Every finding on record at Good Neighbor Home

Based on observation, electronic health record (EHR) review, policy review, and resident and staff interviews the facility failed to utilize Enhanced Barrier Precautions (EBP) during high contact care for 1 of 2 residents sampled (Resident #70). The facility reported a census of 94 residents. Findings Include:Resident #70's admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS assessment Section H for Bladder and Bowel documented no appliances were used and Resident #70 was frequently incontinent of urine and bowel. The MDS assessment included diagnoses of fractures, renal insufficiency, hyperlipidemia, and urinary incontinence. Review of Resident #70's Care Plan Focus area for elimination, initiated on 6/10/26, identified being clean and dry related to incontinence. Interventions directed staff to monitor for signs and symptoms of a urinary tract infection (initiated on 6/10/26), take care of catheter equipment (initiated on 7/3/26), and track urine output (initiated on 7/3/26). The Care Plan Report further identified a Focus area for safety, initiated on 5/29/26, directing staff to utilize EBP (initiated on 7/3/26). A Physician Long Term Care Progress Note with a registration date of 6/1/26 documented Resident #70 began an indwelling foley catheter to promote skin healing and urinary retention. During an observation 7/27/26 at 1:37 PM, EB and Contact Precautions signage posted on the door frame and on an inside wall of Resident #70's room. Resident #70 reported staff didn't always wear gowns when care was provided. On 07/28/26 1:38 PM, observed Staff A, Certified Nursing Assistant (CNA) entered room with a mechanical lift. When the door opened, observed resident covered and sitting on a shower chair, before the door was shut. Staff A exited the room with what appeared to be a battery for the mechanical lift. At 1:39 PM Staff A, re-entered the room with a replacement battery. Staff A lacked a gown with both observations. On 7/28/26 at 1:46 PM, Staff B, CNA opened the resident's room door, and pushed the mechanical lift into the hall. Staff B had gown and gloves on. While the door was open, observed resident lying in bed with Staff A standing between the window and the bed. Resident lying on her right-side facing Staff A. Staff A lacked a gown. On 7/28/26 2:08 PM, Staff A acknowledged she provided care for Resident #70. Staff A verbalized EBP was required when catheter care was provided. Staff A verbalized she didn't provide catheter care and only donned gloves. Staff A acknowledged she did assist with transferring Resident #70 from the shower chair to the bed and had placed her hands on Resident 70's legs. On 7/28/26 2:45 PM, Staff B reported she did provide care to Resident #70 and donned gloves and a gown. Staff B reported Resident #70 required a mechanical lift for transfer with 2 staff members. Staff B identified Staff A as the staff member that assisted with the transfer following Resident #70's shower. Staff B acknowledged Staff A didn't don a gown to assist with the transfer. On 7/29/2026 10:55 AM, Staff C, Licensed Practical Nurse (LPN), reported staff were alerted to residents that required EBP due to the EBP signage on the door and in the room along with information passed on at shift change in report. Staff C verbalized both staff members assisting a resident with a mechanical lift would require gown and gloves if EBP was required. On 7/29/26 11:22 AM, the Director of Nursing verbalized anyone assisting with transfer should wear gown and gloves if the resident requires EBP. Review of the Enhanced Barrier Precautions facility policy dated 2001, included the following:1.Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities.2.Enhanced barrier precautions apply when:a. A resident is infected or colonized with a CDC-targeted MDRO, but does not have a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained;b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; andc. Contact precautions do not otherwise apply 5.Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies. Peripheral IV catheters are not considered an indwelling medical device for purposes of EBPs 7.EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing, bathing/showering . transferring.

Based on observation, clinical record review, staff interview and facility policy review the facility failed to maintain the safety and security for 2 of 5 residents identified as a fall risk (Residents #1 and #3). Resident #1 had a prior history of falls from her recliner. After Resident #1's fall on 5/27/25, the facility put the Intervention in place to have her recliner unplugged. On 6/7/25, the staff observed Resident #1 during the room rounds. One staff member reported seeing Resident #1 in her recliner with her feet elevated. At approximately 3:19 PM, the staff found Resident #1 on the floor with her footrest in an upright position. The failure to follow Resident #1's Intervention to have her recliner unplugged allowed her to put her feet up in the recliner and then trip over her recliner attempting to get up by herself. Due to tripping on the recliner, Resident #1 fell and hit her head resulting in harm due to the hematoma (a buildup of blood from outside the blood vessels usually from an injury that appears as a large bruise sometimes has a bump) to her head. The facility identified a census of 99 residents. Findings include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 7, indicating severely impaired cognitive skills. The MDS indicated Resident #1 had hallucinations and delusions. In addition, they exhibited physical, verbal, and other behaviors for 1 to 3 days in the lookback period. The MDS listed Resident #1 as dependent on staff with transfers and required substantial to maximum assistance with ambulation. The MDS included diagnoses of progressive neurological conditions, non-Alzheimer's dementia, and Parkinson's disease. The Care Plan identified the following as dated: a. 1/29/25 - Resident #1 had a potential to fall down and hurt herself due to medications that caused dizziness, tiredness, confusion and/or weakness. In addition, she sometimes became confused. b. 5/28/25 - Resident #1 fell on 5/27/25. The Care Plan included an Approach which directed the staff to have kept her recliner unplugged. c. 6/9/25 - Resident #1 fell on 6/7/25. The Approach indicated the staff received education. In addition, the facility removed the power cord from the recliner. d. 5/19/25 - Resident #1 needed everyone to know, she required assistance from one staff with a padded gait belt and a walker with ambulation. An Incident Report form dated 6/7/25 at 3:19 p.m. identified the staff found Resident #1 on the floor with her foot rest in an upright position. The ED Note Physician dated 6/7/25 at 8:39 p.m. reflected Resident #1 got up on her own around 3:45 p.m., tripped over her chair causing her to fall onto her right side, and received a hematoma on her head next to her temple with a superficial scratch to her right shoulder. She complained of neck pain, right shoulder pain, and right hip pain. Resident #1 usually transferred with the assistance of 2 staff. The CT (imaging to show inside the body) scan reflected Resident #1 received a right scalp hematoma without fracture.During an interview on 10/9/25 at 11:00 a.m. Resident #1's family member indicated when she arrived the day of the fall, they had her positioned in the recliner in her room with her feet elevated and no staff present. During an interview on 10/9/25 at 10:36 a.m. Staff J, Licensed Practical Nurse (LPN), confirmed she worked as the charge nurse in the unit. She explained when she found Resident #1 on the floor, she had a large hematoma on the right side of her forehead, so she sent her to the hospital. Staff J reported Resident #1 had a habit of getting up on her own. During an interview on 10/9/25 at 12:28 p.m. Staff G, Certified Nursing Assistant (CNA), indicated the schedule had Staff K, CNA, and Staff L, CNA, in [NAME] Place on the first shift. Then the schedule had Staff G, CNA, and Staff B, CNA, on the second shift the day of the fall. When Staff G arrived for work, she received report and then performed walking rounds. When they arrived at Resident #1's room, they all looked at her but none of the staff noted she had her feet up in the recliner. Staff G indicated the first shift staff positioned Resident #1 in her recliner, a family member visited, and assisted her with her lunch. When the family left, they failed to position the resident's foot rest down in the recliner chair. The staff member said she gave the situation a lot of thought and came to the conclusion Resident #1 had a blanket over her legs and the bed kind of restricted the staff's view. During an interview on 10/9/25 at 12:49 p.m. Staff K confirmed she assisted Resident #1 to the bathroom and positioned her in her recliner chair on the day shift, however the staff didn't plug in the chair and/or elevated her feet. Staff K confirmed the staff directed them to not leave Resident #1 unattended in her room with her feet elevated. Staff K indicated on the day of the fall; the staff performed walking rounds with the 2nd shift. They all looked into Resident #1's room and confirmed she had her feet elevated during rounds but the staff failed to enter her room and position her feet on the floor as Care Planned. During an interview on 10/9/25 at 11:13 a.m. Staff M, Registered Nurse (RN), confirmed they knew Resident #1 attempted to self-transfer. She recalled that she coached the staff about fall interventions and the expectation that staff follow all of the interventions because Resident #1 had her feet elevated in her recliner chair at the time of the fall with a hematoma (a pool of blood under the sink that looks similar to a bruise with a bump). Staff M informed the staff it didn't matter who elevated the foot rest, rather the staff had the ultimate responsibility to maintain all resident's safety and security. Staff M indicated she spoke with the day shift about the fall and hematoma but Resident #1 fell around 3:30 p.m., so she worked the 2-10 shift care for a one and 1/2 hour so ultimately the second shift had the responsibility. During an interview on 10/9/25 at 12:27 p.m. Resident #1's Nurse Practitioner (NP) confirmed she expected the facility's staff to follow the fall interventions for her. A Review Discussion Form dated 6/9/25 documented a staff member recently attended a CNA skills fair. One of the stations provided education regarding room to room report and the staff's responsibility to know when each resident last went to the toilet. In addition, the staff provided education regarding the review of the Kardex and ensuring the facility had all fall preventions in place. When Resident #1 fell on 6/7/25, the review of the investigation reported the staff member said she didn't know when Resident #1 last used the toilet. The staff member failed to follow the requirement to take the residents to the toilet every 2 hours. Resident #1 waited 2.5 hours since the last time she used the toilet. If the staff member received the appropriate information during the room-to-room report, they could have avoided the fall. Resident #1 shouldn't have her recliner plugged in. However, at the time of the fall Resident #1 had her recliner plugged in with the foot rest up. An Assessing Falls and Their Causes policy revised March 2018 defined the Purposes as to provide guidance for assessing a resident after a fall and to have assisted staff in the identifying the cause of the fall. The Procedure directed to document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility and any changes in the level of responsiveness/consciousness and overall function. 2. Resident #3's MDS assessments dated 7/11/25 and 7/22/25 identified a Brief Interview for Mental Status (BIMS) score of 1, severely impaired cognition. The MDS indicated Resident #3 had fluctuating inattention, disorganized thinking, and wandered daily. Resident #3 required partial to moderate assistance with transfers and ambulation. The MDS included diagnoses of a non-traumatic brain dysfunction, Alzheimer's Disease, and anxiety. A Care Plan identified the following Need/Preferences and Approaches as dated: The Care Plan identified the following as dated: a. 2/4/24 - Resident #3 needed assistance with transfers due to pain in their back and may be unsteady at times. Resident #3 required assistance to move as he had a potential to fall down and hurt himself due to dementia/Alzheimer's disease. He sometimes got confused and fell due to his impulsive behavior. He exhibited poor judgement by self-transferring or walking, when he couldn't walk independently. b. 12/24/24 - Resident #3 fell on [DATE]. c. 12/28/24 - Resident #3 fell on [DATE]. d. 2/19/25 - Resident #3 fell on 2/7/25 e. 8/1/25 - Resident #3 needed everyone to know he required assistance from 1 staff member with a walker and a gait belt for transfers and/or ambulation.A typed letter from a family member dated 9/27/25 included the following information: They wrote the letter with a concern related to an ongoing problem at [NAME]'s Place/CCDI unit. The situation continued as an ongoing problem which could have resulted in a tragic concern on the previous night had things gotten worse than they did.The facility had the evening shift in particular understaffed. When they arrived at the facility around 7:00 PM to visit the facility didn't have anyone in the open central area to supervise and answer the door. The 2 CNA's gave baths and assisted residents to bed. The medication (med) person on duty went into a patient's room while they gave medicine. The family member probably waited at least 10 minutes in between the doors as they waited for someone to let them into the unit. In the meantime, a resident observed them and walked over to the door. Their family member who required assistance from 1 staff member with a walker saw her and ambulated independently from the puzzle table to the front door without any assistance and/or a walker. He attempted to assist his family member as he pushed on the door which opened in 15 seconds. The alarm sounded and the family member entered the facility but yet, still no staff arrived as they could not leave the other residents they assisted at the time. The family member assisted Resident #3 back to his chair he sat in and had sit him down. In a short time, another resident's family member also came and walked right in much to their surprise.Fortunately, no one fell and injured themselves and no resident walked out of the building into the night and disappeared, but either scenario could have happened. The writer explained they had the situation happened before this incident when no one could assist and open the door for a while.Many residents of [NAME]'s Place require extra time to bathe because of their lack of understanding of what happened and/or their disabilities. The family member indicated extreme concern to have observed the negligence on the facility's part.Review of the facilities video footage along with management staff documentation as stated below: Review of the facility's video footage along with management staff documentation reflected the following below: a. 7:09:54 p.m. - Resident #3's family member/visitor present between the 2 front doors of the unit. b. 7:10:30 p.m. - Resident #3 could be seen as he looked at the family member/visitor at the door. Note: 10 residents present in the lounge area which included Resident #3 and without staff present. c. 7:13:22 p.m. - Resident #3 stood from the table in the lounge area. d. 7:14:08 p.m. - Resident #3 stood at the front door with a gait belt around his waist and no staff present. e. 7:14:19 p.m. - Staff A, Certified Medication Aide (CMA), into the common dining area as she ambulated towards the kitchen with her back to the front door. f. 7:16:15 p.m. - Resident #3 opened the door without staff present and the door alarm sounded. g. 7:17:04 p.m. - The visitor/family member walked into the common area beside the resident. Note: 10 residents remained in the lounge area without staff present. h. 7:17:22 p.m. - Staff B, Certified Nursing Assistant (CNA), present in the common dining area as she assisted another resident. The staff member had her back to the front door and/or lounge area in the video still shot. i. 7:18:49 p.m. - Staff B at door and turned off the alarm as typed by management however video revealed Staff B as she looked towards the door and an unknown family member ambulated away from the door as if he just entered (the Director of Nursing Services identified the family member via email 10/15/25 at 2:59 p.m.).A typed email from Staff B dated 10/26/25 at 8:27 a.m. documented that after supper the CNA's assisted residents scheduled for showers (usually 4 showers), toileted, and provided hour of sleep cares for all 20 residents. As she probably spent a minimum of 20-30 minutes with one resident, she heard the alarm as it sounded, but she didn't know what happened and she had no idea the facility didn't have other staff members in the living room area with the residents. When she completed cares with the resident, she assisted them out of their room and still heard the alarm as it sounded but thought it odd nobody responded to the alarm. So, she walked towards the main entrance with the resident and as she approached, she observed the family member with Resident #3 inside the building close to the front door. The staff member sat the resident down she assisted out of her room on the bench located close to the alarm, shut it off, and approached the family member with Resident #3 and asked if she knew what had been going on. The family member told her she came to the building to spend some time with her family member after supper, as she did daily and stayed at the door for approximately 5 minutes as she waited for some staff to open the door. She mentioned she didn't observe any staff out in the common area, so she decided to stay there and waited until her family member stood up, walked to the door, held the door handle for approximately 15 seconds until it unlocked and she walked in. The staff member recalled that she checked the clock at the time of the incident and it had been between 7:20 p.m. and 7:30 p.m. The staff member didn't know the location of Staff F and Staff A at the moment of the incident but they both claimed to be in resident's rooms.

Based on observation, clinical record review, video footage, staff interview, and family interview the facility failed to maintain an appropriate number of staff to meet the individual needs of residents who resided in a Chronic Confusion or Dementing Illness unit (CCDI). The facility reported 20 residents resided in the CCDI unit. The facility identified a census of 99 residents. Findings include:During an interview 10/8/25 at a time unknown Staff D, Registered Nurse (RN) indicated of the 20 residents who resided in [NAME] Place and/or the Chronic Confusion or Dementing Illness unit (CCDI) unit seven (7) residents required one (1) staff assistance and 1 resident required two (2) staff assistance with activities of daily living (ADL's) Resident #3's MDS assessments dated 7/11/25 and 7/22/25 identified a Brief Interview for Mental Status (BIMS) score of 1, severely impaired cognition. The MDS indicated Resident #3 had fluctuating inattention, disorganized thinking, and wandered daily. Resident #3 required partial to moderate assistance with transfers and ambulation. The MDS included diagnoses of a non-traumatic brain dysfunction, Alzheimer's Disease, and anxiety. The Care Plan identified the following as dated: a. 2/4/24 - Resident #3 needed assistance with transfers due to pain in their back and may be unsteady at times. Resident #3 required assistance to move as he had a potential to fall down and hurt himself due to dementia/Alzheimer's disease. He sometimes got confused and fell due to his impulsive behavior. He exhibited poor judgement by self-transferring or walking, when he couldn't walk independently. b. 12/24/24 - Resident #3 fell on [DATE]. c. 12/28/24 - Resident #3 fell on [DATE]. d. 2/19/25 - Resident #3 fell on 2/7/25 e. 8/1/25 - Resident #3 needed everyone to know he required assistance from 1 staff member with a walker and a gait belt for transfers and/or ambulation.A typed letter from a family member dated 9/27/25 included the following information: They wrote the letter with a concern related to an ongoing problem at [NAME]'s Place/CCDI unit. The situation continued as an ongoing problem which could have resulted in a tragic concern on the previous night had things gotten worse than they did. The facility had the evening shift in particular understaffed. When they arrived at the facility around 7:00 PM to visit the facility didn't have anyone in the open central area to supervise and answer the door. The 2 CNA's gave baths and assisted residents to bed. The medication (med) person on duty went into a patient's room while they gave medicine. The family member probably waited at least 10 minutes in between the doors as they waited for someone to let them into the unit. In the meantime, a resident observed them and walked over to the door. Their family member who required assistance from 1 staff member with a walker saw her and ambulated independently from the puzzle table to the front door without any assistance and/or a walker. He attempted to assist his family member as he pushed on the door which opened in 15 seconds. The alarm sounded and the family member entered the facility but yet, still no staff arrived as they could not leave the other residents they assisted at the time. The family member assisted Resident #3 back to his chair he sat in and had sit him down. In a short time, another resident's family member also came and walked right in much to their surprise.Fortunately, no one fell and injured themselves and no resident walked out of the building into the night and disappeared, but either scenario could have happened. The writer explained they had the situation happened before this incident when no one could assist and open the door for a while.Many residents of [NAME]'s Place require extra time to bathe because of their lack of understanding of what happened and/or their disabilities. The family member indicated extreme concern to have observed the negligence on the facility's part.Review of the facility's video footage along with management staff documentation reflected the following below: a. 7:09:54 p.m. - Resident #3's family member/visitor present between the 2 front doors of the unit. b. 7:10:30 p.m. - Resident #3 could be seen as he looked at the family member/visitor at the door. Note: 10 residents present in the lounge area which included Resident #3 and without staff present. c. 7:13:22 p.m. - Resident #3 stood from the table in the lounge area. d. 7:14:08 p.m. - Resident #3 stood at the front door with a gait belt around his waist and no staff present. e. 7:14:19 p.m. - Staff A, Certified Medication Aide (CMA), into the common dining area as she ambulated towards the kitchen with her back to the front door. f. 7:16:15 p.m. - Resident #3 opened the door without staff present and the door alarm sounded. g. 7:17:04 p.m. - The visitor/family member walked into the common area beside the resident. Note: 10 residents remained in the lounge area without staff present. h. 7:17:22 p.m. - Staff B, Certified Nursing Assistant (CNA) present in the common dining area as she assisted another resident. The staff member had her back to the front door and/or lounge area in the video still shot. i. 7:18:49 p.m. - Staff B at door and turned off the alarm as typed by management however video revealed Staff B as she looked towards the door and an unknown family member ambulated away from the door as if he just entered (the Director of Nursing Services identified the family member via email 10/15/25 at 2:59 p.m.).During an interview on 10/8/25 at 4:25 p.m., Staff F, CNA, indicated sometimes she felt they had enough staff in [NAME] and sometimes the didn't. In addition, she had times she indicated she felt overwhelmed. Staff F declined anything else. During an interview 10/8/25 at 4:35 p.m. Staff G, CNA, indicated the facility didn't have enough staff in [NAME] to meet the individual needs of the residents. The staff member stated, a lot of our residents sun down real strong. The staff member felt if the facility had more staff to keep an eye on people maybe people would not get up by themselves.During an interview 10/8/25 at 3:54 p.m. Staff H, RN indicated there had not been enough staff scheduled in [NAME] because there so many of the residents required at least one staff assistance with cares and both aides could have been busy and someone in the lounge area wants to get up or has behaviors that person had to wait. During an interview 10/8/25 at 3:05 p.m. Staff E, CNA/CMA indicated she felt sometimes there had been enough staff in [NAME] and sometimes no rather it depended on the impulsivity of the residents back in the unit. The staff member stated in a perfect world it would have gone OK if the residents exhibited no behaviors however it had not been like that. During an interview 10/8/25 at 3:39 p.m. Staff D indicated she felt sometimes the facility had enough staff in the CCDI [NAME], but it depended on the clientele.Review of the facility's Town Talk Minutes included the following as dated per month: a. June 2025 - Long wait time for call lights but they received good care. The staff responded slow to call lights. An unknown resident had to use his urinal several times and wet the bed as he waited for staff to respond. b. September 2025 - Short staffed, especially on weekends.The Answering the Call Light policy revised September 2022 directed the facility staff to responded timely to the resident's requests and needs. The Procedure instructed to have staff to answer Resident #3 call system immediately.

Based on observation, clinical record review, video footage, family interview, staff interview, and facility policy review the facility failed to maintain a resident's dignity by failing to remove a gait belt assistive device after usage for 1 of 3 residents reviewed (Resident #3). The facility identified a census of 99 residents. Findings include: Resident #3's MDS assessments dated 7/11/25 and 7/22/25 identified a Brief Interview for Mental Status (BIMS) score of 1, severely impaired cognition. The MDS indicated Resident #3 had fluctuating inattention, disorganized thinking, and wandered daily. Resident #3 required partial to moderate assistance with transfers and ambulation. The MDS included diagnoses of a non-traumatic brain dysfunction, Alzheimer's Disease, and anxiety. The Care Plan Approach dated 8/1/25 identified Resident #3 needed everyone to know he required assistance from 1 staff member with a walker and a gait belt for transfers and/or ambulation. Review of the facility's video footage along with the management staff documentation indicated on 9/26/25 at 7:14:08 p.m. Resident #3 stood at the front door with a gait belt around his waist, without staff present. During an interview on 10/9/25 at 3:49 p.m. Staff A, Certified Nursing Assistant (CNA)/Certified Medication Aide (CMA), confirmed it has never been acceptable to have leave a gait belt around a resident's waist when not in use. A Dignity policy and procedure form revised February 2021 indicated each resident should receive care in a manner the promoted and enhanced their sense of well-being, level of satisfaction with life and feelings of self-work and self-esteem.

Based on observation, Center for Disease Control and Prevention (CDC) COVID 19 Guidelines, and staff interview, the facility failed to ensure housekeeping staff wore appropriate personnel protective equipment (PPE) to prevent the spread of COVID 19 infection during a COVID 19 outbreak within the facility. The facility reported a census of 98 residents. Findings include: During entrance to the facility on [DATE] at approximately 9:00 AM the facility posted a Visitor/Team Stop Sign on the main entrance door directing to please postpone entry to the facility if you have any of the following symptoms that are new or worsening: fever, cough, congestion, chills, headache, body aches, sore throat, runny nose, fatigue, diarrhea, nausea/vomiting, new loss of taste or smell. Please do not visit if you have had a positive COVID test or have had close contact with someone with confirmed COVID 19 infection in the last 14 days. On 8/12/24 at approximately 9:00 AM the Administrator reported the facility was in a COVID 19 outbreak and most of the residents were isolated in the South hallway. The Administrator provided a resident list identifying 12 residents positive for COVID 19 and 3 resident recovered from COVID 19. The list identified Resident #45 as positive for COVID 19 and on isolation precautions. On 8/13/24 the Director of Nursing (DON) notified the surveyors the facility had COVID 19 on the North hallway in addition to the South hallway. Observation on 8/14/24 at 2:12 PM revealed a CDC Contact Precaution and Droplet Precaution sign hanging on the right side of Resident #45 door frame. The Droplet Precaution sign directed the staff to make sure their eyes, nose, and mouth were fully covered before room entry. A three-drawer plastic bin with PPE sat to the right side of Resident #45 doorway and a bedside table with two packages of face shields was positioned to the left side of the doorway. During an observation on 8/14/24 at 2:12 PM Staff A, Housekeeping/Laundry, observed cleaning in Resident #45 room wearing only a gown, gloves and a medical mask that was falling below her nose. Staff A observed coming in and out of the room to the housekeeping cart several times, then went back in the room within three feet of Resident #45 who sat in the room recliner. At 2:14 PM the Surveyor prompted the DON to address the situation. The DON asked Staff A what PPE was required to wear in the isolation room for cleaning. Staff A, wearing a gown, gloves, and a surgical mask falling below her nose, motioned with her hands toward her gown and stated she was wearing the correct PPE. The DON pointed to the CDC signs on the door frame and verbalized the resident was on contact and droplet precautions which required a NIOSH (National Institute for Occupational Safety and Health) N95 mask, face shield, gown and gloves. The DON instructed Staff A at the entrance of the door way to take off her gown. Staff A started to pull her gown off with her right gloved hand over her head. The DON instructed Staff A to roll the gown down away from her to remove the gown with gloves on, then remove the gloves, remove her medical mask and perform hand hygiene. The DON instructed to put on a new gown, N95 mask, and a face shield. Staff A had to ask the DON how to use the face shield. The DON instructed her how to peel the protective layer off the face shield and put on the face shield. The DON then instructed her how to take off the PPE before coming out of the room. On 8/15/24 at 7:48 AM Staff B, Housekeeping and Laundry Aide reported she had worked at the facility 9-10 months. She verbalized she had received education this morning on the proper PPE to wear into the room which included a gown, gloves, N95 mask, and face shield. She stated prior to the morning (8/15/24) education her understanding was they only needed to wear a surgical mask and face shield in the room. Staff B reiterated the facility had been in a COVID outbreak when she had been hired back September/October 2023. During an interview on 8/15/24 at 8:55 AM the Plant Operations Director reported he expects the housekeeping staff to wear a gown, gloves, N95 mask, and face shield when cleaning COVID 19 isolation rooms. He reported all the staff have had extensive training by the staff educator on PPE as well as they utilized CE solutions (a computer- based training system). He reported ultimately it is his responsibility to monitor that staff are following the isolation precautions. He stated the facility does not have a documented audit system that they use, but he has gone out periodically and observed to ensure staff are using the correct PPE. During an interview on 8/15/24 at 9:19 AM the DON reported all the department leaders know the PPE protocols. Leaders are to be watching when they are out on the floor and correcting any issues they see right away. On 8/15/24 at 9:21 AM the Infection Preventionist verbalized they have reviewed the PPE with the charge nurses. She expects the charge nurses to be responsible for daily monitoring of the staff using PPE. The charge nurses are to do immediate education if they observe staff not utilizing the correct PPE. During an interview on 8/15/24 at 9:22 AM the DON reported all staff are to hold each other accountable and address if they notice staff are not doing something right. She reported she expects the housekeepers to utilize a gown, gloves, N95 mask, and face shield for cleaning the COVID isolation rooms. The CDC Infection Control Guidance: SARS-CoV-2 Recommended Routine Infection Prevention and Control (IPC) Practices when caring for a Patient with Suspected or Confirmed SARS-CoV-2 Infection directs health care personnel who enter the room of a patient with suspected or confirmed SARS CoV-2 infection to adhere to Standard Precautions and use a NIOSH approved particulate respirator with N95 filters or higher, gown, glove and eye protection (i.e. goggles, or a face shield that covers the front and sides of the face). The updated 3/18/24 CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic under what PPE should be worn by environmental services (EVS) personnel who clean and disinfect rooms of patients who have SARS COVID 19 infection directed the following: minimize the number of personnel entering the room of patients who have SARS-CoV-2 infection. Healthcare facilities should consider assigning daily cleaning and disinfection of high-touch surfaces to nursing personnel who will already be in the room providing care to the patient. If this responsibility is assigned to EVS personnel, they should wear all recommended PPE when in the room. PPE should be removed upon leaving the room, immediately followed by performance of hand hygiene.

Based on observation, policy review, and staff interview the facility failed to serve meals under sanitary conditions. The facility further failed to store food in a way to prevent food borne illness. The facility reported a census of 94 residents. Findings include: During an observation of the noon meal on 2/05/24 from 11:34 AM to 12:36 PM Staff A- Cook, Staff B- Lead Evening Cook & Dietary Aide, Staff C- Dietary Aide, and Staff D- Dietary Aide served 34 glasses to 24 residents in the general dining area handling the cups with fingers on the drinking rim surface of the glasses. Staff E- Certified Nursing Assistant served 6 glasses to 2 residents in the assisted dining area handling the cups with fingers on the drinking rim surface of the glasses. The facility lacked a policy regarding serving of dishes and glasses to residents. During an interview on 2/08/24 8:42 AM with the Dietary Manager she explained the facility follows the Federal guidelines for serving of dishes and glasses. She further explained her expectation of dietary staff is to never touch a straw without paper on it. They are not to remove the paper wrapper from the straw, the resident is to take the wrapper off themselves. Her expectation is for staff to only touch glasses at the narrow portion on the bottom of the glass or, if absolutely necessary, no higher than an inch from the top of the glass. 42133 2. During an observation on 2/07/24 at 8:26 am Staff M removed the wrapper from two straws, then touched the drinking tip of each straw to place the straws into covered mugs and delivered the mugs to Resident #19 in the assistive dining room. At 8:27 AM staff M pulled her medical mask down below her nose, rubbed her nose with her right hand, replaced her mask above her nose, then poured chocolate milk into a glass and touched the drinking rim of the glass with her right hand, delivered the glass to Resident #196 who drank 100% of the chocolate milk. At 8:32 AM Staff M poured a glass of apple juice and chocolate milk then carried both glasses, one in each hand, with her hands over the top of the drinking rim and delivered the drinks to Resident #3. When asked questions Staff M shrugged her shoulders at the Surveyor stating she was agency and walked away. Staff M at 8:36 AM without performing hand hygiene went and sat down by Resident #37, unwrapped her silverware and started to assist the resident with breakfast while picking and pulling at the front of her medical mask. During an observation on 2/07/24 at 10:55 AM the hand sanitizer unit in the assistive dining room was full of hand sanitizer. 48888 3. On 02/06/24 at 11:15 AM, lunch service observed from the main kitchen, during which, a plastic container full of shredded lettuce sat on the countertop in front of the steam table from 11:35 AM until 12:20 PM without a source to keep the lettuce cool. At 12:20 PM, the Dietary Manager placed a red lid on the plastic container that contained the lettuce and placed it back into the kitchen refrigerator. On 02/06/24 at 12:30 PM, the Dietary Manager informed that lettuce had been left out on the counter for any request of lettuce salad during lunch service. The Dietary Manager stated they would typically put the lettuce back into refrigerator between use to keep cool. On 02/07/24 at 10:45 AM, the kitchen refrigerator continued to hold the plastic container of shredded lettuce with a red lid, dated 02/05/23. On 02/07/24 at 01:15 PM, Dietary Manager stated that in hindsight, the lettuce should have been thrown away after the lunch service observed. 4. On 02/06/24 at 12:25 PM, observed dietary staff, Staff N, pick up a meal ticket dropped on the floor and place the ticket on a resident's meal tray. No hand hygiene performed by Staff N. The ticket remained on the tray as Staff N placed clean cups and lunch plate on top of the tray. Room tray then sent out of the kitchen to a resident room. On 02/0624 at 12:30 PM, the Dietary Manager revealed the expectation that dietary staff perform hand hygiene after any soiled item is touched. On 02/07/24 at 01:15 PM, the Dietary Manager stated hand hygiene should have been completed after an object was picked up from the floor. The facility policy titled, Food Handling for Infection Control, no date, informed that food will be stored, prepared, handled, and served so that the risk of food borne illness is minimized.

Based on clinical record review, resident and staff interview, the facility failed to follow-up after a cognitively intact resident reported a medication omission for 1 of 1 residents reviewed for medication error (Resident #65). The facility identified a census of 94 residents. Findings include: The Minimum Data Set (MDS) Assessment with an assessment reference date 11/27/23 for Resident #65 showed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS included a diagnosis of glaucoma. The Vision Care Plan dated 11/29/23 directed Resident #65 as blind in the left eye with poor vision of the right eye and wears glasses. During an interview on 2/05/24 at 12:50 PM Resident #65 reported she did not get her eye drops the other night. The Certified Medication Aide (CMA) signed the eye drops were given, but they were not. Resident #65 verbalized being very upset stating, that is falsification of records and she wanted her fired. She reported the missed eye drops to Staff F CMA on Saturday (2/03/24). A Physician Order Sheet signed by the Provider on 11/22/23 listed the following medication orders: a. Atropine Sulfate 1 percent (%) Solution one drop in the left eye twice a day for glaucoma. b. Brimonidine Tartrate 0.2% Solution left eye three times a day for open angle glaucoma. c. Timolol Maleate 0.5% Solution one drop in the left eye twice a day. d. Dorzolamide Hydrochloride 2% Solution to the left eye twice a day. e. Latanoprost 0.005% Solution one drop to the left eye daily at hour of sleep. f. Prednisolone Acetate 1% one drop to the left eye four times a day. On 2/06/24 at 2:10 PM the Director of Nursing (DON) reported the facility did not have any medication error reports for Resident #65. On 2/07/24 at 10:44 AM the DON reported the facility did not have any grievances for January 2024. A review of Resident #65's February 2024 Medication Administration Record (MAR) revealed all dosages of the physician ordered medicated eye drops signed off as administered for 2/02/24 and 2/03/24. A 2/07/24 review of the North hallway schedule showed Staff F CMA worked 6-2:30 PM and Staff G CMA worked 2-10:30 PM on 2/02/24. A review of the Progress Notes completed on 2/07/24 revealed no documentation of the incident follow-up on 2/02/24 to 2/06/24. On 02/07/24 at 11:52 AM Staff F reported she worked last Saturday (2/03/24). Resident #65 reported to her Saturday morning she had not received her eye drops the night before. Resident #65 wanted to know why she had not received her eye drops. Staff F verbalized she didn't have an answer for the resident because she didn't know why. Staff F reported the missed eye drops to Staff H Licensed Practical Nurse (LPN) or Staff I Registered Nurse (RN). She couldn't recall which nurse, but had reported to one of the nurses. Staff F didn't know what happened after that. She further stated Resident #65 had not made any comments about not receiving her eye drops before. The Resident is alert, knows what medication she takes and why. On 2/07/24 at 12:09 PM Staff J RN reported Resident #65 is alert and oriented. She did her monthly assessment on Saturday and Resident #65 never informed her of missing any medicated eye drops. She reported Resident #65 is quiet and stays in her room. If a resident reports a missed medication, they do a head to toe assessment, notify the physician/family and put the resident on three days of hot charting to follow-up unless the physician does not order follow-up. Usually there is also an employee write-up and counseling that follows if a medication is missed. On 2/07/24 at 12:19 PM Staff K CNA reported she did not have any residents report missing medications to her when she worked over the weekend. She stated she would immediately report missed medications to the charge nurse. On 02/07/24 at 1:30 PM Staff L CMA reported Resident #65 is alert and oriented. She receives several medicated eye drops. She has never verbalized that she has missed any eye drops. If a resident reports they did not receive their medications, she would report it immediately to the charge nurse. During an interview on 2/07/24 at 1:38 PM Staff H reported she did receive report from Staff F that Resident #65 voiced she missed her evening medicated eye drops. Staff H explained she was going to talk to Resident #65 and totally forgot about it. Staff H verbalized they normally talk to the resident, investigate the situation to see if the medication was signed off, assess the resident and fill out an incident report. Then she is to notify the Patient Care Coordinator on call, the physician and the family. Staff H further explained she had gone in to assess the resident's bruit that day and she was fine, but she forgot to fill out an incident report and follow-up on the situation. On 2/07/24 at 1:56 PM Staff F CMA voiced she had worked Friday (2/02/24). It was her first day working the North hallway after being off for maternity leave. She was 90% sure that she gave Resident #65 her eye drop medications, but hadn't passed medications on the North hallway for a while. She thought she had gone into Resident #65's room, but was now questioning it. Resident #65 does not refuse her medicated eye drops. Staff G verbalized she is pretty sure she gave the Resident her eye drops, but there are so many residents that receive eye drops, she really has to watch the MAR. It is hard to remember. She reported if they sign off medications that are not administered, they get wrote up for a medication error and get talked to by a supervisor. During an interview on 2/07/24 at 2:35 PM the Director of Nursing (DON) voiced after the Surveyor asked for incident reports on 2/06/24, she went out on the North hallways and checked to see if there had been any medication errors. She was notified this morning 2/07/24 that Resident #65 voiced not receiving her eye medication on Friday (2/02/24). She reported she contacted Staff H and Staff H verbalized she had not completed any follow-up after the situation had been reported to her. The DON reported they had done disciplinary action with Staff H. She did not have any paperwork returned, but once they became aware, they did followed-up. She reported Staff F did the right thing by reporting the situation to the nurse. The nurse should have followed-up. The DON explained their process is to follow-up with the resident, fill out an incident report, call the provider and notify the family of the error. The nurses put the resident on three day hot charting to follow-up unless the physician orders that no follow-up is needed. She expected the nurse should have follow-up after the report. The Adverse Consequences and Medication Errors Policy Revised April 2014 provided by the facility specified the following: a. In the event of a significant medication-related error or adverse consequence, immediate action is taken, as necessary, to protect the resident's safety and welfare. b. The attending physician is notified promptly of any significant error or adverse consequence. c. The physician's orders are implemented, and the resident is monitored closely for 24 to 72 hours or as directed. d. The incident is described on the shift change report to alert staff of the need to monitor the resident. e. The following information is documented in an incident report and in the resident's clinical record: 1. Factual description of the error or adverse consequence. 2. Name of physician and time notified. 3. Physician's subsequent orders. 4. Resident's condition for 24 to 72 hours or as directed. 5. Each incident report is forwarded to the: DON, Quality Assurance Nurse, Medical Director and Consulting Pharmacist. Data regarding medication adverse consequences and errors (e.g., total number of incidents, number of incidents by category/type, trends) is compiled and presented to the Quality Assurance and Performance Improvement (QAPI)committee on a monthly or quarterly basis. The QAPI committee conducts a root cause analysis of medication administration errors to determine the source of error, implements process improvement steps, and compare results over time to determine that system improvements are effective in reducing errors.

Based on clinical record review, staff interview, family interview, and the chief of police interview, the facility failed to provide a safe discharge for a resident newly admitted from the emergency room (ED) to the facility on [DATE] after sustaining a fall at work which resulted in a fractured right cuboid bone and calcaneal fracture (ankle). Staff received a verbal telephone order okaying the admission of this resident. The facility accepted the resident into the facility, began the admission process, assisted the resident to a room, provided toilet use assistance, and performed a skin assessment of the gluteal area. The facility performed 2 Covid tests on the resident; a positive test result was received and the facility informed the resident they could not meet her needs due to the positive test. The facility transferred the resident into a bariatric wheelchair and placed the resident outside on a sidewalk with a bedside commode and walker to await transport to home. The facility failed to follow proper notices and documentation for an involuntary discharge for one (1) resident therefore causing an Immediate Jeopardy to the health, safety, and security of the resident (Resident #1). The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of July 28, 2023. The Facility Staff removed the Immediate Jeopardy on July 28, 2023 through the following actions: a. Assurance that all necessary staff had been educated on the Admission and Discharge policy. The scope lowered from a J to G at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 94 residents. Findings include: An X-ray report from a local hospital for Resident #1 dated 6.6.23 at 7:54 a.m. included the following: a. A mildly comminuted cuboid fracture. b. A mildly displaced fracture of the anterior process of the calcaneus. A Discharge Instructions form from the hospital dated 6.6.23 at 9:07 a.m. indicated the resident's diagnoses included: heel pain, morbid obesity, and a right foot injury. The physician orders included the following: a. Keep foot elevated for decreased swelling and pain. b. Non-weight bearing on the foot with the use of a walker. During an interview 7.26.23 at 1:22 p.m. a family member indicated the resident fell as she went into work on 6.6.23. The resident drove herself to the local ED and called this family member. Staff in the ED treated and released the resident. After the ED staff positioned the resident in the family member's car without a crutch, walker, or wheel chair (w/c) and with a directive of a non-weight bearing status, the ED staff directed the family and resident to go home. Family drove the resident to the local long term care equipment company in town and attempted to purchase/rent bariatric adaptive equipment such as a walker and a wheelchair but the equipment had not been in stock so they ordered the items. At that point the family knew they could not care for the resident at home due to her size and no adaptive equipment so they drove to the local nursing facility. The family members left the resident in the car and went into the facility and asked if the facility staff could rehab her to home. The family and Staff A, CNA/Community Development Director went out to the car when Staff A stated absolutely they could have admitted the resident to the facility for care and services. The staff member then took the resident inside of the facility and began the intake paperwork. Then staff took the resident into what would have been her room, performed an exam, rearranged the room, and performed a Covid test which showed a positive result. They said, you got to be kidding me. The staff then looked at the family member and indicated they planned to perform another test but if that test result was positive they had to take the resident home. The 2nd test came back positive also so the facility staff looked at the family member and said they planned to load the resident into the facilities van and take her home. Staff A drove the resident in the facility van to her own home and left her in her front lawn with a commode, wheelchair, and a lift strap (gait belt). During the time Staff A remained at the resident's house she heard another family member as he called public health for guidance. The staff member then became angry and stated she planned to leave as a means not to get caught in the cross fire. The family returned the resident to the ED where they admitted her for 10 days on the medical/surgical floor until her 10 days of quarantine had been completed. The family member indicated she felt bad for the resident because the event traumatized her and she had been in pain as she sat in a w/c for hours that day and never had her foot elevated. During interview 7.27.23 at 1:40 p.m. the above same family member and other family member had been present when staff propelled the resident outside of the facility on 6.6.23 as they waited 10 minutes for the return of the facility van. Staff A then transported the resident home via the facility van and at that point 3 family members had been present when Staff A arrived at the resident's home along with the local chief of police who had arrived off duty and in street clothes. The police chief had been called by family as the resident and himself worked together for [AGE] years. The family member described all people present as hot, sweaty, and emotional. The family member indicated the facility staff had since stated the resident verbalized a desire to have used the restroom when she first presented at the nursing facility as a blatant lie. During an interview 7.26.23 at 12:57 p.m. the resident indicated on 6.6.23 she fell at work which resulted in a broken foot/ankle and had been not able to return to her home due to a non-weight bearing status plus a w/c could not have fit into her home. The Resident stated the hospital discharged her home but the family present stated lets go to the nursing facility. Upon arrival 2 family members entered the facility and Staff A and Staff B, Admissions Director and a family member came out to the car and stated they would take the resident under their care. At that point, a family member drove the resident around to the back of the building where they brought a w/c for assistance to have gotten the resident into the facility. Staff A transferred the resident into the w/c and brought her into a small family type room where Staff A performed an assessment and paperwork. Staff A then left and returned and stated your room is ready and wheeled the resident to her room. Staff assisted the resident to the bathroom and into a bed and that had been when staff performed a Covid test which the result was positive. The staff then looked at 1 of the resident's family members and stated the resident could not have stayed in the facility. The staff left the resident's room and returned all PPE'd (personal protective equipment) up, wheeled the resident outside of the facility with a walker and commode as they waited for maybe 10 minutes for the return of the facility van. The resident described herself as out of it because of the pain. The resident had been loaded into the facility van and transferred home by Staff A who backed the van up to the stairs in front of the resident's home and unloaded her. The resident described the situation as stupid because she had been unable to get into her house anyway. At that point a family member called public health and wanted to know the current Covid restrictions. Staff A heard the call, became upset, and left the resident's house which left 3 family members plus her boss, the chief of police. They all sat outside for approximately 1/2 hour or until the decision had been made to take her back to the hospital. The resident described 6.6.23 as not a good day and that she had been beside herself. The resident stated, not only had the facility placed her in that situation but also her family when they left her as she sat in a w/c by the front steps of her home. Plus when they wheeled her out of the facility and onto a sidewalk with a commode positioned right beside her where family and/or friends of another resident watched her which caused humiliation. During an interview 7.26.23 at 1:42 p.m. Staff A confirmed on 6.6.23 the resident and 2 family members pulled up into the facility parking lot and 1 or both family members entered the facility. The family indicated the resident had been discharged from the hospital and they just drove around and wondered what they could have done and they wondered if the facility could have helped them. Staff A and Staff B went outside with family and found the resident positioned in the front seat of the car and as non-weight bearing due to a fractured foot. The resident stayed in the car and the family and staff members returned to the facility. Staff called the resident's insurance company for approval, the police department, hospital, and workman's compensation. At that time they had been at the 3 hour mark from when the resident left the local ED and had been still waiting on the ED history and physical report so the staff went outside and brought the resident into the facility to have used the restroom in the room they they planned to admit the resident into. The staff members obtained a gait belt, placed it on the resident, and pivot transferred her onto the toilet. Upon conclusion the staff members assisted the resident into a wheel chair. The staff member had been unsure about the length of time the resident sat in the wheel chair but she believed it became painful for the resident so they assisted the resident into bed. At that point Staff B started an assessment and ran a Covid test which had a positive result. At that point the staff members got the Director of Nursing (DON) involved for guidance because they had no paperwork from the ED and now they had a Covid positive resident, not enough staffing to isolate her for Covid and they could not admit her. The staff member stated they left the resident positioned in the bed until the facility van arrived. As the staff member had been shown pictures of the resident as she sat outside the facility the staff member changed her mind and indicated they took the resident to the curb for an unknown amount of time. Once the van arrived the staff member transported her home and when they arrived the Chief of Police and 3 family members had been present. All parties discussed ways to have safely transferred the resident into the house. At one point a family member called Public Health as she had been outside with the resident positioned in a wheel chair on the sidewalk. The staff member stated there had been no way to get her into the house and the situation had not been safe anymore. The staff member indicated the resident and a family member understood because her hands were tied there had been no way for her to have assisted the resident anymore and she felt family wanted her to do something out of her scope of practice even thou she confirmed her status as a CNA. The staff member described the temperature as hot. During an interview 7.27.23 at 3:36 p.m. Staff B stated herself and Staff A had been in her office as they worked on another admission. Staff A went up to the front desk and retrieved some papers they had just printed when she observed 2 of the resident's family members as they stood at the front desk. As Staff B worked on her computer in her office Staff A tapped on her office window as all 3 stood outside and Staff A waved her outside. When they arrived at the resident's car she had been positioned in the passenger seat with the window rolled down. The family and resident tried to explain the situation that the local ED discharged her with a script to go to a local long term medical equipment company for a bariatric walker and they did not have one. Since then they drove around for over an hour. Staff B then invited the family into her office as Staff A planned to stay with the resident however she indicated she would have been fine in the car. Two family members and Staff A and B went into the facility and into their office. The 1st thing Staff B stated was they needed to call the local ED to find out what had been going on. The provider who assessed the resident in ED stated they had no reason for admission following ED treatment. Staff B explained to the provider the family went to the long term medical provider but could not get a walker at that time and the family felt they could not get the resident into her house because as it had not been set up for her current level of care. Staff B indicated Staff A had been on the telephone with workman's compensation at which time a family member offered to have just paid privately. Once the family stated the would pay privately Staff B called the resident's insurance company, completed a Preadmission Screening and Resident Review (PASRR) assessment and checked the resident's status on the sex offender website. Staff B indicated the only thing they did not have at that time had been the ED note because the documentation had not been completed at that time. At that point, Staff A went outside with family and the resident stated she had to go to the bathroom so they obtained a wheel chair and got her into the room they planned to admit the resident into. Staff B called the resident's primary physician and received verbal orders for admission. Staff B indicated they asked family and resident prior if she displayed any Covid symptoms and she denied symptoms and stated the thing she had was allergies. The staff member performed a Covid test and her leg ached and the only way for elevation of the leg had been in bed. The resident had been transferred to bed with 1 staff assistance. As staff elevated the resident's leg she looked over and observed the positive Covid test. The staff members messaged the DON and reported the situation. The DON indicated the facility had not enough staff and they could not have not have the resident in the building right then. Staff B returned to the room and informed the family the resident could not stay at the facility so the family planned to take the resident to her home. The staff member's assisted the resident, along with family, outside and waited for the facilities van to have returned from the hospital which took approximately 10 minutes. As they stood outside another family member arrived and asked if there had been anyway they could have kept the resident at the facility and they said they had not enough staff on duty. The staff member confirmed there had been family of an unknown resident that congregated in the area when the resident had been outside of the facility and awaited the arrival of the van. During an interview 8.2.23 at 9:30 a.m. the state climatologist indicated the weather on 6.6.23 from 12 p.m. until approximately 3:30 p.m. as follows: Temperature 79-80 degrees Fahrenheit (F), humidity at 48-60%, winds at 3-8 miles per hour (mph), hazy, and a heat index of 82 degrees F. Staff A completed An Iowa Level 1 Form Preadmission Screening and Resident Review (PASSR) form dated 6.6.23 at 11:06 a.m. A Wellmark Blue Cross and Blue Shield - Eligibility & Benefits form had been completed by the facility staff 6.6.23 at 11:34 a.m. A Search Results - Iowa Sex Offender Registry form had been performed 6.6.23 at 12:29 p.m. A photo dated 6.6.23 at 1:44 p.m. revealed the resident as she laid supine in one of the facilities beds. A photo dated 6.6.23 at 3 p.m. revealed the resident positioned in a w/c on the sidewalk outside of her home with two (2) family members and Staff A without her foot elevated. During an interview 7.27.23 at 9:26 a.m. the chief of police confirmed he went to the resident's house when the nursing facility dropped her off and because they could not get her into the house they just left her on the sidewalk in front of her house. The chief of police confirmed Staff A had been present but when a family member called public health she became quite agitated and left. During an interview 7.28.23 at 9:38 a.m. the chief of police confirmed he arrived at the resident's house in street clothes and his personal truck on 6.6.23 as a friend and an employer and indicated he felt the facility left the resident in not a good place as she needed to have been in a nursing home which became apparent when she stayed at the hospital for 10 days.

Based on clinical record review, observations, pictures, staff, resident, and family interviews and review of the faculties Residents' Rights form the facility failed to treat 1 resident with dignity and respect during a discharge from the facility. (Resident #1) The facility identified a census of 94 residents: Findings include: An X-ray report from a local hospital for Resident #1 dated 6.6.23 at 7:54 a.m. included the following: a. A mildly comminuted cuboid fracture. b. A mildly displaced fracture of the anterior process of the calcaneus. A Discharge Instructions form from the hospital dated 6.6.23 at 9:07 a.m. indicated the resident's diagnosis included: heel pain, morbid obesity, and a right foot injury. The physician orders included the following: a. Keep foot elevated for decreased swelling and pain. b. Non-weight bearing on the foot with the use of a walker. During an interview 7.26.23 at 1:22 p.m. a family member indicated the resident fell as she went into work on 6.6.23. The resident drove herself to the local ED and called this family member. Staff in the ED treated and released the resident. After the ED staff positioned the resident in the family member's car without a crutch, walker, and wheel chair (w/c) and with a directive of a non-weight bearing status, the ED staff directed the family and resident to go home. Family drove the resident to the local long term care equipment company in town and attempted to purchase/rent bariatric adaptive equipment such as a walker and a w/c but the equipment had not been in stock so they ordered the items. At that point the family knew they could not care for the resident at home due to her size and no adaptive equipment so they drove to the local nursing facility. The family members left the resident in the car and went into the facility and asked if the facility staff could rehab her to home. The family and Staff A, CNA/Community Development Director went out to the car when Staff A stated absolutely they could have admitted the resident to the facility for care and services. The staff member then took the resident inside the facility and began the intake paperwork. Then staff took the resident into what would have been her room, performed an examination, rearranged the room, and performed a Covid test which resulted in a positive result. They said, you got to be kidding me. The staff then looked at the family member and indicated they planned to perform another test but if that test result was positive they had to take the resident home. The 2nd test came back positive also so the facility staff looked at the family member and said they planned to load the resident into the facilities van and take her home. Staff A drove the resident in the facility van to her own home and left her in her front lawn with a commode, wheelchair, and a lift strap (gait belt). During the time Staff A remained at the resident's house she heard another family member as he called public health for guidance. The staff member then became angry and stated she planned to leave as a means not to get caught in the cross fire. The family member indicated she felt bad for the resident because the event traumatized her and she had been in pain as she sat in a wheelchair for hours that day and never had her foot elevated. During an interview 7.27.23 at 1:40 p.m. the above same family member and other family member had been present when staff propelled the resident outside of the facility on 6.6.23 as they waited 10 minutes for the return of the facility van. Staff A then transported the resident home via the facility van and at that point 3 family members had been present when Staff A arrived at the resident's home along with the local chief of police who had arrived off duty and in street clothes. The police chief had been called by family as the resident and himself worked together for [AGE] years. The family member described all people present as hot, sweaty, and emotional. During an interview 7.26.23 at 12:57 p.m. the resident indicated on 6.6.23 she fell at work which resulted in a broken foot and had been not able to return to her home due to a non-weight bearing status plus a wheelchair could not have fit into her home. The Resident stated the hospital discharged her home but the family present stated lets go to the nursing facility. Upon arrival 2 family members entered the facility and Staff A and Staff B, Admissions Director and a family member came out to the car and stated they would take the resident under their care. At that point, a family member drove the resident around to the back of the building where they brought a wheelchair for assistance to have gotten the resident into the facility. Staff A transferred the resident into the wheelchair and brought her into a small family type room where Staff A performed an assessment and paperwork. Staff A then left and returned and stated your room is ready and wheeled the resident to her room. Staff assisted the resident to the bathroom and into a bed and that was when staff performed a Covid test which resulted in a positive result. The staff then looked at 1 of the resident's family members and stated the resident could not stay in the facility. The staff left the resident's room and returned all PPE'd (personal protective equipment) up, wheeled the resident outside of the facility with a walker and commode as they waited for maybe 10 minutes for the return of the facility van. The resident described herself as out of it because of the pain. The resident had been loaded into the facility van and transferred home by Staff A who backed the van up to the stairs in front of the resident's home and unloaded her. The resident described the situation as stupid because she had been unable to get into her house anyway. The resident described 6.6.23 as not a good day and that she had been beside herself. The resident stated, not only had the facility placed her in that situation but also her family when they left her as she sat in a wheelchair by the front steps of her home. Plus when they wheeled her out of the facility and onto a sidewalk with a commode positioned right beside her where family and/or friends of another resident watched her which caused humiliation. During an interview 7.27.23 at 3:36 p.m. Staff B confirmed there had been family of an unknown resident that congregated in the area when the resident had been outside of the facility and awaited the arrival of the van. A photo dated 6.6.23 at 2:01 p.m. revealed the resident positioned in a wheel chair on a sidewalk outside of the facility with two (2) staff members, a commode and a folded up walker. The facilities Residents' [NAME] of Rights dated 11.2016 included the following information: a. The resident had a right to a dignified existence. 1. A must have treated each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life with recognition of each residents individuality.

Based on clinical record review, staff and resident interviews, and facility education documents, facility staff failed to report an allegation of abuse within the acceptable time frame for 1 of 3 sampled residents (Resident #3). The facility reported a census of 99. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required the extensive assistance of 2 staff for transfers, extensive assistance of 1 staff for toilet use and personal hygiene. The resident had a Brief Interview for Mental Status score of 8 which indicated moderate cognitive and memory impairment. Review of the resident's care plan dated 12/5/21 revealed the she had potential problems with memory and communication related to senile dementia. The care plan directed the staff to give step-by-step instructions during her daily routine and to allow extra time to respond to requests. The resident could usually understand staff and they could usually understand her. The care plan documented Resident #3 wanted everyone to know she liked to get ready for bed shortly after supper and often preferred to sleep in her day clothes and not change into her pajamas. Review of a Progress Note dated 11/22/21 at 4:37 p.m. revealed staff noted a dark purple bruise to the top of the resident's left hand. The Progress Note dated 11/24/21 at 4:47 p.m. recorded a late nursing entry with the following information: the staff alerted the resident's primary care provider and the family of an incident on 11/19/21 regarding an allegation of abuse which occurred on the evening shift in the resident's room. The Progress Notes dated 11/24/21 titled Weekly Skin Assessment indicated the resident had a bruise to her left hand and described it dark purple in color. Review of an Incident Report dated 11/22/21 indicated Resident #3 had a dark purple bruise on top of her left hand. During an interview with Staff A, CNA (Certified Nursing Assistant) on 12/8/21 at 2:30 p.m., Staff A stated on 11/19/21 she witnessed Staff D, LPN (Licensed Practical Nurse) gruffly asking the aides why Resident #3 did not have her pajamas on yet. Staff D went to the resident and began to forcefully remove the resident's day clothes. Resident #3 began yelling at the LPN to stop and asking why she was doing that to her. Staff D did not stop when asked to by the resident. Staff A stated she charted and left the facility, she did not report the incident as the nurse she would have reported to was the nurse whom they witnessed being rough with Resident #3. Staff A stated the incident didn't seem right and the LPN should not have done it. Staff A stated Staff D was upset with her and her partner that night and took it out on the resident. Staff A stated she did not report the incident until 11/22/21 when she arrived for her next shift. During an interview with Staff B, CNA on 12/8/21 at 1:00 p.m., Staff B stated on the evening shift on 11/19/21 she witnessed Staff D being upset because the aides did not put Resident #3's pajamas on. Staff B told Staff D they asked the resident twice but she refused both times to change her clothes. Staff B stated the nurse grabbed the resident's wrist and pulled her up to a sitting position in bed. Resident #3 began to yell 'ouch, stop it, you are hurting my wrist'. Staff B stated she did not report the incident until 11/22/21 when she arrived for her next shift. During an interview with Staff C, LPN on 12/9/21 at 12:00 p.m., she stated Staff A and Staff B reported to her on 11/22/21 of an incident involving Resident #3 and Staff D. They reported that Staff D acted extremely too rough with the resident, pulling on her arms and hands and attempting to get her dressed the evening of 11/19/21. Staff C stated she informed the aides they should have reported the incident. Review of an undated Mandatory Reporting staff education form informed the staff that abuse means the willful infliction of injury, unreasonable confinement, intimidation punishment which results in physical harm, pain or mental anguish. The form directed staff they must report all allegations of resident abuse immediately to the charge nurse.

Based on observations, staff interviews and record review the facility failed to follow Preparing for COVID-19 in Nursing Homes Updated November 20, 2020 with the use of shared resident equipment/items on 1 out of 3 units, and failed to maintain clean personal clothing in a covered cart on 1 out of 3 units. The facility reported a census of 88 residents. Findings included: 1. During an observation on 03/08/21 at 12:28 p.m., Resident # 33 sat in the recliner in his room. Two certified nurses aids (CNA) pushed the Resident's wheel chair and the stand lift into the Resident's room from the hall. At 03/08/21 12:33 p.m. staff pushed resident out of the room to the lounge dining room area, staff pushed the stand lift back into the hall. Staff failed to clean the lift after use with the resident. During an observation on 03/10/21 at 01:38 p.m., 2 laundry carts in the 101 hall both the hanging carts are closed, no staff around passing cloths. During an observation on 03/10/21 at 01:40 p.m., staff took the stand lift in room [ROOM NUMBER] staff exited room [ROOM NUMBER] at 01:44 p.m., with the stand lift and parked it in the hall. During an observation on 03/10/21 at 01:51 p.m., Staff A CNA took full body lift from the hall and pushed it into room [ROOM NUMBER]. At 02:03 p.m., Staff A exited room [ROOM NUMBER] with the full body lift, parked it in the hall, and walked away. During an observation on 03/10/21 at 01:45 though 02:12 p.m., Staff B Laundry Aid pushed the laundry cart down to the top of the north hall by room [ROOM NUMBER]. Staff A uncovered the cart and proceeded to pull in down the hall. Staff A took hanging and folded laundry into resident rooms throughout this hall, brought hangers out of resident rooms and hung the hangers on the clean laundry cart. During an observation on the center north hall rooms 101-113 on 03/10/21 at 02:19 through 2:23 p.m., Staff A Laundry delivered resident clothing to resident rooms from the open hanging laundry cart and brought back hangers from the resident rooms hanging the hangers on the clean laundry cart. An observation at 03/10/21 02:22 p.m., a Family member, 2 CNA's and maintenance man walked by the open cart in the hall. During an interview on 03/10/21 at 02:04 p.m., Staff A reported the lifts are cleaned daily, or at the end of shift. Staff A revealed trying to keep a lift per hall but, sometimes goes to another hall. During an interview on 03/10/21 02:27 PM Staff C Patient Care Coordinator reported expecting staff to clean the each lift between each use and expecting the clean laundry carts covered during delivery. Staff C reported hangers from a resident's room should not be placed on the clean laundry cart. During an interview on 03/10/21 at 02:44 p.m., the Director of Nursing (DON) reported expectation is the lifts are cleaned between each use, expected clean laundry covered in the halls, and dirty hangers are not placed on clean laundry cart. The facility provided a policy titled Department (Environmental Services) -Laundry dated 2014, directing at point # 7 Clean linen will remain hygienically clean(free from pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. The facility provided a policy titled Cleaning and disinfecting Non-Critical Resident Care Items dated 2011, directing at point # 3. d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscope, durable medical equipment).

Based on observation, record review and staff interview the facility failed to distribute and serve food in a sanitary manner for 2 of 2 meals observed in the Memory Care Unit and the Assisted Dining Room. The facility identified a census of 111. Findings include: 1. The facility spreadsheet for 6/3/18 showed food for the lunch meal included a bacon, lettuce, tomato sandwich (BLT) and macaroni and cheese. On 6/03/19 at 12:38 p.m., observation of the noon meal in the Memory Care Unit revealed nursing staff assisting the dietary staff with the assembly and distribution of the meal. Staff E, Certified Nursing Assistant, CNA wore the same gloves to deliver the plated food to multiple residents. Staff [NAME] returned to the food counter station and rested her gloved hands on the counter. Staff [NAME] picked up a piece of bread with the gloved hand and placed it on top of the ready made BLT. She picked up a butter knife and placed the same gloved hand on top of the BLT and proceeded to cut the sandwich in two pieces. Staff [NAME] then stood with the same gloved hands on her hips. Without a change of gloves or wash of hands Staff [NAME] continued to distribute food to other residents. At 12:50 p.m., observation revealed Staff F, CNA took a full uncovered plate of food from the counter top through the hallway, approximately 20 feet to room [ROOM NUMBER]. At 12:59 p.m., observation revealed Staff [NAME] assisted a resident to eat using gloves. Staff [NAME] stepped away from assisting the resident and with the same gloves directly touched the back of the tablemate's chair and moved them closer to the table. Without changing gloves or handwashing Staff [NAME] returned to the first resident and continued to assist with eating. 2. The facilities spreadsheet for the breakfast meals showed an open buffet where the resident's have a choice of food items. During observation on 6/04/19 at 8:31 a.m., Staff F, CNA took an uncovered plate of food from the the counter in the Memory Care Unit through the hallway approximately 20 feet to room [ROOM NUMBER]. On 6/05/19 at 2:08 p.m., the Dining Services Supervisor reported during interview gloves are a protocol for assembling and serving food to prevent germs from spreading. She reported the expectation is for staff to change gloves if they assist a resident with cutting up food. The Dining Services Supervisor reported the staff should always use utensils to handle food. She reported room trays should be assembled, placed on a tray and covered prior to going to the resident room. The Dining Services Supervisor also reported all facility staff are required to complete safe food handling education annually. At 3:03 p.m., the facility Dining Services Supervisor provided the surveyor with a copy of the facility policy for Handwashing, undated. The policy included directives under serving to wash hands, use utensils to serve food, never touching food with bare hands or gloved hands. Rewash hands before changing gloves, after touching any new surface ie: face, hair, plates, packaging. 3. Observation on 6/03/19 at 12:20 p.m. in the Assisted Dining Room showed the Food Server, Staff A, Dining Aide and all the Certified Nursing Aides wore plastic gloves while serving the residents their food. Staff A picked up bread by the gloved hand and patted it down, as to keep the bread in place for the BLT sandwiches. This continued for 12 sandwiches served. Staff A did not change the gloves during the entire meal process. 4. The menu for 6/4/19 breakfast showed open buffet where the resident could order anything they wished. Observation on 6/04/19 at 8:26 a.m. revealed the mobile steam table serving the assisted dining room. Staff C, Dining Aide plated the foods and wore gloves during the entire meal process. Staff A handled 1 toast, 7 pancakes, 4 waffles and 1 french toast with the same gloved hands. She removed all those food items from their plastic wrappers, directly touching the food items. Staff C wore the same gloves through out the meal without any change or hand washing. She also continued serving the food while touching cups, bowls, plates, and the handles of the different scoops. 5. On 6/4/19 at 8:39 a.m., observation in the assisted dining room revealed Staff H, Licensed Practical Nurse LPN washed hands and applied gloves. She then proceeded to sit down at the dining table and placed her gloved hands on the arm rest of the chair. She used her gloved hands to pull the chair in while sitting down. She stood up and went to the cupboard labeled garbage, opened and closed the door with her right gloved hand. She returned to the table to feed two residents without changing her gloves. She continued to feed residents throughout the breakfast meal without changing gloves or washing hands at any time.

Based on observation, record review and staff interviews the facility failed to notify the resident and/or resident representative of the bed hold policy for hospitalization for 4 of 4 residents reviewed (Resident #106, #20, #29, and #112). The facility reported a census of 111. Findings include: 1. A Resident Census form provided by the facility identified Resident #106 as discharged to the hospital on [DATE] at 9:20 a.m. The form showed the Resident returned to the facility on [DATE] at 2:35 p.m. The nurse's notes from 4/24/19 through 4/26/19 failed to show any documentation for resident and/or family for notification of bed hold. The Director of Nursing, DON provided a bed hold letter dated 4/25/19 and commented this is what they send to the family in the mail. A Resident Census form provided by the facility identified the resident as discharged to the hospital on [DATE] at 2:00 p.m. The form showed the resident returned to the facility on [DATE] at 11:45 a.m. The nurse's notes from 5/6/19 through 5/13/19 failed to show any documentation for resident and or family for bed hold notification. The DON provided a bed hold letter dated 5/10/19, commented this is the form they send to the family in the mail. 2. Record review of Resident #29 revealed a resident census report with hospital leave 3/21/19 and returned to the facility on [DATE]. The record included no notification of bed hold policy. 3. Record review of Resident #20 revealed a resident census report with hospital leave 3/17/19. The resident returned to the facility on [DATE]. The record included no notification of bed hold policy. The DON stated during interview on 6/06/19 at 8:36 a.m., nursing does not currently give out bed hold policy or document it was given to resident or representative. The facility provided a policy dated 3/2017 which directed staff prior to a resident transferring to a hospital or going on a therapeutic leave, Good Neighbor Home will provide written information to the resident and/or the resident's representative explaining the resident's right to hold the bed until returning to the facility. The facility will document the choice made by the resident or resident representative in regards to holding the bed with the specific response from the resident or resident's representative in the resident's record. 4. The Minimum Data Set (MDS) assessment for Resident # 112 dated 5/22/19, listed [DIAGNOSES REDACTED]. The MDS further listed the resident with a Brief Interview for Mental Status (BIMS) score of 10 indicating mild cognitive impairment. Review of the Resident Census form identified the resident discharged from the facility to the hospital on [DATE], 3/23/19, and 4/15/19. The Nurses Notes lacked documentation of bed hold information provided to the resident or the resident representative. During an interview on 6/05/19 10:55 a.m., the DON stated the nursing department does not do anything with the bed hold notice, that is the office staff. During an interview at 1:20 p.m., Staff J, Assistant Office Manager stated they should send the bed hold notice to the Power of Attorney in 3 to 5 days after the residents go to the hospital. Staff J continued most of the time they are back before 3 days so I don't send anything. Staff J revealed not documenting the bed hold notice's sent in the resident record.

Based on observation, record review and staff interview the facility failed to offer toileting to 1 of 1 resident reviewed who required assistance. (Resident # 3). The facility reported a census of 111 residents. Findings included: The Minimum Data Set (MDS) assessment for Resident #3 dated 5/25/19, included a [DIAGNOSES REDACTED]. The Care Plan for the resident dated 7/3/18, included a directive for staff to assist with toileting. The Care Plan directed staff help the resident use the bathroom upon rising, before, after meals and activities and at bedtime with a goal date of 8/28/19. During an observation on 6/05/19 at 9:25 a.m., Staff N, Certified Nurses Assistant, CNA pushed the resident to the bedroom. At 9:31 a.m. Staff N and Staff L CNA transferred the resident to the bed. During an interview at 9:34 a.m., Staff N confirmed the residents brief had been dry. During observation at 9:34 a.m., Staff N rolled Resident #3 to the side revealing a small amount of bowel movement (BM). Staff L cleaned away the BM. Staff failed to offer the resident the bathroom to complete the BM or empty the bladder. During an interview at 10:36 a.m., Staff L reported the resident is checked and changed before and after meals and activities. During an interview at 3:30 p.m., Staff K Licensed Practical Nurse, LPN confirmed Staff N and Staff L failed to offer the bathroom to the resident when staff transferred the resident to bed and provided cares. Staff K confirmed the resident at the time was not incontinent of bladder. Staff K reported expecting the staff to toilet the resident. During an interview on 6/05/19 at 10:57 a.m., the Director of Nursing, DON reported the staff are expected to take the resident to the bathroom before and after meals and activities even if she has incontinent episodes.

Based on observation, staff interview and record review the facility failed to maintain infection prevention and control for 1 of 3 residents reviewed for catheter cares (Resident #53). The facility identified a census of 111. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #53 dated 4/24/19, showed the resident with memory intact, required staff assistance for daily cares and had an indwelling Foley catheter for bladder functions. The MDS also showed the resident had [DIAGNOSES REDACTED]. The Care Plan dated 4/26/19, included a focus area for bladder management for [MEDICAL CONDITION] and benign prostrate hypertrophy. Interventions for this area directed staff to use facility protocol for cares, monitor for signs and symptoms for urinary tract infection and take care of the equipment. During observation on 6/04/19 at 7:39 a.m. after morning cares, Staff D, Certified Nursing Assistant, CNA hung the catheter bag into a cloth bag which hung beneath the wheelchair. The catheter tubing slightly dragged on the floor and bounced while the resident wheeled self to the bathroom. The resident then wheeled self to the main dining room, approximately 50 to 80 yards through the halls. The catheter tubing, approximately 3 inches, dragged on the hard wood floor through the hall, through another carpeted hall to the television area. At 8:09 a.m., at the dining room entrance staff walked the resident to the table and sat the resident in a chair. The resident's catheter tubing laid just above the floor, but the green clip (that is to hold up the catheter) remained on the floor during the meal. At 8:50 a.m., the resident wheeled self through all the same hallways back to the room with the green clip and a couple of inches of the catheter tubing dragging on the floor. At 3:00 p.m., observation revealed the resident in the wheelchair visiting with their spouse. The catheter tubing, a couple of inches, sat on the carpeted floor. The resident reported they just received a shower. During observation on 6/05/19 at 8:35 a.m., the resident sat in the wheelchair and the catheter tubing, a couple inches, laid directly on the floor. At 9:25 a.m., the resident wheeled down to the bird house and around the television area in the main entrance. The catheter and green clip bounced around on the floor. During interview at 11:45 a.m., Staff G, Certified Nursing Assistant, CNA reported a catheter tubing is not suppose to be touching the floors. The catheter tubing has a green clip to help hold it up away from the floor. During at 11:55 a.m., Nurse Educator, Registered Nurse reported catheter tubing should always be below the resident's waist and should never touch the floor. She commented feeling bad if this happened, as they just had an inservice and skills fair covering this topic. The Nurse Educator also remarked this will be reviewed again to staff. During interview at 1:00 p.m., the Director of Nursing, DON reported the expectation is for staff to keep the tubing off the floor. The facility's Policy for Catheter Care Audits, undated, failed to identify the appropriate positioning of the catheter's tubing.

Based on clinical record review and staff interview, the facility failed to ensure the physician was notified of as needed antipsychotic medication use beyond 14 days for two of two residents reviewed. (Resident #43 & #67) The facility census was 104 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #67 had [DIAGNOSES REDACTED]. The Physician order [REDACTED]. The Medication Administration Record [REDACTED]. The medication was administered on 1/7/18, 1/19/18 and 2/16/18. The care plan with review date of 1/19/18 reveals no interventions to address the review of antipsychotic medications. During interview on 2/21/18 at 2:20 p.m., the Pharmacist stated the medication started as a one time use and was added on as a order. He stated as needed antipsychotic's should have an order for [REDACTED]. During interview on 2/21/18 at 2:40 p.m., the Director of Nursing stated she found out about the as needed antipsychotic use when it was brought up at Quality Assurance (QA) meeting on 1/28/18. She then began to notify physicians when she sent the CMS (Center for Medicare Services) letter about the regulation to educate them on 1/29/18, but failed to complete further follow up. 2. The MDS assessment dated [DATE], documented Resident #43 had [DIAGNOSES REDACTED]. Care Area Assessment (CAA) Summary of the MDS showed the resident triggered for cognitive loss, behavioral symptoms, and [MEDICAL CONDITION] medication use. The resident's Comprehensive Plan of Care, last updated 11/21/17, identified a focus area of disruptive behaviors both verbally/physically, agitated, combative to the staff, delusional with hallucinations and resistive to cares related to dementia with behavioral disturbances. The resident also identified with a focus area of cognitive loss related to the dementia. Nursing staff was directed to administer medications as ordered, assess for effectiveness and adverse effects, request a medication review, identify triggers and /or underlying causes of behavior, evaluate for sensory deficits and encourage family involvement. The Certified Nurse Aides (CNA's) directed to use consistent approach, assist where needed with ADL's and report changes in ability to the nurse. A signed admission medication order dated 8/7/17, documented to continue prior medications to include [MEDICATION NAME] (antipsychotic medication) 25 milligrams (mg) orally, daily as needed for agitation. A signed Physician order [REDACTED]. Clinical record review failed to reveal a 14 day recertification for the as needed antipsychotic medication since the admission order. Review of the resident's behavior reports from 12/3/17 to 2/12/18 showed the resident had occasional behaviors verbally and physically. Review of the Medication Administration Records (MAR's) revealed the as needed [MEDICATION NAME] was administered 6 times in (MONTH) (YEAR), once in (MONTH) (YEAR) and twice in (MONTH) (YEAR).

Based on record review and staff interviews, the facility failed to administer medication as ordered by the physician for one (1) of four (4) residents (Resident #1) reviewed. Resident #1 received ten times the amount of [MEDICATION NAME] medication three (3) times on [DATE] due to a transcription error written on the Medication Administration Record (MAR). The findings constitute an immediate jeopardy to resident's health and safety The facility reported a census of 102 residents. Findings include: According to record review Resident #1 entered the facility on [DATE] and had [DIAGNOSES REDACTED]. Documentation in the facility Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had both short term and long term memory problems and was severely impaired in his/her cognitive skills for daily decision making. The assessment also described Resident #1 as requiring extensive staff assistance with bed mobility and eating, and totally dependent on staff for transferring, toilet use, personal hygiene and bathing. Resident #1 did not ambulate. The facility plan of care for Resident #1, dated [DATE] identified the focus area of potential for pain. The plan of care directed nurses to administer pain medication as ordered; nurse aides were to offer alternatives for pain relief; activities, TV, reading, and/or socialization. Nursing was directed to assist with positioning for comfort. Documentation in the nurse's notes dated [DATE] at 15:36 (3:36 p.m.) indicated a change in the level of care of Resident #1 with the admission to hospice services 4 milligrams (mg) every four hours as PRN (as needed), [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg every 4 hours PRN, [MEDICATION NAME] 12 micrograms (mcg) every 3 days, [MEDICATION NAME] 2 mg every 4 hours PRN, [MEDICATION NAME] drops sublingual (SL) one drop every 30 minutes PRN. Documentation in the nurse's notes dated [DATE] at 1016 (10:16 a.m.) indicated the hospice nurse had assessed Resident #1 and reported an increase in Resident #1's respirations. The following new orders were received and noted: [MEDICATION NAME] 20 mg/ml - 5 mg (0.25 milliliter (ml) SL every 1 hour PRN, [MEDICATION NAME] 0.5 mg [MEDICATION NAME] (0.25 ml) every 2 hours PRN/increased respirations and anxiety. Documentation in the nurse's notes and in the Medication Administration Record (MAR) indicated Resident #1 received [MEDICATION NAME] 2.5 ml/5 mg at the following times. * [DATE] at 9:45 a.m. for anxiety and increased respirations to 36 at time of administration. * [DATE] at 12:43 p.m. per family request to prevent discomfort prior to positioning. * [DATE] at 15:30 (3:30 p.m.) for agitation. * [DATE] at 18:21 (6:21 p.m.) for pain/discomfort * [DATE] at 2102 (9:02 p.m.) for pain/discomfort * [DATE] at 22:11 (10:11 p.m.) for pain/discomfort Documentation in the nurse's notes dated [DATE] at 0022 (12:22 a.m.) indicated staff administered 0.25 ml/0.5 mg of [MEDICATION NAME] to Resident #1 for pain/discomfort. During an interview on [DATE] at 9:14 a.m. Staff A stated she worked on [DATE] and received orders for changes in Resident #1's [MEDICATION NAME] and [MEDICATION NAME] orders. Staff A stated she distinctly recalled that the hospice nurse verbally clarified that they would be giving Resident #1 0.25 ml of both the [MEDICATION NAME] and [MEDICATION NAME]. Staff A stated while she noted the orders of the medication change, she was called away in the process and when she returned to the desk, she set the order and MAR aside and didn't complete the order. Staff A confirmed that she administered [MEDICATION NAME] to Resident #1 (as documented on the MAR) at 9:44 a.m., 12:50 a.m. and 15:30 p.m. Staff A stated she was confident that she administered the amount ordered, 0.25 ml as emphasized by the hospice nurse. Documentation on the MAR dated [DATE] directed staff to administer [MEDICATION NAME] 2 mg/ml Concentrate by mouth, dose ordered: 2.5 ml/5 mg every hour as needed. During an interview on [DATE] at 11:25 a.m. Staff B stated she received change of shift report from Staff A on [DATE] at approximately 4:00 p.m. According to Staff B, Staff A had stated Resident #1 wasn't doing real well, had a restless shift and family was at his/her bedside. Staff B stated she assessed Resident #1 at the beginning of her shift and found him/her restless and with increased respirations. Staff B noted the order on the MAR to give Resident #1 2.5 ml of [MEDICATION NAME]. Staff B stated she questioned the amount to herself, and also asked another (unidentified) nurse about the dosage. Staff B stated she was aware that hospice services was providing direction for Resident #1 and often ordered higher doses of medications as well as more frequent administration times for hospice residents verses typical/non hospice residents. Staff B verified that she administered [MEDICATION NAME] 2.5 ml to Resident #1 three times during the shift. Staff B also stated she checked the orders from the prior shift as facility protocol and at that time identified an error in the transcription of the medication order on the MAR. Staff B stated she contacted the Director of Nursing (who was in house) as well as Resident #1's physician and family regarding the medication error. Staff B also completed a physical assessment of Resident #1 who appeared comfortable but remained restless. According to the nurse's notes Staff B administered the corrected dose of [MEDICATION NAME] at 0022 (12:22 a.m. on [DATE]) noting Resident #1 with occasional labored breathing, short period of hyperventilation and fidgeting. At 0225 (2:25 a.m.) Resident #1 was noted to be deceased , with an absence of lung sounds and pulse. During an interview on [DATE] at 11:44 a.m., the facility Medical Director indicated the incident was a disturbing medication error. The physician did add that even with the higher doses Resident #1 was still interacting with people/family. He also stated that Resident #1's death was considered a natural death as it had been anticipated to occur within 24 hours. The facility incident summary dated [DATE] revealed the Medical Director was contacted and reported the medication error did not cause the resident's death. The Medical Director reported death was imminent and although the attempts to identify medication presence in the resident's blood levels was unsuccessful, medications administration may have been a contributing factor. The facility abated the IJ on [DATE] when they immediately educated both nurses involved in the incident. The facility also updated their requirements for confirmation by a second nurse of accurate data entry for medication on electronic MAR/TAR upon receipt of a new order and prior to the order implementation. In addition, on [DATE], the facility provided 1 to 1 education to the nurses by their nurse educator to review the processing of medication orders and to ensure they always checked the MAR/TAR to confirm accurate medication administration. On [DATE] a nurse meeting was held to discuss and identify associated risk associated with medication errors. The facility reviewed the risk of medication errors due to distractions and methods to reduce the risk by gathering/working at the nurses station and medication check/in exchange. The facility revised the protocol involving new orders and requirements for diagnoses/indications on all medication orders received. The process for checking new orders was revised. On [DATE] education was provided to nurses for all orders to have [DIAGNOSES REDACTED]. The nursing department will continue to monitor and meet routinely for quality assurance and performance improvements to reduce risk for residents.

Based on observation, clinical record review and staff interview, the facility failed to follow fall preventions for one of three residents reviewed (Resident #1). The facility census was 110 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #2 required extensive assistance with bed mobility, transfers, dressing, hygiene and toileting and had no falls since the last admission or entry. The resident's Care Plan updated 12/2/15, identified impairment with mobility and a potential for falls. Interventions included the following: -3/23/15: fell on [DATE]. Placed a sign to wait for assistance, check shoes, and gripper pad on cushion. -4/30/15: fell [DATE]. Placed a sign in the room to remind the resident to wait for help. -6/11/15: fell [DATE]. All interventions were in place. - 10/7/15: fell [DATE]. All interventions in place. The Care Plan also identified the resident with assist of one staff person for transfers with a gaitbelt and walker. Observation on 1/12/16 at 9:05 a.m. revealed staff transferring the resident from the bed to the wheelchair, using a gaitbelt and walker. The wheelchair did not have a gripper pad on top of the cushion. Observation on 1/13/16 at 9:20 a.m., with Staff A, Registered Nurse, revealed no gripper pad on top of the cushion. Staff A reported the gripper pad should be in place and asked a staff person to get one.

Based on clinical record review and staff interview, the facility failed to assure attempts at gradual dosage reductions occurred for 6 of 12 residents reviewed who received psychoactive medications (Residents #'s 10, 11, 12, 13, 17, and 20). The facility further failed to ensure 1 of 12 residents drug regimen remained free from unnecessary drugs through adequate assessment, indications for use and monitoring (Resident #15). The facility reported a census of 112 residents. Findings include: 1. Resident #15's Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition and [DIAGNOSES REDACTED]. Resident #15 had a physician's orders [REDACTED]. Resident #15's Nurse's Notes documented staff had administered the PRN [MEDICATION NAME] on 5/17/14, 6/11/14, 6/13/14, 6/25/14, 7/16/14, 8/3/14, 8/9/14, 9/11/14, 10/4/14 and 1/10/15. The Nurse's Notes lacked documentation that showed staff had assessed the resident for possible causes of anxiety and/or attempted any non-pharmacological interventions to decrease the resident's anxiety prior to administering [MEDICATION NAME]. During interview on 1/28/15 at 11:40 a.m., the Assistant Director of Nursing stated, a couple of weeks ago they noticed that staff were not documenting non-pharmacological interventions attempted prior to administering PRN medications. 3. physician's orders [REDACTED].#11 had a [DIAGNOSES REDACTED]. Resident #11's MAR indicated [REDACTED]. Review of the Monthly Pharmacy Reviews revealed the pharmacist recommended and sent a request for a gradual dose reduction in June 2014. Resident #11's clinical record revealed no evidence of gradual dose reduction. During an interview on 1/28/15 at 11:45 a.m., the DON stated she was unable to locate any documentation in reference to a gradual dose reduction. 4. Resident #12's POS dated 1/15, documented [DIAGNOSES REDACTED]. Resident #12's MAR indicated [REDACTED]. The monthly Pharmacy Review revealed a gradual dose reduction request, dated 12/29/14, to decrease the [MEDICATION NAME] does to 0.25 mg in the a.m. only and discontinuing the bedtime dose. During an interview on 1/28/15 at 9:40 a.m., the DON described the process of Pharmacy review is as follows. The Pharmacist conducts the medication review at the facility, and then gives the completed form to the staff to send to the physician. According to the DON, the facility's expectation is that the physician returns the reviews to the facility within 1-2 weeks. During an interview on 1/28/15 at 10:05 a.m., the DON reported she was unable to find any documentation regarding gradual dose reduction for Resident # 12. 5. Resident #13's MAR indicated [REDACTED]. During an interview on 1/28/15 at 9:55 a.m., the DON reported she was unable to locate 2014 GDR reviews for Resident #13. During an interview on 1/28/15 at 1:00 p.m., the Administrator reported the facility has a system problem with Medication Review. 6. Resident #10's Minimum Data Set (MDS) assessment dated [DATE], documented [DIAGNOSES REDACTED]. The resident's care plan, revised on 3/25/14, directed staff to administer [MEDICAL CONDITION] medications as ordered and monitor for side effects. The care plan also directed staff to monitor the resident for signs of depression and changes in mood. physician's orders [REDACTED]. During an interview on 1/28/15 at 10:10 a.m., the Assistant Director of Nursing (ADON) explained the pharmacy consultant documented a request for a GDR on 7/14. The ADON acknowledged she was unable to find any documentation of a GDR for [MEDICATION NAME]. 7. Resident #20's Minimum Data Set (MDS) assessment dated [DATE], documented [DIAGNOSES REDACTED]. The resident's care plan, revised on 3/11 /14, directed staff to administer [MEDICAL CONDITION] medications as ordered and monitor the resident for side effects. The care plan also directed staff to monitor for signs of depression and changes in mood. Physician orders [REDACTED]. Clinical record review revealed no evidence of any Gradual dose reductions (GDR) attempted for [MEDICATION NAME] or [MEDICATION NAME]. During an interview on 1/29/15 at 7:25 a.m., the Assistant Director of Nursing (ADON) acknowledged she was unable to find any documentation of a GDR attempt in 7/2014 for either medication. 8. Review of the resident's monthly pharmacy reviews, completed by the facility's consultant pharmacist, revealed, in May 2014, staff sent a Gradual Dose Reduction (GDR) request to Resident #17's primary physician for consideration of reducing the dosage of any/all of the residents psychoactive medications. Review of Resident #17's medical record revealed no evidence the primary physician signed and returned the GDR, which delineates whether the facility could reduce the resident's psychoactive medication dose or, if not, what contraindicated a reduction. During an interview on 1/28/15 at 1:20 p.m., the facility Director of Nursing verified the GDR request was not in the medical record for Resident #17 to show that the primary physician reviewed and responded to the dose reduction request.

Based on observation, document review, and staff interview, facility staff failed to remove contaminated gloves after completing incontinence care and don clean gloves before applying an ointment for 1 of 5 residents observed for treatments (Resident #9). The facility had a census of 112. Findings include: Resident #9's Minimum Data Set ((MDS) dated [DATE], documented [DIAGNOSES REDACTED]. Resident #9's Care Plan dated 9/26/14, documented the resident had a potential for impaired skin integrity and directed staff to administer treatments as ordered. physician's orders [REDACTED]. During an observation on 1/27/15 at 10:25 a.m., Staff C, Certified Nursing Assistant (CNA) provided pericare after Resident had a loose bowel movement. Staff C, without changing gloves or washing her hands, placed her finger into the Resinol ointment container, scooped ointment onto her finger and then applied the ointment to the resident's rectal area. During an interview on 1/27/15 at 10:45 a.m., the Assistant Director of Nursing (ADON) reported, she would have expected staff to remove soiled gloves before continuing and put on clean gloves before applying the ointment. Facility document titled Nurse Aide Skills checklist dated 7/2007, documents the following. " ...Before touching uncontaminated items and surfaces, remove contaminated gloves, reglove as needed ... "

Relates to incident # Based on clinical record review and interviews, the facility failed to plan for and direct nursing services to ensure Resident #1 received adequate supervision against hazards. Resident #1 fell during a two staff transfer and fractured his/her right knee. Multiple staff reported Resident #1 had demonstrated an increase of weakness in the knees for over a month and staff reported these concerns to the nursing staff. The care plan lacked any reassessment or new intervention to address Resident #1's increased difficulty with transfers. The facility census was 129 residents. Findings Include: A 8/27/11 Minimum Data Set (MDS) Assessment tool revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 10 out of 15 possible points that indicated short-term memory impairment but no signs or symptoms of delirium or recent mental status changes. The assessment identified the resident ' s weight at 149 pounds. The MDS revealed the resident required minimal set-up assistance needed for eating, however he/she required extensive assistance by 2 or more staff members for transfers to and from bed and wheel chair, bathing, dressing and personal grooming, and usually continent of bowel. The assessment determined Resident #1 ' s balance as unsteady, only able to stabilize with human assistance when moving from seated to standing position, and when moving on and off the toilet and unsteady with surface to surface transfer (between bed and chair). The assessment documented the resident did not perform balance with turning around or walking. A fall assessment tool with most recent date of review on 9/1/11 revealed a score of 20 points, when a score of 10 or greater indicated a high risk for falls. A nursing care plan with risk for falls problem identified on 6/8/11 directed staff to pivot transfer the resident with 2 staff members, gait belt and walker, and goals dated 11/30/11 that the resident would pivot transfer with assist of 2 with gait belt and walker and be free from injuries from falls. Resident #1's October, 2011 Medication Administration Record (MAR) included the following: Acetaminophen (Tylenol) 500 milligrams (mg) administered oral daily at 7 a.m. Acetaminophen 500 mg tablet, administer 2 tablets (1000 mg) oral every 6 hours as needed for pain, and administered on 10/16/11 at 5:00 p.m., 9:06 p.m., 10/17/11 without a time indicated, and 10/18/11 at 6:24 a.m. Resident #1's Nurses Note (NN) entries revealed the following: On 10/17/11 - 11:37 a.m. Phone call placed to the physician regarding the resident's painful red and swollen right knee and order to obtain an X-ray of the right knee, transcribed by Staff R, a Registered Nurse (RN). On 10/18/11 - 11:53 a.m. Resident had a right knee X-ray this a.m. and transferred to the hospital. On 10/19/11 - 5:56 a.m. Recorded as a late entry by the interim Director of Nursing (DON), resident lowered to the floor by 2 Certified Nursing Assistants (CNA's) with gait belt and walker utilized, the fall under investigation, date of incident 10/16/11, time of incident 1:30 p.m. A 10/18/11 right knee X-ray report revealed Resident #1 had a moderately displaced distal right femoral fracture with soft tissue swelling. A 10/18/11 hospital consultation report revealed Resident #1 had [DIAGNOSES REDACTED]. A 10/18/11 surgical operative note revealed the resident required an open reduction and internal fixation of a right femur supracondylar fracture. A typed document with the interim Director of Nursing ' s name at the bottom reported on 10/18/11 she was made aware Resident #1 ' s X-ray had not occurred on Monday October 17, 2011 and instead received the X-ray on 10/18/11. Two Certified Nursing Assistants (Staff W and Staff N) lowered Resident #1 to the floor on 10/16/11 at approximately 1-1:30 p.m., and neither aide reported the fall to the charge nurse. When Staff W was questioned she stated Staff N asked her for help to check and transfer Resident #1. They assisted the resident to stand up with a gait belt and a walker for him/her to hang on to. As Staff N was checking Resident #1 ' s (incontinence pad) the resident ' s knees buckled and they could not hold him/her up and lowered the resident to his/her knees. When Staff N was questioned she reported they transferred the resident from the commode to his/her recliner with a walker and gait belt and the resident did not bear any weight so they eased the resident to the floor. Interviews with facility staff revealed the following: On 10/26/11 at 3:17 p.m., Staff O, a CNA and RA (restorative aide) stated that she worked on 10/16/11 from 11 a.m. to 7 p.m. and transferred Resident #1 out of the dining room chair after lunch with Staff P, the resident told her that he/she had fallen during a transfer and broken his/her knee, Staff O pulled up the resident's pant leg at that time and determined the knee looked swollen, and he/she reported the information to the CNA from the South hall that took Resident #1 back to his/her room. On 10/27/11 at 3:17 p.m., Staff R, an LPN, stated that she worked on the South hall 10/16/11 from 4 p.m. to 4 a.m. 10/17/11, Resident #1 reported that he/she had fallen during a transfer, picked up by someone in white clothes and complained of pain in the right knee. Staff R stated she was called to the resident's room between 2 a.m. and 3 a.m. on 10/17/11 and the resident once again told him/her that someone dressed in white picked him/her up after a fall and the resident had continued complaints of pain in the right knee with swelling and redness. On 10/27/11 at 4:42 p.m., Staff W, a CNA stated she worked the South hall on 10/16/11 from 5:30 a.m. to 1:30 p.m. Staff W reported she assisted Staff N after lunch with Resident #1's transfer between 1 p.m. and 1:15 p.m. Staff W stated Resident #1 had to turn to his/her right to get into the recliner. Staff W was on the resident's right side and Staff N was on the resident's left side. Staff W stated the resident had a walker in front of him/her to hang on to, and was wearing shoes and a gait belt around his/her waist. Staff W had her right hand on the gait belt and her left hand pulled the resident's pants down. Staff W reported Staff N, had held the gait belt with one hand as he/she changed the resident's incontinence brief with the other. Staff W stated Staff N started to change the resident's incontinence pad and during that time the resident's knees started to buckle. The staff tried to hold the resident up and had to ease the resident to the floor on his/her knees. Staff W reported after the resident's knees buckled, together with Staff N, they each held the gait belt with one hand, positioned the other hand under the upper legs, lifted Resident #1 to the recliner chair, and Staff V, another CNA, came at that time and assisted to reposition the resident and pull his/her pants up. Staff W stated he/she left with Staff V after the transfer, did not assist with any other Resident #1 transfers that day, and thought Staff N would report the incident to the nurse as the resident was assigned to her. Staff W reported the resident ' s knees had buckled before but she had been able to get him/her back up without a fall. Staff W reported Resident #1 as dead weight and just one staff would not be able to transfer/pick up him/her. Staff W reported there have been other falls for other residents like Resident #1, whereas their knees buckle. During an interview on 10/28/11 at 8:41 a.m., Staff N, hired on 8/25/11, stated she had been a CNA for [AGE] years, worked the South hall on 10/16/11 from 6 a.m. to 2 p.m. and assigned Resident #1. Staff N stated Resident #1 required 2 staff members to transfer him/her with a gait belt and walker. Staff N stated on 10/16/11 they were transferring the resident from the commode to the recliner and Resident #1 would not stand. (Staff N stated the resident would do that when told by staff they were going to put him/her on the commode, and he/she would not stand). Staff N stated they just lowered the resident to the floor during a transfer that day performed with Staff W after lunch and between 1 and 1:30 p.m. Staff N stated she did not notify the nurse that the resident had been lowered to the floor because she thought Staff W would report it, and knew the facility considered the event a fall. On 10/27/11 at 5:12 p.m., Staff V, a CNA stated she had not assisted with any Resident #1 transfers on 10/16/11 until approximately 1:15 p.m., when she looked for Staff W and came upon Staff N and Staff W after they transferred Resident #1 to the recliner chair, and assisted the 2 staff members with correct positioning and pulled the resident's pants up. Staff V stated neither of the 2 CNA's told him/her that the resident was lowered to the floor during the transfer. Staff V stated she was later informed the resident ' s knees had buckled and that was not unusually. On 10/28/11 at 8:32 a.m., Staff A, (a Certified Medication Aide (CMA)) stated she had not assisted any staff with Resident #1 ' s transfer on 10/16/11. During another interview with Staff A on 10/27/11 at 8:43 a.m., she stated there were times when the resident had to stand longer and he/she would get weak. Staff A stated when transferring Resident #1 to the commode, he/she would get weak at the knees and staff would have to pull him/her up. Staff A stated this had been going on for awhile (2-3 months). On 10/27/11 at 11:22 a.m., Staff U, a CNA reported she had worked at the facility for 9 years. Staff U reported some days Resident#1 would bare weight better than others and some days his/her knees would buckle. Staff U stated this had been going on between a month to six weeks and she would get the resident to the recliner chair right away. Staff U reported she had told one of the day shift nurses the resident was having trouble. Staff U stated she would have thought they would re-evaluate Resident #1 and stated a lift could have been used. Staff U reported some of the rehab girls had reported the resident had trouble with transfers too. Staff interviews conducted between 10/26/11 and 10/28/11 revealed: Staffs' A, N, U, V, W all CNA's that regularly cared for Resident #1 and all aware the resident would become weak in the knees when transferred by 2 to 1 pivot method, the increased weakness present for over one month; and nursing staff reported they had been informed of the increased difficulty with Resident #1's transfers. On 10/27/11 at 1:46 p.m., Staff T, an LPN, stated that he/she worked on the South hall on 10/17/11 from 4 a.m. to approximately 10 a.m. and informed by a day shift CNA that the resident's knees got weak during a transfer and Staff T reported this had happened before. Staff T stated when this had happened before and the resident's knees got weak and they hurried and transferred him/her without the resident falling. On 10/27/11 at 9:23 a.m., Staff Q, an LPN, stated that she worked on 10/16/11 from 4 a.m. to 4 p.m. on the South hall but did not have any interaction with Resident #1. Staff Q stated she was unaware of any fall reports or the resident's complaints of pain in the right knee until contacted by the facility while at home on 10/17/11. Staff Q reported the aides had informed her they were having a harder time with Resident #1 ' s transfers. Staff Q stated the aides had reported this prior to 10/16/11 but could not recall exactly when she was told this. Staff Q stated the aides would normally communicate to her if a resident needed more assistance with transfers and she would inform the MDS nurse(Staff AA). On 10/27/11 at 3:30 p.m., Staff AA, the Quality Assurance nurse (MDS nurse) assigned to review resident falls, stated that even with a fall risk score of 20, Resident #1 did not require any interventions other than the usual bed in low position, shoes on, call light within reach, because the resident wasn't motivated. Staff AA stated the resident had not fallen before and a fall assessment would be completed if he/she had fallen and then new interventions. On 10/28/11 at 9:35 a.m., the interim DON stated he/she became aware on 10/18/11 that 2 CNA's lowered Resident #1 to the floor during a transfer on 10/16/11 between 1 p.m. and 1:30 p.m. and did not report the event to the nurse on duty, and an X-ray ordered on [DATE] for the same resident had not been completed until 10/18/11 and revealed a fractured right knee. The interim DON stated that he/she initiated a fall investigation on 10/18/11, questioned staff that worked between 10/16/11 and 10/18/11, concluded that resident's knee fracture resulted when CNA staff lowered the resident to the floor on 10/16/11, and staff involved in the incident received written reprimands. The interim DON stated that he/she knew the resident complained of knee pain with swelling during the lunch meal on 10/16/11, and without staff report of a fall prior to 1:30 p.m. on 10/16/11, attributed the right knee swelling to an osteoarthritis diagnosis. The interim DON stated per facility policy, a resident lowered to the floor must be assessed by the nurse before staff reposition the resident, and either Staff N or Staff W should have alerted the nurse while the other stayed with the resident. An undated and unsigned document, included with copies of the facility's fall investigation report for Resident #1 directed: All nursing staff need to read the Abuse Prohibition Policy and additional directives that included: If a resident is lowered to the floor, it is considered a fall and the fall policy has to be followed. During an interview on 10/28/11 at 11:45 a.m., Resident #1's family member stated that he/she was unaware that the resident's knee was swollen and painful until notified by the nurse on 10/17/11, informed on 10/18/11 that the resident's knees were weak and lowered to the floor during a transfer on 10/16/11, and questioned why staff had not used a mechanical lift for transfers if they knew the resident's knees became weak when he/she stood. The family member stated that he/she was with the resident during the hospital admission process on 10/18/11 and the resident required Morphine (a strong narcotic analgesic) for relief of severe pain in the right leg, and the resident's pain and suffering would have been reduced if the facility notified the doctor of the knee pain and swelling earlier and obtained the right knee X-ray on 10/17/11 as ordered.