Every finding on record at Havencare at Hancock Hall

Based on observation for 1 of 2 medication storage rooms (One North) and staff interview, the facility failed to remove expired medications from the medication refrigerator and failed to ensure the refrigerator temperatures were monitored. The findings included: A tour of the One North medication storage room on 4/25/25 at 12:09 PM with LPN #1 identified the following medications in the refrigerator inclusive of two medications that were expired: 1a. 2 Boxes of Bisacodyl suppositories package of 12 unopened. b. 2 packages of fleet glycerin suppositories (1 unopened the other ¾ full). c. 6 injectors of Toujeo solo star insulin unopened. d. 1 package of Brimonide eye drops 0.15% ophthalmic solution unopened. e. 1 Lyumjev Kwik pen 100 units/milliliters. f. 8 Prevnar 20 vaccines 0.5 milters unopened g. 7 injectors of Trulicity 0.7 milligrams/0.5 milliliters unopened. h. 2 Comirnaty 24-25 vaccines 0.3 milters, both expired 3/15/25 i. 4 Lanotoprost 0.0005% ophthalmic solution 2.5 milters, unopened j. 1 Ceftriaxone 1 gram vial, unopened. k. 1 lidocaine 1% injection, 10 milliliter unopened. l. 2 vyzalta 0.024% 2.5 milliliters, unopened m. 1 insulin aspart 100 units/milliliters unopened n. 14 Abrysvo ADV 120 micrograms (RSV vaccine) unopened. o. 6 vials of expired hepatitis b vaccines (Engerix-B 20 micrograms/milliliter-1milliliter) with an expirator date of 3/15/25. Also, identified in the One North refrigerator in a brown envelope were medications that were used as stock emergency medications which included: a. 4 insulin glargine 100 unit/milliliter pens unopened b. 2 Insulin lispro Kwik pens 100 units/milliliter unopened c. 2 insulin aspart 100 unit/flex pen unopened d. 2 Levemir flex pen 100 units/milliliter unopened Additionally, the refrigerator temperature logs from One North from January 1, 2025, through April 25, 2025, identified the following: The temperature log reviewed from One North refrigerator from January 1, 2025through April 25, 2025, which is a total of 114 days. The following 25 days the refrigerator temperatures were not monitored: 1/6/25,1/7/25,1/9/25 ,1/10/25,1/30/25,1/31/25, 2/1/25, 2/4/25,2/5/25,2/6/25, 2/7/25 ,2/28/25, 3/4/25, 3/7/25,3/10/25,3/24/24/25, 3/25, 3/26/25,3/31/25, 4/19/25, 4/20/25, 4/21/25, 4/22/25, 4/23/25.4/24/25. b. The temperature log reviewed from January 1, 2025, through April 25, 2025, a total of 74 days out of 114 days the temperature of the One North refrigerator was monitored only 1 time per day. On 4/25/25 at 12:15 PM an interview with LPN #1 identified that outdated or discontinued medications should be immediately removed from stock and given to the Nursing Supervisor and the refrigerator temperature logs are to be completed by the 11:00 PM and 7:00 AM nursing shift. On 4/25/25 at 12:16 PM an interview with RN #1 identified she thought the policy for monitoring refrigerators temperatures was once a day, that checking for expired medication was a nursing responsibility and expired medication should have been removed on a timely basis. After inquiry, RN#1 disposed of all expired vaccines and ran a report which identified no vaccines were administered that had expired. Review of the Policy for Medication Refrigerator Temperature Checks identified the purpose to ensure safe storage of medications and vaccines by maintaining appropriate temperatures, thereby reducing the risk of compromised medication efficacy and patient harm. The policy further identified temperature checks for medication refrigerators will be completed once daily during assigned shifts, vaccines which require stricter monitoring were to be stored in a refrigerator and temperature were to be monitored twice daily. Review of the Policy for Expired Medications identified that all medication carts, cabinets, refrigerators will be routinely checked by nursing personnel, all expired medications will be removed and discarded.

Based on clinical record review, review of facility documentation, and interviews for 1 of 3 sampled residents (Resident #57) reviewed for abuse, the facility failed to ensure a resident was treated in a respectful and dignified manner. The findings include: Resident #57 had diagnoses that included dementia and anxiety disorder. The quarterly MDS assessment dated [DATE] identified Resident #57 was moderately cognitively impaired and required one person assist with bed mobility, and two persons with transfers. The care plan dated 2/4/25 identified Resident #57 had the potential for mood changes related to dementia and was at risk for functional deficits. Interventions included to assist with positive coping skills and help with ADL activities. Physician orders are directed to provide a mechanical (2 person) transfer and assist of one with bed mobility. The nurse's note dated 4/24/25 at 2:30 PM identified at 1:00 PM, Resident #57 reported earlier that morning, s/he was spoken to in an inappropriate manner by a staff member, NA #1. An allegation of verbal abuse had been initiated following the interview. A facility reported event dated 4/24/25 at 2:38 PM identified at 1:00 PM, Resident #57 reported NA #1 called her a rich bitch and s/he did not appreciate the interaction. The physician, police, family and social services were notified. Psychiatry services were contacted with a telehealth evaluation. NA #1 was immediately placed on administrative leave pending the outcome of the investigation. An interview with NA #1 on 4/29/25 at 9:25 AM identified she was assigned to Resident #57 during the 7:00 AM to 3:00 PM shift on 4/24/25. NA #1 identified she and NA #2 were assisting Resident #57 to get ready for a hair salon appointment. During routine conversation, NA #1 stated to Resident #57 that s/he was a rich woman and needed to spend h/her money and feel good about h/herself. At the time, Resident #57 seemed happy and unbothered by the comment. NA #1 was later informed of the concern and was removed from the schedule. An interview with NA #2 on 4/29/25 at 10:41 AM identified she was working during the 7:00 AM to 3:00 PM shift on 4/24/25 when NA #1 requested assistance in preparing Resident #57 for a hair salon appointment. NA #2 identified she and NA #1 were talking to Resident #57 who seemed happy and cheerful. NA #2 identified she observed and heard NA #1 give Resident #57 a hug from behind stating s/he was rich, so spend h/her money. An interview with the Administrator on 4/30/25 at 12:36 PM identified while abuse was unsubstantiated following the completion of the investigation, NA #1 provided education in customer service, perception of reality and handling feedback. An interview with the DNS on 5/01/25 at 10:48 AM abuse was not substantiated in this case but would expect all residents to be treated with respect and dignity. A review of the facility policy for Resident Rights directed the facility to uphold that all residents be treated with respect, dignity and compassion.

Based on interviews and record and policy review for 1 of 3 residents (Resident #58) sampled for abuse, the facility failed to protect a resident from physical abuse. The findings included: Resident #58's diagnoses included Alzheimer's disease, unspecified psychosis and pseudobulbar affect. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 was severely cognitively impaired, required set up help with eating and was dependent on staff for transfers and dressing. The Resident Care Plan dated 2/4/25 identified Resident #58 had a potential risk for behaviors due to delusions. Interventions included identifying behaviors, redirecting as needed and monitoring for target behaviors. A nurse's progress note dated 4/5/25 at 3:00 PM identified that during lunch Resident #58 was self-propelling in a wheelchair and attempted to take a spoon from another resident, then hit the other resident. Staff intervened and Resident #58 was immediately removed from the vicinity and placed on 1:1 monitoring. Resident #58 was calm with no signs of agitation, and unable to recall the events. 2. Resident #5's diagnoses included Alzheimer's disease, dementia, and hypothyroidism. The quarterly MDS assessment dated [DATE] identified Resident #5 was moderately cognitively impaired, required set up help with eating and partial/moderate assistance for transfers and dressing. The March 2025 Resident Care Plan identified Resident #5 was at risk for cognitive/communication decline from baseline related to a diagnosis of Alzheimer's disease, dementia with behavioral disturbances and psychosis. Interventions included asking simple questions/requesting clarification as needed and encouragement to participate in facility activities for socialization. A nurse's progress note dated 4/5/25 at 3:00 PM identified Resident #5 was struck upon his/her cheek during lunch. There was no discoloration, redness, or swelling to his/her right check and Resident #5 was jovial, denying any feelings of anger, sadness or fear. The Accident and Incident Report dated 4/5/25 at 2:00 PM identified that on 4/5/25 at 1:10 PM Resident #58 hit another resident (Resident #5) during lunch while in the second-floor dining room. A psychiatric evaluation and consultation assessment dated [DATE] identified that Resident #58 was not considered a danger to self or others. The summary of the report to the state agency on 4/8/25 at 12:00 AM identified that on 4/5/25 at approximately 1:10 PM, there was witnessed resident to resident altercation without injury. Resident #58 was observed propelling his/her mobility device within the dining room. Resident #58 approached the seating area of Resident #5 and reached for his/her spoon. Per the witness, Resident #5 placed his/her hand over the spoon to prevent Resident #58 from taking it. Subsequently, Resident #58 slapped Resident #5 on the right cheek. Staff members who witnessed the incident immediately intervened, Resident #58 was promptly removed from the dining room area and placed on continuous (1:1) observation. An investigation was initiated, the MD, the local police department and the POAs of both residents. Both residents were assessed by Psychiatry services immediately via telehealth - neither resident had any recollection of the incident. Interview with Nurse Aide (NA) # 4 on 5/1/25 at 10:20 AM identified on 4/5/25 she was in the dining room at lunch time passing out coffee and Resident # 58 was wheeling around the dining room like she usually does, he/she gets weepy sometimes so instead of redirecting him/her immediately, they wait until lunch is served. NA #4 saw Resident #58 trying to grab a spoon that was in front of Resident #5. Resident #5 started to say something along the lines of its mine and without any notice Resident #58 slapped Resident #5 on the cheek. NA #5 stood up but couldn't get there in time. Additionally, NA #4 identified Resident #58 does not have a history of hitting, and both residents forgot about the incident quickly. Interview with NA #5 on 5/1/25 at 10:47 AM identified that on 4/5/25 she was in the dining room, Resident #58 was self-propelling around the room, then approached Resident #5, grabbed his/her utensil off the table and as Resident #5 started to say something, Resident #58 slapped him/her on the cheek. NA #5 identified she has never seen that behavior from Resident #58, nor has she in since the incident. Review of the Abuse, Neglect and Exploitation Policy directed in part that the facility is committed to providing a safe and respectful environment that supports the health and well-being of all people receiving services. Additionally, physical abuse includes but is not limited to hitting, slapping, punching, kicking, and biting.

Based on clinical record reviews, observations, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #61) reviewed for pressure ulcer, the facility failed to ensure an initial comprehensive skin assessment was completed for a newly identified skin condition and failed to regularly assess a resident's weight to ensure a pressure-relieving mattress adjusted according to manufacturer guidelines and for for 1 of 3 residents (Resident #72) reviewed for pressure ulcer/injury, the facility failed to maintain air mattress settings according to manufacture guidelines. The findings included: 1.Resident #61's diagnoses included dementia and protein calorie malnutrition. The quarterly MDS assessment dated [DATE] identified Resident #61 had severely impaired cognition, required two persons assist with bed mobility and transfers, and had no unhealed pressure ulcers. The care plan dated 2/18/25 identified Resident #61was at risk for skin impairment and altered nutritional status related to dementia and protein calorie malnutrition. Interventions included reporting any skin breakdown and monitor weights. a. Nursing progress note dated 3/15/25 at 11:29 AM identified a small irritation to the coccyx area. A zinc-based ointment was applied, and the nursing supervisor was made aware. The Advanced Practiced Registered Nurse (APRN) was to evaluate. The responsible party was notified. The Wound APRN Communication book dated 3/15/25 noted Resident #61 needed an evaluation of the buttock region. The physician's orders dated 3/17/25 directed Triad paste for redness every shift. The Wound APRN Communication book dated 3/17/25 noted Resident #61 had redness and an open area on the buttocks. Orders for triad paste were obtained. However, the area needed wound orders. A Wound specialty progress note dated 3/19/25 identified a consultation was requested for Resident #61 with reported wounds to the sacral area. Two wounds were identified, one on the left sacrum measuring 2.4 Centimeter (CM) x2.0 CM x 0.1 CM and another on the right measuring 1.0 CM x 1.0 CM x 0.1 CM. Both wounds were pink, granular with a small amount of serosanguineous drainage consistent with stage two pressure injuries. An interview and clinical record review with APRN #2 on 4/28/25 at 2:50 PM identified she provided wound consultations for the facility. APRN #2 identified she began seeing Resident #61 on 3/19/25 for newly identified wounds and has continued consultations on a weekly basis for one remaining wound. An interview with the Director of Nursing Services (DNS) on 4/28/25 at 3:20 PM identified he was unable to verify who was responsible for the facility wound tracking, if any wound documentation was maintained separate from the clinical record or if any assessments were completed prior to 3/19/25. The DNS further identified he wound expect an assessment that included color, warmth and measurements to be completed by nursing staff for any change in skin integrity. An interview RN #1, regional [NAME] President of Nursing Services, on 4/28/25 at 3:35 PM identified the DNS is responsible for the weekly wound tracking for the facility. A separate wound tracking was maintained and provided by the DNS to APRN #2 on a weekly basis. RN #1 indicated she and the DNS reviewed the electronic communication of the current resident wound list from the DNS to APRN #2 dated 3/18/25 and confirmed Resident #61 was not included on the list, nor was there a documented assessment completed prior to 3/19/25. An interview with LPN #2 on 4/29/25 at 2:31 PM identified she was the assigned nurse during the 7:00 AM to 3:00 PM shift on 3/15/25 when the open area to the buttocks was first identified. LPN #2 indicated she notified the nursing supervisor, RN #5 who came up to the unit and instructed her to add the information to the APRN wound book requesting an evaluation. An interview and facility documentation review with RN #5 on 4/29/25 at 2:36 PM identified she was the assigned nursing supervisor during the 7:00 AM to 3:00 PM shift on 3/15/25. RN #5 identified for any change in condition, she would complete an assessment, notify the physician and responsible party and document the assessment and any actions taken. RN #5 identified she did not complete an assessment for Resident #61 for the newly identified open area as an oversight and that one should have been completed. Although requested, a policy for assessment and management of a newly identified skin injury was not provided. b. The physician's orders dated 3/1/25 directed an air mattress- non static setting at 100lbs.- check placement and proper inflation every shift. The Weight log dated 4/2024 through 4/2025 identified Resident #61 experienced a 25.41% or 18.8lbs. weight loss in one year with a current weight of 74lbs. A review of the clinical record failed to identify documentation the air mattress settings had been regularly assessed to determine if the current settings remained appropriate. An interview and clinical record review with APRN #2 on 4/28/25 at 2:50 PM identified she provided wound consultations for the facility. APRN #2 identified she would expect the facility to ensure the air mattress was set in accordance with manufacturer's guidelines. An observation on 4/28/25 at 3:10 PM with RN #4 identified the air mattress was set to 100lbs. An interview and clinical record review with APRN #3 on 4/30/25 at 9:34 AM identified she provided medical services to and was responsible for prescribing orders for Resident #61. APRN #3 identified Resident #61 had experienced significant weight loss over the past year. APRN #3 indicated she trusted that the staff would review weights at regular intervals to determine if the current air mattress settings remained appropriate and that it was her expectation the settings be set in accordance with manufacturer's guidelines as Resident #61 was unable to express preference. An interview with the DNS on 5/01/25 at 10:48 AM identified he would expect the air mattress to be set in accordance with manufacturer guidelines and preference. If a resident's weight changes, the DNS would expect nursing staff to have a discussion with the APRN to determine the appropriateness of the mattress settings. A review of the manufactures guidelines for the alternating air loss mattress system recommends determining the patient's weight and setting the control knob to that weight setting on the control unit. A review of the facility policy pressure reducing mattress directed that all residents identified at high risk for skin breakdown or actual pressure area will be provided with an alternating air pressure mattress that is to be checked for proper placement and inflation each shift. 2.Resident #72's diagnoses included fracture of unspecified part of neck of left femur and essential (primary) hypertension. The admission Minimum Data Set assessment dated [DATE] identified Resident #72 was cognitively intact and was dependent for toileting, shower/bath, lower body dressing, and transfers. Additionally, it identified there were two unstageable deep tissue injuries. The Resident Care Plan dated 4/23/2025 identified Resident #72 was at risk for skin impairment related to decreased mobility from left hip fracture, status post left hip hemiarthroplasty, and deep tissue injury to bilateral heels. Interventions included to monitor skin impaired sites for healing/worsening as per facility policy, off and/or encourage frequent turning/positioning for skin integrity and provide pressure relieving devices (mattress/chair cushion) as warranted. A physician's order dated 4/08/2025 for Resident #72 directed to check placement and functions of air mattress every shift. Observation on 4/30/2025 at 6:20 AM, identified that Resident #72 was sleeping in bed. Additionally, it identified that there was an air mattress under the resident and the mattress was set to 200 with normal pressure. Interview with the Wound APRN on 4/28/2025 at 2:50 PM identified the air mattresses should be set according to manufacturer guidelines. Interview, clinical record review, and observation with RN #2 on 4/30/2025 at 7:40 AM, identified Resident #72 was sleeping in bed with the air mattress set to 135. RN #2 stated the air mattress should be set to the residents most recent documented weight and it is the unit nurse responsibility to ensure the correct setting. Review of the clinical record with RN #2 identified the resident's last documented weight was on 4/25/2025 at 106.5 pounds (lbs.). After inquiry, RN #2 adjusted the air mattress setting between the numbers of 80 and 120 on the machine. Interview with the DNS, Administrator, and RN #1 on 4/30/2025 at 8:45 AM identified air mattresses should be set based on resident weight and resident preference per MD order. Additionally, they identified that MD should be notified if set per resident preference. Interview with the Medical Director, MD #1, on 4/30/2025 at 9:26 AM via telephone identified the order for Resident #72 regarding the air mattress did not inform staff of how the air mattress should be set. MD #1 stated that either the nursing staff or Wound APRN would make recommendations for the appropriate settings and the air mattress setting should be to those recommendations. Review of operator's manual for Med-Aire Melody alternating pressure low air mattress replacement system identified in the operating instructions section, step six directed to determine the patient's weight and set the control known to that weight setting on the control unit Review of the pressure reducing mattress policy with a revision date of 1/2024 identified that residents with an identified pressure area will be provided with an alternating pressure air mattress. The policy directed the nurse to update MD/APRN of pressure and to obtain physician's order, Additionally, noted the alternating pressure mattress is to be check for proper placement and inflation each shift and as needed.

Based on clinical record review, policy review and interview for 1of 5 residents (Resident # 36) reviewed for unnecessary medications, the facility failed to address a pharmacy medication/drug regimen review (MRR) regarding a medication in a timely manner. The findings include: Resident # 36's diagnoses included osteoporosis, metabolic encephalopathy and pain. The physician's order dated 2/6/25 directed to apply a Lidocaine External Patch 4 % to the left knee topically one time a day for pain for 12 hours, off at night for 12 hours. The Resident Care Plan dated 3/18/25 identified Resident #36 was at risk for experiencing pain due to age related osteoporosis. Interventions included administering medication and/or treatments per Medical Doctor (MD) orders and monitoring and reporting nonverbal signs and symptoms of pain. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #36 was severely impaired and dependent on staff for dressing, toileting and transfers. The Medication Administration Record identified the Lidocaine External Patch 4 % to be applied to the left knee topically one time a day for pain on for 12 hours, off at night for 12 hours, was signed off as being applied at 6:00 AM, without the benefit of a specified removal time. The Pharmacy Drug Regimen Review dated 3/12/25 directed to please schedule removal of lidocaine patch. and failed to identify a reviewed by signature. Interview and record review with the Director of Nursing (DNS) on 5/01/25 at 10:56 AM identified the DNS is responsible for following up on drug regimen reviews as soon as possible. He could not identify why the 3/12/25 recommendations for Resident #36 were not addressed until after inquiry on 4/30/25 (total of 48 days). The Drug Regimen Review-Monthly Policy directed in part the physician or licensed designee shall respond to the drug regimen review within 7-14 days or more promptly and document on the drug regimen review form whether he/she agrees or disagrees with the recommendations.

Based on clinical record reviews, observations, facility documentation, facility policy and interviews for 1 of 3 sampled residents (Resident #61) reviewed for pressure ulcer, the facility failed to ensure personal protective equipment (PPE) was worn while providing direct care for a resident on enhanced barrier precautions (EBP) and failed to complete hand hygiene in accordance with current infection control practices while providing incontinent care. The findings include: Resident #61 had diagnoses that included dementia and protein calorie malnutrition. The quarterly MDS assessment dated [DATE] identified Resident #61 had severely impaired cognition, required two people assist with bed mobility and transfers, and had no unhealed pressure ulcers. The care plan dated 2/18/25 identified Resident #61 required assistance with ADL's related to decreased mobility was at risk for skin impairment. Interventions included provide assistance as applicable for ADL activities and assistance of two for transfers. Physician orders dated 3/1/25 directed enhanced barrier precautions related to a history of a multidrug resistant organism meaning staff providing direct care must first don PPE. 1. An observation on 4/28/25 at 2:54 PM of NA #3 identified she was providing incontinent care to Resident #61 without the benefit of PPE. NA #3 indicated she was changing Resident #61's brief. An interview with NA #3 on 4/28/25 at 3:07 PM identified she was supposed to have been wearing PPE while providing direct care but did not as an oversight. An interview with the DNS on 04/28/25 03:20 PM identified he would expect any staff caring for a resident on EBP be wearing PPE if providing direct care to that resident. Although requested a policy for enhanced barrier precautions were not provided. 2. An observation on 4/29/25 at 10:20 AM identified LPN #2 was donned in PPE providing incontinent care to Resident #61 while in bed. LPN #2 was observed cleansing Resident 61's perianal area, who was incontinent with both urine and stool with disposable cloths and cleansing solution. On four separate occasions during incontinent care, LPN #2 removed her gloves, discarded them in the garbage receptacle, move the PPE gown aside to reach into her uniform pocket for new set of gloves and don the new gloves to resume incontinent care without first washing hands before reaching into uniform pocket. An interview with LPN #2 on 4/29/25 at 10:20 AM identified she should have washed her hands each time she removed her gloves and did not state she was nervous. An interview RN #1, regional [NAME] President of Nursing Services, on 4/29/25 at 2:45 PM identified hand hygiene should have been performed after doffing gloves when providing incontinent care. A review of the facility policy for Hand Hygiene directed that hand hygiene be performed either by alcohol-based hand rub or soap and water, be performed before and after glove removal. Gloves were not a substitute for hand hygiene. Hand hygiene was to be performed immediately following the removal of gloves.

Based on clinical record reviews, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) who utilized a wheelchair for mobility, the facility failed to ensure the resident was properly positioned in the wheelchair and the footrests were in place prior to transporting the resident to prevent a fall with minor injury. The findings include: Resident #1's diagnoses included syncope and collapse, generalized muscle weakness, falls, and difficulty walking. The admission Minimum Data Set assessment dated [DATE] identified Resident #1 had no memory recall deficits, required maximal assistance with toileting, and personal hygiene, and moderate assistance with getting in and out of the bed and chair, and was always continent of bowel and bladder. The resident care plan dated 7/2/24 identified Resident #1 was at risk for falls related to a diagnosis of syncope, prior falls at home, and potential for unsteady gait. Interventions directed to provide reminders to use call bell prior to rising, provide education and instruction regarding safety measures. A physician's order dated 7/3/24 directed to provide assistance of one (1) with transfers and the assistance of one (1) for ambulation with the use of a rolling walker. The resident care card dated 7/9/24 identified Resident #1 required the assistance of one (1) for transfers and ambulation with the use of a rolling walker. The Facility Reported Incident Form dated 7/10/24 at 10:45 PM identified the 3-11PM nurse aide, Nurse Aide (NA) #1, was transporting Resident #1 who was seated in the wheelchair back to bed from the bathroom. The report indicated NA #1 was actively pushing the chair from behind and while in motion Resident #1 sustained a witnessed fall out of the wheelchair. The report identified Resident #1 required the assistance of one (1) staff with transfers and was able to self-propel in the wheelchair on unit. The nurse's note dated 7/10/24 at 11:40 PM identified the Nursing Supervisor was called to Resident #1's room around 10:45 PM and observed Resident #1 on the floor in a prone position by the foot of the bed with the wheelchair nearby and Resident #1 had sustained a laceration to the forehead. The note identified a pressure dressing was applied to the forehead laceration, a neurological assessment was conducted, and Resident #1 was alert, oriented with baseline mentation. The note indicated the on-call Advanced Practice Registered Nurse (APRN) was notified, orders were obtained to transfer Resident #1 to the Emergency Department (ED) for further evaluation, and Emergency Medical Services was called. The nurse's note dated 7/11/24 at 8:06 AM identified Resident #1 returned from the hospital at approximately 3:30 AM with a dressing on the forehead with staples that needed to be removed within five (5) to seven (7) days. The APRN note dated 7/11/24 at 2:26 PM identified Resident #1 had a fall yesterday evening sustaining a laceration to the forehead, was sent to the ED for further evaluation, and returned with four (4) staples to be removed in seven (7) days. An interview was conducted with the 3-11PM nurse aide, Nurse Aide (NA) #1 on 8/6/24 at 11:15 AM. NA #1 identified on 7/10/24 she was transporting Resident #1 from the bathroom back to bed when Resident #1 fell forward out of the wheelchair. NA #1 stated Resident #1 was seated in the wheelchair and was leaning slightly forward because only the buttocks were against the back of the wheelchair. NA #1 indicated she was standing behind the wheelchair, actively pushing Resident #1, and could not see where Resident #1's feet were positioned. NA #1 identified she did not put the footrests on the wheelchair prior to transporting Resident #1 because Resident #1 was able to independently self-propel the wheelchair. Interview with the Director of Nursing (DON) on 8/6/24 at 12:40 PM identified on 7/10/24 NA #1 did not ensure Resident #1 was properly positioned in the wheelchair and NA #1 should have put the footrests on the wheelchair prior to transporting Resident #1. Review of facility's wheelchair policy identified when transporting a resident in a wheelchair assist the resident with positioning to promote proper body alignment, place the resident's feet on the footrests, and leg rests must always be used when transported by others.

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of eleven (11) residents, (Resident #12) reviewed for medication administration the facility failed to ensure the correct medication was administered to the correct resident, and for eleven (11) of twenty six (26) residents (Resident #1,#2, #3, #4, #5, #6, #7, #8, #9, #10, and #11), the facility failed to ensure all medications were administered in accordance with physician's orders. The findings include: 1. Resident #12 had diagnoses that included Alzheimer's disease and hyperlipidemia. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 was moderately cognitively impaired and required partial assist with activities of daily living. A facility reported Event dated 1/5/24 identified Resident #12 received a dose of Rosuvastatin 10 mg (treats high chloresterol and senna plus (a laxative) 8.6 mg/50 mg tab at 11:30 PM in error. Licensed Practical Nurse, LPN #1 was provided education in properly identifying the resident before medication administration. An interview with Registered Nurse, RN #1 on 1/29/24 at 10:14 AM identified he was the assigned nursing supervisor scheduled during 11:00 PM to 7:00 AM shift on 1/5/24 overnight to 1/6/24. RN #1 stated he was notified between 11:45 PM and 11:50 PM by the 3:00 PM- 11:00 PM shift nursing supervisor, RN #1 identified that Licensed Practical Nurse, LPN #1 had administered the incorrect medication to resident #12, RN #1 identified LPN #1 did not properly identify the resident prior to administering the medications. An interview with LPN #1 on 1/29/24 at 10:54 PM and 11:26 PM identified he worked at the facility for the first time on 1/5/24 and was the assigned nurse on the 3:00 PM- 11:00 PM shift. LPN #1 stated he had not previously worked at the facility and did not know the residents or the facility resulting in giving the wrong medication to the wrong resident. He reported the medication error to the supervisor when he realized the error. LPN #1 could not recall what exactly he did/did not do resulting in the medication error. An interview with the Director of Nursing, DNS on 1/29/24 at 12:10 PM identified she worked until 9:00 PM on 1/5/24 and rounded the building at scheduled times. The DNS stated she asked LPN #1 how everything was going at 7:00 PM and he reported no concerns. The DNS stated although LPN #1 self-reported the medication error, she would have expected him to be more attentive during medication administration. A review of the facility policy for Medication Errors directed that a medication error is defined as a dose that deviates from the physician's order as written in the resident's chart or facility policy and procedure. A medication error includes unauthorized errors defined as administration of a medication to a resident not authorized for that resident including doses given to the wrong resident. The facility contacted the nursing agecy where LPN #1 was employed and asked that he not return to the facility. 2. A review of the Medication Administration Record (MAR) fro 1/5/24 identified that Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 were not administered medications in accordance with physician's orders on the evenong shift. a) Resident #1's diagnoses included polyneuropathy. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderate cognitive impairment and required partial assist with activities of daily living (ADL). The MAR dated 1/5/24 identified Aspercreme 10% ( topical pain reliever) to be applied to midback and dermaphor (a skin lubricant) to the lower extremities during the 3:00 PM -11:00 PM shift, dairy aide tablet 3,000 units at 6:00 PM and House juice supplement at 8:30 PM were signed off as 'Not Administered'. A nurse's note dated 1/6/24 at 10:58 AM identified that Aspercreme, Dairy Aid 3,000 units and Nutritional supplement were not given as ordered. The 11:00 PM-7:00 AM Supervisor made the Director of Nursing (DNS) aware, notified on call advanced practice registered nurse, APRN and physician. The responsible party was notified. No ill effects were noted, and pain was being monitored. b) Resident #2 had diagnoses that included glaucoma. The annual MDS assessment dated [DATE] identified Resident #2 was cognitively intact and required partial assist with ADL's. The MAR dated 1/5/24 identified Dorzolamide-timolol 22.3-6.8 mg/ml ophthalmic solution (given to treat glaucoma) at 4:30 PM and a House Supplement 90 ml at 8:30 PM were signed off as 'Not Administered'. A nurse's note dated 1/6/24 at 11:05 AM identified that Dorzolamide-Timolol eye drops, and Nutritional supplement were not administered as ordered. The 11:00 PM-7:00 AM Supervisor stated he made DNS aware and notified on call APRN and physician. No ill effects were noted, and the responsible party was notified. c) Resident #3 had diagnoses that included glaucoma and dermatitis. The quarterly MDS assessment dated [DATE] identified Resident #3 had moderately impaired cognition and required partial assist with ADL's. The MAR dated 1/5/24 identified Ketoconazole 2% cream (a topical cream used to treat fungal infections) at 4:30 PM, Calazime cream (skin protectant) to coccyx during the 3:00 PM- 11:00 PM shift, Dermaphor cream (a skin protectant) to both upper extremities and both lower extremities at bedtime, Artificial Tears (eye lubricant) 1 drop 8:30 PM, brinzolamide 1% (treats glaucoma) 1 drop at 8:30 PM, Ortho-Biotic probiotic 1 capsule ( a nutritional supplement) at 8:30 PM were signed off as 'Not Administered'. A nurse's note dated 1/6/24 at 11:36 AM identified that Artificial tears, Brinzolamide eye drops, and Probiotic were not given as ordered. Ketoconazole, Calazime and Dermaphor treatments were also not done. The 11:00 PM-7:00 AM Supervisor made DNS aware and notified on call APRN and physician. No ill effects were noted, and the responsible party was notified. d) Resident #4 had diagnoses that included dry eye syndrome. The quarterly MDS assessment dated [DATE] identified Resident #4 was cognitively intact and required partial assist with ADL's. The MAR dated 1/5/24 identified Systane eye drops 0.4-0.3 % 1 drop (and eye lubricant) 8:30 PM was signed off as 'Not Administered'. A nurse's note dated 1/6/24 at 10:42 AM identified that Systane eye drops were not given as ordered. The 11:00 PM-7:00 AM Supervisor made DNS aware and notified on call APRN and physician. No ill effects were noted, and the responsible party was notified. e) Resident #5 had diagnoses that included cellulitis to the pubis. The annual MDS assessment dated [DATE] identified Resident #5 had severe cognitive impairment and required extensive assist with ADL's. The MAR dated 1/5/24 identified Mupirocin 2% surgical pubis wound and skin prep (a topical antimicrobial) to the right thigh scheduled to be administered during the 3:00 PM -11:00 PM shift were signed off as 'Not Administered'. A nurse's note dated 1/6/24 at 12:33 PM identified that Muprirocin and Skin prep treatments were not administered as ordered. The 11:00 PM-7:00 AM Supervisor made DNS aware and notified on call APRN and physician. No ill effects were noted, and the responsible party was notified. The treatment area was being monitored. f) Resident #6 had diagnoses that included type II diabetes, hypertension, and hyperlipidemia. The quarterly MDS assessment dated [DATE] identified Resident #6 was cognitively intact and required partial assist with ADL's. The MAR dated 1/5/24 identified Atorvastatin 40 mg (a medication given to reduce cholesterol levels) at 8:30 PM, Lantus U-100 Insulin (insulin glargine) 18 units ( reduces blood sugar) at 8:30 PM, melatonin 9mg (a sleep medication) at 9:00 PM, metoprolol tartrate 100 mg ( a medication used to treat high blood pressure) at 8:30 PM, Restasis (cyclosporine) 0.05%, 1 drop (treats chronic dry eye) at 8:30 PM, Tylenol Extra Strength (a medication given for pain) 1000 mg at 8:30 PM were signed off as Not administered'. A nurse's note dated 1/6/24 at 7:00 AM identified Resident #6 reported that h/her 8:30 PM dose of Lantus was omitted on the evening of 1/5/24. The Resident's blood sugar was taken by unit charge nurse and noted to be 287, with resident exhibiting no signs or symptoms of ill effects. Resident #6 was monitored through the overnight with blood sugar tracked. Resident blood sugar was checked again at 6:00 AM and found to be 158 (baseline 98-367) with Resident #6 exhibiting no ill effects. The physician was notified. A subsequent nurse's note dated 1/6/24 at 11:20 AM identified the responsible party was notified. g) Resident #7 had diagnoses that included kidney disease, depression, and neuropathy. The quarterly MDS assessment dated [DATE] identified Resident #7 was cognitively intact and required extensive assist with ADL's. The MAR dated 1/5/24 identified Carvedilol 25 mg (used to treat high blood pressure) at 8:30 PM, duloxetine 60 mg (an antidepressant) at 8:30 PM, gabapentin 600 mg (a nerve pain medication) at 8:30 PM, melatonin 3 mg (a sleep medication) at 8:30 PM and Tylenol 500 mg (a pain medication) 8:30 PM were signed off as 'Not Administered'. A nurse's note dated 1/6/2024 at 12:48 PM identified that Carvedilol, Duloxetine, Gabapentin, Melatonin and Tylenol were not given as ordered. The 11:00 PM-7:00 AM Supervisor made DNS aware and notified the on call APRN and physician. No ill effects were noted. The responsible party was notified. The monitoring of blood pressure, apical pulse and increased pain were initiated for 72 hours. h) Resident #8 had diagnoses that included chronic diastolic congestive heart failure and hyperlipidemia. The quarterly MDS assessment dated [DATE] identified Resident #8 was severely cognitively impaired and required partial assist with ADL's. The MAR dated 1/5/24 identified Acetaminophen Extra Strength 1000 mg ( a pain medication) at 8:30 PM, amlodipine 5 mg ( a blood pressure medication) at 8:30 PM, atorvastatin ( a medication for high cholesterol) 40 mg at 8:30 PM, melatonin 6 mg (a sleep medication) at 8:30 PM, metoprolol succinate ER 100 mg (a blood pressure medication) at 8:30 PM, Xarelto ( a blood thinner) 15 mg at 8:30 PM were all signed off as 'Not Administered'. A nurse's note dated 1/6/2024 at 1:17 PM identified that Acetaminophen 1000 mg, Amlodipine 5 mg, Atorvastatin 40 mg, Melatonin 6 mg, Metoprolol Succinate 100 mg and Xarelto not given as ordered last evening. The 11:00 PM-7:00 AM Supervisor made the DNS aware and notified the on call APRN and physician. No ill effects were noted. The responsible party was notified and the monitoring of blood pressure, apical pulse and increase in pain were initiated for 72 hours. i) Resident #9 had diagnoses that included dermatitis of the skin and dry eye syndrome. The quarterly MDS assessment dated [DATE] identified Resident #9 was cognitively intact and required partial assistance with ADL's. The MAR dated 1/5/24 identified Visine eye relief 1% 1 drop (treats dry eyes) at 4:30 PM, Thera honey with foam dressing and calazime lotion (wound care treatments) to inner buttocks during the evening shift, Dermaphor cream (a moisturizer) to the bilateral lower legs during the 3:00 PM-11:00 PM shift, incentive spirometer (a device that measures volume of air inhaled during inspiration) during the 3:00 PM-11:00 PM shift, ketoconazole 2% ( an anti-fungal cream) to knees during the 3:00 PM-11:00 PM shift and skin prep (a skin protectant) to left heel during the 3:00 PM-11:00 PM were signed off as 'Not Administered. A nurse's note dated 1/6/24 at 11:00 AM identified Visine eye drops and nutritional supplement, Ketoconazole, Calazime, Dermaphor, Skin prep and Thera honey treatments were not done as ordered. Resident #9's skin was monitored with treatment and there were no complaints of eye discomfort. j) Resident #10 had diagnoses that included type II diabetes, dementia, and unspecified pain. The quarterly MDS assessment dated [DATE] identified Resident #10 was moderately cognitively impaired and required one to two person assist with ADL's. The MAR dated 1/5/24 identified that Artificial Tears 1.4 % 1 drop at 8:30 PM, House Supplement 120 ml at 8:30 PM and Aspercreme 10% topically to lower back to be administered during the 3:00 PM-11:00 PM shift were all signed off as 'Not Administered'. A nurse's note dated 1/6/24 at 10:19 AM identified that Artificial tears, Aspercreme and Nutritional supplement were not given as ordered. The 11:00 PM-7:00 AM Supervisor stated he made DNS aware and notified the on call APRN and physician. No ill effects were noted. The responsible party was notified. Monitoring for increased back pain was initiated with no complaints. k) Resident #11 had diagnoses that included bipolar disorder and history of non-displaced fracture of the lateral malleolus of the left fibula (end of the lower leg bone) with routine healing. The significant change MDS assessment dated [DATE] identified Resident #10 was cognitively intact and required partial assist with ADL's. The MAR dated 1/5/24 identified Tums 500 mg (an antacid) at 7:00 PM and Depakote (an anticonvulsant) 250 mg at 8:30 PM were signed off as 'Not Administered'. A nurse's note dated 1/6/24 at 10:55 AM identified that Depakote ER 250 mg and Tums 500 mg were not given as ordered last evening. The 11:00 PM-7:00 AM Supervisor made DNS aware and notified the on call APRN and physician. No ill effects were noted. The responsible party was updated, and behavior monitoring was in place. An interview with Registered Nurse, RN #1 on 1/29/24 at 10:14 AM identified he was the assigned nursing supervisor scheduled during 11:00 PM to 7:00 AM shift on 1/5/24 overnight to 1/6/24. RN #1 stated he was notified between 11:45 PM and 11:50 PM by the 3:00 PM- 11:00 PM shift nursing supervisor, that Licensed Practical Nurse, LPN #1 had administered the incorrect medication to the Resident #12. RN #1 was asked to follow up with LPN #1. RN #1 went to the nursing unit to speak to LPN #1 about the medication error. Once the matter with the medication error was reconciled, RN #1 was leaving the unit when he was informed by staff that Resident #6 reported that s/he had not received h/her evening insulin. RN #1 went to speak to Resident #6 who reported s/he did not receive h/her prescribed medication for the evening shift RN #1 then returned to LPN #1 to inquire about the med omission who confirmed he did not administer the medication because he ran out of time. According to RN #1, LPN #1 then stated he needed to leave as he was having a blood sugar issue. LPN #subsequently left the facility without providing any additional information. RN #1 completed a clinical record review of the MAR for the remaining residents on the unit that identified an additional medication omissions for Resident #6 and medication omissions for Resident #1, 2, ,3, 4, 5, 7, 8, 9, 10, and #11. RN #1 stated he notified the APRN, physician and DNS. All residents were monitored with no ill effects were identified. RN #1 indicated LPN #1 had not notified him of the omissions and only became aware subsequent to his inquiry. An interview with LPN #1 on 1/29/24 at 10:54 PM and 11:26 PM identified he worked at the facility for the first time on 1/5/24 and was the assigned nurse on the 3:00 PM- 11:00 PM shift on one North. LPN #1 stated he had a heavy medication assignment and that his shift ended before he could complete his assignment. LPN #1 believed a resident reported not receiving h/her prescribed insulin to RN #1. LPN #1 stated he believed missing one dose of insulin would not be detrimental to the resident's health LPN #1 also stated that he had a medical issue where he needed to eat and had not previously eaten. He reported this to RN #1 before leaving the facility. LPN #1 indicated that he was pretty sure other residents that there were other residents that did not receive their prescribed medications as well. LPN #1 could not recall if he had previously reported any difficulty with completing his assignment earlier in the shift and was unable to say what he would have normally done in the event of running behind in his assignment. An interview with the DNS on 1/29/24 at 12:10 PM identified she worked until 9:00 PM on 1/5/24 and rounded the building at scheduled times. The DNS stated she asked LPN #1 how everything was going at 7:00 PM and he reported no concerns. The DNS stated she would expect that LPN #1 to have reported he was having difficulty with his assignment earlier in the shift. An interview with RN #2 on 1/29/24 at 12:23 PM identified he was the assigned nursing supervisor on the 3:00 PM to 11:00 PM shift on 1/5/24. RN #2 stated LPN #2 stated LPN #1 did not report any issues with not being able to administer all his medications timely. A review of the facility policy for Medication Errors directed that a medication error is defined as a dose that deviates from the physician's order as written in the resident's chart or facility policy and procedure. A medication error includes medication omission errors defined as a failure to administer an ordered dose. Subsequent to the event facility, education was provided to nursing staff related to reporting and medication errors.

Based on clinical record reviews, facility documentation, facility policy and interviews for three residents (Resident #1, Resident #2, and Resident #3), who were reviewed for abuse, the facility neglected to provide incontinent care for a resident(s) who required incontinent care in accordance to their plan of care. The findings include: 1. Resident #1's diagnoses included Alzheimer's disease, depression, and anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was moderately cognitively impaired and required limited (1) assist with bed mobility and maximum (2) person assist with toileting. The Resident Care Plan dated (RCP) 10/31/23 identified Resident #1 had functional ADL deficit, required assist of one with bed mobility and was incontinent of bladder and bowel with interventions that directed to provide briefs for dignity and maintaining skin integrity, provide total assistance with bathing and grooming. A nurse's note dated 11/17/23 at 9:00 PM identified Resident #1 had a delay in the provision of morning care. An RN assessment was completed, and Resident #1 was at baseline. Resident #1 denied complaints. The physician and responsible party were notified. 2. Resident #2 had diagnoses that included atrial fibrillation and adult failure to thrive. The annual MDS assessment dated [DATE] identified Resident #2 was moderately cognitively impaired and required assist of one with bed mobility transfer and toileting. The RCP dated 10/3/23 identified Resident #2 had functional ADL deficit, required assist of one with bed mobility, was incontinent of bladder and bowel, required assist of (2) with transfers and was at risk for skin breakdown with interventions directed to provide bed bath only and check, change and provide peri care after each incontinent episode. A Nurses note dated 11/17/23 at 9:03 PM identified Resident #2 was delayed in receiving morning care. An RN assessment was completed and determined at baseline. Resident #2 denied pain or distress. The physician and responsible party were notified. 3. Resident #3 had diagnoses that included Parkinson's disease and muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #3 as severely cognitively impaired and required one person to assist with bed mobility, and a total (2) person to assist with transfers and toileting. The RCP dated 10/31/23 identified Resident #3 had functional ADL deficit, required assist of one with bed mobility, was incontinent of bladder and bowel and required assist of (2) with transfers and was at risk for skin breakdown with interventions that directed to change and provide peri care after each incontinent episode and encourage turning and positioning. A Nurse's note dated 11/17/23 at 9:01 PM identified Resident #3 was delayed in receiving morning care. An RN assessment was completed and determined at baseline. Resident #3 denied pain or distress. The physician and responsible party were notified. a) A facility Reported Event Summary dated 11/19/23 identified on 11/17/23 at 12:00 PM, Residents #1, #2, and #3 were still in their [NAME] and had a wet brief, an investigation into the delay of care was initiated. An RN assessment was completed on the residents they were all at baseline, all denied pain, discomfort, or distress. The assigned nurse aide, NA #1 was from an agency and working as a team with an experienced, but with a new nurse aide, NA #2. Both aides lost track of time, stated they were very busy, and prioritized care based on who wanted to get out of bed first and that Residents #1, # 2, and #3 had not received incontinent care or any ADL care prior to 12:00 PM (from start of shift at 7:00 AM, a total of five (5) hours). An interview with the Independent Nurse Consultant (INC) for the facility on 12/13/13 at 9:12 AM identified on 11/17/23 at 10:00 AM she was making rounds on the floors when she noted the unit where NA #1 and NA #2 were working was busy with call lights going off and residents were still in bed. The INC reported the concern to the Director of Nursing, DNS who stated scheduling adjustments had been completed for the 7:00 AM to 3:00 PM shift due to staff call outs. The INC returned at 12:00 PM and observed residents still in bed in johnny coats. Upon interviewing NA #1 and NA #2 about a delay in care for those resident(s), they reported care was not provided to Resident #1, #2, and #3 between 7:00 AM to 12:00 PM. The INC and DNS both went to check Resident #1, #2 and #3 who were all still in a johnny coat, all with an adult brief moderately soaked with urine. An interview with NA #1 on 12/19/23 at 12:58 PM identified she was an agency aide who had previously worked one shift prior to 11/17/23. NA #1 was scheduled to work during the 7:00 AM to 3:00 PM shift on 11/17/23. NA #1 stated she had her own assignment but decided to assist NA #2 when she observed her assignment was quite heavy. NA #1 and NA #2 worked together to provide care and it took longer than expected. As a result, Residents #1, #2, and #3 did not receive any incontinent care or AM personal care between 7:00 AM and 12:00 PM (5 hours), although she was aware that residents should be checked and changed every 2 hours. Further, NA #1 did not notify the charge nurse or ask for assistance when she was getting behind with care. An interview with NA #2 on 12/13/23 at 12:10 PM identified she was an experienced nurse aide who had been employed at the facility for three weeks prior to 11/17/23. NA #2 stated she was working during the 7:00 AM to 3:00 PM shift on 11/17/23 and that it had been her first time working on the unit. NA #2 indicated the assignment was heavy with all residents that required assist of two with care. NA #2 worked with NA #1 to provide care and in doing so, the assignment took longer to complete. As a result, Residents #1, #2, and #3 did not receive any incontinent care, or AM personal care between 7:00 AM and 12:00 PM (5 hours), although she was aware that incontinent care should be provided every 2 hours. Further, NA #2 did not notify the charge nurse or ask for assistance when she was getting behind with care. An interview with the Director of nursing, DNS on 12/13/23 at 9:06 AM and at 12:42 PM on 12/13/23 identified NA #1 was an agency nurse and NA #2, although experienced, was new to the facility. NA #1 and NA #2 were working together that morning and reported they did not provide any personal care to Resident #1 before 12:00 PM. The DNS stated she would expect nurse aides to check and change (if needed) for incontinence every 2 hours and to notify the charge nurse if additional assistance was needed. Subsequent to the incident, all staff were provided with education on the timely provision of incontinence care and notifying charge nurses if assistance was needed. Staff education was provided to both facility and agency NA's and Licensed Staff related to timely provision of morning care and communicating with leadership when help is necessary to complete assignment. Weekly audits of incontinent residents were initiated and ongoing. A review of the facility policy for Abuse directs that each resident has the right to be free from abuse and neglect. Neglect is defined as the failure of the facility, its employees, or service providers to provide the goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #46, and 60) reviewed for accidents, the facility failed to ensure an RN assessment was documented after Resident #46 fell and that the resident was not moved prior to the assessment, and the facility failed to ensure neurological assessments were completed after Resident #60 had multiple unwitnessed falls and for for 1of 8 residents (Resident #74) reviewed for medication administration, the facility failed follow the physician's order related to blood pressure parameters. The findings include: 1. Resident #46 was admitted to the facility in May 2022 with diagnoses that included history of fall, Alzheimer's disease, and dementia with behavioral disturbance. A physician's order dated 7/3/22 directed to apply chair alarm for safety, every shift: day, evening, and night. The quarterly MDS dated [DATE] identified Resident #46 had severely impaired cognition, was occasionally incontinent of bladder and required extensive 1-person physical assistance with transfer and toilet use. The care plan dated 8/14/22 identified Resident #46 had a falls/safety risk potential related to mobility decline, use of medication and history of falls. Interventions included to keep the call bell in reach and encourage use, assess footwear for proper fit, non-skid socks, chair alarm and falling star program. A reportable event form dated 11/5/22 at 8:30 PM identified NA #1, who was in an adjacent room with another resident, heard a thump coming from Resident #46's room. NA #1 observed Resident #46 in the bathroom lying on his/her right side with part of the rolling walker under the resident's right leg. NA #1 assisted Resident #46 to a sitting position and called for help. Resident #46 was observed with a small cut on top of the left side of his/her head. Ice was applied to the laceration. Subsequent to APRN notified, Resident #46 was sent to the hospital for further evaluation. Review of the facility fall event and investigation form dated 11/5/22 at 9:41 PM, completed by LPN #2, identified Resident #46 was in a chair prior to the fall which was not witnessed. NA #1 responded to the chair alarm and heard a thump in bathroom. Resident #46 had a left scalp laceration measuring 1.5 cm with approximately 0.5 cm in depth. Left cheek noted with a 2cm faint red area. The nurse's note dated 11/5/22 at 9:00 PM identified LPN #2 was called to Resident #46 room at 8:30 PM. LPN #2 indicated Resident #46 was sitting on the floor bleeding from the left side of the scalp. NA #1 reported she was responding to Resident #46's chair alarm and heard a thump in the bathroom. Review of the nurse's notes dated 11/5/22 through 11/9/22 failed to reflect documentation that the Registered Nurse conducted a thorough assessment after the resident fell on [DATE] at 8:30 AM. The nurse's note dated 11/6/22 at 2:02 AM identified Resident #46 returned to the facility, was alert and not in distress and was transferred to bed with alarm in place. Vital signs and neurological assessment started. The care plan dated 11/7/22 identified status post fall on 11/5/22, the resident hit head with small open area to left side of head. Adhesive glue to 1 cm laceration on left side of scalp. Interventions included to toilet promptly between 8:00 PM - 9:00 PM. Reminder sign on table to call for assistance and priority call light. Review of the summary report dated 11/10/22 identified on 11/5/22 at 8:30 PM NA #1 heard a thump and chair alarm coming from Resident #46 room while she was in the adjacent room with another resident. NA #1 observed Resident #46 in the bathroom lying on his/her right side with part of the rolling walker under his/her right leg. NA #1 removed the rolling walker from under the leg, assisted Resident #46 to a sitting position and called for help. Interview with NA #1 on 4/12/23 at 1:32 PM she was not assigned to Resident #46 but she was in the room next door and heard Resident #46 alarm going off and then a thump. NA #1 indicated she went into Resident #46 room and observed Resident #46 was on the bathroom floor lying on his/her right side with the rolling walker and he/she was in between the rolling walker. NA #1 indicated Resident #46 was bleeding from the left side of head. NA #1 indicated she did not move Resident #46 until the nurse came into the room (this is in conflict with the reportable event form dated 11/5/22 at 8:30 PM that indicated (NA #1 assisted Resident #46 to a sitting position and called for help) and in conflict with the nurse's note dated 11/5/22 at 9:00 PM that indicated LPN #2 found Resident #46 sitting on the floor bleeding from the left side of the scalp). Interview with LPN #2 on 4/13/23 at 9:42 AM indicated she was called to Resident #46's room, and she observed Resident #46 was sitting on the floor in the bathroom and bleeding from the left side of the head. LPN #2 indicated she does not remember who was in the bathroom but believes it was NA #1. LPN #2 indicated she does not know who sat Resident #46 up from the floor. LPN #2 indicated she called the RN supervisor who came and performed the assessment on Resident #46. LPN #46 indicated she performed the vital signs and neurological assessment. LPN #2 indicated after the RN assessed the resident, the resident was transferred via the hoyer lift with 3 assistants. LPN #2 indicated she helped get Resident #46 off the floor and she believed the other 2 assistants were the nurse's aide and the RN supervisor, but she can't remember. LPN #2 indicated she completed the fall form, and the RN supervisor was supposed to complete and closed the form out. Interview and review of the clinical record with the DNS on 4/13/23 at 10:30 AM failed to reflect documentation of the RN assessment after the residents fall on 11/5/22 and indicated there was no RN assessment notes regarding the fall. The DNS indicated the registered nurse should have documented the assessment and the subsequent laceration on the left side of the resident's head. Interview with RN #2 (previous DNS) on 4/14/23 at 11:15 AM identified she was not aware that RN #1 did not document an assessment of the resident's condition after the resident fell on [DATE]. Further, RN #2 indicated NA #1 should not have moved Resident #46 until the RN Supervisor had performed the assessment per facility policy. Interview with RN #1 on 4/14/23 at 1:46 PM identified she did perform an assessment of the resident on 11/5/22 after the resident fell however, she does not remember what position Resident #46 was in when she saw him/her because it was so long ago. RN #1 indicated NA #1 should not have moved Resident #46 until she assessed the resident. RN #1 indicated after she had performed the assessment, she left the room while the staff transferred the resident into bed. RN #1 indicated she was not aware that she did not document the assessment of the resident after the fall and identified she should have documented the assessment in the nurse's note. Although attempted, an interview with LPN #5 was not obtained. Review of the transfers from the floor policy identified in the event a resident falls to the floor or is found on the floor, licensed nursing staff will assess the resident's condition and direct care in a manner so as to minimize the risk of injury to resident and staff. In the event that a resident falls to, or is found on the floor, a staff member is to stay with the resident and the charge nurse notified. The resident is not to be moved. 2. Resident #60 was admitted to the facility with diagnoses that included dementia, progressive supranuclear palsy with essential tremors, and neurocognitive disorder with Lewy Bodies. A physician's order dated 11/18/22 directed to provide the assistance of 1 for transfers. The admission MDS dated [DATE] identified Resident #60 had moderately impaired cognition and required limited assistance with transfers, bed mobility, toileting, and extensive assistance for dressing and personal hygiene. The care plan dated 12/1/22 identified the resident had a history of falls with interventions that included to ensure the call bell was in reach, physical therapy referral, proper footwear, and non-skid soles. a. A reportable event form dated 12/25/22 at 7:10 PM identified Resident #60 had an unwitnessed fall and was found sitting on floor in front of the bed. Neurological assessments were not completed. b. A reportable event form dated 2/15/23 at 7:00 PM identified Resident #60 had an unwitnessed fall in the bathroom and sustained a skin tear to the right hand. Neurological assessments were not completed. c. A reportable event form dated 3/17/23 at 2:40 PM identified Resident #60 had an unwitnessed fall. The nurse aide found Resident #60 sitting on floor stating he/she was looking for the baby. Neurological assessments were not completed. d. A reportable event form dated 3/19/23 at 2:10 PM identified Resident #60 was witnessed by Recreation Staff #1 to fall (this is in conflict with the interview with Recreation Staff #1 on 4/13/23 at 1:20 PM where she denies witnessing the fall on 3/19/23). Neurological assessments were not completed. A progress note dated 3/23/23 indicated Resident #60 had a fall on 3/19/23 and had a diagnosis of progressive supranuclear palsy with essential tremors. The plan included the resident to be on fall precautions. Interview with the DNS on 4/13/23 at 11:00 AM indicated that staff are not always required to do neurological assessments with unwitnessed falls. The DNS indicated if the resident can state if he/she did or did not hit their head it is not required. The DNS indicated that even if a resident was confused there are times the nurse are not required to do the neurological assessment with unwitnessed falls. The DNS indicated that if a resident had an unwitnessed fall out of bed and was sitting or lying on the floor mat the nurse would assume the resident did not hit this/her head and based on the nurse's judgement would not have to do the neurological assessments. The DNS indicated the nurse would assume the resident did not hit his/her head on the bed frame, nightstand, or the overbed table unless it was near the resident and he DNS indicated nursing staff do not write statements for the falls. The DNS indicated the nurse manager investigating the fall will ask the staff but do not require written statements. Interview with the ADNS on 4/13/23 at 12:00 PM indicated all neurological assessments are completed on paper and not in the electronic medical record. The ADNS indicated she could not find neurological assessments completed for the 4 unwitnessed falls on 12/25/22, 2/15/23, 3/17/23 and 3/19/23. The ADNS indicated 3 of the falls were out of bed so if the nurse felt Resident #60 did not hit his/her head they did not need to do the neurological assessments. The ADNS indicated she was not aware based on documentation if Resident #60 could have hit his/her head on the nightstand, over bed table legs, or the bed frame for the falls on 12/25/22 2/15/23, 3/17/23, or 3/19/23. The ADNS indicated she could not verify if Resident #60 did or did not hit his/her head but since the neurological assessments were not done, she would guess that Resident #60 did not hit his/her head at the time of those falls. Interview with MD #1 on 4/13/23 at 12:30 PM indicated falls can be the unplanned change of position. MD #1 indicated the nurses should follow the facility policy for unwitnessed falls and performing neurological assessments. MD #1 indicated if a nurse finds a resident just sitting on the floor and there was no sign of injury then it is based on the facility policy. MD #1 indicated if it looks like they struck their head then the nurse should do the neurological assessments, but it is at the discretion of the nurse based on the facility policy. MD #1 indicated the nurses must do a physical assessment. Interview and review of the clinical record with the DNS on 4/13/23 at 12:55 PM indicated she could not find a neurological assessment sheet for the unwitnessed fall on 12/25/22. The DNS indicated Resident #60 has moments of clarity but if Resident #60 was off his/her baseline she would expect the nurses to do neurological assessments and follow the assessment form. The DNS indicated for the 12/25/22, 2/15/23 and 3/17/23 unwitnessed falls, she would have expected the nurse to have completed the neurological assessments because the resident was confused. The DNS indicated for the fall on 3/19/23, the recreation person was not in the room but was the first person to respond. The DNS indicated this was an unwitnessed fall. The DNS indicated Resident #60 was very mobile and does not stop getting up on his/her own. The DNS indicated if she were to say the nurses would do neurological assessments every time Resident #60 has an unwitnessed fall the nurses would be doing neurological assessments all the time. The DNS indicated the nurse looks at the surrounding area and make an assumption if they think the resident did or did not hit their head and then decide if they need to do the neurological assessments. Interview with Recreation Person #1 on 4/13/23 at 1:20 PM indicated she did not witness the fall on 3/19/23 for Resident #60. Recreation #1 indicated she was across the hallway talking to both residents in room [ROOM NUMBER] when she heard a thud and came out of room and down hallway and saw Resident #60 on the floor. Recreation Person #1 indicated she stepped out of the doorway and notified the charge nurse who was in the hallway. Review of the Neurological Assessment identified the purpose was to detect clinical manifestations of increased intracranial pressure. The assessment should be initiated when a head injury or disorder was suspected. If no specific orders were received from the physician, the frequency of the assessment should be as follows: initially then every 15 minutes x 4 times, then every 1 hours times 4, every 2 hours times 4, every 3 hours times 4, and every 4 hours times 4. Obtain a Neurological Assessment Flow Sheet and document all findings on that form. Document the date and time of each assessment, then precede as follows: level of consciousness, pupil responses, motor functions, pain responses, vital signs, observations, and signature of nurse filling out the section. Notify the physician if any abnormal changes. 3. Resident #74 was admitted to the facility with diagnoses that included primary hypertension and heart disease. A physician's order dated 3/2/23 directed to give metoprolol succinate tablet extended release 25 mg once a day. Special instructions: hold medication if systolic blood pressure is less than 120 or if apical pulse is less than 60 for diagnosis of essential primary hypertension. The admission MDS dated [DATE] identified Resident #74 had intact cognition and required extensive assistance with bed mobility and personal hygiene. Review of the Medication Administration Record dated 4/1/23-4/10/23 identified that metoprolol extended release 25mg once a day was given every morning at 8:30 AM and heart rate and blood pressure were listed. On 4/2/23 the blood pressure was 116/72 and on 4/10/23 blood pressure was 110/60 and the medication was signed off as given. A Reportable Event Form dated 4/10/23 at 9:00 AM identified a medication error. During morning medication pass Resident #74's apical pulse was 78 and blood pressure was 110/60. LPN #1 misread the parameters for the order and gave Resident #74 the metoprolol when she should have held it for the systolic blood pressure less than 120. Intervention was staff education and clarification of the physician's order. Observations on 4/10/23 at 9:10 AM identified LPN #1 was preparing Resident #74's medications. LPN #1 indicated she needed to get a stethoscope to do the apical pulse. Observed nurse do the apical pulse for 1 full minute and noted the apical heart rate was 74 bpm. At 9:15 AM LPN #1 removed the medications aspirin 81mg, Norvasc 10 mg, clopidogrel 75mg, ranolazine ER 500 mg, and metoprolol 25 mg from the blister packs and placed them in the medication cup. LPN #1 entered the room and elevated resident #74's head of bed and began giving 1 pill at a time from medicine cup on a spoon. Resident #74 took all the medications including the metoprolol were provided by LPN #1. Interview with LPN #1 on 4/10/23 at 9:29 AM indicated the metoprolol had a parameter of apical heart rate less than 60 and a parameter for the blood pressure. LPN #1 indicated she had taken Resident #74's blood pressure prior to breakfast at about 8:30 AM and documented it in the vital sign section of the medical record as 110/60. Interview with LPN #1 on 4/10/23 at 12:28 PM indicated that the physicians order for the metoprolol says the systolic less than 120 or heart rate less than 60 and since the heart rate was above the 60 and it was 74 it was okay to give the metoprolol and it did not matter what the systolic blood pressure was. LPN #1 indicated she only had to follow the parameter for the apical heart rate or the systolic blood pressure, not both. Interview with APRN #1 on 4/10/23 at 12:33 PM indicated if Resident #74 had a blood pressure of 110/60 the metoprolol was to be held and then notify the APRN or physician. APRN #1 indicated it was important for the nurses to evaluate the blood pressure and apical heart rate because metoprolol was a beta blocker, and it works by decreasing the heart rate and if a dose was too high it could drive the heart rate down to low. APRN #1 indicated the medication affects the blood pressure too and the APRN or physician needs to tailor the dosage of the medication to Resident #74. APRN #1 indicated for Resident #74 was to treat his/her blood pressure and the heart rate was a safety mechanism. APRN #1 indicated she would expect to be notified if the medication was held for a low blood pressure and what the blood pressure was at that time and review prior blood pressures. APRN #1 indicated she will reevaluate the parameters for this medication for Resident #74. APRN #1 indicated she was not notified today or in the last week or two of Resident #74 having a low blood pressure and the metoprolol being held. Interview with LPN #1 on 04/10/23 at 12:47 PM indicated she updated APRN #1, and the APRN would review and clarify the parameters for the metoprolol for Resident #74. Interview with the unit manager second floor LPN #2 on 4/10/23 at 12:48 PM indicated if the blood pressure for Resident #74 was 110/60 and the apical heart rate was 74 the medication metoprolol would have been held based on the systolic blood pressure parameter by the physician. Review of the medication administration record with LPN #1, from 4/1-4/10/23, LPN #2 indicated the blood pressure was too low on 2 out of 10 occasions and the medication was still given when it should have been held. LPN #2 indicated on 4/2/23 and 4/10/23 the nurses signed off that they gave the metoprolol when the systolic blood pressure was too low per the physician's parameters for the medication, and she thinks the nurses don't understand the order because of the word or. LPN #2 indicated she would do education with LPN #1 and LPN #3 for their medication errors and the other nurses. The nurse's note written by LPN #1 dated 4/10/23 at 3:51 PM identified that during morning medication pass Resident #74's apical pulse was 74 and blood pressure of 110/60, I misread the parameters order and gave Resident #74 the metoprolol when she should have held it. APRN #1 and residents responsible party were updated at 2:30 PM blood pressure was 104/60 and apical heart rate was 78. Interview with the DNS on 4/13/23 at 10:54 AM indicated when she read Resident #74's order for the metoprolol with the parameters she was confused on whether to give the medication and if LPN #1 had made a medication error. The DNS indicated she spoke with the APRN for clarification on the parameters for the medications and she had learned about the and vs or for the parameters and the APRN had informed her that the medication did need to be held based on the physician's orders. The DNS indicated it was a medication error. The DNS indicated when the nurses were being given the education many of them were confused and were not understanding the order the way it was written by the physician and needed clarification. The DNS indicated she wants the APRN to change any of the orders that are written the same way as Resident #74 and write the order clearer so there would be no confusion. Although attempted, an interview with LPN #3 was not obtained. Review of facility Medication Administration Policy identified if there is a question about a medication order, as indicated on the MAR, the original physician's order is checked. Any medication with a parameter for administration such as digoxin must be placed in a separate souffle cup until the parameter is obtained. 42117

Based on observations, review of facility policy and interviews, the facility failed to ensure intravenous (IV) fluid supplies were within their expiration. The findings included: Observation on 4/12/23 at 12:05 PM with the DNS and Corporate Compliance Nurse of the facility's stock of IV supplies identified multiple bags of IV fluids maintained in the Omnicell (a locked automated medication dispensing system) were expired. The expired IV fluids included: A 1-liter bag of 5% Dextrose in 0.9% Sodium Chloride expired 10/2021. A 1-liter bag of 0.9% Sodium Chloride expired 10/2021. A 1-liter bag of 0.45% Sodium Chloride expired 11/2022. Interview with the DNS at the time of the observation identified that facility staff was not responsible to ensure IV fluids stored in the Omnicell were not expired. The DNS indicated nursing staff does not check the IV supplies ever, because the pharmacy does the IV starts, and they bring all the supplies with them, and whenever we need additional supplies, we call the pharmacy and they deliver for our residents twice a day and as needed. The DNS indicated the facility does have a supply for back up but haven't needed to access it for IV fluids. The DNS further identified that the pharmacy was responsible for ensuring the IV fluids were not expired and the expired IV fluids should have been removed by the pharmacy. Immediately following the observation, the DNS identified that the IV fluids were checked for expiration and restocked by the pharmacy. Interview with Pharmacist #1 on 4/12/23 at 1:50 PM identified that a monthly report was printed for the facility the morning of a scheduled visit by the pharmacy staff that identified any medications that needed to be pulled due to expiration or any medications that were in need of restock, and that the pharmacy worked off the report only and did not physically check the dates of any medications. Pharmacist #1 further identified that the IV supplies were backup stock for the facility, and as IV supplies were used, the pharmacy would send replenishment and the facility staff were responsible to update the expiration dates in the Omnicell system. Pharmacist #1 identified that the most current report identified all IV fluid bags were within their expiration date. Pharmacist #1 also identified he could not see any reports for outdated medications or replenishments sent to the facility because their system deletes prior reports for expired medications once they complete a visit to the facility. Pharmacist #1 could not identify why the expired IV fluid bags were in the Omnicell, and that it was the facility's responsibility to ensure that the IV fluids were removed and sent back to the pharmacy if they were expired. The facility policy on use of the Omnicell system directed that the purpose of the system was to securely store emergency medications to ensure residents would have access to initiation and continuation of drug therapy, and the medication was the property of the extended care facility. The facility policy on interim infusion medication and supplies directed that the facility nursing staff would communicate with the pharmacy for medication replacement and contact the pharmacy for supply replenishment when expiration dates were reached.

Based on review of the clinical record and interview for 5 of 5 residents (Residents #7, 11, 14, 23 and 69) reviewed for resident assessment, the facility failed to electronically submit discharge tracking information to the CMS system according to established timeframes after the residents were discharged from the facility. The findings include: Resident #7 was discharged from the facility on 10/20/22. Resident #11 was discharged from the facility on 12/5/22. Resident #14 was discharged from the facility on 10/21/22. Resident #23 was discharged from the facility on 12/21/22. Resident #69 was discharged from the facility on 12/6/22. Review of facility documentation on 4/13/23 identified that discharge tracking information for Residents #7, 11, 14, 23 and 69 had not been transmitted to the CMS system. Interview with LPN #4 on 4/13/23 at 9:00 AM indicated that she had been waiting for information on therapy minutes prior to transmitting the data, however, she identified that discharge tracking information should be transmitted within 14 days of the discharge.

Based on clinical record reviews, observations, review of facility documentation and interviews for one sampled resident (Resident #68) who was reviewed for quality of care the facility failed to accommodate the resident's preference by not consistently utilizing a teaspoon when feeding the resident honey thickened fluids. The findings include: Resident #68's diagnoses included anemia, hypertension, Alzheimer's disease, anxiety, depression, age related osteoporosis and dysphasia. The quarterly Minimum Data Set ( MDS) assessment dated [DATE] identified Resident #68 had severe cognitive impairment, was total dependent and required two persons physical assistance for transfers, toileting and personal hygiene, was total dependent and required one person assist for eating, and was on a mechanically altered diet. A physician's order dated 2/24/2020 directed regular diet, pureed consistency, and honey thickened liquids. The Resident Care Plan (RCP) dated 2/11/2020 identified Resident #68 had a dysphasia diagnosis and staff to offer to set up and provide extensive assist with meals. Interventions directed to provide pureed consistency diet and honey thick fluids, to provide red handled teaspoon silverware, and to spoon feed fluids. Review of Resident #68's clinical record indicated that Person #1 was identified as Resident # 68's Emergency contact. Observation during lunch meal in the 2nd floor dining room of the facility on 3/11/2020 at 12:30 PM identified NA #4 feeding Resident #68 honey thick liquids by using a cup and without the benefits of using a teaspoon as identified in the resident's plan of care. In an interview and review of Resident # 68's diet slip with NA #4 on 3/11/20 at 12:35 PM, NA #4 stated she did not regularly feed residents in the dining room and was not aware of using the red teaspoon to feed Resident #68 fluids. Review of two diet slips located next to the resident's meal tray and within view of NA #4, directed, Fluids by Red Teaspoon Only. An interview with the Food Service Director on 3/11/2020 at 2:30 PM indicated use of the red handled teaspoon was as requested by Person #1 and use of the spoon was still relevant for use when feeding Resident #68. In an interview with the DNS on 3/12/20 at 10:45 AM, the DNS indicated that using the Red teaspoon to feed fluids to Resident #68 was requested by Person #1 and was trialed and the facility realized that using the spoon worked well for the resident. The DNS stated, using the teaspoon to feed fluids to Resident #68 was an approach, not a requirement and was done to accommodate Person #1. The DNS indicated she would have expected NA #4 to utilize the teaspoon when feeding fluids to Resident #68. A facility's policy on accommodation of preferences was not provided.

Based on clinical record reviews, observations, review of facility documentation and interviews for one sampled resident (Resident #68) who was reviewed for quality of care the facility failed to accommodate the resident's preference by not consistently utilizing a teaspoon when feeding the resident honey thickened fluids. The findings include: Resident #68's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set ( MDS) assessment dated [DATE] identified Resident #68 had severe cognitive impairment, was total dependent and required two persons physical assistance for transfers, toileting and personal hygiene, was total dependent and required one person assist for eating, and was on a mechanically altered diet. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan (RCP) dated 2/11/2020 identified Resident #68 had a dysphasia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions directed to provide pureed consistency diet and honey thick fluids, to provide red handled teaspoon silverware, and to spoon feed fluids. Review of Resident #68's clinical record indicated that Person #1 was identified as Resident # 68's Emergency contact. Observation during lunch meal in the 2nd floor dining room of the facility on 3/11/2020 at 12:30 PM identified NA #4 feeding Resident #68 honey thick liquids by using a cup and without the benefits of using a teaspoon as identified in the resident's plan of care. In an interview and review of Resident # 68's diet slip with NA #4 on 3/11/20 at 12:35 PM, NA #4 stated she did not regularly feed residents in the dining room and was not aware of using the red teaspoon to feed Resident #68 fluids. Review of two diet slips located next to the resident's meal tray and within view of NA #4, directed, Fluids by Red Teaspoon Only. An interview with the Food Service Director on 3/11/2020 at 2:30 PM indicated use of the red handled teaspoon was as requested by Person #1 and use of the spoon was still relevant for use when feeding Resident #68. In an interview with the DNS on 3/12/20 at 10:45 AM, the DNS indicated that using the Red teaspoon to feed fluids to Resident #68 was requested by Person #1 and was trialed and the facility realized that using the spoon worked well for the resident. The DNS stated, using the teaspoon to feed fluids to Resident #68 was an approach, not a requirement and was done to accommodate Person #1. The DNS indicated she would have expected NA #4 to utilize the teaspoon when feeding fluids to Resident #68. A facility's policy on accommodation of preferences was not provided.

Based on review of the clinical record, facility documentation, facility policy and/or procedures and interviews for one of five residents reviewed of unnecessary medications (Resident #80), the facility failed to review and revise the plan of care in a timely manner with interventions to address the resident's behavioral of removing oxygen. The findings included: Resident #80's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment dated [DATE] identified the resident as cognitively intact, independent for most activities of daily living and receiving oxygen therapy. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . May titrate up to 0.5 liters to maximum of 4 liters as needed to maintain oxygen saturation greater than 90%. The RCP dated 11/27/19 identified a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included monitor every shift for dyspnea, fatigue, change in color amount and character of sputum including purulence, anxiety, irritability, low grade temperature, excessive somnolence, restlessness, aggressiveness, headache confusion, central cyanosis and shortness of breath at rest. Monitor vital signs, SPO2 as ordered and oxygen as ordered. The nursing notes dated 1/12/20 at 11: PM at 8:00 PM identified in part, the nurse was called into resident's room. Resident appears very agitated. Resident had taken off her/his oxygen, he/she had oral mucosal cyanosis. The nurse instructed resident to put his/her oxygen back on. The nurse's notes dated 1/14/2020 identified in part, that in the afternoon, Resident # 80 self-propelled in halls at a faster pace without oxygen on until lips appeared to be cyanotic and indicated the resident went to bathroom in bath core. The nurse went to bathroom question the resident why he/she was using this bathroom when his/her roommate was in halls, clearly not occupy bathroom. Resident refused oxygen but accepted. The nurse's notes dated 1/14/20 at 10:20 P.M. further identified in part, Resident alert, oriented, anxious, paranoid, removing oxygen throughout the shift, unable to be redirected. Family visited at 6:00 P.M. and (resident) was taken by family to recreational room. Resident # 80's mood and behavior improved instantly. The nurse's notes dated 1/21/20 at 10:00 P.M. identified in part, resident did not have his/her oxygen on. He/she had placed the disconnected tubing from his/her portable tank in his/her nose so he/she could fool the nurse into thinking he/she had his/her oxygen and indicated cyanosis was noted. The nurse returned the resident to recliner and applied the oxygen cannula attached to the concentrator. Review of the clinical record with the DNS on 3/12/20/at 2:40 PM indicated the resident always removes his/her oxygen, and is doing much better since starting [MEDICATION(S)] ( Anti-anxiety ) medication and although the care plan is comprehensive and further noted the resident is monitored for signs and symptoms that included cyanosis, anxiety, irritability, the use of oxygen, shortness of breath/lung sounds, and oxygen saturation according to the plan of care; the care plan failed to provide evident the interventions was put in place to address the resident's behavior of removing his/her oxygen.

Based on clinical record reviews, observations, review of facility documentation, review of policy and interviews for one sampled resident (Resident #68) who was reviewed for pain management, the facility failed to administer the medication in accordance to professional standards. The findings include: Resident #68's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan dated 2/26/19 identified resident # 68 had potential for pain related to arthritis and history of lower back pain, was not always able to express if pain was present, and staff to observe for signs and symptoms of pain such as facial expression, grimacing and rubbing back. Interventions directed, observe, ask resident, and if in pain administer pain medications as ordered and observe for effectiveness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #68 had severe cognitive impairment, was frequently incontinent of urine and occasionally incontinent of bowels, required extensive 2 person assist for bed mobility, transfers, and toilet use, and was on a scheduled pain medication regimen. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. directed [MEDICATION(S)] 50 mg tablet, give .25 tablet (12.5 MG) by oral route every 6 hours. Review of the controlled Substance Disposition Record indicated Resident #68 received [MEDICATION(S)] ½ tab (25MG) on 10/4/19 at 7:00 P.M. In an interview with RN #3 on 3/11/2020 at 12:15 PM, RN #3 indicated she administered the incorrect dose of [MEDICATION(S)] to Resident #68 on 10/4/19. RN #3 identified a current order for [MEDICATION(S)] 12.5 MG was in place, but she inadvertently administered the previously ordered dose of 25 MG as she was distracted. RN #3 also indicated she should have double checked the order and the medication prior to administering the dose. An interview with the DNS on 3/11/2020 at 12:20 PM indicated the medication error was a human error. The DNS further indicated that RN #3 was counseled on the importance of reading the order on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS also further indicated that the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ¼ tablet. Review of the Medication Administration policy directed, administer medication to resident correctly: right resident, right drug, right dose, right route, right time and right frequency.

Based on clinical record reviews, observations, review of facility documentation and interviews for one sampled residents (Resident #68) who was reviewed for pain management and who utilized an anticogulant medication , the facility failed to administer the resident's medications per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1 a.Resident #68's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Care Plan dated 2/26/19 identified resident # 68 had potential for pain related to arthritis and history of lower back pain, was not always able to express if pain was present, and staff to observe for signs and symptoms of pain such as facial expression, grimacing and rubbing back. Interventions directed, observe, ask resident, and if in pain administer pain medications as ordered and observe for effectiveness. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #68 had severe cognitive impairment, was frequently incontinent of urine and occasionally incontinent of bowels, required extensive 2 person assist for bed mobility, transfers, and toilet use, and was on a scheduled pain medication regimen. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. directed [MEDICATION(S)] 50 mg tablet, give .25 tablet (12.5 MG) by oral route every 6 hours. Review of the controlled Substance Disposition Record indicated Resident #68 received [MEDICATION(S)] ½ tab (25MG) on 10/4/19 at 7:00 P.M. In an interview with RN #3 on 3/11/2020 at 12:15 PM, RN #3 indicated she administered the incorrect dose of [MEDICATION(S)] to Resident #68 on 10/4/19. RN #3 identified a current order for [MEDICATION(S)] 12.5 MG was in place, but she inadvertently administered the previously ordered dose of 25 MG as she was distracted. RN #3 also indicated she should have double checked the order and the medication prior to administering the dose. An interview with the DNS on 3/11/2020 at 12:20 PM indicated the medication error was a human error. The DNS further indicated that RN #3 was counseled on the importance of reading the order on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS also further indicated that the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ¼ tablet. b. Resident #68's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] identified Resident #68 had severe cognitive impairment, was frequently incontinent of urine and occasionally incontinent of bowels, required extensive 2 person assist for bed mobility, transfers, and toilet use, and was on a scheduled pain medication regimen. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. directed Resident #68 to administer [MEDICATION(S)] (Anticoagulant) 2.5 MG tablet give 1 tablet (2.5 MG) by oral route once daily for 7 days. Resident # 68's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's [MEDICATION(S)] Therapy worksheet indicated Resident # 68's international normalized ratio (INR) level on 3/13/19 was 2.78 and 2.52 on 3/20/19 (Normal Range 0.8-1.2). An interview with RN #2 (Nursing Supervisor, 3-11 PM shift) on 3/11/2020 at 2:05 PM indicated the facility's practice is to administer [MEDICATION(S)] at 5:30 PM and Resident #68 had been receiving [MEDICATION(S)] at 5:30 PM. RN #2 further indicated she recalled taking the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview with LPN #1 (charge Nurse, 3-11 PM shift) on 3/12/2020 at 9:40 AM, LPN #1 indicated she worked on the 3-11 PM shift on 3/13/19 and the [MEDICATION(S)] was not scheduled during the 3-11 PM shift. LPN #1 also indicated she was not the nurse who usually worked on the unit or she may have identified the error in the timing. In an interview with the DNS on 3/12/2020 at 11:00 AM identified the transcription error led to an omission of a dose of [MEDICATION(S)] and indicated that Resident # 68's INR levels were not negatively affected. Review of the Medication Administration policy directed, administer medication to resident correctly: right resident, right drug, right dose, right route, right time and right frequency.

Based on clinical record reviews, observations, review of facility documentation, review of policy and interviews for one of three sampled residents (Resident #68) who were reviewed for quality of care, the facility failed to ensure hand hygiene was performed after perform hand hygiene to prevent the spread of infection. The findings include: Resident #68's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] identified Resident #68 had severe cognitive impairment, was total dependent and required two persons physical assistance for transfers, toileting and personal hygiene, and was always incontinent of urine and bowel. The RCP dated 2/11/2020 indicated Resident #68 was incontinent of bladder and bowel. Interventions directed to provide briefs to maintain dignity and to provide incontinence care after each incontinent episode. Observation of incontinent care provided to Resident #68 on 3/10/20 at 11:30 AM by NA #1 and NA #2 identified NA #1 and NA #2 performed incontinent care without issues. However, after removing their gloves used during providing incontinent care to Resident #68 NA #1 left the resident's room without the benefits of performing hand hygiene. Also, after removing gloves, NA #2 was observed providing care to Resident #49 without the benefits of performing hand hygiene after providing incontinent care to Resident # 68. In an interview with NA #1 and NA #2 on 3/10/20 at 11:40 AM NA #1 indicated she performed hand hygiene with the use of a hand sanitizer after removing the gloves and after leaving the resident's room. NA #2 identified she should have washed her hands after removing her gloves and before providing care to Resident #49. In an interview with RN #1 (Staff Development) on 3/10/20 at 11:50AM, RN # 1 identified staff were educated to perform hand hygiene by washing hands with soap and water or by using a hand sanitizer. RN #1 also indicated that rev NA #2 was expected to perform hand hygiene after removing gloves after providing care, before leaving a resident's room, and before rendering care to another resident. Review of the facility's Hand Hygiene policy directed the use of gloves does not replace handwashing, Gloves are removed when the need for protection no longer exists and should be disposed of before leaving room and hand hygiene should be practiced after removal of gloves.

Based on interviews with residents, review of policy and interview, the facility failed to ensure that mail was delivered on Saturday to residents. The findings include: 0n 3/10/20 1:07 PM on 12/17/19 during Resident Council Interview identified several residents who indicated they did not receive mail on Saturdays at the facility. Interview with the Administrator on 3/11/20 at 1:35 P.M. identified when she spoke to the receptionist about mail delivery on Saturday, the receptionist indicated she /he indicated mail had not been delivered to residents since September 2019. Subsequent to inquiry, the administrator put a plan in place to ensure mail delivery on Saturday.

Based on clinical record review, observation, review of facility policy and/or procedures and interviews for one sampled resident's reviewed for respiratory care (Resident #41), the facility failed to properly store respiratory equipment when not in use to prevent the spread of infection. The finding include: Resident #41's [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident as moderately impaired for decision-making skills, without behaviors and requiring extensive assistance from staff for most activities of daily living. The physician's monthly orders for (MONTH) 2019 directed [MEDICATION NAME] 0.5 mg - 3 mg (2.5 mg base) 3ml solution for nebulization give 3 ml by nebulization ([MEDICATION NAME]-[MEDICATION NAME]) every 8 hours to be given at 6:00 A.M., 2:00 P.M. and 10:00 P.M. On 1/28/19 at 11:14 P.M. during an interview with Resident #41, the resident expressed a concern that the staff does not properly store his/her respiratory equipment in a plastic protective storage bag after his/her treatment was completed. On 1/29/19 at 11:20 A.M. an interview and review of the clinical record with LPN#1 identified Resident # 41 received a [MEDICATION NAME] treatment (respiratory treatment ) at 6:00 A.M. and the resident was scheduled to receive an additional respiratory treatment at 2:00 P.M. Upon observation of the respiratory mask with LPN#1 identified the mask was dry and free from moisture. The mask was placed with the opening of the mask faced down on a napkin and/or paper towel with the medicine cup attachment placed beside without the benefit of the mask being stored in a protective storage bag. LPN#1 indicated after the resident's respiratory treatment is completed, the respiratory equipment is washed, placed on the paper towel to dry and once it is dried, the mask is placed in the plastic storage bag. Subsequent to surveyor's inquiry, LPN#1 placed the dried respiratory equipment in the protective storage bag. On 1/30/19 at 12:10 P.M. an interview and review of the clinical record, review of facility policy and/or procedures with the DNS indicated following the resident's respiratory treatment, the nebulizer equipment and/or respiratory equipment is washed and set on a clean napkin until it dries and then put away. The DNS further indicated that based on the time which lapsed between the resident receiving his/her treatment (6:00 A.M.) and the time the resident expressed a concern about his/her respiratory equipment the equipment had not been put away (11:14 A.M.). The DNS indicated that once the resident's respiratory equipment was dried staff failed to place the equipment in a storage bag. According to the facility's policy and/or procedures for respiratory care equipment maintenance and cleaning noted in part, respiratory equipment is maintained in a clean and safe manner. Respiratory equipment is stored in plastic bag when not in use and the bags are changed weekly.

Based on clinical record review, review of facility documentation, interview, and policy review for two of six residents' reviewed for accidents (Resident #2 and Resident #3), the facility failed to ensure the plan of care was followed resulting in fall with injury and/or that a system was in place to assess resident's to determine the appropriate size mechanical lift pad to be used for transfers. The findings include: 1. Resident #2's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The annual MDS assessment dated [DATE] identified that Resident #2 was unable to recall the correct day, month or year, was unable to recall words, required total assist of two staff for transfers, and had physical behavior symptoms of hitting, kicking, pushing, scratching, and grabbing others on four to six out of the last seven days. The Resident Care Plan (RCP) dated 5/8/18 identified the resident had behavioral symptoms and was combative with care with interventions that directed, in part, if combative, re-approach at a later time, and if still resistive or combative to enlist the help of licensed staff, and transfer with two assist and Hoyer lift. The nurse's note dated 5/30/18 at 4:30 PM identified that R #2 became combative during a Hoyer lift transfer with two Nurses Aides and the pad attached to the Hoyer lift became disengaged. R #2 was found at the base of the Hoyer on his/her back, RN assessed R #2 with no injuries noted and R #2 was transferred back into bed. Staff then noted a swelling to the left occipital area and a hematoma to the right inner calf and thigh, and R #2 was transferred to the emergency room . Review of the facility incident report dated 5/30/18 at 4:30 PM identified when R #2 was combative during the Hoyer lift transfer, one clip of the Hoyer pad became disengaged and R #2 slipped out of the sling and onto the floor. The Hospital discharge summary dated 5/30/18 identified R #2's CT scan results identified a right posterior falcine subdural hematoma which extended along the right tentorium measuring 0.6 centimeters (cm) thick, a trace subarachnoid hemorrhage in the left frontoparietal sulci medially near the falx, and left parietal soft tissue swelling with underlying left parietal bone fracture. The report further stated neurosurgery felt given R #2's age along with baseline neurological status, no additional interventions was appropriate, and the plan of care was discussed with Resident #2's family who agreed with the plan. Review of the clinical record during the period of 5/30/18 through 6/2/18 identified that the resident continued to decline, the physician was aware, and although requested the resident be transferred to the hospital, the resident's son requested no transfer based on the hospital recommendation that any intervention for the subdural hematoma was not in R #2's best interest due to R #2's age and comorbidities with the plan to focus on comfort care. A nurse's note dated 6/2/18 identified at 11:45 AM, R #2 was noted with no respirations, and RN pronounced death at 11:50 AM. Review of the Death Certificate dated 6/2/18 identified the cause of death was complications of [MEDICATION NAME] force head trauma caused by a fall out of a patient lift assist device. Clinical record review, facility documentation review, and interview with NA #1, on 7/24/18 at 9:57 AM identified that R #2 became combative when NA #1 and NA #2 placed the Hoyer pad under R #2, and then R #2 calmed down. NA #1 stated R #2 became combative (kicking, punching, and grasping at both NA's) when connected to the Hoyer pad, reported she make sure the pad was securely hooked to the lift, and used the Hoyer lift to raise R #2 off the bed, while R #2 was combative and kicking. NA #1 identified that they moved the Hoyer lift away from the bed toward the wheelchair while R #2 continued to kick. NA #1 stated while R #2 was suspended in the air over the floor, the right thigh hook holding the sling in place came undone, and R #2 slipped to the floor. NA #1 stated she should have stopped the transfer when R #2 was combative before being lifted off the bed, and told the nurse. An additional interview with NA #1 on 7/24/18 at 10:50 AM identified she did not remember what size Hoyer lift sling she used to transfer R #2 out of bed on 5/30/18. Interview with NA #2 on 7/26/18 at 9:55 AM identified she was the assigned NA for R #2 on 5/30/18, and when she and NA #1 placed the Hoyer lift sling under R #2, R #2 became combative, and was kicking and grabbing at the NA's. NA #2 further stated when they attached the Hoyer lift, and began to lift R #2 off the bed, R #2 continued to be combative and kick at the NA's. NA #2 stated she did not notify the nurse that R #2 was combative, and did not stop the transfer. NA #2 stated when R #2 was in the air over the floor, R #2 was kicking upwards, and the sling came undone and R #2 slid to the floor. NA #2 further identified she did not remember what size sling was used for R #2's Hoyer lift transfer on 5/30/18, this information was not noted on the NA care card and/or the care plan. NA #2 stated the Nurse Aide's chose whichever size to use at the time of the fall. Interview, record review, and facility documentation review with RN #3 on 7/25/18 at 11 AM identified no staff had notified her that R #2 was agitated or combative when NA #1 and #2 attempted to transfer him/her out of bed on 5/30/18. RN #3 further stated that she had no idea which size sling was used to transfer the resident out of bed that day. Interview, clinical record review, and facility documentation review with the DON and ADON on 7/24/18 at 11:37 AM identified NA #1 and NA #2 should not have transferred R #2 out of bed when combative, and they should have notified the nurse. The ADON stated she responded to the room when R #2 fell , and observed that the clip had come undone but was not broken or damaged. An additional interview with the ADON on 7/25/18 at 10:20 AM stated NA #1 and NA #2 transferred the resident out of bed using an extra-large size Hoyer lift sling, but should have used a large lift pad. The ADON further stated there was no resident assessment completed to determine the correct size sling for R #2, however, the facility did not feel this contributed to the resident's fall because the large and extra-large slings could be interchangeable based on her discussion with the supplier. During this period of time, the Nurse Aides made the decision as to which size Hoyer pad to use, however, subsequent to the resident's fall, all residents have been assessed for the correct Hoyer lift sling size, and that information was added to the NA care cards. Interview, clinical record review, and facility documentation review with Physician #2 on 7/24/18 at 11:48 AM identified although she wrote the cause of death was acute [MEDICAL CONDITION] and subdural hematoma, due to R #2's age she could not say the exact cause of death. Review of facility Nursing Standards Policy, directed in part, the Registered Nurse supervises, plans, and evaluates the total nursing care for each resident. Review of facility Nursing Shift to Shift Report and Guidelines Policy, directed in part, that pertinent information was to be communicated to the Nurse Aides. 2. Resident #3's [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] identified that R #3 was unable to recall the season or staff, that he/she was in a nursing home, and required extensive assistance of two staff for transfers. The Resident Care Plan (RCP) dated 12/6/17 identified the resident was at risk for falls with interventions that directed to use dycem on the wheelchair/recliner seat, and offer nap in recliner. A physician's orders [REDACTED]. The Nurse's Aide care card dated 1/5/18 directed to use dycem in the recliner. A nurse's note dated 1/6/18, with no time noted, identified that R #3 was found on the floor, complained of left rib pain, had redness noted on the left [MEDICATION NAME] area, 911 was called, and R #3 was transferred to the hospital at 6:30 PM. Facility incident report dated 1/6/18 at 6:20 PM identified R #3 was found lying on his/her left side between his/her recliner and bed, and complained of left rib area pain. R #3 was unable to explain how he/she fell , and the report further identified R #3 had been sitting in a leather recliner, and possibly slid out of the recliner. Review of the hospital CT scan report dated 1/6/18 identified the resident had diffuse osseous demineralization, superior endplate [MEDICAL CONDITION] vertebral body new from the previous study, and acute appearing compression deformities of T11, L2, and L3. The nurse's note dated 1/7/18 at 12:30 AM identified R #3 returned from the hospital. The care plan was updated on 1/6/18 to remove the recliner from the room and to utilize the bed for rest periods. Interview, record review, and facility documentation review with NA #3 on 7/26/18 at 11:34 AM identified she found R #3 on the floor, and the chair alarm was not sounding. NA #3 stated although she had seen R #3 earlier in the shift and R #3's chair alarm was attached to R #3, when she found R #3 on the floor the chair alarm was not attached to R #3 and was not alarming. NA #3 further stated although R #3 should have had dycem on his/her recliner chair, she could not recall if the dycem was in the recliner, and could not recall the position/elevation of the recliner seat when she found R #3 on the floor. Interview and record review with the ADON on 7/26/18 at 9:26 AM identified R #3 had been sitting in his/her electric leather recliner and was found on the floor. The ADON stated R #3 would have been sitting on a soaker pad, thought R #3 slid out of the recliner, and stated dycem should have been on R #3's recliner. The ADON stated although staff are interviewed when a fall investigation is completed, this fall investigation did not include, staff/witness statements, documentation of the elevation/position of the recliner seat at the time of the fall, if the chair alarm was in place and/or was alarming, and if dycem was in the recliner in accordance with the plan of care. Review of facility Fall Investigation Policy, directed in part an investigation is to be completed at the time of the fall to assist in developing a plan to decrease falls. Review of facility Falls Prevention Program directed in part, a resident found on the floor will have a fall investigation completed, and will include details on the circumstances surrounding the fall. The policy further directs a thorough investigation of the fall is a fact-finding mission to uncover the cause and remove it if possible, and the goal is to prevent future falls.

Based on review of the clinical records, facility documentation and interviews for two of six residents (Residents #48 and #72) reviewed for accidents, the facility failed to provide care per the care plan and/or appropriate supervision to prevent an accident with injury. The findings include: 1a. Resident #48's [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] identified intact cognition and memory, reports of feeling tired, little energy, no history of refusals of care, extensive assistance of two for bed mobility, transfers and toilet use. The care plan dated 2/5/11 identified decreased balance and a [DIAGNOSES REDACTED]. Additionally, the care plan identified the resident was deconditioned and weak with interventions that included providing extensive assist of two for transfers. The nurse's note dated 2/12/11 identified the resident reported twisting the right ankle when being transferred to bed from the wheelchair. R #48 indicated both legs were dangling when he/she sat on the bed and the right foot was caught in the side rail. Pain was noted on palpation and a 0.2 centimeter (cm) by 0.7cm red mark was noted on the outer right leg. The physician was notified and directed to obtain an x-ray of the right foot and ankle. The x-ray dated 2/12/11 identified a spiral linear fracture of the distal tibia and the resident was transferred to the emergency department for treatment that included application of an air cast. Clinical record review and interview with Registered Nurse Supervisor (RNS) #2 on 7/14/11 at 11:10 AM indicated she was notified of the incident on 2/12/11 and conducted an assessment of the resident. RNS #2 indicated that Nurse Aide (NA) #7 reported she transferred R #48 from the wheelchair to the bed on 2/12/11 alone. RNS #2 indicated NA #7 stated she did not request another staff member to assist because she did not know the resident required two staff members for transfer. RNS #2 identified NA #7 further indicated she did not read the nurse aide assignment prior to conducting the transfer. Interview with NA #7 on 7/14/11 at 2:00 PM indicated she conducted the transfer on 2/12/11 alone by holding the resident under the arms in an embrace and pivoting the resident to sit on the bed. NA #7 indicated she did not use a gait belt to transfer the resident and noted that when R #48 was seated on the bed, the resident reported hitting something and indicated his/her right leg hurt. Interview with Radiologist #1 on 7/14/11 at 3:45 PM identified a spiral fracture which was identified in the 2/12/11 x-ray report is caused from a twisting motion, shearing force or an outside mechanical force. b. Interview with the Director of Nurses (DNS) on 7/15/11 at 9:00 AM indicated facility policy directs to use gait belts to assist in transferring and/or ambulating residents to insure safety of both the resident and the staff member. The DNS indicated that all staff members are in-serviced to use a gait belt for transfers and ambulation unless stated otherwise in the care plan. Review of R #48's care plan with the DNS at the time did not indicate not to use a gait belt for transfers. The DNS was unable to identify why NA #7 failed to use a gait belt per facility policy during the transfer on 2/12/11. 2. Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The resident care plan dated 1/29/11 identified altered mobility with interventions that included providing assistance of two staff with mechanical lift. The nurse's note dated 2/26/11 at 6:45 AM identified that during a transfer from the toilet the resident sustained [REDACTED]. The physician was notified and directed to transfer the resident to the emergency department for an evaluation. The hospital discharge summary dated 2/26/11 identified 12 sutures were required to approximate the laceration. The Reportable Event and investigation dated 2/26/11 identified Nurse Aide (NA) #2 and NA #3 were transferring the resident from the toilet with the use of the Sara mechanical lift. NA #2 stood behind the lift operating the controls and NA #3 stood next to the resident during the transfer. R #72's hands were on the horizontal handles of the Sara lift and when the lift was raised, the resident's fifth finger on the right hand was pinched between the handle of the Sara lift and the bathroom grab bar. The investigation indicated there was a tighter fit in the bathroom with the new Sara lift than was ideal. Interview with the Maintenance Director on 7/13/11 at 2:07 PM identified the bar (side handle) of the Sara mechanical lift caught under the grab bar on the wall in the bathroom during the transfer and bent requiring replacement. Interview with NA #3 on 7/14/11 at 7:25 AM indicated she could not see the resident ' s hand during the transfer on 2/26/11 because she was standing on the opposite side of the resident. NA #3 further indicated she did not use the Sara lift frequently on the night shift. Interview with the Director of Nurses (DNS) and the Administrator on 7/14/11 at 8:05 AM indicated the Sara mechanical lift did not function well in the resident's bathroom because the horizontal handles on the lift protruded outward. The DNS and Administrator indicated the grab bars in the bathroom that were in place on 2/26/11were removed and replaced and the Sara lift was modified by removing the horizontal handles in an effort to prevent any further lift device accidents. Review of the facility weight bearing mechanical lifts policy and procedure identified in part to make sure the brakes are locked and the resident is positioned safely. A facility Mechanical Lift Safety Review in-service dated 1/18/10 identified 2 staff members are required to operate any mechanical lift device. One person is responsible for operating the lift controls and the other person monitors the resident throughout the lift to ensure a safe transfer.