Every finding on record at Meridian Village Care Center

Based on interview and record review the Facility failed to ensure Physician Orders were being followed as ordered for the correct resident for 3 of 6 residents (R22, R77 and R78) reviewed for medication errors in the sample of 37.Findings include: 1.The Facility Incident/Accident Facility Report documents, On 4/18/2025 at approximately 8:30 AM, the nurses administrated resident (R4) morning medications to resident (R78) in error. Medications reviewed in error were metoprolol tartrate 25 milligrams (mg), losartan 100 mg, ferrous sulfate 325 mg, vitamin B12 500 mcg (microgram), furosemide 40 mg, and spironolactone 25 mg. Resident (R78) has no allergies to the above medications. No adverse side effects noted. Resident (R4) was given all morning medications from the (electronic medication dispenser) in the allotted time. The nurse notified the MD (Medical Doctor), family and DON (Director of Nursing) immediately. MD ordered vitals every hour for 24 hours then 3 times a day for 72 hours. Nurse was immediately educated regarding the medication administration policy and verbalized understanding. R78's Physician Order Sheet (POS) for April, 2025 documents a diagnosis of chronic diastolic (congestive) heart failure, hypothyroidism, chronic atrial fibrillation, hyperlipidemia, anxiety disorder, depression, wedge compression fracture of T11 and T12 vertebrae, wedge compression fracture of fourth lumbar vertebra, sequala, age related osteoporosis with current pathological fracture, subsequent encounter for fracture with routine healing; chronic pain, chronic kidney disease, gastro-esophageal reflux disease without esophagitis, spondylitis without myelopathy, lumbar region constipation, long term use of coagulants, long term (current) use of opiate analgesic, arthrodesis status. R78's POS does not document R78 has an order for metoprolol tartrate 25 milligrams (mg), losartan 100 mg, ferrous sulfate 325 mg, vitamin b12m 500 mcg (microgram), furosemide 40 mg, and spironolactone 25 mg. R78's Coaching Opportunity Memorandum dated 4/18/2025 documents, Medication Administration error. Nurse went over medication administration policy in detail and is to look at picture as well before administering medications. R78's Progress Notes do not document any medication errors. On 3/24/2026 at 4:00 PM, V1 (Administrator) stated (V5 Registered Nurse/RN was the staff member who gave (R78) the wrong medication. On 3/24/2026 at 4:25 PM, V5 (RN) stated, I normally work the North Hall, and I remember that day back in April because I was working the [NAME] Hall, and I was not familiar with the residents. I mixed (R4) and (R78's) medication up. They both were small, same height and when I asked if she was (R4), she shook her head yes. Later, I found out she had a hearing problem, and I had given the wrong medication to her because I mixed them up. I did notify the doctor and the family. On 3/26/2026 at 10:44 AM, V2 (Director of Nursing) stated, I would expect all residents to get their correct medications and no resident being given the wrong medications. 2. R77's Undated Face Sheet documents R77 was admitted to the facility on [DATE] and has a medical diagnosis of Pulmonary Hypertension, Peripheral Vascular Disease, Hypothyroidism, Generalized Anxiety Disorder, and Hypertension. R77's Minimum Data Set (MDS) Assessment Reference Date 1/20/2026 documents R77 is moderately cognitively impaired. R77's Nursing Note dated 5/29/2025 at 3:33 PM documents Resident received another resident's medication in error. The Facility's Incident/Accident Facility Report dated 5/29/2025 documents medication error. On 05/29/2025 at approximately 830am, the unit nurse went to administer resident R77 his medications. Upon administering the medications, the nurse asked the resident R77 if his name was R69, resident stated yes. The unit nurse also asked the charge nurse if the resident was R69, she stated yes. The nurse proceeded to administer the following medications to R77 in error: Ceftin 500mg, Colace 100mg, Levothyroxine 25mcg, Lisinopril 20mg, Mybetriq 25mg, Multivitamin and Sodium Chloride 1000mg. Resident R69 proceeded to approach the nurse asking for his morning medications which alerted the nurse to verify the resident. It was determined that the nurse did in fact administer R69's medications to resident R77 in error. Medical Director (MD) and family notified immediately. New orders received to monitor resident for adverse effects and report findings immediately. R77's May 2025 Physician Order Sheet does not document an order for Ceftin 500 mg, Levothyroxine 25 mcg, Lisinopril 20 mg, Mybetriq 25mg, Multivitamin, and Sodium Chloride 1000 mg. R77's May 2025 Physician Order Sheet documents Docusate Sodium (Colace) 100 mg as needed two times a day. On 3/26/2026 at 10:40 AM, V3 (Nurse Supervisor/Licensed Practical Nurse) stated, I remember passing out medications and I looked at the computer and at the photo and the resident looked like the photo but in reality, it is hard to tell because the photos are so small, and you cannot make the photo bigger. I asked the resident if they were (R69) and they said yes, and I gave him the medications only to find out later he was really (R77) and not (R69). I accidently gave out the wrong medication to the wrong resident. 3. R22's face sheet documents an admission date of 2/17/2025. Diagnosis includes Alzheimer's Disease, Dementia, Chronic Diastolic Heart Failure, Abdominal Aortic Aneurysm. R22's Minimum Data Set, MDS, documents R22 is severely cognitively impaired. R22's Care Plan updated 2/10/2026 documents cardiovascular. R22 has potential for complications related to diagnosis or history of cardiac dysfunction as evidenced by hypertension, hypotension, cerebral vascular accident, CVA, Trans ischemic Attack, TIA, edema, atrial fibrillation, other dysrhythmia. Interventions include administering medications as ordered and monitor for side effects and effectiveness (see current physician orders and medication administration record, MAR. Facility Incident report dated 3/12/2026 at 7:30AM documents On 3/12/2026 during morning medication pass, R22 was sitting in the dining room when unit V4 (Licensed Practical Nurse) went to administer R22's medications. V4 asked unknown Certified Nursing Assistant/CNA to verify R22 for accuracy. The CNA did state to V4 that was in fact R22, so V4 administered the medications. Medication received in error: acidophilus, Cipro 500 milligrams, mg, Juven supplement, levetiracetam 500mg, sertraline 100mg, senna plus, potassium 20 milliequivalents/meq, pantoprazole 40 mg, and tamsulosin 0.4mg. Around 30 minutes later, V3 was capturing vitals on R22. When V4 asked what V3 was doing and why, V3 then stated R22's full name, and V4 then realized she administered another resident's medications to R22. Medical Doctor/MD, Power of Attorney/POA, and the nurse supervisor aware. MD ordered vitals every shift for 3 days. R22's order sheet does not document an order for acidophilus, Cipro 500mg, Juven supplement, levetiracetam 500mg, sertraline 100mg, potassium 20 meq, pantoprazole 40 mg, and tamsulosin 0.4mg. R22's order sheet dated 3/26/2025 documents Senna Plus 8.6 mg-50 mg tablet PRN 1 time daily. Medication administration policy dated 8/2017 states A physician's order is required for all medication administered. Medications include those prescribed by the physician, over the counter medications, as well as herbal medications. Lutheran Senior Services clinician administering the medications is responsible for knowledge of the specific medications: actions, indications, side effects, special precautions, contraindications, usual dose, route of administration, patient allergies.

Based on observation, interview, and record review, the Facility failed to ensure food was stored and prepared in a manner that prevents foodborne illness. This has the potential to affect all 62 residents living in the Facility. Findings include: On 11/19/24 at 8:27 AM in the standing freezer there were open bags of hash browns, chicken strips, onion rings, egg rolls, French fries, and chicken drumsticks. These bags were not labeled, dated, or resealed upon opening, leaving the contents open to air. There was an opened package of pepperoni that was not dated or resealed upon opening, leaving the contents open to air. There was a bag of fish and a bag of raw chicken breasts that were labeled and dated upon opening, but were not resealed, leaving the contents open to air. The bag of raw chicken breasts was stored directly above a box of shrimp which had also been opened but was not dated. On 11/19/24 at 8:30 AM in the standing refrigerator to the right of the standing freezer, there were two gallons of skim milk labeled Best by [DATE]. There was a box of brown, unpasteurized shell eggs stored directly above cartons of liquid pasteurized eggs. There was a container with a red liquid substance that was not labeled or dated. V5 (Dietary Supervisor) stated it was tomato soup, and she thinks it was made yesterday. There was a half full container of commercially made tuna salad that was not dated upon opening. There was a container with an unknown substance that V5 stated was creamed corn that was not labeled or dated. There was a package labeled corned beef dated 11/6. V5 stated food should not be kept for that long. On 11/19/24 at 8:32 AM, V8 (Dishwasher) stated she does not test the sanitizer in the dish machine and has only seen test strips when the maintenance company comes in to check the machines periodically. On 11/19/24 at 8:35 AM in the walk-in refrigerator there was commercially prepared container of tuna salad that had been previously opened. The lid was not sealed, and the container was not dated upon opening. There were containers of onions, tomatoes, and black olives that were not labeled or dated. On 11/19/24 at 8:38 AM in the walk-in freezer there was a plastic bag of corn dogs and a plastic bag of breaded meat that had been removed from the original packaging and were not labeled or dated. On 11/19/24 at 8:41 AM in the dry storage room there was a package of coconut flakes that was not dated upon opening. There was plastic bag of raisins inside a large box that had been opened, but was not resealed upon opening, leaving the raisins open to air. On 11/19/24 at 8:44 AM, V6 (Executive Chef) stated the Facility does make eggs over easy and does not believe the shell eggs they use are pasteurized. On 11/19/24 at 8:43 AM, holding temperatures were obtained from the steam table on [NAME] Way during breakfast service with a metal calibrated thermometer. The oatmeal measured 125 Fahrenheit (F). V7 (Dietary Aid) was stated he was not sure of the goal temperature but tries to keep the food warm. On 11/19/24 at 9:40 AM, V4 (Dietary Manager) stated they do keep test strips for the dish machine, but V8 just started working that shift as the dishwasher. On 11/22/24 at 9:20 AM, V1 (Administrator) stated she expects staff to follow food service policies. The Facility's Food Storage Policy revised 10/1/20 documents, It is the policy of the Dining Services Department to develop a mechanism to ensure the safe and accurate storage of food and nonfood products. Items that arrive in their original packaging with a manufacturer's expiration date will utilize that date for discard. Should an item be opened and stored in a different container, it will be labeled with an open date and a discard date. Food Safety practices based on Serv Safe Standards will be followed at all times. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 11/19/24 documents there are 62 residents living in the Facility.

Based on interview and record review the facility failed to provide preventative measures for a safe transfer, free of hazards from one level to the next for 2 out of 8 residents (R39, R59) for falls in a sample of 43. 1. R59's Face Sheet undated documents her pertinent diagnosis as age related physical debility and repeated falls. R59's Minimum Data Set (MDS) dated [DATE] documents R59 has moderate cognitive impairment and is dependent in transferring from sit to stand, chair to bed, toilet, and tub transfer. R59's Fall Risk admitted d 7/26/24 documents High Risk for Falls. Nurse Progress notes dated 11/6/24 documents R59 lost her balance during a transfer from wheelchair to recliner and fell to her right side, staff was present with her. Medical records from an area hospital dated 11/6/24 documents R59 presenting with a ground level fall during transferring a patient, head injury, bruising to forehead, forehead hematoma. 11/6/24 CT with spine obtained documents no acute abnormality, no acute intracranial finding. On 11/21/24 at 12:23 PM, V27 (Certified Nursing Assistant/CNA) stated she was the CNA involved in the transfer of R59 on 11/6/24. V27 stated it was after lunch and she was in the process of transferring R59 to her recliner, she stood R59 up using a gait belt and R59 fell forward. R59 is top heavy. V27 stated she did use a gait belt and was positioned behind R59, tried to hold onto her but could not prevent her fall. She had transferred R59 before and had not had any problems with transferring her. V1 (Administrator) had provided in-service training on the correct way to transfer residents. On 11/21/24 at 12:47 PM, V28 (Certified Occupational Therapy Assistant) stated when using a gait belt with a resident you position yourself in front of the resident to help guide them and prevent resident from falling over. On 11/22/24 at 1:31 PM, V1 (Administrator) stated R59 was new to the facility and had not been assessed by physical therapy for an assistive device for mobility. V1 stated she was unaware of the positioning of the CNA with the gait belt that contributed to R59's falling over during transfer. V1 stated V1 had provided in-service training on transfers to the CNA. 45947 2. R39's Face Sheet documents R39 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, polyneuropathy, heart failure, and fatigue. R39's Minimum Data Set (MDS) dated [DATE] documented R39 was cognitively intact, required substantial assistance with rolling from side to side, and was dependent with transfer. R39's Morse Fall Scale dated 6/4/24 documents R39 was at risk for falls. The Facility's Fall Log documents R39 had falls on 6/20/24 and 6/28/24. R39's Adverse Event Documentation dated 6/20/24 documents R39 fell out of bed, hit his head and nose, and sustained a bruise and hematoma to his forehead. R39 was admitted to the hospital with skull and facial fractures, trace subarachnoid hemorrhage, and small parafalcine subdural hematoma. R39's Adverse Event Documentation dated 6/28/24 documents staff were getting ready to mechanically lift R39 from his wheelchair to bed, and when they removed his footrest, he slid to the floor with his back against the wheelchair. On 11/21/24 at 10:05 AM, V26 (Registered Nurse) stated she did not witness R39's 6/28/24 fall but was notified by V30 and V31 (CNAs) that he had fallen when they were preparing to transfer him via mechanical lift. She stated R39 was supporting himself with the footrest because of the way he was positioned, and when they moved the foot pedals out, he slid down from the chair. On 11/21/24 at 2:00 PM, V30 (CNA) stated she was assisting with (R39's) transfer from wheelchair to bed and did not realize he was supporting himself with the foot pedals on his wheelchair. R39's sling was underneath him but was not yet hooked up to the lift. They moved the foot pedals out, and he slid from the chair to a seated position on the floor. She stated they probably could have prevented this if they had repositioned him or hooked the sling to the lift before removing the foot pedals. On 11/21/24 at 2:17 PM, V31 (CNA) stated she was removing R39's foot pedals from his wheelchair before hooking his sling to the mechanical lift when he started to slide. She was standing behind him and helped lower him to the ground to a seated position. She stated he was slouched to one side in his chair and the foot pedals were keeping him in place, and the moment she took the pedals away he started to slide down. She stated better positioning in his chair may have prevented this from happening. On 11/22/24 at 9:20 AM, V1 (Administrator) stated she expects staff to ensure residents are positioned properly prior to transfer. The facility policy Management of Fall Risk with a review date 1/30/24 documents the definition of a fall is an incident in which the resident unintentionally comes to rest on the ground, floor, or other lower level. Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try prevent the resident from falling from falling and to try to minimize complications from falling.

Based on observation, interview, and record review, the Facility failed to ensure food was prepared according to physician prescribed diet orders for 3 of 3 residents (R6, R38, R47) reviewed for therapeutic diets in the sample of 43. Findings include: 1. R6's Physician Order dated 9/21/24 documents, Diet: IDDSI (International Dysphagia Diet Standardization Initiative) Level 5 Minced & Moist. On 11/19/24 at 12:20 PM, R6 was eating lunch in the dining room. R6's ground chicken did not have a sauce or liquid on top to moisten it. 2. R38's Physician Order dated 1/24/24 documents, Diet IDDSI Level 5 Minced & Moist. On 11/19/24 at 12:14 PM V15 (Licensed Practical Nurse) was assisting R38 with her lunch in the dining room. R38's ground chicken did not have a sauce or liquid on top to moisten it. 3. R47's Physician Order dated 5/5/24 documents, Diet IDDSI Level 5 Minced & Moist. On 11/19/24 at 12:20 PM R47 was eating lunch in the dining room. R47's ground chicken did not have a sauce or liquid on top to moisten it. On 11/19/24 at 12:25 PM V7 (Dietary Aid) stated the cooks have not been preparing sauces or gravies for the mechanically altered diets lately. On 11/19/24 at 3:00 PM, V4 (Dietary Manager) stated all mechanical soft diets should come with some sort of liquid or gravy. On 11/20/24 at 3:30 PM, V17 (Speech Language Pathologist) stated minced and moist meats should be covered with a sauce or gravy or some kind of liquid to ensure the food stays moist. On 11/22/24 at 9:20 AM, V1 (Administrator) stated she expects staff to follow food service policies and physician prescribed diets. The Facility's Therapeutic and Mechanically Altered Diets - Long Term Care Policy reviewed 2/16/24 documents, The CDM (Certified Dietary Manager) and Dining Services supervisor will establish and use and identification system to ensure that each resident receives their diet as ordered. Staff should be trained on the system to ensure that correct procedures are followed.

Based on interview and record review the facility failed to provide antibiotic stewardship for 1 of 2 residents (R116) reviewed for antibiotic stewardship in the sample of 43. Findings Include: The facility's Infection Control Log dated 7/2/24 documents R116 prophylactic use admitted with a UTI (Urinary Tract Infection). The Infection Control Log also documented that R116 received Methenamine Hippurate 1 gram. R116's Nurses Note dated 7/9/24 documents V33 (Attending Physician) gave okay to check a UA (Urinalysis) and C&S (Culture and Sensitivity) to R/O (Rule Out) UTI. PT (Patient) cont. (continues) to c/o (complain of) UTI symptoms. She (R116) is on prophylaxis ABX (antibiotic) daily now and UA on 7/3 was neg (negative). Son cont. to request UA. R116's Medication Administration Record for the month of July documents Methenamine Hippurate 1 gram one tablet per day starting 7/1/24 through 7/26/24 UTI Prophylactic. R116 Physician Order Sheet dated 7/1/24 documents Methenamine Hippurate 1 gram tablet oral Indication: UTI Prophylactic. Discontinued on 7/26/24. R116's Infection Care Plan dated 7/9/24 to present documents (R116) is presenting with infection (R116) will be assessed for signs and symptoms of infection. Intervention: chronic use of antibiotic related to methenamine prior to admitting to the facility current active. On 11/22/24 at 1:25 PM V1 (Administrator) stated, she (R116) was admitted on that chronic antibiotic. We did not discontinue it because she was admitted on it. The facility policy Antibiotic Program dated 1/30/24 documents the antibiotic program promotes the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and reduce antibiotic resistance

Based on interview and record review the facility failed to ensure residents were free from abuse, for 2 of 2 residents (R2 and R13) reviewed for abuse, in the sample of 18. Findings include: On 3/26/2024 at 10:30AM, V15 (Licensed Practical Nurse/LPN) stated that R2 was aggressive and combative often. She also stated that his roommate, R13, may have been sitting in wheelchair going through doorway, but it wasn't intentional, trying to keep R2 out and that the television was outside the room and R13 was probably just watching it. On 3/27/2024 at 1:25PM, V17 (LPN) stated, I was working the night of the altercation between (R2 and R13). I heard (R13) say He hit me. I did not see (R2) hit (R13). The employees were in the common area with the residents. There were no injuries, and the Administrator came in and moved (R2) to a different floor. On 3/22/2024 at 4:00PM, V1 (Administrator) stated that R2 was the aggressor in the altercation with R13 and that it wasn't even an altercation they just bumped into each other. V1 continued to state that R2 was always accommodated and after the incident with R2 and R13, she had to separate them and R2 was moved to give him space and his own room. She continued to state that she personally came in after the altercation with R2 and R13 and moved R2 herself and his daughter and Grandson came in and that she set the room up so they could spend the night. V1 continued to state that R2 did much better after the move. He had less behaviors but R2 eventually moved back to the original floor because the family could not afford a private room. The facility's investigation, dated 4/29/2023, documented, On 04/29/23 at approximately 7:00PM (R2 and R13) started to get into a verbal argument while sitting in the common space. The nurse alerted the CNA's who immediately went to separate the two residents from each other. During separating the (R2) swatted (R13) in (R13's) face. The nurse assessed (R13) for injury, no visible injuries noted. Skin assessment complete. MD and family made aware. (Local Police department) notified around 7:30PM. Police report #23-11967. Notified (R2's) family that he will need to have a private room, and or a sitter due to behaviors. Arranging private room for (R2). Family present with (R2) for the night. R2's nurse's notes, dated 4/30/2023 at 12:56AM, documented, (R2) was seen bypassing (R13) in common area by the bird cage. (R2 and R13) began to argue with one another. Nurse heard the commotion yelled for staff to separate residents. At this time nurse did observe residents start a scuffle while being separated. Then (R13) yelled that (R2) hit him in the face. CNA (Certified Nursing Assistant), who was the one who, separated both residents, stated she observed (R2) hit (R13) in face during separation. (R2) has no physical injuries. (R2) denies pain. (R2) is confused and combative at this time, verbally abusive towards staff also. Once separated (R2) resumed wandering in wheelchair. (V3 R2's Daughter/POA) made aware and is on her way in to sit with (R2). Nurse Manager made aware. Physician notified. Protocol followed. Since residents are roommates (R2) will move to another unit in private room until further investigation. Family is here and will stay with (R2) until he winds down. Bedtime medications taken without difficulty. Staff will assist with moving (R2) over and getting comfortable and accommodated to new space. R2's Face sheet documents an admitted [DATE]. R2's diagnoses include Alzheimer's disease with late onset, Dementia, Hypertensive Chronic Kidney Disease, Chronic Kidney Disease, stage 3, Gastroesophageal Reflux Disease, other symptoms, and weight loss. R2's Minimum Data Set (MDS), dated [DATE], documents that R2 was severely cognitively impaired and requires maximum assistance with Activities of Daily Living. R2's Care Plan, dated 10/31/2023, documented, At times (R2) has physical and verbal behavioral symptoms directed at others especially personal during care. Interventions include comfort R2 during more agitated times with 1:1, walks in wheelchair, activities, family support, hydration / snacks. Consult with Psychiatric Doctor for increased behaviors related to incident 04/29/23. If verbal or physical behavior occur, call family for 1:1, remove from situation; allow time to calm down. approach in calm manner. Provide medication as ordered. During steroid utilization, increase behavioral monitoring due to increased agitation, provide Record behaviors on Behavior Assessments. Monitor pattern of behavior and report to Medical Doctor and family timely. (R2) to have increased behavioral charting during increased agitation times and or steroid use 04/29/23. (R2) transferred to private room on 04/29/23 related to increased behaviors and incident reported. Staff in-serviced on separation of residents during mealtimes and while in common area related to incident on 4/29/2023. R13's Face sheet, documented an admitted [DATE]. R13's diagnoses included Hemiplegia, Focal Traumatic Brain Injury, Muscle Contractures, Foot Drop Left Foot, Chronic Kidney Disease. R13's MDS, dated [DATE], documented that R13 was moderately cognitively impaired. R13 requires substantial assist with lying to sitting and was dependent for transfers. R13's care plan, dated 3/13/2024, documented, (R13) has verbal behavioral symptoms directed at others. Interventions include encourage caregivers to participate in activities with (R13) to promote positive interactions. Record behaviors on Behavior Tracking Form. Monitor pattern of behavior (time of day, precipitating factors, specific staff, or situations). Respond in a calm voice; maintain eye contact. Remove from area if (R13) is verbally abusive to others. Staff in-serviced on separation of residents during mealtimes and while in common area related to incident on 4/29/2023. The facility's policy dated 7/29/2021, documented, Residents and clients of (the corporation) campuses and programs will live and be served in an environment that promotes dignity, respect and strives to be free from abuse, neglect and exploitation. Allegation of potential or actual abuse, neglect or exploitation will be immediately reported to the appropriate leadership and government agency(ies), the resident protected, and the allegation investigated.

Based on observation, interview and record review, the facility failed to utilize a gait belt while transferring a resident and failed to ensure that fall interventions were put into place for 2 of 15 residents (R116 and R21) reviewed for falls in the sample of 41. Findings include: 1. On 12/07/23 12:15 PM R116 was sitting in her wheelchair (w/c) in her bathroom after being assisted with toileting by V5 (Certified Nursing Assistant/CNA). V5 then pushed R116 in her w/c to her bedside and assisted her to stand and pivot and lay down in bed. V5 did not put a gait belt around R116 to transfer her. R116 stated she had two falls before coming to the facility and broke her back. She stated she hit her head both times. R116 stated they have told her not to transfer by herself without assist. R116's Resident Care Summary dated 12/1/23 documents R116 requires assist of 1-2 for toileting, assist of 1-2 for positioning, assist of 1-2 for transferring and assist of 1-2 for mobility with wheelchair assisted. It documents R116 is receiving Physical Therapy and Occupational Therapy. On 12/08/23 at 3:14 PM V2 (Director of Nursing/DON) stated if staff must lay hands on a resident to assist them to transfer from the toilet to the w/c or w/c to bed, they should use a gait belt during the transfer for resident safety. On 12/12/23 at 10:45 AM V5 (CNA) stated she should have used a gait belt when she transferred R116 from the toilet to her w/c and from her w/c to her bed because R116 can do really good when transferring on some days but can be weaker and more unsteady on other days. V5 stated that was a crazy day when she was observed not using the gait belt when she transferred R116 from the toilet to her w/c and then from the wheelchair to her bed, but she should have still used the gait belt during the transfer. 35156 2. R21's Physician Order Sheet (POS) dated December 2023 documents a diagnosis of Neurocognitive disorder with Lewy bodies, Dementia in other disease classified elsewhere, anxiety, unspecific severity with psych disturbances, GERD (Gastroesophageal Reflux Disease) , paroxysmal A-fib (Atrial Fibrillation), spinal stenosis collapsed vertebra, hypothyroidism, overactive bladder, vitamin D deficiency, major depression disorder, hypertension, personal history of COVID, hypothyroidism, low back pain, and solitary pulmonary nodule. R21's Minimum Data Set (MDS) dated [DATE] document R21 was severely impaired for decision making of activities of daily living (ADL). R21's Care Plan document R21 has ADL selfcare deficit related to decreased mobility and muscle weakness (one assist-two assist). The Care Plan Goal documents that (R21) will not sustain a fall related injury by utilizing fall precautions through next review. The Fall Log provided by the facility on 12/7/2023 document R21 had 5 falls that were documented as occurring on 3/20/2023, 6/13/2023, 6/29/2023, 9/9/2023, and 9/17/2023. R21's Fall Report dated 3/20/2023 at 11:30 PM, documents, Resident observed on roommate's fall mat sitting on buttocks. ROM (range of motion) in normal limits for resident. No injuries noted. Describe immediate intervention listed: VS (vital signs), neuro checks and skin assessment. No other intervention was documented for R21. R21's Care Plan does not document any interventions for the fall on 3/20/2023. R21's Clinical Notes dated 3/20/2023 at 11:39 PM documents Observed on fall mat. R21's Fall Report dated 6/13/2023 at 1:40 AM, documents, Resident caught walking out of bedroom independently. Staff tried to redirect, and he became aggressive with staff and lost his balance and fell . Describe immediate intervention, Body assessment completed, and vital signs taken and helped back to bed. No other intervention was documented for this fall on 6/13/2023. R21's Clinical Notes dated 6/13/2023 at 1:44 AM documents, Resident caught walking out of bedroom independently. Staff tried to redirect, and he became aggressive with staff resident tried to yank back and fell to floor. R21's Care Plan does not document any fall intervention for R21 for the fall on 6/13/2023. On 12/13/2023 at 10:45 AM, V2 (Administrator) stated she would expect a new intervention to be initiated after every fall. The facility's policy, Falls and Fall Risk, revised 9/14/22 documents, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall Prevention-Potential Interventions: Staff Education: Gait belt for transfers and ambulation, as appropriate. The facility's policy, Safe Lifting and Movement of Residents, revised 10/14/19, documents, In order to protect the residents, and to promote quality care, this community uses appropriate techniques and devices to lift and move residents. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, slide boards) and mechanical lifting devices.

Based on record review and interview the facility failed to provide a safe transfer and failed to avoid storing medical equipment in resident areas to prevent falls for 2 of 16 residents (R2, R20) reviewed for falls in the sample of 34. Findings include: 1. R2's Face Sheet, run date 10/14/2022, documents R2' diagnoses as Alzheimer's disease, unspecified, Age-related [CONDITION(S)] without current pathological fracture, age-related physical debility, history of falling, Other secondary osteonecrosis, right femur, Unspecified [CONDITION(S)], [CONDITION(S)] disease and [CONDITION(S)] and collapse. R2's Minimum Data Set (MDS) undated documents R2 has severely impaired cognition, requires Extensive Assistance of 2 for transfers and toileting, is not steady and is only able to stabilize with staff assistance when moving on and off the toilet and surface to surface, and is occasionally incontinent with both bowel and bladder. R2's MDS has no documentation of Admission history of falls and documents R2 has had one fall since admission. R2's Care Plan dated 6/30/2020 documents R2 is at risk for falls/injury as evidenced by history of falls, cognitive status/behavior, vision status, continence, mobility, and balance. Interventions include toileting before and after meals related to fall 2/9/22; assess wheelchair safety due to fall on 3/10/22 and staff education related to fall on 9/14/22. R2's Fall Investigation dated 9/14/22 documents CNA (Certified Nursing Assistant) transferring R2 using sit to stand, mechanical lift. Staff stated one side of the harness clip popped off of hook, one side remained hooked, and the resident remained harnessed in. Lift arm lowered , R2 lowered to the floor. R2 assessed for injury and then transferred to sitting chair via staff assist. R2 then transferred to toilet with sit to stand after this nurse inspected harness and clips for defectiveness or breakage. This nurse remained present for the completion of transfer. Transfer completed without further incident. Describe Immediate Interventions Taken after Event Occurred: Staff educated on ensuring harness clips are securely in place. Post Fall Huddle-Mini Root Cause Analysis: Improper use of Assistive Device. Possible Interventions to Minimize Future Falls and Injuries: staff education. On 10/13/22 at 2:25 PM, V8 (CNA) states she was the one transferring R2. V8 states, I was certain that I had attached the sling properly, but it just popped off. Anytime you operate a mechanical lift, it's a 2 person assist. At no time did R2 fall, the other person and I guided R2 and prevented her from hitting the floor. This has been traumatic for me, as well because I would never intentionally do anything to place my residents in harm's way. I did receive in-service training on all mechanical lifts. On 10/13/22 at 1:30 PM, V9 (Licensed Practical Nurse/LPN), states she (V9) did not recall the fall involving R2. V9 could not remember any details but if a fall occurs because of staff error facility does require in-service training in-service is similar to new hire training and do require return demonstrations. No major problems have been reported with the mechanical lifts that required contacting the company. Both types of mechanical lifts are checked before each resident use by staff and monthly by maintenance. R2's Physical Therapy assessment dated [DATE] documents Recommend patient to use sit/stand lift with staff for safety. The Facility Policy Using a Mechanical Lift origination date 4/1/2008; review date 5/6/19 documents Policy statement : The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lift device. It is not a substitute for manufacturing training or instructions. - Before resident is lifted, double check the security of the sling attachment. 2. R20's Face Sheet, run date 10/14/2022, documents pertinent diagnoses as Dementia in other diseases classified elsewhere with behavioral disturbances and [CONDITION(S)] disease. R20's MDS dated documents R20 is moderately impaired-cognitive for daily decision-making , making poor decision, cries and supervision required. R20 is Independent in bed mobility, transfer, walk in room, eating, toilet and personal hygiene; help only in walking in room, locomotion on unit and dressing. Moving from seated to standing position- steady at all times, in walking, turning around and surface to surface transfer- not steady but able to stabilize without staff assistance. R20 does not use a mobility assistive device. Toileting and putting on and taking off footwear, R20 completes the activity (helper only) assists prior to or following the activity. R20 is frequently incontinent of urine and occasionally incontinent of bowel. R20 has adequate hearing and vision. R20's Fall Investigation dated 2/9/22 documents R20 had a witnessed fall in the bathroom, took self to bathroom, no socks or shoes on feet, upon exiting bathroom, R20 bumped into roommate's (geriatric reclining) chair and fell to her (R20) knees. CNA walking past room at time of incident and witnessed incident. CNA states she (R20) did not hit her head and got herself up off the floor before she could be assessed. R20 suffered a small skin tear to right dorsal-lateral, no other injuries noted. Range of Motion (ROM) within normal limits (WNL). Possible Interventions to Minimize Future Falls and Injuries: environmental safety review, appropriate footwear, assess for pain, non-skid socks, (geriatric reclining) chair to be moved in hall at nighttime. R20's Fall Investigation dated 7/17/22 documents R20 was walking in hallway and tripped over mechanical lift in hallway. R20 denied pain, Range of Motion (ROM) within normal limits (WNL). Neuro started per policy. Possible Intervention to Minimize Future Falls and Injuries: Environmental safety review, appropriate footwear, new shoes, educated staff on putting mechanical lift away. R20's Care Plan dated 3/3/21 documents Care area of Falls. R20 is at risk for falls/injury as evidenced by history of falls, cognitive status/behavior, vision status, continence mobility and balance. Progressive interventions include roommate's (geriatric reclining) chair to be removed into hallway at night due to R20's fidgetiness, related to fall dated 2/9/22; remind R20 and reinforce safety awareness, lock brakes on bed, chair, etc. before transferring, educate/remind R20 and/or family to request assistance for all ambulation and transfers; non-skid socks and appropriate footwear for the fall dated 7/17/22. Labs requested, apply shoe to other foot as related to fall on 7/30/22; R20 to wear grip socks at all times, related to shuffling gait in shoes, related to fall on 8/22/22. On 10/14/22 at 11:00 AM, V1 (Administrator) states residents are assessed by therapy for decline or improvement before using any mechanical lifts. If there is an adverse event, like a fall the nurse on duty will begin the process, will involve staff to determine cause of adverse event and then the management team will evaluate and educate to prevent future adverse events. Our lifts are relatively new, and all maintenance is completed by that company. There have not been any major problems with the lifts. The lifts are not left in the room we have restructured the rooms and included a storage space to accommodate the lifts to prevent blocking of the entrance. R20 has shuffling gait problem and we try to keep things out of the way to prevent her falling. The (geriatric reclining) chair was her (R20's) roommate's chair. It was agreed upon by all parties involved that the chair would be placed outside of the room at the end of evening and all residents were in bed. The Facility policy Management of Fall Risk origination date 1/22/17, revision and review date 9/14/22, documents Policy Statement: Based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observation, interview and record review the facility failed to ensure food was stored and prepared in a manner which prevents potential contamination. This has the potential to affect all 57 residents living in the facility. Findings include: On 8/30/21 at 7:02 AM, during the kitchen tour there was a stand-up refrigerator with 6 round plastic foam containers inside with a brown crumbling substance on top. The items were not covered and were exposed to the air. On the refrigerator shelf, there were two 4-quart clear plastic containers covered with a clear lid with a brown pureed smooth substance inside that was not dated and/or labeled. On 8/30/2021 at 7:11 AM, in the refrigerator were 2 small moveable tray carts with wheels on the tray shelves. On the carts, there were 8 small Styrofoam plates with salad. The salads were not labeled and/or dated. On the second moveable cart there were 6 individualized plates of pie slices not labeled with any dates and times. On the floor of the refrigerator was a large industrial bucket of hard-boiled eggs sitting directly on the floor. On 8/30/2021 at 7:39 AM, V5 (Cook) stated, Those trays were from last night and the salads and pies should be thrown out. I am not sure why they are still in the refrigerator. That item on the floor is hard boiled eggs. On 8/30/2021 at 7:21 AM, inside the walk-in freezer were 6 individualized bags of cinnamon rolls with icicles on them that were laying directly on the floor of the freezer. Condensation was dripping from the ceiling in the freezer and there was a buildup of ice in the freezer. The water was dripping directly onto 5 four-pound boxes of corn bread. The sides of the corn bread packages had frozen ice stuck to the containers. There were ice crystals on the top of the packages. On the floor were 6 solid ice blocks from the condensation measuring approximately 4 ounces in diameter scattered on the floor. On 8/31/2021 at 2:15 PM, V5 (Executive Chef) stated, I expect all food to the covered, labeled and dated. I would not expect food to be under any condensation or dripped on. All food should be stored at least 6 inches from the floor. The Food Drug and Dairy (FDA) code states food should be stored 6 inches from the floor and food be protected during storage. The Cook End of Shift undated documents, Check cooler/freezer daily for organization; rotate product on delivery days; dispose of prepared products that are greater than 3 days old. Clean up shelves as needed and wipe down shelving from spills. Make sure all products are labeled and dated. The Facility's SERV Safe Policy dated 2019, Label and Date all stored food. Store Food away from walls and at least six inches (15 centimeters) off the floor. The Facility's Resident Census and Conditions of Residents form, CMS 672, dated 09/01/2021 documents that the facility has 57 residents living in the facility.

Based on interview and record review, the facility failed to provide the resident or the resident's responsible party a written notice of transfer to an acute care facility for evaluation and treatment for 4 of 4 residents (R4, R23, R46, R159) reviewed for transfer notice requirements in the sample of 37. Findings include: 1. R159 was sent to a local hospital on 08/08/2021 after sustaining a fall at the facility. On 09/01/2021 at 02:54 PM, V22 (Registered Nurse/RN) stated that when she sent R159 out to the hospital, V22 sent the transfer sheet that goes to the medics for transfer along with medication list, face sheet, and code status and the bed hold was done in the computer system, but V22 didn't give R159 a notice of transfer. 2. R4's Nurse's Note, dated 5/10/21, documents, Resident observed on floor sitting on buttock with legs out in front of her. Resident bleeding from cut on head and swelling with bruising forming on forehead. Head to toe assessment completed. ROM WNL (range of motion within normal limits). Complaints of nausea and chest pain voiced. EMS (Emergency Medical Services) called. Pressure held on head to stop bleeding and nurse at bedside with resident until EMS arrived. Resident sent to (hospital) for treatment and eval (evaluation). R4's Nurse's Note, dated 5/10/21, documents, Resident admitted to (hospital) with elevated Troponin levels and [CONDITION(S)] (Urinary Tract Infection). There was no documentation in R4's medical record that R4 was given notice of reason for transfer to hospital. On 8/31/21 at 2:45 PM, V9 (Licensed Practical Nurse/LPN) stated that she does not give the resident any paperwork for themselves, only paperwork for the hospital. On 9/1/21 at 1:25 PM, V2 (Director of Nurses/DON) stated, The resident does not get any paperwork just for themselves explaining why they are going to the hospital. 3. R23's Nurse's Note, dated 6/23/21, documents, STAT (now) lab results sent to (V20 Nurse Practitioner). N.O. (new order) received to send to ER (emergency room ) for eval and tx. (treatment). There was no documentation in R23's medical record R23 was given written transfer notice upon going to hospital. 4. R46's clinical note, dated 7/30/21, documented that R46's lab results show critical and abnormal values. The note documented V20 (Nurse Practitioner) recommended to send resident to the hospital for [CONDITION(S)] (CHF) exacerbation. The Note documented R46 was sent to the hospital via ambulance, with copy of labs, and list of medications. R46's clinical note, dated 7/31/21, documented that R46 returned from the hospital via ambulance stretcher with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/01/21, at 9:30 AM, V13 (LPN) stated, I get a copy of the resident's Face Sheet, orders, and current med list and will give to the EMS (Emergency Medical Service) team. I don't give the resident anything. On 9/01/21, at 9:35 AM, V12 (LPN) stated, I will give EMS a copy of the Face Sheet, med list, the DNR (Do Not Resuscitate) form, and maybe the last labs. I don't give the resident anything. On 9/01/21, at 11:23 AM, a note documenting that a notification was given to the resident or resident representative regarding notice of transfer was not available for review. The facility's Transfer or Discharge, Emergency policy, dated 8/2018, failed to document the need for written reason for discharge to be given to the resident or resident representative.

Based on interview and record review, the facility failed to provide the resident or the resident's responsible party a written notice of the bed hold policy upon transfer to an acute care facility for 4 of 4 residents (R4, R23, R46, R159) reviewed for bed hold notice in the sample of 37. Findings include: 1. R159 was sent to a local hospital on 08/08/2021 after sustaining a fall at the facility. On 09/01/2021 at 2:54 PM, V22 (Registered Nurse/RN) stated that when she sent R159 out to the hospital, V22 sent the transfer sheet that goes to the medics for transfer along with medication list, face sheet, and code status, and the bed hold was done in the computer system. V22 stated she didn't give her R159 one. 2. R4's Nurse's Note, dated 5/10/21, documents, Resident observed on floor sitting on buttock with legs out in front of her. Resident bleeding from cut on head and swelling with bruising forming on forehead. Head to toe assessment completed. ROM WNL (range of motion within normal limits). Complaints of nausea and chest pain voiced. EMS (Emergency Medical Services) called. Pressure held on head to stop bleeding and nurse at bedside with resident until EMS arrived. Resident sent to (hospital) for treatment and eval (evaluation). R4's Nurses Note, dated 5/10/21, documents, Resident admitted to (hospital) with elevated Troponin levels and [CONDITION(S)] (Urinary Tract Infection). The facility provided no documentation that R4 and/or R4's responsible party received a notice of the bed hold policy upon transfer to the hospital. 3. R23's Nurse's Note, dated 6/23/21, documents, STAT lab results sent to (V20 Nurse Practitioner). N.O. (new order) received to send to ER (emergency room ) for eval and tx. (treatment). The facility provided no documentation that R23 and/or R23's responsible party received a notice of the bed hold policy upon transfer to the hospital. On 8/31/21 at 11:37 AM, V9 (Licensed Practical Nurse/LPN) stated that she does not give the resident any paperwork for themselves like a bed hold letter or a reason why the resident is going out to the hospital. On 9/1/21 at 1:25 PM, V2 (Director of Nurses/DON) stated, The resident does not get any paperwork just for themselves explaining why they are going to the hospital. On 9/1/21 at 1:27 PM, V19 (Social Service Director/SSD) stated, The resident gets a bed hold letter in their admission packet. I call the family and ask them if they want to place the resident on a bed hold. The resident or the family does not get another bed hold letter. I do not notify the Ombudsman of the transfers and discharges. 4. R46's clinical note, dated 7/30/21, documented that R46's lab results show critical and abnormal values. The note documented V20 (Nurse Practitioner) recommended to send resident to the hospital for [CONDITION(S)] (CHF) exacerbation. The Note documented R46 was sent to the hospital via ambulance, with copy of labs, and list of medications. R46's clinical note, dated 7/31/21, documented that R46 returned from the hospital via ambulance stretcher with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/01/21, at 9:30 AM, V13 (LPN) stated, I get a copy of the resident's Face Sheet, orders, and current med list and will give to the EMS (Emergency Medical Service) team. I don't give the resident anything. On 9/01/21, at 9:35 AM, V12 (LPN) stated, I will give EMS a copy of the Face Sheet, med list, the DNR (Do Not Resuscitate) form, and maybe the last labs. I don't give the resident anything. On 9/01/21, at 11:23 AM when requested from the facility, documentation that a notification was given to the resident or resident representative regarding a bed hold was not available for review. The facility's Bed-Holds and Returns policy, dated 4/26/21, documented that prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold policy. Implementation of the policy documented that prior to a transfer, written information will be given to the resident and the resident representatives that explains in detail: a) The rights and limitations of the resident regarding bed-holds, b) The bed-hold policy as indicated by the state plan, c) The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents), and d) The details of the transfer (per the Notice of Transfer).

Based on observation, interview and record review, the facility failed to perform hand hygiene before and after glove use for 3 of 16 residents (R16, R26, R31) reviewed for infection control in the sample of 37. Findings include: 1. On 8/31/21 at 10:45 AM, R31 was transferred from her reclining geriatric chair to the toilet using a mechanical lift by V3 (Certified Nursing Assistant/CNA) and V6 (CNA). V3 and V6 both donned gloves without hand hygiene before R31's transfer. 2. On 8/31/21 at 1:15 PM, V6 and V3 toileted R16. R16 was incontinent of urine. During the incontinent care, V6 changed gloves without hand hygiene in between. 3. On 8/31/21 at 9:20 AM, V9 (Licensed Practical Nurse/LPN) entered R26's room, donned a glove on the right hand and administered [MEDICATION(S)] into R26's nose. V9 removed her glove and exited the room. V9 went to the medication cart, obtained an alcohol pad and cleansed the [MEDICATION(S)] nozzle and placed the [MEDICATION(S)] back into the medication cart then sanitized her hands. On 9/2/21 at 9:20 AM, V1 (Administrator) stated that she expects her staff to perform hand hygiene before and after using gloves. The policy Handwashing/Hand Hygiene, dated 3/10/20, documents, Applying and Removing Gloves: 1. Perform hand hygiene before applying non-sterile gloves. 2. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. 3. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 4. Perform hand hygiene as indicated.

Based on observation, interview, and record review, the facility failed to assess and implement interventions to prevent contractures and the decrease in range of motion (ROM) for 1 of 1 resident (R32) reviewed for decreased ROM in a sample of 37. Findings include: R32's Minimum Data Set (MDS), dated [DATE], documented that R32 has a severe cognitive impairment, requires extensive assistance from one to two staff for all of her Activities of Daily Living (ADLs). The MDS documents R32 has a functional limitation in ROM affecting both upper extremities. On 8/30/21, at 12:30 PM, V18 (Registered Nurse/RN) was feeding R32 while sitting in her wheelchair in the dining room. R32's eyes were closed, but she opened her mouth for food. R32's arms were contracted up to her chest. No staff were observed providing R32 ROM throughout the day on 8/30/21. On 8/31/21, at 10:15 AM, V16 (Certified Nursing Assistant/CNA) and V15 (CNA) performed perineal care for R32. V15 and V16 did not perform ROM during or after care of R32. On 9/1/21, at 10:30 AM, R32 was sitting in her wheelchair with arms contracted to chest. On 9/01/21, at 9:45 AM, V12 (Licensed Practical Nurse/LPN) stated, (R32) is not on any ROM program. She would not let us do anything like that. Even when we try to straighten her arms, she will pull them back to her chest. On 9/01/21, at 2:20 PM, V15 (CNA) stated, I think (R32) has always been contracted like she is. I don't think she has had any therapy here. On 9/2/21, at 10:30 am, V14 (Restorative Nurse) stated, (R32) has only had speech therapy work with her for swallowing issues. Usually PT (Physical Therapy) would evaluate and make recommendations, but (R32) has not had anything done for her regarding PT or ROM. On 9/02/21, at 11:52 am, V1 (Administrator) stated, I would expect staff to perform ROM on (R32) when performing care, even if she refuses, it should be documented that it was attempted. It should be in her care plan that staff would see when caring for her (R32). R32's Care plan, dated 7/9/21, failed to document or address R32's contractures or ROM. Upon R32's record review, R32 had Speech Therapy (ST) orders and treatments for aspiration precautions with the latest dated 5/18/21 but has not had any PT or Occupational Therapy (OT) orders or services at this facility. The facility's Restorative Nursing Services policy dated 4/26/19, documented that residents will receive restorative nursing care as needed to help promote optimal safety and independence. The Policy documents 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services. 2. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. 3. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's care plan. 4. The resident or representative will be included in determining goals and the plan of care. 5. Restorative goals may include, but are not limited to supporting and assisting the resident in: a) adjusting or adapting to changing abilities, b) developing, maintaining, or strengthening their physiological and psychological resources, c) maintaining their dignity, independence and self-esteem, and d) participating in the development and implementation of their plan of care. The facility's Activities of Daily Living, Supporting policy, dated 2/14/20, documented that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). The Policy documents If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not assume the resident is refusing or declining care.

Based on observation, interview and record review, the facility failed to provide safe transfer techniques when using a mechanical lift for one of 4 residents (R5) reviewed for supervision to prevent accidents in the sample of 37. Findings include: 1. R5's Care Plan, dated 3/19/2018-present, documents, (R5) is at risk for falls/injury as evidenced by: history of falls, cognitive status/behavior, vision status, continence, mobility, balance. It also documents Interventions, Provide environmental adaptations - maintain bed in lowest position while (R5) is in bed; call light within reach; adequate, glare free lighting; area free of clutter; crash mat next to bed. R5's Minimum Data Set, dated dated [DATE], documents R5 is severely cognitively impaired and is totally dependent on staff for transfers. On 08/31/21 at 8:51 AM R5 was in her room alone. No facility staff were present. R5 was lying slightly raised over the bed with bed in high position. R5 was lying on top of a transfer sling that was connected to a full body lift. The transfer lift was in the raised position with R5 raised slightly over the bed. V15 (Certified Nurse's Assistant/CNA) then entered the room and lowered the lift and R5 down onto bed. V15 then left R5's bedside and walked out of the room and asked for help with the transfer. V25 (CNA) entered the room. V15, while operating the controls, lifted R5 into the air and with assist of V25 transferred R5 into her wheelchair. Prior to the transfer, V15 and V25 did not double check the security of the sling attachments. V15 and V25 did not perform a safety check of the stability of the attachments, the fit of the sling and weight distribution. On 8/31/2021 at 8:53 AM V15 (CNA) stated that she was gone to go get help with transferring (R5). On 9/2/21 at 11:10 AM V13 (Licensed Practical Nurse/LPN) stated that R5 is dependent on staff for transfers. V13 stated that the mat on the floor next to the bed is for prevention. V13 stated that R5 must have had falls before. V13 stated that it is not normal practice for a staff to leave a resident in a high bed attached to the full body lift unattended. V13 stated that it's not safe. V13 stated that she expects the staff to stay with the resident or unattached them (resident) from the lift before leaving the room. On 9/2/21 at 11:20 AM V12 (LPN) stated that R5 requires the full body lift and 2 staff members for transfers. V12 stated that it is not safe to leave R5 in her room alone attached to the lift with the bed in the high position. On 9/2/21 at 11:23 AM V15 (CNA) stated that it is not safe to leave R5 unattended in the bed in the high position while attached to the lift. On 9/2/21 at 12:18 PM V1 (Administrator) stated that it is not safe to leave a resident in the full body mechanical lift unattended. V1 stated that they are never to leave a resident unattended in the lift. V1 stated they are to pull the call light and wait. The full mechanical body lift manufactures instructions for use, dated 2020, documents This product is intended to be operated entirely by an attendant. The Facility's Using a mechanical Lift Policy, dated 5/6/19, documents The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It also documents General Guidelines: 10. Before resident is lifted, double check the security of the sling attachment. 11. Lift the resident 2 inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution.

Based on observation, interview, and record review the facility failed to clearly display, in a visible place, the daily nurse staffing information. The has to potential to affect all 57 residents living in the facility. Findings include: From 08/30/2021 at 8:30 AM to 09/01/2021 at 10:04 AM, the nurse staffing information was not posted daily. On 09/01/2021 at 10:03 AM, V2 (Director of Nursing/DON) stated that she did not know what it was or where the nurse staffing is posted but will ask V1 (Administrator). On 09/01/21 at 2:16 PM, V1 (Administrator) presented a clip board with the nurse staffing that was kept at the receptionist desk. V1 stated that if the visitors want to see it, they know to ask the receptionist and it's also on the REACH unit at the desk. The facility's policy, Posting Direct Care Daily Staffing Numbers, dated July 2016, documents, 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RN's (Registered Nurses), LPNs (Licensed Practical Nurses) and LVNs (Licensed Vocational Nurse)) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. The Facility's Resident Census and Conditions of Residents form, CMS 672, dated 09/01/2021 documents that the facility has 57 residents living in the facility.

Based on observation, interview and record review the facility failed to implement proper infection prevention and control practices to prevent the development and transmission of COVID-19 and other communicable diseases and infections for 5 of 5 residents (R1, R2, R3, R4, R5) reviewed for infection control in the total sample of 7. Findings include: 1. R1's Electronic Health Record (EHR) documents R1 was admitted to facility on 3/16/2018. R1's COVID test results, dated 9/10/2020, documents abnormal positive results. R1's Progress Note dated 9/10/20 documents: Resident and POA (Power of Attorney) notified of Positive COVID test results. NP/MD aware. Droplet precautions are maintained. Resident has no symptoms at that time. R1's Progress Note dated 9/11/20 documents: Remains on ISO PREC (isolation precautions) on this shift, due to positive COVID results. no noted s/s (signs/symptoms) of pain, Low grade temp noted this shift. [MEDICATION NAME] (Tylenol) administered. No sore throat or cough noted. Res (resident) in bed at this time, will continue to monitor. R1's Care Plan dated 9/23/20 documents: Reduce cross contamination to visitors and employees through next review. INTERVENTIONS: Droplet Isolation, Follow Standard Precautions, follow transmission-based precautions, monitor symptoms of [DIAGNOSES REDACTED]. On 9/21/2020 at 09:30 AM V2 (Director of Nursing/ON), stated, This hallway is our COVID unit (red); you must wear a mask, gown, gloves and face shield before entering. A small plastic container located outside the closed-door containing PPE (personal protective equipment) was observed. V2 stated, The back area (green) requires a mask and shield to enter, because we do not have any positive COVID residents. On 9/21/2020 at 10:48AM V3 (Licensed Practical Nurse/LPN) stated, Our transitional area (yellow) is upstairs in the rehab to home area for those residents that are newly admitted or go out to appointments outside facility. On 9/21/2020 at 12:30PM V4 (LPN/Nurse Manager) stated, (Staff) wear face shield and masks when outside resident rooms and wear gown and gloves when entering residents' rooms and remove when leaving. V4 stated not all the residents on the COVID hall are positive. V4 stated, We have 4 residents that are negative; they have always been negative. Not sure if we had place to put them. Residents that are negative can have their door cracked open, positive COVID residents' doors are closed. V4 stated that R1 is positive COVID and her roommate, R2 is negative and they share the same room, shower, and bathroom. On 9/21/2020 at 12:45PM R1 was observed lying in bed to her left side facing R2 and R2 was observed sitting up in a chair next to R1. R1's curtain was pulled back to where R2 was sitting next to the head of R1's bed. V11 (Certified Nurse Assistant/CNA) stated R1's curtain needs pulled shut. V11 stated that both residents require assistance from staff for Activities of Daily Living (ADLs) and share the same bathroom and shower. 2. R2's EHR documents R2 was admitted to facility on 7/30/2019 from a local hospital. R2's Progress Note dated 9/10/2020 documents: (R2) continues on Med B therapy. Resting quietly in recliner. Staff ambulates resident within the unit with wheeled walker. R2's Progress Note dated 9/18/2020 documents: [MEDICATION NAME] given for temp of 99.4. No cough or other symptoms noted at this time. will continue to monitor. R2's EHR documents COVID lab results dated 9/23/2020 as positive for COVID. R2's Progress Note dated 9/23/2020 documents: SS (Social Service) contacted residents POA for COVI update. Social Service confirmed results of testing were positive. All questions or concerns addressed during call. POA provided consent for resident to receive IV fluids if needed to manage symptoms related to COVID. Social Service will continue to monitor and support residents' Psychosocial needs. R2's Care Plan dated 8/05/20 documents: Reduce cross contamination to visitors and employees through next review. INTERVENTIONS: Droplet isolation, Follow Standard precautions, follow transmission-based precautions, Monitor symptoms of [DIAGNOSES REDACTED]. 3. R3's EHR documents R3 was admitted to facility on 3/13/2020. R3's EHR documents COVID lab results, dated 9/09/2020, as positive for COVID. On 9/23/2020 at 12:20PM, R3 was sitting in R3'room with door closed. R3 stated that she has been in facility about a year. R3 stated that she had a fever for a couple of days and had a little cough. R3 stated, Staff really weren't paying attention to me until I had experienced those symptoms for about a week, until the positive test returned. R3 stated, Tomorrow or the next day I come off quarantine, then I can leave my room and open the door to my room. R3's documented temps were 99.8 on 9/3, 100.6 on 9/4, 99.8 on 9/5 and 100.2 on 9/6. On 9/23/2020, at 1:40PM, V1 (Administrator) stated, If any resident is displaying fevers or other COVID symptoms then they need to be placed on droplet precautions. We followed the guidance to leave residents where they were and not to move off the hallway because they were already exposed. V1 stated, All the residents on hallway are now positive. V1 stated, Staff are to wear full PPE when in transitional rooms with residents. On 9/23/2020 at 1:41PM, V1 stated, (R3) will remain on the COVID unit in her room after quarantine is over. On 9/23/2020 at 1:42PM, V2 stated, Staff are only wearing masks and face shields when in the transitional rooms, not full PPE. 4. R5's Progress Note, dated9/15/2020 at 8:30AM, documents, Nurse Manager performed rapid COVID test on resident, related to positive symptoms. Rapid test results are positive for COVID. Resident remains on droplet isolation . R5's COVID test results, dated 9/16/2020, documents abnormal positive results. R5's Progress Note, dated 9/21/2020 at 3:41PM, documents Informed per nursing that resident's appetite is persistently poor. Resident seems to be very dry with dry oral cavity and lips. Per nursing, resident was noted to pocket food requiring increased oral care. She is also not drinking much. No n/v/d. She does have a cough . On 9/22/2020 at 10:00AM, R5's room door was left open and remained open based on 15-minute observations until 1:00PM. On 9/21/2020 at 1:20PM, V11 (CNA) stated, This is the COVID unit. All of the COVID positive residents' doors are kept closed. On 9/22/2020 at 1:00PM V8 (CNA) stated, All of the COVID positive residents' doors are to stay closed. We were told by the nurse to keep all their doors closed. 5. R4's Care Plan, dated 8/30/2020, documents (R4) is at risk for Psychosocial well-being concern, r/t (related to) medical and visitation restrictions secondary to COVID-19. R4's Progress Note, dated 9/22/2020 at 10:11PM, documents Rapid swab for COVID completed noted to be positive, resident placed on droplet isolation. R4's COVID test results, dated 9/21/2020, documents abnormal positive results. R4's Progress Note, dated 9/22/2020 at 3:09PM, documents Nurse Practitioner has seen resident and stated stated, Patient is exhibiting death rattle type breathing, where she takes 5-6 very shallow breaths, w/ minimal air movement, and then 1 large snoring/gasping type breath. O2 sats (saturation) are variable, dropping to low 80's then increasing to low 90's, when patient takes a large breath. Suspect patient has started the dying process. Updated R4's POA (Power of Attorney) related to resident's condition. COVID swab done yesterday awaiting results. Family requesting Hospice consult. Orders received for Hospice to eval (evaluate). R4's Electronic Health Record documents temperature of 99.8 on 9/18, 100.1 on 9/19, and 100.5 on 9/21. R4 began to exhibit signs of COVID 19 on 9/18 with elevated temperature of 99.8. She continued to exhibit symptoms with temperature reaching 100.5 on 9/21. (R4) was swabbed for COVID 19 on 9/21 during scheduled weekly testing for all residents. R4's condition continued to decline, with R4 exhibiting the death rattle per the Nurse Practitioner on 9/22/2020. R4's COVID results were positive on 9/22/2020 and placed on droplet isolation. R4 was not placed on precautions prior to positive test results. On 9/22/2020 at 10:08AM, observed V10 (Nurse Practitioner) enter R4's room with face mask and face shield. V10 did not apply gown or gloves prior to entering R4's room. The facility's policy and procedure 'Infection Prevention Control Program' dated 3/10/20 documents: The primary mission is to establish and maintain an organization wide Infection Prevention Control Program,(IPCP) that is designed to provide a safe, sanitary and comfortable environment and to help to prevent the development and transmission of communicable diseases and infections whenever possible. Standard and transmission-based precautions to be followed to prevent the spread of infection.

Based on interview and record review the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents. This has the potential to affect all 12 residents living in that area of the facility. Findings include: The facility Incident/Accident report dated 3/19/19 documents in part, On 3/18/19 facility staff sent a re-order request to pharmacy for [MEDICATION NAME] 0.5 milligrams (mg) for resident (R2) and received notification that the refill request was too soon. Upon notification, Facility Director of Nursing (DON) began an investigation and found a card of 15 count [MEDICATION NAME] 0.5 mg was marked as delivered to the facility on [DATE] by the pharmacy and signed for by (V9) LPN (Licensed Practical Nurse). Delivery receipts show that the [MEDICATION NAME] 0.5 mg was signed as received by (V9) on 3/14/19. All facility medication storage areas were searched for the unaccounted for [MEDICATION NAME] 0.5 mg and it was not located within the facility. (V9) was interviewed regarding the unaccounted for [MEDICATION NAME] 0.5 mg and she stated she recalled receiving a delivery from pharmacy on 3/14/19 and signing for medications received but did not recall placing any controlled substances in the narcotic lock box. (V9) stated that she recalled placing the bag of received medications on her medication cart but not in the lock box. (V9) stated that she may have thrown the bag away without removing the medication. On 4/1/19 at 3:20 PM, V2 stated, How we found out about this was a nurse ordered some [MEDICATION NAME] for (R2) and pharmacy said the refill request was too soon, that [MEDICATION NAME] had been delivered for her on 3/14/19. We looked for it and it wasn't in the med cart. I called the LPN who signed for it and she came into the facility. She was here in the facility about 5 hours searching for the medicine with me. It wasn't found, she told me maybe she threw it away. She should have secured the medication in the locked narcotic box. On 4/3/19 at 8:58 AM, V9 stated, I think this happened on a Thursday, that's when I signed for it. The DON called me on Tuesday and asked me where I would have put the medication. I came into the facility and we searched everywhere and we could not find it anywhere. I didn't even remember getting it. I normally would lock it up, but I can't remember back that many days if I locked it up. The facility Policy and Procedure for Accepting Delivery of Medications dated 8/13/18 documents in part, Policy Statement: All staff shall follow a consistent procedure in accepting medications. Any errors noted in receiving medications shall be brought to the attention of the pharmacist and director of nursing. Policy interpretation and Implementation: 1. A nurse shall personally accept each medication delivery. 2. The nurse shall verify the contents of the delivery against the pharmacy packing slip or log and the order forms, review and if necessary, respond to any communications from the pharmacy contained in the packing slip within 24 hours of delivery receipt. The pharmacy will be promptly notified of any discrepancies or omissions noted on the delivery packing slip or log. 3. Medications should be placed in the appropriate storage area as soon as possible after verification. 5. A nurse shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep a copy of the delivery ticket. Both the receiving nurse and the delivery agent must sign any notations about errors.

Based on observation, interview and record review the facility failed to ensure food is stored safely and prepared in a manner which prevents potential contamination. This has the potential to affect all 66 residents living in the facility. Findings include: On 09/11/18 at 12:31 PM in the hallway V9 (Dining Supply Associate) was bringing a pan of french fries upstairs and the pan was not covered. On 09/11/2018 at 12:32 PM, V9, stated, I am bringing these french fries from the kitchen upstairs to the rehabilitation unit. On 09/11/2018 at 3:00 PM, V7 (Dietary Manager) stated, I expect all food to be covered during transportation. I know V9 was just following directions and it is the responsibility of the Cook to ensure all food is covered before transporting. On 9/14/2018 at 9:58 AM, in the middle of the kitchen is a metal rack and the metal rack has 5 tongs and 15 ladles hanging from it. On the ceiling, air is blowing out of the vent and an accumulation of dust is adhering to the ceiling above the clean utensils. As the air blows, a piece of the dust floats from the ceiling and lands on one of the clean ladles. On 09/14/18 at 9:59 AM in the main kitchen the wall adjacent to the stove is covered with yellow streaks and is shiny and sticky. On 09/14/2018 at 10:00 AM, V7 stated, I will make sure that it gets cleaned. Yes, I can see the grease build up on the wall next to the stove. On 09/14/2018 at 10:01 AM, inside the refrigerator unit are 3 large industrial 3.5 quart containers with items inside with no label or no date. The lids on 5 of the 3.5 quart clear industrial containers are not locked and the containers are open. On 09/14/2018 at 10::00 AM, V7 stated, I know this container is chicken salad. I am not sure what is in the other two; I will make sure they are thrown out. I will make sure staff closes all lids properly. On 09/14/2018 at 10:01 AM, V7 stated, Yes, I see the dust build up on the ceiling. I will make sure we get a cleaning schedule so that it cannot build up in the future. The Facility Preventing Foodborne Illness-Food Handling policy, dated 01/05/2018, documents in part, Food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized. The Facility's Resident Census and Conditions of Residents form dated 9/11/2018 documented the facility had a census of 66 residents.

Based on interview and record review the facility failed to ensure food was palatable, attractive and safe in temperatures for R7, R13, R27, and R29 in the sample of 34. Findings include: On 09/11/2018 at 10:20 AM, R29 was served scrambled eggs. R29 stated My eggs are not hot. On 09/11/18 at 10:25 AM a tray from the locked down unit with scrambled eggs and toast were served to (R7). Upon tasting the eggs R7 stated´My eggs are cold. The food is not good here. They serve us the same thing over and over again, and it is not always hot. On 9/11/18 at 10:28 AM,V8 (Dining Supply Associate) stated, Residents are served breakfast off the steam table and are able to get anything off of the steam tray until 10:30 AM. On 09/11/2018 at 10:28 AM, the food was sitting on the steam table in the main dining room and the following temperatures were taken with a calibrated thermometer: scrambled eggs 124 degrees Fahrenheit (F), French toast 124.0 degrees F, Pancakes 118.0 degrees F, hash browns 150.0 degrees F, sausage 131.4 degrees F, bacon 150.0 degrees F, oatmeal 89.0 degrees F, cream of wheat 87.0 degrees F, gravy 135.0 degrees F, and super bread 117.0 degrees F. On 09/11/18 at 10:29 AM, V8 stated, All of this will go back to the kitchen now and I will not serve out anymore because of the temperatures being off. During the group meeting on 09/12/2018 at 11:15 AM, R13 and R27 both stated their food is not always hot when served. On 09/14/2018 at 3:00 PM, V7 (Dietary Manager) stated, Yes, I expect all food on the steam table to be at least 140 degrees F and not below. If the food is less than 140 degrees than I expect the food to be thrown out. The Food Services Policy with a Revision Date of 01/05/2018, documents in part, 6. Potentially hazardous foods will be cooked to the appropriate internal temperatures and held at those temperatures for the appropriate length of time to destroy pathogenic microorganisms. 7. Potentially hazardous foods held in the danger zone (135 F) for more than 4 hours. Food that has been served to residents without temperature controls will be discarded if not eaten within two hours.

Based on observation, interview and record review, the facility failed to accurately assess and revise the Minimum Data Set (MDS) for 1 of 34 residents (R36) reviewed for MDS accuracy in the sample of 34. Findings Include: R36's Physician order [REDACTED]. R36's MDS dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. On 9/11/18 at 11:01 AM, R36 is laying in bed, bed alarm in place. On 9/18/18 at 10:50 AM, V2 (Director of Nursing/DON) stated that she expects a device to be documented in the care plan, physician orders, and MDS. On 9/18/18 at 11:10 AM, V10 (Registered Nurse/RN - MDS Coordinator) stated, R36's alarms weren't on the MDS. The order wasn't clear to me; it said FYI (for your information), so it wasn't marked on the MDS. R36's POS dated 5/20/18 documents bed alarm and chair alarm. R36's Care Plan revised on 9/11/18 documents, in part, bed alarm as needed (PRN) related to (r/t) unsafe transfers during times of weakness r/t fall on 5/23/18. Revised to continuous starting 9/11/2018. R36's MDS dated [DATE], 7/10/18, and 9/13/18, under Section P, Restraints and Alarms, documents A. Bed Alarm, 0, and B. Chair alarm, 0, indicating alarm not used. The facility's policy, titled Comprehensive Assessments/Resident Assessment Instrument, reviewed on 2/5/18 documents, in part, Assessments will be completed within the guidelines outlined in the Resident Assessment Instrument (RAI) Manual, and include the Care Assessment Area (CAA) and Care Planning processes to lead to the development of a plan of care to address and monitor each resident's needs and function, and to track changes in the resident's status.

Based on record review, observation and interview, the Facility failed to provide supervision during toileting for 1 of 5 residents (R1) reviewed for falls in the sample of 15. The failure resulted in R1 sustaining a laceration to her head which required a staple, and a compression fracture of the lumbar spine. Findings include: R1's Facility form entitled "Incident Details" documents: "8/22/14 - 2:10 PM, Resident noted on the floor. Staff member ambulated resident to her bathroom, staff stepped out of bathroom to grab gloves, resident proceeded to pull her pants down to use commode and lost her balance and fell side ways then on to her bottom. Resident then noted to bump head on the corner of the sink, noted to have laceration to head, appears to be deep, area cleansed and pressure applied to area. Resident insisted on getting up and refused mechanical lift, assist resident to her wheelchair then to her bed. Resident only complaining of head hurting. Range of motion within normal limits for this resident. Orders received to send to emergency room . Paramedics arrived and resident is complaining of left side near ribs and back hurting." R1's "emergency room Care Physicians Document", dated 8/22/14, documents "Patient is an [AGE] year old female presenting to the Emergency Department complaining of a fall with injury. Patient lives in a nursing home and was being assisted to the bathroom. When the nurse aide went to grab gloves, the patient tried to pull her pants down. She pulled her pants down too far and fell . She hit her head on the sink and then fell on her left side. She is currently complaining of pain to her left mid-back. Patient denies loss of consciousness during her fall. Computer Tomography (CT) Scan Interpretation: 1. Acute mild first Lumbar Vertebrae (L1) compression fracture. Fracture may involve the posterior wall of the vertebral body, there is no apparent retropulsion or involvement of the posterior elements. Age-indeterminate superior endplate compression fracture of L1. Patient Visit Information - You were seen today for: Vertebral Compression Fracture. Staple removal from scalp in 10 days." R1 stated in an interview on 9/23/14, at 4:10 PM, that "Exactly 6 weeks ago this Friday at 1:00 PM, the Certified Nurse's Aide (CNA) went to put me on the toilet but, had not set me down on the toilet like they usually do. She forgot to get gloves so she left to get gloves. I was standing in the bathroom. While she was gone, she answered another call - I don't know how long she was gone - at least several minutes. I went to pull one side of my pants down and sit down when I fell ." E14, Licensed Practical Nurse (LPN), stated in an interview on 9/23/14 at 3:48 PM, that she was "called in after the fact", and did not see what had happened. E14 said that R1 initially just said that her head hurt but, when the Paramedics arrived, R1 complained that her back hurt too. E14 stated R1 said that the laceration to R1's head was deep but not too wide and required only 1 staple. E14 confirmed that neither the Facility or hospital documented a description of the laceration to R1's head. R1's current face sheet documents diagnoses, in part, of Parkinson's Disease, Edema, Falls and [DIAGNOSES REDACTED]. R1's Minimum Data Set (MDS), dated [DATE], documents that she requires the extensive assistance of two or more staff members physical assistance for transfers; and the extensive assistance of one staff members physical assistance for walking and toilet use. Section G of the MDS documents that R1 is not steady and only able to stabilize with human assistance for moving from a seated to standing position, walking, turning around, moving on and off the toilet and surface-to-surface transfers. R1's plan of care, dated 6/23/14, documents "Problem: I am at increased risk for falls because of my advanced Parkinson's Disease." The approaches for this Problem include the following documented interventions: "I don't always remember to wait for assistance. Escort/walk with me wherever I need to go please". R1's room and bathroom were observed on 9/24/14 at 3:40 PM. The gloves were located in a dispenser on the wall directly inside the resident room, to the left of the entry door. The entry door to R1's bathroom was 8 feet from the glove dispenser. The toilet is located 6 feet inside the bathroom.

Based on observations, interview and record review, the facility failed to provide adequate supervision, identify causative factors contributing to falls and injuries, implement interventions based on these identified hazards, and failed to monitor and modify interventions when falls and injuries continue to occur for three of five residents (R1, R3, R11) reviewed for bruises and falls in the sample of 15. This failure resulted in R3 sustaining a fractured rib and a fractured hip. Findings include: 1. R3's Electronic Face Sheet, reviewed on 12/10/2013, documented she had the following partial Diagnoses: [REDACTED]. R3's Minimum Data Set (MDS), dated [DATE], documented she had no cognitive impairment but had altered level of consciousness. R3's MDS documented she required extensive assistance from one staff person with transfers and toileting. R3's MDS documented she required limited assistance from one staff person with walking in her room. The MDS documented she was not steady, but able to stabilize without human assistance with moving from seated to standing position, walking, turning around, moving on and off toilet and surface-to-surface transfers. The MDS documented she had a history of [REDACTED]. The Facility's Incident Details from January 2013 through March 2013 documented she had fallen two times during this period. The Facility's Incident Details, dated 3/17/2013, documented R3 was found on her bathroom floor at 8:30 PM. The Details documented "Resident stated she was in the bathroom to get an (adult diaper) to attend to toileting needs, upon reaching for the (the adult diaper), the (adult diaper) fell on the floor and resident reached further to obtain (adult diaper) and fell hitting her head on the right temporal area. A hard raised bruised centered hematoma measuring 2.5 cm (centimeter) x (by) 2 cm intact." The Facility's Investigation Report, dated 3/17/13, documented the following to prevent re-occurrence "Call a work-order to have maintenance place a shelf more accessible for resident to store (adult diapers) to prevent res. (resident) from bending over (and) reaching ." R3's Care Plan was updated on this date and documented "Family will bring in shelf to place briefs in reach." The Facility's Incident Details report, dated 3/29/2013, documented R3 was found in her room on the floor at 10:35 PM. The Details documented "Heard loud clang went to investigate and found resident at the doorway lying on her left side. Resident stated she hit her head on corner of brass stand. Resident stated she was trying to shut off the light. Resident was using wheeled walker. Encourage resident to call for assistance c (with) care - family to provide age appropriate shelving." The Care Plan was not revised to address this specific fall or address progressive interventions to prevent R3 from future falls. The Facility's Incident Details report, dated 4/4/2013 at 10:45 PM documented "Was sitting on the floor next to her husband's bed, it appeared as if she slid from the edge of the bed. No apparent injury noted." The facility's Investigation Report, dated 4/4/13 documented this type of event had occurred before. The Report documented the following steps to prevent re-occurrence "non-skid socks and frequent checks." The Report documented "Informed resident to use the call light for assistance when getting up." R3's Care Plan was revised on 4/5/13. The Care Plan documented "I slid out of bed when trying to get to get walker. Place walker at bedside." The facility did not provide any documentation regarding what type of supervision and how frequently staff should supervise R3 to prevent her from independent ambulation. The Facility's Incident Details report, dated 4/20/2013 at 12:15 PM documented "Care giver went to room to get resident for lunch, resident was sitting on floor by dresser, resident said she was rearranging items in dresser and lost her balance and bumped forehead on dresser drawer." The report documented "Spoke to resident, resident denies pain or discomfort. Encouraged resident to sit in chair when re-arranging dresser drawers. Team met to review fall assessment. Resident has Parkinson's Disease. Family signed a wavier to allow resident unlimited ambulation without supervision. Therapy will eval (evaluate) and treat." The Investigation Report documented "Instructed resident to use call light for help, check on resident frequently." The facility did not provide any documentation regarding what type of supervision and how frequently staff should supervise R3 to prevent her from independent ambulation. R3's Minimum Data Set (MDS), dated [DATE], documented she had no cognitive impairment but had altered level of consciousness. R3's MDS documented she required extensive assistance from one staff person with transfers and toileting. R3's MDS documented she required limited assistance from one staff person with walking in her room. The MDS documented she was not steady, but able to stabilize without human assistance with moving from seated to standing position, walking, turning around, moving on and off toilet and surface-to-surface transfers. The MDS documented she had a history of [REDACTED]. The facility's Reportable Event Form, dated 5/29/2013, documented on 5/25/2013, R3 was found on the floor in her room. The Form documented "Call to room by husband. This resident was lying on floor with her face against the foot of the overbed table. Resident was reaching over the over-the-bed table attempting to plug in cell phone. Overbed table roll and resident landed on the floor. To (local hospital). Transferred to (another hospital). Dx (Diagnosis) closed fx (fracture) of R (Right) 8th rib." On 5/25/2013, the facility revised R3's care plan documenting R3's over-the-bed table would be removed. There was no documentation in R3's medical record indicating the facility had reassessed her for what type of supervision and how frequently staff should supervise R3 to prevent her from future falls in her room. R3's MDS, dated [DATE], documented she had a score of 7 (severely cognitively impaired) on the BIMS (Brief Interview for Mental Status). R3's MDS documented she required extensive assistance one one staff person for transfers, ambulation and toileting. The MDS documented she was not steady, only able to stabilize with human assistance for moving from seated to standing position, walking, turning around, moving on and off toilet and surface-to-surface transfers. The Facility's Incident Details report, dated 7/14/2013, documented at 7:05 PM "Resident was found sitting on the floor next to husbands bed. She states that she did hit her head on the bed when she fell down. No witness present during time of incident but resident sates that she was trying to back up when husband was coming into the room and shutting the bathroom door to get through and she fell backwards." The Facility Investigation Report, dated 7/14/2013 documented "Frequent monitoring (and) encourage her to ask for help and not get up by herself." The Care Plan, dated 7/14/13, documented "staff to escort resident to room after supper." The Facility's Incident Details report, dated 8/1/2013, documented at 11:00 AM she fell in her bathroom. The Report documented " 11:00 AM reported to nurse that resident was observed in the bathroom, knees in contact with floor. Resident denies hitting head. Resident stated she was attempting to get something out her plastic cupboard located in the bathroom by the toilet." Details of Corrective Measures, Taken by Facility, dated 8/1/2013 documented "Spoke to staff and resident. Resident stated that she toileted self and while on toilet, she slid off when reaching into drawer of plastic cupboard. Team met to review fall risk assessment. It was determined that plastic cupboard would be turned sideways to allow easy access to drawers from toilet. Resident agreed." There was no documentation in R3's medical record documenting how and how often the staff should supervise R3 to prevent her from falling in her room. The Facility's Incident Details report, dated 8/9/2013, documented at 7:15 PM R3 was found on the floor in her bathroom. The Report documented "This nurse heard a thug and this nurse to resident's room and found resident sitting on her buttocks in her bathroom in the shower stall, resident assessed for injury and a abrasion to bridge of nose noted and measured 0.5 cm linear in length. Small raised hematoma to the front aspect to the forehead with no break in skin." The Report documented "Risk team to review fall assessment and do investigation. Resident stated that she went to room after supper to do personal care in prep for hs (bedtime). She stated she reached to far and slipped from wc (wheelchair). Explained use of dyceom and resident agreed. Explained importance of leaving dyceom in place and not removing and resident agreed. Will place non- woven dyceom under wc cushion in attempt to prevent sliding." The Facility Investigation documented "Safety education with using call lights for assistance - Assist resident with toileting and changing clothes after meals." The Facility's Incident Details report, dated 8/14/2013, documented at 2:00 PM she was found in her bathroom on the floor. The Incident Details report documented "Resident's husband yelled for help, went to room found resident sitting on bathroom floor, noted abrasion above right eye area, approx (approximately) 2 cm x 2 cm. Resident stated she was trying to get toilet paper, noted no toilet paper on roll." The Details of Corrective Measures Taken by Facility documented "Spoke to resident and husband. Resident stated she was leaning on her wheeled walker, reaching down to put an extra roll of toilet paper on top off the paper of the roll. Team met to review fall assessment and will keeps extra paper in residents reach." The Investigation Report, dated 8/14/2013 documented what steps had been taken to prevent re-occurrence as "monitor resident when going to room." The Report documented "put toilet paper on roll for resident." Again, the facility had no documentation regarding if they assess how and how often staff would supervise R3 to prevent her from future falls. The Facility's Incident Details report, dated 8/27/2013, documented at 3:30 PM R3 was found on the floor in her room. The Report documented "Call to room by Care-giver, noted resident on floor on bottom, noted abrasion over left eye 1.3 cm and hematoma to left forehead, phone was ringing, daughter on phone, she said she was trying to call her mother, notified her of her mother falling while trying to answer the phone., no complaint of pain, moved extremities with no difficulty. Hematoma proxy. (approximately) 3 cm." The details of Corrective Measures taken by Facility documented "Spoke to resident. Resident stated ' I was sitting in chair beside husbands bed and he was lying in his bed. The phone began to ring, when I got up to answer phone, I was hurrying and fell .'' Resident admits to not using wc. Spoke to daughter. Daughter continues to refuse use of wc and bed alarms. Environmental assessment completed. Team met to review fall assessment. Decided to place safety awareness signage around room." Again, the facility had no documentation regarding if they assess how and how often staff would supervise R3 to prevent her from future falls. The Facility's Incident Details report, dated 8/31/2013, documented at 12:40 PM R3 was found on the floor in her room. The Report documented "Heard resident call out. Arrived at room to find resident lying on her left side of floor. Noted right hip shorter. Complaints of pain in right hip. Tylenol 650 mg (milligrams) po (by mouth.)" The Report documented she was sent to the hospital and diagnosed with [REDACTED]. On 12/10/13, at 9:10 AM, during the initial tour of the facility, R3 was seated in a tiltback wheelchair in the dining room. R3 was crying. At 9:10 AM, an interview was conducted with E3, Neighborhood Nurse Coordinator (NNC)/ Registered Nurse (RN) . E3 stated R3 was confused and had fallen and sustained a fractured hip. On 12/10/2013, at 11:20 AM, R3 was seated in her wheelchair. R3 was very confused and was continually asking someone to please remove the puppy next to her wheelchair. There was no puppy next to her wheelchair. At 12:51 PM, R3 was seated in her wheelchair in the dining room. R3 pushed up from the arms of her wheelchair and stood multiple times. No staff attempted to assisted or supervise R3. At 12:56 PM, E15, Registered Nurse asked resident what she was doing. R3 continued to attempted to stand without assistance. On 12/11/2013, at 8:23 AM, R3 was seated in her wheelchair in the common area. R3 was seated at the edge of her wheelchair seat with her right leg hanging over the side of the right leg rest. R3 was crying out for help. There were no staff present at this time. At 8:40 AM, E16 and E17, Certified Nurse's Assistants (CNAs), transferred R3 onto the couch and assisted R3 into the lying position. E15 and E16 left the area. R3 began leaning off the side of the couch reaching for items on the floor which were not there. AT 9:02 AM, R3 sat up independently, scooted to the end of the couch seat and leaned forward and placed her hands on the floor. R3 stated "Feel these. Feel these." R3 attempted to stand independently. There were no staff present. At 9:05 AM , E17 and E18 (CNA), assisted R3 back into her wheelchair. On 12/13/2013, 9:00 AM, an interview was conducted with E2, Director of Nurse's (DON). E2 stated R3 had a long history of falls and was at high risk for falls. E2 stated the family wanted to keep her as independent as possible and had refused alarms. E2 stated the facility had requested the family sign a waiver due to this refusal. E2 stated the facility had implemented 15 minute checks for R3 over a year prior. However, the family did not want the facility to check on R3 frequently because this upset her (R3) . The Facility's Fall Prevention and Management Program, dated 8/13/2012, documents "The interdisciplinary team will develop a plan for services to improve or maintain the resident's standing and sitting balance and other interventions to reduce the resident's risk for falls. The plan will include specific information about the resident's routine and personal habits that may place the resident at risk for falls such as night time voiding, night time wandering. The plan will also identify the level of over-sight required to support both resident safety and autonomy including recommendations for monitoring when alone or in a bathroom. 2. R1's Electronic Face Sheet, reviewed on 12/10/2013, documented R1 had a partial [DIAGNOSES REDACTED]. The Facility's Incident Details Report, dated 6/10/2013, documented he was found on the floor in another resident's room in the bathroom. The Report documented R1 sustained no injuries from this fall. R1's Care Plan was revised on 6/10/2013 and documented "Found on floor in 501 trying to self toilet. Staff will toilet resident before and after meals." R1's MDS dated [DATE] documented he had a score of 1 (severe cognitive impairment) on the BIMS. The MDS documented he required extensive assistance of two staff persons for toileting and transfers. The Facility's Incident Details Report, dated 9/30/2013, documented "Resident placed on commode by this nurse, gave resident call light and instructed resident to pull light. I waited outside the door in the common area, resident placed on light, CNA (E18) went in resident told her he was not finished. A couple mins (minutes) later heard movement in restroom, CNA went into bathroom, resident on the floor in front of commode, alert to person and place, abrasion to right buttock with small amount of notable blood." R1's Care Plan revised on 9/30/2013 documented "fell while self transferring from toilet. Restorative transfer training." The Facility's Details Report,dated 10/24/2013 documented "Resident found sitting on his buttock in front of his wheelchair in the bathroom of 508. Resident asked what he was doing and he stated trying to go to the bathroom. Resident was noted to be seen in the commons area sitting in his wheelchair minutes prior to the fall." The Incident Report documented the incident occurred at 7:15 PM. The "Details of Corrective Measures Taken by Facility" documented "Spoke to resident. Resident stated 'I gotta pee.' RE-educated staff on the importance of toileting resident frequently which includes before and after meals." The Care Plan revised on 10/27/2013 documented "Found on floor in bathroom. Re-educate staff to toilet before and after meals and frequently." On 12/12/2013, an interview was conducted with E2 (DON). She stated staff should not leave R1 alone on the toilet due to his history of falls. 3. During tour of the facility on 12/10/2013, with E3, Registered Nurse (RN)/Care Plan Coordinator, at 9:00 AM, R11 was asleep in the living area in a recliner. Multiple dark purple bruises were on both hands. E3 was interviewed as to the cause of the bruises. E3 stated at that time, "He (R11) has had no recent falls. The bruises are caused from his watch." On 12/11/2013, at 3:25 PM, R11 had a gauze dressing to his right forearm and numerous dark purple bruises to both forearms and the top of both hands. R11 was propelling himself down the hall in a wheelchair. A metal watch with an expandable wrist band was on R11's left wrist. On 12/11/2013, R11's Care Plan, dated 10/02/2013, was reviewed. The Care Plan fails to address R11's bruises, the causes of the bruising or any interventions related to the prevention of further bruising. The physician's orders [REDACTED]. The Incident Details Report, assessed on 12/11/2013, at 5:49 PM, documents R11 had a self inflicted skin tear on 12/08/13 at 10:30 AM to his right forearm and a bruise to the back of his right hand. The Report has a late entry on 12/11/2013, at 5:47 PM, for 12/08/13 documenting R11 reported he was removing the watch from his right arm and a 3 cm (centimeter) X 3 cm skin tear with flap intact was noted. The late entry on 12/11/2013, at 7:28 PM, documents, "Watch inspected-noted to have visible blood. Resident (R11) immediately requested watch returned, and resident placed watch on left arm. Skin tear to right arm". The Report further documents on 12/11/13, at 8:42 PM, "Noted bruise to right hand. Related to struggle with removal of watch on 12/08/13. Daughter made aware and requested to bring in new watch, due to separation of expandable metal band." On 12/12/2013, at 10:05 AM, E2, Director of Nursing (DON) was interviewed about the cause of R11's multiple bruises to both arms and hands. E2 stated, "We know the origin of the bruises. We didn't do such a great job of documenting it. (R11's) daughter was here 12/08/2013, and was there when he obtained a skin tear. A blood draw to his left hand on 12/09/13 caused the bruise to the top of his left hand. We didn't fill out an incident report related to the blood draw because they know where it came from. Everybody knows where the bruises come from, but there is no documentation. We can't prove it. It is what it is." E2 reported the bruises had not been addressed in R11's clinical record until they were focused on by the surveyor. The facility's policy and procedure, entitled, 'Resident Injuries of Unknown Origin' dated, 11/19/2012, documents, in part, "Residents will be screened for possible abuse as a result of serious injuries and injuries of unknown origin. The nurse notified of the injury will assess the situation and take the appropriate action. 1. Conduct an interview with the resident and complete a physical assessment to identify possible changes and causes. 2. The Nurse will complete and incident report."