Every finding on record at Fair Meadow Nursing Home

Based on observation, interview and document review, the facility failed to ensure dependent residents received timely toileting for 2 of 2 residents (R32, R33) reviewed for activities of daily living (ADLs).Findings include:R32R32's quarterly Minimum Data Set (MDS) dated [DATE], identified R32 had severe cognitive impairment and had diagnoses that included Alzheimer's disease, anxiety and dementia. R32 was dependent on staff for toileting.R32's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 1/2/26, identified R32 would be assisted to bed using a full body mechanical lift and R32's incontinence brief would be checked/changed every 2 hours.R32's care plan revised 1/2/26, identified R32 had bladder incontinence related to Alzheimer's dementia. The care plan directed R32 would be transferred into bed using a fully body mechanical lift with a check/change every 2 hours.The facility untitled toileting sheet dated 8/31/26, identified R32 was to have a check and change every 2 hours a.m./p.m. and twice at night. During a continuous observation on 8/31/26 at 1:03 p.m., nursing assistant (NA)-A and NA-C assisted R32 into bed using the full body mechanical lift. R32's incontinence brief was dry. NA-A and NA-C positioned R32 on her right side and covered R32 with a blanket before lowering R32's bed to the lowest position.At 4:11 p.m., NA-A and NA-B entered R32's room and told R32 it was time to get ready for supper. R32's incontinence brief was saturated with urine and R32 had a small bowel movement. NA-A and NA-B provided incontinence care before transferring R32 into her wheelchair using the full body mechanical lift. At 4:21 p.m., NA-B assisted R32 to the dining room.The facility untitled toileting sheet dated 8/31/26 identified R33 was checked/changed at 12:35 p.m., 2:27 p.m., and 4:20 p.m.R33R33's significant change MDS dated [DATE], identified R33 had severe cognitive impairment and diagnoses included Alzheimer's disease, chronic kidney disease and anxiety. R32 was dependent on staff for toileting.R32's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 7/21/26, identified R33 had bladder incontinence related to chronic kidney disease. R33 required a fully body mechanical lift to transfer and routine check/change assistance with incontinence care. R33 was to be offered a bed pan when appropriate. R33's care plan revised 8/2/26, identified R33 had bladder incontinence related to chronic kidney disease, decreased mobility, and dependence for transfers. R33 required a full body mechanical lift for transfers and received routine check and change assistance with incontinence care or was to be offered a bedpan when appropriate. However, the care plan failed to address R33's check/change frequency. R33's Tissue Tolerance Monitoring dated 7/21/26, identified R33 used a bedpan if requested and when staff offer. Staff were to offer every 2 hours in the a.m./p.m. and twice at night. Otherwise, staff were to check and change.During a continuous observation on 8/31/26 at 12:30 p.m., NA-C approached the nursing desk and R33 raised her right hand and asked to be taken back to her room. NA-C pushed R33's wheelchair into R33 room and placed R22 in front of the tv. NA-C gave R33 her call light, water and tv remote before telling R33 NA-C would be back in a few minutes. NA-C stated R33 had been a sit to stand lift transfer but R33 had become uncooperative and was now a full body mechanical lift transfer. At 12:51 p.m., R33 turned on her call light. NA-C and NA-A entered R33's room and transferred R33 to the bedside commode with assist of two and a grab bar on R33's room wall.At 12:57 p.m., NA-A and NA-C transferred R33 back into R33's wheelchair by assist of two and the grab bar.At 12:58 p.m., NA-A and NA-C assisted R33 into her recliner using a full body mechanical lift.At 2:38 p.m., licensed practical nurse (LPN)-A entered R33's room and spoke with R33, however, LPN-A did not offer toileting. At 3:02 p.m., NA-B passed the snack cart and gave R33 a glass of juice and a cookie. However, NA-B did not offer R3.3 toileting. At 4:24 p.m., NA-A and NA-D transferred R33 from R33's recliner to R33's wheelchair then transferred R33 onto the bedside commode with assist of two and the grab bar. R33's incontinence brief was saturated with urine and R33 immediately voided into the commode.During an interview on 8/31/26 at 4:40 p.m., NA-A stated R32 and R33's toileting times were documented on the toileting sheet and NA-A went by the time written. R32 was last toileted at 2:30 p.m. and was toileted timely at 4:20 p.m. even though there was no observation of R32 was offered toileting at 2:30 p.m. During an interview on 8/31/26 at 4:45 p.m., LPN-A stated staff were expected to provide timely toileting to incontinence and skin breakdown.During an interview on 8/31/26 at 4:45 p.m., the director of nursing (DON) stated staff were expected to provide timely toileting to prevent skin breakdown and to promote comfort.During an interview on 8/31/26 at 12:44 p.m., the administrator stated staff were expected to follow the resident's care plan to ensure residents received the care they required.

Based on observation, interview and document review, the facility failed to ensure dependent residents received timely repositioning for 2 of 2 residents (R32, R33) reviewed for pressure ulcers.Findings include:R32R32's quarterly Minimum Data Set (MDS) dated [DATE], identified R32 had severe cognitive impairment and had diagnoses that included Alzheimer's disease, anxiety and dementia. R32 was at risk for pressure ulcers.R32's care plan revised 1/2/26, identified R32 had moderate risk for pressure ulcer development r/t limited sensory perception, chairfast, limited mobility, inadequate nutritional intake, and need for moderate to maximum assistance for movement. Staff were directed to: Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Follow facility policies & protocols for the prevention & treatment of skin breakdown. I require a regular pressure reducing mattress on my bed and a foam pressure relieving cushion in my tilt in space wheelchair. I require the bed as flat as possible to reduce shear. Inform me/family/caregivers of any new area of skin breakdown. Treat pain as per orders prior to transfer and turning if present to ensure my comfort. The care plan failed to identify how often R32 should be repositioned to prevent skin breakdown.R32's Tissue Tolerance Monitoring dated 1/2/26, identified R32 was at moderate risk for pressure ulcer/injury. R32 was to be checked/changed every 2 hours a.m./p.m. and twice at night. During a continuous observation on 8/31/26 at 1:03 p.m., nursing assistant (NA)-A and NA-C assisted R32 into bed using the full body mechanical lift. NA-A and NA-C positioned R32 on her right side and covered R32 with a blanket before lowering R32's bed to the lowest position.At 4:11 p.m., NA-A and NA-B entered R32's room and told R32 it was time to get ready for supper. NA-A and NA-B assisted R32 to R32's wheelchair using a full body mechanical lift. R32's skin was intact.R33R33's significant change MDS dated [DATE], identified R33 had severe cognitive impairment and diagnoses included Alzheimer's disease, chronic kidney disease and anxiety. R32 was dependent on staff for toileting.R32's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 7/21/26, identified R33 had bladder incontinence related to chronic kidney disease. R33 required a fully body mechanical lift to transfer and routine check/change assistance with incontinence care. R33 was to be offered a bed pan when appropriate. R33's care plan revised 8/2/26, identified R33 as a risk for pressure ulcer development related to limited mobility, chairfast, occasionally moist skin, problem for friction or shear, and decrease in functional mobility.R33's Tissue Tolerance Monitoring dated 7/21/26, identified R33 used a bedpan if requested and when staff offer. Staff offered every 2 hours in the a.m./p.m. and twice at night. Otherwise, staff were to check and change.During a continuous observation on 8/31/26 at 12:30 p.m., NA-C approached the nursing desk and R33 raised her right hand and asked to be taken back to her room. NA-C pushed R33's wheelchair into R33's room and placed R22 in front of the tv. NA-C gave R33 her call light, water and tv remote before telling R33 NA-C would be back in a few minutes. NA-C stated R33 had been a sit to stand lift transfer but R33 had become uncooperative and was now a full body mechanical lift transfer. At 12:58 p.m., NA-A and NA-C assisted R33 into her recliner using a full body mechanical lift.At 2:38 p.m., licensed practical nurse (LPN)-A entered R33's room and spoke with R33, however, LPN-A did not offer repositioning. At 3:02 p.m., NA-B passed the snack cart and gave R33 a glass of juice and a cookie. However, NA-B did not offer R33 repositioning. At 4:24 p.m., NA-A and NA-D transferred R33 from R33's recliner to R33's wheelchair using the full body mechanical lift.During an interview on 8/31/26 at 4:40 p.m., NA-A stated R32 and R33's was last repositioned at 2:30 p.m. even though there was no observation.During an interview on 8/31/26 at 4:45 p.m., LPN-A stated staff were expected to provide timely repositioning to prevent skin breakdown.During an interview on 8/31/26 at 4:45 p.m., the director of nursing (DON) stated staff were expected to provide timely repositioning to prevent skin breakdown and to promote comfort.During an interview on 8/31/26 at 12:44 p.m., the administrator stated staff were expected to follow the resident's care plan to ensure residents received the care they required.The facility policy Repositioning/Turning undated, identified the purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Staff were directed to review the resident's care plan to evaluate any special needs of the resident.

Based on observation, interview and document review, the facility failed to ensure accurate toileting documentation occurred for 1 of 2 residents (R32) reviewed for toileting. Findings include:R32's quarterly Minimum Data Set (MDS) dated [DATE], identified R32 had severe cognitive impairment and diagnoses included Alzheimer's disease, anxiety and dementia. R32 was dependent on staff for toileting.R32's care plan revised 1/2/26, identified R32 had bladder incontinence related to Alzheimer's dementia. The care plan directed R32 would be transferred into bed using a fully body mechanical lift with a check/change every 2 hours. The facility untitled toileting sheet dated 8/31/26, identified R32 was to have a check and change every 2 hours a.m./p.m. and twice at night.During a continuous observation on 8/31/26 at 1:03 p.m., nursing assistant (NA)-A and NA-C assisted R32 into bed using the full body mechanical lift. R32's incontinence brief was dry. NA-A and NA-C positioned R32 on her right side and covered R32 with a blanket before lowering R32's bed to the lowest position.At 4:11 p.m., NA-A and NA-B entered R32's room and told R32 it was time to get ready for supper. R32's incontinence brief was saturated with urine and R32 had a small bowel movement. NA-A and NA-B provided incontinence care before transferring R32 into her wheelchair using the full body mechanical lift. At 4:21 p.m., NA-B assisted R32 to the dining room.The facility untitled toileting sheet dated 8/31/26 identified R33 was checked/changed at 12:35 p.m., 2:27 p.m., and 4:20 p.m.During an interview on 8/31/26 at 4:40 p.m., NA-A stated R32's toileting times were documented on the toileting sheet and NA-A went by the time written. R32 was last toileted at 2:30 p.m. and was toileted timely at 4:20 p.m. even though there was no observation of R32 was offered toileting at 2:30 p.m. During an interview on 8/31/26 at 4:45 p.m., the director of nursing (DON) stated staff were expected to document toileting times accurately to ensure the medical record was accurate and to ensure resident were toileted timely.During an interview on 8/31/26 at 12:44 p.m., the administrator stated staff were to accurately document toileting times to ensure an accurate medical record.A medical record policy was requested but not received.

Based on observation, interview and document review, the facility failed to ensure staff removed soiled gloves after performing incontinence care for 1 of 2 (R32) residents reviewed for activities of daily living (ADLs).Findings include:R32's quarterly Minimum Data Set (MDS) dated [DATE], identified R32 had severe cognitive impairment and diagnoses included Alzheimer's disease, anxiety and dementia. R32 was dependent on staff for all care areas.R32's care plan revised 1/2/26, identified R32 had urge and functional bladder incontinence related to Alzheimer's disease and dementia. R32 was incontinent of both bowel and bladder due to progression of Alzheimer's disease and dementia. R32 was unable to recognize toileting needs. Staff were directed to use a full body mechanical lift to assist R32 into bed then check and change R32's incontinence brief every 2 hours.During an observation on 8/31/26 at 4:11 p.m., nursing assistant (NA)-A and NA-B entered R32's room, put on gloves and told R32 it was time for supper. At 4:13 p.m., NA-A and NA-B removed R32's soiled incontinence brief and NA-A cleaned feces and urine from R32's skin using disposable wipes. However, NA-A did not remove her soiled gloves before placing a clean incontinence brief on R32. At 4:16 p.m., NA-A and NA-B pulled up R32's pants and transferred R32 to her wheelchair using a full body mechanical lift. NA-A continued to straighten R32's bed linens while NA-B combed R32's hair. NA-A nor NA-B removed their soiled gloves.At 4:19 p.m., NA-A scratched her face with her right hand which continued to wear a soiled glove. NA-A opened R32's blinds and put the disposable wipe container in r32's bathroom.At 4:21 NA-A and NA-B removed their soiled gloves, used hand sanitizer and assisted R32 to the dining room.During an interview on 8/31/26 at 4:40 p.m., NA-A stated she and NA-B had changed their soiled gloves.During an interview on 8/31/26 at 4:45 p.m., licensed practical nurse (LPN)-A stated staff were expected to change their gloves after providing incontinence care to prevent spreading infectious agents onto clean items.During an interview on 9/1/26 at 1:31 p.m., the director of nursing (DON) stated staff were expected to change their soiled gloves after providing incontinence care for infection prevention. The facility policy Toileting and Repositioning revised 7/16/20, identified the following Toileting Procedure:Wash hands and apply glovesExplain to the client what you are doing prior to starting the procedureEither stay with client while on toilet or close the unlocked bathroom door per client preference.If client wears an incontinence product, check if soiled or wet and change as needed.Pericares should be performed after each bowel movement or each episode of incontinence. Always wipe from front to back and allow clients to clean self if able.Assist with clothing adjustments, as needed. Make sure any incontinence products are positioned correctly.Pay attention to any unusual color, odor, blood or pain with urine or stool and report to the nurse.Encourage clients to wash hands thoroughly with soap and water after using the toilet.

Based on observation, interview and document review the facility failed update the daily posting for nurse staffing. Findings include: On 8/30/26 at 3:04 p.m., the nurse staffing posting was observed and was dated 8/29/26. There was no posting for 8/30/26. On 8/31/26 at 8:31 a.m., 9:57 a.m., and 1:36p.m., the nurse staffing posting was observed and continued to be the same nurse staff posting that was dated 8/29/26. There was no posting for 8/31/26. During an interview on 8/31/26 at 5:15 p.m., the administrator stated the nurse staffing should be done every day and stated the current nurse staffing posting was dated 8/29/26. She stated it should have been updated for 8/30/26 and 8/31/26 but was missed. It is normally done by the overnight nurse, but they had a different nurse filling in the past two nights and that is why it was missed. The facility's Nursing Census policy dated 5/11/26, identified the purpose of the policy is to establish a consistent process for determining the facility's resident census and staffing needs for each shift so that sufficient, competent staff are available to provide safe, person-centered care based on resident number, acuity, diagnoses, care plans, and the facility assessment. The charge nurse or designee will verify the resident census each night shift before the start of the next day.

Based on interviews and document review the facility failed to thoroughly investigate an allegation of injury of unknown origin for 1 of 1 residents (R1) who was sent to the emergency department (ED) for evaluation for left leg swelling, bruising and complaints of pain.Findings include:R1's uarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition without behaviors. R1 had impairment of lower bilateral extremities and used manual wheelchair for mobility. R1 required partial/moderate assistance with toileting hygiene, personal hygiene, sitting on side of bed to lying flat on bed, and substantial/maximal assistance to transfer from chair/bed to chair transfer. R1's diagnoses included anemia (low red blood count), congestive heart failure (CHF), and anxiety.R1's care plan dated 7/13/26, identified:Date initiated: 10/7/24, R1 was high risk for falls due to age related physical disability, decline in activities of daily living (ADLs) since admission, and gait/balance problems. Date revised: 10/23/24, Ensure R1 wore appropriate footwear, non-skid socks and shoes when nursing assistant (NA) ambulated or mobilized in wheelchair.Date revised: 10/23/24, Review information on past falls and attempt to determine cause of falls, record possible root causes, and remove any potential causes is possible.R1 was a vulnerable adult (VA) due to placement, diagnoses, and dependence. Staff were instructed to follow care plans to ensure safety and reviewed at care conferences quarterly and as need to identify changes in risk factors for abuse. Per facility abuse policy guidelines, report episodes of abuse to charge nurse, director of nursing (DON), social services designee (SSD), and administrator. Report to common entry report per policy if intervention or a VA report is needed.R1's progress notes dated 7/2/26, through 7/4/26, identified:7/2/26 at 10:00 a.m., R1 had been having difficulty with transfers and became fearful. Attempted to stand with moderate assist of two staff and became resistant. Due to inconsistency, will be Hoyer (full body mechanical lift) for transfers to/from bed and recliner and assist of two to use grab bar and commode for toileting. 7/2/26 at 11:15 a.m., R1 had bruise to left outer calf and swollen ankle, tender to touch. Staff reported last evening and this morning she had been difficult to transfer. Bruise to calf may have been caused by bed frame during a transfer. Provider gave orders to transfer to local emergency department (ED) for x-ray of left knee and ankle. 7/2/26 at 4:53 p.m., Received update from ED physician, R1 was admitted to hospital with diagnoses of acute renal injury and left ankle fracture non-displaced (bone cracked but remained properly aligned). 7/4/26 at 1:49 p.m., R1 returned to facility at 11:20 a.m., R1 had a CAM boot (walking boot) to left ankle/foot and transferred via Hoyer lift.Staff interviews completed by the facility identified:7/1/26, p.m., nursing assistant (NA) stated she sent male staff NA to R1 because she had to go help a resident that preferred to have no men. Later, certified occupational therapy assistant (COTA) and NA went to R1's room to boost her up in bed.7/1/26, p.m. COTA stated male NA requested help with R1. She went to assist and observed R1 laying close to the edge of the bed. COTA asked male NA to leave the room and asked the other NA in the room how good are you are lifting? NA responded not good at all. COTA asked another NA to assist with R1's boost toward middle of the bed. R1 did not complain of leg pain, only back pain.7/2/26, a.m., COTA was asked by nursing to screen R1 related to difficulty with transfers. R1 used omni cycle (powered exercise device intended for medical and therapeutic purposes), attempted to stand in hallway but was unable, stood for a minute and held onto parallel bars, then brought to room stood and walked with stand by assist (SBA) to her recliner. Later at 11:00 a.m., went to get R1 up for lunch and noted left ankle and outer left calf were swollenFacility internal incident report dated 7/2/26 at 11:15 a.m., R1 was noted to have a bruise on her left outer calf, swollen ankle and tender to touch. Trained medication assistant (TMA) reported this morning, last evening and this morning R1 had been difficult to transfer. Bruise to outer calf may have been caused by bed frame during a transfer. Intervention: screen was placed for R1's increased difficulty with transfers. R1 was presently doing a restorative nursing program working on transfers and ambulation. R1 was unable to give description. Immediate action taken orders given by provider for transfer to ED for evaluation and x-ray of left knee and ankle. R1 rated her ankle pain at 10 out of 10. Tylenol 650 milligrams (mg) was given by mouth. No injuries observed post incident. Mental status: oriented to person confused, weakness, and impaired memory. Predisposing situation factors: during transfer. Statements: no statements found.Emergency Department (ED) provider notes dated 7/2/26 at 2:08 p.m., identified R1 was sent from care facility with signs of trauma. The history is not exactly clear and did not match the physical examination. According to the facility nurse and therapist, R1 sustained bruises on her left breast with the use of the sit to stand device at the facility. R1 walked with the parallel bars by their report this morning and noticed swelling of the ankle later, no history of significant injury, noted R1 possibly bumped her leg on the bed or something during a transfer, but no fall was reported. R1's movement became increasingly difficult, and a Hoyer lift was used instead. ED provider spoke with podiatry MD, x-rays were reviewed and confirmed a fracture of the left ankle, agreed the boot for now and planned a follow-up in one week. Upon physical exam R1 had edema, erythema (redness caused by increased blood flow), some ecchymosis (bruising caused by blood leaking from broken blood vessels into the subcutaneous tissue beneath the skin) on the left and right lower extremities.R1's primary provider medical doctor (MD) visit dated 7/7/26, identified R1 was seen for follow-up from her recent hospitalization for a malleolar fracture of unknown origin. R1 was a poor historian with dementia, and an accurate depiction of events leading up to the fracture could not be obtained. Staff noted bruising and swelling and sent R1 to ED for evaluation. R1 returned to facility with a CAM boot and hospital staff had used a Hoyer lift, avoiding weight bearing activities. Plan: continue CAM boot, use lift with cares, and follow up with podiatry.Interview on 7/13/26 at 1:25 p.m., nursing assistant (NA)-D stated she worked day shift on 7/2/26, night staff reported R1 had a hard standing/transferring to commode at 6:00 a.m. NA-D watched R1 transfer and noted she was hesitant to stand. NA-D asked the COTA to assess R1. The COTA changed R1's transfer status to a hoyer lift. R1 was then sent to hospital. NA-D stated she was not interviewed regarding R1's ankle fracture.Interview on 7/13/26 at 2:11 p.m., NA-E stated she transferred and walked R1 with two staff, three times on 7/1/26, in the morning. R1 did good except she got weak fast. R1 did not complain of ankle or leg pain during transfers or when walking. NA-E stated on 7/2/26, R1 walked a little bit, short steps from wheelchair to the commode with assist of two, R1 was weak and complained of knee pain. R1 did not fall during her shift and had bruises on her left lower leg. NA-E stated that she left for the day before R1 was sent to hospital. NA-E stated she was not interviewed regarding R1's left ankle fracture.Interview on 7/13/26 at 2:29 p.m., licensed practical nurse (LPN)-A stated R1 was alert, forgetful, and confused. R1 had difficulty with understanding how to turn and pivot when she stood up and usually complained of knee pain. R1 did not usually complaint of ankle pain. LPN-A stated she did not know how R1 fractured her ankle and was not interviewed regarding the injury.Interview on 7/13/26 at 4:20 p.m., NA-F stated she worked on 6/29/26, evening shift (2:00 p.m. to 10:15 p.m.). NA-F transferred R1 around 9:11 p.m. R1 was confused at night, with her confusing getting worse around supper time. R1 transferred with assist of two with a walker. NA-F would instruct R1 to take a few steps forward, so NA-F could place the commode behind her as R1 had a hard time moving her feet. NA-F stated on 6/29/26, no bruises were noted on R1's lower legs, only a bruise on her knee. NA-F stated she was not interviewed regarding R1's left ankle fracture.Interview on 7/14/26 at 8:54 a.m., medical director (MD) stated R1 had a diagnosis of osteoporosis and brittle bones. MD was not able to specify what may have caused R1's ankle fracture. MD stated it could have been something simple, and staff did not have knowledge of anything specific happening. R1 did not have a fall or any type of injury that occurred that the MD was aware of. R1's medical history placed her at risk for this fracture more so than someone else, if her leg or foot had got caught she could have easily fractured it. MD stated R1's bruising on her left abdominal side was presumed to be caused by the lift machine. Additionally, R1 was on Eliquis (anticoagulant) and therefore bruised easily. R1's was pleasant, was unaware of what was going on around her and had impaired cognition.Interview on 7/14/26 at 11:37 a.m., occupational therapy assistant (COTA) stated she was the activity and rehab director. R1's cognition had slowly gotten worse, but was always moderately confused. On 6/29/26, R1 was screened due to bruising on left side/breast/underarm. R1 stood in the stand lift with the wide sling around her, was more resistive when she was in the stand lift, pushed backwards, and the sling slid upwards pulling on her left side. R1 was changed to stand pivot transfer to the commode. On 7/1/26, in the early evening, NA-A requested help, stated R1 laid on edge of the bed and would not allow him in her room. COTA stated she entered R1's room and noted she was laying close to the bed railing and was visibility upset. COTA stated NA-A and NA-B had just assisted her to the commode then to the bed. COTA thought R1's leg may have been bumped on the bed frame during the transfer. COTA did not ask the NA's about the transfer but reported it to the nurse on the medication cart. COTA stated she was not aware if the staff knew R1 was fragile and/or on anticoagulants. On 7/2/26 at approximately 11:15 a.m., COTA noticed R1's outer left calf was bruised, R1's ankle was swollen and tender to touch. R1 was sent into ED and diagnosed with a left fractured ankle.Interview on 7/14/26 at 2:09 p.m. NA-B stated on 7/1/26 around 7:00 p.m., NA-A assisted her transferring R1 to the commode. R1 was in her wheelchair, the commode was located behind her, and a gait belt was applied. R1 stood up, the wheelchair was moved and the commode was pulled up behind her. R1's feet would not move, her knees did not support her standing very long. R1's knees gave out and R1 was lowered down onto commode. R1 did not complain of pain. While R1 sat on commode, NA-A pulled her backwards across the floor without assist to the bedside, approximately five feet. NA-B stated together they transferred R1 to the edge of the bed. Once on the bed, R1's feet were not touching floor. NA-A placed one arm around R1's back and one arm underneath her knees then spun her entire body around quickly so that she laid on the very edge of the bed. R1's knees and feet remained off the bed. R1 screamed, stop, stop, then started to cry, and seemed scared with how fast NA-A moved her. NA-B stated the movement was so fast and but R1 did not appear to hit any part of her legs/feet on the bed. NA-B stated she did not know how R1 fractured her ankle and was not interviewed. Interview on 7/15/26 at 2:00 a.m., NA-G stated they usually worked the overnight shift. On 7/1/26 in the early morning, R1 used the commode located next to her bed. She was transferred by a stand pivot with assist of two. R1 frequently had difficulty with standing and complained about not being able to move her feet. NA-G stated it was worse the morning of 7/1/26. NA-G stated were not interviewed regarding R1's fractured ankle. Interview on 7/15/26 at 11:45 a.m., NA-C stated R1 was assist of two to get her onto and into bed. NA-C stated R1 was a larger sized resident, definately required two staff assist to transfer and to lay in bed. NA-C stated if one staff tried to get R1 into bed alone, it would have placed her at higher risk for injury. R1's legs/feet tended to drop down and often bumped on the bed or the mattress during transfers. On 7/1/26, between 9:00 p.m. and 9:30 p.m., NA-C was informed by NA-B, R1 was halfway off the bed and asked for assistance. When NA-C entered R1's room, she noted R1 laid on her back on the edge of the bed diagonally, the head of the bed was slightly elevated. R1's knees were bent at the edge of the mattress, and feet dangled off the bed. NA-C stated three staff boosted R1 up into the middle of bed. R1 panicked when repositioned. NA-C stated she was not interviewed about R1's fractured ankle.Interview on 7/15/26 at 1:25 p.m., unit coordinator/registered nurse (RN)-A stated COTA had informed her in the morning on 7/2/26, R1's bruise on her left calf may have been caused by being hit on the bed frame during a transfer on 7/1/26, on evening shift. The COTA told RN-A, she went into R1's room in the evening on 7/1/26, R1 laid on the edge of the bed due to two staff, NA-A and NA-B, having a hard time getting her onto the bed and they needed to move R1 quickly. The following day, 7/2/26, R1 had a new bruise located on the outer side of the calf down to just above the ankle, and R1's left ankle was swollen and tender to touch. R1 requires assistance from two staff for bed mobility and it would not have been safe for one staff to move her from a sitting to a lying position in bed. One staff assisting with bed mobility placed R1 at higher risk for injury. RN-A stated it was unknown if NA-A and NA-B were interviewed regarding R1's fractured left ankle but it would have been important for them to be interviewed to find out what happened, provide necessary education, prevent it from occurring again, and maintain safety for the resident and staff. The facility should have completed an investigation and all staff that worked with her in the last week should have been interviewed prior to confirmation of the fracture of her ankle to help identify if something went wrong. RN-A stated on 7/2/26, when she observed R1's bruising of the left lower leg as well as R1's swollen and tender left ankle, RN-A did not ask her how it may have happened but should have. Even thought R1 was not cognitively intact, she may have been able to give some information. Interview on 7/15/26 at 2:46 p.m., NA-A stated R1 had impaired cognition and required two staff assist to transfer/lay her down on the bed. NA-A stated he was asked to assist with R1's transfer on 7/1/26 at 7:00 p.m. NA-A placed R1's walker in front of her, held onto the gait belt, and together with NA-B, stood R1 up. NA-B pulled the commode behind R1, R1's clothes were adjusted, and she sat down on the commode. When finished, R1 stood up and NA-B completed peri cares. R1 was weak that day, unable to stand very long and was almost crying. R1 wanted to go to bed, and sat back down on commode. NA-A stated with the help of NA-B, he moved R1 over to the bedside while still on the commode. NA-A did not recall if the commode had wheels on it. R1 was positioned alongside the bed while still on the commode. NA-A stated NA-B stood behind the commode so she could hold onto R1 while she pivoted, and NA-A stood on R1's left side. NA-A grabbed the gait belt with both hands and NA-B grabbed the gait belt from behind. R1 stood up again, NA-B moved the commode away. The transfer was a real long pivot, R1 was unable to move her feet, she stood close to the bed and sat down. R1 was close to the edge of the bed when NA-A placed his right hand /arm on her back and his left hand was placed under both her legs. NA-B grabbed R1's legs/feet, turned her and laid her entire body down on the bed, including feet and legs. There were no concerns about safety or her legs being bumped on anything. We planned to boost her up in bed but she [R1] got angry and told me to get out or she would punch me. NA-A stated he called for help and left the room when other staff arrived. NA-A stated he heard R1 had a fractured ankle and did not know what caused it.Interview on 7/15/26 at 4:27 p.m., DON stated R1 had moderate forgetfulness, impaired cognition and at risk for falls. R1 was unable to process to turn her feet when she stood up, unable to turn around, scared of the stand lift and anything that moved her around. Before R1 fractured her ankle she was assist of two, FWW, and commode. R1 was unable to respond to commands, staff were expected have two physical assistance when R1 transferred and to lay R1 in bed. R1 likely hit or bumped ankle/foot on bed frame, resulted in a bruise on the calf of left leg, and most likely occurred on 7/1/26, when her legs hung over the bed. COTA saw R1's back of the leg rested on the bed frame. R1 was on anticoagulants (blood thinners). R1 was able move forward but unable to turn. DON was unsure if it affected her ankle but could have caused R1 to have a fractured ankle. We did not have a clue she had a fracture until an x-ray was done. We were unable to identify how it happened. DON stated she was made aware of R1's fractured left ankle on 7/2/26, in the afternoon. The DON did not suspect abuse or neglect but thought it was possibly from a transfer. There were no falls or her ankle hitting anything during a transfer that we were aware of. The DON stated the facility would have been expected to investigate the incident. Only R1 was interviewed and R1 thought she broke her ankle at church. Only two staff were interviewed. The investigation should have included review of medical records, NA charting, therapy notes, and assessments (all completed). A replay of the scenarios should have been completed if something was questioned. The DON stated their investigation include a review of polices (abuse and transfers), and education (safe transfers). It would have been important to interview the staff who transferred R1 to bed on 7/1/26, to get a full picture of what happened, to ensure they had the correct staff assistance during the transfer, and provide re-education if needed. The DON stated she was unsure if NAs on 7/1/26 used the appropriate number of staff and technique to assist R1 with bed mobility. Using the appropriate number of staff and technique would have prevented injuries. DON stated the 5-WHY Analysis Template was used to determine root cause of injuries: bruise to left calf on 7/1/26, R1 rested her legs on the bed frame, and did not have a bruise on the calf of her left leg until the following day. The facility identified this most likely was caused from this transfer. On 7/2/26, a left ankle fracture was confirmed by x-ray and MD determined due to R1's history of osteoporosis/decreased bone density, repetitive torsion (repetitive movement) and/or inability to turn foot, could have caused the fracture.Facility policy Vulnerable Adult (VA) Abuse Prohibition Plan, Freedom from Abuse, Neglect, and Exploitation dated 6/15/26, identified a mandated reporter who has reason to believe a VA is being or has been maltreated, or has knowledge that a VA had sustained a physical injury which is not reasonably explained, shall immediately report to his/her immediate supervisor and within two hours to the State Survey Agency and adult protection services where state law provides jurisdiction in long-term care facilities after the allegation is made. The facility's investigation is to be given to the administrator within five days. The person designated to perform the investigation will use the Resident Abuse Investigation Form attached to this policy (form was not attached). Each interview will be conducted separately in a private location. The individual conducting the investigation and other designated individuals will be at minimum: complete abuse form, review medical record to determine events leading up to the incident, interview the persons reporting the incident/witnesses to the incident/resident (as appropriate), and review all events leading up to the alleged incident.

Based on interview and document review, the facility failed to report an allegation of an injury of unknown origin to the State Agency (SA) within two hours for 1 of 1 resident (R1) investigated for injury of unknown origin.Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition without behaviors. R1 had impairment of lower bilateral extremities and used a manual wheelchair for mobility. R1 required partial/moderate assistance with toileting hygiene, personal hygiene, sitting on side of bed to lying flat on bed, substantial/maximal assistance to transfer from chair/bed to chair transfer, and walked 15 feet once standing in a corridor or similar space. R1's diagnoses included anemia (low red blood count), congestive heart failure (CHF), and anxiety.R1's care plan dated 7/10/26, identified R1 was a vulnerable adult (VA) due to placement, diagnoses, and dependence. Staff were instructed to follow care plans to ensure safety. Per facility abuse policy guidelines, report episodes of abuse to charge nurse, director of nursing (DON), social services designee (SSD), and administrator. Report to common entry report per policy if intervention or a VA report is needed.R1's progress notes dated 7/2/26, through 7/4/26, identified:7/2/26 at 10:00 a.m., R1 had been having difficulty with transfers and became fearful. Attempted to stand with moderate assist of two staff and became resistant. Due to inconsistency, will be Hoyer (full body mechanical lift) for transfers to/from bed and recliner and assist of two to use grab bar and commode for toileting. 7/2/26 at 11:15 a.m., R1 had bruise to left outer calf and swollen ankle, tender to touch. Staff reported last evening and this morning she had been difficult to transfer. Bruise to calf may have been caused by bed frame during a transfer. Provider gave orders to transfer to local emergency department (ED) for x-ray of left knee and ankle. 7/2/26 at 4:53 p.m., Received update from ED physician, R1 was admitted to hospital with diagnoses of acute renal injury and left ankle fracture non-displaced (bone cracked but remained properly aligned). 7/4/26 at 1:49 p.m., R1 returned to facility at 11:20 a.m., R1 had a CAM boot (walking boot) to left ankle/foot and transferred via Hoyer lift.Facility internal incident report dated 7/2/26 at 11:15 a.m., R1 was noted to have a bruise on her left outer calf, swollen ankle and tender to touch. Trained medication assistant (TMA) reported this morning, last evening and this morning R1 had been difficult to transfer. Bruise to outer calf may have been caused by bed frame during a transfer. Intervention: screen was placed for R1's increased difficulty with transfers. R1 was presently doing a restorative nursing program working on transfers and ambulation. R1 was unable to give description. Immediate action taken orders given by provider for transfer to ED for evaluation and x-ray of left knee and ankle. R1 rated her ankle pain at 10 out of 10. Tylenol 650 milligrams (mg) was given by mouth. No injuries observed post incident. Mental status: oriented to person confused, weakness, and impaired memory. Predisposing situation factors: during transfer. Statements: no statements found.Emergency Department (ED) provider notes dated 7/2/26 at 2:08 p.m., identified R1 was sent from care facility with signs of trauma. The history is not exactly clear and did not match the physical examination. According to the facility nurse and therapist, R1 sustained bruises on her left breast with the use of the sit to stand device at the facility. R1 walked with the parallel bars by their report this morning and noticed swelling of the ankle later, no history of significant injury, noted R1 possibly bumped her leg on the bed or something during a transfer, but no fall was reported. R1's movement became increasingly difficult, and a Hoyer lift was used instead. ED provider spoke with podiatry MD, x-rays were reviewed and confirmed a fracture of the left ankle, agreed the boot for now and planned a follow-up in one week. Upon physical exam R1 had edema, erythema (redness caused by increased blood flow), some ecchymosis (bruising caused by blood leaking from broken blood vessels into the subcutaneous tissue beneath the skin) on the left and right lower extremities.Radiology Results Report dated 7/2/26 at 3:13 p.m., identified indication: trauma. Findings/Impression: Bones - decreased osseous mineralization (a reduction in the mineral content of bones, primarily calcium and phosphorus, which can lead to weakened bone structure and increased fracture risk).R1's Discharge summary dated [DATE], identified she was admitted to hospital with a presumed fall. R1's cognition was impairment and unfortunately made it difficult to remember how and when she fell. This was an unwitnessed fall that resulted in a closed fracture of the left medial malleolus (inner side of the ankle), non-displaced with extensive bruising on the left side of her body congruent with the fall. Physical therapy recommended Hoyer lift.R1's primary provider medical doctor (MD) visit dated 7/7/26, identified R1 was seen for follow-up from her recent hospitalization for a malleolar fracture of unknown origin. R1 was a poor historian with dementia, and an accurate depiction of events leading up to the fracture could not be obtained. Staff noted bruising and swelling and sent R1 to ED for evaluation. R1 returned to facility with a CAM boot and hospital staff had used a Hoyer lift, avoiding weight bearing activities. Plan: continue CAM boot, use lift with cares, and follow up with podiatry.Interview on 7/15/26 at 4:27 p.m., DON stated R1 had moderate forgetfulness, impaired cognition and at risk for falls. R1 was unable to process to turn her feet when she stood up, unable to turn around, scared of the stand lift and anything that moved her around. Before R1 fractured her ankle she was assist of two, FWW, and commode. R1 was unable to respond to commands, staff were expected have two physical assistance when R1 transferred and to lay R1 in bed. R1 likely hit or bumped ankle/foot on bed frame, resulted in a bruise on the calf of left leg, and most likely occurred on 7/1/26, when her legs hung over the bed. COTA saw R1's back of the leg rested on the bed frame. R1 was on anticoagulants (blood thinners). R1 was able move forward but unable to turn. DON was unsure if it affected her ankle but could have caused R1 to have a fractured ankle. We did not have a clue she had a fracture until an x-ray was done. We were unable to identify how it happened. DON stated she was made aware of R1's fractured left ankle on 7/2/26, in the afternoon. The DON did not suspect abuse or neglect but thought it was possibly from a transfer. There were no falls or her ankle hitting anything during a transfer that we were aware of. DON stated this would have been an injury of unknown origin, should have been reported to the State Agency (SA) within two hours. DON stated this incident was not reported because it was discussed at length as a team and the hospital filed a report with Minnesota Adult Abuse Reporting Center (MARCC). I did not think we had to report it since they already filed one. Facility policy Vulnerable Adult (VA) Abuse Prohibition Plan, Freedom from Abuse, Neglect, and Exploitation dated 6/15/26, identified all resident sand or other person receiving services have the right to be free from any maltreatment, neglect, verbal or mental abuse, physical abuse, sexual abuse, corporal punishment, involuntary seclusion, or misappropriation of funds or property. The facility residents will not tolerate abuse from staff, family, volunteers, or any other persons. All facility staff are mandated reporters of abuse, and any suspected case will be appropriately investigated, reported, and responded to. Definition of injuries of unknown source: the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident. A mandated reporter is (each employee) who has reason to believe a VA is being or has been maltreated or has knowledge that a VA has sustained a physical injury which is not reasonably explained, shall immediately report to his/her immediate supervisor. Ensure that all alleged violations involving abuse, neglect exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the State Survey Agency and adult protection services where state law provides jurisdiction in long-term care facilities but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Unknown injury was defined as: an injury that is not related to a previously known incident or injury and probable cause is not identified.

Based on interviews and document review the facility failed to update the care plan and implement care planned interventions for 1 of 3 residents (R1) reviewed for care plan updates and implementation.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition without behaviors. R1 had impairment of lower bilateral extremities and used a manual wheelchair for mobility. R1 required partial/moderate assistance with toileting hygiene, personal hygiene, sitting on side of bed to lying flat on bed, substantial/maximal assistance to transfer from chair/bed to chair transfer, and walked 15 feet once standing in a corridor or similar space. R1's diagnoses included anemia (low red blood count), congestive heart failure (CHF), and anxiety.Physician signed orders dated 7/7/26, identified: Circulation, Motor, and Sensation (CMS) two times a day (BID) left lower extremity (LLE), may remove boot when resting otherwise on at all other times, and must be on with all transfers.Review of R1's care plan dated 7/13/26, identified:Ambulation, Transfers and Bed MobilityInitiated 12/10/24, revised 7/1/26, resolved 7/13/26, R1 required a walking program due to weakness in knees and staff and provided ambulation with front wheeled-walker (FWW), gait belt, and partial/moderate assistance of one staff member. Restorative Nursing Program offered 6-7 times per week. Ambulation with FWW, gait belt, and partial/moderate assistance of one staff member and wheelchair to follow provided for safety. Revised, R1 was dependent with assist of two for all bed mobility tasks.Initiated 7/1/26, resolved 7/13/26, Staff were directed to have provided directional cueing, monitor gait stability, endurance, utilize appropriate footwear, and observe all fall-prevention and safety precautions during ambulation. Revised 7/2/26, check and change at this time, dependent assist of two via hoyer lift (full body mechanical lift) for transfer/medium body sling, and walking on hold ambulated with therapy only.Revised 7/13/26, Walk: unable at this time. Passive range of motion (PROM) to left extremity, feet up on stool two-pound weight over knees and warm blanket for five minutes.Fall RiskInitiated 10/7/24. Ensure R1 wore appropriate footwear, non-skid socks and shoes when nursing assistant (NA) ambulated or mobilized in wheelchair. Revised: 10/23/24. Review information on past falls and attempt to determine cause of falls, record possible root causes, and remove any potential causes is possible. R1's care plan failed to include use of CAM boot (walking boot) to left ankle/foot following left ankle fracture as well as weight restirctions.R1's care sheet received on 7/13/26, identified R1 was dependent and required assistance from two staff with hoyer lift with medium body sling, walking and locomotion on hold and only with therapy. Care sheet did not include/identify weight restrictions to left foot/leg and use of CAM boot when out of bed.R1's progress notes dated 7/2/26, through 7/4/26, identified:7/2/26 at 10:00 a.m., R1 had been having difficulty with transfers and became fearful. Attempted to stand with moderate assist of two staff and became resistant. Due to inconsistency, will be Hoyer (full body mechanical lift) for transfers to/from bed and recliner and assist of two to use grab bar and commode for toileting. 7/2/26 at 11:15 a.m., R1 had bruise to left outer calf and swollen ankle, tender to touch. Staff reported last evening and this morning she had been difficult to transfer. Bruise to calf may have been caused by bed frame during a transfer. Provider gave orders to transfer to local emergency department (ED) for x-ray of left knee and ankle. 7/2/26 at 4:53 p.m., Received update from ED physician, R1 was admitted to hospital with diagnoses of acute renal injury and left ankle fracture non-displaced (bone cracked but remained properly aligned). 7/4/26 at 1:49 p.m., R1 returned to facility at 11:20 a.m., R1 had a CAM boot (walking boot) to left ankle/foot and transferred via hoyer lift.Hospital physical therapy initial evaluation and discharge date d 7/3/26 at 11:56 a.m., identified admitted to hospital on [DATE] at 2:09 p.m., with a diagnosis of closed fracture of left ankle, ecchymosis (bruising), acute kidney injury, and dehydration. Precautions: left ankle fracture, toe touch weight bearing (TTWB). No history of fall reported. Cognition: confused, unable to express concerns or rate pain, and cried out with pain and/or fear with movement of left rib/cage/lateral chest and left ankle. Right [sic] foot in ankle immobilizer boot. Functional limitations: bed mobility, sitting balance, fall risk and positioning. Recommendation: hoyer transfer for patient and staff safety, dependent upon staff for all functional movement.R1's hospital Discharge summary dated [DATE], identified she was admitted to hospital with a presumed fall. R1's cognition impairment unfortunately made it difficult to remember how and when she fell. This was an unwitnessed fall that resulted in a closed fracture of the left medial malleolus, un-displaced with extensive bruising on the left side of her body congruent with the fall. Physical therapy recommended Hoyer lift.Nursing staff communication book dated 7/4/26, identified R1 returned from hospital, had a CAM boot to be worn at all times she is out of bed, can have off when she is in bed. Use hoyer for all transfers. Non-weight bearing at this time.R1's primary provider medical doctor (MD) visit dated 7/7/26, identified R1 was seen for follow-up from her recent hospitalization for a malleolar fracture of unknown origin. R1 was a poor historian with dementia, and an accurate depiction of events leading up to the fracture could not be obtained. Staff noted bruising and swelling and sent R1 to ED for evaluation. R1 returned to facility with a CAM boot and hospital staff had used a Hoyer lift, avoiding weight bearing activities. Plan: continue CAM boot, use lift with cares, and follow up with podiatry.Physical therapy evaluation dated 7/7/26 at 8:38 p.m., identified R1 had total body weakness, deconditioning, range of motion (ROM) limitations, left ankle pain, and inability to stand, walk, or transfer efficiently due to pain and weight bearing precautions (non-weight (NWB) bearing left lower extremity (LLE)). R1's precautions included fall risk, cognitive decline and NWB LLE. R1 was currently a hoyer lift due to NWB of the left lower extremity and not strong enough to transfer on just her right lower extremity.Occupational therapy evaluation dated 7/8/26 at 6:45 a.m., identified R1 presented for evaluation with the inability to stand with current NWB to LLE restriction in place following left ankle fracture and hospital stay. R1 had a decline in her ability to perform activities of daily living (ADLs), transfers, and was unable to ambulate. R1 rated her left ankle pain at 7 out of 10 with movement.Interview on 7/14/26 at 11:37 a.m., the occupational therapy assistant (COTA) stated she was responsible for updating the care plan sections: lift recliner, activity, and rehab when R1 returned from the hospital. The CAM boot was important to have on when up to prevent her ankle from moving, keep it stable and protect it. COTA stated she thought the nurse placed this in the care plan, Kardex, and care sheets, and verified it was not. COTA stated it would have been important so staff knew how to care for R1's ankle, helped promote healing and protected R1's ankle/foot. COTA stated R1's weight bearing restriction was difficult to clarify when she returned to facility. R1's hospital documents indicated three different weight bearing restrictions: toe touch, weight bearing as tolerated and non-weight bearing. Staff were expected transfer R1 with hoyer lift only and no ambulation. [R1] was evaluated by our therapy department when she returned from the hospital. It was determined [R1] was to be non-weight bearing. COTA stated R1's care plan identified sit to stand: not at this time and hoyer lift: walking on hold. Non-weight bearing should have been added to R1's care plan, Kardex and care sheet so that staff had a better understanding/clarification of R1's abilities and restrictions.Interview on 7/14/26 at 2:09 p.m. NA-B stated she referred to the resident care sheet to identify how to care for the resident. NA-B stated she was unaware R1 was to have a CAM boot on her left ankle, was unsure what that would have been used for, and did not know R1 was non-weight bearing for the left ankle. NA-B state those interventions were listed on the care sheet.Interview on 7/15/26 at 1:25 p.m., unit coordinator/registered nurse (RN)-A stated R1's care plan should have been updated upon re-admission so staff were aware of the CAM boot and non-weight bearing to prevent further injury to R1's ankle. RN-A stated the interventions were not added to care plan, Kardex, or the care sheet.Interview on 7/15/26 at 2:00 a.m., NA-G stated R1 fractured her left ankle. NA-G stated R1 was to have a CAM boot on when up and off when in bed and was non-weight bearing on left leg. NA-G verified this information was not on the care sheet he used to take care of residents. NA-G stated he remembered hearing about the CAM boot and non-weight bearing restrictions in report. Interview on 7/15/26 at 4:27 p.m., the director of nursing (DON) stated when R1 returned from the hospital on 7/4/26, she had a weight restriction on her left foot/leg of toe touch in the hospital and instructions to use CAM boot. Facility therapy assessed R1 to be non-weight bearing and to use a hoyer lift for transfers. DON stated the weight restriction and the CAM boot should have been added to the care plan, Kardex, and care sheet as soon as R1 returned from the hospital so staff would have known how to transfer her, keep her ankle safe, and likely could have affected the healing process of the ankle if weight was placed on it. Facility policy dated 3/10/26, Care Plans identified the facility's Care Planning/Interdisciplinary Team in coordination with the resident, his/her family, or representative, develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Assessments of residents are ongoing, and care plans are revised as information about the residents' and condition changes. The team was responsible for the review and updating of care plans: a. when there has been a significant change in the residents' condition, b. when the resident has been readmitted to the facility from a hospital stay, and c. at least quarterly.

Based on interview and document review, the facility failed to ensure long term residents received routine physician visits consistently every 60 days as required for 1 of 5 residents (R2) reviewed for unnecessary medications.Findings include:R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 was cognitively intact and had diagnoses that included atrial fibrillation (irregular heartbeat), major depressive disorder, morbid obesity and lymphedema (tissue swelling).R2's medical record identified R2 was evaluated by a medical provider on 8/13/24, 11/19/24, 1/14/25, 2/26/25, 4/15/25, 6/11/25 and 8/29/25.During an interview on 9/10/25 at 1:44 p.m., licensed practical nurse (LPN)-D stated she was responsible to ensure residents were evaluated by a medical provider every 60 days. R2 was not seen timely and LPN-D stated she did not have an explanation why. LPN-D stated she keeps a handwritten schedule every month with the provider schedules, and which residents needed evaluation. However, LPN-D disposed of the handwritten schedule after the provider visit was complete. During an interview with the director of nursing (DON) and the administrator on 9/10/25 at 4:07 p.m., the DON stated staff were expected to ensure residents were evaluated by a medical provider every 60 days. This should have been tracked and brought forward to administration. The facility policy Physician Visits revised 1/4/23, identified the resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least every 60 thereafter, a physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. Physician orders must be signed and dated at every routine visit.

Based on observation, interview and document review, the facility failed to ensure a defined perimeter mattress (DPM) was not used in a manner to restrain residents while in bed for 1 of 3 residents (R14) reviewed for restraints.Findings include:R14's quarterly Minimum Data Set (MDS) dated [DATE], identified R14 had a severe cognitive impairment, diagnoses that included bipolar disorder, epilepsy, and vascular dementia and identified R14 used an other restraint while in bed daily.R14's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 1/31/25, identified R14 had impaired cognitive function/impaired thought processes related to dementia. R14's cognitive assessment indicated severe impairment. R14 was able to make her needs known and was understood and understood others.R124's Behavioral Symptoms CAA dated 1/31/25, identified R14 had a potential to demonstrate behaviors related to vascular dementia, bipolar disorders, a history of depression with psychosis, and a generalized anxiety disorder. Behaviors noted during look back period: resistive to cares, hitting out at staff, not wanting to get up in the morning or have breakfast. Staff were directed to provide redirection; leave R14, if safe, and return later; meet R14's needs with toiletings, food, drink, and repositioning and continue to observe. However, the CAA failed to identify R14's DPM and/or interventions used prior to implementing a DPM.R14's care plan reviewed 7/23/25, identified R14 was at high risk for falls related to history stroke with weakness, vascular dementia with forgetfulness, hypertension, history of dizziness, and, at times, R14 was unaware of safety needs, confusion, gait/balance problems. R14 had a history of recurrent falls related to self-transfers and needed to be frequently reminded to ring for assist related to history of not ringing call light for staff assist. R14 needed staff assist with transfers, bed mobility, toileting, and other activities of daily living every day. Staff were directed R14 used a DPM on R14's bed and mats on the floor for safety related to history of self-transfers with falls in the past while in bed. R14's bed should be in low position. When R14 swung her legs out of bed, R14 was ready to get up. Staff assist with mechanical stand-up lift for transfers R14 was unable to walk. Review need for any restraints on annual and/or comprehensive assessments.R14's medical record failed to identify a restraint assessment.R14's physician order dated 11/8/22, identified R14 used assistive devices: 2 short side rails on top left and right DPM mattress with mats on the floor by R14's bed for safety. However, the physician order failed to identify a medical need for a restraint.During an observation on 9/8/25 at 7:13 p.m., R14 was lying in bed on her right side towards wall. A DPM was on R14'a bed and a mat was lying on the floor next to R14's bed.During an observation on 9/9/25 at 1:30 p.m., R14 was lying in bed on her back. A lap blanket was covering to her chest. R14 had her eyes closed and had rhythmic deep breathing. R14 was lowered to the floor with a DPM and a mat on the floor next to Rl14's bed.During an interview on 9/9/25 at 3:20 p.m., licensed practical nurse (LPN)-C stated R14 hadn't tried to get out of her wheelchair on her own in a in a long time. Sometimes, R14 would try to get out of her bed but R14 had a mattress with a lip on it so R14 just could get her feet out but that was it. R14 hadn't done that in a really long time either. R14 used to be more active, but not anymore. Like I said, R10 had that lip on her mattress and can't get out of it.During an interview on 9/9/25 at 3:25 p.m., nursing assistant (NA)-A R14 was usually chill and calm. R15 has her bad days sometimes. R14 would refuse to get up and wanted to fuss. That was about it. R14 would sit up at the side of the bed but that was it. R14 was unable to get out of bed because of the DPM. NA-A could not recall the last time R14 had a fall from bed.During an interview on 9/9/25 at 4:07 p.m., the social work designee (SSD) stated nursing performed the restraint assessments every quarter and annually. SSD stated R14 did not utilize a restraint that SSD was aware of. During an interview on 9/9/25 at 4:10 p.m., RN-B stated R14 used a DPM on her bed. R14 had the DPM before RN-B started working at the facility. R14's physician signed the restraint order for the DPM and the DPM was implemented in the fall of 2019. RN-B stated she did not know if a restraint assessment had been completed for R14, but RN-B knew R14 needed the DPM because R14 could no longer walk and would try to get out of bed and fall. RN-B stated she has walked past R14's room and R14 had her feet sticking out of her bed. RN-B would know that's when it was time to get R14 up. RN-B stated R14 did use a low bed with a mat on the floor so the likelihood of injury from a fall was slight, however, RN-B continued to state R14 required a DPM to prevent R14 from getting out of bed.During an interview on 9/10/25 at 3:02 p.m., RN-B stated, in 2018, R14 had a low bed with mats on the floor, a bed alarm and poor cognition so a DPM was the safest alternative for R14 because R14 was climbing out of bed. But that was a long time ago. RN-B stated, in RN-B's opinion, R14 could fall and injure herself. R14 had not fallen out of bed since the DPM was implemented in 2019. Per MDS coding guidelines, R14's DPM was identified as a restraint because R14 was not able to get out of bed on her own because it was not safe for her do so. RN-B stated she knew staff got R14 up when she was restless because it was a risk or if R14 was awake and exhibited behaviors. However, RN-B had not done a formal restraint assessment for R14 nor had considered possible alternatives to a restraint for R14.During an interview with the director of nursing (DON) and administrator on 9/10/25 at 4:14 p.m., the DON stated restraints were to be assessed quarterly and addressed in the care conference. Staff should be doing the same for not only R14's DPM but all residents with a DPM to make sure all restraints were reviewed to ensure documentation was complete and trials off were attempted. Staff were also expected to utilize all possible alternatives prior to initiating a restraint. The administrator stated it should have been and didn't happen. The facility policy Use of Restraints revised 1/3/23, identified restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for, discipline or staff convenience, or for the prevention of falls. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts-normal access to one's body. 13. The following safety guidelines shall be implemented and documented while a resident is in restraints:a. Restraints shall be used in such a way as not to cause physical injury to the resident and to insure the least possible discomfort to the resident.b. Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency. Restraints with locking devices shall not be used.c. A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record.d. The opportunity for motion and exercise is provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed.e. Restrained residents must be repositioned at least every two (2) hours on all shifts.

Based on interview and document review, the facility failed to perform timely tracking and trending of potential infectious symptoms to prevent the spread of transmissible organisms in a timely and ongoing manner; including a failure to implement timely transmission-based precautions (TBP) and testing for respiratory illness according to the Centers for Disease Control (CDC) for 3 of 3 residents (R10, R21, R39) who were displaying COVID-19 symptoms.Findings include:The facility NON-COVID Illness tracker dated August 2025, identified the following: unit, resident name, room number, infection type, body of infection, diagnostics, treatment, transmission-based precautions and illness resolution. The tracker also identified the following: On 8/2/25, R39 exhibited a runny nose, cough, and slight sore throat. R39's rapid antigen COVID-19 test was negative and R39 with provided comfort for his symptoms. However, the tracker failed to identify if R39 had a confirmatory negative rapid antigen test and/or was placed into transmission-based precautions until the confirmatory test was collected. On 828/25, R21 exhibited dry heaves, fatigue, runny nose, and cough. R21's rapid antigen COVID-19 test was negative and R21 with provided comfort for his symptoms. However, the tracker failed to identify if R21 had a confirmatory negative rapid antigen test and/or was placed into transmission-based precautions until the confirmatory test was collected. On 8/31/25, R10 exhibited cough, congestion, and sore throat. R10's rapid antigen COVID-19 test was negative and R10 with provided comfort for his symptoms. However, the tracker failed to identify if R10 had a confirmatory negative rapid antigen test and/or was placed into transmission-based precautions until the confirmatory test was collected.R39's quarterly Minimum Data Set (MDS) dated [DATE], identified R39 had a moderate cognitive impairment and diagnoses that included heart failure.R39's nursing progress notes identified the following: On 8/28/25 at 9:05 a.m., R39 was observed to be sitting in his wheelchair by the medication cart, R39 had a runny nose with clear drainage. This staff asked R39 how he was feeling R39 and stated, I don't feel good. R39 complained of runny nose with clear nasal drainage, productive cough with grey phlegm and a slight sore throat. R39 denied having a headache or body aches. Lungs were auscultated (listened to) and were clear throughout. Rapid COVID-19 antigen test completed and R39 tested negative for COVID-19. However, the note failed to identify if R39 was placed into transmission-based precautions until a confirmatory rapid antigen test was collected. On 8/29/25 at 11:05 a.m., R39 was complaining of cold symptoms. R39 had a congested, loose, productive cough that R39 said he could give a sputum sample of, if needed. Gave R39 a cup to expectorate into so staff can see what sputum looks like. Lungs were clear, R39 had a loud murmur. On 8/30/25 at 9:58 a.m., R39's rapid COVID-19 antigen test performed, and results were negative. R39 to continue to remain in room until temp was within normal limits, however, the note failed to identify if R39 was in transmission-based precautions. R21's comprehensive MDS dated [DATE], identified R21 had a mild cognitive impairment and diagnoses that included peripheral vascular disease, dementia and chronic kidney disease.R21's nursing progress notes identified the following: On 8/28/25 at 8:40 a.m., staff reported R21 had dry heaves that morning. R21 was alert and sitting up at the side of his bed, R21 stated I don't feel good. R21 complained of feeling tired, runny nose with clear nasal drainage, and of a productive cough. R21 stated he was able to cough up yellowish phlegm. R21 denied having a headache, sore throat or body aches. Rapid COVID-19 test completed and R21 tested negative for COVID-19. Will continue to monitor. On 8/29/25 at 11:39 a.m., R21 had been weak, easily fatigued, and noted confusion. Vitals: temperature 97.6 degrees F, pulse 64, respirations 22, and oxygen saturations 96% on room air. However, R21's bp was low- 85/59 auto, 80/62 manual. Encouraged R21 to drink fluids and monitored for continued concerns. When R21 got back to his room, R21 needed moderate assist of 1 to transfer from wheelchair to recliner. At 1:50 p.m., R21 participated in a small group game of rummy in the activity room with activity staff. At 1:54 p.m., R21 attended church in the activity room. At 3:11 p.m., R21 came to activity room this afternoon for ice cream cone social with other residents and staff. On 8/30/25 at 10:17 a.m., R21's rapid COVID-19 antigen test performed, and results were negative R10's quarterly MDS dated [DATE], identified R10 had a moderate cognitive impairment and diagnoses that included cerebral palsy, epilepsy, and morbid obesity.R10's nursing progress notes identified the following: On 8/31/25 at 7:57 a.m., R10 was showing signs of cough, congestion, and a dry/sore throat. A rapid COVID-19 antigen test which was negative and R10 did not have a fever at this time. However, the note failed to identify if R10 was placed into transmission-based precautions until a confirmatory test could be collected. At 4:14 p.m., R10 complained of congestion: Lungs auscultated and were clear throughout with no adventitious breath sounds (abnormal breath sounds) noted. R10 reported a moist cough with phlegm production which R10 swallowed. R10 educated her on the risks versus benefits of not expelling mucus could result in worsening respiratory conditions. She denied shortness of breath (sob), sore throat, and runny nose. R10 also reported she was congested and not tired. She had allergy medication scheduled every evening. On 9/2/25 at 3:20 p.m., R10 participated in playing word scramble with staff and peers in the activity room. At 4:15 p.m., R10 participated in a group activity passing around the conversation ball in the activity room. On 9/3/25 at 1:13 p.m., R10 participated in a group exercise this morningDuring an interview on 9/9/25 at 11:13 a.m., licensed practical nurse (LPN)-A stated she started her role as the facility's infection preventionist at the end of July 2025. LPN-A performed the facility's surveillance monitoring on Fridays and another nurse covered for her the other days. The facility's nurses had a good team approach and put notes in the electronic medical record and called LPN-A whenever a resident was ill, including weekends, evenings and nights. The nurses had the ability to test for COVID-19 and to place any symptomatic resident into transmission-based precautions at any time. During an interview on 9/9/25 at 11:48 a.m., registered nurse (RN)-A stated R10, R21 and R39 were not placed into transmission-based precautions when they exhibited signs and symptoms of COVID-19 because their COVID-19 rapid antigen tests were negative. R21 went out on a facility planned outing and was played out but improved on his own. The residents had a runny nose for a few days and were tired out. RN-A stated she would place a resident in transmission-based precautions if he/she was coughing or had a positive COVID-19 test, but really any respiratory illness should. Typically, if a resident had a cough, staff would ask the resident to remain in his/her room, but staff would not put on any personal protective equipment (PPE) before entering the room unless the resident tested positive for COVID-19. RN-A stated she was unaware a confirmatory test was required when a rapid antigen test was used. During an interview on 9/9/25 at 12:12 p.m., RN-B stated she would put a resident in transmission-based precautions when the resident had a fever, were actively vomiting or were positive for COVID-19. RN-B stated she was unaware a resident needed to be placed into transmission-based precautions until a confirmatory negative rapid antigen test was collected. During an interview on 9/9/25 at 12:14 p.m., the director of nursing (DON) stated she expected staff to follow facility policy and procedure to protect other residents, staff and the community from potential illness. The Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 3/18/24, identified the decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current SARS-CoV-2 infection for a patient with symptoms of COVID-19 can be made based upon having negative results from at least one viral test.- If using NAAT (molecular) (A Nucleic Acid Amplification Test is a type of viral diagnostic test for SARS-CoV-2, the virus that causes COVID-19. NAATs detect genetic material (nucleic acids). NAATs for SARS-CoV-2 specifically identify the RNA (ribonucleic acid) sequences that comprise the genetic material of the virus), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining Transmission-Based Precautions and confirming with a second negative NAAT.- If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test.- If a patient suspected of having SARS-CoV-2 infection is never tested, the decision to discontinue Transmission-Based Precautions can be made based on time from symptom onset as described in the Isolation section below. Ultimately, clinical judgment and suspicion of SARS-CoV-2 infection determine whether to continue or discontinue empiric Transmission-Based Precautions.The facility COVID-19 policy revised 5/12/23, identify it was the policy of the facility to minimize exposure to respiratory pathogens and promptly identify residents with clinical features and an epidemiologic risk for COVID-19 and to adhere to Federal and State/local recommendations. A resident with suspected COVID-19: Immediate infection prevention and control measures will be put into place. Symptoms may vary in severity. If symptoms are mild and do not require transfer to the hospital:- Place resident in isolation in his/her room with door closed on Special Precautions - including Contact and Droplet Transmission Based Precautions.- Notifications and Communication:- Contact and inform the residents physician when a resident exhibits symptom consistent with Covid-19- Contact and inform DON and/or Infection Preventionist to notify of suspected case.- Contact and inform resident representative to update on status.- Contact and inform the facility Medical Director of suspected or confirmed case of Covid-19 in facility.- Rapid Antigen testing will be performed as ordered by MD.However, the policy failed to direct staff on actions taken when Rapid Antigen testing was negative, and a confirmatory test was required.

Based on observation, interview and document review, the facility failed to ensure a physician order for indwelling urinary catheter for 1 of 1 residents (R21) reviewed for urinary catheter. Findings include:R21's significant change Minimum Data Set (MDS) dated [DATE], identified R21 had a moderate cognitive impairment and diagnoses that included obstructive and reflux uropathy (a blockage in the urinary tract making it difficult to urinate), dementia, and benign prostatic hyperplasia (BPH) (an enlarged prostate). R21 used an indwelling urinary catheter.R21's physician order dated 6/8/22, directed to change foley catheter every 90 days. However, the physician order failed to identify type or size of urinary catheter.R21's care plan revised 12/27/23, identified R21 used an indwelling urinary catheter for obstructive uropathy and BPH. R21 required staff assistance with catheter care and emptying of the urinary bag. R21 used a 16 French (fr) urinary catheter with a 10 milliliter (ml) balloon.During an observation on 9/10/25 at 7:38 a.m., nursing assistant (NA)-B provided catheter care to R21.During an interview on 9/10/25 at 10:30 a.m., registered nurse (RN)-B provided a stock 14 fr urinary catheter with a 30 ml balloon. RN-B stated she would only put in 10 ml of saline into the balloon to match R21's order because it wasn't putting in more saline than what the balloon would hold. RN-B then stated R21's urinary catheter physician order was in R21's care plan, however, the care plan was not a physician order. But that's how staff knew what size to use.During an interview on 9/10/25 at 10:59 a.m., the director of nursing (DON) stated staff were expected to follow the physician orders for urinary catheters and to enter the order into the electronic medical record (EMR) in the physician orders. The care plan was an extension of the order, so all staff were aware how to care for the catheter. When the catheter was changed, nursing was expected to document type and size, how much saline was removed, how much saline was used, was the balloon intact etc. A full description of the procedure. The DON also stated using a 30 ml balloon with only 10 cc of saline was not following the order because the 30 ml balloon would expand and not work accordingly.During a telephone interview on 9/10/25 at 2:16 p.m., nurse practitioner (NP)-A stated R21's urinary catheter should be changed every 90 days due to an increased risk and history of urinary tract infection. However, staff should have an order for foley catheter 16 fr. with a 10 ml balloon and were expected to follow physician order.The facility policy Prevent of Catheter Associated UTIs revised 5/15/23, identified the urinary catheter insertion procedure but failed to identify the need for a physician order.

Based on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders which resulted in a medication error rate 9.09% (percent) for 1 of 7 residents (R11) observed to receive mediations during the survey.Findings include:R11's Order Summary Report, dated 8/28/25, identified R11's current physician-ordered medications and treatments. This included an order for potassium chloride extended release 10 milliequivalent (meq) by mouth two times per day, and vitamin D3 25 micrograms (mcg) give two tablets by mouth in the morning, both with start dates 8/26/25. On 9/10/25, at 9:23 a.m. registered nurse (RN)-B prepared R11's medications at a mobile medication cart in the hallway by the nurses' station. RN-B reviewed R11's electronic Medication Administration Record (MAR) which outlined the same order for potassium and vitamin D3 as listed on R11's Order Summary Report (dated 8/26/25). However, RN-B removed an opened bottle of potassium chloride 10 meq tablets and placed two tablets into the medication cup with R11's other oral medications. RN-B then removed an opened bottle of vitamin D3 25 mcg and placed one tablet into the medication cup with R11's other oral medications. RN-B removed an opened bottle of oxybutynin 5 milligram (mg) tablets and placed one tablet into the medication cup with R11's other oral medications. RN-A placed the non-gel or capsule medications into a separate medication cup and started to place the medications into the pill crusher. RN-B was stopped by the surveyor (SA) and asked to review all medications she had prepared to ensure the SA had recorded the medications correctly. Apon review of the medications, RN-B took out a potassium tablet, stating R11 was only supposed to have one tablet and not the two tablets that were prepared and RN-B retrieved the open vitamin D3 bottle and placed an additional vit D3 tablet into R11's prepared medication cup, stating R11 was supposed to receive two tablets of vitamin D3 and not just the one tablet that had been prepared. RN-B then proceeded to crush the medications that could be crushed and put the crushed medications into a cup with vanilla pudding. RN-B took the crushed medications, and other prepared medications and brought them to R11's room where she administered the prepared medications. Immediately following R11's current physician orders were reviewed. R11's Order Summary Report dated 8/28/25, did not include an order for the medication oxybutynin. During interview on 9/10/25, at 10:00 a.m. RN-B stated she is not sure if she would have caught the incorrect doses of potassium and vitamin D3 if the SA had not stopped and asked to review, she may have. RN-B agreed she would have crushed all the crushable tablets and not be able to identify them once they were crushed if the SA had not stopped her to review them, which would have then been administered to R11. RN-B reviewed the medication bottles in the medication cart and observed R11 did have an opened bottle of oxybutynin 5 mg tablets in her drawer. RN-B stated she must have prepared one tablet in with the other medications for R11 in error. RN-B stated she had been nervous and working too quickly in preparing R11's medications that morning and should have slowed down and reviewed and compared the medications to R11's MAR more closely. RN-B stated she had filled out a medication error report form for the medication error of administering the oxybutynin medication without a current order. When interviewed on 9/10/25, at 4:30 p.m. the director of nursing (DON) stated she expected staff to read resident's MAR's closely and to check it with the medication bottles and double check to prevent medication errors. Staff were to follow the seven rights of medication administration guidelines. The facility policy Medication Administration, dated 5/25/23, directed staff to compare medicine listed on the residents MAR with label on the medication container when taking the medication from the cart, when removing the medication from the container and when returning the medication to the cart for three checks. Staff were to follow the eight rights of medication pass. Right patient, right medication, right dose, right time, right route, right documentation, right reason and right response. Staff were not to administer a medication if it was not listed on the residents MAR, and to check with the charge nurse or unit manager.

Based on observation, interview, and document review, the facility failed to comprehensively assess for ability or safety and then care plan the self-administration of medication for 1 of 1 resident (R36) observed to have medication prepared by staff and then left with him to take on his own. Findings include: R36's admission Minimum Data Set (MDS) assessment dated [DATE], identified R36 had intact cognition. Diagnoses included disorder of the circulatory system, aneurysm of iliac artery and lower extremity and chronic obstructive pulmonary disease (COPD). R36's care plan with last review date 9/3/25, identified R36 admitted to the facility on [DATE]. A focus for altered respiratory status was identified with difficult breathing at times. Interventions included to administer medications and puffers as ordered. However, the care plan lacked any evidence R36 had been assessed or approved to administer nebulized medications independently. On 9/9/25, at 3:33 p.m., licensed practical nurse (LPN)-A prepared R36's medications for administration from a mobile cart in the hallway. LPN-A opened a box labeled Ipratropium 0.5 milligrams (mg) and albuterol sulfate 5 mg inhalation solution and removed one plastic vial of the medication. R36's corresponding electronic medication administration record (MAR) present via computer on the mobile cart, directed to inhale orally via nebulizer four time per day for COPD. LPN-A entered R36's room and poured the vial of medication into R36's nebulizer medication chamber, turned on the nebulizer machine and handed R36 the nebulizer mouthpiece to begin inhaling. LPN-A instructed R36 to ring if he had any trouble and exited the room. LPN-A returned to the medication cart and signed off the medication as administered. R36's medical record lacked evidence R36 was comprehensively assessed for safety with the self-administration of his nebulized medications. During interview on 9/9/25, at 3:56 p.m. LPN-A stated R36 administered his nebulized medications independently. LPN-A stated she also worked night shift and R36 had three different nebulized medications ordered to be administered during the night. Night shift nurse just brought all three of the ordered nebulizer medications to R36 and left them in his room for him to administer one after the other on his own. The nurse would check back with him later, when they brought in his oral medications, to ensure he had administered all of them. R36 was capable of bringing the nebulizer to his mouth and administering the nebulized medication correctly or he would be able to tell the staff if he was having any issues. Typically, there would be a self-administration assessment completed to ensure it was safe for R36 to self-administer the medications. LPN-A had just assumed there had been an assessment completed. During interview on 9/10/25, at 4:00 p.m. registered nurse (RN)-A stated she was responsible for completing resident assessments, including an assessment for ability and safety of resident to self-administer medications. RN-A stated R36 was high functioning and capable of administering his nebulized medications, however, she had not completed a formal assessment and order for the self-administration of the medications. She had not been aware he was doing the nebulized medications independently and so the assessment had been missed. When interviewed on 9/10/25, at 4:30 p.m. the director of nursing (DON) stated if a resident requested to self-administer medications it was the facility's policy to complete a self-administration of medication assessment to ensure they could do so correctly and safely, then it would be noted on the MAR and care planned. The facility's undated policy Self Administration of Medications identified on admission the resident would be asked if they would like to self-administer any medication. If the response was affirmative, the resident would need to demonstrate the ability, cognitively, physically and visually to safely complete the task. When a resident requested to self-administer medications, they would be assessed to determine the ability to do so safely for themselves and other residents. The assessment would be completed by a member of the interdisciplinary team using the facility's assessment form. The resident would need to demonstrate the ability to administer the medication, know the name of the medications, what it was used for, the main side effects of the medication. The resident would also need to be able to physically and visually complete the task.

Based on observation, interview and document review, the facility failed to ensure interventions for safe transfers were implemented for 1 of 5 residents (R23) observed during staff assisted transfers. Findings include:R23's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment. R23 required maximal assistance with transfers and ambulation. Diagnoses included depression, hypertension, osteoporosis, osteoarthritis, muscle weakness, and low back pain. R23's care plan with review date 8/20/25, identified R23 had a self-care performance deficit and a goal was listed to maintain her current level of function in all activities of daily living (ADLs) and mobility. Interventions included to transfer with maximal assist of one and a full wheeled walker with all transfers and to ambulate with moderate assist of one with FWW, gait belt and wheelchair to follow in the hallways. On 9/9/25, at 2:30 p.m. R23 was observed seated in her wheelchair in a common area near the nurse's station. Nursing assistant (NA)-A approached R23 and wheeled her wheelchair next to a nearby recliner, locking the wheelchair brakes. NA-A directed R23 to lift her arms up in the air then NA-A wrapped her arms around R23 just below her armpits. NA-A lifted R23 into a standing position, pivoted her toward the recliner and then sat R23 down into the recliner. A gait belt to assist with the resident transfer was not used. When interviewed on 9/9/23, at 2:35 p.m. NA-A stated it had been such a close transfer, and she would not use a gait belt to transfer a resident when the transfer was so close and did not require steps. NA-A would definitely use a gait belt when walking with a resident. When NA-A had assisted R23 to sit in the recliner, it was such a close transfer, so she just grabbed her around her torso and helped her stand and into the recliner. The wheelchair and recliner had been so close that no gait belt was required. NA-A stated she did not think it would bother R23 to raise her arms and be transferred in that manner. During interview on 9/9/23, at 3:14 p.m. licensed practical nurse (LPN)-A stated staff always transferred R23 with a gait belt and assist of one. Even if it was a close transfer, a gait belt would be required. Any resident that needed any type of staff assistance would need to have a gait belt on for the transfer.During interview on 9/10/23, at 4:30 p.m. the director of nursing (DON) stated any time staff assisted a resident to transfer, they were to use a gait belt. Any resident that needed assistance with transfers needed a gait belt and all the staff were aware of that. NA-A should have used a gait belt when transferring R23. Not using a gait belt and grabbing her around the torso to transfer could have injured R23's shoulders or caused her pain. There would have been nothing to grab a hold of, if R23 were to have started to fall during the transfer. The facility policy Wheelchair Transfer dated 1/3/23, directed staff to apply a gait/transfer belt around the resident's waist. Stand in front of the resident and position self to ensure safety of self and resident during transfer. Staff were to grasp the transfer belt at the resident's side with an underhand grasp. On count of three gradually assist resident to a standing position while continuing to grasp the transfer belt. Assist the resident to pivot and lower the resident into the chair. Remove the transfer belt.

Based on interview and document review, the facility failed to ensure a complete medical record was maintained to include the physician progress notes during routine visits for 4 of 14 residents (R2, R10, R32, R39) reviewed in the sample .Findings include:R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 was cognitively intact and had diagnoses that included atrial fibrillation (irregular heartbeat), major depressive disorder, morbid obesity and lymphedema (tissue swelling).R2's medical record identified an Order Summary Report signed by R2's physician and dated 9/3/24. However, R2's medical record failed to identify a physician progress note dated 9/3/24.A facility list was provided and identified the following residents had missing signed visit notes.R10's quarterly MDS dated [DATE], identified R10 had a moderate cognitive impairment and diagnoses that included cerebral palsy, epilepsy, and morbid obesity.R10's medical record failed to identify a physician progress note dated 6/11/25.R32's comprehensive MDS dated [DATE], identified R32 had a moderate cognitive impairment and diagnoses that included Alzheimer's disease, type 2 diabetes, and dementia.R32's medical record failed to identify a physician progress note dated 6/11/25.R39's quarterly MDS dated [DATE], identified R39 had a moderate cognitive impairment and diagnoses that included hypertension, insomnia, weakness, and osteoarthritis.R39's medical record failed to identify a physician progress noted dated 8/1/25.During an interview on 9/10/25 at 1:44 p.m., licensed practical nurse (LPN)-D stated she was responsible for the facility's medical records. LPN-D provided a word document containing a physician progress note for R2 dated 9/3/24. LPN-D stated R2's physician had recently resigned from her former clinic and did not have access to the medical record to document anything into R2's medical record. LPN-D called R2's physician that morning to remind the physician there were missing physician progress notes and the notes needed to be completed. Whenever a medical provider made rounds at the facility, LPN-D would provide a list of residents that needed evaluation and would wait for the completed physician progress note. Once received, LPN-D would ensure the physician progress note was scanned into the resident medical record. LPN-D stated the physician visit had been conducted more than a year prior, but R2's physician kept handwritten notes for review. From those notes, R2's physician was able to type the physician progress note the morning of 9/10/25. LPN-D stated she frequently reminds physicians of missing notes verbally but does not document any type of reminder. It's more of a frustration. At that time, LPN-D provided a list of residents with missing documentation and stated she had never formally brought the concern to administration.During an interview with the director of nursing (DON) and the administrator on 9/10/25 at 4:07 p.m., the administrator stated she was aware R2's physician had some missing documentation out there but was unaware of how long it had been occurring or how extensive. The administrator stated this concern should have been brought forward timelier, within 3 months, so reminders could be documented, and the facility could ensure all resident medical records were complete. The facility policy Physician Visits revised 1/4/23, identified during routine visits, the physician must:a. Review the resident's total program of care, including medications and treatment, at each visit required.b. Write, sign and date progress notes at each visit.

Based on interview and document review the facility failed to thoroughly investigate an allegation of neglect of care for 1 of 3 residents (R1) reviewed for safety during staff assisted transfers with a mechanical stand device. Findings include: R1's Admission Record identified an admitted [DATE]. Diagnosis included multiple fractures of pelvis, osteoarthritis in left hip and disorder of bone density. R1's significant change Minimum Data Set (MDS) dated [DATE] identified intact cognition. The MDS indicated R1 had lower extremity impairment on both sides and was dependent on staff for transfers. Facility incident report dated 10/5/24, indicated staff nurse responded to a call and found R1 on the bathroom floor with legs stretched forward and her back leaning against staff member's leg. When asked the nursing assistant (NA) stated she had been transferring R1 to the toilet when R1 slipped out of the harness strap and sat on the floor. NA- also stated R1 hit her head during the fall. R1 verbalized having pain in her head. R1 was unable to describe the details of the incident. R1's hospital history and physical notes dated 10/07/24, indicated she presented to the emergency department on 10/7/24 after a fall the previous day at the facility. The notes indicated R1 had landed on her left hip and hit her head on the toilet, was having difficult bearing weight and was more confused than usual. CT of left hip confirmed a non-displaced fracture of the acetabulum (the socket part of the hip joint). R1's care plan updated 10/18/24, identified acute and chronic pain arthritis and fall with pelvic fracture. The care plan indicated she required assist of one staff for transfer via mechanical stand device prior to fall with fracture. During interview on 11/18/24 at 11:54 a.m., R1 stated she remerged falling and said, I just went whoosh. R1 stated she fell in her room and staff helped her get up. R1 stated had not fallen out of a machine and said, could be I hit my head, I don't know. During interview on 11/18/24 at 1:07 p.m., NA-A stated she had put R1 in the mechanical stand and strapped the harness tight. NA-A stated when they got inside the bathroom R1 said she could not hold on anymore and let go of the machine and slipped through the harness. NA-A further stated she had used the medium sized sling and had used the leg straps. NA-A said after the incident occurred, staff received training on reporting a fall from a mechanical device. During interview on 10/18/24 at 1:56 p.m., the director of nursing (DON) stated she was not in the facility when R1 fell from the mechanical stand and said she had received a phone call several hours after the incident. The DON stated she had not looked at the harness following the incident to determine if the size was correct or if the harness was in good condition and said she hoped licensed practical nurse (LPN)-A had looked at them. The DON said the lift had not been inspected after the fall. The DON stated she only knew what was told to her and said she had been told R1 was just about to the toilet, and she raised her arms and slipped out of the sling. During interview on 101/024 at 2:00 p.m., physical therapist (PT)-A was asked what could cause a fall from a mechanical stand device. PT-A stated, I suppose they could fall if a resident's knees were not secure against the barrier, referring to the plate and the base of the machine that the knees of the resident rest against, or if the harness was not securely attached to the torso. PT-A stated if everything were hooked properly it would be almost impossible to fall out the mechanical stand. During interview on 10/18/24 at 2:15 p.m., LPN-A stated when he entered the room after R1 fell , she was seated on the floor and was propped up against NA-A's leg. LPN-A stated he asked R1 if she hit her head and she stated she had. LPN-A stated the lift was in the bathroom by the door. LPN-A said he had not inspected the lift or the harness. Facility policy Reporting of Mistreatment of Vulnerable Adults dated 8/20/24, indicated the social services designee will initiate the internal investigation checklist and conduct an internal investigation which will include staff and resident interviews.

Based on interview and document review, the facility failed to provide education on immunizations per Center for Disease Control and Prevention (CDC) guidance for 3 of 5 residents (R15, R22, R24) reviewed for immunizations. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE] identified they were [AGE] years old with a diagnosis of a history of COVID-19. R15's immunization record dated 8/27/24, identified pneumococcal polysaccharide vaccine (PPSV23) was given on 7/18/05, and the pneumococcal conjugate vaccine (PCV13) on 4/6/16. R15's medical record did not include evidence R15 or R15's representative received education regarding pneumococcal vaccine booster and there was no indication R15 was offered the pneumococcal vaccine per CDC guidance. R22's significant change MDS dated [DATE], identified they were [AGE] years old with diagnosis of chronic pulmonary edema (fluid in the lungs). R22's immunization record dated 8/27/24, identified pneumococcal polysaccharide vaccine (PPSV23) was given on 10/10/13, and the pneumococcal conjugate vaccine (PCV13) on 9/30/15. R22's medical record did not include evidence R22 or R22's representative received education regarding pneumococcal vaccine booster and there was no indication R22 was offered the pneumococcal vaccine per CDC guidance. R36's quarterly MDS dated [DATE], identified they were [AGE] years old with a diagnosis of congestive heart failure. R36's immunization record dated 8/27/24, identified pneumococcal polysaccharide vaccine (PPSV23) was given on 2/13/12. There was no evidence R36 received or was offered the PCV13. R36's medical record did not include evidence R36 or R36's representative received education regarding pneumococcal vaccine booster and there was no indication R36 was offered the pneumococcal vaccine per CDC guidance. During an interview on 8/27/24 at 11:00 a.m., licensed practical nurse (LPN)-B, the infection preventionist, stated when residents come due for immunizations, she would notify the resident or their representative and notify provider and provide education as needed. LPN-B identified education regarding the PCV20 immunization was not sent to family or representative unless they asked about it. During an interview on 8/27/24 at 12:00 p.m. the director of nursing (DON) stated the resident, or their representative should have been educated about the PCV20 and documented in the resident's medical record. The expectation was the CDC guidance would be followed. The facility's Infection Prevention and Control Program policy dated 5/12/23, regarding pneumococcal vaccination documentation identified, resident or representative was provided education regarding the benefits and potential side effects of pneumococcal immunizations. The CDC guidance dated 9/22/23, directed based on shared clinical decision-making (between resident/resident representative and provider) they need to decide whether to administer one dose of PCV20 at least 5 years after the last pneumococcal vaccination. This would have included providing education to the resident/resident representative.

Based observation, interview and document review, the facility failed to ensure a comprehensive reassessment was completed to ensure seat belt use was still warrented for identified medical symptoms; and failed to release the seatbelt according to care planned interventions for 1 of 1 residents (R9) reviewed for restraints. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R9 had a severe cognitive impairment, had diagnoses that included Alzheimer's disease, anxiety disorder, and psychotic disorder with delusions. R9 used a chair that prevented rising every day, and did not identify a trunk restraint. R9 used antipsychotic and antianxiety medications. R9's care plan revised 6/19/22, identified R9 required use of physical restraints: seat belt in a tilt-in-place wheelchair for positioning related to Alzheimer's dementia and R9 leaned forward in her wheelchair. Fall at home prior to admit with Fracture. R9 was continually reaching to her feet or leaning over in wheelchair attempting to fix her pants. R9 was a seamstress and did a lot of sewing for work. R9 continued to think she is sewing, [NAME] up her pants or picking up pins, etcetera. R9 had poor safety awareness. OT provided with new tilt and space type excessive leaning to be used as needed to assist with eating, hair cares, family visits. R9's family representative was aware. The care plan directed the following: - Discuss and record with R9/family/caregivers, the risks, and benefits of the restraint, when the restraints should be applied, routines while restrained and any concerns or issues regarding restraint use. - Ensure R9 was positioned correctly with proper body alignment while restraint was being used: seatbelt in wheelchair daily. Remove seatbelt with care, meals as able, one-on-one with staff, activities, toileting, etc. Fill out restraint release form every shift. - Seatbelt released with repositioning, 1:1 visit when calm, with toileting, when in bed and walking, etc. Document restraint use and release as per facility protocol. - Ensure valid consent on chart prior to initiating restraint. - Evaluate/record continuing risks/benefits of restraint; alternatives to restraint, need for ongoing use, reason for restraint use. Staff were to chart time seatbelt was off. - R9 needed a safe environment with adequate, glare-free light; floors that are even and free from spills or clutter; call light or alarm system; personal items within reach; bed in low position when locked. - R9 needed opportunities for restraint-free time and physical activity daily. Walking, toileting, transfers in and out of bed to rest. When sleeping or not restless place in wheelchair, etc. Per restraint committee, R9 was to have an activity staff remove during 1:1 visit, document time off and how tolerated. - R9 needed to have restraint applied daily. Seatbelt released: with repositioning, with 1:1 visit when calm, with toileting, when in bed, and walking, etc. Document restraint use and release as per facility protocol. Fill out restarting release form every shift. Family signed consent form. R9 used a tilt-in-space wheelchair with a footrest. Assure R9's hips were equally aligned in chair and all the way back. Calf pad placed over footrests when R9 was sitting up in her wheelchair. Do not turn your back on R9 if seat belt was off. Restraint reduction committee to look at ways to help reduce use of restraints and possible discontinue if able. Review quarterly/as needed. Nursing rehab to have her stretch daily on bed in therapy room. Try during activities to take seat belt off during 1:1 and observe closely as able and report skin breakdown. - Monitor/document/report to MD PRN changes regarding effectiveness of restraint, less restrictive device, if appropriate; any negative or adverse effects noted, including decline in mood, change in behavior, decrease in ADL self-performance, decline in cognitive ability or communication, contracture formation, skin breakdown, signs/symptoms of delirium, falls/accidents/injuries, agitation and/or weakness. The undated nurse aide care sheet, identified R9 used a seatbelt when in wheelchair but provided no other direction for staff, such as when it should be used and released. R9's Order Summary Report dated 3/2/21, identified a physician order for Assistive Device: Seat belt on rocking wheelchair (agitation, hallucination, increased restless, leaning, falls) for resident safety. Shoulder strap as needed to help with proper positioning. Remove for care, toileting, 1-1 with staff. R9's physician visit notes 10/10/23 through 7/17/24, failed to address R9's need for continued physical restraint. R9's Physical Restraint Elimination Assessment form dated 8/7/24, identified the following categories of evaluation: ambulation, weight bearing, sitting balance, ADLs (bathing dressing, grooming), physical limitations, orientation, comprehension, behavior/mood, activity participation and medication therapy. The form included the following scoring: 0-20 priority candidate, 21-35 good candidate and 35 plus poor candidate. R9 was complete bedrest/chairbound, non-weight bearing, leaned to the side, forward and backward, required total assist of two, had a history of falls, was legally blind, was disoriented to person place and time, was combative and severely agitated, unable to actively participate in activities and was currently taking antipsychotics. R9's score was 31 indicating R9 was a good candidate for restraint elimination. However, the assessment identified R9's score was good but R9 was not a candidate for restraint reduction or elimination program because R9 wore a seatbelt when sitting up in her wheelchair, video monitoring, used when R9 was in her room, with her bed in low position with a mat on the floor, but did not include supporting information to the frequency of the medical symptoms while seated in the chair warranting continued use without trialing a restraint reduction. R9 was legally blind with a diagnosis of Alzheimer's disease, delirium, psychotic disorder. R9 was unaware of safety or had poor safety awareness The assessment lacked the length of time the restraint is anticipated to be used to treat the medical symptom, the identification of who may apply the restraint, where and how the restraint is to be applied and used, the time and frequency the restraint should be released, and who may determine when the medical symptom has resolved in order to discontinue use of the restraint; the type of specific direct monitoring and supervision provided during the use of the restraint, including documentation of the monitoring; the identification of how the resident may request staff assistance and how needs will be met during use of the restraint, such as for re-positioning, hydration, meals, using the bathroom and hygiene; and the resident's record includes ongoing re-evaluation (based on supporting data) for the need for a restraint and is effective in treating the medical symptom. R9's Behavior/Mood sheets identified the following: - February 2024, R9 exhibited crying/weepy, taking off clothes, kicking, hitting, punching, picking at things not there, talking to herself, crawling out of bed, wakeful at night, hallucinating, difficulty with transfers, calling staff names, refusing cares, and screaming x 6. However, the documentation failed to identify behaviors exhibited while R9 was sitting in her wheelchair. - March 2024, R9 exhibited crying/weeping and kicking, hitting, punching x 1. However, the documentation failed to identify behaviors exhibited while R9 was sitting in her wheelchair. - April 2024, R9 exhibited no behaviors. - May 2024, R9 exhibited taking clothes off x 2, throat punching during cares x 1, picking at things not there, talking to herself, crawling out of bed, and screaming x 1. However, the documentation failed to identify behaviors exhibited while R9 was sitting in her wheelchair. - June 2024, R9 exhibited no behaviors. - July 2024, kicking, hitting, punching, and calling staff names x 3. However, the documentation failed to identify behaviors exhibited while R9 was sitting in her wheelchair. During an interview on 8/25/24 at 1:14 p.m., family member (FM)-A stated R9 had a history of falls. R9 used a low bed with a mat on the floor and used a seatbelt when she was in her wheelchair. FM-A stated the seatbet was used so R9 couldn't fall out of her wheelchair and FM-A was ok with that because it kept R9 safe. During an observation on 8/25/24 at 5:22 p.m., R9's seatbelt was not released during the supper meal with nursing assistant (NA)-G seated immediately next to R9. - At 6:58 p.m., R9 continued to sit in her wheelchair in her room. R9's seatbelt was snuggly fastened over her waist. R9 was quiet, with her head hanging down and her eyes were closed. R9's hands were clasped and lying in her lap. - At 7:26 p.m., R9 continued to sit in her wheelchair with her seatbelt on. R9 exhibited no agitation and sat quietly upright in her wheelchair. On 8/26/24 at 9:22 a.m., NA-C and NA-F assisted R9 with morning cares. R9 was transferred from bed to her wheelchair using a full body mechanical lift. Once R9 was in the wheelchair, NA-F immediately fastened R9's seatbelt. R9 was cooperative with cares. NA-F stated R9 always used a seatbelt. All day, every day. Staff didn't do anything with it except buckle it, but staff did lay R9 down every 2 hours or so for a check and change. NA-F pushed R9's wheelchair to the common area by the front desk. R9 sat quietly upright in her wheelchair and exhibited no agitation or behaviors. - At 9:53 a.m., NA-F pushed R9's wheelchair to R9's room to assist R9 to eat breakfast. NA-F did not remove R9's seatbelt even though NA-F sat immediately next to R9. R9 sat quietly upright in her wheelchair while eating. R9 exhibited no agitation or behaviors. - At 9:54 a.m., NA-D entered the room and told NA-F she could assist R9 to eat. NA-D sat down next to R9 and began assisting R9 to eat but did not remove R9's seatbelt. R9 sat quietly eating and occasionally responded when spoken to. R9 exhibited no agitation or behaviors. - At 10:22 a.m., NA-D assisted R9 to activities. R9's seatbelt continued to remain fastened. R9 sat quietly upright in her wheelchair and exhibited to agitation or behaviors. During an observation on 8/26/24 at 4:14 p.m., NA-B and registered nurse (RN)-A assisted R9 from her bed to her wheelchair using a full body mechanical lift. Once R9 was in her wheelchair, RN-A immediately fastened R9's seatbelt and RN-A pushed R9's wheelchair to the common area by the front desk. R9 sat quietly, upright and responded well when others greeted her. R9 exhibited no agitation or behaviors. During an interview on 8/26/24 at 4:31 p.m., NA-B stated R9's seatbelt was a safety measure because R9 was always fidgeting. If R9 was in her wheelchair, R9 had to always have the seatbelt on. The seatbelt was to prevent R9 from falling in case staff couldn't see it. There was no time frame for removal of the seatbelt and there was no time when it wasn't needed. NA-B then stated the seatbelt was removed when staff laid her down to check for incontinence, but as soon as R9 was back in her wheelchair the seatbelt was put back on. - At 4:35 p.m., NA-B stated she had to change her answer because R9's seatbelt was checked every 30 minutes and removed every 2 hours. During an interview on 8/26/24 at 4:40 p.m., licensed practical nurse (LPN)-A stated R9's seatbelt was removed every 2 hours. R9 used the seatbelt all day, every day. The seatbelt was also removed when R9 was in reach; usually at the supper table because staff were sitting right next to R9. Staff did not remove the seatbelt when R9 was sitting at the common area even though staff were right here but I'm busy and R9 just got up from bed and the seatbelt can be on for 2 hours. R9 was observed sitting quietly upright in her wheelchair. R9 was quiet and exhibited no agitation or behaviors. - At 5:00 p.m., R9 was observed sitting in her wheelchair with the supper table directly in front of her with the seatbelt fastened. R9 was upright and exhibited no agitation or behaviors. During an observation on 8/27/24 at 8:13 a.m., R9 was assisted to the dining room to eat her breakfast meal. Upon arrival, a clothing protector was placed on R9 but R9's seatbelt remained fastened. Activity aide (AA)-C sat down immediately next to R9 and assisted R9 to eat. R9 required total assistance and sat quietly eating; occasionally making sewing motions with her hands. During an interview on 8/27/24 at 8:45 a.m., AA-B stated staff tried to remove R9's seatbelt approximately every 2 hours depending on R9's mood. No, R9's seatbelt was not removed during breakfast but R9 had just gotten up. During an interview on 8/27/24 at 8:47 a.m., AA-C stated she did not undo R9's seatbelt even though she was seated right next to R9 because staff never remove it during meals. During an interview on 8/27/24 at 10:59 a.m., RN-A stated a restraint assessment was completed quarterly for R9's seatbelt. There really hadn't been any changes with R9. The last assessment was completed on 8/7/24, and was deemed necessary due to R9's severe agitation. R9 wasn't always severely agitated but sometimes could be a handful with cares. Staff determined R9 needed the seatbelt because R9 leaned way off to the side of her wheelchair and would lean down to fidget with her socks and shoes. RN-A did not believe R9 was top heavy enough to tip over her wheelchair but could tumble out of the wheelchair if not wearing the seatbelt. RN-A then stated RN-A had worked at the facility for more than 3 years and R9 had never fallen out of the wheelchair during that time. Staff were able to release the seatbelt when sitting by her; like at meals or during activities. RN-A stated staff were expected to follow care planned interventions to ensure the least restrictive intervention as well as to keep R9 safe. During an interview on 8/27/24 at 11:22 a.m., the assistant director of nursing (ADON) stated she would expect staff to check R9's seatbelt every 30 minutes to ensure it was not too tight. The seatbelt should have also been removed during meals and 1:1 activity. Staff were expected to be aware of R9's safety. The facility policy Use of Restraints revised 1/3/23, identified restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot, remove a device in the same way the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. 3. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove. 4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: a. Using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in, bed; bed rail assessments done on admit, readmit, quarterly, & sig. changes. Some residents use bedrails for repositioning. b. Tucking sheets so tightly that a bed-bound resident cannot move. c. Placing a resident in a chair that prevents the resident from rising; and d. Placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising. 5. Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to: a. Treat the medical symptom. b. Protect the resident's safety; and c. Help the resident attain the highest level of his/her physical or psychological well-being. 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. 7. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or resident representative. The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom). b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. 8. Orders for restraints will not be enforced for longer than twelve (12) hours unless the resident's condition requires continued treatment. 9. Reorders are issued only after a review of the resident's condition by his or her physician. 10. The following safety guidelines shall be implemented and documented while a resident is in restraints: a. Restraints shall be used in such a way as not to cause physical injury to the resident and to insure the least possible discomfort to the resident. b. Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency. Restraints with locking devices shall not be used. c.A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record. d. The opportunity for motion and exercise is provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed. e. Restrained residents must be repositioned at least every two (2) hours on all shifts. 11. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. 12. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). 13. Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. 14. Documentation regarding the use of restraints shall include: a. Full documentation of the episode leading to the use of the physical restraint. This includes not only the resident symptoms but also the conditions, circumstances, and environment associated with the episode. b. A description of the resident's medical symptoms (i.e., an indication or a characteristic of a physical or psychological condition) that warranted the use of restraints. c. How the restraint use benefits the resident by addressing the medical symptom. d. The type of the physical restraint used. e.The length of effectiveness of the restraint time; and f. Observation, range of motion and repositioning flow sheets.

Based on observation, interview, and record review the facility failed to comprehensively assess and develop interventions for safety while using a golf cart off campus for 1 of 1 (R23) resident reviewed for safe use of a motorized golf cart. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderate cognition and was independent or needed supervision with activities of daily living (ADL). R23 had upper extremity impairment on one side and no lower extremity impairment. R23's diagnoses included Parkinson's disease with dyskinesia (mild to severe uncontrolled muscle movements). R23's progress notes dated 2/26/24 through 8/27/24, identified multiple occasions of R23 independently leaving the facility on his golf cart and driving to appointments, town, the store, and other activities. The notes identified the resident kept his cell phone on his person, however, the notes failed to identify if R23 was safe while driving the golf cart. R23's medical record lacked an assessment for safe use of a motorized golf cart to include and evaluation and analysis of the the potential hazards and risks and eliminate them, if possible and, if not possible, reduce them as much as possible. R23's care plan dated 8/25/24, failed to identify a focus, goals, or interventions for safe use of a cart. On 8/25/24 at 1:37 p.m., R23 stated he drove his golf cart every day. R23 told the nurses when he was leaving, where he was going and the approximate time he would be returning. R23 also stated he brought his cell phone with him whenever he left the facility. On 8/27/24 at 8:39 a.m., nursing assistant (NA)-E stated R23 took his golf cart independently and was a very safe driver. NA-E stated she had ridden with R23 in the past and felt comfortable with his driving. On 8/27/24 at 8:45 a.m., activities aide (AA)-A stated R23 used a walker at the facility, was steady on his feet and needed very little assistance with ADL's. R23 had a motorized golf cart for the summer months, had a current drivers license, and drove the golf cart independently. R23 also brought his cell phone with him when he drove his cart and was able contact the facility if he needed anything. AA-A stated she had observed R23 driving the golf cart safely. On 8/27/24 at 8:50 a.m., the social services designee (SSD) stated R23 had the golf cart since his admission in 2021, and used the golf cart in the warmer months. The SSD stated she had not completed an assessment to determine if R23 was safe while using the golf cart, and was unable to find a previous assessment in R23's medical record. - At 9:00 a.m., AA-B entered the room and stated R23 had been driving his golf cart for many years and had assumed another staff member completed an assessment to determine if R23 could safely drive the golf cart. AA-B had not looked in his chart to ensure an assessment was there and had not completed one herself. Further, AA-B stated R23 had a drivers license and was supposed to complete an OT evaluation to drive his truck but the resident's family didn't want him driving the truck. The family approved the golf cart and R23 was satisfied driving the cart. An assessment to determine safe operation, including physical and cognitive ability including a safety plan was requested but not received from the facility. On 8/27/24 at 12:20 p.m., the assistant director of nursing (ADON) stated the facility had not assessed R23 for physical or mental ability for safe operation of and had not implemented interventions to ensure R23's safe return after leaving the facility or driving his golf cart. The facility did not have a policy regarding motorized golf cart use. The ADON stated R23 should be assessed at least yearly and as needed, and the golf cart use and safety plan should be added to the residents care plan.

Based on interview and document review, the facility failed to ensure insulin was administered per physician orders [REDACTED]. This failure resulted in actual harm for R1 due to requiring hospitalization following the administration of the incorrect insulin dose. The medication error was identified immediately and the facility developed and implemented corrective actions on 6/19/19, therefore the deficient practice is being issued at a past non-compliance. Findings include: R1's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R1 had moderate cognitive impairment and [DIAGNOSES REDACTED]. R1's physician orders [REDACTED]. -[MEDICATION NAME] Solution 100 units (u)/milliliter (ml) (fast acting insulin), inject 8 units subcutaneous (SQ)(under the skin) in the evening -[MEDICATION NAME] solutions 100 u/ml, inject 5 units SQ 2 times a day with breakfast and lunch. R1's care plan dated 8/7/19, indicated R1 had diabetes. Staff were directed to administer mediations as ordered, monitor and report to medical doctor (MD) any signs or symptoms of [DIAGNOSES REDACTED] including; sweating, tremor, increased heart rate, confusion or slurred speech. Monitor and report to MD any signs or symptoms of [MEDICAL CONDITION] including: increased thirst, frequent urination, fatigue, dry skin, poor wound healing, muscle cramps, stupor or [MEDICATION NAME] breath (fruity smelling) R1's Progress Note (PN) dated 5/28/19, at 5 p.m. indicated R1's medication order was read incorrectly prior to administering R1's supper time insulin dose. R1 was administered 100 units of [MEDICATION NAME]instead of the 8 units ordered. The charge nurse, MD and family were informed immediately and an order was received to send R1 to the emergency room (ER) for hospitalization and overnight monitoring. The medication error was identified immediately after the administration of the wrong dose. PN dated 5/28/19, at 5:57 p.m. indicated registered nurse (RN)-A reported she had given R1 too much insulin in error. R1 normally received [MEDICATION NAME] 8 unit and was given 100 unit SQ. A call was placed to the MD and an order was received to send R1 to the ED for treatment of [REDACTED]. Call was placed for transportation per ambulance. Paper work gathered and sent with ambulance. Family was called and updated. Monitoring Blood sugars while waiting for ambulance. At 5:00 p.m. Blood Sugar (BS) was 145, at 5:20 p.m. BS was 147. Resident was alert and oriented, color pale, skin dry and warm to touch. R1 left per ambulance at 5:35 p.m. PN dated 5/29/19, at 4:41 p.m. indicated R1 was readmitted to the facility following hospitalization . Review of R1's hospital PN and discharge summary indicated R1 was hospitalized and received glucose (sugar) tablets, IV fluids of 5% [MEDICATION NAME] (sugar) and 10% [MEDICATION NAME] to treat [DIAGNOSES REDACTED]. R1 had BSs during hospitalization down into the 30's (normal is 70 or above). Discharge summary dated 5/29/19, indicated R1's BS was stable at 160 prior to discharge back to the nursing home, and no new orders given. On 10/17/19, at 4:15 p.m. RN-B verified the insulin medication error had occurred which required an overnight hospitalization for R1. RN-B stated following this medicaiton error, all licensed staff had received education regarding the five rights of medication administration which included ensuring the correct dose would be administered. On 10/18/19, at 8:50 a.m. RN-C was observed to give R1 the morning dose of insulin. RN-C opened up R1's Medication Administration Record [REDACTED]. RN-C removed R1's insulin pen, verified the medication, attached the needle to the pen, primed the pen with two units of insulin, dialed up the ordered five units, and proceeded to administer the correct dose to R1. Prior to administering, RN-C informed R1 of the medication to be administered, asked which site he would like to receive it, and cleansed the area with an alcohol prep. Following the administration, RN-C disposed of the needle properly. -At 8:58 a.m. R1 stated he been on insulin for over [AGE] years and had no concerns about his blood sugars as they had been doing great. -At 9:29 a.m. the South Med Cart was noted to have an insulin folder which held information pertaining to the different types of insulin, how they work, a picture of fast acting [MEDICATION NAME], information on medications and the directive to double check insulin doses if over 20 units was to be administered. The folder also contained a policy for the administration of insulin and the five rights of administration. -At 9:50 a.m. RN-C said she had started in (MONTH) 2019, and since that time the facility had held monthly inservices on different aspects of patient safety. RN-C confirmed she had received education related to medication administration, the five rights of medication administration as well as insulin administration with her initial training. Shortly there-after, licensed practical nurse (LPN)-B stated the nurses had received education during a staff meeting regarding the different insulin types and there were also handouts taped to the wall by the East and West medication carts titled Rapid Acting Insulin and Types of Insulin for staff review. LPN-B stated the pharmacy attached a High Alert sticker on each rapid acting insulin's bottle. -At 10:12 a.m. LPN-A confirmed education was provided to the licensed nursing staff regarding medication errors and the five rights of proper medication administration. -At 11:05 a.m. The administrator confirmed the insulin medication error had occurred which required R1 to be hospitalized overnight. The administered stated, a medication administration inservice was provided on 6/19/19, which included the administration of insulin and the five rights of medication administration. -At 11:17 a.m. The DON stated confirmed the insulin error had occurred and following the error, all licensed nursing staff attended/received medication administration re-education related to the administration of insulin and the five rights of medication administration. The facility and the local pharmacy had collaborated to ensure that insulin was labeled and high alert stickers were placed on each fast acting insulin bottle. The deficient practice was corrected on 6/19/19, after the facility developed and implemented corrective action which included medication administration including the five rights, collaboration with the pharmacist related to medicaiton labeling and the use of medicaiton high alert stickers, and developing handouts and creating binders which contained information related to insulin types and the action of each which were available on each medicaiton cart for nurse's to reference, when needed. A staff signature sheet was reviewed to ensure education was received to all nursing staff. The facility's Medication Insulin Administration Policy dated 5/30/19, indicated if an order was for greater than 20 units of fast acting insulin, the order must be verified with another licensed nurse.

Based observation, interview and document review, the facility failed to implement increased monitoring and identify symptoms of bleeding which resulted in a [MEDICAL CONDITION] and required hospitalization and subsequent blood [MEDICAL CONDITION] for 1 of 1 resident (R2) who received an antibiotic while on [MEDICATION NAME] therapy. R2 experienced bloody stool without the identification and notification of the physician and was found to have a critically elevated INR (lab test which evaluates the clotting ability of the blood). This failure resulted in an immediate jeopardy situation for R2 and due to the facility's failure to evaluate their monitoring policies and procedures in order to identify areas for improvement and/or opportunities for staff education to prevent or minimize future occurrences resulted in the potential for harm that was not immediate jeopardy for 3 of 3 residents (R19, R13, R29) who also received [MEDICATION NAME]. The immediate jeopardy began on 6/18/18, when R2 was prescribed Bactrim DS (an antibiotic) for the treatment of [REDACTED]. The immediate jeopardy was identified on 8/9/18, at 4:25 p.m. at which time the administrator, director of nursing (DON) and assistant director of nursing (ADON) were notified. The immediate jeopardy was removed on 8/10/18, at 11:00 a.m. but noncompliance remained at the lower scope and severity level of G - isolated scope and severity level, which indicated actual harm that is not immediate jeopardy. Findings include: R2's annual Minimum Data Set ((MDS) dated [DATE], indicated R2 was cognitively intact and had [DIAGNOSES REDACTED]. The MDS also indicated R2 required extensive assistance with all activities of daily living except eating and also received anticoagulant medication daily. R2's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 7/11/18, indicated R2 had a longstanding history of urinary tract infections [MEDICAL CONDITION] with history of increased confusion, hallucinations and delusions associated with a UTI. R2's Falls CAA dated 7/11/18, indicated R2 had a history of [REDACTED]. The CAA indicated R2's [MEDICAL CONDITION] was stable, however, [MEDICATION NAME] (anticoagulant) had recently been discontinued due to a [MEDICAL CONDITION] (GI). R2's care plan dated 7/24/18, indicated R2 had [MEDICAL CONDITION] and required the use of a pacemaker. [MEDICATION NAME] currently discontinued after last hospital stay related to GI bleed and risk for bleeding. Review of R2's clinical record revealed on 4/10/18, medical doctor (MD)-A started R2 on a course of antibiotics (Bactrim DS) due to urinary tract infection [MEDICAL CONDITION] with adjustments made of her [MEDICATION NAME] orders (increased risk of bleeding when an antibiotic and [MEDICATION NAME] are used concurrently) which directed the staff to hold the [MEDICATION NAME] for two days and then give scheduled doses every other day for four days then to resume the regular dose of [MEDICATION NAME] 2.5 mg daily and check INR (laboratory test that monitors the effects of anticoagulant treatment) Monday, 4/16/18. The INR results dated 4/16/18, were elevated at 3.8 (Fair Meadow Lab Flow Sheet indicated normal INR range to be between 2.0 - 3.0). R2 was seen by physician assistant (PA)-A for UTI due to a persistent and worsening confusional state and R2 was subsequently admitted to the hospital. R2's Nursing Home Progress Note (NHPN) by MD-A dated 6/1/18, indicated R2 had had several hospitalization s for UTIs. After hospitalization , R2 had been sent home on chronic urinary tract suppression with [MEDICATION NAME] (an antibiotic) 250 mg daily. However, in the past week R2 had a recurrence of UTI symptoms despite the [MEDICATION NAME] use. Therefore, the [MEDICATION NAME] was discontinued [MEDICATION NAME](an antibiotic) was started with modifications for her INR. The assessment section of the note indicated R2 was doing well on [MEDICATION NAME] the plan was to complete the course of the Cipro. On 6/2/18, R2's INR result was 3.4 therefore MD-A ordered R2's [MEDICATION NAME] to be held on 6/2/18, then resume every other day. MD-A ordered a recheck of R2's INR on 6/6/18. R2's INR dated 6/6/18, was 2.1, for which MD-A ordered R2's [MEDICATION NAME] held for two days and then resumed at 2.5 mg daily with a recheck of the INR on 6/13/18, due to R2 just finishing the course of Cipro. R2's Fair Meadow Nursing Home (FMNH) fax communication dated 6/13/18, indicated R2's INR was 1.6. MD-A responded with an order to increase R2's [MEDICATION NAME] to 4 mg, 1 tablet daily and to recheck in two weeks. Concurrently, R2's nursing Progress Notes (PN) dated 6/13/18, indicated [REDACTED]. The note further indicated an order had been received from MD-A to culture R2's urine and if R2 experienced increased weakness or uncontrolled hallucinations she may be sent to the emergency room . R2's nursing PN dated 6/18/18, indicated MD-B had called the facility and prescribed Bactrim DS 1 tab orally, twice a day for seven days and to recheck the INR on 6/25/18, and send to MD-C. However, neither the note nor telephone order identified any modification to R2's [MEDICATION NAME] dose or the need for increased INR monitoring following the initiation of the antibiotic and R2's history of abnormal INR results while receiving an antibiotic. R2's PN dated 6/23/18, written by licensed practical nurse (LPN)-C, indicated R2 had two loose stools that were maroon in color. R2's temperature was 97. She denied abdominal pain and , Well it is better now that my bowels moved. LPN-C indicated he would monitor for fever, pain and further stools. The note also indicated LPN-C had spoken with R2 at 2:30 p.m. and she had denied abdominal pain. R2 had also stated two days ago she had to strain to have a bowel movement and was wondering if the blood could be from the straining. LPN-C indicated he had offered to have her checked in the emergency room (ER) but R2 refused. LPN-C left a message for R2's daughter to call the nursing home and while doing so, R2's daughter-in-law came to pick her up for an outing. LPN-C informed the daughter-in-law about the stools so family was aware and would watch also. Daughter-in-law aware R2 had declined ER because she declined it again with daughter-in-law present. LPN-C indicated he would continue to monitor when R2 returned and treat as necessary and as R2 and family desired. R2's clinical record lacked evidence of a registered nurse assessment or physician notification of the maroon stool. R2's Medication Administration Record [REDACTED]. R2's PN dated 6/24/18, indicated R2 had increased confusion, fatigue and hallucinations as well as increased clot like appearance and more maroon color to her stools. R2 continues to received Bactrim for a UTI and her INR had been affected in the past by antibiotic use. INR checked today and was found to be 8.0 (at significant risk for major hemorrhage). A stool sample was obtained this afternoon and sent with the ambulance when they departed at 3:25 p.m. A follow up NP noted indicated R2 had been admitted to the hospital. R2's Emergency Department (ED) note dated 6/24/18, indicated R2 had been noted to have intermittent blood in her stool over the course of the previous 3 days. She was on [MEDICATION NAME] chronically due to a history of [MEDICAL CONDITION]. An INR was checked and found to be significantly elevated at 8. R2 had not appeared acutely ill upon arrival to ED and had not offered any acute complaints. R2 was mildly [MEDICAL CONDITION] (heart rate exceeds normal resting rate) and appeared mildly pale. Anoscopy (a scope used to examine the anal canal) revealed black stool with melanotic (having black pigmentation) features. An INR was repeated and was greater than 10. R2's hemoglobin (protein responsible for transporting oxygen in the blood) was 8.9 R2 was given 10 mg of vitamin K (helps the blood clot) intravenously and was admitted to the hospitalist service for further evaluation and treatment. R2's Hospital Consultation Note dated 6/25/18, indicated R2 was evaluated for hematochezia (blood in the stool). R2 reported she had passed some bright red blood per rectum on one occasion on Saturday. Found to have INR >10. R2's son reported her INR had become elevated previously after she had been treated for [REDACTED]. Hematochezia with elevated INR. R2's Hospital Progress Note dated 6/26/18, indicated an assessment which included: 1. Acute lower [MEDICAL CONDITION]. The cause was uncertain. This could have been secondary to [DIAGNOSES REDACTED] (pockets in the digestive tract), hemorrhoids, angio[DIAGNOSES REDACTED] (vascular malformation of the gut) [MEDICAL CONDITION], most likely because of the supratherapeutic INR. 2. Acute blood loss [MEDICAL CONDITION]. R2 dropped her hemoglobin significantly from 8.9 to 7.4. Received 2 units of packed red blood cells. 3. Supratherapeutic INR on admission. It was above 10 on admission. R2 was given vitamin K 10 mg on admission and 2.5 mg orally on 6/25/18. 4. [MEDICAL CONDITION], rate controlled, status [REDACTED]. 5. Chronic anticoagulation with [MEDICATION NAME]. Hold [MEDICATION NAME] for now. 6. Urinary tract infection. History of UTI. Was on Bactrim, is most likely the cause of her increased INR. On 8/6/18, at approximately 3:15 p.m. R2 was observed seated in a recliner, in her room. R2 was alert, well groomed and oriented to person and place. On 8/8/18, at 3:50 p.m. the assistant director of nursing (ADON) verified the facility had the capacity to perform point of care/finger stick testing for INR, however, an MD order for the testing was required and she was not sure if INR testing was included in the facility standing orders. On 8/9/18, at 9:01 a.m. LPN-C stated side effect monitoring for residents who received anticoagulant therapy included testing for INR and the facility also had a machine in house to perform the testing. LPN-C stated the staff monitored for symptoms such as bloody stools, bloody emesis, or bruising. LPN-C confirmed R2 had experienced an elevated INR of 8 which required hospitalization . LPN-C stated the incident happened on a Saturday and verified a nursing assistant (NA) had reported that R2 had bloody stools and he had reported this to the registered nurse (RN). LPN-C stated it was not frank or coffee ground blood and was a weird color. LPN-C stated the next day, R2's stool color was darker than the day before. LPN-C could not remember if the RN had evaluated R2 or not on 6/23/18, when the maroon colored stool was reported. LPN-C also could not remember if R2 had a UTI at the time or if she had just been getting over one. R2's Progress Note dated 6/23/18 was reviewed with LPN-C who confirmed R2 was offered the ER and refused. On 8/9/18, at 9:33 a.m. LPN-B stated anticoagulation monitoring included checking a resident's INR and watching for symptoms such as bleeding or bruises. LPN-B confirmed bloody stools would be a symptom for which they would monitor. LPN-B stated if any symptoms were noted she would notify the RN if it were the day shift, or would contact the MD if it was the evening shift. On 8/9/18, at 9:42 a.m. RN-B confirmed she was R2's primary RN. RN-B stated she did not have a specific identified therapeutic goal range for R2's INR, however, indicated 2.0-3.0 was the reference range identified on the laboratory sheets. RN-B verified the physicians managed the residents' [MEDICATION NAME] doses and monthly and as needed (PRN) INRs were completed with adjustments made to the [MEDICATION NAME] orders according to the INR results. RN-B stated she would expect staff to monitor for any signs or symptoms of bleeding such as prolonged bleeding of cuts, bruises, bleeding to gums, rectal bleeding or any change to stool such as stools that were black, maroon or bright red in color. RN-B stated the NAs were to report any symptoms of bleeding to the charge nurse and any observed symptoms would be documented in a progress note. RN-B also stated she would expect the LPNs to monitor for symptoms of bleeding and notify the RN and/or the doctor. RN-B stated she had not been working on 6/23/18, or 6/24/18, so she was not sure if R2's maroon stool had been reported to the RN or if the RN had assessed R2 once reported to her. R2's medical record was reviewed with RN-B who verified the following: --6/23/18, progress note indicated R2 had maroon stools. --R2 received 4 mg [MEDICATION NAME] on 6/23/18. --Bactrim DS 800-160 mg had been prescribed on 6/18/18, and R2 continued to receive the antibiotic through the morning of 6/24/18. --R2's clinical record contained no documentation to indicate R2 had been assessed by an RN on 6/23/18. --Progress note dated 6/24/18, at 1:30 p.m. indicated the ADON would contact RN-B and MD-A on Monday, 6/25/18, unless R2's status changed. On 8/9/18, at 11:29 a.m. the ADON confirmed the residents on [MEDICATION NAME] were monitored for symptoms such as bruising, blood in urine, color of skin, lethargy, and blood in the stool and would expect any symptoms to be reported to the charge nurse so the RN could assess and monitor to see where the situation was headed. The ADON stated the MDs did not generally give them individual INR therapeutic ranges rather, stated she would refer to the lab report results for INR parameters. In addition, the ADON stated all INR results were reviewed by the physician. The ADON verified on 6/23/18, R2's [MEDICATION NAME] order was for 4 mg daily and R2 had also been prescribed Bactrim DS on 6/18/18. The ADON indicated R2's primary MD (MD-A) had been out so it was another provider, MD-B, who prescribed the antibiotic and the INR results were to have been reported to MD-C, who covered for MD-A. The ADON verified she had worked on 6/23/18, and confirmed LPN-C had reported R2's maroon colored stool to her and they had looked at it. The ADON stated the stool was a weird color. The ADON stated she had LPN-C do a focused assessment of R2 and that they (staff) were in a monitoring state at that point. The ADON stated family had been at the facility to take R2 out for the day and R2 had been coherent and responsive with no signs of confusion. The ADON confirmed R2 had been offered to be evaluated at the ER for which she had refused therefore, when R2 had left the facility with family, she had left in a monitoring state at that time. The ADON stated she had not spoken with the family, however, LPN-C had done so and was not sure if LPN-C had explained the risks and benefits of R2 refusing to be evaluated in the ER. The ADON stated, I guess at that point we were trying to determine what the stool was and passed the information on (to the next shift). The ADON stated she was not aware if R2 had any further stools after she had left the facility. In addition, the ADON confirmed that following the observation of the maroon colored stool, she had not had R2's dose of [MEDICATION NAME] held, nor had she contacted the physician. The ADON stated she was not sure if she would have done anything differently knowing then what she knew now. The ADON stated the stool did not have frank blood and R2 had no other symptoms. ADON stated she even went and checked the menu to see if the residents had been served beets. The ADON stated on 6/24/18, R2 had experienced more maroon stools with a clotting appearance and more lethargy, however, the staff had attributed the lethargy to R2's outing the previous day. R2 then began hallucinating which they attributed to a UTI. The ADON stated just before shift change she had the opportunity to discuss R2 with staff and was able to put it all together so the first thing she did was contact R2's family to discuss possible hospitalization and to notify them she would be testing R2's INR. The ADON performed the INR test which revealed the INR level was 8. The ADON contacted the family again to inform them she was not comfortable with R2's INR results and ask if they would be willing to send R2 to the ER for an evaluation. Once the family had approved, the ADON contacted the physician and received orders to transport R2 to the ER. The ADON verified at the ER, R2 was diagnosed with [REDACTED]. The ADON stated she could have probably tested R2's INR on 6/23/18, as she was aware of the adverse interactions between [MEDICATION NAME] and antibiotics, however, not to make excuses, but she was not R2's primary RN and probably did not know her history as well as RN-B. The ADON stated following R2's adverse medication event, a formal discussion with the interdisciplinary team regarding R2's hospitalization was not conducted, however, she had talked with RN-B and LPN-C about the incident. The ADON stated the facility had not made any changes to the anticoagulant monitoring system because they felt they had done what they should have done and R2 had since had her order of [MEDICATION NAME] discontinued. On 8/9/18, at 11:58 a.m. the unit clerk (UC) verified there were three residents in house who currently received [MEDICATION NAME], R13, R19, and R29. On 8/9/18, at 12:01 p.m. the director of nursing (DON) confirmed R2's maroon stool was a red flag and stated she would have expected the ADON to have assessed the patient herself, checked an INR, held the [MEDICATION NAME], and contacted the physician. The DON also stated she felt the situation should have been reviewed in order to identify areas for facility process improvement. On 8/9/18, at 4:13 p.m. R2's primary physician and facility medical director, MD-A indicated the monitoring for residents who received anticoagulant medication who were also prescribed antibiotics depended on the antibiotic prescribed. MD-A stated usually if the antibiotic was Cipro, [MEDICATION NAME] or [MEDICATION NAME] (Bactrim), staff needed to check the INR more often. R2's antibiotic order from 6/18/18, was reviewed with MD-A who stated he would have done that differently. MD-A stated the physicians relied on the pharmacy to help nursing out. He stated the physician who prescribed the antibiotics should have ordered earlier INR testing, nursing should have asked for earlier INR testing and/or the pharmacist should have also asked for earlier INR testing. MA-D confirmed a maroon colored stool was a cause for concern and should have been a signal to call someone. MD-A stated he would have expected to be notified when R2 had the first maroon colored stool. MD-A indicated the staff had been working on the facility policy to include INR testing to be initiated per nursing discretion, however, stated a maroon stool, with or without policy changes would have been an indication to notify someone, particularly if the resident was on anticoagulant medication. MD-A was unsure of the facility policy regarding nursing staff holding the [MEDICATION NAME] medication without an order but indicated they should have contacted the physician prior to giving the medication. The undated Therapeutic Monitoring of INR policy directed staff to ensure a physician order [REDACTED]. The policy also directed if a resident was on [MEDICATION NAME] ([MEDICATION NAME]) therapy and had signs of bleeding (i.e. bruising, bleeding gums, rectal bleeding, signs of blood in stool, blood in urine, etc.) nursing discretion could be used to complete a finger stick INR in house. The undated Anticoagulation Management policy indicated the physician would identify potentially serious medication interactions with [MEDICATION NAME] for example: concurrent use with [MEDICATION NAME] and many antibiotics. The policy also indicated the physician would stop, taper, or change medications that interacted with [MEDICATION NAME], or monitor PT/INR very closely while the individual received [MEDICATION NAME] to ensure the PT/INR stabilized. The policy also indicated the staff and physician would monitor for possible complications in individuals who were being anticoagulated and would manage related problems. If an individual on anticoagulation therapy showed signs of excessive bruising, hematuria (blood in urine), hemoptysis (coughing up blood), or other evidence of bleeding, the nurse would discuss the situation with the physician before giving the next scheduled dose of anticoagulant. The immediate jeopardy that began on 6/18/18, was removed on 8/10/18, at 11:00 a.m. when the facility implemented the following actions: -checked the current INR levels of residents who currently received [MEDICATION NAME] -updated the facility standing orders regarding INR testing -updated their anticoagulation policy to include increased monitoring while on antibiotics -educated all nursing staff regarding the updated policies including the signs and symptoms of a non-therapeutic INR -developed a plan to educate staff not working to ensure education was received prior to the start of their next shift. -updated their procedures to include interdisciplinary team review of each resident hospital admission for measures to prevent unnecessary hospitalization s or medication related adverse events. R19's [DIAGNOSES REDACTED]. R19's 14 day MDS dated [DATE], indicated R19 had moderately impaired cognition, did not ambulate, and required extensive assistance of one to two staff for ADLs. The MDS also indicated R18 received anticoagulant medication daily during the MDS reference period. R19's Order Summary Report dated 8/10/18, revealed an order for [REDACTED]. The report did not identify the use of antibiotic medication. R19's FMNH fax report sheet dated 8/9/18, indicated R19's most recent INR was 2.0. The physician response was to continue the same dose of [MEDICATION NAME] and recheck the INR in two weeks then monthly. R13's quarterly MDS dated [DATE], indicated R13's [DIAGNOSES REDACTED]. The MDS also indicated R13 had moderately impaired cognition, required extensive assist of one to two staff for activities of daily living (ADL) except for eating, and received anticoagulant medication daily during the MDS reference period. R13's FMNH fax report dated 8/9/18, indicated R13's INR was 1.5 and the physician responded with an order to increase the [MEDICATION NAME] to 2 mg daily and to recheck the INR in two weeks. R29's quarterly MDS dated [DATE], indicated R29's [DIAGNOSES REDACTED]. The MDS also indicated R29 had intact cognition, required extensive staff assistance for all ADLs except for eating in which R29 was independent, required supervision for transfers, and received anticoagulant medicaiton daily during the MDS reference period. R29's FMNH fax report dated 8/9/18, indicated R29's INR was 1.5 which revealed a significant drop since the 8/1/18, INR of 3.7. The physician responded with an order to increase the [MEDICATION NAME] to 3 mg daily and to recheck the INR in two weeks and 4 weeks.

Based on interview and document review, the facility failed to ensure the physician was notified of signs and symptoms of bleeding for 1 of 1 resident (R2) who experienced adverse effects of concurrent anticoagulant and antibiotic use. This failure resulted in actual harm for R2 due to the onset of a [MEDICAL CONDITION] which required hospitalization and blood [MEDICAL CONDITION]. Findings included: R2's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R2 was cognitively intact and had [DIAGNOSES REDACTED]. The MDS also indicated R2 required extensive assistance with all activities of daily living except eating and also received anticoagulant medication daily. R2's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) dated 7/11/18, indicated R2 had a longstanding history of urinary tract infections [MEDICAL CONDITION] with history of increased confusion, hallucinations and delusions associated with UTI. R2's Falls CAA dated 7/11/2018, indicated R2 had a history of [REDACTED]. The CAA indicated R2's [MEDICAL CONDITION] was stable, however [MEDICATION NAME] had recently been discontinued due to a gastrointestinal (GI) bleed. R2's care plan dated 7/24/18, indicated R2 had [MEDICAL CONDITION] and required the use of a pacemaker. [MEDICATION NAME] currently discontinued after last hospital stay related to GI bleed and risk for bleeding with use of [MEDICATION NAME]. The care plan also indicated R2's family would discuss risks/benefits of [MEDICATION NAME] and if it should be restarted, and were aware of current discontinuation of this medication and in agreement at this time Review of R2's medical record from 4/1/18, to 8/13/18, revealed R2 had ongoing issues related to UTI with hallucinations and confusion which required multiple courses of antibiotic therapy. Concurrently, R2's [MEDICATION NAME] regimen required modification and increased monitoring due to fluctuations in INR outside of therapeutic levels. On 6/13/18, R2 experienced INR results outside of therapeutic range at 1.6 for which medical doctor (MD)-A ordered R2's [MEDICATION NAME] be increased from 2.5 mg to 4 mg 1 tablet daily with recheck in two weeks. R2's Progress note dated 6/18/18, indicated a call had been received from MD-B's office with orders to start Bactrim DS 1 tab orally twice daily for 7 days. Check INR on 6/25/18, and send to MD-C. The note did not include modification to R2's [MEDICATION NAME] order or increased INR monitoring with the addition of the antibiotic. R2's Progress Note dated 6/23/18, completed by licensed practical nurse (LPN)-C indicated R2 had two loose stools that were maroon in color. R2's temperature was 97. She denied abdominal pain and stated Well it is better now that my bowels moved. LPN-C indicated he would monitor for fever, pain and further stools. The note also indicated LPN-C had spoken with R2 at 2:30 p.m. and she had denied abdominal pain. R2 had also stated two days ago she had to strain to have a bowel movement and was wondering if the blood could be from the straining. LPN-C indicated he had offered to have her checked in the ER but R2 had refused. LPN-C left a message for R2's daughter to call the nursing home and while doing so R2's daughter-in-law came to pick her up for an outing. LPN-C informed the daughter-in-law about the stools so family was aware and would watch also. Daughter-in-law aware R2 had declined ER because she declined it again with daughter-in-law present. LPN-C indicated he would continue to monitor when R2 returned and treat as necessary and as R2 and family desired. R2's clinical record lacked evidence of a registered nurse assessment or physician notification of R2's maroon colored stool. R2's Medication Administration Record [REDACTED]. R2's Progress Notes dated 6/24/18 revealed the following: --10:39 a.m. note completed by LPN-C indicated R2 took scheduled medications without difficulty. R2 reported being tired, denied abdominal pain. The note indicated LPN-C would continue to monitor and obtain a stool sample if able, to check for blood. --1:30 p.m. note completed by assistant director of nursing (ADON) indicated R2 denied abdominal pain as well as tenderness with palpation. Bowel sounds were present in all four quadrants. The noted indicated ADON would continue to monitor and follow up with primary registered nurse (RN) and MD tomorrow unless status changed. --3:03 p.m. note completed by ADON indicated R2 was noted to have increased confusion, fatigue, and hallucinations this afternoon as well as increased clot like appearance and more maroon color to stools this afternoon. The note indicated R2 was also on Bactrim for a UTI and her INR had been affected in the past by her antibiotics. Finger stick INR 8.0 today. The note indicated MD-E ordered R2 be sent to the hospital. Due to R2 not wanting to go to the hospital yesterday, the family was contacted and agreed to have R2 seen at the hospital. A stool sample was obtained this afternoon and sent with the ambulance when they departed the building at 3:25 p.m. R2's Emergency Department (ED) note dated 6/24/18, indicated R2 had been noted to have intermittent blood in her stool over the course of the previous three days. She was on [MEDICATION NAME] chronically due to a history of [MEDICAL CONDITION]. An INR was checked and found to be significantly elevated at 8 (critical level which could result in a hemorrhage). R2 was mildly [MEDICAL CONDITION] (heart rate exceeds normal resting rate) and appeared mildly pale. Anoscopy (a scope used to examine the anal canal) revealed black stool with melanotic (having black pigmentation) features. An INR was repeated and was greater than 10. R2's hemoglobin (protein responsible for transporting oxygen in the blood) was 8.9. R2 was given 10 mg of vitamin K (clots blood)intravenously and was admitted to the hospitalist service for further evaluation and treatment. R2's Hospital Progress Note dated 6/26/18, indicated an assessment which included: 1. Acute lower [MEDICAL CONDITION]. The cause was uncertain. This could have been secondary to [DIAGNOSES REDACTED], hemorrhoids, angio[DIAGNOSES REDACTED], most likely because of the supratherapeutic INR. 2. Acute blood loss [MEDICAL CONDITION]. R2 dropped her hemoglobin significantly from 8.9 to 7.4. Received two units of packed red blood cells. 3. Supratherapeutic INR on admission. It was above 10 on admission. R2 was given vitamin K 10 mg on admission and 2.5 mg orally on 6/25/18. 4. [MEDICAL CONDITION], rate controlled status [REDACTED]. 5. Chronic anticoagulation with [MEDICATION NAME]. Hold [MEDICATION NAME] for now. 6. Urinary tract infection. History of UTI. Was on Bactrim, is most likely the cause of her increased INR. On 8/8/18, at 3:50 p.m. the ADON verified the facility had the capacity to perform point of care testing for INR, however, stated an MD order for the testing was required and she was not sure if INR testing was included in the facility standing orders. On 8/9/18, at 9:01 a.m. LPN-C indicated side effect monitoring for residents who received anticoagulant therapy included testing for INR and stated the facility had a machine to complete the testing. LPN-C also stated the staff monitored for symptoms such as bloody stools, bloody emesis, or bruising easier. LPN-C indicated the facility had an incident recently related to blood stools when the resident's INR was 8 and the resident had to go into the hospital. LPN-C stated the incident happened on a Saturday and indicated a nursing assistant reported R2 had blood stools and he reported this to the RN. LPN-C stated it wasn't frank blood or coffee ground blood but looked more like something R2 had eaten. LPN-C indicated the stool was a weird color and stated the next day the stool color was darker than the day before. LPN-C did not remember if the registered nurse had come down to look at R2 or not. LPN-C stated he could not remember if R2 had a UTI at the time or if she had just been getting over one, however, confirmed R2 became confused with UTI's. LPN-C stated R2 was not confused on 6/23/18, that he recalled. On 8/9/18, at 9:33 a.m. LPN-B indicated anticoagulation monitoring included checking INR and watching for symptoms such as bleeding or bruises. LPN-B confirmed bloody stools would also be symptom they would monitor. LPN-B stated if any symptoms were noted she would notify the RN if it were the day shift, or would contact the MD if it was the evening shift. On 8/9/18, at 9:42 a.m. registered nurse (RN)-B confirmed she was R2's primary RN. RN-B stated the physicians managed the residents' [MEDICATION NAME] and stated monthly and as needed (PRN) INR's were completed and adjustments made to [MEDICATION NAME] orders as indicated. RN-B stated she would expect staff to monitor for any signs or symptoms of bleeding such as prolonged bleeding of cuts, bruises, bleeding to gums, rectal bleeding or any change to stool such as stools black, maroon or bright red in color. RN-B stated the NAs were to report any symptoms to the charge nurse and the charge nurse would document any observed symptoms in a progress note. RN-B stated she would expect the LPN's to monitor symptoms and notify the RN and/or the doctor. R2's medical record was reviewed with RN-B who verified the following: --6/23/18 progress note indicated R2 had maroon stools --R2 received 4 mg [MEDICATION NAME] on 6/23/18. --Bactrim DS 800-160 mg was prescribed on 6/18/18 and R2 continued to receive the antibiotic through the morning of 6/24/18. --R2's medical record contained no documentation to indicate R2 was assessed by an RN on 6/23/18. --Progress note dated 6/24/18, at 1:30 p.m. indicated ADON would be contact RN-B and MD-A on Monday, 6/25/18, unless R2's status changed. On 8/9/18, at 11:29 a.m. the ADON stated the residents on [MEDICATION NAME] were monitored for symptoms such as bruising, blood in urine, color of skin, lethargy, blood in stool. The ADON stated she would expect symptoms to be reported to the charge nurse and the charge nurse/RN would then assess and monitor to see where the situation was headed. The ADON verified on 6/23/18, R2 had been receiving 4 mg of [MEDICATION NAME] daily and had also been prescribed Bactrim DS on 6/18/18. The ADON stated R2's primary MD (MD-A) had been out so it was another provider, MD-B, who prescribed the antibiotic and the INR results were to have been reported to MD-C who covered for MD-A. The ADON verified she had worked on 6/23/18, and confirmed LPN-C had reported R2's maroon colored stool to her and so they went and looked at it and stated the color was weird. The ADON stated she had LPN-C do a focused assessment of R2 and stated they were in a monitoring state at that point. ADON stated family had been at the facility to take R2 out for the day and R2 had been coherent and responsive with no signs of confusion and R2 had been offered the ER which she had refused. ADON confirmed R2 had left (the facility) in a monitoring state at that time. The ADON verified she had not spoken with the family, however, stated LPN-C had done so. However, the ADON stated she was not sure if LPN-C had explained the risks and benefits of refusing to be evaluated in the ER. The ADON stated I guess at that point we were trying to determine what the stool was and passed the information on (to the next shift) and was not aware if R2 had any further stools after she finished her shift. The ADON verified she had not had R2's dose of [MEDICATION NAME] held, nor had she contacted the physician at that point. In addition, the ADON stated she was not sure she would have done anything differently knowing then what she knew now as R2's stool did not have frank blood and R2 had no other symptoms. The ADON stated she even went an checked the menu to see if they had had beets served during the meal. The ADON verified on 6/24/18, R2 experienced more maroon stools with a clotting appearance later in the day and was more lethargic which she attributed the lethargy to R2's outing the previous day. R2 had begun hallucinating which was attributed to a UTI. The ADON stated just prior to shift change, she had an opportunity to talk with the staff which was when they had put it all together. The ADON stated she contacted R2's family to discuss possible hospitalization and to notify them she would be testing R2's INR. The ADON proceeded to check R2's INR which was 8, so she again contacted the family to see if they would be willing to send R2 to the ER as she was not comfortable with R2's INR result. Once she had obtained the family's approval, she contacted the physician and received orders to transport R2 to the ER. Lastly, the ADON again contacted R2's family to notify them of the plan. The ADON confirmed R2 had been diagnosed with [REDACTED]. The ADON confirmed she could have probably tested R2's INR on 6/23/18, as she was aware of the interactions between [MEDICATION NAME] and antibiotics and stated not to make excuses, but she was not R2's primary RN and probably did not know R2's history as well as RN-B had. On 8/9/18, at 12:01 p.m. the director of nursing (DON) confirmed R2's maroon stool was a red flag and stated she would have expected ADON to assess the patient herself, checked an INR, hold the [MEDICATION NAME] and contact the physician. On 8/9/18, at 4:13 p.m. R2's primary physician and facility medical director, MD-A indicated the monitoring for residents who received anticoagulant who were prescribed antibiotics depended on the antibiotic prescribed. MD-D stated usually if it was Cipro, [MEDICATION NAME] or [MEDICATION NAME] (Bactrim) staff needed to check the INR more often. R2's MD antibiotic order from 6/18/18, was reviewed with MD-A who stated he would have done that differently. MD-A indicated physicians relied on pharmacy to help nursing out. He stated the physician who prescribed the antibiotics should have ordered earlier INR testing, nursing should have asked for earlier INR testing and/or the pharmacist should have also asked for earlier INR testing. MD-A confirmed a maroon colored stool would indicate a cause of concern and should have been a signal to call someone. MD-A indicated he would have expected to be notified when this occurred. MD-A stated they had been working on the facility policy to include INR testing to be initiated per nursing discretions, however, a maroon colored stool, with or without policy changes would have been an indication to notify someone, particularly if the resident was on anticoagulant medication. MD-A was unsure of the facility policy regarding nursing holding the [MEDICATION NAME] medication but indicated they should have contacted the physician prior to giving the medication. The undated Notification of Physician policy directed the primary/on call physician would be notified of any medically unstable condition. The policy directed situations that warranted immediate notification included if the resident's clinical status was unclear or worsening, however, the policy did not address notifications which were not concerning lab or diagnostic test results.

Based on interview and document review, the facility failed to ensure staff implemented a proper transfer technique when the walker was not used for 1 of 1 resident (R1) who required extensive assistance with transfers. R1 experienced actual harm when the unsafe transfer caused a right fibula fracture that required physician intervention. Findings include: R1's medical record was reviewed. R1's face sheet indicated she was diagosed with a stroke and backpain. R1's care plan last reviewed 2/7/18, indicated R1 transferred with the assist of one, gait belt, wore an ankle stabilization orthotic (ASO) brace to the right ankle, and required a walker for all transfers. The quarterly Minimum (MDS) data set [DATE], indicated R1 was cognitively intact and required extensive assistance with transfers. R1's nursing assistant undated care guide current for (MONTH) (YEAR), indicated she was to be transferred with the ASO brace, gait belt, assist of one, and the walker. R1's Incident Report dated 2/27/18, at 8:45 a.m. indicated R1 complained of right ankle pain. R1 stated it occurred yesterday during a transfer. R1's physician was notified at 9:45 a.m. and family was notified at 10:00 a.m. R1's nursing progress notes dated 2/27/18, at 9:03 a.m. indicated R1 stopped registered nurse (RN)-B in the hallway and stated her ankle was hurting. The nursing assistant (not identified) reported she had transferred R1 with a standing lift that morning as R1 had difficulty turning with the transfer. RN-B gently pressed on R1's ankle and she jerked her foot away and stated that really hurts. R1 stated it happened yesterday when the girl was helping me from the wheelchair to the recliner. R1 stated she stood me and told me to grab onto her and then she swung me around to my chair. R1 stated her foot did not have time to move as she was swung around to the chair. R1 stated the walker was not used for the transfer and she was able to state the nursing assistant's (NA) name as NA-G, R1's physician ordered an X-ray on 2/27/18, at 12:30 p.m. to be completed at the clinic. R1's physician progress notes [REDACTED]. R1's physician order [REDACTED]. R1's (MONTH) (YEAR), Medication Administration Record [REDACTED]. R1 was seen by the orthopedic surgeon on 3/1/18. He ordered R1 to wear a short boot brace and she could weight bear as tolerated with the walker. R1 was to return in four weeks. R1 was seen by the physican assistant (PA)-J on 3/6/18 at the facility. R1 stated she was having pain in the right ankle even with taking [MEDICATION NAME] (used to treat moderate to severe pain) 25 milligrams (mg) three times a day. PA-J ordered [MEDICATION NAME] 1000 mg three times a day for pain. R1's (MONTH) (YEAR), Medication Administration Record [REDACTED]. R1 was seen by the orthopedic surgeon on 3/29/18. He indicated the the right ankle fracture was healing. He ordered to discontinue the boot brace, start physical therapy, and return for X-rays in five weeks. An interview was conducted with physical therapy assistant (PTA)-C on 4/16/18, at 3:10 p.m. PTA-C stated she spoke with R1 on 2/27/18, and R1 told her the nursing assistant (NA) did not use the walker for the transfer from the wheelchair to the recliner. PTA-C stated R1 told her the NA wanted her to grab onto her arms and R1 did not have time to turn. R1 felt a pain in her ankle and screamed out in pain. An interview was conducted on 4/16/18, at 1:46 p.m. with NA-E. NA-E stated she did not think it would be possible to transfer R1 without the use of the walker. An interview was conducted on 4/16/18, at 2:34 p.m. with NA-F. NA-F stated the NA care guide directs staff to use one assist, gait belt, and walker for transfers. NA-F stated he had never transferred R1 without the walker. NA-F stated, he did not know how R1 could transfer without the walker. An interview was conducted with RN-B on 4/17/17, at 8:42 a.m. RN-B stated R1 told her on 2/27/18, that NA-G had not used the walker when transferring her from the wheelchair to the recliner. RN-B stated NA-G had not transferred R1 according to the care plan. An interview was conducted on 4/17/18, at 9:02 a.m. with licensed social worker (LSW)-A. LSW-A stated she spoke with R1 on 2/27/18, and R1 reported that NA-G had transferred her yesterday prior to lunch time and her leg did not turn with her. An interview was conducted on 4/17/18, at 10:05 a.m. with the director of nursing (DON). The DON stated R1 was consistent when stating how the incident occurred with several staff. The DON stated the care plan and the NA care guide all indicated R1 was to be transferred with the front wheeled walker. The DON stated it was neglect for not following the care plan. An interview was conducted on 4/17/18, at 8:18 a.m. R1 stated when the incident occurred she reported the girl to staff.An interview was conducted on 4/24/18, at 10:09 a.m. with PA-J. PA-J stated staff should have used the walker when R1 was transferred. PA-J stated when she saw R1 on 3/6/18, the [MEDICATION NAME] 25 mg three times a day was not controlling her pain. PA-J stated she added [MEDICATION NAME] 1000 mg three times a day for ankle pain. PA-J stated currently R1 was no longer having ankle pain. The facility's undated safe patient handling policy, indicated each resident would be assessed upon admission, re-admission, significant changes in status, and quarterly for risks related to safe patient handling tasks. Employees should use proper techniques and other approved equipment/aids during patient handling. Patients will receive assistance appropriate for their functional level, assuring safety and comfort.