Every finding on record at Kendal at Lexington

Based on staff interview, facility document review, and clinical record review, the facility failed to provide staff assistance and supervision for a safe transfer for one of sixteen residents (Resident #1), resulting in a fall with fracture (harm). The findings include: Resident #1 (R1) fell when a privately hired companion/sitter attempted to transfer R1 from the bed to a wheelchair. The private companion did not request facility staff assistance with the transfer and had no prior documented training of facility policies that prohibited private caregivers/companions from performing direct-care activities, including transfers. R1 was diagnosed with a right distal femur fracture, as a result of the fall, and required treatment with immobilization and pain medication. Resident #1 was admitted to the facility with diagnoses that included dementia, hypertension, osteoporosis, urinary tract infection, osteoarthritis, conjunctivitis, gastroesophageal reflux disease, and depression. The minimum data set (MDS - assessment tool), dated 2/22/24, assessed R1 with severely impaired cognitive skills and requiring extensive assistance of two staff for bed mobility and transfers. R1's clinical record documented a nursing note dated 4/20/24 stating, .Incident Time . [9:05 a.m.] . Rsd [Resident's] private caregiver was trying to transfer Rsd from bed to wheelchair without staff assistance. Rsd R [right] Knee gave out and Rsd slid from bed to floor with assistance from caregiver. Rsd c/o [complained of] R knee pain . (sic) The nursing note documented that the family and physician were notified, with the family requesting to not immediately send the R1 to the emergency room but assess the status the next morning. A nursing note on 4/21/24 documented that R1 developed increased swelling, bruising, and pain of the right leg and that R1 was sent to the emergency room for evaluation/treatment. The hospital discharge summary dated 4/22/24 documented that R1 was diagnosed with a distal right femur fracture, as a result of the fall. R1 was assessed by orthopedics and treated with a knee immobilizer to be in place for 6 to 8 weeks, along with pain management. R1 was readmitted to the facility on [DATE] with orders for bed rest with the right leg immobilized as ordered. R1 was administered pain medication due to right leg pain on 4/22/24 at 7:23 p.m. and on 4/23/24 at 8:54 a.m. with effective results. A note by the nurse manager dated 4/22/24 documented, After further investigation and discussion with staff r/t [regarding] fall on 4/20/24 it is determined to be of known cause. The fall is consistent with resident caregiver performing a transfer without assistance from staff causing Resident to fall. The fall resulted in a right femur fx [fracture] . R1's plan of care prior to the fall (revised 4/12/24) documented the resident required the extensive assistance of 1 to 2 staff persons with all transfers and use of a mechanical lift as needed. The care plan also listed the resident required extensive assistance of 1 to 2 staff persons for dressing, bed mobility, and toileting. R1's clinical record documented the resident was assessed/treated for a urinary tract infection starting on 4/8/24. Staff referred R1 for a therapy evaluation on 4/11/24 due to a decline in status and increased need for assistance with activities of daily living. R1's therapy communication form to nursing dated 4/11/24 documented a physical therapy recommendation for transfer with a Hoyer mechanical lift until the resident could stand, step and turn to use a walker. This recommendation was modified on 4/12/24 to use of a Hoyer lift as nursing deems necessary because the family did not want the resident to transition to total dependence with the lift. Therapy documented an additional communication to nursing on 4/16/24 recommending, When transferring pt [patient] 2 person, do not arm and arm unless the chair is touching the bed. On 4/22/24 at 3:25 p.m., the licensed practical nurse (LPN #1) caring for R1 on 4/20/24 was interviewed. LPN #1 stated R1 had private sitters/caregivers during the day. LPN #1 stated that on 4/20/24, the private caregiver was trying to transfer R1 from the bed to wheelchair, when the resident's knee gave out and the resident slid to the floor. LPN #1 stated there were no staff members with R1 at the time of the fall and the private caregiver had not requested or called for assistance with the resident. LPN #1 stated private companions/caregivers were not allowed to perform any resident transfers or provide direct ADL (activities of daily living) care for residents. LPN #1 stated a certified nurses' aide (CNA) had performed incontinence care with R1 earlier in the shift and that the private caregiver (other staff #3) transferred the resident without requesting or calling for assistance from staff. LPN #1 stated R1 required two people for a safe transfer as the resident had experienced a recent decline since diagnosed with a urinary tract infection. LPN #1 stated the resident had been weaker since the infection, was evaluated by therapy, and that two staff members were provided during transfers to ensure safety. LPN #1 stated again that the private caregivers were not supposed to transfer residents and thought they had received training about their role. LPN #1 stated she and two CNAs were working on R1's unit and were available on the morning of 4/20/24. On 4/22/24 at 3:35 p.m., CNA #4 that routinely cared for R1 was interviewed. CNA #4 stated R1 had required two-person assistance during the last several weeks because of weakness following an infection. CNA #4 stated being aware that R1 had a private companion/caregiver, but the private sitters were not supposed to provide direct care or transfers. CNA #4 stated that in the last month, he always had two people when transferring R1. On 4/22/24 at 3:43 p.m., CNA #5 that routinely cared for R1 was interviewed. CNA #5 stated she always used two people when transferring R1 because the resident had been weak in the last several weeks due to an infection. CNA #5 stated there had been times when she entered R1's room and the private caregiver had already assisted the resident into the wheelchair. CNA #5 stated she was not working on 4/20/24 when the resident fell . CNA #5 stated that the private companions/caregivers usually rang the call bell or verbally requested assistance when R1 needed care. On 4/23/24 at 11:35 a.m., CNA #3 that routinely cared for R1 was interviewed. CNA #3 stated only staff members were supposed to perform resident transfers. CNA #3 stated that she always used a two-person transfer with R1. CNA #3 stated R1's care guide required 1 to 2 staff persons or a lift for transfers. CNA #3 stated that the private companions/sitters were not supposed to transfer residents. On 4/23/24 at 11:56 a.m., the nurse manager (LPN #2) was interviewed about R1's fall/injury. LPN #2 stated R1 had sitters during the day. LPN #2 stated facility staff were supposed to perform all transfers with residents. LPN #2 stated that private caregivers had been instructed to use the call bell or come get staff for needed assistance with transfers. LPN #2 stated on 4/20/24, the private companion/caregiver did not request or call for assistance prior to the attempted transfer. LPN #2 stated no staff members were present at the time of the fall to make decisions and provide required assistance for a safe transfer. LPN #2 stated the CNAs knew and had previously provided the needed assistance for safe transfers for R1. LPN #2 stated the CNAs reported the resident's need for assistance increased after a urinary tract infection several weeks ago. LPN #2 stated R1 was referred to therapy in response to the decline. LPN #2 stated the private companions/sitters were supposed to be educated prior to working and should know to get staff for resident needs. On 4/23/24 at 1:51 p.m., the physical therapist (PT - other staff #2) that evaluated R1 was interviewed. The PT stated staff had reported a decline and R1 was recommended on 4/12/24 for transfers with the use of a mechanical Hoyer lift as needed. The PT stated she told the weekday private companion that she should not transfer or walk the resident by herself. The PT stated the fall/fracture occurred on a weekend (4/20/24) and was not sure if the transfer recommendations were communicated to the private caregiver that worked weekends. On 4/23/24 at 2:05 p.m., the director of nursing (DON) was interviewed about R1's fall/fracture. The DON stated private companions/caregivers were not allowed to provide direct ADL care or transfers for residents in the facility. The DON stated private caregivers were required to ring the call bell or verbally request assistance from the nurse or CNA assigned to the resident. The DON stated R1 had a recent decline due to a urinary tract infection, was evaluated by therapy and had the option for a mechanical lift transfer if needed. The DON stated nursing was providing 2-person assistance during transfers with R1 since the decline/infection to ensure safety. The private caregiver with R1 at the time of the fall on 4/20/24 was named by the DON and identified as other staff #3. The DON stated other staff #3 usually worked the weekends. The DON stated families were instructed upon admission that sitters were just companions and were not allowed to perform resident care. The DON stated the private caregivers and CNAs were instructed that companions/sitters were not to provide direct care including transfers. The DON stated on 4/20/24, R1's private caregiver (other staff #3) came in the hall and stated R1 was in the floor. The DON stated other staff #3 said the resident slid from the bed while attempting to transfer R1 from the bed to wheelchair and that other staff #3 had not asked for staff assistance. The DON stated the private caregiver (other staff #3) said that she knew she was supposed to call staff but did not because she thought she could do it. The DON stated it was the facility's policy/protocol for private sitters/caregivers to be only companions and were not to transfer residents. On 4/23/24 at 2:49 p.m., the private companion/caregiver (other staff #3) with R1 at the time of the fall was interviewed. The private companion stated that nurses or CNAs were supposed to transfer residents. The private companion stated on 4/20/24, R1 was sitting on the side of the bed getting ready to get up in the wheelchair. The private companion stated R1 started sliding and I couldn't stop her, so I let her go down. The private companion stated she went in the hall and got the nurse and CNA to come assess the resident. The private companion stated she had not asked or called for assistance from staff prior to getting the resident up on the bedside. The private companion stated she was sure the staff would have responded if she had requested their assistance. The private companion stated she was aware that only facility staff were supposed to provide direct care and transfers for residents. When asked if she had transferred the resident before without staff, the private caregiver stated she had transferred R1 to the wheelchair and taken R1 to the bathroom by herself, but this was prior to the resident's recent urinary tract infection. On 4/24/24 at 8:49 a.m., CNA #6 working on R1's unit on the morning of 4/20/24 was interviewed. CNA #6 stated the R1's weekday sitter always called for help with the resident. CNA #6 stated she did not work with the other sitter (other staff #3) very often because other staff #3 usually worked on the weekends. CNA #6 stated on 4/20/24, the private companion (other staff #3) did not ring the call bell or ask for assistance until after R1 was in the floor. On 4/24/24 at 8:57 a.m., CNA #7 working on R1's unit on the morning of 4/20/24 was interviewed. CNA #7 stated she was helping another resident when R1's private companion (other staff #3) came down the hall and said the resident was in the floor. CNA #7 stated she went to R1's room and saw the resident in the floor, parallel to the bed with her back against the nightstand. CNA #7 stated when she asked what happened, the private companion stated she did not know. CNA #7 stated the private companion did not call or ask for assistance until after R1 was in the floor. CNA #7 stated the private sitter that worked during the weekdays always called staff for transfers and ADL tasks. CNA #7 stated there had been times when the weekend sitter (other staff #3) had transferred R1 without staff assistance because R1 would be up in the wheelchair when she entered the room. CNA #7 stated she did not know why the private companion did not ask for help on the morning of 4/20/24 because she, LPN #1 and CNA #6 were on the unit. The facility's policy titled Guidelines for Companions (revised 5/30/2014) documented, It is our policy, as well as our responsibility, to meet the needs of resident while they are at [the nursing facility]. However, there may be times when residents and/or their families wish to employ companions .The role of the private duty companion is to provide fell owship and social support through activities which might include .Taking residents (in a wheelchair) to programs .Joining residents in recreational activities .Taking the resident to meals at mealtime if needed, and to assist with menu selection .enhancing grooming, manicures, hairstyling, choosing clothing, donning a sweater .Light housekeeping . This policy documented under companion guidelines, .Nursing care will be provided by [nursing facility] staff; a companion in [the nursing facility] may, with proper state approved training and physical ability, assist in the presence of staff .[In the nursing facility] a resident is not lifted or transferred without the assistance of a staff member and only if the companion has proper state approved training and is physically capable .The nursing staff is responsible for all nursing care . This policy documented all companions were required to complete an orientation that included key information such as emergency protocols, safety, infection control, resident rights and that the orientation requirements must be completed prior to the day the companion starts. The policy documented that a list of approved companions meeting the requirements was maintained and available upon request. On 4/24/24 at 8:30 a.m., the administrator and DON were interviewed about R1's private companion/caregiver (other staff #3) and any prior training/orientation regarding the private caregiver role/duties. The administrator stated R1's private companion (other staff #3) had worked with R1 in independent living, prior to her admission to skilled, but had served as companion to R1 mostly on weekends since admission to the long-term care facility. The administrator stated R1's private caregiver (other staff #3) was not included on the facility's list of approved companions. The DON stated that she found no documented training and/or orientation for R1's companion (other staff #3). The DON stated that the companion (other staff #3) had said that she completed paperwork before she started working as a sitter, but the DON stated, We don't have it. The DON stated that the companion (other staff #3) was not a CNA and had no record of any state approved training for resident care. The administrator stated the training and orientation requirements regarding the private companion's role/duties should have been completed prior to her working in the nursing home facility. On 4/24/24 at 9:30 a.m., the human resources assistant (HR - other staff #4) was interviewed about private companion/caregiver (other staff #3). The HR assistant stated that companion candidates required an orientation/training process prior to working with any residents in the long-term care facility. The HR assistant stated he did not know what happened regarding training/orientation for other staff #3. The HR assistant stated he researched back several years and found none of the required training, orientation, or annual in-services for R1's companion (other staff #3) and that other staff #3 was not on the facility's list of approved companions. These findings were reviewed with the administrator, DON and nurse manager during meetings on 4/23/24 at 4:10 p.m. and on 4/24/24 at 11:00 a.m. with no further information presented prior to the end of the survey.

Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections having the potential to affect residents on 2 of 2 nursing units. The findings included: 1. The facility staff failed to respond to and implement quarantine and testing measures in accordance with CDC (The Centers for Disease Control and Prevention) recommendations to manage COVID-19 during an outbreak affecting 1 of 2 units. On 4/22/24 at 4:19 p.m., and again on 4/23/24 at 08:35 a.m., interviews were conducted with the facility's infection preventionist (IP). The IP stated that when they have a COVID case they start a line tracking to track exposure. The facility had a COVID outbreak that began on 3/15/24. The IP reported that they conducted staff testing on days 1, 3 and 5-7. Residents were tested on [DATE] and 3/18/24, both instances revealed additional cases of COVID-19. The IP further reported that residents were quarantined for 5 days and encouraged to wear a mask following the 5 days of isolation. The IP reported that when staff tested positive, they were tested again on days 5 and 7, and could return to work on day 7 if negative on both test but wear a mask until 10 days is over. On the afternoon of 4/23/24, the surveyor showed the IP and facility Administrator the document from CDC titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, with a revision date of March 18, 2024. Both indicated they were not familiar with the document. The surveyor offered to provide a copy, but the facility administrator stated he had obtained a copy. On 4/23/24 at 1:17 p.m., a telephone call was held with the Mitigation Specialist (MS) at the facility's local health district. The MD reported that she didn't recall having a significant conversation with the facility but did receive some line listings to report a COVID outbreak. The MS did report she had difficulty and was never able to make contact with someone at the facility to schedule an on-site visit to offer as a resource. As for specific recommendations, the MD stated that none had been given and that the expectation was that the facility would follow the CDC guidance to include a quarantine period of 10 days. On 4/23/24, clinical record reviews were conducted of a sample of residents who had tested positive for COVID-19. It was revealed that each of the residents had physician orders for droplet isolation for 5 days, with the date of positive test being day 0. On the afternoon of 4/23/24, during an end of day meeting, the facility administrator and director of nursing were made aware of the concern that the facility was not conducting testing and quarantine guidelines within the CDC recommendations. On 4/24/24, the facility administrator provided the survey team with a COVID-19 policy, which had previously been requested on several occasions but not previously received. On the morning of 4/24/24, employee timecards were reviewed which revealed that employees were permitted to return to work on day 7 following 2 negative tests and day 10 following the initial positive test if testing on day 5 or 7 were positive. On 4/24/24, the facility's policy titled, COVID-19 plan was received and reviewed. The policy did not address the duration of the quarantine period for residents or staff who test positive for COVID-19. The policy also did not address the frequency or manner in which COVID-19 testing would be conducted. The facility did provide an additional document titled, COVID Guidelines 2024, with an updated date of 3/18/24, which the IP and administrator reported they were following. This document read in part, Exposed staff, resident: wear mask for x 10 days, COVID test to be done Day 1, Day 3, Day 5. Positive Staff member: Stay home for x 7 days from when symptoms started. Test on day 5 and again on day 7 if both are negative may return to work on day 7. If staff tests positive, can return on day 10 . Positive [resident]: Isolate x 5 days, if there is a roommate, use clinical judgement on moving resident Remain isolated/wear mask around other for x 10 days . According to the CDC guidance document titled, Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, Updated Sept. 23, 2022, which gives recommendations on how to handle nursing facility staff who test positive for COVID-19. The document read in part, HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and At least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g., cough, shortness of breath) have improved . Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html According to the CDC guidance document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, residents who test positive for COVID-19 are to be quarantined for 10 days. If a broad-based approach to testing is conducted, testing was to continue every 3-7 days until there are no new cases for 14 days, which was not done. If testing was conducted based on exposure and contact tracing, three rounds of testing was to be performed. Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#print No additional information was provided. 2. The facility staff failed to maintain an infection surveillance/monitoring program. On 04/22/24 at 04:19 p.m., an interview was conducted with the facility's infection preventionist (IP). When asked about infection surveillance, the IP stated that the only infection she tracks is COVID-19. When asked to explain the purpose and benefit of infection surveillance, the IP was able to verbalize the benefit of seeing where infections are located to identify trends and breaks in infection control that may be causative factors. A review was performed of the facility policy titled, Infection Control Program, with a review date of 12/23. The policy read in part, . Surveillance: Surveillance is the ongoing, systematic collection, analysis, interpretation and dissemination of data to identify infections and infection risks, to reduce morbidity and mortality and to improve resident health status . Identification/Investigation . 6. The IP, with input from the team, will identify trends and complete investigations/root cause analyses as indicated . On 4/23/24, during an end of day meeting, the facility administrator was made aware of the above findings. No additional information was provided.

Based on observation, staff interview and facility document review the facility staff failed to prepare, store, and distribute food in a sanitary manner. The finding included: The dietary staff failed to label open food with an open date and the use by date, failed to dispose of out of date products, failed to ensure metal serving pans were dry before nesting, failed to clean the grill after use, failed to clean trays in the refrigerator after spills occurred, failed to hold proper food temperatures on the steam tables on the units, and failed to ensure beard guards were worn by applicable staff. On [DATE] at 10:59 AM, observations were made in the main kitchen during a tour with the dietary manager (other staff #5, OS#5). During the tour of the walk-in refrigerator there was an open bag of tortilla shells with no open or expiration date, 2 bags of unopened tortilla shells out of the original box with no expiration date, 6 quarts of 2% milk that were expired ([DATE]), 3 trays with tan color sour smelling liquid on them, and 6 eggs with large cracks. The walk-in freezer had chicken fingers wrapped in plastic wrap with no open or expiration date and 5 fish (sealed in bags) that were not in the manufacturer box and expiration dates could not be located. In the main kitchen there were 3 deep serving pans wet nested, 3 loaf pans wet nested, 4 mini loaf pans wet nested. One loaf pan was found to have dry debris on the inside of the pan while nested with other pans. The grill in the main kitchen had dried debris heavily caked on the grate. Staff were also observed in the kitchen with facial hair not wearing beard guards. During the tour OS#5 was made aware of the findings and agreed that all food should be dated if open or out of the original manufacturer package, expired products should have been discarded, trays should be cleaned when spills are observed, and dishes should be clean and dry before nesting. OS#5 stated the grill had not been used since Sunday and should have been cleaned. OS#5 also stated the beard guards are to be worn if facial hair is longer than ,d+[DATE] inch. On [DATE] at 11:48 AM, OS#8, who was a dietary aide, was observed on the 400 unit serving residents food from a steam table. When questioned about checking food temps, OS#8 stated, temps are checked downstairs, sometimes we check up here. When requested to check temps the following were the results: corn O'Brien 158 degree F cheddar mashed potatoes 167 degree F roasted chicken 136 degree F tomato and basil soup 125 degree F steamed broccoli 162 degree F creamed corn 112 degree F meatloaf and gravy (tray empty) On [DATE] at 12:27 PM, the refrigerator on the 400 unit was found to have 1 unopened quart of whole milk that had expired on [DATE]. OS #9, who was a dietary aide was made aware and discarded the product. On 4 ,d+[DATE] at 12:31 PM, OS#10, who was a dietary aide, was observed on the 500 unit serving residents food from a steam table. When requested to check temps the following were the results: corn O'Brien 183 degree F cheddar mashed potatoes 184 degree F mechanical soft chicken 128 degree F roasted chicken 171 degree F tomato basil soup 190 degree F steamed broccoli 192 degree F creamed corn 178 degree F meatloaf 157 degree F gravy 178 degree F OS#10 was questioned about how often food temps are checked and stated they are checked initially downstairs, 30 minutes and in 1 hour if still serving on the unit. When questioned further regarding what temperature hot food should be OS#10 stated, it should be above 165. On [DATE] at 1:09 PM, OS#11, who was a dietary aide, was interviewed regarding food temperatures on the steam table and stated that temperatures are checked before bring them to the units and if still serving in 30 minutes they are rechecked. If temps are below 160, we take it downstairs to reheat. On [DATE] at 1:43 PM, the dietary manager OS#5 was informed of the steam table food temps from both the 400 and 500 units and responded that hot food should be at ,d+[DATE], if it falls below 120 it needs to be brought back to be reheated to 165 internal temp. The food served yesterday should have been brought back to reheat. Facility policy for Hair Restraints with effective date of [DATE] was reviewed. Per the policy all kitchen staff members shall wear either a hair net or a hat at all times while performing job duties. [NAME] covers shall be worn by all staff members with facial hair while performing job duties. Facility policy for Cold Food Storage effective date [DATE] was reviewed. Per the policy perishable dairy items stored for use in the [NAME] and Webster Kitchens will be checked for expiration of use by and best by dates and monitored daily for expiration thereafter. Perishable dairy items already in storage in the pantry shall be inspected daily for expiration of manufacturer's dates. Perishable items that have expired must be discarded. Facility policy for Safe Food and Beverage Temps effective last reviewed ,d+[DATE] was reviewed. Per the policy temperature readings will be recorded prior to the food leaving the main kitchen. One hour after the food has been placed on the hot line another temperature will occur to assure that temperatures are holding. The following criteria will be monitored with the correct temperatures: a) Hot foods will be 140 degrees F or higher b) cold foods will be 41 degrees F of lower c) soup will be 180 degrees F or higher. On [DATE] at 10:55 AM, the administrator, director of nursing, CEO, CFO, and dietary manager were made aware of the above findings. No other information was provided.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to maintain an antibiotic stewardship program to monitor antibiotic use for three residents (Resident #1- R1, Resident #34- R34, and Resident #27- R27) in a survey sample of 3 residents reviewed for antibiotic use. The findings included: On 4/23/24 at 08:48 a.m., an interview was conducted with the facility's infection preventionist (IP). The IP was asked about the antibiotic stewardship program and was asked to explain the facility's process. The IP reported that she doesn't track any infections other than COVID-19. She also reported that, we do have a PIP (performance improvement plan) in place I just created for UTIs (urinary tract infections), we are going to do education with staff on using McGreer criteria to reduce our UTI's. During the above interview the IP was asked when the PIP was developed and when they identified the deficient practice. The IP reported that it was just created last Tuesday, and the steps had not been taken/implemented yet. When the surveyor asked, if anyone is reviewing infections to determine if any specific infection criteria is met before an antibiotic is implemented/ordered. The IP stated she thought the doctor did that. The IP went on to say that it is discussed daily, and antibiotics are reviewed to ensure there is a stop date on the orders. The IP was asked to provide any evidence available for the risk meetings to show that antibiotic use is reviewed and discussed. The IP stated the DON (Director of nursing) had that information. On 4/24/24, in the morning, an interview was conducted with the Director of Nursing (DON). The DON reported that she did not have any evidence of the weekly risk meetings and said it was just written in her daily planner and she shreds that information after a week or so. The DON did state that a risk progress note is entered into each resident's clinical chart during the meeting. On 4/24/24 at 10:13 a.m., the DON provided the survey team with a report generated from the electronic health record of the residents, which listed residents prescribed antibiotics during the month of April 2024. The report listed three residents (R1, R34 and R27), as having been treated for a UTI. The DON reported that she had no evidence of any risk meetings/review and/or risk progress notes for two of th three residents treated with antibiotics. The risk note provided for R34 just indicated that Keflex (an antibiotic) was prescribed for 5 days for a UTI. There was no evidence of the resident's infection being reviewed to ensure that it met criteria for treatment with an antibiotic. A review was conducted of the facility policy titled, Antibiotic Stewardship Plan, with a review/revision date of 3/23. The policy read in part, . 7. Nursing staff will be educated on appropriate assessment of residents and communication to physicians/physician extenders. The criteria for Infection Pathways are a good tool/reference for communicating appropriate information to the physicians/physician extenders. 8. Nursing staff will be educated on the McGreer Criteria for Long Term Care Surveillance, CDC [centers for disease control and prevention] recommendations and Society for Healthcare Epidemiology of America and other resources, such as Leading Age and Health Quality Innovators, as appropriate . 24. The Director of Nursing will track antibiotic use and monitor adherence to evidence-based criteria, including: a. Documentation related to antibiotic selection and use, b. tracking antibiotics used to review patterns of use and determination of the impact of the antibiotic stewardship interventions, c. monitoring for clinical outcomes such as rates of C. difficile infections, antibiotic-resistant organisms or adverse drug events, d. reporting of communicable disease ., e. provide reports related to monitoring antibiotic usage and resistance data to the QAPI (quality assurance and performance improvement) committee . On 4/24/25, at approximately 10 a.m., the facility administrator was made aware of the above concerns. No further information was provided.

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure that residents receive adequate assistance devices to prevent accidents for one resident (Resident #103- R103), in a survey sample of 18 residents. The findings included, For R103, who had two recent incidents, the facility staff failed to ensure the resident had a call bell in reach when sitting in the recliner in her room, to prevent further incidents/accidents. On 6/24/24, the facility administrator provided the survey team with a listing of residents who had recently had incidents. R103 was identified on the list to have had 2 incidents of falls on 6/20/24. On 6/25/24, a clinical record review was conducted of R103's chart. According to the nursing note dated 6/20/24 at 17:30, it read in part, Incident time: 16:30, Incident Type: Falls, Reason for Incident: CNA [certified nursing assistant] called this nurse to RR [resident room]. Rsd's [resident's] recliner back/head had tilted up in the air and the footrest was tiled toward the floor while Rsd was still in the recliner. Rsd stated she was sliding down out of the recliner toward the floor. Rsd did not hit her head. Staff actions at the time of incident; Assessment- Rsd said she was not hurt. Rsd was assisted to w/c [wheelchair] and hand grasps and ROM [range of motion] remained at baseline. VS [vital signs] 107/63 [blood pressure] 97.2 [temperature] 86 [heart rate] O2 96% RA [room air]. No observable injuries noted. Neurochecks started. RP [responsible party] notified, and MD [medical doctor] made aware via provider book notation. According to the nursing note entry dated 6/21/24 at 10:29 a.m., it read, Incident date: 6/20/24, Incident Time: 13:00 [1 p.m.]. Incident Type: Falls Reason for Incident: CNA came out of staff bathroom and stated to this nurse that the other CNA needed her in RR. This nurse followed CNA to RR, Rsd was in recliner buttocks on recliner chair, footrest elevated w/ [with] feet on footrests and CNA was standing in front of the Rsd's feet w/ CNA's legs touching Rsd's feet and CNA's left arm was on the recliner's right arm rest. CNA stated Rsd did not fall. Rsd was not hurt. Rsd was slouched in recliner. Rsd's top of back was touching recliner back. Staff actions at the time of incident: Assessment- No c/o [complaints of] pain or discomfort. No observable injuries. ROM at baseline. Management aware of incident. On 6/25/24, a review of R103's care plan was conducted. The care plan had an entry entered on 6/20/24, following the above noted incidents. The care plan read, I am at risk for falls/injury related to history of falls, high risk identified by fall risk assessments, and muscle weakness. Goal: Staff will provide interventions/approaches in collaboration with MD to help diminish my risk of falls/injury through next review. The interventions, which were all dated 6/20/24, included but were not limited to: Orient me to room and call light system. Encourage me to call for assistance as needed. Keep call light within reach, keep items within reach such has cell phone and grabber, ensure my call bell is within reach while in recliner . On 6/25/24 at 4:07 p.m., RN #1 (registered nurse) was asked to accompany the surveyor to R103's room. Upon entry, R103 was observed to be asleep in the recliner chair and significantly leaning over the left arm rest of the recliner. RN #1 performed a sternal rub to arouse the resident. RN #1 also confirmed that R103 didn't have a personal/pendant electronic transmitter (PET) necklace device [cordless alert system used to alert staff if the resident needed assistance]. When asked about the corded call bell and if R103 could reach it to call for assistance if needed, RN #1 said, not over there, it's clipped to the bed on the other side of room. RN #1 confirmed that R103 should have her call bell in reach to prevent accidents. Review of the facility policy titled, Fall Prevention Policy, was conducted. This policy read in part, . [facility name redacted] is committed to providing a safe environment for all residents by minimizing the risk of falls through a comprehensive falls prevention program. This program includes initial and ongoing assessments, individualized care plans, staff training, environmental modifications, and continuous monitoring and evaluation . 2.1 Development of Care Plan: develop a personalized fall prevention care plan based on the risk assessment findings. Include specific interventions such as: physical therapy and strength training exercises, medication review and adjustment, environmental modifications (e.g., adequate lighting, removal of trip hazards), use of assistive devices (e.g., walkers, canes), proper footwear recommendations . 2.3 Implementation and Monitoring: ensure all staff members are aware of and implement individualized care plans. Monitor the effectiveness of interventions and adjust the care plan as needed .4.2 Resident Rooms . ensure personal items and call buttons are within easy reach . On 6/25/24, during the end of day meeting, the facility administrator and director of nursing were made aware of the above findings. On 6/26/24 at 10:18 a.m., the facility administrator provided a document that read in part, Correction: a. Immediate action: the staff member responsible for the resident's care was immediately instructed to ensure the call bell/ pendant is within the resident's reach while she is sitting in the recliner. b. Immediate action: residents care plan was updated. 1. Ensure my call bell/PET is within reach while in the recliner. ii. Responsible party- added nurse. c. immediate action: an immediate audit of all residents' call bell/pendant accessibility to ensure that no other residents were similarly affected. d. Immediate action: therapy evaluation was requested for positioning. e. Staff reminder: All nursing staff will be reminded to check that residents' call bells/pendants are within reach as part of their routine checks, especially when residents are repositioned or moved The document went on to indicate other potential issues, system changes, monitoring and had a completion date of 7/3/24. No additional information was provided.

Based on observation, staff interview and facility documentation review, the facility staff failed to store medications appropriately in 1 of 2 medication storage rooms and on 1 of 2 medication carts. Findings were: The facility failed to ensure that expired medications were not available for use and failed to monitor the temperature of the refrigerator where medications were stored to ensure they were maintained at an appropriate temperature. On 04/22/24 at 12:04 PM, a review was conducted of the medication storage room on the 500 unit in the presence of RN #1 (registered nurse). A bottle of Tylenol Extra Strength 500 mg tablets was noted to have an expiration date of 03/2024. RN #1 confirmed the observation and stated that the night shift is to check the room daily and remove expired items. During the above observation, the refrigerator in the 500-unit medication storage room was noted to have not had any record of temperature being checked since 4/20/24. Therefore the staff were unaware if the medications within the fridge were being maintained at an appropriate temperature. RN#1 again confirmed the observations and provided the surveyor with a copy of the log of refrigerator temperatures. RN #1 was asked about the risk of having medications that are expired and not checking the temperature of the refrigerator where medications are stored. RN #1 stated, If they are expired or not stored at the right temperature it could decrease the effectiveness of the medication or create an adverse reaction to the resident. On 4/22/24 at approximately 3:30 p.m., an inspection of the medication cart on the 400 unit was conducted with LPN #1 and LPN #2. It was noted that a bottle of stool softener/docusate sodium 100 mg, bottle with a quantity of 30 was present and unopened which had an expiration date of 03/24. The medication was available for use/administration. LPN #1 (Licensed practical nurse) and LPN #2 confirmed the observation. LPN #2 was asked what the risk of expired medications being available for administration and LPN #2 said, it may not be as effective. The facility policy for medication storage was received and reviewed. The policy did not address the storage of medications with regards to temperature control or expiration dates. On 2/23/24 at 4:30 p.m., during an end of day meeting, the Administrator and Director of Nursing were made aware of the above findings. No additional information was provided.

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure that residents receive adequate assistance devices to prevent accidents for one resident (Resident #103- R103), in a survey sample of 18 residents. The findings included, For R103, who had two recent incidents, the facility staff failed to ensure the resident had a call bell in reach when sitting in the recliner in her room, to prevent further incidents/accidents. On 6/24/24, the facility administrator provided the survey team with a listing of residents who had recently had incidents. R103 was identified on the list to have had 2 incidents of falls on 6/20/24. On 6/25/24, a clinical record review was conducted of R103's chart. According to the nursing note dated 6/20/24 at 17:30, it read in part, Incident time: 16:30, Incident Type: Falls, Reason for Incident: CNA [certified nursing assistant] called this nurse to RR [resident room]. Rsd's [resident's] recliner back/head had tilted up in the air and the footrest was tiled toward the floor while Rsd was still in the recliner. Rsd stated she was sliding down out of the recliner toward the floor. Rsd did not hit her head. Staff actions at the time of incident; Assessment- Rsd said she was not hurt. Rsd was assisted to w/c [wheelchair] and hand grasps and ROM [range of motion] remained at baseline. VS [vital signs] 107/63 [blood pressure] 97.2 [temperature] 86 [heart rate] O2 96% RA [room air]. No observable injuries noted. Neurochecks started. RP [responsible party] notified, and MD [medical doctor] made aware via provider book notation. According to the nursing note entry dated 6/21/24 at 10:29 a.m., it read, Incident date: 6/20/24, Incident Time: 13:00 [1 p.m.]. Incident Type: Falls Reason for Incident: CNA came out of staff bathroom and stated to this nurse that the other CNA needed her in RR. This nurse followed CNA to RR, Rsd was in recliner buttocks on recliner chair, footrest elevated w/ [with] feet on footrests and CNA was standing in front of the Rsd's feet w/ CNA's legs touching Rsd's feet and CNA's left arm was on the recliner's right arm rest. CNA stated Rsd did not fall. Rsd was not hurt. Rsd was slouched in recliner. Rsd's top of back was touching recliner back. Staff actions at the time of incident: Assessment- No c/o [complaints of] pain or discomfort. No observable injuries. ROM at baseline. Management aware of incident. On 6/25/24, a review of R103's care plan was conducted. The care plan had an entry entered on 6/20/24, following the above noted incidents. The care plan read, I am at risk for falls/injury related to history of falls, high risk identified by fall risk assessments, and muscle weakness. Goal: Staff will provide interventions/approaches in collaboration with MD to help diminish my risk of falls/injury through next review. The interventions, which were all dated 6/20/24, included but were not limited to: Orient me to room and call light system. Encourage me to call for assistance as needed. Keep call light within reach, keep items within reach such has cell phone and grabber, ensure my call bell is within reach while in recliner . On 6/25/24 at 4:07 p.m., RN #1 (registered nurse) was asked to accompany the surveyor to R103's room. Upon entry, R103 was observed to be asleep in the recliner chair and significantly leaning over the left arm rest of the recliner. RN #1 performed a sternal rub to arouse the resident. RN #1 also confirmed that R103 didn't have a personal/pendant electronic transmitter (PET) necklace device [cordless alert system used to alert staff if the resident needed assistance]. When asked about the corded call bell and if R103 could reach it to call for assistance if needed, RN #1 said, not over there, it's clipped to the bed on the other side of room. RN #1 confirmed that R103 should have her call bell in reach to prevent accidents. Review of the facility policy titled, Fall Prevention Policy, was conducted. This policy read in part, . [facility name redacted] is committed to providing a safe environment for all residents by minimizing the risk of falls through a comprehensive falls prevention program. This program includes initial and ongoing assessments, individualized care plans, staff training, environmental modifications, and continuous monitoring and evaluation . 2.1 Development of Care Plan: develop a personalized fall prevention care plan based on the risk assessment findings. Include specific interventions such as: physical therapy and strength training exercises, medication review and adjustment, environmental modifications (e.g., adequate lighting, removal of trip hazards), use of assistive devices (e.g., walkers, canes), proper footwear recommendations . 2.3 Implementation and Monitoring: ensure all staff members are aware of and implement individualized care plans. Monitor the effectiveness of interventions and adjust the care plan as needed .4.2 Resident Rooms . ensure personal items and call buttons are within easy reach . On 6/25/24, during the end of day meeting, the facility administrator and director of nursing were made aware of the above findings. On 6/26/24 at 10:18 a.m., the facility administrator provided a document that read in part, Correction: a. Immediate action: the staff member responsible for the resident's care was immediately instructed to ensure the call bell/ pendant is within the resident's reach while she is sitting in the recliner. b. Immediate action: residents care plan was updated. 1. Ensure my call bell/PET is within reach while in the recliner. ii. Responsible party- added nurse. c. immediate action: an immediate audit of all residents' call bell/pendant accessibility to ensure that no other residents were similarly affected. d. Immediate action: therapy evaluation was requested for positioning. e. Staff reminder: All nursing staff will be reminded to check that residents' call bells/pendants are within reach as part of their routine checks, especially when residents are repositioned or moved The document went on to indicate other potential issues, system changes, monitoring and had a completion date of 7/3/24. No additional information was provided.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow abuse prevention policies for completion of a criminal background check for a privately hired companion for one of sixteen residents in the survey sample (Resident #1). The findings include: A private companion/sitter working in the facility with Resident #1, had no prior criminal background check as required by the facility's abuse prevention policies. Resident #1 (R1) was admitted to the facility with diagnoses that included dementia, hypertension, osteoporosis, urinary tract infection, osteoarthritis, conjunctivitis, gastroesophageal reflux disease, and depression. The minimum data set (MDS) dated [DATE] assessed R1 with severely impaired cognitive skills and required the extensive assistance of two people for bed mobility and transfers. R1's clinical record documented the resident fell on [DATE] when a privately hired companion (other staff #3) attempted to transfer the resident from bed to a wheelchair without requesting or obtaining staff assistance. The resident was diagnosed with a right femur fracture as a result of the fall. The facility's policy titled Guidelines for Companions (revised 5/30/2014) documented all companions must have a criminal background check prior to their start date. The criminal background check for R1's private companion (other staff #3) was requested. On 4/24/23 at 8:30 a.m., the administrator and director of nursing (DON) were interviewed about other staff #3's criminal background check. The administrator stated they had no criminal background check for other staff #3. The administrator stated the criminal background checks were required for all individuals prior to engagement of care/services with residents in the facility. The DON stated other staff #3 was not licensed but there should have been a criminal background check completed prior to her sitting/working with R1. On 4/24/24 at 9:30 a.m., the human resources assistant (HR - other staff #4) was interviewed about any screening or background checks for R1's private companion (other staff #3). The HR assistant stated he researched back several years and found no criminal background check for other staff #3. The HR assistant stated he did not know why other staff #3 was not screened by human resources prior to working in the facility. The facility's policy titled Abuse and Neglect (revised 12/2023) documented, [The nursing facility] strives to ensure protection of each resident's right to freedom from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion; as well as to ensure protection from neglect, chemical and physical restraints, exploitation, or misappropriation of personal property by anyone, including staff, other residents, visitors, volunteers, students, consultant, contractors, or family members .[the nursing facility] will not engage volunteers, contractors or other individuals who have not been screened through Human Resources .Potential volunteers, contractors, vendors, companions, or other individuals will be screened for a history of abuse or other barrier crimes prior to engagement of service .by the Human Resources Director/designee . This finding was reviewed with the administrator, DON and nurse manager during a meeting on 4/24/24 at 11:00 a.m. with no further information provided prior to the end of the survey.

Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to review and revise the care plan for one resident (Resident #7- R7), in a survey sample of 16 residents. The findings included: For R7, the facility staff failed to review and revise the care plan to include to resident's inability to use a straw in beverages due to the risk of aspiration. On 4/22/24 at the lunch meal, R7 was observed in the dining room and was observed to have several episodes of coughing while eating. The meal/tray ticket for R7 was observed and it was noted that it indicated no straws. A straw was not being used. On 04/22/24 at 03:47 p.m., R7 was visited in their room. It was observed that R7 had a sign in the room that stated, please no straws. I am unable to use straws. R7 was asked about this and reported she can't use a straw because she gets choked. On 04/22/24 at 03:52 p.m., an interview was conducted with CNA #1 (certified nursing assistant). CNA #1 stated that R7 is being evaluated, they think with using a straw the liquid is coming up too fast, she had a speech therapy evaluation last week, they are going to do a swallow test. She [R7] knows when they come, and she tries to cover it up and say she isn't hungry so they can't watch her eat. On 4/23/24, a clinical record review was conducted of R7's chart, to include the care plan. The need to not have straws and the episodes of coughing during meals was not addressed on the care plan. On 4/23/24, during an end of day meeting, the facility administration was made aware of the above concern. On 4/23/24 at 2 p.m., an interview was conducted with RN #2 (registered nurse), who was the MDS (minimum data set/ an assessment) nurse. RN #2 explained that she reviews and revises the resident's care plans in accordance with the scheduled assessments on a quarterly basis, but acute changes in-between assessments are updated on the care plans by the nurses on the units. On 4/24/24, the facility policy titled, Care Plans was reviewed. The policy read in part, . The care plan should describe services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being ., 8. The care plan is a living, breathing document and should be revised as often as changes and approaches are reflected in the resident's well-being . No further information was provided.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of care for one of sixteen residents in the survey sample (Resident #29). The findings include: During a medication pass observation, a medication was not administered and was left in Resident #29's room. The nurse signed off the clinical record indicating administration of the medicine without witnessing that the resident took the medicine. Resident #29 had no assessed ability to safely self-administer the medication. On 4/23/24 at 8:00 a.m., licensed practical nurse (LPN #1) was observed preparing and administering medications to Resident #29 (R29). Medications prepared for R29 included Peroxyl 1.5% oral rinse, 10 milliliters (mls) in a plastic medicine cup. After oral medications were administered, LPN #1 placed the cup of Peroxyl oral rinse on the resident's sink and advised R29 that the rinse was at the sink for use after breakfast and brushing teeth. LPN #1 signed off R29's medication administration record indicating the Peroxyl oral rinse was administered. On 4/23/24 at 8:50 a.m., R29 was observed in the dining area. The cup (10 mls) of Peroxyl oral rinse was still located in the resident's room on the sink counter. R29's clinical record documented a physician's order dated 1/8/24 for Peroxyl 1.5% mucosal solution with instructions to administer twice per day (rinse for 1 minute then spit out) for treatment of ulcerated oral mucosa. R29's clinical record included no physician's order or plan of care indicating the resident was safe to self-administer this medication. On 4/23/24 at 11:30 a.m., LPN #1 was interviewed about the Peroxyl rinse left in R29's room. LPN #1 stated R29 liked to use the rinse after eating and brushing his teeth. LPN #1 stated she would not have left the mouth rinse in the room if the resident was cognitively impaired. LPN #1 stated she was not aware if the resident had a self-administration assessment. On 4/23/24 at 11:50 a.m., the nurse manager (LPN #2) was interviewed about the medication left in R29's bathroom. LPN #2 stated nurses should not leave medicines in resident rooms and should witness residents taking their medications prior to documenting the medicines as given. LPN #2 stated R29 was not assessed to self-administer the Peroxyl oral rinse and LPN #1 should have taken the rinse to the resident after breakfast and watched him use the rinse. The facility's policy titled Medication Administration & Transcription of Physicians Orders (revised 11/23) documented, .Stay with the resident until they have swallowed the medications, unless the resident has been assessed to self-administer . This finding was reviewed with the administrator, director of nursing and nurse manager during a meeting on 4/23/24 at 4:10 p.m. with no further information presented prior to the end of the survey.

Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide ADL (activities of daily living) assistance for a resident who was dependent on facility staff, affecting one Resident (Resident #7) in a survey sample of 16 Residents. The findings included: For Resident #7 (R7), the facility staff failed to provide assistance with oral care/brushing of teeth. On 4/22/24 at 11:59 a.m., R7 was interviewed in their room. R7 was sitting in a wheelchair at the bedside. It was observed that R7's teeth had a film on them and did not appear clean. R7 was questioned about oral care and R7 reported they had not brushed her teeth. On 4/22/24 at approximately 3:45 p.m., R7 was visited in her room again and it was noted that the teeth still had a visible film on them and R7 reported her teeth had not been brushed. On 4/22/24 at 3:54 p.m., an interview was conducted with CNA #1 (certified nursing assistant). CNA #X reported that oral care is provided daily. When asked about R7, CNA #1 reported that she had not brushed R7's teeth that morning and gave no reason as to why it had not been performed. On the afternoon of 4/23/24, interviews were conducted with CNA #2 and CNA #3. Both confirmed oral care is to be performed daily when the resident is gotten up for the day. Both also confirmed R7 requires staff to provide oral care and were unaware of a situation when R7 would refuse such care. On 4/23/24, a clinical record review was conducted of R7's chart, to include the comprehensive care plan. It was noted on the care plan that R7 required total assistance of 2 staff for personal hygiene. Review of the facility policy titled, Mouth care/oral hygiene/denture care was conducted. The policy read in part, A.) A.M. Care . 4. Position resident in chair in bathroom at sink or in chair in room. Set resident up with toothbrush, toothpaste, and basin to complete their mouth care. 5. If in bed, place in high fowlers position with towel under chin. Proceed to cleanse mouth with toothbrush, toothpaste, or special applicator, if necessary, follow up with mouth wash . C.) P.M. Care: 1. Position resident in chair in bathroom at sink or in chair in room. Set resident up with toothbrush, toothpaste, and basin to complete their mouth care. 2. Cleanse mouth with toothbrush, toothpaste, or special applicator if necessary . On 4/23/24, during an end of day meeting held at 4:30 p.m., the facility administrator and director of nursing were made aware of the above findings. On 4/24/24 at 8:10 a.m., the facility administrator reported to the survey team that R7's teeth had been brushed. No further information was provided.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to provide education and offer the COVID-19 immunization, to 1 of 5 residents (Resident #34- R34) and failed to offer the spike vaccine booster for the 2023-2024 season for 5 of 5 staff sampled (LPN #1, LPN #4, Other Staff #12, CNA #3, and Admin Staff #1). The findings included: 1. For R34, the facility staff failed to provide education and offer the COVID-19 vaccine. On 4/22/24, in the afternoon, a clinical record review was conducted of R34's chart. It was noted that there was no information recorded with regards to R34's COVID immunization status. On 04/22/24 at 04:19 p.m., an interview was conducted with the facility's infection preventionist (IP). During the interview, the IP reviewed and confirmed the lack of documentation regarding R34's COVID immunization status, within the clinical record. The IP said, I can get them to pull those records for you, we would have to pull it from the VIIS (Virginia Immunization Information system) system. When asked if this information is obtained prior to a resident's admission, the IP stated that the facility administrator tracks that information. When asked about the facility's process with regards to immunizations, the IP stated, usually we, if there is a new COIVD booster, we will do a clinic through our pharmacy. With the new recommended COVID booster, we have a clinic coming up in May. We will get consent from the resident and/or their family. On 04/23/24 at 09:33 a.m., an interview was conducted with the facility administrator. The administrator stated that he tracks the resident's COVID immunization status so that he can report to the NHSN (National Healthcare Safety Network). The administrator accessed his records and noted that he had R34 listed as partially vaccinated. On 4/23/24 at approximately 10 a.m., the facility administrator reported to the survey team that R34 was not immunized for COVID-19 and there was no credible evidence that the immunization had been discussed with the resident and/or offered. On 04/23/24 at 02:24 p.m., the surveyor called and spoke with a registered pharmacist at the facility's contracted pharmacy. The pharmacist confirmed they currently had in-stock the COVID spike vaccine for 2023-2024 season and could ship it to the facility. On 4/24/24 at 10:17 a.m., the surveyor spoke with a pharmacist at the facility's contracted pharmacy. The pharmacist stated that they can get the COVID vaccine anytime and have it to the facility that afternoon or the next day following the receipt of an order. The pharmacist stated that they do not have to wait for and/or schedule an immunization clinic to receive the vaccines. On 4/24/24 at approximately 10:20 a.m., the facility administrator confirmed that R34 had not been offered COVID immunizations. The facility policy titled; Immunization of Residents was reviewed. The policy read in part, . The facility determines the immunization status of residents upon admission and encourages them to receive the vaccinations as recommended by the Centers for Disease Control (CDC) for adults . The policy listed immunizations to include influenza, tetanus, diphtheria, and pertussis (Tdap), and pneumococcal vaccines, but did not list or reference COVID immunizations. The FDA (Food and Drug Administration) gives information about the 2023-2024 spike vaccine on their website, accessed at:https://www.fda.gov/vaccines-blood-biologics/coronavirus-covid-19-cber-regulated-biologics/novavax-covid-19-vaccine-adjuvanted. The guidance read, On October 3, 2023, the Food and Drug Administration amended the emergency use authorization (EUA) of Novavax COVID-19 Vaccine, Adjuvanted to include the 2023-2024 formula. The Novavax COVID-19 Vaccine, Adjuvanted, a monovalent vaccine, has been updated to include the spike protein from the SARS-CoV-2 Omicron variant lineage XBB.1.5 (2023-2024 formula). The Novavax COVID-19 Vaccine, Adjuvanted (Original monovalent) is no longer authorized for use in the United States. Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is authorized for use in individuals [AGE] years of age and older as follows: Individuals previously vaccinated with any COVID-19 vaccine: one dose of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is administered at least 2 months after receipt of the last previous dose of an original monovalent (Original) or bivalent (Original and Omicron BA.4/BA.5) COVID-19 vaccine. Individuals not previously vaccinated with any COVID-19 vaccine: two doses of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) are administered three weeks apart . On 4/24/24 at approximately 10:30 a.m., the facility administrator was made aware of the above findings. No additional information was received. 2. For 5 of 5 staff sampled, the facility staff failed to provide credible evidence that education and information regarding the 2023-2024 COVID spike vaccine had been provided to the employees. On 4/23/24, a sample of 5 employees was selected for review of COVID immunizations. These employees are identified as LPN #1, LPN #4, Other Staff #12, CNA #3, and Admin #1. On 4/23/24 at 8:42 a.m., LPN #3, a nursing supervisor, assisted the surveyor with reviewing the sampled employee's health records for COVID immunization information. It was determined that the information available indicated that none of the 5 employees had received the COVID spike vaccine booster for the 2023-2024 season. On 4/23/24 at 8:55 a.m., the surveyor then went to the administrator to review the employee's vaccine information, which he had on file. The administrator had a spreadsheet that listed 3 of the 5 employees' immunization information with regards to COVID-19. LPN #4 and CNA #3 were documented as up-to-date. Other Staff #12 was documented as not fully documented. No immunization information was found for LPN #1 or Admin Staff #1. According to the spreadsheet, none of the employees had received the spike vaccine booster for the 2023-2024 season. When questioned about this, the administrator stated that the facility had held an immunization clinic in October 2023. The administrator was asked to provide any evidence of what was communicated to the facility staff regarding the spike vaccine booster. On 4/23/24 at 10:14 a.m., the facility administrator provided a copy of an email that went to 9 employees and the leadership team, which indicated that those 9 employees' had an interest in receiving the COVID vaccine and had been notified of the upcoming clinic. There was no evidence that indicated that those identified employees had attended the 10/23/23 clinic or had received the COVID vaccination. The administrator also provided a sample of a COVID vaccine consent form completed in January 2021, but stated they had not received such consents from staff for the 2023-2024 spike vaccine. The administrator went on to state that they were only able to obtain and administer the vaccine when a clinic was scheduled with the pharmacy. On 4/24/24 at 10:17 a.m., the surveyor spoke with a pharmacist at the facility's contracted pharmacy. The pharmacist stated that the pharmacy can get the COVID vaccine anytime and have it to the facility that afternoon or the next day, following the receipt of an order. The pharmacist stated that the facility does not have to wait for and/or schedule an immunization clinic to receive the vaccines. The pharmacist specifically stated that the 2023-2024 spike vaccine was in-stock and readily available. The facility policy titled, COVID Vaccination Mandate Policy, with a revision date of 03/2023, was reviewed. The policy read in part, . requires all employees, students, and volunteers to receive the COVID-19 vaccine and may also be required to receive future COVID booster vaccines. All employees and volunteers are expected to be fully vaccinated unless they have been approved for a religious or medical exemption . [facility name redacted] provides education regarding the risks and benefits of the COVID vaccine through employee meetings, posting at time clocks and through one-on-one discussions . Although COVID-19 boosters are not required at this time, [facility name redacted] is required to track whether an individual covered by this policy has elected to receive a booster . On 4/24/24 at approximately 10:30 a.m., the facility administrator was made aware of the above findings. No additional information was provided.

Based on observation, staff interview, and clinical record review, the facility staff failed to provide respiratory care, consistent with professional standards of practice, for one resident (Resident #187- R187) in a survey sample of 16 residents. The findings included: For R187, the facility staff failed to store the oxygen nasal cannula to prevent contamination and failed to change the tubing and humidification bottle weekly as per physician order and facility protocol. On 04/22/24 at 11:41 AM, R187 was visited in their room. R187 was lying in bed and an oxygen (O2) concentrator was observed at the bedside, not on/running. The O2 humidification bottle was dated 4/9/24, and the nasal cannula was sitting on top of the concentrator, open to air and dated 4/9/24. R187 reported they no longer use oxygen. On 04/22/24 at 03:27 PM, a clinical record review was conducted. It was noted that R187 had a physician order for 3 liters of oxygen per nasal cannula as needed to maintain oxygen saturation levels >90%. There was another order that read, change 02 tubing every Tuesday on night shift and another order read, change 02 humidifier every Tuesday on night shift. According to the electronic treatment administration record (ETAR), the order to change the O2 tubing and humidifier were both signed off as being changed on 4/16/24. On 04/22/24 at 04:01 PM, an additional observation was made and R187's O2 tubing and nasal cannula remained open to air, sitting on top of the oxygen concentrator. The tubing was dated 4/9/24 and the humidifier bottle was dated 4/9. On 04/22/24 at 04:06 PM, an interview was conducted with RN #1. RN #1 said, tubing is changed on Tues by the night shift, the water is changed as needed and it is labeled with the date, we open them. When asked how the oxygen mask and/or nasal cannula is to be stored if not in use, RN #1 said, we put it in a baggie with the room number and date, the bag is changed on Tues as well. When asked why it is important to store it in a bag when not in use, RN #1 said, to prevent contamination. RN #1 then accompanied the surveyor to R187's room and confirmed that the oxygen tubing and humidification bottle was dated 4/9/24. When asked why the clinical record ETAR would be signed off for it being changed on 4/16/24, RN #1 said that was not accurate and said, it definitely wasn't changed. I will get all of the supplies now. Review of the facility policy titled, Oxygen, Tubing, Cannula, Mask and Humidifier Care was conducted. The policy read in part, III. Procedure: A. To be completed weekly according to the eTAR . 2. Remove cannula or mask from resident. Also remove the used humidifier bottle if applicable. 4. [sic] Place used equipment in trash bag. 5. Open humidifier bottle and fill to designated level with distilled water. The bottle will be marked with staff's initials and date 7. Remove tubing and cannula or mask from sealed bag. 8. Attach new tubing to humidifier bottle ensuring that it has been labeled with staff's initials and date . C. Documentation: 1. When transcribing order of oxygen usage onto eTAR, also provide a block to record replacement of oxygen humidifier bottle. 2. Record initials on appropriate section of eTAR. On 4/23/24 at 4:30 p.m., during an end of day meeting, the facility administrator and director of nursing were notified of the above findings. No additional information was provided.

Based on staff interview, facility document review and clinical record review the facility staff failed to respond to pharmacy recommendations for 2 of 16 residents in the survey sample. (Resident # 22 and Resident # 10). The findings included: 1. The facility staff failed to respond to a pharmacist recommendation to attempt a gradual dose reduction of buspirone for Resident # 22 (R22). R22 had diagnoses that included Alzheimer's Disease, Parkinson's Disease, depression, unspecified dementia, mood disorder, and anxiety disorder. The most current minimum data set (MDS), a quarterly assessment dated [DATE] assessed R22 with severe cognitive impairment. Review of R22 clinical record documented a physician's order dated 12/27/23 for buspirone 5 mg, give 5 mg by mouth three a day as needed for generalized anxiety disorder. On 1/8/24 the physician changed the order to read, give buspirone 5 mg, give 5 mgby mouth 2 times a day for anxiety disorder. On 1/02/24 the consulting pharmacist recommended a gradual dose reduction (GDR) of buspirone. The pharmacist wrote within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. If appropriate, please consider a GDR at this time. If not, please document rationale for contraindication. No physician response was documented for this recommendation. On 4/23/24 at 3:15 PM, licensed practical nurse #2 (LPN #2), who was the unit manager was interviewed. LPN #2 provided a physician progress note dated 3/5/24 that does not address the pharmacist's recommendation for a GDR of buspirone. LPN #2 had no response as to why the GDR was not addressed. On 4/24/24 at 10:55 AM, the findings were reviewed with the facility administrator, CEO and CFO with no additional information provided. 28106 2. The facility staff failed to respond to a pharmacist recommendation to attempt a gradual dose reduction of Diphenhydramine (used for insomnia) for Resident #10 (R10). The findings included: R10 Diagnoses for R10 included; Insomnia. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 3/6/24. R10 was assessed with a cognitive score of 15 indicating cognitively intact. Review of R10's pharmacy medication record review (MRR) dated 1/2/24 documented: This resident is receiving Diphenhydramine for control of insomnia. This antihistamine is rarely considered the agent of choice due to its strong anticholinergic properties. Patient is also on melatonin and zolpidem and may be a duplication of therapy. Another medication review performed by the pharmacy dated 2/7/24 recommended a gradual dose reduction (GDR) for Dipehnhydramine and melatonin (both medications were being prescribed for insomnia). R10's electronic record did not indicate a response from R10's physician. Review of R10's current medications indicated R10 was ordered, Diphenhydramine 75 MG (milligrams), Melatonin 10 MG, and Zolpidem 5 MG every day for insomnia and were ordered on 3/12/23. On 4/23/24 at 1:32 PM license practical nurse (LPN #2, nurse manager) said that R10 has a recommendation for GDR for psychotropic medications. Pharmacy sends the GDR's through email to facility and facility prints the GDR to have physician review. LPN #2 said that the physician has not responded to the GDR and not sure why. On 4/23/24 at 1:37 PM the director of nursing (DON) was interviewed. The DON verbalized reaching out to previous DON regarding pharmacy medication reviews and said that the previous DON had put the medication reviews in binder, but the binder was unable to be located. On 4/23/24 at 4:11 PM, the above information was presented to the DON and administrator. On 4/24/24 the administrator presented the MEDICAL DIRECTION SERVICE AGREEMENT that read in part 3.4.11 Review consultant recommendation that affect Facility's resident care policies and procedures or the care of an individual resident; [ .] No other information was provided prior to exit conference on 4/24/24.

Based on observation, staff interview, and clinical record review, the facility staff failed to maintain an accurate clinical record for one resident (Resident #187- R187) in a survey sample of 16 residents. The findings included: For R187, the facility staff failed to maintain accurate documentation with regards to when the oxygen tubing and humidification bottle was changed. On 04/22/24 at 11:41 AM, R187 was visited in their room. R187 was lying in bed and an oxygen (O2) concentrator was observed at the bedside, not on/running. The O2 humidification bottle was dated 4/9/24, and the nasal cannula was sitting on top of the concentrator, open to air and dated 4/9/24. R187 reported she doesn't use oxygen. On 04/22/24 at 03:27 PM, a clinical record review was conducted. It was noted that R187 had a physician order for 3 liters of oxygen per nasal cannula as needed to maintain oxygen saturation levels >90%. There was another order that read, change 02 tubing every Tuesday on night shift and one that read, change O2 humidifier every Tuesday on night shift. According to the electronic treatment administration record (ETAR), the order to change the O2 tubing and humidifier were signed off as being changed 4/16/24. On 04/22/24 at 04:01 PM, an additional observation was made and R187's O2 tubing and nasal cannula remained open to air, sitting on top of the oxygen concentrator. The tubing was dated 4/9/24 and the humidifier bottle was dated 4/9. On 04/22/24 at 04:06 PM, an interview was conducted with RN #1. RN #1 then accompanied the surveyor to R187's room and confirmed that the oxygen tubing and humidification bottle was dated 4/9/24. When asked why the clinical record ETAR would be signed off for it being changed on 4/16/24, RN #1 said that was not accurate and said, it definitely wasn't changed, I will get all of the supplies now. Review of the facility policy titled, Oxygen, Tubing, Cannula, Mask and Humidifier Care was conducted. The policy read in part, . C. Documentation: 1. When transcribing order of oxygen usage onto eTAR, also provide a block to record replacement of oxygen humidifier bottle. 2. Record initials on appropriate section of eTAR. On 4/23/24 at 4:30 p.m., during an end of day meeting, the facility administrator and director of nursing were notified of the above findings. No additional information was provided.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure 1 of 16 residents in the survey sample were free of unnecessary medications. The findings included: The facility staff failed to attempt a pharmacy recommended gradual dose reduction of Diphenhydramine for Resident #10 (R10). The findings included: R10 Diagnoses for R10 included Insomnia. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 3/6/24. R10 was assessed with a cognitive score of 15 out of 15, indicating cognitively intact. Review of R10's pharmacy medication record review (MRR), dated 1/2/24, documented: This resident is receiving Diphenhydramine for control of insomnia. This antihistamine is rarely considered the agent of choice due to its strong anticholinergic properties. Patient is also on melatonin and zolpidem and may be a duplication of therapy. Another MRR, performed by the pharmacy and dated 2/7/24, recommended a gradual dose reduction (GDR) for Dipehnhydramine and melatonin (both medications were being prescribed for insomnia). R10's electronic record did not indicate a response from R10's physician. Review of R10's current medications indicated R10 was ordered, Diphenhydramine 75 MG (milligrams), Melatonin 10 MG, and Zolpidem 5 MG every day for insomnia and were ordered on 3/12/23. On 4/23/24 at 1:32 PM, license practical nurse (LPN #2, nurse manager) stated that R10 has a recommendation for GDR for psychotropic medications. LPN #2 stated that the Pharmacy sends the GDRs through email to facility and facility prints the GDR to have physician review. LPN #2 said that the physician has not responded to the GDR and not sure why. On 4/23/24 at 1:37 PM, the director of nursing (DON) was interviewed. The DON verbalized reaching out to the previous DON regarding pharmacy medication reviews and said that the previous DON had put the medication reviews in a binder, but the binder was unable to be located. On 4/23/24 at 4:11 PM, the above information was presented to the DON and administrator. On 4/24/24, the administrator presented the MEDICAL DIRECTION SERVICE AGREEMENT that read in part 3.4.11 Review consultant recommendation that affect Facility's resident care policies and procedures or the care of an individual resident; [ .] No other information was provided prior to exit conference on 4/24/24.

Based on staff interview and facility document review, the facility staff failed to maintain complete and accurate COVID-19 testing logs for staff with documentation of each instance of testing with results for all staff members. Findings include: A FIC (focused infection control) survey was conducted on 01/31/23. During the entrance conference on 01/31/23 at approximately 8:45 AM, the DON (director of nursing) was asked for testing logs for residents and staff members, along with COVID-19 policies and procedures. The DON stated that she and RN (Registered Nurse) #2 were the infection control preventionists. On 01/31/23 at approximately 11:00 AM, the DON presented the policies and procedures for COVID-19. The DON was again asked for all testing logs for residents and staff. On 01/31/23 at approximately 1:00 PM, the DON and RN #2 were again asked for testing logs for staff and residents. On 01/31/23 at approximately 1:30 PM, the DON presented the testing logs for residents and stated that she didn't have current testing logs for staff. The DON was asked how the facility was to track staff members testing positive for COVID-19, if they are not tested . The DON stated that the facility did test staff, but did not have all the documentation. The DON stated that she only documented the positive staff members and did not have evidence that all staff were tested . The DON was asked to present any and all documentation available regarding testing of staff members. The DON stated that she had only been tracking the positive staff members. When the DON was asked why, no direct response was given. At approximately 3:10 PM, RN #2 presented the testing logs for the residents and staff. The staff testing log only included eight staff members, all of which were positive. There was no evidence that any other staff had been tested . RN #2 stated that she was unable to find anything else with staff testing. RN #2 stated that the last evidence of tracking/testing logs for all staff was back in August and that she did not find anything from September to present to evidence that all staff were or/had been tested as required. RN #2 stated that the documentation presented, was all that could be found. The facility policy titled, COVID-19 Plan Summary of Policies and Procedures documented, .minimize exposure to respiratory pathogens and promptly identify .risk for COVID-19 .follow current testing plan regarding testing .if outbreak, assess staff exposures .any staff or resident with symptoms of COVID-19, regardless of vaccination status, should receive a viral test immediately .testing is required for new admission/readmission .facilities located in counties with substantial to high community transmission .test twice a week . The facility policy titled, Infection Control Program documented, .perform surveillance and investigation to prevent, when possible, the onset and spread of infection .prevent and control outbreaks .collecting, analyzing and providing infection data and trends to the interdisciplinary team .reports data to the administrator, medical director, and QAPI committee .infection data is reported monthly .utilizes reports to detect clusters and trends and track prevalence of infections . On 01/31/23 at approximately 5:00 PM, the administrator, DON, and RN #2 were made aware of concerns regarding the above findings and the lack of complete and accurate testing log records and documentation for staff COVID-19 testing. No further information and/or documentation was presented prior to the exit conference on 01/31/23 at 6:00 PM.

Based on staff interview and clinical record review, the facility staff failed to provide care and services for a Foley catheter as ordered by the physician for one of six residents in the survey sample (Resident # 1). Findings include: Resident #1 had an order to change the Foley catheter once every three weeks, but the medical device went unchanged for three months. Resident #1 was added to the survey sample as a closed record review, as there were no current residents with a catheter, Resident # 1 was admitted to the facility 2/25/22 with a readmitted [DATE]. Diagnoses for Resident #1 included, but were not limited to, stage 4 kidney disease, GERD, diabetes, congestive heart failure, obstructive uropathy, and history of stroke. A quarterly MDS (minimum data set) dated 6/22/22 had Resident # 1 assessed as cognitively intact for daily decision making, with a total summary score of 15/15. The clinical record was reviewed 1/31/23 beginning at approximately 10:40 a.m. A physician order dated 3/11/22 directed Change Foley Cath every month and PRN [as needed] to maintain patency and for leakage/blockage. That order was updated on 3/31/22 to Change Foley every 3 weeks and PRN. A review of the progress notes revealed the following: 4/1/22- Foley changed at urology appointment due to UTI (urinary tract infection) and blood in urine. 4/27/22- Foley changed due to rsd pulling it out. 5/10/22- Foley changed per urology order. There was no further documentation located in the clinical record about the Foley catheter until 8/8/22 which documented Removed 16 fr [french] Foley and replaced with 16 fr Foley. Resident tolerated procedure well without any difficulty A review of the TAR (treatment administration record) revealed the order was on the TAR, but there were no staff initials to indicate the Foley was changed per order. On 1/31/23 at 1:20 p.m., the DON (director of nursing), administrator, and director of quality and compliance were interviewed. The administrator stated he had been with the facility for approximately four months, and was not the administrator of record when the allegations occurred. The director of quality and compliance stated the same. The DON was interviewed about the documentation, TAR, and whether she knew if the catheter had been changed per order. The DON stated, No, the catheter was not changed as ordered; what you have seen in the record is correct; the cath was not changed from 5/10/22 until 8/8/22. In our investigation, we found that the nurse entering the order did not enter it correctly .there was no 'time code' identified for it to show up to change per the order, which meant it did not populate to the TAR to alert staff the Foley needed to be changed. A 24 hour chart check was done, but it was not identified as a problem. When the order changed from once a month to every three weeks, again no time code populated to alert the nurse the cath needed to be changed. Chart checks only look at what orders were done that day; there is no look back. We [performed a process review], and I do have a plan of correction. The plan of correction, dated 8/8/22, was reviewed, and included: Regarding other residents potentially affected: there are no other residents who have Foley catheters at this time. Systematic Changes: 1. Staff were educated to ensure that when placing order all fields are filled out. When reviewing the order to not just look at the days of the week or month ensure that a time is assigned on the left side of the MAR/TAR. 2. Staff were educated to ensure that when chart checking orders to ensure they are reviewing all fields 3. The date the Foley needs to be changed will be added to the end of the Foley catheter tube as a visual cue 4. 100% chart audits x 4 weeks 5. date of compliance 10/8/22. This deficiency was cited as past noncompliance. No further information was provided prior to the exit conference.

Based on observation, staff interview and facility document review, the facility staff failed to maintain an infection prevention and control program for the spread and prevention of COVID 19 and failed to ensure written policies and procedures included standard and transmission-based precautions to be followed to prevent spread of infections for COVID 19. Findings include: On 01/31/23 at approximately 8:15 AM, the nursing unit (Shenandoah) was observed. At the nurse's station was a staff member (later identified as PA (physician's assistant) #1). The staff member was wearing a surgical mask that was not covering the face, the surgical mask was looped over the staff member's left ear and was hanging down by the staff member's face. The staff member was asked for the DON (director of nursing) and/or administrator. The staff member stated that they were up front, took the mask completely off and proceeded through the double doors (exiting the Shenandoah nursing unit) to the DON's office. The staff member went into the office and came back and donned the surgical mask and went back toward the Shenandoah nursing unit. At approximately 8:20 AM, the DON was met for the entrance conference. The DON was made aware of the FIC (focused infection control) survey and was asked about COVID positive residents and what type of PPE (personal protective equipment) was requires on the units. The DON stated that they had three positive COVID cases that were isolating in their room and that they were located on the Shenandoah unit. The DON stated that everyone is wearing an N-95 on the nursing units while they have positive cases in house. The DON was asked who the staff member earlier. The DON stated that was the facility's PA. The DON was made aware of the observation on the Shenandoah unit of the PA with a surgical mask hanging off the ear, then removing the surgical mask and then donned prior to going back to the Shenandoah unit. The DON stated that everyone should be wearing an N-95 (if they are fit tested ) or a surgical mask with a face shield. The DON stated that all of their staff are fit tested and should be wearing an N-95 on the units at this time. The DON was asked for infection control and COVID -19 policies and procedures, On 01/31/23 at approximately 2:00 PM, the DON stated that she had a call out to PA#1 to asked why he was not wearing an N-95. At approximately 3:00 PM, the DON stated that she contacted PA #1 via phone and that he said he just took his mask off for a minute. The DON was again made aware of the observation and was asked why wasn't the PA wearing an N-95. The facility policy on face masks documented, .During an outbreak staff are to wear N-95 masks . At approximately 3:30 PM, RN #2 was also made aware of the observation regarding PA#1. RN #2 stated, All physicians and/or practitioners are to wear what we wear, if we are in N-95's they are too. On 01/31/23 at approximately 5:45 PM, the administrator, DON and RN #2 were again made aware of concerns regarding the observation of the staff member without a mask (later identified as PA #1) being on a unit with three positive COVID-19 residents. The administrator stated that PA #1 had been educated on wearing the appropriate PPE and this was not the first time. The administrator stated that the correct PPE was also provided, but stated that the PA had not been consistently compliant regarding this and as a result would no longer be provider at this facility. No further information and/or documentation was provided prior to the exit conference on 01/31/23 at 6:00 PM.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure four of five emergency exit doors were functioning properly; failed to ensure that one of 14 residents had a safety device correctly applied to his wheelchair, Resident # 37; and failed to ensure that physician ordered fall mats were in place for one of 14 residents, Resident #36. Findings were: 1. On 11/17/2021 at approximately 9:30 a.m., Resident #10's medical record was reviewed. Documentation in the clinical record included an elopement that had occurred on 09/08/2021. At approximately 10:00 a.m., the administrator was asked if an investigation had been completed, and if so to provide the information. At approximately 11:00 a.m., the administrator reported that there had not been an investigation regarding the incident. She stated, He went out the door at the CNA (Certified nursing assistant) desk near the dining area (400 unit). He went out into the courtyard that is an enclosed area, his wanderguard alarmed and we brought him back in. We would consider that a 'near miss' not an actual elopement but the system (the electronic health record) doesn't give us that option. LPN (licensed practical nurse) #2 who had written the note regarding the elopement was interviewed on 11/17/2021 at approximately 11:10 a.m. She stated, Yes, I remember that .Maybe his wanderguard didn't work, I don't know, but the alarm went off when he opened the door .he was outside. He was only out there a minute or two and we brought him back in. She was asked which door Resident #10 had exited and if she could demonstrate how it worked. The door was located on the side of the building. Outside the door was a sidewalk that led to an enclosed courtyard. The door was marked as Emergency Exit Only Door Can be Opened in 15 seconds Alarm will sound. She stated, He has a wanderguard, that's the alarm panel down there. She pointed to an oblong white enclosed shape. That locks the door, but if it's pushed on for 15 seconds, it's going to open. A button higher up on the wall beside the door was labeled Push to exit. She stated, You can push that to override the alarm. She was asked to open the door. She pushed the door open and the alarm did not sound. She was asked why the alarm had not sounded. She stated, I'm not sure. She was asked if there were any more Emergency Exits on that end of the hall. She stated, Yes, in the dining area. A door from the dining area to an enclosed patio was observed with the same emergency exit signage. She pushed on that door and it alarmed. An override button was observed on the wall. When LPN #2 pushed the button which was lit up and red, it turned green and she could open the door without it alarming. LPN #2 then went back to the first door and pushed the override button and pushed the door open. An alarm sounded. She stated, I think this door is wired backwards. She was asked who checked the doors for functionality. She stated, I know maintenance checks them everyday for the wanderguards. I don't know about anything else. The maintenance director, Other Staff #2 was interviewed at approximately 11:30 a.m. He went to the emergency exit door that had not alarmed. He stated, I don't know why it is unlocked. He was asked who checked the doors to ensure the alarms were working. He stated, We check them everyday to make sure the wanderguards are working .the doors can be programmed in different ways. They can be on a nighttime lock where they lock at 9:00 p.m., and unlock in the mornings. He then went to the door in the dining area, which alarmed when opened if the override button was not pressed. He stated, I think that other door is wired backwards. He was asked how long it had been like that. He stated, I don't know, I don't have a work order on it. He was asked if there were other emergency exit doors on resident units. He stated, Yes. Two emergency doors in the dining area of the 500 hallway were observed. One door was not locked and led out into an enclosed patio. He stated, This one must be on the nighttime lock .the residents have a right to go outside. The other emergency door was also not locked. That door opened up to a sidewalk that led down a hill to the parking lot of the facility. He was asked why a door that was not opening up to an enclosed area was not locked. He stated, I don't know, it doesn't make sense. The last emergency door that was observed was on the 600 unit. It was also not locked but was also not labeled as an emergency door. He stated, I don't know what is going on. This door should be labeled as an emergency exit .that's something we should be checking. At approximately 12:15 p.m. OS #2 came to the conference room. He stated, We don't check the doors to see if the emergency locks are working, we check to see if the wanderguard panel is working. Our doors lock and unlock at different times during the day. The residents have a right to go outside. He was asked if there was a policy regarding the door lock/unlock times. He stated he would check. The administrator and the DON (director of nursing) were interviewed at approximately 12:25 p.m. about the emergency exit doors. Concerns were voiced that residents with dementia or confusion without wanderguards could easily exit the building without an alarm sounding to alert staff that they were outside potentially resulting in injury to a resident. The administrator stated, The emergency exit doors should be locked and should alarm when opened .we need to be checking those doors for safety. The above information was discussed during an end of the day meeting on 11/17/2021. Concerns were voiced that four of five emergency exit doors in resident areas were not alarming when opened to alert staff that residents were outside. The administrator was asked if a policy regarding the locking and unlocking of the emergency exit doors had been located. She stated, No .when the survey is over we are going to discuss what the we should be doing with the doors. We are going to do a performance improvement plan, the doors should be locked and alarming for safety. We may need to call the (name) company back in that did our renovations and see what the problem is. No further information was obtained prior to the exit conference on 11/17/2021. 2. Resident # 37 was admitted to the facility 10/2/21 with diagnoses to include, but were not limited to: [CONDITION(S)], right femur fracture, [CONDITION(S)], GERD, high blood pressure, and [CONDITION(S)]. The most recent MDS (minimum data set) was a significant change assessment dated [DATE]. Resident # 37 was coded as having impairment in long term and short term memory, and moderately impaired in cognition. On 11/16/21 at 12:30 p.m. a dining observation was conducted. Resident # 37 was brought to the table for lunch by CNA (certified nursing assistant) # 1 in his wheelchair. Resident # 37 was seated at the table and immediately began propelling backwards as if leaving. Various staff called his name and asking where he was going and Resident # 37 was brought back to his place at the table. When he was brought back to the table, his wheelchair was not locked, and this behavior continued. Resident # 37's wheelchair was also observed with only one anti-rollback device applied to back of the chair. On 11/16/21 at 12:49 p.m. CNA # 1 was asked why the resident's wheelchair wasn't locked, and where the other anti-rollback device was for the wheelchair. CNA # 1 stated I don't know why the chair wasn't locked. I have no answer for that .but he can propel with his feet .I don't have an answer for why there's only one anti-rollback on the back of his [NAME], that's done by therapy. At that time, OS (other staff) # 1, an OT (occupational therapist), came into the dining room. OS # 1 was shown the back of the wheelchair, and asked about the device(s). OS # 1 stated I think staff said one fell off. I just put him in that wheelchair with the anti-rollback devices, there should be two applied. Thank you for noticing because it's my responsibility to make sure they're on there. If staff notice that, they are to alert me immediately so I can fix it. OS # 1 stated a staff member thought the other device was in the resident's room. Resident # 37's room was then observed with OS # 1, but the device was not located. OS # 1 stated as soon as Resident # 37 was finished with lunch, she would take him to the therapy room and apply the second anti-rollback device. OS # 1 further stated Resident # 37 had had some falls without injury, and this intervention was to help prevent a fall. The administrator, vice president of operations, and charge nurse were informed of the above findings during a meeting with facility staff 11/17/21 at 2:30 p.m. No further information was provided prior to the exit conference. 3. Resident #36 was admitted to the facility on [DATE]. Diagnoses for Resident #36 included: fracture of right femur secondary to fall at home, muscle weakness, joint disorder, and [CONDITION(S)]. The most current MDS (minimum data set) was an entry assessment with an ARD (assessment reference date) of 11/01/21. Resident #36 was assessed with a cognitive score of 14 indicating cognitively intact. On 11/16/21 at 2:32 PM, Resident #36 was interviewed. During the interview Resident #36 said she had fallen at home and broken her leg and was at the facility for therapy. At the time of the interview Resident #36 was laying in bed. No fall mats were observed in the resident's room. On 11/16/21 Resident #36's clinical record was reviewed. A physician's order dated 10/25/21 read Fall Mat- Continuous. Resident #36's care plan for falls was also reviewed and incuded implementation of a fall mat for Resident #36. On 11/17/21 at 9:07 AM, Resident #36 was again observed laying in bed without a fall mat. On 11/17/21 at 9:11 AM, certified nursing assistant, (CNA #2, assigned to Resident #36) was interviewed concerning fall mats being in place. CNA #2 verbalized unawareness that Resident #36 needed a fall mat. On 11/17/21 at 9:17 AM, license practical nurse (LPN #1) was interviewed regarding Resident #36's fall mat. LPN #1 observed Resident #36 without a fall mat, reviewed Resident #36's orders, and stated that Resident #36 was supposed to have a fall mat. On 11/17/21 at 2:30 PM, the above information was provided to the administrator. No other information was provided prior to exit conference on 11/17/21.

Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation, the facility staff failed to ensure one of 16 residents in the survey sample, Resident #5, was free from a significant medication error. Resident #5 erroneously received her roommates medications on 12/19/2016. The medications included, but not limited to an antihypertensive medication and a pain pill. Resident #5 was sent to a local hospital after a decrease in her blood pressure. There she received [MEDICATION NAME] and IV fluids. This resulted in harm. A facility reported incident (FRI) was received in the Office of Licensure and Certification (OLC) on 12/20/2016 regarding the medication error. The OLC converted the FRI into a complaint. Findings were: Resident #5 was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The minimum data set in place at the time of the incident, was a quarterly assessment with an ARD (assessment reference date) of 08/07/2015. Resident #5 was assessed as being severely impaired in her cognitive status with a summary score of 03. The clinical record was reviewed on 03/06/2018. Information regarding the incident was requested from the administrator and received. Review of the FRI and the facility investigation, provided the following information: On 12/19/2016 the evening medications were being administered on the 400 hall. The LPN (licensed practical nurse) #2 (no longer employed by the facility), was new to the facility and although she was no longer on orientation, she had only administered medications to seven residents in a 2 1/2/ hour period. According to the investigation, the residents were becoming restless while waiting for their medications. Another nurse, LPN #3 stepped in to help LPN #2. LPN #3 poured the medications to expedite the process and handed them to LPN #2 to give to the residents. Medications were prepared for the resident in Bed A. The medications were handed to LPN #2 and she was told to administer them to the resident in the first bed she came to. LPN #2 pointed to a bed in the room and stated, this is the first bed, LPN #3 clarified and pointed to the right side of the room and stated, no that's the first bed. LPN #3 overheard LPN #2 interacting with Resident #5 and realized LPN #2 was speaking with the wrong resident (Resident #5). The error was immediately identified. The physician was notified and orders were obtained to monitor Resident #5's blood pressure every hour for 12 hours. Resident #5's blood pressure dropped to 74/57 with a heart rate of 54. The facility staff lowered her head and elevated her feet without results. The blood pressure went down to 73/54 and her heart rate decreased to 51. The physician was notified and Resident #5 was transported to the local emergency room via 911. The emergency room records were reviewed. Resident #5's blood pressure upon arrival to the emergency room was 117/68 and her heart rate was 57. Per the brief MDM (medical decision making) documentation [MEDICATION NAME] was given to Resident #5 with mild response, but per her husband Resident was very much at her baseline with her responses. Also per the emergency room notes, Resident #5 received 800 mls of NS (normal saline) IV. During an interview with the administrator on 03/07/2018 she was asked why one nurse was pouring/preparing medications for another nurse to give. She stated that the facility had revised the medication administration policy after the incident to include: If a nurse needs assistance during a medication administration and another nurse assists, he/she should assume responsibility for administration to specific residents. At no time should the nurses split responsibility for administration to the same resident (example: one nurse pour meds and document administration and another nurse actually administer the medication.) The facility staff presented a plan of correction developed at the time of this incident. The five points of the plan were reviewed by the survey team and accepted as written. Plan stated: 1. Regarding the resident affected; Physician and Responsible Party were contacted regarding the error. MD order obtained to monitor blood pressure hourly for 12 hours. During the night, resident's blood pressure dropped. MD order obtained to send resident to emergency room via EMS. resident sustained [REDACTED]. Staff monitored resident after incident. No further injury or change in demeanor has been identified. Resident appears to be at baseline. (Resident suffers from advanced dementia and cannot consistently communicate needs and concerns.) 12/27/16 2. Regarding other residents potentially affected: No other residents were identified as being affected. 12/20/16 3. Systematic changes: As a result of this incident and investigation for allegation of abuse that also occurred 12/19/16, LPN was suspended and then terminated. 12/22/16 Complaint was filed with Department of Health Professions regarding LPN involved. 12/22/16 Staff will complete audit of all rooms to identify which do not have pictures of residents posted outside of the rooms. Staff will ask residents/responsible parties for permission to post pictures of those not yet posted. 1/3/17 Letters A and B have been printed and will be posted in companion rooms to indicate which room is A and which is B. 1/3/17 Staff reeducated on the medication administration policy (five rights of medication administration) and the resident identification policy. 1/5/17 New system initiated in which the signage outside of rooms is labeled with a letter A or letter B to correlate with the resident name posted. 1/9/17 Staff educated on the new systems. 1/9/17 4. Auditing: Director of Nursing and Administrator will monitor to ensure another resident does not receive medications intended for roommate. 12/22/16 Director of Nursing, Administrator and/or designee, will randomly audit for resident satisfaction related to medication pass three times a week for 2 weeks. 12/29/16 Marketing Associate/Admissions Coordinator will ensure resident names, pictures and signage updated for any new admissions, room changes, etc. 1/5/17 5. Results of audits will be reported to QA. There were no current issues with significant medication error identified during the onsite survey. The above information was discussed during an end of day meeting on 03/07/2018. The administrator and the DON (director of nursing) were informed that the survey team would recommend the incident at harm level with past noncompliance. No further information was obtained prior to the exit conference. This is a complaint deficiency and cited at PAST NON COMPLIANCE.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to identify a known allergy prior to dispensing a medication for one of 15 residents in the survey sample and failed to ensure availability of medication for one of 15 residents in the survey sample. 1. The pharmacy dispensed an order for [REDACTED].#14 causing an allergic reaction that resulted in hospitalization and transfer to a specialized burn center for care/treatment. The resident experienced large blisters with clear fluid on the palms of both hands, the sole of her left foot, inner thighs, both knees and on her buttocks/sacral area in addition to redness over her arms and legs in response to the medication. 2. The facility staff failed to ensure the physician ordered medication, Simvastin, was available for administration for one of 15 residents. (Resident #8) The findings include: 1. Resident #14 was admitted to the facility on [DATE], was re-admitted on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED].* The minimum data set ((MDS) dated [DATE] assessed Resident #14 as cognitively intact. A facility reported incident report dated 12/3/13 documented Resident #14, identified as allergic to Allopurinol, was administered a dose of the medication on 11/30/13 and experienced an allergic reaction. The resident's reaction included formation of large blisters with clear fluid on the palms of both hands, the sole of her left foot, inner thighs, both knees and on her buttocks/sacral area in addition to redness over her arms and legs. Resident #14 required hospitalization and was transferred to a specialized burn center for care/treatment of [REDACTED]. Resident #14's clinical record was reviewed on 3/6/14. The clinical record documented a physician's orders [REDACTED]. 11/30/13 at 10:37 p.m. - "...face flushed, arms and legs flushed, resident c/o (complained of) her palms being numb and tingling, palms red, resident diaphoretic, B/P 152/80, HR (heart rate) 112 and with periods of irregularity...(physician) notified ordered Solumedrol 60 mg IM time one, Benadryl 25 mg times one, Ranitidine 150 mg times one..." 11/30/13 at 11:53 p.m. - "...flushing remains present on the arms, face, hands and neck, resident states that most of the feeling in her palms has returned but they are still tingling..." 12/1/13 at 12:11 a.m. - "...flushing remains present on the arms, hands, and neck...resident is now c/o (complaining of) itching in the legs bilaterally, states 'my legs are kinda feeling like my palms did earlier,'..." 12/1/13 at 2:24 p.m. - "...resident states that she has full feeling in her palms at this time but they are still tingling as well as her legs bilaterally..." 12/1/13 at 6:56 p.m. - "...Right arm has reddened rash and reddened rash located between thighs..." 12/2/13 at 4:32 a.m. - "...noted resident's face was flushed, upon assessment this nurse noted facial flushing and a red rash on the bilateral upper extremities and trunk..." 12/2/13 at 4:10 p.m. - "Spoke with R/P (responsible party) and discussed why the Allupurinol was administered when listed as resident being allergic...I asked if the symptoms were the same as when she was deemed allergic...the (RP) indicated the she (resident) did have redness and that she developed blistered and became short of breath..." (sic) 12/2/13 at 5:45 p.m. - "Resident has mild redness still occurring up her back but no other symptoms..." 12/3/13 at 9:50 a.m. - "...skin remains light red throughout the body except the face, palms red and resident to complain of discomfort/tingling bilaterally..." 12/3/13 at 4:59 p.m. - "New order received from (physician) stating that if resident is to develop any further blisters in addition to the ones on the palms, left buttock and left inner thigh...resident to be taken to (local hospital)..." 12/4/13 at 12:07 a.m. - "...at 1845 (12/3/13 at 6:45 p.m.)...this nurse took her (Resident #14's) shoe off to find a fluid filled blister on the bottom of her left foot that measured 4 cm x 4 cm x .3 cm (length by width by depth in centimeters). She also had one on the inner side of her left foot that was fluid filled and measured 4 cm x 3 cm x .2 cm...found another blistered that had busted open in the bend of her right leg measuring 3 cm x 8 cm..." Resident #14 was sent to the emergency roiagnom on [DATE] at 6:45 p.m. after the assessment of increased blistering. A hospital history and physical dated 12/4/13 documented, "...evaluation for possible Stevens Johnso[DIAGNOSES REDACTED]...allopurinol...She has a known allergy to allopurinol but states she was given a dose for her gout on Saturday (11/30/13). On Monday night/Tuesday she noticed blistering and rash on her palms, soles and behind her right leg. States that the allergy was noted one year ago when she took allopurinol and developed blisters on her hands and abdomen and has not taken the medication since..." The hospital skin assessment dated [DATE] described the resident's skin condition as, "bilateral palmer bullae spreading into fingers, left buttock and right inner knee bullae ruptured. Left foot bulla on plantar aspect. Minimally raised [DIAGNOSES REDACTED]tous rash on right inner forearm, lower abdomen, inner thigh all warm to the touch..." The assessment/plan documented, "Per pt's h/o (history of) allopurinol allergy with resulting fluid-filled vesicles in the past, this is most likely due to her allopurinol administration on Saturday (11/30/13)...now with large bullae on palms, left sole, right inner knee, left buttock..." Resident #14 was admitted to the hospital for treatment of [REDACTED]. A hospital skin assessment dated [DATE] documented, "Large soft bullae to bilateral palms, red small loose bullae to bilateral anterior forearms, posterior upper arms bilaterally, large ruptured bulle to left buttock, ruptured bullae left medial calf/thigh, large loose bullae to left medial foot, bullae on right breast, bilateral medial thighs, [DIAGNOSES REDACTED]tous patches to dorsal forearms without bullae. Skin redness to lowe (lower) back improved." (sic) Resident #14 was transferred 12/6/13 to a specialized burn center for management of the skin blisters. The history and physical form dated 12/6/13 documented, "Pt has a history of gout, and developed a gout flare in her right foot. She was initially started on prednisone, and eventually given Allopurinol - to which she is allergic. Shortly afterwards, she began to develop blisters on her palms, hands, legs and abdomen and was sent to (local hospital) for evaluation and for presumed Stevens Johnson...was transferred as her primary team thought she would be better served at a facility with an available burn center..On arrival, pt reports mild 'burning' pain to her arms and legs..." The burn center skin assessment dated [DATE] stated the resident had, "Blisters with clear fluid noted on palms, upper and lower extremities, sole of left foot, and buttocks. One open blister on medial right knee..." An internal medicine report dated 12/7/13 documented the resident had "[DIAGNOSES REDACTED] multiforme." This assessment stated "...transfer from (local hospital) for treatment of [REDACTED]. The resident was ordered/administered Tylenol for scheduled pain management, morphine prior to dressing changes and heparin for the prevention of deep vein thrombosis. After treatment in the burn center the resident returned to the nursing facility on 12/10/13. An admission assessment dated [DATE] stated the resident had "multiple open blisters noted throughout body, bright red, small amount of bleeding...3 sutures noted in right upper arm on the inside near elbow from biopsy..." Skin assessments dated 12/10/13 documented the following upon return to the nursing facility. Measurements were length by width in centimeters. Open blister to bottom of left foot, 9.5 x 7.5, treatment with calcium alginate, border dressing Blue/green bruise to left lower leg near shin, 2.5 x 5.5 Open, bright red blisters on left inner thigh measuring 7.5 x 7; 2 x 1.5; 3.5 x 3.5; 2 x 3 with small amount of bleeding, treatment with calcium alginate, dressing Old blister, dry, pink to left lower abdomen, 3 x 4.5 Blue/green bruises from heparin injections on left lower abdomen Old, dry dark red blister covering the entire left palm and all 5 fingers, scabbing on 3rd, 4th and 5th fingers Old, dried, pink blister to left upper/inner arm, 5 x 4 Dried, pink blister/open to the back of left thigh, 2.5 x 2.5 Open, bright red blister on left buttock, small amount of bleeding, 7.5 x 4, treatment with calcium alginate, dressing Open, pink blisters to back of right thigh, 2 x 2.5; 1.5 x 5 Open, bright red blister to right inner thigh, small amount of bleeding, 1.5 x 2.5, treatment with calcium alginate, dressing Open, dried, pink blisters to back of right thigh, 6.5 x 8.5; 5 x 4.5 Open, red blister to right calf, small amount of bleeding, 3.5 x 5 Open, bright red blister covering entire right palm and all 5 fingers, treatment with eucerine ointment Dark blue/green bruises to right arm, 4 x 4; 5 x 4 Open, dry pink blisters to underside of right upper arm, 7 x 9; 5 x 5 Surgical incision from biopsy of blister on right mid-arm, 3 sutures present, 3 x 1 Open red blister on right breast, small amount of bleeding, 3 x 6, treatment with calcium alginate, dressing Open, red blisters to right calf, small amount of bleeding, 5 x 3; 3.5 x 5, treatment with calcium alginate, dressing Open, red blister on right buttock, small amount bleeding, 1.5 x 2, treatment with calcium alginate, dressing Follow up assessments documented peeling of the resident's skin as the blisters healed. A nursing note dated 12/17/13 stated, "Dry skin noted to hands and are peeling...Skin continues to peel on arms, inner thigh and L (left) foot. All areas are closed..." A nursing note dated 12/24/13 stated, "...went to (burn center) today for a followup appt. (appointment). They stated that her areas are healed..." The resident's clinical record documented the resident's allergy to Allopurinol prior to the physician's orders [REDACTED]. Resident #14's face sheet completed upon admission on 10/14/13 listed the Allopurinol allergy along with allergies [REDACTED]. The MAR indicated [REDACTED]." On 3/6/14 at 8:00 a.m. the director of nursing (DON) was interviewed concerning the administration of Allopurinol to Resident #14. The DON stated when the order for Allopurinol was received from the physician the nurse entered it into their computer system. The DON stated, "I believe the allergy was in there (computer system) but the system didn't alert us." The DON stated the resident was administered one dose of Allopurinol on 11/30/13 and the next day a nurse recognized the error. The DON stated, "Pharmacy should never have sent the drug." The DON stated the facility was aware of the resident's Allopurinol allergy prior to the order and the allergy was listed on the resident's admission records/face sheet and medication record. The DON stated the physician should not have ordered the medication and the nurse failed to check the medication against the resident's listed allergies [REDACTED].#14)." On 3/6/14 at 11:15 a.m. the DON stated the resident's Allopurinol allergy was included with the admission documents and was known to the staff from prior history and prior to the order for the medication. On 3/6/14 at 11:30 a.m. the resident's physician was interviewed about Resident #14's allergic reaction to Allopurinol. The physician stated the resident had episodes of gout that he had treated with prednisone. The physician stated he prescribed the Allopurinol as a maintenance drug to manage the gout. The physician stated he did not reference the resident's allergy information in the computer prior to ordering the Allopurinol. The physician stated, "I usually look at the computer but I failed to look at the computer this time." The physician stated, "The mistake (ordering Allopurinol) began from me. It (allergy) was clearly on the face sheet." The physician stated the resident's allergic reaction resulted in blistered skin and the resident was diagnosed with [REDACTED]. On 3/6/14 at 1:45 p.m. the general manager of the facility's pharmacy was interviewed by telephone about how the order for Allopurinol was filled when the resident had a listed allergy to the medication. The pharmacy manager stated when the resident was admitted the resident's information, including drug allergies [REDACTED]. The pharmacy manager stated, "In this case (Resident #14's) the allergy was not entered." The pharmacy manager stated the technician failed to enter the Resident #14's allergy information into the pharmacy system so when the order for Allopurinol came through there was nothing in the system to catch or stop the order. The general manager stated, "Pharmacy missed it (allergy). The tech missed it." The Drug Information Handbook for Nursing 13th Edition on page 49 describes Allopurinol as a xantine oxidase inhibitor used for the prevention of gouty arthritis and [DIAGNOSES REDACTED]. This reference states use of Allopurinol is contraindicated for patients with hypersensitivity to allopurinol or any component of the formulation. Warning/Precautions listed include, "Has been associated with a number of hypersensitivity reactions, including severe reactions (vasculitis and Stevens-Johnso[DIAGNOSES REDACTED]); discontinue at first sign of rash..." (1) These findings were reviewed with the administrator and director of nursing on 3/6/14 at 2:45 p.m. *The Miller-Keane Encyclopedia & Dictionary of Medicine, Nursing & Allied Health on page 619 defines [DIAGNOSES REDACTED] multiforme as, "a symptom complex representing a reaction of the skin and mucous membranes secondary to various known, suspected, and unknown factors, including infections, ingestants, physical agents...characterized by the sudden onset of a reddened macular, bullous, papular, or vesicular eruption. The complex includes a mild self-limited mucocutaneous form ([DIAGNOSES REDACTED] multiforme minor) and a severe, sometimes fatal, multisystem form (Stevens-Johnso[DIAGNOSES REDACTED])." (2) (1) Turkoski, Beatrice B., Brenda R. Lance and Elizabeth A. Tomsik. Drug Information Handbook for Nursing. Hudson, Ohio: Lexi-Comp, 2011. (2) O ' Toole, Marie T. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing and Allied Health. Philadelphia, Pennsylvania: Elsevier, 2003. 2. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS), an annual with an assessment reference date (ARD) of 12/19/13 documented the resident as having both short and long term memory loss and needing extensive assistance with decision making. The electronic clinical record was reviewed on 3/4/14, 3/5/14 and 3/6/14. An "Interdisciplinary Note" from 2/22/14 at 06:14 (6:14 a.m.) documented "Dr (doctor named, resident's husband) asked (for) resident's Simvastin and removed it from inventory in the med cart. He stated he only started her on it because he heard it delayed dementia. States it was never for her cholesterol and he feels she no longer needs it. Informed MD (medical doctor) of the Simvastin." The 2/14 electronic Medication Administration Record [REDACTED]" with a start date of 8/3/13 and a stop date of 2/24/14. On the MAR indicated [REDACTED]. For the dates of 2/21/14, 2/22/14, and 2/24/14 "(N)" was documented. The last page of the eMAR documented "Simvastin Tablet 20 mg - 2/21/14 - 16:29 (4:29 p.m.) - Med Not Administered - dr (resident's last name) removed from stock...Simvastin Tablet 20 mg - 2/22/14 - 16:16 (4:16 p.m.) - Med Not Administered - not available...Simvastin Tablet 20 mg - 2/24/14 - 16:26 p.m. (4:26 p.m.) - Med Not Administered - Out of medication and husband does not want resident taking this medication any longer. MD made aware." On 3/5/14 at 10:30 a.m., licensed practical nurse (LPN) #1 was asked about the resident's Simvastin order. LPN #1 stated "The resident's husband gets her medications from a mail order pharmacy and brings them into the facility for us to use. Some of the medications he won't reorder and won't let us order from our pharmacy, so we have to get an order from the resident's attending physician to discontinue the order or give us other guidance. He (resident's husband) did not want her to have Simvastin anymore." On 3/5/14 at 5:10 p.m., the administrative team was made aware of the findings during a meeting with the survey team. The facility's policy regarding unavailable medications was requested at this time as well as the discontinue order from the attending physician. On 3/6/14 at 9:00 a.m., this surveyor was provided with the order to discontinue the medication, Simvastin for Resident #8. The order documented "2/25/14 at 13:13 (1:13 p.m.) - Received order to discontinue simvastin, per family request." On 3/6/14 at 10:31 a.m., the resident's attending physician was asked about the Simvastin. The physician stated "I have a good relationship with him (the resident's husband), he is a retired physician. He will bring me articles and say that he read this and asks if this could be tried, like he did with the medication Simvastin." He went on to state "I order and discontinue the medications; we do talk about it though." On 3/6/14 at 1:45 p.m., this surveyor was provided with the facility's policy regarding unavailable medications. There was no mention of what staff are to do if the family gets the medication from a mail order pharmacy and brings it to the facility for the resident to use. On 3/6/14 at 2:45 p.m., during a meeting with the survey team, the administration was asked about the facility's policy regarding unavailable medications and what staff are to do if a medication is not available that the family receives from a mail order pharmacy. The director of nurses stated "the staff are to contact the family member then contact the attending physician. If the medication is not available from the mail order pharmacy, we will order a seven day supply from our pharmacy that they are responsible for paying for." She went on to state "He (the resident's husband) wouldn't let us order it and there was a delay in getting the order to discontinue the medication." When asked if the facility was responsible for providing the physician ordered medication for a resident regardless of where it comes from, the director of nurses stated "yes." No other information was provided to this surveyor prior to the exit conference on 3/6/14.

Based on observation, staff interview, family interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure three of 15 residents (Resident # 6, Resident # 9, and Resident # 12) were provided adequate supervision and/or safety devices for the prevention of an accident. 1. The facility staff failed to ensure appropriate safety interventions were in place for the use of an electric recliner for Resident # 6, as a result the resident had a fall that resulted in a contusion to the forehead with a subdural hematoma (bleed in the brain). 2. The facility staff failed to provide adequate supervision to Resident # 9 while toileting, as a result the resident fell . 3. The facility staff failed to ensure physician ordered safety devices were in place for the prevention of accidents for Resident # 12. Findings include: 1. Resident # 6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) with CAAS (care area assessment summary) was the admission assessment dated [DATE]. This MDS assessed the resident with short and long term memory impairment with severe impairment in daily decision making skills. The resident was also assessed as requiring extensive assistance from staff, with at least 2 staff physical assistance for transfers and toileting. The resident was also assessed as "Not steady, only able to stabilize with human assistance" for transfers and toileting. The CAAS triggered for Resident # 6 included, but were not limited to: cognition, communication, ADL function, urinary incontinence, and falls. The most current quarterly MDS dated [DATE] was reviewed for comparison. This MDS assessed the resident exactly the same as above, in the specified areas. On 03/04/14 at approximately 3:10 p.m., Resident # 6 was observed in her room, sitting in an electric recliner (with the foot rest up) covered with a blanket and her eyes closed. During clinical record review 03/05/14, nursing notes for Resident # 6 were reviewed and revealed the following: A nursing noted dated 10/26/13 and timed 3:07 p.m. documented: "...Presently resting in recliner. Will observe...signature of nurse." A nursing note dated 10/26/13 and timed 5:37 p.m. documented: "At 1520 (3:20 p.m.) this nurse heard chair alarm sounding. Upon entering resident's room, resident was found on floor laying on left side in front of recliner...Resident had an incontinent bowel movement...signature of nurse." A note by the Resident Support Coordinator (RSC) dated 10/31/13 and timed 10:43 a.m. documented: "...dementia, frequently incontinent of bladder... insomnia...anxiety, fall risk-decreased safety awareness-dementia...communication risk-dementia..." A note by the RSC dated 11/04/13 and timed 3:43 p.m. documented: "...history of anxiety disorder...also has a [DIAGNOSES REDACTED]. A nursing note dated 11/15/13 and timed 9:56 p.m. documented: "...Date of last fall: 10/26/13...Found resident sitting on her bottom in front of her wheelchair...her alarm was sounding...signature of nurse." A nursing note dated 12/13/13 and timed 2:11 a.m. documented: "At 1200 a.m. (midnight) Resident's bed alarm was sounding...resident trying to sit up in bed. Staff sat with resident at bedside approximately 5 minutes...1215 resident's alarm sounded. Staff entered room to find resident lying in a supine position with feet out of bed...resident refused to lie back in bed and staff assisted resident to recliner at bedside with personal alarm on and intact with the foot of the recliner in an up position with resident covered with a blanket...Remote to chair was tucked in the side of the recliner. 1225 a.m. staff was walking past resident's room and heard a thump and personal alarm sounded as staff heard the thump. Resident was lying at the base of the recliner with foot rest in a down position with chair up in the air...hematoma on left side of forehead that measures 5cm (centimeters) by 6cm by 2cm, abrasion to left cheek 1cm by 1.5cm...resident cried out in pain....911, rp (responsible party), and DON (director of nursing) where (sic) phoned...signature of nurse." The resident's CCP (comprehensive care plan) was reviewed from admission to present (March 2014). The resident's CCP dated 10/12/13 documented: "...Transfers: Provide me with limited assistance of 1-2 staff...allay apprehension and offer 1:1 support...Falls: Assure adequate lighting, assure clear pathways, ensure that I have proper fitting, nonskid footwear when ambulating or transferring..." The resident's CCP dated 10/31/13 documented: "...Transfers: Provide me with limited assistance of 1-2 staff...allay apprehension and offer 1:1 support...Falls: Assure adequate lighting, assure clear pathways, ensure that I have proper fitting, nonskid footwear when ambulating or transferring...Start: 11/18/13- Use a flat pillow on back of recliner to improve upright posture in sitting...Start: 11/21/13-Give me something to hold in my hands (baby doll, stuffed animal, blanket)...I have a bed and chair alarm. Please make sure these are in working order per policy. Start: 01/31/14" Resident # 6's fall risk assessments were reviewed and documented: 10/11/13-Falls Risk Assessment-Total Score= 14 High Risk for falls 10/25/13-Falls Risk Assessment-Total Score= 8 Moderate Risk for falls 11/17/13-Falls Risk Assessment-Total Score= 10 High Risk for falls The hospital discharge summary dated 12/13/13 documented: "...Your [DIAGNOSES REDACTED]. No other intracranial hemorrhage ...demonstrated ...Condition: Guarded ...Final Impression: 1. Fall at nursing home 2. Subdural hematoma, post-traumatic 3. Forehead Contusion 4. UTI 5. Knee abrasion..." On 03/05/14 at approximately 9:45 a.m., any and all documentation and/or investigations related to Resident # 6's falls since admission were requested from the DON. At approximately 11:55 p.m., the administrator presented the investigations/incident reports for Resident # 6's falls. The incident/investigation reports were reviewed. No additional details were documented in the reports/investigations to evidence a complete and accurate investigation had been completed on the falls for Resident # 6, specifically the fall on 12/13/13, which resulted in injury. At approximately 3:15 p.m., Resident # 6 was observed again in her room. The resident was sitting in the electric recliner, the foot rest in the up position, the resident's tv was on. No chair alarm was observed on the electric recliner, nor was the remote control to the recliner observed. At approximately 3:25 p.m., CNA # 7 was asked for assistance in obtaining more information on the alarm/recliner. CNA # 7 was asked if the resident had an alarm on her recliner. CNA # 7 stated, "...she should..." The CNA began looking around the chair and then reached down into the seat area of the chair, between the resident's right hip and the arm of the recliner and stated, "...yes, here it is..." The CNA held up a control box for the chair alarm, tested it and then put it back down in the seat of the chair between the resident's hip/buttock area and the arm of the chair; the CNA then reached in the same area and removed the remote control to the chair (the remote control was attached to the chair with a coiled cord) the CNA pushed on it a couple of times and then put the remote control into the side pocket of the recliner, located on the outside of the chair, on the resident's right side. The CNA was asked about the remote. The CNA retrieved the remote from the outside pocket and stated that, the resident's daughter likes the chair "locked" and that she (the CNA) put it in the outside pocket to keep the resident from "playing with it." The CNA stated, "See, when this is red-it's locked." The CNA further stated, "We (staff) aren't allowed to lock it, the daughter locks it when she is here...we can unlock when we need to get her up. At 5:45 p.m., the resident was still sitting in her recliner in her room. CNA # 7 was interviewed again regarding Resident # 6's electric recliner. CNA # 7 stated that the resident has had the chair since being admitted to the facility, that the chair came from home. The CNA verbalized again that the resident's daughter locks the remote and wants "us" (staff) to lock it, we (staff) aren't suppose to lock it, she (the daughter) locks it when she's here. The CNA was asked if she knew when "locking" the chair started. CNA # 7 stated, "...pretty sure that started (locking the remote) after the fall (December 2013)..." The CNA was asked if she knew anything about "tucking" the remote down into the seat area, where it had been found on the previous observation. The CNA stated that she didn't know, and further stated that she puts the remote in the outside pocket to keep the resident from "playing with it." On 03/06/14 at 1:30 p.m., the daughter of the resident was interviewed via telephone. The daughter stated that resident's electric recliner had come from home. The daughter was asked if she knew the resident had fallen out of the recliner in October (no injury), prior to the fall in December. The daughter stated, "No." The daughter was asked about locking the chair. The daughter stated, "No, I've never locked it, I don't know how it's done and wouldn't begin to know; the staff lock it." The daughter was asked about the resident and the chair prior to admission (at home). The daughter stated that the resident had 1:1 sitters at home and there had never been a problem with the chair or the resident falling out of the chair. The daughter was asked about the remote control and the resident "playing" with it. The daughter stated, "If she can get hold of it..." The daughter was asked if she had attended any care plan meetings for the resident and if any so, had the recliner been discussed. The daughter stated that she had attended "two" (meetings), one on "October 23, 2013" and one on "January 30, 2014." The daughter stated that neither the recliner or safety regarding the recliner was discussed at either care plan meeting. On 03/06/14 at 2:00 p.m., the administrator and the DON were interviewed and informed of the above findings and the serious safety concerns for Resident # 6. The administrator and DON were made aware of the concerns regarding the remote being "tucked" into the chair on December 13, when the resident sustained [REDACTED]. The administrator stated, "Where was that documented?" The administrator was made aware that the information was in a nursing note dated December 13, 2013. The administrator and DON were then made aware of the observations and the interview with the CNA and the family member. The DON stated, "What did she (the family) say?" The DON and administrator were both made aware that the investigation/incident report did not even address the findings above, did not have employee or family statements. The DON stated, "I didn't even know that the chair locked." The administrator made no comment. The DON and administrator were both reminded that the resident was admitted [DATE] and that the resident has been using the recliner for over 4 months and throughout the survey process, no one knew exactly what was going with this chair; the chair that the resident has had two falls out of, one being with significant injury (December 2013). The DON and administrator were further made aware that there was no mention of the resident's chair (recliner) regarding safety in the resident's CCP (comprehensive care plan). The DON and administrator verbalized and acknowledged that the investigations were not complete and accurate and agreed with the serious concerns regarding the chair. The DON stated, "Everybody is responsible for the care plans." The administrator stated, "We (staff) have been working with nurses regarding the care plans for quite some time." 03/06/14 at approximately 3:15 p.m. in a meeting with the surveyors, the DON and administrator were again made aware of significant concerns regarding Resident # 6 sustaining a major injury after falling out of her recliner, in a meeting with the survey team. The DON and administrator were additionally made aware of the resident's Fall Risk Assessment scores reviewed in the clinical record. The results of the 10/11/13-Falls Risk Assessment, with a total Score= 14 (High Risk for falls), the 10/25/13-Falls Risk Assessment-Total Score= 8 (Moderate Risk for falls), and the 11/17/13-Falls Risk Assessment-Total Score= 10 (High Risk for falls). The DON was informed that based on the information on the assessment, the calculations were wrong for Resident # 6 and was asked to explain how the total score decreased after the resident had two falls, instead of increasing. The DON stated, "Those are not correct!" The DON further stated, "Was there not one (fall risk assessment) for December..." The DON and administrator were informed that another fall risk assessment was not completed until February 2014. The DON nodded her head back and forth stated that they should be done "monthly." No further information or documentation was provided prior to the exit conference on 03/06/14 at 4:15 p.m. 2. Resident #9 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: [DIAGNOSES REDACTED], spinal stenosis, hypertension, anxiety, depression, and generalized pain. Resident #9 had been a resident On the ALF (assisted living side) of the facility immediately prior to this admission. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 02/06/2014. Resident #9 was assessed as having a cognitive summary score of "04" indicating severe impairment with her cognitive status. On 03/04/2014 at approximately 3:00 p.m., Resident#9 was observed lying supine on her bed. This Surveyor entered the room to talk with her. During the conversation Resident #9 was asked about a fall in the bathroom that had resulted in a rib fracture (the fall had been reported to the State Agency as a facility reported incident). Resident #9 did not remember the fall and could not provide any information. On 03/05/2014 at approximately 8:30 a.m., a copy of the facility investigation regarding the fall on 12/5/13 for Resident #9 was requested. The investigation included four handwritten witness statements. The administrator was asked if the employees involved could be contacted. She checked the schedule and stated that the LPN (licensed practical nurse) was no longer employed at the facility and one of the CNAs was out on medical leave. She stated she would have the other two come in as soon as possible. The facility follow-up and witness statements were reviewed and contained the following information: The first witness statement was written by the LPN no longer employed at the facility. It contained the following information: "CNA (name) came to tell me that she (Resident #9) was found on the floor by her (the CNA) when she went to get her off the toilet...the call bell in the bathroom was within her reach while she was sitting on the toilet but resident says that she did not pull it. She thought they had taken to (sic) long to come back for her, so she was going to get herself up. The elevated toilet seat was on its right side proving that she fell while either on it or trying to get off of it...rib pain, 8th rib fracture per X-ray results. Resident complained to this nurse and her niece...that the aids were rough and rude to her when placing her on the toilet. They (the CNAs) indicated to me that she is almost dead weight, cannot offer any help when they are transferring..." The second witness statement, written by CNA #12 contained the following information: "...the resident rang the call bell to go to the bathroom...(name of CNA #13) and myself went to transfer the resident from the recliner to her wheel chair and the resident was saying she couldn't help much because her left shoulder felt like it was broken, so she let us pick her up. When we got the resident to the toilet she tried to help us by pulling up on the bar, but couldn't really do anything. So by that time she was almost in the floor because she wouldn't pivot around. Then she got mad because (Name of CNA #13) had to grab her bottom to sit her on the toilet, and told (name of CNA #13) that she was white to get out, then (name of CNA #13) shut the door and we both told her to pull the call bell string when she was ready like she always does. We went out side and told (name of LPN no longer employed at the facility) about the situation and prior to that had spoken to (name of LPN no longer employed at the facility) about her transfer and her complaining of her arm. After I had put a resident to bed and possibly toileted a resident I noticed the resident (Resident #9) had not rang (sic) so I went to check on the resident. That's when I found resident in the floor." The third witness statement written by CNA #13 contained the following: "...Nurse ask (sic) us to take her (Resident #9) to the bathroom. Myself (name) and another CNA (name of CNA #12) put her on tolilted (sic) . Said she would pull call bell when finished. I left to go to lunch. When (name of CNA #12) returned to check on her she had fallen on to bathroom floor." The fourth witness statement was written by the CNA on medical leave. It contained the following information: "I was putting (name of another resident) to bed. When I was through I went to (Name of Resident #9) room to see if they needed help. I walked in they had already had her our of the wheelchair transfering (sic) her to the toilet. (Name of CNA #12 and #13) turned her toward the toilet. (Name of Resident #9) yelled at (Name of CNA #13) saying she was throwing her around. (Name of CNA #13) walked away and (Name of CNA #12) and I told (Name of Resident #9) to pull the alarm when she was through. I did not assist them in transferring while I was in there that time." An addendum to the statement included the following: "Before (name of CNA #12) and I left the room we made sure that the pull cord was in (Name of Resident #9) hand. When we left (name of CNA #13) went on her lunch break...I checked on (name of another resident) and (Name of CNA #12) assisted a resident to the restroom. After that we went to check on (Name of Resident #9) because she hadn't rang yet and we found her in the bathroom floor at 9:15...she was on the toilet about 5 or 10 minutes max..." Also included in the investigation report was a typed Incident Report which contained the following information: "Resident was found on her bathroom floor tonight by CNA (name of CNA #12). (Name of CNA #12) went to bathroom to check to see if resident was ready to get off of the toilet since she did not ring. Resident had fallen off of the toilet lift onto the floor while trying to transfer herself. She said that the CNAs took too long getting there to help her back to bed. CNAs didn't wait outside the door as resident thought they had (she says that is why she didn't ring, she thought they were outside the door.) Injury: Resident c/o pain in her ribs and sternum area. X-ray was performed and the result was the 8th rib on the left side is fractured." Further information included an interview the administrator conducted with the resident on 12/06/2013. "The administrator met with (Name of Resident #9). She said when she was done and no one came back she got up on her own, I asked if she used her pull cord and she said she didn't think of doing that. I inquired how long she might have waited and she said 10 minutes...I asked about her complaint that it was a rough transfer. She commented she got upset at the time, but understands she was about to fall and they likely prevented the fall." The Follow-up Investigation included the following: "Staff assisted (Resident #9) to the bathroom. Resident is alert and oriented and prefers privacy during toileting...Resident stated that staff came back to check on her, but she communicated she was not done and to please come back. The two CNAs went to assist two different residents. When they had not heard from (Resident #9) they went back to check on her a second time, at which point they found her on the floor...Staff members are being instructed to not leave this resident alone during toileting. They are to wait outside the bathroom door to allow privacy, but stay nearby to ensure safety..." The clinical record was reviewed beginning on 03/05/2014 at approximately 9:00 a.m. The admission MDS was reviewed. Section G-Functional Status was not completed. Section G0110, Activities of Daily Living and Section G0120, Bathing, did not contain any information. Each blank was filled with a "dash". Section H0300, Urinary Continence and Section H0400, Bowel Incontinence were also completed with a "dash". On 03/05/2014 at approximately 10:20 a.m., the MDS coordinator, RN (registered nurse) #1 was interviewed about the blanks on the admission MDS. She stated, "The CNAs enter their information in the computer. When I do the MDS assessment I look at what they are doing and code the resident. The CNAs did not document anything on that resident for the 7 day look back period. I went to the CNAs and they told me that they couldn't put anything in the system, it wouldn't let them...they hadn't told anyone." RN #1 was asked which CNAs she spoke with. She stated, "I don' remember." RN #1 was asked if she talked to the CNAs about what they were doing with the resident. She stated, "Yes, they told me 'the usual stuff...get her up, take her to the bathroom, give her a bath'...I emailed the RN supervisors and told them I didn't have any information and didn't know what else to do except put the dashes... I never got a response, so that's what I did." RN #1 was asked who completed care plans for the residents. She stated, "The RN supervisors." She then provided the names of the supervisors and stated, "(name of one of the supervisors) is off right now." A copy of the care plan that was in place at the time of the fall was requested. The care plan contained the following information: "ADL Function Rehab: Transfers: Provide me with limited to extensive assistance of 1-2 staff. Toileting: I need limited to extensive assistance from 1-2 staff with toileting." The interventions were dated 11/04/2013. A "Resident ADL/Daily Care List" was also provided, interventions on this list were dated 11/16/2013 and included: "Transfer...provide me with extensive assistance of 2 staff. I am occasionally so weak that I require total assistance...Toilet Use...I need extensive assistance from 2 staff with toileting." The resident admission and assessment dated [DATE] was reviewed. The ADL Assessment included toileting and transfer needs. Both areas were marked as "assist." Information from the ALF (assisted living facility) was included in the electronic record including the following correspondence between the ALF and the LTC facility dated 10/30/13: "Resident Care Committee met this a.m. to discuss (Resident #9) continued decline in strength now requiring 2 person assist at all times, increasing personal care needs, safety risks, etc. It was determined that she would be best served in the (name of facility)..." On 03/05/2014 at approximately 2:45 p.m., the RN #2 was interviewed. RN #2 was the supervisor whose name was listed as having completed the initial care plan. RN #2 was asked if the MDS was utilized to obtain information for the resident's care plans. She stated, "Yes, that is one source." RN #2 was asked where the information regarding ADL and toileting needs came from since the MDS sections were blank and the CNAs were unable to enter information into the system. She stated, "I don't know where the information came from...I don't remember doing that care plan...I wasn't here the day it is dated...If I did do it, I probably got the information from the POC (point of care) from the ALF side." RN #2 was asked why Resident #9 moved from the ALF side to the LTC side. She stated, "Because she had declined in her ADLs." RN #2 was asked if the POC from the ALF was a good reflection of the Resident's status when she came to the LTC side. She stated, "I don't know...I really don't know where I got the information from." CNA #12 was interviewed on 03/05/2014 at approximately 3:40 p.m. She stated, "It was on her care plan that we could leave her...she is weak, some days she is better than others...she was weak that night...when we were getting her on the toilet she couldn't turn around ...She got mad because (name of CNA #13) had to pick her up from her bottom and put her on the toilet." CNA #12 was asked if she thought a resident that weak should be left in the bathroom. She stated, "The care plan said we could leave her...we weren't gone but about 10 minutes." CNA #13 was interviewed on 03/05/2014 at approximately 4:25 p.m. She stated, "We had taken her to the bathroom about five times that night...she got weaker with every trip...by that time she was so weak she couldn't stand up, she was going down and I got her and lifted her up on the toilet...she thought I was being rough, but I thought she was going to fall...she asked for privacy...we walked out and I went on break, next thing I heard was that she had fallen." CNA #13 was asked if someone asked for privacy do you normally leave the room or wait outside the bathroom door. She stated, "We don't leave anybody now." CNA #13 was asked if Resident #9 was strong enough to sit on the toilet on the last trip. She stated, "She looked pretty steady sitting there...she normally rang for help...I don't know how long she was there, I went on break." An end of the day meeting was held on 03/05/2014 with the administrator and the DON (director of nursing) at approximately 5:00 p.m. The above information was discussed. Concerns were voiced by this surveyor that the areas concerning ADL's were not completed on the MDS, the care plan completed used the resident's status at the ALF to indicate her needs on the LTC side and the CNAs had taken the resident to the bathroom and completely left her room knowing she had almost "gone down" while attempting to get on the toilet. The resident did fall in the bathroom and sustained a rib fracture. The DON stated, "There was a glitch in our system...for some reason the POC (point of care) side had not been linked so the CNAs could document...and the RN supervisors name that is on the care plan wasn't here the day it is dated....we are looking into that." On 03/06/2014 at approximately 10:00 a.m. the DON provided this surveyor with additional information regarding Resident #9. Included in the information was a care plan from the ALF which did not address Resident #9's toileting needs. Also provided was an assessment from the ALF dated 09/03/2013 . Included on that assessment was a functional status assessment. In the area of toileting the following was checked: Needs Help? Yes; Mechanical and Human Help: Physical Assistance was checked. At the bottom of the last page the following was written: "Revise to add Phy/Mech (physical mechanical) bedside commode with toileting..." The revision was also dated 09/03/2013. The DON was asked if there was any counseling/disciplinary action taken with any of the CNAs regarding Resident #9's fall. The DON nodded her head up and down. The DON was asked to provide that information. The information was not received prior to the exit conference. No further information was obtained prior to the exit conference on 03/06/2014. 3. Resident #12 was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The MDS (minimum data set) was not yet completed on Resident #12 due to her recent admission. The clinical record was reviewed on 03/06/2014 beginning at approximately 9:00 a.m. Observed in the progress note section was a note which stated that the resident had a fall at the facility on 02/25/2014. According to the note, Resident #12 was found on her back with the alarm sounding. The resident stated she was "trying to get into the other chair." Observed in the physician's orders [REDACTED]." On 03/06/2014 at approximately 11:10 a.m., Resident #12 was observed sitting in her wheelchair in her room. This surveyor knocked and entered the room. A sensor pad was observed in the recliner chair in the room and a motion sensor alarm was observed attached to the bottom of Resident #12's bed. No pad was observed in the wheelchair where Resident #12 was siting. Resident #12 was asked if there was a pad under her that alarmed when she got up. She stated, "I don't think so." She then felt underneath herself and stated, "I don't feel anything." CNA (certified nursing assistant) #3 was in the hallway outside of Resident #12's room. She was asked if she was taking care of Resident #12. She stated, "Yes." CNA #3 was asked if Resident #12 had an alarm in her wheelchair. She stated, "You know, there wasn't one in her chair yesterday...let me check." CNA #12 entered the room and confirmed that she did not see an alarm on the wheelchair. CNA #3 then went to the nurse's station to speak with LPN (licensed practical nurse) #2. LPN #2 looked at the care plan and stated, "I don't see anything on there about an alarm. I don't know if she is suppose to have one or not." CNA #3 stated, "Let me go look at my care plan." At 12:00 noon CNA #3 and CNA #10 stopped this surveyor in the hallway. They stated, "(Name of LPN #2 told us that the residents can't have an alarm without an order...it isn't on our care plan either, maybe there isn't an order." LPN #2 came down the hallway at that time. She and this surveyor looked at the physician orders. LPN #2 stated, "There it is chair and bed alarm." LPN #2 was asked what that meant. She stated, "She should have the alarm in where she is sitting." An end of the day meeting was held on 03/06/2014 at approximately 3:00 p.m. with the administrator and the DON (director of nursing). They were informed of the above information. No further information was obtained prior to the exit conference on 03/06/2014.