure that we have corrected the deficient practice for her as well as the other residents at risk for falling. Audits of the common area supervision sign-off sheets began on [DATE]. Those audits are completed by RN Supervisors and indicate which team member is supervising residents every 30 minutes. 2. How the deficient practice for other residents having the potential to be affected by the same deficient practice was corrected: A list containing residents at risk for falls was placed at each nursing station on [DATE] so team members would have heightened awareness of residents at risk for falling and serious injuries. All team members (including housekeeping, maintenance, dining, life enrichment and nursing) have been made aware of the need to supervise the common areas/dining room. All residents at risk for falling are given a different individualized intervention for falls based on their risk and needs. One of the interventions used for residents who are often in common areas instead of their rooms is for them to be supervised by team members. Some residents enjoy being in their rooms more and different interventions are put into place for those residents. Common area sign-off sheets for all common areas/dining rooms were implemented in an effort to supervise all residents at risk on [DATE]. There is one team member supervising residents in dining room and one team member supervising residents in common area when residents are in those locations. Team members work together at the beginning of the shift to decide who is going to supervise when and they work out the schedule throughout their shift according to resident care needs. Team members were already notified about the need for supervision prior to these incidents, however, re-enforcement and re-education was completed on [DATE] to assure compliance with supervision. Most in-services were completed by [DATE] and we (did not) allow team members to work until they received the in-service. 3. What the facility put in place to ensure that deficient practice will not occur again: On [DATE], the facility implemented a new sign-off sheet on team members supervising the common areas/dining room. The form indicates which team member supervised residents in the common areas/dining room in 30 minute increments. Team members initial the sign-off form when they are supervising residents in that area. If residents (are not) in the common areas (for example when they are sleeping), team members indicate that as well. Team members knew that the residents should be supervised but we implemented the sign-off sheets as an extra measure to assure that a team member was accountable at all times. Audits of the common area supervision sign-off sheets began on [DATE]. Those audits are completed by RN Supervisors and indicate which team member is supervising residents every 30 minutes. On [DATE], in-services began for all team members regarding supervision of residents at risk for falling while they are in common areas. 100% of team members were in-serviced by [DATE]. This included all PRN team members as well. Most in-services were completed by [DATE] and we (did not) allow team members to work until they received the in-service. Our orientation/annual review checklist for new hires will include the review of supervision in common areas. The supervision in common areas was added to orientation/annual review checklist on [DATE]. Team members directly involved in the deficient practice for the first resident were in-serviced by [DATE]. Team members directly involved in the deficient practice for the second resident were in-serviced on [DATE] and disciplinary action was taken by [DATE] on all involved in the second resident issue. Walkie-talkies were purchased on [DATE] for the C.N.A.'s and Nurses to carry in order to communicate emergencies when help is needed. On [DATE] at 5:00 PM, verification of the credible allegation was conducted via interviews with s upervising nurses, other licensed staff, and support staff who stated they received in-service education regarding the importance of following interventions to provide safety for residents who are at high risk for falls, such as referring to the nursing care plan and resident care guide alerts to check for new interventions, referring to the list of residents who are at risk for falls located at the nurse's station, and initialing a log to ensure adequate supervision to residents in the common areas of the facility. Interviews with the acting DON and the unit administrator confirmed the order for additional cameras to be installed and for communication equipment for alerting staff members for emergencies. Observations of the common areas of the facility revealed staff members were present upon each observation, and a review of the sign-in sheets for staff initials in 30 minute increments were complete.

Based on observation, physician interview, staff interview, and record review the facility failed to provide staff supervision in commons areas where residents were residing which resulted in serious injury to 2 of 4 residents (Resident #1 and #2) who were reviewed for falls which caused injury. (Resident #1 sustained a subdural hematoma which was later identified as the primary cause of death on a death certificate and Resident #2 sustained multiple bone fractures and hospitalization in intensive care). Findings included: Immediate Jeopardy for Resident #1 began on [DATE] during the lunch meal (exact time could not be established from review of progress notes and accident/incident reports) when Nurse #2 found Resident #1 lying on the floor of the dining room without staff being present in this commons area. The resident was diagnosed with [REDACTED]. Immediate Jeopardy began for Resident #2 on [DATE] at 6:45 PM when Nurse #1 found Resident #2 lying face down on the floor beside a column in the common area of the facility with a contusion to the right forehead area and bruising radiating to the right eye. Immediate Jeopardy was removed on [DATE] at 5:00 PM when the facility provided and implemented a credible allegation of compliance. The facility will remain out of compliance at a scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy (D). The facility was in the process of full implementation of corrective action at that time. 1. Resident #1 was admitted to the facility on [DATE]. Her documented [DIAGNOSES REDACTED]. Progress notes between [DATE] and [DATE] documented Resident #1 was alert with confusion, ambulated with a walker, and was unsteady in her gait. The resident's [DATE] admission minimum data set (MDS) documented her cognition was severely impaired, she required extensive assistance from a staff member with bed mobility/transferring/dressing/toilet use, she required limited assistance by a staff member for walking in her room and the corridor, was occasionally incontinent of urine, was frequently incontinent of bowel, and had one fall since admission with no injury. A [DATE] care plan progress note documented, Some progress made with upright standing. Very poor perception of balance and safety. Weakness in ankles and legs noted. Safety is a concern for ambulation without standby assistance. Able to ambulate the length of the hallway. Moderate assistance needed for ADLs (activities of daily living) for self-care, with maximum cueing. An accident/incident report documented Resident #1 had a witnessed fall just outside the living room near the medication cart at 1:30 PM on [DATE]. The report also documented the resident tried to get up without assistance, lost her balance, and staff were unable to catch the resident who hit the top left side of her head on the medication cart with no apparent injury. A [DATE] interdisciplinary team (IDT) progress note documented Resident #1's [DATE] fall was reviewed. It was noted the resident attempted to self-ambulate with her rollator in a common area. The intervention was for staff to provide cueing and supervision to the resident when she was ambulating. A [DATE] care plan progress note documented, Balance continues to be a significant issue. Resident is unable to recognize when she is falling backward while standing and ambulating. She is able to participate in ADLs, but has no safety awareness .needs supervision to standby assistance when ambulating due to balance and safety awareness. A [DATE] progress note documented Resident #1 was found in the floor. No injuries. Unable to verbalize what she was attempting to do prior to fall. Confused at baseline. An accident/incident report documented Resident #1 had an unwitnessed fall in her room on [DATE] at 5:00 AM. The resident was found in a sitting position in the middle of the floor. The resident's brief was wet and soiled, but the resident's nursing assistant (NA) stated she had checked the resident not too long before. However, she could not provide the exact time. The report documented there was a fall with no injury. A [DATE] IDT progress note documented Resident #1's [DATE] fall was reviewed. It was noted the resident attempted to get out of bed unassisted, and was incontinent of urine at the time of the fall. The intervention was for staff to do incontinent checks on the resident everyone to one and a half hours when Resident #1 was in bed. A [DATE] progress note document Resident #1 was found on the floor, and was unable to verbalize what happened. An accident/incident report documented Resident #1 had an unwitnessed fall on [DATE] at 4:32 PM. It was surmised the resident was sitting in a chair when she tried to get up unassisted and fell on to her side. A [DATE] IDT progress note documented Resident #1's [DATE] fall was reviewed. It was noted the resident attempted to stand unassisted in the living room. The intervention was Continue to encourage resident to be in commons areas while awake as appropriate for safety and supervision. A [DATE] Resident Care Guide for Resident #1 documented, Safety: Walks with walker. No alarms. Staff to provide stand by assist for transfers and ambulation for safety. Encourage resident to be in common areas for safety. Apply non-skid surface to w/c (wheelchair). Encourage resident to participate in diversional activities while in common area for safety. Do not leave resident unsupervised in common areas or hallways. A [DATE] progress note documented Resident #1 had a fall which was witnessed by a nursing student and her instructor in the commons area. An accident/incident report documented Resident #1 had a witnessed fall on [DATE] at 7:20 PM. The resident was seen sliding out of her wheelchair as she tried to transfer to the couch in the living room. No injury was noted. A [DATE] IDT progress note documented the intervention for Resident #1's fall was the application of a non-skid surface to the resident's wheelchair seat. A [DATE] progress note documented Resident #1 was found in a sitting position outside her bathroom on the floor. The resident complained of pain to the top of her head. However, a computed tomography (CT) scan of the resident's head and x-rays of her spine, hip, and pelvis were negative for fracture/injury when the resident was assessed at the hospital. An accident/incident report documented Resident #1 had an unwitnessed fall on [DATE] at 12:50 AM. There was a small amount of fecal matter on the resident's bed and a large bowel movement in the toilet. The fall caused an open wound to the right knee of less than three centimeters (cm) with scant bleeding. A [DATE] IDT progress note documented the intervention for Resident #1's [DATE] fall was to provide safety checks every 45 - 60 minutes after giving the resident a laxative. Per facility investigation, it was found Resident #1 was given a laxative early in the day on [DATE] due to constipation. A [DATE] progress note documented Resident #1, Attempts to get up w/o (without) assistance while oblivious to safety. Maintained in common area for observation r/t hx (due to history) of falls and fall risk. Increased agitation/anxiety continues and initiates after dinner almost immediately. Difficult to redirect and get meds in her at that point w/o several attempts. On [DATE] I have a potential for fall related injuries. Resident requires assistance with transfers and requires 1 with ambulation (wears a left knee immobilizer) was identified as problem in the resident's care plan. Approaches to this problem which were developed on [DATE] included 1. I require assistance with transfers and ambulation. Follow facility policy and MD orders for safe transfers. 2. Staff to provide cueing and supervision when ambulating. 3. Staff to provide safety checks Q (every) 45 minutes - 1 hour while in room. Staff to provide safety checks and offer toileting. Resident #1's [DATE] quarterly MDS documented she had impaired short and long term memory, was moderately impaired in decision making skills, required extensive assist by a staff member with bed mobility/locomotion on the unit/dressing/toileting/hygiene, required extensive assist by two staff members with transfers, only walked in the room/corridor and locomoted off the unit once or twice during the look-back period, was occasionally incontinent of urine, was always continent of bowel, and had one fall with no injury and one fall with injury (but not major) since her last assessment. An accident/incident report documented Resident #1 had a witnessed fall on [DATE] at 7:30 AM. It was noted the resident was sitting in her wheelchair in the living room, decided to get up, and sat on the floor without injury. A [DATE] IDT progress note documented the new intervention for Resident #1 after her [DATE] fall was to encourage the resident to participate in diversional activities when in a commons area for safety. A [DATE] progress note documented Resident #1 was found sitting on the floor undressed from the waist down as the NA was making rounds at 3:35 AM. The resident was last observed by the NA resting in bed at 3:15 AM the same morning. An accident/incident report documented Resident #1 had an unwitnessed fall on [DATE] at 3:35 AM. The resident's bed sheets were wet, and the resident had removed her brief and pajama bottoms. The resident sustained [REDACTED]. A [DATE] IDT progress note documented the new intervention put in place for Resident #1 after her [DATE] fall was to complete checks on the resident every ,[DATE] minutes while she was in her room. A [DATE] progress note documented Resident #1 was sitting in her wheelchair in the hallway, at 5:40 AM attempted to get up and ambulate without assistance, lost her balance, and fell backwards hitting her posterior head on the floor. Swelling the size of a golf ball was observed to the left side of the resident's head. The resident complained of pain to her head, and was transported to the emergency room . [DATE] hospital x-rays of the resident's thoracic spine documented, Diffuse osteopenia .There is a compression fracture of what is favored to represent the T9 vertebral body, which appears new or increased compared to chest radiograph [DATE]. A [DATE] physician order [REDACTED].wear back brace whenever sitting up or standing x 3 months. A [DATE] progress note documented, Resident up at 12:30 AM. Noted insomnia with periods of agitation. Constant attempts to get up and ambulate without assistance. Resident in common area with staff for safety and supervision. Activities provided by staff for resident, kept calm for short period of time. Hydration and snack provided. Noted restlessness. Refused 6 AM meds, Refused to wear back brace. A [DATE] IDT progress note documented not to leave Resident #1 unsupervised in commons areas or the hallway. .thoracic CT showed T8 fx (fracture) of unknown chronicity--surgery not beneficial, fitted with a . brace, instructed to wear for 3 mos (months), f/u (follow-up) in 6 wks (weeks) with neurosurgery. On [DATE] an approach was added to Resident #1's care plan for fall risk: 4. Staff to not leave resident unsupervised in common area or hallways. An accident/incident report documented Resident #1 had an unwitnessed fall on [DATE]. The resident was found on the dining room floor during the lunch meal, and it was surmised the resident hit her head due to a lump on the back right side of her head. The resident complained of pain all over, and was sent out to the ER. The resident's [DATE] discharge MDS documented she had impaired short term memory (her long term memory was not assessed), she was moderately impaired in decision making, and she had one fall with no injury and two falls with injury (but not major) since her last assessment. A [DATE] late entry progress note related to the fall on [DATE] documented the intervention put in place due to the fall was staff re-education about staying in dining room (a commons area) during meal times when residents were in the dining room eating. A [DATE] hospital discharge summary documented Resident #1 was hospitalized from [DATE] until [DATE]. The primary [DIAGNOSES REDACTED]. .On [DATE], patient was afebrile with stable vital signs and was transferred to an in-patient hospice facility for end of life care and comfort measures. Review of Resident #1's [DATE] death certificate identified the primary cause of death as subdural hematoma. Observations on [DATE] and [DATE] revealed the unit living room and the dining room were not visible from the unit nurse's station. There was a wall/partition in front of these common areas which prevented staff from monitoring residents in these areas from the nursing station. At 11:50 AM on [DATE] the interim director of nursing (DON)/facility administrator stated the facility always investigated falls with injury, and interviewed staff to determine if care approaches or systems needed to be changed to provide better care and needed to be incorporate into the facility's quality assurance (QA) process. She commented falls were going to happen in nursing homes, but the facility tried its best to prevent them. She reported the facility was alarm and restraint free, but if families requested a restraint or alarm, and the physician would sign off on them, then the facility would utilize them. According to the facility investigation, the facility administrator explained Resident #1 fell on [DATE] at lunch in the dining room with no staff present. She reported a NA was pulled to the hall to change a resident which left the commons area without staff supervision. The administrator stated the facility began discussion on [DATE] about ways it could improve management and registered nurse (RN) presence in the facility to make sure safety interventions were in place and being followed. She reported on [DATE] formal in-servicing began with all disciplines to make sure staff were assigned and present in 30 minutes increments when residents were residing in commons areas. At 12:35 PM on [DATE] the physician/medical director stated she had cared for Resident #1 for a long time, and the resident had on-going and long term cognitive and psychiatric problems including extreme bouts with anxiety and depression. She reported the resident lacked safety awareness, and would try to ambulate and transfer without staff assistance because she wanted to remain independent. She commented the facility tried to avoid the use of restraints and alarms so about all the facility could do was to check on the resident frequently when she was in her room and to keep the resident in commons areas as much as possible where staff could supervise her. At 2:11 PM on [DATE] NA # 5 stated Resident #1 was very confused, thinking that she was back in her home state working for a living. She reported the resident always tried to get up unassisted, but when attempts were made to redirect the resident, the resident would become verbally abusive, agitated, and anxious. The NA commented the staff tried to keep the resident in commons areas when she was out of bed so staff could supervise her. At 3:12 PM on [DATE] NA #6 stated she took Resident #1 to the bathroom before the lunch meal began on [DATE]. She reported there were supposed to be two NAs in the dining room during meals. She explained as lunch progressed on [DATE] she left the dining room to provide care to a resident on the hall, but NA #7 was still present in the dining room when she left. At 3:35 PM on [DATE] NA #7 stated Resident #1 could be very confused at times, would try to get up unassisted, and staff kept the resident close in commons areas to keep an eye on her. She reported she and NA #6 were in the dining room at the beginning of the lunch meal on [DATE]. According to NA #7, Nurse #2 approached her in the dining room, stating she needed her help because family was unhappy on the hall. The NA explained the nurse asked her to change a resident whose family was complaining about call bell response and the resident being wet and soiled. NA #7 commented when she left the dining room she did not notice that NA #6 was not present. She stated it was facility expectation that two NAs be present during meal to supervise and assist residents with eating. At 3:50 PM on [DATE] Nurse #2 stated Resident #1 was confused, could not be redirected, and worked herself up into anxious and agitated states which sometimes involved crying spells. She reported the resident had numerous falls in the facility because she would try to get up unassisted. Nurse #2 remarked some of the fall interventions for this resident included staying close to the resident in commons areas, checking on the resident frequently when she was in her room, involving the resident in activities, offering the resident snacks, and placement of a non-skid cushion in the resident's wheelchair. According to Nurse #2, during the lunch meal on [DATE] a family member became upset about a resident on the hall due to call bell problems and the resident being wet and soiled. She reported she retrieved NA #7 from the dining room to change this resident while she took care of the call bell. She commented she though there was another NA in the dining room. Nurse #2 explained when she resolved the call bell issue, she noticed NA #7 was still changing the resident on the hall so she began walking back to the dining room. However, she reported before she could get there a dietary employee approached her stating that Resident #1 was on the dining room floor. At 5:04 PM on [DATE] the unit administrator stated the living rooms and dining rooms were considered common areas, and it was the community or cultural standard and facility expectation that when residents were present in these areas that a staff member also be present to check on them and monitor their activities. At 9:33 AM on [DATE] Nurse #4 (nurse manager) stated Resident #1 was not on hospice while residing in the facility between [DATE] and [DATE]; nor did she know of any condition that would have shortened the resident's life span. She reported the resident had poor safety awareness, and was repeatedly trying to get up from the chair and bed without staff assistance. According to Nurse #4, there was a fall intervention in place when Resident #1 fell on [DATE] that she was not to be left unsupervised in any commons area. The acting DON/facility administrator and the unit administrator were notified of the immediate jeopardy on [DATE] at 5:15 PM. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing care plan which was initiated on [DATE] included a goal dated [DATE] for Resident #2 to be free from fall related injuries. There were 2 interventions included on the nursing care plan to achieve this goal as follows: 1) Please assist with toileting and incontinence care every ,[DATE] hours and prn (as needed), and 2) Staff to have resident sit at table while in common area to prevent resident from falling forward. The second intervention included a date of [DATE]. A review of Resident #2's quarterly Minimum Data Set assessment dated [DATE] revealed she was moderately cognitively impaired for making decisions regarding her activities of daily living. The assessment also indicated that Resident #1 was totally dependent upon nursing staff for bed mobility and surface to surface transfers. Locomotion on the unit did not occur during this assessment period, however the assessment indicated the resident used a wheelchair for mobility. The same quarterly assessment of [DATE] also indicated Resident #2 was not steady on her feet, that she was only able to stabilize (balance) with staff assistance, and that she had a history of [REDACTED]. Review the facility's fall investigation report revealed Resident #2 had a witnessed fall on [DATE] at 3:05 PM. The description of the fall indicated a nurse witnessed the resident standing up from her wheelchair while in the common area, and that the nurse ran to the resident to break her fall. The description also indicated that the resident denied any pain and stated, I 'll stand up and fall again. An interdisciplinary note dated [DATE] indicated that Resident #2 had a fall on [DATE] and the resident was sent to the emergency room for an evaluation. Another interdisciplinary note dated [DATE] indicated that on [DATE], Nurse #1 was on her way to another resident's room when she heard a loud noise, then ran toward the noise, and found Resident #2 on the floor in the common area with notable swelling to the right frontal lobe with scant bleeding and bruising radiating to the right eye. The note was signed by Nurse #1. Review of the facility's fall investigation report indicated that Resident #2's fall on [DATE] was unwitnessed. An interview was conducted with Nurse #1 on [DATE] at 6:31 PM. She explained that when she heard the noise on [DATE] she ran to the common area toward the noise, and found Resident #2 on the floor next to a column in the common area, face down, with buttocks elevated, knees bent, and arms folded. Nurse #1 stated that she immediately called out for assistance, then assessed the resident and found the contusion to her right forehead area. Nurse #1 added that she was unable to get a blood pressure on Resident #2 after the fall due to pain the resident was having in her arm. She explained that she was aware that the resident was not to be left alone in the common area, but as a prn (who works only as needed in the facility) she was not aware of any other intervention to prevent falls for Resident #2. In a follow-up interview with Nurse #1 on [DATE] at 10:50 AM, she stated that before the fall occurred on [DATE], she had witnessed the resident to be in her wheelchair at a table in the common area during the 3:00 PM to 11:00 PM shift before her fall, but she was not sure of the time. She stated when she found Resident #2 face down on the floor after her fall on [DATE], she was about 3 feet away from where she was last seen seated in her wheelchair at the table. Nurse #1 stated there were three nursing assistants (NAs) with her at that time, NA #1, NA #2, and NA #3. These nursing assistants were the only NAs who worked on the unit for the 3:00 to 11:00 PM shift on [DATE] on the unit. She also stated that Resident #2 was capable of unlocking her wheelchair and moving it on her own. The administrator stated in an interview on [DATE] at 4:38 PM that there was an expectation that staff members needed to be present at all times in the common areas to supervise the residents. She explained that the expectation was not documented in a policy, but staff members were aware of the expectation. During an interview with NA #1 on [DATE] at 10:20 AM, she stated she was on duty on [DATE] at the time of Resident #2 ' s fall, but she did not witness the fall. NA #1 stated the time she last saw Resident #2 before her fall on [DATE], she was seated beside the table in the commons area, but was not pushed up to the table and that 2 other NAs were with her. NA #1 stated staff members were not supposed to leave the common area whenever any residents were there. NA #1 further explained she was providing care for another resident in his room at the time when Resident #2's fall occurred. During an interview with NA #2 on [DATE] at 2:00 PM, she stated that she was on duty on [DATE] when Resident #2 fell , but she did not witness the fall. She explained that the staff were not supposed to leave Resident #2 alone in the common area, and that if a staff member needed to leave the common area, they were supposed to find someone else to stay in the common area before leaving. NA #2 stated that the last time she observed Resident #2 prior to her fall on [DATE], she was seated in her wheelchair in the common area with another NA. On [DATE] at 4:15 PM, NA #3 stated in an interview that she was on duty on [DATE] during the 3:00 PM to 11:00 PM shift when Resident #2 fell , but did not witness the fall. NA #3 stated the last time she observed Resident #2 that day, she was in the common area in her wheelchair, seated at one of the tables. NA #3 stated she took a break, but she did not recall leaving Resident #2 unattended in the commons area. She also explained that before her fall that day, she was not aware of the intervention to keep the resident pushed up to a table to prevent her from falling forward. A review of the facility's incident investigation report regarding Resident #2's fall on [DATE] revealed the fall was unwitnessed. The report indicated Nurse #1 administered first aid after she discovered her lying face down on the floor by the column. The emergency medical technicians were called, and Resident #2 left the facility via emergency medical transport at 7:33 PM. Resident #2's Discharge Summary from the hospital dated [DATE] indicated that Resident #2 was admitted to the hospital ' s surgical intensive care unit (SICU) on [DATE] following a fall at the skilled nursing facility, and that her injuries included: 1. a fracture at the base of the right greater trochanter (hip) 2. a fracture at the base of the dens at level C2 (fracture at the base of the second cervical spine bone at the neck) 3. C2 spinous process fracture (fracture on the outer portion of the second cervical bone in the neck) 4. T3 and T4 fractures (the third and fourth of twelve bones in the thoracic section of the spine) 5. right radius/ulna fracture (wrist) Further review of the same Discharge Summary from the hospital dated [DATE] indicated Resident #2 had a right frontal scalp hematoma which extended to the eyelid, and that she remained in the SICU until [DATE] when she was transferred to the hospital ' s long term acute care section. Additionally, Resident #1 initially required a lidocaine drip for pain control, and the use of a Minerva brace (a cervical thoracic orthotic device and a thoracic collar to stabilize her spine fractures. Resident #2 was discharged from the hospital to another rehabilitation facility on [DATE]. Resident #2's physician stated in an interview on [DATE] at 12:36 PM, that the resident had osteoporosis, and that the injuries she received during the fall on [DATE] were possibly more extensive due to her osteoporosis. The physician also stated she would have wanted to nursing staff to follow nursing interventions in place to provide safety for the resident. The acting DON/facility administrator and the unit administrator were notified of the immediate jeopardy on [DATE] at 5:15 PM. The facility provided the following credible allegation on [DATE] at 2:40 PM: 1. How the facility corrected the deficient practice for each resident found to have been affected by the deficient practice: On [DATE], the facility completed an internal investigation for Resident #1 due to a fall on [DATE]. In-servicing with team members began on [DATE] regarding resident supervision in common areas. Common area sign-off sheets were implemented [DATE] to assure supervision of residents in common areas. Unfortunately, the first resident passed away on [DATE] and (did not) return to our facility. On 01//,[DATE], the facility began an internal investigation for Resident #2 due to a fall on [DATE]. In-servicing with team members began on [DATE] regarding resident supervision in common areas and continued until 100% of team members were in-serviced. Common area sign-off sheets were implemented [DATE] to assure supervision of residents in common areas. The second resident involved was transferred from the hospital to another facility on [DATE] in (city) to receive extensive therapy. The resident's family said that she should be there ,[DATE] weeks and that their plan was to bring her back here once (she is) ready for discharge. We will continue supervising the common areas/dining rooms when she returns to assure that we have corrected the deficient practice for her as well as the other residents at risk for falling. Audits of the common area supervision sign-off sheets began on [DATE]. Those audits are completed by RN Supervisors and indicate which team member is supervising residents every 30 minutes. 2. How the deficient practice for other residents having the potential to be affected by the same deficient practice was corrected: A list containing residents at risk for falls was placed at each nursing station on [DATE] so team members would have heightened awareness of residents at risk for falling and serious injuries. All team members (including housekeeping, maintenance, dining, life enrichment and nursing) have been made aware of the need to supervise the common areas/dining room. All residents at risk for falling are given a different individualized intervention for falls based on their risk and needs. One of the interventions used for residents who are often in common areas instead of their rooms is for them to be supervised by team members. Some residents enjoy being in their rooms more and different interventions are put into place for those residents. Common area sign-off sheets for all common areas/dining rooms were implemented in an effort to supervise all residents at risk on [DATE]. There is one team member supervising residents in dining room and one team member supervising residents in common area when residents are in those locations. Team members work together at the beginning of the shift to decide who is going to supervise when and they work out the schedule throughout their shift according to resident care needs. Team members were already notified about the need for supervision prior to these incidents, however, re-enforcement and re-education was completed on [DATE] to assure compliance with supervision. Most in-services were completed by [DATE] and we (did not) allow team members to work until they received the in-service. 3. What the facility put in place to ensure that deficient practice will not occur again: On [DATE], the facility implemented a new sign-off sheet on team members supervising the common areas/dining room. The form indicates which team member supervised residents in the common areas/dining room in 30 minute increments. Team members initial the sign-off form when they are supervising residents in that area. If residents (are not) in the common areas (for example when they are sleeping), team members indicate that as well. Team members knew that the residents should be supervised but we implemented the sign-off sheets as an extra measure to assure that a team member was accountable at all times. Audits of the common area supervision sign-off sheets began on [DATE]. Those audits are completed by RN Supervisors and indicate which team member is supervising residents every 30 minutes. On [DATE], in-services began for all team members regarding supervision of residents at risk for falling while they are in common areas. 100% of team members were in-serviced by [DATE]. This included all PRN team members as well. Most in-services were completed by [DATE] and we (did not) allow team members to work until they received the in-service. Our orientation/annual review checklist for new hires will include the review of supervision in common areas. The supervision in common areas was added to orientation/annual review checklist on [DATE]. Team members directly involved in the deficient practice for the first resident were in-serviced by [DATE]. Team members directly involved in the deficient practice for the se

Based upon record review and staff and nurse practitioner interviews, the facility did not notify the physician, the nurse practitioner, or the family after an allegation of abuse was made for one of three residents who were reviewed for abuse allegations, Resident #1. Findings included: A review of the admission assessment dated [DATE] indicated that Resident #1 was re-admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. The same assessment revealed Resident #1 had short term and long term memory problems, had moderate impairment for making decisions regarding her daily tasks of life, and that she required extensive assistance with most of her activities of daily living. An updated assessment for Resident #1 dated 11/19/2015 revealed that she required limited assistance with eating, that she had no difficulties with swallowing, and that she had exhibited behavioral symptoms which included rejection of care. A review of the nursing care plan initiated on 11/19/2015 revealed Resident #1 had a measurable goal and interventions in place related to her behavior problems. One of the interventions included, Please approach me calmly, speak slowly, smile, and give me personal space when I appear to be upset. A review of the facility's 24-Hour Report to the Health Care Personnel Registry revealed that an allegation of abuse was made regarding an incident that occurred on 12/05/2015 at 9:00 AM. The description of the allegation was as follows: It was reported on 12/06/2015 that (Nurse #1) forced the resident to take her medications on 12/05/2015. It was also reported that the nurse asked the (Nursing Assistant Name) to hold the resident's hands so she could give her medications. There was no indication on the report that the physician, family nurse practitioner, or family was notified of the allegation. A review of the nursing progress notes revealed there were no notes from 12/05/2015 through 12/07/2015 to indicate the physician, nurse practitioner, or family had been notified regarding the abuse allegation. An observation of the resident on 12/08/2015 at 8:40 AM revealed Resident #1 had a red scratch to her forehead about 1 inch long, 3 light greenish yellow bruises around the left wrist and on her right forearm and right wrist. In an interview with the facility's administrator on 12/09/2015 at 4:20 PM, she stated that she received a telephone call on 12/06/2015 at 11:36 AM from Nurse #3, who made the allegation of staff to resident abuse by Nurse #1. The administrator stated she had just suspended both Nurse #3 and Nurse #1 because of another issue, and she was so focused on the suspension that she did not report the abuse allegation to the physician on-call or the nurse practitioner. The Administrator stated in retrospect, she should have reported the allegation to the physician or the nurse practitioner after she received the allegation. In an interview with the Campus Administrator on 12/10/2015 at 12:25 PM, she stated that Resident #1's family had not been notified regarding the abuse allegation at all since the incident had been reported. She explained that a nurse had left a message with her physician on 12/07/2015, but that the physician was away for that week and probably did not receive the message. On 12/10/2015 at 1:15 PM, an interview was conducted with the nurse practitioner (NP) who provided care for Resident #1. During the interview, she stated she had not received a report that an allegation of abuse to Resident #1 had been made. The NP stated she was taking care of the resident while Resident #1's regular physician was away that week, and that she had not received any notification regarding the allegation or about any new bruising until 12/10/2015. The NP stated she was in the facility to see Resident #1 and her family member on 12/07/2015 at around 4:00 PM to discuss her medications and she could have assessed the resident for bruises and any other issues at that time if she had been aware of the abuse allegation. In a telephone interview with Nurse #2 on 12/10/2015 at 4:45 PM, she stated she notified a family member on 12/07/2015 about some new bruises that were noted on the resident's forearms and wrists, but did not report any allegations of abuse to the physician or family.

Based on record review and staff interviews, the facility did not prevent a staff member from making a verbally threatening statement to 1 of 3 residents reviewed for abuse allegations, Resident #1. Findings included: A review of the admission assessment dated [DATE] indicated that Resident #1 was re-admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. The same assessment revealed Resident #1 had short term and long term memory problems, had moderate impairment for making decisions regarding her daily tasks of life, and that she required extensive assistance with most of her activities of daily living. An updated assessment for Resident #1 dated 11/19/2015 revealed that she required limited assistance with eating, that she had no difficulties with swallowing, and that she had exhibited behavioral symptoms which included rejection of care. A review of the nursing care plan initiated on 11/19/2015 revealed Resident #1 had a measurable goal and interventions in place related to her behavior problems. One of the interventions included, Please approach me calmly, speak slowly, smile, and give me personal space when I appear to be upset. On 12/09/2015 at 10:30 AM, an interview was conducted with the Nursing Assistant #1 (NA #1), who was present during part of the alleged medication event of 12/05/2015. NA #1 stated that on 12/05/2015 she was seated in the common area where residents often sit to play games or watch television, and that she witnessed Nurse #1 attempt to give Resident #1 her medications from a cup using a spoon, but the resident refused, stating she was not going to take them. NA stated she could not remember exactly what Nurse #1 said to the resident after she refused the medicine, but that she was concerned about the situation because Nurse #1 told NA #2 to come across the hall to a vacant room to assist her with giving the medications. NA #1 stated that when NA #2 got up to assist Nurse #1, she told NA #2, Don't touch the resident, we do not hold hands. NA #1 explained she made the statement to NA #2 because only the nurse should give medications, and that a nursing assistant should not assist with meds or holding the resident's hands. NA #1 stated she did not report the incident to anyone on 12/05/2015. During an interview on 12/09/2015 at 11:19 AM with the nursing assistant who was asked to assist Nurse #1 with the medication administration, NA #2, she stated that while she and 2 other nursing assistants were in the common area, she witnessed Nurse #1 attempt to give Resident #1 her medications which were crushed and mixed with food. NA #2 stated the resident was a little agitated that day and that she refused to take her medications. NA #2 stated that Nurse #1 then said to the resident, We can take it the easy way or the hard way. NA #2 explained that Nurse #1 asked her (NA#2) to come across the hall and hold the resident's hands while she gave the medications. NA #2 stated she then went with Nurse #1 and Resident #1 into a vacant room across the hall from common area. NA #2 confirmed that NA #1 told her not to hold the resident's hands down because that would be abuse. In an interview conducted with Nurse #1 on 12/09/2015 at 12:21 PM, she stated that on 12/05/2015, Resident #1 was seated in the common area when she was going to administer her medications around 9:00 AM. Nurse #1 explained that she crushed Resident #1's medications, mixed them with applesauce, and then used a spoon to attempt to administer the medications to her. Nurse #1 added that the resident was agitated that day and that she refused to take her medications, making a face and saying, Yuck. Nurse #1 stated the resident never said, No. Nurse #1 stated that she said something to the resident similar to, I know this isn't easy, or, I know this is hard for you. Nurse #1 stated that after Resident #1 refused the medications, she left her in the commons area a while, then returned to try to administer the medications again. Nurse #1 stated the common area was very chaotic, so she asked NA #2 to take the resident to the vacant room across the hall to assist her as she gave the medications. Nurse #1 added that she did not say, We can do this the easy way or the hard way, and that those who witnessed that she made this statement might have misunderstood her or misconstrued her statement. In an interview with NA #3 on 12/09/2015 at 2:21 PM, she stated that she was present in the common area on 12/05/2015 when Nurse #1 attempted to give medications to Resident #1. NA #3 stated that Nurse #1 crushed the resident's medication at the medication cart and mixed it with a food item, perhaps pudding (unsure which type of food) then approached Resident #1 with the medications and told her it was time to take them. NA #3 explained that Resident #1 shook her head side to side (to indicate no) and said clearly, I'm not going to take it. NA #3 stated that Nurse #1 tried again to give a spoonful of the medications to her, but the resident was agitated and that she refused to take them again, shaking her head, no and stating she was not going to take them. NA #3 stated Resident #1 refused at least twice, perhaps three times. NA #3 stated Nurse #1 said, We can take it the easy way or the hard way. NA #3 stated she felt the statement was disturbing to her, so she reported it on 12/06/2015. In an interview with the facility's campus administrator (CA) on 12/10/2015 at on 12/09/2015 at 11:50 AM, she stated that the alleged statement by Nurse #1, We can take it the easy way or the hard way, was disturbing to her and that it could be taken as a threat to a resident or to others who heard the statement.

Based on observation, record review, and staff and nurse practitioner interviews, the facility failed to follow its Abuse and Neglect Policy when, a) the facility did not identify a reported incident as suspected abuse or perform an assessment of the resident after an allegation of abuse was made, and b) staff members failed to recognize and report suspected abuse, for one of three residents reviewed in an abuse investigation, Resident #1. Findings included: A review of the facility's Abuse and Neglect Policy, effective January 14, 2014 and revised on May 13, 2014, revealed the following in Section II B. on page 3, Employees are instructed during new hire orientation, periodic in-services, .on the importance of immediate reporting witnessed or suspected instances of abuse/neglect. In Section IV A., page 4, the policy stated, All employees need to be able to detect potential abuse or neglect: unexplained open wounds, cuts, bruises, welts, or discoloration . Section V, page 4 of the policy revealed: The Community internal investigation shall include: Examination and interview of resident by risk manager/designee coordinator and by two qualified professionals (i.e., interdisciplinary team). A review of the admission assessment dated [DATE] indicated that Resident #1 was re-admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. The same assessment revealed Resident #1 had short term and long term memory problems, had moderate impairment for making decisions regarding her daily tasks of life, and that she required extensive assistance with most of her activities of daily living. An updated assessment for Resident #1 dated 11/19/2015 revealed that she required limited assistance with eating, that she had no difficulties with swallowing, and that she had exhibited behavioral symptoms which included rejection of care. A review of the nursing care plan initiated on 11/19/2015 revealed Resident #1 had a measurable goal and interventions in place related to her behavior problems. One of the interventions included, Please approach me calmly, speak slowly, smile, and give me personal space when I appear to be upset. In an interview with the Director of Nursing (DON) on 12/08/2015 at 10:03 AM on 12/08/2015, she stated that the facility had submitted a 24-Hour Report to the Health Care Personnel Registry dated 12/07/2015 at 11:51 AM regarding an allegation of abuse to Resident #1. The facility's 24-Hour Report to the Health Care Personnel Registry revealed that an allegation of abuse was made regarding an incident that occurred on 12/05/2015 at 9:00 AM. The description of the allegation on the report was as follows: It was reported on 12/06/2015 that (Nurse #1) forced the resident to take her medications on 12/05/2015. It was also reported that the nurse asked the (Nursing Assistant Name) to hold the resident ' s hands so she could give her medications. a) A review of the Medication Administration Record [REDACTED]. (A side effect of Xarelto is increased risk of bleeding.) A Skin Assessment Form for Resident #1 dated 12/07/2015 at 11:59 AM included the following description of the resident ' s skin condition: Has three bruises going up her right forearm, bruise to inner arm close to wrist 0.5 inches long and 0.2 inches wide, bruise to outer forearm on top of wrist 1 inch long and 0.5 inches wide, bruise to outer forearm 1.5 inches long and 0.5 inches wide. All pink in color. Review of an Inter-Disciplinary Team (IDT) Note dated 12/08/2015 at 12:04 PM revealed the following: . Res (resident) reviewed by IDT committee related to discolored areas to bilateral hands and red abrasion to resident's forehead. Areas to right hand is believed to be self-inflicted and area to left hand is consistent with watch placement. Red abrasion to forehead is believed to be from resident scratching area. Resident is on anticoagulation and has had multiple episodes of combative behaviors . A review of the nursing progress notes revealed there was no other documentation that an assessment of Resident #1 was made after the allegation of abuse was reported on 12/06/2015 at 11:36 AM. In an interview with the Director of Nursing (DON) on 12/09/2015 at 4:00 PM, she explained that she stated that she would have expected Resident #1 to have received a skin assessment after the allegation of abuse was made on 12/06/2015 if there was implied physical harm from the alleged abuse of 12/05/2016. She explained she was unaware of the abuse allegation until she came in to the facility on Monday, 12/07/2015, and that the investigation did not start until she was in the facility that day. In an interview with the Administrator on 12/09/2015 at 4:20 PM, she stated the investigation for abuse should have started on 12/06/2015 after she received the allegation of abuse on 12/06/2015 at 11:36 AM. The Administrator explained that a skin assessment was not completed by the nurse on duty or the staff supervisor on Sunday, 12/06/2015, and that the investigation and assessment of the resident did not begin until Monday, 12/07/2015. The Administrator also stated she was so focused on another urgent staff problem that she did not recognize the reported incident to be abuse when it was first reported to her on 12/06/2015 at 11:36 AM. b) On 12/09/2015 at 10:30 AM, an interview was conducted with the Nursing Assistant #1 (NA #1), who was present during part of the alleged medication event of 12/05/2015. NA #1 stated that on 12/05/2015 she was seated in the common area where residents often sit to play games or watch television, and that she witnessed Nurse #1 attempt to give Resident #1 her medications from a cup using a spoon, but the resident refused, stating she was not going to take them. NA stated she could not remember exactly what Nurse #1 said to the resident after she refused the medicine, but that she was concerned about the situation because Nurse #1 told NA #2 to come across the hall to a vacant room to assist her with giving the medications. NA #1 stated that when NA #2 got up to assist Nurse #1, she told NA #2, Don't touch the resident, we do not hold hands. NA #1 explained she made the statement to NA #2 because only the nurse should give medications, and that a nursing assistant should not assist with meds or holding the resident's hands. An interview was conducted with the Unit Manager on 12/09/2015 at 10:56 AM. She explained that she was supervising the section of the facility where Resident #1 resided, and that no staff members reported to her any suspected abuse or a medication incident involving Resident #1 on 12/05/2015. During an interview on 12/09/2015 at 11:19 AM with the nursing assistant who was asked to assist Nurse #1 with the medication administration, NA #2, she stated that while she and 2 other nursing assistants were in the common area, she witnessed Nurse #1 attempt to give Resident #1 her medications which were crushed and mixed with food. NA #2 stated the resident was a little agitated that day and that she refused to take her medications. NA #2 stated that Nurse #1 then said to the resident, We can take it the easy way or the hard way. NA #2 explained that Nurse #1 asked her (NA#2) to come across the hall and hold the resident's hands while she gave the medications. NA #2 stated she then went with Nurse #1 and Resident #1 into a vacant room across the hall from common area. NA #2 confirmed that NA #1 told her not to hold the resident's hands down because that would be abuse. In an interview with NA #3 on 12/09/2015 at 2:21 PM, she stated that she was present in the common area on 12/05/2015 when Nurse #1 attempted to give medications to Resident #1. NA #3 stated that Nurse #1 crushed the resident's medication at the medication cart and mixed it with a food item, perhaps pudding (unsure which type of food) then approached Resident #1 with the medications and told her it was time to take them. NA #3 explained that Resident #1 shook her head side to side (to indicate no) and said clearly, I'm not going to take it. NA #3 stated that Nurse #1 tried again to give a spoonful of the medications to her, but the resident was agitated and that she refused to take them again, shaking her head, no and stating she was not to going to take them. NA #3 stated Resident #1 refused at least twice, perhaps three times. NA #3 stated Nurse #1 said, We can take it the easy way or the hard way. NA #3 stated she felt the statement was disturbing, but she did not report the statement to anyone at that time. In addition, NA #3 stated that she witnessed Nurse #1 and NA #2 come back out of the vacant room a short while later, and that Resident #1 had a pinkish stain on her sweater that had not been present when she was taken into the vacant room. NA #3 stated she was concerned about the resident because her behavior she did not look up as she was brought back into the common area. NA #3 stated she thought her expression was odd, so she went to the resident and asked her if she was okay, and the resident replied, You just don't want to know. NA #3 stated she knew she should have recognized the incident as suspected abuse and should have reported the incident on 12/05/2015 right after it happened, but that she did report it the next day. In an interview with the Director of Nursing on 12/09/2015 at 4:00 PM. She stated that she would expect for a staff member to report suspected abuse immediately or within a timely manner.

Based on record review and staff interviews, the facility did not provide medications in a dignified manner for 1 of 3 residents, Resident #1. Findings included: A review of the admission assessment dated [DATE] indicated that Resident #1 was re-admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. The same assessment revealed Resident #1 had short term and long term memory problems, had moderate impairment for making decisions regarding her daily tasks of life, and that she required extensive assistance with most of her activities of daily living. An updated assessment for Resident #1 dated 11/19/2015 revealed that she required limited assistance with eating, that she had no difficulties with swallowing, and that she had exhibited behavioral symptoms which included rejection of care. A review of the nursing care plan initiated on 11/19/2015 revealed Resident #1 had a measurable goal and interventions in place related to her behavior problems. One of the interventions included, Please approach me calmly, speak slowly, smile, and give me personal space when I appear to be upset. During an interview on 12/09/2015 at 11:19 AM with the nursing assistant who was asked to assist Nurse #1 with the medication administration, NA #2, she stated that while she and 2 other nursing assistants were in the common area, she witnessed Nurse #1 attempt to give Resident #1 her medications which were crushed and mixed with food. NA #2 stated the resident was a little agitated that day and that she refused to take her medications. NA #2 stated that Nurse #1 then said to the resident, We can take it the easy way or the hard way. NA #2 explained that Nurse #1 asked her (NA#2) to come across the hall and hold the resident's hands while she gave the medications. NA #2 stated she then went with Nurse #1 and Resident #1 into a vacant room across the hall from common area. NA #2 added that when she was in the room observing the medication administration, Nurse #1 explained to the resident why she needed to take her medication, then drew up the medication from the medication cup using a syringe and administered the medication by pushing the plunger on the syringe into Resident #1's mouth. In an interview conducted with Nurse #1 on 12/09/2015 at 12:21 PM, she stated that on 12/05/2015, Resident #1 was seated in the common area when she was going to administer her medications around 9:00 AM. Nurse #1 explained that she crushed Resident #1's medications, mixed them with applesauce, and then used a spoon to attempt to administer the medications to her. Nurse #1 added that the resident was agitated that day and that she refused to take her medications, making a face and saying, Yuck. Nurse #1 stated the resident never said, No. Nurse #1 stated that she said something to the resident similar to, I know this isn't easy, or, I know this is hard for you. Nurse #1 stated that after Resident #1 refused the medications, she left her in the commons area a while, then returned to try to administer the medications again. Nurse #1 stated the common area was very chaotic, so she asked NA #2 to take the resident to the vacant room across the hall to assist her as she gave the medications. Nurse #1 added that she did not use a syringe to administer the medications. She explained that the medications were already mixed with applesauce in a medicine cup due to her earlier attempt to administer the medications, and that she added thickened cranberry juice to the medications at that time in order to administer them. During an interview with Nurse #3 on 12/10/2015 at 2:38 PM, she explained that she provided care for Resident #1 frequently and that she had no problems with administering medications to Resident #1, and that she did not crush her medications because the resident had no problems with swallowing. Nurse #3 also added that the resident had documented behaviors, but that she did not have problems with Resident #1 refusing her medications. In an interview with the Director of Nursing on 12/09/2015 at 3:45 PM, she stated she would not expect a nurse to continue to attempt to give medication after it had been refused 2 or 3 times. She also stated that it was not the usual procedure to administer oral medications via syringe. A review of the 60-Day scheduled assessment revealed Resident #1 was re-admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. The same assessment revealed Resident #1 had short-term and long-term memory problems and had moderate impairment for making decisions regarding her daily tasks of life. The assessment also indicated that Resident #1 required limited assistance with eating and extensive assistance with most of her other activities of daily living, including personal hygiene, bathing, and locomotion on the facility unit. The resident was totally dependent upon staff for dressing, bed mobility, and transfers.

Based upon family, physician and staff interviews and record reviews, the facility failed to notify a resident ' s legal representative and physician of a wrist fracture requiring physician intervention for 1 of 3 Residents (Resident #1) with a change in condition. Findings Include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] indicated Resident #1 had a low mental status. She required limited to extensive assistance with ambulation, transfer and activities of daily living. Her balance was indicated as unsteady and she exhibited wandering behaviors. The care plan dated 9/7/11 indicated Resident #1 as a fall risk and exhibited episodes of wandering behavior. There were interventions documented for the fall risk and wandering behavior. A record review of the facility fall report for Resident #1 was conducted. It indicated a fall occurred on 9/13/11 at 3:30pm. There were no injuries indicated. Resident #1 vital signs were obtained. The contributing factors to the fall were decline in cognition. An interview with Nurse #1 on 9/28/11 at 3:00pm revealed she worked the day of the fall on 9/13/11. Nurse #1 indicated Resident #1 was unsteady and gets up frequently without her walker. Nurse #1 indicated her vitals were taken and the physician was notified the day of the fall. Nurse #1 checked Resident #1 from her toes up to her arms. She asked Resident #1 to wiggle her fingers. Resident #1 did not complain of pain. Nurse #1 did not notice any swelling or bruising. She indicated Resident #1 was monitored throughout the shift. A record review of the nurse notes was conducted. The nurse note dated 9/13/11 at 3:30pm indicated Resident #1 was found on the floor in the door way of room [ROOM NUMBER]. There were no injuries or pain indicated. At 8:10pm the Family Member #1 was notified of the fall. At 8:20pm the physician was notified of the fall and no new orders was indicated. The nurse note dated 9/14/11 at 2:10pm indicated the falls committee recommended keeping the resident in supervised areas when awake. It indicated Family Member #2 came to the facility that afternoon and saw Resident #1 wrist swollen. Family Member #2 wanted an x-ray of the left wrist. The physician was notified for an x-ray to be conducted on the left wrist and hand. The x-ray results were indicated as moderate [MEDICAL CONDITION] of the left hand but no fractures present. The results were reported to Family Member #1. An interview with Family Member #2 on 9/29/11 at 12:00pm revealed Family Member #1 was notified of the fall on 9/13/11 and was told there were no injuries. Family Member #2 visited the facility on 9/14/11 around 1:30pm. She noticed Resident #1 was sitting in a wheelchair across from the nurse station. Resident #1 was leaning over sweeping her hands across the floor. Family Member #2 bent over and barely touched Resident #1 left wrist to get her attention. Upon contact with the left wrist, Resident #1 yelled out " That hurts. " Family Member #2 then noticed the left wrist was swollen and misshapen. There was a bruise and cut on the elbow. The cut had dried up blood on it. She indicated to the Nurse to come over and view the wrist. The Nurse wanted to compare both wrists. Family Member #2 indicated the nurse decided not to implement anything for the wrist. Family Member #2 then requested an x-ray be conducted. The x-ray report was reported as negative for fractures to Family Member #1. Family Member #2 had then talked to Nurse #3 on 9/14/11 after the x-ray results. Family Member #2 felt there was something wrong with the wrist despite the x-ray results due to the increased swelling, bruising and pain. Family Member #2 indicated Nurse #3 reinterred the results only showed arthritis. Family Member #2 then requested the physician come by to see Resident #1 about the wrist. An interview with Nurse #3 on 9/28/11 at 3:28pm indicated Resident #1 family complained to her about the left arm being swollen and painful on 9/14/11. An x-ray was then requested around 6:00pm. The x-ray results came back around 8:00pm. Nurse #3 indicated she read the x-ray results. She only saw that Resident #1 had arthritis to the left hand. She called the family and notified them the results were negative. Nurse #3 revealed she had misread the results. She indicated when a positive or out-of-range test resulted, the physician should be called. The medication, Tylenol was given to Resident #1 due to the family had complained of pain. A record review of the x-ray report dated 9/14/11 indicated modest [MEDICAL CONDITION] of the left hand but no fracture or dislocation. The left wrist was indicated to have an acute fracture. An interview with Nurse #4 on 9/29/11 at 3:37pm revealed she was working the third shift on 9/13/11 and 9/14/11. Nurse #4 indicated she received a report from Nurse #3 that the x-ray results were negative for fractures. There was no description of her arm reported. Later the evening of 9/14/11, she was getting paper work prepared and came upon the x-ray report in the physician ' s mailbox. Nurse #4 saw the x-ray report and noticed there was a fracture present. She did not call the physician. She did report the fracture to the next shift Nurse, Nurse #2. Nurse #4 indicated she should have called the physician regarding the x-ray results. An interview with Nursing Assistant (NA) #1 on 9/28/11 at 5:36pm revealed she was working the second shift on 9/14/11. She indicated Resident #1 was sitting out in front of the nursing station throughout most of her shift. She noticed Resident #1 had been more agitated after her fall. An interview with NA #2 on 9/29/11 at 10:12am revealed she was assigned to Resident #1 for 9/13/11, 9/14/11, and 9/15/11 on day shifts. On 9/15/11 at 7:00am she noticed swelling and discoloration to the left arm. She reported this to Nurse #2. Resident #1 was eating lunch around 11:30am on 9/15/11. NA #4 saw a hot dog was placed in Resident #1 left hand. Resident #1 dropped the hot dog onto the plate as if she might have been in pain and could not hold the hot dog. The Nurse #2 note dated 9/15/11 at 10:30am indicated there was [MEDICAL CONDITION] to the left wrist. The color of the left wrist was purple and blue with warmth to the touch. The resident was brought back to bed. At 12:30pm Resident #1 was seen by the physician after reviewing the x-ray report. An order was sent for Resident #1 to go to an orthopedic clinic for a fracture to the left wrist. An interview with Nurse #2 on 9/28/11 at 3:21pm revealed a third shift nurse reported to her that an x-ray was obtained on Resident #1 arm on 9/15/11. There were no results reported to her regarding the x-ray. The third shift nurse also indicated to her the family had complained about Resident #1 left arm being painful and swollen. Nurse #2 then went to check Resident #1 arm. She indicated Resident #1 left arm was swollen and bruised. On 9/15/11, Nurse #2 noticed the physician was in use of Resident #1 medical chart and was viewing what appeared to be a piece of paper in his hand. She assumed that the Physician was probably looking at the x-ray report in his hand. She concluded the physician was going to see Resident #1 and did not report the physical changes in Resident #1 arm. She indicated the physician was there for his regular weekly visit. The physician did see her and noticed the x-ray report indicated a fracture. A record review of the facility 24-hour report was conducted from 9/13/11 through 9/15/11. There was an indication of a fall without injuries on 9/13/11. There was an indication of a negative result for the left wrist x-ray on 9/14/11. There was then an indication of a fracture to the left wrist during the day shift on 9/15/11. A record review of the physician progress notes [REDACTED].#1 had a fall two days ago and sustained an injury to her left wrist. There was swelling and tenderness with bruising. The physician indicated the x-ray showed a [MEDICAL CONDITION] radius. Resident #1 was to be sent to an orthopedic clinic for evaluation. The physician note dated 9/22/11 indicated Resident #1 has been more agitated since her fall. An interview with the physician on 9/28/11 at 4:37pm revealed he received an email of no injuries regarding the x-ray. He indicated he visits the facility every Thursday for his regular rounds. There were no reports to him regarding bruising, pain or swelling of the arm. Upon his regular visit, he pulled the x-ray report from his mailbox and saw Resident #1 had a [MEDICAL CONDITION] wrist. He visited Resident #1 for an examination of the left arm. He reported the arm was swollen with bruising. When he touched Resident #1 left arm, she snatched back her arm away from him. The physician sent Resident #1 to the orthopedic clinic after the examination. An interview with Family Member #1 on 9/28/11 at 5:05pm revealed Family Member #1 met with the Director of Nursing (DON) and Administrator on 9/27/11. They admitted to Family Member #1 that the x-ray results were misread. An interview with the DON on 9/29/11 at 12:32pm revealed she was notified of the fall on 9/14/11 by viewing the incident report. She indicated when there is a fall or injury; it should be reported on the incident sheet and to the physician. If an injury was noticed or suspected after the fall, an x-ray should have been obtained. When the x-ray reports are received with positive findings of a fracture, the physician should be contacted immediately.

Based upon staff, physician and family interviews and record reviews, the facility failed to identify, assess and report a fractured wrist for 1 of 3 Residents Sampled (Resident #1). Findings Include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum (MDS) data set [DATE] indicated Resident #1 had a low cognitive status. She required limited to extensive assistance with ambulation, transfer and activities of daily living. Her balance was indicated as unsteady and she exhibited wandering behaviors. The care plan dated 9/7/11 indicated Resident #1 as a fall risk and exhibited episodes of wandering behavior. There were interventions documented for the fall risk and wandering behavior. A record review of the facility fall report for Resident #1 was conducted. It indicated a fall occurred on 9/13/11 at 3:30pm. There were no injuries indicated. Resident #1 vital signs were obtained. The contributing factors to the fall were decline in cognition. An interview with Nurse #1 on 9/28/11 at 3:00pm revealed she worked the day of the fall on 9/13/11. Nurse #1 indicated Resident #1 was unsteady and gets up frequently without her walker. Nurse #1 indicated her vitals were taken and the physician was notified the day of the fall. Nurse #1 checked Resident #1 from her toes up to her arms. She asked Resident #1 to wiggle her fingers. Resident #1 did not complain of pain. Nurse #1 did not notice any swelling or bruising. She indicated Resident #1 was monitored throughout the shift. A record review of the nurse notes was conducted. The nurse note dated 9/13/11 at 3:30pm indicated Resident #1 was found on the floor in the door way of room [ROOM NUMBER]. There were no injuries or pain indicated. At 8:10pm the Family Member #1 was notified of the fall. At 8:20pm the physician was notified of the fall and no new orders was indicated. The nurse note dated 9/14/11 at 2:10pm indicated the falls committee recommended keeping the resident in supervised areas when awake. It indicated Family Member #2 came to the facility that afternoon and saw Resident #1 wrist swollen. Family Member #2 wanted an x-ray of the left wrist. The physician was notified for an x-ray to be conducted on the left wrist and hand. The x-ray results were indicated as moderate [MEDICAL CONDITION] of the left hand but no fractures present. The results were reported to Family Member #1. An interview with Family Member #2 on 9/29/11 at 12:00pm revealed Family Member #1 was notified of the fall on 9/13/11 and was told there were no injuries. Family Member #2 visited the facility on 9/14/11 around 1:30pm. She noticed Resident #1 was sitting in a wheelchair across from the nurse station. Resident #1 was leaning over sweeping her hands across the floor. Family Member #2 bent over and barely touched Resident #1 left wrist to get her attention. Upon contact with the left wrist, Resident #1 yelled out " That hurts. " Family Member #2 then noticed the left wrist was swollen and misshapen. There was a bruise and cut on the elbow. The cut had dried up blood on it. She indicated to the Nurse to come over and view the wrist. The Nurse wanted to compare both wrists. Family Member #2 indicated the nurse decided not to implement anything for the wrist. Family Member #2 then requested an x-ray be conducted. The x-ray report was reported as negative for fractures to Family Member #1. Family Member #2 had then talked to Nurse #3 on 9/14/11 after the x-ray results. Family Member #2 felt there was something wrong with the wrist despite the x-ray results due to the increased swelling, bruising and pain. Family Member #2 indicated Nurse #3 reinterred the results only showed arthritis. Family Member #2 then requested the physician come by to see Resident #1 about the wrist. An interview with Nurse #3 on 9/28/11 at 3:28pm indicated Resident #1 family complained to her about the left arm being swollen and painful on 9/14/11. An x-ray was then requested around 6:00pm. The x-ray results came back around 8:00pm. Nurse #3 indicated she read the x-ray results. She only saw that Resident #1 had arthritis to the left hand. She called the family and notified them the results were negative. Nurse #3 revealed she had misread the results. She indicated when a positive or out-of-range test resulted, the physician should be called. The medication, Tylenol was given due to the family had complained of pain. A record review of the x-ray report dated 9/14/11 indicated modest [MEDICAL CONDITION] of the left hand but no fracture or dislocation. The left wrist was indicated to have an acute fracture. An interview with Nurse #4 on 9/29/11 at 3:37pm revealed she was working the third shift on 9/13/11 and 9/14/11. Nurse #4 indicated she received a report from Nurse #3 that the x-ray results were negative for fractures. There was no description of her arm reported. Later the evening of 9/14/11, she was getting paper work prepared and came upon the x-ray report in the physician ' s mailbox. Nurse #4 saw the x-ray report and noticed there was a fracture present. She did not call the physician. She did report the fracture to the next shift Nurse, Nurse #2. Nurse #4 indicated she should have called the physician regarding the x-ray results. An interview with Nursing Assistant (NA) #1 on 9/28/11 at 5:36pm revealed she was working the second shift on 9/14/11. She indicated Resident #1 was sitting out in front of the nursing station throughout most of her shift. She noticed Resident #1 had been more agitated after her fall. An interview with NA #2 on 9/29/11 at 10:12am revealed she was assigned to Resident #1 for 9/13/11, 9/14/11, and 9/15/11 on day shifts. On 9/15/11 at 7:00am she noticed swelling and discoloration to the left arm. She reported this to Nurse #2. Resident #1 was eating lunch around 11:30am on 9/15/11. NA #4 saw a hot dog was placed in Resident #1 left hand. Resident #1 dropped the hot dog onto the plate as if she might have been in pain and could not hold the hot dog. The Nurse #2 note dated 9/15/11 at 10:30am indicated there was [MEDICAL CONDITION] to the left wrist. The color of the left wrist was purple and blue with warmth to the touch. The resident was brought back to bed. At 12:30pm Resident #1 was seen by the physician after reviewing the x-ray report. An order was sent for Resident #1 to go to an orthopedic clinic for a fracture to the left wrist. An interview with Nurse #2 on 9/28/11 at 3:21pm revealed a third shift nurse reported to her that an x-ray was obtained on Resident #1 arm on 9/15/11. There were no results reported to her regarding the x-ray. The third shift nurse also indicated to her the family had complained about Resident #1 left arm being painful and swollen. Nurse #2 then went to check Resident #1 arm. She indicated Resident #1 left arm was swollen and bruised. On 9/15/11, Nurse #2 noticed the physician was in use of Resident #1 medical chart and was viewing what appeared to be a piece of paper in his hand. She assumed that the Physician was probably looking at the x-ray report in his hand. She concluded the physician was going to see Resident #1 and did not report the physical changes in Resident #1 arm. She indicated the physician was there for his regular weekly visit. The physician did see her and noticed the x-ray report indicated a fracture. An interview with Nurse #2 on 9/28/11 at 4:30pm indicated she did not recheck Resident #1 left arm after her initial observation on 9/15/11. An interview with Nurse #2 on 9/29/11 at 9:32am revealed when she examined Resident #1 wrist around 8:00am on 9/15/11. The third shift nurse reported to her about the family complaints of pain, swelling and bruising of the left arm. Her examination of the arm involved looking at the left arm. She touched the front of the forearm and hand. This was documented on a 24-hour report. She indicated nurses communicate with each shift. Their reports are documented on the 24 hour report. The day shift nurse gets a new sheet at the beginning of the shift. When third shift approaches, the sheet is completely filled out and filed. A record review of the facility 24-hour report was conducted from 9/13/11 through 9/15/11. There was an indication of a fall without injuries on 9/13/11. There was an indication of a negative result for the left wrist x-ray on 9/14/11. There was then an indication of a fracture to the left wrist during the day shift on 9/15/11. A record review of the physician progress notes [REDACTED].#1 had a fall two days ago and sustained an injury to her left wrist. There was swelling and tenderness with bruising. The physician indicated the x-ray showed a [MEDICAL CONDITION] radius. Resident #1 was to be sent to an orthopedic clinic for evaluation. The physician note dated 9/22/11 indicated Resident #1 has been more agitated since her fall. An interview with the physician on 9/28/11 at 4:37pm revealed he received an email of no injuries regarding the x-ray. He indicated he visits the facility every Thursday for his regular rounds. There were no reports to him regarding bruising, pain or swelling of the arm. Upon his regular visit, he pulled the x-ray report from his mailbox and saw Resident #1 had a [MEDICAL CONDITION] wrist. He visited Resident #1 for an examination of the left arm. He reported the arm was swollen with bruising. When he touched Resident #1 left arm, she snatched back her arm away from him. The physician sent Resident #1 to the orthopedic clinic after the examination. A record review of medications revealed a physician order [REDACTED]. The order was changed 9/22/11 to 650mg four times daily. The indicated use for the medication was for pain. An interview with Family Member #1 on 9/28/11 at 5:05pm revealed Family Member #1 met with the Director of Nursing (DON) and Administrator on 9/27/11. They admitted to Family Member #1 that the x-ray results were misread. An interview with the DON on 9/29/11 at 12:32pm revealed she was notified of the fall on 9/14/11 by viewing the incident report. She indicated when there is a fall or injury; it should be reported on the incident sheet and to the physician. If an injury was noticed or suspected after the fall, an x-ray should have been obtained. When the x-ray reports are received with positive findings of a fracture, the physician should be contacted immediately.