Every finding on record at Metro West Nursing and Rehab Center

Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures for medication administration were sustained. Findings:A review of the facility's QAPI plan revised October 2024, stated for their purpose, that it provided guidance for their overall quality improvement program and that the Administrator would ensure that the QAPI plan was reviewed minimally on an annual basis by the QAA committee and conduct at least one distinct performance improvement project annually. Ongoing revisions would be made to the plan, as the need arose, to reflect current practices within the center. The revisions would be made by the QAA committee.Their QAPI plan included the policies and procedures used to Identify and use Data to monitor our performance Establish goals and thresholds for our performance measurement Utilize resident, staff and family input Identify and prioritize problems and opportunities for improvement Systematically analyze underlying causes of systematic problems and adverse events Develop corrective action or performance improvement activitiesThe QAA committee will review data and input monthly to look for potential topics for Performance Improvement Projects (PIPs). The QAA will prioritize topics based on the current needs of the residents. Priority will be given to areas we define as high-risk to residents and staff, high prevalence, or high-volume areas, and areas that are problem prone.The facility had deficiency cited at F755 for pharmacy services and F842 for accuracy of medical records during the previous recertification survey conducted 2/22/24. During the current survey, the facility was found to be in noncompliance with F 755 and F 842. As a result of the repeat deficiency, it was identified there was insufficient auditing and oversight to prevent the citation.On 8/28/25 at 5:50 PM, the Nursing Home Administrator (NHA), the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) explained the facility had two PIPS which they were actively working on, Elopement and the use of Mechanical Lifts. The NHA explained she did not know what to say about the repeat concerns but there were changes in leadership with Unit Managers, the facility did a lot of cleanup and there was high turnover for staff which was their biggest issue. The NHA continued to explain they needed strong competent staff but also needed the leadership team to keep on top of things. The NHA explained she thought the issue would have decreased, or maybe at one time, it just dropped off. The RNC mentioned that the issues identified were not the same, however they all acknowledged that the QAPI process is supposed to outlive the staff and it should have lasted but did not.

Based on observation, interview, and record review, the facility failed to promote a dignified existence during dining for cognitively impaired residents in the special-focus dining area and failed to maintain dignity for one resident during transport through facility hallway, (#104), of a total sample of 43 residents.Findings: 1. Resident #123 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including aphasia (loss of speech), hemiplegia and hemiparesis (partial paralysis) following cerebral infarction affecting right dominant side, dysphagia (trouble swallowing) and unspecified dementia. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 8/26/25 revealed resident #123 had a Brief Interview for Mental Status (BIMS) score of 9/15 which indicated she had moderate cognitive impairment. The assessment indicated resident #123 required supervision or touching assistance for eating. 2. Resident #76 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, congestive heart failure, chronic kidney disease, anxiety disorder, dysphagia and unspecified dementia. Review of the MDS 5-Day Medicare assessment with ARD of 8/26/25 revealed resident #76 had a BIMS score of 5/15 which indicated she had severe cognitive impairment. The assessment revealed resident #76 required partial to moderate assistance for eating. 3. Resident #9 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, essential hypertension, and atherosclerotic heart disease. Review of the MDS quarterly assessment with ARD of 7/29/25 revealed resident #9 had long-term and short-term memory problems and had severely impaired cognitive skills for daily decision making. The assessment indicated resident #9 required supervision or touching assistance for eating. 4. Resident #11 was admitted to the facility on [DATE] with diagnoses including dementia, dysphagia, hemiplegia and essential hypertension. Review of the MDS quarterly assessment with ARD of 6/26/25 revealed resident #11 had a BIMS score of 1/15 which indicated she had severe cognitive impairment. The assessment detailed resident #11 required set up or clean-up assistance for eating. 5. Resident #89 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, type 2 diabetes, acute kidney failure and heart failure. Review of the MDS significant change in status assessment with ARD of 6/27/25 revealed resident #89 had a BIMS score of 00/15 which indicated she had severe cognitive impairment. The assessment described resident #89 required substantial to maximal assistance for eating. On 8/25/25 at 12:35 PM, during meal observation in the special-focus dining area on the 100 unit, 17 residents were observed seated at tables in the area. Staff were observed serving meals to the residents. Meal trays were placed in front of each resident. The plates, cups, bowls and eating utensils remained on the tray and were not removed from the tray at the table. During the observation, it was noted that all residents at one table were not served at the same time. One tray was placed on a table between two residents which allowed resident #123 to remove items from the tray which belonged to resident #76. Resident #9 sat at the same table and began to eat with her fingers without staff intervention. At another table, resident #11 gave a drink from her tray to resident #89 who took the cup, drank a few sips from it and gave it back to resident #11. On 8/27/25 at 12:14 PM, during meal observation in the special focus dining area, resident #9 was observed eating lunch with the silverware still wrapped while Licensed Practical Nurse L assisted setting up a meal tray for resident #76, sitting at the same table. Resident #9 took several bites of the meal using the wrapped silverware. On 8/28/25 at 12:25 PM, 12 residents were observed seated in the special-focus dining area. Each resident had a meal tray in front of them with their meal, dinnerware and eating utensils on the tray. On 8/28/25 at 12:31 PM, the restorative certified nursing assistant (CNA) verified residents were usually served on a tray instead of the items being placed on the table. She explained they tried taking the items off the tray, but explained the residents were cognitively impaired and might get items confused. The CNA was not sure if a placemat would work to delineate each resident's meal but did not recall having used them before. On 8/28/25 at 1:41 PM, the Unit Manager for the 100 Wing stated the dining room was usually monitored by nurses and/or CNAs. She explained that the restorative CNA sometimes came to help as well. The Unit Manager stated she went to the dining room during lunch if there was no meeting. She verified she was in the dining area on 8/25/25 and acknowledged the residents were served on trays instead of placing the items on the table for a more home-like environment. 6. Resident #104 was admitted to the facility on [DATE] with diagnoses including other toxic encephalopathy (brain disorder), type 2 diabetes, congestive heart failure and cardiomyopathy. Review of the MDS quarterly assessment with ARD of 7/18/25 revealed resident #104 had a BIMS score of 4/15 which indicated she had severe cognitive impairment. The assessment detailed resident #104 was dependent on staff for transfer and mobility. On 8/25/25 at 2:53 PM, resident #110 was positioned in a reclined geri-chair. CNA N pulled the reclined geri-chair backwards (with the resident facing backwards) from the day room, down the hallway and entered the shower room. CNA N exited the shower room at 2:58 PM, with resident #110 again in the geri-chair. The CNA continued to pull the reclined geri-chair behind him, backwards down the hallway as they returned to the dayroom. On 8/28/25 at 10:15 AM, resident #110 was again in a reclined geri-chair as CNA O pulled the reclined geri-chair behind them, backwards down the hallway and into the resident's room. At 10:23 AM, CNA O exited the room with resident #110 and pulled the reclined geri-chair backwards down the hallway and entered the dayroom. On 8/28/25 at 10:25 AM, CNA O stated she was assigned to the special-focus dayroom. She acknowledged she was not supposed to pull the Geri-chair backwards when a resident was seated in it. CNA O was unable to explain why she had pulled the resident in the geri-chair backwards if she knew she was not supposed to. On 8/28/25 at 2:31 PM, the Administrator acknowledged residents in the special-focus dining room should have their meals removed from trays. She confirmed resident #104 should not have been pulled backwards down the hall in the reclined geri-chair. She stated her expectation was that staff treated all residents with the same level of dignity. The facility policy and procedure for Resident Dignity and Personal Privacy effective April 2024 indicated the purpose was to provide care for residents in a manner that respected and enhanced each resident's dignity, individuality and right to personal privacy. The document defined dignity as when staff carried out activities that assisted the resident in maintaining and enhancing his or her self-esteem and self-worth. The document specifically indicated that wheelchairs and geri-chairs were to be rolled in a forward direction.

Based on observation, interview, and record review, the facility failed to maintain oxygen flow rates as ordered by the physician for 1 of 2 residents reviewed for respiratory care, of a total sample of 43 residents, (#111).Findings:Review of the medical record revealed resident #111 was admitted to the facility on [DATE] from the hospital. Her diagnoses included chronic obstructive pulmonary disease, unspecified atrial fibrillation, altered mental status and chronic kidney disease. Review of the quarterly Minimum Data Set assessment with reference date 8/16/25 revealed resident #111's cognition was severely impaired. Resident #111's Order Summary Report showed an active physician's order for oxygen (O2) at 2 liters per minute (LPM) via nasal cannula dated 4/12/25. The medical record further revealed a care plan initiated on 2/29/24 that indicated the resident was to be administered oxygen via nasal cannula as ordered by the physician. The care plan did not indicate resident #111 had any behaviors of refusals nor adjusting the amount of oxygen as ordered. On 8/25/25 at 2:58 PM, resident #111 was sitting up in bed, using O2 administered through a nasal cannula connected to an O2 concentrator. The concentrator's flow rate was set at 3 LPM of O2. The assigned nurse, Licensed Practical Nurse (LPN) D, was standing nearby and verified resident #111's oxygen concentrator was set at 3 LPM. LPN D the concentrator flow rate was correct and should be 3 LPM of O2. A few moments later LPN D verified the physician's order in the medical record was actually for 2 LPM, not 3. The nurse acknowledged she should have verified the physician's order. The Staff Development Coordinator (SDC) who was in the immediate area, stated that the assigned nurse was a new nurse and that this was not her normal unit, she only floated here to take over an assignment from a nurse who called out sick, but she should have checked the orders. A few minutes later, the Director of Nursing (DON) who had been made aware of the situation, said nurses should always verify the orders. On 8/28/25 at 10:37 AM, the SDC said her expectation was for nurses to check and verify the physician's orders for oxygen at least once during the shift. The Facility's Policy for Oxygen Administration revised August 2023 indicated the procedure for setting up the O2 concentrator in section 2. The procedure directed staff to Turn to proper flow rate as ordered by the physician.

Based on interview, and record review, the facility failed to administer blood pressure medication according to physician ordered parameters for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 43 residents, (#89).Findings: Resident #89 was admitted to the facility on [DATE] with diagnoses including nonrheumatic mitral valve insufficiency, heart failure, essential hypertension and personal history of transient ischemic attack and cerebral infarction (stroke). Review of the Minimum Data Set (MDS) significant change assessment with assessment reference date (ARD) of 6/07/25 revealed resident #89's active diagnoses included anemia, heart failure and hypertension. Review of the electronic medical record (EMR) revealed resident #89 had a physician order for Amlodipine Besylate 10 milligrams (mg) to be given one time a day for hypertension. The order included parameters to hold the medication if resident #89's systolic blood pressure was below 110 millimeters of mercury (mmHg), diastolic blood pressure was below 60 mmHg or her heart rate was less than 60 beats per minute (bpm). The record also contained an order for Lisinopril Oral Tablet 20 mg to be given one time a day for hypertension. The order included parameters to hold the medication if resident #89's systolic blood pressure was below 110 mmHg, diastolic blood pressure was below 60 mmHg or her heart rate was less than 60 bpm. Review of the Medication Administration Record (MAR) for July 2025 and August 2025, revealed over a 59-day period in facility, four nurses administered both blood pressure medicine to resident #89 outside of specified parameters and one nurse administered blood pressure medication without consideration of parameters. Documentation showed resident #89 received blood pressure medications 11 times on 6 days. The medications were administered on 7/05/25 with a blood pressure of 123/56, on 7/06/25 with a blood pressure of 100/73, on 7/20/25 with a blood pressure 112/44, on 8/12/25 with a blood pressure of 108/51, on 8/18/25 with a blood pressure of 108/38 and on 8/22/25 with a blood pressure of 101/70. Resident #89 also received blood pressure medications 11 times with a blood pressure listed as not applicable (N/A) on 7/7/25, 7/12/25, 7/21/25, 7/26/25, 7/27/25, 8/04/25, 8/09/25, 8/10/25, 8/18/25, 8/23/25 and 8/24/25. Review of Progress Notes for July 2025 and August 2025 revealed no associated documentation for the above dates to explain why the blood pressure medications were given outside of the physician ordered parameters. On 8/28/25 at 2:01 PM, Registered Nurse (RN) P explained Amlodipine and Lisinopril were medications used to lower blood pressure. She reviewed resident #89's MAR for July 2025 and August 2025 and acknowledged she gave medications outside of the physician ordered parameters. RN P stated she rechecked resident #89's blood pressure before administering medication but was unable to show documentation that this had been done or of any new blood pressure results. She acknowledged that without the additional blood pressure reading, the MAR indicated the medication was administered outside of parameters. RN P explained that administering blood pressure medications to lower blood pressure when blood pressure was already low could cause a resident's heart rate to drop lower and the resident could become unresponsive. On 8/28/25 at 2:37 PM, the Director of Nursing (DON) reviewed the physician orders and MAR for resident #89. She acknowledged resident #89's blood pressure medications were given by nurses outside of physician ordered parameters. The DON stated her expectation was for staff to follow parameters ordered by the physician for medications.

Based on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for 2 of 2 residents reviewed for discharge, (#127 and #126); and for 1 of 2 residents reviewed for hemodialysis, (# 100), of a total sample 43 residents.Findings: 1. Resident #127 was admitted to the facility on [DATE] and discharged to the hospital on 7/11/25. His diagnoses included syncope and collapse, cerebral cysts, dementia, anxiety and seizures. A review of the Discharge Return Anticipated Minimum Data Set (MDS) assessment with assessment reference date 7/11/25 revealed resident #127 had a Brief Interview for Mental Status Score of 9/15 which meant his cognition was moderately impaired. On 8/26/25 at 3:56 PM, the Director of Nursing (DON) explained the Change in Condition (CIC) form in resident #127's record dated 7/12/25 at 7:00 AM. According to the CIC form, it indicated the resident was discharged to the hospital on 7/12/25 for low oxygen however, on the census line in resident #127's electronic medical record it showed the resident was discharged the day before, on 7/11/25. The vital signs documented on the CIC form indicated they were from 7/10/25 at 9:26 PM and revealed the blood pressure was 128/76, pulse 68, respirations 18 and oxygen 97% SpO2 (blood oxygen saturation level). There was no indication from documentation in the medical record that resident #127 had a low percentage of oxygen saturation which caused him to be sent to the hospital as the CIC form detailed. The DON said she understood the form was unclear and stated she would try to gather as much information as she could because she was not on duty on 7/11/25. A few minutes later, the DON referred to her own notebook of residents discharged to the hospital, and said resident #127 was discharged on 7/11/25 and was noted to have a low oxygen saturation rate in the 70s and generalized weakness. She said the physician was called, and the resident was given oxygen, and the saturation level went up to 97%. She gave the vital signs that mirrored the vital signs documented in the CIC form. The DON confirmed the date on the CIC form was not accurate and did not provide a true description of what occurred with the resident. She confirmed the nurse should have documented the actual vital signs on the CIC form, written a progress note about the event and documented the findings accurately. SpO2 measures how much oxygen is circulating in your bloodstream for use by your cells. This can be measured with a pulse oximeter which is placed on your finger and gives a percentage of oxygen saturation in your blood. The normal percentage range for oxygen saturation is 90-100%, if it is low, you should call your physician, (retrieved on 9/12/25 from www.clevelandclinic.org). On 8/26/25 at 4:37 PM, in a joint interview with the DON, the Assistant DON (ADON), who was on duty on 7/11/25, the Unit 1 Manager (UM 1), and the Regional Nurse Consultant (RNC); the ADON explained that on 7/11/25 at approximately 8:30 AM he was summoned to resident #127’s room for help because the resident was diaphoretic and unarousable. The ADON said he immediately called a rapid response for help. He recalled he provided oxygen to the resident because “his oxygen was in the 70s and his blood pressure was low maybe 90/60.” The ADON continued that resident #127 ’s status improved, the oxygen level came up, and he became more alert, however, his wife insisted he should go to the hospital, so she called 911. The ADON remembered that the Emergency Medical Technicians arrived and said resident #127 was stable, but his wife asked for him to be transferred. The ADON explained he expected the assigned nurse to document the CIC form completely and accurately in the medical record when changes in condition occurred. The Unit 1 UM confirmed she actually documented the CIC form on 7/12/25 after the event as a late entry, even though she was not present when it happened. The Unit one Manager did not reply as to whether this was facility procedure to have someone document an event that had no actual knowledge of the event other than what they heard from someone else. The UM looked at the ADON, who shrugged and said, “I see.” The UM reviewed the transfer form on which she documented resident #127 was transferred to the hospital on 7/12/25 at 7:00 AM and did not reply as to whether the documentation concerning the transfer was inaccurate. The ADON was unsure who the actual nurse that was responsible to document about resident #127’s CIC when it occurred but thought it might be the Unit 2 UM. A few minutes later, the Unit 2 UM joined the interview and denied she assumed care of the resident and said she did not remember anything about the resident. The Unit 2 UM stated she believed the resident had already left the facility when she came on duty that morning, because she was called in to work due to a call out. The DON and RNC agreed that because of the inaccuracies and lack of documentation it appeared that no nurse was assigned to resident #126, but said it was “impossible.” They said they needed to review the employees' timecards to find out who the actual assigned nurse when the CIC occurred was that should have documented the actual details of the event. On 8/27/25 at 10:50 AM, the Business Office Manager stated that based on her records, resident #127 was admitted on [DATE] at 3:29 PM, and discharged on 7/11/25 at 10:00 AM. On 8/27/25 at 11:25 AM, the Staffing Coordinator provided the names of the nurses who worked on the morning shift of 7/11/25; Licensed Practical Nurse (LPN) Q and LPN R. On 8/27/25 at 11:30 AM, Certified Nursing Assistant (CNA) N confirmed he worked on 7/11/25. He confirmed LPN R was assigned to resident #127 the day he was re-hospitalized . On 8/27/25 at 11:57 AM, the Unit 1 UM recalled she was at the facility on 7/11/25 but was not working on Unit 1. She said she was not involved with the rapid response for resident #127. She explained as the UM she took it upon herself to document the CIC form two days after it happened when the Interdisciplinary Team later realized that both the CIC form and the transfer to hospital form were not completed by the nurse. She acknowledged both forms were inaccurate and did not give a clear description of what transpired. The UM confirmed she should have asked the assigned LPN R to complete the CIC form when she learned it had not been done. Phone calls were made to LPN R resident #127’s assigned nurse, with no reply. On 8/27/25 at 2:56 PM, the ADON said he did not verify documentation was completed because he expected the assigned nurse to document the CIC and transfer form. The ADON acknowledged in hindsight, he should have documented what occurred himself as he was present. He explained he left for vacation the next day and did not return to the facility until 7/21/25. When he came back, he realized the forms had been completed. The ADON said he spoke to the physician about resident #127’s CIC but acknowledged the conversation was not documented. He repeated that the expectation was for the assigned nurse to complete the CIC and hospital transfer form. On 8/27/25 at 3:36 PM, LPN Q in a telephone interview said she remembered a little of what happened that day but was unsure if LPN R was assigned to resident #127. She said she heard an overhead page for a rapid response and assisted LPN R and the ADON. LPN Q explained since it was an emergency, they all were busy and worked together to help the resident. She did not recall the details of who did what and did not remember documenting any of the events. The nurse explained that because it was an emergency, they might have written down the vital signs on a glove or a piece of paper and it could have been lost since they were documented in the medical record. She was unsure who followed up with the paperwork because they were waiting on a nurse to come in that day. LPN Q explained she thought whoever came in should have documented or the assigned nurse. “When it’s your resident, you chart, in this building it’s the assigned nurse who should do the charting.” On 8/27/25 at 4:00 PM, the Nursing Home Administrator, the Medical Director, DON, RNC, and [NAME] President of Operations acknowledged the inaccuracies and incompleteness of resident #127’s medical record and CIC documentation. 2. Resident # 100 was admitted to the facility on [DATE] with diagnoses that included language deficits following cerebral infarction (stroke), encephalopathy (brain disorder) and dependence on renal dialysis. The admission MDS with reference date of 6/02/25 revealed resident #100 had severe cognitive impairment and received hemodialysis. Review of the medical record revealed physician’s orders for resident #14’s dialysis center on Mondays, Wednesdays, and Fridays; dialysis arteriovenous (AV) fistula: Left Arm; and no blood pressure (BP) in the left arm. An AV fistula or dialysis fistula is a connection made between an artery and a vein for hemodialysis access created by a surgeon. It is the most efficient was to access your bloodstream. It takes at least a few months for the fistula to heal in order to utilize for hemodialysis, it can last for several years but should be protected from squeezing of the arm, (retrieved on 9/12/25 from www.clevelandclinic.org). The medical record revealed nurses documented taking the resident’s blood pressure on the left arm when there were specific orders not to use this arm because of the dialysis fistula. A review of the vital signs documented for August 2025 revealed out of a total of 98 times the blood pressure was taken, nurses documented the blood pressure was taken on the left arm 37 times; right arm 28 times; and “other,” 33 times. For the month of July 2025, out of a total of 121 times the blood pressure was taken, nurses documented the blood pressure on the left arm 24 times; on the right arm 58 times, and “other,” 39 times. For June 2025, out of a total of 121 times the blood pressure was taken, nurses documented the blood pressure was taken on the left arm 54 times; the right arm 37 times and “other,” 30 times. On 8/28/25 at 10:05 AM, resident # 100’s assigned nurse, LPN E explained she took the blood pressure on the right arm because of the fistula on the resident’s left arm. The Assistant Director of Nursing (ADON) present at the time, and LPN E verified in the medical record that different nurses documented the blood pressure was taken on the left arm. They both explained it was data entry error, and that the documentation was inaccurate. On 8/28/25 at 12:25 PM, in a joint interview, the ADON and DON acknowledged no weights were listed in the medical record after 6/23/25 for resident #100. The DON stated that the Restorative CNA and Dietician had resident weights, but acknowledged they were not entered in the medical record. On 8/28/25 at 1:45 PM, the DON said she was aware nurses’ documentation was inaccurate in regard to where the blood pressure was taken. She acknowledged it was contraindicated to take the blood pressure on the arm that had the AV fistula and it should be avoided. The facility had no policy on accuracy of documentation of medical records. 3. Resident #126 was admitted to the facility from the community on 6/20/25 with diagnoses including fracture of shaft of right tibia, fracture of left ring finger, paroxysmal atrial fibrillation and major depressive disorder. Review of facility incident reporting dated 7/31/25 revealed documentation from staff who interacted with the resident the night before his change in condition on 7/25/25. Per the incident report the evening shift staff on 7/24/25 noted the resident to be out of breath and sweating. The facility's report detailed that the nurse assessed the resident, obtained vital signs and administered a Covid-19 test. The facility reported the resident’s vital signs were within normal limits, his Covid-19 test was negative, and the resident had no further concerns throughout the night. A review of resident #126’s electronic medical record (EMAR) revealed a physician order to administer the Covid-19 testing as needed with a start date of 6/30/25. Review of the EMAR revealed the test was not documented as administered during the resident’s entire stay at the facility. A review of the residents’ progress notes revealed no documentation of the facility reported shortness of breath or of the Covid-19 test. Further facility incident reporting dated 7/29/25 included steps immediately taken by the facility in response to the incident on 7/25/25 during the day shift. This included resident #126 was dizzy and felt like he had a fever. They reported the resident's vital signs were taken at 8:55 AM, blood pressure of 102/89, pulse 124 beats per minute (bpm), temperature of 97.3 degrees Fahrenheit (F), respirations of 18, oxygen saturation of 91% SpO2. The facility detailed a Covid-19 test was administered which was negative. Review of the resident’s medical record revealed vital signs taken on 7/25/25 at 8:54 AM as blood pressure of 110/88, temperature of 97.5 degrees F, pulse of 92 bpm, respirations of 18, and oxygen saturation of 97% SpO2 on room air. Vital signs documented at 9:42 AM, were blood pressure of 102/89, pulse 124 bpm with new irregular onset, temperature of 97.3 degrees F, oxygen saturation of 91% SpO2 by nasal cannula. No respirations were documented at this time. The medical record revealed no documentation of a Covid-19 test being administered on 7/25/25. Facility submitted incident reporting documentation dated 7/29/25 revealed the changes reported on the CIC evaluation were a functional decline and possible stroke/new neurological signs/symptoms. The reported positive findings included increased confusion, sleepy but easily arousable, decreased mobility, abnormal speech, and a question of right eye droop. The report detailed resident #126's smile was normal; his tongue midline and grasp strength was normal. The resident was noted to have low blood pressure (hypotensive), a high heart rate (tachycardic), diaphoretic (sweaty) and to have mild shortness of breath. The report indicated the physician was notified and gave an order for supplemental oxygen at 3 liters per minute. The document revealed a repeat oxygen saturation was taken, which was 96% SpO2 (normal), the shortness of breath had improved however the resident was still tachycardic and hypotensive. The facility noted the physician gave an order to send the resident to the emergency room for further evaluation and treatment. A review of resident #126's medical record revealed a CIC form dated 7/25/25 at 9:32 AM, which indicated the change in condition symptoms were functional decline and/or mobility and possible stroke/new neurological signs which started on 7/25/25 in the morning. The form listed the most recent vital signs taken after the change in condition to be a blood pressure of 110/88, pulse of 92 bpm, respirations of 18, temperature of 97.5 degrees F and oxygen saturation of 97% SpO2 on room air at 8:54 AM on 7/25/25. The evaluation of body systems section revealed the resident had abrupt increased confusion, difficulty walking, right sided facial drooping, slurred speech, and abnormal vital signs. There was no summary of observations, evaluations or recommendations documented on the form. The form detailed the primary care physician was notified at 9:30 AM on 7/25/25 but no physician recommendations were documented on the form. Further review of the medical record revealed there was no documentation of the initial notification to the physician of the resident’s condition or for the order for supplemental oxygen at 3 liters per minute. The resident medical record showed no documentation of that an oxygen saturation was repeated and read 96% SpO2. The improvement of the resident’s shortness of breath but not his tachycardia and hypotension was not reflected in the resident’s medical record. Additional facility incident reporting dated 7/31/25 included information about staff involved with the change in condition on the morning of 7/25/25. Review of the facility report revealed on the morning of 7/25/25 at approximately 9:15 AM, the assigned nurse responded to concerns over the resident's condition. The facility narrative described the resident was assessed by the nurse who initiated a rapid response after the assessment. The report indicated resident #126 was noted to be sleepy but arousable, hypotensive, tachycardic, diaphoretic and have a functional decline. The facility report detailed the resident had a slight right eye droop, but the rest of the neurological exam was normal. The resident’s vital signs were blood pressure of 110/88, temperature of 97.5 degrees F, respirations of 18, and oxygen saturation of 93% SpO2 on room air. The report described the resident’s oxygen saturation increased to 97% on 3 liters per minute of supplemental oxygen. Review of the resident’s medical record revealed there was no documentation of a rapid response being initiated in contrast to the facility's reporting. The medical record contained no documentation of the resident’s initial oxygen saturation of 93% on room air, nor a repeated oxygen saturation of 97% SpO2 on 3 liters per minute of supplemental oxygen. On 7/25/25 at 8:54 AM, the oxygen saturation was documented in the residents’ medical record by nurses as 97% on room air, not on supplemental oxygen as reported by the facility. On 7/25/25 at 9:42 AM, the oxygen saturation was documented as 91% SpO2 by nasal cannula. On 8/27/25 at 1:20 PM, the facility's incident investigation and incident reporting was reviewed with the DON. She said that through their investigation it was revealed that on 7/24/25 during the night shift the staff reported the resident felt warm and sweaty. The DON continued that staff took vital signs which were within normal limits and administered a Covid-19 test. The DON confirmed the order to administer a Covid-19 test was not documented as administered and the results were not recorded in the resident’s medical record. She confirmed two different dates, 7/24/25 and 7/25/25 were given in the report submitted to the state agency but she stated the test was administered on 7/24/25. The DON stated on the morning of 7/25/25 at approximately 9:00 AM, the resident was noted to be more lethargic and had a decline in function, a rapid response was initiated but she could not give a time. She continued, upon assessment of the resident, it was noted he was hypotensive, tachycardic and had a slight right eye droop, so the physician was notified, who gave an order to apply 3 liters per minute of supplemental oxygen. The DON confirmed the first notification to the physician and the order given for oxygen were not documented in the resident's medical record. She explained that after applying the 3 liters per minute of oxygen staff noticed the resident’s condition did not improve, so a second call was placed to the physician. The physician gave an order to send the resident to the emergency room. The DON stated the time of the call to the physician was 9:30 AM which was documented in the change in condition form. She confirmed there was no documentation that 3 liters per minute of oxygen was ineffective nor was there documentation of the further decline of the resident’s status which led to the second call to the physician. The DON conveyed the resident was sent to the emergency room with emergency medical services (EMS). She was unable to give details of what occurred including a time for when EMS was called, when they arrived or when they left the facility. The DON stated that typically they did not document those types of things. The DON acknowledged there were gaps in the resident's medical record which failed to show a full picture of the resident's change in condition, nor of staff interventions administered during that time. The facility's policy entitled “Physician Order’s” most recently updated 6/28/24 indicated the facility should ensure resident information was complete and accurate. The facility did not have a policy on medical records or documentation.

Based on observation, interview, and record review, the facility failed to provide routine dental care services to 1 of 2 residents reviewed for dental care, (#101), of a total sample of 43 residents. Findings:Review of the medical record revealed resident #101, a [AGE] year-old female was admitted to the facility from an acute care hospital on 5/30/25 with diagnoses that included bipolar disorder, major depressive disorder recurrent, dysphagia (difficulty swallowing), hypotension (low blood pressure), hypertension (high blood pressure), and abdominal tenderness.The Modified Minimum Data Set admission 5-day Comprehensive Assessment with an Assessment Reference Date of 6/07/25 noted resident #101 scored 15 out of 15 on the Brief Interview for Mental Status which indicated she was cognitively intact and did not reject evaluation or care. Section L (Dental) was modified on 8/28/25 to indicate the resident had, obvious or likely cavity or broken natural teeth.The Care Plan Report included a focus initiated on 6/02/25 for risk for/has oral/dental health problems related to poor dentition and missing teeth. An intervention dated 6/02/25 showed resident #101 was to receive coordination arrangements for dental care, transportation as needed or ordered. The admission Data Set evaluation dated 6/02/25 noted the nurse assessed resident #101 with obvious or likely cavity or broken natural teeth.On 8/26/25 at 2:52 PM, resident #101 relayed she was supposed to see a dentist, but the facility had not made arrangements for her yet. She said, I need to see the dentist for my teeth.On 8/28/25 at 10:27 AM, resident #101 opened her mouth to reveal multiple missing and discolored natural teeth. Upon counting, she identified she had six remaining teeth. The resident pointed to her mouth and said, I only have six left; I need some dentures.In an interview, the 200 Unit Manager explained all referrals for dental services were handled by the Social Services Director.On 8/27/25 at 2:10 PM, the Social Services Director explained she was aware resident #101 needed dental services but because she was in a private pay/Medicaid pending status, there was an issue with who would pay for the services. She said all long-term care residents received an annual evaluation. The Social Services Director stated, it's kind of a weird gap, she explained once the resident's payment source changed, she could be enrolled in the Medicaid dental program.Review of the facility's contracted dental provider's list of residents noted resident #101 was listed however, an annual assessment was not done nor scheduled. The Payor Source read, Med Pending [Medicaid pending].On 8/28/25 at 2:03 PM, the Director of Nursing explained that all residents had access to routine and emergency dental services regardless of their payor source and individual available benefits or the facility's onsite provider were utilized. She said if a resident needed services, the facility was responsible for providing the services, and stated, we will deal with the payment source later.On 8/28/25 at 6:15 PM, the Nursing Home Administrator conveyed the Social Services Director came to her two days prior and let her know she was unaware resident #101 needed services but she was now on their list.Review of the Facility assessment dated [DATE] noted the facility provided person-centered care and services based off their unique care plan. The Medical/Physician services included, Dentist.

Based on observation, interview, and record review, the facility failed to prevent medication administration error rate of 5% or greater for 4 of 4 residents sampled for medication administration, (#3, #41, #77, #204). There were 8 medication errors in 27 opportunities for a medication error rate of 27%. Findings: 1. Resident #41 was admitted to the facility on [DATE] with diagnoses that included hypertension, schizophrenia, major depressive disorder, and type II diabetes mellitus. On 02/21/24 at 9:21 AM, Registered Nurse (RN) G, was by her medication cart preparing to administer morning diabetic medications. She stated it was her regular process to obtain blood sugars and administer insulin to all diabetic residents on her assignment first before administering all other medications. She stated that resident #41's morning blood sugar was 238 and he had orders for Novolog injection solution 5 units before meals as well as Novolog injection solution per sliding scale give 5 units for blood sugars between 201 and 250 before meals and at bedtime. RN G drew up 10 units of Novolog and prepared the second diabetic medication, Levemir Solution 35 units, which was in a dial pen. She then approached resident #41 who had just finished breakfast, as evidenced by the empty breakfast tray on the bedside table and proceeded to inject both diabetic medications. Record review for resident #41 post medication administration revealed that Novolog, both regular and sliding scale, should be administered before meals starting at 7:30 AM. The Medication Administration Record (MAR) further revealed that RN G had been documenting under Unit Manager's (UM) name that morning. On 02/21/24 at 11:29 AM, a fallow up interview was conducted with RN G and she stated that she was late administering the insulin for resident #41 due to being asked to meet with the Director of Nursing (DON) before starting her shift that morning. She further clarified she did not notice she was not signed into the computer since she was in a rush to get morning medications completed. RN G stated she knew that insulin needed to be administered as ordered so the body has time to absorb it before a meal. On 02/21/24 at 11:37 AM, the Unit Manager (UM) from the 200 unit, confirmed she had not administered the 7:30 AM insulin to resident #41 even though her name was signed off on the MAR. The UM stated she mistakenly forgot to sign off the medication cart computer before RN G started medication rounds that morning. She admitted resident #41 should have had his 7:30 AM insulin before his meal as ordered. 2. Resident #77 was readmitted to the facility on [DATE] from an acute care hospital. His diagnoses included pancytopenia, gastrointestinal hemorrhage, gastro-esophageal reflux disease without esophagitis, and chronic obstructive pulmonary disease. Pancytopenia is a condition in which there is a lower-than-normal number of red and white blood cells and platelets in the blood. Pancytopenia occurs when there is a problem with the blood-forming stem cells in the bone marrow (retrieved on 02/29/24 from www.cancer.gov). The most common cause of pancytopenia is Megaloblastic anemia, followed by acute myeloid leukemia and aplastic anemia (retrieved on 02/29/24 from www.ncbi.nlm.nih.gov). On 02/21/24 at 9:33 AM, RN F, was ready to administer 10 AM morning medications to resident #77. She had two medication cups and a metered dose inhaler. One medication cup contained two chewable tablets of Calcium Carbonate 500 mg (Tums) and the other contained seven tablets, which did not include Polysaccharide Iron Complex Capsule 150 mg for iron deficiency. RN F counted the medications and confirmed she had two in one cup, seven in the other cup, and one metered dose inhaler. RN F entered resident #77's room and administered seven tablets by mouth. The resident refused the Calcium Carbonate 500 mg. After exiting the resident's room, RN F counted how many medications she had administered as she signed for them on the computer. She stated she administered seven tablets plus an inhaler. RN F then stated she had omitted the Polysaccharide Iron tablet and said she had made a mistake. Resident #77's medical records revealed Calcium Carbonate 500 mg was ordered to be administered by mouth before meals for supplementation starting at 8:00 AM On 02/21/24 at 11:40 AM an interview with UM from the 200 unit and the Regional Nurse Consultant (RNC) revealed they expected medications to be administered as ordered. 44313 3. Resident #3 was admitted to the facility on [DATE] with diagnoses that included chronic lung disease, bipolar disorder, type 2 diabetes mellitus, and hypertension. Resident #3 had a care plan for altered cardiovascular status related to her elevated cholesterol and hypertension. On 2/19/24 at 12:14 PM, RN H dispensed and administered medications for resident #3 including Amlodipine Besylate tablet 5 milligrams (mg) for hypertension. Review of the Physician Orders on 2/19/24 revealed a physician's order for Amlodipine Besylate 5 mg tablet. The order directed, give 10 mg once a day for hypertension, and to hold for systolic blood pressure less than 110. Review of the Medication Administration Record for February 2024 revealed RN H documented 10 mg of Amlodipine Besylate as given on 2/19/24. On 2/19/24 at 1:09 PM, RN H stated she realized the physician's order was for 10 mg, but explained she decided to only give 25mg because she didn't think resident #3 would take two tablets. She explained she didn't have to call the physician to make them aware of the change in resident #3's dosage because the physicians came in and reviewed the charts for that. RN H then changed her explanation and stated she decided to hold part of resident #3's blood pressure medication because she thought 25mg of the Amlodipine was enough. RN H did not give an explanation as to why she documented 10 mg was given, instead of the 5 mg she actually gave. On 2/19/24 at 1:18 PM, the Director of Nursing (DON) stated the nurse should notify the physician if a resident refused medications or if there was a concern about vital signs. He stated the nurse could not make the decision to hold or change the dosage of a medication if there were not parameters given by the physician. The DON explained it was not in a nurse's scope of practice to change a medication order, without calling the physician for clarification or new orders. On 2/20/24 at 10:43 AM, the Medical Director confirmed nurses should not decide to change medication orders and they should follow what the physician ordered. He agreed it was not in their scope of practice to decide not to give or change a medication and they should notify the physician first. 43192 4. Review of resident #204's medical record revealed she was admitted to the facility on [DATE] with diagnoses including cellulitis of right lower limb, atrial fibrillation, and obstructive sleep apnea. Review of resident #204's physician orders included Cyanocobalamin 1000 micrograms (mcg) 1 tablet one time a day for supplement, Magnesium Oxide 250 milligrams (mg) 1 tablet one time a day for supplement, Folic Acid 1 mg 1 tablet one time a day for supplement, and Fexofenadine 180 mg one time a day for allergies. On 2/20/24 at 10:53 AM, Licensed Practical Nurse (LPN) I prepared morning medications for resident #204. She pulled the following medications: Potassium 15 milliequivalents 1 tablet, Furosemide 40 mg 1 tablet, Alopurinol 100 mg 1 tablet, Digoxin 125 mcg 1 tablet, Cefdinir 300 mg 1 capsule, Metronidazole 500 mg 1 tablet, Magnesium Oxide 400 mg 1 tablet, Acidophilus with pectin 1 tablet, and Iron 325 mg 1 tablet. LPN I confirmed she had prepared a total of 9 pills for resident #204 which were verified by comparing the actual pills against the medication cards and bottles. LPN I administered the medications to resident #204. Later at 4:26 PM, LPN I looked at the bottle for Magnesium Oxide and stated it was 400 mg. She reviewed resident #204's order, and stated it read 250 mg 1 tablet daily. She said it was her mistake and added she was supposed to inform the physician what she had available, obtain order, and document it. She indicated she was not following the physician's orders. She said she should have held the medication and consulted the physician prior to administering the magnesium oxide tablet for 400 mg. When asked about Cyanocobalamin 1000 micrograms, Folic Acid 1 mg, and Fexofenadine 180 mg which showed documented as given around the same time of the medication administration observation, she stated she did not pull all the medications together and had given those 3 medications before the observation with the surveyor. LPN I immediately changed the details and stated the documentation was an error. She explained she did not have the medications available in the medication cart and confirmed she did not administer Cyanocobalamin, Folic Acid, or Fexofenadine. She acknowledged she should not document medications as administered when they were not. On 2/20/24 at 5:01 PM, the DON stated nurses must follow the physician orders when administering medications. He explained if a medication was unavailable or there was a discrepancy, the nurses must notify the physician, enter any new order, and implement it. He stated the process for over-the-counter supplements was the same. He indicated resident #204's Medication Administration Record needed to reflect the medications were not given with the proper explanation. The DON explained his expectation was nurses followed the physician's orders and documented accurately. Review of the Medication Pass and Med Pass with Medication Cart guidelines not dated revealed purpose was To assure the most complete and accurate implementation of physicians' medication order to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. The document read, Medications are administered in accordance with written orders of the attending physician.

Based on interview, and record review, the facility failed to provide written Notification of Transfer or Discharge forms to the residents or their representative for 2 of 3 residents reviewed for hospitalization s out of a total sample of 47 residents, (#28 and #52). Findings: 1. Resident #28 was admitted to the facility on [DATE] with diagnoses including quadriplegia, intracranial injury with loss of consciousness, thrombocytopenia, encephalopathy, and gastrostomy malfunction. Review of the resident's medical record revealed a nursing progress dated 02/16/24 that noted the resident's gastrostomy tube was displaced. He was transferred to the hospital on 2/17/24 by non-emergency transportation for replacement. As of 02/22/24, the resident remained in the hospital but was expected to return to the facility. The medical record did not contain a Notification of Transfer or Discharge form for the hospitalization . 2. Resident #52 was admitted to the facility on [DATE] with diagnoses including calculus of ureter, hydronephrosis with ureteropelvic junction obstruction and functional quadriplegia. Review of resident #52's medical record revealed he was hospitalized on [DATE]. Review of the progress notes revealed resident #52 had complaints of nausea, vomiting, abdominal pain, and discomfort when urinating. Resident became diaphoretic and was transferred to the hospital 1/12/24 by emergency transportation. The resident returned to the facility on [DATE]. The medical record did not contain a Notification of Transfer or Discharge form for the hospitalization . On 2/21/24 at 2:48 PM, the Social Services Director (SSD) stated nurses were responsible for completing the Notification of Transfer or Discharge forms and scanned them into the electronic medical record (EMR). He explained he printed a list from the EMR and submitted it to the Ombudsman's office. The SSD confirmed he had not completed a Notification of Transfer or Discharge form for any resident sent to the hospital in the 2 1/2 years he had been the SSD. On 2/21/24 at 3:02 PM, the Director of Nursing (DON) stated the Social Services department was responsible for completing the Notification of Transfer or Discharge forms. He explained he would discuss the process with the clinical team to determine the correct procedure. On 2/22/24 at 10:38 AM, the Regional Nurse Consultant (RNC) stated the facility policy was for nursing to start the Notification of Transfer or Discharge form and Social Services followed up and completed the form as well as notified the Ombudsman's office. The RNC confirmed the forms were not being completed and could not determine how long it had been since the process was followed correctly.

Based on observation, record review, and interview the facilty failed to ensure dishes and eating utensils were sanitized to prevent foodborne illness. Findings: On 2/19/24 at 10:33 AM, Dietary Aide A was observed at the dishmachine, washing the breakfast dishes. The Aide stated the dishmachine was low temperature and utilized a chlorine base chemical for sanitation. A minimum of 50 parts per million (PPM) for the sanitizer level was required. She explained she tested the sanitizer solution with a test strip, when she started washing the dishes, and the sanitizer was at 75 ppm. A rack of dishes came out of the machine and the Dietary Technician used a test strip to determine if the chemical sanitation solution was at the appropriate level. After she swabbed the dishes with the test strip, the test strip remained white in color instead of turning purple indicating none or less than minimum level of sanitizer. The Dietary Technician ran several racks of dishes through the dish machine and each was swabbed with a test strip. The sanitizer solution could not be detected. After several attempts, the Dietary Technician was directed to the container of sanitizer solution that was underneath the dishmachine. It was pointed out the sanitizer solution was not being drawn up the intake line to the dishmachine. Observation of the sanitizer container noted the intake line was floating on top of the sanitizer solution instead of below the sanitizer solution.

Based on observation, interview, and record review, the facility failed to provide appropriate care and services for splinting to maintain mobility and/or prevent worsening of contractures for 1 of 1 resident reviewed for limited range of motion, out of a total sample of 47 residents, (#66). Findings: Review of the medical record revealed resident #66 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, osteoarthritis, stroke with right side weakness and paralysis, and right hand contracture. The American Stroke Association indicates after a stroke, limb contractures occur when muscles in the arm or leg shorten or contract, due to inactivity or inability to move. The untreated stiff muscles can cause joints to become stuck in an abnormal and possibly painful position called a contracture. Treatments include range of motion exercises, physical therapy, and the use of splints and braces to stretch muscles and maintain full range of motion or prevent permanent muscle shortening (retrieved on 2/24/24 from https://www.stroke.org/en/help-and-support/resource-library/lets-talk-about-stroke/complications-after-stroke). Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 2/06/24 revealed resident #66 did not reject evaluation or care that was necessary to achieve his goals for health and well-being. The MDS assessment indicated he received Restorative Nursing Program (RNP) services for splint or brace assistance on two days in the 7-day look back period. Resident #66 had a care plan created on 3/20/23 and revised on 2/14/24 with focus area of upper extremity splints as tolerated to prevent further contractures and maintain joint mobility. The goals were the resident would maintain his current level of function and not experience complications related to use of splints. Review of an Order Audit Report revealed resident #66 had a physician order dated 2/16/24 that read, Right hand splint and right elbow brace to be donned in AM, doffed in PM or for daily care. On 2/19/24 at 11:26 AM, resident #66 was in a supine position in bed. His arms were bent at the elbows and his hands were noted close to his shoulders. The resident's right hand was closed with the fingers curled towards his palm. A blue brace was noted on the night stand and a blue hand/wrist splint was on top of the dresser across from the foot of his bed. On 2/19/24 at 2:10 PM, resident #66 was in his room with his daughter at his bedside. The orthotic devices remained on the night stand and dresser in the same positions. When asked if her father received RNP services, she stated she was not sure if his splints were applied regularly. The daughter explained she visited almost every day and often saw the devices in the same places she observed them on the previous day. She stated her father used to have a soft pad for his palm to protect the skin from breakdown related to moisture. Resident #66's daughter checked the dresser, night stand, and closet and did not find the padding she described. On 2/20/24 at 9:43 AM, resident #66 was in a supine position in bed with both arms uncovered. The resident did not have his right hand and right elbow splints in place. On 2/20/24 at 12:01 PM, resident #66 sat in a reclining chair in the common area in front of nurses' station. His arms were curled upwards, his hands were closed and rested on his chest. A rolled white washcloth was in his right hand. On 2/20/24 at 4:24 PM, resident #66 was in the 100 unit's dining/activity area. The resident did not have his right hand and right elbow orthotic devices. On 2/20/24 at 4:49 PM, Certified Nursing Assistant (CNA) D stated she was regularly assigned to resident #66 since he was transferred from the other unit a few weeks ago. She confirmed the resident had two splints in his room but explained she did not put them on him as RNP or therapy staff were responsible for that task. On 2/21/24 at 10:13 AM, RNP Aide E stated she was responsible for application of splints and braces. She verified resident #66's splints were to be placed daily, which she usually did at the start of her shift. When RNP Aide E was informed resident #66 was observed without his splints on Monday 2/19/24 and Tuesday 2/20/24, she stated it was very important for him to wear the splints to prevent his contractures from worsening. She was not aware CNAs did not reapply the splints if they removed devices to provide morning care, and she acknowledged she did not go back to check the devices during the shift. On 2/21/24 at 5:15 PM, the Rehab Director stated resident #66 was recently on Occupational Therapy caseload for treatment of his right arm contractures. She explained he was discharged from therapy to RNP services with orders for his right elbow and hand splints. The Rehab Director validated proper use of splints and braces prevented contractures from developing or worsening and promoted maintenance of the gains made in therapy. She was informed after the concern regarding resident #66 not wearing his splints for the previous two days was brought to staff attention, he was observed today, 2/21/24, at 9:59 AM and 2:57 PM with the right hand splint applied. During joint observation of resident #66's room, the Rehab Director was shown the orthotic device that had been on the night stand since 2/19/24. She confirmed it was the resident's elbow brace and stated RNP Aides were trained to alternate application of the resident's elbow and hand splints. On 2/21/24 at 5:43 PM, the Director of Nursing (DON) stated he was responsible for oversight of the RNP. He stated his expectation was RNP staff would apply orthotic devices as ordered and seek clarification of orders from him or the therapy department if necessary. The DON confirmed CNAs should replace splints or braces if they needed to remove them for care, and seek guidance if unfamiliar with a device. Review of the Facility/Center Assessment Tool, dated 10/17/23, revealed the facility would accept residents with common diseases and conditions including disorders of the neurological system to include stroke, and one-sided paralysis or weakness. The document indicated staff would provide general care related to mobility, and specific care such as restorative nursing services, therapy services, the management of splints and braces, and contracture prevention and care.

Based on interview, and record review, the facility failed to ensure completion and accuracy of Level I Preadmission Screening and Resident Reviews (PASARRs) on admission, and/or failed to make referrals for newly evident or possible mental disorders, to evaluate the need for specialized mental health services or alternate placement, for 3 of 3 residents reviewed for PASARRs, out of a total sample of 47 residents, (#24, #62 #34). Findings: The Preadmission Screening and Resident Review (PASARR) is a federal requirement to ensure individuals are not inappropriately placed in nursing homes for long term care. The PASARR process requires Medicaid-certified nursing facilities to evaluate all residents for serious mental illness (SMI) and/or intellectual disability (ID). The Level I screen is a preliminary assessment to determine if there might be SMI or ID. If the Level I screen is positive, then referral for an in-depth Level II screen is required to determine the need for additional services and the appropriate setting, and recommend necessary services to be included in the plan of care (retrieved on 2/26/24 from www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/preadmission-screening-and-resident-review/index.html). 1. Review of the medical record revealed resident #24 was initially admitted to the facility on [DATE] and recently readmitted on [DATE]. Her admission diagnoses included paranoid schizophrenia and mood disorder, and her medical record was updated to reflect new onset diagnoses of delusional disorders (10/28/21), recurrent moderate major depressive disorder (10/28/21), suicidal ideation (1/12/23), mild mixed bipolar disorder (4/27/23), psychosis (11/06/23), and bipolar-type schizoaffective disorder (11/06/23). Review of resident #24's PASARR Level I form dated 8/13/21 revealed the document was completed and signed by a Registered Nurse (RN) screener at the facility. The PASARR form showed the resident had mental illnesses including bipolar disorder and schizophrenia. The findings were based on documented history only, with no behavioral observations or discussions with the resident and/or her representative. The form revealed resident #24 did not typically or possibly have difficulty with interpersonal functioning, concentration, or adaptation to change, nor that she had required inpatient psychiatric hospitalization . Section III of the form indicated resident #24 was admitted to the facility under a Hospital Discharge Exemption and a Level II evaluation must be completed no later than the 40th day of admission. The instructions on the form revealed a physician's signature was required for any resident admitted under a 30-day hospital discharge exemption; however, the area designated for the attending physician's signature was blank. Section IV of the screening form, PASARR Screen Completion, indicated the resident may be admitted to a nursing facility as she had no diagnosis or suspicion of serious mental illness, and a Level II PASARR evaluation was not required. The RN screener did not identify the resident's hospital discharge exemption status as noted in Section III of the form. Review of resident #24's medical record revealed on 10/09/23, a Clinical Psychologist examined resident #24 and noted diagnoses of paranoid schizophrenia and severe manic bipolar disorder with psychotic features. A Certificate of Professional Initiating Involuntary Examination form was completed during the visit, and the document indicated the resident presented with paranoid delusions and hallucinations. She refused her medications, meals, and nursing care, and was agitated, illogical, and disorganized. Resident #24 was determined to pose threat of serious bodily harm to herself or others and was transferred to a psychiatric care facility for treatment. The resident was readmitted to the facility, and on 10/31/23, a Licensed Mental Health Counselor examined her and determined she had unspecified psychosis with substantial likelihood that without care or treatment she would harm herself. The resident was again involuntarily transferred to a psychiatric care facility due to paranoia and visual and auditory hallucinations. Review of a progress note dated 11/09/23 revealed resident #24 was assessed by a Psychiatric Advanced Practice Nurse Practitioner (APRN). The document indicated the resident reported an extensive past psychiatric history of schizophrenia spectrum disorder that was diagnosed in 1983 when she was incarcerated.she started to experience auditory and visual hallucinations. The note revealed resident #24 described a history of multiple medication adjustments during stays in psychiatric hospitals. A Psychology Subsequent Note dated 12/05/23 revealed resident #24's chief complaint was schizophrenia and bipolar disorder and she was illogical due to psychosis. The resident exhibited religious and paranoid delusions, rapid changes in mood, anxiety, and ruminating thoughts and behaviors. The practitioner described the resident's symptoms as occurring daily and causing moderate distress. Review of resident #24's medical record from August 2021 to February 2024 revealed no evidence of PASARR prior to her readmissions from psychiatric inpatient treatments or re-screening due to new behavioral, psychiatric, and mood-related diagnoses and continued symptoms. On 2/20/24 at 3:56 PM, the Social Services Director (SSD) confirmed he was aware resident #24 was involuntarily transferred out of the facility for psychiatric treatment on a few occasions. He acknowledged the resident had a significant psychiatric history, frequently refused necessary medications, and regularly required special approaches by staff as she had difficulty interacting and communicating with people. The SSD confirmed the facility did not refer resident #24 for a Level II PASARR, but she definitely needed one due to her diagnoses and behaviors. On 2/21/24 at 5:57 PM, the Director of Nursing (DON) stated his responsibilities included completion of PASARRs to ensure the facility was the appropriate setting to meet residents' needs. He verified resident #24 was involuntarily transferred out from the facility for treatment of escalating psychiatric symptoms several times in the past year. The DON explained the resident was not compliant with her medication regimen so mental health crises were the expected result. He stated a previous DON completed resident #24's Level I PASARR on admission, but the screening was inaccurate as questions related to her behaviors were not answered correctly. The DON stated the facility did not identify that resident #24 required a revised PASARR as a recent audit of forms focused on the presence of a PASARR for each resident, but not the accuracy of the screening. He explained the facility did not have policies and procedures related to PASARR. 44313 2. Resident #62 was readmitted to the facility on [DATE] with diagnoses that included pathological hip fracture, stroke, Obsessive-Compulsive Disorder, Major depressive disorder, and mood disorder due to known physiological condition. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section A-Identification Information indicated resident #62 had no serious mental illness or intellectual disability and no PASARR was completed. Section B and C of the Admission assessment revealed resident #62 had no behaviors toward herself or others during the lookback period. Section I-Active Diagnoses of the assessment also revealed no diagnoses of serious mental illness. Review of the Annual MDS assessment dated [DATE] Section A indicated no serious mental illness and no PASARR was completed. This conflicted with the information submitted in Section I-Active Diagnoses of the assessment with documentation of obsessive-compulsive disorder, mood disorder and depression (other than bipolar) as current diagnoses. Resident #62 had a care plan for resisting care related to refusal of showers, getting changed by staff, cleaning her room and hoarding food and trash in her room. Review of resident #62's Order Summary Report dated 2/22/24 revealed she had orders for Fluvoxamine Maleate once a day and at bedtime for treatment of mood disorder. On 1/03/24 a Change in Condition note for altered mental status indicated resident #62 was observed as verbally aggressive with staff when they attempted to re-direct her for positioning. The document described resident #62 as screaming, spitting, and hallucinating. The physician was notified and recommended an involuntary psychiatric evaluation at the hospital. A nurse's note dated 1/04/24 revealed resident #62 was evaluated by the psychiatric nurse practitioner and physician for hoarding and other behaviors. The nurse documented resident #62 became agitated and acutely psychotic with elevated mood and pressured speech when interviewed by them. A Psychology note on 1/04/24 detailed resident #62 as stable and compliant with medications previously but was seen that day due to multiple behavioral issues. Resident #62 was noted to have questionable mental capacity for decision making including general safety concerns or issues about her health and surroundings. The provider noted resident #62 frequently refused medications, hygiene care, housekeeping and was verbally aggressive. The provider's plan was to continue to educate and continue psychotropic medications as ordered. Diagnoses documented in the note included mood disorder, major depressive disorder, and obsessive-compulsive disorder. Review of resident #62's medical record revealed a level I PASARR dated 3/30/20. The document indicated Section 1 that listed serious mental illnesses was not checked based on documented history. Section 2 of the assessment also had nothing checked, and therefore no level 2 PASARR was warranted. No other level I PASARR or level II PASARR was in resident #62's medical record. On 2/20/24 at 5:13 PM, the Nursing Home Administrator/Risk Manager described an incident on 1/03/24 when staff had attempted to re-direct and educate resident #62 about her hoarding of food and trash and refusal of cleaning and hygiene care. He said resident #62 told the psychiatrist and Advance Practice Registered Nurse that she didn't need to hear their communist comments and to never come back. He said resident #62's behaviors had escalated at that time and her physician felt she needed to be admitted involuntarily to an inpatient psychiatric facility for those behaviors. On 2/21/24 at 5:35 PM, the Social Service Director stated the DON completed the PASARR assessments as he did not have his master's degree in social work. He explained the facility had a psych meeting monthly where they discussed residents who took psychotropic medications and their care. He described the level II PASARR was triggered from a diagnosis of a serious mental illness and from a list of behaviors. The Social Service Director agreed resident #62's diagnoses of obsessive compulsive disorder, major depressive disorder and mood disorder qualified as a serious mental illness. He stated resident #62 did not have a level II PASARR done nor a revised level I with her psychiatric diagnoses. On 2/22/24 at approximately 12:55 PM, the DON stated he was responsible for the level I PASARR screening and requests of level II screening. He acknowledged a level I PASARR was not done for resident #62 when she was diagnosed with serious mental illness after her admission in September of 2020 to the facility. He also acknowledged the MDS annual assessment dated [DATE] with the new mental health diagnoses should have triggered a new level I PASARR screen to be performed. Request was made to the facility for a policy and procedure for level I and level II PASARR screens. The regional nurse confirmed the facility did not have a policy and procedure for PASARR screenings. 50131 3. Resident #34 was admitted to the facility on [DATE]. Her diagnoses included Anxiety, Bipolar Disorder and Depression. Review of the annual MDS assessment dated [DATE] noted the resident scored 7 out 15 for the Brief Interview for Mental Status, which indicated moderately impaired cognition. Review of a PASARR dated 12/18/20 did not note the resident's diagnoses of Bipolar Disorder, Anxiety and Depression. On 2/22/24 at 2:24 PM, the DON explained he determined if a resident needed to have a Level II PASARR. He added the PASARRs were not being completed at the hospital and the Facility did not have a process in place to ensure PASARR Level I and Level II were being completed.

Based on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected use of a mobility device, (#5), use of corrective lens, (#24), and limitation in range of motion, (#66), for 3 of 32 residents reviewed for MDS accuracy, out of a total sample of 47 residents. Findings: 1. Review of the medical record revealed resident #5 was admitted to the facility on [DATE] with diagnoses including right lower leg fracture, falls, generalized muscle weakness, and abnormal gait. Review of resident #5's MDS Admission assessment with assessment reference date (ARD) of 1/19/24, Section GG - Functional Abilities and Goals, revealed she had functional limitation in range of motion due to impairment of one lower extremity. The document indicated the resident did not use any mobility devices during the 7-day look back period. On 2/22/24 at 4:54 PM, the Licensed Practical Nurse (LPN) MDS Coordinator confirmed resident #5 was admitted to the facility with a cast on her right lower leg and foot. She acknowledged the MDS assessment indicated resident #5 did not use a wheelchair during the look back period. The LPN MDS Coordinator verified the resident now used a wheelchair and propelled herself around the facility, but might not have used the mobility device in the days after admission. On 2/22/24 at approximately 4:58 PM, the Rehab Director stated resident #24 used a wheelchair for mobility from the time of admission. She informed the LPN MDS Coordinator that therapy staff assisted the resident into the wheelchair and took her to the rehab gym for her sessions. The LPN MDS Coordinator confirmed the MDS was inaccurate. 2. Review of the medical record revealed resident #24 was admitted to the facility on [DATE] with diagnoses including dementia, secondary Parkinsonism, and the need for assistance with personal care. The MDS Quarterly assessment with ARD of 2/12/24, Section B - Hearing, Speech, Vision, revealed resident #24 had adequate vision and she could see regular print without corrective lens. On 2/20/24 at 9:59 AM, resident #1 wore large-framed reading glasses as she reviewed paperwork and made notes on a legal pad. On 2/22/24 at 4:40 PM, the LPN MDS Coordinator was informed although corrective lens were not noted on the most recent MDS assessment, resident #24 wore reading glasses. She explained her process was to interview staff and residents and check medical records to obtain information for MDS assessments. However, the LPN MDS Coordinator stated she had never interviewed resident #24. She said, I have not been able to go into her room. I do talk to the staff. I am sure I asked someone. 3. Review of the medical record revealed resident #66 was admitted to the facility on [DATE] with diagnoses including stroke with right side weakness and paralysis, and right hand contracture. A contracture is an abnormal and often permanent shortening of a muscle that results in stiffness or deformity of a joint (retrieved on 2/24/24 from www.medical-dictionary.thefreedictionary.com/contracture). Review of the MDS Quarterly assessment with ARD of 2/06/24, Section GG - Functional Abilities and Goals, revealed the document did not reflect resident #66's right upper extremity contracture. The MDS assessment showed he had no impairment of his upper and lower extremities. On 2/21/24 at 5:15 PM, the Rehab Director verified resident #66 had a right hand contracture and required right elbow and right hand splints to prevent worsening. Review of the facility's policy and procedure for Resident Assessment Instrument (RAI) Process, revised on 3/27/18, revealed the purpose of the RAI was to provide staff with ongoing assessment information necessary to develop care plans and ensure the provision of appropriate care and services. The document read, The facility is expected to use resident observation and communication as the primary source of information when completing the MDS whenever possible. but information would also be obtained from staff on all shifts and the medical record. The procedure indicated the RAI was completed by an interdisciplinary team comprised of staff members who had clinical knowledge of the resident. Each team member would sign the section he/she completed to attest to accuracy of the information, and all were responsible for reviewing the entire MDS assessment for accuracy.

Based on observation, interview, and record review, the facility failed to provide necessary activities of daily (ADL) care related to personal hygiene and incontinence care for 1 of 4 residents reviewed for ADLs, out of a total sample of 47 residents, (#256). Findings: Review of the medical record revealed resident #256 was admitted to the facility on [DATE] with diagnoses including left leg cellulitis (bacterial skin infection), type 2 diabetes, morbid severe obesity, and obstructive and reflux uropathy (a condition in which urine flows backward into the kidneys due to an obstruction). Review of the Minimum Data Set (MDS) Admission assessment with assessment reference date of 2/11/24 revealed resident #256's speech was clear, she was able to express her ideas and wants, and she had no issues comprehending verbal content. The resident had a Brief Interview for Mental Status score of 15 out of 15 which indicated she was cognitively intact. The MDS assessment showed the resident had functional limitation in range of motion related to impairment of both legs, required substantial to maximal assistance for bathing and personal hygiene, and was totally dependent on staff for toileting hygiene and lower body dressing. Resident #256 had an indwelling urinary catheter and was frequently incontinent of bowel. Review of resident #256's medical record revealed a care plan for ADL self-care performance deficit was initiated on 2/04/24. The interventions included extensive assistance of two people for bathing, bed mobility, personal hygiene, and toilet use. A care plan for bowel incontinence, created on 2/04/24, had interventions such as perineal care after each episode and use of disposable briefs. A care plan for impaired skin integrity, initiated on 2/04/24, included the care directive to keep the resident's skin clean and dry and turn and reposition her with care rounds as needed. On 2/19/24 at 12:55 PM, during observation of resident #256's skin, Licensed Practical Nurse (LPN) A and Certified Nursing Assistant (CNA) B assisted the resident to roll onto her left side. The fabric pad underneath the resident had a yellow-stained area that measured approximately six inches in diameter. When CNA B removed the resident's incontinence brief, there was a large amount of stool noted in the brief and on her skin. Resident #256 stated she was last changed during the overnight shift. She said, I'm tired of being on my back. I've been on my back since last night. The resident explained her urinary catheter was replaced by the night shift nurse and the urine on the bed had been there since the previous shift. On 2/19/24 at 1:23 PM, CNA B verified she started the day shift at 7:00 AM that morning and did not check the resident's brief during the next six hours, until she was asked to assist LPN A. She explained the resident required assistance from two or three CNAs for bed mobility and toileting hygiene, and all staff had been too busy to assist her. CNA B explained at about 9:00 AM, she washed resident #256's upper body, but did not provide any care for the lower half of her body. On 2/21/24 at 5:53 PM, the Director of Nursing stated CNAs were expected to do rounds at least every two hours to check on assigned residents, provide incontinence care and reposition them if needed, and ensure their skin was clean and dry. Review of the job description for Certified Nursing Assistant, revised on 1/07/17, revealed essential duties and responsibilities included provision of personal care and services. The CNA was to assist with ADLs such as turning, repositioning, toileting, cleanliness, and bathing, and makes routine rounds on each assigned resident and patient in accordance with established procedures. Review of the Facility/Center Assessment Tool dated 10/17/23 revealed facility staff would provide care and services for residents including bathing, incontinence care, and skin care.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice related to physician-ordered dressing changes, for 2 of 3 residents reviewed for non-pressure skin conditions, (#59 & #256), and application of compression stockings to treat edema, for 1 of 2 residents reviewed for edema, (#6), out of a total sample of 47 residents. Findings: Cross Reference F842 1. Resident #59 was readmitted to the facility from an acute care hospital on 01/2/2023 with diagnoses that included encounter for orthopedic aftercare following surgical amputation, type II diabetes with foot ulcer, non-pressure chronic ulcer of unspecified heel and midfoot with unspecified severity, and diabetes mellitus with mild non-proliferative diabetic retinopathy without edema. The Minimum Data Set (MDS) Admission assessment dated [DATE] revealed resident #59 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated moderate cognitive impairment. He presented with frequent changes in mood but did not display any behaviors towards himself or others. He also required partial to moderate assistance for persona care. Skin assessment further revealed that resident #59 had a venous and arterial foot ulcer for which he received wound care. Review of the order summary report from 01/02/24 through 02/22/24 revealed resident #59 had wound treatment orders to be started on 01/12/24 that read cleanse right heel with normal saline, pat dry, apply collagen with silver to wound base, cover with abdominal pad, then rolled gauze, secure with tape once daily. Protect peri wound with skin prep every dressing change. To be completed daily during day shift. Review of the medical record revealed the resident had a care plan for impairment of skin integrity related to right heel arterial ulcer, initiated 10/21/22 and revised on 02/14/24. The goal was for the risk of complications related to skin impairment to be minimized through the review date of 01/25/24. Interventions included to administer medications and perform treatments as ordered, and to identify potential causative factors and eliminate/resolve where possible. On 02/19/24 at 2:50 PM, resident #59 was observed in his room sitting up in bed with eyes open. The resident stated he was legally blind in both eyes. He had a dressing on his right heel that appeared to be clean, dry, and intact dated 02/16/24 with initials of the nurse. Resident #59 stated he was recently hospitalized due to an infection to the wound on his right heel. He said dressing changes were completed by the nurse every two days. On 02/19/24 at 5:17 PM, resident #59's assigned nurse, Registered Nurse (RN) C, was asked to check the dressing on resident #59. She confirmed the date it was last changed was 02/16/24 by the wound nurse. RN C stated the wound nurse completed dressing changes for all residents in the facility and when she was not available, it was the responsibility of the assigned day shift nurse. RN C acknowledged the date of the dressing indicated it was applied three days ago. On 02/19/24 at 5:25 PM, the Wound Nurse explained she was responsible for completing dressing changes for all residents in the facility. She noted when she was not available, it was the responsibility of the resident's assigned nurse. She stated she did not work on the weekends. She stated the resident was being treated for an unstageable vascular wound on his right heel and the wound was healing nicely. She indicated the dressing changes were to be completed daily during the day shift. The Wound Nurse confirmed she had completed resident #59's dressing change on 02/16/24 and review of the Treatment Administration Record (TAR) revealed the same. The record showed that on 02/17/24 and 02/18/2024 dressing changes had been documented as completed by RN G, and wound care on 02/19/24 had not yet been completed. The wound nurse stated she had not completed the dressing change that morning because she was busy and had asked resident #59's assigned nurse, RN C, to complete it. She was not sure why RN C had not completed the dressing change. On 02/21/24 2:04 PM, RN G, confirmed she was the assigned nurse for resident #59 on the weekend of 02/17/24 and 02/18/24. She reported she was very busy and not feeling well during the weekend. She acknowledged she had documented the dressing change with the intention of completing it but got caught up with other tasks. RN G stated she made a mistake and should not have documented the wound care until after it was completed. 36489 2. Review of the medical record revealed resident #256 was admitted to the facility on [DATE] with diagnoses including left leg cellulitis (bacterial skin infection), type 2 diabetes, and open wounds on her toes. The MDS Admission assessment with assessment reference date of 2/11/24 revealed resident #256 had no venous or arterial wounds and ulcers on her feet. Review of a Wound Evaluation & Management Summary progress note dated 2/16/24 revealed resident #256 was assessed by a Wound Specialist Physician. The note indicated she had a full thickness diabetic wound on her right heel that measured 4.3 centimeters (cm) x 4.7 cm x 0.2 cm. The wound was described as an open blister with moderate serous exudate, and the wound specialist physician noted he surgically removed dead tissue from the wound during the visit. Review of the Order Summary Report revealed a physician order dated 2/16/24 for a right heel wound treatment. The order instructed nurses to cleanse resident #256's right heel wound with normal saline, pat dry, apply honey alginate to the wound base, cover with an absorbent abdominal pad, and wrap with rolled gauze. The order also included application of a skin protectant around the edges of the wound with every dressing change. The physician order indicated the dressing was to be changed once daily, during the 7:00 AM to 7:00 PM day shift. Review of resident #256's medical record revealed a care plan for impaired skin integrity related to left leg cellulitis, abdominal and groin rashes, a skin tear, and her right heel wound. The care plan, initiated on 2/04/24 and revised on 2/19/24, had a goal to minimize the risk of complications for skin impairments. The interventions included keep skin clean and dry and observe for signs and symptoms of infection. However, the care plan approaches did not reflect ordered treatments such as the daily dressing change for her right heel. On 2/19/24 at 12:46 PM, resident #256 had a white gauze dressing that was dated 2/16 on her right foot. The resident's assigned nurse, Licensed Practical Nurse (LPN) A, confirmed the date on the dressing indicated it was applied three days before. She stated to her knowledge, it should be changed once daily. On 2/19/24 at 1:11 PM, the Wound Nurse reviewed resident #256's physician orders and confirmed her right heel dressing was to be changed once daily, during the day shift. She was informed the resident's dressing was currently dated 2/16/24. The Wound Nurse stated that date meant neither of the assigned nurses on the weekend provided wound care. She acknowledged it was necessary for nurses to complete wound care and dressing changes as ordered to promote healing and prevent worsening of wounds. The Wound Nurse reviewed the resident's care plans and explained she had not yet revised the document to include wound treatments or instructions to float her heels and apply soft boots. On 2/22/24 at 4:44 PM, in a telephone interview, the Wound Specialist Physician was informed nurses had not followed the plan of care related to daily dressing changes for resident #256 over the weekend. He confirmed his expectation was nurses would follow his orders for wound care and treatments. 3. Review of the medical record revealed resident #6 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, morbid obesity, left leg cellulitis, and need for assistance with personal care. Resident #6 had a care plan for complications related to edema initiated on 12/06/23. The goal was to decrease the risk of complications associated with edema. The interventions included encourage the resident to keep the affected area elevated; monitor for complications such as redness, discoloration, and breaks in the skin; and provide pressure reduction devices or equipment as ordered. Edema is swelling caused by too much fluid trapped in the body's tissues. It can occur in any part of the body but is more likely in the legs and feet. Edema is often a result of diseases including congestive heart failure. Wearing compression stockings, sleeves or gloves helps by keeping pressure on the limbs to prevent fluid from building up and prevent additional swelling (retrieved on 2/24/24 from www.mayoclinic.org/diseases-conditions/edema/symptoms-causes/syc-20366493). A Podiatry progress note dated 2/15/24 revealed resident #6 had a comprehensive foot exam with findings including poor circulation and swelling. The podiatrist noted the resident's edema was probably due to his legs being in a dependent position throughout the day, and he suggested elevation of the legs as much as possible. In addition, the podiatrist recommended knee-high thromboembolic disease (TED) hose or compression stockings to be worn while awake and removed at bedtime. Review of resident #6's Order Summary Report revealed a physician order dated 2/16/24 for knee high TED hose for gentle compression bilateral lower extremity in the morning. and to be removed at bedtime. A care plan for risk for impaired skin integrity was revised on 2/19/24 to reflect application of the (TED) hose as ordered. On 2/19/24 at 10:39 AM, resident #6 was seated in his wheelchair at the 100 unit nurses' station. He had significant edema to both lower legs and his skin was shiny, taut, and red around and above his ankles. Resident #6 stated he had been waiting for someone to measure his legs for new stockings. On 2/19/24 at 11:37 AM, LPN A stated she was informed during change of shift report at 7:00 AM that resident #6 needed compression stockings. She reviewed the medical record and confirmed the order was entered on 2/16/24 at 10:12 AM. When asked why he did not have the stockings three days after they were ordered, LPN A explained she was waiting for therapy staff to measure the resident's legs to determine the correct size. On 2/19/24 at 11:49 AM, the Rehab Director stated therapy staff did not measure residents for compression stocking size. She explained that was the responsibility of nursing staff and the appropriate size would obtained from central supply. On 2/19/24 at 1:38 PM, the Director of Nursing (DON) recalled on Friday 2/16/24, resident #6 was given compression stockings that were too small. He explained Central Supply staff went out to buy an appropriate size earlier today. The DON was asked why resident #6 was not measured and provided with the correct size compression stockings on the date they were ordered. He stated there was no physician order for measuring the resident's legs and said, It is okay for the nurse to eyeball the resident. The DON was not aware it was a standard of nursing practice to obtain calf and ankle measurements in order to select the appropriate size compression stockings. On 2/19/24 at 1:39 PM, the Central Supply staff was informed resident #6's compression stockings were ordered on Friday 2/16/24. She stated nurses had not informed her he needed the item until this morning. She explained she was in the facility until about 5:30 PM on Friday, and if she had been aware of the resident's need for this item, she would have purchased the compression stockings at a nearby pharmacy, as she did this morning. The Central Supply staff checked the facility's storage area and confirmed there were no regular or extended size compression hose in the facility. Review of the Facility/Center Assessment Tool, dated 10/17/23, revealed the facility would accept and care for residents with conditions including diabetes, skin ulcers, and congestive heart failure. The document indicated staff would provide care and services to promote skin integrity including skin and wound care.

Based on observation, interview, and record review, the facility failed to identify and monitor a notable weight loss trend, and failed to provide meal portions as ordered to promote weight stability and/or weight gain for 1 of 4 residents reviewed for nutrition, out of a total sample of 47 residents, (#66). Findings: Review of the medical record revealed resident #66 was admitted to the facility on [DATE] with diagnoses including mild protein-calorie malnutrition, type 2 diabetes, acute pancreatitis, gastroesophageal reflux disease, iron deficiency anemia, and vitamin deficiency. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 2/06/24 revealed resident #66 required maximal assistance from staff for eating. The MDS assessment, Section K - Swallowing/Nutritional Status, revealed he did not exhibit any signs and symptoms of a swallowing disorder. The resident's height was 5 feet 11 inches and he weighed 154 pounds. The document indicated resident #66 had not lost or gained weight of 5% or more in the last month, or 10% or more in the last six months, and he did not require a mechanically altered or therapeutic diet. Review of the medical record revealed resident #66 had a care plan for decreased nutritional status and dehydration related to advanced age, dementia, and multiple medications, initiated on 5/19/22 and revised on 11/15/23. The goals were the resident would remain free from significant weight changes and tolerate his diet as ordered. The interventions included assist with meals as needed, provide diet as ordered, monitor oral intake, monitor weight as ordered, and evaluation by the dietitian as needed. Review of resident #66's weight record revealed on 7/10/23 he weighed 175 pounds, and one month later on 8/08/23, he weighed 169 pounds, which was a 6-pound or 3.42% weight loss. The following month, on 9/08/23, resident #66 weighed 162 pounds, a 7-pound or 4.14% weight loss. His weight remained stable on 10/10/23 and 11/06/23 at 164 pounds, although it reflected a total loss of 11 pounds or 6.28% over 90 days. On 12/08/23, resident #66 weighed 155 pounds, a 9-pound or 5.48% significant weight loss in 30 days. On 1/05/24, the resident weighed 152# which indicated severe weight loss of over 10% in 180 days and over 13% since July 2023. Review of the Order Summary Report revealed a physician order dated 12/22/23 for fortified foods with meals for weight maintenance and encourage oral intake. Resident #66 had an order dated 1/15/24 for daily House Shake for nutritional support, and an order dated 1/29/24 for a regular diet, regular texture, with large portions for all meals. Review of resident #66's medical record revealed a Nutrition Comprehensive Evaluation dated 11/15/23 that indicated his usual body weight was between 164 and 172 pounds, and he consumed 51% to 76% of his meals. The comprehensive evaluation did not address the resident's weight of 164 pounds which was at the lower limit of his usual body weight, and his less than optimal meal intake percentages. The document did not include interventions related to the unplanned loss of 11 pounds over the previous three months to prevent additional weight loss. Review of a Nutrition Quarterly Note dated 11/20/23 revealed the facility's Certified Dietary Manager (CDM) reviewed resident #66's weights over the same period and noted, Weights stable 30/90 days. A Dietary progress note dated 12/09/23 read, Consult: Per family request, would like double portion with meals. Will honor request and follow as needed. Resident on regular diet. A note dated 12/22/23 indicated resident #66 triggered for significant weight loss of greater than 5% in 30 days, and the dietitian recommended the addition of fortified foods to his meals. According to the abovementioned Order Summary Report, double portions were never ordered, and large portions were ordered seven weeks after the daughter's request, by which time, resident #66 lost another three pounds and was noted to have severe weight loss. A dietary progress note dated 1/15/24 revealed the facility's Registered Nutrition and Dietetics Technician (NDTR) evaluated resident #66 and noted he had a 13.1% weight loss over 180 days and was underweight for his age. The note indicated resident #66 had inadequate energy intake as evidenced by his oral intake and weight loss. The NDTR recommended a daily House Shake that would provide an additional 200 calories and 6 grams of protein, and promote weight stability. On 2/19/24 at 2:10 PM, resident #66's daughter confirmed her father had lost weight while in the facility. She stated during a visit a few months ago, she noticed his ribs were showing prominently and she discovered he lost about ten pounds. She described her father as a big guy and explained the portions of food provided for him were not adequate. The resident's daughter explained she requested larger portions for him to ensure he received enough food. On 2/20/24 at 12:51 PM, Certified Nursing Assistant (CNA) D fed resident #66 in the 100 unit dining area. Review of the resident's meal ticket revealed he was to receive large portions and fortified mashed potatoes. Observation of his tray revealed items including one pork chop, carrots, one scoop of mashed potatoes, a side salad, and one piece of cake. Comparison with other residents' trays in the dining room revealed no difference in resident #66's portion sizes. On 2/20/24 at 12:56 PM, the CDM confirmed resident #66's tray had one pork chop which was a regular portion. She explained a large portion was one and one half servings of protein. She verified the scoop of potatoes and the cake were regular portions, as the term large portion applied only to meats. On 2/21/24 at 3:34 PM, the NDTR validated resident #66 had a significant weight loss of 13.1%. She explained weight loss of over 10% in 180 days or over 5% in 30 days triggered an alert in the system. The NDTR stated the resident ate well and he now received fortified foods and supplements to increase his caloric intake. She confirmed the resident had an order for a regular diet with large portions, which was one and one half portions of all items. The NDTR said, That should be one and a half of everything. He should have received one and a half pork chops and one and a half scoops of potatoes. On 2/22/24 at 9:53 AM, the Director of Nursing (DON) stated the facility conducted a weekly review of weights in the Focus meeting, a type of Risk Management meeting, that was attended by a dietitian or the NDTR. He stated the Nursing department only reviewed weights if they were triggered by the dietitian as 5% in 30 days or 10% in 180 days. When asked to review resident #66's weights, the DON validated there was a weight loss trend. He acknowledged the notable monthly weight losses should definitely have been identified by restorative aides who weighed the resident and the CDM who reviewed the weights when she made monthly notes. The DON stated the dietitian should also have noted the weight loss trend. He stated resident #66 ate well and to his knowledge, did not have any clinical conditions that would have caused the weight loss. He explained it was facility standard for the Nursing department to request weekly weights for residents who had significant weight losses. He was informed resident #66 was never placed on weekly weights even after the 5% and 10% losses triggered alerts. The DON stated if he had been aware, he would have obtained and implemented a physician order for weekly weights. He acknowledged the resident's daughter asked him to arrange large meal portions for her father as she felt the quantity of food provided for him was not enough. On 2/22/24 10:20 AM, the CDM stated the restorative aides obtained residents' weights and she recorded them. She reviewed resident #66's weights from July 2023 to February 2024 and acknowledged she did not notice his weight loss trend. She said, If I had, I would have referred to the dietitian. She confirmed residents who had significant weight loss should be monitored by weekly weights, but this was not initiated for resident #66. The CDM stated she misspoke in the earlier interview, as she knew large portions referred to all foods, not just the meat. On 2/22/24 at 3:05 PM, the NDTR was asked if she addressed weight loss only when triggered as significant or severe. She explained during weekly Focus meetings she also proactively reviewed residents who were at higher risk for weight loss, for example, those who lost five pounds in 30 days even if less than 5% of their weight. The NDTR reviewed resident #66's weight record and acknowledged although he lost five pounds in two consecutive months, August and September, the facility did not implement proactive interventions. She stated she was not on staff during that period, but the previous NDTR probably followed the protocol for losses of 5% in 30 days, 7.5% in 90 days, or 10% in 180 days. The NDTR acknowledged in that situation, she would have implemented an appropriate intervention to prevent further weight loss. The facility's policy and procedure for Nutritional Risk Evaluation dated 5/22/18 read, The nutritional evaluation is an approach to screen, define, and treat the resident's nutritional status. The Comprehensive Evaluation was to include diet order, supplement(s), height, weight, usual body weight, recent changes in weight, and estimated intake. The narrative evaluation and plan should address contributing factors for weight loss and interventions to correct or prevent negative outcomes.

Based on observation, interview, and record review, the facility failed to ensure transdermal medication patches were removed according to accepted professional nursing standards of practice for 1 of 2 residents observed for mood and behaviors out of a total sample of 47 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, unspecified psychosis not due to a substance or known physiological condition, unspecified dementia with unspecified severity and other behavioral disturbance, bipolar disorder (diagnosed [DATE]), and residual schizophrenia (diagnosed [DATE]). Residual schizophrenia is a subtype of schizophrenia in which the individual has suffered an episode of schizophrenia but there are no longer any delusions, hallucinations, disorganized speech or behavior (retrieved on 02/28/24 from Natural Library of Medicine, https://www.ncbi.nlm.nih.gov). The Minimum Data Set (MDS) Quarterly Assessment with Assessment Review Date (ARD) 01/02/24 revealed resident #1 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated she had severe cognitive function. The assessment noted she exhibited both physical and verbal behaviors towards others with frequent rejections of care. Review of the Order Summary Report revealed resident #1 had medication orders for Secuado Transdermal Patch 3.8 milligrams (mg) every 24 hrs to be applied once per day for mood disorder, Nudexta 20-10 mg give one capsule by mouth twice a day for pseudobulbar affect, and Depakote Sprinkles 125 mg give four capsules by mouth twice a day related to bipolar disorder and two capsules by mouth in the afternoon for mood disorder. Resident #1 had a care plan for behaviors that included yelling out, and fixation with the over-the-bed light cord due to diagnosis of psychosis, dementia, and multiple sclerosis. Interventions included administering medications as ordered and psych services as needed. A care plan was noted for use of psychotropic medications related to schizophrenia, bipolar disorder, depression, dementia, and history of psychosis. Interventions included evaluating for dose reduction and administering medications as ordered. On 02/19/24 at 9:30 AM, resident #1 was in bed on her back with eyes open and head of bed elevated. There was a transdermal patch, Secuado, stuck to the front top right corner of her gown dated 02/18/24. The patch was not in contact with her skin and there was another similar patch on the floor to the right side of her bed dated 2/8/24. On 02/20/24 at 11:52 AM, the transdermal patch was no longer on her gown. The patch on the ground dated 02/08/24 was still there. On 02/20/24 at 4:41 PM, the resident's assigned nurse, Registered Nurse (RN) C, explained that resident #1 often took off the transdermal patch if it was placed in an area she could reach. RN C stated that normally the patch was placed in an area the resident could not be reach such as upper chest and upper back. On 02/21/24 at 11:14 AM, Registered Nurse (RN) G was observed applying the transdermal patch on resident #1. RN G verified the order and confirmed the transdermal patch was to be applied once per day every 24 hours. RN G informed the resident what she was doing and then chose to place the transdermal patch dated 02/21/24 to the resident's upper chest. RN G then located two other patches that had not been removed dated 02/19/24 and 02/20/24 on resident #1's upper right arm. RN G stated the nurse should have removed the old one before applying the new one. She explained the importance of removing a used transdermal patch was to make sure the resident was not getting more medication than prescribed. RN G was made aware there was a patch on the floor dated 02/08/24 that had not been properly disposed of. She acknowledged it should have been properly disposed to prevent another resident from picking it up. RN G returned to medication cart to document medication patch had been administered and location of the new patch. She stated that nurses were able to see where the previous patch had been placed before putting the new patch on. RN G admitted she had not checked where the old patch had been placed before she entered the resident's room. She noted there was no order to remove the old patch but that it was nursing knowledge that transdermal patches had to be removed before placing a new one to prevent accidental overdosing. On 02/21/24 at 11:33 AM, the 200 Unit Manager stated it was important to remember to put the transdermal patch in an area that had no hair and where a resident with behaviors could not reach it. She explained that before applying a new transdermal patch, it was important to remove the old one to prevent forgetting it and accidentally administering more than the ordered dose. The UM confirmed there was no order for the transdermal patch to be removed before applying the new one.

Based on observation, interview, and record review, the facility failed to ensure medical records accurately documented wound care treatments in accordance with professional standards of practice for 2 of 3 residents reviewed for non-pressure related skin conditions, out of a total sample of 47 residents, (#59 and #256). Findings: Cross Reference F684 1. Resident #59 was readmitted to the facility from an acute care hospital on 01/2/2023 with diagnoses that included encounter for orthopedic aftercare following surgical amputation, type II diabetes with foot ulcer, non-pressure chronic ulcer of unspecified heel and midfoot with unspecified severity, and diabetes mellitus with mild non-proliferative diabetic retinopathy without edema. The Minimum Data Set (MDS) Admission assessment dated [DATE] revealed resident #59 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated moderate cognitive impairment. He presented with frequent changes in mood but did not display any behaviors towards himself or others. He also required partial to moderate assistance for personal care. Review of skin assessments noted resident #59 had venous and arterial foot ulcer for which he received wound care. Review of the order summary report from 01/02/24 through 02/22/24 revealed resident #59 had a wound treatment order to be started on 01/12/24 that read, right heel cleanse with normal saline, pat dry, apply collagen with silver to wound base, cover with abdominal pad, then rolled gauze, secure with tape once daily. Protect peri wound with skin prep every dressing change. To be completed daily during day shift. Review of the medical record revealed resident #59 had a care plan for impairment to skin integrity related to right heel arterial ulcer, initiated on 10/21/22 and revised on 02/14/24. The goal was for the risk of complications related to skin impairment to be minimized through the review date of 01/25/24. Interventions included to administer medications and perform treatments as ordered, and to identify potential causative factors and eliminate/resolve where possible. On 02/19/24 at 2:50 PM, resident #59 was observed in his room, sitting up in bed with eyes open. The resident stated he was legally blind in both eyes. He had a dressing on his right heel that appeared to be clean, dry, and intact dated 02/16/24 with the nurse's initials. Resident #59 stated he was recently hospitalized due to an infection to the wound on his right heel. He stated that dressing changes were completed by the nurse every two days. On 02/19/24 at 5:17 PM, the assigned nurse for resident #59, Registered Nurse (RN) C, was asked to check the dressing on resident #59. She confirmed the date it was last changed was 02/16/24 by the Wound Nurse. RN C stated the Wound Nurse was responsible for completing dressing changes for all residents in the facility and when she was not available, it was the responsibility of the assigned day shift nurse to complete. RN C stated she was unsure why resident #59's dressing had not been changed. On 02/19/24 at 5:25 PM, the Wound Nurse stated she was responsible for completing dressing changes for all residents in the facility and when she was not available, it was the responsibility of the resident's assigned nurse. She stated she did not work on the weekends. She explained the resident was being treated for an unstageable vascular wound on his right heel and the wound was healing nicely. She noted dressing changes were to be completed daily during the day shift. She confirmed she had completed resident #59's dressing change on 02/16/24 and review of the Treatment Administration Record (TAR) revealed the same. The record also showed on 02/17/24 and 02/18/2024 dressing change had been documented as completed by RN G, and 02/19/24 had not yet been completed. The Wound Nurse stated she had not completed the dressing change that morning because she was busy and had asked resident #59's assigned nurse, RN C, to complete it. She was not sure why RN C had not completed the dressing change. On 02/21/24 2:04 PM, RN G, confirmed she was the assigned nurse for resident #59 on the weekend of 02/17/24 and 02/18/24. She stated she was very busy and not feeling well on the weekend. She said she had documented the dressing change with the intention of completing it but got caught up with other tasks. RN G noted she made a mistake and should not have documented the wound care until after it was completed. On 02/21/24 at 2:24 PM, the Staffing Development Coordinator (SDC), stated she was actively involved in educating staff about proper documentation. She explained nurses were supposed to accurately and truthfully complete required resident documentation such as Daily Skilled Notes, and Medication and Treatment Administration Records. The SDC said a treatment, procedure, or medication should not be documented first before it had been completed due to possibly forgetting to complete it or resident refusal. She reported she expected nurses and staff to document tasks as they were done or soon after. She added that accurate and precise documentation was important for continuity of care. 36489 2. Review of the medical record revealed resident #256 was admitted to the facility on [DATE] with diagnoses including left leg cellulitis (bacterial skin infection), type 2 diabetes, and open wounds on her toes. Review of the Order Summary Report revealed a physician order dated 2/16/24 for a right heel wound treatment. The order instructed nurses to cleanse resident #256's right heel wound with normal saline, pat dry, apply honey alginate to the wound base, cover with an absorbent abdominal pad, and wrap with rolled gauze. The order also included application of a skin protectant around the edges of the wound with every dressing change. The physician order indicated the dressing was to be changed once daily, during the 7:00 AM to 7:00 PM day shift. On 2/19/24 at 12:46 PM, resident #256 had a white gauze dressing that was dated 2/16 on her right foot. The resident's assigned nurse, Licensed Practical Nurse (LPN) A, confirmed the date on the dressing indicated it was applied three days before. She stated to her knowledge, it should be changed once daily. On 2/19/24 at 1:11 PM, the Wound Nurse reviewed resident #256's physician orders and confirmed her right heel dressing was to be changed once daily, during the day shift. She was informed that the resident's dressing was currently dated 2/16/24. The Wound Nurse stated that date meant neither of the assigned nurses on the weekend provided wound care. Review of resident #256's Treatment Administration Record (TAR) for February 2024 revealed the document reflected the physician order for the resident's right heel wound care and dressing. The TAR was initialed by LPN L on 2/17/24 with a code 13 that indicated resident #256 refused to have her right foot dressing changed. On 2/18/24, Registered Nurse (RN) K initialed the TAR to verify she completed the treatment which conflicted with the date of 2/16/24 observed on the dressing. Review of the Medication Administration Audit Report for the day shifts on 2/17/24 to 2/18/24 revealed LPN L documented resident #256's refusal of wound care at the end of the shift, 2/17/24 at 7:08 PM. The report showed RN K documented completion of the treatment on 2/18/24 at 1:15 PM. Review of nursing progress notes for 2/17/24 revealed no associated documentation regarding resident #256's refusal of care, and no evidence that LPN L attempted to complete the dressing change during the 12-hour day shift. On 2/21/24 at 9:30 AM, resident #256 emphasized she did not refuse wound care or dressing changes over the past weekend. On 2/21/24 at 5:53 PM, the Director of Nursing (DON) confirmed the medical record should be an accurate reflection of a resident's status and the care and services provided by staff. The DON verified nurses were to document a task as completed only after it was done, and his expectation was that nurses would not take shortcuts related to care or documentation. Review of the facility's policy and procedure for Computerized Medical Records, dated 5/19/15, revealed computer-based medical records supported the clinical decision-making process and improved the quality of resident care. The document indicated the medical record was .specifically designed to support users by providing access to complete and accurate clinical and related information concerning a resident.

Based on observation, interview, and record review, the facility failed to follow procedures to ensure accurate records and documentation of controlled medication reconciliation to prevent diversion for 6 of 27 residents sampled for accuracy of administering opioid medications, (#800, #14, #802, #803 #804 and #805). Findings: 1. Resident #800 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)] of right knee, and chronic pain syndrome. Review of the Plan of Care initiated 5/28/22 revealed a focus for chronic pain related to multiple comorbidities and an intervention for analgesics as ordered. Review of the May and June 2022 physician order sheets showed an order dated 5/28/22 for [MEDICATION(S)] 15 milligrams (mg) tablet give 1 by mouth every 6 hours as needed for severe pain. On 6/20/22 at 12:20 PM, resident #800 stated he did not get all his pain pills. He said he told administration and the Unit Manager and added they knew all about it. On 6/20/22 at 12:25 PM, the 100 hallway Unit Manager acknowledged she was informed by resident #800 this morning that he did not get his pain medication last night. She indicated she checked the Medication Administration Record (MAR) and the medication was signed as administered. Review of resident #800's narcotic sign out sheet revealed [MEDICATION(S)] 15 mg tablet was signed out on the narcotic sheet on 6/20/22 at 5:45 PM but it was not signed as administered on the MAR at 5:45 PM on 6/20/22. Further review of the narcotic sign out sheet for May and June 2022 revealed [MEDICATION(S)] doses were signed out as given but not signed as administered on the MAR on 5/29/22 at 2:30 PM, 5/29/22 at 9:00 PM, 5/30/22 at 3:00 PM, 5/31/22 at 1:15 AM, 6/4/22 at 8:23 PM, 6/5/22 at 3:30 PM, 6/5/22 at 9:30 PM, 6/7/22 at 6:30 AM, 6/7/22 at 10:30 AM, 6/10/22 at 4:30 AM, 6/13/22 at 10:00 PM, 6/14/22 at 6:50 PM, 6/15/22 at 7:20 AM, 6/15/22 at 9:00 PM, 6/19/22 at 3:22 AM, 6/20/22 at 4:45 PM. The inaccuracies of dispensing, administering and reconciliation of the [MEDICATION(S)] 15 mg tablet totaled 16 doses signed out in 22 days, from May 29, 2022- 6/20/22 on the controlled narcotic sheet by various nurses, over different shifts and not documented as administered on the MAR for resident #800. On 6/20/22 at 3:42 PM, the Director of Nursing (DON) said, My expectation is for nurses to sign for medications when they are given. She noted the narcotic sheets should show complete documentation which should match the MAR. On 6/21/22 at 4:34 PM, the narcotic sing out sheet and MAR for resident #800 were reviewed with Licensed Practical Nurse (LPN) G. She stated she signed for the [MEDICATION(S)] for the resident on 5/30/22 at 3:00 AM, and 5/31/22 at 1:15 AM. She acknowledged she signed for the medication on the narcotic sheet but not on the MAR. She reported the medication must be checked as being given on the MAR at the same time it is signed for on the narcotic sheet. She said she was provided a packet of education during orientation for signing out for narcotics and signing on the MAR and indicated she was responsible. On 6/21/22 at 4:55 PM, LPN A revealed she gave the resident [MEDICATION(S)] on 6/13/22 at 10:00 PM, and 6/15/22 at 9:00 PM. LPN A stated the process for administering [MEDICATION(S)] was to ask the resident about pain level, sign out the medication in the narcotic count sheet, administer the medication then sign as given on the electronic MAR. She stated she forgot to sign the MAR to show the medication was administered. On 6/21/22 at 5:26 PM, LPN I stated he gave the resident [MEDICATION(S)] on 6/14/22 at 6:50 PM. He reviewed the narcotic sign out sheet and the MAR and noted he must have been busy and forgot to sign for the medication in the MAR. He stated he was responsible to complete the narcotic sheet and document on the MAR. On 6/21/22 at 5:40 PM, Registered Nurse (RN) D reviewed the narcotic sign out sheet and the MAR for resident #800 and indicated she gave the resident medication on 6/7/22 at 10:30 AM. RN D stated after administering the medication, she should have signed as being given on the MAR but was not sure what happened on 6/7/22. On 6/21/22 at 5:42 PM, the Regional Nurse acknowledged nurses throughout the facility were not documenting accurately on medications after administering. On 6/22/22 at 2:38 PM, the Pharmacy Consultant stated she randomly reviewed residents' controlled drug sheets and compared them to the MAR. She validated the narcotic sign out sheets should be filled out completely and match the residents' MAR. She stated the nurses giving the opioid medications were responsible for documenting in both places. 2. Resident #14 was admitted to the facility on [DATE] with diagnoses which included kidney failure and spinal enthesopathy. Review of resident #14's physician orders for the month of April, May and June 2022 revealed an order start date of 3/15/22 for [MEDICATION(S)] Tablet ([MEDICATION(S)] Acetaminophen) 7.5 mg-325 mg give 1 tablet by mouth every 6 hours as needed for pain. Review of the resident's MAR and narcotic sign out sheet revealed [MEDICATION(S)] was signed out on the narcotic sign out sheet but not signed as given on the MAR on the following dates and times: 4/29/22 at 8:00 PM, 5/1/22 at 12 PM, 5/1/22 at 10:00 PM, 5/2/22 at 6:00 AM, 5/2/22 at 9:00 PM, 5/3/22 at 12:00 PM, 5/3/22 at 9:00 PM, 5/5/22 at 12:00 PM, 5/8/22 at 12:00 PM, 5/8/22 at 6:30 PM, 5/9/22 at 9:00 PM, 5/11/22 at 8:00AM, 5/11/22 at 9:00 PM, 5/12/22 at 10:00 PM, 5/13/22 at 9:00 PM, 5/14/22 at 1:00AM, 5/14/22 at 6:00AM, 5/18/22 at 10:00 PM, 5/19/22 at 9:00AM, 5/20/22 at 6:30 AM 5/20/22 at 9:00 PM, 5/21/22 at 11:00 PM, 5/28/22 at 6:00AM, 5/28/22 at 9:45 PM, 6/1/22 at 9:42 PM, 6/2/22 at 9:00 PM, 6/4/22 at 9:00 PM, 6/5/22 at 7:30 PM, 6/7/22 at 2:00 PM, 6/9/22 at 6:15 AM, 6/10/22 at 5:49 PM, 6/12/22 at 12:00 PM, 6/13/22 at 10:30 PM, 6/14/22 at 5:00 PM, 6/15/22 at 5:00AM, 6/15/22 at 10:05 PM, 6/16/22 at 9:00 PM, 6/18/22 at 6:49 AM, 6/20/22 at 2:00 PM, and 6/22/22 at 4:08 AM. There was a total of 40 doses signed out on the narcotic sheet by various nurses from April 2022- June 2022 but not documented as administered on the resident's MAR. 3. Resident #802 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)] disease, and malignant neoplasm of skin. Review of resident #802's physician orders showed [MEDICATION(S)] solution 20 mg/milliliter (ml) give 5 mg by mouth every 12 hours and [MEDICATION(S)] solution 20 mg/ml give 5 mg by mouth every 6 hours as needed for pain. Both orders were dated 6/21/22. On 6/22/22 at 10:09 AM, the DON provided a sheet of paper with handwritten dates and nurses' signatures for 6/22/22 at 7:30 PM and 6/22/22 at 6:00 AM. Review of the narcotic sign out record dated 6/22/22, revealed a blank form, that showed [MEDICATION(S)] was received by two nurses with signatures for [MEDICATION(S)] 100 mg/5 ml Concentrate take 0.25 ml (25mg) by mouth every 12 hours scheduled and every 6 hours as needed. There was no date, time or amount of dose given, signature of administering nurse, or amount of narcotic remaining on the narcotic sign out sheet. 4. Resident # #803 was admitted to the facility on [DATE] with rectal abscess and acute kidney failure. Review of the resident's physician orders for the month of June 2022 revealed an order dated 6/16/22 for [MEDICATION(S)] 7.5-325 mg give 1 tablet by mouth every 4 hours as needed for severe pain for 3 days. An order dated 6/20/22 read, [MEDICATION(S)] 7.5-325 mg give 1 tablet by mouth every 4 hours as needed for severe pain, and an order dated 6/22/22 for [MEDICATION(S)] 7.5-325 mg give 1 tablet by mouth every 6 hours for sacral wound pain. Review of the narcotic sign out sheet revealed the medication was signed out on 6/18/22 at 3:08 AM, 6/20/22 at 12:25 AM, 6/20/22 at 5:40 AM, 6/20/22 at 6:15 PM, 6/20/22 at 11:45 PM. A total of 5 doses were signed out on the narcotic sheets by various nurses in the month of June and not documented as administered on the resident's MAR. 5. Resident #804 was admitted to the facility on [DATE] with diagnoses which included low back pain, muscle spasms, and chronic pain syndrome. Review of resident #804's physician orders for the months of May and June 2022 showed physician order dated 5/19/22 for [MEDICATION(S)]-Acetaminophen tablet 5-325 mg give 1 tablet by mouth every 6 hours as needed for Chronic Pain Syndrome. Review of the narcotic sign out sheet and MAR revealed [MEDICATION(S)] 5-325 mg was signed out on the narcotic sign out sheet on 5/19/22 with no time documented, 5/22/22 at 10:00 PM, 5/23/22 at 9:00 PM, 5/26/22 at 10:00 PM, 5/29/22 at 8:00 PM, 5/30/22 at 10:00 PM, 5/31/22 at 9:45 PM, 6/13/22 at 7:30 AM, 6/14/22 at 1:00 AM, 6/14/22 at 9:00 PM, 6/15/22 at 9:00 PM, 6/16/22 at 3:00 AM, 6/16/22 at 7:00 PM, 6/17/22 at 8:00 PM, and 6/19/22 at 8:00 PM. There was a total of 15 doses of [MEDICATION(S)] signed out on the narcotic sheet by various nurses from May 2022- June 2022 but not documented as administered on the resident's MAR. 6. Resident #805 was admitted to the facility on [DATE] with diagnoses which included acute [CONDITION(S)] right ankle and foot, peripheral vascular disease, gout, and foot ulcer. Review of resident #805's physician orders for May and June showed an order dated 5/10/22 for [MEDICATION(S)] 5-325 mg tablet give 1 tablet by mouth every 6 hours as needed for pain level of 4-6, and [MEDICATION(S)] 5-325 mg tablet give 2 by mouth every 6 hours as needed for pain level of 7-10. Review of the narcotic sign out sheets revealed doses of [MEDICATION(S)] were signed out on 5/13/22 at 12:00 AM, 5/16/22 at 6:10 AM, 5/16/22 at 7:15 PM, 5/24/22 at 10:15 PM, 5/25/22 at 5:35 PM, 5/26/22 with no time documented, 5/28/22 at 6:00 PM, 5/30/22 at 3:00 AM, 5/31/22 at 7:50 PM, 6/1/22 at 6:00 PM, 6/3/22 at 2:00 PM 6/6/22 at 8:00 PM 6/14/22 at 9:00 PM, 6/16/22 at 10:00 PM, and on 6/17/22 at 9:45 PM. There was no documentation on the MAR to show the above doses were administered. A total of 15 doses were signed out on the narcotic sheet by various nurses from May to June 2022 but were not documented as administered on the resident's MAR. Review of the facility's Pharmacy Services and Procedure Manual 5.4 Inventory Control of Controlled Substances revealed 1.1 Controlled Substances Declining Inventory Record. These records should include: 1.1.5 Date and time of administration. 5. Facility representative should regularly check the inventory records to reconcile inventory. Facility should regularly reconcile 5.1 Current and discontinued inventory of controlled substances to the log used in Facility's controlled medication inventory system. 5.2 Current inventory to the controlled medication declining inventory record and to the resident's MAR .

Based on interview and and record review, the facility failed to complete, encode and transmit a required Minimum Data Set (MDS) Discharge assessment for 1 of 5 residents reviewed for hospitalization , of a total sample of 42 residents (#28). Findings: Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note dated 2/22/22 read, Resident's daughter is concerned about her mother's left lower leg feeling cold because she had a stent put in.As per daughter's request she wants her mother to go to the hospital. As per Dr. [name of physician], we may send resident 911. Resident left via 911. Clinical record review revealed a SNF/NF[Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form dated 2/22/22 that indicated the resident was transferred to the hospital on 2/22/22. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no MDS Discharge assessment to reflect resident #28's discharge from the facility on 2/22/22. On 5/12/22 at 12:04 PM, the 2nd Chair MDS Coordinator stated resident #28 was discharged to the hospital on 2/22/22. She explained an MDS Discharge assessment should be completed for all residents discharged from the facility. She verbalized the assessment would be completed by the Lead MDS/Care Plan Coordinator. During review of resident #28's MDS assessments with the 2nd chair MDS Coordinator, she confirmed an Entry MDS assessment with ARD of 2/09/22, and an MDS Admission assessment with ARD of 2/16/22 were completed. She acknowledged no MDS Discharge assessment for this resident could be identified and confirmed it had been missed. On 5/12/22 at 12:10 PM and 2: 28 PM, the Lead MDS/Care Plan Coordinator stated MDS Discharge assessments should be completed, encoded and transmitted within fourteen days of the resident's discharge from the facility. She acknowledged resident #28 was discharged from the facility, and although an MDS Discharge assessment should have been completed for the resident, it was not done. She described the issue as an oversight. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 Version 1.17.1, effective October 2019, provided instructions for MDS staff. Chapter 2 entitled Tracking Records and Discharge Assessments indicated the MDS Discharge assessment - Return Not anticipated or Return Anticipated must be completed when the resident is discharged from the facility and the resident is not expected/[expected] to return to the facility within 30 days. Must be completed within 14 days after the discharge date . The facility's policy Resident Assessment Instrument (RAI) Process revised on 3/27/18 indicated the Resident Care Specialist was responsible for completion of comprehensive assessments for each resident from admission to discharge.

Based on interview and record review, the facility failed to provide a care plan meeting invitation, and failed to ensure participation of the resident and all required members of the interdisciplinary team (IDT) in the care plan meeting for 1 of 1 resident reviewed for care plans, out of the total sample of 42 residents (#94). Findings: Resident #94 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) admission assessment with assessment reference date of 4/09/22 revealed the resident's Brief Interview for Mental Status score was 13, which indicated he was cognitively intact. The MDS assessment showed that the resident and the family participated in the assessment. On 5/10/22 at 9:35 AM, resident #94 stated he did not remember participating in any care plan meetings since he was admitted to the facility. Review of Progress Notes from 4/08/22 to 4/13/22 revealed a care plan meeting note dated 4/12/22 at 3:15 PM that read, Care plan meeting held with IDT, spoke to neighbor who states he will return home to live with his father upon discharge. There were no progress notes entered by individual members of the IDT and no summary of discussions held in the meeting regarding the resident's plan of care. On 5/12/22 at 11:11 AM, the Lead MDS/Care Plan Coordinator explained the care planning process. She stated all residents had their comprehensive care plans completed within the first 21 days in the facility. The Lead MDS/Care Plan Coordinator explained the facility either hand-delivered care plan invitation meeting letters to residents who were alert and oriented, or mailed the letters to the families of residents who were cognitively impaired. She stated she met with resident #94 on 4/12/22 and he gave her permission to discuss his care plans with his neighbor as his father was not available. The Lead MDS/Care Plan Coordinator reviewed documentation in her office and was unable to find a copy of the care plan meeting invitation letter for resident #94. She provided a Care Plan Attendance Log form dated 4/12/22 which showed signatures for meeting attendees that included herself, the Unit Manager, Therapy Manager, Social Services and Certified Dietary Manager. She confirmed the sections for the resident and family attendance were left blank, and there was no documentation on the form to show resident #94 was informed about his plan of care or that the resident/family was invited. When asked why it was important for the resident to attend his care plan meeting, she stated it was the opportunity for the IDT to explain his care and answer his questions. She confirmed each member of the IDT was expected to be present at the meeting. On 5/12/22 at 11:31 AM, resident #94 reviewed a sample Care Plan Meeting Invitation Letter and reiterated he had never received that letter. He stated he did not attend a care plan meeting with the 5 members of the IDT listed on the attendance log provided by the Lead MDS/Care Plan Coordinator. On 5/12/22 at 12:14 PM, the Lead MDS/Care Plan Coordinator reviewed the resident's electronic medical record and his paper chart and validated there were no copies of the Care Plan Meeting Invitation Letter. She recalled resident #94 was on isolation precautions on the scheduled day of the care plan meeting, so she was the only member of IDT who went to the room. She stated she did not bring the pen or the paperwork to the room and resident #94 was not able to sign for his attendance. The Lead MDS/Care Plan Coordinator did not respond when asked why the care plan meeting was not held by phone, or at a later date when the resident was off isolation precautions. She could not explain why she was able to enter the resident's room, but the other members of the IDT could not do so. Review of the facility's Policies and Procedures Care Plan Conference revised on 2/18/19 revealed staff were responsible for assisting residents to engage in the care planning process. The document indicated a copy of the care plan meeting notification letter would be retained in the medical record. The policy indicated that care plan meeting should be documented in the progress notes and should include a summary of the meeting and attendees including a licensed nurse and the nurse's aid and a member of dietary staff, social service representative and to the extent practicable, the participation of the resident and the resident's representative(s). On 5/12/22 at 2:26 PM, the Lead MDS/Care Plan Coordinator validated the facility's policy required inclusion of residents' direct care aides in the IDT and documentation if the nurses' aide was not available. She stated the facility did not include nurses' aides in care plan meetings. However, the Lead MDS/Care Plan Coordinator confirmed input from nurses' aides was important as they spent more time with residents than any other member of the IDT.

Based on observation, interview and record review, the facility failed to ensure the resident's right to be free from abuse for 1 of 3 sampled residents, (#60). A certified nursing assistant (CNA) hit/punched resident #60 after the resident resisted care and exhibited behaviors of distress. The failure to keep resident #60 free from a willful infliction of injury as he experienced behavioral distress resulted in a finding of actual harm. Findings: Resident #60 was a [AGE] year old male who was admitted to the facility for long term care in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. On 12/10/18 at 1:35 AM, CNA E was providing incontinence care alone for resident #60. While she was providing care, she was observed striking the resident multiple times with both hands to his left side. This abuse was witnessed by registered nurse (RN) F, who immediately told CNA E to stop hitting the resident, and told CNA E to leave the room. In a written statement dated 12/10/18 at 8:43 AM, CNA E stated, at approximately 1:35 AM, I was doing my rounds. I went in to do resident #60 and he was doing his usual hitting at me towards me. But knowing how to maneuver my way around him. As soon as I finished putting on the brief I went to cover him up with the sheet and as soon as I looked up he spit directly in my face and I just reacted immediately. I just lifted my hand, balled up my fist, and hit him on the thigh with the side of my fist. The nurse told me don't hit him and I then left. In a written statement dated 12/10/18, RN F stated, Around 1:35 AM on 12/10/18, I came to unit two and I was looking for the CNA. The CNA (E) came out of resident #60's room to get some linen. When she went back into the room, I followed shortly behind her. I went to give her a list for the vital signs and she asked me to leave it at the bedside. When I got close to the bedside I witnessed her hitting resident #60 multiple times with an open hand. She was hitting him with both hands on his left side. I immediately told her not to hit him and she said, he spit on me. I had her leave the room and started making phone calls to management to report the incident. After speaking with the Director of Nursing (DON), CNA E was sent home. Resident #60 had physician orders [REDACTED]. On 12/10/18, approximately 7 hours after the abuse incident, a behavior of continuous screaming/yelling was documented and the resident received [MEDICATION NAME] 2 mg as needed (PRN) at 8:58 AM. A nurse's progress notes dated 12/10/18 at 3:26 PM, read, He was very agitated and [MEDICATION NAME] 2 mg PRN was given as prescribed . On 12/12/18, resident #60 was seen by a psychiatrist upon the request of the facility post abuse incident. The psychiatrist recommended behavioral interventions for staff to follow. These interventions included: ensure a visual connection was made by presenting within the patient's line of vision at the initiation of any interaction. After patient has visually connected, verbally communicate with patient before initiating physical touch. Provide visual cues by demonstrating physical touch on self to reduce anxiety and combativeness associated with perceived infringement on interpersonal boundaries. A review of the annual minimum data set (MDS) assessment, with a reference date of 12/5/18, identified the resident's ability to express himself to be severely impaired with no speech, rarely or never understood, rarely or never understands and highly impaired vision. He had a cognitive deficit assessment using the Brief Interview for Mental Status which did not generate a score. It indicated he had short term and long term memory problems, and his cognitive skills for daily decision making were severely impaired. His Activities of Daily Living (ADL) assistance indicated he was totally dependent on 2 staff for dressing, personal hygiene, toilet use, bed mobility and transfers. Further review of subsequent psychiatric visit notes dated 1/07/19 and 1/22/19 all indicated the same recommendations for behavioral interventions for staff to follow. Ensure a visual connection is made by presenting within the patient's line of vision at the initiation of any interaction. After patient has visually connected, verbally communicate with patient before initiating physical touch. Provide visual cues by demonstrating physical touch on self to reduce anxiety and combativeness associated with perceived infringement on interpersonal boundaries. A review of the resident's current plan of care for ADL's, initiated on 1/22/16 read, provide physical assistance to resident as needed (total care) for personal care tasks (dressing, bathing, toileting, hygiene). The care plan described the behaviors exhibited by the resident that included spitting, hitting, yelling and hitting self during care. The interventions included: explain all procedures to resident before starting and allow time to adjust to changes, minimize potential disruptive behaviors by offering tasks which divert attention such as music, talk to the resident, ensure comfort, provide peri-care as needed, approach resident in a calm manner, attempt to distract resident when he is observed to be hitting himself on the head, private sitter to assist staff with observation for behaviors and attempts at diversional activities, communication and interactions as able, resident enjoys listening to the radio, singing along with music, administering medication as ordered, when resident is observed hitting himself in the head, attempt to communicate with resident (have him write or encourage him to try to tell) to see if he has a headache, pain. The resident's plan of care did not specify that the resident required 2 staff assistance as indicated on the annual MDS assessment dated [DATE]. The care plan also did not specify interventions for the second person to utilize while care was being provided. The care plan did not address that the resident's vision was highly impaired and did not include the interventions recommended by the psychiatrist on 12/12/18, 1/7/19 and 1/22/19. A review of resident #60's Kardex read, Provide physical assistance to resident as needed (total care) for personal care tasks (dressing, bathing, toileting, hygiene). The Kardex did not specify that the resident required 2 staff assistance as indicated on the MDS assessment and did not include the specific interventions for staff to follow which were recommended by the psychiatrist. On 4/01/19 at 2:55 PM, CNA G provided incontinence care to resident #60 alone. The resident was clean and groomed, and cooperative during care except for once when he spat on the CNA. The resident did not respond to questions but never took his eyes off the CNA providing care. The resident was restless, moved his arms and legs often and punched the bed repeatedly with his fist. CNA G stated that she could usually provide care for him by herself but sometimes needed help of another staff member. She said she took care of him a few days per week, and was not sure what the care plan or kardex said about how many staff were required to give care. She did not explain what type of help the second CNA would provide. On 4/05/19 at 11:17 AM, CNA G stated she had taken care of resident #60 for the past 2 years. She stated, when he is agitated I talk calmly and back away from him until he calms down. When he is calm I can take care of him alone. When he is not I get someone to help me. When asked what the other person would do to help her, she did not answer. She stated that she was not aware of anyone mistreating the resident. We had some abuse training in the past few months. Last night we had in-services on dementia and behaviors but they did not talk about spiting and kicking. When asked if she received any training on techniques to use when a resident hits or spits, she stated no. She stated that she learned by watching other CNAs providing care to the resident. When asked what she learned, she stated that she backs away when he tried to hit or spit. On 4/04/19 at 5:17 PM, CNA H stated she recently started working at the facility and had taken care of resident #60 a few times. She said the resident had good and bad days. On good days, she was able to provide care by herself. On bad days she needed help to give care to the resident. When asked how she managed the resident's behaviors during care, CNA H stated I learned how to take care of him by watching the other CNAs. You see and then you learn. She said she did not recall what the care plan or Kardex said about his care. She stated that she had not received any training on how to care for this resident. On 4/05/19 at 11:36 AM, CNA K said she had an in-service this morning but could not remember what it was about. She stated, it was something about privacy at all times. She said she wasn't told why they had the in-service today. No one told me about a resident being abused. We had an in-service in (MONTH) about abuse and how to report it. I have taken care of resident #60 before and I get a 2nd person for his incontinence care. She did not answer when asked what the second person did while she provided incontinence care. She stated that she had not received any training on how to take care of resident #60 and added, we do the best we can. On 4/04/19 at 9:41 AM, CNA M stated, I take care of resident #60 about once a week on day shift. It takes 2 people for me and I prefer to ask for help when I'm changing him. He hits, kicks and spits during ADL care. I explain to him when I'm changing him to let him know what I'm doing. He only becomes combative during incontinence care. I remember getting an in-service on abuse policy in December. She stated that she had not received any training on how to care for the resident when he became combative during care. She would not elaborate when asked what the second person did when he became combative during incontinence care. On 4/03/19 at 9:36 AM Licensed Practical Nurse (LPN) L stated, I give him his medications through the peg tube and he doesn't give me a hard time about it. He does best with CNA G, but with others he will kick and act out more. There was an incident that happened with abuse sometime in (MONTH) and we had an in-service about the abuse policy and how to report abuse. When she was asked if she was monitoring how CNAs provided care, she did not provide an answer. When asked why he did best with CNA G, she did not provide any specific details. On 4/05/19 at 3:01 PM, the MDS coordinator RN J explained that if the MDS triggered that a resident was total assist of 2 persons then the resident's plan of care should include care by 2 staff persons. She further stated that when the MDS assessment is initiated, there is a 7 day look back window for care and regardless of fluctuations in care, the MDS assessment will code the highest level of care needed for the resident. RN J confirmed that resident #60's care plan did not include that the resident required total dependence of 2 staff for dressing, personal hygiene, toilet use, bed mobility and transfers. She did not elaborate on why 2 people were needed to provide care to the resident. RN J also confirmed that the psychiatrist's recommendations for interventions for resident #60 should have been added to the resident's plan of care. She did not explain why the recommendations were not included in the care plan or taught to staff. An interview was conducted with the facility Administrator and Social Services Director on 4/04/19 at 11:14 AM. The administrator stated that the abuse against resident #60 on 12/10/18 was substantiated and an investigation was started immediately. She explained that the root cause of the abuse was, the unexpected reaction of the employee due to the resident's behaviors. She stated that the CNA E was terminated on 12/17/18 and had told them that she didn't know why they were making a big deal of the situation and was surprised that she was being terminated. The administrator revealed that the sitter who was with resident #60 during the incident refused to give a verbal or written statement about what happened. She stated that the resident was assessed after the incident and there were no physical injuries noted. When asked what steps the facility took to ensure that this would not happen again, the administrator stated that they re-educated all staff on the abuse and neglect policy. The in-services were conducted by the Staff Development Coordinator on facility policy, Abuse & Neglect Prohibition. Brief outline: Abuse reporting policy. 1. Report all suspicions of abuse immediately. 2. The facility has 2 hours to report the suspicion to DCF. The education was done from 12/10/18-12/12/18. Abuse training will now be quarterly instead of annually. The facility started rotating the CNA staff caring for the resident and now 2 staff were required to assist with incontinence care. When asked why 2 staff were needed, she stated that it was for safety. When asked if the resident's care was being monitored, the administrator was not sure. When asked if any training was given to staff on how to provide care in a manner that did not inflict distress upon the resident, the administrator stated that she was not sure. The administrator could not provide any documentation that training had been provided to staff on how to care for resident #60 in a safe manner. She stated that staff were told to retreat when behaviors started and explain what was to be done to the resident. She stated that the care plan was individualized for the resident's behaviors/responses. The administrator was informed that the psychiatrist had seen the resident several times after the abuse incident and had provided interventions for staff to use when providing care to the resident. The interventions however were not communicated to the staff or included in the care plan. The administrator could not explain why the recommended psychiatric recommendations had not been implemented or added to the care plan. On 4/4/19 at 3:33 PM, the Regional Nurse Consultant, Administrator and Social services Director verified that there was no specific training provided to staff related to resident #60's behaviors. On 4/5/19 at 10:23 AM, the Regional Nurse Consultant stated that they had started re-educating staff last night on handling aggressive behaviors and Dementia Care: Managing Challenging Behaviors which was 114 days after the incident of abuse occurred. On 4/05/19 at 11:55 AM, the Medical Director stated that the resident's, care has been a challenge to preserve his autonomy. He can be aggressive and combative when he feels threatened. With his [DIAGNOSES REDACTED]. Psychiatry had the recommendation of [MEDICATION NAME] and we tried to see if it would help his behaviors but it did not change them and the [MEDICATION NAME] was discontinued. He stated, there is no justification for what the CNA did. There is no way to excuse what the CNA did as she knew to expect these types of behaviors from the resident. On 4/05/19 phone calls were made to both CNA E and RN F to obtain interviews. Although voicemails were left, neither one called back. Resident #60 had behaviors that significantly interfered with his care and put himself and others at risk for physical injury. Although the facility was aware of these behaviors they failed to protect the resident from abuse by not training, communicating and monitoring the care he received to ensure he received care from staff in a safe manner.

Based on observation, interview, and record review, the facility failed to identify and implement appropriate interventions to prevent falls for 1 of 4 sampled residents reviewed for falls. The facility's failure to identify and implement appropriate interventions to prevent falls resulted in actual harm due to an acute left femoral neck fracture with impaction that required transfer to the hospital for surgical intervention. Findings: Cross reference to F280 Review of the medical record revealed resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] after hospitalization for a fractured left femoral neck (fractured left hip) and surgery-open reduction and internal fixation (ORIF), of her left hip after her 6th fall at the facility. Other [DIAGNOSES REDACTED]. Review of resident #1's fall risk assessments completed on 1/20/15 revealed she was at risk for falls. A fall risk assessment completed on 6/02/15 revealed she continued to be at risk for falls. Review of her quarterly minimum data set ((MDS) dated [DATE] revealed resident #1 has short and long term memory problems, severely impaired decision making, and requires extensive assistance with one person for all activities of daily living (ADLs) and transfers. Walking in room and corridor did not occur. She uses a wheelchair for mobility. She is always incontinent of bowel and frequently incontinent of bladder. Review of resident #1's progress notes from 1/01/15-6/12/15 revealed daily episodes of confusion, agitation, disorientation to time and place, attention seeking, anxiety, and high risk for falls. Review of resident #1's care plans initiated on 1/07/15 revealed a care plan for risk for falls and injury related to weakness, confusion, use of medications, need for assistance, history of altered mental status, and subdural hemorrhage due to falls. The care plan indicated resident #1 had a brief interview for mental status (BIMS) score of 3 out of 15 on 1/27/15. The BIMS is an aid in detecting cognitive impairment and a score of 0-7 indicates severe cognitive impairment. The care plan goal was for falls to be minimized/eliminated by the next revision date of 4/15/15. Interventions initiated on 1/07/15 included: be sure call light is within reach and encourage to use it for assistance as needed, encourage to participate in activities that promote exercise, physical activity for strengthening, and improved mobility, anticipate and meet needs, needs activities that minimize the potential for falls while providing diversion and distraction, physical therapy evaluation as ordered or as needed, will provide a safe environment. As of the survey date on 6/10/15, the care plan did not include any new interventions for the fall and fracture on 5/25/15. The care plan was not updated upon readmission on 6/02/15. In an interview with the care plan coordinator on 6/11/15 at 12:45 PM, she said she uses a care plan with standard interventions for all residents at risk for falls. She said the individualized interventions are added as needed after they are identified in the morning meeting after a resident falls. Review of resident #1's progress note revealed the notes are entered by type. The type of note was listed as any of the following: occurrence note, calling card, health status, daily skilled note, and IDT (interdisciplinary team). The calling card note text for a fall includes a standard list of items required for documentation including but not limited to: time, name of physician called, blood pressure, temperature, pulse, respirations, when did falls occur, was resident injured, describe injury, new intervention added. The occurrence note for falls documented resident #1 sustained her first fall on 2/15/15 at 7:30 PM while in her room. She was found in her room scooting on the floor between her bed and her roommate's bed. The note indicated the resident was placed, under staff supervision on one on one and 15 minutes check. Review of the facility investigation dated 2/15/15 revealed it did not include any fall prevention interventions. It indicated the resident was confused and had increased anxiety. While still on every 15 minute checks for 72 hours and one on one supervision, resident #1 sustained her second fall on 2/16/15 at 12:20 PM during the lunch meal in the wing 2 dining room. Review of the dining room times revealed lunch time was from 11:30 to 12:30 PM. An observation in the wing 2 dining room on 6/10/15 at 12:20 PM revealed several residents and certified nursing assistants present in the room. The 2/16/15 calling card for the fall documented the resident was a high risk for falls, agitated, confused, and tries to get out of her wheel chair. New intervention included: every 15 minute checks for 72 hours, monitor every 30 minutes, and one on one supervision. One on one supervision and every 15 minute checks interventions were the same as the ones implemented for the fall on 2/15/15, 17 hours earlier. The occurrence note dated 2/16/15 at 12:20 PM indicated the resident was found sitting on the floor in the wing 2 dining room. She was confused and said she tried to reach something on the floor. According to the fall investigation form for the same date and time, resident #1 was found sitting on the floor in the dining room area. Resident is confused and stated that she tried to reach something from the floor. Review of both the 2/15/15 and 2/16/15 falls revealed that the falls occurred at different times and in different locations. However, the interventions remained the same. An interview conducted on 6/11/15 at 2:30 PM with the director of nursing (DON) and regional nurse consultant (RNC) revealed that every 15 minute checks are completed for 72 hours for all residents sustaining a fall. The regional nurse consultant stated every 15 minute checks are not really interventions, they are nursing judgement and part of what we do with every resident who falls. When asked to provide the facility policy and procedure for falls, the RNC provided several documents. The Task Force Initiative provided by the RNC indicated residents who fall will have safety checks every 15 minutes for 72 hours after the fall. The program included a Fall Program Intervention List that listed approximately 48 possible interventions. One on one supervision and 15 minutes checks were included on the list. The program required documentation of the safety checks for 72 hours, but it did not outline what was to be done during the 15 minute checks. When asked on 7/13/15 at approximately 3 PM about documentation of safety checks for resident #1, the RNC provided a printed out computerized sheet that listed CNA Resident Safety Check-every 15 minutes. She said it was for resident #1 for February to May 2015. No times were documented starting at 7:45 PM on 2/15/15. The documentation was missing and/or inconsistent for February through May 2015. It did not include the resident name, room number, or any other identifier. Review of the interdisciplinary team (IDT) documentation revealed no documentation for the fall on 2/15/15 on that day. On 2/16/15 at 10:55 AM the IDT documentation noted the resident continues with in room monitoring. She continues with increased agitation and risk for fall. The IDT note for the fall from 2/16/15 was not done on that day. It was completed on 2/17/15 at 8:50 PM. The note documented the review for falls on 2/15 and 2/16 and noted the resident is easily distracted and will impulsively get out of wheelchair. She is anxious and agitated, but is easily redirected when talking one on one with staff. She returns quickly to previous state when one to one attention has stopped. Currently resident being visited by rotating staff in 30 minute increments during episodes of increased agitation and psychiatric services involved for medication review. The IDT notes and fall investigation form did not include any determination of the possible cause of the fall. Review of resident #1's psychiatric progress notes revealed she was seen on 1/10/15, 1/25/15, 2/18/15 and 3/15/15. On 1/10/15 the psychiatric nurse practitioner noted unstable mood secondary to Alzheimer's, multiple fears and anxiety related to placement and she ordered Depakote sprinkles 125 milligrams (mg) an anticonvulsant every bedtime. The resident was already receiving Remeron-an antidepressant, Zoloft-an antidepressant, and Buspar-an antianxiety medication. On 1/25/15 the notes indicated the resident was stable and was able to be redirected. On 2/18/15 the nurse practitioner noted the resident had no signs of agitation or lethargy. On 3/15/15 the psychiatric note indicated the resident was resting quietly during the visit, but nursing staff reported frequent episodes of agitated behavior that need regular redirection. The nurse practitioner increased the resident's Buspar from 7.5 mg twice a day to 10 mg twice a day. These medications can increase the risk for falls due to side effects. The side effects for anticonvulsant medication can include: dizziness, drowsiness. Some common side effects for antidepressants are fatigue, drowsiness, dizziness (WebMD.com). Side effects of Buspar-antianxiety can include: vertigo, light-headedness, disturbed vision, confusion, fatigue, weakness (Drugdetox.org). On 3/09/15 at 12:15 PM the third fall occurred while the resident was sitting in her locked wheel chair outside of the wing 2 dining room. Review of the 3/09/15 occurrence note and calling card for the fall documented that resident #1 was observed sitting on the floor in front of her wheel chair by the wing 2 dining room. She complained of pain in her right thigh and an X-ray was ordered. It was negative for fracture. The new intervention was to keep her wheel chair unlocked so the resident can propel herself. Review of the social service admission note dated 1/12/15 revealed that resident is out of bed to wheel chair and propels self for short distances. Review of the nurses notes dated 2/20/15 and 2/24/15 documented the resident propels self in wheel chair. Review of the care plan in place prior to the 3/09/15 fall revealed no intervention for the resident's wheelchair to be locked. Review of the investigation for the 3/09/15 fall revealed resident #1 was incontinent at the time of the fall. The Incident/Accident Investigation Follow-Up form, summary of investigation, revealed wheel chair was locked, as resident tried to self-propel she came out of the wheel chair. Past intervention attempted, was blank. Recommendations/new interventions: safety checks every 15 minutes for 72 hours, wheelchair to be unlocked, and physical therapy referral. The new interventions did not address the resident's incontinence at the time of the fall. The facility continued to use 15 minute checks as an intervention even though that intervention was ineffective at preventing falls for resident #1. Review of the health status note dated 3/10/15 7:04 PM, documented the resident had a change in mental status and the resident was sent to the hospital for evaluation. The resident returned the following day on 3/11/15 at 1:15 PM with a [DIAGNOSES REDACTED]. The IDT note dated 3/12/15 documented the fall care plan was reviewed. It did not include any new interventions for fall prevention related the new [DIAGNOSES REDACTED]. On 3/20/15 at 4:10 PM the fourth fall occurred while the resident was in her room. Review of the 3/20/15 calling card for fall and health status note documented that resident #1 was observed on the floor at 4:10 PM and the only new intervention added was one on one staff supervision and it did not include a time frame. Review of the 3/20/14 IDT note revealed resident fell on [DATE] when attempting to ambulate from bed to the bathroom. Resident #1 was placed on 72 hour observation and toileting program. The care plan intervention dated 3/23/15, 3 days later, indicated toilet before/after meals and at bedtime. The facility investigation form dated 3/20/15 revealed that resident #1 was observed sitting on the floor in the bathroom area. Review of the Incident/Accident Investigation Follow up documented the resident was observed sitting on the floor in the bathroom facing the toilet. Past interventions attempted included: call light within reach, reading life story book at the nurses station, unlock wheel chair for self-locomotion, and medication review. Interventions included: safety checks, neurological checks, and physical therapy evaluation. Fall Program Intervention List included an intervention for a bowel and bladder evaluation/program to use with falls that occurred while the resident was going to the bathroom, but it was not initiated on 3/20/15. Appropriate footwear was not addressed on the care plan or in the IDT notes. On 4/26/15 at 2:40 PM the fifth fall occurred while resident #1 was in the wing 2 day room. Review of the 4/26/15 occurrence note and calling card for fall documented the fall occurred in the wing 2 day room, no time documented. The note indicated resident #1 was observed by the nurse sitting her wheel chair in day room listening to music. When the nurse returned from completing a resident treatment, she observed resident #1 ambulating towards her wheel chair in the day room. Resident #1 fell , scraping the right side of her back on the front leg of the wheel chair. An intervention was added for every 15 minute safety checks. Review of the 4/27/15 IDT note documented interventions of every 15 minute safety checks, neurological checks, physical therapy referral, X-ray of the lumbar spine, resident has poor safety awareness and high risk for falls. Non-skid socks while in bed was added to the fall care plan, although the fall did not occur from the bed. On 5/25/15 at 8:40 AM the sixth fall occurred while the resident was in her room. Review of the 5/25/15 occurrence note and calling card for the fall documented resident #1 was observed on the floor by the therapist, resident falls frequently and new intervention added included every 15 minute safety checks. Review of the facility investigation form revealed resident #1 was observed on the floor at the foot of the bed. Resident stated I was trying to go to the bathroom. Review of meals times revealed breakfast was 7:30 AM to 8:30 AM. The facility could not provide any evidence that the resident was toileted before or after breakfast per the plan of care. Review of the 5/25/15 calling card for any problem at 11:41 PM revealed resident #1 complained of left leg pain at 10:50 PM. A left leg X-ray was completed and the results documented an acute left femoral neck fracture with impaction. Review of the transfer form indicated resident #1 was then sent to the hospital via ambulance for evaluation and need for surgical intervention. The IDT notes dated 5/26/15 at 2:00 PM indicated the resident went to the emergency room earlier that morning at 3:40 AM on 5/26/15. A review of the IDT documentation for resident #1 completed on 2/16/15, 2/17/15, 2/18/15, 2/19/15, 2/25/15, 3/12/15, 3/24/15, 3/25/15, 4/15/15, 4/27/15, and 5/26/15 did not consistently include: the number of falls sustained, review of the fall, reason for the fall, review of the interventions, effectiveness of the interventions or revisions to the plan. Resident #1's interventions continually included being placed on every 15 minute safety checks for 72 hours and one on one supervision, however she continued to fall until she sustained a fracture requiring surgical intervention. The IDT documentation did not consistently address any other interventions for fall preventions after the 72 hour checks were completed. Two of the resident's 6 falls, 3/20/15 and 5/25/15, occurred while the resident was attempting to go to the bathroom. An observation conducted on 6/11/15 at 6:11 PM revealed the resident was in bed in her room. She was moaning and moving her arms and legs trying to remove the bed sheets so she could sit up in the bed as she was repeating, I have to go to the bathroom. CNA A was sitting in a chair next to the bed at that time. When the resident attempted to sit up, CNA A stood up and put her hands on the resident's shoulders and guided her to lay back down in the bed. The CNA told the resident to lie down and did not acknowledge the resident's repeated requests to go to the bathroom. At 6:30 PM the activities director and licensed practical nurse (LPN) B entered the room. The activities director asked resident #1 if she wanted to take a walk and resident #1 replied I can't go for a walk, I need to go to the bathroom. At 6:40 PM, after 29 minutes of repeatedly asking to go to the bathroom and exhibiting anxiety, the resident was taken to the bathroom.

Based on interview and record review the facility failed to ensure an ongoing quality assessment and assurance (QA & A) program that identifies quality deficiencies, develops and implements plans of action to correct identified quality deficiencies, monitors the effects of the implemented changes, and makes needed revisions to the action plans related to resident falls and continued compliance with 42 CFR 483.25 (h) accidents F323. The facility QA did not identify a concern with ineffective interventions to prevent repeated falls. This failure resulted in repeated falls and actual harm due to a fall with a fracture that required transfer to the hospital for surgery for [REDACTED].#1). Findings: Cross reference to F323 In an interview conducted on 6/11/15 at 2:30 PM with the director of nursing and regional nurse consultant (RNC), when asked to provide the facility policy and procedure for falls, the RNC provided several documents. The Task Force Initiative provided by the RNC indicated residents who fall will have safety checks every 15 minutes for 72 hours after the fall. The program included a Fall Program Intervention List that listed approximately 48 possible interventions. One on one supervision and 15 minutes checks were included on the list. The program required documentation of the safety checks for 72 hours, but it did not outline what was to be done during the 15 minute checks. An incident/accident investigation follow up form was included in the procedure for falls. The directions instructed the user to answer the questions as applicable to the incident and come to a reasonable conclusion. Summarize the facts to establish a reasonable cause for the incident/accident or the need for further investigation. Review of the falls review documents provided for resident #1 revealed the investigation follow up form was not completed for the falls on 4/26/15 and 5/25/15. The investigation follow up form for the falls that occurred on 3/09/15 and 3/20/15 did not address the questions to establish a reasonable cause for the incident/accident or the need for further investigation. On 6/11/15 at 3:15 PM an interview was conducted with the administrator and director of nursing (DON). The administrator stated that the facility has monthly quality assurance (QA) meetings and falls are reviewed at every meeting. The medical director attends all QA meetings and has completed a medical record review for all residents sustaining falls. The administrator said, we have a 10 step guidelines to educate staff on what to do when a resident falls and we are watching for patterns and tracking and trending our falls but we have not had any issues. The administrator did not acknowledge resident #1's repeated falls and fracture as an issue. He said a clinical review of falls are completed every morning and the interdisciplinary team (IDT) discusses each fall. We refer all falls for therapy screen and there is 72 hour nurse charting after a fall has occurred. No evidence was provided by the administrator of medical record reviews for falls by the medical director, auditing of falls, training and education related to falls or tracking and trending of falls were completed. The administrator also stated that resident #1 will be on one to one supervision indefinitely for safety reasons so she will not fall. We just don't know what to really do with her. The facility QA failed to identify reasonable cause for the incident/accident or the need for further investigation. The administrator did not acknowledge the resident had been on one on one observation as an intervention, but she still fell . A second QA interview was conducted on 7/13/15 at 4:47 PM with the new current administrator and the regional vice president of operations. The administrator stated that the QA meetings are held monthly and quality indicators including falls are reviewed. The administrator said they look at trends, interventions, and their effectiveness. The investigations consist of interviews, reenactment and the team goes to look and interview the resident to find out how and why the resident fell . They get statements from the staff regarding the fall including when the last time the staff interacted with the resident. No evidence was presented at the time of the interview regarding resident #1's falls or any other residents sustaining falls. The administrator said the IDT team reviews the gathered data at the morning meetings, but he was unable to provide an explanation as to why they chose the interventions for resident #1 or when she was placed on one on one supervision how she continued to fall. The administrator then stated that the tracking of all falls is done by the administrator and the DON and the trending of the falls is done by the IDT. The interventions are decided by the licensed nurse at the time of the fall and then the IDT reviews the fall to determine if the interventions are appropriate. The administrator did not present any discussion or evidence regarding the ineffectiveness of the fall prevention interventions for resident #1 and how she continued to fall and sustained a fracture. The administrator and regional vice president of operations were not unable to outline a detailed facility QA process which included: identification of quality deficiencies, development of action plans, implementation of their action plans, monitoring the effects of implemented action plans, and monitoring the effectiveness of action plans to improve the delivery of services and resident outcomes related to resident falls. Review of the Individual Resident Fall QA&A Log for resident #1 documented 4 falls dated 3/09/15, 3/20/15, 4/26/15 and 5/25/15. Falls occurring prior to 3/09/15 (2/15/15 and 2/16/15) were not included on the QA&A log. One of the 4 falls occurred in the morning at 8:40 AM and 3 other falls occurred at 12:15 PM, 2:40 PM, 4:10 PM. Action taken included: all four falls had care plan revisions and one of the 4 falls resulted in hospitalization . The proactive measures/follow up included: life story book, unlock wheel chair, every 15 minute checks, neurological checks, toileting program, non-skid socks and one on one supervision. The follow up column was not completed. A review of the IDT documentation for resident #1 completed on 2/16/15, 2/17/15, 2/18/15, 2/19/15, 2/25/15, 3/12/15, 3/24/15, 3/25/15, 4/15/15, 4/27/15, and 5/26/15 did not consistently include: the number of falls sustained, review of the fall, reason for the fall, review of the interventions, effectiveness of the interventions or revisions to the plan. Resident #1 interventions continually included being placed on every 15 minute safety checks for 72 hours and one on one supervision, however she continued to fall until she sustained a fracture requiring surgical intervention. On 2/05/15 the facility was out of compliance with the regulation F323 Free of accidents hazards/supervision/devices at a G level, actual harm. The noncompliance resulted in a resident fall that resulted in a fracture. Review of the facility's plan of correction with completion date of 3/09/15 included: audits of residents at risk for falls, revisions of resident's interventions for falls, nursing staff will be re-in-serviced and the DON/designee will perform daily audits and report results to the QA/A committee monthly for three months and as needed thereafter. Two separate interviews completed on 6/11/15 and on 7/13/15 with the facility administrator and DON revealed the facility failed to implement an on-going QA program which includes continuous evaluation of facility systems that are directed towards enhancing quality of care and quality of life for the residents. The facility QA program was ineffective at monitoring compliance with their plan of correction for F323 dated 3/09/15. Due to this noncompliance, resident #1 sustained multiple falls and eventually a fracture requiring surgical intervention.

Based on interview and record review, the facility failed to revise the fall care plan with individualized interventions for 1 of 4 sampled residents reviewed for falls. The facility's failure to include individualized interventions in the plan of care for fall prevention resulted in actual harm and the resident sustained [REDACTED].#1). Findings: Review of resident #1's care plans initiated on 1/07/15 revealed a care plan for risk for falls and injury related to weakness, confusion, use of medications, need for assistance, urinary tract infection, altered mental status, subdural hemorrhage, and history of falls. The care plan goal was for falls to be minimized/eliminated by the next revision date of 4/15/15. The occurrence note for falls documented resident #1 sustained her first fall on 2/15/15 at 7:30 PM while in her room. She was found in her room scooting on the floor between her bed and her roommate's bed. The note indicated the resident was placed, under staff supervision on one on one and 15 minutes check. The fall care plan listed an intervention for every 15 minute checks for 72 hours and medication review dated 2/16/15. No other interventions were listed in regards to the fall on 2/15/15. The one on one listed on the occurrence note was not on the fall care plan. The care plan did not address individualized interventions for fall prevention. While still on every 15 minute checks for 72 hours and one on one supervision, resident #1 sustained her second fall on 2/16/15 at 12:20 PM during the lunch meal in the wing 2 dining room. The fall care plan listed an intervention to continue every 15 minute checks for 72 hours dated 2/17/15, the same intervention already in place as the resident fell . No other interventions were listed on the care plan in regards to the fall on 2/16/15. The progress note/calling card dated 2/16/15 listed other interventions, including monitor every 30 minutes and one on one supervision, but they were not included on fall care plan. The care plan did not address individualized interventions for fall prevention. An interview conducted on 6/11/15 at 2:30 PM with the director of nursing and regional nurse consultant, revealed that every 15 minute checks for 72 hours are completed for all residents sustaining a fall and neurological assessments are required for all residents who sustain head trauma during a fall, regardless of the circumstances surrounding the fall or the resident's fall risk. The regional nurse consultant stated every 15 minute checks and neurological checks are not really interventions, they are nursing judgement and part of what we do with every resident who falls. In an interview with the care plan coordinator on 6/11/15 at 12:45 PM, she said she uses a care plan with standard interventions for all residents at risk for falls. She said the individualized interventions are added as needed after they are identified in the morning meeting after a resident falls. A third fall occurred on 3/09/15 at 12:15 PM and review of the fall care plan revealed the same interventions used for the previous 2 falls, that included 15 minute safety checks for 72 hours. A new intervention was added to the care plan on 3/10/15 for neurological checks for 72 hours and resident prefers to have wheelchair unlocked for self-locomotion. Review of the nursing progress notes dated 2/20/15, 2/24/15 and social service admission note dated 1/12/15 documented resident is out of bed to wheel chair and propels self for short distances. There was no documentation as to why resident #1's wheel chair was locked when the facility staff were already aware of her preference for locomotion in the wheelchair. The care plan did not address individualized interventions for fall prevention. A fourth fall occurred on 3/20/15 at 4:10 PM. Review of the 3/20/14 interdisciplinary team (IDT) note revealed the resident fell on [DATE] when attempting to ambulate from the bed to the bathroom. Review of the nursing progress notes: calling card for fall dated 3/20/15 documented intervention of one on one supervision, even though this intervention was not effective for the previous falls. Review of the fall care plan revealed every 15 minute checks for 72 hours, neurological checks for 72 hours, and physical therapy evaluation were added on 3/23/15. The fall care plan was not updated with the intervention of one on one supervision. On 3/23/15, 3 days after the fall on 3/20/15, an intervention to toilet resident before/after meals and bedtime was added. The resident had an overnight stay at the hospital on [DATE] and was admitted back to the facility on [DATE] with a urinary tract infection [MEDICAL CONDITION], but no revisions to the care plan to address toileting were added until 3/23/15. Review of resident #1 care plans for activity of daily living/toileting and antibiotic therapy revealed no update regarding need for increased toileting or the resident's possible increased urge to urinate due to the UTI. The care plan did not address individualized interventions for fall prevention. On 4/26/15 at 2:40 PM the fifth fall occurred while resident #1 was in the wing 2 day room. Review of the 4/26/15 occurrence note and calling card for the fall documented the fall occurred in the wing 2 day room, no time documented. The note indicated resident #1 was observed by the nurse sitting her wheel chair in the day room listening to music. When the nurse returned from completing a resident treatment, she observed resident #1 ambulating towards her wheel chair in the day room. Resident #1 fell , scraping the right side of her back on the front leg of the wheel chair. An intervention was added for every 15 minute safety checks. Review of the fall care plan revealed similar interventions that were ineffective at preventing prior falls including: every 15 minute safety checks for 72 hours and neurological checks for 72 hours. Non-skid socks while in bed was added to the interventions, but the resident did not fall from the bed and the progress notes and investigation did not identify improper footwear as a cause of the fall. The care plan did not address individualized interventions for fall prevention. Resident #1's sixth fall occurred on 5/25/15 at 8:40 AM. Review of the 5/25/15 calling card for the fall revealed the only intervention was every 15 minute safety checks for 72 hours. The fall care plan dated 5/25/15 documented every 15 minute safety checks and neurological checks for 72 hours. There were no new interventions based on the current fall on 5/25/15. Review of resident #1's nursing progress notes: calling card for change in condition dated 5/26/15 3:02 AM, 16 hours after the sixth fall, revealed an X-ray was completed and resident #1 had a left femoral fracture due to her fall on 5/25/15 at 8:40 AM. After the resident returned to the facility on [DATE] after sustaining a [MEDICAL CONDITION] and surgery from the fall on 5/25/15, the fall care plan that was initiated on 1/07/15 with a revision date of 4/15/15 was still in place. The care plan did not address individualized interventions for fall prevention. As of the survey date on 6/10/15, the care plan did not include any new interventions for the fall and fracture on 5/25/15. The care plan was not updated upon readmission on 6/02/15. In an interview on 6/12/15 at 12:10 PM, the MDS/care plan nurse confirmed they had not met to consider individualized interventions for resident #1 until the evening of 6/11/15, 9 days after the resident returned.

Based on interview and record review, the facility failed to notify the physician in a timely manner when a fall that resulted in a fractured left lower leg and pain for 1 resident (#3) reviewed for accidents with a known falls risk, use of a right below the knee prosthesis, and left leg muscle weakness in a sample of 4 residents (#3). The facility ' s failure to notify the physician when the accident occurred led to a delay in treatment for [REDACTED]. Findings: Review of the clinical record revealed resident #3 was readmitted to the facility on [DATE] from a local hospital with [DIAGNOSES REDACTED]. Review of the resident's 01/18/15 Brief Interview for Mental Status (BIMS) revealed a score of 15, which indicated the resident was cognitively intact. The BIMS is a brief screener that aids in detecting cognitive impairment. Her hearing is adequate, speech is clear, is understood, has the ability to understand others with clear comprehension, is able to recall with no cue required, and has no hallucinations or delusions. The resident did not exhibit any behavioral symptoms physical or verbal, including rejection of care. In an interview with resident #3 on 2/04/15 at 12:30 p.m., she revealed that on 1/19/15 at 10:10 a.m., she requested to be assisted to shower room I of station II by her certified nursing assistant (CNA) A. After being assisted to shower room I, the resident said: "I requested for (CNA A) to wait outside the shower room door, to give me some privacy. After I finished, I put the call light on, and (CNA A) came in the shower room right away. I grabbed hold of the safety bar and I stood up from the commode on my own. The CNA did not help me to stand, as she stood beside me. She cleansed me and put on my brief. She left me standing with my face to the wall. While I held onto the bar, she went to get my wheel chair that was near the shower room door." The resident said when CNA A returned with the wheelchair, the resident said to the CNA, "I asked her 3 different times, as I was trying to feel for the seat of the wheelchair in the back of my knees, 'Can I sit? Are the brakes on? Can I sit? Are the brakes on? Can I Sit? Are the brakes on?' She (the CNA) said, 'Yes, you can sit'. As I attempted to sit, the wheelchair flew fastly backward. I fell straight down on the floor, landing on the shower room floor. I was screaming loud, and my left leg was twisted under my body as I lie on the floor. The CNA did not lock the wheelchair, after I asked her 3 times and she said 'Yes, you can sit now.' Five people came in to help assist me off the floor using a sheet that was placed under me. They were able to put me in the wheelchair and wheeled me to my room. After sitting up in the wheelchair for a while, I was assisted back to bed. I told (physical therapist B) that I was having pain in my left ankle, after I was put back to bed. She left out of my room to go and tell the nurse. She had put ice and 'Biofreeze' on my left ankle and knees earlier that day for pain." During the interview on 2/04/15 at 12:30 p.m., resident #3 said, "I learned in PT (physical therapy) to always try to feel for the seat of the wheelchair with the back of your knees, before trying to sit down in the wheelchair." The resident said an X-ray was done on Tuesday 1/20/15 at 7 a.m. and "the doctor to me that my bone was broken in 3 different places. I went to the emergency room in the evening of 1/20/15 and I had surgery on 1/20/15. " Interviews on 2/04/15 at 3:35 p.m. was conducted with the administrator/risk manager, director of nursing (DON), station 2 unit manager (UM), station 2 RN C, the nurse who cared for the resident at the time of the fall, the staff development coordinator, the minimum data set (MDS) coordinator, and the rehabilitation director (RD). The DON revealed that resident #3 fell in shower room [ROOM NUMBER] of station 2 on 1/19/15 at 10:10 a.m., after being assisted to the toilet and provided ADL and peri-care by CNA A. The DON said the resident said, "I can't stand up any longer" so the resident was assisted by the CNA with the fall. In an interview on 2/04/15 at 4 p.m., RN C revealed that the accident happen on 1/19/15 at 10:10 a.m. She said, "I heard (CNA A) yelling for help from station 1 shower room. I immediately went in the shower room, and I observed the resident on the floor. Her left leg was turned outward against the shower room wall." She said she assessed the resident while still in shower room [ROOM NUMBER]. She said the resident was "nervous, short of breath, and the resident did not complain of any pain." She said the physician was notified via telephone on 1/19/15 at 10:30 a.m., but never returned the call. "I gave the 3-11 shift nurse (licensed practical nurse (LPN) D) my report at 3 p.m." When asked if she tried to call the physician again before leaving for the day, RN C said "No, I charted again on 1/19/15 at 4:17 p.m., that the resident was in good condition and she did not complain of any pain before I left the facility." Review of progress notes 1/19/15 at 11:52 p.m., revealed that an "X-ray to left ankle was ordered due the resident's pain and swelling. The resident was made aware of X-ray schedule in a.m., left ankle elevated on pillow." On 2/05/15 at 12:15 p.m., LPN D, the 3-11 shift nurse who received report from RN C on 1/19/15,was interviewed. She revealed that she was given a report about the resident between 3-3:20 p.m. At approximately at 3 p.m., she said she assessed the resident and she was not having any pain, but I did not document that. When asked if she removed the top bed sheet to assess the resident's lower extremities for any swelling, she said, "No, I did not." She revealed that between 10-10:30 p.m., she gave the resident medication for complaint of pain in her left ankle and notified the physician of the pain and swelling seen at that time. She said the resident was made aware of X-ray scheduled for the morning, and elevated her left ankle on a pillow. She said she entered the documentation in the computer at 11:52 p.m. Review of X-ray report on 1/20/15 revealed "Soft tissue swelling. There is an acute displaced [MEDICAL CONDITION] media tibia." A message was left for call back with the physician's office about 10:36 a.m. Review of progress notes 1/20/15 at 12:40 p.m., revealed that the physician was notified the following: left ankle pain and swelling that started last night, pain medication given for the pain but remains persistent, leg elevated for the swelling, and X-ray done 1/20/15 with abnormal findings. The physician gave orders to send the resident to local emergency room for evaluation of left ankle pain and swelling. A local ambulance was called telephone to transport the resident to the hospital. During an interview on 2/5/15 at 7 p.m., the DON revealed that the resident was transferred to a localER on [DATE] at 12:21 p.m. via a local non-emergent ambulance transport service. The resident returned to the facility from the hospital on [DATE] at 6:20 p.m. via stretcher with a left leg cast. Resident #3 had a fall during a transfer on 1/19/15 at 10:10 a.m. The facility failed to ensure the physician was contacted. When after calling the physician on 1/19/15 at 10:30 a.m., the facility did not receive a return call, the facility did not attempt to contact the physician again until 1/19/15 at 10:30 p.m. and the resident had pain and swelling of her left ankle. A total of 12 hours passed before LPN D, of the 3-11 shift, notified the physician after the resident had swelling and pain in the left ankle, resulting in a delay in the physician orders [REDACTED].

Based on observation, interview, and record review, the facility failed to provide adequate assistance and provide assistive devices appropriately to prevent a fall that resulted in a fractured left tibia and pain that required a transfer to a higher level of care for surgical intervention for 1 (#3) resident reviewed for accidents with a falls risk of 4 sampled residents. The facility's failure to keep the resident's wheelchair (w/c) within reach and failure to lock the wheels prior to transfer resulted in actual harm due to a fall and fracture of the distal media tibia (lower leg), pain, and a decline in function regarding mobility and ambulation. Findings: Review of the clinical record revealed resident #3's initial admitted to the facility was listed on the medical record as 1/20/12. She was readmitted to the facility on [DATE] from a local hospital with [DIAGNOSES REDACTED]. The nursing progress note dated 1/24/15 indicated the resident had a cast on her left leg that extended from below her knee to her toes. Review of current Quarterly Minimum Data Set (MDS) assessment reference date 01/18/15 indicated the following: the resident Brief Interview for Mental Status (BIMS) revealed a score of 15. The BIMS is a brief screener that aids in detecting cognitive impairment. A score of 13-15 indicates cognitively intact. The resident makes herself understood and she understands others. The resident did not exhibit any physical or verbal behavioral symptoms. For transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair & standing position), she needs extensive assistance and two plus persons physical assist. Toilet use was total dependence with one person assist. The resident's mobility devices are wheelchair and right limb prosthesis. Her balance is not steady, and only able to stabilize with staff assistance when moving from seated to standing position and moving on and off the toilet. The resident had no limitation that interfered with daily functions or placed the resident at risk of injury in her upper or lower extremities. The resident had no falls since the previous assessment in November 2014. The resident's care plan for risk for falls, initiated on 2/22/12 and revised on 2/05/15 after the accident, included the resident's need for extensive to total assistance for activities of daily living (ADLs). The goal was to minimize falls. The care plan interventions included assistive devices as ordered-wheelchair, keep environment clear and safe, out of bed to wheelchair with assist with staff of 1-2 persons, cue for safety awareness, encourage to ask for assistance prior to transfers. Review of the facility procedures for resident transfers revised on 8/23/11 revealed that all staff are responsible "for using proper body mechanic and techniques during transfers, assess resident to determine functional ability and type of assist needed. Be sure to obtain assistance, when necessary. If assistance is not immediately available, make the resident comfortable until help arrives. Before the transfer, consider where and when equipment will be moved. Lock the wheels on the wheelchair before attempting the transfer. Explain the procedure to the resident. Break the procedure down into small steps. Ensure that the resident completely understands the procedure before attempting the transfer." During an interview on 2/04/15 at 3:45 p.m., the rehabilitation director revealed that the resident was receiving physical therapy (PT) and occupational therapy (OT), services from 11/18/14 to 1/20/15 for a decrease in mobility with generalized muscle weakness. She said the resident was in skilled PT from 11/18/14 to 1/20/15 and was discharged after her admission to the hospital due to swelling and discomfort at the left ankle and her transfer to a local hospital on [DATE]. Review of PT evaluation and plan of treatment dated 1/26/15 indicated the resident exhibits a new onset of decrease in functional mobility, bed mobility, supine to sit, standing, transfers, and gait. Her previous function indicated she was able to walk with a rolling walker with minimum assist for 15 steps. The PT note for date of service on 1/19/15 indicated the resident required minimum contact assist to roll on right and left in bed. She required contact guard with stand by assistance from the therapist to transfer from the bed to the wheelchair. The time of service was not listed, but in the resident reported she had seen PT at approximately 7 a.m. on 1/19/15. Review of the OT notes for service on 1/19/15 indicated the resident transferred from the edge of the bed to the w/c with stand by assistance. The treatment was performed at approximately 6:30 a.m. on 1/19/15. In an interview on 2/04/15 at 12:30 p.m., resident #3 revealed that on 1/19/15 at 10:10 a.m., she asked certified nursing assistant (CNA) A for help to shower room I of station II. She said, "After being assisted to shower room I, I requested for CNA A to wait out side the shower room door, to give me some privacy. After I finished, I put the call light on, and CNA A came in the shower room right away. I grabbed hold of the safety bar and I stood up from the commode on my own. The CNA did not help me to stand, she stood beside me. She cleansed me and put on my brief. She left me standing with my face to the wall, holding on the grab bar, while she went to get my wheel chair that was near the shower room door. When CNA A returned with the wheelchair, I asked her 3 different times, as I was trying to feel for the seat of the wheelchair in the back of my knees, 'Can I sit, Is the brakes on? Can I sit, Is the brakes on? Can I sit, Is the brakes on?' The CNA said, 'Yes you can sit.' As I attempted to sit, the wheelchair flew...backward, I fell straight down on the floor, landing on the shower room floor. I was screaming loud. My left leg was twisted under my body as I lie on the floor. The CNA did not lock the wheelchair, even after I asked her 3 times and she said 'Yes,You Can Sit Now.' Five people came in to help to assist me off the floor using a sheet that was placed under me. They were able to put me in the wheelchair and wheeled me to my room. After sitting up in the wheelchair for a while, I was assisted back to bed. " At that time, the resident continued to say, "I told physical therapy (PT) B that I was having pain in my left ankle, after I was put back to bed, she left out of my room to go and tell the nurse....Registered nurse (RN) C came into my room later and she said that we are going to get you an X-ray...." The resident said, "an X-ray was done on Tuesday 1/20/15 at 7 a.m., in the morning, and the doctor told me that my bone was broken in 3 different places. I went to the emergency room in the evening of 1/20/15 and I had surgery on 1/20/15." During the interview. resident #3 revealed, "I learned in PT, to always try to feel for the seat of the wheelchair with the back of your knees, before trying to sit down in the wheelchair." During an interview on 2/04/15 at 3:35 p.m., the director of nursing (DON) revealed that resident #3 fell in shower room one of station II on 1/19/15 at 10:10 a.m. after being assisted to the toilet and provided ADL and peri-care by CNA A. The DON said the resident revealed "I can't stand up any longer and the resident was assisted by the CNA with the fall...." An observation was conducted of shower room one on station II with the DON and station two unit manager on 2/05/15 at 3:10 p.m. The DON walked the distance from the shower room door to wheelchair and revealed a distance of 15 feet. The resident reported in her interview on 2/04/15 at 12:30 p.m. that the CNA left her standing while holding the bar to go get the w/c that was located near the shower room door and not next to the resident. In an interview on 2/04/15 at 4 p.m., RN C revealed that the accident involving resident #3 happened on 1/19/15 at 10:10 a.m. She said, "I heard (CNA A) yelling for help from station one shower room, I immediately went in the shower room, and I observed the resident on the floor. Her left leg was turned outward." She said she assessed the resident while still in shower room and said the resident was nervous, short of breath and did not complain of any pain. She indicated that the physician was notified via telephone on 1/19/15 at 10:30 a.m., but never returned the call. "I gave the 3-11 shift nurse licensed practical nurse (LPN) D my report at 3 p.m. " When asked if she attempted to call the physician again before she left the facility for the evening, she said, "No, I charted again on 1/19/15 at 4:17 p.m., that the resident was in good condition and she did not complain of any pain before I left the facility." Review of progress notes dated 1/19/15 at 1:45 p.m. revealed RN C documented, " resident slide to the floor as a "result of wheelchair unestable (unstable). CNA helped resident to slide over floor to avoid hit resident's head. No injury." Review of the nursing progress note for RN C for 1/19/15 at 4:17 p.m. revealed it did not include documentation of whether or not the resident complained of pain. During an interview on 2/04/15 at 5:25 p.m., CNA A revealed that on 1/19/15, resident #3 wanted to use the bathroom in shower room one of station II. She said the resident asked her to wait outside the door. She said she did, and when the resident put the call light on, she went back into the shower room to assist the resident. She said the resident stood up, holding on to the grab bar, facing the wall. She said she tried to move to the back of the wheelchair, and told the resident, "Don't sit down yet," but the resident started to sit down anyway, saying, "I can't stand any longer." She said the resident's "buttock was past the seat of the wheelchair, when she went down." The CNA said, "I could not lock the wheelchair, and I never made it to the back of the wheelchair to push the chair to the resident's knees while the resident was still standing." CNA A revealed, "I could not handle the resident, she was to big....I am small compared to her." CNA A said "This was only my second time ever caring for this resident...." During an interview on 2/05/15 at 12:15 p.m., LPN D revealed that she was given a report about the resident between 3-3:20 p.m., and at approximately at 3 p.m., she assessed the resident. When asked if she removed the top bed sheet to check the resident's lower extremities for any swelling, she said, "No, I did not." She said the resident was not having any pain at that time, but she said she did not document it. She said that between 10-10:30 p.m., she gave the resident pain medication and notified the doctor at that time because the resident complained of pain in her left ankle and the ankle was swollen. Progress notes documented by LPN D on 1/19/15 at at 11:52 p.m. revealed that a left ankle X-ray was ordered due the resident's pain and swollen leg. The resident's physician's orders [REDACTED]." The medication was signed out as given to the resident on 1/19/15 at 10:30 p.m., but the documentation on the MAR for 1/19/15 for this pain medication was not signed out as given. The DON indicated that the medication was given to the resident for pain at that time. Review of the radiology report dated 1/20/15 for X-ray results of the ankle revealed soft tissue swelling and an acute displaced fracture of the distal media tibia with dislocation. The report conclusion included, " A message was left for call back with the physician's office about 10:36 a.m. " Review of progress notes 1/20/15 at 12:40 p.m. revealed that the physician was notified of left ankle pain and swelling that started last night, pain medication given, leg elevated, but pain remained persistent, and X-ray done performed that morning was abnormal. The physician ordered the resident to be sent to the hospital emergency room (ER) for evaluation of left ankle pain and swelling. A local ambulance was called to transport the resident to the hospital. During an interview on 2/05/15 at 7 p.m., the DON revealed that the resident was transferred to a localER on [DATE] at 12:21 p.m., via a local non emergency ambulance transport service. She said the resident returned to the facility from the hospital on [DATE] at 6:20 p.m. via stretcher with a left leg cast. The facility did not keep the resident's wheelchair accessible and within reach at the time of the transfer back to the wheelchair and the brakes were not locked, despite the resident's repeated inquiry that the brakes be locked. When the wheelchair was unstable, the resident fell to the floor and sustained a fracture to the left lower leg. The physician was not notified of the fall until 12 hours after the incident. The resident experienced a delay in transfer to the hospital for emergency treatment to the fracture for 26 hours.

Based on interview and record review, the facility failed to provide adequate supervision to prevent an accident of unknown origin that resulted in a fracture which required surgical intervention and head injury for 1 of 5 sampled residents dependent on all activities of daily living (ADLs) services and at risk for accidents (#1). Findings: Resident #1's medical record review found the following information. She was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Past surgical history included right knee replacement. Her quarterly minimum data set (MDS) assessment dated [DATE] indicated she was not steady on surface to surface transfers and only able to stabilize with staff assistance. She was scored a "4/3" in bed mobility and transferring to or from bed or chair, meaning she needed total dependence requiring the assistance of 2 people. She was scored "8/8" for walking in the room and in the corridor on the unit, meaning the activity did not occur. The MDS also indicated passive range of motion (PROM) was performed three times a week and a splint brace was to be worn. The MDS assessment dated [DATE] indicated the resident had severe cognitive deficits with unclear speech and is only sometimes understood and only sometimes understands. The resident required total care for all ADLs. The care plan for "at risk for developing or has an impairment in functional joint mobility" was initiated on 5/02/13 and revised on 7/02/13. It directed restorative nursing staff to conduct "PROM exercises to bilateral lower extremities with stretching on all planes 10 repetitions X 5 sets in all planes." These interventions were initiated on 9/26/13. The care plan for "ADL Self Care Performance deficit r/t (related to) total assist with ADLs" was initiated on 4/08/13. Interventions included "nursing don L (left) knee brace in AM and remove at the end of day shift." This intervention was initiated on 7/31/13. Because the resident has aphasia, another intervention was that nursing was to "anticipate all care needs." The resident's shower days, listed on the interventions for this care plan, were "Wednesday/Saturday." This care plan did not identify a Hoyer lift to be used by the facility to transfer the resident. However, on interview below, both RN #B and the director of nursing (DON) both said the Hoyer lift was used to transfer the resident. The care plan for the resident "at risk for falls r/t non-ambulatory status" was initiated on 4/11/13. Interventions included to have the resident "OOB (out of bed) to wheelchair with assist." This care plan did not identified a Hoyer lift to be used by the facility to transfer the resident. Review of the "Shower List 7-3" revealed resident #1 received a shower by CNA #J on 11/13/13 and a bed bath by CNA #K on 11/16/13. Facility record titled "Follow-Up Question Report" revealed documentation on 11/11/13 and 11/14/13 that resident #1 bathes with "total dependence". Review of the "Bedside Kardex Report" read, "Bed mobility: resident requires 1-2 staff participation to reposition and turn in bed" and "PROM ex (exercises) to BLEs (bilateral lower extremities) with stretching on all planes 10 reps (repetitions) X 5 sets in all planes." Resident #1's medical record revealed daily skin checks were done from 11/10-16/13 and her skin was "clear". Review of the "Restorative Nursing Note, dated 11/10/13 at 10:54 a.m. read, "Resident continues to receive gentle stretch to both UEs (upper extremities) before applying both elbow and left hand splints. Also, PROM to both LEs (lower extremities) and gentle stretch before applying L (left) knee brace after AM care and remove by end of shift. Also, bilateral comfy boots when OOB (out of bed) and remove when in bed." Review of licensed practical nurse (LPN) #H's note on 11/13/13 at 2:50 PM read, "Resident assisted to shower bed with hoyer lift for shower at approx. (approximately 10:45 AM. Daughter in facility at that time, and assisted CNA (certified nursing assistant) with shower. Tolerated well. No signs and symptoms of distress or discomfort at this time." Review of CNA documentation by CNA #I on how the resident is bathed indicated the resident was totally dependent for bathing on 11/11/13 and 11/14/13. Review of RN #B's nurse's note from 11/16/13 at 11:48 PM revealed that the "evening CNA reported observing bump on patient's (resident's) forehead. Assigned nurse assessed patient at approx (approximately) 2250 (10:50 PM), bump to head is on left forehead just at the hairline measuring approx 1.5 inches in diameter, small abrasion at center is noted...." RN #B's nurse's note dated 11/17/13 at 12:13 AM read, "full head to toe skin check was performed. Noted swelling to the right knee. Suggested that a request be made for....an x-ray" but resident's son "insisted she be sent directly to an area hospital for evaluation....order was given (by the physician) to transfer the patient out for x-ray." The next nurse's note at 2:12 AM on 11/17/13 read, "Resident left....via stretcher....non-emergency, in no apparent distress/discomfort. Alert and responsive, VS (vital signs) WNL (within normal limits)...." During an interview with the RN #B at 5:30 p.m. on 11/26/13, she stated she was working the 3-11 p.m. shift on 11/16/13 and was responsible for resident #1's care. She stated the resident was non-verbal because she was aphasic, had limited vision and was severely impaired cognitively. She said the resident was contracted on her left side, hip, knee, shoulder, arm and hand. She said the resident was usually in a fetal position because of her contractions. She explained a low bed was not needed as the resident was total care and did not move herself. The resident was supported by wedges and pillows. She said the resident used a Geri chair when out of bed and a Hoyer lift was used by nursing staff to transfer the resident out of bed. She stated that CNA #A was assigned to the resident that evening and observed a bump on the resident's head. She said the CNA reported this to her but did not notify anyone, including her supervisor, about the incident and did not document anything about the incident. She said that at approximately 9:30 p.m., she assessed the resident and observed a 1 inch area on the resident's forehead with a small abrasion at the center of the abrasion. She said she then performed neurological checks which were normal and that the resident was in no distress. She said the resident did not get up on the 3-11 p.m. shift on 11/16/13. She stated that when the resident's son arrived at 11:30 p.m. on 11/16/13 and asked what happened because the resident's right knee was swollen. She stated that she called the doctor who told her to send the resident to the hospital. She said that she later found out, after the resident had already been sent to the hospital, that the resident had a right knee replacement in the past and there was now a new fracture of that knee but the CT Scan of the resident's head was negative. During an interview with CNA #A at 6 p.m. on 11/26/13, she said she was responsible for resident #1 on 11/16/13. At 3 p.m. that day, she checked the resident and observed the resident lying on her back. She did not notice the bump on the resident's head at that time. At 5:30 p.m., she repositioned the resident to her left side. She stated that she did not observe the bump on the resident's head. At 8:30 p.m., she went to wash the resident's face and that was when she observed the bump on her head. She told RN #B. She explained that she had to tell RN #B two times before RN #B assessed the resident. She said RN #B checked the resident, then went to care for other residents, and did not see the resident after that. CNA #A said resident #1 never moved on her own. During an interview with CNA #A at 5:30 p.m. on 12/02/13, she stated that she would re-position resident #1 by herself as the resident was a 1 or 2 person assist. During an interview with the DON and administrator/risk manager at 6:15 p.m. on 11/26/13, they stated the resident's family was very involved with the resident's care. They said the daughter visited the resident frequently and directed the care of the resident. The POA, resident #1's son, agreed that when the daughter visited, she could direct the CNAs regarding the care she wanted the resident to receive that day. The DON stated the resident was total care with a 1 to 2 person assist, especially when she was lifted by the Hoyer Lift. She stated that on 11/17/13, she was notified about the resident's injury. During a phone interview with resident #1's daughter on 12/02/13 at approximately 2 p.m., she stated that she visited the resident on 11/16/13 and left the facility at 1 p.m. She said the resident was okay and did not have any bump on her head or swelling to her knee when she left the facility. She explained that she was confident of this as she admitted to pulling back the covers from her mother, resident #1, and checking her from head to toe each time she visited, which was usually daily. She said that on the day shift, there were 2 CNAs who turned her mother. During an interview with the resident's son on 12/03/13 at 9:15 a.m., he stated that on 11/16/13, he arrived at the facility at 11:20 p.m., entered his mother's room, saw the head of her bed was flat, and went to the nurses' station and asked the 11 p.m. to 7 a.m. shift nurse to have the 3-11 p.m. nurse come to the resident's room. He said that he then noticed the bump on the resident's head, and said the nurse told him that nobody had verbally reported the bump on the resident's head to her. She called the 11 p.m. to 7 a.m. nurse back into the room to verify the bump on the resident's head. He said the nurse then checked the rest of the resident's body and while she was doing this and they both saw the swollen right side of the resident's knee. On 12/03/13 at 8:30 a.m. during an interview with resident #1's assigned licensed practical nurse (LPN) #C on the 11 p.m. to 7 a.m. shift on 11/16-17/13, she stated on the evening of 11/16/13, she arrived at approximately 11:30 p.m. Upon arrival, resident #1's son approached her asking questions about his mother. She informed him she just came on duty and did not have report from RN #B. She went to get RN #B. She denied having any contact with the resident at that time. She said later in report, RN #B told her CNA #A reported a raised area to right forehead of resident, neurological checks were done, the physician was called, and transportation was on the way to pick up the resident. She denied knowledge of the right swollen knee. She said she took over the neurological checks at midnight and recorded another check at 12:30 a.m. Review of the Radiology Imaging Studies performed at the hospital on [DATE] revealed the X-RAY report of the Knee/Patella: "there is the sequelae of a total knee arthroplasty with a complex distal femoral fracture above the femoral hardware as above. There is some impaction and anterior apical angulation at the fracture site. There is some anterior heterotopic [DIAGNOSES REDACTED] within the soft tissues." The CT Head or Brain w/o Contrast report read, "global parenchymal loss is present. Hypodensity in the white matter around the lateral ventricles is consistent with small vessel white matter damage. No acute sequelae of injury found. No mass, infarction, or hemorrhage is shown." Review of RN #B's daily work schedule indicated that she worked on 11/16/13 from 3-11 p.m., on 11/17/13 from 3-11 p.m. and 11 p.m. to 7 a.m., and on 11/18/13 from 3-11 p.m. Review of CNA #A's daily work schedule indicated that she worked on 11/16/13 from 3-11 p.m., on 11/18/13 from 3-11 p.m., and from 11 p.m. to 7 a.m. Review of CNA #F's daily work schedule indicated that she worked on 11/16/13 from 7 a.m. to 3 p.m. and 3-11 p.m., and on 11/17/13 from 7 a.m. to 3 p.m. and 3-11 p.m. Resident #1 sustained injury to her head and right knee, causing her to have surgery to the right femur fracture on 11/19/13. She depended upon nursing staff for all activities of daily living and care.