Every finding on record at Leonard Florence Center for Living

Based on records reviewed and interviews, for one of six sampled residents (Resident #1), who experienced an acute change in medical status, the Facility failed to ensure they maintained an accurate and complete medical record that included nursing documentation related to the life saving measures initiated and provided by staff.Findings include:The Facility Policy, titled Charting and Documentation, undated, indicated all observations, medications administered, services performed, incidents, accidents, and changes in the resident's condition would be documented in the resident's clinical record. Resident #1 was admitted to the Facility in [DATE], diagnoses included irritable bowel syndrome, aortic valve insufficiency, and history of stroke. During an interview on [DATE] at 03:38 P.M., Respiratory Therapist #1 said that on [DATE] at 05:45 A.M., she responded to a code blue for Resident #1, and Cardiopulmonary Resuscitation (CPR) was administered to him/her by herself and nursing staff.During a telephone interview on [DATE] at 09:13 A.M., Certified Nurse Aide (CNA) #1 said that during rounds on [DATE] at 05:45 A.M., she found Resident #1 unresponsive and not breathing. CNA #1 said she immediately called a code blue, nursing staff responded, and CPR was administered to Resident #1. During a telephone interview on [DATE] at 09:02 A.M., Nurse #1 said that on [DATE] at 05:45 A.M., Resident #1 was found by CNA #1, a code blue was called, and she performed CPR on Resident #1. During a telephone interview on [DATE] at 10:14 A.M., Nurse Supervisor #1 said that on [DATE] at 05:45 A.M., he responded to the code blue that was called and that himself, along with other nursing staff helped perform CPR on Resident #1.Review of Resident #1's Nurse Progress Note, dated [DATE], indicated that at 05:45 A.M., Resident #1 was found unresponsive, nursing staff initiated a Code Blue emergency response and 911 was called. The Progress Note also indicated Resident #1 was pronounced dead at 07:00 A.M.However, further review of the progress note indicated there was no nursing documentation to support that CPR had been administered by staff.Upon further review of Resident #1's medical record, there was no nursing documentation anywhere else to support that CPR had been performed.During an interview on [DATE] at 01:22 P.M., the Director of Nurses (DON) said nursing staff should have documented in Resident #1's medical record that CPR was administered to him/her but had not.

Based on observations, interviews, and records reviewed, the facility failed to ensure it was free from a medication error rate of greater than 5% when one Nurse observed made 4 errors out of 38 opportunities, resulting in a medication error rate of 10.53 %. Those errors impacted two Residents (#102 and #98), out of 3 residents observed.Findings include: Review of the facility policy titled, Administering Medications, undated, indicated: Medications shall be administered in a safe and timely manner, and as prescribed.4. Medications must be administered in accordance with the orders, including any required time frame.5. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).7. Medication administration will be documented in PointClickCare (PCC).17. If a drug is withheld, refused, or given at time other than the scheduled time, the individual administering the medication shall mark it accordingly in PCC.18. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site (if applicable); e. Any complaints or symptoms of which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug.1.Resident #102 was admitted to the facility in November 2025 with diagnoses that include type two diabetes mellitus, congestive heart failure (heart does not pump blood effectively), atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of plaque in the arteries), essential primary hypertension (high blood pressure) and dyspnea (shortness of breath).Review of Resident #102's medical record indicated the Minimum Data Set (MDS) was not available due to just being admitted to the facility. For Resident #102, the facility failed to ensure nursing administered medications as prescribed.On 11/20/25 at 8:14 A.M., the surveyor observed Nurse #1 administer medications to Resident #102 including: -One Carvedilol Oral Tablet 25MG (milligrams). Review of the pharmacy medication card indicated take with food.-2 Inhalations (sprays) of Fluticasone-Salmeterol Aerosol 45mcg. (micrograms)/21mcg. Metered inhaler used to treat shortness of breath.Resident #102 did not eat breakfast prior to or during the medication administration observation and Resident #102 said he/she has not had anything to eat yet and needs to order breakfast.Review of the physician's orders indicated the following:-Coreg Oral Tablet 25 MG (Carvedilol) Give 1 tablet by mouth two times a day for HTN (hypertension) *give with breakfast and dinner*. Start Date 11/18/25.-(Fluticasone-Salmeterol) 2 puff inhale orally two times a day for allergies *Please rinse mouth with water after each use. Start Date 11/18/25.Review of the Fluticasone Propionate and Salmeterol HFA metered Inhaler manufacturer's guidelines indicated the following administration information: 120 Metered Actuations (uses/doses).Priming-Prime Fluticasone Propionate and Salmeterol HFA before using for the first time by releasing 4 sprays into the air away from the face, shaking well for 5 seconds before each spray. In cases where the inhaler has not been used for more than 4 weeks or when it has been dropped, prime the inhaler again by releasing 2 sprays into the air away from the face, shaking well for 5 seconds before each spray. Avoid spraying in eyes.The surveyor observed the meter dial on the side of the inhaler indicating 122 remaining doses prior to Nurse #1 administering the medication to Resident #102.During an interview on 11/20/25 at 9:39 A.M., Nurse #1 said he should have administered the medication with food and said he did not prime the inhaler and said he does not know if the inhaler had been primed.During an interview on 11/20/24 at 1:09 P.M., the Director of Nurses said physician orders should be followed, and medications should be administered with food as indicated and according to manufacturer guidelines.2. For Resident #98, the facility failed to ensure nursing administered medications as prescribed.Resident #98 was admitted to the facility in November 2025 with diagnoses that include type two diabetes mellitus, thrombocytopenia (low blood count), atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of plaque in the arteries), essential primary hypertension (high blood pressure), and acute on chronic diastolic congestive heart failure (heart does not pump blood effectively).Review of Resident #98's medical record indicated the Minimum Data Set (MDS) was not available due to just being admitted to the facility.On 11/20/25 at 8:36 A.M., the surveyor observed Nurse #1 administer medications to Resident #98 including: -One Carvedilol Oral Tablet 25MG (milligrams). Review of the pharmacy medication card indicated take with food.-Two Metformin HCI Oral Tablets 500MG each. Review of the pharmacy medication card indicated take with food. Resident #98 did not eat breakfast prior to or during the medication administration observation and Resident #98 said he/she has not had anything to eat yet. The resident was observed exiting the room with a staff member and walking down the hall to be weighed and was observed at 8:56 A.M., still without a breakfast meal. Review of the physician's orders indicated the following:-Carvedilol Oral Tablet 25 MG (Carvedilol). Give 1 tablet by mouth two times a day for CAD (coronary artery disease). Scheduled for 9:00 A.M., and 9:00 P.M. Start Date 11/9/25.-Metformin HCI Oral Tablet 500MG (Metformin HCI). Give 2 tablet by mouth two times a day for DM2 (type two diabetes) take with meals. Scheduled for 9:00 A.M., and 6:00 P.M. Start Date 11/9/25.During an interview on 11/20/25 at 9:42 A.M., Nurse #1 said he should have administered the medication with food. During an interview on 11/20/25 at 1:12 P.M., the Director of Nurses said physician orders should be followed, and medications should be administered with food as indicated.

Based on observations, and interviews, the facility failed to ensure medications were labeled, and dated once opened, according to manufacturer's guidelines on one out of five units. Findings include:Review of the facility policy titled, Storage of Medications, undated, indicated: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 4. Expired medications cannot be stored or kept in the medication or treatment carts. Expired medications may be kept in the medication room before being destroyed.7. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.11. Dispose insulins, eye drops, ointments and inhalers according to the following: Inhalers: Dispose after 90 days of initial opening or within 90 days of delivery when open and undated, or according to manufacturer's guidelines. Review of the facility policy titled, Administering Medications, undated, indicated: 11. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. On 11/19/25 at 8:29 A.M., the surveyor and Nurse #2 observed the following in the [NAME] House medication storage room:-One 30mL (milliliter) vial of Acetylcysteine Solution, USP., open, undated, in the refrigerator. Clear liquid was observed inside the vial.Review of the manufacturer's instructions indicated the following: Discard opened containers after 96 hours. Store in refrigerator (36-46 degrees Fahrenheit) after opening.-Two 3ml vials of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution, USP., opened, undated, and removed from the foil pouch.Review of the manufacturer's instructions indicated the following: Unit dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within one week.On 11/19/25 at 8:42 A.M., the surveyor and Nurse #2 observed the following medications in Resident #16's room.-Five 3ml vials of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution, USP., opened, undated, and removed from the foil pouch.-One 16fl. Oz. (fluid ounce) 473mL. bottle of Iron Supplement Liquid, Ferrous Sulfate 220mg/5mL., open and undated.During an interview on 11/19/25 at 8:47 A.M., Nurse #2 said the open and used medications should have been dated when opened.During an interview on 11/20/25 at 1:09 P.M., the Director of Nursing (DON) said he would expect the medications to be dated when opened.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alert, oriented and able to make his/her needs known, the Facility failed to ensure he/she was treated in a dignified and respectful manner by staff, when on 06/02/25 a staff member witnessed Certified Nurse Aide (CNA) #1 interact with Resident #1 in a rude, disrespectfully manner, which included CNA #1 yelling at Resident #1 to shut up. Findings include: The Facility's Policy titled, Resident Rights, undated, indicated that employees shall treat all residents with kindness, respect, and dignity. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Resident #1 was admitted to the Facility in December 2020, with diagnoses that included quadriplegia (loss of movement and sensation in all four limbs) unspecified, displaced fracture of sixth cervical vertebra sequela, chronic respiratory failure, tracheostomy, and dependence on respirator ventilator. Review of Resident #1's most recent Minimum Data Set Assessment, dated 04/08/25, indicated his/her cognitive patterns were intact, and he/she was able to make his/her needs known to staff. The MDS also indicated that Resident #1 required assistance from staff members to meet his/her care needs. The Facility's Internal Investigation, dated 06/02/25, indicated that on 06/02/25 at 12:45 P.M., Resident # 1 reported that a staff member told him/her to shut up. The Internal Investigation indicated that Resident #1 was able to identify the staff member as Certified Nurse Aide (CNA) #1, and the staff member was removed from the schedule and suspended immediately. The Investigation indicated that another staff member was present (later identified as CNA #2) and stated that CNA #1 told Resident #1 to shut up forcefully. The Investigation indicated that the Facility concluded CNA #1 told Resident #1 to shut up, which was considered verbal abuse. During an interview on 06/25/25 at 1:15 P.M., Resident #1 said that on 06/02/25, he/she was asking a question of Certified Nurse Aide (CNA) #1, that she dismissed his/her question and that CNA #1 responded to him/her by saying Shut up, shut up. Resident #1 said it was disrespectful and wrong for CNA #1 to say what she said, and that it had not made him/her feel very good. During an interview on 06/25/25, at 2:33 P.M., Certified Nurse Aide (CNA) #2 said she was feeding Resident #1 in the TV room area when CNA #1 came to speak to her (CNA #2), and Resident #1 was attempting to talk to her (CNA #1). CNA #2 said that CNA #1 did not care what Resident #1 was saying, and instead responding kindly to him/her, CNA #1 was rude and disrespectful to Resident #1 and forcefully said to him/her, Shut up, I am not talking to you. During an interview on 06/25/25 at 4:30 p.m., the Director of Social Services (DSS) said that Resident #1 reported CNA #1 was rude and disrespectful. The DSS said Resident #1 felt disrespected during interaction with CNA #1 and emphasized the importance of being treated with respect. During a telephone interview on 06/26/25, at 11:16 A.M., Certified Nurse Aide (CNA) #1 denied speaking loudly or telling Resident #1 to Shut up, but acknowledged that when Resident #1 was trying to speak to her, that she did not respond to him/her. During a telephone interview on 07/01/25 at 12:11 P.M., Nurse #1 said that Resident #1 was upset and reported he/she was asking CNA #1 a question, that CNA #1 dismissed him/her and told him/her to shut up. During an interview on 06/25/25 at 4:00 P.M., the Director of Nursing (DON) said he interviewed CNA #1, and she denied the allegations. The DON said the interaction between CNA #1 and Resident #1, was witnessed by CNA #2, who reported that CNA #1 responded by yelling Shut up, shut up, when Resident #1 asked her a question. The DON said that based on the Facility's Investigation and CNA #1's behavior, they terminated CNA #1's employment at the Facility. On 06/25/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 06/02/25, Resident #1 was immediately assessed for any signs of injury or emotional distress, none were noted, and he/she continues to be monitored by staff, with support provided as needed. B. On 06/02/25, all residents on CNA #1's assignment were immediately assessed for the potential to be adversely affected by the Facility's identified area of concern. C. On 06/02/25, clinical and management staff conducted resident interviews to ensure their safety and determine if there were any other concerns identified (there were none). D. 06/03/25 through 06/10/25, re-education was provided to all the facility staff by the Director of Nursing (DON), Assistant Director of Nursing (ADNS), Staff Development Coordinator (SDC), and Nursing Supervisor on the following: - The definition of the Abuse Prohibition, Resident Rights, and Customer Services: - Interaction with residents should be appropriate and professional. E. During the June 2025 monthly QAPI meeting, the committee reviewed and discussed the incident and area of concern. F. The QAPI committee will continue to review the issue for a period of two months to ensure substantial compliance. G. The Director of Nursing and/or designee are responsible for overall compliance.

Based on observation and interview, the facility failed to maintain a functioning call system for 1 Resident (#52) out of a total sample for 24 residents. Findings include: Resident #52 was admitted to the facility September 2023 with diagnoses including a left arm fracture. Review of Resident #52's medical record did not indicate he/she had a cognitive disorder. During an interview on 9/12/23 at 9:45 A.M., Resident #52 said his/her call light cord has been broken since her admission to the facility, approximately one week ago. Resident #52 said the call light cord worked only half of the time and he/she reported it every day to nursing staff. On 9/12/23 at 9:45 A.M., the surveyor observed Resident #52 did not have an alternative way to alert staff if he/she needed help. On 9/12/23 at 9:47 A.M., the surveyor pressed the button on the call light cord and it did not work. During an interview on 9/13/23 at 1:21 P.M., Nurse #2 said the call light cord was replaced with a functioning cord the previous night (9/12/23). Nurse #2 said staff were aware on 9/10/23 and over the weekend that the call light cord was not functioning and she thought it would be fixed, but that it was not. During an Interview with Maintenance Director on 9/13/23 at 2:11 P.M., he said he was not aware that Resident #52's call light cord had not been functioning over the past week. Review of the Maintenance Log for dates from March 2023 to current date failed to indicate any call light concerns for Resident #52.

Based on observations, record review, policy review, and staff interviews, the facility failed to ensure that it was free of a medication error rate of 5 percent or greater. The surveyor observed 2 of 3 licensed nurses (Nurse #3, Nurse#2) make errors while administering medications on 2 of 3 units. Two medication errors were observed out of 32 opportunities, resulting in a medication error rate of 6.25%. This affected two Residents (#21, #398), out of a total of four residents observed. Findings include: Review of the facility policy titled Administering Medications, undated, indicated the following: -medications shall be administered in a safe and timely manner, and as prescribed. -the individual administering medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medications. For Residents #21 and #398, the facility staff failed administer the correct form of aspirin (anti-platelet medication) as ordered. 1. Review of Resident #21's Physician's Orders, dated September 2023 indicated: -Aspirin Delayed Release (enteric coated) 81 mg, give 1 tablet by mouth daily. During an observation of the medication pass on 9/13/23 at 8:59 A.M., on the [NAME] House, Nurse #3 prepared and administered the following medications for Resident #21: -Aspirin chewable 81 mg, 1 tablet -Omeprazole (a medication used to treat gastroesophageal reflux disease) 20 milligrams (mg), 1 tablet. -Trazadone (a medication used to treat depression) 25 mg, 1 tablet. -Tylenol 500 mg, 2 tablets -Lisinopril (a medication used to treat high blood pressure), 1 tablet. During an interview on 9/13/23 at 10:50 A.M., Nurse #3 said she would look into getting the order for the chewable Aspirin 81 mg to be changed to enteric coated (delayed release) Aspirin 81 mg. 2. Review of Resident #398's September 2023 Physician's Orders indicated: -Aspirin Chewable 81 mg, give 1 tablet by mouth daily. During an observation of the medication pass on 9/13/23 at 9:41 A.M., at the [NAME] House, Nurse #2 prepared and administered the following medications for Resident #398. -Aspirin Enteric coated 81 mg, 1 tablet. -Omeprazole 20 mg, 1 tablet. -Amlodipine (a medication used to treat high blood pressure), 2.5 mg, 1 tablet. -Vitamin B-12 500 micrograms (mcg), 2 tablets. -Ferrous sulfate (a medication used to treat/prevent low level of iron in blood) 325 mg, 1 tablet. -Lasix (a medication used to treat fluid retention) 10 mg, 1 tablet. -Metformin (a medication used to treat diabetes)1000 mg, 1 tablet. -Lisinopril 30 mg, 1 tablet. -Lamotrigine (a medication used to seizure/bipolar) 100 mg, 1 tablet. -Magnesium Oxide (a medication used to treat digestive problems )400 mg, 1 tablet. -Vitamin D3 1000 international unit (IU), 1 tablet. During an interview on 9/13/23 at 10:45 A.M., Nurse #2 said she did not notice that chewable Aspirin 81 mg was administered instead of enteric coated Aspirin 81 mg.

Based on observation, record review, and interview, the facility failed to ensure it stored a prescribed albuterol inhaler, located on an over bed table, in a safe and secure manner for 1 Resident (#11) out of a total sample of 24 residents. Findings include: Resident #11 was admitted to the facility in June 2023 with diagnoses including congestive heart failure and chronic atrial fibrillation. Review of Resident #11's physician orders dated 6/28/23, indicated an order for albuterol inhaler, to be used every six hours, as needed. On 9/12/23, at 9:22 A.M., the surveyor observed an albuterol inhaler on Resident #11's over the bed table. No staff were present in the room. On 9/13/23, at 8:32 A.M., the surveyor observed an albuterol inhaler on Resident #11's over the bed table. No staff were present in the room. Review of the facility's Administering Medications policy (undated) indicated the medication cart will be kept closed and locked when out of sight of the nurse or aide and no medications are kept on top of cart. It indicates that residents who are capable of self-administering medications can keep some medications, like inhalers, at bedside when in a private room. Review of Resident #11's medical record failed to indicate the facility assessed Resident #11 to determine if he/she was capable of safely administering prescribed medications, or if he/she consented to self-administer medications. During an interview on 9/13/23 at 2:15 P.M., Nurse #2 said she was not sure why or how the albuterol inhaler was left at bedside but that it should not have been without an assessment for self-administration of medication or consent by Resident #11. Nurse #2 said Resident #11 had not consented or been assessed for self-administration of the albuterol inhaler.

Based on record review and interview, the facility failed to follow a physician's order; specifically related to parameters for cardiac medications, for 1 Resident (#62) out of a total sample of 24 residents. Findings include: Resident #62 was admitted in December 2020 with diagnoses including hypertension. Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #62 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the MDS indicated Resident #62 was totally dependent on staff for all activities of daily living. Review of Resident #62's physician's orders for August 2023 indicated Resident #62 was prescribed the following medications: * Amlodipine 5 milligrams - at 9:00 A.M. Give 1 tablet and hold if SBP (systolic blood pressure) is less than 110 * Hydrochlorothiazide 25 milligrams- at 9:00 A.M. Give 1 tablet and hold if SBP is less than 110 Review of the blood pressure vitals for August 2023 indicated Resident #62's systolic blood pressure was below 110 on 8/20/23, 8/21/23, and 8/23/23. Review of the Medication Administration Record (MAR) for August 2023 indicated Resident #62 received the amlodipine on 8/23/23 and the hydrochlorothiazide on 8/21/23 and 8/23/23, despite his/her blood pressure being outside the ordered parameters. Review of Resident #62's physician's orders for September 2023 indicated Resident #62 was prescribed the following medications: * Amlodipine 5 milligrams - at 9:00 A.M. Give 1 tablet and hold if SBP (systolic blood pressure) is less than 110 * Hydrochlorothiazide 25 milligrams- at 9:00 A.M. Give 1 tablet and hold if SBP is less than 110 * Metoprolol Tartrate 25 milligrams - at 9:00 A.M. Give 1 tablet and hold if SBP is less than 110 Review of the blood pressure vitals for September 2023 indicated Resident #62's systolic blood pressure was 102 on 9/6/23 and 90 on 9/7/23. Review of the medication administration record for September 2023 indicated Resident #62 received the amlodipine and hydrochlorothiazide on 9/6/23 and 9/7/23, and the metoprolol tartrate on 9/7/23, despite his/her blood pressure was outside the ordered parameters. During an interview on 9/14/23 at 8:57 A.M., Nurse #1 said she knows to obtain the blood pressure before administering the medication and records it in the vitals section of the chart, which shows up on the MAR. During an interview with the Director of Nursing (DON) on 9/14/23 at 12:02 P.M., he said the Nurse Practitioner (NP) told nursing staff to give Resident #62 the amlodipine, hydrochlorothiazide and metoprolol tartrate even though Resident #62's blood pressure was outside the parameters. The DON said he did not provide any documentation to indicate the Nurse Practitioner approved of this administration. Review of the clinical record did not indicate that any of the orders had been changed or that the NP was notified. During an interview on 9/14/23 at 12:30 P.M., the NP said if a resident's blood pressure was outside the ordered parameters he would expect nursing staff to contact him and to not have given the medication unless he gave approval. The NP said the professional standard of care is to obtain a blood pressure before administering these medications.

Based on observation, record review, and interview, the facility failed to assess for self-administration of medication for 1 Resident (#11) out of a total sample of 24 residents. Findings include: Review of the Self-Administration of Medication policy (undated) indicated residents in the facility who wish to self-administer medication may do so, if it is determined they are capable of doing so. It indicates that staff and/or a practitioner will assess each resident's mental and physical abilities to determine whether a resident is capable of self-administering medications. Resident #11 was admitted to the facility in June 2023 with diagnoses including congestive heart failure and chronic atrial fibrillation. Review of Resident #11's physician orders dated 6/28/23, indicated an order for albuterol inhaler, to be used every six hours, as needed. On 9/12/23, at 9:22 A.M., the surveyor observed an albuterol inhaler on Resident #11's over the bed table. No staff were present in the room. On 9/13/23, at 8:32 A.M., the surveyor observed an albuterol inhaler on Resident #11's over the bed table. No staff were present in the room. During an interview on 9/13/23 at 2:07 P.M., Resident #11 said he/she usually self-administers his/her albuterol inhaler, that was observed on bedside table. Review of Resident #11's Self Administration of Medication Assessment and Consent form indicated Resident #11 did not request or consent to self-administer any medications nor was he/she assessed for self-administration of medications. During an interview on 9/13/23 at 2:15 P.M., Nurse #2 said she was not aware Resident #11 self-administered an inhaler. Nurse #2 said if a resident wished to self-administer then a Self-Administration of Medication Assessment and Consent form should be completed. Nurse #2 said and signed by the resident and staff. Nurse #11 reviewed Resident #11's Self-Administration of Medication Assessment and Consent form and said this form does not indicate that Resident #11 consented self-administration or could safely self-administer medications.

Based on observation, interview and record review, the facility failed to ensure that they were free from a medication error rate of 5% or greater. There were 2 errors in 29 opportunities for a medication error rate of 6.9%, during observations made on 2 of 4 houses with 2 of 4 nurses (#3 and #4); 2 residents (#48 and #72) were involved. Findings include: 1. On 8/23/22 at 8:21 A.M., the surveyor observed Nurse #3, on the [NAME] house, administer medications to Resident #48, including [MEDICATION(S)] 240 milligram(mg) tablet, 1 tablet. Review of Resident #48's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/23/22 at 8:25 A.M., Nurse #3 said that he thought the tablets were 400 mg tablets. When he reviewed the medication bottle again he said one tablet was 240 mg and the manufacturer listed a serving size as 2 tablets which compares to 400 mg. He said he should have given two tablets. 2. On 8/23/22 at 9:50 A.M., the surveyor observed Nurse #4, on the [NAME] house, administer medications to Resident #72, including calcium plus vitamin D 600/400 mg, 2 tablets. Review of Resident #72's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/23/22 at 11:32 A.M., Nurse #4 said that she administered the calcium plus vitamin D that was available. She said it is not the strength that is ordered.

Based on record review and interview, the facility failed to ensure for one Resident (#67), out of a total sample of 27 residents, that he/she participated with interdisciplinary team to review his/her person-centered goals. Findings include: Resident #67 was admitted to the facility in July 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set Assessment (MDS), with an assessment reference date of 7/23/22, indicated Resident #67 scored a 14 out of 15 on the Brief Interview for Mental Status assessment, which indicated intact cognition. Further review of the MDS indicated Resident #67 participated in the MDS assessment and was expected to remain in the facility. During an interview on 8/22/22 at 8:03 A.M., Resident #67 said he/she was admitted to the facility a few weeks ago. Resident #67 said he/she was concerned about getting a particular ALS medication that is taken intermittently and had concerns about staffing. When asked by the surveyor, if he/she had an interdisciplinary team meeting to discuss his/her goals of care with his/her care team, he/she replied no, but said he/she did express concerns last week to a social worker. Review of the medical record indicated care plans were initiated on 7/14/22 and on 7/28/22 to address Resident #67's care. Although the care plans were developed on 7/14/22 and 7/28/22, there was no evidence within the medical record to indicate that a care plan conference with Resident #67 was conducted. During an interview on 8/23/22 at 1:51 P.M., Social Worker (SW)#1 said care plan meetings are conducted routinely within a few days of admission and every three months along with the MDS schedule. SW #1 said notes of the meeting are in the medical record. She said she was not aware if Resident #67 had a care plan meeting and would look into it. During a subsequent interview on 8/23/22 at 3:07 P.M., SW #1 said that Resident #67 wanted his/her family invited to the care plan meeting. SW #1 said Resident #67's family did not respond and she never returned to Resident #67 to ask if he/she would want a meeting without family present.

Based on observation, interview and record review, the facility failed to obtain a pulse prior to administration of a cardiac medication with a special instruction, during observations of 1 of 4 nurses (#4) on 1 of 4 nursing units. Findings include: On 8/23/22 at 9:50 A.M., the surveyor observed Nurse #4 administer medications to Resident #72 in the [NAME] house which included [MEDICATION(S)] (cardiac medication) 25 milligrams (mg) extended release. The surveyor did not observe vital signs being obtained prior to administration. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, immediately after the administration, Nurse #4 said that there were no parameters that required vital signs to be taken for the [MEDICATION(S)]. When she further reviewed the order, she said that she had forgotten to take a pulse before administering.

Based on record review, observation and interview, the facility failed to ensure that management of peripherally inserted central catheters (PICC) was followed in regard to PICC line dressing changes, in accordance with the physicians' order, for 2 of 2 residents (#143 and #144) with PICC lines, and failed to ensure an intravenous (IV) access line was discontinued timely for 1 resident (#67) out of a total sample of 27 residents. Findings include: 1. For Resident #143, facility staff failed to change the resident's PICC line dressing on admission per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #143 was admitted to the facility in 8/2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/22/22 at 10:45 A.M., during observation on the Frank House, the surveyor observed Resident #143 sitting on the side of his/her bed. The surveyor observed a transparent dressing covering intravenous tubing on Resident #143's right upper arm. The upper portion of the dressing had lifted away from Resident #143's arm and was marked with the date 8/11/22. During an interview on 8/22/22 at 10:55 A.M., Resident #143 said that he/she got the PICC line put in when he/she was in the hospital, and the hospital staff put the dressing on. Resident #143 said the staff here haven't changed the dressing yet. During an interview on 8/23/22 at 8:20 A.M., after observation of Resident #143's right upper arm transparent PICC line dressing, Nurse #1 said that the PICC line dressing should have been changed the day Resident #143 was admitted to the facility from the hospital. Nurse #1 said the PICC line dressing was dated 8/11/22, which was prior to the resident's admission to the facility. 2. For Resident #144, facility staff failed to change the resident's PICC line dressing on admission per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #144 was admitted to the facility in 8/2022, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/22/22 at 12:15 P.M., during observation on the [NAME] House, the surveyor observed Resident #143 sitting in his/her bed. The surveyor observed a transparent dressing covering intravenous tubing on Resident #144's right upper arm. The transparent dressing was marked with the date of 8/12/22. During an interview on 8/22/22 at 12:20 P.M., Resident #144 said he/she had a PICC line placed while he/she was in the hospital. Resident #144 said the staff will change the dressing at some point. During an interview on 8/23/22 at 8:20 A.M., after observation of Resident #144's right upper arm transparent PICC line dressing, Nurse #2 said that he was new and wasn't sure of when the PICC line dressing should be changed and he would check with the supervisor. Nurse #2 said the dressing was dated 8/12/22. Nurse #2 said he wasn't aware of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. For Resident #67, the facility failed to discontinue a peripherally placed IV per the facility policy. Review of the facility's policy entitled, Removal of a Peripheral IV (over the needle, peripheral short) Catheter, not dated, indicated at General guidelines: 3. The peripheral IV catheter is also removed when therapy is discontinued. Resident #67 was admitted to the facility in July 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set Assessment (MDS), with an assessment reference date of 7/23/22, indicated Resident #67 scored a 14 out of 15 on the brief interview of mental status, which indicated he/she has intact cognition. During an interview on 8/22/22 at 8:01 A.M., Resident #67 was observed with an intravenous access in his/her left lower arm. Resident #67 said he/she had dehydration last week and the IV was put in for fluids, but that he/she was never was administered the fluids. On 8/23/22 at 11:36 A.M., Resident #67 was observed without the intravenous access line. He/she said nursing staff removed it. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -place a peripheral line in patient for IV rehydration one time only for IV rehydration for one day. Active date 8/13/22 end date 8/14/22. -sodium chloride solution 0.9% use 125 milliliters (ml) intravenously every 4 hours for decreased fluid intake, d/c (discontinue) order after admission of 2 liters. Review of the Treatment Administration Record (TAR) indicated the following: -sodium chloride solution 0.9 % use 125 ml intravenously every 4 hours for decreased fluid intake d/c order after admission of 2 liters. Hold date from 8/13/22 to 8/17/22 dc date 8/18/22. Further review of the TAR indicated the following: dates 8/12/22 at 1600 hours (4:00 P.M.), coded as other, 8/13/22, 8/14/22, 8/16/22, 8/17/22 all timed areas were coded as H (hold) 8/18/22 was coded at 0000 hours as other, the remainder times were coded as H (hold.) The TAR indicated that the administration of the sodium chloride solution 0.9 % was not administered and was placed on hold. Review of the TAR indicated the IV access site remained in place 6 days beyond the discontinue date of 8/18/22. During an interview on 8/23/22 at 5:06 P.M., with Nurse #6, who was caring for Resident #67 on this date, said that Resident #67 had an IV recently for dehydration and she believed he/she was administered 2 liters of fluids. Nurse #6 said she was not aware if the IV was pulled (taken out.)

Based on observation, interview and record review, the facility failed to ensure physician's orders were in place relative to the use of oxygen therapy for one Resident (#1), out of a total of 27 sampled residents. Findings include: Resident #1 was admitted to the facility in August, 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 8/2022 Physician's Orders, indicated that there was no order which would determine the oxygen flow rate for Resident #1. Review of the 8/2022 Treatment Administration Record, indicated to obtain oxygen saturations with oxygen every shift, but did not indicate what the oxygen flow rate should be. During an observation on 8/22/22 at 2:02 P.M., the surveyor observed Resident #1 sitting up in bed with oxygen nasal prongs in place. The oxygen concentrator indicated the oxygen flow rate was set at 3 liters per minute. During an observation on 8/23/22 at 2:34 P.M., the surveyor observed Resident #1 sitting up in bed with oxygen nasal prongs in place. The oxygen concentrator indicated the the oxygen flow rate was set at 3 liters per minute. During an interview on 8/23/22 at 2:35 P.M., Nurse #1 said that Resident #1 uses oxygen at all times. Nurse #1 said she reviewed the physician orders and there wasn't one in place. Nurse #1 said she would obtain a doctor's order for the oxygen flow rate.

Based on observation, interview and policy review, the facility failed to ensure that medications were properly stored and labeled in 2 of 5 medication drawers observed on 2 of 4 nursing units. Findings include: Review of the facility's undated Storage and Labeling of Medication policy, included the following: * Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. 1. On 8/23/22 at 8:03 A.M., the surveyor observed Nurse #5 administer medications to a resident in the [NAME] house. There was a medication cup in the drawer with unidentified pills in it and there was a loose pill in the bottom of the drawer. During an interview on 8/23/22 at 8:06 A.M., Nurse #5 said the pills in the cup looked like Tums and the pill on the bottom of the drawer looked like vitamin D. She said pills should not be left loose and unlabeled in the medication drawer. 2. On 8/23/22 at 9:13 A.M., the surveyor observed Nurse #2 administer medications to a resident in the [NAME] house. There was a loose pill in the bottom of the drawer. During an interview on 8/23/22 at 9:16 A.M., Nurse #2 was not sure what the pill was, but said it should not be there and should be thrown away.

Based on observation, interview and policy review, the facility failed to ensure that appropriate hand hygiene was performed to reduce the risk of spread of infection during observation of medication administration with 1 of 4 nurses (Nurse #5) on 1 of 4 nursing units. Findings include: Review of the undated, facility Infection Control Guidelines for All Nursing Procedures, included the following: * In most situations, the preferred method of hand hygiene is with an alcohol based hand rub. If hands are not visibly soiled, use an alcohol based hand rub or wash hands. * Employees must wash their hands or use antimicrobial or non-antimicrobial or non-antimicrobial soap and water under the following conditions: before preparing or handling medications. On 8/23/22 at 8:03 A.M., the surveyor observed Nurse #5 administer medications to a resident in the [NAME] house. During administration, one of the pills fell on to the floor. Nurse #5 picked the pill up from the floor, contaminating her hand. Without performing hand hygiene, Nurse #5 prepared and administered an appropriate replacement pill. During an interview, immediately after the observation, Nurse #5 said she should have washed her hands before preparing the medication to replace the pill that had fallen.

Based on observation and interview the Facility failed to ensure medications and biological's that were available for administration were at full potency and effective for the use intended in 4 of 5 medication rooms. Findings include: 1. On 10/17/19, at 11:23 [NAME]M., in the Dapper house medication room the surveyor observed the following: 1 bottle of [MEDICATION NAME] Silver vitamins with an expiration date of 9/2019 1 bottle of cranberry supplement tablets with an expiration date of 6/2019 1 bottle of lubricating eye drops with an expiration date of 9/2019 1 bottle of magnesium [MEDICATION NAME] with an expiration date of 3/2019 2. On 10/17/19, at 11:39 [NAME]M., in the Perlman house medication room the surveyor observed the following: 1 bottle of [MEDICATION NAME] (an anti-diarrheal) with an expiration date of 8/2019 1 container of Breeze nutritional supplement with an expiration date of (MONTH) 31, 2019 1 intravenous bag of [MEDICATION NAME] (an antibiotic) with an expiration date of 10/3/19 During an interview on 10/17/19, at 11:44 [NAME]M., Nurse #1 acknowledged the expired medications. 3. On 10/17/19, at 11:46 [NAME]M., in the Weiner house medication room the surveyor observed the following: 1 bottle of ear drops with an expiration date of 5/2019 During an interview on 10/17/19, at 12:12 P.M., Nurse #2 acknowledged the expired medications. 4. On 10/17/19, at 2:01 P.M., in the Feldman house medication room the following: a. 25 vials of sodium chloride inhalation solution with an expiration date of 5/21/19 b. 3 syringes of [MEDICATION NAME] lock solution (a blood thinner) with an expiration date of 6/30/19 c. 1 syringe of [MEDICATION NAME] lock solution with an expiration date of 8/31/19 d. 1 tube of an anti-fungal cream with an expiration date of 7/2019 During an interview on 10/17/19, at 2:04 P.M., Nurse #3 acknowledged the expired medications. Review of the facility policy titled Storage of Medications failed to indicate that expired medication should not be stored with medication available for use in the medication rooms.

Based on observation and interview, the facility failed to provide a home like environment for 1 unit. Findings include: On 10/16/19, at 8:20 [NAME]M., the surveyor observed the following in the Slifka house: a. room [ROOM NUMBER] had a hole of approximately 10 inches in diameter in the wall. b. room [ROOM NUMBER] had gouged and scraped walls. c. room [ROOM NUMBER] had gouged and scraped walls and a hole in the dark blue wall, which had been patched with a white substance and not painted. d. room [ROOM NUMBER] had gouges out of the wood door approximately 12 inches by 5 inches, which had been partly patched with a white substance. e. Under the kitchen sink the pipe leading from the sink was cut approximately 2 feet down from the top of the pipe. This led to an open trap that the water and old food drains into. The water and food had not completely fallen into the trap and a significant amount of food waste was found on the bottom of the under sink cabinet. There was a strong rotting odor and small black flies flying within the cabinet. During an interview on 10/16/19 at 10:51 [NAME]M., the Administrator was notified of the second unit sink issue. She said she was unaware of the cut pipe and that food waste was collecting underneath. During an interview on 10/17/19, at 1:25 P.M., the Maintenance Director said that there were no scheduled formal environmental rounds that he was aware of. He said that he walks around the building in the mornings and puts a work order in for the damages he sees. He said that the door outside of room [ROOM NUMBER] had been started but had not been completed. He was unable to recall how long the door had been in that condition. The surveyor pointed out the damage to room [ROOM NUMBER] and he said that room [ROOM NUMBER] needed to be fixed as well. He said that he was not aware of any holes in the walls in the Slifka house. The Maintenance Director then said that there was no policy for the process for environmental maintenance and things got done when he became aware of them but could not say how long it took for issues to be resolved.

Based on interview and record review, Facility staff failed to treat pain symptoms for 1 resident, (#145), out of a total of 19 sampled residents. Findings include: Resident #145 was admitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. Resident #145 was documented as being alert and oriented and cognitively intact upon admission. During interview with Resident #145 on 10/30/18 at 1:29 P.M., he/she said that he/she was in a lot of pain upon his/her arrival to the facility. Resident #145 said he/she had come to the Facility between 2:00 P.M., and 2:30 P.M. and had told the staff that his/her pain was excruciating. Resident #145 said that staff told him/her that the pharmacy had not delivered Resident #145's medication so he/she would have to wait. Resident #145 said he/she waited hours before being given medication to ease his/her pain and was not offered any alternative medications. Review of Resident #145's physician's orders [REDACTED]. Review of Resident #145's hospital transfer paperwork indicated he/she was last medicated with [MEDICATION NAME] on the date of admission at 10:07 A.M. Review of the facility's Receptionists Calendar indicated Resident #145 arrived on the date of admission at 1:57 P.M. On 10/30/18 at 1:45 P.M., Nurse #1 said she had assessed Resident #145 upon his/her arrival and that he/she was in pain. Nurse #1 said that Resident #145's [MEDICATION NAME] was not available and she called the pharmacy to request the medications be delivered stat. Nurse #1 said that the Nurse Practitioner, (NP) was in the building and assessed the resident. Nurse #1 said that the NP would not order any other pain medications for Resident #145 due to allergies. On 10/31/18 at 9:43 A.M., Nurse #1 said that she attempted to relieve Resident #145's pain by giving him/her ice packs, but the Resident continued to report pain. She said that she called the Pharmacy at 7:00 P.M., to determine the status of the delivery of the medications. Nurse #1 said that she was later told by Nurse #2 that [MEDICATION NAME] was in the Emergency Kit, (E-kit), and was available to give to the resident. During interview with Nurse #2 on 10/30/18 at 2:18 P.M., she said that she was working as the Nursing Supervisor on the day that Resident #145 was admitted to the facility, and Resident #145 reported he/she was in pain upon arrival. Nurse #2 said that the Resident had a standing order for [MEDICATION NAME], but that the resident declined it. Review of Resident #145's Physicians Orders indicated no order for [MEDICATION NAME], and Nurse #1 said that the NP would not allow the Resident to have [MEDICATION NAME]. Nurse #2 said that there was a delay in getting Resident #145 his/her medications because they had not been delivered by the pharmacy. Nurse #2 said that she and Nurse #1 eventually obtained [MEDICATION NAME] for Resident #145 in the facility's E-Kit. Nurse #2 said that Resident #145 was then medicated by Nurse #1. During interview with Family Member #1 on 10/30/18 at 4:30 P.M., Family Member #1 said he/she went to the Facility after Resident #145 arrived and reported to Nurse #1 and Nurse #2 that the Resident was in excruciating pain. Family Member #1 said that Nurse #1 and Nurse #2 told him/her that the medications were not available to the Resident and they were waiting for the pharmacy to deliver them. Family Member #1 said that Nurse #2 had informed him/her that some medications were available in the E-kit, but Resident #145 could not have any due to allergies. Family Member #1 said that at 10:40 P.M., Nurse #1 said that the pharmacy had delivered the medications and medicated Resident #145. During interview with the NP on 10/30/18 at 4:50 P.M., she said that Resident #145 arrived at the facility in the afternoon and that the EMT who drove him/her notified staff that he/she was due for pain medication. The NP said that she told staff to give Resident #145 [MEDICATION NAME], as he/she has multiple allergies and could not take other narcotics in the facility E -Kit. (This contradicts the statement from Nurse #1, who stated that the NP would not allow the resident to have [MEDICATION NAME]). The NP said she was not aware that the facility had [MEDICATION NAME] on hand in the E-Kit and if she had known, she would have told staff to medicate him/her immediately. Review of the Facility Narcotic Book and Resident #145's Medication Administration Record [REDACTED].M.; 8 and a half hours after his/her arrival to the facility and first report of pain, and 12 hours after the resident received the last dose at the hospital. During interview with the Director of Nursing and the Assistant Director of Nursing on 10/31/18 at 8:48 A.M., they said that the expectation is for all nurses to know what medications are stored in the E-Kit or to check the E-kit if they're not sure. On 10/31/18 at 10:00 A.M., the DON told the Surveyor that Nurse #1 did not know that [MEDICATION NAME] was available for Resident #145 in the E-Kit. Subsequently, Resident #145's pain was not effectively treated for [REDACTED].

Based on observation, record review and interview, the facility staff failed to ensure the care plan was implemented by not applying Prevalon boots to the feet only while in bed, as ordered for 1 resident (#87) in a sample of 19 residents. Findings include: Resident #87 was admitted to the facility in 8/2018 with a [MEDICAL CONDITION]. An admission Minimum Data Set ((MDS) dated [DATE], indicated the resident is cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS), needs extensive assistance for Activities of Daily Living (ADLs), and did not have any pressure ulcers. Review of the resident's record indicated he/she was sent to the hospital on [DATE] with chest pain. The resident returned to the facility on [DATE] with pressure sores on both heels. Review of the physician's orders [REDACTED]. - No pressure to both heels. - Apply Prevalon boots when in bed. Review of the treatment administration record (TAR) for the month of (MONTH) (YEAR) indicated nursing staff signed off that the Prevalon boots were applied to the resident daily. The Resident was observed in bed on 10/30/18, at 11:16 A.M., with no Prevalon boots on. The Resident's heels were on the mattress applying pressure to both heels. On 10/31/18, at 1:53 P.M., an interview was conducted with the Resident. The Resident stated he/she came back from the hospital with pressure sores on both heels. The Resident did not have Prevalon boots on. The Resident was lying in bed with his/her feet elevated on a pillow. The right foot was slightly turned outward placing pressure on the outside of the Resident's foot. The Resident stated he/she does have Prevalon boots, but does not wear them. On 10/31/18 2:15 P.M., the surveyor observed the Resident's feet with the wound doctor and Nurse #3. The wound doctor stated that the Resident was readmitted from the hospital with the pressure sores. The wound doctor and Nurse #3 stated the Resident is supposed to wear Prevalon boots while in bed. The Resident stated that he/she has not been wearing the Prevalon boots because he/she needs to get up and go to the bathroom and cannot walk in them.

Based on observation, record review, and staff interviews, the facility failed to provide adequate supervision and effective interventions to prevent falls with injury for 3 residents (#9, #17, #18,) out of a total sample of 20 residents. Findings include: 1. For Resident #18, the facility documented a fall on 1/17/14 which resulted in injury. Review of the incident report and plan of care for falls, revealed that the resident bumped his/her back, at the back of the toilet, due to the toilet seat shifting /moving as he/she sat down. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) conducted on 12/13/13, identified the resident with a Brief Interview of Mental Status Assessment (BIMS) of 12, indicating that the resident has altered cognition and impaired communication . Additionally, the resident needed maximum assistance for ADL's and was incontinent of urine. The resident was also at high risk for falls because of impaired mobility, secondary to Arthritic pain and [DIAGNOSES REDACTED]. The plan of care for "potential for falls" dated 12/9/13 and updated on 12/15/13, identified the resident as being at risk for falls due to weakness and unsteady gait. Interventions included: -PT/OT evaluation as indicated -assure pathways are free of clutter -keep frequently used items within reach -place bed in low position -toilet on regular basis, upon waking, before and after meals, prior to bed and as needed. Toilet throughout the night . -call bell within reach -non skid socks when out of bed -monitor resident for toileting needs Record review indicated that on 1/18/14 (no time documented), the resident complained of pain to his/her back. He/she ranked the severity of the pain as a 7/10. The resident remembered that he/she bumped his/her back, a few days earlier, while trying to sit on an unstable over the commode toilet. At that time the over commode toilet seat shifted, as the resident tried to sit down An xray ordered by the physician, showed osteoarthritis and a mild compression fracture of the lower thoracic vertebra, resulting in severe pain to right shoulder and left knee. The resident's family chose not to have a hospital evaluation but preferred to have the resident treated in the facility with pain medication. This incident was not witnessed and occurred when the resident attempted to toilet himself/herself. Although a plan of care was in place to address falls and Incontinence, interventions were not developed to guide staff on how the resident should be toileted, given his/her physical history, pain level, muscle weakness, decreased mobility and frequent incontinence. Interview with the Charge Nurse on 4/10/14 at 11:00 AM, revealed that this resident had slight cognitive impairment but appeared to understand the safety instructions. However, the resident did find it difficult to adhere to these instructions. Staff interview confirmed that specifics were not included in the plan of care for dealing with or handling this resident, who was at high risk for falls and who was adamant about trying to help out with her own care. Review of the incident report and facility's investigation summary dated 1/17/14, indicated that although the over the toilet commode was removed following the fall, the facility failed to assess the reason for the shifting commode and did not identify any corrective action to prevent this type of accident from recurring. In addition, additional care plan interventions, such as use of an alarm and intermittent visual checks for safety, that would allow the staff to care for the resident without the risk of falls resulting in injury, were not put in place. 2. For Resident #9, the facility documented a total of 7 falls between 4/9/13 and 2/11/14 of which 3 falls resulted in injury. Review of the incident reports, revealed a lack of supervision and failure to carry out the interventions outlined in the plan of care for this resident, which resulted in falls with injury. Resident #9 was admitted to the facility in 8/2012 with [DIAGNOSES REDACTED]. Review of the initial admission assessment information indicated the following: the resident was admitted to the facility with plans for Long Term Care, the resident required continuous oxygen use and use of bed and chair alarms to facilitate staff assistance for bathroom services, the resident required a powered wheelchair for facility travel. This assessment also revealed that the resident had unsteady gait, poor endurance, shortness of breath with minimal exertion, secondary to End stage Chronic Obstructive Pulmonary Disease (COPD) and poor safety awareness. An Annual Minimum Data Set (MDS) conducted on 8/23/13 and a Quarterly Assessment conducted on 3/23/14, both identified the resident with a Brief Interview of Mental Status Assessment (BIMS) of 14 and 15 respectively, indicating that the resident had minimal cognitive impairment and was at high risk for falls, based upon his/her admission assessment. The plan of care addressing "potential for falls" dated 10/11/13, identified the resident as being at risk for falls due to unsteady gait, poor endurance, shortness of breath with minimal exertion, poor safety awareness and a prior history of falls. - assist with 1-2 during transfers. - assure pathway is clear -mats to side of bed at night -monitor for toileting needs and provide extensive assist of one -oxygen with long tubing in room -call light within reach and encourage it's use - encourage resident to rise slowly -nonskid socks when out of bed (a) On 12/17/13, at 4:00 AM, the resident was seated in his/her room when he/she got up unassisted and fell , scraping the left forehead and under the left eye on the rug. This fall was unwitnessed. The facility failed to consistently provide 1-2 Aides to assist the resident with transfers to and from the bathroom, as outlined in the plan of care dated 10/11/13. New intervention: Resident advised to rise slowly. (b) On 12/26/13, at 2:00 PM, the resident was found sitting on the floor in his/her room, facing the bathroom door. The resident stated he/she woke up, sat himself/herself at the edge of the bed, fell forward hitting his/her head, sustaining an abrasion on face and right knee. This fall was again unwitnessed. Per the plan of care dated 10/11/13, the resident was to be monitored for toileting needs as the resident required extensive assistance of one. Documentation in the clinical record failed to identify any such monitoring having taken place. New Intervention: Floor mats placed. (c) On 4/9/13 at 4:30 AM, the resident went to the bathroom unassisted, stepped on the oxygen tubing causing the resident to fall. The resident sustained [REDACTED]. This was an unwitnessed fall. The facility failed to pattern this resident's bathroom needs, so that he/she would not try to toilet himself/herself independently. New Intervention: None Review of the current physician's orders [REDACTED]. The alarm was supposed to be worn at all times and checked every shift. Both the clip alarm and bedside mats were ordered on [DATE]. The mats were to be used specifically at night. During interview on 4/10/14 at 2:00 P.M, Unit Manager #1 said that resident #9 is alert and fairly oriented and likes to do as he/she pleases. Family brings in food and stores in a refrigerator for resident's convenience. Resident tries to get up unassisted and falls. Most of his/her falls have been unwitnessed although "we try to be there for him/her." Observation of the resident on 4 of 5 days of survey (4/7/14- 4/10/14) at various times of the day, revealed an alert resident, pleasant, talkative, well dressed and groomed. The resident was seated out of bed in a chair with oxygen provided at 4 liters per minute through extra long tubing. The bed was in the low position . Both the electric wheel chair and 4 pronged cane were in the resident's room, but at each visit the resident was alone in his/her room. The clip alarm was in place. When asked how he/she gets to the bathroom , he/she stated " I ring the bell. When they don't come, I get up and try to do it myself. When I have to go I have to go. Sometimes it takes too long for them to come." Through nursing assessment, this resident is identified as being at risk for falls. Although a plan of care was developed with interventions designed to keep the resident safe, documentation on the incident reports failed to indicate that the plan of care interventions were always followed. The facility failed to consistently implement interventions already in place, and/or revise the care plan interventions to include increased monitoring and supervision to prevent falls with injury. 3. For Resident #17, the facility documented a total of 8 falls between 11/23/13 and 2/15/14 of which 4 falls resulted in injury. Review of the incident reports and plan of care for falls indicated a lack of supervision and failure to consistently carry out the interventions outlined in the plan of care, for this resident, which resulted in falls with injury. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minium Data Set ((MDS) dated [DATE], indicated a Brief Interview of Mental Status (BIMS) of 15, which indicates that the resident is alert and oriented. The MDS also indicated a high risk for falls based on a history of many falls prior to admission due to a [DIAGNOSES REDACTED]. Review of the plan of care dated 12/2/13, indicated a high risk for falls due to a history of multiple falls, unsteady gait, psychotropic medication use and included interventions as follows: -bed alarms on when resident in bed. -low bed with call light in place -encourage to use call light for transfers/toileting -frequent checks when resident in bed Review of Incident Reports indicated the following: -On 2/5/14 at 4:45 PM, this resident was found on the floor in the bathroom . He/she twisted his/her foot while transferring from wheelchair to toilet . Resident fell against the bathroom wall and sustained a laceration to the left side of his/her face . The resident was sent to the emergency room for evaluation and received 7 stitches to the face. The care plan interventions for frequent checks when the resident was in his/her room and use of call bell to summon help for toileting needs, were not carried out consistently, resulting in a fall with injury. New Intervention: Commode by bedside, bed alarm, ambulation program, frequent checks. Signs to remind resident to use wheelchair or walker. -On 1/15/14 at 8:00 PM, the resident was found sitting on the floor in the bathroom. The resident had sustained a 1 x 1 centimeter skin tear to the right inner hand. The Incident report indicated the resident was self transferring from toilet to wheel chair. The facility failed to ensure that the care plan interventions relative to the use of call bell for toileting needs and frequent checks when resident is in room, were carried out consistently. This resulted in the resident falling and hurting himself/herself. New intervention: None -On 12/14/13 at 6:00 PM the resident attempted to self transfer from wheel chair to toilet without assistance, lost his/her balance, fell to the floor, landing on left side. resident sustained [REDACTED]. The care plan called for the resident to call for assistance for toileting and transfers as well as to be checked frequently when in bed. There is no documentation to indicate that staff were checking this resident frequently to ensure compliance with call bell usage. The facility failed to implement the interventions outlined in the plan of care that relates to frequent checks and use of call bell for toileting. -On 11/23/13 at 5:15 PM the resident slid off the edge of the bed while using the urinal and hit his/her left forehead on the rug. The resident sustained [REDACTED]. There is no mention of an alarm sounding at the time of the fall. If the resident had an alarm which malfunctioned, staff were not aware of this malfunction. The facility failed to utilize an alarm as outlined in the plan of care, in order that staff may be made aware that the resident is trying to get up. This resulted in the resident falling and sustaining an injury. New interventions : Remind resident to ask for assistance. Check resident every 15 minutes for 72 hours. Although there was a care plan in place for falls with interventions to prevent falls, the interventions were generic and not consistently followed. Despite these falls, an assessment regarding the time of the falls (early evening) was not conducted, to determine what could be done differently at these times, to engage the resident in an activity that was liked or enjoyed. Although there was an MD's order in place for the use of alarms at night, no mention is made of any alarm being used. Observation of the resident on 4 of 5 days of survey (4/7/14 - 4/10/14) at various times of the day, revealed an alert, oriented resident, ambulatory with a walker, pleasant, well dressed and groomed. Resident stated that he/she had received therapy but continued to fall because of the Paralysis Agitans (Parkinson's Disease), weakness and unsteady gait. The resident also stated that he/she was afraid that he/she would seriously hurt himself/herself one day and expressed fear of having to stay in the Nursing Home, rather than be allowed home. The facility failed to consistently implement care plan interventions and to revise those interventions where necessary to include specific, individualized measures to prevent falls with injury. Increased monitoring and supervision at the times that the resident was most likely to fall (Evenings) was never considered.