Every finding on record at Halcyon House

Based on clinical record review, facility policy review, resident and staff interviews, the facility failed to conduct post assessment after resident received dialysis for 1 of 1 residents reviewed for dialysis (Resident #42). The facility reported a census of 50 residents. Findings include: Review of the MDS assessment, dated 2/9/26 revealed Resident #42 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated medical diagnosis for end stage renal disease (ESRD). The MDS indicated Resident #42 did not receive dialysis. The Care Plan included a focus area revised 2/7/26 for resident needed dialysis related to ESRD.Review of the electronic health record (EHR) revealed a diagnosis of dependence on renal dialysisReview of the EHR Pre and Post Dialysis Assessments revealed a lack of completed post assessments for: 1/23/26; 1/30/26; 2/2/26; 2/6/26; 2/9/26; 2/11/26; 2/13/26; 2/18/26; 2/25/26; 2/27/26; 3/13/26; and 3/16/26. During an interview on 3/16/26 at 2:56 PM, Resident #42 queried on dialysis and Resident #42 stated staff assessed her before and after dialysis treatment. Resident #42 stated she went to dialysis for 4 hours on Monday, Wednesday, and Friday.During an interview on 3/18/26 at 9:11 AM, Staff A, Licensed Practical Nurse (LPN), queried on when assessments completed for Resident #42 dialysis and Staff A stated pre and post assessments completed in the computer. During an interview on 3/18/26 at 3:36 PM, Staff B, LPN queried about assessments with dialysis, and Staff B stated pre and post assessments completed in the computer. Staff B stated the assessments included checking the bruit, bleeding, and vitals signs. During an interview on 3/19/26 at 10:21 AM, Staff C, Registered Nurse (RN) queried on assessments completed for dialysis for Resident #42 and Staff C stated nurses completed pre and post assessments. Staff C stated she worked on Resident #42 household on Monday and did the pre assessment. Staff C stated Resident #42 usually came back from dialysis around noon. Staff C stated she never had completed a post assessment for Resident #42, but the second shift nurses could also do them, it just depended on who was available. During an interview on 3/19/2026 at 10:28 AM, Staff D, RN, queried if she completed a post assessment for Resident #42, and Staff D stated no, she didn't do post assessment on Resident #42. Staff D stated she worked as the float nurse on 3/13/26 and wasn't even aware the resident left for dialysis, but now talking about it, Staff D realized a post assessment should have been completed. Staff D stated most tasks pop up on the computer to complete, but the assessments for the pre and post assessments were not scheduled on the computer. During an interview on 3/19/26 at 12:00 PM, the Interim Director of Nursing (DON) informed of the lack of dialysis indicated on Resident #42 most recent MDS. The Interim DON confirmed Resident #42 receives dialysis. The Interim DON informed of dates a post dialysis assessment not completed for Resident. She stated more coordination and communication needed done. The Interim DON stated they would need to put in a process for it. Review of the facility policy, titled Dialysis Process, 3/2026 revealed: a. The Nurse will complete the assessments pre and post dialysis via the established assessment/UDA (user-defined assessments) present in the EHR.1. Vital signs2. Assessment of the venous access site3. Weight (if ordered)4. Lab results (if ordered)5. Potential dialysis related complications (i.e. dizziness, falls, bleeding, access site infection, change in cognition or condition or hypotension.

Based on clinical record review, facility policy review, observation, resident and staff interviews, the facility failed to assess and implement interventions and communication with the provider in response to Resident #1's rising blood sugar levels. Resident #1 admitted to the facility on [DATE] at approximately 12:00 PM. Resident #1 list of diagnoses included type 1 diabetes, which required insulin several times a day. At 5:16 PM, facility staff completed a bedside glucose check with a result of 245 mg/dL (milligrams/deciliter). Resident #1 requested insulin be administered. The nursing staff reported to the resident the facility did not have an order for insulin. At 8:02 PM, a second bedside glucose check completed with a result of 324 mg/dL. Resident #1 reported symptoms of hyperglycemia which included cotton mouth, fruity breath, dizziness, brain fog, and unsteadiness. On 10/03/25, at 9:30 AM nursing staff reported to the provider the resident did not feel well and the lab called to report critical values. The provider ordered Resident #1 to go to the emergency room (ER) for an evaluation and treatment. At approximately 9:55 AM, while at the ER, Resident #1 had a blood glucose lab result of 701 mg/dL. The resident admitted to the hospital with a diagnosis of diabetic ketoacidosis (DKA), and acute kidney injury. (DKA is a serious condition that can be life threatening. DKA developed when the body did not have enough insulin to allow the blood sugar into the cells for use as energy. The body responded by breaking down fat in the liver for fuel. The result is the production of ketones, which if produced too fast build up to dangerous levels.) The facility identified a census of 52 residents. On October 9, 2025 at 12:00 PM, the State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of October 2, 2025 at 12:00 p.m. The facility staff removed the Immediate Jeopardy on October 13, 2025 at 3:00 PM by implementing the following actions: 1. Resident #1 discharged to the hospital on [DATE].2. The facility contacted pharmacy to notify of missing insulin on 10/3/25.3. The facility investigated and discovered the pharmacy had not entered orders accurately.4. The facility faxed correct discharge orders.5. Facility educated nurses completing admission to verify orders and the correct order process with pharmacy on 10/3/25.6. Pharmacy will provide facility their plan of corrections to ensure orders are entered accurately by 10/6/25.7. The facility will educate all nurses by end of day 10/3/25 on medication regimen review and confirm all orders. Including the correct process to ensure the orders they confirm match the discharge orders sent from the hospital.8. All nurses working that day were educated on double checking the discharge order from the physician against the orders entered by the pharmacy. All nurses are to call a physician, pharmacy, director of nursing (DON) or assistant director of nursing (ADON) if there are discrepancies.9. The facility will update the admission checklist and review with all nurses by end of day 10/3/25.10. admission checklist will be updated to include: Confirming orders within 4hrs of admission. Notify the provider, pharmacy and the DON or the ADON if any discrepancies in orders or if medication has not come in.11. Any Agency Nurses will be trained on a detailed training plan of assessments, competencies and policies and pharmacy communication.12. The facility will complete admission audits the next business day to ensure all orders and assessments are accurate.13. The facility will educate nurses by 10/9/25 on assessment with blood sugars and to notify the physician if out of parameters. The scope lowered from J to G at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings Include:Review of Resident #1's Care Plan revealed a Focus area, dated 10/02/25, to address The resident has Diabetes Mellitus. Interventions included, in part:a. Medications and labs as per order. Date Initiated: 10/02/2025.b. Monitor/document/report PRN any s/sx (sign and symptoms) hyperglycemia (high blood sugar): increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd (abdominal) pain, Kussmaul breathing (type of rapid, deep, and labored breathing pattern that is typically seen in severe metabolic acidosis, such as diabetic ketoacidosis), acetone breath (fruity smelling breath), stupor coma. Date Initiated: 10/02/25.During an interview on 10/07/25 at 2:48 PM, Resident #1 stated she entered the facility on 10/02/25 after she was hospitalized for heart failure. She stated after she arrived the staff did not assess her heart, lungs or check her for swelling. She stated she was asked if she had lunch and had answered no. Resident #1 stated the staff did not bring her lunch or check her blood sugar. Resident #1 added the staff did not weigh her upon admission. She explained while in the hospital she had 10 pounds of fluid removed (heart failure caused an accumulation of fluid) but continued to be hypoxic (low oxygen levels). Resident #1 stated while she waited for an oxygen concentrator to be delivered, she used her portable oxygen. She explained she dozed off and was awakened by the portable oxygen alarm which indicated the machine was out of oxygen. Resident #1 explained she was not thinking clearly at that point and did not know if it was due to low oxygen levels, or low blood sugar, so she asked the nurse to test her blood. Resident #1 stated the blood sugar result was high and she requested insulin. Resident #1 recalled the nurse told her they did not have an order for insulin. Resident #1 stated What nurse who is made aware that a person is a type 1 diabetic does not provide required insulin? Resident #1 did not recall if she ate supper. She stated the 8:00 PM her blood sugar result was also elevated and she again requested insulin. Resident #1 stated the night nurse did not come back to complete an assessment. She described early in the morning she was thirsty with cotton mouth (mouth feels dry), and her breath smelled. Resident #1 stated the doctor ordered a blood draw be done by the lab. Resident #1 stated the kitchen staff inquired about food and orange juice and she had refused due to not having blood sugar check by that time. Resident #1 stated the nursing staff entered her room and reported she had to return to the hospital due to critical lab values. She stated her blood sugar reading at the ER was 701. Resident #1 recalled her physician telling her was close to death, and if it had been any longer she would have died. Resident #1 stated she had been to this facility three times before, I love it here but this was serious, they knew I was a type 1 diabetic and required insulin and someone should have checked into this because you don't discontinue insulin.Review of a document titled Grievance Form dated 10/03/25 revealed Date/Time of Occurrence: 10/03/25. Location of Occurrence: Resident room. Staff or Residents involved: [Resident #1 name redacted]. Summary of Concern: Resident was sent to ER on Friday [10/03/25] morning. Resident had not been given insulin Thursday [10/02/25] night (40 units). Name of Individual Filling out this form: [Administrator signature/name redacted]. Date: 10/03/25.Review of a hospital Discharge summary, dated [DATE] revealed a Hospital Course section, which documented, in part: [Resident name redacted] .with a PMHx (previous medical history) of coronary artery disease post CABG with multiple stents (also known as open heart surgery), combined systolic and diastolic heart failure.chronic pain, fibromyalgia.type 1 diabetes on an insulin pump, and chronic kidney disease staff IIIB. She was hospitalized for acute on chronic heart failure.She does not use her pump when she is at the skilled care facility therefore we did not resume it.The hospital Discharge Summary included a Recent Labs section. The BMP (Basic Metabolic Panel, a grouping of various labs such as glucose, creatine, potassium, etc) recent labs as of 10/02/25 at 5:19 AM included a glucose result of 267 [mg/dL].The Discharge Summary also included a Discharge Medication List. The Start taking these medications section listed the following insulin orders:a. insulin glargine 100 unit/mL (3 mL) injection pen Commonly known as LanTUS SOLOSTAR (long acting insulin). Details: Inject 40 units subcutaneously (under the skin) daily at bedtime. Diagnoses: Type 1 diabetes mellitus with stage 3b chronic kidney disease.b. insulin lispro 100 unit/mL injection vial Commonly known as: HumaLOG, ADMELOG (fast acting insulin). Details: Inject 0-20 units subcutaneously every 6 hours. Diagnoses: Type 1 diabetes mellitus with stage 3b chronic kidney disease.The 10/02/24 hospital Discharge Summary included Hospital Discharge Instructions, which included, in part: [Doctor name redacted] to follow closely with labs BMP and CBC (Complete Blood Count which includes white blood cell count, red blood cell count, etc) to be obtained tomorrow [10/0325]. Review of the October 2025 Medication Administration Record (MAR) revealed: a. Blood Sugar checks 4 times per day. Notify PCP (primary care provider) if blood glucose less than 70 or greater than 400. Start Date: 10/02/2025.b. Insulin pump basal rate of 0.55 units/hour. Start Date: not indicated. Revision Date: 10/6/25.Review of the EHR Blood Sugar Summary revealed the following bedside glucose check results:a. On 10/02/25 at 5:16 PM value of 245.0 mg/dL recorded.b. On 10/02/25 at 8:02 PM value of 324.0 mg/dL recorded.Review of a Nurses Note entered on 10/2/25 at 7:05 PM, documented.blood sugars have been high since MD (medical doctor) at hospital stopped internal insulin pump. Review of a Nurses Note entered on 10/3/25 at 9:02 AM, revealed Labs drawn this morning and came back at critical levels. States that she doesn't feel good and has very dry mouth. Dr. [name redacted] instructing to send to the [hospital emergency room name redacted] for eval and treat.Ambulance here at 0845 and left with resident at 0900. She took her duffel bag with insulin and insulin pump with her and her red blanket. Review of a Nurses Note entered on 10/3/25 at 3:53 PM, revealed Charge Nurse noted that the resident did not have insulin orders when glucometer read high during am glucose check. Dr. [name redacted] was notified and ordered to have resident sent to ER. Pharmacist voiced they simply missed putting the insulin orders in. Resident has been readmitted to [hospital name redacted]. Review of a document titled [provider name redacted] Comprehensive Metabolic Panel (CMP, a grouping of labs that included testing electrolytes, glucose, and liver, kidney and thyroid function) with Status: Final result (Collected 10/3/25) printed in the top left hand of the document revealed the following Glucose lab results for Resident #1:a. 10 d (day) ago - 9/28/25 290 mg/dLb. 9 d ago - 9/29/25 - 294 mg/dLc. 8 d ago - 9/30/25 - 295 mg/dLd. 7 d ago - 10/1/25 - 332 mg/dLe. 6 d ago - 10/2/25 - 267 mg/dLf. 5 d ago - 10/3/25 - 650 mg/dLg. 5 d ago - 10/3/25 - 701 mg/dL Comment: Critical called to [name redacted] at 10:33 AM by [initials redacted]. Review of the hospital Discharge summary, dated [DATE] revealed, in part: admit date : [DATE]. discharge date : [DATE]. Primary Diagnosis: DKA (diabetic ketoacidosis) .Brief History and Physical: [Name redacted, Resident #1] .She presented to the emergency room at [hospital name redacted] on 10/3/25 with report of hyperglycemia (high blood sugar). The patient was discharged from [hospital name redacted] to [facility name redacted] for skilled care on 10/2/25. She is unable to use her insulin pump while at [facility name redacted], so she was discharged with orders for Lantus (name of a long-acting insulin) and sliding scale Humalog (a short acting insulin). The patient did not received insulin while at [facility name redacted], and on the morning of 10/3/25 her blood sugars were reading high' on the glucometer, so she was sent to the emergency room for evaluation. On arrival lab work was obtained and showered to have sodium 125, potassium 5.2, chloride 75, AG 27, BUN 89, creatinine 4.9, glucose 650.The patient was given IV (intravenous) fluids and lantus (insulin). She is being admitted to the hospital for an acute inpatient treatment of DKA and AKI (acute kidney injury). During an interview on 10/08/25 at 12:15 PM, the Medical Director (MD) stated Resident #1 was admitted to the skilled nursing facility for heart failure, chronic respiratory failure, had a diabetic disease history of 40 years, sleep apnea with use of a non-invasive machine, and this time she came in with fluid over load. The MD stated Resident #1 takes a large amount of insulin and it was not recommended to use that high of an amount in the pump and the facility pharmacy does not use pumps, therefore it was ordered for the facility staff to give long-acting insulin and a sliding scale insulin. He stated the expectation was for the facility staff to be checking the admitting orders. The MD stated the facility staff could call the hospital 24hrs/7 days a week and should have called. He stated Any nurse would know that a type 1 diabetic required insulin, would you not verify that she does not have insulin? The MD added the facility nursing staff should have not missed that. The hospital interdisciplinary team conducted rounds on 10/03/25 at 8:00 AM, the facility called and reported that they did not have insulin orders. The Medical Director stated when Resident #1 would go into DKA, It is serious. He stated the lab values at 9:55 AM were glucose 701 mg/dL and a BUN (Blood Urea Nitrogen, a lab test that measures the amount of urea nitrogen in the blood, a waste product) of 89 mg/dL (normal range 6 to 20 mg/dL) with blood gasses of 7.36. The MD stated he questioned the hospital team whom reported they had written and faxed orders to the facility on admit 10/02/25. He stated he did not know how the facility staff missed this, It was a perfect storm. The Medical Director stated Resident #1 had history of 3 different admissions to the facility for SNF and the staff were aware she was diabetic. During an interview on 10/08/25 at 1:44 PM, Staff G, one of the Consulting Pharmacist stated the facility contracted the pharmacy to provide medications and consulting services. Staff G described the process as the facility faxed orders to the pharmacy and e-prescriptions from an external provider. The nursing facility initiated the process and were aware of the orders and delivery time Monday through Friday from 9:00 PM to 11:00 PM and Saturday 6:00 PM to 8:00 PM. Staff G stated the facility had a E-Kit (Emergency Kit, which is a supply of medications a pharmacy provided to the facility for use in the event of a critical need or before the next scheduled delivery of medications) which included insulin if needed before those hours. Staff G explained the discharge facility would provide a diagnosis list that would have been reviewed with the orders, then if the insulin order was not there with a type 1 diabetic, it would be put into the clarification folder for review. Staff G stated the diagnosis was entered into the system by the facility.During an interview on 10/08/25 at 1:56 PM, Staff H, Pharmacist stated the new admission orders are integrated into the EHR system messaging system, initiated by the facility, who then faxed the discharge paperwork or discharge orders. Staff H stated the medication list was then entered and put on the resident profile and if a script was needed, the facility and the provider would be notified. The facility can call the provider to expedite the process. Staff H stated the nurse would call the pharmacy to obtain authorization to remove medications from the emergency tackle box (E-Kit) or the pharmacy would STAT (immediately) out the medication to the facility to avoid the depletion of the medication and do not want a resident to be without needed medication. Staff H stated the pharmacy would work with a back-up pharmacy to obtain a medication if necessary. Staff H stated she did not know how the order was missed or why it was not put into EHR to be delivered as there are check and balances on both sides. During an interview on 10/14/25 at 11:11 AM, Staff I, Registered Nurse (RN) stated she had worked at the facility for 8 months on as needed (PRN) basis. She verified she had worked on 10/02/25 when Resident #1 was admitted and it was her first admission since working at the facility. Staff I stated she had received a verbal report from the hospital which included, Resident #1 was being admitted for skilled care, had a wound, and a chronic list of comorbidities (2 or more diseases). She stated the diagnoses list included diabetes and the use of a [brand name of device redacted] a continuous glucose monitoring device and an insulin pump which were disconnected, or not working. Staff I stated the hospital did not send any medications with the resident. Staff I explained she relayed the hospital report to Staff D, RN who was the admission nurse. Staff I stated the Director of Nursing (DON) or Assistant Director of Nursing (ADON) usually do the admission orders. Staff I stated she provided care for an hour and half then gave report to the 2:00 PM to 10:00 PM nurse, Staff C, RN who was informed that Resident #1 was a diabetic and her pump and continuous glucose monitoring device were not working. During an interview on 10/08/25 at 2:49 OM, Staff C, RN stated she was working on a contract for the facility and had worked at the facility for 3 weeks. Staff C stated when she arrived to the facility on [DATE] for the 2:00 PM to 10:00 PM shift, a paper was given to her that listed Resident #1's diagnosis, and she had called the DON to obtain the hospital discharge orders but was told she [the DON] was working on the orders. Staff C recalled on 10/02/25 the pharmacy delivered medication between 10:00 PM and 11:00 PM for Resident #1 but the insulin was not sent. Staff C reported that when she started her contract, she had received a training packet but did not have access to the E-Kit for emergency medications and was unaware of E-Kit location. Staff C stated she tested Resident #1's blood sugar two times that evening and the results were going up and she did not administer insulin. Staff C stated she also had to find an oxygen concentrator due to Resident #1 portable oxygen supply having been depleted. Staff C stated she was aware there were other nurses in the building but did not request assistance and did not call the physician to receive insulin. Staff C stated at 10:00 PM she gave report to Staff E, LPN. She stated she informed Staff E that the pharmacy delivered Resident #1's medication and Staff E stated she would confirm the orders.During an interview on 10/08/25 at 3:17 PM, Staff E, Licensed Practical Nurse (LPN) stated she had been employed at the facility for two years and was aware of the admission process. Staff E explained that when a resident is discharged the hospital nurse would call a report to the day nurse, fax or send the discharge information with the admission orders. Staff E stated then the facility staff faxed the medication list to the pharmacy and the 2:00 PM -10:00 PM nurse could review the orders in the EHR. Staff E stated the orders in the EHR should be checked with the discharge orders, and that final order would have made it possible to access the E-Kit. She explained a nurse could then remove needed medications, such as insulin from the E-Kit. Staff E explained if a medication was not in the E-Kit then the nurse should call the doctor to get the order.Staff E, LPN stated she had provided care for Resident #1 before and there had always been discharge paperwork, except for the admit on 10/02/25. Staff E stated Staff C, RN had provided a diagnoses paper and reported the medication arrived from the pharmacy and claimed she was not trained to confirm orders. Staff E stated Staff C did not mention high blood sugar without an insulin order. Staff E stated she was unable to remember completing an assessment or charting for Resident #1 on the overnight shift. Staff E reported Resident #1 had a C-PAP with tubing tangled up and had assisted her to the bathroom. Staff E stated she was aware that Resident #1 was a diabetic due to providing care during recent skilled admissions when she had utilized the insulin pump. Staff E stated she did not look for an insulin pump and did not ask Resident #1 if she had one. Staff E stated she did not check or confirm Resident #1's orders that night due to another resident passing and had a printer not functioning. Staff E stated it was busy. During an interview on 10/13/25 at 11:43 AM, Staff J, LPN verified she worked on 10/03/25. Staff J stated she did not provide care for Resident #1 during her admission on [DATE]. Staff J stated on 10/03/25 she completed a bedside glucose check for Resident #1. She stated the meter gave a HIGH reading. Staff J explained that usually meant there is a blood sugar reading over 400 mg/dL. Staff J reported that Resident #1 complained she was battling nausea. Staff J stated she checked the MAR and did not find insulin listed or parameters to follow for glucose levels. Staff J stated she reported the situation immediately to Staff B, ADON. Staff J she then received a called from the county hospital lab to report a critical lab value from the CBC and BMP labs drawn earlier in the morning [10/3/25]. Staff J stated that Resident #1 was then transferred to the hospital. During an interview on 10/13/25 at 12:07 PM, Staff D, RN reported she worked at the facility for 2 and a half months. Staff D stated she completed Resident #1's admission assessment on 10/02/25. Staff D stated it was tricky as she did not get a verbal report from the hospital. Staff D stated she was not aware Resident #1 had a diagnosis of type 1 diabetes, and did not review the [hospital] discharge orders and thought the orders would be faxed to the facility. Staff D stated it was her first admission and the DON was in a meeting and was not present when she completed the assessment. Staff D stated she had asked for the admission check list but by the time the checklist arrived, it was not clear who was doing what. Staff D explained the DON told her that she would tag team it [the admission] and enter the orders. Staff D explained there was very little time left in the shift, and she did not think she did anything else for Resident #1. Staff D recalled Staff I, RN told her that she did not need a report after the admission assessment since she was familiar with Resident #1 and had taken the hospital verbal report. Staff D commented, it was a messy admission and the nurses were not ready to take Resident #1, it was last minute rush and she was alone during the admit, which was her first. During an interview on 10/13/25 at 1:54 PM, Staff B, RN, stated she has been the ADON since March 2025 and employed at the facility for 2 years. Staff B stated she was not in the facility on 10/02/25 and was not involved with Resident #1's admission. Staff B stated she worked on 10/03/25 and on arrival in the morning she received a call from Staff J, LPN who reported the high blood sugar result for Resident #1. Staff B stated she called the Medical Director to report the result and he asked how did that happened. Staff B communicated the Medical Director there was no order for insulin. Staff B requested a STAT order, and was directed to transfer Resident #1 to the hospital. Staff B stated she directed Staff J, LPN and Staff D, RN to transfer Resident #1 to the hospital. Staff B stated she did not see Resident #1 but knew the resident from previous admissions and knew she was diabetic. During an interview on 10/13/25 at 9:29 AM, the Administrator stated her expectation was to have the nursing staff follow the admission check list and to confirm the admission orders by reviewing the discharge orders received to the Medication Administration Record (MAR) received from the pharmacy. If the documents do not match, notify the DON for further assistance. During an interview on 10/13/25 at 9:34 AM, the DON stated the expectation for Resident #1 was not met on the day of admission from the hospital on [DATE]. The DON stated she would expect the nursing staff to follow the admission check list. The DON stated administration added a time frame to the check list to be completed within four hours of the resident admission to the facility. During a follow-up interview on 10/13/25 at 11:17 AM, the DON stated she had discovered that Staff C, RN fingerprint was not registered and would not work to open the E-Kit where the insulin was located that should have been administered to Resident #1. The DON stated the agency or contracted nurses do not admit residents. Review of an undated document titled admission Checklist Medication Orders instructions, which included:a. Need to fax over to pharmacy with proper face sheet indicating if resident is a Private pay/Medicaid or Skilled admission. Please include scripts for narcotics.b. Call pharmacy and confirm they received orders and communicate if there is anything you need from [brand name of E-Kit provider redacted] or if something needs stat to community.c. All medications must have an ICD 10 (International Classification of Diseases, 10th Revision, a diagnostic and procedure coding system) code written next to the medication in order for the pharmacy to enter those diagnosis. If not, we will be responsible to enter the diagnosis.d. After medications have been put in by the pharmacy the NURSE must go under orders and confirm them to be correct from here we can change the time or ensure a stop date is in place. Nurse must ensure that the time has been changed from the default of - as directed by pharmacy. However, the pharmacy CANNOT see what we have changed and they also need us to put that information on the fax sheet and send it over to them so moving forward it all matches. e. Community will need to enter all house orders/standing orders. Pharmacy will not do this.

Based on clinical record review, facility policy review, resident and staff interviews, the facility failed to provide pain medication after a newly admitted resident reported a pain at 8 out of 10 for 1 of 3 residents (Resident #1) reviewed for pain. The facility reported a census of 52 residents.Findings include:Review of the electronic health record (EHR) revealed a hospital Discharge summary, dated [DATE], which indicated: admission Date: 9/22/2025. discharge: [DATE]. Disposition (discharge arrangements): SNF (Skilled Nursing facility) at HH (abbreviation for facility) .Discharge Diagnoses, in part: Chronic pain, PMR (polymyalgia rheumatica - an inflammatory condition that causes joint and muscle pain in multiple locations), Anxiety, Insomnia, Stage 3b chronic kidney disease, Fibromyalgia (chronic condition that causes widespread body pain), Type 1 diabetes mellitus, AKI (acute kidney injury). The Discharge Summary included a Discharge Medication List, which under the Continue taking these medications section listed the following pain medications orders:a. acetAMINOPHEN 325 mg tablet Take 2 tablets (650 mg total) by mouth every 4 hours as needed for pain or fever.b. cyclobenzaprine 10 mg tablet. Take 1 tablet (10 mg total) by mouth three times daily as needed. Diagnosis: Spasms of the hand or feet.c. oxyCODONE- acetAMINOPHEN 5-325 mg per tablet. Take 1-2 tablets by mouth every 6 hours as needed. Diagnoses: Other chronic pain. d. traZODone 50 mg tablet. Take 1-2 tablets (50-100 mg) by mouth daily at bedtime. Diagnoses: Primary insomnia. Review of the EHR revealed a progress note titled ADV Clinical admission Note, entered on 10/2/25 at 12:20 PM, which included, in part: admission Details: Arrived by private transportation service. Review of the Care Plan, Date Initiated 10/2/25 included a Focus area to address The resident has risk of pain r/t fibromyalgia, PMR, decreased mobility. Interventions included, in part:a. Give pain medication as ordered. Date Initiated. 10/02/25.b. Measure/rate pain on a scale of 1-10 with 10 being the highest. Date Initiated: 10/02/25.c. Monitor/record/report to Nurse any s/sx (sign and symptoms) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Date Initiated: 10/02/2025d. Notify Dr. (doctor) current pain regime is not effective. Date Initiated: 10/02/25. Review of the resident's EHR revealed Physician Orders, which included, in part:a. Oxycod (oxycodone)/APAP (acetaminophen) tab 5-325 mg (milligrams) take 1 tablet by mouth every 6 hours as needed for pain. Start Date: 10/2/25. b. Acetaminophen (APAP) tab 325 mg take 2 tablets (650 mg) by mouth every 4 hours as needed.(indications for Use: pain). Start Date: 10/2/25. c. Cyclobenzaprine (generic name of a muscle relaxant) 10 mg take 1 tablet by mouth three times daily (TID) as needed for spasms of the hands/feet (indications for Use: muscle spasms). Start Date: 10/02/25.d. Trazodone tab 50 mg take 1 tablet by mouth at bedtime as needed for primary insomnia. Start Date: 10/02/25.e. Trazodone tab 50 mg take 1 tablet by mouth at bedtime as needed for primary insomnia (give w/ (with) scheduled 50 mg=100mg). Start Date: 10/02/25.During an interview on 10/7/25 at 2:48 PM, Resident #1 stated she entered the facility on 10/2/25 for skilled care after a hospitalization for heart failure. She stated she arrived at the facility around noon. Resident #1 explained she suffered from fibromyalgia and routinely took oxycodone for the pain, which she described as being an 8 out of 10. Resident #1 stated she reported her pain to the nurse on admission to the facility. Resident #1 stated she was told that the order for Percocet (a brand name for a pain medication containing oxycodone with APAP) was as needed (commonly called PRN) and not available. The resident reported she was informed the facility only had one dose [Percocet] in the Emergency Kit (or E-Kit, which is a supply of medications provided by the pharmacy for use in the event of a critical need or before the next scheduled delivery of medications). Resident #1 stated she did not receive pain medication on 10/2/25, and was hurting everywhere. Resident #1 stated staff told her that someone could go to her house to get her Percocet, and she told them no she did not want anyone in her house. Resident #1 stated the night nurse did not come back to complete an assessment. Review of the October 2025 Medication Administration Record (MAR) revealed: a. Oxycodone/APAP 5-325 mg 2 tablets every 6 hours as needed. No documentation the medication administered on 10/2/25 or on 10/3/25. b. Acetaminophen 325 mg 2 tablets QID as needed for pain. No documentation the medication administered on 10/2/25 or on 10/3/25.c. Cyclobenzaprine 10 mg TID as needed for spasms of hands/feet. No documentation the medication administered on 10/2/25 or on 10/3/25.d. Trazodone 50mg 1 tablet at bedtime for insomnia. No documentation the medication administered on 10/2/25. e. Trazodone 50mg 1 tablet at bedtime as needed for insomnia. No documentation the medication administered on 10/2/25Review of the Pain Level Summary printed on 10/8/25 revealed the following pain assessments:a. On 10/02/25 at 12:25 PM pain level 8 out of 10 recorded. b. On 10/03/25 at 9:39 AM pain level 8 out of 10 recorded. c. On 10/03/25 at 9:48 AM pain level of 8 out of 10 recorded. During an interview on 10/14/25 at 11:11 AM, Staff I, Registered Nurse (RN) verified she worked on 10/2/25, and completed the admission for Resident #1, Staff I explained the admission was her first at the facility since she started working as a PRN staff eight months ago. Staff I stated she had received a verbal report from the hospital prior to the resident's admission, and the hospital did not send any medications with the resident. Staff I stated she had given a report to Staff D, RN, the admission nurse for Resident #1, which included the information from the hospital report. Staff I stated she had assisted Staff D, RN with the admission. Staff I stated Resident #1 complained of pain and that the resident took oxycodone routinely but the MAR did not reflect the order at the time of the admission assessment. Staff I explained she was not able to access any medications until they were processed and listed in the EHR MAR. Staff I explained she provided Resident #1 with an ice pack and fan as the resident's biggest complaint was her room being hot. Staff I stated she provided care for an hour and half then gave report to the 2:00 PM-10:00 PM nurse, Staff C, RN, which she recalled included a report of the residents pain level. During an interview on 10/8/25 at 2:49 PM, Staff C, RN stated she worked as a contract staff for the facility and started approximately 3 weeks ago. Staff C reported that she had received a training packet but did not have access to the E-Kit and had not known the location of the E-Kit. Staff C recalled on 10/2/25 the pharmacy delivered medication between 10:00 PM and 11:00 PM for Resident #1 but the pain medication was not sent. Staff C stated she assessed Resident #1's pain at 8 out of 10. Staff C stated she was unable to administer pain medication due to not having access to the E-Kit. Staff C stated she was aware there were other nurses in the building but did not request assistance, or call the physician. During an interview on 10/8/25 at 3:17 PM, Staff E, Licensed Practical Nurse (LPN) stated she had been employed at the facility for two years and was aware of the admission process. Staff E stated she was unable to remember completing an assessment or charting for Resident #1 on the overnight [10/2/25 to 10/3/25] shift due to a busy night. Staff E stated she was unaware Resident #1 reported pain to the previous nurse. During an interview on 10/13/25 at 12:07 PM, Staff D, RN worked at the facility for 2 and a half months. Staff D stated she completed Resident #1's admission assessment on 10/2/25. Staff D described the admission as tricky as she did not get the verbal report from the hospital, and did not have the discharge orders at the time of the assessment. She explained the Director of Nursing (DON) had the orders and was in a meeting. Staff D stated she was not able to treat Resident #1 pain, but was aware Staff I, RN gave the resident a cold pack. Staff D described the admission as messy, and the nurses were not ready to take Resident #1. During an interview on 10/8/25 at 12:15 PM, the Medical Director stated Resident #1 was admitted for skilled nursing after a hospitalization for heart failure. The Medical Director stated he would expect the facility to call either the discharging hospital pharmacist and/or provider or his on-call group right away if a resident is experiencing pain so it can be treated. During an interview on 10/13/25 at 9:34 AM, the DON stated the expectation for Resident #1 was not met on the day of admission from the hospital on [DATE]. Review of the facility policy, titled Pain Evaluation and Management, origination 7/2016, last revised 10/2025 revealed a Protocol statement, which declared: It is the policy of [company name redacted] that all residents have the right to appropriate pain assessment and pain management. All resident will be evaluated for indicators of a history of pain on admission, quarterly, with a significant change in status and with the new onset of potential pain or discomfort. Data will be collected through resident interview, staff interviews and observations. The Procedure section directed, in part:#8. If the resident has a diagnosis which could cause pain or discomfort, and they show no sign or symptoms of pain or discomfort, continue to reassess for indicators of pain and behavioral changes.#9. Notify PCP (primary care provider) of pain assessment findings if pain is indicated to start or change pain management program as necessary with on-going evaluation of effectiveness of medications prescribed.#10. Follow prescribed orders for pain management - documenting for PRN medications using provided pain scale of 0-10.

Based on clinical record review, facility incident reports, and facility staff interview, the facility failed to administer two doses of insulin for 1 of 3 residents (Resident #1), and remove a transdermal pain patch prior to application of a new patch and notify physician and responsible party of the error for 1 of 3 residents (Resident #2) reviewed for medication administration. The facility reported a census of 51 residents. Findings include: 1. A review of [name redacted] hospital discharge orders, dated 3/6/24, Medication List revealed the following orders, in part: a. Insulin glargine 100 unit/ml (milliliters) (3 ml) injection pen. Dosage: Inject 18 units subcutaneously daily. Last time this was given: 18 units on March 5, 2024 8:50 PM. Diagnosis: Type 2 diabetes mellitus without complication, without long-term current use of insulin. b. CONTOUR NEXT EZ METER Dosage: USE TO CHECK BLOOD SUGAR THREE TIMES A DAY c. SUPPLY CONTOUR NEXT test strips Dosage: Use 1 strip three times a day to test blood sugars. d. SUPPLY lancets Dosage: Use to test blood sugar 4 times daily. Diagnosis: Type 2 diabetes mellitus without complication, without long-term current use of insulin. A review of a N ADV-Clinical Admission document revealed Resident #1 admitted to the facility on [DATE]. The Mental Status section of the document indicated Resident #1 verbal, confused, oriented to person, and a mild cognitive impairment. The assessment did not include information about the need for blood sugar checks. The Baseline Care Plan, Section 3. Health Conditions, dated 3/06/24, indicated Resident #1 diabetic. The D. Medications section did not indicate resident taking insulin. The Care Plan, Date Initiated 3/21/24 and 3/25/24, did not include a Focus area to address a diagnosis of diabetes mellitus, and the use of insulin. A review of the March 2024 Medication Administration Record (MAR), revealed an order for Insulin Glargine Subcutaneous Solution Pen-Injector 100 UNIT/ML (insulin Glargine) Inject 18 units subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (high blood sugar) Start Date 3/7/24 with D/C (discontinue) Date 3/10/24. A review of the MAR indicated the medication administered in the AM on 3/7/24, 3/8/24, and 3/9/24. A review of the March 2024 MAR revealed an order for Insulin Glargine Subcutaneous Solution Pen-Injector 100 UNIT/ML (insulin Glargine) Inject 18 units subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA , State Date 3/10/24, D/C Date 4/1/24. A review of the MAR indicated the medication administered HS (bedtime) on 3/10/24 through 3/31/24. A review of the March 2024 MAR revealed an order for HumaLOG KwikPen Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Lispro) Inject 6 unit subcutaneously with meals related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. Start Date 3/10/24, D/C Date 4/1/24. A review of the MAR indicated Insulin Lispro not administered to the resident three times daily on 3/15/24. The AM and NOON dose coded with a number 9'. The Chart Codes listed on the MAR indicated a 9 is used to communicate Other/See Progress Notes. A review of the March 2024 MAR revealed an order for Blood sugar checks TID (three times) three times a day related TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED Start Date 3/6/24, D/C Date 5/10/24 revealed a number 9 coded for both morning and noon blood sugar checks on 3/15/24. A clinical record review revealed the following notes related to the code number 9: a. On 3/15/24 at 3:57 PM, a X-Orders-Administration Note Note Text: Blood sugars checks TID three times a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED forgot b. On 3/15/24 at 3:58 PM, a X-Orders-Administration Note Note Text: HumaLOG KwikPen Subcutaneous Solution Pen-Injector 100 UNIT/ML Inject 6 unit subcutaneously with meals related to TYPE @ DIABETES MELLITUS WITHOUT COMPLICATIONS forgot c. On 3/15/24 at 3:59 PM, a X-Orders-Administration Note Note Text: Blood sugars checks TID three times a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED forgot d. On 3/15/24 at 3:59 PM, a X-Orders-Administration Note Note Text: HumaLOG KwikPen Subcutaneous Solution Pen-Injector 100 UNIT/ML Inject 6 unit subcutaneously with meals related to TYPE @ DIABETES MELLITUS WITHOUT COMPLICATIONS forgot A Nurses Note, dated 3/15/24 at 7:15 PM documented Dexcom (a device for continuous blood sugar monitoring) alarming for high glucose. Monitor reads 268. Fingerstick done shows 300. Monitor calibrated. no s/s (signs/symptoms) hyperglycemia. Scheduled insulin given. Will check again prior to bedtime. An incident report documenting missed insulin doses and blood sugar checks not present in Resident #1 clinical record. During an interview on 10/24/24 at 1:30 PM, Staff A, Registered Nurse (RN), stated nurses are instructed to alert the Director of Nursing (DON), notify the resident's Primary Care Provider for any additional instructions and notify the resident's responsible party for any omitted medications and then complete an incident report for the occurrence. During an interview 10/24/24 at 2:00 PM, Staff B, Licensed Practical Nurse (LPN), stated if a resident's medication had not been administered, the nurse should notify the doctor and let the family know. On 10/25/24 at 2:33 PM, an email received from the Administrator confirmed Resident #1 morning and noon doses of HumaLOG had been omitted and the facility lacked an incident report on the occurrence. During an interview on 10/28/24 at 10:10 AM, Director of Nursing (DON), stated she would expect nurses to complete a risk management (incident report) for any medication errors and notify the Primary Care Provider right away with medication errors. 2. The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 for Resident #2, which indicated moderate cognitive impairment. Diagnoses included cancer, arthritis, fractures of left side ribs, and non-Alzheimer's dementia. The MDS indicated Resident #2 required opioid (pain) medication. The Care Plan, revised 8/14/24, revealed Resident #2 utilized pain medication. The Care Plan instructed staff to provide medications as ordered and to monitor/document side effects and effectiveness. A review of the August 2024 MAR revealed an order for Fentanyl 12MCG/HR (micrograms per hour) APPLY ONE PATCH TOPICALLY TO SKIN EVERY 3 DAYS REMOVE OLD PATCH PRIOR TO NEW PATCH, ROTATE SITES (Related Diagnoses: Other chronic pain) Start Date 8/9/24. The MAR revealed Resident #2's Fentanyl patch was changed on 8/30/24 with a new patch applied to the upper back. A review of the September MAR revealed Staff A, Registered Nurse (RN) changed Resident #2's Fentanyl patch on 9/02/24, with a new patch applied to the upper back. The facility provided a document, dated 9/5/24, titled Medication Error. Incident Description Section, Nursing Description: Resident [Resident #2] found 2 fentanyl patches on. One dated 8/30 & one dated 9/2. Patch on 9/2 applied by [name redacted] RN (Registered Nurse). Immediate Action Taken Section, Description: Both patches removed as new one due today. Statement Section: No Statements Found. Agencies/People Notified: [name redacted] Director of Nursing. Notes Section: 9/5/24 Education to staff to check for placement of all patches and remove before applying new patch. DON initialed. A review of Nurses Notes revealed no entry regarding notification of physician and responsible party regarding the medication error. During an interview on 10/24/24 at 1:30 PM, Staff A, RN stated the process for changing a Fentanyl patch included a check of the resident to ensure the old patch is found and removed before a new patch is applied. Staff A stated she had changed Resident #2's Fentanyl patch on 9/02/24 and recalled being unable to find the old patch on the resident. Staff A revealed that the nurse would complete an incident report when any medication error had been found, which included notification to physician and responsible party. During an interview on 10/28/24 at 10:10 AM, Director of Nursing (DON), stated the expectation of nurses to complete an incident report for any medication error and for timely notification to the provider of incident. DON informed that staff had watched Resident #2 following incident for any side effects and confirmed that Electronic Health Record (EHR) had lacked this documentation.

Based on observation, clinical record review, policy review, and staff interview, staff combined medications without an order to do so during the administration of g-tube (gastrostomy tube-a tube inserted through the abdomen which brought nutrition and medications directly to the stomach) medications for 1 of 1 residents reviewed with a g-tube(Resident #10). The facility reported a census of 50 residents. Findings: The Minimum Data Set (MDS) assessment tool, dated 1/19/24, listed diagnoses for Resident #10 which included non-Alzheimer's dementia, Parkinson's disease (progressive disorder that affected the nervous system and the parts of the body controlled by the nerves), and depression. The MDS stated the resident had a feeding tube and listed the resident's Brief Interview for Mental Status (BIMS) score as 1 out of 15, indicating severely impaired cognition. The facility policy Medication Administration Through Tube Feeding, last revised 7/2016, directed staff to administer each medication separately. A 3/30/22 Care Plan entry stated the resident had a g-tube for supplemental feedings. A 3/5/23 Care Plan entry directed staff to provide medications per the order. The April 2024 Medication Administration Record (MAR) listed a 2/19/24 order for carbidopa/levodopa(a medication used to treat Parkinson's) 25-100 milligrams(mg) 1.5 tablets three times daily and a 2/20/24 order for quetiapine (an antipsychotic) 50 mg three times daily. The MAR lacked an order to combine the medications during g-tube medication administration. During an observation on 4/2/24 at 11:00 a.m., Staff A Licensed Practical Nurse(LPN) crushed the following medications and mixed them with water: 1. carbidopa/levodopa 25-100 mg 1.5 tablets 2. quetiapine 50 mg tablet Staff A then instilled a water flush, instilled the medications mixed with the water, and instilled a water flush. On 4/2/24 at 1:08 p.m., Staff A stated there should be an order to combine medications during g-tube medication administration and stated she would check. On 4/2/24 at 2:05 p.m., Staff A stated she obtained an order to combine the medications.

Based on observations, policy review, and resident, and staff interviews, the facility failed to timely assist residents who needed assistance for 3 of 16 residents reviewed (Resident #12, #42, #40). The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #12 dated 2/7/23 documented a Brief Interview Mental Status (BIMS) score of 03, which indicated severely impaired cognition. The MDS identified that Resident #12 needed extensive assistance with bed mobility, walking, transfers, dressing, toilet use, and personal hygiene. The MDS listed the following diagnoses of Non Alzheimer's Dementia and Parkinson's disease. The Care Plan Focus dated 1/6/23 identified goals for communication, nutrition, fall prevention, UTI prevention and continence; The Care Plan interventions dated 1/6/23 included: 1. Ensure the resident has an unobstructed path to the bathroom. 2. Assist to the toilet 4 x per shift and prn. 3.The resident would like to have time to consume meals, not be rushed. 4. Anticipate and meet The resident's needs On 2/20/23 at 3:31 PM a family member of Resident #12 stated she believed staffing problems resulted in multiple falls and an injury for Resident #12. Family member of Resident #12 said there were enough staff on the weekends and the facility needed more help. On 2/21/23 at 7:26 AM revealed Resident #12 at the breakfast table in his wheelchair waiting for food. Resident #12 raised his hand for assistance but staff did not see him. Resident #12 pushed himself in his chair toward Staff A, Cook and tried several times to get her attention. On 2/21/23 at 7:29 AM Resident #12 was noticed by Staff A. Resident #12 stated he needed to use the bathroom. Staff A, said she would get someone else to help Resident #12. On 2/21/23 at 7:34 AM Resident #12 waited in the wheelchair. He moved himself close to the kitchen where Staff A stood. On 2/21/23 at 7:43 AM Resident #12 raised his hand again for assistance. Staff A was present but did not note the wave. On 2/21/23 at 7:44 AM Resident #12 raised his hand again and shook it in the air for a few seconds. No staff noted Resident #12. On 2/21/23 at 7:45 AM Staff A asked Staff B Licensed Practical Nurse (LPN) for assistance with changing paper towels. Staff A did not mention Resident #12 or his need to use the restroom. On 2/21/23 at 7:47 AM Staff A stated Resident #12, you still haven't gotten there? I'm sure they are coming, they must be busy with someone else. On 2/21/23 at 7:52 AM Resident #12 was greeted by Staff E, Housekeeper. Resident #12 told Staff E he needed to use the restroom. Staff E consulted with Staff A who advised that Resident #12 needed to wait for assistance. Staff E pushed Resident #12 from the dining room to the hallway facing his room. On 2/21/23 at 7:57 AM Staff C, Certified Medication Aide (CMA) took Resident #12 to the bathroom. On 2/21/23 at 8:20 AM Resident #12 returned to the dining room. On 2/21/23 silverware was brought to the table for Resident #12 On 2/21/23 at 9:01 AM juice and water were provided to Resident #12. On 2/21/23 at 9:53 AM food was delivered to Resident #12 who used an adaptive plate and utensil to feed himself. 2. The Minimum Data Set (MDS) for Resident #42 dated 12/29/22 documented a Brief Interview Mental Status (BIMS) score of 04, which indicated severely impaired cognition. The MDS identified that Resident #42 needed extensive assistance with bed mobility, walking, transfers, dressing, toilet use, eating and personal hygiene. The MDS listed the following diagnoses of Alzheimer's Disease and Parkinson's disease. The Care Plan Focus dated 1/6/23 identified goals for communication and nutrition. The Care Plan interventions dated 1/6/23 included: 1. Encourage adequate nutrition and hydration. 2. The resident would like assist of one with eating 3. Anticipate and meet needs. On 2/21/23 at 7:27 AM Resident #42 spilled a drink at the dining room table. The plastic glass made a loud noise heard by two DIA staff in the area. There was no response from staff A, Cook or Staff C CMA who were also in the room. A puddle of liquid formed to the left of Resident #42's wheelchair. On 2/21/23 at 7:48 AM Staff E, Housekeeper noted the spill and alerted Staff B, LPN who assessed Resident #42 for wet clothing. On 2/22/23 01:29 PM the Administrator stated that the expectation for staff response to residents is 12 to 15 minutes or less. The administrator stated that she expected food to be delivered as soon as possible to residents. The Administrator agreed that being in the dining room at 8:30AM and getting food at 10:00 AM would be too long to wait. A call light policy for the facility stated a purpose of the call light is to respond promptly to resident's call for assistance. 3. Significant Change MDS for Resident#40 dated 1/30/23 documented diagnoses which included, heart and lung disease included chronic obstructive pulmonary disease (COPD), Spinal stenosis, arthritis, osteoporosis, weakness. The MDS documented that the resident needed assistance with personal cares, and extensive assistance of one for transfers, walking, dressing and toilet use. Resident #40 BIMS score coded 15 which indicated cognitively intact. Care plan dated 11/4/22 for Resident #40 documented focus area, activities of daily living self-care performance deficit related to activity intolerance. Interventions included ambulation to assist of one using a gait belt and walker, for toileting, assisted of one with toileting. Interview on 2/21/2023 at 10:23AM Res.#40 reported up to 45 minutes for staff response to the call button, and reported to watch the clock. The resident also stated sometimes my bladder can't wait. On 2/21/2023 the Assistant Director of Nursing (ADON) reported the expectation is call lights should be answered 10-15 minutes. A call light report was requested, policy was provided. Review of call light report provided by the Director of Nursing (DON) for 2/20/23 revealed for Resident #40: a. On 2/20/23 at 7:19 AM response was 21 minutes. b. On 2/20/23 at 1:02 PM response was 19 minutes. c. On 2/20/23 at 2:10 PM response was 24 minutes.

Based on observation, record review and staff interview the facility failed to ensure the spread of potential infections with hairnets not covering all hair. The facility reported a census of 50. Findings include: An observation on 1/6/20 at 10:59 a.m., Staff A (Cook) in the Sagewood Unit had exposed hair not covered by a hairnet, approximately 3 inches above the neck. An observation on 1/6/20 at 12:40 p.m., Staff B (Cook) in the Rosewood Unit had exposed hair not covered by a hairnet, approximately 2 inches around the neck and side of face. An observation on 1/6/20 at 12:40 p.m., Staff C (Cook) in the Rosewood Unit had exposed hair not covered by a hairnet; approximately 2 inches above the neck. An observation on 1/7/20 at 9:07 a.m., Staff D (Cook) in the Rosewood Unit had exposed hair not covered by a hairnet, approximately 2 inches above the neck. An observation on 1/8/20 at 7:45 a.m., Staff A (Cook) in the Sagewood Unit had 2 to 3 inches of exposed hair not covered by a hairnet above the neck and on the side of the face. An observation on 1/08/20 at 11:45 a.m., Staff D (Cook) in the Rosewood Unit and Staff [NAME] (Cook) had exposed hair of 1 to 2 inches not covered by a hairnet above the neck and on the side of the face. During an interview on 1/8/20 at 03:40 p.m., the Certified Dietary Manager (CDM) stated an expectation of staff to cover all hair with the hairnet. The undated Dress Code and Personal Hygiene policy instructed staff to wear a hairnet that sufficiently covers the hair while in the kitchen or serving food.

Based on observation, record review, and interview, the facility failed to prime insulin pens prior to administration and failed to administer medications in a timely manner for 2 of 5 sampled (Residents #14 and #31). The facility reported a census of 50. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #14 had [DIAGNOSES REDACTED]. The MDS listed Resident #14's cognition as severely impaired. During an observation on 1/8/20 at 10:20 a.m., Staff F (Registered Nurse) dialed up 20 units on a Basalgar (insulin) pen, 10 units on a [MEDICATION NAME] R(insulin) pen, and 2 units on a [MEDICATION NAME] (insulin) pen. Staff F commented the staff primed the pens on the very first use. Staff F approached Resident #14 with the pens. Staff F reported she planned to administer the insulin. The surveyor intervened and asked Staff F about the priming. Staff F again stated they only primed with pen when it was new. Staff F then primed all of the pens and administered the insulin. The (MONTH) Medication Administration Record [REDACTED] a. Basalgar insulin 20 units subcutaneously (SQ) every day. b. [MEDICATION NAME] sliding scale insulin SQ three times a day (2 units for blood sugars 201-250). c. [MEDICATION NAME]10 units SQ four times a day. The Director of Nursing (DON) provided the Basalgar instructions. The instructions directed staff to prime the needle before each injection to remove air so the pen worked properly. The DON provided the [MEDICATION NAME] R insulin instructions. The instructions directed staff to prime the needle before each injection to remove air so that the pen worked properly. The DON provided the [MEDICATION NAME]instructions. The instructions directed staff to prime the needle before each injection to ensure proper dosing. The Insulin Pen policy revised 7/25/16, directed staff to prime the pen prior to the administration of the injection to ensure accurate dosing. 2. During an observation on 1/8/20 at 10:53 a.m., Staff F (Registered Nurse) administered the following medications via Resident #31's gastrostomy tube ([DEVICE]): a. Pantoprazole 40 milligrams (mg). b. [MEDICATION NAME] 40 mg. c. [MEDICATION NAME] 125 mg. d. [MEDICATION NAME] 20 mg. e. Potassium 20 milliequivalents. f. Pedia-lax 200 mg. The physician's orders [REDACTED].#31: a. Pantoprazole 20 milliliter (mL) every day by mouth at 8:00 a.m. b. [MEDICATION NAME] 40 mg capsule via [DEVICE] every day at 8:00 a.m. c. [MEDICATION NAME] 125 micrograms via [DEVICE] every day at 8:00 a.m. d. [MEDICATION NAME] 20 mg via [DEVICE] every day at 8:00 a.m. e. Potassium 15 mL/20 mEq(milliequivalents) via [DEVICE] every day at 8 :00 a.m. f. Pedia-lax 60 mL/200 mg via [DEVICE] every day at 8:00 a.m. During an interview on 1/8/19 at 3:03 p.m., the DON stated the facility only primed the insulin needles prior to the first use. She stated this was her thought because they had a pharmacist provide training with these directions. On 1/9/20 at 9:15 a.m., the DON provided the survey team with a handwritten document which stated Med Soft Times and listed the morning medication time frame was 7:00 a.m.-10:00 a.m. The DON stated staff should give 8:00 a.m. medications by 10:00 a.m. and should call for help if they were behind in the medication pass.

Based on observation, record review, and interview, the facility failed to check gastrostomy tube ([DEVICE]) placement prior to administering medications for 1 of 1 sampled (Resident #31). The facility reported a census of 50. Findings include: 1. The Minimum Data Set assessment dated [DATE] documented Resident #31 had [DIAGNOSES REDACTED]. Resident #31 required extensive assistance of 2 staff for bed mobility, dressing, toilet use, and personal hygiene, depended completely on 1 staff for bathing and eating, and depended completely on 2 staff for transfers. Resident #31 had moderate cognitive impairments. During an observation on 1/8/20 at 10:53 a.m., revealed Resident #31 had [MEDICATION NAME] 1.2 solution running continuously at 60 milliliters (mL) an hour. Staff F RN (Registered Nurse) stopped the infusion, flushed the tube with 30 mL of water, and administered the following medications via the resident's [DEVICE]: a. Pantoprazole 40 milligrams (mg). b. [MEDICATION NAME] 40 mg. c. [MEDICATION NAME] 125 mg. d. [MEDICATION NAME] 20 mg. e. Potassium 20 milliequivalents. f. Pedia-lax 200 mg. Staff F failed to check for tube placement prior to flushing the tube and medication administration. During the observation, Staff F commented she remembered the facility policy did not direct staff to check the placement prior to administering medications for residents with continuous [DEVICE] feedings. The Enteral Feeding Tube Care policy revised 7/27/19 and Enteral Nutritional Feeding policy revised 7/29/19 failed to direct the staff to check the tube placement prior to the administration of [DEVICE] medications. During an interview on 1/8/20 at 3:03 p.m., the Director of Nursing stated an expectation of the nurses to check for residual to determine placement anytime they unhooked the tube feeding to administer a medication.

Based on record review and interview, the facility failed to document a clinical rationale and a specific duration for a as needed (prn) anti-anxiety medication for 1 of 1 sampled (Resident #14). The facility reported a census of 50. Findings include: 1. The Minimum Data Set assessment dated [DATE] documented Resident #14 had [DIAGNOSES REDACTED]. Resident #14 had severe cognitive impairments. The (MONTH) 2020 Medication Administration Record [REDACTED]. The Pharmacist/Provider note dated 1/6/20 directed staff to continue the prn [MEDICATION NAME] while on hospice services. The note failed to list a rationale and did not list the duration. The [MEDICAL CONDITION] Medications Process policy revised 10/31/17, stated the facility would limit all prn medications to 14 days unless the physician identified a clinical rationale for an extension. During an interview on 1/9/19 at 9:50 a.m., the Director of Nursing stated she thought no additional documentation was required due to the resident receiving Hospice services.

Based on record review and staff interviews, the facility failed to immediately report allegations of abuse to the administrator of the facility and to the Department of Inspections and Appeals for 2 of 4 sampled (Residents #1, #2). The facility reported a census of 47. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 had short and long-term memory deficits and severely impaired cognitive abilities for daily decision-making. Resident #2 required extensive assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. Resident #2 had [DIAGNOSES REDACTED]. According to a letter dated 8/27/19 address to the Administrator, Staff A, (Registered Nurse Hospice) documented she witnessed Resident #2 attempting to stand up from her recliner and Staff A pushing Resident #2 with one hand on her chest back into the recliner. During an interview on 11/14/19 at 1:55 p.m., Staff A, Nurse Aide, reported the Director of Nursing asked her about an event in which she pushed Resident #2 back into her recliner. Staff A stated Resident #2 was leaning forward in her recliner and she placed her hand on her chest to prevent her from falling. Staff A stated she was directing Resident #2 to sit back down. Staff A stated at that same time a hospice worker entered the room and asked for the hospice nurse. Staff A stated she would go find the nurse and left the room. Staff A denied pushing or forcing Resident #2 back into her recliner. During an interview on 11/14/19 at 1:20 p.m. the Director of Nursing (DON), stated she recalls there being a letter from a hospice agency alleging Staff A pushed Resident #2 back into her recliner. The DON stated she spoke with Staff A, who stated to her that Resident #2 was leaning forward in her recliner and fearing she would fall she placed her hand on her chest. Staff A denied pushing Resident #2 back into her recliner. The DON stated she trusts Staff A and doesn't believe she would ever intentionally harm a resident. The DON stated the event was misinterpreted and not reported to the Department of Inspections and Appeals. During an interview on 11/14/19 at 1:15 p.m., the Administrator stated the Director of Nurses investigated the incident and determined it a misinterpretation by the hospice staff member. The Administrator stated they found no evidence to corroborate the allegation, therefore believed no abuse occurred and did not report the allegation to the Department of Inspections and Appeals. 2. According to the MDS assessment dated [DATE], Resident #1 had a severe cognitive impairment. Resident #1 required extensive assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. Resident #1 had [DIAGNOSES REDACTED]. During an interview on 11/13/19 at 11:35 a.m., Staff G, Nurse Aide, stated Resident #1 complained of a sore left upper arm and had a light bruise on the morning of Thursday, 9/6/19. Resident #1 reported she did not want to bathe last night and got ornery. Resident #1 reported the girl with the long hair and ponytail wanted her to take a bath. Resident #1 pointed at her left arm and stated see what she did to me. Staff G reported the description matched Staff G. Staff D had no knowledge of Staff G mistreating the residents and did not believe Resident #1. Staff G did not report the incident. During an interview on 11/13/19 at 1:30 p.m., Staff A, Nurse Aide, stated on Sunday, 9/8/19 at 12:00 p.m., Resident #1 stated she didn't like that girl. Resident #1 provided a description of brown hair, glasses and bigger. Staff A stated the description fit Staff D. Resident #1 stated she also did not care for her partner, who Staff A believed to be Staff E. Resident #1 reported the girl kicked her in the abdomen. Staff A stated she did not report the allegation. At 2:00 p.m., Staff D arrived and Staff A noticed Resident #1 went from happy and talkative to tearful. Staff A then reported her concerns to the Director of Nursing. During an interview on 11/13/19 at 2:21 p.m., Staff B, Nurse Aide, stated on Friday, 9/6/19 at 4:30 p.m. Staff [NAME] had just given Resident #1 a shower. Staff B was giving shift change report to Staff A when they heard Resident #1 scream. Staff B and Staff A went to Resident #1's room. Resident #1 was yelling and wanting Staff [NAME] out of her room, claiming she had been rough, mean and made her take a shower. Staff [NAME] and Staff A left the room as Staff B stayed. Resident #1 stated those two girls are always mean, describing one is bigger with glasses and brown hair which fit the description of Staff D. Staff B stated she noticed a bruise on Resident #1's arm and stated she reported the bruise to the nurse, Staff F, but did not report Resident #1's comment that she felt staff were mistreating her. On Sunday, 9/8/19 Resident #1 was sitting in the dining room when Staff D arrived. Resident #1's mood immediately changed and she went to her room. Staff B stated she asked Staff D why Resident #1 does not like her and Staff D stated she did not know. Staff B then went to Resident #1's room. Resident #1 was upset and crying, stating she did not want Staff D here. Resident #1 then stated no one wants to be hurt. Staff B stated at this point she contacted the DON and reported her concerns. In an interview on 11/13/19 at 2:55 p.m. Staff C, certified nurse aide, stated on Saturday, 9/7/19 shortly after arriving on shift at 2:00 p.m. she heard Resident #1 screaming. Staff C entered her room and saw Staff D laughing and holding the white board and Resident #1 visibly upset. Resident #1 stated get her out of here, I do not want her here. Staff C asked what was going on and Staff D stated she does not like me. Later in the shift, after supper, Staff C stated Resident #1 again that she didn't want Staff D around her and when asked why, Resident #1 stated she did me wrong, but didn't elaborate. On Sunday, 9/8/19 Staff C again asked Resident #1 what had happened the day before between her and Staff D. Resident #1 stated she had corrected Staff D and Staff D got mad and hurt her. Staff C stated she reported her concern to the nurse who suggested re-approaching her later. Later on, Staff C, Staff A and Staff B spoke with Resident #1 and she told them about being mistreated. All three staff notified the DON and reported their concerns. The Dependent Adult Abuse policy revised 4/3/17 directed the staff to notify the Administrator and Director of Nurses immediately in the event of suspected maltreatment/dependent adult abuse.

Based on observation, record review, and interview, the facility failed to maintain hot holding temperatures for 1 of 2 meals observed. The facility reported a census of 53 residents. Findings: During the group interview on 11/5/18 at 9:28 a.m., 3 of 5 interviewable residents in attendance stated the food was not hot enough. One resident commented the plates were cold as well. During an observation of the noon meal service on the Sagewood unit on 11/6/18 at 12:23 p.m., Staff B Cook served the last resident tray and the surveyor immediately requested a test plate. Using a facility thermometer, Staff B obtained the following temperatures: a. Pork: 124 degrees Fahrenheit b. Mashed potatoes: 112 degrees Fahrenheit During an observation of the noon meal service on the Wedgewood unit on 11/6/18 at 12:39 p.m., Staff A Cook served the last resident tray and the surveyor immediately requested a test plate. Using a facility thermometer, the Dietary Manager obtained the following temperatures: a. Mashed potatoes: 127 degrees Fahrenheit b. Beans: 124 degrees Fahrenheit c. Pork: 114 degrees Fahrenheit Review of Resident Council minutes, dated 8/31/18, revealed 1 resident stated pancakes were cold at breakfast and 1 resident stated the sausage was cold. Review of Resident Council minutes, dated 9/28/18, revealed 1 resident stated food became cold quickly because staff served on cold plates and 1 resident stated the soup needed to be warmer. Review of Resident Council minutes, dated 10/30/18, revealed 1 resident stated they would like their room tray served in a different container to keep the food warmer. The facility Dietary Policy No: 2.5 stated food would be held at correct temperatures to maintain safety and should not enter the danger zone between 41-135 degrees Fahrenheit. During an interview on 11/6/18 at 2:12 p.m., the Dietary Manger stated hot holding temperatures should be at least 145-150 degrees. She stated they had a plate warmer but it did not fit their current plates.

Based on observation, record review, and interview, the facility failed to maintain adequate kitchen sanitization and/or carry out proper food handling practices for 3 of 3 kitchenettes reviewed. The facility reported a census of 53 residents. Findings: A tour of the Wedgewood unit on 11/5/18 at 10:40 a.m. revealed the following concerns: a. Multiple colored splatters on all inside walls of the microwave and the microwave ceiling. b. Brown food debris and crumbs on the floor of the white upright pantry fridge. c. Crumbs and food debris on the floor of a cabinet in contact with cutting boards. d. Crumbs and food debris on the floor of a cabinet in contact with the bottoms of pans. e. Crumbs and food debris on the floor of a cupboard in contact with the bottoms of plates and dishes. A tour of the Sagewood unit on 11/5/18 at 11:59 a.m. revealed the following concerns: a. Staff A Cook cut lettuce with gloves on, touched a knife handle and the outside of a lettuce bag with both hands and without changing gloves picked up the lettuce with both hands and placed it into a container. Staff A stated to the surveyor the lettuce was for the resident's lunch. b. A red substance dripped from a bag of thawing meat located on the second from bottom shelf of the stainless steel refrigerator in the pantry. The bag dripped onto the bottom shelf containing another container of meat nearby. c. Crumbs and food debris on the floor of a cupboard in contact with the bottoms of plates and dishes. d. Multiple colored splatters on all inside walls of the microwave and the microwave ceiling. e. Crumbs on the top shelf, a white substance spilled on the second shelf, and crumbs and splatters on the floor of the white upright fridge in the pantry. f. Crumbs and food debris on the floor of a cabinet in contact with cutting boards. g. Crumbs and food debris on the floor of a cabinet in contact with the bottoms of pans. An 11/5/18 12:06 p.m. observation of the noon meal service on the Wedgewood unit revealed the following concerns: a. Dust particles hung down from vents located on the front interior wall of the oven. Staff B served the resident's lunch from pans located on an oven shelf directly below the hanging dust particles. b. Staff B wore gloves and touched the outside of a frosting package, a door handle, plates, and the counter. Without changing gloves, Staff B touched cake as she removed it from the pan to place on resident plates. c. Staff B removed a pair of gloves and touched the top of the garbage lid and pushed down on the garbage with her bare hands in order to discard her gloves. Without washing her hands she donned new gloves and continued to serve food. d. Staff B removed a pair of gloves and placed them on a plate holding tongs on the prep counter. She later used the tongs to serve fish to residents. e. Staff B wore gloves and touched plates, menus, a marshmallow package, tartar sauce packages, and a stove handle. Without changing gloves, Staff B removed coating from fish and touched the fish in the process with her gloves. The undated facility policy on glove usage stated safe food handling would begin with correct preparation. The policy directed staff to: a. use gloves when preparing ready to eat food b. remove gloves after touching another surface prior to touching food again. The facility kitchen Daily Cleaning Schedule directed staff to clean the oven front/handle, walls, and interior/exterior cabinets. The facility kitchen Weekly Cleaning Schedule directed staff to clean the oven interiors and the microwave. During an interview on 11/6/18 at 2:12 p.m., the Dietary Manager stated the facility had cleaning schedules for staff to follow. During an interview on 11/6/18 at 2:12 p.m., the Dietician stated she preferred staff to use tongs instead of gloves during meal service/preparation. A tour of the Rosewood unit on 11/6/18 at 1:30 pm revealed the following concerns: a.) 3 out of 4 upper cabinet pulls covered with a red sticky substance. The cabinets were located to the left of the microwave. b.) Cabinet door fronts were visibly soiled with a brown and red residue. c.) Cabinets containing serving bowls had crumbs on the floor. The bottom of the bowls were in contact with the crumbs. d.) Cabinets containing pots and pans had brown, yellow, and red residue and crumbs on the floor. The bottom of the pots and pans were in contact with the debris. e.) A drawer containing measuring devices had red, yellow, and brown colored stains, crumbs and spills. f.) The walls in the kitchen had black, brown, and white splatters and a black grime build up on the baseboards. A return tour of the Rosewood unit kitchen on 11/7/18 at 10:45 am revealed a red sticky substance remained on 2 of the 4 cabinet pulls. During observation of the lunch meal service in the Sagewood Household kitchenette on 11/5/18 at 12:09 PM, Staff A, Cook, took a ringing cell phone out of her pocket, pushed a button on the phone, and put the cell phone back in her pocket. Staff A then touched the Oster blender container, placed the lid over the container, and grounded the meat inside the container. Staff A donned a glove on her right hand, emptied some of the ground meat contents into a bowl, and then replaced the blade in the blender container. After Staff A blended the meat, she removed the blender lid and blade with her gloved hand. Staff A poured the contents into a bowl, and then removed her glove.

Based on observation, record review, and interview, the facility failed to ensure consumption of medications for 1 of 5 residents observed during the medication administration pass (Resident #24). The facility reported a census of 53 residents. Findings: 1. The MDS (Minimum Data Set) assessment tool, dated 9/10/18, listed [DIAGNOSES REDACTED]. The MDS stated the resident required supervision (oversight, encouragement or cueing) assistance of 1 staff for eating, limited assistance of 1 staff for bathing, extensive assistance of 1 staff for bed mobility, transfers, walking, dressing, and toilet use, and extensive assistance of 2 staff for personal hygiene. The MDS listed the resident's BIMS (Brief Interview for Mental Status) score as 3 out of 15, indicating severely impaired cognition. During a medication pass observation in the dementia care unit (Rosewood) on 11/6/18 at 8:20 a.m., Staff C RN (Registered Nurse) mixed [MEDICATION NAME] (a laxative) into a glass of orange juice and gave it to Resident #24. Staff C left the area before the resident consumed all of the orange juice and went into another resident's room and also back to the nursing charting area. Surveyor observations of the area throughout the survey week revealed other residents wandering in the vicinity. The resident's (MONTH) (YEAR) MAR (Medication Administration Record) displayed an order for [REDACTED]. A care plan entry, dated 9/19/18, stated the resident struggled with her memory and abilities due to dementia. The facility competency for passing medications, revised 7/18/18, stated staff should observe residents swallowing medications. During an interview on 11/7/18 at 1:00 p.m., the DON (Director of Nursing) stated nurses should stay with residents when administering medications including [MEDICATION NAME] to ensure consumption of all medications and to ensure another resident didn't take it.

Based on observation, record review, and interview, the facility failed to ensure adequate cleansing of a shared glucometer for 2 of 2 blood sugar checks observed. The facility reported a census of 53 residents. Findings: During an observation on 11/5/18 at 8:07 a.m., Staff D RN(Registered Nurse) obtained a blood sugar on Resident #196 and wiped the glucometer off with a Microkill Bleach wipe. Staff D did not let the wipe sit on the glucometer for 30 seconds. During an observation on 11/5/18 at 8:34 a.m., Staff D obtained a blood sugar on Resident #38 and wiped the glucometer off with a Microkill Bleach wipe. Staff D did not let the wipe sit on the glucometer for 30 seconds. The Microkill Bleach wipe instructions stated a 30 second contact time was required to kill all bacteria [MEDICAL CONDITION]. The facility competency for cleaning of a glucometer directed staff to cleanse the meter according to the manufacturer's recommendations. The glucometer manufacturer's instructions for cleaning directed to clean with a mild cleaning agent. The instructions did not include information on cleaning the meter when staff utilized it for multiple residents. During an interview on 11/7/18 at 1:00 p.m., the DON(Director of Nursing) stated staff should wrap the glucometer in the wipe to achieve the 30 second contact time and stated she would carry out education with the nurse. She stated at 1:30 p.m. the facility obtained an individual glucometer for Resident #196.

Based on observation, record review, and interview, the facility failed to post the survey results in an area readily accessible to residents, family members, and resident representatives. The facility reported a census of 53 residents. Findings: During the group interview on 11/5/18 at 9:28 a.m., only 1 of 5 residents in attendance knew the location of the survey results. An observation on 11/6/18 at approximately 2:00 p.m. revealed the survey results located in a hallway in between the 3 units of the facility. In order for residents to get to this location, they had to have a staff member utilize a key card to assist them out of the units into this area. During an interview immediately following this observation, the Administrator stated the survey results were located in this area because it was a part of the healthcare center. Observations throughout the survey week revealed the facility lacked survey results in the 3 resident units. A list of resident's rights, included in the admission packet, stated residents had the right to examine the survey results.

Based on record review and staff interviews, the facility failed to ensure residents received adequate supervision during transfers to prevent accidents for two (2) of four (4) residents at risk for falls. Resident #4 fell on [DATE] and sustained an arm fracture when staff transferred her without a gait belt for her safety. Resident #2 sustained minor injuries when staff failed to follow her care plan for transfers. The facility census was 47 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] Resident #4 had [DIAGNOSES REDACTED]. The MDS revealed Resident #4 had no cognitive impairments. Resident #4 required extensive assistance of two staff with transfers. Resident #4 had balance issues and only able to stabilize with staff assistance. The CNA (Nurse Aide) Pocket Care Plan directed staff to transfer Resident #4 with assist of one staff and a walker; if not using a walker provide assistance of two staff, refuses walker at times and prefers to spend time in bed. The Care Plan revealed Resident #4's abilities vary from day to day and during the day based on level of pain, weakness, fatigue and shortness of breath and may need more help at times than others. The Incident Report dated 11/28/17 revealed the Nurse walked with Resident #4 to the bathroom using the front wheeled walker. Resident #4's gait slow and steady. Resident #4 complained of the right arm hurting on the way to the bathroom. Resident #4 pivoted in front of the toilet and grabbed the grab bars on both sides of the toilet. Resident #4's hands grasped the bars and elbows rested on the bar. Resident #4 lowered on the toilet and ended up crooked on the toilet with a thud. Three popping sounds heard and then Resident #4's arm went slack to the floor and Resident #4 complained of pain. The Nurse administered pain and anxiety medications and called hospice. An interview on 2/1/18 at 1:26 p.m. Staff B reported he/she answered Resident #4's call light. Resident #4 wanted pain medication. Staff B left to get the pain medication. When Staff B returned with the pain medication Resident #4 reported he/she needed to go to the bathroom really bad. Staff B assisted Resident #4 to the toilet without a gait belt. The Radiology Consultation Report dated 11/28/17 of the right shoulder revealed Resident #4 sustained a mildly displaced mid right humerus fracture. Resident #4 had [MEDICAL CONDITION] changes of the right shoulder. The Care Plan updated 11/28/17 revealed Resident #4 sat down hard on the toilet and sustained a right arm fracture from the safety rail. The Care Plan directed the staff to provide assistance of two staff with transfers and ambulation. An interview on 2/1/18 at 2:17 p.m. the Interim Director of Nurses reported she expected staff to use a gait belt for all transfers that require one to two staff physical assist. The Interim Director of Nurses reported the staff received education on the use of gait belts and also implemented the nurses wear a gait belt as part of the uniform in addition to the nurse aides. 2. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #2 had [DIAGNOSES REDACTED]. The MDS revealed Resident #2 had moderate cognitive impairments. Resident #2 required extensive assistance of two staff with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #2 had balance issues and only able to stabilize with staff assistance. The Care Plan updated 9/7/17 directed the staff to transfer with a sit to stand lift and two staff. The CNA (Certified Nurse Aide) Pocket Care Plan directed the staff to transfer Resident #2 with a sit to stand lift and two staff. The Incident Report dated 1/29/18 at 3:50 p.m. revealed Resident #2 at the edge of the bed and Nurse Aide assisting Resident #2 to get up. The Nurse Aide had a gait belt in place and providing assistance of one staff. The Nurse Aide reported the wheelchair slipped backwards and Resident #2 fell to the floor. Resident #2 sustained skin tears to both wrists. The staff administered first aid. The fall investigation revealed the Nurse Aide called in to cover the evening shift. The Nurse Aide failed to have a pocket care plan and transferred Resident #2 without the sit to stand lift. The investigation revealed a coaching session completed with the staff. The Care Plan updated 1/29/18 revealed an intervention of teaching for staff on transferring Resident #2 safely. An interview on 2/1/18 at 4:51 p.m. Staff A reported he/she just started working at the facility. Staff A reported this was his/her first time working on Resident #2's household. Staff A did not get a pocket care plan at the start of the shift. Staff A did not know how much assist Resident #2 required for transfers. Staff A asked Resident #2 if he/she required one or two staff. Resident #2 told Staff A one staff. Staff A reported he/she took Resident #2's word. Staff A reported he/she placed a gait belt around Resident #2. Resident #2 was sitting in the recliner. Staff A locked the wheelchair. Staff A assisted Resident #2 to stand and pivot to the wheelchair. Resident #2 started to sit in the wheelchair. The wheelchair moved backwards and Resident #2 grabbed Staff A's arms. Staff A reported he/she lowered Resident #2 to the floor. Resident #2 had skin tears on each wrist. Staff A reported it was his/her mistake and he/she should have had a pocket care plan. Staff reported feeling awful that Resident #2 has bandages on both wrists.

Based on observation, record review and interview, the facility failed to maintain adequate hot and cold holding temperatures during meal services for 3 of 3 dining rooms observed. The facility reported a census of 50 residents. Findings include: 1. During an observation of the noon meal service on 9/26/17 in the Rosewood unit, Staff A Cook obtained the following temperatures prior to the meal service: a. Fruit - 49 degrees Fahrenheit (F ) at 11:24 a.m. b. Pasta salad - 50 degrees F at 11:24 a.m. Staff A served the last tray in the unit at 12:25 p.m. The surveyor requested temperatures and Staff A obtained the following: a. Fruit - 52.3 degrees F at 12:29 p.m. b. Pasta salad - 42.8 degrees F at 12:30 p.m. c. Mixed vegetables - 122.5 degrees F at 12:28 p.m. 2. During an observation of the noon meal service on 9/27/17 in the Rosewood unit, Staff A obtained the following temperatures after serving the last resident's tray: a. Cranberry Peach Cole Slaw - 47 degrees F b. Mixed fruit - 48 degrees F 3. During an observation of the noon meal service on 9/27/17 in the Sagewood unit, the Dietary Manager obtained the following temperatures prior to the meal service: a. Boiled egg - 43 degrees F 4. During an observation of the noon meal service on 9/27/17 in the Wedgewood unit, Staff B Cook obtained the following temperatures prior to the meal service: a. Cranberry Peach Cole Slaw - 46 degrees F Staff B obtained the following temperatures after serving the last resident's tray: a. Cranberry Peach Cole Slaw - 44 degrees F b. Cottage Cheese - 45 degrees F The undated facility policy Cold Food Holding directed staff to maintain cold foods at 40 degrees or below. The undated facility policy Hot Food Holding directed staff to maintain hot foods at 140 degrees or above. During an interview on 9/27/17 at 2:00 p.m., the Dietary Manager stated cold holding temperatures should be 41 degrees Fahrenheit or below and hot holding temperatures 145 degrees Fahrenheit or above.

Based on clinical record review, facility record review and resident, family member and staff interviews, the facility failed to answer call lights and provide assistance when requested for 4 of 4 interviewable residents attending the group interview and 2 of 12 current residents reviewed (Residents #6 and #8). The facility reported a census of 50 residents. Findings included: 1. During the group interview on 9/25/17 at 1:00 p.m., 4 of 4 interviewable resident stated they did not feel the facility had enough staff. The stated they often had to wait 20-30 minutes for staff to answer their call lights and had to wait longer in the mornings. 2. Review of facility call light logs revealed 3 of 4 residents sampled with call light responses longer than 20 minutes for the period of 9/13/17 - 9/27/17. During an interview on 9/27/17 at 2:16 p.m., the Director of Nursing stated staff strive for a call light response time of 15 minutes or less. 3. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental (BIMS) score of 15 for Resident # 6, which indicated intact memory and cognition. The assessment documents she required the assistance of one staff member in order to walk, dress, eat and perform personal hygiene. The resident's [DIAGNOSES REDACTED]. The Plan of Care dated 9/21/17 directed staff to encourage Resident # 6 to use the call light and wait for assistance. The call light should remain in reach at all times. The Device Activity Report from 9/13/17 to 9/27/17 reported overtime lights 3 times during that period. During an interview on 9/26/17 at 11:00 A.M., Resident # 6 stated that staff would answer the call light (within 15 minutes) and then shut off the call light only to inform her they were busy and would be back. The staff might or might not ever return for over an hour. 4. The MDS assessment dated [DATE] recorded Resident #8 had a BIMS score of 15. The resident required the assistance of 2 staff for transfers, bed mobility, dressing, toilet use and the assistance of one with personal hygiene two activities. Resident #8 experienced occasional urinary incontinence and routine bowel incontinence. The resident's [DIAGNOSES REDACTED]. The Plan of Care dated 7/14/17 directed staff to assist the resident with toileting upon rising, before and after meals, before bedtime and as needed and provide per cares with any incontinent episodes. The Device Activity Report date 9/13/17 through 9/27/17 revealed 26 times occasions when staff answered Resident #8's call light from 16 to 52 minutes after activation. During an interview on 9/25/17 at 2:00 P.M., Resident # 8's spouse confided the resident felt impatient about call lights not being answered in good time. Resident # 8 threatened to call 911 if staff could not get to the light quickly. The spouse stated the resident's left-side [MEDICAL CONDITION] left the resident in continued nerve pain which caused the increased impatience when the staff would answer the call light, shut it off, leave the room and not return for twenty minutes or longer.

Based on observation, record review, and interview, the facility failed to carry out interventions to promote the healing of a pressure ulcer for 1 of 1 sampled residents with a pressure ulcer(Resident #2). The facility reported a census of 50 residents. Findings include: 1. The MDS (Minimum Data Set) assessment dated [DATE] listed [DIAGNOSES REDACTED]. The MDS recorded Resident #2 required the assistance of one staff with eating and bathing and the assistance of two staff with bed mobility, transfers, dressing, toilet use, walking and personal hygiene. The assessment documented Resident #2 had the risk of pressure ulcer development and she had no unhealed pressure ulcers at the time of the assessment. The MDS stated the resident as not on a turning/repositioning program and listed the resident's BIMS (Brief Interview for Mental Status) score as 5 out of 15, indicating severely impaired cognition. The MDS assessment dated [DATE] listed [DIAGNOSES REDACTED]. The assessment recorded she required the assistance of one staff for eating and personal hygiene, the assistance of two staff with bed mobility, transfers, dressing, toilet use and bathing and that she did not walk during the MDS review period. The assessment documented s/he had one unhealed Stage 2 pressure ulcer (a partial thickness loss of dermis(skin) presenting as a shallow open ulcer with a red or pink wound bed). The MDS recorded staff provided a turning/repositioning program and listed the resident had continued severe impairment of memory and cognition. During an observation on 9/26/17 at 9:08 a.m., Staff C CNA (Certified Nursing Assistant) and Staff D CNA assisted the resident with personal cares while the resident laid in bed. The resident stated to the staff her rear end hurt and the resident had a foam dressing covering the coccyx. After completing personal cares at 9:45 a.m., Staff C and Staff D assisted the resident to transfer to a geri chair (a high back reclining chair on wheels) with a pressure relieving cushion in the seat of the chair. The staff wheeled the resident to the breakfast table at 9:52 a.m. An observation on 9/26/17 at 10:25 a.m. revealed the resident sitting in the geri chair at breakfast in the dining room in the geri chair. At 10:28 a.m., the resident sat in the geri chair at an activity in the lounge area. At 11:02 a.m. the resident sat in the geri chair in the back hallway near the nursing station. At 11:11 a.m. Resident #2 sat in the geri chair in the dining room. Continuous observation on 9/26/17 at from 11:27 a.m. -12:33 p.m. revealed the resident continued to sit in the geri chair at the dining room table. At 12:33 p.m., Staff C took the resident to his/her room to assist him/her to lie down. During an observation on 9/26/17 at 2:59 p.m., Staff B RN (Registered Nurse) removed the old Allevyn dressing (a foam dressing used to treat wounds) from the resident's coccyx. The resident had a red, open wound with white edges. Staff B measured the wound (in centimeters length x width x depth) as 1.1 x 0.6 x 0.2. Staff B then cleansed the wound with normal saline, applied Triple Helix Collagen Powder (a powder used to treat wounds) and applied a new Allevyn dressing (a foam dressing used to treat wounds) over the top. A Skin Evaluation Form, dated 3/6/17, revealed the resident had a partial thickness wound on the coccyx measuring 2.0 x 1.0 x 0.1. The form indicated staff turned the resident every 2 hours. A Skin Evaluation Form, dated 9/18/17, revealed the resident had a partial thickness pressure wound on the coccyx measuring 1.0 x 0.5 x 0.3. The form indicated staff turned the resident every 2 hours. The care plan, dated 6/15/17, directed staff to turn/reposition the resident every 2 hours with every 2 hours crossed out. A 9/5/17 notation near the entry directed staff to turn/reposition the resident 2 to 3 times per shift. The TAR (Treatment Administration Record) for the period of 9/20/17 - 9/27/17 recorded an order for [REDACTED]. During an interview on 9/27/17 at 10:00 a.m., the DON (Director of Nursing) stated she would like staff to attempt to reposition resident every 2 hours. During an interview on 9/28/17 at 9:00 a.m., the DON stated a staff member informed her she carried out the treatment on 9/22/17. The DON stated she would look into the other treatment dates lacking initials.

Based on record review and staff interviews, the facility failed to provide adequate supervision to prevent accidents for 1 of 3 residents reviewed (Resident #1). The facility identified a census of 35 residents. Findings include: The admission MDS ( Minimum Data Set Assessment Tool ) dated 05/13/16 identified Resident # 1 with a BIMS (Brief Interview for Mental Status) of 3 which indicated severely compromised cognitive function related to daily decision making skills. The MDS indicated the resident required extensive assistance of two staff members for transfers, toileting, dressing, personal hygiene and bathing. The MDS indicated the resident [DIAGNOSES REDACTED]. Resident's #1 Care Plan dated 10/23/15 noted the resident had a potential for falls. The staff were instructed to encourage the resident to use call button to request staff assistance and to reinforce the need to wait for assistance to arrive. The staff were instructed to keep the call light within easy reach. The staff were instructed to encourage/assist the resident to toilet before and after meals, before bedtime and every two hours as needed. The care plan noted the resident utilized a bed and chair alarms to be used to alert staff of resident attempts to get up on own. The care plan instructed staff to keep the monitor box out of the resident's reach to ensure the resident did not unhook the device. The care plan noted the resident had the habit of crawling on the floor related to visual deficits. The Activities of Daily Living (ADL) care plan identified the resident had a low bed, and his/her bed should be in the low positon. The ADL care plan noted the resident used a mat on the floor. 1). Review of the Incident Report dated 12/24/15 at 1:50 p.m. documented the resident had been left unattended in the day room watching movies, a visitor saw the resident moving and heard the chair alarm sounding, the visitor shut off the alarm, the resident slid out of chair and onto the floor. Interventions: Resident to only attend supervised activities. 2). Review of the Incident Report dated 04/25/16 at 4:00 a.m., staff observed the resident pushing self off a piece of furniture to rise from knee to standing position. The alarm had been on but the pad did not sound. Intervention: Scheduled toileting at night. 3). An Incident report dated 05/01/16 at 10:30 p.m. noted Staff A, Certified Nurse Aide (CNA) heard an odd noise coming from the resident's room. When investigating she found the resident on the floor in a sitting position vomiting. The nurse assessed the resident for possible hip fracture, the doctor notified and resident sent to the emergency room . In the Interdisciplinary notes dated 05/01/16 at 10:39 a.m., Staff B, RN noted Staff A, CNA had been walking by the resident's room and heard noise like vomiting, entered the room and found the resident vomiting onto his/her hands. The staff called for assistance. The nurse documented the resident's left knee lying on the floor in an unnatural angle. The nurse notified the physician and the emergency room as the CNA cleaned the resident up and Staff C, RN stayed with the resident. Interdisciplinary notes dated 05/02/16 at 2:56 p.m. documented the resident had a fractured hip at the head of the femur and would be transferred to a higher level of care hospital. The hospital progress noted dated 5/5/16 identified Resident #1 sustained a left subtrochanteric femur facture secondary to fall. The assessment identified the resident had osteoporosis and they would start him/her on vitamin D. The resident had open-reduction and internal fixation of a subtrochanteric femur fracture on the left side. Interdisciplinary Notes dated 5/6/16 documented Resident #1 returned to the nursing home on 5/6/16 with the assist of 2 staff for toe touch weight bearing. The Fall Investigation form related to Resident #1 ' s fall on 5/1/16 identified risk factors for unsteady gait and decline in functioning. The form identified the nurse had last seen the resident at 10 p.m., and should have noticed the fall mat was not in place. The Coaching Statement dated 5/1/16 documented Resident #1 disconnected his/her alarm (at bedside), toileted him/her(self) and fell going back to bed. The fall mat was not beside his/her bed, it had been between the wardrobe and the wall. The form noted the injury might have been prevented by the fall mat. Interviews with staff regarding the 5/1/16 fall: a). On 05/24/16 at 10:30 a.m. Staff D, CNA, stated on she had put Resident #1 to bed around 7:00 p.m. She stated the resident had been in the bedroom undressing and indicated he/she were tired and wanted to use the toilet and go to bed. Staff D stated she did place the alarm on the resident and thought the alarm had been functioning when she left the resident. Staff D stated the resident didn't attempt to get up the rest of the time she worked on the hallway. She stated she peeked in the resident's room between 8:15 and 8:30 p.m. and again about 9:55 p.m. and resident had been sleeping both times. Staff D stated she had gone to another section of the facility for the remaining time on her 12 hour shift. She stated that Staff B, RN called her and told her the resident had fallen and fractured his/her hip. She stated Staff B, RN told her the floor mat had not been placed on the floor. When asked why she had not placed the floor mat in place, Staff D stated that she did not see one in the room and did not know the resident required a floor mat. When asked if she had been sure she placed the alarm on the resident she stated she was sure she did but could not recall if it was the bed pad alarm or the clip alarm. b). On 05/24/16 at 10:50 a.m. Staff A, CNA stated she had started her shift at 10:00 p.m. Staff A had been across the hall from Resident #1's room when she heard a weird cough coming from the resident's room. She stated she went into Resident #1's room and found the resident on the floor in a sitting position next to the bed. She stated the resident had been vomiting. Staff B stated she had asked the resident if she/he had sat on the floor or if she/he had fallen. The resident confirmed he/she had fallen. She stated she then sent Staff E, CNA to get the charge nurse. Staff A stated the resident started to vomit again. She stated the charge nurses, Staff B, RN and Staff C, RN came in and assessed the resident. They decided the resident had probably fractured a hip. Staff A stated she cleaned the resident up as the nurses did what they needed to do to get the resident ready to go to the emergency room . Staff A stated she had not heard the alarm sounding but did not know if it had been on because Resident #1 tends to take the alarm off. Staff A stated she did not remember if the floor mat had been put down or not. c.) On 05/23/16 at 3:25 p.m. Staff C, Registered Nurse (RN) stated she had worked the 2-10 shift and had been at the nurses station with Staff B, RN giving report when they were told the resident had been found on the floor. She stated when the nurses entered the resident's room, the resident had been sitting on the floor with hands behind his/her back on the floor with the left leg at a funny angle. She stated they assessed him/her for pain, but the resident did not act like she/he were having pain until they attempted to move the left leg and the resident yelled out. Staff C stated they decided the resident may have a fracture and needed to go to the emergency room . She stated she stayed with the resident as Staff B, called the appropriate people. Staff B stated she did not hear the alarm sounding when they got to the room. d). On 05/24/16 at 9:45 a.m. Staff B, RN stated she had been getting sift to shift report from Staff C, RN when Staff A called her to Resident #1's bedroom. She stated they found the resident on the floor and had obviously fractured his/her leg/hip. She stated the leg had been at an odd angle so knew it had been injured. Staff B stated the resident had vomited all over self so they had to cut the pajamas off the resident. Staff B stated Resident #1 had a history of [REDACTED]. Staff B stated they had assumed the resident had taken self to the bathroom and fell going back to the bed. Staff B stated the resident had been ambulatory prior to this fall and injury. Staff B stated that the resident had only required hand guidance related to his/her blindness. Staff B stated that after they found the resident on the floor, she called the appropriate people as Staff C stayed with the resident and Staff A cleaned the resident up. Staff B stated she does not know if the alarm sounded or not. e). On 05/24/16 at 11:45 a.m. Staff E, CNA stated she and Staff A, CNA were in a room across the hall from Resident #1 when Staff A stated she heard something in Resident #1's bedroom. She stated Staff A went to the room and found Resident #1 sitting on the floor vomiting. Staff E stated when she went into the room, Staff A told her to get the nurse, she went to the nurses' desk and told Staff B, RN and Staff C, RN. She stated both nurses went to the resident's room to assess the resident. Staff E stated she did not recall the alarm sounding, that the only think that alerted them was the coughing and had been found covered in vomit. Staff E stated she tends to get nauseous around people vomiting so Staff A state she would take care of Resident #1 with the nurses so she stayed on the floor to help other residents. Interdisciplinary Notes dated 5/7/16 revealed Resident #1 had been in a lot of pain and uncontrolled by hydromorphone alone. The physician ordered Morphine sulfate. Resident's #1 Care Plan dated 5/12/16 noted the resident had a potential for falls. The staff were instructed to encourage the resident to use call button to request staff assistance and to reinforce the need to wait for assistance to arrive. The staff were instructed to keep the call light within easy reach. The staff were instructed to encourage/assist the resident to toilet before and after meals, before bedtime and every two hours as needed. The care plan noted the resident utilized a bed and chair alarms to be used to alert staff of resident attempts to get up on own. The care plan instructed staff to keep the monitor box out of the resident's reach to ensure the resident did not unhook the device. The care plan noted the resident had the habit of crawling on the floor related to visual deficits. The Activities of Daily Living (ADL) care plan identified the resident had a low bed, and his/her bed should be in the low positon. The ADL care plan noted the resident used a mat on the floor. Review of the Resident #1's fall incident reports, revealed the resident had three falls following the fall on 05/01/16. a. Review of the Incident Report dated 05/13/16 at 5:30 a.m. documented the staff found the resident sitting on the floor mat next to the bed. Intervention: Frequent room checks at night. Interdisciplinary Notes dated 5/13/16, documented Resident #1 remained on skilled care for left hip fracture and used one staff to assist. b. Review of the Incident Report dated 05/14/15 at 10:30 p.m. documented the resident had been found seated on floor beside bed, alarm sounding and fall mat in place. Intervention: Lipped mattress. A fall risk assessment dated [DATE] indicated a score of 14 that indicated the resident to be a high fall risk. A score of 10 or higher indicates a high fall risk. c. Review of the Incident Report dated 05/19/16 at 5:10 p.m. documented the nurse heard an alarm, found the resident in the bathroom, sitting on the floor with the left foot caught on the wheel chair pedal and resting on arms with head above the floor. Intervention: Scheduled toileting every 2 to 3 hours at night. On 05/24/16 at 2:30 p.m. the Director of Nursing (DON) stated she would expect the staff to follow the resident's care plans and if the care plan required interventions for preventing falls she would expect the staff to follow them. The DON stated that Resident #1 would remove the safety alarms at times because the resident wanted to be independent. She stated the staff would explain to the resident the need to get staff assistance but they would often find the resident attempting to ambulate by self. The DON stated that Resident #1 would put him/her(self) on floor at times when moving from place to place when in his/her bedroom.

Based on observation, clinical record review, staff and physician interview, the facility failed to direct nursing services to ensure two of four residents received adequate supervision against hazards and failed to implement care plan directives to meet the residents' safety needs. In addition the facility failed to provide a hazard free resident environment. The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident had short and long-term memory loss. The MDS indicated the resident required extensive assist of one person for transfers, bed mobility, toilet use, and personal hygiene. The resident's test for balance identified he/she not steady and only able to stabilize with staff assistance when moving from seated to standing; when walking; when moving on and off the toilet; and during surface to surface transfer (transfers between the bed and chair or wheelchair). The MDS documented the resident had limited mobility to both lower extremities. The Care Plan identified a problem for the resident as impaired mobility and self- care deficits related to diagnosis, prognosis, and weakness. The Care Plan directed staff to provide assistance with transfers with one or two staff, with use of a gait belt, and to provide assistive device a walker. The care plan also had an undated intervention which directed 1 or 2 staff to transfer the resident to and from bed or wheelchair using a gait belt. Care Plan included documentation dated 7/19/13 which revealed entry of resident sustained [REDACTED]. Nurses Notes dated 7/19/13 at 3:40 p.m. revealed the resident's fall to the floor in the shower room had been witnessed by a staff member. The resident complained of severe pain, with very minimal movement of the left leg observed. The resident's left leg turned outward when attempted to roll the resident to their back. The family and doctor were then notified. The resident had been sent by ambulance to the hospital. The Incident Report dated 7/19/13 with time 3:40 p.m. described the incident as follows, the Certified Nurse Aide, CNA assisted Resident #1 to stand to transfer to the whirlpool chair, and the resident fell backward on to the edge of the wheelchair. The CNA lowered Resident #1 to the floor. The Radiology Consultant Report dated 7/19/13 documented the resident sustained [REDACTED]. During interview on 8/26/13 Staff I, registered nurse, RN reported on initial tour that the resident had a history of [REDACTED]. During interview on 8/28/13 at 10:50 a.m. Staff A, CNA reported that she/he had attempted to transfer the resident from the wheelchair to the whirlpool chair on 7/19/13. Staff A reported when she/he turned the resident toward the whirlpool chair the resident started to lean backward and the resident went down towards the floor hit the wheelchair seat on the way down and then landed on the resident's side. Staff A reported the resident complained of pain in his/her groin (after the fall). Staff A then yelled out for help, Staff E, CNA entered the room shortly afterwards, then went to get the nurse. The Nurse assessed the resident, and then the ambulance arrived and took the resident to the hospital. Staff A reported that a gait belt and walker were not used for the transfer, and he/she will always remember to use a gait belt with transfers now. During interview on 8/28/13 at 5:10 p.m. Staff E, CNA reported that she/he did not see a gait belt on the resident when entering the shower room on 7/19/13 when the resident fell . Staff E reported that gait belts are to be used with all residents for transfers. During interview on 8/27/13 at 11:00 a.m. Staff I, RN reported that a gait belt had not been used the day that the resident fell , and gait belts should be used with all transfers. During interview Staff F, CNA reported that the resident had been a transfer assist of one staff member prior to the fall and fracture, and the resident had been starting to have more problems with following directions for ambulation and transfers prior to the fall. Staff F reported that a gait belt should be used with all transfers. During interview on 8/27/13 at 9:55 a.m., the residents family member reported being concerned the resident would not be able to regain his/her strength to walk after the fall. The Policy and Procedure Manual Wesley Retirement Services Gait Belt Use with date of 2008 purpose directed staff as follows: To assure the safety of the residents and staff when assisting with a transfer or ambulation a gait belt will be used. 2. Resident #4 had [DIAGNOSES REDACTED]. The MDS documented the resident as requiring extensive assistance of 2 staff members for bed mobility, transfers and toilet use. The MDS documented extensive assistance of 1 staff person for dressing, personal hygiene and bathing and totally dependent on 2 staff for walking between locations in his/her room and with no ability to walk in the corridor. The MDS documented the resident as not steady and only able to stabilize his/her self with assistance for moving from a seated to standing position, for walking with an assistive device if used, for turning around and facing the opposite direction while walking, for moving on and off the toilet, and for surface -to-surface transfers. The MDS documented impairment on one side of the body with an upper extremity (shoulder, elbow, wrist, hand) and on one side of the body for a lower extremity (hip, knee, ankle, foot) The MDS documented the resident with short and long term memory problems and with moderately impaired decision making skills. Review of a Fall Risk assessment dated [DATE] documented a fall risk score of 12. A score of 10 or above indicated the individual had a high risk for falls. Review of a Resident Incident Report dated 3/7/13 revealed the resident as transferring from the wheelchair to the recliner with facility staff. A fall resulted when the resident's legs went out from under the resident. The resident had been lowered to the recliner by the Certified Nursing Assistant with the resident at that time with the use of a gait belt. A plan of care for Resident #4 dated 8/29/12 and previously updated on 3/7/13 directed staff to transfer Resident #4 with 2 staff assist and/or an E-Z lift. The care plan also had an undated intervention which directed 1 or 2 staff to transfer the resident to and from bed or wheelchair using a gait belt. Review of facility Incident Report dated 7/26/13 at 7:15 a.m. revealed the resident fell in the shower room of the facility and fell on to his/her right side onto the floor. The incident report documented the fall had been witnessed and Staff E, CNA had been with the resident. The reported noted the shower chair wheels stuck out and the floor did not have slip preventers (non-skid strips).The incident report documented an injury of skin tears to the right lateral anti-cubitus area (region of the arm in front of the elbow). The CNA/Witness Statement (regarding the fall on 7/26/13) documented Staff E, CNA stood the resident up after his/her bath to dry the resident off and to pull up his/her pants. The resident started leaning to the right side with the pants up and fell to the ground and landed on their right side. The documentation indicated the right elbow as bleeding, the resident as not hitting their head and having no other injuries. Review of a Fall Investigation form documenting the fall of 7/26/13 revealed the resident as in the whirlpool room and the resident as stating he/she did not know why they fell . The fall investigation form documented the resident with a history of falls with the last fall as fore mentioned on 3/7/13. The fall investigation form documented the plan of care had not been followed as the resident required 2 staff per the care plan 3/7/13. The form identified the root cause of the fall as the following: damp floor, care plan not followed, (resident needed assist of 2 staff for transfers), and a decline in functioning. The form revealed the resident did not use a gait belt during the transfer. A Nurses Notes Skin Sheet dated 7/26/13 documented the right lateral anteccubital skin tears as consisting of 3 areas and the measurements as follows: 1. 2.1 centimeters (cm.) X 2.5 cm. 2. 1 cm. X 1 cm. 3. 2.3 cm. X 0.1 cm. Area cleansed and wrapped with Telfa and Kling with the physician notified. The hospital Department of Radiology x-ray report dated 7/29/13 revealed the resident had right hip pain after the fall. The x-ray identified no evidence of acute traumatic injury in a probably osteoporotic patient. The hospital Department of Radiology x-ray report dated 7/29/213 of the resident ' s Lumbar Spine indicated the resident had low back pain after the fall. The x-ray revealed the following: a. Osteoporosis (decrease in bone mass/density that leads to an increase risk of fracture) b. Mild to moderate anterior wedge compression deformity of the T12 (the last vertebra of the middle back) vertebral body of indeterminate age. If this requires further evaluation a lumbar spine MRI could be considered). c. Severe multilevel degenerative changes throughout the lumbar spine, worse at L 4-5 (area between the rib cage and the pelvis). Interview with Staff I, RN on 8/27/13 at 11:05 a.m. related to Resident #4's fall on 7/26/13 at 7:15 a.m. revealed a gait belt had not been used with the July (2013) fall . Staff I stated the standard expectation for gait belt usage for the facility is that gait belts absolutely must be used. Interview on 8/28/13 at 5:10 p.m. Staff E, CNA verified she was the only staff person with Resident #4 on 7/26/13 at approximately 7:15 a.m. when a fall occurred. Staff E reported no gait belt had been used to when he/she stood the resident up. Staff E indicted with completion of the resident's bath he/she stood pretty well for approximately 2 seconds and then fell to his/her right side. Staff E indicted the resident's wheelchair had been in front of the resident. Staff E reported when the resident fell to the right, she tried to grab the resident's pants so he/she would not fall. Staff E reported the resident landed on their right side, and sustained a cut on the arm. Staff E reported the resident did not have a gait belt on (around him/her). Staff E reported it only took 1 person (to assist) with Resident #4. When Staff E was asked by the surveyor how staff in the facility know how to care for residents in the facility he/she indicated a communication book in the facility had notes and staff look at this communication book before caring for residents in the facility. A physician statement dated 8-28-13 documented they cannot determine with absolute medical certainty that the fall Resident #4 suffered on July 27th was the direct cause of the compression fracture that was noted on X-rays. The indeterminate age of the fracture on the X-ray suggests the compression may have occurred at an earlier date in time prior to documented July 27th( 2013) fall. 3. During tour on 8/26/13 at 11:05 a.m., with Staff H, licensed practical nurse, LPN an unlocked and unattended tubroom on the 300 Hallway revealed an unlocked cupboard with a 7 ounce aerosol can of Wild Berry Spray Scents. A cautionary label on the product documented keep out of reach of children. Staff H indicated at the time the cupboard needed to be locked. Further inspection of the tubroom revealed a one quart bottle of TB Disinfectant and Deodorizer hanging on the grab bar to the right of the whirlpool tub. A cautionary label on the product stated hazardous to humans and keep out of reach of children. Staff H placed both products in the cupboard and locked the door. 4. On 8/28/13 at 7:45 a.m., an unlocked metal cabinet in the therapy room held one 1 quart bottle of Ecolab 23 TB Disinfectant and Deodorizer. A cautionary label stated keep out of reach of children. The therapy room revealed no staff in attendance. Staff N, rehab aide entered the room and indicted the cabinet was to be locked all the time. The facility identified 15 cognitively impaired residents in the facility.