Every finding on record at Harbour Health Center

Based on observation, record review, resident and staff interviews, the facility failed to ensure 1 (Resident #7) of 3 residents reviewed, received care and services in accordance with the care plan and physician's orders to maintain skin integrity.The findings included:Review of the clinical record for Resident #7 revealed a readmission date of 6/8/23. Diagnoses included dementia, heart failure and type 2 diabetes.The Quarterly Minimum Data Set (MDS) with an assessment reference date of 1/15/26 revealed Resident #7 scored 13 on the Brief Interview for Mental Status, indicating intact cognition.The care plan initiated on 6/12/23 and revised on 12/08/25 revealed Resident #7 had a potential for impaired skin integrity related to impaired mobility, fragile skin, diabetes, neuropathy (damage to peripheral nerves), edema (swelling), impaired cognition, incontinence. The care plan noted that Resident #7 has a history of noncompliance with Geri sleeve (protective sleeve).On 10/7/25, the care plan was updated to reflect a skin tear to the resident's left hand and on 12/8/25, a skin tear to the resident's left lower leg.The interventions included:Apply/maintain Geri sleeves to bilateral upper and lower extremities as tolerated. Document refusal as needed.Apply /maintain offload heel boots to bilateral feet while in bed as tolerated. The current physician's orders included:Apply/maintain offload heel boots to bilateral feet while in bed as tolerated, every shift for skin protection (Start date 7/14/23).Apply/maintain Geri sleeves to bilateral upper extremities as tolerated, every shift for protection. Document refusal as needed (Start date 4/28/25).Apply/maintain Geri legs to bilateral lower extremities as tolerated, every shift for skin protection. Document refusal as needed (Start date 7/22/25).On 3/23/26 at 12:03 p.m., and on 3/24/26 at 2:00 p.m., Resident #7 was observed in her wheelchair. The Geri sleeves were not applied to the resident's upper and lower extremities.On 3/25/26 at 12:01 p.m., Resident #7 was observed in bed. She was not wearing the Geri sleeves to her upper or lower extremities. The resident did not have the offloading heel boots on as ordered. In an interview, Resident #7 said she did not know why the staff did not apply the Geri sleeves or the offloading heel boots.On 3/26/26 at 10:12 a.m., Resident #7 was observed in her wheelchair. She was not wearing the Geri sleeves to her upper or lower extremities as ordered.On 3/26/26 at 10:15 a.m., in an interview Certified Nursing Assistant (CNA) Staff A said she was assigned to Resident #7. She said she had just provided morning care to the resident and transferred her to the wheelchair with the assistance of another CNA. Staff A said when she is assigned to Resident #7, the resident never refuses care. CNA Staff A verified that Resident #7 was not wearing Geri sleeves to her arms or legs. She said that Resident #7 did not have Geri sleeves for her arms or legs and had never seen heel boots for the resident's feet.On 3/26/26 at 10:20 a.m., review of the Treatment Administration Record (TAR) for March 2026 revealed the licensed nurses signed the TAR on 3/23/26, and 3/24/26 verifying the Geri sleeves were applied to the resident's arms and legs for the day shift. On 3/25/26, the TAR noted that the offloading heel boots were applied as ordered for the day shift. On 3/26/26, Registered Nurse (RN) Staff B signed the TAR, verifying the Geri Sleeves were applied to Resident #7's arms and legs for the morning shift. On 3/26/26 at 10:27 a.m., the Director of Nursing (DON) verified through observation that Resident #7 was not wearing the Geri sleeves to her arms and legs as ordered. She said she could not locate Geri sleeves or heel boots in the resident's room.On 3/26/26 at 10:40 a.m., in an interview, RN Staff B confirmed she signed the TAR on 3/26/26 verifying that the Geri sleeves were applied to Resident #7's arms and legs. When asked about signing the TAR when the Geri sleeves were not applied, RN Staff B did not explain and replied, I know.

Based on record review, review of facility's policy and procedure, and staff interviews, the facility failed to ensure the medical record for 1 (Resident #1) of 3 residents reviewed was complete by failing to safeguard medical record information against destruction.The findings included:Review of the facility's policy and procedure titled, admission Assessment and Follow Up: Role of the Nurse revealed the steps in the procedure included, .Reconcile the list of medications from the medication history, admitting orders, the previous Medication Administration Record (if available), and the discharge summary from the previous institution, according to established procedures. 12) Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders. Documentation: The following information should be recorded in the resident's medical record: 5) Orders obtained from the physician; 6) the signature and title of the person recording the data.Review of the facility's Policy titled, Retention of Medical Records revised 2006 revealed, Medical records shall be retained by the facility in accordance with current applicable laws. Policy Interpretation and Implementation: 1) Medical records of discharged residents will be retained for a period of 5 years. 2) Inactive medical records, those that extend beyond the above requirements, will be destroyed. 3) Persons delegated by the administrator shall witness the destroying of the medical records. 4) A record of the medical records destroyed shall be maintained and shall include at least the following: a) Date and time destroyed; b) medical record number; c) how records were destroyed; d) where medical records were destroyed e) signature of personnel destroying records; and f) others as appropriate or necessary.Review of the Medical Records Coordinator job description revealed the medical records secretary is responsible for the proper recording, filing and upkeep of the Health Center medical records.Review of the medical record for Resident #1 revealed an admission date of 7/4/25 from an acute care hospital. Diagnoses included hip fracture, post hip surgery, hypothyroidism (abnormally low activity of the thyroid gland), hypertension (high blood pressure) and arthritis.The medical record lacked documentation of signed admission physician's orders. There was no documentation the discharge summary and list of medications from the acute care hospital were reviewed and communicated to the attending physician.On 12/30/25 at 12:32 p.m., in an interview Unit Manager Registered Nurse (RN) Staff A said hospital discharge orders are sent with the resident from the hospital. She said the Unit Managers are responsible for entering new admission orders into the electronic medical record. She said the physician is notified to verify the orders. She said the nurse who calls the physician should write a progress note including date, time the physician was contacted and any new orders. Unit Manager RN Staff A said a second nurse checks the medications and initials the hospital discharge orders. She said the completed admission orders are placed in the physician's binder for signature. She said once the admission orders are signed, it goes to medical records for filing.On 12/30/25 at 12:50 p.m., in an interview the Medical Records Coordinator Staff B said the admissions orders for Resident #1 had been shredded. She said sometime around July an Interim Director of Nursing (DON) told her there would be no paper charts going forward and told her to shred the residents' records. Staff B said she shredded residents' records from July 2025 through October 2025 until the Administrator told her not to shred residents' records. She said there was no record of the medical records that were destroyed.On 12/30/25 at 2:30 p.m., in an interview the Director of Nursing (DON) said that she could not find any documentation or evidence that the nurse called the physician to verify Resident #1's admission orders. She said no progress note was written and Medical Record Coordinator Staff B shredded Resident #1's original hospital discharge orders. The DON said it was not the facility's current practice to shred residents' medical records. She said a prior interim DON had asked Staff B to shred the documents.On 12/30/25 at 4:30 p.m., in an interview, the Administrator said he was not aware until today that medical records were being shredded. Staff B told him she was following orders. He said, Shredding medical records is not our practice. The Administrator said they have to look at proper destruction procedures and the whole medical record retention process.

Based on record review, review of facility policy and procedures, resident and staff interviews, the facility failed to protect the resident's right to be free from physical abuse for 1 (Resident #899) of 3 residents reviewed for abuse. The findings included:A review of the facility policy Identifying Types of Abuse documented, Abuse of any kind against residents is strictly prohibited. Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur. It is understood by the leadership in this facility that preventing abuse requires staff education, training, and support, and a facility wide culture of compassion and caring. Possible indicators of physical abuse include an injury that is suspicious because the source of the injury is not observed, the extent or location of the injury is unusual or because of the number of injuries either at a single point in time or overtime .Examples of injuries that could indicate physical abuse include but are not limited to: fractures, sprains or dislocations . Review of the facility's incident investigations revealed on 6/25/25 Resident #899 reported that on 6/23/25 Certified Nursing Assistant (CNA) Staff A handed her the call light and then tried to take it back. Resident #899 did not want to give the call light back. She alleged that the CNA tore the call light out of her hand, twisted her fingers around and pulled the call light out of her hands. The investigation noted Resident #899 left hand with bruising to the left 4th and 5th fingers.The facility interviewed CNA Staff A who stated on 6/25/25 she took care of Resident #899 and did not recall any issues with the resident who was on her regular assignment. CNA Staff A said Resident #899 asked for a pain pill that morning and to talk to the nurse. She advised the nurse of the resident's request. Around 1:00 p.m., Resident #899 asked to get out of bed for her care plan meeting. The resident's representative showed her that she had a bruise on her left hand. The representative and the resident did not say that anyone had hurt the resident.On 6/25/25 at 4:07 p.m., CNA Staff A wrote on a witness statement, On 6/25/25 at 1:30 p.m., I got her out of bed to get into her w/c so I can take her to the care plan meeting. The caregiver showed me she had a bruised hand. She did not say anything else or tell me anyone hurt her, only that look that the bruise is there.Licensed Practical Nurse (LPN) Staff B said Resident #899 requested to speak with a nurse. The resident stated that the nurse last night was rough and twisted my hand. Resident #899 showed her left hand to LPN Staff B who observed swelling and bruising of the resident's left 5th finger. Resident #899 could not recall the name or provide a description of the staff who was rough and twisted her hand. LPN Staff B notified the Administrator and Director of Nursing (DON).The facility's investigation documented on 7/7/25 the analysis of the incident (apparent cause): This injury was found to be an injury of unknown origin. All allegations have been unsubstantiated.Review of the clinical record for Resident #899 revealed an admission date of 5/6/25. Diagnoses included history of breast cancer, malignant neoplasm of lung and brain. Resident #899 was admitted to hospice services on 6/9/25.Review of the admission Minimum Data Set (MDS) assessment with a target date of 6/15/25 documented Resident #899 required partial to moderate assistance with bed mobility and hygiene. The MDS noted the resident scored 8 on the Brief Interview for Mental Status, indicating the residents' cognitive skills for daily decision making were moderately impaired.On 7/8/25 at 8:45 a.m., in an interview Resident #899 said a Certified Nursing Assistant (CNA) grabbed the call light out of her hand. She said she did not know the name of the CNA but she was very strong. Resident #899 pointed to her left hand. Dark bruising was observed on the dorsal area of the resident's left hand, and the palmar area of the 4th and 5th fingers.Resident #899 said, She (the CNA) was angry and was very strong. I was very upset that day about it. I think I was telling her to stop when she was trying to get the call light out of my hand, and she let up after a couple of minutes. It happened so fast, I think I was yelling. She was trying to get the wires out of my hand, and I was being grabbed. I don't know why she was trying to take it from me. They removed her and she has not been back since. When I use the call light now, they come. The facility did an x-ray and they took pictures of my hand and I have a fractured finger on the pinky finger of the left hand.The resident said, I felt and still feel when caring for people who have disabilities that you should treat them well.On 6/25/25 the Physician documented in a progress note, Chief Complaint: Per nursing, left small finger swelling and pain, and abdominal rash. The nurse reports today that there is some swelling and pain of the left little finger. Apparently, the patient is reporting that her hand may have been twisted and states she was trying to use a remote by a caregiver. When seen in her room, she was enjoying an eclair dessert using her left arm. There is swelling and an area of ecchymosis (bruising). She said that she did have some pain with movement but was able to use her hand. Otherwise, she was alert and enjoying her desert. She does have some forgetfulness. The left hand particularly the left fifth finger has an area of ecchymosis, tracking down to the left anterior hands with evident swelling. There was decreased range of motion. No gross dislocation. She was able to do some range of motion. The wrist has full range of motion including the elbow and she was able to raise her left upper extremity. Alert and oriented x I to 2, oriented to self with some confusion. Assessment: Left fifth finger swelling ecchymosis. Generalized weakness. Lung cancer with brain metastasis. Plan: Ordered stat (without delay) x-ray of the hand, focusing on the left fifth finger to see. She was wanting to use her left hand. Will await results. I did meet the POA (Power of Attorney) in the hallway and I did report that x-ray was being done. I did ask the nurse to call Director of Nursing (DON) to report incident at this time.Review of Resident #899's left-hand x-ray obtained 6/25/25 revealed an acute mildly displaced fracture of the fifth finger.On 7/8/25 at 10:12 a.m., in an interview CNA Staff A said on 6/25/25, she was asked to get Resident #899 up and dressed for a care plan meeting. CNA Staff A said, That day I saw her hand bruised. I told the nurse, the DON came and spoke to me. She said the resident was confused and always grabs the side rail when you turn her, and she yells. CNA Staff A said The resident holds the side rail so tight, she could have hit her hand on it, and she moves her hands around, maybe she hit something. I never tried to take the call light from her, it is my job to give it and answer it. The CNA said she always puts the bed down when she is done providing care and always gives the resident the call light, the bed control, the table and remote control for the television.CNA Staff A said, The resident's friend came to visit on 6/25/25, and showed me her hand and I told the nurse. They gave me education in person and in writing on abuse. I never tried to take the call light from her, I don't know why she says that.A follow-up observation of Resident #899's bed noted there were no side rails attached to the bed.On 7/8/25 at 2:26 p.m., in a telephone interview LPN Staff B said on 6/25/25 she was working the day shift and went to give Resident #899 her medication.She said, The resident told me a nurse came in last night and twisted her hand. Her left hand was swollen, and she had bruising from the left pinky to the wrist. I don't think she can tell the difference between a CNA or a nurse but I believe she can tell you what happened to her. I notified the supervisor and called the doctor. The Abuse person is the Administrator, so I told him too.On 7/8/25 at 1:05 p.m., in an interview the Administrator verified he was the abuse coordinator for the facility. He said he spoke with Resident #899's Health Care Surrogate after the incident. He said, I spoke to her in person but did not take her statement, she seemed exhausted, and she spoke to the police department at length. I did not get a copy of the police report.The Administrator said the root cause of Resident #899's injury was, We determined the cause with the primary care physician, and we could not determine if the cause was forceful. The physician thought the fracture would be splintered if it was abuse. We checked to see if she hit her hand on something. We could not rule out that it was trauma. The Physician said it could have happened by bumping it on something. Ultimately, we could not pinpoint the cause of the fracture itself. He said CNA Staff A does not have access to the resident; she is not allowed in her room. He said the CNA is supervised on each shift so the Supervisor will ensure the CNA is not going in the room. The Supervisor will ensure that they are providing care in pairs.On 7/8/25 at 2:20 p.m., in an interview the Medical Director said she was aware of the incident with Resident #899's fracture. She said, I saw her right after, and she had swelling and bruising to the left hand. I figured some type of trauma occurred and ordered a STAT X-ray. The X-ray showed demineralization which means the bone is thin and there was a fracture of the 5th finger. The resident is very frail. She has lung cancer with metastasis (spreading) to the brain and the bone. She has some confusion, and she did tell me the aid tried to grab the call light out of her hand. It is up to the facility to investigate it and see what happened. The resident was seen last week, and she had no pain, the bruising was there but the swelling was gone. I did not want to order any splint because she could move the fingers and she was feeding herself. The injury could be you could bang it. It was some kind of trauma because there was swelling and bruising. The fracture was caused by trauma, but what, I don't know. The resident has some confusion but she has some thought and insight.On 7/9/25 at 5:07 p.m., in a telephone interview Resident #999's friend said she saw Resident #899 the day before the incident and her left hand was fine. There was no swelling or bruising. The next day she came again and her left hand was swollen and bruised. Resident #899 said they tried to take the call light from her hand and that is how she hurt her hand. She said the person twisted her hand trying to get the call light.The friend said she was not there when it happened but she did not have any injury the day before. She let the nurse know. The DON came and spoke with me. The police were notified and she spoke to them for a long while.

Based on record review and interviews, the facility failed to protect the resident(s') right to be free from neglect when it failed: 1) to provide to structural processes necessary to ensure ongoing incontinence care to two residents (#1 and #2); and 2.) to prevent emotional anguish to 1 resident (#2). The findings included: Record Review of Abuse and Neglect-Clinical Protocol Policy last revised in March 2018 stated that neglect is defined as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Record Review of ADL Policy, last revised on March 2018 stated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, including Hygiene (bathing, dressing, grooming, and oral care). Resident #1 was admitted to the facility on [DATE] for skilled nursing care. Resident #1 has a diagnosis of Alzheimer's disease, impaired gait and mobility, and generalized muscle weakness. Resident #1 requires staff assistance with hygiene care and transfers in and out of her wheelchair. Record Review of the facility's neglect allegation showed that the facility verified the Certified Nursing Assistant (CNA) who was assigned to this resident did not provide incontinent care during breakfast service or lunch service resulting in the resident sitting in a puddle of urine at breakfast and lunch time on 2/20/25. Record review of staff training logs for neglect at the time surrounding the incident involving Resident #1 showed facility lacked ongoing training for staff regarding the incident, and that the only staff trained on neglect at the time of the incident were the 24 staff working at the facility on 2/26/25. Record review of facility's Quality Assurance Performance Improvement (QAPI) agenda shows that the incident involving Resident #1 was included on the agenda dated 3/19/25. Resident #2 was admitted on [DATE] with history of Dementia and requires staff assistance with getting out of bed and into the wheelchair. Interview with Resident #2 on 3/20/25 at 10:47 a.m. who stated that the Certified Nursing Assistants (CNA's) don't assist with toileting or incontinence during dinner time, they will tell you they are too busy. Resident #2 said, someone told me just go in the diaper, as if that's what it is supposed to be for, they tell you they'll be back and then you never see them again. On 3/20/25 at 2:50 p.m., during an interview the Administrator stated that he was aware of an incident in which a former staff member had told another resident to just go in your diaper. The facility had recently terminated that employee but was not aware of other residents with the same complaint. Interview with Resident #2 on 3/25/25 at 10:47 a.m., who stated that she recently refused to allow staff to care for her because she was uncomfortable with them telling her to just go in your diaper. She stated that she was so upset by the interaction that she reported the incident to her nurse, and the facility agreed to remove the staff from caring for her, but no one ever asked her why or what had happened. On 3/20/25 at 2:50 p.m., an interview was conducted with the Administrator who stated that there were currently no ongoing audits in place to ensure that neglect was not occurring in the facility because QAPI was not held until 3/19/25, and that audits had not been considered prior to the meeting. The Administrator also stated that the facility had not conducted training to all caregivers after the neglect allegation was made for Resident #1, but that ongoing training would be something the facility would look into going forward.

Based on record review and interview, as a result of a facility's investigation, when an alleged violation was verified, the facility failed to take appropriate corrective action to protect residents and oversee the implementation of corrective action and evaluate whether it is effective for 2 of 2 incidents reported by the facility. The findings included: On 10/30/24, the facility reported an investigation into 19 possible instances of drug diversion regarding prescribed, as needed, pain medications. During the investigation, the facility interviewed staff and residents, in-serviced staff on misappropriation of property, and discussed the incident in a Quality Assurance Performance Improvement (QAPI) meeting on 11/20/24. The facility investigation concluded that they could not verify any medications were diverted but did verify documentation was incomplete in 19 instances involving 9 separate residents' as needed pain medications. Staff members involved was subsequently terminated. There was no further actions taken to verify this action was effective. On 2/20/25, the facility reported in investigation regarding incontinence care. During the investigation, the facility interviewed staff and residents, in-serviced staff on abuse and neglect and discussed the incident in a Quality Assurance Performance Improvement (QAPI) meeting on 3/19/25. Facility investigation verified the allegation of neglect and terminated the staff member involved. There was no further actions taken to verify this action was effective. On 3/20/25 at 2:56 p.m., the Administrator said no Performance Improvement Plans (PIPs) had been put in place and no continued monitoring/audits had been conducted for either reported incident. The Administrator agreed there was no way to prove the actions taken by the facility had been effective in dealing with the problems related to the investigation.

Based on record review and interviews, the facility failed to ensure incontinence care was provided to 2 residents (#1 and #2). The findings included: Record review of the Activities of Daily Living (ADL) Policy, last revised on March 2018 said, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, including Hygiene (bathing, dressing, grooming, and oral care). Resident #1 was admitted to the facility on [DATE] for skilled nursing care. Resident #1 has a diagnosis of Alzheimer's disease, impaired gait and mobility, and generalized muscle weakness. Resident #1 requires staff assistance with hygiene care and transfers in and out of her wheelchair. Record review of the facility's investigation of the ADL care received by Resident #1 showed that the Certified Nursing Assistant (CNA) was made aware on 2/20/25 the resident was sitting in a puddle of urine at 8:00 a.m. and did not receive incontinence care until after lunch. On 3/20/25 at 10:47 a.m. an interview with Resident #2 who stated that I have to ask for help to the bathroom, the CNA never offers to help or anything, and one time recently I waited so long I had to go in my diaper and had to wait until after dinner to be changed when someone finally came and helped me. On 3/20/25 at 12:00 p.m., in an interview the Administrator verified that he was made aware that incontinent care had not been done for Resident #1 and verified that the CNA documented that the resident was not available for incontinence care. The Administrator confirmed this was determined to be falsely documented. On 3/20/25 at 12:15 p.m., in an interview the Administrator stated that there are currently no performance improvement plans in place to monitor for toileting and incontinence care at the facility.

Based on observation and interview, the facility failed to ensure they posted and updated the nurse staffing information with the facility name and an updated census per shift. The facility further failed to maintain the nursing staffing information for 18 months. The findings included: On 2/5/24 at 9:10 a.m. via observation, the nurse staffing information form dated 2/5/24 located in the main lobby did not have the facility's name and the current census. On 2/5/24 at 4:00 p.m. via observation, the nurse staffing information form posted in the main lobby was dated 2/05/24 and did not contain the resident census, the facility's name, the updated total number of staff, and the actual hours worked by the licensed and unlicensed nursing staff for 2/05/24. On 2/06/24 at 10:10 a.m. via observation, the nurse staffing information form posted in the main lobby was dated 2/05/24 and did not contain the resident census, the facility's name, the updated total number of staff, and the actual hours worked by the licensed and unlicensed nursing staff for 2/06/24. On 2/06/24 at 4:10 p.m. via observation, the nurse staffing information form posted in the main lobby was dated 2/05/24 and did not contain the updated resident census, the facility's name, the updated total number of staff, and the actual hours worked by the licensed and unlicensed nursing staff for 2/06/24. On 2/07/24 at 9:10 a.m. via observation, the nurse staffing information form posted in the main lobby was dated 2/05/24 and did not contain the updated resident census, the facility's name, the updated total number of staff, and the actual hours worked by the licensed and unlicensed nursing staff for 2/07/24. On 2/07/24 at 1:45 p.m. in an interview with the Director of Nursing (DON), he confirmed the nurse staffing information form posted in the main lobby was dated 2/05/24 and did not contain the facility's name, the current resident census, the current number of staff, and the actual hours worked by the licensed and unlicensed nursing staff working 2/07/24. On 2/07/24 at 2:00 p.m., in an interview with the facility's Scheduler, she said she was responsible for posting the nurse staffing information form every morning. She confirmed the nurse staffing information form did not contain the facility's name and resident census. She further said she was unaware the nurse staffing information needed to be updated daily with the resident census, the current number of staff, and the actual hours worked by the licensed and unlicensed nursing staff. She also said she would throw away the nursing staffing information form the next day because she was unaware the facility was required to retain the nurse staffing information form for 18 months.

Based on observation, record review, staff, resident and family interview, the facility failed to ensure 2 (Residents #12, #29) of 4 residents reviewed received care and services in accordance with professional standards, by failing to implement physician's orders for protective skin sleeves. The findings included: 1. Clinical record review revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included Dementia. The physician order effective 10/22/23 included to apply Geri-sleeves (protective sleeves) to both arms for protection. The Care Plan initiated 5/27/21 documented Resident #29, has the potential for impaired skin integrity r/t (related to) impaired cognition, impaired mobility, anorexia, incontinence, malnutrition. The resident needs assistance to apply protective garments; Geri-sleeves to BUE (bilateral upper extremities). On 2/5/24 at 1:56 p.m., 2:51p.m., and on 2/6/24 at 8:45 a.m., Resident #29 was observed in the activity area wearing a short sleeve shirt without Geri-sleeves as ordered by physician. On 2/6/24 at 11:30 a.m., Certified Nursing Assistant (CNA) Staff B removed the blanket revealing both arms for Resident #29 and verified she was not wearing Geri sleeves. On 2/6/24 at 2:08 p.m., Resident #29 was observed in the activity area wearing a short sleeve shirt without Geri-sleeves as ordered by physician. On 2/7/24 at 8:45 a.m., Resident #29 was observed without Geri sleeves on either arm. CNA Staff B verified resident was not wearing Geri-sleeves. On 2/7/24 at 10:23 a.m., CNA Staff B verified she was assigned to care for Resident #29 but said she did not know she was supposed to wear the Geri sleeves. On 2/7/24 at 10:25 a.m., Registered Nurse (RN) Staff O, verified Resident #29 was supposed to wear Geri sleeves. On 2/7/24 at 3:50 p.m., Unit Manager Staff L, said he was told today Resident #29 was not wearing the Geri-sleeves as ordered by the physician. On 2/7/24 at 4:11 p.m. the Director of Nursing (DON) said if the resident could tolerate the Geri sleeves, they would be on. He verified there was no documentation of refusal or taking them off. The DON said there was no policy related to following physician orders, that was the expectation. 2. Clinical record review revealed Resident #12 was admitted to the facility on [DATE]. Diagnoses included Congestive Heart Failure, Interstitial Pulmonary Disease, Chronic Obstructive Pulmonary Disease (COPD) and Chronic Pulmonary Edema. The physician order effective 11/10/23 included, Incentive Spirometer (a device used to improve air movement in the lungs) 10 X(times) hour every shift while awake. The Care Plan revised on 11/7/23 said Resident #12 has the potential for altered respiratory status/difficulty breathing related to interstitial pulmonary disease, pleural effusion, respiratory failure, pulmonary edema, Congestive Heart Failure, pulmonary hypertension, COPD and wheezing. The intervention as of 11/6/23 included incentive spirometer as ordered. On 2/6/24 at 8:31 a.m., Resident #12 was observed in bed with a private duty aide at the bedside. She said she stays with the resident throughout the day and has never seen anyone use the Incentive Spirometer with the resident before. On 2/6/24 at 9:35 a.m., Resident #12's Incentive Spirometer was noted at the bedside. Resident #12's daughter said she took the incentive spirometer out of the cabinet for staff to help her mother use it. The daughter said she has not seen staff using the Incentive Spirometer. She said, Do you hear her wheezing? On 2/7/24 at 3:00 p.m., Unit Manager Staff L, verified the resident was not able to use the Incentive Spirometer on her own, but nurses were signing off on the treatment record that was being done. On 2/7/24 at 3:10 p.m., Licensed Practical Nurse (LPN) Staff D said he does not recall if he assisted resident #12 with the Incentive Spirometer. On 2/8/24 at 9:20 a.m., Resident #12's private duty aid said she's been with the resident all morning and no one has come in to help Resident #12 with the incentive spirometry. On 2/8/24 at 9:29 a.m., Licensed Practical Nurse (LPN) Staff H, said Resident #12 can do the incentive spirometer once in the morning but verified it was not done 10 times per hour. On 2/8/24 at 11:03 a.m., The DON verified the order was revised to say, encourage to use Incentive Spirometer every hour while awake, every hour document refusal. The DON verified LPN Staff G documented on 2/7/24., every hour from midnight to 7:00 a.m., Resident #12 used the incentive spirometer. On 2/8/24 at approximately 11:10 a.m., in a telephone interview LPN staff G verified Resident #12 did not use the Incentive Spirometer every hour during the night of 2/7/24 as documented. The resident refused when he woke her up to use the spirometer.

Based on observation, record review, and staff interviews, the facility failed to ensure 1 (Resident #29) of 1 dependent resident received the appropriate assistance to apply corrective lenses as per the physician's orders and care plan to maintain vision. The findings included: Review of the clinical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included Dementia and unspecified age-related cataract. The physician's orders dated 6/30/21 included for the nurse to verify the resident's glasses were on in the morning and remove the glasses at bedtime. The Care Plan revised on 7/1/2021 noted Resident #29 had impaired visual function related to cataracts and used glasses. The interventions included to remind the resident to wear glasses when up. Assist with placing glasses on in the morning, remove at bedtime. The Quarterly Minimum Data Set (MDS) assessment with a target date of 12/7/23 indicated the resident's vision was adequate with corrective lenses. The care plan summary meetings dated 2/15/23, 4/11/23, 5/18/23, 12/14/23 noted the resident wears glasses. Review of the Treatment Administration Record (TAR) for February 2024 noted on 2/5/24 (Day, evening, and night shift), on 2/6/24 (Day, evening, and night shift), and 2/7/24 (Day shift) Resident #29's glasses were on. On 2/5/24 at 1:53 p.m., and 2:50 p.m., Resident #29 was observed sitting in the activity area in front of nursing station. Resident #29 was not wearing glasses. Resident #29 was not able to respond to interview questions. On 2/6/24 at 1:05 p.m., Resident #29 was observed sitting in front of the nursing station without glasses. On 2/6/24 at 1:07 p.m., Certified Nursing Assistant (CNA) Staff K said everything you need to know about the resident can be found on the care plan. On 2/7/24 at 2:51 p.m., Unit Manager Licensed Practical Nurse (LPN) Staff L verified the resident should be wearing glasses. On 2/7/2024 at 6:04 p.m., A nursing progress noted documented by the unit manager said, Pt eye glass is missing room was searched. Pt husband was notified and was offered to have glasses replace .

Based on observations, resident and staff interviews, clinical records review and facility policy review the facility failed to follow physician's ordered fluid restrictions for 1 (Resident #14) of 2 residents reviewed for hydration management. The findings included: Review of facility policy titled Encouraging and Restricting Fluids, revised October 2010 which stated, Purpose: The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. Preparation: 1. Verify that there is a physician's order for this procedure . General Guidelines: 1. Follow specific instructions concerning fluid intake or restrictions. 2. Be accurate when recording fluid intake. 3. Record fluid intake on the intake side of the intake and output record. Record fluid intake in ml (milliliter) . 8. Be sure an intake and output record is maintained in the resident's room . Documentation: . 6. The amount (in mLs) of fluids consumed by the resident during the shift. 7. The type of liquids consumed (i.e., tea, milk, coffee, soup, etc.) . 9. The signature and title of the person recording the data. Review of facility policy titled, Dietary Tray Card, revised 9/4/18 which stated, Policy: The Food and Nutrition Services Department should maintain a tray card system in order to record dietary information necessary to use on resident's tray card . Update any changes in the diet order; change the tray card, production count and nourishment list when applicable. Review of facility policy titled, Fluid Restriction, revised 5/20/20 which stated, Policy: To provide residents who have a written physician order for fluid restriction an appropriate amount of fluid each day while allowing nursing adequate fluid to supply medication, etc. each shift . Procedure: 2. For a diet with fluid restrictions, the following distribution may be used by nursing and dietary. Recommend dietary put ml allowed on tray card, and nursing note the ml allowed on the MARs. Review of clinical records revealed Resident #14 was admitted to the facility on [DATE] for short term rehabilitation. Primary admitting diagnosis was Chronic Obstructive Pulmonary Disease (COPD) with secondary diagnoses including acute and chronic respiratory failure, pleural effusion, chronic pulmonary edema, weeping edema both lower extremities and heart failure. Review of physician's order dated 2/1/24 documented, Fluid Restriction 1200cc/24 hrs:11-7 provide 60 ml; 7-3 Nursing provide 120 ml, dietary breakfast 420 ml, lunch 240 ml, 3-11 nursing provide 120 ml, dinner 240 ml every shift. Resident #14 care plan dated 2/2/24 documented the resident had altered cardiovascular status with intervention of restricted fluids as ordered by the physician. The Certified Nursing Assistant (CNA) Kardex (Provides instructions for care) for Resident #14 documented restricted fluids as ordered by the physician. On 2/5/24 at 10:00 a.m., in an interview, when asked about meals at the facility, Resident #14 said, They put me on water restrictions last week. Observed Resident #14 with two juice six ounce (360 cc) cups on bedside table. Resident #14 said, Yeah, there is no reason, I get my other drinks but water is restricted. I will need to talk with the doctor. On 2/6/24 at 8:40 a.m., observed Resident #14 eating breakfast. Resident #14 had six ounces of orange juice, eight ounces of coffee, six ounces of water and eight ounces of milk on the breakfast tray. CNA Staff B verified Resident #14 had six ounces of orange juice, eight ounces of coffee, six ounces of water and eight ounces of milk on the breakfast tray. During the observation, Registered Nurse (RN) Staff C provided Resident #14 with an additional eight ounces of chocolate (brand name) supplement. The total fluid provided to the resident with breakfast was 1080 cc. While interviewing Resident #14, RN Staff C came into room to administer medications to the resident. RN Staff C offered six ounces of water with medications. While RN Staff C was administering the medications, Resident #14 was observed taking a pair of pliers which he said was to open the milk bottle. RN Staff C opened the eight-ounce milk container for the resident. RN Staff C did not comment on the multiple drinks on the resident's breakfast tray. Review of the meal ticket failed to reveal instructions for the fluid restriction. On 2/6/24 at 12:53 p.m., observed Resident #14 finishing lunch with six-ounce cranberry juice partially consumed and six ounce orange juice partially consumed half on bedside. Lunch tray reviewed with CNA Staff B who confirmed resident drank eight ounces of milk and eight ounces of coffee with lunch. Review of the lunch meal ticket failed to show documentation of fluid restrictions. The total amount of fluids offered with the meal was 840 cc. On 2/7/24 at 8:23 a.m., in an interview Resident #14 said his dinner meal on 2/6/24 included regular fluids. The Resident said, I got juice, water and coffee. They are only restricting my water. I need to talk with the doctor about that. On 2/7/24 at 8:52 am., in an interview CNA Staff A confirmed Resident #14 was on fluid restrictions. When asked how much fluid resident is allowed each day CNA Staff A replied, 1400 cc I think. When asked if the1400 cc were for the shift or the entire day, CNA Staff A replied, 1400 cc for my shift. The CNA said she does not chart the fluid intake. She tells the nurses, and the nurses chart the amount. On 2/7/24 at 9:06 a.m., in an interview CNA Staff B who had cared for resident 2/6/24 confirmed she knew resident was on fluid restrictions. She said Resident #14 was allowed 1200 cc of fluids per day. CNA Staff B said, He had about 500 cc in the morning. I might have calculated it wrong; I knew he was on a fluid restriction that's why I only provided him with the juice. He did not get any Styrofoam cups of water. CNA reviewed drinks provided for both breakfast and lunch. CNA Staff B said, I should have been more aware of what he was supposed to have. The nurse tells me. I was told 1200cc for the day shift. On 2/7/24 at 11:07 a.m., in a phone interview RN Staff C confirmed she was aware of Resident #14 physician ordered fluid restriction was for 1200 cc over a 24 hour period. RN Staff C said she had communicated to the CNAs about the fluid restrictions. When shared the observed fluids provided to the resident for breakfast and lunch, RN Staff C said, Wow, I don't know what to say. RN Staff C said she did not notice the fluids on the breakfast tray on 2/6/24 when she administered the medications to the resident. On 2/7/24 at 11:39 a.m., in an interview Unit Manager Staff E said the nurses are the only ones who are supposed to provide the fluids with meals and medication pass. When shared the observation of the fluids provided to the resident at breakfast and lunch on 2/6/24, RN Staff E said, It's obvious the fluid restriction is not being followed. On 2/7/24 at 12:01 p.m., in an interview the Director of Nursing (DON) confirmed Resident #14 was on 1200 cc daily fluid restriction, as ordered on 2/1/24. The DON said the process for providing fluids when on restriction is for nursing not dietary to provide the fluids. CNAs can provide fluids based on the nurse's instructions. The DON confirmed staff did not follow the physician's order for fluid restriction for Resident #14. The DON said not following the fluid restriction could lead to complications of the congestive heart failure or the COPD. On 2/7/24 at 12:31 p.m., in an interview, the Registered Dietitian (RD) verified the meal tickets should reflect the fluid restriction for Resident #14. The RD said the meal tickets should have been reprinted when the fluid restriction was ordered and they were not. The RD said the supervisor needs to check the preprinted meal tickets to ensure they are correct and the menus handed to the residents are correct, especially when a change in orders occurs. On 2/7/24 at 1:00 p.m., in a telephone interview Resident #14's physician said she expects staff to follow orders, including orders for fluid restriction. She said they will need to work as a team to improve and not let it happen again.

Based on observation, record review, and staff interview the facility failed to ensure its medication error rate remained below 5%. Four licensed nurses with 27 opportunities were observed. Two medication errors were identified resulting in a 7.41% error rate. The findings included: Policies and Procedures titled Administering Medications (reviewed/revised April 2019), specified Medications are administered in a safe and timely manner, and as prescribed. The policy states 4. Medications are administered in accordance with prescriber orders, including any required time frame. On 2/7/24 at 9:01 a.m., Licensed Practical Nurse (LPN) Staff D was observed administering two medications to Resident #23, including Entresto and metoprolol. The physician's orders specified to hold the medications if the systolic blood pressure was less than110 or the heart rate was less than 65 beats per minute. Resident #23 had a heart rate of 60 beats per minute. This indicates the medication should be held per the physician order parameters. On 2/7/24 at 10:50 a.m., in an interview LPN Staff D verified the physician's orders for the Entresto and Metoprolol specified to hold if systolic blood pressure was less than110 or the heart rate was less than 65 beats per minute. He stated he gave the medication and should have held it due to the parameters. On 2/7/24 at 10:52 a.m., the Director of Nursing reviewed the Medication Administration Record for Resident #23 and verified the medications should have been held per the specified physician ordered parameters.

On 2/06/24 10:08 a.m. the medication storage room C wing checked with the Assistant Director of Nursing (ADON). During the observation a large white oval pill was found in the sink. Internet search shows it is Metformin (a pill to control blood sugar). Photographic evidence obtained. During an interview on 2/6/24 at 10:09 a.m. ADON stated that she did not know what the large white pill was and she acknowledged that it should not be in the sink in the medication room. On 2/06/24 at 11:25 a.m., LPN Staff Q's medication cart C left was checked and found to have opened over the counter (OTC) liquid medication not labeled with the open date. LPN staff Q confirmed 3 of the bottles did not have an open date on them and she could not know how long they had been in the drawer open. The following medication bottles were observed not dated with open date. -Geri-tussin DM -Liquid pain relief acetaminophen -Iron supplement During an interview on 02/07/24 at 11:45 a.m. the Director of Nursing (DON) stated that her expectation was for nurses when opening OTC liquid medication is to place an open date on the bottle. They dispose of the medication when the expiration date is reached. No policy of labeling open date on the bottle. Just a higher standard they want the nurse to practice. 44307 Based on observation, and staff interviews, the facility failed to administer and store medications in accordance with professional practice and standards for 1(Resident #14) of 1 resident observed with unsecured medications at the bedside. The findings included: On 2/7/24 at 8:39 a.m., observed Registered Nurse (RN) Staff D enter Resident #14 room with glass of water and medicine cup of pills. Observed RN leave medicine cup on bedside table next resident. RN did not stay with the resident to ensure medications were taken as ordered. On 2/7/24 at 8:42 a.m., interviewed RN Staff D who confirmed he had left resident #14 with pills in medicine cup on bedside table. RN Staff D said, I was looking for an iron pill when I left the room. I know I'm not supposed to do that. RN confirmed it was against medication administration policy to leave medication unattended. On 2/7/24 at 8:48 am., interviewed unit manager Staff E who confirmed it was not acceptable to leave medications at the bedside and to not wait for the resident to take medication when administering medications. On 2/7/24 at 12:01 p.m., interviewed Director of Nursing (DON) who confirmed medications are not to be left at bedside and the nurse is expected to stay with the resident until the medications have been taken.

Based on observation, review of facility's policy and procedure, record review, and staff interview, the facility failed to establish a complete and accurate system to prevent misappropriation of residents' narcotic medications. The findings included: The facility's policy titled Abuse Prevention Program revised December 2016 read, Our residents have the right to be free from . misappropriation of resident property and exploitation . The facility's policy for, Investigating Incidents of Theft and/or Misappropriation of Resident Property read, Residents have the right to be free from theft and/or misappropriation of personal property. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. On 5/9/22 at 10:49 a.m., the Human Resources Director said the Assistant Director of Nursing (ADON) was recently terminated for stealing residents' narcotics for personal use. She said the previous ADON's background check and license were current and clear. On 5/9/22 at 11:42 a.m., Unit Manager Staff A said she gave 2 new narcotic bubble packs with 30 each of [MEDICATION(S)] 4 milligrams (mg) (Pain medication used to treat moderate to severe pain) for Resident #281 to Licensed Practical Nurse (LPN) Staff B at the beginning of the day shift on 3/29/22. She said LPN Staff B signed for them and locked them in the narcotic drawer of the medication cart. She said the two corresponding narcotic sheets were placed in the narcotic book at the cart. Staff A said she realized one of the two narcotic cards for Resident #281 was missing at the end of the day shift when the narcotics were counted. On 5/9/22 at 11:57 a.m., the Director of Nursing (DON) confirmed the Assistant Director of Nursing (ADON) took the narcotic bubble packs and narcotic sheet belonging to Resident #281 along with narcotic medications belonging to other residents at the facility at that time. She said the incident was investigated, reported to the police and State Agency, and the ADON was terminated. She said since then, the procedure for counting narcotic medication has changed to include counting the number of narcotic bubble packs in addition to each individual narcotic pill in the medication cart. The DON said the procedure for disposing of narcotics did not change. She said she removes narcotics from the medication carts twice a week when they are no longer in use. The DON said she places the narcotics in a double-locked cabinet in her office. She said she is the only person with a key to that cabinet. Observation of the narcotics in the cabinet in the DON's office during the interview revealed over 50 bubble packs of narcotics in the drawer. The DON said she did not have an inventory of the narcotic bubble packs and did not know how many narcotics were in the cabinet. The DON said she did not create a log of the narcotic medications in the drawer with another nurse for reconciliation at the time of disposing the medication. On 5/9/22 at 1:07 p.m., during a telephone interview with the Pharmacy consultant, she said she began consulting the facility in January 2022 before the narcotic misappropriation of 3/29/22. She said after the incident, she spoke to the DON and offered to dispose of the narcotic drugs with her. The Pharmacy Consultant said the DON told her no, and she would dispose of the drugs with another nurse at the facility. She said she was aware the facility now counts the narcotic bubble packs, but that is not fool proof. She said she is asked to sign the controlled substance inventory form when she visits the facility, but she does not witness the disposing of the narcotics. She said the disposing of the narcotics was usually done by the DON and the ADON at the facility. She said she would not be able to tell if someone had taken one of the narcotic bubble packs because the meds for destruction are not reconciled with an inventory sheet. She said she is being asked to sign something she has not witnessed, the destruction of the narcotics, and she does feel uncomfortable about that. On 5/9/22 at 1:28 p.m., Staff B said she was working the day shift on 3/29/22 and received the two narcotic cards of [MEDICATION(S)] 4 mg for Resident #281. She said the narcotics were placed in the locked drawer of the medication cart, and the narcotic sheets were placed in the narcotic book. Staff B said later during the shift, the ADON came to her and said she needed to look through the narcotics in the locked drawer. At that time, the ADON removed and took with her one of the narcotic bubble packs of [MEDICATION(S)] 4 mg and the corresponding narcotic sheet for Resident #281. Staff B said she asked the ADON why she was taking the card of narcotics and the ADON told her it was not safe to have more than one in the drawer at a time. Staff B said she believed the ADON. Staff B said she left at 2:00 p.m. on 3/29/22 and did not realize there was a problem until she received a call from the facility asking her what happened to the missing [MEDICATION(S)] bubble pack for Resident #281. She said the ADON originally tried to blame her for taking the narcotic bubble pack, but she did not. That is when she told the facility the ADON removed them and the corresponding sheet from the medication cart earlier in the shift. The ADON ultimately admitted to taking the narcotics belonging to Resident #281, and other residents' narcotics were also found in her car. On 5/9/22 at 2:30 p.m., the following narcotic bubble packs and corresponding control sheets were observed in the DON's office cabinet: [MEDICATION(S)] 5/325 mg., six bubble packs; [MEDICATION(S)] 50 mg., 20 bubble packs; [MEDICATION(S)] 0.5 mg., four bubble packs; [MEDICATION(S)] 5/325 mg., two bubble packs; [MEDICATION(S)] 0.25 mg., five bubble packs; [MEDICATION(S)] 0.5 mg., six bubble packs; [MEDICATION(S)] 0.5 mg., one bubble pack; [MEDICATION(S)] 30 mg., one bubble pack; [MEDICATION(S)] Instant Release (IR) 10 mg., one bubble pack; [MEDICATION(S)] 4 mg., one bubble pack; [MEDICATION(S)] 7.5 mg., one bubble pack; [MEDICATION(S)] 10/325 mg., one bubble pack; [MEDICATION(S)] 2 mg., two bubble packs; [MEDICATION(S)] 10/325 mg., three bubble packs; [MEDICATION(S)] IR 5 mg., one bubble pack; [MEDICATION(S)] 100 mg., one bubble pack; [MEDICATION(S)] Liquid 100 mg. /5 milliliters (ml), 15 ml. remaining. On 5/9/22 at 4:58 p.m., the Nursing Home Administrator (NHA) said the DON and ADON usually disposed of the narcotics together. She said she was not aware the Consultant Pharmacist offered to dispose of the narcotics with the DON after the incident on 3/29/22. She said none of the narcotics have been destroyed since 3/29/22. On 5/9/22 at 3:36 p.m., the NHA said there were other narcotics and control sheets found in the ADON's car when the police searched it that day on 3/29/22. The NHA said these included: [MEDICATION(S)] / Acetaminophen 5/32 mg. for Resident #900, [MEDICATION(S)] 5mg for Resident #901, and [MEDICATION(S)] 0.5mg for Resident #902.

Based on observation, review of facility's policy, record review and staff interview, the facility failed to establish a reliable system to dispose of unused narcotics, creating a potential for drug diversion by staff. The findings included: Record Review of the facility policy Controlled Substances, Revised April 2019 read, . Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. On 5/9/22 at 10:49 a.m., the Human Resources Director said the Assistant Director of Nursing (ADON) was recently terminated for stealing residents' narcotics for personal use. On 5/9/22 at 11:42 a.m., Unit Manager Staff A said she gave two new narcotic bubble packs with 30 each of [MEDICATION(S)] 4 milligrams (mg) (Pain medication used to treat moderate to severe pain) for Resident #281 to Licensed Practical Nurse (LPN) Staff B at the beginning of the day shift on 3/29/22. She said Staff B signed for them and locked them in the narcotic drawer of the medication cart. She said the two corresponding narcotic sheets were placed in the narcotic book at the cart. Staff A said she realized one of the two narcotic cards for Resident #281 was missing at the end of the day shift when the narcotics were counted. On 5/9/22 at 11:57 a.m., the Director of Nursing (DON) confirmed the Assistant Director of Nursing (ADON) took the missing narcotic bubble packs and narcotic sheet belonging to Resident #281 along with narcotic medication belonging to other residents at the facility at that time. She said since then, the procedure for counting narcotic medication has changed to include counting the number of narcotic bubble packs in addition to each individual narcotic pill in the medication cart but the procedure for disposing of narcotics did not change. The DON said she removes narcotics from the medication carts twice a week when they are no longer in use. The DON said she places the narcotics in a double-locked cabinet in her office. She said she is the only person with a key to that cabinet. During an observation of the narcotics in the cabinet in the DON's office at the time of interview, there were over 50 bubble packs of narcotics in the drawer. The DON said she did not have an inventory of the narcotic bubble packs and did not know how many narcotics are in the cabinet. The DON said she did not create a log of the narcotic medication in the drawer with another nurse for reconciliation at the time of disposing the medication. On 5/9/22 at 1:07 p.m., during a telephone interview with the Pharmacy consultant, she said she began consulting the facility in January 2022 before the drug diversion incident of 3/29/22. She said after the incident, she spoke to the DON and offered to dispose of the narcotic drugs with her. The Pharmacy Consultant said the DON told her no, and she would dispose of the drugs with another nurse at the facility. She said she is aware the facility now counts the narcotic bubble packs, but that is not fool proof. She said she is asked to sign the controlled substance inventory form when she visits the facility, but she does not witness the disposing of the narcotics. Disposing of the narcotics was done by the DON and the ADON at the facility. She said she would not be able to tell if someone had taken one of the narcotic bubble packs because the meds for destruction are not reconciled with an inventory sheet. She said she is being asked to sign something she has not witnessed, the destruction of the narcotics, and she does feel uncomfortable about that. On 5/9/22 at 1:28 p.m., Staff B said she was working the day shift on 3/29/22 and received the two narcotic cards of [MEDICATION(S)] 4 mg for Resident #281. She said the narcotics were placed in the locked drawer of the medication cart, and the narcotic sheets were placed in the narcotic book. Staff B said later during the shift, the ADON came to her and said she needed to look through the narcotics in the locked drawer. At that time, the ADON removed and took with her one of the narcotic bubble packs of [MEDICATION(S)] 4 mg and the corresponding narcotic sheet for Resident #281. Staff B said she asked the ADON why she was taking the card of narcotics and the ADON told her it was not safe to have more than one in the drawer at a time. Staff B said she believed the ADON. Staff B said she left at 2:00 p.m. on 3/29/22 and did not realize there was a problem until she received a call from the facility asking her what happened to the missing [MEDICATION(S)] bubble pack for Resident #281. She said the ADON originally tried to blame her for taking the narcotic bubble pack, but she did not. That is when she told the facility the ADON removed them and the corresponding sheet from the medication cart earlier in the shift. The ADON ultimately admitted to taking the narcotics belonging to Resident #281, and other residents' narcotics were also found in her car. On 5/9/22 at 2:30 p.m., the following narcotic bubble packs and corresponding control sheets were observed in the DON's office cabinet: [MEDICATION(S)] 5/325 mg., six bubble packs; [MEDICATION(S)] 50 mg., 20 bubble packs; [MEDICATION(S)] 0.5 mg., four bubble packs; [MEDICATION(S)] 5/325 mg., two bubble packs; [MEDICATION(S)] 0.25 mg., five bubble packs; [MEDICATION(S)] 0.5 mg., six bubble packs; [MEDICATION(S)] 0.5 mg., one bubble pack; [MEDICATION(S)] 30 mg., one bubble pack; [MEDICATION(S)] Instant Release (IR) 10 mg., one bubble pack; [MEDICATION(S)] 4 mg., one bubble pack; [MEDICATION(S)] 7.5 mg., one bubble pack; [MEDICATION(S)] 10/325 mg., one bubble pack; [MEDICATION(S)] 2 mg., two bubble packs; [MEDICATION(S)] 10/325 mg., three bubble packs; [MEDICATION(S)] IR 5 mg., one bubble pack; [MEDICATION(S)] 100 mg., one bubble pack; [MEDICATION(S)] Liquid 100 mg. / 5 milliliters (ml) - 15 ml. remaining. On 5/9/22 at 4:58 p.m., the Nursing Home Administrator (NHA) said the DON and ADON usually disposed of the narcotics together. She said she was not aware the Consultant Pharmacist offered to dispose of the narcotics with the DON after the incident on 3/29/22. She said none of the narcotics have been destroyed since 3/29/22. On 5/9/22 at 3:36 p.m., the NHA said there were other narcotics and control sheets found in the ADON's car when the police searched it that day on 3/29/22. The NHA said these included: [MEDICATION(S)] / Acetaminophen 5/32 mg. for Resident #900, [MEDICATION(S)] 5 mg for Resident #901, and [MEDICATION(S)] 0.5 mg for Resident #902.

Based on interviews and record reviews, the facility failed to ensure a monthly Medication Regimen Review (MRR) for 2 (#24 and #61) of 5 residents reviewed. The findings included: The facility Policy for Medication Regimen Review (MRR) with an effective date of 12/1/07 noted, The Consultant Pharmacist will conduct MMRs if required under a Pharmacy Consultant Agreement . The facility should maintain copies of MRRs on file in the facility, either as part of the resident's permanent medical record or in a special file, in accordance with applicable law. Review of the clinical records showed Resident's #24 and #61 were admitted to the facility respectively on 6/12/20 and 3/19/21. The clinical records lacked documentation of a medication regimen review for September 2021. Review of the Consultant Pharmacy Reports for September 2021 showed MRRs were conducted for 17 residents without recommendation and for two residents with recommendations. Residents #24 and #61 were not included in the MMRs. Review of the facility Detailed Census Report for September 2021 showed there were between 84 and 93 residents at the facility during the month of September 2021. On 3/9/22 at 11:17 a.m., in an interview the Assistant Director of Nursing (ADON) confirmed there was no MRR for September 2021 for Residents #24 and #61. The ADON also confirmed there were Consultant Pharmacy MMRs conducted for only 19 residents during September 2021. The ADON said she discovered the problem in October 2021 and contacted the Consultant Pharmacist. The Consultant Pharmacist's reply was they were missed. On 3/9/22 at 03:22 p.m., in a telephone interview, the Consultant Pharmacy Supervisor confirmed MRRs were not conducted for Resident #24 and #61 in September 2021.

Based on observation, record review and staff interview the facility failed to administer medications according to the physician's orders for 1 (Resident #283) of 5 residents observed for medication administration. Three Licensed nurses and 25 opportunities were observed. Two medication errors were identified resulting in an 8% error rate. The findings included: The facility's Instructional Guidelines Manual for Medication Administration revised 08/05/2015 reads, . All medications must be ordered by the Physician . Administer medications within a two (2) hour time frame (one hour before to one hour after the time prescribed by the physician) . When administering medications, always check for the six R's. Right resident, right medications, right time, right route, right dosage, right documentation . On 3/7/22 at 12:00 p.m., Licensed Practical Nurse (LPN) Staff A was observed administering seven (7) different medications to Resident #283, including one tablet of [MEDICATION(S)] 25 milligrams Extended Release and one tablet of [MEDICATION(S)] 300 milligrams. The physician's orders dated 3/2/22 specified to administer one tablet of [MEDICATION(S)] XL Extended release 25 milligrams every 12 hours at 9:00 a.m., and 9:00 p.m., related to hypertensive [CONDITION(S)] with heart failure. The physician's orders dated 3/2/22 specified to give one tablet of [MEDICATION(S)] Capsule 300 milligrams by mouth every 12 hours at 9:00 a.m., and 9:00 p.m., related to urinary tract infection. On 3/7/22 at 12:00 p.m., at the time of the observation LPN Staff A verified she administered the [MEDICATION(S)] and the [MEDICATION(S)] late, three hours past the scheduled time. On 3/9/22 at 11:45 a.m., in an interview the Director of Nursing (DON) said the medications were late because the nurse administering the medications was a new agency nurse.

Based on observation, record review, review of facility policy, staff and resident interviews, the facility failed to ensure proper storage of medications for 1 (Resident #7) of 1 resident observed with unsecured prescribed eye drops at the bedside. The findings included: Review of the Policy and Procedure for Storage and Expiration of Medication, Biological, Syringes and Needles with an effective of 12/1/07 (revised 1/1/13) documented . Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked/cabinet/cart or locked medication room that is inaccessible by residents and visitors . Facility should store bedside medications or biologicals in a locked compartment within the resident's room . On 3/9/22 at 9:30 a.m., observed a bottle of [MEDICATION(S)] eye drops and a bottle of [MEDICATION(S)] eye drops stored in an empty tissue box on Resident #7's overbed table. In an interview at the time of the observation Resident #7 said she has been using the drops for years and sometimes the nurses just leave the medications in her room and sometimes they pick them up and bring them back. Photographic Evidence Obtained. On 3/9/22 at 10:45 a.m., The Director of Nursing (DON) verified a bottle of [MEDICATION(S)] eye drops and a bottle of [MEDICATION(S)] eye drops were stored unsecured in an empty tissue box on Resident #7's overbed table. The DON removed the eye drops from the Resident's room and said they were not supposed to be in there. She said if Resident #7 was deemed competent to administer her own medications, they were supposed to be stored in a locked box. On 3/9/22 at 12:05 p.m., review of the clinical record showed a Self-administration of Medication Data Collection form completed on 5/27/20 noted Resident #7 could self-administer [MEDICATION(S)] solution 2% and [MEDICATION(S)] solution 0.5 % eye drops. The form noted the medication storage was with licensed staff.

Based on record review and staff interview, the facility failed to have a completed annual facility assessment. The findings included: Review of documentation presented contained no completed annual facility assessment. The documents presented by administration did not fulfill the requirements listed in the regulation. There was not a comprehensive unified assessment document. The facility produced tables of data collected but no analysis or assessment was completed. In an interview with the interim Administrator on 2/28/19 at 2:10 p.m., when asked for the facility assessment, said she did not have one. I don't know what it is. I don't know if one was done.

Based on observation, record review, staff and resident interviews, the facility failed to ensure 7 (Residents #54, #30, #8, #36, #41, #50 and #93) of 7 residents reviewed were assessed for alternative interventions and assessed for entrapment prior to the use of bed rails/assist bars. Total sample size was 24. The findings included: 1. On 2/26/19 at 9:41 a.m., Resident #54 was observed in her bed with both bed rails in the up position. Resident #54 said she was admitted to the facility in (MONTH) (YEAR) and the facility staff always put her bed rails up when they put her to bed. The staff told her the bed rails were for her safety and to help her turn in bed easier. On 2/27/19, a review of Resident #54's medical records revealed a readmission date of [DATE] with an original admission date of [DATE]. A Negotiated Risk Agreement form dated 7/23/18 stated the form was used to describe the Resident's choice for the use of the assist bars and to identify the alternatives offered to decrease the risk. The alternative offered was to encourage the resident to use the call light and wait for assistance. The form listed the benefits of using the assist bars was to decrease the risk of falling when being assisted by staff. There was no documentation in the medical record, the facility assessed Resident #54 for entrapment prior to the use of the assist bar/bed rails when the resident is in her bed. Resident #54's plan of care does not state the assist bars are to be used when Resident #54 is in her bed. When Resident #54 was readmitted on [DATE], the Negotiated Risk Agreement form was not updated. 2. On 2/26/19 at 8:00 a.m., Resident #30 was observed in her bed with both bed rails in the up position. On 2/27/19, a review of Resident #30's medical record revealed she was admitted to the facility on [DATE]. A Negotiated Risk Agreement form dated 9/6/16 and signed on 9/19/16 stated the form was used to describe the Resident's choice for the use of assist bars in bed. It noted the potential risk to the resident as harm due to entrapment and the benefit to the resident as allowing the resident to turn and reposition herself in bed. On the line for alternatives offered and attempted, N/A (not applicable) was written. There was no documentation in the medical record the facility assessed Resident #30 for entrapment prior to the use of the assist bar/bed rails when the resident was in her bed. Resident #30's plan of care did not state the assist bars were to be used when Resident #30 was in her bed. 3. On 2/25/19 and 2/26/19, Resident #8 was observed in bed with both bed rails in the up position. On 2/27/19, a review of Resident #8's medical record revealed she was admitted to the facility on [DATE]. Further review of the medical record revealed she did not have a Negotiated Risk Agreement form stating the risk and benefits with the use of the assist bar/bed rails. There was no documentation in the medical record the facility assessed Resident #8 for entrapment prior to the use of the assist bar/bed rails when the resident was in her bed. Resident #8's plan of care did not state the assist bars were to be used when Resident #8 is in her bed. 4. In an interview on 2/28/19 at 9:17 a.m., Certified Nursing Assistant (CNA) Staff C said she was taught when a resident was in bed, staff was required to put the assist bar in the raised position. She said whenever she worked with any resident, she made sure the assist bars were up and in place before she left the room. She further said the assist bars were not always listed in the resident's plan of care but they know to make sure they were up at all times. In an interview on 2/28/19 at 9:43 a.m., CNA Staff D said she had worked with Residents #54, #30 and #8 and she was told it was the facility's policy for the assist bars to be in place when the residents were in their bed. She reviewed the CNA's plan of care for Residents #54, #30 and #8 and said the assist bars were not listed in their plan of care as being used for these residents. Review of the Negotiated Risk Policy with the effective date of 9/1998 and last revised on 8/2017, revealed the purpose of this form was to help ensure the resident and/or the resident's legally responsible party were making an informed choice when a resident's wants and/or needs were identified as a potential safety or health risk. When they decided to use the device, identified as a potential safety or health risk, the resident or responsible party were required to sign the Negotiated Risk Agreement form. In section E-4 it stated the facility was required to identify and discuss alternatives proposed or attempted to reduce the risks and in section H of same policy, the facility was required to incorporate the identified potential safety hazard into the resident's assessment and care plan. In an interview on 2/28/19 at 10:12 a.m., with the Assistant Director of Nursing (ADON) and the Director of Nursing, they said the Negotiated Risk Agreement form was used as the documentation staff had done education with the resident or their legal representative related to the risk and benefit for the use of the assist bar. They confirmed the assist bars/bed rails were being used for Residents #54, #30 and #8. The ADON said the potential for harm due to entrapment related to the use of the assist bars was possible as noted on Resident #30's Negotiated Risk Agreement form. They reviewed Residents #54, #30 and #8's medical records and said they were unable to find documentation the facility staff had assessed Residents #54, #30 and #8 prior to the use of assist bars. They confirmed the Negotiated Risk Policy effective on 9/1998 revealed the facility was required to incorporate the identified potential safety hazard into the resident's assessment, care plan and should identify the alternatives proposed or attempted to reduce the risk. They confirmed this was not done for Residents #54, #30 and #8 as required. The ADON said they were unable to find the Negotiated Risk Assessment form for Resident #8 and/or documentation they had informed and educated Resident #8 of the risks and benefits related to the use of assist bars as required. 5. On 2/25/19 at 2:19 p.m., Resident #36 was observed up in a wheelchair in his room. The resident's bed was equipped with positioning devices, assist bar/bed rail, attached bilaterally at head of bed. The attachment swings on a pivot and may be locked in position toward the head of bed or locked toward the middle of bed. At time of observation the assist bar/bed rail was singing freely and not in a locked position. In an interview on 2/25/19 at 2:30 p.m., Unit Manager Licensed Practical Nurse Staff A said when the staff were helping residents out of bed, the positioning device was unlatched and swung out of the way. Left unlatched until the resident was back in bed and then secured. In an interview on 2/26/19 at 1:55 p.m., the ADON (Risk Manager)/RM said the resident or responsible person signed the negotiated risk agreement upon explanation of potential for harm from entrapment in the positioning device. The ADON/RM said the risk assessment was part of the fall risk assessment completed on each resident. On 2/27/19, a review of Resident #36's medical records revealed an admission date of [DATE]. A Negotiated Risk Agreement form dated 3/31/16 showed the form was used to describe the Resident's choice for the use of the assist bars and to identify the alternatives offered to decrease the risk. There were no alternatives offered. The form listed the benefits of using the assist bars was to allow the resident to turn and reposition. There was no documentation in the medical record, the facility assessed Resident #36 for entrapment prior to the use of the assist bar/bed rails when the resident was in bed. On 2/28/19, a review of the Fall Risk Data Collection, dated 9/12/18, for Resident #36 found risk of entrapment or other risks associated with the use of bed rails were not addressed. 6. On 2/25/19 at 1:52 p.m., Resident #41 was observed in bed with assist bar/bed rails locked in position at the head of the bed. In an interview on 2/25/19 at 2:30 p.m., Unit Manager Staff A said Resident #41 was not capable of repositioning himself. In an interview on 2/26/19 at 1:55 p.m., the ADON/RM (Risk Manager) said the resident or responsible person signed the negotiated risk agreement upon explanation of potential for harm from entrapment in the positioning device. The ADON/RM said the risk assessment was part of the fall risk assessment completed on each resident. A review of records for Resident #41 on 2/28/19 found, an unsigned Negotiated Risk Agreement with the stated benefit of side rails was to decrease the risk of falling when being assisted by staff. The fall risk assessment did not address risk of entrapment. There were no documented attempts at alternative measures. The care plan did not address the use of side rails. 7. On 2/25/19 at 2:50 p.m. Resident #50 was observed in bed with assist bar/bed rails locked in position at the head of the bed. In an interview on 2/26/19 at 1:55 p.m., the ADON/RM said the resident or responsible person signed the negotiated risk agreement upon explanation of potential for harm from entrapment in the positioning device. The RM said the risk assessment was part of the fall risk assessment completed on each resident. On 2/27/19, a review of Resident #50's medical records revealed an admission date of [DATE]. A Negotiated Risk Agreement form dated 4/21/16 revealed the form was used to describe the Resident's choice for the use of the assist bars and to identify the alternatives offered to decrease the risk. The form listed the benefits of using the assist bars was to allow the resident to turn and reposition. There were no alternatives offered. There was no documentation, in the medical record, the facility assessed Resident #50 for entrapment prior to the use of the assist bar/bed rails when the resident is in bed. 8. On 2/25/19 at 2:50 p.m. Resident #93 was observed in bed with assist bar/bed rails locked in position at the head of the bed. In an interview on 2/26/19 at 1:55 p.m., the ADON/RM said the resident or responsible person signed the negotiated risk agreement upon explanation of potential for harm from entrapment in the positioning device. The RM said the risk assessment was part of the fall risk assessment completed on each resident. On 2/27/19, a review of Resident #93's medical records revealed an admission date of [DATE]. A Negotiated Risk Agreement form dated 6/30/17 stated the form was used to describe the Resident's choice for the use of the assist bars and to identify the alternatives offered to decrease the risk. The form listed the benefits of using the assist bars was to decrease the risk of falling when being assisted by staff. There were no alternatives offered. There was no documentation, in the medical record, the facility assessed Resident #93 for entrapment prior to the use of the assist bar/bed rails when the resident was in bed. There was no care plan for use of side rails, and no nursing monitoring of side rails.

Based on staff interview, resident interview, and record review, the facility failed to coordinate care and services for 1 (Resident #65) of 1 resident who received [MEDICAL TREATMENT]. This was evidenced by licensed nurses failing to review [MEDICAL TREATMENT] communication forms upon return from [MEDICAL TREATMENT]. The findings included: Record review of the [MEDICAL TREATMENT] Care-CS-60-2 (revised (MONTH) (YEAR)) revealed the facility policy for Record Keeping included It is the policy of this community to document the information below on the resident's care plan: [MEDICAL TREATMENT] order, transportation, [MEDICAL TREATMENT] center name, fluid restrictions, labs, intake and output to name a few. It also contained the following: Communication on resident status to the outpatient [MEDICAL TREATMENT] facility will include the information identified above using the Skilled Nursing [MEDICAL TREATMENT] Center Communication form (BSL-103). The outpatient [MEDICAL TREATMENT] facility will communicate the resident's status while at the facility upon the resident's return to the community. Review of facility records revealed Resident #65 was admitted on [DATE] with a [DIAGNOSES REDACTED]. In an interview on 2/26/19 at 9:00 a.m., Resident #65 was alert and oriented Had had access on his right upper arm and a tessio catheter to his left chest to be able to receive [MEDICAL TREATMENT] treatment. Review of the facility's [MEDICAL TREATMENT] Communication Record forms dated 2/9/19, 2/16/19, 2/22/19, and 2/26/19 revealed information provided by the [MEDICAL TREATMENT] facility regarding the resident's [MEDICAL TREATMENT] treatments. Review of the section with instructions Community charge nurse to complete this section when resident returns from [MEDICAL TREATMENT] was found not signed or dated by a licensed nurse. On 2/27/19 at 10:00 a.m., Registered Nurse Staff B confirmed the information sent back from the [MEDICAL TREATMENT] center regarding Resident #65 was not reviewed, signed, and/or dated.

Based on record review, observation and interview, the facility failed to ensure that 3 (Residents #96, #100, and #226) out of a sample of 38 residents, received adequate supervision and assistance to prevent accidents. The findings include: 1. A Minimum Data Set (MDS) assessment, dated 12/19/12, completed for Resident #96, revealed the resident requires extensive assistance of 2 for bed mobility, toilet, and transfer; and total assist of 1 for locomotion (wheelchair mobility), dressing, eating, and personal hygiene. The resident does not walk. The MDS also states the resident is frequently incontinent of bowel and bladder and did not experience a fall or fracture in the past 6 months. Nurse's note, dated 2/5/12, state, "Resident observed with dark discoloration to left eye upper and lower lid (outer aspect). Resident stated she was in the bathroom with CNA H and ______ this morning getting washed when she fell and hit her face on the sink. Mental State: normal. Family notified (husband) and stated he was in the facility at 8:00 a.m. to feed resident this morning. He stepped out of the resident's room to allow staff to give resident care. After care was given, (husband) stated he took his wife to eat (breakfast) when she told him she fell and hit her face on the wash basin. (Husband) states he did not tell staff what his wife told him." This entry was signed by Nurse I. On 2/29/12 at 3:10 p.m. during an interview, Nurse I, who documented the incident/progress note on 2/5/12, substantiated that her documentation of the incident was accurate. Nurse I also verified, at this time, the resident communicated the incident to her and the husband told her he knew about the incident, because his wife told him; but, he did not report it to anyone. When asked if she had any difficulty interviewing Resident #96 to find out what happened, Nurse I said, "She (the resident) speaks softly, but I had no difficulty interviewing her and she was very clear about what happened." A Comprehensive Care Plan (CCP), dated 12/21/11, identifies that the resident is a "risk for falls and injury related to C.V.A., decline in functional status, decreased strength/endurance." The evaluation section states, "2/7/12, Fall 2/5/12." No revision in the care plan was evidenced. In addition, a Hospice Care Plan states, "Activity/Mobility Diminished due to Disease progression." A CNA (Certified Nursing Assistant) Assignment Card, dated 12/21/11, states resident "is a risk for falls and/or injury" with approach to "assist in ambulating, transferring, toileting, anticipate needs, gentle handling of resident when care provided and with resident transfers." The assignment card also states resident "has potential for bleeding and bruising" with approach to "use gentle approach with cares, encourage not to bump self, gentle oral hygiene." A Resident Status Sheet (used by the CNA) states, "Bed to chair/2 assists, position/2 assists, bath/total care, mouth care/total care, dress/total care, grooming/total care, fall precaution, bedpan total care for bowel and bladder." On 2/29/12 at 2:15 p.m. during an interview, the Risk Manager stated an incident report was completed by Nurse I at 5:00 p.m. on 2/5/12 documenting the resident stated she "was in the bathroom with CNA H and this morning when she fell and hit her face on the sink. Resident observed with dark purple discoloration on L (left) eye (upper and lower)." The Risk Manager stated she interviewed the husband, who said the resident did not fall but because of jerky body motions, she leaned forward and hit her eye on the sink." When asked if any of the staff members were interviewed regarding this incident, the Risk Manager said, "No." When asked if the resident's husband was a witness to the event, she said, "I think so." When asked where the husband said the incident occurred, the Risk Manager stated, "he (husband) sits in her bathroom and braces his feet against hers so she doesn't fall when she is on the toilet." An entry on the incident report, signed by the Risk Manager, documents, "2/6/12 - Resident and husband interviewed regarding discoloration around L eye, informed RM (Risk Manager) that she did not fall but because of jerky body motions she leaned forward and hit eye on the sink. Denies abuse." In an interview at 3:15 p.m. on 2/29/12, CNA named on the incident report revealed he only works the evening shift (3:00 p.m. to 11:00 p.m.) and did not work the day shift (7:00 a.m. - 3:00 p.m.) on 2/5/12. Interview of the Risk Manager 2/29/12 at 3:30 p.m. revealed she did not know what CNA was assigned to the resident on the day shift of 2/5/12, but would obtain the information and give it to the surveyor. On 3/1/11 at 9:30 a.m., the surveyor again requested the Risk Manager to provide the name of the CNA assigned to the resident on the day shift on 2/5/12. At 9:55 a.m. this date, the Risk Manager brought CNA H to the conference room of the facility and introduced her as the CNA who took care of the resident on the 7:00 a.m. - 3:00 p.m. shift on 2/5/12. In an interview on 3/1/12 at 9:30 a.m., CNA H stated she took care of Resident #96 on the day shift on 2/5/11 and she washed and dressed the resident while she was in bed, and then transferred the resident to her wheelchair and brought her to the day room. When asked if she had help transferring the resident out of bed, CNA H said, "No, I can do it myself." She continued to state she toileted the resident, without assistance of any other CNA, after breakfast, "with her husband around in the (resident) room. Then I got another CNA to help me take her off the toilet because I need help to clean (the resident) and adjust her clothing." CNA H stated she toileted the resident before lunch, using the same procedure, but a different CNA helped her remove the resident from the toilet. When asked if she usually takes care of Resident #96, CNA H said, "No, that's why I can remember it very well." When asked if the resident's husband is ever in the toilet room, CNA H stated, "Yes, he's always there." When asked if she saw the resident on 2/6/11 with a discolored eye; CNA H said, "Yes, I wondered what happened. No one told me about it or talked to me about it (discoloration of eye)." Resident #96 was observed with her husband, sitting next to the fish pond, on 3/1/12 at 10:45 a.m. When the surveyor asked about the resident's discolored eye, the husband stated he was in the facility the day of the incident 2/5/12. He came in at 8:00 a.m. that date and when asked how he thought the resident got an injury to her eye that date, the husband stated, "I think the aides slipped up." He continued to state, "she (the resident) is suppose to hold on to the rail when they transfer her, but sometimes she lets go." When asked what he thought happened, he stated the resident was put on the toilet about 10:00 a.m. and he went into the toilet area and sat next to her and put his feet in front of her feet because her feet slip and then she slides. When asked if the CNA also stayed in the toilet area with him, he said, "No. The CNA left the area, like always, and I put on the call light when she (the resident) was ready to get off the toilet. 2 CNAs came and I left the bathroom and they took her off the toilet. Then later, when we were sitting having lunch (12:00 p.m.) I noticed a red area above her eye and asked her what happened and she told me that she hit her face on the sink when the CNAs were taking care of her." When the surveyor asked what eye was red, the husband hesitated. Resident #96 raised her hand and pointed to her left eye and stated, "This one." The husband then said, "That's right, it was the left one." The surveyor then asked Resident #96 what happened to that eye and she stated, "He (husband) told you, that's what happened." On 3/2/12 at 3:30 p.m. the surveyor asked the facility Administrator and Director of Nursing if there was a policy and/or procedure that addressed under what circumstances a resident can be left unattended on the toilet when they require 1 or 2 person assistance with toileting/transfer. The Director of Nursing advised that the facility did not have that type of policy. The current MDS assessment, for this resident states that she requires assistance of 2 with transfer and toileting. A Resident Status Sheet states "bed to chair with 2 assists" for locomotion and "bedpan total care" for bowel and bladder. The CNA Assignment Card and the CCP, both dated 12/21/11, state that the resident is incontinent of bowel and bladder with some control with approaches as follows: Provide honey thickened fluids at and between meals. Keep clean and dry, Pericare when incontinent, Use protective pads, Provide privacy, Report changes in voiding pattern or appearance of urine. These documents also state that the resident has a potential for constipation with approaches that include, but are not limited to: Help with bedpan and commode (a chair or box shaped piece of furniture holding a chamber pot). A commode chair was not observed in the resident room during the survey period of 2/27/12 through 3/2/12. The current MDS assessment for this resident states that she requires assistance of 2 with transfer and toileting. A Resident Status Sheet states "bed to chair with 2 assists" for locomotion and "bedpan total care" for bowel and bladder. 2. Resident #100 was admitted to the facility on [DATE] with cellulitis and infected shoulder, status [REDACTED]. The primary physician noted, on 12/7/11, that the resident's condition was guarded. Review of the resident during Stage I Admission Pressure Ulcer review revealed the resident had a wound to the right leg. Interview of the Wound Care Nurse on 2/28/11 at 3:00 p.m. revealed the wound was not a pressure ulcer, but was caused by "trauma due to injury during transfer" of the resident and the use of leg rests on the resident's wheelchair. Wound care documentation was initiated 1/17/12 on a form titled "Cutting Edge Healthcare" stating "Based on the wound bed description shown above, debridement is necessary. (Granulation 60% Slough 40%). The dissection was done slightly beyond the point of visible necrotic tissue until viable bleeding tissue was encountered. A total of .78 square cm (centimeter) was debrided. This wound located at the Leg: Lateral: Right is a Trauma wound." In addition, another site was listed on this form (Cutting Edge Healthcare), dated 1/17/12, stating, "This wound located at the Leg: Posterior, Right: (Cluster) is a Trauma wound." and "1/24/12 Necrosis 10%" and "1/31/12 a total of .13 square cm was debrided today." An MDS assessment dated [DATE] (prior to the trauma) and an MDS assessment dated [DATE] (status [REDACTED]. Another trauma site was listed on the Cutting Edge Healthcare form, dated 2/16/12, stating, "Necrosis 100%. This wound located at the Leg: Lateral: Left is a Trauma wound, a total of 0.6 square cm was debrided today." On 2/28/12 at 2:00 p.m. during an interview, the facility risk manager stated there was no incident report on record, dated 1/17/12, regarding trauma to the resident's right leg. The facility stated there was an incident report, dated 1/6/12, involving a fall. Review of the nurse's note, dated 1/6/12, stated, "Fall; found on floor laceration (back of head)." An incident report, dated 1/6/12 at 12:45 p.m., states, "CNA doing rounds found resident on floor; blood was noted coming from back of head; small laceration was noted, pressure was applied - once bleeding stopped, ice applied. Resident also complained with left hip pain called Dr. ____, got new order to send to emergency room . Resident has removed clip alarm, new order for sensor pad." The Fall Risk Manager entered a notation on the incident report; "1/9/12 - Encourage resident to use call light; sensor alarm initiated." The incident report did not identify any injury to the right leg. Upon interview at 9:30 a.m. on 3/2/12, the Risk Manager (when asked if anyone interviewed the resident to ascertain what happened) stated she interviewed the resident, but did not document the interview stating, "I have to improve on that (documentation)." Review of the nurses' notes revealed entries that stated: 1/9/12 - "bruises to legs dressing intact to skin tear R (right) leg;" 1/10/12 - "Weekly skin observation tx (treatment) in place on right lower leg and small laceration healing well on back of head," and 1/11/12 - "Weekly skin observation on right shin has skin tear 1.5x1.5x0.1, 100% granulation noted, no odor or drainage noted, responding well to tx." During an interview on 3/2/12 at 2:30 p.m., the Director of Nursing stated, "I can't find an incident report (relating to the leg wounds)." A physician order, dated 1/9/12, states, "Cleanse right lower leg with wound cleanse and apply intrasite gel and cover with border gauze." The Comprehensive Care Plan, dated 12/29/12, states resident "was admitted with impairment of skin integrity related to limited mobility, urine and bowel incontinence, RUE cellulitis and right shoulder surgical incision; manifested by reddened area, present on admission, to coccyx and surgical incision present on admission. Additional entries document: 1/10/12 - right lower leg skin tear; 1/17/12 right posterior leg, and 2/16/12 left lateral leg." The plan of care was updated to address the wounds, but no revision of the care plan was evidenced to prevent reoccurrence. The facility knew, or should have known, that the wounds occurred; and failed to identify the safety hazard causing the wounds, and provide supervision/assistance to prevent the possible avoidable injury that was noted on 2/16/12. 3. Observation on 2/28/12 at 9:00 a.m. of Resident #226 revealed approximately 10 steristrips (adhesive strips used to close wounds) attached to the outer aspect of the right lower leg. On 2/29/12 at 1:28 p.m. in an interview, the Unit Manager of C wing stated on 1/23/12 Resident #226 was being transferred manually by 2 Certified Nursing Assistants (CNAs) and his leg got caught in the siderails. She stated the resident obtained a very large skin tear during the transfer. They changed the method of transfer to a Hoyer lift afterwards. Review of the clinical record on 2/29/12 revealed a comprehensive MDS assessment, dated 1/9/12, indicating the resident required maximum assistance of 2 people for all transfers. The nurse's note, dated 1/23/12 at 1:31 p.m., revealed the resident sustained [REDACTED]. A dressing was immediately applied to the wound and the resident was sent out to the hospital for emergent care. He returned with staples to the right calf, a dressing, and order for Keflex 500 mg (antibiotic) every 12 hours for 10 days. On 2/7/12, the wound care doctor removed the staples and applied steristrips to the wound. Review of the clinical record revealed upon admission to the facility, on 12/29/11, the physician ordered an Occupational Therapy evaluation and treatment. Review of the Occupational Therapy evaluation, dated 12/29/11, revealed documentation the therapist obtained a verbal order from the attending physician for the patient and staff to receive training for low pivot transfer or slide board transfer from bed to wheelchair and wheelchair to bed, wheelchair to commode. The resident received Occupational Therapy until his discharge from therapy on 1/19/12. Review of the Occupational Therapy discharge summary revealed, "Instructed on 2 person slide board transfer." The complete investigation of the injury was requested from the Risk Manager. The documentation in the incident report form, dated 1/23/12, revealed the resident's right lower leg was caught in the wheelchair while being transferred into bed. The resident sustained [REDACTED]. Pressure applied and the physician was notified. The resident was transferred to the emergency room . The investigation failed to include a complete analysis of the incident, including possible causes as to what caused the resident's leg to be caught in the wheelchair. Interview on 2/29/12 at 1:45 p.m., with The Risk Manager revealed the resident's legs were very edematous. Two staff members were putting him back into bed and his leg bumped the part of the wheelchair where the leg rests attach. The Risk Manager was asked why the staff was not using a slide board for the transfer. She stated she didn't know why the CNAs didn't use the slide board. An interview was conducted on 2/29/12 at 2:45 p.m. with the Occupational Therapist. She stated Resident #226 does not have use of the right leg due to a fractured pelvis (that was possibly pathological due to cancer) and they placed him on non weight bearing status. The resident also couldn't use the right arm because of the metastasis of the cancer. The family wanted a transfer from the bed to the chair, but because of the pelvic fracture, the Hoyer was not recommended at that time. The physician asked for a pivot transfer on the left leg, but the resident was not able to do that. The safest way was a slide board. The Occupational Therapist stated she trained 2 nurses' assistants from 2 different shifts on safe transfer with the slide board and they were instructed to use 2 people for transfer to prevent the board from moving. She stated she only trained the ones she knew were working with the resident. The Occupational Therapist revealed she didn't write the name of the CNAs she trained, she was told not to. She further revealed she didn't write an order for [REDACTED]. However, she informed the charge nurse. The Therapy Supervisor provided the survey team with copies of the morning meetings, dated 1/3/12 and 1/4/12, with documentation Resident #226 was non weight bearing to the right lower extremity, and using a slide board for transfer. In an interview on 2/29/12 at 3:15 p.m., CNA D stated the day of the incident was the very first time she was caring for Resident #226. The CNA stated she heard the alarm and went to check on Resident #226. The resident was trying to get up from the chair unassisted. She quickly grabbed another CNA and together they lifted the resident from the wheelchair to the bed. She stated the resident obtained the skin tear on the part of the wheelchair where the leg rests are attached. She stated she did not know this particular resident was supposed to use a slide board. CNA D said she has been trained in the use of a slide board, but no one had told her the resident requires a slide board, so she lifted Resident #226 up with the help of another CNA. The care plan for Resident #226 failed to include documentation indicating the safe method of transfer was through the use of a slide board. Interview on 3/1/12 at 9:30 a.m. with the MDS (Minimum Data Set) coordinator revealed the information about the slide board wasn't relayed to her, so it wouldn't have made it to the care plan. She stated the Occupational Therapist should have written an order and at that time she would have updated the care plan. The Unit Manager on C wing stated, in an interview on 3/1/12 at10:15 a.m., Resident #226 was transferred from A wing to C wing on 1/20/12. Upon transfer, she gets a nurse-to-nurse report. She stated the resident was discharged from therapy and put on hospice care the same day he was transferred. The transfer report includes medications, skin condition and transfer information as well. The transfer equipment needed is usually included in the report. There is no form for transfer report, but the whole chart comes over. During a second interview on 3/1/12 at 9:15 a.m., the Risk Manager stated, "The CNAs stopped the resident from falling. They reacted to a catastrophic situation. The laceration, although it wasn't a desired result, was the least of two evils." She stated the CNAs did not know about the board and absolutely there was a lack of communication. The Risk Manager stated there was no malice or intent, it was an emergency situation and the CNAs did the best they could do in an emergency situation. The Risk Manager stated the resident was transferred from the A wing, but because the Occupational Therapist never wrote an order, she didn't know the resident was supposed to use a slide board for transfer. In an interview on 3/2/12 at 9:20 a.m., the resident's physician stated the slide board transfer is the same as a 2 people transfer. The physician stated the resident cannot walk, has no use of the right leg and the right arm and also had some fracture of the left lower extremity. He added the best way to transfer this resident is through the use of a Hoyer lift. During a second telephone interview on 3/2/12 at approximately 10:30 a.m., CNA D stated when she responded to the alarm, the resident was sliding off the wheelchair. She left the room to get assistance. She returned with CNA E. Together they repositioned the resident, then stood him up, supported him and turned with him until he sat on the bed. She stated she knew the resident could not stand, but they supported him until he sat on the bed. His leg got caught in the wheelchair and they immediately notified the Licensed Nurse.