Every finding on record at Guilford Health Care Center

Based on observations and staff interviews, the facility failed to label and date leftover food stored for use, discard food past its use-by-date and discard food showing signs of spoilage in 1 of 1 walk-in cooler and 1 of 1 walk-in freezer. The facility also failed to maintain clean walls and ceilings that were free from damage and black substances in the facility's main kitchen area including the dish washing area, steamtable/food line, and food preparation area. These practices had the potential to affect food served to all residents. The findings included:a. During an initial observation of the facility's kitchen with the Dietary Manager on 3/15/2026 at 9:22 AM, the walk-in freezer was noted to have the following concerns: - An opened unsealed package of square cheese raviolis with signs of frost bite spots and discolored grayish brown patches. - An opened, unlabeled, and unsealed package of lasagna pasta sheets with signs of frost bite spots and discolored grayish brown patches. - One opened, unlabeled, unsealed box of dinner rolls with signs of frost bite spots and discolored grayish brown patches. - One opened, unlabeled, unsealed package of hamburger patties with ice crystal formation. b. During an initial observation of the facility's kitchen with the Dietary Manager on 3/15/2026 at 9:22 AM the walk-in refrigerator was noted to have the following concerns: - An opened and unlabeled 5-pound (lb.) bag of parmesan fancy shredded cheese. -An opened, and unlabeled, container of stewed apples with signs of brownish discolored surface and fruit appeared mushy and slimy. -An opened, and unlabeled 1lb. bag of shredded cheese. An interview was conducted with the Dietary Manager on 3/15/2026 at 11:34 AM. The Dietary Manager stated that labels and dates on open food items should be checked daily. The Dietary Manager further stated the items in the walk-in freezer needed to be discarded. The Dietary Manager stated items in the walk-in freezer should have an open date, be closed and sealed in the walk-in freezer and walk-in refrigerator. He further indicated whenever a staff member used an item they were to label when opened and the item should be closed. He further revealed any items needing to be discarded from the walk-in freezer will be removed by the cook or by himself daily. An interview with the Administrator on 3/18/2026 at 10:49 AM revealed all food and beverage items should be dated when they were opened, food with signs of spoilage should be discarded, and food items should be used or discarded according to use-by policies. He further stated the dietary department was responsible for food storage and safety daily. c. During an initial observation of the facility's kitchen with the Dietary Manager on 3/15/2026 at 10:00 AM the walls and ceilings were noted to have the following concerns: -A wall surface and ceiling surface in the dishwashing area was noted to have a black substance. -A ceiling area with an Air Conditioning (AC) vent covered with a black substance over the steamtable/food line area showing signs of deterioration on the sheetrock and plaster no longer being supported. -A ceiling area with an AC vent covered with a black substance over the food prep table showing signs of sheetrock deterioration and plaster no longer being supported. An interview with [NAME] #1 on 3/18/2026 at 10:30 AM revealed there was a cleaning schedule in the kitchen. He stated the dietary staff have assignments to clean the kitchen on their shift. He further revealed the dietary staff were not responsible for cleaning high walls or ceilings. On 3/18/2026 at 10:30 AM the Administrator, Dietary Manager and Maintenance Supervisor observed the black substance on the wall and ceiling during the observation. The Maintenance Supervisor stated he was working on getting proposals from outside vendors to have the repair work completed in the facility kitchen. The Administrator stated the facility was going to correct issues in-house when the issues had been identified August 2025 with their own staff but then decided to correct using outside vendors. The Administrator stated there had been no corrective actions taken to resolve the black substance on the walls or on the ceiling since August 2025. Both the Administrator and Maintenance Supervisor confirmed there was no work performed to remove the black substance on the walls and ceiling. They also confirmed there was no work performed to repair the ceiling sheetrock or plaster deterioration.

Based on record review and interviews with resident, Assisted Living Executive Director, contracted Transportation Aide, Nurse Practitioner, and staff, the facility failed to provide the assisted living facility Resident #117 was discharging to with an accurate FL2 Form (a mandatory medical documented completed by a physician to certify a patient's medical needs and required level of care) resulting in the resident being denied admission. This was for 1 of 3 residents reviewed for discharge (Resident #117).The findings included:Resident #117 was admitted to the facility on [DATE] with diagnoses that included fracture of upper end of right tibia (a break of the upper part of the shinbone), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (type of stroke) affecting the right non-dominate side, and difficulty in walking.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #117 was cognitively intact and required partial assistance with wheeling self in wheelchair 50 feet. Her discharge goal was to return to the community.Resident #117's care plan dated 3/31/25 with a revision on 4/22/25 revealed a problem area that indicated the need for staff assistance with activities of daily living (ADL) due to chronic health conditions. Interventions included reminding the resident to use a quad cane for transfers and to use a wheelchair. The care plan also included a discharge goal to successfully return to the community with interventions that included coordinating with the resident's physician regarding discharge plans.A review of the Adult Care Home FL2 signed by Nurse Practitioner #1 on 5/5/25 revealed Resident #117's recommended level of care was assisted living level. The FL2 form indicated Resident #117 was semi-ambulatory and noted the initials of Nurse Practitioner #1 beside it. The FL2 form further revealed the medication list included three medications that were struck through and did not indicate Nurse Practitioner #1 had approved the medication changes. The names of the three medications were unreadable due to the strike through.An MDS discharge assessment dated [DATE] revealed Resident #117 was discharged to an assisted living facility.An MDS entry tracking record dated 5/13/25 revealed Resident#117 was admitted from the community.A telephone interview was conducted with Resident #117 on 3/16/26 at 3:48 PM. The resident indicated that on the morning of 5/13/25 she was transported to the assisted living facility for admission but when she arrived, the Assisted Living Executive Director came out to the parking lot and told Transportation Aide #1 and Resident #117 that he could not accept Resident #117 because the nursing facility had not provided the required paperwork for admission. Transportation Aide #1 transported her (the resident) back to the nursing facility, and she was admitted back the same day. Resident #117 indicated at the time of discharge from the nursing facility on 5/13/25 she was able to transfer from her wheelchair to bed while using her cane and she used her wheelchair to ambulate long distances. Resident #117 further revealed she remained at the nursing facility until 5/17/25 and she chose to discharge home. A telephone interview was conducted with the contracted Transportation Aide #1 on 3/18/26 at10:47 AM. He indicated he transported Resident #117 to the assisted living facility on the morning of 5/13/25 and when they (the resident and Transportation Aide #1) arrived the Assisted Living Executive Director met them in the parking lot and told them Resident #117 would not be able to be admitted to the assisted living facility because he did not have an approved FL2 which was required for admission. Transportation Aide #1 indicated that he contacted the nursing facility and spoke with the Social Work Assistant and she sent over another FL2 but the Assisted Living Executive Director continued to refuse to admit Resident #117. He reported that he transported Resident #117 back to the nursing facility.An interview was conducted with the Social Work Assistant on 3/18/26 at 12:47 PM and she indicated she was contacted by Transportation Aide #1 on 5/13/25 regarding Resident #117 not being allowed admission to the assisted living facility. She further revealed she spoke with the Assisted Living Executive Director and an amended FL2 had been provided to the Assisted Living Executive Director while Resident #117 was still in the transportation van. She could not recall if she personally sent the amended FL2, or if it was sent by the Discharge Planner. She explained that the Assisted Living Executive Director continued to refuse admission as the changes to the FL2 form had not been approved by a provider. The Social Work Assistant indicated she did not recall who wrote Nurse Practitioner #1's initials beside the change in ambulatory status. A telephone interview was conducted with the Assisted Living Executive Director on 3/16/26 at 3:39 PM. He revealed he contacted the nursing facility's Discharge Planner on the afternoon of 5/12/25 to rescind the bed offer he had made to Resident #117 due to the FL2 form indicating that Resident #117 was non-ambulatory. The Assisted Living Executive Director revealed that Transportation Aide #1 and Resident #117 arrived at the assisted living facility on the morning 5/13/25 and he (the Assisted Living Executive Director) came to the parking lot and inquired about the identity of the resident. The Assisted Living Executive Director reported he was told by Transportation Aide #1 that he had transported Resident #117 for her admission to the assisted living facility. The Assisted Living Executive Director explained he made the Transportation Aide #1 aware that he could not accept Resident #117 because the facility had not provided an approved FL2 form that was required for admission. He further explained that Transportation Aide #1 called someone at the nursing facility (he was not aware who was called) and then he (the Assisted Living Executive Director) received another FL2 form dated 5/5/25 (the same date as the initial FL2 form that was sent by the nursing facility). The FL2 form indicated a check mark by semi-ambulatory status and the box next to non-ambulatory status appeared to have been whited out and there were three unreadable medications that had been struck through. The Assisted Living Executive Director further revealed that he contacted the Social Work Assistant to let her know that he would not be able to admit Resident #117 as the changes to the FL2 form did not contain a provider's signature which was needed to indicate the provider approved of the changes. The Assisted Living Executive Director indicated he then requested that Transportation Aide #1 transport Resident #117 back to her nursing facility.An interview was conducted with the Discharge Planner on 3/16/26 at 4:44 PM. She indicated Resident #117 was scheduled to discharge to an assisted living facility on the morning of 5/13/25. The Discharge Planner revealed that the Assisted Living Executive Director contacted her (the Discharge Planner) during the afternoon of 5/12/25 to let her know that the FL2 form that he received indicated Resident #117 was non-ambulatory and therefore he would not be able to admit Resident #117 to the assisted living facility. The Discharge Planner indicated that she made the Assisted Living Executive Director aware that Resident #117 was semi-ambulatory and she would provide a corrected FL2 form to the assisted living facility. The Discharge Planner indicated that she felt that after the issue was clarified with the Assisted Living Executive Director that the admission to the assisted living facility was still set to occur on 5/13/25. The Discharge Planner further explained she had made four corrections to the FL2 form which included changing Resident #117's ambulatory status from non-ambulatory to semi-ambulatory and she had struck through three medications that Resident #117 was no longer prescribed. The Discharge Planner explained that it was her intention to have a provider review and sign the revised FL2 form prior to the resident's discharge. The Discharge Planner indicated she did not recall who wrote Nurse Practitioner #1's initials beside the change in ambulatory status. The Discharge Planner further revealed at the time of Resident #117's discharge to the assisted living facility on 5/13/25 the changes to the FL2 form were an accurate reflection of Resident #117 but had not yet been approved by a provider. The Discharge Planner explained that the provider had not come into the facility to approve the FL2 before Resident #117 was scheduled to be transported to the assisted living facility at 9:00 AM. The Discharge Planner indicated it was her intention to have the provider approve the change to the FL2 and send the approved FL2 to the assisted living facility that day. The Discharge Planner indicated when Resident #117 arrived at the assisted living facility on the morning of 5/13/25 the Assisted Living Executive Director met Transportation Aide #1 in the parking lot and refused to admit Resident #117. The Discharge Planner revealed that the corrected FL2 was sent over while Resident #117 was still onsite at the assisted living facility but the Assisted Living Executive Director refused to accept Resident #117 because the changes that were made to the FL2 form had not been approved by the provider. The Discharge Planner indicated Resident #117 was then admitted back to the facility. On 3/17/26 at 11:43 AM a telephone interview was conducted with Nurse Practitioner #1. She indicated that she signed Resident #117's FL2 on 5/5/25 but did not approve any changes to the FL2 form. Nurse Practitioner #1 indicated that she was not able to recall any specifics about the FL2 she signed on 5/5/25. She further revealed her last working day at the facility was on 5/5/25.An interview was conducted with the Administrator on 3/17/26 3:05 PM and he indicated that Resident #117 should have remained at the facility until the Discharge Planner had provided the assisted living facility with an accurate and provider approved FL2 and he did not know why this had not been done.

Based on observations, record review, and staff interviews, the facility failed to post cautionary, safety signage that indicated the use of oxygen for Resident #3 and Resident #13 and failed to have a physician order for oxygen use for Resident #13 for 2 of 3 residents reviewed for respiratory care (Resident #3 and Resident #13).The findings included: The facility permits smoking for residents, staff and visitors. This was confirmed with the Administrator on 3/15/2026 at 9:55 AM. The facilities policy dated 1/29/2024 stated Oxygen therapy will be administered by provider's order, according to current standards of practice and equipment will be maintained and stored in a safe and appropriate manner. Included under the safety guidelines it stated post oxygen in use signage on all door frames of rooms with oxygen in use. a. Resident #3 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure. Resident #3's physician orders dated 7/22/2025 revealed an order for oxygen to be administered continuously via nasal cannula at 2 liters per minute (lpm). Resident #3's annual Minimum Data Set (MDS) dated [DATE] indicated Resident #3 was coded for receiving oxygen. Observations on 3/15/2026 at 9:50 AM and 11:42 AM, and 3/16/26 at 11:25 AM and 2:38 PM revealed Resident #3 was lying in bed in her room wearing a nasal cannula with oxygen administered at 2 lpm. There was no cautionary or safety signage posted at Resident #3's room to indicate oxygen was in use during the observations. An interview with Nurse #6 was completed on 3/16/2026 at 3:38 PM. He stated Resident #3 was not assigned to him that day but had cared for her on other days. Nurse #6 was unaware of why there wasn't a sign on the door. He stated if oxygen was being used the cautionary oxygen in use sign should be posted at the doorway. NA # 5 was interviewed on 3/17/2026 at 11:40 AM. The NA stated she was aware that the residents assigned to her were on oxygen from the staff briefing before shift and observation of the concentrator and nasal canula. She stated she doesn't always observe the cautionary signage at the door. The NA could not recall if Resident #3 had a sign and was unable to explain why a sign had not been placed at the door. An interview was conducted with Nurse #3 on 3/17/2026 at 11:58 AM. Nurse #3 stated that the facility will post oxygen in use signs on the door of residents that were receiving oxygen. She stated she had not observed that there was no sign on Resident #3's door. Nurse #3 was unaware of why Resident #3 did not have cautionary oxygen in use signage on her door. NA #6 was interviewed on 03/17/2026 at 2:03 PM. NA #6 stated the facility had oxygen in use signs on doors for residents using oxygen. She stated she does not recall if Resident #3 had a sign posted at any time. NA #6 was unaware of why Resident #3 did not have cautionary sign at her door. b. Resident #13 was admitted to the facility on [DATE] with a history of congestive heart failure (CHF) and tracheostomy status (surgical intervention that establishes an airway through an incision in the neck into the trachea). The quarterly MDS dated [DATE] revealed Resident #13 had moderate cognitive impairment. Oxygen use was not indicated on the MDS. A progress note from NP #3 was dated 3/13/26 at 12:45 PM and stated Resident #13 was seen for hypoxia and nursing reports with oxygen levels in the 80's with room air. Resident #13 was placed on 3 lpm of supplemental oxygen and his oxygen levels then were noted for 95%. A phone interview was completed with Nurse Practitioner (NP) #3 on 3/17/2026 at 11:06 AM. She stated she treated Resident #13 on 3/13/2026 for concerns with his oxygen levels. NP #3 stated Resident #13's oxygen levels were dropping below 90 percent. NP #3 stated she gave a verbal order for continuous oxygen at 2 to 5 lpm through tracheostomy mask to maintain Resident #13's oxygen level at 90 percent or greater for oxygen saturations. She stated she expected the facility to follow her order and have the order in the record. NP #3 stated there was no reason for the order not to be in resident #13 record on 3/13/2026. She was unaware of why an order was not in Resident #13's record before 3/16/2026. The NP stated the verbal order was given to Nurse #7 who was assigned to Resident #13 on 3/13/2026. Multiple attempts to interview Nurse #7 by phone were made and were unsuccessful. Nurse #7 did not return messages left to speak with her. Observations on 3/15/2026 at 10:00 AM, 11:38 AM, 12:49 PM, and 3/16/26 at 11:26 AM and 2:42 PM revealed Resident #13 was in wheelchair in his room receiving oxygen at 2 liters per minute (lpm) through his tracheostomy mask. Observation on 3/16/2026 at 11:26 AM Resident #13 was ambulating in his wheelchair with a portable tank attached appropriately to the back of his wheelchair. Oxygen was being administered at 2 lpm. There was no cautionary or safety signage posted at Resident #13's room to indicate oxygen was in use during the observations. Resident #13 had a physician order dated 3/16/26 at 7:00 AM for oxygen to be administered continuously via trach mask at 2 lpm to keep oxygen level above 90% (normal range for oxygen level is 92-96%). An interview with Nurse #6 was conducted on 3/16/2026 at 3:38 PM. Nurse #6 stated he was assigned to Resident #13 that day and he did not work the previous weekend (3/13/2026-3/15/2026). Nurse #6 was unsure why there was no oxygen order in place until 3/16/2026 for Resident #13. He stated that if Resident #13 was using oxygen there should have been an order in his medical record. Nurse #6 confirmed there was no PRN (as needed) order or order for oxygen prior to the order on 3/16/2026. He confirmed there was no oxygen signage on Resident #13's door and was unable to give a reason why there was no cautionary oxygen signage on the door. On 03/17/2026 at 12:15 PM NA #3 was interviewed and stated he was aware of resident using oxygen with observation. He stated the facility post signs on the resident's door that are using oxygen. NA #3 was unaware of why there was not a sign resident #13 door earlier in the week. Oxygen in use sign was posted on resident #13 door at this time. The Director of Nursing (DON) was interviewed on 03/18/2026 at 1:48 PM. She stated she expected staff to follow policy and post oxygen in use signs on the residents' doors where oxygen was being used. The DON was unable to explain why there was no oxygen in use signs posted on Resident #3 and Resident #13's doors during observations on 3/15/2026 and 3/16/2026. The DON stated the residents should have had cautionary oxygen signage posted on their doorways per the facilities oxygen policy. The DON was unable to explain why Resident #13 did not have an order for oxygen from 3/13/26 to 3/15/2026. She stated an order should have been in Resident #13's medical record when oxygen was ordered by NP #3 and was being administered. The DON agreed that the facility should have followed through with putting NP #3's verbal order for oxygen to be administered in Resident #13's medical record. An interview with the Administrator was completed on 03/18/26 at 2:40 PM. The Administrator was unaware that Resident #3 and Resident #13 did not have oxygen in use signs posted on their doorways on 3/15/2026 and 3/16/2026. He stated signs should have been posted per the facilities oxygen policy regarding cautionary signage would be posted where oxygen was being used. The Administrator was unable to explain why the order for oxygen for Resident #13 was not in place from 3/13/26 to 3/15/2026. He stated he expected his staff to follow NP #3's orders, and an order should have been in Resident #13's medical record when the verbal order for oxygen was given on 3/13/2026.

Based on record review, observations and staff interviews, the facility failed to secure a medication cart that was left unlocked and unattended, failed to secure insulin syringes that were left unsecured on top of an unattended medication cart, failed to dispose of medications that were refused and dropped on the floor that were stored in 1 of 6 medication carts reviewed for medication storage (100 Hall Bottom Medication Cart).The findings included:a. A continuous observation and interview were conducted on 3/17/26 from 8:35 am to 9:35 am of the 100 Hall Bottom Medication Cart and Nurse #1. The medication cart was unlocked (lock was out indicating it was unlocked) while Nurse #1 was in a Resident's room. When Nurse #1 returned to the cart at 8:38 am she started preparing medication for another resident and confirmed that the medication cart was unlocked. During the continuous observation at 8:52 am, Nurse #1 prepared medication for another resident and when she went to administer the medications, Nurse #1 left three unused multiple dose insulin syringes in a plastic bag on top of the medication cart unattended. When Nurse #1 returned to the medication cart an unlabeled medicine cup containing digoxin 125 micrograms (mcg), docusate 100 milligram (mg), two torsemide 20 mg, and spironolactone 50 mg was observed in the top drawer of the cart. Nurse #1 stated she prepared the digoxin 125 mcg, docusate 100 mg, two torsemide 20 mg, and spironolactone 50 mg for Resident #119 and he refused. Nurse #1 stated she placed the medication in the drawer because she was going to offer the medication again. Further observation at 9:00 am revealed Nurse #1 preparing Resident #125's medication which included a finasteride (used to treat enlarged prostrate) 5 mg. When Nurse #1 administered the medication to Resident #125 at 9:10 am, the finasteride tablet dropped on the floor. Nurse #1 was observed picking the tablet up off the floor and placing the finasteride 5mg in a medicine cup and placing it in the medication drawer beside another cup of medications that were unlabeled.An interview was conducted on 3/17/26 at 9:51 am with Nurse #1, the nurse responsible for administering medication during the day shift (7:00 am to 3:00 pm). Nurse #1 confirmed she left the medication cart unlocked and unattended. Nurse #1 stated the medication cart should have been locked before she stepped away. Nurse #1 stated someone gave her the plastic bag with the three unused multiple dose insulin syringes earlier, and they should not have been left sitting unattended on top of the medication cart. When she received the insulin, it should have been locked inside the medication cart. Nurse #1 stated she prepared the digoxin 125 mcg, docusate 100 mg, two torsemide 20 mg, and spironolactone 50 mg for Resident #119 and he refused. She placed the medication in the drawer because she was going to offer the medication again. Nurse #1 stated she still needed to waste the finasteride that was dropped on the floor.b. During observations of drug storage in the 100 Hall Bottom Medication Cart with Nurse #1 on 3/17/26 at 9:40 am three unlabeled medication cups containing medications were observed in the top right drawer. One cup contained one pill, one cup contained 5 pills of various size, shapes, and colors, and one cup contained 3 pills of various size, shapes, and colors. Nurse #1 indicated that one cup of the medications was left by Nurse #2 from the previous shift. She indicated she should have wasted the medications and not stored them on the cart and typically wasted medications in the sharp's container on the medication cart.An interview was conducted on 3/17/26 at 9:47 am with Nurse #2 who confirmed that a resident had refused his medications at 6:00 AM and that she should have disposed of the medications and not left them on the 100 Hall Bottom Medication Cart.An interview was conducted on 3/17/26 at 10:05 am with the Director of Nursing (DON) in the presence of the Nurse Consultant. The DON stated she would expect her staff to secure the medication cart when they stepped away, and the three insulin syringes should have been secured inside the medication cart. She also indicated that unlabeled medication that had been refused or medication that needed to be wasted should not be stored inside a medication cart together and should have been disposed of. She stated the medication should have been wasted in the Drug Buster (a substance use to deactivate non-hazardous medications).An interview was conducted on 3/18/26 at 3:40 pm with the Administrator. The Administrator stated he would expect his staff to keep the medication carts locked and follow the facility's policy and procedures for storing medication.

Based on record review and Family Member and staff interviews, the facility failed to report an allegation of employee to resident physical abuse to law enforcement and State Survey Agency for Resident #82 within the required time frame. Adult Protective Services (APS) was not notified of the allegation of employee to resident abuse. The deficient practice occurred for 1 of 3 residents reviewed for reporting of abuse allegations (Resident #82). Findings included: Review of facility Abuse/Investigative Reporting Policy indicated all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of patient property are to be reported immediately but (a) not later than 2 hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury or (b) not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Any staff member observing or suspecting abuse, neglect or mistreatment will remove the patient from danger immediately and report to their immediate supervisor. A licensed nurse will notify the Administrator and/or Director of Nursing immediately. The Administrator or Director of Nursing will notify their Regional Director of Clinical Services of the incident and will provide an update to the status of the center's immediate investigation and the plans for initiating the initial notification to the State Survey Agency and other appropriate agencies. The Administrator and/or his/her designee will immediately notify the State Survey Agency by filing the initial Facility Reported Incident Form, and other appropriate agencies. If the incident is reasonably believed to constitute a crime, the Administrator and/or his/her designee will also notify law enforcement. The Administrator is to maintain a copy. Resident #82 was admitted to the facility on [DATE]. An interview conducted with the Nurse Practitioner (NP) on 3/17/2026 at 11:08 AM revealed she was the NP on duty at the facility on 2/21/2026. She stated she entered Resident #82's room and observed the resident wiping water from the floor, along with a few ice cubes present. The NP stated Resident #82 told her that staff were throwing things at me, like mashed bananas. The NP further reported she did not observe any mashed bananas on the resident, nor did she observe the resident to be wet. She stated she contacted Nurse #5 so the Director of Nursing (DON) and Administrator could be notified. An interview was Nurse #5 on 3/17/2026 at 10:30 AM revealed she was the nurse manager on duty 2/21/2026. She received a telephone call from the Nurse Practitioner (NP) on 2/21/2026. She stated the NP informed her Resident #82 had thrown a banana at Nurse #3 and Resident #82 alleged water was thrown back at her. Nurse #5 stated she called the DON and the Administrator on 2/21/2026 at 3:13 PM. An interview was conducted with the Administrator on 3/17/2026 at 3:50 PM, revealed he was called on 2/21/2026 by Nurse #5 regarding an incident with Resident #82. He stated he asked Nurse #5 to call the DON and inform her of the altercation. The Administrator stated he called the Rehabilitation Manager and asked him to return to the facility on 2/21/2026 and investigate the concern with Resident #82. The Administrator indicated he received a call from the Rehabilitation Manager at 4:27 PM on 2/21/2026. The Administrator revealed Resident #82 was upset but there was no evidence of abuse at the time of the call being received. He further revealed this information was not reported to Adult Protective Services (APS) for an allegation of abuse. An interview with Rehabilitation Manager on 3/15/2026 at 12:30 PM revealed he was the manager on duty on 2/21/2026. He stated he received a call from the Administrator about an incident between a resident and a staff member and asked him if he would check on the concern. The Rehabilitation Manager indicated he came back to the facility at approximately 3:30 PM and interviewed staff as well as Resident #82. He stated Nurse #3 said Resident #82 threw a banana on her and Resident #82 confirmed a banana and water was thrown on her but did not state which staff members. The Rehabilitation Manager stated he called the Administrator and DON on 2/21/2026 at 4:27 PM and informed both of his investigation. A telephone interview conducted with Family Member #1 on 3/15/2026 at 12:44 PM revealed she had received a call from Resident #82 on Saturday 2/21/2026 and Resident #82 told her a banana was thrown on her as well as water. She further revealed she spoke with the Rehabilitation Manager on 2/21/2026 and he told her that he was going to be taking care of the matter. The Family Member stated she called the facility on Monday 2/23/2026 and was told there was an investigation on-going. Initial Allegation Report completed by the Divisional Director of Nursing on 2/23/2026 revealed on 2/21/2026 at 1:30 PM Resident #82 alleged she had requested ice cream from staff three times. However, because she never received ice cream, she then threw mashed bananas on the nurse at the nurse's station and went back to her room. Later the nurse went to Resident #82 room and threw mashed bananas back on Resident #82. Another alleged staff member went into Resident #82 room and threw ice water on Resident #82. The confirmation sheet for the fax of the Initial Allegation Report indicated the report was submitted to the State Survey Agency on 2/23/2026 at 1:47 PM by the Divisional Director of Nursing. Local law enforcement was notified of the allegation on 2/23/2026 at 12:40 PM. Notification to Adult Protective Services (APS) was not documented in the Initial Allegation Report. A telephone interview conducted with the Divisional Director of Nursing on 3/17/2026 at 10:34 AM revealed she completed the Initial Allegation Report for Resident #82 on 2/23/2026. She stated she was first informed of the allegation on 2/23/2026 and subsequently notified Law Enforcement and the State Survey Agency. The Divisional Director of Nursing further reported the Administrator was not in the facility on 2/23/2026 therefore she completed the initial allegation report. The Divisional Director of Nursing stated the allegation of abuse made by Resident #82 on 2/21/2026 should have been reported on the day of the allegation. She acknowledged the report was not submitted timely. Review of the Investigation Report dated 2/27/2026 completed by DON revealed the facility's investigation determined Nurse #3 and Nurse Aide #1 were suspended pending investigation and terminated. The facility's Investigation Report further revealed the termination was not related to the allegation for either Nurse #3 or Nurse Aide #1. Notification to Adult Protective Services (APS) was not documented in the Investigation Report. An interview conducted with the DON at 3/17/2026 at 2:55 PM revealed she completed the Investigation Report for the allegation of abuse on 2/27/2026. The DON stated she was unaware she needed to report the allegation of abuse to Adult Protective Services (APS). The DON indicated she received a call from Nurse #5 on 2/21/2026 at approximately 3:19 PM. She stated Nurse #5 informed her there was an issue with a resident and a nurse and items being thrown. The DON explained she asked that statements be collected and to contact Resident #82's family. The DON further revealed she was unaware of any other issues with abuse until further investigation completed on 2/23/2026. The DON stated an allegation of abuse was revealed after speaking with multiple staff and Resident #82 on 2/23/2026, and an investigation was started along with the suspension of Nurse #3 and Nurse Aide #1 pending investigation.

Based on observations, resident and staff interviews, the facility failed to provide snacks when requested for 4 of 4 residents reviewed for resident council and 1 of 1 resident who reported feeling hungry between meals (Resident #17, Resident #32, Resident #84, Resident #52, and Resident #90). The findings included: a. Resident #17 was admitted to the facility on [DATE]. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed that Resident #17 was cognitively intact for daily decision making and was independent with eating. b. Resident #32 was readmitted to the facility on [DATE]. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed that Resident #32 was cognitively intact for daily decision making and was independent with eating. c. Resident #84 was admitted to the facility on [DATE]. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed that Resident #84 was cognitively intact for daily decision making and was independent with eating. d. Resident #52 was readmitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #30 was moderately cognitively impaired for daily decision making and required set up assistance with eating. e. Resident #90 was readmitted to the facility on [DATE]. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed that Resident #90 was cognitively intact for daily decision making and was independent with eating. In an interview on 4/14/25 at 10:12 AM, Residents #84 and #90 said they did not get any snacks throughout the day. They said when they would get hungry, they would ask the staff, who would tell them there were no snacks and that they were busy and could not go to dietary to get snacks. The residents said they would go themselves to the kitchen to request snacks but were also told by dietary there were no snacks. The residents reported that snacks were put into each unit's nourishment room, which had a cabinet that used to be full of snacks. They said the kitchen staff would bring 1-2 trays full of variety of sandwiches and cookies that would be put in the unit fridge, but snacks were no longer always available between meals. The residents said they had met with the Dietary Manager several times and he knows and his response is corporate tells the kitchen manager what food can be ordered/ served so he has tried to do what he could to help but not able to resolve the concern. Interviews conducted during a Resident Council meeting on 4/16/25 at 1:00 PM with four residents, Residents # 17, # 32, #84, and #52, revealed residents voiced concerns about snacks not being available throughout the day. Residents reported they were told by nursing staff (Nurse Aides and Nurses) they did not have snacks available. The residents stated they were hungry throughout the day and would have to go to the dietary department to request snacks, which they said were sometimes not available. The Resident Council Minutes noted concerns that snacks were not available at the meetings on 3/27/25, 12/16/24, and 10/21/24. In an observation on 4/16/25 at 3:04 PM, the nourishment room on the 200 hall did not have any snacks in the snack cabinet. In an interview with Nurse Aide (NA) #3, who was present during the observation, said the dietary department would send evening snacks in the late afternoon, but snacks were not consistently brought to the unit during the day. If a resident requested a snack, the resident or the staff would have to go to the kitchen. She said at times when staff was busy, the resident would go to the kitchen themselves. An observation on 4/16/25 at 3:17 PM of the 100 Hall nourishment room-revealed there was a bag of bread with three slices in it and a bottle of mustard in the snack cabinet. In an interview with NA #4, who was present during the observation, she said the dietary department would bring snacks for the evening, such as cookies and sandwiches. She said there would be gelatin and pudding snacks in the refrigerator during the day. She looked in the refrigerator and identified one snack container of mandarin oranges but no pudding or gelatin. She said families would mostly bring in snacks for the residents on the unit, so residents had snacks they liked. In an interview on 4/17/25 at 8:31 AM, the Dietary Manager (DM) indicated that he has been the DM at the facility for about 8 months. He shared that he had been made aware verbally by the residents and the Activity Director of dietary concerns from the resident council members and had attended 3 resident council meetings, the last meeting he attended was in March. Residents expressed concern that there were not enough snacks, soups, and sandwiches available and that they were hungry between meals. He explained that the contracted dietary company determined the budget and provided him with an order guide that did not include snacks. He said he attempted to address their concerns by ordering additional turkey and ham for sandwiches but it was still not enough for the residents to not feel hungry. In an interview on 4/17/25 at 5:17 PM, the Administrator said he knew that the residents had concerns about snacks and said snacks should be available for the residents. He said he knew the DM was working with the contracted dietary company to supply snacks for the residents, but was not aware there were no snacks in the nourishment rooms.

Based on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 5 medication errors out of 25 opportunities, resulting in a medication error rate of 20% for 1 of 5 residents (Resident #36) observed during the medication administration observation. The findings included: Resident #36 was admitted to the facility on [DATE]. Her cumulative diagnoses included dysphagia (difficulty swallowing) and the presence of a percutaneous endoscopic gastrostomy (PEG) tube. A PEG tube is a feeding tube inserted through the skin and the stomach wall to provide nutrition and a route for medication administration. A review of Resident #36's current physician orders included the following, in part: ---Flush the PEG-tube with 20 - 30 milliliters (ml) of water before and after administration of medication pass (Order Date 11/11/24); ---Flush the PEG-tube with 30 ml of water before and after each medication (Order Date 11/11/24). On 4/16/25 at 8:15 AM, Nurse #2 was observed as she began to prepare medications for administration to Resident #36 via a PEG-tube. The medications included, in part: one - 100 micrograms (mcg) levothyroxine tablet (a thyroid medication); two - 8.6 milligrams (mg)/50 mg sennosides/docusate tablets (a combination stimulant laxative and stool softener); one - 100 mg lamotrigine tablet (an antiseizure medication); one - 10 mg midodrine tablet (a medication used to treat low blood pressure); and one - 5 mg metoclopramide tablet (a gastrointestinal or GI medication which may be used to treat nausea). All 5 medications (6 tablets) were placed into one small medication cup. On 4/16/25 at 8:21 AM, Nurse #2 was observed as she transferred all the tablets into a single plastic sleeve, crushed the tablets together, and then poured the contents of the plastic sleeve back into one medication cup. Nurse #2 was observed on 4/16/25 at 8:25 AM as she brought the medications for administration into Resident #36's room. After the nurse connected a syringe to the resident's PEG-tube, she flushed the tube with 20 - 30 milliliters (ml) of water prior to initiating the medication administration. The crushed tablets were observed to be mixed with approximately 30 ml of water in a cup and the solution was poured into the syringe connected to Resident #36's PEG-tube. The nurse added an additional 15 ml of water into the cup to dissolve the remaining solids from the crushed tablets, then poured this solution into the syringe and PEG-tubing. Nurse #2 completed the medication administration by flushing the resident's PEG-tube with 20 - 30 ml of water. An interview was conducted with Nurse #2 on 4/16/25 at 12:30 PM. Nurse #2 reported she was an agency nurse (a temporary employee) who was assigned to care for Resident #36. During the interview, concerns regarding the resident's medications (tablets) being crushed and administered together via the PEG-tube were discussed. Resident #36's physician orders instructing the PEG-tube to be flushed with water before and after each individual medication's administration were also discussed. At that time, Nurse #2 reviewed the resident's current physician orders. She acknowledged there were no physician orders that allowed Resident #36's tablets to be crushed and administered together via her PEG-tube. The nurse reported she was not aware the medications should be administered individually, with water flushes used before and after each medication. An interview was conducted on 4/16/25 at 3:19 PM with the facility's Director of Nursing (DON). During the interview, the DON stated she would expect that the orders are followed for all medications administered to a resident.

Based on record review, and staff and resident interviews, the facility failed to act upon grievances that were reported by the Resident Council, resolve repeat grievances, and communicate the facility's efforts to address grievances voiced during Resident Council meetings for 7 of 7 consecutive months: September 2024, October 2024, November 2024, December 2024, January 2025, February 2025, and March 2025. The findings included: a. A review of the Resident Council minutes completed by the Activities Director dated 9/18/24 revealed the following grievance was expressed: banking hours 9-3pm. b. A review of the Resident Council minutes completed by the Activities Director dated 10/21/24 revealed the following grievances were expressed: would like monthly billing statements, larger size people want proper care and handle accordingly, portion size has gotten smaller, and they want to know why they can't get sandwiches and snacks, think rights have been violated with noise level at night. There was no documented resolution from the previous month's grievance related to banking hours. c. A review of the Resident Council minutes completed by the Activities Director dated 11/18/24 revealed the following grievances were expressed: call lights turned off but don't address the reason for being on, portion still small. The resolution addressed only one of the previous month's grievances related to monthly billing statements. d. A review of the Resident council minutes completed by the Activities Director dated 12/16/24 revealed the following grievances were expressed: staff not knocking on doors, still on phones and talking through ear buds, portions small and can't get seconds, still no snacks. There was no documented resolution from the previous month. e. A review of the Resident Council minutes completed by the Activities Director dated 1/13/25 revealed the following grievances were expressed: baseboards need cleaning. There was no documented resolution from the previous month. f. A review of the Resident council minutes completed by the Activities Director dated 2/20/25 revealed the following grievances were expressed: staff still wearing earbuds and on phones, want less pasta and more condiments. The stated resolution was the dietary manager spoke about what they are doing in the kitchen so it can get better. g. A review of the Resident Council minutes completed by the Activities Director dated 3/27/25 revealed the following grievances were expressed: ear buds, staff on the phone, loud noises, why can't snacks not as plentiful, nursing assistants not assisting residents unless they are the assigned nursing assistant, too many sandwiches for dinner, snacks not as plentiful, food mediocre, noise on hall. There was no documented resolution from the previous month. A Resident Council meeting was held on 4/17/25 at 1:00 PM with Residents #17, #52, #84 and #32. During the meeting, Resident #17 , the resident council president, expressed frustrations that the Resident Council has made repeated grievances month after month which had not been addressed or resolved. Resident #52 stated the resident council's complaints did not seem to matter to corporate. The members present at the Resident Council meeting expressed their collective frustration in attempting to get their voices heard by corporate staff and the previous administrator. An interview with the Activities Director on 4/16/25 at 3:44 PM revealed that she did not fill out a grievance form for grievances or concerns brought up in Resident Council. She indicated she would try to tell the department heads about concerns but did not document the follow-up in the minutes for each concern. An interview with the Administrator on 4/16/25 at 4:05 PM revealed he just started in the position about four weeks ago and he was not aware that the Activities Director had not documented Resident Council grievances on a form and had not received follow-up to all grievances voiced during the meetings. He further indicated that all Resident Council grievances should be documented on a grievance form, provided to the appropriate department head and signed off by the Administrator each month.

Based on a lunch meal tray line observation, staff interviews and record review the facility failed to follow the approved menu when pureed bread was not served to 11 of 11 residents on a pureed diet, salisbury steak was not served to 3 of 3 residents on a renal diet and 15 of 15 residents on a heart healthy diet, and the recipe for beef stroganoff was not followed for 55 residents receiving a regular and mechanical soft texture diet (200 Hall). The findings included: Review of the resident diet order report dated 4/16/25 documented 11 residents had orders for a pureed diet, 3 residents had orders for a renal diet, and 15 residents had orders for a heart healthy diet. The order report documented 55 residents received a regular or mechanical soft textured diet on the 200 Hall. Review of the facility's dietitian approved menu for 4/16/25 revealed the meal was beef stroganoff (beef in a cream sauce), buttered egg noodles, green peas, and a dinner roll. Residents on a heart healthy (lower fat) and renal (for residents with kidney disease) diet were to receive 3 ounces of salisbury steak instead of the beef stroganoff. Residents on a pureed diet were to receive pureed beef stroganoff, pureed noodles, pureed peas, and one #30 (standard size 1.22 ounce) scoop of pureed bread in place of the regular dinner roll. Continuous observation of the lunch meal on 4/16/25 from 12:05 PM to 1:27 PM revealed the Dietary Manager (DM) served beef stroganoff to all residents on a regular, mechanical soft, and a puree diet. Residents on a pureed diet received pureed beef stroganoff, pureed noodles, and pureed peas as their entree. There was no pureed bread served to residents on a pureed diet in place of the dinner roll served to residents on a regular diet and no pureed bread on the serving line. Residents on a heart healthy diet and a renal diet were served egg noodles, beef stroganoff, peas, and a dinner roll. There was no salisbury steak on the serving line. An observation on 4/16/25 at 12:32 PM revealed the DM went to the stove, took a large saucepan off the stove, and poured additional cream sauce onto the beef. The DM did not add more beef to the pan, just the sauce. Service continued with resident trays being put into the first cart for the 200 Hall. In an interview on 4/16/25 at 12:54 PM, the DM said all residents received the beef stroganoff, including residents on a renal diet and a heart healthy diet. He said the menu was the same as the regular diet, so they received the same meal. He said he did not serve a puree option in place of the regular dinner roll. He said he normally would puree the bread but he forgot that day and no other bread was served to residents on a puree diet. He said the extended menu with the detailed diet listing was kept in a drawer in his filing cabinet and not within easy reach to consult when needed. In an interview on 4/17/25 at 11:45 AM, the DM reviewed the menu and said he did not realize residents on a renal diet and a heart healthy diet should have received the salisbury steak instead of the beef stroganoff. He said he added approximately 5 cups of sauce to the beef stroganoff. He said the beef had absorbed a lot of the sauce, and he was adding extra to make sure the meat did not dry out. He said he did not use the recipe to make the sauce and did not think adding more sauce would change the composition of the beef in cream sauce. In an interview on 4/17/25 at 12:28 PM, the Registered Dietitian said the beef stroganoff would have more fat because of the cream sauce that was added. She said the menus should have been followed so residents would get the nutrition they needed.

Based on staff and resident interviews, the facility failed to provide residents with access to their personal fund accounts for 2 of 2 residents reviewed for management of personal funds (Resident #17 and #52). The findings included: 1. Resident #17 was admitted to the facility 9/27/23. Review of #17's annual Minimum Data Set (MDS) dated 1/6/25 revealed Resident #17 was cognitively intact. An interview conducted with Resident #17 on 4/16/25 at 1:00 PM revealed he was a Medicaid recipient, and he was only allowed to withdraw $20 dollars a day and could not retrieve any money after hours or on the weekends. Resident #17 indicated this had been an issue for as long as he has been a resident at the facility. An interview was conducted with the Business Office Manager (BOM) on 4/16/25 at 2:49PM. The Business Office Manager indicated that corporate staff only allows residents to receive $20 a day and if they request funds over that amount the money would be provided in a check form by the following business day. The BOM further revealed that residents can only withdraw funds Monday-Friday between the hours of 9:00 AM and 3:00 PM. An interview conducted with the Administrator on 4/16/25 at 3:37 PM revealed he had only been in this position for four weeks and he was not aware residents were only able to withdraw $20 a day and did not have access to personal funds after hours on the weekends and weekdays. The Administrator further revealed he had expected all residents to always have access. 2. Resident #52 was admitted to the facility 9/23/22. Resident # 52's 3/28/25 quarterly Minimum Data Set assessment revealed Resident #52 was cognitively intact. An interview was conducted with Resident #52 on 4/16/25 at 1:05 PM. Resident #52 indicated she had not been able to buy the things she wants because the facility will allow residents to withdraw $20 a day and the banking hours are only during the week from 9:00 AM- 3:00 PM and the facility offered no options to residents to access any of their funds during the weekends. An interview was conducted with the Business Office Manager (BOM) on 4/16/25 at 2:49PM. The Business Office Manager indicated that corporate staff only allows residents to receive $20 a day and if they request funds over that amount the money would be provided in a check form by the following business day. The BOM further revealed that residents can only withdraw funds Monday-Friday between the hours of 9:00 AM and 3:00 PM. An interview conducted with the Administrator on 4/16/25 at 3:37 PM revealed he had only been in this position for four weeks and he was not aware residents were only able to withdraw $20 a day and did not have access to personal funds after hours on the weekends and weekdays. The Administrator further revealed he had expected all residents to always have access.

Based on record review and staff interview the facility failed to complete the comprehensive Minimum Data Set (MDS) assessment within the regulatory timeframe as specified in the Resident Assessment Instrument (RAI) Manual for 1 of 1 resident reviewed for completion of a comprehensive MDS assessment (Resident #204). The findings included: Resident #204 was admitted to the facility on [DATE]. Review of the admission Comprehensive Minimum Data Set (MDS) assessment on 4/16/25 revealed the assessment had not been completed and was still in progress. An interview was conducted with MDS Nurse #1 on 4/17/25 at 5:15 PM. MDS Nurse #1 stated that they had 14 days from the assessment reference date (ARD) to complete the MDS assessment and indicated that this assessment was late due to the influx of new admissions that had recently occurred. An interview was conducted with the Director of Nursing (DON) on 4/17/25 at 5:25 PM. The DON stated she had no idea why the MDS assessment for Resident #204 was not completed within 14 days of admission but stated she would expect that it would be completed within 14 days of admission.

Based on record review, observation, and interviews with residents and staff, the facility failed to provide fluids in accordance with the physician ordered fluid restriction and failed to provide a bagged meal/snack on dialysis days for 2 of 3 residents reviewed for dialysis (Resident #41 and Resident #159). The findings included: 1. Resident #41 admitted to the facility on [DATE] with diagnoses including end-stage renal disease and dependence on dialysis. Resident #41's physician orders dated 8/15/24 noted he was on a 1200 milliliter (ml) fluid restriction per day due to end-stage renal disease. The order did not indicate how much fluid should be given from dietary with his meals and how much was to be provided by the nursing staff throughout the day. Resident #41's Minimum Data Set, dated dated dated [DATE] indicated he was cognitively intact, had no behaviors, and was receiving dialysis care. Resident #41's comprehensive care plan updated 11/13/24 indicated he attended dialysis care three times a week with an intervention of a fluid restriction. Resident #41's dialysis laboratory result summary for March 2025 indicated his fluid weight gain had increased from the month prior and he needed to focus on taking in less fluids during the day. Observation and interview with Resident #41 on 4/14/25 at 12:50 PM revealed him in his room with a cup of water on his table. He indicated he had just finished lunch and had the cup of water already in his room. Resident #41's fluid intake record from 3/17/25 to 4/14/25 noted he drank more than 1200 ml per day on 3/28/25, 4/07/25, 4/11/25, and 4/13/25. In an interview on 4/17/25 at 9:53 AM Nurse Aide #1 was passing out water to residents on the 200 hall. She said Resident #41 was on a fluid restriction but the amount of fluids he had per day varied. She said sometimes he would drink between 450-600 ml in the morning because he liked coffee, had milk in his cereal, and would have a glass of juice. She said the nurse would tell her how many fluids to give him throughout the day due to his fluid restriction. In an interview on 4/17/25 at10:08 AM, Nurse #3 said Resident #41 would be given 120 ml when she passed medications, and he would not drink all of that amount. She said he would drink 120 ml at breakfast, but didn't drink much throughout the day. Nurse #2 said she thought the dietitian liberalized his diet and had allowed for more fluids during the day. She said the physician's orders would detail how much fluid Resident #41 should receive from dietary with meals and how much the nursing staff should provide. She looked at the orders during the interview and said the order did not specify the amount of fluids to be given by the different departments. In an interview on 4/17/25 at 12:28 PM, the consultant Registered Dietitian (RD) said the dietary meal tracking system calculated how many fluids would be given by dietary with meals. She said he would get 840 ml per day with his meals, leaving 360 ml to be given by the nursing staff. She did not know if the nursing staff knew how many fluids to give him. In an interview on 4/17/25 at 4:01 PM, the Director of Nurses (DON) said she was not aware that the nursing staff did not know how the fluid restriction breakdowns were done for Resident #41. She said Resident #41 was noncompliant with his fluid restriction and would drink what he wanted throughout the day and would ask staff for fluids which they would give him because he was noncompliant. In an interview on 4/17/25 at 5:17 PM, the Administrator said the dietary department and the nursing department would need to coordinate how the fluid restriction amounts would be divided. 2. Resident #159 admitted to the facility on [DATE] with diagnoses including end-stage renal disease and dependence on dialysis. Review of physician orders dated 4/11/25 revealed Resident #159 was on a renal diet. A review of Resident #159's nursing admission assessment dated [DATE] indicated Resident was cognitively intact. Reviewed baseline care plan dated 4/12/25 and it revealed Resident #159 received dialysis three times a week. A review of Resident 159's physician orders revealed an order dated 4/13/25 for Dialysis three times weekly Monday, Wednesday and Friday. During an interview with Resident #159 on 4/16/25 at 09:12 AM Resident indicated he did not receive any food or lunch when going to dialysis. The resident stated, he be hungry a little, can't eat while on machine but can eat before getting on or when get off. Resident #159 indicated he would like to have something to eat when he went to dialysis. Resident #159 stated he had not reported the lack of a lunch meal on dialysis days to anyone at the facility. An interview was conducted 4/16/25 at 09:17 AM with the Dietary Manager and he indicated generic food bags were placed in the refrigerator and the receptionist would retrieve the food bags for dialysis residents prior to them leaving for dialysis. He indicated they had a list of dialysis residents and presented the list, however Resident #159's name was not on the list. On 4/16/25 at 09:20 AM an interview was conducted with Nurse # 7, and she indicated staff would take dialysis residents to the front lobby for pickup and they would get a bag of food to take with them from the receptionist. Nurse #7 indicated if the food bag was not at the reception desk staff would go to the kitchen and get one for the resident. She stated, this is my first day working this week and I haven't met him (Resident #159) yet. An interview was conducted on 4/16/25 at 09:26 AM with the Assistant Business Office Manager, and she indicated the regular receptionist was on vacation this week. She indicated she was aware of the dialysis residents from the dialysis listed and she would get a bag of food from the kitchen to take with them to dialysis. She stated, I'm not sure who he is (Resident #159), he is not on the list. Assistant Business Office Manager indicated she did not recall giving Resident #159 a food bag before going to dialysis on Monday. On 4/16/24 at 09:27 AM, an observation of the dialysis list was presented by the Assistant Business office Manager, and Resident #159 was not on the list. During an interview on 4/16/25 at 09:28 AM with the Director of Nursing (DON) she indicated Resident #159 should have been given a snack to take with him to dialysis and she would make sure he had one now. The DON stated she was not sure what happened. An interview with the Administrator was conducted on 4/17/25 at 04:38 PM and he indicated there should be a procedure in place for any new residents that were admitted to the facility for reports to be updated and communicated to the kitchen that were on dialysis and for dietary to have accurate information about diets, and appropriate information needed to be documented for resident needs.

Based on record review, observations, and staff interviews, the facility failed to secure an indwelling catheter tubing to prevent tension and/or trauma and to keep a urinary catheter bag and its tubing from touching the floor to reduce the risk of infection for 1 of 1 resident (Resident #153) reviewed. Findings included: Resident #153 was admitted to the facility on [DATE] and had diagnoses that included urinary retention. A Physician's Order dated 04/11/25 indicated Resident #153 required an indwelling urinary catheter for urinary retention. An admission nursing assessment dated [DATE] indicated Resident #153 was cognitively intact. A review of the Nurse Practitioner admission note dated 04/11/25 revealed Resident #153 had an indwelling urinary catheter in place for urinary retention. During an observation of Resident #153 on 04/14/25 at 10:04 AM she was found to be in bed and her urinary catheter drainage bag was lying on the floor beside her bed. An observation was conducted on 04/17/25 at 10:08 AM of Nursing Assistant (NA) #2 performing catheter care on Resident #153. The indwelling catheter tubing was not secured to the resident's leg, and the tubing was noted on the floor bedside the bed. NA #2 attempted to secure the indwelling urinary tubing to the bed with clips, however she was unable to do so, and the tubing remained on the floor. During an interview at the end of the observation, NA #2 indicated she had informed Nurse #5, Resident #153 needed catheter to be secured on 04/16/25 and would inform Nurse 5 again. An interview was conducted on 04/17/25 at 10:48 AM with Nurse #5 and she indicated NA #2 had informed her on 04/16/25 about Resident #153 not having a secure strap. She stated, I got busy and forgot. She indicated the drainage tubing should not be on the floor. The Director of Nursing was interviewed on 04/17/25 at11:39 AM, and she stated Resident #153's indwelling catheter drainage bag or the tubing should not have been on the floor and it should have had a device to keep the indwelling catheter tubing in place. During an interview with the Administrator on 04/17/25 at 04:43 PM he stated he expected staff to follow proper procedures to keep the indwelling catheter secured and the tubing off the floor. He further stated Resident #153's urinary catheter bag should not have been on the floor.

Based on observation, record review, and Responsible Party and staff interviews, the facility failed to complete a smoking assessment for 1 of 1 resident reviewed for smoking (Resident # 94). Findings included: Resident #94 was admitted to the facility on [DATE] which included nontraumatic intracerebral hemorrhage. A review of the smoking safety screen completed on 2/5/25 indicated Resident #94 was not a smoker. Review of Resident #94's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and was not coded for tobacco use. Review of Resident #94's care plan revised on 2/18/25 revealed no care plan related to smoking. Review of Resident #94's medical record revealed the resident had not been assessed for safe smoking. An observation of Resident #94 was made on 04/15/25 2:21 PM. Resident #94 was observed smoking a cigarette in the facility's designated smoking area without staff present. There was no safety concern observed. An interview was conducted with the Responsible Party on 04/15/25 01:34 PM and he indicated that Resident #94 did not smoke upon admission but after he improved, he started to smoke again about three weeks after his admission. The Responsible Party had no concerns with Resident #94 smoking independently. An interview was conducted with Nurse #6 on 4/15/25 1:45 PM. Nurse #6 indicated that Resident # 94 was a smoker, and he was safe to smoke independently. Nurse #6 was not sure why there was not a smoking assessment on file. An interview was conducted with Unit Manager #1 on 4/15/25 1:50 PM. She indicated Resident #94 was an independent smoker and a smoking assessment was supposed to be completed by the admitting nurse. An interview was conducted with the Director of Nursing (DON) on 4/15/25 at 3:32 PM. She indicated that the admitting nurse was responsible for completing resident smoking assessments on admission and the charge nurse was responsible for completing the smoking assessment when a resident started smoking after they were admitted . The DON further explained that she was not aware that Resident #94 did not have a smoking assessment, and it should have been completed by the charge nurse when he started smoking. An interview was conducted with the Administrator on 4/15/25 at 3:40 PM. He indicated that any residents who smoked should be assessed for safety and have a smoking care plan created.

Based on record review, resident, and staff interview, the facility failed to create a person-centered baseline care plan and provide a summary to the residents and/or responsible party within 48 hours of admission for 5 of 14 residents reviewed for new admission procedures (Resident #153, #159, Resident #94, Resident #26 and Resident #11). Findings included: 1. Resident # 153 admitted to the facility on [DATE] with an diagnosis that included urinary retention. A Physician's Order dated 04/11/2025 indicated Resident #153 required an indwelling urinary catheter for urinary retention. A review of Resident #153's baseline care plan dated 04/10/2025 was conducted and there was no indication for urinary catheter use. An interview was conducted with Nurse #6 on 4/17/2025 at 11:18 AM and she indicated when a new resident admits to the facility, she completes a nursing admission assessment. She stated the information she identifies as a concern on the admission assessment triggers the baseline care plan to be developed. Attempts were made to contact the Nurse that admitted Resident #153 and were unsuccessful. An interview was conducted on 4/17/2025 at 11:39 AM with the DON and she stated, the basics of care should be on the baseline care plan and the catheter should have been put on the baseline care plan. The DON indicated she would need to come up with a process to put the needed information on the baseline care plan. During an interview with the Administrator on 04/17/2025 at 4:43 PM he indicated the baseline care plan should be accurate with the needs of the residents to be identified. 2. Resident #159 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, congestive heart failure, coronary artery disease, hypertension and type 2 diabetes. A review of Resident #159's physician orders dated 4/11/2025 revealed an order for a life vest (LifeVest is a wearable defibrillator that can detect and treat abnormal heart rhythms). A review of the baseline care plan dated 4/12/2025 revealed there was no mention of the life vest. An interview was conducted with Nurse #6 on 4/17/2025 at 11:18 AM and she indicated when a new resident admits to the facility, she completes a nursing admission assessment. She stated the information she identifies as a concern on the admission assessment triggers the baseline care plan to be developed. Attempts were made to contact the Nurse who admitted on Resident #159 and were unsuccessful. During an interview with the Director of Nursing (DON) on 4/17/2025 at 11:39 AM she indicated the life vest should have been on the baseline care plan. An interview was conducted on 4/17/2025 at 04:38 PM with the Administrator and he indicated the life vest should have been on the baseline care plan. 45045 3. Resident #11 was admitted to the facility on [DATE]. Review of the admission assessment dated [DATE] by Nurse #4 revealed no documentation that the baseline care plan or list of medications were reviewed or provided to Resident #11 or the Responsible Party (RP). Review of the Baseline Care Plan assessment initiated on 3/27/25 by Unit Manager #1 revealed the following: the baseline care plan was marked as initiated and completed. The baseline care plan was not marked as being reviewed with Resident #11 and/or the RP and was not marked that a copy of the baseline care plan and copy of the medications were provided to the resident and/or RP. Review of the progress notes revealed no documentation that Resident #11's baseline care plan was reviewed with the Resident or the RP. The progress notes further revealed no documentation that Resident #11 or the RP received a copy of the baseline care plan or list of medications. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #11 had moderate cognitive impairment. An interview was conducted with the MDS Nurse on 4/16/25 at 9:22 AM and she indicated that the baseline care plan was initiated on the day of admission by the admitting nurse and nursing staff were responsible to review and provide a copy to Resident #11 and/or the RP. An interview was conducted on 4/16/25 at 2:41 pm with Unit Manager #1 who revealed she opened and completed the baseline care plan assessment at the time of the admission but she did not review it with Resident #11 or provide the Resident with a copy of the care plan or medications. Unit Manager #1 stated the nurse that completed the admission assessment for Resident #11 was responsible to review and provide a copy of the baseline care plan and the current medications to Resident #11 and the RP. A telephone interview was conducted on 4/16/25 at 3:13 pm with Nurse #4 who revealed she was not responsible for completing the baseline care plan or reviewing the information with Resident #11 or his RP. Nurse #4 stated she was an agency nurse and she believed that the facility staff were responsible to review the baseline care plan and medications with Resident #11. An interview was conducted with the Director of Nursing (DON) on 04/16/25 at 11:28 AM. The DON indicated that she had determined that nurses were not completing all sections of the baseline care plan and should have been reviewing the care plan and providing a copy of the summary to the resident and responsible party as appropriate with 48 hours of admission. 46725 4. Resident #94 was admitted to the facility on [DATE]. Diagnosis included, in part, nontraumatic intracerebral hemorrhage. The medical record was reviewed and revealed a baseline care plan was completed on 2/6/25. There was no documented evidence that a summary of the baseline care plan was offered or given to Resident #94 or to the responsible party. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 was severely cognitively impaired. An interview was conducted with Resident #94's responsible party on 4/16/25 at 9:14 AM and he indicated he was not provided with the opportunity to review or get a copy of the summary of the baseline care plan. An interview was conducted with the MDS Nurse #1 on 4/16/25 at 9:22 AM and she indicated that the baseline care plan was initiated on the day of admission by the admitting nurse and nursing staff are responsible for reviewing and providing a copy to the resident and/or the responsible party. An interview was conducted with the Director of Nursing (DON) on 04/16/25 at 11:28 AM. The DON indicated that she had determined that nurses were not completing all sections of the baseline care plan and should have been reviewing the care plan and providing a copy of the summary to the resident and responsible party as appropriate with 48 hours of admission. 5. Resient #26 was admitted to the facility on [DATE]. Diagnosis included in part, Nondisplaced fracture of fifth metatarsal bone in left foot. The medical record was reviewed and revealed a baseline care plan was completed on 3/26/25. There was no documented evidence that a summary of the baseline care plan was offered or given to Resident #26. The Admission Minimum Data Set, dated dated dated [DATE] indicated Resident #26 was cognitively intact. An interview was conducted with Resident #26 on 4/15/25 at 4/11/25 and she indicated she was not offered or provided a copy of the summary of the baseline care plan. An interview was conducted with the MDS Nurse #1 on 4/16/25 at 9:22 AM and she indicated that the baseline care plan was initiated on the day of admission by the admitting nurse and nursing staff are responsible for reviewing and providing a copy to the resident and/or the responsible party. An interview was conducted with the Director of Nursing (DON) on 04/16/25 at 11:28 AM. The DON indicated that she had determined that nurses were not completing all sections of the baseline care plan and should have been reviewing the care plan and providing a copy of the summary to the resident and responsible party as appropriate with 48 hours of admission.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of discharge location for 1 of 4 residents (Resident #100) and in the area of feeding tubes for 1 of 3 residents (Resident #36) whose MDS assessment was reviewed. The findings included: 1. Resident #100 was admitted to the facility on [DATE]. Review of the discharge planning note dated 3/14/25 at 2:36 pm by the Discharge Planner revealed Resident #100 was noted to have been ready for discharge on 3/15/25 to another facility. The Discharge Planner further noted that transportation arrangements were made, and the admission paperwork was signed and returned to the accepting facility. The Nursing progress note dated 3/15/25 at 2:02 pm revealed Resident #100 was discharged to another facility with transport team. The Minimum Data Set (MDS) return not anticipated assessment dated [DATE] and completed by the Discharge Planner revealed Resident #100 was noted to have a discharge status of short-term general hospital. An interview was conducted with the Discharge Planner on 4/15/25 at 3:18 pm who revealed Resident #100 was discharged to another skilled nursing facility on 3/15/25 with the anticipation to transition to long-term care after therapy services were completed. The Discharge Planner confirmed she completed the MDS assessment in error and should have chosen discharge to skilled nursing facility instead of short-term general hospital for Resident #100. During an interview on 4/16/25 at 10:22 am with the MDS Nurse she revealed she did not review the sections of the assessment that were completed by the other departments for accuracy. She stated the person that completed their assigned sections was responsible to ensure the information was accurate. An interview was conducted with the Administrator on 4/16/25 at 10:26 am who revealed the Discharge Planner should have reviewed Resident #100's information to ensure the assessment was correct before completing it. 50234 2. Resident #36 was admitted to the facility on [DATE] with diagnoses that included severe protein-calorie malnutrition, adult failure to thrive, and gastrostomy status. A physician order dated 11/15/24 read Resident #36 was to receive the prescribed tube feeding formula continuously at 65 milliters per hour from 2:00 PM to 9:00 AM for a total of 19 hours via gastrostomy tube. Resident #36's annual Minimum Data Set (MDS) dated [DATE] noted she had impaired cognition, did not have any behaviors or rejection of care. The MDS did not code that Resident #36 took her nutrition and hydration through a feeding tube. A progress note dated 2/3/25 at 7:17 PM by the MDS Nurse documented a MDS Reconciliation Note for the assessment reference date 1/20/25 which indicated after observation of the resident, interview with staff, and per progress notes, it was determined that the resident did not eat or drink by mouth and was fed by tube feeding only.

Based on observation, staff interviews and record review, the facility failed to maintain accurate advance directive information (code status) throughout both the electronic medical record and paper record kept at the Nursing Station for 1 of 32 residents reviewed for advance directives (Resident #5). The findings included: Resident #5 was admitted to the facility on [DATE] with cumulative diagnoses which included heart failure, renal insufficiency, and a history of respiratory failure. A 3-ring binder containing paper copies of the residents' advance directives was observed at the nursing station. A review of Resident #5's record kept in this binder revealed it included a signed Do Not Resuscitate (DNR) form printed on bright yellow/orange-colored paper, which indicated the resident had a DNR status. The DNR form was dated 6/19/23 and indicated by a checked box that this DNR directive had No Expiration Date. A review of Resident #5's electronic medical record (EMR) revealed the banner at the top of Resident #5's EMR page documented that her advance directive was, Full Code. A review of the resident's physician orders in the EMR revealed an order was received on 9/19/24 for Resident #5 to have a code status of Full code. The resident's care plan included an area of focus last revised on 9/23/24 which read, The resident has an advance directive of full code. Resident #5's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. A review of the MDS assessment revealed Resident #5 had moderately impaired cognition. An interview was conducted on 4/15/25 at 9:17 AM with the facility's Admission Director. During the interview, the Admission Director stated that the initial information on Advance Directives was addressed in the resident's contract upon admission. When asked, she reported nursing staff was responsible for inputting the resident's code status after admission into the resident's EMR. An interview was conducted on 4/15/25 at 10:30 AM with Nurse #1. Nurse #1 identified herself as the hall nurse assigned to care for Resident #5. Upon inquiry, Nurse #1 was asked where she would locate a resident's advance directive to identify his/her code status in the event this was needed. The nurse reported she could access this information from the resident's EMR. She also stated there was a binder kept at the nursing station where she could check a resident's code status. At that time, Nurse #1 reviewed Resident #5's advance directive in her EMR. The EMR indicated the resident had a Full Code status. Next, Nurse #1 reviewed the resident's paper record kept in the Advance Directives binder. The paper record was observed to include a signed DNR form which indicated Resident #5 had a DNR status. When asked, the nurse stated both the EMR and the paper record in the Advance Directives binder should contain the same information. Nurse #1 reported if the resident coded, she would need to initiate a full code for her but then added, There would be some confusion. An interview was conducted on 4/15/25 at 3:26 PM with the facility's Unit 2 Manager. During the interview, the Unit Manager was asked where the nursing staff could find a resident's code status. She stated it was on the MAR [Medication Administration Record] in the resident's EMR. Additionally, the Unit Manager reported the residents' code status was kept in a binder at the nursing station. She stated the provider was typically responsible to put any change in code status into a resident's EMR. If a resident returned from the hospital, then nursing needed to add it into the EMR as part of his/her admission orders. When the Unit Manager was informed of the discrepancy between Resident #5's two sources of information for code status, she reviewed the resident's EMR and confirmed it indicated she was a Full Code. The Unit Manager stated, I'm going to take it [the DNR form] out [of the binder]. An interview was conducted on 4/16/25 at 3:19 PM with the facility's Director of Nursing (DON). During the interview, the DON reported there needed to be only one source of information for a resident's code status. She stated, I'm going to remove the binder.

Based on record review, and interim Guardian and staff interviews, the facility failed to provide a safe and orderly discharge. The facility failed to make a referral to law enforcement and adult protective services on the day of discharge which caused a delay in Resident #203 receiving support in the home. This was for 1 of 2 residents reviewed for discharge (Resident #203). Findings included: Resident #203 was admitted to the facility on [DATE] which included metabolic encephalopathy, mood disorder, anxiety disorder and hallucinations. Resident #203's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Resident #203's care plan revised on 5/9/24 revealed a focus area for assistance with activities of daily living due to chronic health conditions, muscle weakness and recent hospitalization related to acute metabolic encephalopathy. Interventions included one person assisting with transfers. Resident #203's medical record revealed an interim guardianship document that was uploaded into the system on 5/17/24. Resident #203's demographic sheet indicated guardian on the face sheet. Physical therapy discharge summary note dated 5/23/24 indicated Resident #203 was able to sit up on the side of the bed, roll left and right independently and required supervision/touching assistance while standing up, transferring from bed to chair and transferring to and from the toilet. An attempt was made to interview Resident #203, but the attempt was unsuccessful. A progress note dated 5/25/24 written by Nurse #7 indicated Resident #203 left the facility Against Medical Advice (AMA) the morning of 5/25/25 with a unidentified individual in a private vehicle. The progress note indicated that Nurse #7 notified the family member and the Nurse Practitioner. The progress note also indicated that Resident is own Power of Attorney (POA). An interview was conducted Nurse #7 on 4/17/25 at 12:39 PM. Nurse #7 indicated that at the time of Resident #203's discharge on [DATE] she was not aware that the family member she notified had also been appointed the interim Guardian for Resident #203 on 5/17/24. A telephone interview was conducted with the interim Guardian on 4/17/25 at 11:34 AM. She indicated that she was notified on 5/25/24 that Resident #203 was discharged from the facility AMA. She further revealed she felt the discharge was unsafe and the facility should have notified adult protective services and law enforcement at the time of discharge. The interim Guardian indicated that she eventually had to contact law enforcement for well checks because Resident #203 was hallucinating and would not allow anyone in her home. The department of social services was also made aware of the situation by law enforcement, and they provided Resident #203 with services to remain in the home under their oversight. A telephone interview was conducted with the former Administrator on 4/17/25 at 12:39 PM. He indicated that he first became aware of the discharge on Monday 5/27/24 and was informed that Resident #203 had discharged AMA, and that adult protective services nor law enforcement had been notified on the day of discharge. The former Administrator indicated that he felt the discharge was not handled properly because the facility could not confirm if Resident #203 was safe and adult protective services and law enforcement was not contacted on the day of discharge. He further revealed that he contacted adult protective services and law enforcement on 5/27/24 to make a referral and contacted the interim Guardian on 5/27/24 and offered Resident #203 to return to facility, but the offer was declined. The facility implemented the following Corrective Action Plan with a compliance date of 5/28/24. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #203 no longer resides in the facility. The resident was offered to return to the facility but refused offer from facility. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents are at risk for this deficient practice. The Regional Director of Clinical Services completed an audit of current residents and created a list of current residents as of 5/27/2024. The Regional Director of Discharge planning completed an audit of the last 30 days of discharges to home or lower level of care to ensure guardian notification has been completed. Audit was completed on May 28, 2024. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Beginning May 27th, 2024, the administrator and assistant administrator provided in-person education for all licensed nurses, admissions team, and service ambassadors. Education included: - How to conduct a proper discharge, including confirming with the responsible party, power of attorney, and guardianship process. - Education for service ambassadors included not allowing residents to exit the center without verifying the appropriateness of their leaving with the assigned nurse. - Verifying the process before letting any resident depart the facility. - If permission is denied, Immediate action will be taken to notify the law enforcement and staff will keep the residents inside until law enforcement arrives. All new licensed nurses, service ambassadors, and admissions staff will receive this training as part of their onboarding process before starting on the floor. The admission team will be responsible for updating PCC if the resident has under the profile tab if the resident has a guardian. This also must be communicated on an admission alert. Admissions will communicate during the daily morning meeting if a resident with a guardian is admitted . Education was validated by verbal recall and just in time teaching reinforcement and re-education if needed. After May 28, 2024, before residents depart the facility, service ambassadors will check with the resident's assigned nurse for the shift to verify the responsible party/guardianship/power of attorney status before granting access to open the doors. This information will be passed to the customer service ambassador/receptionist for door access. Licensed nurses will make sure to review the face sheet/profile before allowing any patient to be discharged or leave the facility. If the profile indicates guardian, then the guardian must approve all discharges, transfers, or leaving the facility. Licensed nurses were also educated on action steps regarding if a resident has a guardian and insisted on leaving the facility, if they do not have the guardian's permission, the local law enforcement will be immediately notified. 4. Indicate how the facility plans to monitor its performance to make sure that the solutions are sustained. The facility Administrator or the designee will audit all discharges weekly x 12 weeks. Audits will include AMA and planned discharges to lower-level care. Audits will consist of proper notification of the party/guardians responsible. These audits will include proper notification of the responsible party/guardian. These audits will be reported to the monthly QAPI committee for review of compliance. Date of Compliance May 28, 2024 The Corrective Action plan was validated on 4/17/15 by reviewing the completed audit of all residents discharged in the last 30 days, the education provided to the staff regarding safe discharged and reviewing the monthly Quality Monitoring documentation. The correction date of 5/28/24 was validated.

Based on observation, record review, and staff and Registered Dietitian interviews, the facility failed to administer tube feedings via a gastrostomy tube as ordered by the physician for 1 of 3 residents reviewed for tube feeding (Resident #36). The findings included: Resident #36 was admitted to the facility on [DATE] with diagnoses that included severe protein-calorie malnutrition, adult failure to thrive, and gastrostomy status. Resident #36's annual Minimum Data Set (MDS) dated [DATE] noted she had impaired cognition and did not have any behaviors or rejection of care. The MDS did not include she had a feeding tube and received all of her nutrition and hydration through the tube feedings. Resident #36's comprehensive care plan dated 11/17/22 noted she was dependent on tube feedings to meet her estimated nutrition and hydration needs with interventions including to provide tube feedings per order. A physician order dated 11/15/24 read Resident #36 was to receive the prescribed tube feeding formula continuously at 65 ml (milliters) per hour from 2:00 PM to 9:00 AM for a total of 19 hours via gastrostomy tube. An observation was made of Resident #36 on 4/16/25 at 4:06 PM. Resident #36 was asleep in bed. There was a feeding tube pump mounted to a pole beside Resident #36's bed. The pump was not turned on and the tubing connected to the pump was not connected to the resident's gastrostomy tube. There was a bottle of the prescribed tube feeding formula hanging from the pole which was dated 4/16/25 and timed 6:00 AM. According to the graduated lines on the tube feeding bag there were 900 ml of formula remaining in the bag. Resident #36's private attendant was not observed to be in the resident's room. Nurse #2 was interviewed on 4/16/25 at 4:10 PM. She stated when she came to the facility that morning at approximately 7:30 AM, Resident #36's tube feeding was not running. She explained she hooked up the tube feeding to administer the prescribed tube feeding formula at 65 ml per hour at approximately 8:15 AM and disconnected it at 9:30 AM when the resident requested. She stated in the mid-afternoon (she was unable to remember the time), she hooked up Resident #36's prescribed tube feeding formula at 65 ml per hour until Resident #36 wanted to be taken outside by her private attendant. The nurse explained it was at that time she disconnected the tube feeding. Nurse #2 stated she was not sure when Resident #36 had returned from being outside. She said the resident had not been reconnected to the tube feeding since the resident came in from outside. She stated she had not observed that Resident #36 had any complications such as gastric reflux or too much residual (formula which remained undigested in the stomach) that would have necessitated holding the resident's tube feeding. She stated she was an agency nurse and that was her first time in the facility, and she was not aware of Resident #36's tube feeding orders. The Registered Dietitian (RD) was interviewed on 4/17/25 at 12:28 PM. She explained Resident #36's tube feeding order hours were set for the evening so Resident #36 was able to visit with her private attendant outside of her room throughout the day. The RD indicated Resident #36's private attendant had a history of turning off the resident's tube feeding when she felt Resident #36 had too much formula or when the resident wanted it off. She stated Resident #36 had been gaining weight over the last few months but not significantly. The Registered Dietitian indicated Resident #36 needed her tube feeding to be administered as ordered to ensure the resident received the daily caloric intake she needed. She stated if there was 900 milliliters remaining in the formula bottle which was scheduled to start at 6:00 AM, it meant Resident #36 only received 100 ml of the 1,000 ml bag. The RD explained 100 ml of formula would have been 150 calories. The RD further stated Resident #36 should have received 325 ml since 6:00 AM (65 ml/hour from 6:00 AM through 9:00 AM and 65 ml/hour from 2:00 PM to 4:00 PM, a total of 5 hours at 65 ml/hour which would equate to a total 325 ml) and the resident would have received a total of 487.5 calories for that 5 hour period. In an interview on 4/17/25 at 4:01 PM, the Director of Nursing (DON) stated Nurse #2 should have ensured the tube feeding was running as ordered. She said Resident #36's private attendant had a history of turning off the feeding pump, but Nurse #2 should have started it. Attempts made to interview the resident's physician were unsuccessful.

Based on observations and staff interviews, the facility failed to keep food preparation areas, food service equipment clean, free from debris, grease buildup, and/or dried spills during two kitchen observations. The facility failed to clean the floor and ceiling vents located over the food prep and food service area. This practice had the potential to affect food served to all residents. The findings included: During a kitchen tour on 1/21/24 at 9:14 AM, the following observations were made with the kitchen Cook: a. The 6- stove burners had heavy grease build-up on the stove burners, walls behind the stove, and front of the stove. There were large amounts of burnt foods, dried, encrusted, liquid and splatters throughout the stove area. The inside and outside of the combination stove and oven doors had grease buildup, dried foods, and liquid spills. b. The 4-compartment ovens had a heavy grease build-up, dried food, and liquids on the inside and outside. The grease buildup was encrusted on doors/shelves where food was being cooked. There was a dried grease buildup observed on the fronts of the ovens and on the walls on the inner walls of the oven or on the walls behind the oven. c. The fryer had dried brown/yellow liquid matter encrusted on edges inside and outside. The fryer had heavy grease and food build-up inside and outside, food products behind the fryer. d. The 3 plate warmers had 2 rows of clean plates stored in the warmer. The inside of warmer had dried liquid spills and food particles inside and dried liquid spills on the outside. The inside also had old food crumbs all around. e. The 3-compartment insulated plate base warmer had 3 rows of clean bases stored in the warmer. The inside had dried liquid spills and food particles inside and outside. The inside also had old food crumbs all around. The 2 bottom covers warmers had 2 rows of clean bottom covers stored with a large volume of liquid spills, food particles inside and dried liquids spills on the outside. The inside also had old food crumbs all around. f. The floor underneath the stove, fryer, steamer, and ovens had large amounts of dried food, grease puddles and trash. g. The 4 ceiling vents and 2 air conditioning units had large volumes of black dust/debris blowing over food service and prep surfaces. h. The 3 shelves drying rack had 12 steam table lids, 9 plastic storage containers, 15 silver cooking pans stored on dirty rack, that had a large volume of dried liquids and food crumbs/particles. i. The walls behind the hand wash sink had a knife storage rack which had food splashed all over the wall and the knife storage rack. j. There were 2 refrigerators that had left over food and dried liquids on the walls inside and outside. An interview was conducted on 1/21/24 at 9:35 AM, Cook #1 stated there was no cleaning checklist, available . He further stated he was unaware of when the kitchen equipment was last cleaned. An observation was conducted on 1/21/24 at 10:04 AM, the Dietary Aide #1(DA) placed 2 rows of clean plates in the plate warmer and 3 rows of clean plate bases into the base warmer. When asked when the last time was the plate and base warmer had been cleaned the response was I don't know, and I am not sure if there was a cleaning checklist. DA #1 stated there were not enough staff to clean and cook and they were doing the best they could to get things done and the meal served. An interview was conducted on 1/22/24 at 10:15 AM, the DA#2 stated all staff try to pitch in a much as possible to clean the kitchen after each shift, if the scheduled staff does not show up, it put them even further behind and some things may get wiped down when it should really be deep cleaned. An interview was conducted on 1/22/24 at 11:30 AM, Cook #2 stated there was a cleaning checklist, but the Dietary Manager (DM) kept that information in the office. She further stated she was unaware of when the kitchen equipment was last cleaned. Follow-up observation was conducted on 1/23/24 at 11:17 AM-12:30 PM, the previous identified kitchen concerns of the kitchen equipment, food prep areas, floors, ceiling vents and air condition remained in the same condition as the initial tour on 1/21/24. An interview was conducted on 1/22/42 at 11:45 AM, the Dietary Manager (DM), and Regional Dietician (RD) stated the kitchen staff were required to wipe down kitchen equipment after each meal and deep cleaned weekly in accordance with the kitchen cleaning checklist. The DM and Regional Dietician further stated they were responsible for ensuring the kitchen staff kept the equipment clean and orderly. The Dietary Manager (DM) and Regional Dietician(RD) acknowledged the identified kitchen equipment, the floors, ceiling fan and air condition units had not been cleaned in several months. The DM stated all cleaning checklists and responsibilities would be updated and available for all kitchen staff. An interview was conducted on 1/23/24 at 1:34 PM, the Administrator stated the Dietary Manager and Kitchen Supervisor were responsible for ensuring the kitchen was cleaned and maintained. The Administrator stated the expectation would be for the Dietary Manager to ensure all kitchen cleaning protocols were in place and followed in accordance with kitchen sanitation guidelines.

Based on observations, record reviews, staff interviews, Nurse practitioner and Wound Doctor interviews the facility failed to apply an air mattress to prevent skin impairment, transcribe wound treatment to the right heel and sacrum according to and, provide pressure ulcer care according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #17 was at risk for pressure ulcers and acquired 3 pressure ulcers (sacrum area, left heel, and right heel) since admission. The wounds to the left heel and sacrum had some bloody drainage with maceration at observation. The resident was started on antibiotics due to infection to the wounds. Findings included: Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident was not diagnosed with Peripheral vascular disease (PVD) and was not end of life. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The comprehensive admission Minimum Data Set (MDS) dated [DATE] revealed the resident was moderately cognitively impaired. The resident required extensive to total assistance of one-person physical assist for activities of daily living. Resident #17 was assessed as at risk for pressure ulcers. Assessment indicated the resident did not have any pressure ulcers at the time of admission. The MDS indicated the resident had a pressure reducing device for bed and ointment/treatment were applied. Review of Nurse Practitioner note dated 5/19/21 revealed the resident prior to admission had chronic wounds to sacrum and heels. These wounds were recently healed. Note indicated the resident would need to have her heels always elevated, and skin prep applied. Air mattress recommended due to her frequent skin breakdown. Recommendations were to cleanse, wash and dry both feet and apply Vaseline liberally. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Float heels on pillows while in bed. Orders also indicated the following med Review of the Wound Doctor notes dated 5/27/21 revealed the following: 1) Left heel -unstageable deep tissue injury (DTI): Wound measurement 3.5 X2.5 X not measurable centimeters (cm). Treatment indicated was skin prep apply once a day x 30 days. Gauze roll nonsterile apply once a day x 30 day. Recommendations included offloading the wound and reposition by facility protocol. 2) Sacrum - Stage 3 Pressure ulcer: Wound measurement 4 x 3.1 x 0.1 cm. granulation tissue 100%. Treatment indicated was Alginate calcium apply once daily x 30 days. Gauze island applied once daily x 30 days. Recommendations were off loading wound, reposition per facility protocol and group 2 mattress. Note indicated the factors complicating healing was type 2 Diabetes Mellitus. A review of the care plan revised on 6/1/20 revealed the resident was care planned for actual skin impairment to sacrum site #1, and site #2 left heel with the potential for more skin impairments. The goal was for the resident to have no further evidence of skin impairment. Interventions included keeping skin clean and dry, providing peri care with incontinent care and weekly skin assessments. Review of the Wound Doctor notes dated 6/3/21 revealed the following 1) Left heel unstageable DTI: Wound measurement 4 X 2.5 X not measurable cm. 2) Sacrum - Stage 3 Pressure ulcer: Wound measurement 6 x 3.6 x 0.1 cm. Granulation tissue 70%. Wound deteriorated. Note also indicated the factors complicating healing was type 2 Diabetes Mellitus. Surgical excisional debridement procedure done to the sacrum wound on 6/3/21. Review of the Nurse Practitioner note dated 6/3/21 revealed the resident had developed 2 new wounds since admission. These were old wounds that have reopened. The resident seen by the Wound doctor for pressure ulcer to sacrum and to left heel deep tissue injury. The note read in part pt. (resident) still does not have air mattress. Will discuss with DON (Director of Nursing). She will require an air mattress due to her fragile skin and high risk for pressure wounds and skin breakdown. No other acute issues. She has no acute complaints. Review of the Wound Doctor notes dated 6/17/21 revealed: 1) Left heel unstageable DTI: Wound measurements - 8 X 4 X not measurable cm. Wound deteriorated. 2) Sacrum - Stage 3 Pressure ulcer: Wound measurements- 4. x 3.9x 0.8 cm. granulation tissue 90%. Wound improved. 3) Right heel unstageable DTI: Wound measurements- 1 x 0.8 X not measurable cm. Review of the Wound Doctor notes dated 6/24/21 revealed: 1) Left heel unstageable DTI: Wound measurement 5.2 X 4.5 X not measurable cm. Wound improved. 2) Sacrum - Stage 3 Pressure ulcer: Wound measurement 3.2 x 3 x 0.2 cm. granulation tissue 90%. Wound improved. 3) Right heel unstageable DTI: Wound measurement 1.4 x 1 X not measurable cm. No change in wound. Review of the Wound Doctor notes dated 7/1/21 revealed: 1) Left heel unstageable DTI: wound measurement 5.5 X 4 X not measurable cm. Wound improved. 2) Sacrum - Stage 3 Pressure ulcer: Wound measurement 3 x 1.8 x 0.2 cm. granulation tissue 90%. Wound improved. 3) Right heel unstageable DTI: Wound measurement 1.1 x 0.9 X not measurable cm. Wound -improved. Review of the Wound Doctor notes dated 7/9/21 revealed 1) Left heel unstageable DTI: wound measurement 5 X 3 X not measurable cm. Wound improved. 2) Sacrum - Stage 3 Pressure ulcer: Wound measurement 3 x 1.8 x 0.2 cm. granulation tissue 90%. Wound improved. 3) Right heel unstageable DTI: Wound measurement 1.4 x 0.9 X not measurable cm. No change in wound. Review of the Wound Doctor notes dated 7/15/21 revealed 1) Left heel unstageable DTI: wound measurement 4.5 X 2.5 X not measurable cm. Wound deteriorated. 2) Sacrum - Stage 3 Pressure ulcer: wound measurement 2.5 x 1.6 x 0.2 cm. granulation tissue 90%. Wound improved. 3) Right heel unstageable DTI: wound measurement 5.5 x 5 X not measurable cm. Wound deteriorated. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse practitioner note dated 7/21/21 revealed the resident was seen by the nurse practitioner as follow up on bilateral heels wounds. The dressing was changed. Both heels draining with foul odor. Note indicated the resident was started on antibiotics due to worsening of the wounds, foul smell, and drainage. Resident's right heel with DTI had no open areas. Left heel with open area, DTI, drainage and foul odor and tender to touch. Note revealed the resident was not in any pain. Review of the wound doctor notes dated 7/22/21 revealed: 1) Left heel unstageable DTI: wound measurement 5 X 2.1 X not measurable centimeters (cm). Wound deteriorated. Treatment - Leptospermum honey apply once a day x 23 days. Gauze rolls nonsterile apply once a day x 23 day. Recommendations included offloading wound and reposition by facility protocol. 2) Sacrum - Stage 3 Pressure ulcer: wound measurement 2.5 x 1.5 x 0.2 cm. granulation tissue 100%. Wound improved. Treatment - Leptospermum honey apply once a day x 23 days. Gauze rolls nonsterile apply once a day x 30 day. Alginate calcium apply once daily x 9 days. Recommendations included offloading wound, reposition per facility protocol. 3) Right heel unstageable DTI: wound measurement 5 x 5 X not measurable cm. Wound improved. Treatment - [MEDICATION(S)] apply once a day x 17 days. Gauze roll nonsterile apply once a dayx17 days. Recommendations included offloading wound and reposition by facility protocol. A review of a Treatment administration record (TAR) revealed the following: 1) Cleanse left heel with normal saline, apply Medi honey and cover with dry dressing every day shift wound care (order date 7/22/21). 2) Cleanse area to sacrum, apply Medi honey and cover with dry dressing every day shift for wound care (order date 7/22/21). The TAR did not include Alginate Calcium as indicated in the Wound doctor treatment notes 3) Cleanse right heel with normal saline, apply Medi honey and cover with dry dressing every day shift for wound care (order date 7/22/21). The Wound Doctor note indicated [MEDICATION(S)] apply once a day x 17 days. Gauze roll nonsterile apply once a day x 17 day. This was not indicated on the TAR . During an interview on 7/28/21 at 7:47 AM, Nurse #3 stated she was assisting the Wound Doctor during the weekly rounds. Nurse #3 stated the Wound Doctor's treatment orders were transcribed in the system by her. Related to the difference in the orders transcribed, to the orders in the Wound Doctor's recommendations, she indicated it was how the physician had stated while the physician was assessing the resident. [MEDICATION(S)] was not transcribed for right heel DTI, instead Medi honey was transcribed. Alginate calcium was not transcribed for sacrum wound. During a telephone interview on 7/27/21 at 1:37, the previous Director of Nursing (DON) stated she was working for the facility from 4/12/21 to 7/20/21. The previous DON stated the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Doctor was followed by a nurse who would transcribe the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON indicated that she would cross check to see if the orders were transcript correctly and per Wound Doctor's notes. During an interview on 7/30/21 at 1:43 PM, Corporate nurse consultant stated the verification of the wound doctor's order should be done once the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse consultant confirmed she had not verified the orders last week. During an interview and observation on 7/26/21 at 12:38 PM, the resident stated she had pressure ulcers on both her heels and on her back. The resident stated that staff were treating the wounds. Resident further stated the staff repositioned her frequently and kept her feet floated. Resident was observed on an air mattress. Resident heels were floated on pillows. On 7/27/21 at 11:30am, the resident's wound dressings were observed with the nurse practitioner. The resident was observed lying in bed on an air mattress. The resident's feet were noted to be floating off a pillow and the bandages on both feet were dated 7-26-21. Observed the resident's sacrum with the nurse practitioner and noted the dressing on the resident's sacrum was intact and dated 7-26-21. Wound care was observed with Nurse #2 on 7/27/21 at 1:55 PM. Nurse kept clean field and performed hand hygiene. Observation of Left and Right Heels: Nurse #2 removed gauze and a dressing of Vaseline gauze from right heel. Right heel was noted to be closed with no drainage, but skin was boggy and white. The left heel was noted to have the Vaseline gauze and a piece a foam. Left heel was noted to have bloody drainage with maceration around the edges. Treatment: Nurse #2 washed the wounds with normal saline, applied Medi honey and a dry gauze dressing but also had 2 pieces of foam. Sacrum: Removed dressing which was a foam border dressing that was clean, no remanence of a treatment applied to wound. Wound bed and surrounding skin were clean, some bloody drainage with maceration in the center. Treatment: Nurse #2 washed with normal saline, applied Medi honey and a piece of foam then covered with a gauze border dressing. Nurse #2 did not apply Alginate calcium to the wound. During an interview on 7/27/21 at 2:00 PM, Nurse #2 stated she only applies the foam dressing to the heels if she feels they are needed but the order called for a dry dressing. She also acknowledged there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #2 also denied knowing what the yellow gauze was on the resident's heels but stated it was not the correct dressing. During an interview on 7/28/21 at 1:15 PM, Nurse Aide (NA)# 3 stated she was frequently assigned to the resident. The resident was alert and oriented and able to verbalize her needs. NA stated when she begins her shift, the resident was usually repositioned to her side by the outgoing NA. The resident was repositioned to center when breakfast was served so that she could consume her meals. The resident after her ADL care during mid-morning was repositioned to the side and later around lunch when family visited the resident was transferred to the wheelchair. The resident's feet were floated using pillows. Pillows are placed on both bed and wheelchair. NA #3 stated the resident was repositioned every 2 hours. During an interview on 7/27/21 at 10:47 AM. Nurse Practitioner stated the resident had peripheral vascular disease, diabetes and was immobile. The resident used a mechanical lift for transfer. Nurse practitioner further stated based on resident's medical condition, the resident was at a high risk for developing pressure wounds. Nurse Practitioner indicated prior to admission the resident had wounds to the sacrum area and both her heels. These wounds were healed at admission. The resident's sacrum wound had developed on 5/27/21. The Nurse practitioner stated on 6/3/21 when she was assessing the resident, she had noticed that the resident was not lying on an air mattress. Nurse practitioner further stated that she had a conversation with the previous Director of Nursing and the resident's mattress was changed. The resident was seen by the wound doctor and both DTI of left and right heel and stage 3 sacrum were assessed. Nurse Practitioner stated the resident's feet were kept floating of a pillow for pressure relief. Nurse Practitioner stated the resident's wounds need to be dressed daily as ordered by the wound doctor for healing. During a telephone interview on 7/29/21 at 2:30 PM, the Wound Doctor stated the resident had wounds to the sacrum and both heel, which were healed prior to admission. The resident had contributing factors like diabetes mellitus type 2 and other medical conditions that would put the resident at risk for pressure ulcers. The Wound Doctor indicated the resident's feet were floated with pillows to help with pressure relief. The Wound Doctor stated the foam placed with the dressing would help with keeping the wound dry. The Wound Doctor further stated that [MEDICATION(S)] was ordered for the right heel to keep the wound dry and help with wound healing. He indicated the Medi honey would not help dry the wound and could deteriorate the wound. The Wound Doctor stated Vaseline gauze should not be used to the heels as it would not keep the wounds dry and cause maceration. The Wound Doctor further stated the Vaseline gauze would cause the wound to deteriorate. The wound doctor was also made aware that Alginate calcium was not used while dressing the sacrum wound. The Wound Doctor stated Alginate calcium would assist in keeping the wound dry and help with speeding wound healing. The Wound Doctor indicated the resident's wounds were healing. The Wound Doctor further indicated that by nurses not following his orders the resident's wounds could deteriorate. The Wound Doctor stated the nurses should be following his orders for wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, staff and resident interviews, physician and nurse practitioner (NP) interview the facility failed to supervise a cognitively impaired resident to prevent wandering from the facility and smoking off campus without staff ' s presence The failure of the facility to supervise this resident while smoking and walking around the outside of the facility resulted in no injury, but placed the resident at a high likelihood for injury or accident. Immediate jeopardy began on 6/12/18 when Resident #16 who had impaired cognition, poor safety awareness, and was wheelchair bound was found 440 feet off the facility premises. Immediate jeopardy was removed on 9/27/18 at 5:00 PM after validation of the credible allegation of removal of the immediate jeopardy. The facility remains out of compliance at a lower scope and severity D (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring. Findings included: Resident #16 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), a quarterly review, dated 3/7/18 indicated he had short and long-term memory impairment. His Brief Interview for Mental Status (BIMS) was a score of 7, which indicated moderate impairment with memory. There were no behaviors of wandering exhibited during the 7 days of review for the assessment. Resident #16 required extensive assistance of one staff person for bed mobility and transfers. He required supervision of one staff person for locomotion on/off the unit. The MDS indicated Resident #16 had impairment of functional movement on one side of his body affecting his upper and lower extremity. The Wandering Risk assessment dated [DATE] indicated the resident was forgetful/short attention span, exhibits fear/anxiety, early dementia, and received antipsychotics and antidepressants. This assessment did not indicate he had made attempts to exit or expressed desire to leave the facility. The care plan dated 3/20/18 included problems of: - Exhibiting adverse behavioral symptoms as evidenced by poor safety awareness, physical aggression, agitation, anxiety crying due to [MEDICAL CONDITION], refusing medications, wants to go to the hospital, receives antipsychotic. - Communication problem related to intracranial bleed. At times he cannot say what he wants to and is not able to understand what is said to him. The interventions included for staff to allow him time to process information and form a response, anticipate and meet needs. - Impaired cognitive function/dementia and impaired thought processes related to stroke. Interventions included for staff to ask yes/no question, keep the resident ' s routine consistent, and provide consistent care givers as much as possible in order to decrease confusion. - Actual fall with high risk for future falls related to unaware of safety needs, paralysis, poor communication/comprehension and gait/balance problems, use of [MEDICAL CONDITION]/narcotic medications. The facility Campus Free Smoking Plan, with a revised date of 5/18/2018 included the following: All new admissions that smoke and any other resident who begins smoking while at the center will receive a patient smoking acknowledgement form. The resident is expected to read, understand and sign the acknowledgement. These residents are educated on where the established smoking area is off of Guilford Healthcare property. Any resident whom is found to be noncompliant with this will be reeducated and notified that any further noncompliance may result in potential discharge. A revised smoking acknowledgement form was not available for review for Resident #16. Review of the Patient Smoking Acknowledgement form signed by Resident #16 on 8/31/16 did not include the smoking was to be off the facility property. The form did not include where the resident was to smoke off the facility property. The form indicated the Administrator may choose or may not choose to designate areas outside of the building for any smoking activities. Assessments of residents were to be completed if the resident smoked on the facility grounds. Review of nurse ' s note dated 5/25/18 at 11:24 AM revealed the resident continued to go outside of the facility to smoke. He had refused all of the morning medications for that shift. Psychiatric progress note dated 5/29/18 included [DIAGNOSES REDACTED]. The Nurse Practitioner (NP) documented changes in his mood as irritable, threatening gestures with balled up fist towards roommate. The resident was refusing his medications on a daily basis. He had poor insight, judgement, concentration and short- term memory. Long term memory was fair. He was oriented to person and surroundings. His thought process was disorganized. The [MEDICATION NAME] (for mood disorder) was increased to treat his mood. Review of the nurse ' s note dated 5/29/18 at 1:54 PM revealed the resident continued to smoke outside near sidewalk. Interview with Nursing Assistant (NA) #5 on 9/29/18 at 9:09 AM revealed she knew the resident and was aware of his behaviors. She said his memory was poor, and it had always been poor. He would make comments that he wanted to go to the super store. Further interview revealed she had no knowledge Resident #16 had gone to a super store. He would not tell staff if he was going outside the facility. She had knowledge of him smoking, and he would smoke cigarette butts. During the interview the NA#5 thought the resident could go outside to smoke. Interview on 9/26/18 at 1:15 PM with Resident #5 revealed he had been outside with Resident #16 when he was smoking. He explained Resident #16 had his own cigarettes and lighter. Review of the nurse ' s note dated 6/2/18 at 3:27 PM revealed the resident was having some concerns with right leg being contracted. The charge nurse educated the resident as to the reason for having contraction to right leg. Resident understood and continued to go outside to smoke on sidewalk. Review of a nurse ' s note dated 6/9/18 revealed the resident was observed smoking outside of the facility on the sidewalk smoking cigarettes. It was unknown at that time how he was able to get cigarettes. Educated the resident about smoking and importance of his health. Staff will continue to monitor for any behavior and health changes. An interview with Nurse #4 on 9/26/18 at 4:30 PM revealed she had worked with Resident #16 when he went out to smoke on second shift. She explained he would go to the facility sign on the sidewalk to smoke. She explained he had not signed out to go smoke and she had educated him so many times about signing out. She had noted changes in his behavior during (MONTH) and June. During the interview, Nurse #4 was not aware of any other interventions for the resident ' s non-compliance with not signing out to leave the facility. Interview with the Director of Nursing (DON) on 9/26/18 at 12:45 PM revealed they did not do assessments of residents for safe smoking. The residents were aware on admission the facility was a nonsmoking facility. If the residents wanted to smoke, they were to go off the facility property. She explained Resident #16 was able to make his own decisions and could smoke independently. Further interview revealed the facility was a no smoking facility, assessments were not completed due to residents were supposed to smoke off the facility ' s property. She did not know where he obtained the cigarettes or lighter. She explained the resident must have bummed one from another resident. She explained she did not know if he had his own smoking materials and she had not checked his room to see if he did. When the DON was asked what the criteria for not allowing a resident to smoke due to safety reasons, she did not have an answer. She further explained Resident #16 had a change in cognition around (MONTH) (YEAR). The change in his cognition was described as being fixated on things, ie his leg and not being able to stand. The care plan was discussed regarding his impaired cognition, impaired thought processes related to a stroke and actual fall with high risk for future falls related to unaware of safety needs, paralysis, poor communication/comprehension and gait balance problems. The DON indicated those care plan problems were accurate when they were created. Continued interview revealed the resident had gone to a super store down the street in his wheelchair previously, and he would sign himself out of the facility. When asked when the last time he signed himself out and went to a store, a definite date and time was not provided. The DON explained recently Resident #16 had attempted to go to a store, and an employee brought him back because he did not sign himself out. The employee saw him down the block from the facility in the church parking lot. Review of a nurse ' s note dated 6/12/18 at 1:30 PM revealed Resident #16 was found wondering (sic) near a church parking lot headed to a super store on MLK (Martin Luther King) Drive. He stated, ' I to buy my own batteries, I do not want to use ya ' ll batteries. ' Front office staff safely escorted resident back to . facility without any injuries. Notified NP (Nurse Practitioner) whom recommended resident not to go out of facility until further evaluation Educated (the resident) importance on the safety of resident/policy for leaving (facility) unattended . Interview with business office staff #2 on 9/26/18 at 3:30 PM revealed she was walking back from the church on 6/12/18. During the interview, she explained she did not remember the time, but she saw Resident #16 at the corner next to the church parking lot. The business office staff #2 explained she asked Resident #16 if he had signed out before leaving the facility and he replied He did not remember if he signed out. Further interview revealed she asked the resident to return to the facility to sign out and he went back to the facility. Interview with the receptionist on 9/27/18 at 9:50 AM revealed she was working on 6/12/18 and was at the front desk beside the front door of the facility. She explained Resident #16 was out of the facility and waving at people. She saw him go to the sidewalk next to the facility sign, and then up the sidewalk beside the highway. She further explained he had gone to the end of the block and a staff person brought him back to the facility. During the interview she was not aware Resident #16 was not safe to be outside alone. Interview with the DON on 9/26/18 at 4:45 PM revealed she had evaluated the resident after the 6/12/18 incident and found him to be able to make his own decisions. She explained she did not document or use an assessment form for her evaluation. Further interview revealed she had no explanation for misunderstanding what the NP had intended for the type of evaluation (by a psychiatrist). Review of the MDS, quarterly 6/19/18 indicated he had short and long- term memory impairment with a BIMs of 10. The MDS indicated Resident #16 had behaviors of verbal and physical aggression towards others and no wandering behaviors were included. Resident #16 was assessed as having no changes in activities of daily living except for eating. Review of the care plan dated 6/26/18 did not include problems of smoking or elopement risk. There were no changes to the care plan for additional problems related to behaviors or cognition. Review of the MDS, an annual, dated 7/1/18 indicated he had short and long- term memory impairment with a BIMS of 2 (severe impairment). This assessment had included behaviors of physical and verbal aggressiveness towards others, and no wandering behaviors were included. Review of the Care Area Assessments (CAA ' s) dated 7/9/18 included the following Analysis of Findings included no new diagnoses, a new score of 2 out of 15 with the BIMs interview. Areas of consideration were due to frequent lack of reorientation, reminders to help make sense of things, and hearing or vision impairment may have an impact on ability to process information (directions, reminders environmental cues). Review of the updated care plan of 7/16/18 revealed no changes in the problems or interventions were made in the areas of cognition, behaviors, safety awareness, fall risk, smoking or wandering. Interview with the MDS nurse on 9/27/18 at 9:00 AM revealed Resident #16 had disorganized thinking, inattention, short term memory with answers to interview questions that were not appropriate and he never remembered the year. The MDS ' s dated 6/1/18, 6/19/18 and 7/1/18 were reviewed with the MDS nurse. She verified he continued to have disorganized thinking, inattention, short term memory impairment. The MDS nurse explained the MDS dated [DATE] indicated his long- term memory had become more impaired. After reading the note of 6/12/18, the MDS nurse explained she would consider that incident as wandering. She had no knowledge of him going to a super store. She considered he was not able to make safety decisions and he could not walk but thought he could and wanted to walk. During interview, the MDS nurse explained Resident #16 ' s cognition assessment would vary depending on his mood and who was asking him the questions in the interview. Follow up interview with the MDS nurse on 9/27/18 at 2:00 PM revealed the 7/1/18 was accurate regarding wandering due to the timeframe of the assessment reference date. Review of a nurse ' s note written by the Director of Nursing, dated 7/23/18 at 2:45 PM revealed the resident continued with poor decision-making abilities. Leaving center without signing out. We have spoke (sic) to resident before and continues to be non-complaint (sic). Resident with recent acute change in cognition. Will place wander guard at this time. Review of a nurse ' s note dated 8/20/18 at 10:07 PM revealed the resident tried to hit writer in face with fist. He was trying to cut off wander guard with toenail clipper. Review of the physician orders [REDACTED]. Resident #16 continued to receive [MEDICATION NAME] through (MONTH) 27, (YEAR). Interview with the Social Worker on 9/26/18 at 11:45 AM revealed the resident had short term memory problems. He could remember things at the moment but then would forget what was said to him. He would forget to sign out to go outside. A wander guard was placed on the resident due to not being compliant about signing out. She had no knowledge of his smoking outside or attempting to go to a super store and was found up the road at the church parking lot. Review of the sign out log for Resident #16 revealed he was last signed out on 2/3/18 at 4:30 PM by a staff member and was signed back in at 7:30 PM by the same staff member. The resident had not signed himself out since 8/27/17. The smoking area for the residents was viewed with the DON on 9/26/18 at 1:00 PM. A resident was in the driveway of the facility. Two residents were on a sidewalk leading to the sidewalk by the roadway. The DON instructed the resident in the driveway to go to the sidewalk past the facility sign. When asked if that was facility property, she said she would have to check. Interview with the Administrator on 9/26/18 at 1:10 PM revealed the facility was a no smoking facility. Further interview revealed assessments for safe smoking were not completed on residents and they were to smoke off the facility property. The wander guard was placed on the resident due to his noncompliance with signing out of the facility. During the interview, she explained the DON had assessed Resident #16 as being safe to go outside without supervision after the 6/12/18 incident. On 9/26/18 at 3:00 PM, the surveyor, accompanied by the therapy manager, measured the distance using his rolling measuring device for distances. The distance from the threshold of the front door to the facility sign was 180 feet. The distance from the threshold of the front door to the corner of the block was 440 feet. The distance measured by the surveyor via car, from the end of the facility driveway to the point where the sidewalk ended, was 0.3 of a mile. The final destination to the super store was 0.5 miles from the facility driveway. This route was in the opposite direction Resident #16 was taking when he said he was going to a super store. Resident #16 turned left and proceeded up the sidewalk away from the facility. The route to the super store would have been a right turn, go down an incline using the sidewalk for 0.3 of a mile. After the sidewalk ended, a resident in a wheelchair would have had to go down a steep hill on a two- lane highway without the use of a sidewalk for 0.2 of a mile, cross to the left on the two-lane highway to enter the Walmart parking lot. Interview with the NP on 9/26/18 at 3:15 PM revealed she would expect a psychiatric evaluation to be completed before the resident went outside after the incident on 6/12/18. Interview revealed the resident had a change in cognition over the last month. He could not remember to sign himself out and was more fixated on his leg and being able to walk again. She was not involved in smoking assessments and explained the resident had been able to sign himself out or tell the staff he was going outside. The resident was able to go outside and smoke independently prior to his change in cognition in the last month. Interview with the NP on 9/26/18 at 3:30 PM revealed she had written a progress note indicating Resident #16 had attempted to get on a public transportation bus. She explained staff had informed her, but she did not have details about the incident. Interview with the primary physician on 9/26/18 at 4:10 PM revealed Resident #16 was getting forgetful. He had a stroke with right sided [MEDICAL CONDITION] and moved about in a wheelchair. The resident ' s usual behavior was to ask if he could walk and why could he not walk again. The resident attempted to leave the facility and due to the safety issue, the resident should not be outside unaccompanied. He explained the mental status decline had occurred in the last 3-4 months. As far as smoking, the physician explained that would be a safety concern in his opinion. During the time of his mental status change, he would not consider Resident #16 to be safe smoking. He would expect the nursing staff to accompany Resident #16 outside. The resident had safety issues, would not know consequences and could get lost. He was forgetful and that could impact his life/safety. On 9/26/17 at 5:00 PM the Administrator and DON were informed of the immediate jeopardy. The facility provided a credible allegation of the removal of the immediate jeopardy on 9/27/18. The credible allegation included: The statements included are not an admission and do not constitute agreement with the alleged deficiencies herein. This plan of correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center ' s allegation of compliance. All alleged deficiencies have been or will be completed by the dates indicated. The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited; Deficit practice is evident by, 06/12/2018, resident # 16, 1 of 5 smokers, left facility unattended without signing out or informing staff. Facility failed to provide supervision to ensure safety of resident # 16. Resident #16 left from the facility unattended from the front lobby door. Resident #16 was a smoker and left the center unattended to smoke unsupervised without signing out. Resident #16 had not been assessed as cognitively impaired with poor safety awareness until 07/23/2018 when resident #16 attempted to leave center without signing out again. At that time a wander prevention device was placed on resident #16, and continues to be in place. Facility failed to determine he was at risk, related to his impaired cognition and poor decision making skills, and being independently mobile in wheelchair. Facility could have prevented this by determining the resident could have been at risk based on his impaired cognition and poor decision making skills, and independently mobile in wheelchair. All doors are locked 24 hours per day with the exception of the front door. The front door was locked from 8pm to 6am. Root cause analysis: The facility failed to establish a set of criteria for determining which residents are appropriate to leave the center unattended. Facility Action · 06/12/2018 resident # 16 Power of Attorney was notified that he left facility without signing out. Nurse Practitioner was notified. Recommended resident #16 not go out of facility until further evaluation. Director of Nursing evaluated resident on 6/12 and deemed safe to continue to leave facility unattended and provided reeducation on signing out when he leaves the center. This evaluation was not placed in the medical record. Resident was evaluated by psychiatrist on 7/25/2018. The psychiatrist recommendation was to implement slight increase to [MEDICATION NAME] to reduce baseline impaired reality, perseverations and distress, will continue to monitor patient response. · Resident left center on 6/12/2018 to go to Walmart to get certain batteries as he did not want center ' s batteries. The receptionist saw resident move toward the facility sign at which time he continued down the sidewalk toward the church. The receptionist recalls a front office staff member bringing patient back to center. Upon return to facility resident #16 was assessed by the Licensed Nurse for any injuries, none were noted. On 6/20/2018 it was identified the resident continued to leave the center to smoke off the property unattended and failed to sign out. Resident was reeducated on sign in/out when leaving to smoke. The center is non-smoking therefore a smoking assessment was not completed to deem the resident safe or not. Director of nursing used nursing judgement and knowledge of patient for two years. The resident knew where he was going and why he wanted to leave the center. The resident demonstrated capability of making good judgement such as not leaving the center in poor weather conditions, not leaving the center for long periods of time and wearing proper attire. He demonstrated ability to retain information as evidenced by resident frequently coming to Director of Nursing and Administrator to apologize for leaving the center without signing out. · On 7/23/2018 resident #16 attempted to leave facility unattended. Nurse Practitioner and Power of attorney were notified. Wandering assessment completed and wander prevention device placed on resident. · Education with all facility staff was completed on 09/27/2018 to ensure 100% coverage of the front door for any resident attempting to leave the facility between the hours of 8am and 8pm, doors locked between 8pm and 8am. In-service will emphasize the importance of monitoring to make sure all cognitively impaired residents do not exit the center. Facility will utilize a single check in/out book for all residents that enter and leave the facility. All visitors will receive a visitor pass. Visitor passes must be worn during visit and returned to the front desk upon exiting the building. Any person to be a visitor in the building will be required to have a pass. Those that do not have passes will be residents. Receptionist to nurse verification will be required for any resident that signs out that is leaving unattended. Between the hours of 8:00PM and 8:00AM a clinical staff member will then make the determination as to let a resident out unattended or not using a list of residents deemed unsafe to leave facility unattended will be kept on each unit in patient information notebooks. · On 09/27/2018 all current residents with [DIAGNOSES REDACTED]. Discussion with Responsible Party, Medical Doctor/NP, and Interdisciplinary team will occur 9/27/2018 to accurately assess safety of the resident, that have been deemed at risk, based off [DIAGNOSES REDACTED]. List of residents deemed unsafe to leave facility unattended will be kept on each unit in patient information notebooks and their care plans will be updated accordingly. The procedure for implementing the acceptable plan of correction for the specific deficiency cited; · On 09/27/2018 all current residents with [DIAGNOSES REDACTED]. Discussion with Responsible Party, Medical Doctor/NP, and Interdisciplinary team will occur on 9/27/2018 to accurately assess safety of the resident, that have been deemed at risk, based off [DIAGNOSES REDACTED]. List of residents deemed unsafe to leave facility unattended will be kept on each unit in patient information notebooks and their care plans will be updated accordingly. · Front door lock times changed on 09/27/2018 to 8p to 8am. · On 09/27/2018 and ongoing, facility receptionist remained posted in the front lobby to monitor for any attempts by any resident to exit the facility. The hours of this were 8AM-8PM. From 8PM to 8AM the doors remain locked and any person has to be badged out by a staff member. · To open doors, a person must be badged out by a staff member. Badging members out of the building has been in process since (MONTH) (YEAR). Receptionist to nurse verification will be required for any resident that signs out that is leaving unattended. Between the hours of 8:00PM and 8:00AM a clinical staff member will then make the determination as to let a resident out unattended or not using a list of residents deemed unsafe to leave facility unattended will be kept on each unit in patient information notebooks. · Education started on 09/26/2018 by Administrator or designee. New hires will be educated during general orientation. 1) All facility staff will be in-serviced, by the Administrator or their designee, on resident check in/out procedures. Facility will utilize a single check in/out book for all residents that enter and leave the facility. All visitors will receive a visitor pass. Visitor passes must be worn during visit and returned to the front desk upon exiting the building. Any person to be a visitor in the building will be required to have a pass. Those that do not have passes will be residents. Receptionist to nurse verification will be required for any resident that signs out that is leaving unattended. Between the hours of 8:00PM and 8:00AM a clinical staff member will then make the determination as to let a resident out unattended or not. 2) No Nurse, C.N.A, weekend manager on duty, front office staff and receptionist will be allowed to work unless they have completed the required in-servicing. · Any new potential admissions will be notified by facility representative that center is a non-smoking campus. Any current smoker who is later deemed incapable of leaving the center unsupervised will be supervised and their care plans will be updated accordingly. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; · All new admissions will be audited by the Director of Nursing or designee for [DIAGNOSES REDACTED]. Discussion with Responsible Party, Medical Doctor/NP, and Interdisciplinary team will occur to accurately assess safety of the resident, that have been deemed at risk, based off [DIAGNOSES REDACTED]. List of residents deemed unsafe to leave facility unattended will be kept on each unit in patient information notebooks and their care plans will be updated accordingly . QA committee met 9/27/2018 on 100% coverage of the front door for any resident attempting to leave the facility between the hours of 8am and 8pm, doors locked between 8pm and 8am. Facility will utilize a single check in/out book for all residents that enter and leave the facility. All visitors will receive a visitor pass. Visitor passes must be worn during visit and returned to the front desk upon exiting the building. Any person to be a visitor in the building will be required to have a pass. Those that do not have passes will be residents. Receptionist to nurse verification will be required for any resident that signs out that is leaving unattended. Between the hours of 8:00PM and 8:00AM a clinical staff member will then make the determination as to let a resident out unattended or not using a list of residents deemed unsafe to leave facility unattended will be kept on each unit in patient information notebooks. All current residents with [DIAGNOSES REDACTED]. Discussion with Responsible Party, Medical Doctor/NP, and Interdisciplinary team will occur on 9/27/2018 to accurately assess safety of the resident, that have been deemed at risk, based off [DIAGNOSES REDACTED]. Audits will be weekly for one months, bi-weekly for 2 weeks, and monthly for one month. Determination included discussion with Responsible Party, Medical Doctor/NP, and Interdisciplinary team. Audits will be reviewed in quarterly quality assurance process improvement meeting X ' s 2 quarters. The title of the person responsible for implementing the acceptable plan of correction. · Administrator approved that the above is accurate and complete as of 09/27/2018. Validation of the credible allegation for removal of the immediate jeopardy was conducted on 9/27/18 at 5:00 PM. Validation included review of the audits of residents, record review for a sample of 4 residents identified as not safe to be unaccompanied off the facility premise, review of the assessments, care plan updates, notification of physician of the assessments, review of the inservice information provided to all staff and follow up interviews with various staff members.

323 - G Based on Observation, resident interview, staff interview, record review, and hospital records the facility failed to use the mechanical lift during transfer which resulted in injury for 1 of 3 sampled residents (Resident #1) reviewed for accidents. Findings include: Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) dated 8/27/12 revealed Resident #1 was totally dependent upon, and required the assistance of two staff members for transfers. The MDS further identified the resident as being cognitively intact. A review of Resident #1's Care Plan dated 8/28/12 revealed the resident had a Care Plan for Activities of daily Living (ADL). The Care Plan indicated the resident required assistance with ADL's with interventions that included the use of a mechanical lift for Resident #1's transfer needs. A review of the Physical Therapy Evaluation for Resident #1 dated 8/29/12 revealed Resident #1's functional status as dependent for bed mobility. The Physical Therapy Evaluation further indicated the resident was dependent with transfers with a Hoyer lift. A Progress Note dated 1/16/13 at 11:52pm was reviewed as written by Nurse #3. The Nurse ' s note stated that she was called to the resident ' s room by a Nurse Aid (NA). The note included, "Asked what happened, (unidentified NA) stated, 'did you know (Resident #1) can walk.' " The note also indicated that the NA told the nurse that Resident #1 could stand and that the NA said she and another NA had walked the resident to bed. The note further stated the NA reported a "pop sound from the resident's leg" when they were lifted onto her bed. The Progress Note further revealed that Resident #1 continued to report her right leg was hurting and swelling was observed. The Progress Note indicated the physician was notified of Resident #1's injury and Resident #1 was sent to the emergency room for evaluation. Review of the incident report dated 1/16/13 revealed Resident #1 sustained an injury during a transfer. The incident report indicated Nurse #3 was called to Resident #1's room by NA#2. NA #2 heard a pop sound when assisting (Resident #1) to bed. The incident report further indicated (Resident #1) stated her right knee was hurting "really bad" and the resident thought it was broken. The incident report identified the resident as being alert at the time of the incident. A review of Resident #1's hospital record reveal radiology report dated 1/17/13 indicated Resident #1 had an acute displaced spiral type fracture of the left distal femur above the knee. Hospital records further revealed Resident #1's bones appeared Osteopenic and [DIAGNOSES REDACTED] was noted. emergency room physicians Recommendations indicated a posterior splint, pain control and follow up due to patient's status and history of [DIAGNOSES REDACTED] and being non-ambulatory. An interview conducted on 1/29/13 at 2:50pm with Nurse #1 revealed Resident #1 was an alert and oriented resident who could communicate her wants and needs. Nurse #1 indicated that the resident was transferred by mechanical lift. Nurse #1 further stated that a mechanical lift was used to transfer the resident from bed to chair and 2 staff had to be present to use the mechanical lift. Nurse revealed the resident's legs did not bend and her body was very stiff. Resident #1 required total assistance from staff to complete most ADL's (activities of Daily living). Nurse #1 further stated that she had always observed staff transfer the resident using a mechanical lift. An interview conducted on 1/29/13 at 3:19pm with Resident #1 revealed she requested assistance from NA #1 to get into bed. Resident #1 stated that NA #3 came in with NA #1 but the two NAs were unable to get the mechanical lift pad from up under the resident to position it for lift with the lift. Resident #1 revealed that the NAs told Resident #1 that there was a rumor that she could walk, which Resident #1 denied. Resident #1 stated, "They (NA#2 and NA#3) tried leaning me forward and tried getting it (the lift pad) from under my legs and they couldn't get it." Resident #1 said NA #2 and NA #3 put the wheelchair close to the bed, stood her up on her legs and pivoted Resident #1 onto the bed by holding the resident up under her arms. Resident#1 stated a pop was heard when NA #2 and NA #3 stood her up on her feet to pivot and a second pop while NA #2 positioned the resident's legs in bed. Resident #1 revealed that until that day she was always transferred from chair to bed by the mechanical lift. An interview conducted on 1/30/13 at 3:53pm with NA #3 revealed that Resident #1 was supposed to be transferred by mechanical lift. NA #3 revealed on 1/16/12, she and two other NA transferred Resident #1 from the wheelchair to the bed. NA#3 indicated NA#1 requested assistance with putting Resident #1 to bed but they were unable to get the mechanical lift pad from under Resident #1. NA #3 revealed with the additional assistance of NA #2 the mechanical lift pad still could not be positioned under the resident properly. NA#3 stated we asked Resident #1 if she could transfer with the assistance of two people. NA#3 indicated Resident #1 stated that she would attempt to transfer. NA #3 said she (NA#3) got under one arm and NA #2 got under another arm and lifted Resident #1 and transferred her to the bed with the NAs bearing all of Resident #1's weight. NA # 3 stated Resident #1's feet never touched the ground during the transfer. NA #3 stated she did not hear a pop during the transfer. An interview conducted on 1/30/13 at 4:17pm with Nursing Assistant (NA#2) revealed on 1/16/13 NA #1 needed help putting Resident #1 in bed. NA#2 revealed the NA ' s were unable to get pad from under resident due to resident's electronic wheelchair being too small for the resident and no room being available to put another mechanical lift pad under the resident. Resident #1 was persistent about wanting to get into bed. NA #2 stated, "We (NA#2 and NA#3) decided to use a two person transfer". NA #2 revealed NA #2 and NA #3 grabbed Resident #1 under her arms, bore most of the weight and positioned the resident into bed. NA #2 stated the resident's feet never hit the ground during the transfer. Following the transfer, NA #2 heard a pop while positioning resident legs in the bed. NA#2 stated Resident #1 stated that her knee was hurting. NA #2 said she told the nurse about Resident #1's knee was hurting after a pop was heard while positioning resident legs in bed. An interview conducted on 1/31/13 at 3:00pm with Nurse #2. Nurse #2 indicated that NA #1 revealed NA #2 and NA #3 had transferred Resident #1 without the required mechanical lift. Nurse #2 stated Resident #1 should never be moved without a mechanical lift. Nurse #1 told Nurse #2 that NA #2 stated that Resident #1 could walk. Nurse #2 stated Resident #1 revealed NA #2 and NA #3 stood Resident #1 and put her in the bed. Nurse #2 said Resident #1 also revealed NA #2 and NA #3 did not use the mechanical lift. An interview conducted on 1/31/13 at 3:22pm with Nursing Assistant (NA#1) revealed on 1/16/13 Resident #1 requested to get into bed. NA #1 indicated she was aware that Resident #1 used a mechanical lift for transfers. NA #1 indicated NA #3 attempted to assist initially but the pad was under the resident and could not be retrieved. NA #3 got NA #2 for additional assistance to retrieve the pad from under the resident. NA #1 stated the resident was sitting on the part of the pad that went around the resident's shoulders. NA #1 revealed a decision was made that NA #2 and NA #3 would transfer Resident #1. NA #1 stated that the chair was positioned as close to the bed as possible and NA #2 and NA #3 transferred Resident #1 to bed. NA #1 indicated the resident's feet never hit the ground during the transfer. NA #1 stated she did not hear a pop during the transfer of Resident #1. NA #1 further revealed that she had left the room to attend to another resident while NA #2 was positioning Resident #1 in the bed. An Interview conducted on 2/1/13 at 1:30pm with Nurse #3 revealed the resident was heard to yell from down the hall as if in pain on 1/16/13. Nurse #3 indicated NA #2 said to her, 'did you know (Resident #1) can walk?' Nurse #3 revealed Resident #1 had never been observed to walk and was transferred by mechanical lift only. Nurse #3 further revealed that NA #1, NA #2, and NA #3 assisted the resident with the transfer. Nurse #3 stated that the resident communicated that her knee was hurting. Nurse #3 further indicated Resident #1 also revealed NA #2 and NA #3 stood the resident up on her feet and pivoted the resident into the bed. Nurse #3 indicated that she contacted the Doctor and ER for the resident to be transferred due to the pain the resident was in. Nurse #1 stated Resident's leg appeared to be broken.

Based on resident interviews, record reviews, staff interviews and physician interview the facility did not re- notify the physician that an ordered x-ray could not be done on the date of the original physician order, resulting in a delay of treatment of [REDACTED]. The X-ray when completed on 12/27/11 showed that the resident had a fractured ankle in two places, This is for 1 of 3 residents, Resident #2. The facility failed to notify the resident's physician for 2 of 3 sampled residents that fell and hit their heads during falls (Resident #7 and #8). The findings included: Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS), dated [DATE] revealed the resident had short- and long-term memory problems and was moderately impaired in decision making. The MDS indicated the resident required one-person physical assistance for activities of daily living (ADLs), including bed mobility, dressing, toilet use, personal hygiene, and bathing. The MDS indicated the resident had functional limitation in range of motion of his upper and lower extremities on one side. The resident's fall Care Area Assessment (CAA), dated 12/21/11, read in part: "per medical record resident is alert and oriented, however is confused at times. Requires extensive-to-dependent assistance with transfers. Right sided weakness secondary [MEDICAL CONDITION]. Resident at risk for falls due to above information." The resident's ADL CAA, dated 12/21/11, read in part: "per medical record resident has right-sided weakness, analysis of findings - Requires extensive-to-dependent assistance with most ADLs. Resident at risk for complications related to ADL function and/or further decline in ADL functional status. " The resident's Care Plan, dated 12/8/11, indicated "resident is at risk for fall." The approaches included monitoring vital signs, administering medications as ordered, and arranging the environment for maximum functioning. Record review revealed a facility Incident/Accident Report dated 12/22/11. The description of the incident read, "Resident rolled out of bed during ADL care, Resident rolled on bedside mat. " The report indicated that the resident had no apparent injury. The resident's physician was notified of this fall on the same date of the fall. Nursing notes dated 12/23/11 at 6:22 pm read in part, " resident alert and verbal. No signs of distress. Resident had no further complications or falls during the shift. Respiration even and unlabored. " Nursing notes dated 12/24/11 at 10:48 am read in part, " patient is alert and verbal. Voiced no pain. Respiration non-labored. " Nursing notes dated 12/25/11 at 5:54 pm read in part, " resident alert and able to voice needs. Complained of left ankle pain, assessed area, swelling noted, tender to touch. Medical director received new order for x-ray of left ankle. Mobile x-ray called and aware of order. Pain medication given as needed. No further pain voiced. " Record review of telephone physician's order [REDACTED]. " Nursing notes dated 12/26/11 read in part, " resident alert and verbal. No signs of distress. Resident complained of left ankle pain. X-ray ordered for left ankle. Medication x 1 for complaint of pain. Continue to monitor. " Record review of radiology report dated 12/27/11: " [MEDICAL CONDITION] fibula is noted. [MEDICAL CONDITION] tibia is present. Soft tissue swelling is noted in the region of the ankle joint. " Nursing notes dated 12/27/11 read in part, " received x-ray results. [MEDICAL CONDITION] tibia and fibular metaphysis are noted with no significant displacement. Medical director notified. New order to send resident to emergency room for further evaluation. Resident left facility via ambulance. " An Emergency Department report dated 12/27/11 revealed the resident was seen for an accidental fall on 12/22/11 resulting in distal tibia and fibula fracture. Nursing notes dated 12/27/11 read in part, " resident back from emergency department. Splint to the left leg. New order for [MEDICATION NAME] 5/325 mg (medication used to relieve moderate to severe pain) 1-2 tablets by mouth every 4-6 hours as needed and to follow up with orthopedic doctor 1-2 days. No pain or discomfort upon return. Received x-ray results. [MEDICAL CONDITION] tibia and fibular metaphysis are noted with no significant displacement. Medical director notified. " Review of radiology report dated 12/27/11 read in part, " the bones are demineralized. [MEDICAL CONDITION] metaphysis of the the fibula is noted. Fracture of distal metaphysis of the tibia is present. Soft tissue swelling is noted in the region of ankle joint. " Review of orthopedic consultation report dated 12/29/11 read in part " Recommendation 4. Follow up 2 weeks for cast change. " Record review of the physician progress notes [REDACTED]. The patient had a [MEDICAL CONDITION] tibial and fibular metaphysis on the left side and is in a cast. He denies any symptoms except for pain in his left lower extremity. " In an interview on 1/17/12 at 2:44 pm the interim administrator stated that " an order for [REDACTED]. to the schedule. I have in-serviced my staff on the importance of having x-rays done in a timely manner. My expectations are that for any acute episode that might rule out bone fracture the x-ray must be done the same day. In event the x-ray company is not able to come the same day within a reasonable time frame, the medical director should be notified and the resident should be sent out to the hospital. " The interim administrator added that this was not done. In a telephone interview on 1/18/12 at 8:30 am the medical director stated that his expectations are that if an order is written by himself or an on-call physician for an x-ray, it should be done on the day it was written. He added that the mobile unit normally comes to the facility when requested, so it should be done within the day. If the x-ray is not done when ordered he expects communications from the facility immediately so the resident can be sent to the emergency department. In an interview on 1/18/12 at 10:38 am Nurse #2, the nurse responsible for the resident's care on 12/25/11, stated " I was on duty 12/25/11 and the resident's family member told me that (name of the resident) had fallen 3 days ago and the resident was in pain. I went in his room and assessed his ankle and it was swollen. I called the medical director and he gave me an order for [REDACTED]. " In an interview with the attending physician on 2/1/12 at 6:55 pm, he stated, " I think it was bad and unacceptable that the x-ray was not done in timely manner. But the resident was not walking on the ankle and the fracture was not displaced, so it did not impact his bone exceptionally. Hopefully, they would call and notify me that the x-ray was not done, but they never called. " The attending physician was asked, " How do you monitor x-ray results? " He answered that two doctors visit the facility 5 days a week; if there is a critical matter, the facility calls one of the doctors. If the situation is not critical, the facility puts the results in a box to be reviewed. The results normally stay in the box for up to two days, no more. During a follow-up visit 2/2/12 at 9:30 am, Nurse #1, a Licensed Practical Nurse stated that NA #1 " came and told me told that the resident rolled to the floor. She stated she was turning the resident and the resident rolled to the floor. When I went to the room, he was on his right side and his leg was extended. The resident said that he was experiencing no pain. I touched his legs; he had no pain. I did not do any range of motion checks. I believe I gave him pain medication. His legs were not bigger that normal (Resident #2 has routine [MEDICAL CONDITION]). Before we removed him from off the floor, we did vital signs and checked his pupils and I asked him if he had pain. I did not assess him again. The expectation is that if the fall is witnessed, we do not have to assess again, but if it is not witnessed, we have to assess the resident for 3 days. On the 26th, the family told me that the resident fell , and he was supposed to have an x-ray, and it was not done. I called the x-ray company, and they came out that day to do the x-ray. " Record review showed the x-ray was not taken until 12/27/11. In an interview on 2/2/12 at 11:29 am with Nurse # 12, she stated, " no one told me that the resident had a fall. On 12/24/11 the family member came and told me that the resident fell and no one was doing anything about it. I told my DON and my nurse manager about the family ' s concerns. I looked in the nurses notes and I saw where they were elevating the resident ' s leg with a pillow. I checked the resident, and his leg was already elevated so I did nothing. I did not give him pain medication because he said he had no pain. On December 25, I gave him his medication, he had no pain, and his ankle was swollen. I did not do anything to the ankle because his arm and leg were always puffy. " She added, " as far as I know the x-ray was done. " Surveyor and Nurse #12 checked the nursing notes; there was no documentation of a swollen ankle. 2. Resident #8 was admitted on [DATE] and readmitted on [DATE]. The resident cumulative [DIAGNOSES REDACTED].#8 had short term and long term memory problems and severely impaired cognition for daily decision making. Review of Nurses Notes revealed written by Nurse #15 on 12/12/2011 at 3:53am. The Nurse documented that Resident #8 was found lying on the fall mat beside the roommate's bed around 3:15am. The resident was previously in her wheelchair and refused to be helped to her bed. Nurse #15 documented that there was a 1/2 inch cut on the middle of Resident # 8's forehead and that the cut was cleaned, antibiotic ointment and a bandage was applied, the resident stated no pain. The Nurse documented vital signs and neurological checks were within normal limits. Communication was sent to the MD (medical doctor), email sent to unit manager and RP (responsible party) to be notified later in the morning. A Nurses Note at 6:55am indicated that Nurse #15 spoke to the RP about the resident's fall earlier in the night. An interview with Nurse #15 was unsuccessful by telephone and at the facility on 2/03/2012 at 3:10pm and again at 6pm. The Administrator said the nurse worked on 11pm-7am shift. A Review of the Incident/Accident Report dated 12/12/2011 at 3:15am, revealed the Physician was notified by "communication " (fax communication) on 12/12/2011 and no time was documented. A review of the clinical record conducted on 2/03/2012 at 10:00am, revealed there was not a copy of a communication form addressed to the physician related to Resident #8's fall on 12/12/2012. An interview on 2/03/2012 at 12:25pm, was conducted with the Interim Administrator. The Administrator checked the resident's medical record and confirmed that the communication form was not in the chart. The Administrator said the physician should have been called instead of a fax communication form because this was an injury. The Administrator said she would expect with an injury for the Charge Nurse to notify the RN on call by telephone and the MD to be called for orders. 3. Resident # 7 was admitted to the facility on [DATE], the Minimum (MDS) data set [DATE], diagnosis include [MEDICAL CONDITIONS], hypertension, [MEDICAL CONDITIONS] reflux disease , end stage [MEDICAL CONDITION], arthritis , cerebral vascular disease. He had good long and short term memory and was able to make his decisions and judgments for his daily care. He had fluctuating disorganized thinking, and had no behavioral symptoms, towards others. Review of the Incident Accident Report dated Saturday 12/31/11 at 3:15p.m., indicated Resident #7 fell in his room which result in swelling above the right eye. The nurse supervisor had been notified via telephone 12/31/11 at 3:30p.m., the doctor was not notified and the responsible party was not notified. During an interview on 2/3/12 at 2:25p.m., nurse #12 indicated she had thought she had completed a communication form regarding the fall 12/31/11(Saturday) to the doctor and put it into a folder for the doctor to read the next time he made rounds (during the week). She indicated she did not know where the notification forms were filed after they were placed in the doctor ' s folder. The nurse stated that she had not contacted the doctor by phone and she had thought she had written a note. She indicated she had called the nurse supervisor. She did not call the responsible party. During an interview on 2/3/12 at 2:28p.m., Nurse #9(nurse supervisor) indicated she was aware of the fall on 12/31/12 (Saturday) She indicated the doctor or the responsible party was not contacted about the fall on Saturday 12/31/11.

Based on resident interviews, record reviews, staff interviews, and a physician interview, the facility failed to assess Resident #2's ankle on 12/22/11 resulting in a delay of treatment. The X-Ray of 12/27/11 showed: " [MEDICAL CONDITION] fibula is noted. [MEDICAL CONDITION] metaphysis of the tibia is present. Soft tissue swelling is noted in the region of the ankle joint." This is for 1 of 2 residents, Resident #2. The facility failed to assess the condition of a resident after two consecutive falls for 1 of 3 residents that fell hitting his head (Resident #7). The findings included: 1. Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS), dated [DATE] revealed the resident had short- and long-term memory problems and was moderately impaired in decision making. The MDS indicated the resident required one-person physical assistance for activities of daily living (ADLs), including bed mobility, dressing, toilet use, personal hygiene, and bathing. The MDS indicated the resident had functional limitation in range of motion of his upper and lower extremities on one side. The resident's fall Care Area Assessment (CAA), dated 12/21/11, read in part: "per medical record resident is alert and oriented, however is confused at times. Requires extensive-to-dependent assistance with transfers. Right sided weakness secondary [MEDICAL CONDITION]. Resident at risk for falls due to above information." The resident's ADL CAA, dated 12/21/11, read in part: "per medical record resident has right-sided weakness, analysis of findings - Requires extensive-to-dependent assistance with most ADLs. Resident at risk for complications related to ADL function and/or further decline in ADL functional status. " The resident's Care Plan, dated 12/8/11, indicated "resident is at risk for fall." The approaches included monitoring vital signs, administering medications as ordered, and arranging the environment for maximum functioning. Record review of the Medication Administration Record, [REDACTED]. On 12/15/11, 12/19/11 and 12/20/11 Narco x 1 (this is the brand name for [MEDICATION NAME] and [MEDICATION NAME] which is used for moderate pain) was administered to the resident. Record review revealed a facility Incident/Accident Report dated 12/22/11. The description of the incident read, "Resident rolled out of bed during ADL care, Resident rolled on bedside mat. " The report indicated that the resident had no apparent injury. In an interview on 1/17/11 at 11:00 am with Nurse #1, she stated that " on 12/22/11 the resident rolled off the bed to the fall mat during morning care. The aide that was giving care got me, we assisted the resident back to the bed. I assessed the resident I did neurological checks and asked him if he was having pain. He denied pain. He was able to move his lower extremity as well as upper extremity. I did not check his ankle because denied pain " Nurse #1 added that there was no bleeding, no bruising, no skin tears or swelling from fall, and NA #1 took the resident ' s vital signs. Record review of resident ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 12/23/11 at 9:00 pm [MEDICATION NAME] was administered (reason: pain level 7/10; recheck, 2/10). On 12/24/11 at 8:30 am [MEDICATION NAME] was administered (reason: pain level 7/10; recheck, 2/10). On 12/25/11 at 8:30 am [MEDICATION NAME] was administered (reason: pain level 7/10; recheck, blank). On 12/25/11 at 4:00 pm [MEDICATION NAME] was administered (reason: pain level 8/10; recheck, 2/10). On 12/26/11 at 8:00 am [MEDICATION NAME] was administered (reason: pain level 8/10; recheck, 2/10. On 12/27/11 at 4:00 pm [MEDICATION NAME] was administered (reason: pain level 8/10; recheck, 2/10. [MEDICATION NAME] was administered due to the resident's phantom pain from his amputation on the left leg. Record review of physical therapy progress notes dated 12/23/11 at 1:02 pm read as follows: " pt (patient) rolled off bed on fall mat during ADL care on 12/2211. Pt recalled the incident. Nursing to place wing mattress to reduce risk of further falls. Physical therapy is ongoing to improve bed mobility skills/transfer skills and wheel mobility. " Nursing notes dated 12/23/11 at 6:22 pm read in part, " resident alert and verbal. No signs of distress. Resident had no further complications or falls during the shift. Respiration even and unlabored. " Record review of physical therapy progress notes dated 12/24/11 at 10:07 am read, " resident seen in bed for bed mobility tasks requires plus one (+1) max(imum ) rolling to left side and moda/mina (person performing 50% or more or 40% or less) to right using right rail to pull self. Low-level exercises to left leg that appears swollen, resident reports sliding out of bed on Thursday and injured it started to feel pain in the ankle. Nsg (nursing) told of this input. "There was no further assessment from nursing staff of the complaint of pain. Nursing notes dated 12/24/11 at 10:48 am read in part, " patient is alert and verbal. Voiced no pain. Respiration non-labored. " Nursing notes dated 12/25/11 at 5:54 pm read in part, " resident alert and able to voice needs. Complained of left ankle pain, assessed area, swelling noted, tender to touch. Medical director received new order for x-ray of left ankle. Mobile x-ray called and aware of order. Pain medication given as needed. No further pain voiced. " Record review of telephone physician 's order dated 12/25/11 at 5:00pm read in part, " x-ray left ankle related to pain and swelling. " Nursing notes dated 12/26/11 at 1:29 pm read in part, " resident alert and verbal. No signs of distress. Resident complained of left ankle pain. X-ray ordered for left ankle. Medication x 1 for complaint of pain. Continue to monitor. " In a follow-up interview with the resident # 2 on 2/2/12 at 9:00 am (in the presence of NA #1 and nurse #3), the resident stated that he had fallen and hurt his ankle sometime in December. " A lot of people came in the room, " he said. " I told them that my ankle hurt, but they did not give me anything until that night. I hurt for many days before they took care of it. " Record review of radiology report dated 12/27/11: " [MEDICAL CONDITION] fibula is noted. [MEDICAL CONDITION] metaphysis of the tibia is present. Soft tissue swelling is noted in the region of the ankle joint. " Nursing notes dated 12/27/11 at 10:30 pm read in part, " received x-ray results. [MEDICAL CONDITION] tibia and fibular metaphysis are noted with no significant displacement. Medical director notified. New order to send resident to emergency room for further evaluation. Resident left facility via ambulance. " An Emergency Department report dated 12/27/11 revealed the resident was seen for an accidental fall on 12/22/11 resulting in distal tibia and fibula fracture. Nursing notes dated 12/27/11 at 11:55pm read in part, " resident back from emergency department. Splint to the left leg. New order for [MEDICATION NAME] 5/325 mg (medication used to relieve moderate to severe pain) 1-2 tablets by mouth every 4-6 hours as needed and to follow up with orthopedic doctor 1-2 days. No pain or discomfort upon return. Received x-ray results. [MEDICAL CONDITION] tibia and fibular metaphysis are noted with no significant displacement. Medical director notified. " Review of radiology report dated 12/27/11 read in part, " the bones are demineralized. [MEDICAL CONDITION] metaphysis of the the fibula is noted. Fracture of distal metaphysis of the tibia is present. Soft tissue swelling is noted in the region of ankle joint. " Review of orthopedic consultation report dated 12/29/11 read in part " Recommendation 4. Follow up 2 weeks for cast change. " Record review of the physician progress notes [REDACTED]. The patient had a [MEDICAL CONDITION] tibial and fibular metaphysis on the left side and is in a cast. He denies any symptoms except for pain in his left lower extremity. " Record review of Nurse #5 ' s statement submitted as part of the investigation dated 1/12/12 read in part, " I (name of nurse, who no longer works in the facility) was the scheduled 11-7 nurse for (name of the resident) on December 23rd 24th, 25th, and 26th. He had fallen on December 22nd on 1st shift. When I came to work Friday night the 23rd the second shift nurse had given pain medication at 8:30 pm and he had no pain. He slept through the shift. Resident ' s extremities appear to be [MEDICAL CONDITION] most of the time. On Saturday the 24th resident had no pain all during shift. On Sunday the 25th resident complained of pain to the second shift nurse. An order received for x-ray to left ankle. The x-ray company was called by Nurse #2 (name of the nurse). " This nurse told Nurse #3 that the x-ray company would not come out until 12/26/11. On 12/26/11 Nurse #2 told Nurse on the first shift that the x-ray was not done. The x-ray was not done until 12/27/12. " The surveyor attempted three times during the survey but was unable to contact Nurse #5. In an interview on 1/17/12 at 10:41 am NA #1 (nursing assistant) who was responsible for the resident's daily care, and who witnessed the fall, stated that " on 12/22/11, I was trying to turn the resident while doing his (morning) care and he rolled off the bed on to the floor mat. I went and got the nurse (Nurse #1) and two aides, and they assisted the resident to the bed. " NA #1 added that when the nurse asked the resident if he was experiencing pain, he denied any pain. She further stated that " I took his vital signs. " In an interview on 1/17/11 at 11:00 am with Nurse #1, she stated that " on 12/22/11 the resident rolled off the bed to the fall mat during morning care. The aide that was giving care got me, we assisted the resident back to the bed. I assessed the resident I did neurological checks and asked him if he was having pain. He denied pain. He was able to move his lower extremity as well as upper extremity. " Nurse #1 added that there was no bleeding, no bruising, no skin tears or swelling from fall, and NA #1 took the resident ' s vital signs. In an interview on 1/17/12 at 2:44 pm the interim administrator stated that " (name of the resident) rolled out of the bed to the floor mat on 12/22/11. I went to the the resident ' s room to discuss the incident with the resident. I performed a visual inspection of the resident ' s body, the resident ' s heel was bloated because he has a history of a wound to his heel. The resident was noted to have [MEDICAL CONDITION] to the upper right arm and a trace of [MEDICAL CONDITION] to left lower extremity. This was no different from any other day since admission. This resident had a history of [REDACTED]. No misalignment was noted to the extremity. The family member was notified. On 12/25/11 the family member complained to the nurse who was in charge of the resident ' s care that the resident ' s ankle was swollen and he was experiencing pain. an order for [REDACTED]. to the schedule. I have in-serviced my staff on the importance of having x-rays done in a timely manner. My expectations are that for any acute episode that might rule out bone fracture the x-ray must be done the same day. In event the x-ray company is not able to come the same day within a reasonable time frame, the medical director should be notified and the resident should be sent out to the hospital. " The interim administrator added that this was not done. She further stated NA #1 had been in-serviced on the proper procedure for ADL care of residents with weakness in one or both sides. She further stated that the resident has not had another fall. In an interview on 1/17/12 at 3:44 pm, Resident #2 stated " I fell off my bed to the floor and broke my ankle. " He added the ankle was swollen and hurting. In a telephone interview on 1/18/12 at 8:30 am the medical director stated that his expectations are that if an order is written by himself or an on-call physician for an x-ray, it should be done on the day it was written. He added that the mobile unit normally comes to the facility when requested, so it should be done within the day. If the x-ray is not done when ordered he expects communications from the facility immediately so the resident can be sent to the emergency department. In an interview on 1/18/12 at 9:52 am, NA #2 stated that " I was responsible for the resident ' s care on 12/24/11; he did not experience any pain while I was giving care, but his ankle was swollen and I elevated the ankle with a pillow. " During a follow up telephone interview on 1/27/12 at 11:40am NA #2 she stated that an aide told her to elevate the resident ' s ankle with a pillow but she does not remember which aide. In an interview on 1/18/12 at 10:38 am Nurse #2, the nurse responsible for the resident's care on 12/25/11, stated " I was on duty 12/25/11 and the resident's family member told me that (name of the resident) had fallen 3 days ago and the resident was in pain. I went in his room and assessed his ankle and it was swollen. I called the medical director and he gave me an order for [REDACTED]. " During a telephone interview on 1/18/12 at 3:10 pm Nurse #4 who worked with the resident on 12/26/11, stated that the resident was alert and verbal. The resident was administered [MEDICATION NAME] for his phantom pain. The resident did not complain of any ankle pain, nor was the ankle swollen. In a telephone interview on 1/26/12 at 5:30 pm NA #1 stated that I was performing a bed bath, and after washing his back, I put a lot of lotion on him because he has very dry skin. I turned him away from me. The resident held on and began to turn, and his lower body began to slide off the bed. My hands were greasy; I attempted to catch him but I was unable to, and the resident slid to the floor. I called my nurse, and she assisted him off the floor with the help of 2 aides. NA#1 further indicated the bed rails (small rails) opposite to where she would turn the resident were lowered, but the small rail away from her were raised, and the resident held on to the small rail and attempted to turn. The bed was in the normal position; she reiterated that the bed was not in the low position. In a telephone interview on 1/27/12 at 12:20 pm with the interim administrator , she stated that Resident #2 slid out of bed while ADL care was performed on 12/22/11. The resident care plan reflected a 1-person assist with ADLs for bed mobility. NA #1 is well aware of the care for Resident #2 as she has cared for him on multiple occasions prior to the incident. " The interim administrator further stated that Resident #2 was in bed. NA #1 was in his room with a fall mat on both sides of the bed. NA #1 was performing a bed bath on the resident and moisturizer his skin on the front side. After bathing and moisturizing the resident ' s front side, NA #1 began to turn the resident towards his left side as she needed to complete the bed bath. When NA #1 began to turn the resident, the resident ' s lower body slid out of the bed. NA #1 attempted to catch the resident but she was unable, and the resident rolled on the fall mat. Nurse #1 completed a full assessment of the resident. The resident declined pain. There was no new swelling or bruising. The family and the medical director were notified. In a follow-up interview on 2/1/12 at 5:50 pm with Nurse # 2, the nurse stated that " 12/25/11 was the first time I ever worked with the resident. The resident ' s family member came and asked me to look at the resident ' s ankle because it was swollen and tender to the touch. The resident was in pain. I did not know that he had a fall until the family member told me. Vital signs were done; the resident was not hollering or in any acute distress. I gave the resident [MEDICATION NAME], and afterwards he only had a small amount of pain. I called the attending physician and told him the resident a had swollen ankle. I explained that he had fallen a couple days prior, and he was in pain. The attending physician gave me an x-ray order. Because it was not a stat and it was Christmas Day, the x-ray company stated that they would be in the following the morning to do the x-ray. I did not call the attending physician back because we normally wait until the x-ray is done and because the x-ray company stated they would be coming the following day. I told this to the nurse who was coming on the next shift. " In a follow-up interview on 2/1/12 at 6:16 pm with Nurse #4, he stated, " to my knowledge on 12/23/11 the resident had no swelling, no pain, no bruising. Later in the shift the resident requested pain medication for phantom pain. " When the surveyor asked the nurse, " How do you know it was phantom pain, " he stated that the resident pointed to his stump. In an interview with the attending physician on 2/1/12 at 6:55 pm, he stated, " I think it was bad and unacceptable that the x-ray was not done in timely manner. But the resident was not walking on the ankle and the fracture was not displaced, so it did not impact his bone exceptionally. Hopefully, they would call and notify me that the x-ray was not done, but they never called. " The surveyor asked the attending physician, " How do you monitor x-ray results? " He answered that two doctors visit the facility 5 days a week; if there is a critical matter, the facility calls one of the doctors. If the situation is not critical, the facility puts the results in a box to be reviewed. The results normally stay in the box for up to two days, no more. In a follow-up interview with the resident # 2 on 2/2/12 at 9:00 am (in the presence of NA #1 and nurse #3,) the resident stated that he had fallen and hurt his ankle sometime in December. " A lot of people came in the room, " he said. " I told them that my ankle hurt, but they did not give me anything until that night. I hurt for many days before they took care of it. " During a follow-up interview on 2/2/12 at 9:30 am, Nurse #1 stated that NA #1 " came and told me told that the resident rolled to the floor. She stated she was turning the resident and the resident rolled to the floor. When I went to the room, he was on his right side and his leg was extended. The resident said that he was experiencing no pain. I touched his legs; he had no pain. I did not do any range of motion checks. I believe I gave him pain medication. His legs were not bigger that normal ( Nurse # 1 stated that Resident #2 has routine [MEDICAL CONDITION]). Before we removed him from off the floor, we did vital signs and checked his pupils and I asked him if he had pain. I did not assess him again. The expectation is that if the fall is witnessed, we do not have to assess again, but if it is not witnessed, we have to assess the resident for 3 days. On the 26th, the family told me that the resident fell , and he was supposed to have an x-ray, and it was not done. I called the x-ray company, and they came out that day to do the x-ray. " Record review showed the x-ray was not taken until 12/27/11. In an interview on 2/2/12 at 11:29 am with Nurse # 12 , she stated, " no one told me that the resident had a fall. On 12/24/11 the family member came and told me that the resident fell and no one was doing anything about it. I told my DON and my nurse manager about the family ' s concerns. I looked in the nurses notes and I saw where they were elevating the resident ' s leg with a pillow. I checked the resident, and his leg was already elevated so I did nothing. I did not give him pain medication because he said he had no pain. On December 25, I gave him his medication, he had no pain, and his ankle was swollen. I did not do anything to the ankle because his arm and leg were always puffy. " She added, " as far as I know the x-ray was done. " Surveyor and Nurse # 12 checked the nursing notes; there was no documentation of a swollen ankle documented by this nurse. In an interview on 02/2/12 at 3:00 pm with the physical therapy supervisor, he stated, " On 12/24/11 the resident ' s ankle was observed to be swollen; it was bigger than normal. The resident stated that he was experiencing pain in the ankle and the physical therapy assistant, who was working on a per diem basis, told the morning nurse immediately. Several calls were made to the physical therapy assistant, but he never returned the call. " During a follow up interview on 2/2/12 at 3:30 pm with the interim administrator, she stated that the facility was trying to get in touch with the physical therapy assistant to see who he spoke to. She further stated that " we have not heard from him and whenever we know something we will let me know. " The administrator never got back to the surveyor on that matter. During a telephone interview on 2/2/12 at 4:12 pm with the family member, he stated that on 12/25/11 at about 10:30 am, the resident told him he had fallen a couple days ago and his leg was hurting and swollen. " I spoke with the nurse and she told me she would get an x-ray order. I came back on 12/26/11, and the x-ray was not done. I came back on 12/27/11; the x-ray was not done. I got mad and left the facility. " 2. Resident # 7 was admitted to the facility on [DATE] current active [DIAGNOSES REDACTED]. Review of the MDS revealed moderately impaired cognitive skills, long and short term memory problems. The assessment revealed no behavioral symptoms towards others. Resident #7 required extensive assistance of one person to physically assist him with transferring between the surfaces and toileting. Review of the Incident accident reported dated 12/31/11, indicated Resident #7 had an unwitnessed fall in his room at 3:15 p.m., which resulted in a swollen area above the right eye. Review of the medical record revealed the Neurological Assessment was completed 12/31/11, began at 3:15p.m and was completed at 10:00p.m. No Post Fall Assessment was completed for 12/31/11. Review of the nursing notes to determine the continued monitoring of Resident #7 after the fall on 12/31/11 revealed: No nursing note addressing the actual fall on 12/31/11. No nursing note 12/31/11 during the 3p.m.-11 p.m. shift. No nursing note 1/1/12 during the 11p.m-7am shift. A nursing noted dated 1/1/12 2:12 p.m., read in part, " patient is alert and verbal, no c/o from f/u fall, " No nursing note during 1/1/12, 3p.m.-11p.m. shift. An Incident Accident Report Dated 1/2/12 indicated Resident #7 had an unwitnessed fall in his room at 2:48a.m., resulting in a black eye, skin tear to his left arm. A Neurological Assessment sheet dated 1/2/12 began at 2:45a.m., and was completed at 9:30a.m. A Post Fall Assessment sheet was completed 1/2/12. Review of the nursing noted dated 1/2/12 at 3:38 p.m., read, " was walking past resident room and heard a thumping /knocking sound coming(sic) from his room, found resident on bathroom floor, had a skin tear to the left upper forearm and a right black eye, asked resident what happened, stated he was trying to get onto the toilet and fell , asked why didn't (sic) he yell out for help, resident stated " I don ' t know. " , showed him again how to use the call light...cont to monitor " Review of the nursing note dated 1/2/12 at 11:46a.m read in part, " Bruised, discolored swollen rt eye from(sic)post fall this morning. Rt eye sensitive to light covered eye with 4x4 gauze. " Review of the nursing note dated 1/2/12 at 5:55p.m. in part " Resident alert and verbal..No complaints voiced. " No nursing note dated 1/3/12, or 1/4/12. During an interview on 2/3/12 at 10:52a.m., nurse # 12 indicated she was the nurse who responded to the fall dated 12/31/11, she did not complete a Post Fall assessment form, and she thought she had completed a note on 12/31/11 but it did not save. During an interview on 2/3/12 at 11:18a.m., nurse#9 indicated there was no Post Fall Assessment document or nursing notes for monitoring dated 12/31/11, 1/1/12 during 3rd shift, 1/3/1 or 1/4/12. She concluded nurses notes should have been completed per the policy for each shift. The facility did not evaluate, monitor and document Resident #7 response per the policy for the first 24 /48 hours, after the fall as indicated in their policy.

Based on resident interviews,family interview, record reviews, staff interviews, and a physician interview, the facility failed to safely provide a resident a bed bath resulting in the resident rolling out of bed onto the floor for 1 of 1 resident (resident# 2) resulting in a fall with a fractured ankle. The X-Ray of 12/27/11 showed: " Fracture of the distal fibula is noted. Fracture of the distal metaphysis of the tibia is present. Soft tissue swelling is noted in the region of the ankle joint. " The facility failed to ensure safety device was in place to prevent falls from wheelchair for 1 of 3 residents.(Resident #7). The findings included: 1. Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS), dated [DATE] revealed the resident had short- and long-term memory problems and was moderately impaired in decision making. The MDS indicated the resident required one-person physical assistance for activities of daily living (ADLs), including bed mobility, dressing, toilet use, personal hygiene, and bathing. The MDS indicated the resident had functional limitation in range of motion of his upper and lower extremities on one side. The resident's fall Care Area Assessment (CAA), dated 12/21/11, read in part: "per medical record resident is alert and oriented, however is confused at times. Requires extensive-to-dependent assistance with transfers. Right sided weakness secondary to CVA noted. Resident at risk for falls due to above information." The resident's ADL CAA, dated 12/21/11, read in part: "per medical record resident has right-sided weakness, analysis of findings - Requires extensive-to-dependent assistance with most ADLs. Resident at risk for complications related to ADL function and/or further decline in ADL functional status. " The resident's Care Plan, dated 12/8/11, indicated "resident is at risk for fall." The approaches included monitoring vital signs, administering medications as ordered, and arranging the environment for maximum functioning. Record review revealed a facility Incident/Accident Report dated 12/22/11. The description of the incident read, "Resident rolled out of bed during ADL care, Resident rolled on bedside mat. " The report indicated that the resident had no apparent injury. Record review of resident ' s medication administration record dated 12/22 to 12/27/11 read as follows: On 12/22/11 at 9:00 pm Vicodin was administered for pain, level 8 out of 10; recheck of pain level was 2/10. On 12/23/11 at 9:00 pm Vicodin was administered (reason: pain level 7/10; recheck, 2/10). On 12/24/11 at 8:30 am Vicodin was administered (reason: pain level 7/10; recheck, 2/10). On 12/25/11 at 8:30 am Vicodin was administered (reason: pain level 7/10; recheck, blank). On 12/25/11 at 4:00 pm Vicodin was administered (reason: pain level 8/10; recheck, 2/10). On 12/26/11 at 8:00 am Vicodin was administered (reason: pain level 8/10; recheck, 2/10. On 12/27/11 at 4:00 pm Vicodin was administered (reason: pain level 8/10; recheck, 2/10. Record review of physical therapy progress notes dated 12/23/11 at 1:02 pm read as follows: " pt (patient) rolled off bed on fall mat during ADL care on 12/2211. Pt recalled the incident. Nursing to place wing mattress to reduce risk of further falls. Physical therapy is ongoing to improve bed mobility skills/transfer skills and wheel mobility. " There was no further assessment from nursing staff of the complaint of pain. Nursing notes dated 12/23/11 at 6:22 pm read in part, " resident alert and verbal. No signs of distress. Resident had no further complications or falls during the shift. Respiration even and unlabored. " Record review of physical therapy progress notes dated 12/24/11 at 10:07 am read, " resident seen in bed for bed mobility tasks requires plus one (+1) max(imum ) rolling to left side and moda/mina (person performing 50% or more or 40% or less) to right using right rail to pull self. Low-level exercises to left leg that appears swollen, resident reports sliding out of bed on Thursday and injured, started to feel pain in the ankle. Nsg (nursing) told of this input. " Nursing notes dated 12/24/11 at 10:48 am read in part, " patient is alert and verbal. Voiced no pain. Respiration non-labored. " Nursing notes dated 12/25/11 at 5:54 pm read in part, " resident alert and able to voice needs. Complained of left ankle pain, assessed area, swelling noted, tender to touch. Medical director received new order for x-ray of left ankle. Mobile x-ray called and aware of order. Pain medication given as needed. No further pain voiced. " Record review of telephone physician ' s order dated 12/25/11 at 5:00pm read in part, " x-ray left ankle related to pain and swelling. " Nursing notes dated 12/26/11 at 1:29 pm read in part, " resident alert and verbal. No signs of distress. Resident complained of left ankle pain. X-ray ordered for left ankle. Medication x 1 for complaint of pain. Continue to monitor. " Nursing notes dated 12/27/11 at 10:30 pm read in part, " received x-ray results. Fracture of the distal tibia and fibular metaphysis are noted with no significant displacement. Medical director notified. New order to send resident to emergency room for further evaluation. Resident left facility via ambulance. " Record review of radiology report dated 12/27/11: " Fracture of the distal fibula is noted. Fracture of the distal metaphysis of the tibia is present. Soft tissue swelling is noted in the region of the ankle joint. " An Emergency Department report dated 12/27/11 revealed the resident was seen for an accidental fall on 12/22/11 resulting in distal tibia and fibula fracture. Nursing notes dated 12/27/11 at 11:55pm read in part, " resident back from emergency department. Splint to the left leg. New order for norco 5/325 mg (medication used to relieve moderate to severe pain) 1-2 tablets by mouth every 4-6 hours as needed and to follow up with orthopedic doctor 1-2 days. No pain or discomfort upon return. " Review of radiology report dated 12/27/11 read in part, " the bones are demineralized. Fracture of the distal metaphysis of the the fibula is noted. Fracture of distal metaphysis of the tibia is present. Soft tissue swelling is noted in the region of ankle joint. " Review of orthopedic consultation report dated 12/29/11 read in part " Recommendation 4. Follow up 2 weeks for cast change. " Record review of the physician progress notes [REDACTED]. The patient had a fracture of the distal tibial and fibular metaphysis on the left side and is in a cast. He denies any symptoms except for pain in his left lower extremity. " Record review of Nurse #5 ' s statement submitted as part of the investigation dated 1/12/12 read in part, " I (name of nurse, who no longer works in the facility) was the scheduled 11-7 nurse for (name of the resident) on December 23rd 24th, 25th, and 26th. He had fallen on December 22nd on 1st shift. When I came to work Friday night the 23rd the second shift nurse had given pain medication at 8:30 pm and he had no pain. He slept through the shift. Resident ' s extremities appear to be edematous most of the time. On Saturday the 24th resident had no pain all during shift. On Sunday the 25th resident complained of pain to the second shift nurse. An order received for x-ray to left ankle. The x-ray company was called by Nurse #2 (name of the nurse). " This nurse told Nurse #5 that the x-ray company would not come out until 12/26/11. On 12/26/11 Nurse #2 told Nurse on the first shift that the x-ray was not done. The x-ray was not done until 12/27/12. " The surveyor attempted three times during the survey but was unable to contact Nurse #5. In an interview on 1/17/12 at 10:41 am NA #1 (nursing assistant) who was responsible for the resident's daily care, and who witnessed the fall, stated that " on 12/22/11, I was trying to turn the resident while doing his (morning) care and he rolled off the bed on to the floor mat. I went and got the nurse (Nurse #1) and two aides, and they assisted the resident to the bed. " NA #1 added that when the nurse asked the resident if he was experiencing pain, he denied any pain. She further stated that " I took his vital signs. " In an interview on 1/17/12 at 11:00 am with Nurse #1, she stated that " on 12/22/11 the resident rolled off the bed to the fall mat during morning care. The aide that was giving care got me, we assisted the resident back to the bed. I assessed the resident. I did neurological checks and asked him if he was having pain. He denied pain. He was able to move his lower extremity as well as upper extremity. " Nurse #1 added that there was no bleeding, no bruising, no skin tears or swelling from fall, and NA #1 took the resident ' s vital signs. In an interview on 1/17/12 at 2:44 pm the interim administrator stated that " (name of the resident) rolled out of the bed to the floor mat on 12/22/11. I went to the the resident ' s room to discuss the incident with the resident. I performed a visual inspection of the resident ' s body, the resident ' s heel was bloated because he has a history of a wound to his heel. The resident was noted to have edema to the upper right arm and a trace of edema to left lower extremity. This was no different from any other day since admission. This resident had a history of [REDACTED]. No misalignment was noted to the extremity. The family member was notified. On 12/25/11 the family member complained to the nurse who was in charge of the resident ' s care that the resident ' s ankle was swollen and he was experiencing pain. an order for [REDACTED]. This x-ray was not done until 12/27/11 because on 12/25/11 the mobile x-ray unit was only doing stats and on 12/26/11 the scheduler for the mobile unit forgot to add the resident ' s name to the schedule. I have in-serviced my staff on the importance of having x-rays done in a timely manner. My expectations are that for any acute episode that might rule out bone fracture the x-ray must be done the same day. In event the x-ray company is not able to come the same day within a reasonable time frame, the medical director should be notified and the resident should be sent out to the hospital. " The interim administrator added that this was not done. She further stated NA #1 had been in-serviced on the proper procedure for ADL care of residents with weakness in one or both sides. She further stated that the resident has not had another fall. In an interview on 1/17/12 at 3:44 pm, Resident #2 stated " I fell off my bed to the floor and broke my ankle. " He added the ankle was swollen and hurting. In a telephone interview on 1/18/12 at 8:30 am the medical director stated that his expectations are that if an order is written by himself or an on-call physician for an x-ray, it should be done on the day it was written. He added that the mobile unit normally comes to the facility when requested, so it should be done within the day. If the x-ray is not done when ordered he expects communications from the facility immediately so the resident can be sent to the emergency department. In an interview on 1/18/12 at 9:52 am, NA #2 stated that " I was responsible for the resident ' s care on 12/24/11; he did not experience any pain while I was giving care, but his ankle was swollen and I elevated the ankle with a pillow. " During a follow up telephone interview on 1/27/12 at 11:40am NA #2 stated that an aide told her to elevate the resident ' s ankle with a pillow but she does not remember which aide. In an interview on 1/18/12 at 10:38 am Nurse #2, the nurse responsible for the resident's care on 12/25/11, stated " I was on duty 12/25/11 and the resident's family member told me that (name of the resident) had fallen 3 days ago and the resident was in pain. I went in his room and assessed his ankle and it was swollen. I called the medical director and he gave me an order for [REDACTED]. I made the nurse coming on the next shift aware. " During a telephone interview on 1/18/12 at 3:10 pm Nurse #4 who worked with the resident on 12/26/11, stated that the resident was alert and verbal. The resident was administered Vicodin for his phantom pain. The resident did not complain of any ankle pain, nor was the ankle swollen. In a telephone interview on 1/26/12 at 5:30 pm NA #1 stated that I was performing a bed bath, and after washing his back, I put a lot of lotion on him because he has very dry skin. I turned him away from me. The resident held on and began to turn, and his lower body began to slide off the bed. My hands were greasy; I attempted to catch him but I was unable to, and the resident slid to the floor. I called my nurse, and she assisted him off the floor with the help of 2 aides. NA#1 further indicated the bed rails (small rails) opposite to where she would turn the resident were lowered, but the small rail away from her were raised, and the resident held on to the small rail and attempted to turn. The bed was in the normal position; she reiterated that the bed was not in the low position. In a follow up telephone interview on 1/27/12 at 12:20 pm with the interim, administrator she stated that Resident #2 slid out of bed while ADL care was performed on 12/22/11. The resident care plan reflected a 1-person assist with ADLs for bed mobility. NA #1 is well aware of the care for Resident #2 as she has cared for him on multiple occasions prior to the incident. " The interim administrator further stated that Resident #2 was in bed. NA #1 was in his room with a fall mat on both sides of the bed. NA #1 was performing a bed bath on the resident and used moisturizer on his skin on the front side. After bathing and moisturizing the resident ' s front side, NA #1 began to turn the resident towards his left side as she needed to complete the bed bath. When NA #1 began to turn the resident, the resident ' s lower body slid out of the bed. NA #1 attempted to catch the resident but she was unable, and the resident rolled on the fall mat. Nurse #1 completed a full assessment of the resident. The resident declined pain. There was no new swelling or bruising. The family and the medical director were notified. In a follow-up interview on 2/1/12 at 5:50 pm with Nurse # 2, the nurse stated that " 12/25/11 was the first time I ever worked with the resident. The resident ' s family member came and asked me to look at the resident ' s ankle because it was swollen and tender to the touch. The resident was in pain. I did not know that he had a fall until the family member told me. Vital signs were done; the resident was not hollering or in any acute distress. I gave the resident Vicodin, and afterwards he only had a small amount of pain. I called the attending physician and told him the resident had a swollen ankle. I explained that he had fallen a couple days prior, and he was in pain. The attending physician gave me an x-ray order. Because it was not a stat and it was Christmas Day, the x-ray company stated that they would be in the following the morning to do the x-ray. I did not call the attending physician back because we normally wait until the x-ray is done and because the x-ray company stated they would be coming the following day. I told this to the nurse who was coming on the next shift. " In a follow-up interview on 2/1/12 at 6:16 pm with Nurse #4, he stated, " to my knowledge on 12/23/11 the resident had no swelling, no pain, no bruising. Later in the shift the resident requested pain medication for phantom pain. " When the surveyor asked the nurse, " How do you know it was phantom pain, " he stated that the resident pointed to his stump. In an interview with the attending physician on 2/1/12 at 6:55 pm, he stated, " I think it was bad and unacceptable that the x-ray was not done in timely manner. But the resident was not walking on the ankle and the fracture was not displaced, so it did not impact his bone exceptionally. Hopefully, they would call and notify me that the x-ray was not done, but they never called. " The surveyor asked the attending physician, " How do you monitor x-ray results? " He answered that two doctors visit the facility 5 days a week; if there is a critical matter, the facility calls one of the doctors. If the situation is not critical, the facility puts the results in a box to be reviewed. The results normally stay in the box for up to two days, no more. In a follow-up interview with the resident # 2 on 2/2/12 at 9:00 am (in the presence of NA #1 and nurse #3), the resident stated that he had fallen and hurt his ankle sometime in December. " A lot of people came in the room, " he said. " I told them that my ankle hurt, but they did not give me anything until that night. I hurt for many days before they took care of it. " During a follow-up interview on 2/2/12 at 9:30 am, Nurse #1 stated that NA #1 " came and told me told that the resident rolled to the floor. She stated she was turning the resident and the resident rolled to the floor. When I went to the room, he was on his right side and his leg was extended. The resident said that he was experiencing no pain. I touched his legs; he had no pain. I did not do any range of motion checks. I believe I gave him pain medication. His legs were not bigger that normal ( Nurse # 1 stated that Resident #2 has routine edema). Before we removed him from off the floor, we did vital signs and checked his pupils and I asked him if he had pain. I did not assess him again. The expectation is that if the fall is witnessed, we do not have to assess again, but if it is not witnessed, we have to assess the resident for 3 days. On the 26th, the family told me that the resident fell , and he was supposed to have an x-ray, and it was not done. I called the x-ray company, and they came out that day to do the x-ray. " Record review showed the x-ray was not taken until 12/27/11. In an interview on 2/2/12 at 11:29 am with Nurse # 12 , she stated, " no one told me that the resident had a fall. On 12/24/11 the family member came and told me that the resident fell and no one was doing anything about it. I told my DON and my nurse manager about the family ' s concerns. I looked in the nurses notes and I saw where they were elevating the resident ' s leg with a pillow. I checked the resident, and his leg was already elevated so I did nothing. I did not give him pain medication because he said he had no pain. On December 25, I gave him his medication, he had no pain, and his ankle was swollen. I did not do anything to the ankle because his arm and leg were always puffy. " She added, " as far as I know the x-ray was done. " Surveyor and Nurse # 12 checked the nursing notes; there was no documentation of a swollen ankle on 12/24/11. In an interview on 02/2/12 at 3:00 pm with the physical therapy supervisor, he stated, " On 12/24/11 the resident ' s ankle was observed to be swollen; it was bigger than normal. The resident stated that he was experiencing pain in the ankle and the physical therapy assistant, who was working on a per diem basis, told the morning nurse immediately. Several calls were made to the physical therapy assistant, but he never returned the call. " During a follow up interview on 2/2/12 at 3:30 pm with the interim administrator, she stated that the facility was trying to get in touch with the physical therapy assistant to see who he spoke to. She further stated that " we have not heard from him and whenever we know something we will let me know. " The administrator never got back to the surveyor on that matter. During a telephone interview on 2/2/12 at 4:12 pm with the family member, he stated that on 12/25/11 at about 10:30 am, the resident told him he had fallen a couple days ago and his leg was hurting and swollen. " I spoke with the nurse and she told me she would get an x-ray order. I came back on 12/26/11, and the x-ray was not done. I came back on 12/27/11; the x-ray was not done. I got mad and left the facility. " Review of the facility documentation revealed: Review of the facility policy " Falls Management Program " effective dated 10/12/11, per the procedure in the Fall Occurrence section , in part, ? Notify the physician, responsible party, and / or EMS as well as the Supervisor / Administrative personal as appropriate. 2. Resident # 7 was admitted to the facility on [DATE] current active [DIAGNOSES REDACTED]. Review of the MDS revealed moderately impaired cognitive skills, long and short term memory problems. The assessment revealed no behavioral symptoms towards others. Resident #7 required extensive assistance of one person to physically assist him with transferring between the surfaces and toileting. The most recent Care Area Assessment Summary (CAA) dated 5/2/11, triggered falls, findings included in part; Resident had one fall while in the hospital. Resident has had 3 falls since admission, and did have some pain in his arm related to falls. Resident is currently working with both PT (physical therapy) and OT (occupational therapy). He also has a chair alarm in place. Staff will continue to monitor. The most recent Care Plan dated 12/23/11 in part, Problem Fall-ACT: Actual falls related to history of fall r/t (related to) bilateral AKA (above the knee amputation) and history of non complaint behaviors. Resident continues to transfer without notifying staff for assistance. Resident continues to get up without using self release harness and also removes it. Goal: Resident will be free from falls or injury by next review. Approaches: 12/23/11, 1. anticipate resident needs. 2. Frequent bed checks while in bed. 3. Frequent monitoring for placement of self-releases harness (a hook and loop harness that resident can remove) 4. Charge motorized wheelchair every night. 5. (Name brand) matt with wings. 6. Supervise & assist with transfers as indicted. 7. (Name brand) fall mat. 8. Motorized chair with self release harness for trunk control due to bilateral AKA. 9. Low bed position to aid in prevention of falls. 10. Instruct resident to call for assistance when getting out of bed or out of chair. 11. Call bell with reach. 12. Bedside commode frame moved to bathroom so resident can have privacy. 13. Bed alarm. (Added 1/2/12) Review of the Incident Accident Report dated 12/31/11,revealed Resident #7 fell in his room at 3:15p.m. on 12/31/11. His condition prior to incident was alert and chairbound. Restraint ordered restraint applied : ( brand name) hook and loop safety strapes(sic) Description of incident : "Patient was found on floor in room by c.n.a. Patient stated he fell asleep and fell out chair. He took his safety belt a loose." Location of injury : picture indicated swollen above right eye. Result of Incident: Ice applied to area on right side of head. No Post Fall assessment dated [DATE] was completed by the nursing staff for the fall dated 12/31/11. Review of the second incident report dated 1/2/12, revealed revealed resident fell in his bathroom at 2:45a.m. Type of Incident check one or more : Fall/ Bruise Description of incident : Nurse was walking past room down the hall and heard a thumping knocking sound opened the door to ask if Resident #7 was alright his wheelchair was in the bathroom and Resident #7 was on the floor. Vital signs were taken Location of injury : Black eye , skin tear left arm. Result of Incident: First Aid Skin tear cleaned /dressed: Comment and follow up Skin tear on Left upper forearm and right black eye. A Post Fall assessment dated [DATE] was completed by nursing. Falls Risk assessment dated [DATE], revealed Risk areas medications (pain medications listed ), Mobility bilateral AKA , unsafe behavior observed or history tries to stand, transfer, or walk alone unsafely. Tries to climb out of bed alone unsafely. History of falls the last six (6) months, chair bound and requires assistance with toileting , poor balance in wheelchair. Device assessment dated [DATE], completed by Nurse #9 revealed Medical Diagnosis: [REDACTED]. Symptoms: Poor balance, forgetful, confused at times. Devices: assist bars, bed alarm seat belt. Purpose of the Devices: (name brand) matt with wings to help define parameters of bed. Alarming seat belt to prevent falls. Bed position against wall for safety. Physician Order dated 1/12/12, Seat belt alarm to motorized wheelchair due to bilateral above the knee amputations, with poor balance, forgetfulness and confusion at times. Medical Reason for Restraint: Poor balance, forgetfulness, intermittent confusion Resident /RP(responsible party) Education , " Resident is aware that seat belt with alarm is on motorized wheelchair to remind him to ask for assistance. Resident is currently able to release seat belt on command. " Alternative: Self release harness to motorized wheelchair. Resident Response: Resident would release harness, fall asleep in the chair or attempt to transfer without assistance. Physician Order dated 1/12/12 Seat belt alarm to motorized wheelchair due to bilateral above the knee amputations, with poor balance, forgetfulness and confusion at times. Release every 2 hours. Resident #7 was observed on 2/2/12 at 11:34a.m., in his room sitting in his motorized wheelchair, engaged in watching a television show. He turned the television down and turned the wheelchair around. It was noted he was a bilateral above the knee amputee; he had a bandaged left hand and forearm. The wheel chair seat belt was dangling at the sides of the wheelchair. No alarm box was noted on the chair at this observation. When asked if he had fallen recently, he indicated he had, but could not recall the day. Resident #7 stated he had fallen when he had leaned forward to turn on the radio sitting on the night stand at the end of his bed. He rolled out forward of the wheelchair and hit his head on the end of the bed and gave himself a black eye. He demonstrated how he leaned forward, he then realized he did not have his seat belt fastened and he clicked it together. He indicated he knew he was suppose to keep his seatbelt fastened but would forget to buckle it. He indicated he had several falls because he thought it was buckled but it was not. He stated he fell on ce when he thought the belt was buckled, his shirt was covering it, and he had to go to the hospital. He chuckled, he continued by saying he used to use a harness to help him stay in the chair. The belt he likes much better. He concluded by saying he still forgets to keep it buckled. During an observation of Resident #7 on 2/3/12 at 8:38a.m., revealed sitting in his motorized wheelchair at his night table eating breakfast. An alarm box on the side of the chair was observed. The seat belt was buckled, and bed alarm was observed. Upon interview Resident #7 indicted the facility had added an alarm to his chair and to his bed to help him remember to ask for help. During an interview on 2/3/12 at 9:00a.m., Nurse #11 indicated he had a bed and chair alarm in his wheelchair. This will alert the staff if Resident #7 was attempting to transfer. The assigned staff was checking on Resident #7 more often and when he was in bed his wheelchair would be placed out of his reach, to remind him to call for assistance when transferring. The aids check it when they transfer him it will alarm. The wheelchair was placed against the wall out of his reach to prevent him from transferring alone. During an interview on 2/3/12 at 10:52p.m., Nurse #12 indicated Resident #7 used a harness that he could remove. He fell asleep and he fell out of the chair. We would remind him to keep his harness buckled. During an interview on 2/3/12 at 11:49 a.m., the director of nursing indicated the self release seat belt was supposed to alarm when it was unbuckled. She indicated she did not know why the belt was not alarming on 2/2/12 during the observation the day before. During an interview on 2/3/12 at 12:13p.m., Nurse #9 indicated the self release hook loop harness was discontinued because there was no alarm on the harness. The seat belt was implemented because it alarmed. She indicated she had no other residents with this type of belt she did not know where the facility had gotten it. She indicated there was no documentation or monitoring tool to ensure the belt was working or monitored. When the resident told had buckled his seat belt yesterday during the observation and there was no alarm. She indicated she did not know why the belt had not alarmed. During an interview on 2/3/12 at 2:55pm, Aide #3 indicated she had worked with Resident #7 on and off prior to the last week and had him steady for this week. She indicated he had a self release seatbelt that he removed. She indicated the seatbelt alarm would go off if it was unlatched. She indicated the seat belt alarm worked this morning. She was asked to demonstrate the belt, she indicated Resident #7 was out of the building. Aid # 3 indicated she did not know of any other residents with that type of alarm. She indicated she does not check the alarm unless she removed it from the resident to provide care. The sound it makes was different from the bed alarm. She indicated the wheelchair was kept out of his reach when he was in bed to prevent him from getting into his chair on his own. She indicated she checked the alarm about lunch time, when she removed it to give him a whirl pool bath. During an interview on 2/3/12 at 4:21p.m., physical therapy director indicated a fall occurred on 12/31/11 (Saturday) and 1/2/12(Monday) and one physical therapy screen covered both falls. During the stand up meeting nursing had indicated they were going to implement a bed alarm and a seat belt alarm. He was not picked up for physical therapy services because he had no changes that warranted physical therapy services. All falls are screened by the physical therapy department the next business day, a screening does not indicate a resident will be picked up for an evaluation. The self release harness was the best option for Resident #7 at the time of the screening. Nursing had made the decision to discontinue the self release harness. He could not describe the new belt and indicated the physical therapy department had not supplied the belt. Therapy had seen Resident #7 previously for use of his bilateral prosthetic legs. During an interview via telephone on 2/4/12 at 10:00a.m., Aide #4 indicated Resident #7 came back from the hospital and was moved to his current room. Up until two weeks ago Resident #7 was able to transfer him self. He was no longer allowed to do so, the staff was to keep his wheelchair out of his reach and he was to call for assistance. She went on to say to keep him safe in the wheelchair a hook and loop vest was used that crisscrosses across him and the chair. If he took it off it would alarm, " it always works " . The vest goes around his shoulders and his waist. She indicated it was not checked regularly. She indicated when the vest was taken off and makes a loud noise. Recalling the fall on 1/2/12 she indicated Resident #7 was independent with his transferring at that time. She indicated he had taken himself to the toilet and was found by the nurse between the toilet and the wheelchair on the floor, he had a black eye left eye and a skin tear to his left arm. We got him up and put him to bed. We put a brief on him, and gave him a urinal and a bedpan. We told him to use the call bell for help. He was very confused he could not recall