Every finding on record at Legacy Village Rehabilitation

Based on interview and record review, for 9 of 25 sampled residents, the facility did not transmit completed Minimum Data Set (MDS) to the CMS (Center for Medicare/Medicaid Services) for discharge assessment within 14 days. Specifically, residents discharged MDS's were not signed by a Registered Nurse and transmitted within the required timeframe. In addition, one resident was discharged and did not have a discharge assessment. Resident identifier: 1, 2, 3, 4, 5, 13, 44, 58 and 66. Findings included:1. Resident 1 was admitted to the facility on [DATE] and discharged on 4/10/26 with diagnoses which included sepsis, heart failure and altered mental status. Resident 1 had a Minimum Data Set (MDS) with an assessment reference date of 4/10/26 for discharge with return not anticipated. The MDS was completed and signed by the MDS coordinator on 4/13/26. The Registered Nurse (RN) Assessment Coordinator did not sign the MDS and submit it to the Centers for Medicare/Medicaid Services (CMS) until 5/26/26. 2. Resident 13 was admitted to the facility on [DATE] and discharged on 4/13/26 with diagnoses which included respiratory failure with hypoxia, hypertension and anxiety disorder. Resident 13 had an MDS with an assessment reference date of 4/14/26 for a discharge return not anticipated. The MDS coordinator completed the MDS on 4/13/26. The RN Assessment Coordinator had not signed the MDS and submitted it to CMS. 3. Resident 4 was admitted [DATE] and discharged [DATE] with diagnoses which included, but was not limited to intestinal adhesions and unspecified intestinal obstruction.A discharge MDS assessment with an assessment reference date of 4/24/26 was completed by the facility, but was not transmitted to CMS.4. Resident 5 was admitted [DATE] and discharged [DATE] with diagnoses which included, but was not limited to urinary tract infection, constipation, and fall.A discharge MDS assessment with an assessment reference date of 4/9/26 was completed by the facility, but was not transmitted to CMS. 5. Resident 58 was admitted to the facility on [DATE] with diagnoses which included periprosthetic fracture around internal prosthetic left knee joint.Resident 58 had an MDS with an assessment reference date of 3/13/26 for a scheduled 5-day assesment. The MDS coordinator completed the MDS on 3/17/26. The RN Assessment Coordinator had not signed the MDS and submitted it to CMS until 4/20/26.6. Resident 44 was admitted to the facility on [DATE] and discharged on 1/24/26 with diagnoses which included palliative care, dementia with anxiety, and hemiplegia. Resident 44 had an MDS with an assessment reference date of 1/24/26 for a discharge return not anticipated. The MDS coordinator completed the MDS on 1/26/26. The RN Assessment Coordinator had not signed the MDS and submitted it to CMS until 5/8/26.7. Resident 3 was admitted to the facility on [DATE] and discharged on 4/7/26 with diagnoses which included acute kidney failure. Resident 3 had an MDS with an assessment reference date of 4/7/26 for a discharge return not anticipated. The MDS coordinator completed the MDS on 4/7/26. The RN Assessment Coordinator had not signed the MDS and submitted it to CMS until 5/26/26. 8. Resident 66 was admitted to the facility on [DATE] and discharged on 3/7/26 with diagnoses which included acute ischemic heart disease, peripheral vascular disease, and cerebral infarction. Resident 66 had an MDS with an assessment reference date of 3/9/26 for a discharge return not anticipated. The MDS coordinator completed the MDS on 3/9/26. The RN Assessment Coordinator had not signed the MDS and submitted it to CMS until 5/11/26. 9. Resident 2 was admitted to the facility on [DATE] and discharged [DATE] with diagnoses which included acute kidney failure, anxiety disorder, and unspecified dementia. Resident 2 did not have a discharge assessment started. On 5/27/26 at 1:14 PM, an interview was conducted with the MDS coordinator. The MDS Coordinator stated that resident 2's discharge assessment was not completed or submitted, noting, that one slipped through the cracks. The MDS Coordinator stated the above MDS's had not been submitted within 21 days of discharge. The MDS Coordinator stated that discharge assessments are routinely processed and completed within 14 days of discharge and the RN Assessment Coordinator reviewed the assessment findings within 7 days of completion and submitted them to CMS.

Based on interview and record review, the facility failed to ensure that the State Long-Term Care Ombudsman was systematically notified of facility-initiated discharges. Specifically, 2 out of 25 residents there was no documentation that the State Long-Term Care Ombudsman was notified of their discharge. Resident identifiers: 3 and 66.Findings included:1. Resident 3 was admitted to the facility on [DATE] and discharged on 4/7/26 with diagnoses which included acute kidney failure. Review of resident 3's medical record was completed on 5/26/26 through 5/27/26. It should be noted that a record for resident 3's discharge notice to the State Long-Term Care Ombudsman was not located. 2. Resident 66 was admitted to the facility on [DATE] and discharged on 3/7/26 with diagnoses which included acute ischemic heart disease, peripheral vascular disease, and cerebral infarction. Review of resident 66's medical record was completed on 5/26/26 through 5/27/26. It should be noted that a record for resident 66's discharge notice to the State Long-Term Care Ombudsman was not located. On 5/27/26 at 1:08 PM, an interview was conducted with the Administrator (ADM). The ADM stated that resident departures from the facility were typically triggered because insurance is done paying or the resident is ready to leave. The ADM stated that due to reasons the residents leave, he did not send notices to the Long-Term Care Ombudsman when a resident was discharged or transferred from the facility.

Based on interview and record review, it was determined the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not review their infection control policy and procedures annually. Findings Include:On 5/26/26, the infection control policy and procedures were provided by the Administrator. The Surveillance for Infections policy and procedures were revised September 2017. The Antibiotic Stewardship Program and COVID-19 Vaccine Education policy and procedure did not have a date on it. The Influenza Vaccine and Pneumococcal Vaccine policy and procedure was revised October 2019. On 5/27/26 at 1:40 PM, an interview was conducted with the Infection Preventionist (IP). The IP stated that they reviewed the antibiotic stewardship policy and procedure October of 2024. The IP stated the other infection control policy and procedures had not been reviewed annually.

Based on interview and record review it was determined, for 1 out of 5 sampled residents, that the facility did not immediately consult with the resident's physician when there was a significant change in the resident's physical status or a need to alter treatment. Specifically, a resident experienced a change in condition after a fall and the medical provider was not notified of the change timely. This resulted in a finding of harm to the resident. Resident identifier: 2.Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included, traumatic subarachnoid hemorrhage, nontraumatic acute subdural hemorrhage, difficulty in walking, epileptic seizures, and obstructive hydrocephalus.Resident 2's medical record was reviewed on 12/1/25. A review of resident 2's medical record revealed the following: a. On 10/13/25 at 3:44 AM, a note documented, Event Fall: Pt [patient] had an unwitnessed fall at 0230 [2:30 AM] in her bathroom and was found on the floor sitting upright by her husband who was sleeping in the bedside bed. Pt states that she needed to use the restroom and took herself. When she was through using the toilet she attempted to pull up her pants and lost her balance and fell towards her right side. Upon assessment pt was alert and reporting having no pain, had strong facial expressions, clear speech, equal bilateral grips, and reported having no pain. Pt was then stood up, walked to her bed, vitals were taken: BP [blood pressure]: 120/62. Temp [temperature]: 96.1. HR [heart rate]:77. R [respirations]:16. O2 [oxygen]: 90%. Neuro [neurological] checks were initiated. Pt is currently in bed resting with her husband awake at the bedside. Pt is still reporting no pain, stable, and with call light and water within reach. MD [Medical Doctor], DON [Director of Nursing], and family notified. Observation complete, unusual occurrence report done. b. On 10/13/25 at 9:42 AM, a physician note documented as a late entry on 10/19/25 at 9:43 AM documented, HISTORY Room: [number redacted] Chief Complaint / Nature of Presenting Problem: Unwitnessed fall History Of Present Illness: [Resident 2] is a [AGE] year female with recent Subarachnoid hemorrhage/IVH [intraventricular hemorrhage] caysed [sic] by left P [posterior communicating] aneursym [sic]. She is s/p [status post] craniotomy with clipping fof [sic] the aneursym [sic]. She also had a VP [ventriculoperitoneal] shunt and developed UE [upper extremity] DVT's [deep vein thromboses]. On blood thinner. Suffered an unwitnessed fall today. She was trying to get herself up and ambulate to the bathroom. Was found on the bathroom floor. She has had episodes of emesis today and seems to have a change of LOC [level of consciousness] more diffcult [sic] to arouse. No new neuro deficits noted on exam per Nurse.Follow-up Plan:This is a patient with history of subarachnoid and intraventricular hemorrhage due to left posterior communicating artery aneurysm, status post surgical clipping, now with residual neurological deficits undergoing comprehensive rehabilitation that suffered unwitnessed fall with change in condition. Will send out stat [immediately] imaging of the brain given h ER [sic] history and change of condition. Especially since she is on blood thinners. Husband at bedside. He agrees to POC [plan of care]. Nurse notified and pt transported to local hospital for further evaluation. c. On 10/13/25 at 1:19 PM, a note documented, Patient sent out Via [local ambulance company] @1220 [12:20 PM] to [local hospital] per recommendation from NP [Nurse Practitioner]. assessment completed by NP, patient unable to answer questions and open eyes when told to do so. pt had vomited 2 times during AM shift, having a decrease in LOC [level of consciousness]. family at bedside agreed to have patient sent out.It should be noted that a neurological assessment for the fall on 10/13/25 could not be located by the facility and resident 2 was sent to the emergency room via non-emergent ambulance transport. A review of the Medication Administration Record (MAR) revealed that on 10/13/25 at 8:34 AM, resident 2 was administered an ondansetron disintegrating tablet 4 milligrams for nausea and vomiting. A review of the Treatment Administration Record (TAR) revealed that on 10/13/25 at 10:20 AM an order for Hypnotic/Sedative/Tranquilizer monitoring showed a side effect of morning hangover. On 12/1/25 at 11:26 AM, an interview was conducted with the MD. The MD stated that she was notified of the fall via a text from the night nurse around 3:00 AM on 10/13/25. The MD stated that the Nurse Practitioner saw resident 2 the next day and sent her to the hospital because she was vomiting. The MD stated that resident 2 seemed fine after the fall and then experienced a change in condition. On 12/1/25 at 11:38 AM, an interview was conducted with the DON. The DON stated that she was not sure what the morning hangover on the TAR meant. The DON stated resident 2 was more tired than usual. The DON stated that after a fall if a resident had a decrease in level of consciousness or vomiting then she expected staff to contact the doctor or send the resident to the hospital. On 12/1/25 at 12:32 PM, an interview was conducted with the NP. The NP stated that she usually arrived at the facility between 11:00 AM and 12:00 PM. The NP stated that she relied on the nursing staff to inform her about a resident's condition. The NP stated that resident 2 had a brain bleed history and had multiple falls while at the facility. The NP stated that the nurse texted her around 11:00 AM on 10/13/25 that resident 2 was lethargic and had vomited. The NP stated that within a few minutes of assessing resident 2 she knew that resident 2 needed to go to the hospital because she was more lethargic and not easily arousable and the vomiting worried her. The NP stated that nurses should contact her if there was a change with the resident while performing neurological checks. The NP stated that a lot of the time the nurses liked to get her approval before sending a resident to the hospital, but she would like them to send a resident to the hospital if they were not doing well. The NP stated that from the time she was notified by the nurse about resident 2's change in condition was about an hour. It should be noted that the NP entered her progress note on 10/19/25 at 9:43 AM and this was documented as a late entry.On 12/1/25 at 12:52 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that he started his shift on 10/13/25 at 6:30 AM and got the report from another nurse that resident 2 had fallen earlier in the morning. LPN 1 stated that the night nurse had passed on in report that resident 2 was having a hard time opening her eyes and had to have her eyes opened by hand to perform neurological checks to assess her pupils and that resident 2's family did not want her to go to the hospital. LPN 1 stated that he assumed the night nurse had contacted the MD. LPN 1 stated that he continued the neurological checks when he started his shift and resident 2 was less responsive than her baseline and he also had to use his hands to open resident 2's eyes to perform the pupil assessment to see if they were more reactive. LPN 1 stated that he sat resident 2 up for breakfast and administered morning medications which resident 2 vomited up. LPN 1 stated that the vomiting episode was unwitnessed by him and resident 2's husband came and informed him. LPN 1 stated that resident 2 continued to not be at baseline and was still out of it. LPN 1 stated that he was concerned because resident 2 had vomited and he wanted the NP to see her because of this. LPN 1 stated that he waited for the NP to come in before sending resident 2 to the hospital because resident 2 had a Do Not Resuscitate (DNR) order and the last time he had sent her to the hospital after a fall the family was upset because resident 2 had not been injured. LPN 1 stated resident 2 was pretty tired on 10/13/25 and not at baseline. On 12/1/25 at 1:08 PM, a follow-up interview was conducted with the DON. The DON stated that it would be concerning if staff had to open a resident's eyes to perform pupil assessments during neurological checks and would expect staff to call the doctor immediately and not wait until later for a medical provider to come into the facility. On 12/1/25 at 1:13 PM, resident 2's family member was interviewed via email. The family member stated that resident 2 fell on the morning of 10/13/25 and the facility had not immediately sent her to the emergency room to check for internal bleeding. The family member stated that this was concerning given resident 2's history of falls while at the facility. The family member stated that resident 2 had a massive new brain bleed that was confirmed by a CT (cat) scan that was catastrophic and resident 2 passed away on 10/17/25. It should be noted that when the facility submitted to the State Survey Agency (SSA) their 5-day investigation findings, they concluded that resident 2 had an unfortunate fall and had not addressed the resident's change in condition.

Based on interview and record review it was determined, for 1 out of 5 sampled residents, that the facility did not ensure residents received treatment and care in accordance with professional standards of practice. Specifically, a resident sustained a fall, experienced a change in condition and the physician was not notified. Additionally, when the physician assessed the resident the resident was sent to the emergency room where she was diagnosed with a brain bleed and passed away four days later. This resulted in a finding of harm for the resident. Resident identifier: 2.Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included, traumatic subarachnoid hemorrhage, nontraumatic acute subdural hemorrhage, difficulty in walking, epileptic seizures, and obstructive hydrocephalus.Resident 2's medical record was reviewed on 12/1/25. A review of resident 2's medical record revealed the following: a. On 10/13/25 at 3:44 AM, a note documented, Event Fall: Pt [patient] had an unwitnessed fall at 0230 [2:30 AM] in her bathroom and was found on the floor sitting upright by her husband who was sleeping in the bedside bed. Pt states that she needed to use the restroom and took herself. When she was through using the toilet she attempted to pull up her pants and lost her balance and fell towards her right side. Upon assessment pt was alert and reporting having no pain, had strong facial expressions, clear speech, equal bilateral grips, and reported having no pain. Pt was then stood up, walked to her bed, vitals were taken: BP [blood pressure]: 120/62. Temp [temperature]: 96.1. HR [heart rate]:77. R [respirations]:16. O2 [oxygen]: 90%. Neuro [neurological] checks were initiated. Pt is currently in bed resting with her husband awake at the bedside. Pt is still reporting no pain, stable, and with call light and water within reach. MD [Medical Doctor], DON [Director of Nursing], and family notified. Observation complete, unusual occurrence report done. b. On 10/13/25 at 9:42 AM, a physician note documented as a late entry on 10/19/25 at 9:43 AM documented, HISTORY Room: [number redacted] Chief Complaint / Nature of Presenting Problem: Unwitnessed fall History Of Present Illness: [Resident 2] is a [AGE] year female with recent Subarachnoid hemorrhage/IVH [intraventricular hemorrhage] caysed [sic] by left P [posterior communicating] aneursym [sic]. She is s/p [status post] craniotomy with clipping fof [sic] the aneursym [sic]. She also had a VP [ventriculoperitoneal] shunt and developed UE [upper extremity] DVT's [deep vein thromboses]. On blood thinner. Suffered an unwitnessed fall today. She was trying to get herself up and ambulate to the bathroom. Was found on the bathroom floor. She has had episodes of emesis today and seems to have a change of LOC [level of consciousness] more diffcult [sic] to arouse. No new neuro deficits noted on exam per Nurse.Follow-up Plan: This is a patient with history of subarachnoid and intraventricular hemorrhage due to left posterior communicating artery aneurysm, status post surgical clipping, now with residual neurological deficits undergoing comprehensive rehabilitation that suffered unwitnessed fall with change in condition. Will send out stat [immediately] imaging of the brain given h ER [sic] history and change of condition. Especially since she is on blood thinners. Husband at bedside. He agrees to POC [plan of care]. Nurse notified and pt transported to local hospital for further evaluation. c. On 10/13/25 at 1:19 PM, a note documented, Patient sent out Via [local ambulance company] @ [at] 1220 [12:20 PM] to [local hospital] per recommendation from NP [nurse practitioner]. assessment completed by NP, patient unable to answer questions and open eyes when told to do so. pt had vomited 2 times during AM [morning] shift, having a decrease in LOC. family at bedside agreed to have patient sent out.It should be noted that resident 2 was sent out to the Emergency Department by a non-emergent ambulance company, a neurological assessment for the fall on 10/13/25 could not be located by the facility and that resident 2 fell six times between 9/14/25 through 10/13/25. A review of the Medication Administration Record (MAR) revealed that on 10/13/25 at 8:34 AM, resident 2 was administered an ondansetron disintegrating tablet 4 milligrams for nausea and vomiting. A review of the Treatment Administration Record (TAR) revealed that on 10/13/25 at 10:20 AM an order for Hypnotic/Sedative/Tranquilizer monitoring showed a side effect of morning hangover. On 12/1/25 at 10:19 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that neurological checks were conducted on unwitnessed falls and if a resident hit their head when they fell. CNA 1 stated that there was a neuro check form that was kept in a binder on the medication cart. The CNA stated that she was not sure what happened with the form once neurological checks were completed. On 12/1/25 at 10:28 AM, an interview was conducted with the Director of Therapy (DOT). The DOT stated that resident 2 was impulsive and required cues for safety. The DOT stated that resident 2 had a history of not using her call light and waiting for staff assistance and required verbal and visual cues to follow directions. On 12/1/25 at 10:49 AM, an interview was conducted with the DON. The DON stated if a resident experienced an unwitnessed fall or hit their head then neurological checks were started. The DON stated that neurological checks were completed on a piece of paper and once it was completed it came to her office and stored in a file. The DON stated nurses were expected to text the physician unless there were concerns with the neuro logical check, then the nurse needed to call the physician. On 12/1/25 at 11:26 AM, an interview was conducted with the MD. The MD stated that staff should notify her of every fall and if the fall was unwitnessed then neurological checks needed to be done. The MD stated that she was notified of resident 2's fall via a text from the night nurse around 3:00 AM on 10/13/25. The MD stated that the Nurse Practitioner saw resident 2 the next day and sent her to the hospital because she was vomiting. The MD stated that resident 2 seemed fine after the fall and then experienced a change in condition. On 12/1/25 at 11:38 AM, a follow-up interview was conducted with the DON. The DON stated that she was not sure what the morning hangover on the TAR meant. The DON stated resident 2 was more tired than usual. The DON stated that after a fall if a resident had a decrease in level of consciousness or vomiting then she expected staff to contact the doctor or send the resident to the hospital. On 12/1/25 at 12:28 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that neurological checks were important because if a resident hit their head during a fall and neurological checks were not done then a nurse would not be able to pick up on something that might be wrong with the resident. RN 1 stated that if a resident was not able to respond during neurological checks then that would be concerning for a brain injury. RN 1 stated that she assumed the DON kept the neurological sheets, but it was important to have them in the medical record to view if a resident fell often. On 12/1/25 at 12:32 PM, an interview was conducted with the NP. The NP stated that she usually arrived at the facility between 11:00 AM and 12:00 PM. The NP stated that she relied on the nursing staff to inform her about a resident's condition. The NP stated that resident 2 had a brain bleed history and had multiple falls while at the facility. The NP stated that the nurse texted her around 11:00 AM on 10/13/25 that resident 2 was lethargic and had vomited. The NP stated she assessed resident 2 when she got to the facility and knew within minutes of assessing resident 2, knew she needed to go to the hospital. The NP stated resident 2 was more lethargic, not easily arousable, and had vomited. The NP stated that nurses should contact her if there was a change with the resident while performing neurological checks. The NP stated that a lot of the time the nurses liked to get her approval before sending a resident to the hospital, but she would like them to send a resident to the hospital if they were not doing well. The NP stated that from the time she was notified by the nurse about resident 2's change in condition was about an hour. The NP stated she would have liked resident 2 to be sent to the ER sooner. On 12/1/25 at 12:52 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that he started his shift on 10/13/25 at 6:30 AM and got the report from another nurse that resident 2 had fallen earlier in the morning. LPN 1 stated that the night nurse had passed on in report that resident 2 was having a hard time opening her eyes and had to have her eyes opened by hand to perform neurological checks to assess her pupils and that resident 2's family did not want her to go to the hospital. LPN 1 stated that he assumed the night nurse had contacted the MD. LPN 1 stated that he continued the neurological checks when he started his shift and resident 2 was less responsive than her baseline and he also had to use his hands to open resident 2's eyes to perform the pupil assessment to see if they were more reactive. LPN 1 stated that he sat resident 2 up for breakfast and administered morning medications which resident 2 vomited up. LPN 1 stated that the vomiting episode was unwitnessed by him and resident 2's husband came and informed him. LPN 1 stated that resident 2 continued to not be at baseline and was still out of it. LPN 1 stated that he was concerned because resident 2 had vomited and he wanted the NP to see her because of this. LPN 1 stated that he waited for the NP to come in before sending resident 2 to the hospital because resident 2 had a Do Not Resuscitate (DNR) order and the last time he had sent her to the hospital after a fall the family was upset because resident 2 had not been injured. LPN 1 stated resident 2 was pretty tired on 10/13/25 and not at baseline. LPN 1 stated that the facility did not have alarms to alert staff if a resident got out of bed or a chair for high risk fall residents which resident 2 was.On 12/1/25 at 1:08 PM, a follow-up interview was conducted with the DON. The DON stated that it would be concerning if staff had to open a resident's eyes to perform pupil assessments during neurological checks and would expect staff to call the doctor immediately and not wait for a medical provider to come into the facility. On 12/1/25 at 1:13 PM, resident 2's family member was interviewed via email. The family member stated that resident 2 fell on the morning of 10/13/25 and the facility had not immediately sent her to the emergency room to check for internal bleeding. The family member stated that this was concerning given resident 2's history of falls while at the facility. The family member stated that resident 2 had a massive new brain bleed that was confirmed by a CT (cat) scan that was catastrophic and resident 2 passed away on 10/17/25. It should be noted that when the facility submitted to the State Survey Agency (SSA) their 5-day investigation findings, they concluded that resident 2 had an unfortunate fall and had not addressed the resident's change in condition.

Based on interview and record review, it was determined that for 16 of 40 sampled residents, that the facility did not electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS System. Specifically, the facility did not electronically transmit 16 discharge MDS assessments to the CMS System. Resident Identifiers: 4, 10, 12, 30, 42, 46, 54, 62, 64, 68, 69, 70, 71, 72, 73, and 75. Findings Include: Minimum Data Set (MDS) Assessments and medical records were reviewed from 5/12/25 through 5/15/25 for residents 4, 10, 12, 30, 42, 46, 54, 62, 64, 68, 69, 70, 71, 72, 73, and 75. Resident 4's discharge assessment date was 1/4/25. Resident 10's discharge assessment date was 1/21/25. Resident 12's discharge assessment date was 4/7/25. Resident 30's discharge assessment date was 1/2/25. Resident 42's discharge assessment date was 1/8/25. Resident 46's discharge assessment date was 1/10/25. Resident 54's discharge assessment date was 1/22/25. Resident 62's discharge assessment date was 1/24/25. Resident 64's discharge assessment date was 1/7/25. Resident 68's discharge assessment date was 1/9/25. Resident 69's discharge assessment date was 1/11/25. Resident 70's discharge assessment date was 1/5/25. Resident 71's discharge assessment date was 2/19/25. Resident 72's discharge assessment date was 1/25/25. Resident 73's discharge assessment date was 1/2/25. Resident 75's discharge assessment date was 1/8/25. The MDS discharge assessment for all of these residents had been completed, but not transmitted to CMS. On 5/15/25 at 11:11 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that he meets weekly with a Registered Nurse from the memory care side of the building and that the registered nurse signs off on the MDS assessments. The MDS Coordinator stated that after the MDS is signed, a transmission file is generated. The MDS Coordinator stated that if there are any rejections, the MDS is corrected and then resent. On 5/15/25 at 1:19 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the MDS coordinator was responsible for completing MDS assessments.

Based on observation, interview and record review, the facility did not ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice. Specifically, for 1 of 40 sampled residents, the resident did not have properly labeled oxygen tubing and the humidification bottle was not being changed in a timely manner. Resident identifier: 298. Findings included: Resident 298 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, acute respiratory distress syndrome, respiratory failure with hypoxia, chronic obstructive pulmonary disease, and obstructive sleep apnea. On 5/12/25 at 9:24 AM, an observation was made in resident 298's bathroom of the oxygen concentrator. The humidifier had no water and was not dated. There was a dry white substance on the inside of the humidifier container. The nasal cannula was observed not to be dated. The concentrator was set at 6 LPM (liters per minute). There was no indication that the cannula had been changed. On 5/12/25 at 12:56 PM, a second observation was made in resident 298's bathroom of the oxygen concentrator. The humidifier was still empty. On 5/13/25 at 10:18 AM, a third observation was made in resident 298's bathroom of the oxygen concentrator. The humidifier was still empty. On 5/13/25 at 10:15 AM, an interview was conducted with Registered Nurse (RN) 1 who stated she was not sure who was in charge of oxygen. RN 1 stated the Certified Nursing Assistants (CNA) set up the rooms with oxygen. RN 1 stated the residents should have orders to change the oxygen tubing. On 5/13/25 at 10:31 AM, an interview was conducted with CNA 1 who stated the CNAs have access to the oxygen storage room. CNA 1 stated they put on the cannulas and connect them to the oxygen tanks or concentrators. CNA 1 stated when a resident was admitted they were asked if they were using oxygen. CNA 1 stated portable oxygen tanks were behind wheelchairs in a safe area. CNA 1 stated distilled water was in the humidifiers and all the residents had them. CNA 1 stated the humidifiers had a water trapper on the cannula. CNA 1 stated he believed the night shift CNA's were responsible for changing out the cannulas on Wednesdays. CNA 1 stated the humidifiers did not get changed. CNA 1 stated there were orange stickers with the date that were placed on the cannulas, humidifiers and concentrators. On 5/13/25 at 11:49 AM, an interview was conducted with RN 2 who stated the CNAs were responsible for changing out the cannulas. RN 2 stated she thought the cannulas were changed every 72 hours. RN 2 stated if she found a cannula on the floor she would discard it and replace it. RN 2 stated the cannulas were supposed to be dated and she thought there were tags with the dates on them. RN 2 stated when the cannulas were not in use they should go into a bag that zips. RN 2 stated all residents should have humidified oxygen that was managed by the CNAs. On 5/13/25 at 11:53 AM, RN 2 was taken to resident 298's bathroom to observe the oxygen concentrator. The humidifier was observed to be empty. RN 2 stated that resident 298 was on the highest level of oxygen and needed the humidification. On 5/13/25 at 11:55 AM, an interview was conducted with the Director of Nursing (DON) who stated the CNAs on the night shift on Fridays were responsible for changing the oxygen tubing. The DON stated she was told by CNA 2 that oxygen tubing was being changed out on Wednesdays. The DON stated it should be done weekly. The DON stated the CNAs were supposed to label and date the nasal cannulas. The DON stated a ziplock bag should be provided for the nasal cannula when it was not being used. The DON stated she was unsure if all residents had humidifiers. The DON stated if a resident used 2 liters of oxygen or more, typically they had humidification. On 5/14/25 at 1:56 PM, a second interview was conducted with the DON who stated residents had physician orders to change oxygen tubing on Fridays. The DON stated humidification should be used if a resident used 2 liters of oxygen or more. The DON stated the humidifiers should be changed when they were empty and the bottles were disposable so they could be taken off and a new one could be placed on.

Based on observation, interview, and record review, it was determined that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility was not able to provide documentation that the facility had conducted testing of the facility water supply for Legionella since 2021, there were observations of staff collecting dirty laundry in an uncovered bin that was pushed through resident hallways, and there were observations of staff not using aprons while loading soiled laundry into the washing machine. Findings Include: 1. On 5/13/25 at 8:05 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated that the maintenance department is responsible for testing the facility water supply for Legionella. On 5/13/25 at 10:53 AM, an interview was conducted with the Director of Maintenance (DOM). The DOM stated that he tests to see how hard the water is at the facility. The DOM stated that he needed to test the water at the facility for Legionella and that he was not sure if there was documentation of the testing. On 5/13/25 at 11:44 AM, an interview was conducted with the Administrator. The Administrator stated that the maintenance department is in charge of testing the facility water supply for Legionella. The Administrator stated that he would have to ask the maintenance department for testing records. The Administrator stated that he would look for records of tests for Legionella in the water. On 5/13/25 at 11:50 AM, the Administrator provided a copy of the facility's Water Management Program plan dated 7/19/18. The plan stated that, Twice per year we do internal testing with a water kit to test for Legionella and waterborne pathogens. The plan contained documentation of Legionella tests dated 1/22/21, 1/20/20, and 1/18/19. On 5/15/25 at 11:44 AM, an additional interview was conducted with the Administrator. The Administrator stated that the facility contacted the former Director of Maintenance and that he did not have documentation of water testing for Legionella from 2022 or subsequent years. 2. On 5/15/25 at 10:08 AM, an observation was made of Laundry Aide (LA) 1 traveling down the hallway with a bin that contained soiled linens. The bin did not have a cover on top. On 5/15/25 at 1:04 PM, an observation was made of LA 2 placing soiled laundry into a washing machine without wearing an apron or protective gown. On 5/15/25 at 9:56 AM, an interview was conducted with LA 2. LA 2 stated that the laundry staff do not put on a gown when putting soiled laundry into the washing machine, but that they do wear gloves. On 5/15/25 at 1:11 PM, an interview was conducted with the Director of Maintenance (DOM). The DOM stated when staff gather laundry from resident rooms, they should place the laundry in a bin and cover the bin with a lid on the way to the laundry room. The DOM stated that laundry staff should wear an apron while putting soiled laundry into the washing machine.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer and walk-in refrigerator were open to the air. Findings included: On 5/12/25 at 8:53 AM, an initial walk-through was conducted in the kitchen. In the walk-in freezer, a box of plant based patties was observed to be open to air and a box of frozen dinner rolls was open to air. On 5/15/25 at 10:11 AM, a second walk-through was conducted in the kitchen. In the dry storage room, a bag of potato chips was observed not to be closed. In the walk-in refrigerator, a bag of sliced ham was not sealed and was open to air. In the walk-in freezer, a box of pork sausage was observed open to air, a box of ground beef patties was open to air, a box of plant based patties was open to air, a box of bread dough was open to air, a box of mixed vegetables was open to air, and a box of cut green beans was open to air. On 5/15/25 at 10:33 AM, an interview was conducted with the Dietary Manager (DM) who stated the Registered Dietitian (RD) performed an audit of the kitchen once per month that included checking the temperatures of the refrigerators and freezers, taking the temperatures of the food, watching the staff plate the food, doing a meal audit, and checking the dates on the food items in the refrigerator. The DM stated the RD would provide education if she found mistakes. The DM stated he also provided education to the kitchen staff once per month. The DM stated he conducted his own audits for the freezers and refrigerators. The DM stated the food in the refrigerators and freezers should be sealed up properly to prevent ice burn and preserve food quality.

Based on interview and record review, it was determined that for 3 of 40 sample residents, that the facility did not ensure that a registered nurse signed and certified that the assessment was completed. Specifically, there were three MDS assessments submitted to CMS that did not have a registered nurse signature certifying that that assessment was completed. Resident Identifiers: 90, 246, and 249. Findings Include: Minimum Data Set (MDS) Assessments and medical records were reviewed from 5/12/25 through 5/15/25 for residents 90, 246, and 249. Resident 90's entry MDS dated [DATE] did not have a Registered Nurse (RN) signature certifying that the assessment was completed. Resident 246's entry MDS dated [DATE] did not have a RN signature certifying that the assessment was completed. Resident 249's entry MDS dated [DATE] did not have a RN signature certifying that the assessment was completed. On 5/15/25 at 11:11 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that he meets weekly with a Registered Nurse from the memory care side of the building and that the registered nurse signs off on the MDS assessments. On 5/15/25 at 1:19 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the MDS coordinator was responsible for completing MDS assessments.

Based on observation and interview, it was determined, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, meal tray items were uncovered when delivered by staff throughout resident hallways. Findings Included: 1. Lunch meal trays, which included, uncovered desserts were transported through resident hallway 200. The meal cart was stationed near resident room [ROOM NUMBER]. On 8/28/23 at 1:00 PM, a Certified Nursing Assistant (CNA) was observed to carry a meal tray to resident room [ROOM NUMBER]. On 8/28/23 at 1:00 PM, a CNA was observed to carry a meal tray to resident room [ROOM NUMBER]. On 8/28/23 at 1:02 PM, a CNA was observed to carry a meal tray to resident room [ROOM NUMBER]. 2. Lunch meal trays, which included, uncovered desserts were transported through resident hallway 300. The meal cart was stationed near resident room [ROOM NUMBER]. On 8/28/23 at 1:06 PM, a CNA was observed to carry a meal tray to resident room [ROOM NUMBER]. On 8/28/23 at 1:06 PM, a CNA was observed to carry a meal tray to resident room [ROOM NUMBER]. On 8/28/23 at 1:06 PM, a CNA was observed to carry a meal tray to resident room [ROOM NUMBER]. On 8/28/23 at 1:07 PM, a CNA was observed to carry a meal tray to resident room [ROOM NUMBER]. On 8/28/23 at 1:07 PM, a CNA was observed to carry a meal tray to resident room [ROOM NUMBER]. On 8/28/23 at 1:07 PM, a CNA was observed to carry a meal tray to resident room [ROOM NUMBER]. 3. On 8/29/23 at 12:52 PM, an observation of lunch tray delivery was made. The food cart was rolled and parked in the middle of the 100 hallway, in-between room [ROOM NUMBER] and 107. At 12:52 PM, a CNA pulled a food tray from the meal cart and walked it to room [ROOM NUMBER]. The dessert and the salad were uncovered. At 12:53 PM, a CNA pulled a food tray from the meal cart and walked it to room [ROOM NUMBER]. The dessert and the salad were uncovered. At 12:52 PM, a CNA pulled a food tray from the meal cart and walked it to room [ROOM NUMBER]. The dessert and the salad were uncovered. At 12:53 PM, a CNA pulled a food tray from the meal cart and walked it to room [ROOM NUMBER]. The dessert and the salad were uncovered. At 12:54 PM, a CNA pulled a food tray from the meal cart and walked it to room [ROOM NUMBER]. The dessert was uncovered. At 12:55 PM, a CNA pulled a food tray from the meal cart and walked it to room [ROOM NUMBER]. The dessert and the salad were uncovered. On 8/30/23 at 8:53 AM, an interview with the Dietary Manager (DM) was conducted. The DM stated that when residents ate in their rooms, the meal tray was prepared at the main line, the food was placed in the meal cart, and the CNA's delivered the food trays. The DM stated that the main entree meal was covered, the desserts were covered, the dinner rolls were wrapped in plastic, and the drinks had lids or plastic wrap. The DM stated that all food items should have been covered on the tray line. 33215

Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 2 out of 15 sampled residents, a resident's cardiac medications were not monitored according to the physician's ordered parameters and long acting insulin was held without physician's ordered parameters. In addition, the Medical Doctor (MD) was not notified per the physician's orders when a resident's blood sugar was outside of the physician's ordered parameters. Resident identifiers: 10 and 89. Findings included: 1. Resident 10 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, esophagitis, essential hypertension, type 2 diabetes mellitus with diabetic nephropathy, type 2 diabetes mellitus with diabetic chronic kidney disease, major depressive disorder, panic disorder, anxiety disorder, mild cognitive impairment, and chronic kidney disease stage 3. Resident 10's medical record was reviewed on 8/29/23. On 7/22/23, a physician's order documented Blood Sugar Check BID [twice a day] Twice A Day Notify MD if BS [blood sugar] > [greater than] 250 or < [less than] 60. A review of the August 2023 Medication Administration Record (MAR) documented the following blood sugars greater than 250. a. On 8/9/23 at 6:30 PM to 9:30 PM, 267. b. On 8/10/23 at 6:30 PM to 9:30 PM, 265. c. On 8/26/23 at 6:30 PM to 9:30 PM, 265. No documentation could be located in the medical record indicating that the MD had been notified when resident 10's blood sugars were greater than 250. 2. Resident 89 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, cellulitis of right lower limb, anxiety disorder, essential hypertension, atherosclerosis of coronary artery bypass graft without angina pectoris, paroxysmal atrial fibrillation, heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, type 2 diabetes mellitus with diabetic neuropathy, and major depressive disorder. Resident 89's medical record was reviewed on 8/28/23. A physician's order dated 8/24/23, documented amiodarone tablet; 200 mg [milligrams]; Amount to Administer: 200 mg; oral Once A Day ***HOLD IF HR [heart rate] <60*** [DX [Diagnosis]: Paroxysmal atrial fibrillation]. The August 2023 MAR was reviewed. On 8/26/23, a pulse of 59 was documented and the amiodarone was administered. A physician's order dated 8/24/23, documented metoprolol succinate tablet extended release 24 hr [hour]; 25 mg; Amount to Administer: 25 mg; oral Once A Day ***Hold for SBP [systolic blood pressure <110 AND/OR HR <60*** [DX: Cellulitis of right lower limb]. The August 2023 MAR was reviewed. On 8/26/23, a pulse of 59 was documented and the metoprolol was administered. A physician's order dated 8/22/23, documented Tresiba FlexTouch U-200 (insulin degludec) insulin pen; 200 unit/mL [milliliter] (3 mL); Amount to Administer: 32 UNITS; subcutaneous Once A Day [DX: Type 2 diabetes mellitus with diabetic chronic kidney disease]. The August 2023 MAR was reviewed. On 8/25/23, a BS of 97 was documented. The insulin was not administered due to Not Administered: Other Comment: not appropriate at this time On 8/29/23 at 10:09 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that most Cardiologist do not want to hold medications unless the heart rate was less the 55. RN 1 stated that she would try and verify the hold parameters with the MD. RN 1 stated if the MD was notified the documentation would be in a progress note or the MAR. RN 1 stated that resident 89's medications should have been held when the heart rate was below 60. RN 1 stated for long acting insulin the MD would not put a blood sugar hold parameter. RN 1 stated for short acting insulin she would hold per the protocol of a blood sugar less than 110. On 8/29/23 at 10:51 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she has had to audit every single blood pressure medication that the facility administered and it was time consuming. The DON stated the standing hold parameters for cardiac medications were for a SBP <110 and a Pulse <60. The DON stated there were no specific hold parameters for insulin unless ordered by the physician. The DON stated if the MD was notified by staff they were to document on the MAR or in a progress note.

Based on interview and record review it was determined, the facility did not ensure that a transfer or discharge was documented in the resident's medical record and that appropriate information was communicated to the receiving health care institution or provider. Specifically, for 2 out of 19 sampled residents, no documentation was found in the resident's medical record to indicate the basis for the transfer or that the receiving provider was provided contact information of the practitioner responsible for the resident's care, resident representative contact information, advance directive information, all special instructions for care, a discharge summary, and any other documentation necessary for a safe and effective transition of care. Resident identifiers: 8 and 22. Findings included: 1. Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 8's medical record was reviewed on 12/29/21. On 12/27/21 at 11:31 AM, an interview was conducted with resident 8. Resident 8 stated he had been hospitalized during his stay at the facility a couple of times. Review of resident 8's census record documented a discharge on 10/15/21 and an admission on 10/18/21. Review of resident 8's progress notes revealed the following: a. On 10/14/21 at 11:31 PM, a Nursing Progress Note documented Received new order to check CBC (complete blood count), CMP (comprehensive metabolic panel) tomorrow. b. On 10/18/21 at 7:00 PM, a Nursing Progress Note documented Admit note: Patient arrived prior to 1830 (6:30 PM) from [name of local hospital]. He was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient arrived with a foley catheter in place r/t (related to) urinary retention due to obstruction. He has a follow up scheduled with urology. No documentation could be found in resident 8's medical record of a transfer form, a transfer assessment, a discharge summary or a progress note detailing the events of the transfer to the hospital. On 12/29/21 at 9:25 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated there was no note within resident 8's medical record regarding discharge. 2. Resident 22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 22's medical record was reviewed on 12/28/21. Review of resident 22's census record documented a discharge on 11/5/21. A Nursing Progress Note dated 11/5/21 at 12:54 PM, documented New order to add 1.7 med pass 120 mls (milliliters) TID (three times a day). [Note: The Nursing Progress Note was the last documented progress note in resident 22's medical record.] No documentation could be found in resident 22's medical record detailing the events of the discharge. On 12/28/21 at 3:36 PM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 22 was discharged to the hospital for a change of condition. The DON stated resident 22 had an infusion related to his kidneys prior to discharge. The DON stated resident 22 was in kidney and liver failure. On 12/29/21 at 9:23 AM, an interview was conducted with the ADON. The ADON stated if a resident had a change of condition she would talk with the doctor and sometimes the family. The ADON stated she would call 911 or the local transportation company to transport the resident to the hospital. The ADON stated she would call 911 for a more emergent need. The ADON stated she would print the resident face sheet, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON further stated she would call the hospital to give them report and make a progress note in the resident medical record. On 12/29/21 at 11:17 AM, an interview was conducted with the DON. The DON stated if a resident was discharged from the facility the nursing staff should chart in a nurses note what was going on with the resident, when the resident left the facility, and how they left the facility. The DON stated the nursing staff should notify the doctor and resident family.

Based on interview and record review it was determined, for 1 out of 19 sampled residents, that each resident was not free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; excessive duration; without adequate monitoring; without adequate indication for its use; or in the presence of adverse consequences which indicated the dose should have been reduced or discontinued. Specifically, a resident was administered blood pressure medications when her blood pressure was low and a [CONDITION(S)] medication was delivered late. Resident identifier: 130. Findings include: Resident 130 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 130's medical record review was completed on 12/29/21. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] 25 milligram (mg) tablet, extended release 24 hour. Give 1/2 tablet [12.5 mg] once a day. Hold for systolic blood pressure (SBP) <110, heart rate <60. Medication start date 11/22/21. b. [MEDICATION(S)]-[MEDICATION(S)] 25-100 mg tablet, 3 times per day. Medication start date 11/22/21. A review of the December 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 12/2/21, SBP 106 b. On 12/5/21, SBP 106 c. On 12/12/21, SBP 105 d. On 12/15/21, SBP 102 e. On 12/20/21, SBP 106 A review of the December 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)]-[MEDICATION(S)] was scheduled for 8:00 AM, 2:00 PM, and 8:00 PM.] a. On 12/11/21 at 3:11 PM, administration documented 1 hour and 11 minutes after the scheduled time. b. On 12/12/21 at 9:04 PM, administration documented 1 hour and 4 minutes after the scheduled time. c. On 12/24/21 at 10:37 AM, administration documented 2 hours and 37 minutes after the scheduled time. d. On 12/26/21 at 10:06 PM, administration documented 2 hours and 6 minutes after the scheduled time. e. On 12/27/21 at 9:21 PM, administration documented 1 hour and 21 minutes after the scheduled time. On 12/28/21 at 9:25 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that there were nurse resources during the day if a nurse was running late, but at night there was not another nurse to help with medications if there was a late admission or other issues. On 12/28/21 at 10:00 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the [MEDICATION(S)] was administered out of parameters. On 12/29/21 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that training had been provided by management to educate nurses about delivering medications according to physician's parameters.

Based on observation and interview, it was determined that the facility did not implement an effective infection prevention and control program (IPCP), or establish and maintain an IPCP designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, one staff member was observed not following proper hand hygiene, and staff members did not wear personal protective equipment (PPE) to maintain infection control. Findings include: 1. On 6/10/2020 at 9:43 AM, an observation was made of a Physical Therapy Assistant (PTA) washing hands before work at the nurses' station. The PTA washed, then turned off the faucet with a bare hand. The PTA stated that he was nervous due to being questioned about his name and occupation, and forgot to use a paper towel to turn off the water. The PTA stated that the proper procedure would be to wash again, and proceeded to wash a second time. 2. On 6/10/2020 at 9:45 AM, the facility's Administrator (ADM) was observed wearing a surgical mask. The mask was not pressed against the cheeks and nose, causing a gap in the masks' fit. The mask was observed to move on the ADM's face while the ADM moved or spoke. The ADM stated that he was one of the staff members who had contact with a Certified Nursing Assistant (CNA) who was positive for COVID-19. The ADM stated that the National Guard would be testing all staff members that day to determine if any were positive after exposure. On 6/10/2020 at approximately 9:49 AM, an interview was conducted with the infection preventionist (IP). The IP stated that that she taught the staff proper use of surgical masks covering both the mouth and nose, and ensured an understanding of the use of other personal protective equipment (PPE). The IP stated that extra PPE was located in the Admission's Office, and demonstrated that there was additional PPE located there. The IP stated that hand washing should take at least 20 seconds and the faucet should be turned off using a paper towel. On 6/10/2020 at approximately 9:52 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that masks should be worn in the building at all times by the staff members. The DON stated that residents were also encouraged to wear masks while in the common areas of the facility. The DON stated that she had completed spot checks for proper use of PPE and hand hygiene but did not produce requested documentation. 3. On 6/10/2020 at approximately 9:30 AM, an observation was made of dietary staff member in the kitchen wearing a cloth mask over her mouth but exposing her nose. The dietary manager was immediately interviewed and stated that kitchen staff members do not have direct contact with residents. 4. On 6/10/2020 at approximately 9:40 AM, an observation was made of the laundry room. A laundry staff member (LSM) was observed to be sorting soiled clothing. She was wearing a full face mask and gloves. She was not wearing a gown and there were no gowns observed in the room. The LSM was immediately interviewed and stated that she did not think that gowns were needed. The LSM stated that she did not have a gown. On 6/10/2020 at approximately 9:50 AM, an interview was conducted with the maintenance director (MD). The MD stated that he provides maintenance to the assisted living side of the facility as well as the long term care side. The MD stated that he had recently exposed to a CNA working on the assisted living side of the building that tested positive for COVID-19. The MD stated that he did not wear a gown when entering the long term care area, but sprayed the disinfectant, Microban, on his clothing for protection from COVID-19.

Based on interview and record review, it was determined for 1 of 5 sampled Nursing Assistants (NA), the facility must not use any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, unless that individual has completed a training and competency evaluation program approved by the State. Specifically, one nursing assistant did not pass a CNA (Certified Nursing Assistant) competency evaluation approved by the State in the required timeframe. Findings include: On 8/14/19, a record review was completed. Five personnel files were reviewed. Three CNAs had current licenses, one nursing assistant had worked in the facility approximately 90 days and was scheduled to take the CNA test, and one Nursing Assistant (NA) 1 was hired by the facility in August, (YEAR). NA 1's file did not contain a CNA license. Review of the (MONTH) 2019 schedule revealed that NA 1 was scheduled to work 15 full time shifts. NA 1 worked the night shift, having joint responsibility for all residents in the facility with two other aides on the night shift. Employee schedules were reviewed for the months of (MONTH) and (MONTH) 2019. Work schedules revealed that NA 1 worked the night shift for 9 days in (MONTH) and 10 days in June. On 8/14/19 at 11:32 AM, an interview was conducted with the Staffing Coordinator (SC). The SC stated that NA 1 did not have a CNA license. On 8/14/19 at 11:37 AM, an interview was conducted with the Assistant Administrator (AA). The AA stated that the facility took uncertified aides off the schedule if they had not passed the CNA course in 120 days. The AA stated that NA 1 did not have a CNA license. The AA stated that she was aware that she should have taken NA 1 off the schedule, but had not because NA 1 was a great CN[NAME]

Based on observation, interview, and record review, it was determined that the facility failed to ensure that all residents were assessed to self-administer medications. This occurred for 1 of 22 sampled residents. Specifically, resident 248 was not assessed to ensure she could safely self-administer her own medications through the interdisciplinary team and self-medication assessment. Resident identifier: 248. Findings include: Resident 248 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/12/19 at approximately 11:50 AM, resident 248 was observed drawing up a syringe of medication. Resident 248 then handed the syringe to her visitor. The visitor then injected resident 248 with [MEDICATION NAME] ([MEDICAL CONDITION] medication) in her right upper arm. During an interview on 8/12/19 at approximately 11:54 AM, resident 248 and her visitor both stated that they had not been educated regarding self-medications at this facility. During the interview, resident 248 activated her call light and Registered Nurse (RN) 1 came in to answer the call light. RN 1 saw the syringe and empty medication bottle. RN 1 asked resident 248 questions about the medication, syringe, and where the medication came from. On 8/13/19 at 1:00 PM, a review of resident 248's record revealed that there was not any evidence of an assessment for self-administration of medication nor was this addressed on resident 248's care plan. On 8/13/19 at approximately 10:00 AM, a record review of resident 248's clinical record revealed that there was not a progress note pertaining to the self-administered medications. RN 1 signed the Medication Administration Record [REDACTED]. On 8/13/19 at approximately at 1:05 PM, RN 1 was interviewed about her signing the MAR for the medication that resident 248's visitor had given resident 248. RN 1 stated that she signed the MAR indicated [REDACTED]. RN 1 stated she didn't know the process the facility had in place, when residents were on self-medications. On 8/13/19 at 1:32 PM, during an interview with the Director of Nursing (DON), the DON stated that she had not completed an assessment for resident 248 so she could self-administer medications. The DON stated that the assessment would be in electronic medical record (EMR) in the orders section and a nurse should stand by and watch the resident take the medication to determine if a resident could safely self-medicate. A note for self-medication should have been included in the Special Instructions in the EMR. On 8/13/19 at 2:21 PM, during a follow-up interview with the DON, the DON stated that resident 248 was a new resident. The DON stated that RN 1 found out after the fact that Resident 248 had taken the medication. The DON stated that once the facility found out that a resident wanted to administer medication, the nurse would contact the doctor who determined if they were alert enough. After this process was completed, the resident could self-administer medications if they could do so safely. The doctor was not notified after RN 1 retrieved the syringe and documented in the MAR indicated [REDACTED] On 8/13/19 at approximately 2:45 PM, a follow-up interview was conducted with RN 1. RN 1 stated she had not written an incident report for resident 248's medication self administration. On 8/14/19 at approximately 8:00 AM, during a review of resident 248's medical record, the following note was found in resident 248's progress notes. The note had a time stamp of 8/13/19 at 3:05 p.m. and was documented by the DON. Talked to pt (patient) regarding [MEDICATION NAME] medication, pt was educated that facility can provide that medication and we have available on hand. Pt prefers to bring [MEDICATION NAME] medication from home and prefers that her (visitor) administer the medication. Pt stated, 'she has 6 weeks of supply and she will use that up.' Will edit the [MEDICATION NAME] order and inform staff. (Resident's doctor) made aware of the pt preference and ok with pt decision. On 8/14/19 at 10:35 AM, a follow-up interview was conducted with the DON. The DON stated that they just had a meeting that morning where they were informed that there was a change in a medication status for resident 248. The change to the order was that resident 248's visitor would be bringing the medication from home and would administer the medication to resident 248. The DON stated that the meeting was an Interdisciplinary meeting, and was held every morning. The DON stated that all managers were in attendance at the meeting. The DON was asked for copies of the meeting minutes but stated that meeting minutes were not taken. On 8/14/19 at 10:50 AM, during an interview with the Administrator, he stated that managers had been informed of resident 248's medication change. The Administrator stated that the doctor was okay with the change to self-administration the medication. The Interdisciplinary team was informed of the change, and no evaluation of resident 248 or the visitor's ability to give the medication was reviewed, documented or evaluated.

Based on interview and record review it was determined for 4 of 22 sampled residents, that the facility did not ensure timely transmission of encoded, accurate and complete MDS (Minimum Data Set) data. Specifically, resident's who had been discharged did not have discharge MDS data completed and transmitted. Resident identifiers: 2, 3, 4, and 5. Findings include: 1. Resident 2 was admitted to the facility on [DATE]. On 8/14/19, resident 2's MDS records were reviewed. Resident 2 was discharged on [DATE]. Resident 2's discharge MDS was in progress. Resident 2's discharge MDS had not been transmitted electronically. 2. Resident 3 was admitted to the facility on [DATE]. On 8/14/19, resident 3's MDS records were reviewed. Resident 3 was discharged on [DATE]. Resident 3's discharge MDS was in progress. Resident 3's discharge MDS had not been transmitted electronically. 3. Resident 4 was admitted to the facility on [DATE]. On 8/14/19, resident 4's MDS records were reviewed. Resident 4 was discharged on [DATE]. Resident 4's discharge MDS was in progress. Resident 4's discharge MDS had not been transmitted electronically. 4. Resident 5 was admitted to the facility on [DATE]. On 8/14/19, resident 5's MDS records were reviewed. Resident 5 was discharged on [DATE]. Resident 5's discharge MDS was completed but not transmitted. On 8/14/19 at 1:45 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the MDS coordinator was no longer working in the building. The ADON stated that she would attempt to contact the previous MDS Coordinator. On 8/1/419 at 2:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she had attempted to contact the MDS coordinator for verification that the discharge MDS forms had been completed and electronically transmitted. The DON stated that she did not know the status of the MDS files. (Note: No verification could be provided.) On 8/20/19, the facility Administrator provided additional information. Included in the list were 15 residents who did not have their discharge MDS completed timely and transmitted electronically. The report revealed that for the 15 discharge assessments, Assessment is late.

Based on interview and record review, it was determined that the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. Specifically, 6 of 27 sample residents did not have a prescribed medication available in the facility. Resident identifiers: 8, 56, 83, 199, 206, 216. Findings include: 1. Resident 216 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 216's medical record was completed on 3/30/16. Resident 216's March 2016 physician orders [REDACTED]. Resident 216's March 2016 Medication Administration Record [REDACTED] a. On 3/22/16 the 5 PM dose of vancomycin was not administered. The comments revealed Not Administered: Drug/Item unavailable Comment: PT JUST ARRIVED TO FACILITY; NEW ADMIT. On 3/31/16 the director of nursing (DON) confirmed that resident 216's last dose of vancomycin prior to arriving at the facility was administered at 10:29 AM. The DON confirmed resident 216 should have received an afternoon dose after arriving at the facility but the medication was not yet available at the facility. 2. Resident 206 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 206's medical record was completed on 3/30/16. Resident 206's March 2016 physician orders [REDACTED]. Resident 206's March 2016 MAR indicated [REDACTED] a. On 3/25/16 the 8 PM dose of Azelastine was not administered. The comments reveled Not Administered: Drug/Item unavailable. b. On 3/26/16 the 8 AM dose of Azelastine was not administered. The comments reveled Not Administered: Drug/Item unavailable. c. On 3/26/16 the 8 PM dose of Azelastine was not administered. The comments reveled Not Administered: Drug/Item unavailable. d. On 3/27/16 the 8 AM dose of Azelastine was not administered. The comments reveled Not Administered: Drug/Item unavailable. e. On 3/27/16 the 8 PM dose of Azelastine was not administered. The comments reveled Not Administered: Drug/Item unavailable Comment: pharmacy notified. f. On 3/27/16 the 8 AM dose of Azelastine was not administered. The comments reveled Not Administered: Drug/Item unavailable. 3. Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 8's medical record was completed on 3/30/16. Resident 8's February 2016 physician orders [REDACTED]. Resident 8's February 2016 MAR indicated [REDACTED] a. On 2/18/16 allopurinol was not administered. The comments revealed Not Administered: Drug/Item unavailable. b. On 2/19/16 allopurinol was not administered. The comments revealed Not Administered: Drug/Item unavailable. c. On 2/20/16 allopurinol was not administered. The comments revealed Not Administered: Drug/Item unavailable. d. On 2/17/16 lansoprazole was not administered. The comments revealed Not Administered: Drug/Item unavailable. Comment: unable to locate. e. On 2/18/16 lansoprazole was not administered. The comments revealed Not Administered: Drug/Item unavailable. f. On 2/19/16 lansoprazole was not administered. The comments revealed Not Administered: Drug/Item unavailable. g. On 2/20/16 lansoprazole was not administered. The comments revealed Not Administered: Drug/Item unavailable. h. On 2/21/16 lansoprazole was not administered. The comments revealed Not Administered: Drug/Item unavailable. i. On 2/22/16 lansoprazole was not administered. The comments revealed Not Administered: Drug/Item unavailable. There was no documentation to indicate that the pharmacy or physician were notified of the three missed doses of allopurinol or the six missed doses of lansoprazole. 4. Resident 56 was admitted to the facility on [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. A review of resident 56's medical record was completed on 3/30/16. Resident 56's January 2016 physician orders [REDACTED]. On 1/16/16 at 2:02 PM a progress note revealed Pharmacy sent note stating omeprazole is out of stock and will be ordered and delivered to facility on 1/18/16, MD notified, new order continue protonix on 1/17/18 (sic) then start omeprazole after delivered, WCTM. Resident 56's January 2016 MAR indicated [REDACTED] a. On 1/18/16 the 8 AM dose of Prilosec (omeprazole magnesium) was not administered. The comments revealed Not Administered: Drug/Item unavailable. 5. Resident 199 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 199's medical record was reviewed on 3/30/16. Review of resident 199's physician's orders [REDACTED]. Review of resident 199's March 2016 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. On 3/20/16 at 7:15 PM, the licensed nursing staff documented the following nursing progress note: New order for chlorpromazine 25 mg TID (three times daily) for intractable hiccups. Monitor for sedation. Per pharmacy, they are out of med (medication), will be delivered tomorrow. Further review of resident 199's physician's orders [REDACTED]. Review of resident 199's March MAR indicated [REDACTED]. The MAR indicated [REDACTED]. 6. Resident 83 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 83's medical record was reviewed on 3/30/16. Review of resident 83's physician's orders [REDACTED]. a. escitalopram 10 mg by mouth once a day for major depressive disorder. b. ropinirole 1 mg by mouth three times a day for hypertension. c. trazadone 50 mg 1-2 tablets by mouth at bedtime for insomnia. Review of resident 83's January 2016 MAR indicated [REDACTED] a. escitalopram on 1/31/16 at 8:00 AM b. ripinorole on 1/20/16 at 8:00 AM or 2:00 PM c. trazadone on 1/6/16 at 9:06 PM Review of resident 83's January 2016 MAR indicated [REDACTED]. On 3/30/16 at 8:25 AM an interview was conducted with RN 1. RN 1 stated that if a medication was unavailable for administration the nurse should document the reason why and what the next step would be. If the medication was available in the emergency kits it could be taken from there. RN 1 stated that the pharmacy should be contacted to see when the medication could be delivered. RN 1 stated that the doctor should be notified to see if the medication could be given later. RN 1 stated that the pharmacy dropped off medication to the facility twice a day and could usually deliver missing medications the same day or by the next day. On 3/30/16 an interview was conducted with the DON. The DON stated that if a medication was unavailable for administration the nurse should contact the pharmacy and see when the medication could be delivered. The DON stated the doctor should be notified to determine if the medication could be given when delivered. The DON stated that the pharmacy usually delivered twice a day, at 2 PM and in the evening.

Based on observation and interview, it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles. Specifically, medications were left unattended on one of the med carts. Findings include: On 03/28/16 at 12:57 PM, observations were made of the medication cart on the 100 hall. An IV (intravenous) bag of Ampicilin and a plastic cup with medications in it were observed on the medication cart. There were no licensed nursing staff within site of the unlocked and unsecured medications. 03/30/16 at 2:26 PM, Director of nursing (DON) was interviewed. The DON stated that medications should never be left unattended on the medication cart at all, not even for 5 seconds.

Based on interview and record review, it was determined, for 1 of 24 sample residents, that the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the plan of care. Specifically, one sample resident sustained [REDACTED]. Resident identifier: 212. Findings include: Resident 212 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 3/3/15 at 9:30 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 reported that resident 212 had fallen and sustained a fracture to the right ankle on 2/10/15. Resident 212's medical record was reviewed on 3/3/15. On 2/10/15 at 2:25 PM, the licensed nursing staff completed an Observation Report for resident 212. The Observation Report revealed that resident 212 experienced a fall in his room on 2/10/15 at 2:05 PM. The Observation Report revealed that resident 212 was exhibiting pain, swelling and painful/limited range of motion (ROM) to the right ankle. A review of resident 212's Progress Notes revealed the following entries: a. 2/10/15 at 2:32 PM: Pt (patient) was standing with assistance to use urinal at bedside and became lightheaded and weak. Started to fall over and was lowered to the ground. Pt states he has some pain to right knee and also to right ankle, which he says feels sprained. Minimal swelling at this time, but WCTM (will continue to monitor). Ice applied and encouraged to elevate. PT (physical therapy) to evaluate. Vitals are stable. Pt is somewhat drowsy, but is still A&O (alert and oriented) x (times) 4. MD (medical doctor) and family notified. b. 2/11/15 at 9:53 AM: x72 (72 hours) EVENT CHARTING: Res c/o (complains of) moderate pain to right ankle d/t (due to) fall. Unable to rotate or flex. Will consult with MD today to decide if an x-ray is appropriate. Res c/o pain to left hand d/t gout. c. 2/11/15 at 11:43 AM: Res (resident) c/o pain to right ankle d/t (due to) fall. Unable to rotate or flex without severe pain. Wrapped with ace bandage and applied ace (sic). Will consult with MD today to decide if an x-ray is appropriate. Res c/o pain to left hand d/t gout. d. 2/11/15 at 12:08 PM (Occupational Therapy Progress Note): . Pt c/o pain in R (right) ankle from fall yesterday (nursing fully notified & checked Pt out after fall yesterday). Response to Treatment: . Pt reports his R ankle is painful & swollen after yesterday's fall from EOB (Edge of Bed) (9/10 pain when touched or weight-bearing on it & 7/10 when untouched & NWB (non-weight bearing)). Pt's R ankle does appear swollen & painful to touch. Pt stated he did not feel safe to attempt transfers during OT (occupational therapy) tx (treatment) 2/2 (sic) dizziness & pain in R ankle. Patient Remarks/Goals: Pt stated, 'I can't believe how all this has happened since my knee replacements.' e. 2/11/15 at 2:43 PM (Physical Therapy Progress Note): R ankle assessment d/t fall yesterday: pt tender to palpation along lateral malleolus and dorsum of foot, increased swelling of lateral malleolus but no discoloration nor bruising, reciprocated pain with active DF (dorsiflexion) and PF (plantar flexion), limited active and passive ROM d/t increased pain iof (sic) ankle in all planes. Pt referred to have x-ray of R foot to rule ou/in (sic) any fractures; pt presents with sifns (sic) and symptoms of lateral ankle sprain with potential fibularis longis and brevis tendon strain. Pt presents with decreased pallor today compared to yesterday. f. 2/12/15 at 12:13 PM (Physical Therapy Progress Note): Reassessment of R ankle in supine; pt demos (demonstrates) increased ROM, does not present with increased swelling, cont (continues) to c/o tenderness to palpation along lateral malleolus superior aspect of dorsum of foot and along fibularis muscles. Pt has not had x-ray to R foot yet . g. 2/12/15 at 1:34 PM: This nurse placed call to (name of radiology company) and scheduled xray for R (right) ankle. Report came back and shows a fracture. Call placed to (Physician 1) office and notified (Physician 2). h. 2/12/15 at 3:34 PM: Received return phone call from (Physician 2) order to send to ER (emergency room ) for eval (evaluation) and treat of RLE (right lower extremity) fracture. i. 2/12/15 at 3:46 PM: Transferred to (name of hospital) (name of transport company) stretcher transport accompanied by wife. j. 2/12/15 at 3:59 PM (Occupational Therapy Progress Note): . Education w/ Pt & family (spouse) on treating RLE (right lower extremity) NWB (after x-ray positive for R lateral tibial fracture). Response to Treatment: Pt participated w/ (with) OT tx. Spouse present as well. Nursing reported x-ray of Pt's R ankle/tibia is positive for RLE lateral tibial fx (fracture) & Pt now has NWB RLE precaution. Pt & spouse reporting Pt is feeling very depressed (about medical situation since complication w/ R knee after bilateral TKA (total knee arthroplasty)). Nursing notified of Pt & spouses' report of Pt's depression. Patient Remarks/Goals: Pt stated, 'I just want to get better and get out of here forever.' k. 2/12/15 at 10:57 PM: Pt returned from (name of hospital) at approx. (approximately) 1930 (7:30 PM). Pt's wife was him (sic). No new orders from hospital just general information for pt. l. 2/13/15 at 1:04 AM: Fall Charting: Pt has a fracture of his R fibula. Came back from hospital. Pt has a soft cast (ace wrap). Pt requested his regular pain meds prior to bed. pt is resting in bed call light in reach. m. 2/13/15 at 9:47 AM: Resident remains on follow up for recent fall. R fibular fx. Soft cast in place with NWB (non weight bearing) status at this time. Denies pain or discomfort. On 2/11/15, a physician's orders [REDACTED]. On 2/12/15 at 10:11 AM, an x-ray was performed on resident 212's right ankle. The x-ray report revealed the following: a. Exam Date: 2/12/15 @ (at) 10:11 b. Procedure: x-ray study of the right ankle, 3+ views c. Indications: fell . pain rt ankle d. Findings: The study demonstrates an oblique [MEDICAL CONDITION] fibula. The ankle mortise appears symmetric. the fracture is a (sic) the level of the tibiofibular joint. Alignment is near-anatomic. e. Conclusion: Oblique distal fibular fracture just above the level of the tibiofibular joint space. f. The fax transmission cover letter revealed that the x-ray results were faxed to the facility on [DATE] at 10:52 AM. g. The facility nursing staff documented the following on the x-ray report: left vm (voicemail) with (Physician 2). notified (Physician 1's) office - closed on Thurs (Thursday). (Note: The x-ray report did not reveal the time at which the physician was notified of resident 212's x-ray results of a fractured ankle which were obtained on 2/12/15 at 10:11 AM. Resident 212's progress notes revealed an entry on 2/12/15 at 1:34 PM documenting a phone call to notify the physician of the x-ray results. A progress note on 2/12/15 at 3:34 PM documented a return phone call from the physician and orders to send resident 212 to the ER.) A review of resident 212's February 2015 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED] a. 2/4/15 at 5:30 PM and 10:58 PM b. 2/5/15 at 6:43 PM and 9:48 AM c. 2/6/15 at 3:01 AM, 12:38 PM, and 7:47 PM d. 2/7/15 at 3:26 AM and 9:41 AM e. 2/8/15 at 9:41 AM f. 2/9/15 at 8:29 AM, 12:39 AM, 4:43 PM, and 11:46 PM g. 2/10/15 at 4:12 AM, 7:53 AM, 1:58 PM, and 8:54 PM h. 2/11/15 at 3:37 AM, 7:53 AM, 2:39 PM, and 8:25 PM i. 2/12/15 at 5:42 AM j. 2/13/15 (did not receive [MEDICATION NAME] as needed for pain) k. 2/14/15 at 7:35 AM and 8:23 PM l. 2/15/15 at 5:04 AM and 7:34 PM m. 2:16 PM at 10:50 AM and 4:37 PM o. 2/17/15 (did not receive [MEDICATION NAME] as needed for pain) p. 2/18/15 at 5:10 PM and 11:04 PM q. 2/19/15 at 9:06 AM and 7:52 PM r. 2/20/15 (did not receive [MEDICATION NAME] as needed for pain On 3/3/15 at 1:15 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 reported that she had texted the MD after resident 212 had fallen. LPN 1 stated that the MD instructed LPN 1 to monitor resident 212's right ankle and if there was increased swelling then they could get an x-ray. (Note: No documentation could be located to indicate instructions to monitor the resident's ankle.) LPN 1 was unable to provide documentation of the MD's instructions to monitor the ankle. LPN 1 further stated that the physical therapist also assessed resident 212's ankle and they all thought it was a sprain. LPN 1 stated that she had asked the MD later in the day on 2/11/15 and the MD ordered an x-ray. LPN 1 stated that the order for an x-ray was passed on to the next shift and was to be obtained the following morning. LPN 1 stated that she was unaware that an x-ray could be obtained that late in the day. On 3/3/15 at 1:25 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she would have to check with radiology to see why the x-ray which was ordered on [DATE] was not done until 2/12/15. On 3/3/15 at 2:05 PM, an interview was conducted with resident 212. Resident 212 confirmed that he had fallen on 2/10/15 and fractured his ankle. Resident 212 stated that he was in increased pain and had decreased ROM directly after the fall. Resident 212 reported that he was in increased pain from the time of the fall until the time he went to the ER. Resident 212 stated that he was taking pain medication more frequently during that time and that the pain medication would lower his pain from about a 7 to a 4, on a pain scale of 0-10. Resident 212 reported that he was taking pain medication as needed every four hours for the 2 days after his fall. Resident 212 reported that this was an increase in his intake of pain medication when compared to prior to the fall. Resident 212 stated it hurt pretty good. Resident 212 stated that he did not know why it took 2 days from the time he fell to the time he had an x-ray to his right ankle. Resident 212 stated that he did not see the MD during those 2 days from after the fall to the time he had an x-ray or was sent to the ER. Resident 212 reported that the facility staff thought it was a sprain. On 3/3/15 at 2:20 PM, an interview was conducted with the ADON and Minimum Data Set (MDS) Coordinator. The ADON reported that an x-ray was not taken for resident 212's foot on 2/10/15 because they thought it was related to the resident's gout and because there was no swelling. (Note: The Observation Report completed on 2/10/15 noted swelling to the right ankle related to the fall.) The MDS Coordinator reported that the nurse who received the order for the x-ray on 2/11/15 was confused with the imaging and lab orders which caused a delay in obtaining the x-ray until 2/12/15. The MDS Coordinator reported that the order was entered into the computer as a lab order rather than an imaging order, which caused the delay in obtaining the x-ray. The ADON further stated that they were trying to verify when the MD was notified of the x-ray results and when the resident was sent to the ER, as progress notes may have been documented later than when the resident was sent out. On 3/4/15 at 11:10 AM, an interview was conducted with Physical Therapist (PT) 1. PT 1 stated that he saw resident 212 the morning of 2/11/15 at around 8:30 AM or 9:00 AM. PT 1 reported that resident 212 was complaining more about his foot hurting. PT 1 stated that he did a quick assessment and resident 212 did not have any ROM to the right ankle, it was tender on palpation, but there were no visible signs or symptoms of swelling or bruising. PT 1 stated that he was thinking it was a possible fracture, but did not know. PT 1 stated that he kept resident 212 in bed due to a potential fracture to the right ankle. PT 1 stated that he did not think there was a fracture, but he still recommended obtaining an x-ray to the nursing staff. PT 1 stated that Physician 2 was present when he recommended the x-ray to the nursing staff. PT 1 reported that this communication took place around 9:30 AM or 10:00 AM on 2/11/15 at the latest. (Note: The x-ray report revealed that the x-ray was completed on 2/12/15 at 10:11 AM.) PT 1 reported that resident 212 had never complained of pain to the right ankle prior the fall on 2/10/15. PT 1 reported that resident 212 had gout present in the upper extremities only, particularly in the left wrist, but had never had gout symptoms in the lower extremities. PT 1 stated that resident 212 was able to ambulate with a walker during the week prior to his fall. On 3/4/15 at 11:30 AM, an interview was conducted with Certified Occupational Therapist Assistant (COTA) 1. COTA 1 stated that she was working with resident 212 on 2/10/15 around the time he fell . COTA 1 stated that the resident was receiving assistance from the CNA (Certified Nursing Assistant) during the time of the fall. COTA 1 stated that after the fall, 3 staff members assisted resident 212 back into bed. COTA 1 reported that prior to the fall, resident 212 required only 1 person to assist with transfers. COTA 1 reported that she also worked with resident 212 on 2/11/15. COTA 1 stated that she did not stand resident 212 up on 2/11/15 because he had mentioned that he felt pain on the lateral lower tibial area near the ankle. COTA 1 stated that she had the nurse assess resident 212's ankle on 2/11/15 and the nurse wrapped it in an ace bandage with ice, as it looked a little swollen and he was in pain. COTA 1 stated that she only did upper body exercises with resident 212 on 2/11/15. COTA 1 stated that resident 212 had not complained of pain to the right ankle prior to the fall. COTA 1 reported that resident 212 had some gout in the upper extremities, but never in the lower extremities. COTA 1 reported that she first noticed pain and swelling to resident 212's right ankle on 2/11/15. COTA 1 reported that she did not want to stand the resident up or bear weight on it just in case there was something more serious. COTA 1 stated that they did not really know if it was sprained or broken by just looking at it. COTA 1 stated that they did not stand resident 212 up or bear weight on the right ankle just in case it was fractured. COTA 1 reported that she discussed obtaining an x-ray with LPN 1 on 2/11/15 and that LPN 1 agreed that an x-ray was necessary. On 3/4/15, the Administrator provided the following written statements regarding resident 212: a. Patient (resident 212) experienced fall in his room on 2/10/15 with Nursing Assistant present. Nurse (LPN 1) was notified immediately of Pt's fall & examined Pt before people safely transferred Pt up onto bed. I am not sure what Pt reported to nursing about any pain he felt immediately (or still on 2/10/15) after the fall. The next day on 2/11/15, COTA saw him for OT (occupational therapy) tx (treatment) and Pt reported pain & swelling in R ankle area. COTA let Nurse on hall ((LPN 1) again) know about Pt's c/o pain & swelling in R ankle area (during OT tx & Nurse (LPN 1) examined Pt's R ankle area w/ COTA present) & COTA got a bag of ice & ace bandages for Nurse to wrap Pt's ankle and apply ice to assist in pain & swelling. COTA & Nurse discussed Pt may need x-ray to determine if sprain or fracture of R ankle area on Pt. COTA did not stand Pt up on 2/11/15 or have Pt provide weight-bearing to RLE 2/2 to Pt's c/o pain resulting from the previous day's fall on 2/10/15. I am not sure what exact time or day an x-ray was performed on Pt's lower RLE to determine if fracture. The day after on 2/12/15, when COTA arrived to do OT tx w/ Pt, Pt now had on orthopedic boot on RLE & nursing had reported Pt's x-ray was positive for RLE lateral tibial fracture & Pt now has NWB RLE precaution until next follow up with Pt's ortho surgeon. b. In reviewing the series of events that occurred between 2/10/15-2/12/15, we agree with your finding that we could have and should have been more timely in our ordering of (resident 212's) x-ray. In speaking with our nurse who was on duty at the time, she reported confusing the hours and availability of our mobile x-ray company with that of our lab services company. As a result, she entered an order for [REDACTED]. Cross refer F508