Every finding on record at Edgewood Convalescent Home

Based on clinical record review, 2025 Disease Control and Prevention (CDC) Adult Immunization Schedule and staff interview, the facility failed to offer updated pneumococcal vaccination to 2 of 5 residents sampled (Resident #7 and #36). The facility identified a census of 41 residents.Findings include:1.Resident #7's Electronic Healthcare Record (EHR) Census Report showed he admitted to the facility on [DATE]. Resident #7 Pneumococcal Immunization Informed Consent signed by the resident on 7/16/24 documented the resident had a Pneumococcal Polysaccharide Vaccine 23 (PPSV 23) vaccination on 12/02/13. The Consent Form lacked documentation Resident #7 had received the Prevnar 13, Prevnar 20, or a pneumococcal conjugate vaccine (PCV) 15 vaccination.Resident #7's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating a severe cognitive loss. The MDS documented diagnoses of multiple sclerosis, high blood pressure, diabetes mellitus, hemiplegia/hemiparesis (paralysis or weakness on one side of the body), and obstructive sleep apnea (OSA, a disorder where the upper airway collapses during sleep causing breathing to repeatedly stop and start). The resident's admission Record revealed a diagnosis of chronic obstructive pulmonary disease (COPD, lung disease that causes airflow obstruction and breathing difficulties which can be complicated by lung infections). The MDS documented the pneumococcal vaccine had not been received and had not been offered.2. Resident #36's EHR Census Report showed she admitted to the facility on [DATE]. Resident #36's MDS dated [DATE] showed a BIMS score of 15 out 15 indicating intact cognition. The MDS documented diagnoses of intraspinal abscess (a collection of pus that forms within the body's tissues) and granuloma (inflammatory cells that form around the spine), anemia, high blood pressure, diabetes mellitus, stroke, paraplegia, anxiety disorder, depression, morbid obesity, and narcolepsy (a chronic neurological disorder that affects the body's ability to regulate sleep and is characterized by excessive daytime sleepiness). The MDS documented the pneumococcal vaccine had not been received and had not been assessed.A 9/23/25 review of the EHR Immunizations revealed Resident #7 received the Pneumococcal 23 vaccination on 12/02/13. Resident #36 received the Pneumococcal 23 vaccination on 11/18/16.A 9/24/25 review of Resident #7 and Resident #36 Clinical Records (Progress Notes, Assessments, Immunizations and Miscellaneous Records lacked documentation either resident had been offered an updated pneumococcal vaccination.During an interview on 9/24/25 at 11:30 AM the Interim Director of Nursing (IDON) reported they had reviewed Resident #36 medical record and could not find any documentation an updated pneumococcal vaccination had been offered. She voiced the facility had not offered an updated pneumococcal vaccination to Resident #7. The IDON voiced they would start looking at pneumococcal vaccinations annually. On 9/24/25 the IDON provided a Pneumococcal Vaccination Policy and stated the facility policy was to assess pneumococcal vaccination upon admission.The Pneumococcal Vaccination Policy revised 12/20/24 documented pneumococcal disease is known to lead to serious infections in the resident population (pneumonia, bacteremia (a condition where bacteria enter the blood that can be life threatening), meningitis (inflammation and swelling of the fluid and membranes around the brain and spinal cord) and because pneumococcal disease has proved resistant to antibiotics that were once effective in treatment, the facility would provide vaccination against pneumococcal disease to prevent the spread of infection. The Policy Procedure directed all persons, upon admission, would be assessed for receiving a PPSV and/or PCV vaccine and that current CDC recommendations as outlined in the policy would be followed. The Policy directed to administer an updated pneumococcal vaccination 15, 20, of 21 for all adults [AGE] years of age or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown.The 2025 CDC Adult Immunization Schedule specified Pneumococcal Vaccination age [AGE] years of age or older who have not previously received a dose of PCV 13, 15, 20 of 21 should receive one dose of PCV 15, 20 or 21. If they previously received only the PPSV 23, one dose of PCV 15, 20, 21 should be administered one year after the last PPSV 23 dose.

Based on record review, Facility Assessment review, and resident and staff interviews the facility failed to employ sufficient numbers of staff on the weekends to meet resident needs. The facility reported a census of 43 residents. Findings include: A review of the Centers for Medicare & Medicaid Services (CMS) PBJ Staffing Data Report revealed the facility triggered for excessively low weekend staffing for Quarter 3, 2024 (April 1-June 30). A review of the Edgewood Convalescent Home Shift assignment sheets from April 1st through June 30th, 2024 revealed required staff were absent for either partial or whole shifts as follows: First shift- Certified Nursing Aides (CNA) 23 days Second shift- CNA 19 days, Nurse 3 days Third shift- CNA 1 day In an interview on 10/30/24 at 9:25 AM Resident #2 expressed the facility needed more staff, especially CNA's on weekends. She noted there just didn't seem to be enough. In an interview on 10/30/24 at 9:32 AM Resident #21 verbalized they [the facility] needed more staff on the weekends. They treated her well but she has had several episodes of incontinence because she had to wait too long for them to come and help. They just run short on the weekends. In an interview on 10/30/24 at 10:13 AM Staff A, CNA reported she did not feel like they had enough staff during the weekend, and noted they can't get their normal tasks done during the day because of this. In an interview on 10/30/24 at 11:25 AM Staff B, CNA explained she did not feel they had enough staff on the weekends. When the facility was full, or even now, it was not enough. They did not have enough time to get everything done during the shift and didn't have the extra staff around like during the week. Toileting got missed the most. In an interview on 10/30/24 at 12:59 PM the Administrator explained the facility receives a sheet from Corporate that tells them how many staff they should have per resident. It is a document based off of the census, not acuity. Corporate utilizes the Facility Assessment to create the sheets that inform the staffing numbers. In an interview on 10/30/24 at 1:04 PM the Director of Nursing (DON) explained Corporate decided what staffing ratios should be, based on census, not acuity. The facility goes off of the staffing sheets sent to the Administrator. The Facility Assessment Tool, undated expressed the following: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. The intent of the Facility Assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. The facility assessment is used to inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill set necessary to care for residents' needs as identified through resident assessments and plans of care. Staffing needs for each shift and each unit area adjusted as necessary based on changes to the resident population. It instructed staff ratios to be the following: First shift- 2 nurses, 5 CNA's Second shift- 2 nurses, 5 CNA's Third shift- 1 nurse, 2 CNA's

Based on observation, clinical record review, insulin pen competency review, Novolog highlights of prescribing information (manufacturer's directions for use), and staff interview, the facility failed to prime the insulin pen with 2 units of insulin prior to the administration of the physician ordered dose of insulin for 1 of 1 residents observed for insulin administration (Resident #5). The facility identified a census of 48 residents. Findings include: Resident #5 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status score of 14 indicating intact cognition. The MDS listed a diagnosis of diabetes mellitus and documented Resident #5 received insulin injections 7 days per week. The Care Plan revised 8/25/23 noted a diagnosis of diabetes and directed the staff to check blood sugars and administer diabetic medications as physician ordered. The October 2023 Medication Administration Record (MAR) detailed the following physician orders: a. Novolog Solution 100 Units (u) per Milliliter (ml) inject 14 units subcutaneously (under the skin) before meals related to type 2 diabetes mellitus without complications. b. Novolog Injection Solution 100 u/ml inject as per sliding scale insulin (SSI): if 151 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units ; 401 - 450 = 6 units. Call the medical doctor if the blood sugar is greater than 400, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus without complications. An Order Summary Report signed by the Provider on 10/03/23 listed the following physician orders: a. Novolog Solution 100 u/ml inject 14 units subcutaneously before meals related to type 2 diabetes mellitus without complications. b. Novolog Injection Solution 100 u/ml inject as per sliding scale insulin (SSI): if 151 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units; 401 - 450 = 6 units. Call the medical doctor if the blood sugar is greater than 400, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus without complications. During an observation on 10/03/23 at 11:17 AM Staff A, Registered Nurse (RN) verbalized she would administer 14 units of Novolog insulin and 1 unit of Novolog SSI for a blood sugar of 167. Staff A reviewed the MAR orders and set the Novolog insulin pen to a total of 15 units and prepared to administer the insulin. At 11:24 AM the Surveyor stopped Staff A from administering the Novolog insulin flex pen. Staff A verbalized she didn't know what she had done wrong. Staff A referred to the Director of Nursing (DON) and asked what she had done wrong. The DON stated she needed to prime the pen with 1-2 units of insulin prior to setting the dose on the insulin pen. At 11:26 AM Staff A administered the correct amount of insulin to Resident #5. On 10/04/23 at 9:04 AM Staff B RN reported she received training by the facility on administration of insulin per pen. She explained the pen should be set to 2 units to prime the pen prior to setting the dial to the amount of insulin ordered by the physician. During an interview on 10/05/23 at 8:50 AM the DON reported she expected the nurses to follow the Insulin Pen Competency for proper priming of the pen. The undated Insulin Pen Competency provided by the facility directed the nurses in the following procedure: a. Prime the pen by dialing up 2 units of insulin. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. b. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero. c. If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and perform the test again. d. Make sure the window says 0 and then select the dose. The Novolog Highlights of Prescribing Information under priming the Novolog Flex Touch Pen instructed the following: a. Turn the pen dose selector to select 2 units. b. Hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top. c. Hold the pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. d. A drop of insulin should be seen at needle tip. If you do not see a drop of insulin repeat the priming steps, no more than 6 times. e. If you still do not see a drop of insulin, change the needle and repeat the priming steps. f. Turn the dose selector to select the number of units you need to inject.

Based on Continuous Quality Improvement Attendance sheets, policy review, and staff interviews the facility failed to have routine quarterly Quality Assurance and Performance Improvement (QAPI) meetings in the years of 2021 and 2022. In addition the facility failed to have the Medical Director attend 1 of 2 QAPI meetings held in 2021. The facility identified a census of 42 residents. Findings include: A review of the facility Continuous Quality Improvement (CQI) Attendance sheets completed on 6/8/22 revealed the facility held two QAPI meetings in the year 2021 on 8/31/21 and 9/30/21. The facility lacked documentation of a QAPI meeting held in the year 2022. The CQI Attendance sign-in sheet dated 8/31/21 documented that the facility held a QAPI meeting at 8:00 a.m. with the Medical Director, the Director of Nursing (DON), and two additional staff members as required. The CQI Attendance sign-in sheet for the QAPI meeting held on 9/30/21 lacked documentation of the Medical Directors signature for attendance. On 6/8/22 at 2:12 p.m. the Administrator reported that she started working at the facility in January (2022). The facility had a quality meeting in January with the Medical Director, but she didn't know that they needed to keep notes and have a sign-in sheet. The Administrator explained that they did miss the April 2022 quality meeting. She stated they developed an action plan and the Medical Director would come to the facility that week to get a quality meeting completed. The undated QAPI Plan Policy provided by the facility, documented the Administrator responsible and accountable to the board of directors and/or executive leadership for ensuring that QAPI is implemented throughout the organization. The Administrator is responsible for assuring that all QAPI activities and required documentation is provided to the governing body. All department managers, the Administrator, the Director of Nursing, infection control and prevention office, medical director, consulting pharmacist and up to three additional staff will provide QAPI leadership as the Quality Assessment and Assurance (QAA) committee. The QAA committee will meet monthly.

Based on clinical record reviews, staff interviews, and facility policy review the facility failed to offer Bed Hold agreements to 2 of 2 residents reviewed who transferred to the hospital (Residents #7 and #23). The facility reported a census of 42 residents. Findings include: 1. Resident #7's Minimum Data Set (MDS) assessment dated [DATE] documented a reentry date as 3/9/22 from an acute hospital stay. The electronic health record's (EHR) section reviewed on 6/9/22 indicated the following discharges with return anticipated to the facility on [DATE], 2/11/22, and 3/6/22. The MDS discharge assessment - return anticipated dated 12/29/21 indicated that Resident #7 discharged to an acute hospital. The MDS discharge assessment - return anticipated dated 2/11/22 indicated that Resident #7 discharged to an acute hospital. The MDS discharge assessment - return anticipated dated 3/6/22 indicated that Resident #7 discharged to an acute hospital. Resident #7's clinical record lacked documentation that she got offered a Bed Hold agreement to her or her family on any of the three discharges that resulted in an admission to the hospital. 2. Resident #23's MDS assessment dated [DATE] documented a reentry date of 4/6/22 from an acute hospital. The EHR section reviewed on 6/9/22 indicated the following discharges with return anticipated to the facility on [DATE] and 4/3/22. The MDS discharge assessment - return anticipated dated 2/22/22 indicated that Resident #23 discharged to an acute hospital. The MDS discharge assessment - return anticipated dated 4/3/22 indicated that Resident #23 discharged to an acute hospital. Resident #23's clinical record lacked documentation that she got offered a Bed Hold agreement to her or her family on any of the three discharges that resulted in an admission to the hospital. On 6/8/22 at 1:15 PM the Facility's Corporate Consultant reported that the facility had staff turnover in their office. The person in the office now didn't know of the requirement that all residents who transferred out of the facility due to an admission to the hospital must be offered a Bed Hold agreement to ensure their bed is held for their planned return to the facility after their hospitalization . The Facility Corporate Consultant acknowledged that neither Resident #7 or Resident #23 got offered a Bed Hold agreement for any of their hospitalization s. The undated Bed Hold Notice form provided by the facility informed residents and/or their families of their right to pay to have the residents bed held during their absence to ensure the resident had a bed for them at the facility after they returned from the hospital, or they could waive their right to pay to have a bed held.

Based on observations and staff interviews, the facility failed to store dishware properly, failed to maintain clean fans in dishware areas, and failed to maintain dishware in good condition for cooking. The facility reported a census of 53 residents. Findings include: During initial tour of the kitchen on 9/3/19 at 8:53 a.m., observations revealed the following concerns: a. A large fan in the dish room was covered by a mesh net which contained a large amount of fuzzy debris on the mesh netting blowing on clean dishes. b. The clean dish storage rack in the center of the kitchen contained two large, flat baking sheets and two large stainless steel bowls with dripping water between both items. c. The clean dish storage rack in the center of the kitchen contained a medium size Teflon skillet. The Teflon on the skillet was scratched, bubbled and peeling. During a kitchen re-visit on 9/4/19 at 12:55 p.m., observations revealed the following concerns: a. A large fan in the dish room was covered by a mesh net which contained a large amount of fuzzy debris blowing directly on two racks of clean dishes. b. The dish storage rack in the center of the kitchen contained a medium size Teflon skillet hanging that was covered by a large pot. The Teflon skillet was scratched, bubbled and peeling. A during a staff interview conducted on 9/4/19 at 12:57 p.m., the Dietary Supervisor, stated the fans are cleaned weekly according to the deep clean list and as needed. She also stated dishes should be allowed to air dry before being stored. On 9/4/19 at 1:00 p.m., the Dietary Supervisor confirmed the Teflon skillet was hanging on the dish rack inside another pot and could have been used. Interview with the Dietician on 9/4/19 at 1:27 p.m., confirmed the cleaning lists do not address the cleaning of fans. The Dietician stated the facility does not have policies or procedures on dish storage or cleaning.

Based on observation, record review, resident and staff interviews the facility failed to assure physician's orders were followed for 1 resident upon admission to facility (Resident #254). The facility reported a census of 53 residents. The Face Sheet for Resident #254 listed [DIAGNOSES REDACTED]. During an initial interview with the resident on 9/3/19 at 11:23 a.m., the resident reported she was admitted on [DATE] from the hospital. During review of the Physician's orders on 9/3/19 documentation shown the resident taking [MEDICATION NAME] Capsule (an antibiotic) 300 milligrams (mg), give 1 capsule by mouth two times a day with no stop date on order. Resident #254 also noted taking [MEDICATION NAME] Tablet (an antibiotic) 250 mg, give 1 tablet by mouth one time a day with a stop date of 9/3/19. Review of admission orders [REDACTED]. Two clarification orders dated 9/4/2019, directed to discontinue [MEDICATION NAME] after the morning dose on 9/4/19 and the [MEDICATION NAME] will be completed 9/3/19. During an interview with the Director of Nursing (DON) at 7:35 AM on 9/5/19, regarding expectations for physicians orders; she stated the admitting nurse, the nurse on the floor, or any nurse can note, transcribe, and put orders into the system. The DON expected the nurses would put orders in accurately and correctly. If there were any questions with orders, they would seek clarification and write the order. The DON reported Staff D, Licensed Practical Nurse (LPN) called the hospital to get clarification on 8/30/2019 for the end dates of the antibiotics, and indicated the end date for both antibiotics would be 9/3/2019. The hospital called back and spoke with Staff E, Registered Nurse (RN) regarding the clarification order. No clarification orders were written until 9/4/2019.

Based on observation and staff interview, the facility failed to ensure medications in the Emergency Drug Kit (E-Kit) current and not expired. The facility reported a census of 53 residents. Findings include: During an audit of the medication room from 2:,[DATE]:20 PM on [DATE], with Staff E, Registered Nurse (RN), revealed an E-Kit containing a variety of prescription medications for use until a prescription could be filled for an individual resident or in an emergency situation. Labeling on the outside of the locked container listed all medications stored in the container with no expiration date for the [NAME] Kit itself. A white sticker on the top of the [NAME] Kit documented a Pharmacist had checked the kit on [DATE] and identified the following three medications inside the kit were expiring ,[DATE]: a. [MEDICATION NAME] b. Quetiapine c. [MEDICATION NAME] kit The E-Kit was opened to check the expiration dates of the medications listed on the white sticker. The following medications contained in the kit were found to be expired: a. [MEDICATION NAME] 100 milligrams (mg.) 2 capsules with an expiration date of ,[DATE] b. [MEDICATION NAME] 250 mg. 3 tablets with an expiration date of ,[DATE] c. Quetiapine 25 mg. 4 tablets with an expiration date of ,[DATE] d. [MEDICATION NAME]/Clavonate ,[DATE] mg. one tablet with an expiration date of ,[DATE] e. [MEDICATION NAME] kit with an expiration date of [DATE] f. [MEDICATION NAME] 20 mg. one tablet with an expiration date of ,[DATE] During an interview on [DATE] at 2:15 p.m., Staff A, Licensed Practical Nurse (LPN) stated the Pharmacist checks the E-Kit at the end of every month for expired medication. Staff A stated anytime a medication is used out of the kit the pharmacy brings a whole new E-Kit to the facility. Staff A reported the E-Kit is usually secured with a green lock and when a medication is removed, the nurse puts a red replacement lock on the kit, faxes a copy of the medication and lock number sign-out sheet to the pharmacy, and then the pharmacy knows to come and replace the kit. During an interview on [DATE] at 7:30 a.m.,the Director of Nursing (DON), stated her expectation was that medications in the E-Kit are not expired. The DON stated all nurses should be keeping an eye on the expiration dates when getting in the kit as well as the Pharmacist that checks the kit.

Based on observation, policy review, and staff interview, the facility failed to utilize infection control techniques during incontinence/toileting care for 1 out of 2 residents reviewed (#15). The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS) with a completion date of 6/26/19 documented the resident independent with ambulation and transfers but needs supervision of one staff for toileting. A Brief Interview for Mental Status (BIMS) score of 15 indicated no cognitive impairment for decision-making. The MDS documented that the resident is occasionally incontinent of urine and frequently incontinent of bowels. During an observation at 1:40 PM on 9/3/19, Staff B and C both Certified Nurse's Aides (CNA's) entered the room. The resident had urinated a large amount on the floor of the bathroom and out into his roommate's part of the room. Staff B brought in 3 wash clothes to clean up the floor. She had the resident walk back to the toilet and sit down so he wouldn't fall in the urine. Staff B donned gloves, removed the resident's pants and brief that were wet, picked up all wet linens off the floor, placed them in a trash bag and took them out into the hall to the laundry hamper. Staff B returned to the resident's room with the same gloves still on. Staff B shut the room door, opened the resident's closet door, picked out a new outfit, turned on the light switch for the room lights, and touched the bathroom door to enter. It was noted that there was still urine on the floor so Staff B used hand towels to wipe it up. Staff B placed the wet linen in a trash bag, laid the trash bag on the resident's bed, turned his sheets down, then removed her gloves. Without performing hand hygiene, she walked to the window and closed the drapes then proceeded to dress the resident in clean pants, socks and shoes. Staff B pulled the resident's clean pants up over unwashed hips and buttocks and had him ambulate to his bed and lay down for incontinence care. Staff B removed the soiled shirt, pants, socks, and shoes in bed. Staff B completed cares, redressed resident in clean clothes and a clean brief. Care basin water dumped and placed in trash bag to store in the resident's nightstand. Staff B and C washed their hands before exiting the room. Review of a facility policy labeled Hand Hygiene, Center for Disease Control (CDC) Guidelines with an effective date of 8/1/17 directed hand hygiene should be performed after working on a contaminated body site and then moving to a clean body site on the same resident. Change gloves when moving from a contaminated body site to a clean body site on the same resident. During an interview on 9/5/19 at 7:30 a.m., the Director of Nursing (DON) stated the expectation is that staff will remove their gloves when moving from areas of dirty to clean, wash or sanitize hands after glove removal and not touch multiple surfaces in the resident's room with dirty gloves on.

Based on observation and staff interview the facility failed to ensure oxygen tanks were stored in a safe and secure manner. The facility census was 57. Findings include: During the facility environmental tour on 5/2/17 at 1:30 p.m., observation revealed the door to an oxygen storage room unlocked and slightly open. The facility Administrator stated at that time the door did not routinely get locked. Upon entering the room the temperature felt warm. The Administrator stated the room is directly over the boiler room and that's the reason for the room being so warm. At that time the surveyor left a thermometer in the room. At 1:55 p.m., observation revealed the thermometer in the room read 95.7 degrees Fahrenheit. The Administrator stated it would be difficult to leave the door to the room closed due to other equipment in the room that should not get too warm. The Administrator stated they had even put a fan in the room to try to cool the room. On 5/3/17 at 2:33 p.m., the facility Administrator stated the oxygen tanks would be moved to a different room which could be locked.

Based on observation and staff interview the facility failed to ensure all hazardous items were stored in a secured area. The facility reported a census of 54. Findings include: During the facility environmental tour on 5/22/16 at 10:21 a.m., the shower room at the end of the West hall had been left unlocked. Observation revealed the room under construction, with equipment on the floor which included a circular saw. At that time the facility Administrator stated the shower room should have been locked. The facility Director of Nursing stated during interview at 2:55 p.m., the facility had seven residents who were cognitively impaired and independently moved about the facility.

Based on observation and staff interview the facility failed to ensure a refrigerator with resident foods was maintained in a sanitary manner and foods in it were dated and labeled, failed to ensure all areas of the kitchen were clean and sanitizable, failed to ensure the quaternary solution used to sanitize food preparation surfaces was at an appropriate chemical level, and failed to ensure staff changed gloves appropriately during meal service. The facility census was 54. Findings include: 1. During the facility environmental tour on 5/22/16 at 10:21 a.m., observation revealed a refrigerator in the clean utility room with dried red drips on the inside bottom surface. The refrigerator had a small plastic container with watermelon that had no date or label, and a small plastic container with an unidentifiable food with no date or label. The refrigerator had dried food and a dried sticky substance on one of the shelves, with one of the plastic shelves being cracked and not sanitizable. The facility Environmental Supervisor stated during interview at 11:12 a.m., the refrigerator contained resident food and had been on a Wednesday cleaning schedule for the housekeeping department. The Environmental Supervisor stated staff should have cleaned up spills as they occurred. 2. During preparation of the lunch meal on 5/22/16 at 11:30 a.m., observation revealed a large stand mixer in the kitchen with peeling paint directly over the mixer bowl. At that time the facility Administrator stated the Maintenance staff had paint to resurface the areas of chipped paint on the mixer. During the same observation Staff A, Cook, used a rag from a red bucket of quaternary solution to sanitize a food preparation counter. At that time the surveyor asked Staff A to check the chemical level of the solution. Staff A held a strip in the bucket of solution for greater than ten seconds. The strip changed color to reflect 100 parts per million. At that time Staff A verified the solution should have been 200 parts per million to sanitize effectively. Staff A re-filled the bucket with fresh quaternary solution and tested it to be 200 parts per million. Staff A stated the bucket of solution had been re-filled within the past half-hour. Observation at that time revealed a vent over the steam table with food had a visible build-up of dust and debris. The facility Administrator verified they could see the build-up. During the same observation, Staff A dropped a pair of glasses on the floor. Staff A wore plastic gloves and picked the glasses up from the floor and without changing gloves, plated food on two resident lunch trays. During an interview immediately after the observation Staff A stated they should have changed their gloves after picking something up off the floor and before plating the food.

Based on observation and staff interview the facility failed to ensure resident clinical records were stored in a secure area. The facility reported a census of 54. Findings include: During the facility environmental tour on 5/22/16 at 10:21 a.m., observation revealed an office near the front lobby with the door open and no staff inside. In the office were three large file cabinets which contained resident records. All of the files sat unlocked in the open office. At 2:10 p.m., the facility Administrator stated the front office had usually been locked but staff let residents in to make phone calls. The Administrator stated they did not know why the files had not been locked.

Based on clinical record review and staff interviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for one of four residents reviewed. (Resident #1) The facility census was 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The Care Plan dated 1/6/16, identified the resident as at risk for falls related to a cognitive impairment and the use of antidepressant. The Care Plan directed staff to keep the resident's bed in low position, keep personal items and frequently used items within reach, transfer with a Hoyer lift and the assistance of two staff. The resident was non-ambulatory and required wheelchair assistance. The Certified Nursing Assistant plan of care, located in the resident ' s room, identified the resident to use a Hoyer lift transfer with the assistance of two staff. The document identified the resident as non-ambulatory and assist for positioning. The plan of care directed the staff that the resident used 2 half side rails on the bed. A physician progress notes [REDACTED]. It is not clear how it happened. The nurse ' s note identified that usually the resident was completely immobile in bed and required considerable assistance for transfers and really did not move around on their own. The notation indicated additional measures would be taken to prevent falls, namely lower the bed close to the floor at night. The physician notation identified the incident seemed to be a fluke. Nurse notes dated 1/13/16 at 12:10 a.m.; documented staff were called to the resident's room and found him/her lying on the floor next to the bed. An incident report dated 1/13/16, documented the nurse (Staff A) was called to the resident's room by certified nurse aide (Staff B) and found the resident lying on the floor next to the bed. Staff B reported she was doing cares and the resident rolled out of bed while Staff B was turning the resident. Staff A indicated the resident was laying on his/her left side in a fetal position. Staff A noted a deformity in the resident's right upper thigh, and indicated the area was tender to touch. Staff A noted the resident's fall was from approximately 4 feet from the bed to the floor. On 1/28/16 at 11:03 a.m., Staff B (certified nurse aide) was interviewed and stated she went to the resident's room on 1/13/16, during the overnight shift to provide personal cares. Staff B stated she lowered the side rail while providing cares and went to the opposite side of the bed, but did not put the side rail back in place. As Staff B attempted to reposition the resident he/she rolled and slid off the bed. Staff B stated she thought two staff should assist residents at all times, but admitted she provided cares to residents by herself. Staff B stated she thought another staff person was going to assist her, but she did not wait for help to arrive before initiating cares. On 1/27/16 at 1:22 p.m., the Director of Nursing stated it was her understanding that Staff B initially provided cares for the resident while the resident was laying on his/her right side. Staff B positioned the resident on his/her back and went to the opposite side of the bed, pulled the bed away from the wall and pulled on the soaker that was under the resident and the resident rolled right out of bed. The Director of Nursing stated she felt if the side rail had been in the proper position, it would have prevented the resident from rolling out of bed. On 1/27/16, Staff E (RCT) was interviewed and stated the resident required 2 staff members since now using a Hoyer lift. Staff E stated she could probably work alone with the resident but if rolled the resident over, then staff went to the opposite side of the bed and the side rail should be engaged and in place. Staff E stated she felt it would have prevented the resident from rolling out of bed. On 1/28/16 at 9:39 a.m., Staff F (RCT) was interviewed and stated she had never performed cares for the resident alone. Staff F stated the side rails would be in an up position but one staff on each side to roll resident back and forth. Staff F stated she had never cared for the resident alone. On 1/28/16 at 9:40 a.m. Staff G (RCT) was interviewed and stated she never provided cares alone with the resident. Staff G stated she could do with one person but needed to have the side rail in a proper position if only one person caring for the resident. On 1/28/16 at 9:51 p.m., Staff H (CNA) was interviewed and stated she would not be comfortable providing cares alone. Staff H stated it would be safer with 2 people when transferring the resident and she would have 2 people for all cares. Staff H stated if for some reason one staff did cares, definitely would have side rails in an up position. On 1/28/16 at 11:20 a.m., Staff D (CNA) was interviewed and stated 2 staff members usually worked with the resident. Staff D stated she had never worked alone with the resident. Staff D stated usually one staff person go in the room and get supplies ready but wait for the 2nd staff person to initiate cares and when turning the resident. The resident transferred to the emergency room where a closed fracture of the right femur was identified as a result of the fall.

Based on observation, clinical record review and staff interview, the facility failed to take in consideration two of 11 residents reviewed preferences when to rise and dress in the morning. (Resident #4 & #6) The facility census was 45 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #6 had a Brief Interview for Mental Status (BIMS) score of 6 indicating severely impaired cognition. The MDS assessment documented the resident required total assistance for transfers and wheel chair mobility and extensive assistance for bed mobility, dressing and hygiene needs. During observation on 7/7/15 at 6:20 a.m., Staff A, certified nurse aide, CNA and Staff B, CNA were in the residents room as the surveyor knocked and informed the staff they would like to observe cares for the resident. Staff A replied the resident was already done but it was not time to get the resident up yet. Observation revealed the resident was in bed with their eyes closed fully dressed. At 6:27 a.m., Staff A approached the surveyor and stated they were ready to get the resident out of bed now. Staff A and Staff B transferred the resident (fully dressed) using a mechanical lift to the wheel chair. 2. The MDS assessment dated [DATE], documented Resident #4 had a BIMS score of 5, indicating severely impaired cognition. The MDS assessment documented the resident required extensive assistance for Activities of Daily Living. During observation on 7/7/15 at 7:15 a.m., the resident was observed in bed and appeared to have a long sleeved print shirt on. Observation at 7:25 a.m., during medication pass, the nurse checked the resident's blood sugar and administered scheduled insulin. Observation reveled the resident to be fully dressed at the time. The Administrator observing at the time was asked why the resident was fully dressed. The Administrator stated if one staff person can get a resident cleaned up and dressed by themselves they may have to find a second staff person to transfer them. During observation on 7/7/15 at 8:10 a.m., staff assisted the resident up for breakfast and propelled the resident out of the room wearing the same clothing they had on at 7:15 a.m.

Based on clinical record review and staff interview, the facility failed to request a gradual dose reduction (GDR) of an antidepressant for one of four residents reviewed. (Resident #3) The facility census was 45 residents. Findings include: 1. The Minimum Date Set (MDS) assessment dated [DATE], identified [DIAGNOSES REDACTED]. The MDS identified the resident required assistance for activities of daily living. A Physician order [REDACTED]. The Care Plan dated 7/8/15, directed if status stable and physician agrees, may attempt to titrate medications every 12 months. Review of the Medication Review Sheet for the last 6 months lack any recommendation from the pharmacy to attempt a GDR. During interview on 7/8/15 at 12:35 a.m., the Director of Nursing (DON) reported not finding the Medication Review Sheet form from 2014. No recommendations from the pharmacy and the DON stated no GDR was done because the Physician did not one. During interview on 7/9/15 at 7:38 a.m., the DON reported the pharmacy should request a GDR on an anti-depressant with in the first 6 months a resident was in the facility then every year after. It was the pharmacy's job to request a GDR. During interview on 7/9/15 at 9:50 a.m., the DON reported the facility does not have a policy regarding gradual dose reduction.

Based on record review and staff interviews, the facility failed to provide adequate supervision and implement care plan intervention identified to prevent accidents for 1 of 4 residents reviewed (Resident #1). The facility used a bed/chair alarms to alert staff when Resident #1 had risen from their bed or chair. On 1/29/14, the alarm did not sound as staff did not have the cord plugged in. Resident #1 fell and fractured his/her hip, wrist and sustained a hematoma on their forehead. The facility reported a census of 53 residents. Findings include: According to the MDS (Minimum Data Set) dated 12/26/2013 Resident #1 had [DIAGNOSES REDACTED]. The resident had severe cognitive impairments skills necessary for daily decision making. Resident #1 required the assistance of one staff to transfer from one surface to another, ambulate, dress and use the toilet. The resident had unsteady balance during transitions and walking and required staff assistance to stabilize. Resident #1 used a wheelchair and walker for mobility. The MDS also indicated the resident had one fall since admission or prior assessment without injury. The Care Plan initiated on 7/1/2013, identified Resident #1 had a risk for falls related to history of fall, medication use, and need for assist with ADL's (Activities of Daily Living). The Care Plan instructed staff to provide a low bed, bed and chair alarms. On 2/5/14 staff were directed to use a motion sensor. The resident received anti-anxiety medication related to anxiety disorder and instructed staff to administer the medication and monitor adverse reactions including drowsiness, lack of energy, clumsiness, slow reflexes and impaired judgment. An Incident Report dated 9/13/2013 at 11:00 a.m., revealed Resident #1 rose from his/her low bed, stood up and took a few steps and fell hitting his/her head, and no other injuries. Staff B, LPN completed the report, and indicated the unwitnessed fall resulted in no injury. An Incident Report dated 10/22/2013 at 9:30 p.m. revealed Resident #1 fell (without injury) from the Merry Walker device when the seat clasp malfunctioned. Nurse's Progress Notes dated 12/23/2013 at 3:45 p.m. revealed Resident #1 could get his/her legs into and out of bed, but required assist of one to use the restroom. Nurse's Progress Notes dated 12/8/13 and 11/29/2013, identified Resident #1made multiple attempts to exit the bed by him/her(self). The Unwitnessed report dated 1/29/2014 at 9:30 p.m. revealed Staff A, Nurse, reported being called to Resident #1's room by a RCT (Resident Care Tech). The resident yelled "help me" repeatedly. The RCT found the resident lying on the left side guarding the left wrist and complained of pain when they attempted to roll the resident onto his/her back. The resident had an abrasion on the forehead with some bleeding noted. Staff A did an assessment, notified the resident's physician and family and transferred the resident to the emergency department via ambulance. The Hospital Emergency Department notes included Resident #1 had an unwitnessed fall out of bed from a height of 1 to 2 feet, landed on a hard floor. The resident had head pain, and pain in the left wrist and left hip. Radiology studies determined the resident had a mildly impacted, slightly laterally displaced fracture of the left radial metaphysis with swelling (wrist), intertrochanteric fracture of the left hip and old healed fractures of the pubic rami (pelvis), and a hematoma of the left temporal area (forehead). The resident had surgical repair of the left hip fracture and a splint applied to the left arm. The Hospital Discharge Summary dated 2/4/2014 reported Resident #1 had [DIAGNOSES REDACTED]. Nurse's Progress Notes dated 2/4/2014 the resident readmitted to the facility via ambulance with a splint on the left arm, bruise to the left forehead and tricep and staples to the left hip incision. The resident had non weight bearing status, a Foley catheter, and orders for hospice care. The facility used Secure Universal Alarm (product Model # SUA-1) designed for use as a pad alarm, seat belt alarm or personal alarm. The product information sheet instructed staff to: insert the metal pin of pad/seat belt being used into opening at top of alarm. Alarm will allow for normal movement. If resident gets off pad, the alarm will sound to alert staff. When resident gets back on pad, the alarm will automatically reset. The information sheet revealed the product is designed as a monitor, alerting the staff when the resident has risen from their bed or chair. During an interview on 2/18/2014 at 4:15 p.m., Resident #1's family member reported the resident had a bed sensor, they never saw the resident disconnect the alarm and they visited the resident earlier that afternoon, on 1/29/2014, and everything seemed fine. Observation on 2/18/2014 at 11:15 a.m. revealed Resident #1 in bed with a splint on the left arm, a wedge between the legs, call light within reach, and a bed alarm on. Observation on 2/18/2014 at 12:20 p.m. revealed three (3) RCT's transfer Resident #1 from the bed to the wheelchair with pressure alarm in place, and transported to the dining room. During an interview on 2/19/2014 at 3:11 p.m., the Administrator reported he/she did the investigation along with the DON when Resident #1 fell on [DATE]. Staff F, RCT failed to recall if he/she connected the alarm. Staff provided a low bed, alarms, medication and supervision to prevent falls. Staff E assisted another resident in a nearby room and heard the resident call for help, but failed to hear an alarm sound. The Administrator reported alarms malfunction at times. During an interview on 2/19/2014 at 2:00 p.m., the DON and the surveyor observed Resident #1 in bed with the bed alarm in place and the box at the head of the bed. The DON pulled the cord from the box and it sounded. The DON had to press the red, reset button three times to silence the alarm. The DON replaced the cord to activate it or turn it on. The DON said the night the resident fell , Staff A called and reported the incident and indicated the resident's alarm box sat on top of the night stand by the bed, without the cord plugged in. According to the DON, Staff A said Staff F thought he/she plugged it in, though not certain. When the resident returned from the hospital, they added a sensor alarm and implemented a new policy that required staff perform rounds together at the change of shift. The DON did not recall any other concerns regarding Staff F's job performance. Staff F received education and discipline as a result of Resident #1's incident on 1/29/2014. Maintenance replaces alarm batteries monthly and as needed. During an interview on 2/19/2914 at 3:50 p.m., Staff F, RCT reported working part time at the facility, and worked from 4 - 9 p.m. on 1/29/2014. Staff F revealed he/she assisted Resident #1 to bed that night around 7:45 p.m. and recalled placing the bed in low position, covering the resident up, removing the alarm box from his/her pocket and putting it on the bedside table. Staff F had no memory if he/she connected the box to the pressure pad on the resident's bed. Staff F had no further observations of the resident that night. In the past, Staff F observed the resident rise from the bed and the alarm functioned. The box had no on and off switch, only a reset button on the side of the box, and when the cord is connected, it functions. Staff F revealed the resident had no history of disconnecting the alarm. Staff F said he/she most likely failed to connect the cord to the box. After the incident Staff F received education regarding alarms. The facility now purchases alarm boxes with an on and off switch. During an interview on 2/18/2014 at 3:00 p.m., Staff A, RN (registered nurse) reported working second shift, from 2 - 10 p.m. on 1/29/2014. At approximately 9:30 p.m., Staff E, RCT called Staff A to Resident #1's room. Staff A observed the resident on the floor, lying on the left side, said "help me" and complained of pain in the left leg and left arm. Staff A observed the resident's bed in the low position, call light tied to the hand rail and a pressure alarm on the bed and not plugged into the alarm box. Staff A observed the alarm box on top of the night stand next to the bed. Staff A reported when staff insert the cord into the alarm box, the alarm is "on". That night Staff A reported the incident to Staff F, Resident #1's assigned RCT and he/she appeared upset but failed to say anything. Staff A said the resident never attempted to disconnect the alarm to his/her knowledge. On occasion, Staff A observed the resident rise from the bed and stand, even with the bed in low position. Since this incident, staff goes room to room and checks alarms at the change of shift. During an interview on 2/18/2014 at 3:15 p.m., Staff E, RCT reported working from 2-10 p.m. on 1/29/2014 on South. At approximately 9:15 - 9:30 p.m. he/she heard Resident #1 calling for help, but failed to hear an alarm sound. Staff E responded to the resident's call for help and observed the bed alarm not plugged in. Staff E observed the cord on the floor with no box attached and the resident lying on the floor facing the door, approximately four feet from the bed. Staff F, assigned to the resident, put him/her to bed. At the time the resident required assistance of one staff to transfer. In the past, Staff E observed the resident rise from the low bed independently, sounding the alarm. The resident had a previous fall with no injury from the Merry Walker when the belt unbuckled. During an interview on 2/18/2014 at 3:45 p.m. Staff G, RCT reported working on 1/29/2014 from 2-10 p.m. At approximately 3 o'clock p.m. Staff G assisted Resident #1 to the bathroom and back to his/her Merry Walker. Staff G saw her again at the supper table. Staff F assisted the resident to bed that night. On other nights, when Staff G put the resident to bed, he/she placed the alarm box on the Velcro strip on the night stand. The alarm cord could reach it, but the resident could not. Staff G never entered the resident's room that night and never heard the alarm sound. The alarm sounded every time the resident made any little movement. Staff G never witnessed the resident "mess" with the alarm. In the past, Staff G witnessed the resident sit up in bed, or put a leg over the side of the bed and the alarm sounded. The resident failed to use the call light. During an interview on 2/19/2014 at 9:27 a.m., Staff B, LPN reported working restorative. Staff B reported checking resident alarms routinely, and Resident #1's alarm functioned correctly. The resident had a low bed, but could rise from it. The resident had bed and chair alarms in place prior to the fall on 1/29/2014, and they added a motion sensor alarm after that fall. Staff placed the alarm box on the floor out of reach or on the Velcro strip at the side of the night stand, out of reach. No staff ever reported the resident ever attempted to take the alarm apart. If the resident sat up in bed, the alarm sounded. If the box had the cord attached, it functioned. The surveyor and Staff B observed the resident seated in the wheel chair at the front lounge visiting. Staff B pulled the alarm cord from the box and it sounded. When Staff B inserted the cord, it silenced. The box had no on and off switch, but a black button on the side of the box that staff needed to press to reset it. During an interview on 2/19/2014 at 12:05 p.m. Staff D, RN reported working the day shift on 1/29/2014. Staff D reported the Resident #1 had very few behaviors at that time, spent most of the day shift in the Merry Walker other than meal times and had no recall of his/her alarm not functioning correctly, and no reports from staff.

Based on observation, manufacturers recommendation review, and staff interview, the facility failed to follow manufacturers recommendations for sanitizing surfaces in order to prevent transmission of disease. The facility census was 44 residents. Findings include: 1. During observation on 1/23/13 at 8:52 a.m., staff completed personal cares to Resident #3. Observation revealed bowel movement was left on the toilet seat in the resident's bathroom and an approximate 1/2 inch diameter area of bowel movement was on the bathroom floor in front of the toilet as the resident exited the room. At 9:28 a.m., housekeeping was paged to come to Resident #3's room. Observation at 9:30 a.m., revealed Staff A, Housekeeper proceeded to the resident's room with a mop and bucket. Staff A reported a disinfectant was in the water to mop the floor. Staff A assessed the bathroom and noted the bowel movement on the toilet seat and reported they needed to get a spray bottle of disinfectant to spray on the toilet seat. At 9:35 a.m., Staff A returned with a spray bottle of HDQ Neutral Disinfectant. Staff A thoroughly sprayed the top surface of the toilet seat till wet and wiped the seat off with a cleaning towel in less than 30 seconds. Staff A sprayed the underside of the toilet seat till wet and wiped the seat off in less than 30 seconds. Staff A took the mop out of the bucket and washed the entire floor and left the floor wet to dry and left a wet floor sign at doorway entrance. During interview on 1/23/13 at 9:40 a.m., Staff A reported the mop bucket would be emptied out and the mop head replaced after used to clean the resident's bathroom and before cleaning more rooms. Staff A was not sure if there was a contact time when using the HDQ Neutral Disinfectant product. During interview on 1/23/13 at 9:43 a.m., Staff A returned with a gallon sized bottle of the HDQ Neutral Disinfectant cleaner. Staff A reviewed the label on the bottle and reported the contact time per label directions indicated 10 minutes. During interview on 1/23/13 at 9:45 a.m., the Environmental Services Supervisor (ESS) reported the contact time for the HDQ Neutral Disinfectant was 10 minutes. The ESS stated all housekeepers were trained on the contact time at the annual staff meeting. Review of the Super HDQ Neutral Disinfectant label described the product as a one-step disinfectant, germicidal detergent and deodorant. Further review of the label indicated the product as a disinfectant, mildewstat, fungicide, and virucide. The directions on the label stated a 10-minute contact time found to be effective on viruses. Preparation of disinfection/fungicidal/virucidal solution directed staff on sprayer application to spray 6-8 inches from surface, rub with a brush, cloth or sponge. Treated surfaces must remain wet for 10 minutes. Wipe off excess liquid and allow to air dry.

Based on record review and staff and family interviews, the facility failed to adequately supervise Resident #1 to ensure against hazards from self and the environment and the health service supervisor failed to supervise the implementation of the care plan to prevent the resident from falling. The sample consisted of 4 residents and the facility reported a census of 43 residents. Findings include: 1. Resident #1 had an MDS with a reference date of 06/20/2012 which revealed Resident #1 had moderately impaired cognitive skills for daily decision making, poor; cues and supervision required, required extensive assistance of two staff to transfer, ambulated in the corridor and use the toilet, used mobility devices including a walker and wheelchair and had [DIAGNOSES REDACTED]. The MDS reported no falls since admission, entry or re-entry, or prior assessment. The Fall Report dated 07/21/2012 indicated Resident #1 fell at 7:20 p.m. during an attempt to self-transfer from the wheel chair to the recliner, fell and landed on buttocks. Staff added to the care plan that the resident needed to be in the recliner or bed when in room. The Nurse's Notes dated 07/21/2012 at 7:30 p.m. indicated the resident was found by the RCT (Resident Care Tech). The resident sat on the floor and stated he/she tried to transfer self from the wheelchair to the recliner. The resident could move all extremities and denied pain at that time. A Resident #1's Care Sign dated 7/22/2012 directed staff with instructions for the resident to sit in the recliner or lay in bed. On 07/21/2012 the Communication Book directed staff not to leave Resident #1 in the wheel chair unattended in room, must be in recliner or bed; the resident fell . The Fall Report dated 09/01/2012 reported Resident #1 fell at 5:30 p.m., the aide got the resident ready for supper, heard a noise and found the resident on the floor on left side. The resident offered no complaints. The resident had a skin tear to the left elbow. On 09/02/2012 the resident transferred to the hospital for x-rays do to left hip pain. All nursing staff received education on reading and following the care signs and communication book. The Nurse's Notes dated 09/01/2012 at 5:30 p.m. indicated Staff A documented the staff found the resident on the floor on the left side next to the wheel chair and had a skin tear to the left elbow. The resident reported soreness "all over". Staff assessed the resident, obtained vitals, applied a steri strip to the left elbow and contacted the physician. At 8:30 p.m. Staff A staff documented the resident had normal range of motion, continued to complain of "sore all over". Staff A explained to the resident he/she didn't think the resident had a fracture since he/she could bear weight, complete range of motion, and denied pain specifically to the left hip. The resident now yelling that the left hip painful when simply sitting and yelling out at times, not appropriate with ambulation occurring at that time. Staff A indicated he/she continued to monitor and passed information on to the next shift. The Nurse's Notes dated 09/02/2012 at 1:15 a.m., indicated Staff L, LPN (Licensed Practical Nurse) reported Resident #1 had a skin tear with bloody discharge without bruising from the fall and the resident starts yelling with pain before staff touches or goes to move him/her. The resident moves all extremities per self as normal, and able to communicate needs. The Nurse's Notes dated 09/02/2012 at 7:45 a.m., indicated Staff J, LPN reported the resident screamed with left hip pain when staff up for shower and failed to stand. Staff J updated the physician and re-assessed the resident when back in bed. The resident had breakfast and staff assisted the resident back to bed, the resident screamed when staff lifted the left leg, and Staff J informed the physician and received an order to transfer the resident to the hospital. At 12:30 p.m. the resident returned from the hospital with new orders for pain medication. The Radiology report dated 09/02/2012 reported Resident #1 had bilateral hip pain and fell last evening. The hip and pelvis x-ray report revealed: Impression - moderately displaced left femoral neck fracture with superior migration of the distal fragment and increased apical lateral angulation at the fracture site, no other definite acute fracture, degenerative changes, and diffuse osteopenia. The hospital emergency room Report dated 09/10/2012 reported Resident #1 admitted to the emergency room with fever and dyspnea. The Care Plan with a run date of 06/27/2012 and updated revealed Resident #1 had problems including: 1. Cognitive impairment, forgetful/occasionally confused, takes anti-depressant, hard of hearing, glaucoma, dementia, to amputated and slow to heal wounds. The Care Plan directed staff to provide re-orientation, administer anti-depressant and eye drops, speak louder and clearly, and offer calm reassurance. 2. ADL (Activities of Daily Living) impaired: needs one to assist to transfer/ambulate, uses walker/gait belt, needs help with grooming/dressing/toileting. The Care Plan directed staff to provide half side rails, encourage assistance as necessary to turn and reposition in bed, uses urinal during night, assure call light is within reach and assist with dressing and cares and provide baths weekly. 3. Potential for Falls related to peripheral vascular disease, weakness, lower extremity pain, wound to right foot and amputation of toe, wears open toe shoes, gets dizzy and has poor balance at times, and fracture right lower extremity. The Care Plan directed staff to provide a clutter free environment, encourage to sit back down if dizzy, monitor blood pressures, elevate leg/foot on pillow as tolerated when up in chair, wear open toe shoe, assess heel, lintex mattress to bed, in the event of a fall provide first aid as needed, assess causes and prevention, notify physician and power of attorney. On 07/22/2012, staff added don't allow resident to sit in room in wheel chair alone, assist to recliner or bed. Staff crossed out "for extended periods of time" and initialed the correction dated 07/22/2012. On 09/13/2012 the physician dictated a note to the facility identifying Pneumonia as the immediate cause of death, as a result of immobility caused by the hip fracture. The fracture was a result of progressive decline in functional and mental status, with multiple contributing causes, terminal status with no hope of recovery or improvement in functional capacity or quality of life long before the hip fracture. The hip fracture could not be aggressively managed due to co-morbidities and poor pre-existing functional status, therefore the hip fracture hastened what was a slow decline to death. During a telephone interview on 09/18/2012 at 2:00 p.m., Resident #1's family member reported the facility works short of help a lot, they knew not to leave the resident in the wheel chair alone in the room and the resident had one other similar fall. After the fall on 09/01/2012 the resident had a lot of pain, kind of snowed from the medicine and remained in bed a lot. The family member stated the resident ended up back at the hospital and passed away. On 09/18/2012 at approximately 10:10 a.m., the Administrator was interviewed and reported Resident #1 had no alarm on the wheel chair and liked to putter around with things in the room. The resident had a previous fall in July from the wheel chair. The fall occurred in the room and the intervention added directed staff to not leave him/her alone in the wheel chair in the room. Initially the resident had no complaints of pain and then later reported hip pain and staff sent the resident to the emergency room the next day. The resident returned without repair, but orders for pain medication and no weight bearing. The resident began running a temperature and returned to the hospital on comfort measures and passed away due to multi system failure. After the fall on 09/01 they provided re-education to staff reminding them to read the care cards in the room and the communication book. Every day when the aides report to work they go into the clean utility room to get their assignments and read the communication book. During an interview on 09/19/2012 at approximately 1:00 p.m. the DON (Director of Nursing) reported instructing new hires to read the care cards and communication book during the initial tour of the facility. The nurse's listen to report when they get to work and then pass on pertinent information to the aides. Staff tapes report, and have no overlap in shifts. During an interview on 09/18/2012 at 4:00 p.m. the DON reported Staff B, CNA (Certified Nurse's Aide) admitted he/she left Resident #1 in the room seated in the wheel chair. Staff B had no other disciplines on file and had a good work history the previous couple of years. Staff B resigned after the incident. The facility requires all nursing staff read the communication book daily. On 09/01/12, Staff B and Staff C assisted the resident up from bed and transferred to the wheel chair. Staff C went to help other residents while Staff B completed the resident's cares. Shortly after, they heard a noise in the resident's room and found him/her on the floor. The resident's health had a steady decline related to poor health. The DON provided staff education again to make sure all staff knew to read the care cards in resident rooms and the communication book. On 09/01/12 the facility had 48 residents with two nurses and four aides on the second shift. During a phone interview on 09/19/2012 at 8:45 a.m., Staff A, RN (Registered Nurse) reported on 09/21/2012 just before supper staff paged him/her to Resident #1's room. Staff B and C, were in the room and the resident lay on the floor on his/her left side after falling from the wheel chair. At that time the resident complained of pain all over and no complaint of left hip pain. After supper when staff assisted the resident to bed, he/she complained of back pain. Staff knew not to leave the resident alone in the when chair in the room after the first fall occurred in July. Typically staff parks the resident in the hall or at the lounge for closer supervision. During a phone interview on 09/18/2012 at 11:25 a.m., Staff B, CNA reported working 09/01/2012 on second shift. Staff B and Staff C assisted Resident #1 up from bed and to the wheel chair before supper. Staff C, a new employee would not have known the resident should not stay in the wheel chair in the room unsupervised. The care plan instructed staff to have the resident in bed or recliner when in the room, and did not say not to leave in wheel chair alone in room. The Communication Book directed staff the resident needed to be out of the room when in a wheel chair after the first fall. Staff B and C left the resident in the wheel chair in front of the television in the room. Normally Staff B placed the resident in the hall before supper; Staff B stated he/she forgot. The resident had difficulty transferring, and not expected to get up on his/her own. Staff B reported observations of other staff leaving the resident in the room unattended while in wheel chair. During a phone interview on 09/18/2012 at 11:00 a.m., Staff C, CNA reported working at the facility for a couple of weeks. On 09/01/2012 Staff B needed help transferring Resident #1 to the wheel chair. Staff C assisted Staff B to transfer the resident and returned to his/her duties. A short time later, approximately ten minutes later, they heard a noise and they found the resident on the floor. The wheel chair sat in the middle of the room and the resident lay up against the wall. It appeared the resident took a step. Each room has a paper informing staff of transfer assistance, alarms, etc. Staff C never saw Resident #1's prior to the fall, and did not know the papers were there until after the fall. Staff C orientated and worked day shift, but picked up the extra hours that day since another staff called in. Staff A told Staff C to make sure to check the Care Cards after the fall. During an interview on 09/18/2012 at 2:50 p.m., Staff F, LPN reported working on 09/01/2012 when Resident #1 fell , but on another wing. The resident's Care Card in the room directed staff not to leave him/her alone in the room if in the wheel chair due to a prior fall. Any nurse can update the Care Card. During an interview on 09/18/2012 and 09/19/2012 Staff E, I, G, K, and M CNA's reported they knew not to leave Resident #1 alone in the room in the wheel chair, and they knew to read the Care Card in resident rooms and the Communication Book.

Based on observation, product information review and staff interview, the facility failed to secure hazards to ensure the resident environment remained free of accident hazards. The facility census was 52 residents. Findings include: During initial tour of the facility on 1/03/2012 at 11:00 a.m. the west hall tub room revealed an unlocked door which contained the following hazard in an unlocked cupboard: 1. One 101.4 fluid ounce container of Cen-Kleen IV cleaner 1 step disinfectant (an ammonium type disinfectant). A cautionary label on the product stated: Keep out of reach of children. Danger. The right side of the cupboard revealed a locking mechanism and the cupboard locked and the left unlocked side held a key on the knob of the unlocked left cupboard. When interviewed at the time of the facility tour, Staff B, licensed practical nurse (LPN), said the cupboard needed locked at all times. An interview with Staff B on 1/03/12 at 11:30 a.m. revealed 7 residents as up without assistance on the west hall. Review of the resident tour information revealed six of the seven residents as cognitively impaired.